Every finding on record at Marquis Forest Grove Post Acute Rehab

Based on interview and record review it was determined the facility failed to ensure staff adhered to professional standards during medication administration for 1 of 1 licensed nurse (#3) reviewed for significant medication error. Resident 49 required emergency treatment and was hospitalized for monitoring due to a methadone overdose. Findings include:Resident 49 admitted to the facility in 2021 with diagnoses including COPD and diabetes. Staff 3's employee file indicated on 10/13/25 education was provided regarding where to find crushed medication orders for Resident 49. The education was provided because Staff 3 gave whole medications to the resident and she/he choked on the whole medications. Resident 49's orders were reviewed with Staff 3. Resident 49's medications were to be crushed in applesauce as described in the special instructions.The 11/3/25 8:37 AM signed medication error report written by Staff 3 (LPN) indicated the following: This LN [licensed nurse] asked CNA in dining room who room [Resident 41] was and when she pointed with her head it was towards [Resident 49], so this LN gave methadone to [Resident 49] instead of [Resident 41], no side effects noted at this time. Unclear which patient was pointed at, seemed like this patient's direction was pointed at. The 11/3/25 11:10 AM progress note by Staff 2 (DNS) indicated the following: Called [physician] to report change in condition. Resident somnolent and with slurred speech. Taken back to room and developed nausea/vomiting. Awake and talking during episode. Alert and oriented self and place with history of dementia, unchanged level of orientation from baseline. Blood pressure 180/64, pulse 52, respirations 14, oxygen saturation 96% on room air. New orders to administer Narcan nasal spray 4 mg x 1, and Zofran [antiemetic medication] 4 mg po x 1. Call physician back if no improvement after Narcan administration. Resident was assisted into bed and closely monitored.The 11/3/25 11:40 AM progress note by Staff 2 indicated the following: Resident no longer with emesis, however, remains with GI upset and stating 'I don't feel good.' Heart rate 44 and irregular, pauses noted when listening to apical pulse. Heart rate 44, respirations 18, oxygen saturation 95% on room air. One liter oxygen per nasal canula placed and [the physician] called back .and ordered to transfer the resident to the emergency room for monitoring and evaluation.The 11/7/25 facility investigation indicated the following:-On 11/3/25 at approximately 8:30 AM a medication error occurred, Staff 3 administered Resident 41's methadone 40 mg to Resident 49. -At 11:45 AM the provider was again contacted due to continued changes in condition and instructed staff to send to the emergency room for hospital evaluation.-At 11:53 AM, 911 was called and Resident 49 was transferred to the hospital for evaluation and was subsequently admitted for further monitoring.-The licensed nurse responsible for the medication error was educated by Staff 2 (DNS) on the five rights of medication administration, starting with their photo identification on record and verification of name. Staff 3 was subsequently placed on administrative leave pending investigation.-In conclusion, the investigation determined that the licensed nurse did not follow proper resident identification procedures and failed to confirm the resident's identity prior to medication administration. As a result, the incorrect medication was administered, leading to Resident 49 requiring hospital evaluation and continued monitoring. Staff 3 was terminated from employment. The 11/7/25 hospital records indicated Resident 49 was hospitalized for a primary diagnosis of accidental methadone overdose and bradycardia (slow heart rate). On 4/9/26 at 9:34 AM Staff 3 stated she remembered the incident when Resident 49 received Resident 41's methadone medication. She stated the resident was not in her/his room and she went to the dining room and asked CNA staff who Resident 49 was and they pointed her to the resident sitting up. Staff 3 stated she asked the resident if she/he was Resident 41's name and the resident stated Yes, yes, yes. She was unaware Resident 49 had confusion. Staff 3 stated she gave Resident 49 the liquid methadone medication and the nurse that was in the dining room told her that was not the correct resident and she did not administer additional medications to the resident. Staff 3 stated she then reported the medication error to the resident care managers. She stated she heard about the pulse being 44 and stated Staff 2 sent Resident 49 to the hospital.On 4/9/26 at 10:17 AM Staff 4 (LPN) stated on 11/3/25 she was in the dining room assisting a resident with a meal and heard Staff 3 say she could not crush medications, then observed Staff 3 next to Resident 49 with a medication cup with Resident 41's room number on it and Staff 3 already administered Resident 41's liquid medication to Resident 49. Staff 4 stated Staff 3 was going to give additional medications and she stopped her as she recognized that Resident 49 did not get liquid medication and the incorrect resident's room number was on the medication cup. Staff 4 stated Staff 2 and Resident Care Managers were notified of the incident.On 4/8/26 at 12:09 PM, 4/8/26 at 12:45 PM and 4/10/26 at 10:20 AM Staff 2 stated Staff 3 refused to give a written statement regarding the medication error. Staff 2 stated Staff 3 worked with Resident 49 previously and a few weeks prior to the medication error she had a conversation with Staff 3 specifically because another staff reported they observed the resident having difficulty swallowing medication when Staff 3 administered medications to the resident. Staff 2 stated Staff 1 (Administrator) was present and they called Staff 3 in and reviewed Resident 49 in the electronic health record including her/his photo and specific orders to have medications crushed. Staff 2 stated on 11/3/25 Staff 3 administered Resident 41's methadone 40 mg to Resident 49 due to Staff 3 not confirming who the resident was prior to administering medication. Staff 2 stated the physician was notified and Resident 49 was sent to the hospital due to Staff 3 administering Resident 41's 40 mg of methadone to Resident 49 in error resulting in a change of condition.No evidence was found to indicate additional deficient practice occurred after 11/3/25. Due to the facility's identification of the deficient practice, and corrective measures put in place on 11/10/25, the deficient practice was determined to be past noncompliance.Refer to F760.

Based on interview and record review it was determined the facility failed to ensure a resident was free from a significant medication error for 1 of 1 sampled resident (#49) reviewed for significant medication error. Resident 49 required emergency treatment and was hospitalized for monitoring due to a methadone (narcotic pain medication) overdose. Findings include:Resident 49 admitted to the facility in 2021 with diagnoses including COPD and diabetes. The 11/3/25 8:37 AM signed medication error report written by Staff 3 (LPN) indicated the following: This LN [licensed nurse] asked CNA in dining room who room [Resident 41] was and when she pointed with her head it was towards [Resident 49], so this LN gave methadone to [Resident 49] instead of [Resident 41], no side effects noted at this time. Unclear which patient was pointed at, seemed like this patient's direction was pointed at. The note indicated the physician responded to monitor for somnolence for the rest of the day, and if noted, administer Narcan (opioid antagonist medication). The 11/3/25 11:10 AM progress note by Staff 2 (DNS) indicated the following: Called [physician] to report change in condition. Resident somnolent and with slurred speech. Taken back to room and developed nausea/vomiting. Awake and talking during episode. Alert and oriented self and place with history of dementia, unchanged level of orientation from baseline. Blood pressure 180/64, pulse 52, respirations 14, oxygen saturation 96% on room air. New orders to administer Narcan nasal spray 4 mg x 1, and Zofran [antiemetic medication] 4 mg po x 1. Call physician back if no improvement after Narcan administration. Resident was assisted into bed and closely monitored.The 11/3/25 11:40 AM progress note by Staff 2 indicated the following: Resident no longer with emesis, however, remains with GI upset and stating 'I don't feel good.' Heart rate 44 and irregular, pauses noted when listening to apical pulse. Heart rate 44, respirations 18, oxygen saturation 95% on room air. One liter oxygen per nasal canula placed and [the physician] called back .and ordered to transfer the resident to the emergency room for monitoring and evaluation.The 11/7/25 facility investigation indicated the following:-On 11/3/25 at approximately 8:30 AM a medication error occurred. Staff 3 administered Resident 41's methadone 40 mg to Resident 49. The provider was notified immediately, and Resident 49 was placed on close monitoring. -At approximately 11:00 AM Resident 49 exhibited a change in condition. Narcan and Zofran were administered per provider orders, and staff continued to monitor the resident closely. At 11:45 AM the provider was again contacted due to continued changes in condition and instructed staff to send the resident to the emergency room for hospital evaluation.-At 11:53 AM, 911 was called and Resident 49 was transferred to the hospital for evaluation and was subsequently admitted for further monitoring.-The licensed nurse responsible for the medication error was educated by Staff 2 on the five rights of medication administration, starting with their photo identification on record and verification of name. Staff 3 was subsequently placed on administrative leave pending investigation.-In conclusion, the investigation determined Staff 3 did not follow proper resident identification procedures and failed to confirm the resident's identity prior to medication administration.-Resident 49 readmitted to the facility on [DATE].The 11/7/25 hospital records indicated Resident 49 was hospitalized for a primary diagnosis of accidental methadone overdose and bradycardia (slow heart rate). The resident accidentally received 40 mg of liquid methadone that was meant for another resident. The emergency department called poison control who recommended 8-hour monitoring due to increases of arrhythmias, bradycardia, nausea and vomiting. After the eight hours, the resident continued to have intermittent bradycardia and atrial fibrillation and the resident was admitted for observation of unintentional methadone overdose. On 4/9/26 at 9:34 AM Staff 3 stated she remembered the incident when Resident 49 received Resident 41's methadone medication. She stated the resident was not in her/his room and she went to the dining room and asked CNA staff who Resident 49 was and they pointed her to the resident sitting up. Staff 3 stated she asked the resident if she/he was Resident 41's name and the resident stated Yes, yes, yes. She was unaware Resident 49 had confusion. Staff 3 stated she gave Resident 49 the liquid methadone medication and the nurse that was in the dining room told her that was not the correct resident and she did not administer additional medications to the resident. Staff 3 stated she then reported the medication error to the resident care managers. She stated she heard about the pulse being 44 and stated Staff 2 sent Resident 49 to the hospital.On 4/9/26 at 10:17 AM Staff 4 (LPN) stated on 11/3/25 she was in the dining room assisting a resident with a meal and heard Staff 3 say she could not crush medications, then observed Staff 3 next to Resident 49 with a medication cup with Resident 41's room number on it and Staff 3 already administered Resident 41's liquid medication to Resident 49. Staff 4 stated Staff 3 was going to give additional medications and she stopped her as she recognized that Resident 49 did not get liquid medication and the incorrect resident's room number was on the medication cup. Staff 4 stated Staff 2 and Resident Care Managers were notified of the incident.On 4/8/26 at 12:09 PM and 12:45 PM Staff 2 stated on 11/3/25 Staff 3 administered Resident 41's methadone 40 mg to Resident 49 due to the staff not confirming who the resident was prior to administering medication. Staff 2 stated Resident 49 was monitored and appeared to be sleepy and started throwing up so Staff 3 stayed in the room with the resident and CNAs. Staff 2 stated she obtained Narcan and Zofran, returned to the room and administered both medications to the resident. Staff 2 stated the physician was notified and Resident 49 was sent to the hospital due to Staff 3 administering Resident 41's 40 mg of methadone to Resident 49 in error resulting in a change of condition.On 4/10/26 at 10:20 AM Staff 1 (Administrator) stated education was completed for all nursing staff after the 11/3/25 medication error and all staff were in serviced by 11/10/25.No evidence was found to indicate additional deficient practice occurred after 11/3/25. Due to the facility's identification of the deficient practice, and corrective measures put in place on 11/10/25, the deficient practice was determined to be past noncompliance.

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 storage refrigerator and 1 of 3 treatment carts reviewed for safe medication storage. This placed residents at risk for receiving medications with reduced efficacy. Findings include: 1. On 11/21/24 at 11:18 AM one open, undated vial of tuberculin (used for the testing in the diagnosis of Tuberculosis) was observed in the medication room refrigerator. The manufacturer's instructions indicated to discard the medication 30 days after opening. On 11/21/24 at 11:18 AM Staff 4 (LPN) acknowledged the vial of tuberculin was open and not labeled with the date opened. On 11/21/24 at 12:38 PM Staff 2 (DNS) stated the expectation was for staff to label tuberculin with an open date. 2. On 11/21/24 at 11:32 AM one open insulin lispro pen was open with no open date in the East Hall treatment cart. The manufacturer's instructions indicated to discard the medication 28 days after opening. On 11/21/24 at 11:32 AM Staff 13 (LPN) acknowledged the insulin lispro pen was open with no open date. On 11/21/24 at 12:38 PM Staff 2 (DNS) stated the expectation was for staff to label insulin with open dates. 3. On 11/21/24 at 11:54 AM the medication room refrigerator temperature logs were reviewed for 10/2024 and 11/2024 and revealed no temperatures were recorded for 10/6, 10/26, 10/28 and 11/16. On 11/21/24 at 12:38 PM Staff 2 (DNS) acknowledged the medication refrigerator logs had no temperatures recorded on the identified dates and the expectation was for staff to log temperatures twice daily. 4. On 11/21/24 at 11:54 AM the 10/2024 and 11/2024 medication room refrigerator temperature logs were reviewed and indicated the following: -Temperatures were to be kept within 36 F to 46 F. -On 10/2, 10/5, 10/8, and 10/9 the medication refrigerator was 48 F. On 11/21/24 at 12:38 PM Staff 2 (DNS) stated the expectation was for the medication room refrigerator to be kept between 36 F and 46 F. Staff 2 acknowledged the medication room refrigerator temperature logs indicated temperatures exceeded 46 F on the identified dates and the refrigerator contained vaccines and insulin.

Based on observation, interview, and record review it was determined the facility failed to process laundry to produce hygienically clean laundry and prevent the spread of infection for 1 of 1 laundry room reviewed for infection control. This placed residents at risk for contaminated laundry. Findings include: According to the Center for Disease Control and Prevention: Guidelines for Environmental Control in Healthcare Facilities (2003); Laundry and Bedding Section G.II.D, damp laundry was not to be left in machines overnight. On 11/21/24 at 1:48 PM Staff 11 (Housekeeping) stated her shift ended at 2:30 PM and she had the last shift of the day. Staff 11 stated when wet laundry was not completed in the washing machine at the end of her shift, she left the wet laundry in the washing machine overnight. Staff 11 stated the next morning she or other housekeeping staff transferred the wet laundry to the dryer and did not rewash the laundry. On 11/21/24 at 2:45 PM the washing machine was observed to contain damp clothing protectors after housekeeping staff left the facility for the day. On 11/21/24 at 2:46 PM 1 (Administrator) stated she was unaware of a laundry policy regarding damp laundry left in the washing machine overnight.

Based on observation, interview, and record review it was determined the facility failed to ensure resident respiratory equipment was maintained for 1 of 1 sampled resident (#12) reviewed for respiratory care. This placed residents at risk for increased respiratory concerns. Findings include: A 3/2015 Oxygen Administration facility policy indicated oxygen concentrator filters were to be cleaned weekly. Resident 12 was admitted to the facility in 10/2023 with diagnoses including Chronic Obstructive Pulmonary Disorder (a lung disease causing restricted airflow and breathing problems) and depression. The 10/19/24 Annual MDS indicated Resident 12 was cognitively intact. Resident 12's physician order dated 11/1/24 revealed she/he required oxygen nightly and as needed. The 11/2024 Task log to Replace oxygen tubing and filter every seven days indicated it was last completed on 11/17/24 by Staff 3 (RN). On 11/18/24 at 10:47 AM the oxygen concentrator was observed to have two foam external filters. The right-side foam filter appeared clean, and the left-side foam filter had a thick layer of dust. Resident 12 stated she/he used the oxygen concentrator nightly and as needed during the day. On 11/19/24 at 4:59 PM Staff 3 stated Resident 12's oxygen concentrator had one external foam filter that she cleaned every Sunday and last cleaned on 11/17/24. Staff 3 stated she was unaware the oxygen concentrator had two external foam filters. On 11/20/24 at 8:57 AM Staff 2 observed Resident 12's oxygen concentrator filters and acknowledged the left-side foam filter appeared dirty.

Based on interview and record review it was determined the facility failed to provide the necessary care and services to prevent resident falls for 1 of 3 sampled residents (#2) reviewed for falls. This placed residents at risk for increased falls and injury. Findings include: Resident 2 admitted to the facility on [DATE] with diagnoses including traumatic brain injury, dementia and seizures. A review of Resident 2's medical record revealed Resident 2 fell on the following dates: *December 2020: 5, 8, 9, 11, 13 (twice), 15, 17, 22 and 23 *January 2021: 9 1. The 12/23/20 Post Fall Assessment revealed Resident 2 wore slippers without non-skid soles when she/he fell . The 12/2/20 Fall Care Plan revealed a revised intervention on 1/6/21 which indicated the resident was to wear non-skid shoes and slippers. [The care plan did not have the intervention to wear non-skid footwear in place upon admission which is considered a standard fall prevention practice.] On 1/31/23 at 12:35 PM Staff 2 (DNS) stated non-skid footwear was the standard of practice and generally put on care plans. Staff 2 verified Resident 2 wore shoes that did not have non-skid soles on 12/23/20. 2. A review of Resident 2's medical record revealed she/he had four prior unwitnessed falls between 12/2/20 through 12/12/20, was impulsive, had decreased cognition and experienced both hallucinations and delusions. The 12/13/20 Post Fall Assessment revealed Resident 2 fell when she/he attempted to self-transfer off the toilet. The resident was observed by staff one minute prior to the fall. The 12/2/20 Urinary Incontinence Care Plan revealed no supervision requirements prior to the resident's fall. A revised intervention dated 1/14/21 for the resident to have one person constant supervision and physical assist for safety. On 1/31/22 at 12:35 PM Staff 2 (DNS) stated Resident 2 should have been under constant supervision in the bathroom.

Based on interview and record review it was determined the facility failed to administer medication as ordered by the physician for 1 of 3 sampled residents (#1) reviewed for medications. This placed residents at risk for not receiving a PRN medication for stomach distress at the proper time. Findings include: Resident 1 was admitted to the facility in 11/2019 with [DIAGNOSES REDACTED]. On 12/7/19 the physician ordered [MEDICATION NAME] (anti-nausea) 4 mg every 8 hours as needed for nausea and vomiting. The 12/12/19 progress note revealed Resident 1 requested the [MEDICATION NAME] for stomach distress around 10:00 PM. Staff 4 (LPN) checked the MAR and attempted to let Resident 1 know she/he wasn't due for the medication until 2:00 AM because it was every eight ours. Staff 4 attempted to let Resident know of the time delay and the resident was asleep. Staff 4 returned to Resident 1's room at 2:00 AM to administer the medication. There were no notes of the resident complaining of stomach distress from 10:00 PM until 2:00 AM. The 12/2019 MAR revealed the resident did not receive a PRN [MEDICATION NAME] on 12/11/19 and the resident was able to receive the medication at 10:00 PM instead of waiting until 2:00 AM. On 1/9/20 Staff 4 indicated Resident 1 requested a PRN [MEDICATION NAME] around 10:00 PM and Staff 4 stated he looked at the MAR and saw the resident was not able to receive the medication until 2:00 AM due to the PRN was every eight hours. He indicated he thought he saw the resident received a dose that day (12/11/19). On 1/9/20 at 2:05 PM Staff 2 (DNS) indicated she looked at the 12/2019 MAR and indicated there was no documentation of the resident receiving a PRN [MEDICATION NAME] on 12/11/19 and the resident should have received the [MEDICATION NAME] at 10:00 PM when the resident asked for the medication.

Based on interview and record review it was determined the facility failed to ensure residents were safe from accidents related to the use of bed rails (adjustable bars attached to bed and can range in size, used as an assistive device) and assessed the safety of grab bars (small cane shaped bar used as an assistive device) for 1 of 1 sampled resident (#43) reviewed for accidents. This placed residents at risk for continued accidents and possible injury. Findings include: Resident 43 admitted to the facility in 12/2018 with [DIAGNOSES REDACTED]. Resident 43's 12/28/18 care plan for falls indicated she/he was at risk for falls. Interventions included to encourage the resident to use assistive devices properly. The care plan did not indicate if the resident used bed rails or grab bars. The 1/9/2019 MDS assessment indicated the resident was cognitively intact. The assessment further indicated she/he received extensive assist by two staff people for bed mobility and transfers. The 1/10/19 Falls Assessment for Resident 43 indicated she/he had a history of [REDACTED]. The assessment did not indicate if the resident used assistive devices on her/his bed. The 2/7/19 revised care plan for mobility and falls indicated she/he used the assistance of bilateral grab bars. The care plan further indicated the resident frequently attempted to self-transfer. Resident 43's current Kardex (CNA Care Plan) indicated she/he was a fall risk and used the assistance of bilateral grab bars. The resident was also noted to have a catheter in place. Review of Resident 43's clinical record revealed no safety assessment related to the use of either bed rails or grab bars. The 3/8/19 Assistive Device Assessment indicated Resident 43 read and agreed to the use of bed rails at the head of and foot of her/his bed. The resident was noted to be independent with bed mobility, required supervision for transfers and had a history of [REDACTED]. The device was noted to not restrict Resident 43's mobility and noted she/he used the upper bed rails to assist her/himself to re-position in bed. The assessment indicated the lower side rails were kept down and were not in use. Risks discussed with the resident included the potential she/he could get stuck in the open area of (the) handle. The resident was noted to have brought in her/his own bed with bed rails from her/his home. The assessment did not indicate when the resident brought in her/his own bed with bed rails. The 9/4/19 Fall Assessment indicated Resident 43 was found on the floor in her/his room after being in her/his bed. The assessment further indicated she/he was found suspended between her/his bed and the floor at 4:05 PM. The resident's right leg was caught on the bed rail. Resident 43 was noted to be confused and unable to describe the events of the fall, and was last seen by staff at 4:00 PM. The assistive/restrictive devises in use were noted to include bed canes to the foot and (head of bed)). The Prevention Plans Detail portion of the assessment included the following, Staff continue to anticipate transfer needs, (r)found on (her/him) frequently. (Ensure) safety measures (are) in place during each assessment (and) rounds. Assess bed cane placement and need for bed cane mobility. 9/4/19 Post-Fall Staff Questionnaire indicated Staff 5 (CNA) found the resident after her/his unwitnessed fall. Staff 5 noted Resident 43 was found suspended from her/his bed. She noted the resident's head was dangling above the ground, and her/his leg was entrapped in the bed rail. It was noted that her/his catheter was attached to the far rail. Staff 5 further indicated the resident's call light was not within reach, and had a suspected UTI with increased confusion. A 9/6/19 maintenance request from Staff 8 (RCM) indicated the grab bar on the resident's left side of the bed, appeared to be pushed out. The work order further indicated if the grab bar could not be fixed, could it be removed. A 9/9/19 maintenance request indicated Resident 43 had a mattress that was too small for her/his bedframe and to replace it if necessary. A 9/9/19 progress note indicated a larger mattress was placed on the bed and further indicated there was no longer a gap between the grab bars and the mattress. On 9/25/19 at 1:45 PM and 2:40 PM Staff 3 (Maintenance Manger) stated at one point in time, Resident 43 had a 42 inch wide bed with a 36 inch standard sized mattress on it. Staff 3 acknowledged there was a gap between the bed rails and the mattress that could have caused the resident to become entrapped. Staff 3 stated the resident had her/his own bed rails on both the head and the foot of the bed, and administrative staff requested those to be removed and replaced with facility approved grab bars. Review of Resident 43's clinical record on 9/25/19 revealed no safety assessment related to the placement of grab bars. On 9/25/19 at 2:45 PM Staff 6 (LPN) stated when the resident fell her/his foot became caught in the bed rail, but did not have any pain or injury from the incident. Staff 6 also stated the resident had a catheter that was attached to the opposite side of the bed that was pulling on the resident's genital area. On 9/25/19 at 3:14 PM Staff 5 (CNA) stated she could not remember how the resident's leg or foot looked, but stated she had to dislodge it from the side rail. On 9/27/19 at 9:15 PM Staff 2 (DNS) acknowledged Resident 43's use of side rails at the time of her/his fall, and acknowledged the resident's clinical record did not indicate when the side rails were first placed on the bed. Staff 2 acknowledged the resident's care plan did not accurately reflect the use of her/his side rails. Staff 2 also acknowledged the 9/4/19 Fall Assessment inaccurately used the term bed canes (grab bars) in place of the correct terminology of side rails. Staff 2 acknowledged the resident's clinical record indicated the resident had a mattress that was too small for the bed frame. Staff 2 additionally acknowledged the residents care plan was not updated to reflect new interventions put into place following Resident 43's accident on 9/4/19, and a safety assessment of the placement of grab bars was not completed until 9/27/19.

Based on observation and interview it was determined the facility failed to ensure proper food handling during meal service was conducted for 1 of 1 kitchens reviewed for food sanitation. This placed residents at risk for cross contamination. Findings include: Observations of the tray line service on 2/15/18 at 11:44 am, revealed Staff 6 (Cook) wore gloves and was observed to use her gloved hands to pick up meal tickets, touch the shelves on the serving station, touch the plate and lids and then with the same gloves pick up the garlic bread and place it on the residents plates. Staff 6 was stopped during the tray service to use a serving utensil for the garlic bread. Staff 6 acknowledged she should have used a utensil instead of her gloved hands. On 2/15/18 at 2:04 pm, Staff 7 (Dietary Manger) acknowledged Staff 6 should have used a utensil to handle the bread instead of her gloved hands.

Based on observation, interview and record review it was determined the facility failed to monitor, follow physician orders [REDACTED].#s 34 & 39) who were reviewed for [MEDICAL CONDITION] and skin non-pressure. This placed residents at risk for delayed treatment and increased risk for complications related to care. Findings include: 1. Resident 34 was admitted to the facility in 1/2018 with [DIAGNOSES REDACTED]. The resident's 1/2018 Pressure Ulcer CAA indicated Resident 34 was admitted with moisture-associated skin damage to the resident's buttocks and sacrum. The resident was at risk for skin breakdown due to the resident's incontinence and decreased mobility due to weakness, poor balance and recent hospitalization . The resident's 1/13/18 Skin and Wound Assessment identified she/he admitted with a blister to her/his left buttock which measured 24.8 x 5.3 x 6.7 cm. Subsequent Skin and Wound Assessment's assessed the resident's left buttock blister as follows: - On 1/17/18 the resident's blister measured 4.8 x 2.8 x 2.4 cm and her/his wound was improving. - On 1/24/18 the resident's blister measure 6.5 x 3.4 x 2.3 cm and her/his wound was improving. - On 1/31/18 the resident's blister measured 1.4 x 1.5 x 1.4 cm and her/his wound was improving. - On 2/7/18 the resident's wound measured 17.7 x 7.7 x 4.8 cm and her/his wound was improving. The resident's wound bed had 70% of [MEDICATION NAME] (wound coverage) and 30% of granulation (new tissue). On 2/16/18 at 9:30 am, Resident 34 was observed to have a wound on top of her/his coccyx, the wound was open and had pale and pink tissue with macerated (soft) skin around the wound. Resident 34's 1/2018 TAR indicated to apply Butt Paste to the resident's sacrum/coccyx every day and evening shift for skin impairment started on 1/24/18, 11 days after the resident's blister was identified. In addition, the resident's Skin and Wound Assessment forms did not assess when the resident's blister opened nor was a treatment change considered despite an increase in the resident's wound measurements on 2/7/18. In an interview on 2/14/18 at 12:37 pm, Staff 5 (RN) stated Resident 34 had an open area/wound to her/his left buttock which was a blister when first discovered. Staff 5 stated the resident's only treatment was butt paste to the resident's left buttock area, which had been in place since 1/24/18. In an interview on 2/15/18 at 12:44 pm, Staff 3 (RNCM) confirmed there had been no treatment initiated until 1/24/18. Staff 3 also acknowledged she had not regularly monitored Resident 34's wound as the wound was not a pressure area. In an interview on 1/25/18 at 1:22 pm, Staff 2 (DNS) confirmed there had been a delay in initiating treatment and a delay in implementing new treatment orders. After reviewing the resident's skin and wound assessments, Staff 2 stated she agreed the resident's wound had worsened as of 2/7/18. 2. Resident 39 was admitted to the facility in 1/2018 with [DIAGNOSES REDACTED]. The 1/14/18 Physicians orders directed staff to administer [MEDICATION NAME] 40 mg (an anti-diuretic) one tablet three times a week as needed for swelling. The order was transcribed to the 1/2018 and 2/2018 MAR. The 1/14/18 Nursing Admission Assessment revealed the resident had [MEDICAL CONDITION] present and had a pacemaker. The 1/14/18 Care Plan revealed: -The resident required assistance with mobility related to impairment and weakness. -The resident was at risk for dehydration related to the use of [MEDICATION NAME]. -The resident was at risk for skin impairment related to decreased mobility and staff were to notify the charge nurse of impairments. The 1/14/18 through 2/15/18 TASK for [MEDICAL CONDITION] monitoring was blank. On 1/30/18 the Nurse Practitioner Progress Note revealed the resident had bilateral lower extremity two plus [MEDICAL CONDITION] (moderate swelling) and to continue current orders. The 1/2018 MAR indicated [REDACTED] On 2/7/18 the Progress Note revealed the resident had bilateral lower extremity [MEDICAL CONDITION]. The 2/2018 MAR indicated [REDACTED] An observation on 2/12/18 at 10:32 am revealed the resident was wearing oxygen and had swelling in her/his bilateral feet and lower extremities. On 2/13/18 Nurse Practitioner Progress Note revealed the resident had bilateral lower extremity two plus [MEDICAL CONDITION]. The 2/2018 MAR indicated [REDACTED] An observation on 2/15/18 at 9:41 am revealed therapy staff wheeled the resident to a medication cart and asked Staff 5 (RN) about Resident 39's lower extremity [MEDICAL CONDITION]. Staff 5 indicated he would have to check and see if there was an assessment. On 2/15/18 at 9:51 am, Staff 3 (RNCM) acknowledged there was swelling and tenderness in the resident's bilateral lower extremities and stated a PRN [MEDICATION NAME] would be administered. Staff 3 acknowledged the daily Task for [MEDICAL CONDITION] monitoring was blank and the staff should have monitored Resident 39's [MEDICAL CONDITION].

Based on observation, interview and record review the facility failed to implement care planned fall interventions for 1 of 2 sampled residents (#5) reviewed for accidents. This placed residents at risk for injury. Findings include: Resident 5 was admitted to the facility in 9/2014 with [DIAGNOSES REDACTED]. The 12/7/17 care plan indicated Resident 5 was at risk for falls related to weakness, impaired mobility with right sided weakness, a history of falls and stroke. Fall interventions included a non-skid material on Resident 5's wheelchair seat. A Progress Note dated 2/4/18 indicated Resident 5 had an unwitnessed fall with injury. The investigation to the incident dated 2/4/18 indicated Resident 5 was found on the floor in her/his room after falling from her/his wheelchair. Resident 5 reported she/he was attempting to re-arrange some things on her/his dresser and fell forward. Resident 5 struck the right side of her/his head and face resulting in a hematoma (a solid swelling of clotted blood within the tissues). The investigation concluded the fall occurred due to the resident leaning forward to reach objects on the dresser without placing herself/himself in close enough proximity and her/his non-skid material was not on the wheelchair seat. On 2/12/18 at 11:45 am, Resident 45 was observed sitting in her/his wheelchair. A non-skid mat was observed on the seat of the wheelchair. Resident 45 had bruising under both eyes and stated it was from a fall. Resident 45 was unable to recall how she/he fell . On 2/14/18 at 11:55 am and 2/15/18 at 11:07 am, Staff 9 (CNA) stated Resident 5 was a fall risk and sometimes leaned forward to pick things up off the floor. Staff 9 stated Resident 5 used to slide in her/his wheelchair so a non-skid mat was used to prevent the resident from sliding down and out. On 2/15/18 at 12:35 pm, Staff 11 (RNCM) stated Resident 5 fell out of her/his wheelchair while reaching for something and slid out of the wheelchair. Staff 11 stated the non-skid mat intervention was not put into place and likely contributed to Resident 5's fall. On 2/15/18 at 1:00 pm, Staff 2 (DNS) acknowledged Resident 5's care planned fall intervention was not followed.

Based on interview and record review, it was determined the facility failed to convey resident funds within 30 days after death to the Oregon Estate Administration for 2 of 2 sampled residents (#s 109 and 110) who were reviewed for conveyance of personal funds. This prevented the residents' personal funds from being dispersed in a timely manner. Findings include: On [DATE] at 12:13 pm, the facility accounting record revealed Resident 109 died in ,[DATE] and the remaining personal funds were not dispersed as of [DATE], six months after the resident's death. The facility accounting record also revealed Resident 110 died in ,[DATE] and the remaining personal funds were not dispersed as of [DATE], six months after the resident's death. On [DATE] at 12:13 pm, Staff 11, Business Office Manager, confirmed the remaining personal funds were not refunded to the Oregon Estate Administration for Residents 109 and 110 as of [DATE], which exceeded the 30 day required time limit for refunding the proceeds after death.

Based on observation, interview and record review, it was determined the facility failed to ensure interventions assessed as needed and/or care planned were implemented for 1 of 1 sampled resident (#16) who was reviewed for [MEDICAL TREATMENT] services. This placed the residents at risk for unmet needs. Findings include: Resident 16 was admitted to the facility in 5/2016, with a [DIAGNOSES REDACTED]. a. According to surgical records dated 5/22/16, a jugular catheter with two access ports was surgically inserted into the resident's right upper chest/neck area to allow access for completing [MEDICAL TREATMENT] treatments. The resident's care plan dated 11/3/16, included a problem of [MEDICAL CONDITION] with [MEDICAL TREATMENT]. Care planned interventions included an emergency dressing kit with 4 x 4 gauze and a clamp was to be placed above the resident's bed on the wall, as an emergency measure, in case of increased bleeding from the catheter site. Observations on 12/12/16 at 9:17 am, 12/12/16 at 12:27 pm and 12/13/16 at 2:22 pm revealed no emergency dressing kit was visible in the resident's room in the area designated by the care plan. During an observation on 12/12/16 at 9:17 am and 12:27 pm, a bandage was observed over the resident's port site, located on the right side of her/his chest/neck area. During an interview on 12/13/16 at 2:30 pm, Staff 5 (CNA) was caring for the resident and asked where the emergency dressing kit for Resident 16 was located. Staff 5 stated she had no idea and suggested we would need to talk to nursing staff. During an interview on 12/13/16 at 2:35 pm, when asked where she would find an emergency kit for a [MEDICAL TREATMENT] patient, Staff 4 (Charge Nurse) stated she had no idea, thinking it would be in the resident's room. Staff 4 later stated she thought it was located in Central supply. During an interview on 12/13/16 at 2:34 pm, Staff 2 (RNCM for Resident 16) stated the resident had a port without an external catheter beyond the level of the skin and a clamp would not be necessary. During an interview with Staff 10 (RNCM) on 12/13/16 at 2:51 pm, Staff 10 indicated she had looked beneath the resident's dressing and the resident had two external catheters visible one red, one blue. b. The resident's dietary assessment dated [DATE], indicated the resident was to receive on additional ounce of protein every meal. Resident 16's care plan dated 11/3/16 included interventions for providing diet and supplements per MD order and per dietician recommendations. The resident's labs dated 11/17/16 indicated the resident's [MEDICATION NAME] level (a protein indicator) was below the normal range (3.5 to 5.2) at 3.3. During breakfast dining observations on 12/12/16 at 9:17 am and 12/14/16 at 8:24 am, the resident was served approximately 1/3 cup of yogurt. This was the only protein source on the resident's breakfast trays. The dietary tray card for Resident 16 indicated a 1/2 cup of yogurt was to be provided. The diet card did not include the 1 ounce of extra protein as indicated by the dietary assessment. During the lunch dining observation on 12/14/16 at 12:35 pm, the only protein source on the resident's tray was a small serving (less than 4 ounces) of ground sweet and sour meatballs. The resident's dietary card indicated the resident should have received a minimum of 5 oz of protein. During an interview on 12/14/16 at 9:08 am, Staff 7 (Dietary Manager) stated the resident was provided with a little extra protein. Staff 7 confirmed the resident's tray cards did not contain instructions for dietary staff to add one additional ounce of protein to each meal. Staff 7 also stated he experienced difficulty with the electronic system when entering special dietary instructions and confirmed the extra ounce of protein was not on the dietary card. During an interview on 12/14/16 at 10:32 am, Staff 8 (RN) reported the dietician from the [MEDICAL TREATMENT] unit called on 12/12/16 and wanted to make sure Resident 16 received extra protein servings due to low protein levels.

Based on interview and record review, it was determined the facility failed to complete a gradual dose reduction (GDR) for 1 of 5 sampled residents (#17) who was reviewed for unnecessary medications. This placed residents at risk for excessive [MEDICAL CONDITION] medication dosing. Findings include: Resident 17 was readmitted to the facility in 2015, with [DIAGNOSES REDACTED]. The 11/22/16 Physician order [REDACTED].>The December MARs indicated [MEDICATION NAME] was administered daily. Review of Resident 17's medical record indicated a GDR was not completed in the past 14 months. On 12/14/16 at 8:58 am Staff 2 (RNCM) verified a GDR was not completed in the past 14 months.

Based on interview and record review it was determined the facility failed to monitor [MEDICAL TREATMENT] and complete alert charting for an infected [MEDICAL TREATMENT] for 2 of 3 sampled residents (#s 1 and 5) reviewed for [MEDICAL TREATMENT]. Resident 1 was at risk of complications with [MEDICAL TREATMENT] and Resident 5 was at risk of complications from infection. Findings include: 1. Resident 1 was admitted to the facility in 1/2015 with [DIAGNOSES REDACTED]. The 1/2015 care plan noted Resident 1 received [MEDICAL TREATMENT] (an artificial process to eliminate the body waste when the kidneys did not function properly) three times a week. Staff were directed to monitor the access site for bleeding or swelling after [MEDICAL TREATMENT] visits. The care plan did not include directives to monitor the site for thrill and bruit (the thrill is a rhythmic vibration that can be felt over the access site and bruit is a sound heard when listening to the access site with a stethoscope). There was no documented evidence the [MEDICAL TREATMENT] was monitored, including the thrill and bruit. On 12/7/15 at 10:00 am Staff 1, DNS, stated nursing staff should have documented monitoring the [MEDICAL TREATMENT], including checking the thrill and bruit. 2. Resident 5 was admitted to the facility in 10/2015 with [DIAGNOSES REDACTED]. The 10/19/15 Nurse Practitioner Progress Note disclosed a previous [MEDICAL TREATMENT] on the left upper extremity had purulent (pus) drainage. A wound culture was obtained. The 10/21/15 at 11:00 am Progress Note revealed the physician planned to treat the resident for infection with IV antibiotics while at [MEDICAL TREATMENT] three times a week. The Wound Culture Final Report was positive for organisms [MEDICAL CONDITION] ([MEDICAL CONDITION]-Resistant Staphylococcus aureus). There was no documentation the facility nursing staff identified the potential infection nor performed on-going alert charting in the clinical record. The facility's 6/2012 Alert Charting - Clinical Assessment included: The Nurse shall assess and document identified changes in condition of residents, as identified. The facility policy is to assure the adequate monitoring and appropriate interventions for all residents whenever a change of condition .occurs . Alert charting: Term used to identify residents that require monitoring, assessment, and documentation in the clinical records at least once a shift, or as determined by the RCM care manager. Change of Condition: Any changes in the resident's physical, medical .status. Alert charting to continue until determined stable by RCM and/or physician .The licensed nurse shall initiate alert charting if the resident meets any of the criteria listed in the above conditions/definitions The resident will be assessed by licensed nurse on duty. Assessment shall include as appropriate, but not limited to; a. Vital Signs; b. neurological status .f. Skin assessment .h. Onset, duration, severity of the change Assessment findings shall be clearly documented in the clinical record .Resident will be placed on 'Alert' for charting and follow-up .All residents placed on alert charting, shall have documentation as scheduled/with frequency and content adjusted per resident condition .Alert changing to be documented in the resident's progress notes of their clinical record . On 12/8/15 at 1:30 pm Staff 8, RN stated on 10/19/15 the drainage from the resident's previous [MEDICAL TREATMENT] site was different, had an odor and was pus-like. Staff 8 had the Nurse Practitioner examine the area. Staff 8 stated he did not document his findings and did not know if alert charting was initiated. On 12/7/15 at 10:00 am and 12/8/15 at 1:17 pm Staff 1, DNS stated she expected staff to document everything about the infection, to paint a picture, which did not occur. Staff 1 stated Staff 8 should have documented his findings.

Based on interview and record review it was determined the facility failed to comprehensively assess 1 of 3 (#59) sampled residents reviewed for ADL services. Failure to provide accurate assessments puts residents at risk for unmet needs. Findings include: Resident 59 was admitted to the facility in 2014 with [DIAGNOSES REDACTED]. The annual MDS dated [DATE] indicated Resident 59 had a visual field deficit. The vision CAA noted the resident used glasses. The vision CAA did not include a comprehensive analysis regarding contributing factors affecting vision to include in a care plan. On 8/31/15 at 11:07 am Resident 59 stated the glasses she/he had were not hers/his and were given to her/him by staff. Resident 59 stated she/he had different glasses when she/he came to the facility which were broken. On 9/3/15 at 9:47 am Staff 5 (Social Service Director) acknowledged Resident 59's MDS annual assessment dated [DATE] indicated the resident had a vision deficit and utilized corrective lenses. Staff 5 did not know if the resident was admitted with bi-focals or magnified reading glasses. Staff 5 agreed the vision assessment was not accurate or comprehensive. On 9/3/15 at 10:13 am Staff 4 (CNA) stated Resident 59 had bi-focals when she/he was admitted to the facility that were broken or misplaced sometime after admission. On 9/4/15 at 2:34 pm Witness 4 (Family member) stated Resident 59 was legally blind. Witness 4 further stated she/he was involved in the resident's admission process and was not interviewed regarding the resident's vision impairment by facility staff. On 9/4/15 at 3:30 pm Staff 1 (DNS) acknowledged Resident 59's MDS annual assessment dated [DATE] included a visual CAA which was not comprehensive and did not include a resident or family interview, or a comprehensive analysis of the resident's visual deficit.

Based on observation, interview and record review it was determined the facility failed to develop a comprehensive care plan for 1 of 3 (#59) sampled residents reviewed for dental services. Failure to develop a plan of care puts residents at risk for unmet dental needs. Findings include: Resident 59 was admitted to the facility in 2014 with [DIAGNOSES REDACTED]. The MDS admission assessment dated [DATE] included a Dental CAA which indicated Resident 59 had discolored, impaired and cracked teeth. The assessment indicated the oral status would be addressed in the care plan. Resident 59's current care plan did not include the impaired and cracked teeth. There were no goals or interventions regarding oral care. On 8/31/15 at 10:58 am Resident 59 was observed with several discolored, broken and cracked teeth On 8/31/15 at 11:01 am Resident 59 stated her/his teeth were broken and needed she/he needed to see the dentist. On 9/3/15 at 10:13 am Staff 4 (CNA) stated she used a swab for oral care because the resident's teeth were very fragile. Staff 4 further stated Resident 59 had recently complained about oral pain recently. On 9/4/15 at 1:15 pm Staff 2 (RNCM) and (DNS) acknowledged Resident 59 had no comprehensive plan of care to address the dental issues assessed when she/he was admitted to the facility.

Based on interview and record review it was determined the facility failed to update/revise the care plan for 1 of 3 (#58) sampled residents reviewed for ADL care. Failure to update resident care plans puts residents at risk for unmet needs. Findings include: Resident 58 was admitted to the facility in 2014 with [DIAGNOSES REDACTED]. The annual MDS assessment dated [DATE] included an ADLCAA which indicated Resident 58 had a restorative program to ambulate with the use of a four wheeled walker and a two person extensive assist. The assessment further noted the resident had frequently declined recently. Resident 58's care plan dated 7/9/15 indicated the resident had a restorative program to maintain/improve functional status. The interventions included walking twice a day with a four wheeled walker and two staff members when the spouse was present. The care plan noted the spouse or a nursing student would walk behind the resident with a wheel chair. Resident 58's ambulation record indicated the resident had completed five out of 58 care planned walks from 8/5/15 through 9/3/15. The record noted the restorative service was not offered on 21 occasions and the resident declined the restorative service on 32 occasions. On 9/3/15 at 8:58 am Witness 1 (Family member) stated the resident had not walked for at least a month because the resident's restorative program required two staff members and aides repeatedly said there was not enough staff to assist. Witness 1 further stated she/he visited everyday and asked to walk the resident to maintain the resident's strength. On 9/3/15 at 9:58 am Staff 4 (CNA) stated she worked with Resident 58 regularly. Staff 4 acknowledged the care plan included a restorative program which included walking with the resident twice a day. Staff 4 stated she had not walked with the resident in the last three weeks because the resident seemed more lethargic and tired. On 9/4/15 at 11:01 am Staff 6 (CNA) acknowledged she was assigned to work with Resident 58 and had not walked the resident. Staff 6 acknowledged the restorative program included walking the resident twice a day. Staff 6 stated she did not think the resident could use the four wheeled walker and further stated she couldn't imagine the resident walking. On 9/4/15 at 1:15 pm Staff 2 (RNCM) and Staff 1 (DNS) acknowledged Resident 58 had not been walking recently. Staff 2 stated the resident did not have the energy to do the restorative walking twice and day. Staff 2 acknowledged the care plan was not revised to reflect the current functional status of the resident.

Based on interview and record review, the facility failed to document, assess and/or provide care in a timely manner for pressure ulcers 2 of 2 sampled residents (#s 3 and 81) reviewed for pressure ulcers. This placed residents at increased risk for unmet needs. Findings include: 1. Resident 81 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 81's Skin/Wound Integrity Admission Assessment, dated 7/31/15, indicated the resident did not have a pressure ulcer, but had a bruise and blanchable redness on her/his coccyx. A Progress Note dated 8/5/15 stated, Blanchable redness to coccyx now opened. Resident 81's care plan was updated on 8/7/15 regarding the presence of Pressure Ulcer: Stage II Coccyx and stated, See Skin Integrity Plan of Care. No information was found in the Skin Integrity Plan of Care regarding treatment for [REDACTED]. On 9/2/15 at 10:46 am Staff 8 (RNCM) indicated documentation of treatment to the resident's coccyx was located in TAR. Resident 81's August 2015 TAR did not indicate any treatment for [REDACTED]. On 9/2/15 at 1:27 pm Staff 1 (DNS) stated pressure ulcer care was provided as per the corporate wound guide, which indicated Stage II Pressure Ulcers were to be cleaned with wound cleanser or saline, protected with barrier film, and covered with a dressing to be changed 1-2 times per week and as needed. On 9/4/15 at 10:56 am Staff 1 was informed no records were found to indicate Resident 81 received care for her/his Stage II pressure ulcer from the time it was identified on 8/5/15 until 8/12/15. Staff 1 stated she would provide those records. No further information was provided. 2. Resident 3 was readmitted to the facility in 4/2015 with [DIAGNOSES REDACTED]. The Skin/Wound integrity Admission assessment dated [DATE] revealed Resident 3 did not have a pressure ulcer on admission and noted abrasions on bilateral buttocks. A nursing progress noted dated 4/30/15 indicated received orders for wound care to bilateral buttock pressure ulcers per wound nurse recommendations. The resident's medical record did not include a skin assessment which indicated the resident had a pressure ulcers on bilateral buttocks. On 9/2/15 at 4:05 pm, Staff 1 (DNS) stated she was not able to find an assessment of the pressure ulcers on the resident's buttocks.

Based on observation, interview and record review it was determined the facility failed to provide routine dental services for 1 of 3 (#59) sampled residents reviewed for dental needs. Failure to provide dental services puts residents at risk for unmet dental needs. Findings include: Resident 59 was admitted to the facility in 2014 with [DIAGNOSES REDACTED]. The MDS admission assessment dated [DATE] included a Dental CAA which indicated Resident 59 had discolored, impaired and cracked teeth. The assessment indicated the oral status would be addressed in the care plan. On 8/31/15 at 10:58 am Resident 59 was observed with several discolored, broken and cracked teeth. On 8/31/15 at 11:01 am Resident 59 stated her/his teeth were broken and rotten and needed to be taken out. On 9/3/15 at 10:13 am Staff 4 (CNA) stated she used a swab for oral care because the resident's teeth were very fragile. Staff 4 further stated Resident 59 had recently complained about oral pain. On 9/3/15 at 10:55 am Staff 5 (Social Service Director) acknowledged Resident 59 had broken and cracked teeth when admitted to the facility and had not received dental care. On 9/4/15 at 1:15 pm Staff 1 (DNS) acknowledged Resident 59 had dental needs and had not received dental services in a timely manner.

Based on interview and record review it was determined the facility failed ensure professional standards were followed by nursing staff regarding pressure ulcer assessment, tracking and treatment for 2 of 3 sampled residents (#s 1 & 2) with pressure ulcers. Resident 1 developed a recurrent pressure ulcer. Resident 2 was at risk of complications from lack of treatment of [REDACTED]. Division 45 Scope of Practice for Licensed Practical Nurses 851-045-0050 (2) (a) Conduct and document initial and ongoing focused nursing assessments of the health status of clients by: (d) Implement the plan of care by: (A) Implementing treatments and therapy, appropriate to the context of care, including but not limited to, medication administration, nursing activities.... (B) Documenting nursing interventions and responses to care in an accurate, timely, thorough and clear manner. Scope of Practice for Registered Nurses 851-045-0060 (2) (a) Conduct and document comprehensive and focused nursing assessments of the health status of clients by: (d) Implement the plan of care by: A) Implementing treatments and therapy, appropriate to the context of care, including emergency measures, interpretation of medical orders, medication administration, independent nursing activities... (B) Documenting nursing interventions and responses to care in an accurate, timely, thorough and clear manner. 1. Resident 1 was admitted to the facility from a local hospital on [DATE] with [DIAGNOSES REDACTED]. The hospital discharge physician orders [REDACTED]. The 9/1/12 Skin/Wound Integrity Admission Assessment documented Resident 1 admitted with a Stage 1 pressure ulcer on the coccyx. The area was described as diffuse redness that was intact. A wound tracking report noted Resident 1 had MASD (moisture associated skin damage) on the coccyx. On 9/4/12 and 9/11/12, it was documented the area was "Progressing toward healing/resolution." There was no other documented assessment of the skin breakdown. A 9/8/12 Progress Note indicated a dressing to the sacrum was changed. A 9/11/12 Progress Note indicated a dressing to the coccyx was changed. Progress Notes dated 9/14/12 and 9/15/12 documented the treatment of [REDACTED]. A 9/16/12 Progress Note indicated Resident 1 was sent to a local hospital for an unrelated condition. A 9/16/12 Hospital History and Physical Report revealed upon admission, Resident 1 had a 1 cm round sacral ulcer and a second Stage II ulcer to the right anterior of the sacral ulcer. In interview on 10/1/12 at 11:35 am, Witness 1, Complainant, stated, she was concerned about Resident 1's pressure ulcer due to his/her history of amputations and the resident not being repositioned every two hours. In interviews on 10/1/12 at 11:00 am, 11:20 am and 2:40 pm, Staff 3, RNCM, stated Resident 1 admitted from the hospital with a resolved skin breakdown on his/her coccyx. At admission to the facility, the area was red and noted as MASD. Staff 3 stated staff used the barrier cream for protection and placed a dressing on the area due to the resident not staying positioned on his/her side. Nursing staff had observed the skin either the day of or the day before the hospitalization and the area was a Stage II. Staff 3 stated when the area was identified as an open pressure ulcer, nursing should have notified the physician, initiated treatment and documented the wound status. In interviews on 10/1/12 at 11:20 am and 1:13 pm, Staff 4, LPN, stated she noted in the admission assessment the resident admitted with a compromised area and had orders for the barrier cream. Staff repositioned the resident and the resident would reposition himself/herself on his/her back. During Resident 1's first week of admission, she had observed his/her entire buttocks to be reddened, with a small open area on the coccyx. Staff 4 stated the next time she saw the area, there was a dressing in place. Staff 4 stated the wound documentation was done by the evening shift nurse and she "presumed" the tracking of wound for any changes was done by that shift. In interview on 10/1/12 at 12:10 pm, Staff 5, RN, stated on 9/8/12, she observed Resident 1 had an open pressure ulcer on the coccyx. At that time there was a dressing on it and she "assumed" there was already a treatment order in place. Staff 5 stated when residents were found to have a pressure ulcer, a skin assessment was to be completed, the RNCM informed and wound care initiated. In interview on 10/1/12 at 3:00 pm, Staff 6, RN, stated when Resident 1 was first admitted , the skin on the coccyx was intact. Staff 6 stated the next time she observed the resident's skin, there was a dressing on the breakdown that needed to be changed. Staff 6 did not recall the date of that observation. Resident 1 had a possible Stage II pressure ulcer, but due to slough in the wound bed, it was unstageable. Staff 6 stated she had documented the 9/4/12 and 9/11/12 wound tracking entries as the wound was progressing towards healing, but "probably did not look at it (the wound)." When asked how she would have known the breakdown was getting better, Staff 6 stated "I have no answer for that." In interview on 10/1/12 at 3:35 pm with Staff 1, Administrator and Staff 2, DNS, Staff 2 stated there had been a system breakdown regarding Resident's 1 pressure ulcer. At the time of the survey, the clinical record lacked documented evidence of assessment or tracking of Resident 1's pressure ulcer, accurate documentation of the wound status including the location, physician notification or initiation of treatment of [REDACTED]. 2. Resident 2 was admitted to the facility in 2008 with [DIAGNOSES REDACTED]. A 7/24/12 Skin Event Assessment revealed Resident 2 had a Stage II pressure ulcer to the coccyx. It noted a treatment of [REDACTED]. At the time of the survey, there was no corresponding physician order [REDACTED]. The coccyx pressure ulcer treatment was not included on the 7/2012 - 9/2012 TARs. There was no documented evidence the coccyx pressure ulcer had been treated until 9/8/12, when a new treatment was initiated. In interviews on 10/2/12 at 2:35 pm and 3:40 pm, Staff 2, DNS, stated when the resident was found to have skin breakdown on the coccyx, Staff 10, LPN, spoke with a nurse practitioner, who ordered dressing changes. Staff 2 stated Staff 10 forgot to write up the order or transcribe the orders onto the TAR. Staff had reported doing the treatment, however, had not documented completing the treatment. In interview on 10/2/12 at 3:45 pm, Staff 10, LPN stated she had identified Resident 2's coccyx pressure ulcer on 7/24/12. Staff 10 stated she had obtained treatment orders and failed to transcribe it onto the TAR. Staff 10 stated staff had changed the dressing more frequently than every three days due soiling, but had not documented the treatments on the TAR. Per Staff 10, Resident 2 refused for the surveyor to observe the wound. In interviews on 10/1/12 at 4:16 pm and 10/3/12 at 8:17 am, Staff 11 stated she recalled placing a foam dressing on Resident 2's coccyx wound, but could not recall when the treatment was done. Staff 11 stated the treatment should have been documented. When asked how she would know what treatment was ordered, Staff 11 stated she would look to see what was being done by the previous nurse and follow that treatment for [REDACTED]. In interview on 10/3/12 at 8:12 am, Staff 12 stated she had applied a dressing to Resident 2's coccyx wound starting in July 2012. Staff 12 stated there was a physician order [REDACTED]. In interview on 10/3/12 at 2:50 pm, Staff 5, RN, stated staff were monitoring Resident 2's coccyx pressure area with a foam dressing due to the skin not being opened. Staff 5 stated she was not sure when the pressure ulcer opened and thought there were physician orders [REDACTED].

Based on observation, interview and record review it was determined the facility failed to comprehensively and/or accurately assess, notify the physician, initiate treatment, track wound status or ensure physician orders [REDACTED]. Resident 1 developed a recurrent pressure ulcer. Resident 2 was at risk of complications from lack of treatment of [REDACTED]. 1. Resident 1 was admitted to the facility from a local hospital on [DATE] with [DIAGNOSES REDACTED]. The hospital discharge physician orders [REDACTED]. The 9/1/12 Skin/Wound Integrity Admission Assessment documented Resident 1 admitted with a Stage 1 pressure ulcer on the coccyx. The area was described as diffuse redness that was intact. A wound tracking report noted Resident 1 had MASD (moisture associated skin damage) on the coccyx. On 9/4/12 and 9/11/12, it was documented the area was "Progressing toward healing/resolution." There was no other documented assessment of the skin breakdown. A 9/8/12 Progress Note indicated a dressing to the sacrum was changed. A 9/11/12 Progress Note indicated a dressing to the coccyx was changed. Progress Notes dated 9/14/12 and 9/15/12 documented the treatment of [REDACTED]. A 9/16/12 Progress Note indicated Resident 1 was sent to a local hospital for an unrelated condition. A 9/16/12 Hospital History and Physical Report revealed upon admission, Resident 1 had a 1 cm round sacral ulcer and a second Stage II ulcer to the right anterior of the sacral ulcer. In interview on 10/1/12 at 11:35 am, Witness 1, Complainant, stated, she was concerned about Resident 1's pressure ulcer due to his/her history of amputations and staff not repositioning the resident every two hours. In interviews on 10/1/12 at 11:00 am, 11:20 am and 2:40 pm, Staff 3, RNCM, stated Resident 1 admitted from the hospital with a resolved skin breakdown on his/her coccyx. At admission to the facility, the area was red and noted as MASD. Staff 3 stated staff used the barrier cream for protection and placed a dressing on the area due to the resident not staying positioned on his/her side. Nursing staff had observed the skin either the day of or the day before the hospitalization and the area was a Stage II. Staff 3 stated when the area was identified as an open pressure ulcer, nursing should have notified the physician, initiated treatment and documented the wound status. In interviews on 10/1/12 at 11:20 am and 1:13 pm, Staff 4, LPN, stated she noted in the admission assessment the resident admitted with a compromised area and had orders for the barrier cream. Staff repositioned the resident and the resident would reposition himself/herself on his/her back. During Resident 1's first week of admission, she had observed his/her entire buttocks to be reddened, with a small open area on the coccyx. Staff 4 stated the next time she saw the area, there was a dressing in place. Staff 4 stated the wound documentation was done by the evening shift nurse and she "presumed" the tracking of wound for any changes was done by that shift. In interview on 10/1/12 at 12:10 pm, Staff 5, RN, stated on 9/8/12, she observed Resident 1 had an open pressure ulcer on the coccyx. At that time there was a dressing on it and she "assumed" there was already a treatment order in place. Staff 5 stated when residents were found to have a pressure ulcer, a skin assessment was to be completed, the RNCM informed and wound care initiated. In interview on 10/1/12 at 3:00 pm, Staff 6, RN, stated when Resident 1 was first admitted , the skin on the coccyx was intact. Staff 6 stated the next time she observed the resident's skin, there was a dressing on the breakdown that needed to be changed. Staff 6 did not recall the date of that observation. Resident 1 had a possible Stage II pressure ulcer, but due to slough in the wound bed, it was unstageable. Staff 6 stated she had documented the 9/4/12 and 9/11/12 wound tracking entries as the wound was progressing towards healing, but "probably did not look at it (the wound)." When asked how she would have known the breakdown was getting better, Staff 6 stated "I have no answer for that." In interview on 10/1/12 at 3:35 pm with Staff 1, Administrator and Staff 2, DNS, Staff 2 stated there had been a system breakdown regarding Resident's 1 pressure ulcer. At the time of the survey, the clinical record lacked documented evidence of assessment or tracking of Resident 1's pressure ulcer, accurate documentation of the wound status including the location, physician notification or initiation of treatment of [REDACTED]. 2. Resident 2 was admitted to the facility in 2008 with [DIAGNOSES REDACTED]. A 7/24/12 Skin Event Assessment revealed Resident 2 had a Stage II pressure ulcer to the coccyx. It noted a treatment of [REDACTED]. At the time of the survey, there was no corresponding physician order [REDACTED]. The coccyx pressure ulcer treatment was not included on the 7/2012 - 9/2012 TARs. There was no documented evidence the coccyx pressure ulcer had been treated until 9/8/12, when a new treatment was initiated. On 10/1/12 at 1:22 pm, Resident 2 was observed sitting in a wheelchair. Resident 2 stated she/he had skin breakdown on her/his bottom that was improving. In interviews on 10/2/12 at 2:35 pm and 3:40 pm, Staff 2, DNS, stated when the resident was found to have skin breakdown on the coccyx, Staff 10, LPN, spoke with a nurse practitioner, who ordered dressing changes. Staff 2 stated Staff 10 forgot to write up the order or transcribe the orders onto the TAR. Staff had reported doing the treatment, however, had not documented completing the treatment. In interview on 10/2/12 at 3:45 pm, Staff 10, LPN stated she had identified Resident 2's coccyx pressure ulcer on 7/24/12. Staff 10 stated she had obtained treatment orders and failed to transcribe them onto the TAR. Staff 10 stated staff had changed the dressing more frequently than every three days due soiling, but had not documented the treatments on the TAR. Per Staff 10, Resident 2 refused for the surveyor to observe the wound. In interviews on 10/1/12 at 4:16 pm and 10/3/12 at 8:17 am, Staff 11 stated she recalled placing a foam dressing on Resident 2's coccyx wound, but could not recall when the treatment was done. Staff 11 stated the treatment should have been documented. When asked how she would know what treatment was ordered, Staff 11 stated she would look to see what was being done by the previous nurse and follow that treatment for [REDACTED]. In interview on 10/3/12 at 8:12 am, Staff 12 stated she had applied a dressing to Resident 2's coccyx wound starting in July 2012. Staff 12 stated there was a physician order [REDACTED]. In interview on 10/3/12 at 2:50 pm, Staff 5, RN, stated staff were monitoring Resident 2's coccyx pressure area with a foam dressing due to the skin not being opened. Staff 5 stated she was not sure when the pressure ulcer opened and thought there were physician orders [REDACTED].

Based on interview and record review it was determined facility staff failed to implement care plan interventions to prevent falls for 1 of 2 sampled residents (#1) reviewed for falls. Resident 1 fell from bed while being turned with only one person's assistance and sustained a fractured rib. Findings include: The Oregon State Board of Nursing (OSBN) Standards of Care for Certified Nursing Assistants [PHONE NUMBER](6)(d) In the process of client care the CNA shall consistently: Follow the care plan as directed by the licensed nurse. Resident 1 was admitted on [DATE] with [DIAGNOSES REDACTED]. An Incident Report dated 5/16/12 included an interview with Resident 1. The resident statement included: At 5:00 am one staff person, (Staff 2, CNA) started to change the resident, turned the resident on her/his side and "(the resident ) rolled right out of bed." The resident felt "that this person should have had another staff for assistance with (her/him)." On 6/6/12 at 2:00 pm Staff 1, DNS confirmed the Kardex (care plan) in place at the time of the fall indicated Resident 1 needed 2 persons' assistance with bed mobility. Staff 1 believed the Kardex was updated for the 2 person assistance with Bed Mobility just one day prior to the fall on 5/16/12. Staff 1 stated the resident sustained [REDACTED]. On 6/6/12 at 4:15 pm Staff 2, CNA stated she did not review the Kardex at the beginning of her shift, even though it was the first time she had cared for Resident 1. After the fall Staff 2 reviewed the Kardex which indicated Bed Mobility required 2 persons' assistance. Staff 2 stated she thought "Bed Mobility" meant pulling the resident up in bed and getting the resident out of bed, but did not include repositioning in bed. On 6/12/12 at 2:50 pm Staff 3, CNA stated she provided orientation for new CNAs on the night shift, and oriented Staff 2, CNA. Staff 3 listed six components, including Bed Mobility, listed in the Kardex, which she always instructed CNAs to check prior to caring for residents. Staff 3 stressed to CNAs during orientation, they could not care for a resident without reviewing those six items. Staff 3, CNA stated on the skilled unit where Resident 1 resided, the needs of the residents could change daily and it was very important to check the Kardex daily for changes for at least the first week of the residents' stay. In Resident 1's case, the resident was used to having side rails on (her/his) bed at home, and when turned in the facility (in a bed without side rails) the resident would reach out to grab for the side rails (or anything else) to prevent rolling out of bed. She believed that was the reason for 2 persons' assistance with turning (bed mobility). On 6/7/12 from 10:25 am to 12:00 noon, eight CNAs (Staff #s 4 through 11) were interviewed regarding the definition of "Bed Mobility: 2 person assist." All eight of the CNAs stated any movement of the resident in bed, including turning the resident, required 2 persons' assistance. Refer to F 323.

Based on interview and record review it was determined the facility failed to provide adequate supervision to ensure care planned interventions were implemented to prevent falls for 1 of 2 sampled residents (#1) reviewed for falls. Resident 1 fell from bed while being turned with only one person's assistance and sustained a fractured rib. Findings include: Resident 1 was admitted on [DATE] with [DIAGNOSES REDACTED]. An Incident Report dated 5/16/12 included an interview with Resident 1. The resident statement included: At 5:00 am one staff person, (Staff 2, CNA) started to change the resident, turned the resident on her/his side and "(the resident ) rolled right out of bed." The resident felt "that this person should have had another staff for assistance with (her/him)." SNF (Skilled Nursing Facility) Progress Notes dated 5/17/12 indicated Resident 1 began complaining of right upper, lateral rib pain. MARs indicated the resident's use of Oxycodone for pain increased from 5/17/12 through 5/19/12. A Final X-Ray Report dated 5/19/12 indicated Resident 1 had an acute fracture of the right 7th rib with mild angulation. On 6/6/12 at 2:00 pm Staff 1, DNS confirmed the Kardex (care plan) in place at the time of the fall indicated Resident 1 needed 2 persons' assistance with bed mobility. Staff 1 believed the Kardex was updated for the 2 persons' assistance with Bed Mobility one day prior to the fall on 5/16/12. Staff 1 stated the resident sustained [REDACTED]. On 6/6/12 at 4:15 pm Staff 2, CNA stated she did not look at the Kardex before caring for the resident, even though Resident 1 was new to her. On 6/25/12 at 10: 25 am Resident 1 was observed in bed with a family member present. Resident 1 stated (she/he) fell when one staff person came in to reposition the resident. When the staff rolled the resident over, Resident 1 reached over for the side rail, but there was no side rail, and (she/he) rolled out of bed. The resident's family stated when the aide pulled the sheet under the resident to roll (her/him) over the resident rolled out of bed. On 6/12/12 at 2:50 pm Staff 3, CNA stated she provided orientation for new CNAs on the night shift, and oriented Staff 2, CNA. Staff 3 listed six components, including Bed Mobility, listed in the Kardex, which she always instructed CNAs to check prior to caring for residents. Staff 3 stressed to CNAs during orientation, they could not care for a resident without reviewing those six items. Staff 3, CNA stated on the skilled unit, where Resident 1 resided, the needs of the residents could change daily and it was very important to check the Kardex daily for changes for at least the first week of the residents' stay. In Resident 1's case, the resident was used to having side rails on (her/his) bed at home, and when turned in the facility (in a bed without side rails) the resident would reach out to grab for the side rails (or anything else) to prevent rolling out of bed. She believed that was the reason for 2 persons' assistance with turning (bed mobility).

Based on interview and record review it was determined the facility failed to assess, document, and provide treatment within professional standards for 1 of 1 sampled resident (#1) who sustained a burn from a neck wrap and was hospitalized . Findings include: The Oregon State Board of Nursing (OSBN) Scope of Practice for All Licensed Nurses [PHONE NUMBER](5)(a)Assigns to another person, tasks of nursing that fall within the nursing scope of practice. Scope of Practice for Licensed Practical Nurses [PHONE NUMBER](2)(a)(d)(B)(e)(B)Document nursing interventions and responses to care in an accurate, timely, thorough, and clear manner and outcome data shall be documented and communicated to appropriate members of the healthcare team. Authorized Duties and Standards for Certified Nursing Assistants [PHONE NUMBER]. Conduct Unbecoming a Nursing Assistant [PHONE NUMBER](6)(b)Performing acts beyond the authorized duties for which the individual is certified. Resident 1 was admitted in 9/2009 with [DIAGNOSES REDACTED]. Symptoms of autonomic dysreflexia include hypertension with pounding headaches. Resident 1 had a physician's orders [REDACTED]." A Pain assessment dated [DATE] indicated the "Resident is (without) pain from neck down. Resident has HA (headache) at times..." There was no assessment of headaches related to autonomic dysreflexia, or the impact that a heat wrap to the neck might have on blood pressure. The type and cause of neck pain and indications for use of the warm pack were not assessed. The Care Plan dated 5/11/11 did not include neck pain, or the warm packs as an intervention for pain. According to nurses Progress Notes dated 6/23/11, an Incident Report dated 6/23/11, and hospital History and Physical dated 6/24/11, Resident 1 had neck pain treated with a warm pack on 6/23/11, [MEDICAL CONDITION] the neck and was hospitalized . A Licensed Nurse Skin Event assessment dated [DATE] at 4:00 pm indicated the resident had a posterior neck burn with a 1.5 x 1.5 cm reddened area with tiny blisters at the left base of the neck; a 4 x 3.5 cm reddened area, sensitive to touch at the left base of the neck at the shoulder; and a 2.5 x 3.5 cm reddened area, tender to touch at the medial base of the neck. An Incident Report dated 6/23/11 indicated Staff 1, LPN observed "very tiny blisters" on the left side of the resident's neck at about 4:30 pm. The rest of the neck looked reddened, "like a sunburn." The hospital History and Physical dated 6/24/11 indicated the resident had a heating pad placed on her/his neck and left in place for 1 1/2 hours. "During the interim (the resident) had flare of (her/his) autonomic dysreflexia with tension surging through (her/his) neck and head that lasted until arrival to ER and treatment with [MEDICATION NAME]." The neck burn was described as "Mostly stage 1 with some areas of stage 2." The physical examination indicated redness around the neck with three areas of "early blistering." The resident was admitted to the hospital with [REDACTED]. A Skin/wound Integrity Admission assessment dated [DATE], after the resident returned to the facility indicated a 1.5 x 3 cm dried blister at the left base of the neck; and a 2.5 x 2.5 cm reddened area just below the hairline at the medial posterior neck. In an interview on 7/5/11 at 12:50 pm Staff 5, LPN stated the resident was administered a warm neck wrap at 10:30 to 11:00 am, and Staff 5 instructed Staff 3, NA (Nurse's Aide) on how to prepare the warm pack. Staff 5 did not document the neck wrap on the Treatment Sheet for 6/23/11. Staff 3, NA stated on 7/5/11 at 1:10 pm that she had received instruction on how to warm the neck wrap from Staff 5 in the morning on 6/23/11. At 1:40 to 1:50 pm on 6/23/11, Staff 3 prepared and placed a warm pack on Resident 1's neck. Staff 3 then left the facility, and did not remember if she told the oncoming shift CNA about the warm pack. Staff 3 did not report the warm pack to Staff 5, LPN. Staff 5, LPN stated on 7/5/11 at 12:20 pm she was unaware that the heat pack had been reapplied on 6/23/11. Staff 5 agreed that LNs (Licensed Nurses) needed to assess the need for the heat pack and reassess for effectiveness, and that information should be documented. Staff 6, CNA stated on 7/5/11 at 12:50 pm that she was not told by Staff 3 that the heat wrap was on Resident 1 when she came on duty for evening shift on 6/23/11. Staff 4, CMA stated on 7/5/11 at 2:15 pm that Resident 1 was yelling "help me, help me" when she entered the resident's room with medication at 3:00 pm on 6/23/11. The resident told her the warm pack had been on since 1:30 pm, and it was too hot. The resident could not move the pack due to [MEDICAL CONDITION]. The little movement the resident was able to make, placed the call light out of reach and the resident could not activate it for help. No staff had checked on the resident after the warm pack was placed. Staff 4 removed the warm pack and observed the resident's neck and face to be red. Staff 4 believed Staff 1, LPN was aware of the burn. Staff 1, LPN stated on 7/5/11 at 2:30 pm that on 6/23/11 on the evening shift, she was told by Staff 4 that the resident's neck was sore, and she had given Tylenol. Staff 1 stated the resident looked sunburned, and the resident's face was red. Staff 1 did not report the burned neck to the resident's CNA, Staff 6. On 7/5/11 at 12:50 pm Staff 6, CNA stated on 6/23/11 at 3:40 pm the resident was red-faced and complained of headache. Staff 6 placed a warm pack on the resident's neck. Staff 6 did not remember reporting to Staff 1 that she had applied a warm pack, and Staff 1 did not tell her of the resident's burns. Staff 6 continued that she did not learn of the resident's burn until she overheard Staff 1 and the resident's friend talking about blisters on the resident's neck. When Staff 6 asked if she had caused the burn by giving a warm pack, she was told no, that the burn had been caused by a warm pack placed on the day shift by Staff 3, NA. Staff 6 asked Staff 1 why she hadn't told her about the burn, and Staff 1 responded that "everything was so crazy" and Staff 1 did not remember when she found out about the burn. Staff 6 checked frequently on the resident after she learned of the burn. One time when she checked a warm pack was again on the resident's neck, but the resident refused to have it removed. On 7/7/11 at 3:00 pm, the resident's friend admitted to placing a warm pack on the resident's neck at around 5:30 to 6:00 pm. The friend stated it was above the burned areas on the resident's neck. The facility's procedure for Applying a Warm Compress or Soak included that unless otherwise instructed staff were to check the skin under the application about every five minutes. There was no evidence through interview or record review that this was done. The Treatment Sheet dated 6/2011 included "WARM PACK TO NECK PRN" with a start date of 4/23/11, for PRN muscle ache. There was no documentation that the warm pack had been used. On 7/5/11 at 5:15 pm, Staff 8, DNS acknowledged the pain assessment and care plan did not address neck pain, autonomic dysreflexia related to headaches and the use of warm packs. Staff 8 stated that CNAs did not have the skills to assess the need or effectiveness of warm packs, and the facility procedure for applying warm compresses was not followed. It was an LN (licensed nurse) function to assess and document use of the warm packs in the treatment sheets, but LNs were unaware when warm packs were used. Staff 8 agreed that staff did not communicate the use of warm packs to oncoming staff, and that warm packs continued to be used after the burn was reported at 3:00 pm. Refer to F 309.

Based on observation, interview and record review it was determined the facility failed to provide care and services related to a pain assessment, care plan and treatment of [REDACTED]. Resident 1 [MEDICAL CONDITION] a neck wrap and was hospitalized . Findings include: Resident 1 was admitted in 9/2009 with [DIAGNOSES REDACTED]. According to the Handbook of Diseases, Third Edition, autonomic dysreflexia (also known as autonomic hyper-reflexia) is a complication of spinal injuries. Hypertension with a pounding headache are common symptoms of autonomic dysreflexia. Resident 1 had a physician's orders [REDACTED]." A Pain assessment dated [DATE] indicated the "Resident is (without) pain from neck down. Resident has HA (headache) at times..." There was no assessment of headaches related to autonomic dysreflexia, or the impact that a heat wrap to the neck might have on blood pressure or autonomic dysreflexia. The type and cause of neck pain and indications for use of the warm pack were not assessed. The Care Plan dated 5/11/11 did not include neck pain, or the warm packs as an intervention for pain. The facility's procedure for Applying a Warm Compress or Soak included that unless otherwise instructed staff were to check the skin under the application about every five minutes. If the skin appeared red, the compress was to be removed and the Charge Nurse/Director of Nursing summoned. Warm compresses were to be applied for twenty minutes at a time. According to nurses Progress Notes dated 6/23/11, an Incident Report dated 6/23/11, and hospital History and Physical dated 6/24/11, Resident 1 had neck pain treated with a warm pack on 6/23/11, [MEDICAL CONDITION] the neck and was hospitalized . A Licensed Nurse Skin Event assessment dated [DATE] at 4:00 pm indicated the resident had a posterior neck burn with a 1.5 x 1.5 cm reddened area with tiny blisters at the left base of the neck; a 4 x 3.5 cm reddened area, sensitive to touch at the left base of the neck at the shoulder; and a 2.5 x 3.5 cm reddened area, tender to touch at the medial base of the neck. An Incident Report dated 6/23/11 indicated Staff 1, LPN observed "very tiny blisters" on the left side of the resident's neck at about 4:30 pm. The rest of the neck looked reddened, "like a sunburn." The hospital History and Physical dated 6/24/11 indicated the resident had a heating pad placed on her/his neck and left in place for 1 1/2 hours. "During the interim (the resident) had flare of (her/his) autonomic dysreflexia with tension surging through (her/his) neck and head that lasted until arrival to ER and treatment with [MEDICATION NAME]." The neck burn was described as "Mostly stage 1 with some areas of stage 2." The physical examination indicated redness around the neck with three areas of "early blistering." The resident was admitted to the hospital with [REDACTED]. On 7/5/11 from 12:20 pm to 4:30 pm, interviews with Staff 5, LPN on day shift, Staff 3, NA (Nurse's Aide) on day shift, Staff 4, CMA on evening shift, Staff 6, CNA on evening shift, Staff 1, LPN on evening shift; the resident's friend on 7/7/11 at 3:00 pm, and Resident 1 on 7/5/11 at 4:00 pm; review of the nurse's Progress Notes and a Licensed Nurse Skin Event Assessment completed by Staff 1 on 6/24/11 indicated the following progression of events on 6/23/11 related to Resident 1 and neck burns: 10:30 to 11:00 am: Staff 5, LPN heated Resident 1's neck wrap in the microwave according to the resident's instructions, and placed it on the resident's neck. Staff 5 instructed Staff 3, NA (Nurse's Aide) on how to prepare the warm pack. 1:40 to 1:50 pm: Staff 3, NA administered a warm pack on the resident's neck. Staff 3 gave the resident the call light and told the resident she was leaving, but if the resident needed anything to use the call light. Staff 3 did not remember if she told the oncoming shift CNA about the warm pack, and did not report the warm pack to the nurse. 3:00 pm: Staff 4, CMA heard the resident yelling "help me, help me" when she entered the resident's room with medication. The resident told her the warm pack had been on since 1:30 pm, and it was too hot. The resident could not move her/himself off the pack due to [MEDICAL CONDITION]. The little movement the resident was able to make, placed the call light out of reach and the resident could not activate it for help. No staff had checked on the resident after the warm pack was placed. Staff 4 removed the warm pack and observed the resident's neck and face to be red. Staff 4 believed Staff 1, LPN was aware of the burn. There were no blisters observed at that time. 3:40 pm: The resident was red-faced and complained of headache. Staff 6, CNA placed a warm pack on the resident's neck. She reported to Staff 1 that Resident 1 was "hurting" and was refusing to have her/his temperature taken. Staff 6 did not remember reporting the use of the warm pack, and Staff 1 did not tell her of the resident's burns. 4:00 pm: Staff 1, LPN was notified by Staff 4, CMA of the resident's red neck. The resident's neck looked sunburned and the resident's face was red. The resident's statement was the "CNA from day shift put on resident's personal hot pack, then left room before checking if hot pack was too cold or too warm. The hot pack was too hot." Tylenol was given for neck soreness. 5:00 to 5:30 pm: The resident's friend found a heat wrap on the resident's neck and asked Staff 1, LPN to look at blisters on the resident's neck. 5:30 to 9:00 pm: The friend placed a warm pack on the resident's neck. She placed it "higher" than [MEDICAL CONDITION] did not report it to the nurse. 9:06 pm: Resident 1's temperature was 101.5 degrees F, and Tylenol extra strength was given. 10:00 pm: The friend observed the resident shaking. The resident reported that she/he felt "really sick" and "like (she/he) was dying... systems were shutting down." The friend reported that to the nurse. 10:30 pm: The resident complained of being shaky, was dizzy and had a headache. Resident 1 told Staff 2, RN for night shift, "I think it's autonomic dysreflexia." Blood pressure was 140/99, pulse was 110, respirations 24 and temperature was 102.9 degrees F. The resident wanted to go to the hospital. An order was obtained from the physician, and the resident was sent to the hospital. The hospital "overview" and History and Physical dated 6/23/11 and 6/24/11 indicated Resident 1's [DIAGNOSES REDACTED]. On 7/5/11 at 4:00 pm Resident 1 was observed in bed with a call light activated by mouth. The resident's posterior neck was observed to have a quarter sized scar, that Resident 1 stated was from the burn/blister. Resident 1 stated after the morning CNA put the warm pack on her/his neck, she did not wait long enough for the resident to tell that it was burning. Resident 1 moved her/his head to get off the hot pack, and then was unable to activate the call light. Resident 1 stated subsequent warm packs were higher on the neck, and that Tylenol eased the pain, but then the tension and stress caused autonomic dysreflexia. The resident felt like she/he was dying prior to going to the hospital. The Treatment Sheet dated 6/2011 included "WARM PACK TO NECK PRN" with a start date of 4/23/11, for PRN muscle ache. There was no documentation that the warm pack had been used. On 7/5/11 at 5:15 pm, Staff 8, DNS acknowledged the pain assessment and care plan did not address neck pain, autonomic dysreflexia related to headaches and the use of warm packs. Staff 8 stated that CNAs did not have the skills to assess the need or effectiveness of warm packs, and the facility procedure for applying warm compresses was not followed. It was an LN (licensed nurse) function to assess and document use of the warm packs in the treatment sheets, but LNs were unaware when warm packs were used. Staff 8 agreed that staff did not communicate the use of warm packs to oncoming staff, and that warm packs continued to be used after the burn was reported at 3:00 pm.