Every finding on record at Marquis Tualatin Post Acute Rehab

Based on observation, interview and record review it was determined the facility failed to properly disinfect a shared glucometer between resident uses for 1 of 5 sampled residents (#1) reviewed for infection control during CBG checks. This failure, determined to be an Immediate Jeopardy situation, placed all residents who required CBG checks at significant risk for bloodborne illness. Findings include: The undated facility Glucometer Disinfection Policy indicated to disinfect after each individual patient use with EPA disinfectant wipes.A 2017 Evencare G2 Glucometer Manufacturer Manual indicated, Disinfect common use glucometers with the use of approved disinfectant wipes. The glucometer was to be wiped with the disinfecting wipe and left wet for two minutes to ensure disinfection. Resident 1 was admitted to the facility in 3/2023 with diagnoses including Hepatitis B (a highly contagious viral infection that can lead to severe liver damage and cancer).The 3/2026 and 4/2026 MARs indicated Resident 1 received CBG monitoring before meals and at bedtime from varying staff members including Staff 6 (RN). On 5/19/26 at 12:12 PM, Staff 6 was observed to obtain a CBG for Resident 31. Staff 6 returned to the medication cart, wiped the glucometer with an alcohol pad wipe, which was not an EPA-approved disinfecting wipe, and placed the glucometer back inside the cart. Staff 6 stated she always cleaned the glucometers with an alcohol pad wipe after use, and she believed other staff cleaned it the same way. Staff 6 stated her work assignments rotated and she sometimes worked in all three halls of the facility. On 5/19/26 at 3:30 PM, Staff 2 (DNS) stated she expected staff to use EPA-approved disinfecting wipes to clean the glucometers after each resident use. Staff 2 acknowledged using alcohol pad wipes to disinfect glucometers was not sufficient. A facility census provided by Staff 2, dated 5/18/26, indicated there were 13 residents who received daily CBG monitoring, including Resident 1. On 5/19/26 at 4:30 PM, the facility administrative staff, including Staff 1 (Administrator), and Staff 2 were notified that the deficient practice related to the failure to properly disinfect the common use glucometer constituted an Immediate Jeopardy (IJ) situation and were provided a copy of the IJ Template. On 5/20/26 at 2:49 PM, an acceptable plan to remove the IJ situation was submitted by the facility. The plan indicated the facility would implement the following actions: - The three additional residents on the same hallway as Resident 1 that have CBGs being monitored have the potential to be impacted by this deficient practice.- All glucometers in the facility have been disinfected using MicroKill 1 disinfectant versus the alcohol pad wipes with the isopropyl 70%. - The three additional residents on the same hallway, providers have been notified for lab test monitoring PRN. - All licensed nurses on shift have been educated on appropriate disinfecting of the glucometer. - All licensed nurses on shift were re-educated on cleaning of the glucometer during shift huddle. - All licensed nurses not on site will be contacted via phone to be inserviced on appropriate disinfecting of the glucometer by the end of the day on 5/19/26. - Any nurses on vacation or leave of absence will be in serviced prior to their first shift back. - DNS or designee will audit twice daily for one week to ensure appropriate disinfection has occurred, After one week audits will be daily for one week. Then weekly for four weeks to ensure ongoing compliance, - QAPI meeting will be held on 5/19/26 with DNS, Administrator, Medical Director and [NAME] VP Clinical Services to determine root cause analysis and ensure ongoing compliance. From 5/19/26 through 5/20/26 the IJ removal plan was verified as implemented by the survey team. No additional concerns related to the IJ situation were noted. The immediacy was removed on 5/20/26 after verification of completion of the IJ removal plan. Following removal of the immediacy, remaining noncompliance remained with no actual harm, with potential for more than minimal harm that is not Immediate Jeopardy.

Based on observation and interview it was determined the facility failed to store food in a sanitary manner for 1 of 1 resident refrigerator reviewed for sanitary food storage and handling. This placed residents at risk for food-borne illness and contamination. Findings include:On 5/18/26 at 10:46 AM during the initial tour of the facility's dining room and kitchenette the following was observed in the communal freezer:-An opened ice cream bar, uncovered, not labeled or dated.-A small ice cream container covered with a plastic lid, not labeled or dated.-Dried brown substance smudged on the sides of the freezer wall.-Spilled substance stuck on the bottom of the freezer shelf.On 5/18/26 Staff 1 (Administrator) and Staff 17 (Dietary Manager) observed the items with the surveyor and indicated the items in the freezer needed to be thrown away and the spilled substances needed to be cleaned.

Based on observation, interview and record review it was determined the facility failed to provide personal hygiene for 1 of 2 sampled residents (#26) reviewed for ADLs. This placed residents at risk for poor hygiene. Findings include: Resident 26 was admitted to the facility in 10/2022 with diagnoses including Parkinson's.The 2022 [NAME] Standards of Care indicated the following: -Staff were required to shave residents as needed. A 10/2022 Care Plan indicated Resident 26 required supervision with cueing and assistance during shaving. A 4/27/26 Quarterly MDS indicated Resident 26 had a BIMS score of 15 indicating she/he was cognitively intact. The 5/18/26 and 5/21/26 Medical Record indicated Staff 8 (CNA) and Staff 9 (CNA) provided assistance to complete personal hygiene.During random observations from 5/18/26 through 5/21/26 from 8:00 AM to 4:00 PM, Resident 9's beard was unkempt. Resident 9's beard was overgrown with gray and brown hairs. On 5/20/26 at 9:18 AM, Resident 26 stated staff did not offer to assist her/him during personal hygiene after she/he showered on 5/18/26. Resident 26 stated she/he asked staff on multiple occasions to assist with shaving and staff were not available. Resident 26 stated she/he had a right-hand tremor and shaving herself/himself was challenging. On 5/21/26 at 12:47 PM, Resident 26 stated staff did not offer to assist her/him with shaving after she/he showered. Resident 26 touched her/his chin hair and stated she/he wanted to shave. Resident 26 stated she/he did not feel good because staff did not have time to help shave her/him. On 5/21/26 at 1:26 PM, Staff 8 stated Resident 26 had occasional tremors to her/his hands. Staff 8 stated Resident 26 required staff to set up and help her/him shave. Staff 8 stated she did not offer to shave Resident 26 because she did not notice overgrown hair on her/his face.On 5/21/26 at 1:32 PM, Staff 9 stated Resident 26 had occasional tremors to her/his hand. Staff 9 stated Resident 26 required minimal assistance to complete personal hygiene including shaving. Staff 9 stated she did not have time to shave Resident 26 on 5/18/26 and she did not tell staff. On 5/22/26 at 1:43 PM, Staff 5 (RNCM) stated Resident 26 required supervision with cueing and assistance during shaving. Staff 5 stated she expected staff to offer to shave residents after showers. Staff 5 stated she was unaware staff were not completing personal hygiene after showers.

Based on observation, interview and record review it was determined the facility failed to ensure staff assisted residents with use of a prescribed boot to prevent a potential decrease in ROM or mobility for 1 of 1 sampled resident (#5) reviewed for ADLs. This placed residents at risk for loss of ROM and mobility. Findings include:Resident 5 was admitted to the facility in 2/2026 with diagnoses including a stroke.Resident 5's 2/15/26 admission MDS indicated the resident had severe cognitive impairment and a range of motion impairment on her/his lower extremity.Resident 5's revised 4/27/26 Care Plan revealed the resident required a contracture boot to be placed on her/his right foot for two hours on and two hours off.Random observations between 5/18/26 from 10:00 AM and 5/21/26 at 9:05 AM revealed Resident 5's contracture boot sat on the chair next to the resident's bed and revealed no instances of Resident 5 with the contracture boot on her/his foot.On 5/19/26 at 12:28 AM Witness 3 (Family Member) stated Resident 5 was supposed to have a support boot placed onto her/his right foot. Witness 3 stated staff failed to place the boot regularly and she was concerned the resident would develop a contracture.On 5/19/26 at 1:24 PM Staff 14 (CNA) stated Resident 5 was required to wear a splint on her/his right arm to prevent swelling and was unable to provide information related to the resident's contracture boot.On 5/20/26 at 9:45 AM Staff 15 (CNA) stated Resident 5 was unable to move her/his upper and lower extremities on her/his right side due to a severe stroke and was unable to speak to any interventions in place to prevent range of motion decline.On 5/20/26 at 11:46 AM Staff 13 (Rehab Director) stated Resident 5 admitted to the facility with a therapy evaluation which indicated the resident benefited from the boot to prevent the development of a contracture. Staff 13 stated it was important for Resident 5 to continue and wear the boot to prevent a right food drop or foot inversion.On 5/22/26 at 12:48 PM Staff 2 (DNS) stated it was important for Resident 5 to have her/his contracture boot placed and acknowledged staff did not regularly assist the resident to use the contracture boot.

Based on interview and record review it was determined the facility failed to follow physician orders for 2 of 6 sampled residents (#s 18 and 31) reviewed for dialysis and medications. This placed residents at risk for worsening medical conditions. Findings include:1. Resident 18 was admitted to the facility in 5/2026 with diagnoses including kidney failure and diabetes. A review of Resident 18's current physician orders indicated the following medication and treatment: -Aspirin daily for heart health. -Vitamin B12 for a daily supplement. -CBGs were to be taken in the morning and at bedtime. Resident 18's 5/2026 MAR revealed the resident did not receive Aspirin, Vitamin B12 or have her/his CBGs checked on the mornings of 5/9, 5/12, 5/14, 5/16, 5/19 and 5/20. On 5/21/26 at 10:23 AM Staff 6 (RN) stated Resident 18 had dialysis early in the morning on Tuesday, Thursday and Saturday. Staff 6 stated on the days the resident had dialysis she/he did not receive her/his morning medications and CBG checks due to being out of the facility. On 5/21/26 at 12:17 PM Staff 3 (RNCM) acknowledged Resident 18 did not receive medication and treatment as the physician ordered on mornings the resident was sent out to dialysis. 2. Resident 31 was readmitted to the facility on [DATE] with diagnoses including deafness and hydronephrosis with renal and ureter obstruction (a condition where one or more kidneys swell because urine cannot drain properly into the bladder). The 4/19/26 admission MDS indicated Resident 31 had a BIMS score of zero which indicated the resident was not cognitively intact. The MDS indicated Resident 31 had a history of vomiting. On 5/18/26 at 12:47 PM, Witness 2 (Family Member) stated Resident 31 had daily nausea and vomiting. Witness 2 stated Resident 31 was a poor historian and communication was difficult. Witness 2 stated nausea and vomiting symptoms were not managed consistently and Resident 31 was not able to keep food or drinks down. Witness 2 stated Resident 31 was uncomfortable every day. On 5/19/26 at 10:52 AM, Resident 31 was observed in her/his room vomiting. Resident 31 frowned and pointed to her/his belly and throat. Resident 31 screamed and curled back into fetal position. The 5/19/26 MAR indicated Staff 6 (RN) administered PRN ondansetron (anti-nausea medication) to Resident 31 for nausea symptoms at 4:52 PM (seven hours later). Staff reassessed effectiveness at 8:41 PM and Resident 31's nausea was not resolved and medication was ineffective. On 5/22/26 at 8:15 AM and 8:22 AM, Resident 31 was observed coughing and gagging after she/he finished eating breakfast. When Staff 10 approached the resident, Resident 31 pointed to her/his belly and grimaced indicating she/he was painful. Resident 31 pointed to her/his throat and opened her/his mouth. Staff 10 (CNA) approached the resident and she wheeled the resident back into her/his room. No information was found in the resident's clinical record to indicate Resident 31 was offered PRN medication for the resident's nausea when the resident returned to her/his room. On 5/22/26 at 10:12 AM, Resident 31 was observed in her/his room pointing to her/his belly, lower back and gestured indicating she/he was painful. The resident was observed coughing and gagging. Resident 31 grabbed a bucket and vomited. Resident 31 returned to bed and was dry heaving. The 5/22/26 MAR indicated Staff 11 (LPN) administered PRN ondansetron to Resident 31 for nausea and vomiting symptoms at 10:24 AM. On 5/22/26 at 10:32 AM, Staff 10 stated Resident 31 was deaf and communication was difficult. Staff 10 stated Resident 31 had nausea, vomiting and lower back pain since admission. Staff 10 stated she did not report to the nurse when Resident 31 pointed to her/his belly and throat after breakfast. On 5/22/26 at 11:20 AM, Staff 11 stated Resident 31 was deaf and communication was difficult. Staff 11 stated Resident 31 depended on staff to assess and address her/his daily needs. Staff 12 stated he was unaware Resident 31 had daily nausea and vomiting. Staff 12 stated he was unaware Resident 31 was nauseous after breakfast. Staff 11 stated Resident 31's nausea and vomiting PRN medication was not consistently administered. On 5/22/26 at 11:29 AM, Staff 6 stated Resident 31 had daily nausea and vomiting since admission. Staff 6 stated management of nausea and vomiting was not consistent. Staff 6 stated she was Resident 31's nurse during the morning of 5/19/26 and acknowledged she did not provide PRN nausea medication to Resident 31. On 5/22/26 at 12:27 PM, Staff 3 (RN Resident Care Manager) stated staff did not consistently offer PRN ondansetron to address Resident 31's nausea and vomiting.

Based on observation, interview and record review it was determined the facility failed to ensure medications and biologicals were secured for 1 of 4 medication and treatment carts reviewed for safe medication storage. This placed residents at risk for unauthorized access to medications. Findings include: The facility's 5/2010 Security of Medication Cart Policy specified the following: -The nurse must secure the medication cart during the medication pass to prevent unauthorized entry. -The medication cart must be securely locked at all times when out of the nurse's view. a. On 2/26/25 at 11:38 AM, the medication cart adjacent to the nursing station entered A-hall was unlocked and unattended. At 11:40 AM Staff 6 (RN) entered the A-hallway with a different medication and treatment cart. As Staff 6 passed by the unlocked and unattended cart she was observed to push in the lock on the cart to secure it and kept walking. Staff 6 went to a resident's room nearby and Staff 5 (RN) was observed to exit that same resident's room. During an interview with Staff 5 and Staff 6 on 2/26/25 at 11:42 AM Staff 5 stated he did leave the medication and treatment cart unlocked and it should have been locked when he was out of sight of the cart. Staff 6 confirmed she locked the cart as she walked by. b. On 2/26/25 at 12:29 PM, the medication cart adjacent to the nursing station on the A-hall was unlocked and unattended. At 12:31 PM Staff 5 approached the medication and treatment cart, and was observed to have pushed in the lock on the cart to secure it. On 2/26/25 at 12:32 PM Staff 5 acknowledged he left the medication and treatment cart unlocked and was out of sight. On 2/26/25 at 12:45 PM Staff 2 (DNS) was notified the medication and treatment cart on the A-hall was left unlocked and unattended with the contents accessible to unauthorized staff and residents on two separate occasions by the same staff member. Staff 2 acknowledged the cart was to be locked when unattended.

Based on interview and record review it was determined the facility failed to prevent misappropriation of financial resources by Staff 7 (Former Agency CNA) for 1 of 1 sampled resident (#145) reviewed for misappropriation of property. This placed residents at risk for misuse of personal funds. Findings include: The facility's 5/2010 Misappropriation of Property- Lost Items policy specified misappropriation of resident property as the patterned or deliberate exploitation of a resident's belongings or money without the resident's consent. Resident 145 was admitted to the facility in 10/2024 with diagnoses including right femur fracture (a break in the thigh bone). The 10/16/24 Admission MDS indicated Resident 145 was cognitively intact. Resident 145 discharged from the facility on 11/2/24. A 12/4/24 FRI indicated on 12/4/24 Witness 1 (Family) reported to Staff 1 (Administrator) a fraudulent check was written from Resident 145's check book while a resident at the facility. The check was made out to Staff 7 while she/he was a resident On 12/4/24 Staff 1 contacted local law enforcement, and a report was made. It was noted Staff 7 would not return to work at the facility. The 12/10/24 facility investigation indicated Staff 7 was assigned as Resident 145's CNA on 11/3/24, 11/7/24, 11/8/24, and 11/9/24. Staff 7 was asked not to return to the facility on [DATE] due to declining to take care of residents in her assigned section. On 11/9/24 the fraudulent check was cashed, and it was noted Resident 145's signature was forged. The Oregon Board of Nursing was notified of Staff 7's misconduct and law enforcement was also notified. The facility investigation concluded that abuse occurred but was limited to Resident 145. On 2/26/25 at 1:57 PM Witness 1 stated the fraudulent check was written to Staff 7 for $2,000. Witness 1 stated the signature on the check was not Resident 145's. On 2/26/25, 2/27/25 and 2/28/25 attempts to contact Staff 7 were unsuccessful. On 2/27/25 at 9:53 AM Resident 145 stated she/he first became aware of the fraudulent check when the monthly bank statement was received. Resident 145 stated her/his check book was kept in the nightstand drawer next to the bed at the facility. Resident 145 stated she/he never offered staff money, staff never asked her/him for money and there were no pre-signed checks in the check book. Resident 145 stated she/he did not sign the check made out to Staff 7 for $2,000. On 2/28/25 at 9:14 AM and 10:55 AM Staff 1 acknowledged Resident 145's misappropriation of funds and indicated there were no other reports of misappropriation of property.

Based on interview and record review it was determined the facility failed to thoroughly investigate alleged misappropriation of property for 1 of 1 sampled resident (#145) reviewed for abuse. This placed residents at risk for misuse of personal funds. Findings include: The facility's 5/2010 Misappropriation of Property- Lost Items policy specified when an incident of misappropriation of resident property was reported, the administrator would appoint a staff member to investigate the incident. The investigation would consist of the following: -An interview with the resident. -An interview with the employee(s) accused of taking the resident's property. -A review of the resident's personal inventory record to determine if missing items were recorded on the report. -Interviews with staff members (on all shifts as applicable) having contact with the resident. Resident 145 was admitted to the facility in 10/2024 with diagnoses including right femur fracture (a break in the thigh bone). The 10/16/24 Admission MDS indicated Resident 145 was cognitively intact. Resident 145 discharged from the facility on 11/2/24. A 12/4/24 FRI indicated on 12/4/24 Witness 1 (Family) reported to Staff 1 (Administrator) a fraudulent check was written from Resident 145's check book while she/he resided at the facility. The check was made out to Staff 7 (Former Agency CNA). On 12/4/24 Staff 1 contacted local law enforcement, and a report was made. It was noted Staff 7 would not return to work at the facility. The 12/10/24 facility investigation indicated Staff 7 was assigned as Resident 145's CNA on 11/3/24, 11/7/24, 11/8/24, and 11/9/24. Staff 7 was asked not to return to the facility on [DATE] due to declining to take care of residents in her assigned section. On 11/9/24 the fraudulent check was cashed, and it was noted Resident 145's signature was forged. The Oregon Board of Nursing was notified of Staff 7's misconduct, law enforcement was also notified. The facility investigation concluded that abuse occurred but was limited to Resident 145. The facility's investigation included an interview with Staff 8 (CNA) and Staff 9 (CNA) who worked with Staff 7 on several shifts and two residents who resided on the same hallway as Resident 145. Review of the facility's 12/10/24 investigation revealed it was not thorough and did not address the following: -An interview with the resident. -An interview with the employee(s) accused of taking the resident's property. -A review of the resident's personal inventory record to determine if missing items were recorded on the report. -Interviews with staff members (on all shifts as applicable) having contact with the resident. On 2/28/25 at 9:14 AM and 10:55 AM Staff 1 acknowledged Resident 145 and Staff 7 were not interviewed as part of the investigation. Staff 1 stated Resident 145's personal inventory record could not be found and staff members who had contact with Resident 145 were not interviewed. Staff 1 verified the facility investigation was not thorough.

Based on interview and record review it was determined the facility failed to ensure residents received care plan interventions for safe transfer and failed to ensure residents were monitored after a fall for 1 of 3 sampled residents (#1) reviewed for accidents. This placed residents at risk for latent injury. Findings include: Resident 1 was admitted to the facility in 11/2023 with diagnoses including BPH (benign prostatic hyperplasia) and depression. A review of the resident's care plan, dated 11/28/23, indicated Resident 1 required a two-person mechanical lift with transfers, wore non skid socks when out of bed, and the call light was to be within reach. a. A Fall/Post Fall Assessment and Investigation dated 12/3/24 revealed the following: -At 9:45 AM, Resident 1 was found on the floor next to the left side of her/his bed by Staff 12 (LPN). -The resident was previously sitting in her/his wheelchair and Staff 12 heard Resident 1 calling for help. -Resident 1 stated she/he became dizzy and fell forward out of the wheelchair. -The resident was toileted at 7:00 AM and was last observed at 8:30 AM while eating breakfast. The resident received her/his medications, and was offered fluids. -Staff 12 assessed the resident, who denied pain and her/his range of motion was within normal limits. The resident was injured with a bruise to the left side of her/his forehead. A neurological (assessing mental status and level of consciousness, pupillary response, motor strength, sensation, and gait) assessment was completed. The resident was assisted back into bed. No abuse or neglect was identified. -The investigation indicated Resident 1 was her/his own responsible party and was marked as no requirement to notify others. The Resident Representative section was blank. No information was found in Resident 1's clinical record to indicate she/he was monitored for latent injuries after the 12/3/23 fall. On 6/5/24 at 12:48 PM Witness 15 (Family Member) stated Resident 1 fell at the facility on the morning of 12/3/23. Witness 15 stated the facility did not monitor the resident appropriately prior to and after the resident fell out of her/his wheelchair. On 6/6/24 at 11:22 AM Staff 12 stated she recalled when Resident 1 fell out of her/his wheelchair due to dizziness on 12/3/24. Staff 12 stated the resident sustained a bruise to her/his left forehead. Staff 12 stated she did not contact Witness 15 but notified the physician. Staff 12 stated Resident 1 was to be placed on alert charting to monitor for latent injury, but she did not recall if this occurred or not. On 6/6/24 at 12:47 PM Staff 4 (RNCM) stated she expected staff to place Resident 1 on 72-hour alert charting to monitor for latent injury. Staff 4 acknowledged and verified Resident 1 was not placed on alert charting from her/his fall on 12/3/24. On 6/7/24 at 10:52 AM Staff 2 (Administrator) acknowledged Resident 1 was not placed on alert charting after the fall on 12/3/24 to monitor for latent injuries b. On 6/5/24 at 12:48 PM, Witness 15 (Family Member) stated an incident occurred during an evening visit with Resident 1 on an unknown date. Witness 15 stated he observed two CNAs using a mechanical lift to transfer Resident 1. The CNA operating the lift was in a hurry, which caused the mechanical lift to strike Resident 1's head as the two CNAs lowered the resident into the wheelchair. Witness 15 stated the CNA guiding Resident 1's legs yelled at the other CNA to slow down, but the CNA operating the mechanical lift did not listen, which resulted in Resident 1's head being struck. Witness 15 stated after the CNAs placed Resident 1 in the wheelchair, both CNAs left the room without assessing the resident for potential injuries. Witness 15 stated Resident 1 was not a complainer, and did not call out in pain, but staff should have reported the incident to a nurse so the resident could be evaluated. On 6/5/24 at 4:33 PM Staff 10 (Agency CNA) stated she recalled transferring Resident 1 with another CNA using a mechanical lift. The CNA operating the lift was not paying attention and moving quickly. Staff 10 stated she was guiding Resident 1's feet and hollered at the other CNA to slow down, but the CNA operating the lift did not listen, and the lift struck Resident 1 in the head. Staff 10 stated she asked Resident 1 if she/he was hurt, and the resident said she/he was not hurt. Staff 10 stated she did not report the incident to a nurse and acknowledged the incident should have been reported to rule out an injury. On 6/6/24 at 12:47 PM Staff 4 (RNCM) stated she was unaware Resident 1 was struck in the head while being transferred with a mechanical lift. Staff 4 stated she expected staff to report any incident involving a potential injury to the charge nurse right away to ensure an assessment was completed. On 6/7/24 at 10:52 AM Staff 2 (Administrator) acknowledged the findings and stated CNAs were to report any potential injury with a mechanical lift to a charge nurse so the resident could be assessed appropriately.

Based on interview and record review the facility failed to notify a resident's representative of a fall for 1 of 3 sampled residents (#1) reviewed for falls. This placed resident representatives at risk for being uninformed of resident accidents. Findings include: Resident 1 was admitted to the facility in 11/2023 with diagnoses including BPH (benign prostatic hyperplasia) and depression. Resident 1's Admission Record revealed Witness 15 (Family Member) was Resident 1's resident representative and emergency contact. No information was found in the clinical record to indicate Witness 15 signed paperwork as Resident 1's resident representative. On 6/5/24 at 12:48 PM Witness 15 stated Resident 1 fell at the facility on the morning of 12/3/23, and no one from the facility contacted Witness 15 regarding the incident. On 6/6/24 at 11:22 AM Staff 12 (LPN) stated she did not contact the family after Resident 1's fall because the resident was her/his own representative. On 6/6/24 at 12:47 PM Staff 4 (RNCM) stated Witness 15 should have been notified of the fall if Witness 15 was Resident 1's resident representative. On 6/7/24 at 10:15 AM Staff 3 (Admissions Director) stated she reviewed all admission paperwork with residents and family members. Staff 3 stated Witness 15 was Resident 1's resident representative. Staff 3 stated Resident 1 appointed Witness 15 to be her/his resident representative. Staff 3 stated she was present and there was a verbal agreement, but no paperwork signed during the admission process. Staff 3 stated she ensured the information was entered into the resident's medical record. On 6/7/24 at 10:52 AM Staff 2 (Administrator) acknowledged Witness 15 was Resident 1's representative and should have been notified regarding Resident 1's fall on 12/3/23. Refer to F689

Based on interview and record review it was determined the facility failed to provide appropriate catheter care for a resident's urinary catheter for 1 of 3 sampled residents (#1) reviewed for catheter care. This placed residents at increased risk for infection. Findings include: Resident 1 was admitted to the facility in 11/2023 with diagnoses including BPH (benign prostatic hyperplasia) and hematuria (blood in the urine). A Nursing Admission Assessment, dated 11/28/23 at 9:19 AM, revealed Resident 1 admitted due to urosepsis (a urinary tract infection which spreads to the kidneys) with hematuria. The resident had a urinary catheter with a large amount of hematuria present. The resident was at risk for functional incontinence related to weakness, impaired mobility, and dependence on staff to meet mobility and toileting needs. Resident 1 was care planned for staff assistance with toileting, used a large brief, received daily urinary catheter care, and skilled therapy services to promote toileting safety and mobility. A review of the resident's care plan, dated 11/28/23, indicated the presence of a urinary catheter. The care plan indicated staff were to provide catheter care with soap and water every day and were to monitor for signs and symptoms of infection. A 12/2/23 Skilled Nursing Progress Note revealed Resident 1 was alert but disoriented, was able to follow simple instructions and cooperative with care and services. The urinary catheter was in place with adequate output. Hematuria was noted around the genital area. A 12/5/23 Progress Note revealed at the beginning of evening shift Resident 1 had a temperature of 99.3. The resident's temperature was taken again at 6:00 PM and was 102.2. Tylenol was given, and the physician was called. Due to the resident's current symptoms and history, it was decided the resident would be sent out to the hospital for further evaluation. Resident 1 had a urinary analysis collected and the results were a high white blood cell count. A Lab Results Report dated 12/5/23 revealed Resident 1's white blood cell count was elevated. On 12/7/23 a public complaint was received from Witness 16 (Complainant), alleging Resident 1 arrived at the hospital on 12/5/23 with a catheter and UTI. When the catheter was removed, it was leaking and caused pain, accompanied by dark cloudy urine. Additionally, there were also sores on the resident's genitalia. On 6/5/24 and 6/6/24 attempts were made to reach Witness 16 but were unsuccessful. On 6/5/24 at 12:48 PM Witness 15 (Family Member) stated the facility did not provide adequate catheter care for Resident 1. Witness 15 stated the resident was sent to the hospital on 12/5/23, and hospital staff observed and reported to Witness 15 that Resident 1 had blood and discharge coming from the genitalia. Witness 15 stated hospital staff reported Resident 1 had erosion at the catheter entry point which indicated possible improper positioning of the catheter. Witness 15 stated the situation was gruesome and upsetting. On 6/5/24 at 2:32 PM Staff 9 (CNA) stated Resident 1 required daily catheter care to maintain cleanliness and prevent infection. Staff 9 expressed concerns that residents did not receive appropriate catheter care in 11/2023 and 12/2023. Staff 9 stated agency staff did not consistently provide appropriate ADL care. On 6/5/24 at 4:33 PM Staff 10 (Agency CNA) stated Resident 1 had a catheter, and she emptied the catheter bag at the end of her shift but did not provide any other care related to the catheter, such as cleaning the catheter or providing peri care. On 6/6/24 at 10:26 AM Staff 11 (CNA) stated Resident 1 was alert and oriented but had some baseline confusion. Staff 11 stated she provided catheter care and the resident's catheter, was uncomfortable and caused tugging. Staff 11 recalled the resident had redness and blood coming out of the tip of the resident's genitalia a few times and she informed the nurse. Staff 11 stated a skin protective barrier was applied to the tender, red area. Staff 11 stated catheter care was to be performed once daily using soap and water. On 6/6/24 at 10:46 AM Staff 7 (LPN) stated Resident 1 required catheter care provided by CNA staff. Staff 7 stated catheter care was not always provided adequately and depended on which CNAs were working. Staff 7 expressed concerns about a lack of appropriate catheter care in 11/2023 and 12/2023 due to staff unfamiliarity with the residents. On 6/6/24 at 11:48 AM Staff 8 (LPN) stated Resident 1 was confused at baseline and admitted with a catheter and hematuria. Staff 8 stated catheter care was provided during day shift. Staff 8 stated she assumed CNAs provided catheter care and expected CNAs to review Resident 1's care plan prior to starting their shift. Staff 8 recalled Resident 1 had dried blood on the tip of her/his genitalia, and the area was red but did not appear painful. Staff 8 stated she did not remove the stat lock (stabilization device and support) to the catheter but provided the resident with a little more slack in the tubing that inserted into her/his genitalia. Staff 8 stated the resident was not alert enough to respond to questions. On 6/6/24 at 12:47 PM Staff 4 (RNCM) acknowledged Resident 1 was not provided with appropriate catheter care. Staff 4 stated staff were expected to provide appropriate catheter care to residents and to report any new concerns to herself or the physician. On 6/7/24 at 10:27 AM Staff 5 (Regional Nurse Consultant) and at 10:52 AM Staff 2 (Administrator) stated all CNA staff were expected to know and provide daily catheter care once daily with soap and water. Staff 5 stated if staff were unable to provide catheter care, they were to report to the charge nurse to ensure residents' received appropriate catheter care. Staff 2 acknowledged Resident 1 was not provided with appropriate catheter care.

Based on interview and record review it was determined the facility failed to inform residents, resident representatives and families by five PM the next calendar day following the occurrence of a suspected or confirmed COVID-19 infection. This placed residents, resident representatives and families at risk for not being informed of the facility's COVID-19 outbreak status. Findings include: Review of COVID-19 Line Listing tracking records from 11/2022 revealed two staff members were found to be COVID-19 positive on 11/17/22. Review of COVID-19 Updates notification records from 11/2022 revealed the first notification of two positive COVID-19 staff members was not sent out until 11/19/22. On 2/1/23 at 12:37 PM Staff 1 (Administrator) confirmed a delay occurrred in notifications provided to residents, resident representatives and families of potential exposure to COVID-19.

Based on interview and record review it was determined the facility failed to ensure an RN worked as the charge nurse for eight hours a day, seven days a week. This placed residents at risk for unmet assessment needs. Findings include: Direct Care Staff Daily Reports on 6/21/22 and from 7/1/22 through 8/8/22 were reviewed. A RN did not provide direct resident care for seven out of the 40 days reviewed: 6/21/22, 7/4/22, 7/19/22, 7/20/22, 7/21/22, 7/26/22 and 8/7/22. On 8/11/22 at 1:37 PM Staff 10 (Staffing Coordinator) stated he was aware there were multiple days when there was no RN coverage and policy changes to cover those shifts were in process. On 8/12/22 at 11:04 AM Staff 1 (Administrator) acknowledged the requirement to have a RN each day.

Based on interview and record review it was determined the facility failed to develop and implement policies and procedures regarding residents' rights to formulate an advance directive for 4 of 5 residents (#s 5, 8, 13, and 22) reviewed for advance directives. This placed residents at risk for not having their health care preferences honored. Findings include: Records reviewed for Residents 5, 8, 13, and 22 revealed no documentation of an advance directive or documentation to indicate the residents were informed of or provided written information concerning their right to formulate an advance directive. On 8/10/22 at 10:53 AM Staff 3 (Admissions Director) stated the facility did not have a process for discussing advance directives with residents upon admission to the facility. Staff 3 was unable to provide documentation to verify residents were notified of their right to formulate an advance directive. On 8/10/22 at 11:03 AM Staff 4 (Social Services) stated she would ask about a POLST (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff 4 stated she asked new admissions if they had an advance directive and if they had any questions to let her know. No documentation was found in Resident 5, 8, 13, or 22's medical records or social services notes to verify the facility offered, assisted, obtained or periodically reviewed advance directives. On 8/10/22 at 12:27 PM Staff 1 (Administrator) stated it was her expectation for staff to go over advance directives upon admission and she would provide education to Staff 3 and Staff 4.

Based on observation and interview it was determined the facility failed ensure facial hair was restrained by staff preparing food in 1 of 1 kitchen surveyed. This placed residents at risk for contaminated foods. Findings include: On 8/8/22 at 1:09 PM Staff 16 (Dietary Manager) and Staff 15 (Cook) were observed working directly with food preparing lunches for resdents. Both staff members had beards and were not wearing beard restraints. Staff 16 confirmed he and Staff 15 should have been wearing beard restraints while working in the kitchen. On 8/11/22 at 9:58 AM Staff 15 was observed emptying cans of beans into holding trays and did not wear a beard restraint. On 8/11/22 at 10:04 AM Staff 16 (Dietary Manager) reported beard restraints were available to all dietary employees and confirmed Staff 15 should wear a beard restraint while working in the kitchen.

Based on observation and interview it was determined the facility failed to maintain a clean and homelike environment on 2 of 2 halls due to soiled, stained flooring and damaged wall surfaces reviewed for environment. This placed residents at risk of an unkempt and non-homelike environment. Findings include: Resident 5 was admitted to the facility in 2020 with a diagnosis including dementia. Resident 5 resided in Room 125-B. On 8/8/22 at 2:51 PM Witness 2 (Family) stated the floor in the resident's room was dirty. Observations of 125-B's floor on 8/8/22 through 8/10/22 revealed crumb debris scattered on the floor and under the bed along with a sock, a tube of lotion, a wadded napkin and a broken handle from a coffee cup. The wall behind Resident 5's bed had exposed, crumbling plaster. Observation on 8/11/22 at 9:47 AM revealed Resident 5's floor was swept of the crumb debris but the sock, tube of lotion, wadded napkin remained on the floor. Observations of resident rooms on 8/8/22 through 8/12/22 identified the following: Hall A room 105, 109, 110, 112 and 113 had stained and soiled carpet. Hall B room 122, 126, 127, 128, 129 and 133 had stained and soiled carpet. On 8/11/22 at 1:36 PM Staff 13 (Maintenance Assistant) stated he was aware of the exposed plaster in Room 125-B. Staff 13 stated he could not complete the wall repair while Resident 5 was in the room due to the fumes. On 8/12/22 at 10:11 AM Staff 17 (Housekeeping Supervisor) stated housekeeping staff provide daily cleaning of resident's floors, including vacuuming and sweeping. Staff 17 stated all staff, including CNAs and nurses should pick up items off resident's floors. On 8/12/22 at 12:39 PM Staff 1 (Administrator) stated housekeepers provided daily floor care to all residents' rooms and all staff should help keep resident rooms tidy including picking up items off resident's floors. Staff 1 acknowledged the stained and soiled carpet.

Based on interview and record review it was determined the facility failed to provide sufficient staffing to timely address care needs for 1 of 1 sampled residents (#8) reviewed for dental services. This placed residents at risk for unmet needs. Resident 8 was admitted to the facility in 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/21/22 Quarterly MDS indicated Resident 8 was totally dependent on staff for locomotion in her/his room and required two person assistance for transfers. The 7/2022 updated care plan revealed to observe Resident 8 for signs of fatigue when sitting in the chair. On 8/10/22 at 10:58 AM Resident 8 stated on 6/21/22 she/he returned to the facility after an appointment during the day and a long time in her/his wheelchair. Resident 8 requested assistance to be transferred from her/his wheelchair to the bed and remained in her/his wheelchair for a total of three hours. Resident 8 stated staff informed her/him they were short-handed when she/he returned from the appointment and became more uncomfortable during the wait for care. On 8/10/22 at 11:13 AM Staff 9 (CNA) recalled the event on 6/21/22 and stated Resident 8 did not like to remain in her/his wheelchair for more than 30 minutes due to pain. Staff 9 stated she was aware Resident 8 was left in her/his chair and Staff 9 worked overtime to eventually assist the CNA assigned to Resident 8's care. Staff 9 commented that residents who required two person transfers may remain for extended periods of time without timely transfers due to lack of staff or time management. On 8/12/22 at 11:04 AM Staff 1 (Administrator) stated she expected Resident 8 should be transferred into her/his bed when she/he requested. Staff 1 also stated the CNA assigned to Resident 8's care should have sought assistance to timely transfer Resident 8 even if the CNA needed to ask the RN for the day. The Direct Care Staff Daily Report and Daily Staffing Assignment by Zone for 6/21/22 were reviewed with Staff 1 which indicated there was no RN coverage for the day and one CNA worked the designated COVID-19 unit and unavailable to assist in other units. No additional comments were provided.

Based on interview and record review it was determined the facility failed to ensure bowel care was appropriately provided to 1 of 5 sampled residents (#17) reviewed for medications. This placed residents at risk for bowel complications. Findings include: Resident 17 was admitted to the facility in 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 6/26/22 Annual MDS revealed the resident had a BIMS of three (severe cognitive impairment) and was incontinent of bowel with no constipation present. The resident's 5/18/21 Care Plan lacked information regarding her/his multiple three to five day periods without having a documented BM (bowel movement). Resident 17's medical record revealed the following PRN bowel care protocol: -[MEDICATION(S)] Powder (osmotic type [MEDICATION(S)], holds water in the stool) daily every morning, or PRN bowel care for no BM (bowel movement) in 48 hours. -Senna (stimulant [MEDICATION(S)], increases intestinal activity) daily at HS, or PRN bowel care for no BM in 48 hours. -Dulcolax Suppository (stimulant [MEDICATION(S)]) PRN bowel care if no BM when the [MEDICATION(S)] or Senna are not effective within 24 hours. -[MEDICATION(S)] Sodium (combination of stool softener and [MEDICATION(S)]) every 24 hours PRN for bowel care. -Tap water enema (used to stimulate a BM), if Dulcolax suppository does not yield at least medium stool results within eight hours, may repeat one time PRN for bowel care. Resident 17's 5/2022 through 8/2022 MAR/TARs and medical record revealed the following information: *May 2022: 5/11/22 at 10:25 PM through 5/14/22 at 9:34 PM: three days (nine shifts) without a documented BM. 5/30/22 at 4:46 AM through 6/3/22 at 1:09 PM: four days (14 shifts) without a documented BM. Bowel care medications provided: -[MEDICATION(S)] Sodium: 5/11/22 at 11:07 AM, results noted as I (Ineffective). 5/22/22 at 11:55 AM, results note as U (Unknown). -Senna: 5/15/22 at 12:02 PM, results noted as I. 5/16/22 at 9:58 AM, results noted as E (Effective). 5/19/22 at 12:37 PM, results noted as E. *June 2022: 6/3/22 at 8:58 PM through 6/7/22 at 9:27 PM: four days (13 shifts) without a documented BM. 6/8/22 at 9:18 PM through 6/12/22 at 11:15 PM: four days (13 shifts) without a documented BM. 6/18/22 at 1:54 PM through 6/22/22 at 8:30 PM: four days (12 shifts) without a documented BM. 6/23/22 at 8:58 AM through 6/27/22 at 5:30 AM: four days (13 shifts) without a documented BM. Bowel care medications provided: -[MEDICATION(S)] Sodium: 6/1/22 at 2:52 PM, results noted as I. 6/2/22 at 8:12 PM, results noted as I. 6/7/22 at 1:38 PM, results noted as I. 6/21/22 at 1:25 PM, results noted as I. 6/25/22 at 9:28 PM, results noted as refused. 6/26/22 at 9:28 AM, results noted as I. -Senna: 6/2/22 at 12:15 PM, results noted as I. 6/6/22 at 8:50 AM, results noted as I. 6/11/22 at 8:26 AM, results noted as I. 6/12/22 at 8:18 AM, results noted as I. 6/21/22 at 9:56 PM, results noted as I. 6/22/22 at 8:43 AM, results noted as I. 6/25/22 at 8:28 AM, results noted as I. -Dulcolax Suppository: 6/12/22 at 7:22 PM, results noted as U. 6/22/22 at 7:04 PM, results noted as E. *July 2022: 7/2/22 at 9:42 PM through 7/7/22 at 1:31 PM: five days (15 shifts) without a documented BM. Bowel care medications provided: -Senna: 7/5/22 at 1:22 PM, results noted as I. 7/6/22 at 12:21 PM, results noted as I. 7/7/22 at 1:10 PM, results noted as I. 7/19/22 at 9:31 AM, results noted as I. 7/20/22 at 8:49 AM, results noted as I. -Dulcolax Suppository: 7/6/22 at 12:27 PM, noted as resident refused. 7/7/22 at 1:10 PM, noted as resident refused. 7/8/22 at 6:56 PM, results noted as U. 7/20/22 at 3:57 AM, results noted as E. 7/25/22 at 12:10 PM, results noted as E. -[MEDICATION(S)] Powder: 17 gm; PRN: 7/7/22 at 1:10 PM, results noted as I. *August: 8/7/22 at 8:21 PM through 8/11/22 4:38 PM: four days (12 shifts) without a documented BM. Bowel care medications provided: -Senna: 8/6/22 at 8:27 AM, results were documented as E. 8/11/22 at 12:50 PM, results were documented E. -[MEDICATION(S)]: 8/11/22 at 12:50 PM, results were documented as E. From 5/11/22 through 8/11/22 Resident 17 experienced multiple periods of three to five days without having a documented BM. The resident's PRN bowel care medications were not administered according to the physician's protocol and there was a lack of follow up provided when the medications were documented as ineffective or the results were unknown. On 8/12/22 at 9:54 AM Staff 22 (Licensed Nurse) stated when residents have a BM it was documented in the Task system and when a resident did not have a BM it was reported to the charge nurse. On 8/12/22 at 9:57 AM Staff 8 (LPN) acknowledged Resident 17 was not having regular BMs and required PRN bowel care. Staff 8 stated their system triggered an alert if a resident went 48 hours without a BM, so [MEDICATION(S)] was offered and a bowel care list was generated. The bowel care list was provided to the day shift charge nurses to follow up. In an interview on 8/12/22 at 10:10 AM Staff 7 (LPN) stated Resident 17 was on the bowel list frequently. Staff 7 indicated the senna usually worked for her/him and she/he sometimes refused the PRN bowel medications. Staff 7 stated they also tried prune juice or apple juice along with the [MEDICATION(S)] or senna. On 8/12/22 at 1:24 PM Staff 2 (DNS) and this surveyor reviewed Resident 17's bowel care and staff failure to follow her/his physician-order protocol. Staff 2 confirmed the resident's BMs were tracked in their system and alerted staff when PRN interventions were required. Staff 2 voiced understanding regarding Resident 17's frequent periods without BMs and the need to ensure the bowel care protocol was administered and monitored appropriately.

Based on observation, interview, and record review it was determined the facility failed to ensure staff followed the care plan related to fall safety for 2 of 3 sampled residents (#s 4 and 11) reviewed for falls. Resident 4 was left unattended in the bathroom, fell off the toilet and sustained significant cranial trauma. Findings include: 1. Resident 4 admitted to the facility in 2020 with diagnoses including a neck fracture and repeated falls. A comprehensive care plan dated 9/15/20 indicated Resident 4 required one-person constant supervision and physical assistance during toileting. A Post Fall Assessment initiated on 9/21/20 at 11:45 AM revealed the following: -Resident 4 had an unwitnessed fall in her/his bathroom. The resident was found lying face down on the floor, legs twisted under her/him, a hematoma (a pooling of blood under the skin) was noted to the upper left portion of the head and Resident 4 was noted to be bleeding from her/his head. Resident 4 was assisted to a seated position at which time it was noted her/his pulse was barely palpable, she/he had a rapid respiratory rate, could not support her/his own weight in a seated position and was unable to verbally respond to questions from the nurse. Resident 4 was evaluated by the house doctor and immediately sent to the hospital for evaluation. -In the Prevention Plan Details it was documented that the resident was being treated in the hospital for brain hemorrhage (bleeding inside the brain) and it was unlikely the resident would return to this facility. On 9/8/21 and 9/9/21 attempts were made to contact Staff 24 (Former CNA), and Staff 30 (Former CNA) who were responsible for transferring and attending Resident 4 while she/he was on the toilet. Neither staff responded to repeated attempts for an interview. On 9/6/21 through 9/13/21, between 10:00AM and 4:00 PM Staff 27 (LPN), Staff 28 (LPN), Staff 23 (CNA), Staff 26 (clinical support RN), Staff 25 (RN), Staff 10 (CNA), and Staff 31 (CNA), confirmed continuous monitoring was a common care plan intervention and meant you did not leave a resident alone for any reason. The staff stated if something else happened while a resident was being monitored, staff could call for assistance and someone else could respond to the new situation that needed to be addressed. On 9/13/21 at 2:07 PM Staff 14 (RNCM) stated he was in the room when the resident was found and participated in the assessment and the investigation. Staff 14 confirmed the information in the investigation was correct. Staff 14 further stated he was aware resident 4 was treated for some type of hemorrhage in her/his head in the hospital due to the fall. Staff 14 confirmed the care plan was not followed and Resident 4 should not have been left alone for any reason while on the toilet. 2. Resident 11 was admitted to the facility in 2019 with diagnoses including spinal fractures. The 8/9/21 CAAs indicated Resident 11 had impaired cognition and had difficulty if presented with too many options. The resident had decreased safety awareness, poor judgement and was unable to follow precautions. The resident required one person for transfers and was at risk for falls. An 8/20/21 Fall/Post Fall assessment indicated Resident 11 was found on the floor in the fetal position under her/his television on her/his right side. The resident had a baseball size blood stain on the carpet near the resident's head. The resident was not able to state how she/he fell and became aggressive when staff tried to assist the resident. The resident had a scalp laceration and reported neck pain. Contributing factors to the fall included the resident self transferred. The plan to prevent falls included the resident was to be seated in an area of high visibility for supervision and staff were to ensure the resident wore nonskid footwear. The Care Plan was updated on 8/24/21 and indicated the resident was to sit in a highly visible area for supervision. On 9/2/21 at 11:00 AM Resident 11 was observed to be in a wheelchair in her/his room. The resident was not visible from the doorway. A bedside table was in front of the resident with a breakfast tray. The resident wore shoes and the call light was within reach. On 9/2/21 at 11:00 AM Staff 22 (LPN) stated when a resident was to be in a high visibility area the resident should be in the dining area or in an area in the room in which staff can visualize the resident when they walk by the room. On 9/2/21 at 11:00 AM Staff 4 (CNA) reviewed the care plan and she indicated the resident was to be in a high visibility area when seated. Staff 4 verified the resident was not visible from the door way and repositioned the resident to where the resident's legs were visible from the doorway. On 9/2/21 at 1:02 PM Staff 2 (RNCM) acknowledged the care plan directed staff to assist the resident to an area with high visibility when the resident sat in a chair.

Based on observation, interview, and record review it was determined the facility failed to ensure residents who chose to self-administer medications were assessed for 2 of 3 sampled residents (#s 1 and 9) reviewed for medication administration. This placed residents at risk for lack of dignity and safe medication administration. Findings include: 1. Resident 1 was admitted to the facility in 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The 7/27/21 Care Area Assessments indicated Resident 1 was alert, oriented and able to make needs known. A 7/31/21 Progress Note indicated Resident 1 and her/his family was upset because the resident reported Staff 11(LPN) performed a genital test on her/him. The note indicated the resident did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/2/21 Investigation indicated Resident 1 reported Staff 11 (LPN) administered her/his genital medication and she/he was tearful when describing the events. On 9/3/21 at 12:44 PM Staff 11 indicated a CNA accompanied him when he administered Resident 1 her/his genital medication. The resident was informed prior to the administration and the resident did not request to self-administer the medication. On 9/3/21 at 12:40 PM Staff 7 (RN) indicated she administered Resident 1 her/his genital medication on one occasion. The resident indicated she/he was able to administer the medication. The resident did not have an order to self-administer, therefore, Staff 7 observed the resident administer the medication and Staff 7 did not have concerns with the resident's ability to administer the medication. On 9/1/21 at 1:01 PM Resident 1, with Witness 5 (Complainant) present, stated she/he administered the genital mediation without issues for multiple years. Witness 5 stated on 7/31/21 Resident 1 was very upset when Staff 11 administered the genital medication. The next day Staff 13 (Agency LPN) entered the room to administer the same medication. The resident was able to stop Staff 13 from administering the medication. On 9/8/21 at 9:08 AM Staff 14 (RNCM) indicated Resident 1 was admitted to the facility on multiple occasions and he was familiar with her/him. In previous admissions the resident requested to self-administer the genital medication and was assessed to do so. Staff 14 acknowledged the resident reported an incident when Staff 11 administered her/his medication and it upset the resident. Staff 14 indicated he should have assessed the resident to allow her/him to administer the medication to ensure the resident did not feel compromised. 2. Resident 9 was admitted to the facility in 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The resident's 8/11/21 MDS indicated the resident was cognitively intact. The 8/2020 and 9/2020 MARs revealed the resident was to be administered saline nasal spray PRN. There was no documentation to indicate the resident or staff administered the spray. On 9/2/21 at 11:00 AM Resident 9 was observed to have a bottle of saline nasal spray on her/his bedside table. Resident 9 indicated she/he used it every night. On 9/2/21 Staff 7 (RN) indicated if a resident was to self-administer medications the RNCM was to assess the resident to ensure the resident had the ability to administer the medications safely and the medications were stored in the resident's room in a safe manner. Staff 7 indicated the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/2/21 at 12:55 PM Staff 14 (RNCM) indicated if a resident requested to self administer medications the resident was assessed. Resident 14 was not aware the resident had the spray at her/his bedside.