Every finding on record at Marquis Newberg

Based on interview and record review it was determined the facility failed to ensure the responsible party was involved in decisions related to the resident's day to day activities for 1 of 1 sampled resident (#46) reviewed for resident rights and care planning. This placed residents at risk for their representatives not being informed of the resident's health status. Findings include: Resident 46 was admitted to the facility on 7/2025 with diagnoses including anoxic brain damage (The brain lacks oxygen causing the brain cells to die permanently). A 10/27/25 Quarterly MDS indicated Resident 46 had a BIMS of 7 indicating severe cognitive impairment. A 11/20/25 Court Order indicated Witness 2 (Guardian) was appointed guardianship for Resident 46.Progress Notes reviewed from 11/29/25 through 12/7/25 indicated Resident 46 left the facility with her/his friend on two occasions. No evidence was found to indicate Witness 2 was notified of Resident 46 leaving the facility. On 1/12/26 at 11:43 AM, Witness 2 stated he was frustrated and concerned because the facility allowed Resident 46 to leave the facility with friends. Witness 2 stated the facility didn't tell him about Resident 46 leaving. Witness 2 stated Staff 1 (Administrator) and Staff 3 (LPN Resident Care Manager) were aware and agreed to notify him. Witness 2 was concerned because Resident 46 wanted to go home and feared she/he would elope back home.On 1/14/26 at 10:56 AM, Resident 46 stated she/he was allowed to leave the facility anytime and was expected to return by sunset. Resident 46 stated she/he didn't care about notifying her/his health representative when leaving the facility.On 1/15/26 at 11:30 AM, Staff 6 (CNA) stated Resident 46 was allowed to leave the facility with friends. Resident 46 notified nursing when leaving the facility. On 1/15/26 at 12:46 PM, Staff 7 (LPN) stated Resident 46's cognition was not good and she/he wasn't allowed to make decisions independently. Staff 7 stated Witness 2 was her/his guardian. Staff 7 acknowledged Witness 2 was not notified when Resident 46 left the building but Witness 2 was required to be notified due to Resident 46's impaired cognition.On 1/16/26 at 9:18 AM, Staff 3 stated Witness 2 was required to be notified when Resident 46 left the facility. Staff 3 stated Witness 2 was concerned when Resident 46 left with friends and requested the facility provide education for friends and requested notification about out of facility outings. On 1/16/26 10:29 AM, Staff 1 stated Witness 2 had specific concerns and requests for Resident 46 prior to leaving the facility. Staff 1 stated floor staff were expected to notify Witness 2 before Resident 46 left the building with friends and thought a communication plan was added on the care plan. Staff 2 stated floor staff were aware notification was required since Witness 2 was Resident 46's guardian.

Based on observation, interview and record review it was determined the facility failed to ensure ordered services were obtained to increase ROM for 1 of 2 sampled residents (#46) reviewed for mobility and choices. This placed residents at risk for decreased mobility. Findings include:Resident 46 was admitted to the facility in 7/2025 with diagnoses including hemiplegia (paralysis to one side of the body) and suicidal ideation. A 10/27/25 Quarterly MDS indicated Resident 46 had a BIMS of 7 indicating severe cognitive impairment. A 9/30/25 Orthopedic After Visit Summary indicated Resident 46 had significant tightness and shortening of her/his left knee hamstrings (muscles that help bend the knee, extending the hip and walking). Resident 46 required aggressive daily therapy and was required to use a range of motion brace. Resident 46 was to start a contracture training program.A 1/12/26 Provider Note indicated Resident 46 was waiting for an outpatient contracture management appointment. On 1/12/26 at 11:43 AM, Witness 2 (Health Representative) stated Resident 46 graduated from physical therapy and required outpatient services. Witness 2 stated an outpatient referral was entered in July 2025 but he didn't hear back from the facility with updates. Witness 2 stated Resident 46 required an outpatient contracture training program for left leg contractures. Witness 2 stated Resident 46 stopped walking since physical therapy ended and he asked for alternative physical activities, but staff didn't communicate any plans. On 1/14/26 at 10:56 AM, Resident 46 stated she/he graduated from physical therapy and stated she/he dragged her/his left foot while walking due to lost muscle tone.On 1/15/26 at 12:46 PM, Staff 7 (LPN) stated Resident 46 didn't perform daily exercises and was unsure about recent outpatient orthopedic appointments. On 1/16/26 at 9:06 AM, Staff 10 (OT Rehab Director) stated Resident 46 stopped working with physical therapy because she/he required an outpatient contracture management program. On 1/16/26 at 9:18 AM, Staff 3 (LPN Resident Care Manager) stated Resident 46 was referred to outpatient orthopedic services on 8/29/25 for left leg contractures. Staff 3 stated staff hit a dead end and Resident 46 didn't have a scheduled appointment. Staff 3 stated Resident 46 didn't wear a range of motion brace and one was not ordered. Staff 3 acknowledged care was delayed for Resident 46. On 1/16/26 at 11:45 AM, Staff 2 (Interim DNS) stated staff were expected to follow up after residents returned from outpatient appointments. Staff 2 acknowledged Resident 46 was not scheduled for an orthopedic outpatient appointment.

Based on observation and interview it was determined the facility failed to perform hand hygiene for 1 of 1 sampled resident (#6) reviewed for pressure ulcers. This placed the resident at risk for cross contamination. Findings include:A 11/2022 Wound Care -Level II Policy indicated performing hand hygiene after removing gloves was expected. Resident 6 was admitted to the facility on [DATE] with diagnoses including diabetes.A 1/2026 TAR indicated Resident 6 had a facility acquired pressure ulcer on her/his coccyx (the last bone at the bottom of the spine) and had daily wound care orders. On 1/15/26 at 10:34 AM, Staff 8 (LPN) and Staff 9 (Hospice CNA) entered Resident 6's room and performed wound care. Staff 8 and Staff 9 repositioned Resident 6 onto the right side. Staff 8 removed the old dressing, removed her gloves and applied new gloves. Staff 8 did not perform hand hygiene. Staff 8 finished packing the wound with gauze and removed her gloves and new gloves were applied. Staff 8 did not perform hand hygiene. Staff 8 applied a new dressing. Staff 8 removed her gloves and new gloves were applied. Staff 8 did not perform hand hygiene. After wound care, Staff 9 performed personal hygiene for the resident, changed Resident 6's brief, obtained clean linen from the bathroom, removed linen and applied new linen and she did not change her gloves. On 1/15/26 at 10:50 AM, Staff 8 stated she did not perform hand hygiene because her hands weren't visibly soiled and she didn't have hand sanitizer. Staff 8 stated she completed hand hygiene after care and not in-between changing gloves. Staff 9 stated she did not touch the dirty linen so gloves were changed before leaving the room. Staff 8 acknowledged Staff 9 touched the dirty linen. On 1/16/26 at 11:45 AM, Staff 2 (Interim DNS) stated she expected staff to perform hand hygiene after removing gloves.

Based on interview and record review it was determined the facility failed to follow physician orders for 1 of 5 sampled residents (#1) reviewed for medications. This placed residents at risk for adverse medication side effects. Findings include: Resident 1 admitted to the facility in 2024 with diagnoses including heart failure. The 9/20/24 progress note by Staff 3 (LPN) indicated Resident 1 received another resident's scheduled medications. Resident 1, her/his family and the physician were notified, and no adverse effects were noted. The resident was placed on alert monitoring. The 9/20/24 Medication Error Report indicated Staff 3 administered Resident 242's medications to Resident 1 and the medications included: -apixaban 2.5 mg (anticoagulant medication); -atorvastatin 20 mg (lipid lowering medication). On 9/25/24 at 3:58 PM Staff 3 stated she was on orientation and worked with Staff 4 (LPN). Staff 3 stated she went into Resident 1's room independently and was confused on which bed was bed A and bed B. Staff 3 stated she told Resident 1, You must be [Resident 242's name]. Staff 3 stated Resident 1 was very quiet and did not say if she/he was Resident 242. Staff 3 stated she administered Resident 242's medication to Resident 1 which included apixaban and atorvastatin and did not verify it was the correct resident. Staff 3 stated the physician was notified and the resident was monitored for adverse side effects. Resident 1's progress notes and physician notes from 9/20/24 through 9/24/24 revealed there were no adverse reactions to the apixaban and atorvastatin. On 9/26/24 at 10:59 AM Staff 2 (Corporate RN) acknowledged Staff 3 administered Resident 242's medications to Resident 1 in error on 9/20/24 and did not verify it was the correct resident prior to administration. Staff 2 acknowledged the medications administered to Resident 1 included apixaban and atorvastatin and Resident 1 did not have an order for those medications.

Based on interview and record review it was determined the facility failed to notify a resident's representative timely of a change of condition for 1 of 3 (#3) sampled residents reviewed for resident rights. This placed residents at risk for delayed treatment. Findings include: Resident 3 admitted to the facility in 7/2023 with diagnoses including Pleural Effusion (a buildup of fluid between the tissues that line the lungs and chest). Resident 3's 7/13/23 facility admission form indicated Witness 1 (family member) was the primary emergency contact. On 2/13/24, a concern was received which alleged Witness 1 was not nofified about a change of condition for Resident 3 on 11/24/23 until after 1:00 PM when the resident exhibited symptoms for several hours prior. The complainant further stated Staff 5 (CNA) had repeatedly asked Staff 7 (LPN) to contact Witness 1 but Staff 7 said she didn't want Witness 1 to come to the facility and panic. On 2/16/24 at 7:58 AM, Witness 1 stated she was very involved in the daily activities of Resident 3 and was her/his emergency contact. She stated after Resident 3 was hospitalized , she was informed by Staff 5 the resident's change of condition was known much earlier in the day. Staff 7 was made aware of the change of condition by Staff 5 early in the shift but did not contact Witness 1 until after 1:00 PM. Witness 1 stated she would have immediately requested Resident 3 be sent to the hospital if she had been contacted in the morning. On 2/16/24 at 12:45 PM Staff 5 stated she observed Resident 3 on 11/24/23 shortly after her shift started at 6:00 AM. She stated Resident 3 was off - staring at the ceiling, and was unable to talk, which Staff 5 said was off her/his baseline. Staff 5 took the resident's vital signs and noticed the resident's blood pressure was higher than her/his baseline readings. She reported the changes to Staff 7 but nothing was done. Later in the morning a new skin condition was identified and assessed by Staff 7. Staff 5 said she was concerned enough to ask Staff 6 (CNA), who also was very familiar with Resident 3's care needs, to check on her/him as well. Staff 5 stated she continued to check the resident every half hour and made more than one request for Staff 7 to contact Resident 3's family but this wasn't done until after 1:00 PM. On 2/26/24 at 9:35 AM Staff 6 stated he saw Resident 3 earlier in the morning on 11/24/23, noted she/he recognized and smiled at him but couldn't talk, which was not typical for her/his baseline. Staff 6 stated he saw Resident 3 two hours later, the resident no longer recognized Staff 6 and her/his condition had deteriorated. He confirmed he and Staff 5 informed Staff 7 of the resident's change in condition. He wasn't aware when the resident was assessed by Staff 7. Efforts to contact Staff 7 on 2/22/24 were unsuccessful, so no interview was completed. Resident 33's clinical record was reviewed and a progress note dated 11/24/23 at 1:18 PM revealed Resident 3 was observed by Staff 5 at the beginning of her shift to have experienced a change in mental status, which included a dazed affect, slurring of her/his speech and the inability to speak. Resident 5's mentation continued to deteriorate and she/he was sent to the hospital at approximately 1:15 PM. A skin report dated 11/24/23 at 10:15 AM revealed Resident 3 had a new skin condition. The physician and Witness 1 were contacted at or after 1:00 PM, several hours after she/he exhibited signs and symptoms of a change in her/his mental status and skin condition. On 2/26/24 at 1:15 PM AM Staff 1 (Administrator) and Staff 2 (DNS) were informed of the investigative findings and provided no further information.

Based on interview and record review it was determined the facility failed to ensure staff had the appropriate skills and competencies necessary to care for resident needs related to external catheter devices for 1 of 3 sampled residents (#3) reviewed for incontinence care. This placed residents at risk for unmet needs. Findings include: Resident 3 was admitted to the facility in 7/2023 with diagnoses including Pleural Effusion (a buildup of fluid between the tissues that line the lungs and chest). Resident 3's Care Plan dated 7/13/23 revealed she/he used a Purewick system (an external urine collection system which used suction and a wick to draw urine away from the body). The device instructions directed the device was to be placed in the groin area adjacent to the urethral opening and had to be correctly placed in order to wick the urine into the tubing and deposit in the attached canister. On 2/13/24 a concern was received stating staff who provided incontinence care did not know how to use the Purewick system, placed it too low in the groin area, which caused the resident's tailbone to hurt and the device to suction fecal matter into the canister. On 2/16/24 at 12:45 PM Staff 5 (CNA) stated Resident 3 was the only resident in the facility who used the Purewick system. She stated CNAs provided incontinence care and were responsible for using the Purewick system. Staff 5 stated Resident 3 was very particular about where the device was placed and wanted it placed to the side (of the urethral opening, rather than the middle) and the off centered device may have caused sores in the resident's groin area. Staff 5 stated she had not received training on how to use the device. On 2/26/24 at 9:35 AM Staff 6 (CNA) stated he was familiar with Resident 3's care needs and she/he was care planned for the Purewick system. He stated the staff providing inontinence care for the resident did not know how to use it, had overheard staff talking about the catch basin which contained feces rather than urine due to the incorrect placement of the catheter. Staff 6 stated there were a lot of agency staff working in the facility and if training were provided, agency staff would stay on the floor during staff meetings. On 2/26/24 at 10:30 AM Staff 4 (CNA 2) stated she was familiar with the Purewick system due to working in hospitals. She stated she told CNAs how to place the device but several times she would come on shift, provide incontinence care to Resident 3 and the device would be placed too low. As a result, Resident 3 had indentations on the skin surrounding the groin/buttock area and the device would suction fecal matter. Staff 4 stated the Purewick system was primarily used in hospitals and at home so facility staff were unfamiliar with the system. She stated the placement of the device couldn't be too high or it would not extract urine and if the device were too low, fecal matter would be caught in the tubing and clog the device. On 2/22/24, Staff 2 (Acting DNS) provided notes from a CNA meeting held on 12/20/23. The form indicated a notation Purewick video but no staff signatures were attached to the meeting notes. Staff 2 also provided incontinence training records for several staff but the list did not contain dates of completion. On 2/26/24 at 11:29 AM, Staff 2 stated no competencies or assessments had been completed with CNA staff regarding the use of the Purewick system.

Based on observation, interview and record review it was determined the facility failed to ensure call lights were within reach for 1 of 4 sampled residents (#1) reviewed for accommodation of need. This placed residents at risk for lack of ADL care. Findings include: Resident 1 admitted to the facility in 4/2023 with diagnoses including cervical (neck) fracture and stroke. On 6/12/23 at 10:00 AM Resident 1 was observed in bed wearing a neck brace and her/his call light was attached and hanging over the right backside of her/his bed out of reach. At 10:09 AM Staff 7 (CNA) entered the room and stated oh the call light was out of Resident 1's reach and moved the call light within reach for Resident 1. On 6/12/23 at 10:25 AM Resident 1 stated she/he did not always have access to her/his call light and it was often out of reach or on the floor. Resident 1 stated she/he had limited range of motion with her/his arms due to the neck brace. On 6/13/23 at 10:39 AM Staff 7 and at 2:53 PM Staff 8 (CNA) stated Resident 1 wore her/his neck brace at all times and had limited range of motion in her/his arms. Staff 7 and Staff 8 stated call lights were to be within reach of Resident 1 at all times. On 6/16/23 at 1:30 PM Staff 2 (DNS) stated staff were expected to ensure call lights were within reach for Resident 1 at all times.

Based on observation, interview, and record review it was determined the facility failed to provide nail care for 2 of 4 sampled residents (#s 15 and 16) reviewed for activities of daily living. This placed residents at risk for unmet nail care needs. Findings include: 1. Resident 16 admitted to the facility in 2018 with diagnoses including diabetes. The 6/7/19 Care Plan indicated Resident 16 was to have diabetic foot and nail care checks weekly by nursing staff. The 5/2023 and 6/2023 Diabetic foot and nail care task sheet indicated weekly checks were completed by nursing staff. On 6/12/23 at 11:00 AM Resident 16's finger nails were observed to be long, curved and touching the nail bed. Resident 16 stated she/he would like to have her/his finger nails trimmed. Resident 16 stated she/he believed it had been at least a month since her/his finger nails were trimmed. On 6/13/23 at 11:25 AM Staff 3 (RN) stated Resident 16 was diabetic and required nursing staff to check her/his finger and toe nails weekly. Staff 3 stated the nail task sheet indicated visual checks of the finger and toe nails. Staff 3 stated Resident 16's finger and toe nails were trimmed by an outside provider about two months ago. Staff 3 stated nursing staff tried to trim Resident 16's finger and toe nails if they were too long. On 6/13/23 at 11:27 AM Staff 3 acknowledged Resident 16's finger nails were long and needed to be trimmed. Resident 16 stated to Staff 3 that she/he would love to have her/his finger nails trimmed as they were long and dirty underneath. On 6/13/23 at 11:34 AM Staff 2 (DNS) acknowledged Resident 16's finger nails needed to be trimmed. 41453 2. Resident 15 was admitted to the facility in 2019 with diagnoses including heart failure. On 6/12/23 at 10:42 AM Resident 15's right hand was observed to have long, discolored, dirty and thick fingernails. Resident 15 stated they were trimmed recently. On 6/14/23 at 11:00 AM Resident 15's fingernails were observed to be trimmed but still long. There was what appeared to be debris and stains under the fingernails. Resident 15 stated she/he desired to have them look better. On 6/15/23 at 9:07 AM Staff 9 (RNCM) stated fingernails were to be viewed, cleaned, and trimmed on shower days. Resident 15's last shower day was 6/12/23. Staff 9 confirmed she instructed a CNA to clean and trim Resident 15's fingernails because it was not completed.

Based on interview and record review it was determined the facility failed to follow physician orders for 1 of 5 sampled residents (#20) reviewed for unnecessary medications. This placed residents at risk for improper administration. Findings include: Resident 20 admitted to the facility in 8/2022 with diagnoses including bipolar disorder (manic and depressive episodes), anxiety and schizoaffective (experience of psychosis as well as mood symptoms) disorder. A 5/22/23 physician order revealed staff were to administer two puffs of fluticasone propionate (nasal allergy) spray into each nostril in the morning for shortness of breath. A 6/8/23 physician order revealed Voltaren (pain gel) one percent to be applied to affected area of pain topically as needed for pain. Measure out two grams for unsupervised self-administration. The 6/2023 TARs revealed Resident 20 received her/his fluticasone propionate and she/he requested and received Voltaren on 6/8/23, 6/9/23, 6/10/23 and 6/11/23. The TARs were marked as unsupervised self-administration. On 6/12/23 at 9:38 AM and 10:05 AM an observation revealed on Resident 20's bedside table there were three small cups with a white cream substance and one of the containers in the middle had the name Voltaren written on it. Next to the three small cups was a bottle of fluticasone propionate spray dated 6/9/23 with the residtent's room number written on the outside of the bottle. Resident 20 was not present in her/his room. On 6/13/23 at 2:49 PM Resident 20 stated the three small containers of Voltaren and fluticasone propionate were left on the bedside table and she/he did not recall who placed them there or for how long. Resident 20 stated she/he used the Voltaren cream on her/his own but staff were supposed to watch her/him take the medication and apply the Voltaren cream to her/his knees. On 6/14/23 at 1:25 PM Staff 11 (LPN) stated Resident 20 was able to apply her/his own Voltaren cream and she completed a self-medication assessment on 6/8/23 for Resident 20 but stated the self-medication assessment was meant only to be used for the Voltaren and did not include self-administration of the fluticasone propionate. Staff 11 stated staff were expected to be present when administering Resident 20's medication except for the Voltaren and the Voltaren was to be handed to Resident 20 to apply within a reasonable amount of time. Staff 11 stated she was unsure why three containers of Voltaren and the fluticasone propionate was left on the bedside table. On 6/15/23 at 12:51 PM Staff 2 (DNS) stated she was aware of the three small containers of Voltaren and fluticasone propionate left on Resident 20's bedside table. Staff 2 stated she expected staff to administer the fluticasone propionate per physician order. Staff 2 stated the Voltaren cream was to be given to Resident 20 in the small container and should not have had three containers of Voltaren cream left on her/his bedside table. Staff 2 stated staff were expected to follow up with Resident 20 within the hour to ensure the Voltaren cream was applied or be disposed of appropriately.

Based on observation, interview and record review the facility failed to provide sufficient nursing staff to ensure residents attained or maintained their highest practicable mental, physical and psychosocial well-being for 1 of 4 sampled residents (#1) reviewed for accommodation of need and staffing. This placed residents at risk for unmet ADL care needs. Findings include: Resident 1 admitted to the facility in 4/2023 with diagnoses including cervical (neck) fracture and stroke. A 5/11/23 Multidisciplinary Care Conference revealed Resident 1 discussed call light timing at night and Resident 1 used her/his call light, a grievance was completed regarding the issue. No documentation was found in the medical record regarding a grievance being completed regarding call light concerns. On 6/12/23 at 10:00 AM Resident 1 was observed in bed wearing a neck brace and her/his call light was attached and hanging over the right backside of her/his bed out of reach. At 10:09 AM Staff 7 (CNA) entered the room and stated oh the call light was out of Resident 1's reach and moved the call light within reach for Resident 1. On 6/12/23 at 10:25 AM Resident 1 stated she/he did not always have access to her/his call light and it was often out of reach or on the floor. Resident 1 stated she had limited range of motion with her/his arms due to the neck brace. Resident 1 stated call light response times were greater than 15 minutes and she/he sat in wet and soiled briefs for long periods of time. Review of call light wait time records from 5/1/23 through 6/13/23 revealed Resident 1 utilized her/his call light 365 times and revealed the following call light wait times: *Resident 1 initiated her/his call light 51 times and the call light response times were 15 minutes up to 35 minutes. *Resident 1 initiated her/his call light 13 times and the call light response times were 36 minutes up to 59 minutes. On 6/13/23 at 2:53 PM Staff 8 (CNA) stated call lights were to be answered in under five minutes and all staff were responsible for answering call lights. Staff 8 stated not all staff assisted with answering call lights. On 6/14/23 at 9:08 AM Staff 15 (CNA) stated all staff were responsible for answering call lights and this did not always occur. Staff 15 stated staff were expected to answer call lights within five minutes. On 6/16/23 at 9:04 AM Staff 1 (Administrator) stated she could not locate a grievance form regarding call light concerns for Resident 1 from the 5/11/23 Multidisciplinary Care Conference. On 6/16/23 at 1:30 PM Staff 2 (DNS) stated all staff were expected to answer call lights within five minutes and call lights should always be within reach of residents.

Based on observation and interview it was determined the facility failed to secure a treatment cart for 1 of 3 halls observed for medication storage. This placed residents at risk for lost or missing medications. Findings include: On 6/13/23 at 11:21 AM an unlocked treatment cart was observed on hall 300 unattended. Review of the contents of the treatment cart revealed injectable insulin. There were two CNAs charting, not watching the cart and no other staff were visible in the hallway. On 6/13/23 at 11:24 AM Staff 21 (LPN) confirmed insulin was kept in the treatment cart and it should have been locked. On 6/15/23 at 11 AM Staff 2 (DNS) confirmed carts with medications should be locked when a nurse was not present.

Based on interview and record review it was determined the facility failed to ensure resident self-administration of medication assessment records were complete and accurate for 1 of 5 sampled residents (#20) reviewed for medications. This placed residents at risk for inaccurate medication assessments. Findings include: Resident 20 admitted to the facility in 8/2022 with diagnoses including bipolar disorder (manic and depressive episodes), anxiety and schizoaffective (experience of psychosis as well as mood symptoms) disorder. A 6/8/23 Self-Administration of Medication Assessment revealed the following: -Resident 20 had no limitations to administration of medications. -Resident 20 demonstrated appropriate knowledge and use of medications, distinguished color, shape and size. -Able to read medication label and repeat back to RN, punch blister care package, open flip-cap bottle and open screw-cap bottle. -Readiness to handle and administer own medication, no past history of medication mismanagement and was able to come to the medication cart to obtain medications. -The completed form identified Resident 20 was not a candidate for self-administration with a no on the form. -Physician was contacted for the order on 6/8/23. On 6/12/23 at 10:05 AM and 9:38 AM an observation revealed on Resident 20's bed side table there were three small cups with a white cream substance and one of the containers in the middle had the name Voltaren (pain gel) written on it. Next to the three small cups was a bottle of fluticasone propionate (nasal allergy) spray dated 6/9/23 with the residents room number written on the outside of the bottle. Resident 20 was not present in her/his room. On 6/14/23 at 1:25 PM Staff 11 (LPN) stated Resident 20 was able to apply her/his own Voltaren cream and she completed a self-medication assessment on 6/8/23 for Resident 20 but stated the self-medication assessment was meant only to be used for the Voltaren and did not include self-administration of the fluticasone propionate. On 6/15/23 at 12:51 PM Staff 2 (DNS) acknowledged the self-assessment completed on 6/8/23 was inaccurate and should have indicated self-administration for the Voltaren use only, and had conflicting information regarding the resident's ability to self-administer medication.

Based on interview and record review it was determined the facility failed to ensure residents were provided pain management prior to physical therapy for 1 of 3 sampled resident (#6) reviewed for pain medication. This placed residents at risk for pain and poor participation in physical therapy related to unmanaged pain. Findings include: Resident 6 was admitted to the facility in 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] On 12/20/21 at 1:59 PM Witness 1 (Complainant) stated he/she had multiple conversations with unnamed facility administration staff regarding concerns about ensuring Resident 6 received pain medication prior to physical therapy sessions. A review of Resident 6's 8/12/21 through 10/15/21 Progress Notes, Care Plan and MARs revealed no documented plan, orders or procedure to ensure the resident received pain medication in a timely manner prior to physical therapy sessions. A review of Resident 6's August 2021 through October 2021 MARs revealed 20 of 24 opportunities where the facility failed to administer pain medication prior to physical therapy sessions. On eight occasions Resident 6 refused to participate in physical therapy sessions due to pain or expressed fear or crying. On 1/4/22 at 10:58 AM Staff 1 (LPN/Resident Care Manager) confirmed the facility had conversations with Witness 1 regarding pain medication administration prior to physical therapy and follow up concerns from Witness 1 that Resident 6 still was not receiving pain medication prior to physical therapy. Staff 1 confirmed there was no documented plan for ensuring pain medication was administered prior to physical therapy.

Based on interview and record review it was determined the facility failed to ensure residents were free from significant medication errors for 1 of 3 sampled residents (#4) reviewed for medication administration. This placed residents at risk for adverse medication consequences. Findings include: Resident 4 was admitted to the facility in 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident 4's Progress Notes revealed on 9/21/20 the resident's [MEDICATION(S)] (antibiotic) order was reviewed by the physician and the correct order was for [MEDICATION(S)] 500 mg administered by IV once every 24 hours. Resident 4's September 2020 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/14/21 at 4:23 PM Staff 2 (DNS), by email, verified the double dose of [MEDICATION(S)] was a medication error. Staff 2 indicated the resident and physician were notified. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview and record review it was determined the facility failed to ensure residents were provided pain management prior to physical therapy for 1 of 3 sampled resident (#6) reviewed for pain medication. This placed residents at risk for pain and poor participation in physical therapy related to unmanaged pain. Findings include: Resident 6 was admitted to the facility in 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] On 12/20/21 at 1:59 PM Witness 1 (Complainant) stated he/she had multiple conversations with unnamed facility administration staff regarding concerns about ensuring Resident 6 received pain medication prior to physical therapy sessions. A review of Resident 6's 8/12/21 through 10/15/21 Progress Notes, Care Plan and MARs revealed no documented plan, orders or procedure to ensure the resident received pain medication in a timely manner prior to physical therapy sessions. A review of Resident 6's August 2021 through October 2021 MARs revealed 20 of 24 opportunities where the facility failed to administer pain medication prior to physical therapy sessions. On eight occasions Resident 6 refused to participate in physical therapy sessions due to pain or expressed fear or crying. On 1/4/22 at 10:58 AM Staff 1 (LPN/Resident Care Manager) confirmed the facility had conversations with Witness 1 regarding pain medication administration prior to physical therapy and follow up concerns from Witness 1 that Resident 6 still was not receiving pain medication prior to physical therapy. Staff 1 confirmed there was no documented plan for ensuring pain medication was administered prior to physical therapy.

Based on interview and record review it was determined the facility failed to ensure residents were free from significant medication errors for 1 of 3 sampled residents (#4) reviewed for medication administration. This placed residents at risk for adverse medication consequences. Findings include: Resident 4 was admitted to the facility in 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident 4's Progress Notes revealed on 9/21/20 the resident's [MEDICATION(S)] (antibiotic) order was reviewed by the physician and the correct order was for [MEDICATION(S)] 500 mg administered by IV once every 24 hours. Resident 4's September 2020 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/14/21 at 4:23 PM Staff 2 (DNS), by email, verified the double dose of [MEDICATION(S)] was a medication error. Staff 2 indicated the resident and physician were notified. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interview and record review it was determined the facility failed to ensure a resident's pressure ulcer was assessed weekly for 1 of 3 sampled residents (#11) reviewed for pressure ulcers. This placed residents at risk for worsening wounds. Findings include: Resident 11 was readmitted to the facility 3/17/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The 3/17/21 Skin and Wound Evaluation form revealed Resident 11 was admitted to the facility with an unstagebale pressure ulcer (full thickness skin loss in which the base of the ulcer is covered by slough [yellow, tan, gray, green or brown tissue] and or eschar [tan, brown or black tissue) to the left heel. The wound was assessed for size, location, wound bed condition, drainage and the condition of the skin around the wound. There was no assessment documented from 3/18/21 through 4/15/21. On 4/16/21 the ulcer was documented to have decreased in size. The 3/17/21 Skin and Wound Evaluation form revealed Resident 11 was admitted the the facility with a Stage II pressure ulcer (partial thickness skin loss) to the sacrum. The wound was assessed for size, location, wound bed condition, drainage and the condition of the skin around the wound. There was no assessment documented from 3/18/21 through 4/13/21. On 4/14/21 the ulcer was documented to be decreased in size. The 3/17/21 Skin and Wound Evaluation form revealed Resident 11 was admitted to the facility with a Stage II pressure ulcer to the right buttock. The wound was assessed for size, location, wound bed condition, drainage and the condition of the skin around the wound. There was no assessment documented from 3/18/21 through 4/13/21. The ulcer decreased in size but was covered with slough. The March and April 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 4/21/21 with Staff 14 (RN) revealed wound care was provided as ordered. On 4/20/21 Staff 3 (DNS) indicated pressure ulcer assessments were to be done weekly and acknowledge the resident's ulcers were not documented as assessed for almost one month. Staff 3 indicated the resident's [CONDITION(S)] days changed and the skin assessment dates/times were scheduled when the resident was out to [CONDITION(S)].

Based on interview and record review it was determined the facility failed to treat residents with respect and dignity for 1 of 4 sampled residents (# 1) reviewed for respect and dignity. This placed residents were at risk of receiving care in a manner that did not promote their respect and dignity. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1's 6/5/20 care plan indicated the resident required a two person assist with bed mobility and required total assistance with toileting. An incident report dated 6/8/20 indicated on night shift two CNAs assisted Resident 1 with incontinent care. The resident indicated as soon as Witness 2 (former CNA) entered the room she indicated she needed to hurry because someone needed help on the other hall. Witness 2 assisted Staff 5 (CNA) with rolling the resident on her/his side and the resident felt it was rushed. The resident stated she/he felt Witness 2 refused to listen to her/him when she/he wanted to explain things needed to be done slowly due to her/his MS. On 2/1/21 at 12:30 PM Witness 1 (Complainant) stated in the middle of the night Resident 1 was incontinent and needed to be changed. Witness 1 stated Staff 5 went and got Witness 2 to assist. Witness 1 stated due to the MS the resident had ongoing pain and needed to go slow and move slow when cared for. Witness 1 stated the resident preferred to give direction on how to move her/him. Witness 1 indicated the resident felt he/his was not listened to and respected. Witness 1 stated the incident occurred one time with one staff member. On 2/1/21 at 2:11 PM Witness 2 stated Staff 5 asked her to assist with Resident 1 with incontinent care. Witness 2 stated the resident kept talking and she told her/him to let them help because she had to return back to her hall. On 2/2/21 at 4:15 PM Staff 5 stated she had asked Witness 2 to assist her with Resident 1. She stated Witness 2 and the resident were not getting along during the care. Staff 5 stated the resident felt Witness 2 was rushing and had told her if she needed to leave then to leave. She stated after the incident Resident 1 called her back into the room and indicated she/he could not be rushed because of her/his conditions. Staff 5 stated she was aware the resident moved slow, could not move well and was very particular about how she/he wanted things done. Staff 5 stated she felt the resident was disrespected as Witness 2 could have slowed down and listened to what Resident 1 was telling them. Staff 5 stated it was not particularly busy the night of the incident. On 2/2/21 at 4:32 PM Staff 6 (RN) stated she was the charge nurse on the night of the incident. She stated Staff 5 asked Witness 2 to assist her with turning Resident 1. She stated Staff 5 had informed her the resident complained that Witness 2 went to fast during the care and told the resident she had to things to do and had to return to her hall. Staff 6 stated the CNAs on night shift have the time to ensure the resident's needs are met and it was not busy the night of the incident. 2/3/21 at 10:34 AM Staff 4 (SSD) stated Resident 1 had a specific way she/he liked to be cared for. She stated at the time of admission the resident's spouse indicated the resident was very particular about her/his care. She stated the resident was not respected as they informed the staff to slow down and felt no listened to. On 2/3/21 at 11:00 AM Staff 3 (RCM) stated Resident 1 was alert and oriented and was able to direct her/his own care. She stated the resident felt she/he was not listened to and a lot of her/his dignity was being able to direct how she/he wanted care to be done. She stated if a resident requested to go at a certain pace then the staff are expected to follow. On 2/3/21 at 11:08 AM Staff 2 (DNS) Stated Resident 1 told her that Witness 2 was in a hurry during incontinent care. Staff 2 stated staff were aware of the resident being particular on how she/he wanted things. She stated the resident let the facility know from the very beginning about her/his care and she/he needed to be turned slowly. She stated the resident felt he/she was not listened to by Witness 2 and not respected. Staff 2 further stated she stressed to staff to work at a resident's pace.

Based on observations, interviews, and record reviews, the facility failed to provide a sanitary environment to prevent infections when staff did not implement measures to help prevent the development of urinary tract infections for 1 of 1 resident (R) (R1) observed for indwelling catheter and did not clean and disinfect, per manufacturer's instructions, to ensure the decontamination of durable medical equipment used in the care of 2 of 2 residents (R3 and R4) observed for use of the equipment. These failures increased the risk for infection and its associated discomfort and complications. Findings include: *Indwelling catheter care Record review of the facility's policy titled, Catheter Care, Urinary-Level III, dated 3/2018, showed the purpose of the procedure is to prevent infection of the resident's urinary tract and included be sure the catheter tubing is kept off the floor. Review of R1's record showed the facility admitted the resident on 4/22/20 with [DIAGNOSES REDACTED]. Review of R1's care plan showed problem for risk for history of UTI related to history of UTI, [MEDICATION NAME] (artificial opening in the abdominal area to drain urine), date initiated was 4/27/19, with interventions of foley (flexible tube in the bladder that drains urine) catheter care per MD order. Observation on 4/29/20 at 10:00 AM showed R1 sat in his wheelchair in the 400 hall bistro. A urinary catheter bag and tubing hung from the Resident's wheelchair underneath the seat. About 3 inches of the tubing rested on the carpeted floor. Licensed Nurse (LN) 1 wheeled resident to his room about 50 feet down the hall and administered medications. When done, LN1 wheeled resident back to 400 hall bistro with catheter tubing dragging on the carpet. During interview on 4/29/20 at about 10:10 AM LN1 stated that R1's catheter tubing was touching the carpet and it shouldn't be because it was an infection control issue. LN1 stated that was a good catch. LN1 adjusted the tubing so it wasn't touching the carpet. When R1 asked what LN1 was doing, LN1 stated that she was lifting up tubing because it was dragging on the floor. *Durable medical equipment Record review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, dated 8/2018, showed reusable items are cleaned and disinfected between residents (e.g., durable medical equipment). Durable medical equipment (DME) must be cleaned and disinfected before reuse by another resident. Reusable resident care equipment will be decontaminated and/or sterilized between residents according to manufacturer's instructions. Sani-Cloth® Bleach Germicidal Disposable Wipe container label showed To clean, disinfect and deodorize: use a wipe to remove heavy soil. Unfold a clean wipe and thoroughly wet surface. Treated surface must remain visibly wet for a full four (4) minutes. Use additional wipe(s) if needed to assure continuous 4 minute wet contact time. During concurrent observation and interview on 4/29/20 at 9:50 AM showed Physical Therapist (PT)1 wiping down Sara Stedy sit to stand manual lift durable medical equipment device (device that allows residents to pull themselves up into a standing position) outside of room [ROOM NUMBER]A (R4). PT1 used several cloth wipes on multiple surfaces of stedy device. When asked what was used to wipe down stedy, PT1 showed surveyor Sani-cloth germicidal disposable wipe container (orange top). During interview on 4/29/20 at 9:52 AM Certified Nursing Assistant (CNA)1 was asked to touched stedy that was just wiped down by PT1. CNA1 stated that the stedy was not too wet now and when asked how long the stedy should stay wet, CNA1 stated, 2 minutes. Observation on 4/29/20 at 10:20 AM showed CNA2 moved stedy from nursing station across bistro to room [ROOM NUMBER](R3). After about 10 minutes, CNA2 removed stedy from room [ROOM NUMBER] and wiped it down with Sani-cloth Bleach wipes. During interview on 4/29/20 at 1035 AM CNA1 and CNA2, when asked what the contact time was for Sani-cloth bleach wipes, CNA2 stated that the stedy is not used on residents right after each other, it sits in the hallway between uses. When asked how long the stedy needed to stay wet from the sani-cloth bleach wipes, CNA2 stated 2 minutes. CNA1 and CNA2 looked at the Sani-cloth bleach wipe container and stated that the label says 4 minutes contact time and they didn't know this. During interview on 4/29/20 at 11:20 AM when asked what the Sani-cloth bleach wipe contact time was, PT1 stated that when she cleaned/disinfected stedy she tried to make sure she wiped down all the areas that the resident touched and had contact with. When asked how long the stedy needed to stay wet from the sani-cloth bleach wipes to ensure the stedy was cleaned and disinfected, PT1 stated, I don't know how long it needs to stay wet, but I can check the container and find out. When asked when she wiped down stedy after use with resident in room [ROOM NUMBER]A how long was stedy kept wet with sani cloths, PT1 stated 15 to 30 seconds. PT1 looked at the sani-cloth bleach wipe container and stated that the label says 4 minutes contact time and said, That's a long time. During interview on 4/29/20 at 5:15 PM with Administrator, Director of Nursing/Infection Preventionist (DON/IP) and Corporate Nurse, the above findings were shared. DON/IP stated that R1's urinary catheter tubing should not be touching the carpet and nodded head that R1 has a history of UTIs. No further information was provided for lack of staff knowledge with disinfecting wipes contact time.

Based on observation, interview and record review it was determined the facility failed to revise resident care plans for 4 of 10 sampled residents (#s 4, 11, 18 and 20) reviewed for pressure ulcers, medications and [MEDICAL TREATMENT]. This placed residents at risk for unmet needs. Findings include: 1. Resident 4 was admitted to the facility in 2019 with a [DIAGNOSES REDACTED]. Review of the resident's 2/26/19 care plan indicated the resident was at risk for pressure ulcers. The care plan did not indicate the use of protective boots. Review of Residents 4's current Kardex (CNA Care PLan) did not indicate the use of the protective boots. A 5/8/19 discontinued order indicated the resident had placement of boots for protection to lower extremities. The following observations were made of Resident 4: -6/21/19 at 9:32 AM the resident was in bed wearing pressure reducing protective boots. -6/24/19 at 1:55 PM the resident was up in her/his wheelchair wearing sneakers. -6/26/19 at 8:46 AM the resident was in bed wearing protective boots. On 6/24/19 Staff 13 (Charge Nurse) stated Resident 4 was wearing the protective boots but the last couple of days was just wearing her/his sneakers. On 6/25/19 at 10:04 AM Staff 3 (CNA) stated Resident 4 wore the protective boots in and out of bed. He stated the resident had always worn the boots. Staff 3 stated he would refer to the care plan and Kardex to verify the resident's care needs. Staff 3 confirmed the use of the protective boots for Resident 4 was not on the care plan or Kardex. On 6/26/19 at 8:57 AM Staff 2 (DNS) indicated there were no current orders for the use of the protective boots for Resident 4. She stated the resident wore both sneakers and the protective boots. She stated the resident sometimes preferred to wear the protective boots. Staff 2 confirmed the resident's preference for the use of protective boots was not on the care plan or Kardex. 2. Resident 11 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. A review of Resident 11's orders indicated the use of [MEDICATION NAME] (antidepressant) with a start date of 9/4/18 and an end date of 11/13/18. A 12/10/18 Behavior/[MEDICAL CONDITION] meeting indicated there were no [MEDICAL CONDITION] medications ordered. The resident's 4/11/19 care plan indicated the resident used [MEDICAL CONDITION] medication related to anxiety and depression. On 06/26/19 at 8:53 AM Staff 2 (DNS) confirmed Resident 11's care plan was not updated to reflect the discontinuation of the antidepressant. 3. Resident 18 was admitted to the facility 12/2018 with [DIAGNOSES REDACTED]. Review of Resident 18's current care plan, initiated 12/4/18, and Kardex (CNA Care Plan) indicated the resident went out of the facility for [MEDICAL TREATMENT] treatment two times a week on Tuesdays and Saturdays. A Nephrology Consultation document dated 1/8/19 indicated Resident 18 received [MEDICAL TREATMENT] three times a week on Tuesday, Thursday and Saturday. On 6/20/19 at 11:36 AM Resident 18 stated she/he received [MEDICAL TREATMENT] three times a week on Tuesday, Thursday and Saturday. On 6/26/19 at 8:53 AM Staff 2 (DNS) acknowledged Resident 18 no longer received [MEDICAL TREATMENT] two times a week and the care plan was not updated to reflect she/he received [MEDICAL TREATMENT] three times a week. 4. Resident 20 was admitted to the facility on ,[DATE] with [DIAGNOSES REDACTED]. The 11/21/18 Admission MDS indicated the resident was not cognitively intact and was at risk for pressure ulcers. Review of Resident 20's 3/7/19 Skin and Wound Care Evaluation indicated a new right lateral calf unstageable wound measuring 4.3 cm long and 3.9 cm wide with eschar (hard plaque covering an ulcer, implying extensive tissue necrosis) covering the wound bed. The wound was further described as a Medical Device Related Pressure Injury. Review of Resident 20's 3/7/19 Skin Event indicated a new skin impairment was discovered during a skin check in the shower. The preliminary cause was determined to be pressure from the wheelchair leg rest. The facility added a cushion to the wheelchair leg rests. It further indicated Resident 20 was only able to make minor shifts in position without staff assistance. The resident spent most of her/his day alternating between her/his bed and the wheelchair. Resident 20 continued to be at high risk for skin impairments due to her/his [MEDICAL CONDITION] and thin, dry and fragile skin. A physician's orders [REDACTED]. Review of Resident 20's 5/1/19 quarterly nursing summary indicated the resident had multiple interventions in place for pressure prevention which included additional padding added to the wheel chair legs. The following observations were made of Resident 20: -6/24/19 at 9:00 AM the resident was up in a chair in sun room with padded leg protection on the wheelchair legs. -6/26/19 at 1:44 PM the resident was resting in bed with her/his eyes closed and her/his wheelchair next to the bed with the legs removed and placed on floor. The wheelchair leg padding was also on the floor leaning on the wall. -6/26/19 at 11:15 PM the resident was resting in bed with her/his eyes closed and her/his wheelchair was next to the bed with the legs removed and placed on floor. The wheelchair leg padding was also on the floor. The resident's care plan and Kardex were reviewed and they were not updated to reflect the use of padding. The padding applied to the wheelchair was observed to be removable and needed to be replaced each time. Resident 20 was transferred from her/his bed to the wheelchair each time. On 6/26/19 at 1:36 PM Staff 14 (RNCM) stated Resident 20's left lateral calf wound was discovered 3/7/19. She confirmed the wheel chair leg padding was not added to the care plan or Kardex.

Based on interview and record review it was determined facility staff failed to maintain the health and safety of 1 of 3 sampled residents (#1) with medication errors. Resident 1 required hospitalization for treatment of [REDACTED]. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. 1. Oregon State Board of Nursing, Nurse Practice Act, Conduct Derogatory to the Standards of Nursing Defined [PHONE NUMBER] (1) Conduct related to the client's safety and integrity: (a) Developing, modifying, or implementing standards of nursing practice/care which jeopardize patient safety. NN dated 12/18/10 at 8:30 pm revealed at 7:00 pm the resident was given another resident's medications: 75 mg [MEDICATION NAME](long acting [MEDICATION NAME], narcotic), [MEDICATION NAME] (anti-[MEDICAL CONDITION]/nerve pain), iron (supplement), [MEDICATION NAME] (stool softener), [MEDICATION NAME] (anti-depressant), [MEDICATION NAME] (diuretic/blood pressure), potassium chloride (supplement) and [MEDICATION NAME] (lowers cholesterol). NN dated 12/19/10 at 5:50 am revealed the resident had shallow respirations, needed increased oxygen and was unable to speak. 911 was called. Paramedics started an intravenous (IV) line and administered [MEDICATION NAME], a medication to reverse narcotic overdose, and transported the resident to the hospital. Review of the hospital Emergency Department Clinical Report dated 12/19/10 revealed paramedics gave the resident two doses of [MEDICATION NAME]. emergency room staff gave an additional dose of [MEDICATION NAME], started an IV drip of [MEDICATION NAME] (slow continuous administration) and admitted the resident to the Intensive Care Unit. In a telephone interview on 1/8/11 at 3:40 pm Witness 2 (RN) stated she was the charge nurse the evening of the medication error. Witness 2 stated the CMA was needed to work as a CNA that evening. Witness 2 was then responsible for passing medications and she attempted to pass Resident 2's medications. Witness 2 stated Resident 1 and Resident 2 were new residents. Witness 2 stated she asked Resident 1, "Is your name (Resident 2)?" Witness 2 stated it "looked like (Resident 1) nodded yes" and she proceeded to administer Resident 2's evening medications to Resident 1. 2. Oregon State Board of Nursing, Nurse Practice Act, Conduct Derogatory to the Standards of Nursing Defined [PHONE NUMBER] (3) Conduct related to communication: (h) Failing to communicate information regarding the client's status to members of the health care team (... nursing supervisor ... ) in an ongoing and timely manner. Review of an investigation dated 12/20/10 of the medication error revealed on the evening of 12/18/10 at 8:00 pm Witness 2 (RN) called Staff 2 (DNS) to inform her of the medication error. Staff 2 wrote "She (Witness 2) explained to me that she had given 75 mg of [MEDICATION NAME] the wrong resident (at 7:00 pm)." Staff monitored the resident through the night and the resident's condition changed at 5:45 am the next morning. 911 was called and the resident was transferred to the hospital. "Upon further assessment of the investigation I (Staff 2) learned that more than just the 75 mg of [MEDICATION NAME] been given to that resident ...." In an interview on 1/5/11 at 2:55 pm Staff 2 stated she did not know about all the medications the resident had been given until the morning after the error. Staff 2 stated she would have called the family and the physician herself if she had known about all the medications involved in the error. In a telephone interview on 1/8/11 at 3:40 pm Witness 2 confirmed Staff 2 was told about the [MEDICATION NAME] error only. Refer to F 329

Based on interviews and record review it was determined the facility failed to prevent a resident receiving the wrong medications for 1 of 3 sampled residents (#1) with medication errors. Resident 1 required hospitalization for treatment of [REDACTED]. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the clinical record revealed physician's orders [REDACTED]. The resident had an order for [REDACTED]." Because of [MEDICAL CONDITION] and increased blood potassium level, the resident was to have a low potassium diet. NN dated 12/18/10 at 8:30 pm revealed at 7:00 pm the resident was given another resident's medications: 75 mg [MEDICATION NAME](extended release [MEDICATION NAME], narcotic), [MEDICATION NAME] (anti-[MEDICAL CONDITION]/nerve pain), iron (supplement), [MEDICATION NAME] (stool softener), [MEDICATION NAME] (anti-depressant), [MEDICATION NAME] (diuretic/blood pressure), potassium chloride (supplement) and [MEDICATION NAME] (statin/lowers cholesterol). The resident had no allergies [REDACTED]. Staff notified the on call physician who ordered [MEDICATION NAME] (injectable medication to reverse narcotic overdose) to be used if the resident became too sedated or the respiratory rate decreased to eight respirations per minute. "Call (the physician) back before giving PRN [MEDICATION NAME]." According to the 2010 Nursing Drug Handbook, extended release [MEDICATION NAME] is for adults who need around-the-clock [MEDICATION NAME] and who have developed tolerance to [MEDICATION NAME] (an increasing dose is required to produce the same pain relief). A common dose for extended release [MEDICATION NAME] is 15 to 30 mg every 8 to 12 hours and increased as needed to meet the patient's need. [MEDICATION NAME] should be used with caution in the elderly or debilitated patients (including those with chronic [MEDICAL CONDITION] disease and severe liver or kidney disease). Common [MEDICATION NAME] side effects include sleepiness and sedation. Severe side effects (bold print) include [MEDICAL CONDITION], respiratory depression and respiratory arrest. Review of the MAR indicated [REDACTED]. NN dated 12/18/10 at 9:30 pm indicated staff were doing visual checks of the resident every 15 minutes. The resident remained alert with appropriate responses. At 11:30 pm the resident had dozed off, and aroused easily for vital signs. Visual checks were done every 15 minutes and respirations ranged form 20 to 24 breaths per minute. NN dated 12/19/10 at 3:30 am, 4:30 am and 5:30 am indicated the resident's blood pressure and respirations were within normal limits. At 5:50 am the resident's "respirations are now shallow, sternal rub given, O2 (increased) to 6 lpm (liters per minute), rs (resident) opened his/her eyes but did not speak 911 called." (A sternal rub was forceful pressure on the breastbone to cause a reflex reaction indicating pain. If a person did not react to a sternal rub, it was an indication of sedation or a lower level of consciousness.) Staff called the physician and began preparing a [MEDICATION NAME] injection. Paramedics arrived, started an intravenous (IV) line and administered [MEDICATION NAME] to the resident. The physician returned the call and was updated. At 6:10 am the paramedics took the resident to the hospital. At 6:30 am staff notified the DNS who telephoned the resident's family. Review of the hospital Emergency Department Clinical Report dated 12/19/10 revealed paramedics gave the resident two doses of [MEDICATION NAME]. emergency room staff gave an additional dose of [MEDICATION NAME], had the resident on oxygen at 15 liters per minute, started an IV drip of [MEDICATION NAME] (slow continuous administration) and admitted the resident to the Intensive Care Unit. The normal range of potassium in the blood was 3.4 to 5.2 but the resident's potassium was "5.7 (was 5.3 2 days ago)." The resident's [DIAGNOSES REDACTED]." Review of an investigation of a medication error dated 12/20/10 revealed that at 7:00 pm on 12/18/10, Witness 2 (RN) gave Resident 1 the [MEDICATION NAME] intended for Resident 2. Staff 2 (DNS) instructed Witness 2 to call the physician, get an order for [REDACTED]." At 5:45 am on 12/19/10 the resident's condition changed, the resident was given "medication to reverse the side effects" and was transported to the hospital. After additional investigation, Staff 2 discovered the resident was given seven other medications in error including: [MEDICATION NAME] 300 mg, [MEDICATION NAME] sulfate 325 mg (iron), [MEDICATION NAME] 100 mg, [MEDICATION NAME] 60 mg, potassium 20 milliequivalents, [MEDICATION NAME] 20 mg and [MEDICATION NAME] 40 mg. According to the 2010 Nursing Drug Handbook, the dose of [MEDICATION NAME] in patients with kidney disease is 100 to 700 mg per day and the dose for [MEDICATION NAME] in the elderly is 20 mg. Both medications have sleepiness as a side effect. In an interview on 1/5/11 at 2:55 pm Staff 2 (DNS) stated after Resident 1 received Resident 2's medications in error, Resident 1 was also given his/her own scheduled medications with the exception of the [MEDICATION NAME]. Staff 2 stated both Resident 1 and Resident 2 were new to the facility but were not in the same room. Staff 2 checked all the facility's documentation and the proper resident names and room numbers were on all the records. Staff 2 stated Witness 2 was "too distraught" to notify the family and Staff 2 stated she would call the family. Staff 2 called Staff 1 (Administrator) and he decided to contact the family first thing in the morning. Staff 2 stated the evening of the medication error she was unaware other medications besides [MEDICATION NAME] were given to the resident. Staff 2 added she would have called the family and the physician herself if she had known about all the medications. In a telephone interview on 1/8/11 at 3:40 pm Witness 2 (RN) stated the evening of 12/18/10 the CMA was pulled to work as a CNA. Witness 2, as the charge nurse, was then responsible for passing medications. Residents 1 and 2 were new residents and that evening was the first time Witness 2 had worked with them. Witness 2 stated she asked Resident 1, "Is your name (Resident 2)?" and it "looked like (Resident 1) nodded yes," so Witness 2 proceeded to administer Resident 2's evening medications. When she discovered her error, she called the DNS and physician and received instructions. Witness 2 stated a CNA told her Resident 1 was hard of hearing and Witness 2 felt that, and the lack of picture identification, may have led to the error. Witness 2 stated the resident was monitored throughout the night with visual checks every 15 minutes to assess breathing and vital signs were taken every hour. The resident was stable through the 5:30 am check but at the 5:45 am check, the respiration pattern changed from deep to shallow and the resident was unresponsive, including to a sternal rub. Witness 2 called 911, then left a message for the on call physician. The paramedics arrived in three to four minutes and administered [MEDICATION NAME], just as the physician returned the call and ordered [MEDICATION NAME]. The resident then left with the paramedics. Witness 2 stated the physician was aware of all the medications the resident had received in error from the beginning, but when asked if the DNS knew, Witness 2 replied, "I don't think she did." Witness 2 stated the [MEDICATION NAME] was the one drug she was really concerned about. Witness 2 stated Staff 1 (Administrator) interviewed her about the medication error and asked if there was a break in the system. Witness 2 stated she told him there was no picture identification in the MAR, no identification bracelet and no name in the corridor outside of the room.