Every finding on record at Mennonite Home

Based on observation, interview, and record review it was determined the facility failed to ensure appropriate medication storage temperatures were logged and maintained for 2 of 2 medication rooms reviewed for medication storage. This placed residents at risk for reduced efficacy of medication. Findings include:1. On 3/25/26 at 8:24 AM the third floor medication refrigerator temperature logs were observed to be blank on the following dates: 3/1/26; 3/4/26; 3/7/26; 3/8/26; 3/13/26; 3/14/26; 3/15/26; 3/16/26; 3/17/26; 3/18/26; 3/19/26; 3/21/26; 3/22/26; 3/23/26 and 3/24/26. The medication refrigerator contained insulin and other medications. On 3/25/26 at 8:24 AM Staff 3 (LPN) acknowledged the temperature logs were blank on the identified dates and acknowledged the refrigerator contained insulin and other medications. On 3/25/26 at 9:04 AM Staff 2 (DNS) acknowledged the identified dates with blank temperature logs and provided no additional information.2. On 3/25/26 at 8:55 AM the second floor medication refrigerator temperature logs were observed to be blank on the following dates: 3/11/26; 3/12/26; 3/13/26; 3/18/26 and 3/19/26. The medication refrigerator contained insulin and flu vaccines.On 3/25/25 at 8:55 AM Staff 4 (LPN) acknowledged the temperature logs were blank on the identified dates and acknowledged the refrigerator contained insulin and flu vaccines.On 3/25/26 at 9:04 AM Staff 2 (DNS) acknowledged the identified dates with blank temperature logs and provided no additional information.

Based on observation, interview, and record review it was determined the facility failed to ensure residents the right to a dignified dining experience for 1 of 1 sampled resident (#32) reviewed for dignity. This placed residents at risk for lack of dignity. Findings include:Resident 32 was admitted to the facility in 1/2026 with diagnoses including hospice care and Alzheimer's disease. The 1/28/26 Care Plan revealed Resident 32 needed limited to one-on-one assistance with all food and fluids, to assist as needed with meals, and required two-person assistance with mobility. The 2/3/26 admission MDS revealed Resident 32 was severely cognitively impaired and required substantial to maximum assistance with eating.On 3/23/26 at 12:00 PM Resident 32 was observed in a wheelchair in the dining room while staff served meals to other residents. At 12:31 PM Resident 32 received her/his meal and a CNA assisted with one bite. The CNA then walked away from the resident and did not return until 12:46 PM, 15 minutes later. During that time Resident 32 did not independently feed herself/himself and no other staff approached her/him to help with eating. On 3/25/26 at 8:08 AM Resident 32 was observed in a wheelchair in the dining room at a table alone. There were three other residents in the dining room sitting together and staff served their breakfasts. At 8:52 AM, 44 minutes later, Resident 32 was served breakfast and a CNA assisted her/him with eating. On 3/25/26 at 12:19 PM Resident 32 was observed in the dining room with a full beverage in front of her/him, but the resident did not independently pick up the cup to take sips. Resident 32 was observed continuously until 1:17 PM, 58 minutes later, and was not approached by any staff to assist her/him with the beverage or offer a meal. On 3/25/26 at 2:46 PM Staff 5 (CNA) reported dependent residents waited until all other residents were served their meals before staff were available to assist them with eating. On 3/26/26 at 9:07 AM Staff 6 (CNA) stated Resident 32 required full assistance from staff for eating and drinking. On 3/26/26 at 10:17 AM Staff 7 (RNCM) stated residents who were able to independently eat were served first, and residents dependent for eating had to wait to be served until a CNA was free to assist them. On 3/26/26 at 10:51 AM Staff 2 (DNS) acknowledged dependent residents having extended wait times in the dining room while other residents ate did not meet facility standards.

Based on interview and record review it was determined the facility failed to inform residents and the resident's responsible party of the risks and benefits, and to ensure consent was obtained, for the use of psychotropic medications for 1 of 5 sampled residents (#4) reviewed for unnecessary medications. This placed residents at risk for lack of informed consent of psychotropic medications. Findings include:Resident 4 admitted to the facility in 2025 with diagnoses including mild episode of depressive disorder.A 12/13/25 physician order indicated the following medications to be administered to Resident 4:- Duloxetine (antidepressant) for depression and pain.A review of the clinical record revealed no indication the risks and benefits of the antidepressant medication were reviewed, or consent was obtained for the use of Duloxetine for Resident 4.On 3/25/26 at 1:54 PM Staff 1 (Administrator) stated he was unable to locate any information to indicate the risks and benefits were reviewed, or a consent was obtained for Resident 4's use of the antidepressant.

Based on observation, interview, and record review it was determined the facility failed to provide hygiene and grooming care to 1 of 1 sampled resident (#32) reviewed for ADLs. This placed residents at risk for unmet hygiene and grooming needs. Findings include: Resident 32 was admitted to the facility in 1/2026 with diagnoses including hospice care and Alzheimer's disease. The 1/28/26 Care Plan revealed Resident 32 needed one-person assistance for hygiene and bathing. The 2/3/26 admission MDS for Resident 32 revealed she/he needed substantial to maximum assistance with hygiene tasks, was dependent for mobility, and received a BIMS score of 1 indicating severe cognitive impairment.The daily care documentation for 3/2026 revealed Resident received no bathing or nail care from 3/1/26 to 3/19/26. On 3/26/26 at 12:45 PM Witness 2 (Family Member) expressed concern for Resident 32's cleanliness and hygiene, as well as the length and cleanliness of her/his fingernails and toenails. Witness 2 removed the resident's blanket and socks and prompted her/him to open her/his mouth. There was white build-up around and between the resident's teeth. Resident 32 had a brown substance under all fingernails and her/his toenails extended past the toe tips. Witness 2 started to clean and clip the resident's toenails and was observed to remove a large amount of white build-up from around the left big toenail. Witness 2 indicated Resident 32's feet had a foul odor, which was also observed by the surveyor. On 3/26/26 at 1:29 PM Staff 6 (CNA) reported Resident 32 started receiving bathing through her/his hospice agency the previous week, but facility staff continued to be responsible for hygiene and grooming care. On 3/26/26 at 1:45 PM Staff 8 (CNA) stated she assisted Resident 32 that morning and acknowledged she did not wash the resident's hands or brush her/his teeth. Staff 8 stated she did not have time to complete all of Resident 32's hygiene care that morning.On 3/26/26 at 2:33 PM Witness 5 (Hospice Nurse) stated Resident 32 received bathing services through hospice but did not have nail care on her/his hospice care plan.On 3/27/26 at 8:54 AM Staff 9 (CNA) stated hygiene tasks were to be completed daily and as needed, and nail care typically occurred after showers and as needed. On 3/27/26 at 9:09 AM Witness 3 (Hospice Aide) reported Resident 32 received her/his first shower from hospice on Thursday 3/19/26 but she did not recall the condition of the resident's toenails at that visit. On 3/27/26 at 9:16 AM Staff 7 (RNCM) acknowledged all hygiene care was to be completed twice per day, and nail care was to be done weekly and as needed. Staff 7 was unable to identify a reason the facility did not provide bathing or nail care services from 3/1/26 to 3/19/26.

Based on interview and record review it was determined the facility failed to ensure residents received seizure medications for 1 of 1 sampled resident (#25) reviewed for medications. This placed residents at risk for seizures. Findings include:Resident 25 was admitted to the facility in 10/2025 with diagnoses including stroke and hemiplegia (paralysis affecting one side of the body). A 1/22/26 Physician Order revealed prescriptions for two anti-seizure medications: Briviact 50 mg given twice daily, and Clobazam 10 mg given at bedtime. The 2/2026 MAR revealed Resident 25 missed her/his dose of Clobazam on 2/3/26, 2/4/26, and 2/5/26, as well as a dose of Briviact on 2/5/26. Each missed dose was documented as med not available by Staff 10 (Certified Medication Assistant). On 3/26/26 at 3:10 PM Staff 10 (Certified Medication Assistant) acknowledged he was able to order medications but did not order Resident 25's anti-seizure medication when he saw it was out. Staff 10 stated nursing staff, not him, was responsible for contacting a physician regarding missed medications but was unable to recall if he informed nursing staff of the missed medications. On 3/26/26 at 3:26 PM Staff 11 (LPN) stated on 2/5/26 she was notified Resident 25 was out of Briviact and would not receive her/his second dose that day. Staff 11 further stated she was unaware of the three missed doses of Clobazam until 2/5/26. On 3/27/26 at 8:27 AM Witness 4 (Physician) stated Briviact and Clobazam were important medications for preventing Resident 25 from having seizures. Witness 4 reported missed doses of those medications could result in a grand mal seizure On 3/27/26 at 10:23 AM Staff 7 (RNCM) acknowledged Resident 25 missed anti-seizure medications on 2/3/26, 2/4/26, and 2/5/26. Staff 7 further acknowledged the missed medications increased Resident 25's risk for seizures.

Based on observation, interview, and record review, it was determined the facility failed to ensure an environment free from accident hazards for 1 of 3 (#10) sampled residents reviewed for accidents. The facility failed to properly attach the sling with the lower leg straps to the Hoyer (a mechanical lift device used to transfer residents) during a transfer. As a result, Resident 10 sustained a left leg femoral (largest leg bone) fracture and an avulsion injury to the left foot (occurs when an injury causes a ligament or tendon to break off a small piece of a bone that is attached to it). Findings include: Resident 10 was admitted to the facility in 8/2015, with diagnoses including Alzheimer's and restless leg syndrome. The resident was was not able to be observed or interviewed as she/he had passed away. The 1/1998 Mennonite Village Policy and Procedure on Mechanical Lifts stated to follow the manufacturer's instructions when using any type of mechanical lift. The undated Invacare Owner's Operator and Maintenance Manual for Electric Portable Patient Lift included the following instructions: When the sling is elevated a few inches off the surface of the bed/chair and before moving the patient, check again to make sure that the sling is properly connected to the hooks of the swivel bar (Hoyer). Adjustments for safety and comfort should be made before moving the patient. Resident 10's 12/18/24 Care Plan revealed the resident had cognitive deficits related to advanced Alzheimer's/Dementia. Resident 10's care plan revealed she/he was non ambulatory and a fall risk. Interventions included Resident 10 was kept in a high traffic area, sat in the reclining chair off the dining area and was a two person assist with a Hoyer lift. On 2/24/25 the facility submitted a report to the State Survey Agency (SSA) which revealed Resident 10 was transferred via Hoyer lift from the recliner to the wheelchair with two CNAs (using the U-shaped sling) as care planned. During the transfer Resident 10 slid from the sling and fell to the floor. Resident 10 had a blanket covering her/him during the transfer. Resident 10 was immediately assessed by Staff 4 (LPN) and transferred to the hospital. Staff 1 (Administrator), Staff 2 (DNS) and Staff 8 (COO) reviewed the facility's video footage of the incident. The video revealed a blanket was covering up the view of the placement of the leg straps (sling). It was determined the straps were not attached properly. On 3/4/25 at 10:36 AM, Staff 4 (LPN) stated she was called to assess Resident 10 who fell on the floor. Staff 4 stated the sling was not hooked up correctly on the legs. Staff 4 stated the sling normally was placed between the legs, crisscrossed in front, then hooked to the Hoyer lift. On 3/4/25 at 10:51 AM, Staff 7 (CNA) stated she finished up in a resident's room around 1:30 PM on 2/24/25 and then assisted Staff 6 with the transfer of Resident 10. Staff 7 stated she was not sure about the placement of the sling, there was a blanket over Resident 10's legs and she did not verify the placement of the straps. On 3/4/25 at 11:11 AM, Staff 6 (CNA) stated she was assigned to Resident 10 on 2/24/25. Staff 6 stated Resident 10 was seated in a recliner in the alcove area outside of the dining room. Staff 6 stated she hooked Resident 10's straps from the sling up to the Hoyer lift, made sure everything was ok, then placed a blanket over the resident and stepped away to assist another resident. Staff 6 returned to Resident 10 and stated she did not double check the straps on the Hoyer lift, but stated she was sure it was the right way between the legs and she hooked it up the way she was trained. Staff 6 stated she was not gone long, and Resident 10 was in the same position when she had left. On 3/4/25 at 2:06 PM, Staff 5 (Light duty CNA) stated she was not present when Staff 6 (CNA) hooked Resident 10 up to the Hoyer lift. Staff 5 stated she was standing behind Resident 10 and did not physically have hands on Resident 10 while Staff 6 lifted Resident 10 with the Hoyer. Resident 10 suddenly slid out of the front of the sling on to the floor. Staff 5 stated after Resident 10 fell she noticed the sling was still hooked up and it made her think it was not crisscrossed through Resident 10's legs because she/he would not have been able to slide out. On 3/4/25 at 11:31 AM, two angles of the video footage of the incident were reviewed with Staff 8 (COO). The video revealed: Staff 6 (CNA) with Resident 10 hooking up four straps to the Hoyer lift, then placing a blanket over the resident's lap. Staff 6 left Resident 10 hooked up to the Hoyer lift seated in the recliner and left to attend to another resident. Moments later, Staff 6 returned to Resident 10, did not verify strap placement or remove the blanket, and started to lift Resident 10 up out of the recliner. Staff 6 swung Resident 10 around to the reclining wheelchair which was approximately six to ten feet away. Staff 5 (CNA) was visualized standing on the back side of Resident 10 and Staff 7 (CNA) was standing in front of Resident 10 next to Staff 6. Staff 8 stated it looked like Resident 10 was moving her/his left foot and then swung both her/his legs and the movement of the Hoyer and the swinging of the legs caused Resident 10 to slip out of the sling on to the floor, feet first and her/his legs buckled underneath her/him. On 3/4/25 at 3:39 PM, Staff 9 (CNA) and Staff 13 (CNA) were observed to transfer a resident using the Hoyer lift. Staff used the full body sling with no concerns identified. Staff 9 demonstrated how the U-shape sling was to be used. Staff 9 stated it was not possible for a resident to slip out of the U-sling if it was hooked up correctly under the thighs and crisscrossed in front and loops attached to the Hoyer. On 3/4/25 at 4:33 PM, Staff 1 (Administrator), Staff 2 (DNS) and Staff 8 (COO) acknowledged the sling was not set up properly and contributed to Resident 10's fall and leg fracture.

Based on observation, interview, and record review it was determined the facility failed to serve food in a sanitary manner for 2 of 2 dining rooms. This placed residents at risk for foodborne illness. Findings include: On 11/18/24 at 12:14 PM the lunch meal service was observed on the third floor dining room. Staff 7 (CNA) donned gloves and touched multiple surfaces including cupboards, clean cups, clean plates, a refrigerator and serving utensils multiple times throughout the meal and did not change her gloves. On 11/18/24 Staff 7 stated gloves were to be worn in the kitchen, and staff should change gloves after touching multiple surfaces in the kitchen before touching clean plates, cups, or food items. On 11/19/24 at 8:42 AM the breakfast meal service was observed in the second floor dining room. Staff 11 (Cook) served multiple food item and touched plates and serving utensils, but did not wear gloves throughout the meal service. On 11/19/24 at 11:58 AM the lunch meal service was observed on the third floor dining room. Staff 6 (RNCM) donned gloves and touched multiple surfaces including cupboards, clean cups, clean plates, a refrigerator and serving utensils multiple times throughout the meal and did not change her gloves On 11/19/24 at 12:25 PM Staff 6 stated she wore the same gloves while assisting in the kitchen during lunch. Staff 6 confirmed she touched cupboards, clean cups, clean utensils, a refrigerator, and juice containers. Staff 6 stated she always wore the same gloves while assisting in the kitchen. On 11/19/24 at 12:28 PM Staff 11 was observed serving lunch in the second floor dining room without wearing any gloves. Staff 11 used utensils to serve food and directly touched the residents' plates. On 11/19/24 at 12:23 PM Staff 18 (Server) assisted with meal service. She removed her gloves and with ungloved hands touched multiple meal trays to be delivered. Staff 18 then then sanitized her hands. On 11/19/24 at 12:46 PM Staff 19 (Infection Preventionist) stated staff should change their gloves and sanitize their hands after touching any equipment before they touch clean cups, dishes, silverware, and food items. 42270 2. On 11/19/24 at 12:31 PM Staff 12 (CMA) was observed in the second floor dining room. Staff 12 picked up a chair and moved it next to Resident 30's table, after which no hand hygiene was completed. Staff 12 sat down next to Resident 30 and assisted Resident 30 with the meal by picking up her/his fork, encouraging her/him to eat, then placing the fork down, looked through a newspaper on the table, and then picked up the resident's fork again and assisted her/him to eat. No hand hygiene was completed. On 11/19/24 at 12:42 PM Staff 12 acknowledged she did not do hand hygiene after moving a chair to Resident 30's table, and did not do hand hygiene before assisting Resident 30 with her/his meal when she should have.

Based on observation, interview, and record review it was determined the facility failed to ensure residents were treated with dignity for 1 of 10 sampled residents (#29) reviewed for dining. This placed residents at risk for lack of dignity. Finding include: Resident 29 admitted to the facility in 11/2023 with diagnoses including kidney disease. On 11/18/24 at 12:24 PM during the lunch meal on the third floor Resident 29 and Resident 7 were observed seated at a dining table together. Staff delivered Resident 7's lunch but not Resident 29's. Staff then proceeded to deliver lunch to other residents in the dining room. Resident 7 was observed to stop and ask multiple staff multiple times where Resident 29's lunch was. Staff acknowledged Resident 29 waited for a long time for lunch since Resident 7's lunch was served. Staff's response to Resident 7 was Resident 29's meal was getting dished up. Resident 29 began asking staff were her/his meal was and staff stated her/his lunch was being dished up. Staff 7 stopped eating and stated she/he did not want to eat in front of Resident 29, so she/he would wait for Resident 29 to receive her/his lunch. On 11/18/24 at 12:42 PM Resident 29 was served her/his lunch, which was 18 minutes after Resident 7 was served her/his lunch. On 11/18/24 at 1:10 PM Staff 1 (Administrator) stated she expected staff to serve meals one table at a time, and make sure each resident at the table had their meal served before moving to another table to serve.

Based on interview and record review it was determined the facility failed to timely inform the resident representative of the risks and benefits of psychotropic medication use for 1 of 5 sampled residents (#18) reviewed for medications. This placed residents at risk for the lack of informed consent. Findings include: Resident 18 admitted to the facility in 10/2024 with diagnoses including dementia. An 10/24/24 Admission MDS revealed Resident 18's cognition was severely impaired. A review of Resident 18's 11/2024 MAR revealed she/he had an 10/18/24 order to for lorazapam (an anti-anxiety medication) as needed, and received the medication on 11/1/24, 11/3/24, and 11/10/24. A Consent for Treatment for Anti-Anxiety to administer lorazapam was completed on 11/12/24 by Resident 18's representative. In an interview on 11/20/24 at 10:42 AM Staff 3 (LPN Resident Care Manager) stated Resident 18 did not have a consent for lorazapam, so she completed one on 11/12/24 after the medication was administered.

Based on interview and record review it was determined the facility failed to complete a comprehensive assessment within the required timeframe for 1 of 2 sampled residents (#2) reviewed for resident assessment. This placed residents at risk for unassessed needs. Findings include: Resident 2 admitted to the facility in 6/2018 with diagnoses including respiratory failure. The Assessment Lookup for Resident 2 revealed the following MDS assessments were completed: 9/7/23 Annual MDS, 12/8/23 Quarterly MDS, 3/9/24 Quarterly MDS, and 6/10/24 Quarterly MDS. A 11/15/24 Annual MDS was open and in progress. On 11/18/24 at 10:50 AM Staff 1 (Administrator) confirmed the facility did not complete the Annual MDS due in 9/2024 for Resident 2 within the required timeframe.

Based on observation, interview, and record review it was determined the facility failed to ensure accurate assessments for 1 of 1 sampled resident (#31) reviewed for limited range of motion. This placed residents at risk for unassessed needs. Findings include: Resident 31 admitted to the facility in 10/2024 with diagnoses including Alzheimer's disease and Type 2 Diabetes The Admission MDS dated [DATE] revealed Resident 31 had no limitations of her/his upper extremities (shoulder, elbow, wrist, hand). Review of Resident 31's Active Care Plan dated 10/3/24 revealed the resident had impaired functional status in bed mobility, transfers, walking, toileting, dressing, locomotion, eating, grooming, hygiene, and bathing. Interventions included to insert a rolled ace wrap or washcloth in her/his hands daily to prevent progression of her/his bilateral hand contractures (fingers bent toward the palm of the hand, the affected fingers could not straighten completely). On 11/18/24 Resident 31 was observed to have contractures to both hands. No splinting was observed. On 11/20/24 at 1:14 PM Witness 1 (Family Member) stated they were aware of the hand contractures present on admission and brought cloth covered intervention devices from the previous facility. On 11/20/24 at 12:36 PM Staff 3 (LPN Resident Care Manager) confirmed the hand contractures were present on admission and were not coded on the MDS.

Based on observation, interview, and record review it was determined the facility failed to ensure a resident with limited ROM received appropriate treatment and services to prevent further decline for 1 of 1 sampled resident (#31) reviewed for ROM. This placed residents at risk for worsening contractures. Findings include: Resident 31 admitted to the facility in 10/2024 with diagnoses including Alzheimer's disease and Type 2 Diabetes. Review of Resident 31's Active Care Plan dated 10/3/2024 revealed the resident had impaired functional status in bed mobility, transfers, walking, toileting, dressing, locomotion, eating, grooming, hygiene, and bathing. Interventions included to insert a rolled ace wrap or washcloth into her/his hands daily to prevent progression of her/his bilateral hand contractures (fingers bent toward the palm of the hand, the affected fingers cannot straighten completely). On 11/18/24 Resident 31 was observed to have contractures to both hands. No contracture interventions were observed. On 11/21/24 at 7:27 AM Staff 15 CNA stated care of Resident 31's hands included cleaning hands and nails. Staff 15 was not aware of any care related to the resident's contractures. On 11/20/24 at 1:14 PM Witness 1 (Family Member) stated they were aware of the hand contractures and brought cloth-covered intervention devices from the previous facility. Additionally she stated the devices were now difficult to get into the resident's hands because her/his fingers were more tight, and staff did not use the devices much. On 11/20/24 at 12:36 PM Staff 3 (LPN resident Care Manager) confirmed the hand contractures were present on admission, and a care plan intervention was put in place. She confirmed staff should have followed the care plan.

Based on interview and record review it was determined the facility failed to timely evaluate and analyze repeated falls to ensure fall interventions were effective for 1 of 3 sampled residents (#4) and failed to ensure fall interventions were followed for 1 of 3 sampled residents (#1) reviewed for accidents. As a result, Resident 1 fell and sustained a fracture. Findings include: 1. Resident 1 was admitted to the facility in 2018, with a diagnosis of Parkinson's disease. A 11/2/23 Significant Change MDS revealed Resident 1 had dementia and did not ask staff for ADL assistance. Resident 1 was assessed to be at risk for falls and interventions included a motion sensor (device placed near the resident and alerts staff when the resident moves) was to be used when she/he sat in a recliner. The assessment indicated Resident 1 liked to sit in a recliner near the dining room. An Investigation revealed Resident 1 fell on [DATE] at 6:19 PM. The investigation indicated Resident 1 had a history of falls and staff were to place a motion sensor near her/him to detect movement. The motion sensor was not in place at the time of the fall. Staff 5 (CNA) was interviewed and reported she did not place the sensor after Resident 1 was transferred to the recliner. Staff 4 (LPN Resident Care Manager) reviewed the facility video footage which revealed the following: -6:12 PM staff visualized the Resident 1 in her/his recliner. -6:15 PM Resident 1 was eating dinner. -6:18 PM Resident 1 stood up from her/his chair and held onto a table with one hand as she/he attempted to walk. -6:19 PM Resident 1 fell on to her/his right side. A 3/13/24 Hospital After Visit Summary revealed Resident 1 was transferred to the hospital for right arm pain. The resident was diagnosed to have a right arm fracture and a sling (device made from material to keep the arm stable and provide support to allow a fracture to heal) was placed. On 7/23/24 and 7/24/24 attempts to interview Staff 5 were unsuccessful. On 7/23/24 at 12:50 PM, Staff 4 (LPN Resident Care Manager) stated she completed a comprehensive investigation for Resident 1's 3/13/24 fall because the resident sustained an arm fracture. She was able to interview all staff and view video footage to determine the sensor was not placed at the time of the fall. A former resident notified staff of the fall, staff assessed the resident, and she/he was transported to the local hospital for evaluation and treatment. 2. Resident 3 was admitted to the facility in 2024, with a diagnosis of dementia and weakness. A 4/16/24 Significant Change MDS revealed Resident 3 was at risk for falls due to severe cognitive impairment and poor safety awareness. Incident Investigation Summaries revealed: -Resident 3 was found on the floor on 4/18/24. The investigation was not completed until 5/17/24. -Resident 3 was found on the floor on 5/4/24. The investigation was not completed until 7/2/24. -Resident 3 was found on the floor on 5/12/24. The investigation was not completed until 7/2/24. On 7/23/24 at 1:56 PM, Staff 4 (LPN Resident Care Manager) stated she was behind on completing fall investigations. On 7/23/224 at 2:33 PM, Staff 2 (DNS) and Staff 1 (Administrator) acknowledged the investigations should be completed timely to ensure the care plan was followed, an analysis of the fall was completed to ensure current care plans were appropriate, and neglect of care or abuse did not occur.

Based on interview it was determined the facility failed to implement a water management program for 1 of 1 facility reviewed for infection control. This placed residents at risk for exposure to water-borne illnesses. Findings include: On 9/8/23 at 8:59 AM Staff 13 (IP) and Staff 14 (Environmental Services Director) confirmed the facility did not have a program and system in place for the prevention of the spread of water-borne pathogens, such as Legionella, in the facility's main water system.

Based on interview and record review it was determined the facility failed to ensure residents were able to participate in care conferences for 1 of 1 sampled resident (#7) reviewed for care planning. This placed residents at risk for lack of participation in the care planning process. Findings include: Resident 7 was admitted to the facility in 2022 with diagnoses including hip fracture. Resident 7's Care Conference Sheet revealed she/he had a care conference on 2/15/23. The 2/15/23 care conference notes indicated the resident attended and participated in the meeting. The sheet had additional notes indicating care conferences were scheduled for 5/11/23 and 8/2/23, and the resident and family were invited. There were no notes associated with the 5/11/23 and 8/2/23 conferences indicating they occurred, and the resident was provided the opportunity to participate in her/his care decisions. An 8/2/23 Quarterly MDS indicated the resident was cognitively intact. On 9/6/23 at 8:10 AM Resident 7 stated she/he was not recently involved with care planning. On 9/7/23 at 9:21 AM Staff 12 (LPN Resident Care Manager) stated care conferences were to occur quarterly, the resident and family were invited and the resident participated with decisions as able. Staff 12 stated she was responsible for generating care conference notes, but did not have notes for the 5/2023 conference. Staff 12 indicated she was on vacation on 8/2/23, but another staff member should have filled in for her and generated notes. A request was made to Staff 12 to provide notes for the 5/2023 and 8/2023 care conferences to indicate Resident 7 participated in her/his care planning. No additional information was provided.

Based on interview and record review it was determined the facility failed to periodically follow-up on advanced directives for 1 of 2 sampled residents (#10) reviewed for advanced directives. This placed residents at risk for healthcare decisions not being honored. Findings include: Resident 10 was admitted to the facility in 2021 with diagnoses including osteoarthritis (pain in joints). The 11/2/18 facility Advanced (sic) Directive Policy and Procedure indicated staff would review a resident's existing care instructions quarterly referencing the advance directive or POLST (Physician Orders for Life Sustaining Treatment). A 9/2021 facility Admission Agreement indicated Resident 10 did not have an advance directive. 9/28/22, 12/18/22, 4/12/23 and 6/28/23 Interdisciplinary Notes (care conference) and Care Conference Sheet revealed no indication of follow-up with Resident 10 regarding an advance directive. A 3/30/23 Annual MDS revealed Resident 10 was cognitively intact and able to make her/his own decisions. On 9/7/23 at 5:02 PM Staff 12 (LPN Resident Care Manager) stated during quarterly meetings with Resident 10 her/his POLST was reviewed but follow-up regarding her/his advance directive was not addressed.

Based on interview and record review it was determined the facility failed to complete and submit a discharge tracker for 1 of 1 sampled resident (#19) reviewed for assessments. This placed residents at risk for incomplete records. Findings include: Resident 19 was admitted to the facility in 2023 with diagnoses including stroke. An Admission MDS dated [DATE] was completed and Resident 19 discharged from the facility in 7/2023. There were no other MDS assessments completed for Resident 19. On 9/8/23 at 8:41 AM Staff 17 (Medical Records) stated the discharge assessment was not completed and submitted as required.

Based on observation, interview and record review it was determined the facility failed to develop and implement a comprehensive care plan for 1 of 1 sampled resident (#17) reviewed for skin conditions. This placed resident at risk for unmet skin care needs. Findings include: Resident 17 was admitted to the facility in 2022 with diagnoses including Alzheimer's disease. Observations from 9/6/23 to 9/8/23 revealed Resident 17 had several light brown and dark red scab-like areas on her/his face and neck. Skin assessments completed in 1/2023 and 2/2023 indicated Resident 17 had a skin condition that caused small, raised scab-like areas to form on her/his skin that gradually fell off when care was provided. The 4/19/23 care plan did not address Resident 17's skin condition. On 9/7/23 at 9:27 AM Staff 5 (CNA) stated the scab-like areas on Resident 17's face often fell off and bled after showers or when caught on Resident 17's clothing. On 9/7/23 at 9:30 AM Staff 6 (LPN) stated Resident 17's raised scab-like areas on her/his nose and cheek did bleed. Staff 6 stated CNAs that care for Resident 17 were to look at the care plan regarding her/his skin condition. On 9/7/23 at 12:44 PM Staff 8 (RNCM) acknowledged Resident 17's care plan did not address her/his skin condition.

Based on interview and record review it was determined the facility failed to honor activity preferences for 2 of 2 sampled residents (#s 10 and 30) reviewed for activities. This placed residents at risk for decline in psychosocial well-being. Findings include: 1. Resident 10 was admitted to the facility in 2021 with diagnoses including osteoarthritis (pain in joints). The 3/30/23 Annual MDS indicated it was very important for Resident 10 to go outside and get fresh air when the weather was good. The 6/30/23 Quarterly MDS revealed Resident 10 was cognitively intact and she/he required one-person assistance to transfer into her/his wheelchair. A 9/1/23 revised care plan for life enrichment revealed Resident 10 was independent for activities and to provide her/him with independent activities as needed. The psychosocial well-being care plan revealed Resident 10 was compromised due to occasional reports of feeling claustrophobic (fear of confined spaces) in her/his room and should be invited to life enrichment programs of interest including bingo, cooking and outings. The 8/1/23 through 9/7/23 Daily Charting for activities for Resident 10 revealed no outside activity participation and no activities from 9/1/23 through 9/7/23. On 9/5/23 at 12:19 PM and 1:31 PM Resident 10 stated because of COVID-19 in the building she/he was not allowed to go outside even though there was a garden outdoors and she/he could get outside independently once she/he was in her/his wheelchair. Resident 10 stated she/he normally attended activities like cooking or bingo but none were offered to her/him for over a week. On 9/7/23 at approximately 2:30 PM and 9/8/23 at 8:41 AM Staff 10 (Life Enrichment Director) stated around 9/1/23 activities were no longer allowed in Resident 10's unit due to COVID-19, and other options for activities should have been considered but were not. Staff 10 indicated Resident 10's care plan needed to be updated to include the outdoor access Resident 10 wanted and direct staff how to assist to ensure the resident's desire to be outdoors was met. Staff 10 stated there was no indication Resident 10 went outdoors because unless Staff 10 observed Resident 10 outdoors it was not documented. 2. Resident 30 admitted to the facility in 2022 with diagnoses including heart disease. A 2/21/23 Significant Change MDS revealed Resident 30 was mildly cognitively impaired, completed the preference interview for activities and indicated it was very important to get outside when weather was good and to participate in religious activities. The 8/1/23 through 9/7/23 Daily Charting for activities for Resident 30 revealed no outside activity participation and one religious event. An 8/24/23 Quarterly MDS revealed Resident 30 required one-person assistance to transfer to her/his wheelchair or walker. The current care plan was last revised on 9/5/23. Resident 30's activity care plan did not reflect her/his wishes to go outside and to routinely participate in religious activities. On 9/5/23 Resident 30 stated she/he wished she/he could get outdoors more than twice monthly when family came. Resident 30 stated staff did not offer to assist her/him to go outdoors. On 9/7/23 at 1:01 PM Staff 9 (CNA) confirmed Resident 30 was taken outdoors by family a few weeks earlier and staff did not offer to take Resident 30 outdoors. On 9/7/23 at approximately 2:30 PM and 9/8/23 at 8:41 AM Staff 10 (Life Enrichment Director) stated she did not recall it was important for Resident 30 to be outdoors when the weather was nice and outdoor activities for Resident 30 were not documented unless she observed it. Staff 10 acknowledged Resident 30's care plan was not updated to include details on her/his preferences for activities so staff could assist to ensure the important activities for Resident 30 were offered, including access to the outdoors.

Based on interview and record review it was determined the facility failed to ensure pharmacy identified drug interactions were reviewed by a resident's physician for 1 of 5 sampled residents (#33) reviewed for medications. This placed residents at risk for adverse medication reactions. Findings include: Resident 33 was admitted to the facility in 2023 with diagnoses including irregular heart rate and depression. A 6/22/23 Admission Orders revealed Resident 33 was to be administered medications including eliquis (blood thinner) and fluoxetine (antidepresant). A 6/22/23 pharmacy Potential Drug Interaction form revealed eliquis and fluoxetine should be used with caution. Resident 33 should be monitored for blood loss. The interaction was a level 3. On 9/7/23 at 9:33 AM Staff 12 (LPN Resident Care Manager) stated when the pharmacy sent a drug interaction form to the facility, the staff were to notify the physician. The physician would review the notification and make changes if indicated. Staff 12 stated the physician would usually initial the note as an acknowledgement if there were no changes to be made. Staff 12 stated she was not sure if the physician was aware of the pharmacy review because there was no physician signature, comment or initials on the form. A request was made to Staff 12 to provide documentation to indicate Resident 33's physician acknowledged the potential drug to drug interaction with eliquis and fluoxetine. No additional information was provided. On 9/7/23 at 1:00 PM Witness 1 (Pharmacist) stated a Level 3 interaction was a mild to moderate concern.

Based on observation, interview and record review it was determined the facility failed to ensure residents were free from abuse for 5 of 5 sampled residents (#s 2, 3, 4, 5 and 6). Due to the facility's lack of supervision and monitoring Resident 2, Resident 3, Resident 4, Resident 5 and Resident 6 were sexually abused. This was determined to be an Immediate Jeopardy (IJ) situation. Findings include: Resident 1 was admitted to the facility in 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 2 was admitted to the facility in 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 2 had a BIMS score of 15 which indicated she/he was cognitively intact. Resident 3 was admitted to the facility in 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 3 had a BIMS score of 8 which indicated moderate cognitive impairment. Resident 4 was admitted to the facility in 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 4 had a BIMS score 8 of which indicated moderate cognitive impairment. Resident 5 was admitted to the facility in 2016 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 5 had a BIMS score of 3 which indicated severe cognitive impairment. Resident 6 was admitted to the facility in 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 6 had a BIMS score of 1 which indicated severe cognitive impairment. A comprehensive care plan dated 5/26/22 revealed Resident 1 was a registered sex offender and was incarcerated. Resident 1 was not to be left alone or unsupervised with female residents, was to have close supervision and was not to touch or kiss other residents without their consent. The 8/5/22 FRI revealed on 8/5/22 Staff brought Resident 1 to bingo. Resident 1 proceeded to scoot her/his chair next to Resident 2 and touched her/his arm, leg and breasts. The incident was observed on video and Staff 12 (CNA) witnessed the incident but did not intervene. An 8/5/22 Facility Investigation revealed the following: -Resident 1 was brought to the second floor living room area by Staff 11 (CNA) to play Bingo and was seated in the back row table next to Resident 2. -Resident 1 was visualized (on video footage) to scoot her/his chair close to Resident 2 three times until she/he was near Resident 2's hand, arm, legs and breasts. -The video footage showed Resident 1 rubbing Resident 2's hand, arm, legs and breasts but she/he stopped touching Resident 2 when staff entered the area. -Staff 10 (Activities Director) was observed on the video footage in and out of the living room area where Resident 1 was inappropriately touching Resident 2. -Staff 12 (CNA) was in the living room area and went to the second floor nurse's office and reported he witnessed Resident 1 touch Resident 2's breasts while waiting to play bingo and Staff 12 stated he did not separate the residents. The 8/5/22 video footage confirmed the incident. Random observations on 8/10/22 from 9:00 AM through 3:00 PM revealed Resident 1 walked independently with her/his walker outside of her/his room on the 300 hall unsupervised. On 8/10/22 at 10:45 AM Staff 3 (CNA) stated Resident 1 was able to come and go around the facility as she/he pleased. Staff 3 stated Resident 1 liked to touch female residents and female staff inappropriately. Staff 3 stated Resident 1 touched and kissed female residents who were cognitively impaired including Residents 3, 4 and 5. Staff 3 stated she witnessed Resident 1 walk into Resident 4's room and touch her/him on the arm, leg and kiss her/him but was not sure if she/he was touched in other places. Staff 3 stated Resident 1 was aware of her/his inappropriate behavior because Resident 1 stated she/he touched female residents to staff. Staff 3 stated 15 minute checks were implemented for Resident 1 but Resident 1 went into residents' rooms in between the 15 minute checks because she/he was ambulatory with her/his walker. On 8/10/22 at 11:03 AM Resident 1 stated she/he rubbed Resident 2's arm, leg and her/his breasts while sitting at the bingo table. Resident 1 stated Resident 2 did not give consent for her/him to touch her/his breast but Resident 2 took off her/his sweater and Resident 1 took this as an invitation to touch Resident 2's breasts. Resident 1 stated she/he stopped touching Resident 2's breasts when staff came near. Resident 1 stated there were other female residents she/he kissed and stroked. Resident 1 stated she/he touched Resident 3's leg and went up higher towards the groin area and Resident 3 did not tell her/him to stop. Resident 1 stated she/he kissed and touched Resident 3 at every meal. Resident 1 stated there were other females she/he touched and kissed which included Resident 2, Resident 4 and Resident 5. Resident 1 stated the female residents she/he kissed and touched never said she/he could not kiss or touch them so she/he took it as an invitation that it was ok to touch them. On 8/10/22 at 11:17 AM Staff 6 (LPN) stated she observed Resident 1 touch and kiss other female residents without their consent. Staff 6 stated there were vulnerable female residents on the 300 Hall. On 8/10/22 at 11:22 AM Staff 7 (RNCM) stated Staff 11 (CNA) took Resident 1 to bingo and did not read the care plan which indicated not to leave Resident 1 alone with female residents. Staff 7 stated she was aware Resident 1 fondled female residents. Staff 7 stated there were 11 female residents on the 300 hall, seven of them were vulnerable and did not always come out of their rooms. Staff 7 stated the female residents would not understand what was happening and could not call for help. Staff 7 acknowledged the incident on 8/5/22 between Resident 1 and Resident 2 met the definition of sexual abuse and further stated the ongoing incidents with Resident 3, Resident 4 and Resident 5 also met the criteria for sexual abuse. On 8/10/22 at 12:46 PM Resident 2 stated Resident 1 rubbed her/his hand, leg and touched her/his breasts a couple of times. Resident 2 stated Resident 1 did not ask permission but just touched her/his breasts. On 8/10/22 at 2:36 PM Staff 14 (CNA) stated he witnessed Resident 1 grab and kiss Resident 4 and Resident 5 hard and Resident 4 or Resident 5 neither were able to tell Resident 1 to stop or call for help due to their cognitive impairments. On 8/10/22 at 2:42 PM Staff 8 (LPN) stated he witnessed Resident 1 touch and kiss Resident 3 and Resident 5. On 8/11/22 at 11:16 AM Staff 20 (LPN) stated he witnessed Resident 1 kiss Resident 5 and rub Resident 3's face. Staff 20 stated he removed Resident 5 but did not speak with Resident 1 about her/his inappropriate sexual behaviors. Staff 20 stated he had not spoken with Resident 1 before about being inappropriate with female residents. Staff 20 stated he did not complete investigations regarding the inappropriate touching and kissing by Resident 1 with other female residents due to being told, it was supposed to be at the nurses's discretion if we do anything or investigate the incident. On 8/11/22 at 1:46 PM Staff 10 stated on 8/5/22 staff gathered residents to play Bingo on the 200 Hall dining area. Staff 10 stated Staff 12 spoke to her and wanted to speak to the nurse because of what he witnessed Resident 1 do to Resident 2. Staff 10 was aware Resident 1 was not to be left alone with female residents and usually staff brought her/him down to activities last so she/he did not sit by female residents. Staff 10 stated she moved Resident 2 to another table on 8/5/22. Staff 10 stated she recalled roughly two months prior Resident 1 sat next to Resident 6 for Bingo. Resident 6 yelled Resident 1 grabbed her/his groin. Staff 10 stated Resident 6 was moved and she reported the incident to a nurse but was not sure if the incident was looked into. Staff 10 acknowledged the incident with Resident 2 and Resident 6 met the criteria for sexual abuse. On 8/10/22 at 5:16 PM Staff 2 (DNS) and Staff 7 both stated Resident 1 kissed Resident 3 on 8/10/22 then walked away. Staff 7 stated she spoke with Resident 3 but did not speak to Resident 1 regarding the incident. Staff 2 and Staff 7 acknowledged the incidents by Resident 1 met the criteria for sexual abuse for Resident 3, Resident 4 and Resident 5. Staff 7 stated there were seven vulnerable female residents on the 300 Hall identified as potential victims for Resident 1. Resident 1 was placed on 15 minute safety checks and staff were aware of Resident 1's behaviors however Resident 1 was independent and highly mobile when up with her/his walker and was able to move from place to place very quickly. Resident 1 had the potential to seriously harm any vulnerable resident between the 15 minute safety checks. On 8/10/22 at 5:31 PM the facility was informed of the identified Immediate Jeopardy for the failure to ensure ongoing safety of vulnerable female residents related to potential sexual abuse after Resident 1 sexually abused Resident 2. On 8/10/22 at 7:41 PM the IJ Abatement Plan was received and approved. The Plan included: -One on one supervision was provided for Resident 1 and would be 24 hours a day, seven days a week. -Education for staff was provided regarding sexual abuse, what was considered non-consensual touching and how or when to intervene and report sexual abuse. -Education was provided to ensure all staff were aware of changes to care plans at the beginning of each shift for those residents who were assessed as being at risk for sexual abuse. -Administration would conduct audits to ensure staff were educated on sexual abuse and ensure care plans were reviewed and implemented regarding sexual abuse. On 8/11/22 at 3:56 PM the facility's implementation of the abatement plan was verified.

Based on observation, interview and record review it was determined the facility failed to ensure care and services were provided to maintain acceptable nutritional parameters for 1 of 3 sampled residents (# 133) reviewed for nutrition. Resident 133 experienced a severe weight loss of ten pounds in one month. Resident 133's plan of care was not fully implemented, the effectiveness of the interventions were not evaluated timely and Resident 133 experienced a subsequent severe weight loss of 13.5 pounds in one month. Findings include: Resident 133 admitted to the facility in 2016 with [DIAGNOSES REDACTED]. Resident 133's 2/9/16 Admission MDS and corresponding Nutritional Status and Dehydration/Fluid Maintenance CAAs indicated the resident ate independently with set-up and had no dental issues. The resident's weight during the assessment period was 173 pounds, with a recent weight gain and bilateral lower extremity [MEDICAL CONDITION]. The resident received a regular texture diet and had good intake. Compression stockings, lower extremity elevation and daily weights appeared to improve the [MEDICAL CONDITION]. Resident 133's 2/2/16 comprehensive care plan indicated the resident had potential for fluid volume imbalance related to [MEDICAL CONDITION]. The resident's vital signs and weight were to be obtained and recorded daily. A 4/1/16 progress note revealed Staff 23 (Registered Dietitian, RD) assessed Resident 133's weight was 163 pounds on 4/1/16. The resident was within her/his ideal body weight range, had recent bilateral [MEDICAL CONDITION] and good meal intake. It was noted 90 ml of house supplement (enhanced calorie drink) was ordered on [DATE] but had not been implemented, . may be just below kcal (caloric requirements) without the house supp(lement) . the house supp will be added to the MAR. Will proceed to care plan and monitor (her/his weight) at the NAR (Nutrition at Risk) meetings. Resident 133's Weight Tracking Report revealed the following weights: 2/6/16 172 pounds; 3/2/16 160 pounds; 4/2/16 162 pounds; and 5/2/16 152 pounds. This was a loss of ten pounds (6%) in one month and 20 pounds (11.6%) in three months, which constituted a severe weight loss. Resident 133's clinical record revealed the 5/2/16 weight of 152 pounds was the only weight documented in May 2016. Resident 133's 5/11/16 Quarterly MDS indicated the resident's weight was 152 pounds, the resident had a weight loss of 5% or more in the last month and was not on a physician-prescribed weight-loss regimen. On 5/24/16 Staff 22 (Dietary Manager) completed a Quarterly Dietary Assessment, . has lost 7% wt (weight) in 30 days and 7% since admit . is weighed daily . related to [MEDICAL CONDITION] . has a history of fluctuating wts . RD evaluation done 4/1/16 and (she/he) is discussed at NAR. Supplements were increased to three times daily on 5/14/16 . is not a picky eater . does have a small appetite . Care plan wt goal was not met and was changed to maintain wt. at or near 150# . Continue to monitor at NAR. On 5/24/16 Staff 5 (RNCM) documented a Quarterly Assessment which noted the resident was independent in nature and chose to spend most of her/his days in recliner or bed. The assessment addressed recent changes in the resident's condition related to syncopal episodes ([MEDICAL CONDITION], at times with loss of consciousness) and hospitalization s, but it did not address the resident's nutrition, weight or weight loss. Resident 133's comprehensive care plan, updated 5/24/16, identified nutritional concerns related to potential for weight fluctuations due to [MEDICAL CONDITION] and weight loss. Interventions included daily weights, diet as ordered, offer menu choices, Dietitian consult PRN and house supplements as ordered. The resident required set-up assistance as needed, and fed her/himself. Resident 133's clinical record lacked documented evidence of daily weights between 5/2/16 and 5/20/16. A 6/1/16 progress note, documented by Staff 23 revealed, 5/2/16 wt reflects an overall 11# (pound) wt loss from the month before or 6.7% decrease . It further noted the resident readmitted to the facility after a hospitalization , had improved [MEDICAL CONDITION] and a new [MEDICAL CONDITION] medication which may help to explain wt loss . House supps were increased to TID (90 ml each) in response to wt loss . Will proceed to careplan and monitor (her/his) wt at the NAR meetings. Meal intake and acceptance of house supplements were noted to be good. Resident 133's Weight Tracking Report revealed the resident weighed 138.5 pounds on 6/4/16, this was an additional loss of 13.5 pounds (8.8%) in one month, and constituted a subsequent severe weight loss. There was no documented assessment or evaluation of Resident 133's continued weight loss. A 6/8/16 progress note, written by Staff 5 revealed, Wt loss increased health shake supplement from 90 ml to 120 ml, physician and (family) notified, will recheck wt (every two weeks). There was no documented assessment or evaluation of Resident 133's weight loss. On 6/14/16 at 2:32 pm Resident 133 was observed in bed. When asked about the food and if staff spoke to her/him about her/his weight, the resident said the food was ok, but she/he was not a big eater. The resident also said the head nurse spoke to her/him and said they thought she/he lost weight. On 6/16/16 at 7:33 am Staff 18 (CNA) stated the resident's appetite varied. The resident ate in her/his room and needed set-up. The resident liked breakfast and fresh fruit. Staff 18 also stated she weighed the resident on the scale in the west shower room. Staff 18 said all residents were weighed monthly and if a resident's care plan identified daily weights, it showed up on the computer as an assignment for the CNAs. On 6/16/16 at 7:38 am Staff 17 (CNA) stated she regularly worked with Resident 133 and thought the resident was weighed monthly. Staff 17 stated weights were documented on paper and in the electronic system. Staff 17 indicated she weighed the resident earlier in the month and used the wheelchair scale in the shower room. She stated she generally weighed the resident and her/his wheelchair separately. She stated the resident did not eat well and it was not a new issue. On 6/16/16 at 9:08 am Resident 133 was observed awake in bed. A covered breakfast tray was on the tray table in front of the resident and she/he was setting up straws. The resident uncovered the plate to reveal one large pancake with syrup, a cup of peaches, a glass of milk, cup of coffee and two glasses of ice water. At 9:35 am the resident stated she/he ate everything and the surveyor observed the empty plate and fruit cup. The glass of milk remained full. On 6/16/16 at 9:18 am Staff 5 said the resident did not eat like she/he should and sometimes said she/he was not hungry. Staff 5 stated the resident had weight loss and she thought it was related to depression and pain. The resident was started on an antidepressant. Staff 5 stated Staff 3 (DNS), Staff 22, Staff 23, and RNCMs met monthly and as needed for the NAR. She stated Staff 3 maintained meeting notes and RNCMs were responsible for implementing recommendations. On 6/16/16 at 10:09 am the RN surveyor observed staff weigh Resident 133 on the wheelchair scale. The total weight was 181 pounds and the wheelchair was reported to weigh 43 pounds. Resident 133's weight was 138 pounds. On 6/16/16 at 1:00 pm Staff 17 delivered and set up the resident's lunch tray. Fresh fruit, a hamburger with condiments and potato chips were served to the resident. At 1:47 pm the resident no longer had the tray and Staff 17 stated the resident ate 100%. On 6/16/16 at 1:04 pm Staff 23 said she was on-site weekly and NAR was held monthly. Staff 23 stated the resident lost 11 pounds from April, which she contributed to the hospitalization and supplements were increased. Staff 23 said in May the resident's weight was stable. When asked about which residents were followed at NAR, Staff 23 said weights for the building were reviewed and residents with significant changes were discussed. Staff 23 stated NAR was done last Friday (6/10/16), and Resident 133 was weighed and assessed today (6/16/16). Staff 23 stated she recommended a fortified diet (caloric dense diet), stop the no-added salt diet, and evaluate the antidepressant medication, which she thought caused the weight loss. When asked if she reviewed the care plan and CNA charting as part of her review, Staff 23 stated, Yes. When asked if she was aware Resident 133's care plan had an intervention of daily weights, Staff 23 stated she deleted the intervention today (6/16/16). Staff 23 stated she wanted to review why Staff 22 indicated the resident was weighed daily. On 6/16/16 at 1:55 pm Staff 22 stated she obtained her information for dietary reviews from residents, interviews with staff and the residents' charts. Specific diet orders came from the nursing staff as did information such as skin issues, and changes in preferences or health status. Staff 22 stated she reviewed weights from the electronic record and wrote nutritional care plans. Staff 22 stated she was familiar with the resident and the last time she spoke with her/him the resident was focused on recent health changes and it was difficult to get the resident to talk about food. Staff 22 was not sure if the resident was weighed daily. On 6/16/16 at 2:13 pm and 3:10 pm Staff 23 stated Resident 133 was on the list of residents to be reviewed at the 5/9/16 NAR. She said she notified Staff 5 she was not able to assess the resident that week due to the number of other residents to review but they decided to increase the house supplement from 90 ml once daily to 90 ml TID. Staff 23 stated she did not assess Resident 133 until 6/1/16 and no recommendations were made because the supplement was increased. Staff 23 said the June NAR was last week and the resident was assessed today (6/16/16). When asked if a more current weight should have been reviewed for the 6/1/16 assessment, Staff 23 stated she thought the resident's weight was on the up-swing, with an upward trend and a monthly weight was fine. The 6/16/16 RD Assessment revealed, Wt 6/16/16 138# reflects an overall 14# wt loss since RD eval(ulation on) 6/1/16 . or 9.2% decrease. RCM reports no [MEDICAL CONDITION]. Current wt is below (ideal body weight range) 139-169 and is low for (her/him) . From 4/2/16 to 5/2/16 Resident 133 experienced a severe weight loss of ten pounds (6%) in one month. Between 5/2/16 and 5/20/16 the resident was not weighed daily in accordance with her/his care plan. On 6/1/16 the ten pound weight loss from April 2016 to May 2016 was evaluated and the house supplement was increased from 90 ml TID to 120 ml TID. On 6/4/16 the resident's weight was 138.5 pounds, which was an additional loss of 13.5 pounds (8.8%) in one month, and constituted a severe weight loss. There was no documented assessment or evaluation of the resident, the care plan and effectiveness of the nutritional interventions regarding Resident 133's continued weight loss until 6/16/16. On 6/17/16 at 10:49 am Resident 133's continued weight loss, the failure to timely and accurately evaluate the resident's nutritional status and implement the care plan was discussed with Staff 3, Staff 5 and Staff 23. Staff 3 stated RNCMs were responsible for updating care plans and charge nurses were responsible for care planned daily weight monitoring. Staff 5 stated she thought the health shake increase would stabilize the weight and they followed the resident at NAR.

Based on interviews and record review it was determined Staff 3 (CNA) failed to ensure a resident was transferred according to the plan of care and a fall was reported to the charge nurse for 1 of 3 sampled residents (#1). Resident 1 sustained a [MEDICAL CONDITION] after an improper transfer with delayed treatment of [REDACTED]. According to Oregon Standards and Authorized Duties for Certified Nurses Assistants [PHONE NUMBER] (6)(d) the CNA shall consistently follow the care plan as directed by the licensed nurse and [PHONE NUMBER] Conduct Unbecoming a Nursing Assistant (3)(g) Failing to communicate information regarding the client's status to the supervising nurse or other appropriate person in a timely manner. Resident 1 was a long term resident of the facility with [DIAGNOSES REDACTED]. The resident's care plan dated 7/20/12 indicated the resident required "2 person pivot transfer load with right side" with a gait belt for transfers. The resident was noted to have a flaccid left extremity and the left hand was to be placed on the resident's chest to protect it during transfers. The resident was noted to be alert and oriented to self with some confusion. The resident additionally had occasional lower back pain that was relieved with rest breaks in bed and pain medication. A facility investigation dated 9/24/12 indicated Staff 3 (CNA) informed Staff 2 (RNCM) she transferred the resident without assistance on 9/21/12. The resident's legs buckled and Staff 3 lowered the resident to the floor onto her/his right side. Staff 3 then obtained assistance from Staff 4 (CNA) to transfer the resident from the floor into the wheelchair. According to the investigation Staff 3 did not inform the charge nurse the transfer was unsuccessful and the resident was placed on the floor. The resident was taken to dinner where she/he ate and continued within her/his normal limits. The resident began to complain of leg pain on 9/22/12. The resident was treated with Tylenol and monitored for any further changes. The resident's pain increased on 9/23/12 with assessment showing no bruising, swelling or rotation of either of the resident's legs. There were no nursing staff aware of the resident's fall on 9/21/12 until the afternoon of 9/24/12 when Staff 3 reported the incident. The resident's physician was contacted, X-rays were obtained and the resident was sent to the hospital for evaluation of a [MEDICAL CONDITION] on 9/26/12. In an interview on 10/10/12 at 12:00 pm Staff 3 (CNA) indicated she knew the resident required two staff and a gait belt for all transfers. She thought she could transfer the resident quickly to the wheelchair for dinner but the resident's legs buckled and she had to lower her/him to the floor. The resident was lowered "very gently" onto her/his right side. Staff 3 stated she was sick on 9/21/12 and was not thinking straight. Staff 3 got another aide to help lift the resident back into the wheelchair. Staff 3 did not tell the charge nurse the resident was put on the floor and the resident was not assessed by the nurse. Staff 3 further indicated the resident did not complain of pain and seemed her/his usual self through dinner. Staff 3 stated she spent the weekend worried about what had happened and when she came to work on Monday 9/24/12 she went to Staff 2 (RNCM) and reported the incident. Staff 3 indicated she knew the nurse should have been told at the time of the fall. In an interview on 10/10/12 at 11:01 am Staff 4 indicated he was assisting his assigned residents when Staff 3 came and asked for help with an emergency. Staff 4 went to the resident's room and saw the resident was on the floor on her/his side. He assisted Staff 3 to lift the resident up and into the wheelchair. Staff 4 assumed the nurse had already been informed, assessed the resident and cleared the resident for transfer. Staff 4 indicated the resident did not complain of pain when he assisted to get the resident up into the wheelchair. In an interview on 10/10/12 at 10:40 am Staff 2 (RNCM) indicated the resident's care plan required two staff to assist with transfers due to the resident's height and left sided flaccidity. Staff 2 was told on 9/24/12 the resident was transferred on 9/21/12 with only one staff assisting; which resulted in the resident being lowered to the floor. Staff 2 was surprised Staff 3 (CNA) did not follow the care plan and did not inform the charge nurse of the incident. Staff 2 indicated Staff 3 was a long term and very skilled aide with no similar problems ever reported. The interviews Staff 2 conducted during the incident investigation showed nursing staff were not informed of the resident fall at the time of the occurrence. The resident had increased pain during 9/22/12 and 9/23/12 and was later found to have a [MEDICAL CONDITION]. Refer to F-323

Based on interviews and record review it was determined the facility staff failed to ensure a resident was transferred as care planned with two staff for 1 of 3 sampled residents (#1). As a result Resident 1 experienced an avoidable fall and sustained a hip fracture. Findings include: Resident 1 was a long term resident at the facility with [DIAGNOSES REDACTED]. The resident's care plan dated 7/20/12 indicated the resident required "2 person pivot transfer load with right side" with a gait belt for transfers. The resident was noted to have a flaccid left extremity and the left hand was to be placed on the resident's chest to protect it during transfers. The resident was noted to be alert and oriented to self with some confusion. The resident additionally had occasional lower back pain that was relieved with rest breaks in bed and pain medication. A facility investigation dated 9/24/12 indicated Staff 3 (CNA) informed Staff 2 (RNCM) she transferred the resident without assistance on 9/21/12. The resident's legs buckled and Staff 3 lowered the resident to the floor onto her/his right side. Staff 3 obtained assistance from Staff 4 (CNA) to transfer the resident from the floor into the wheelchair. According to the investigation Staff 3 did not inform the charge nurse the transfer was unsuccessful and the resident was placed on the floor. The resident was taken to dinner where she/he ate and continued within her/his normal limits. The resident began to complain of leg pain on 9/22/12. The resident was treated with Tylenol and monitored for any further changes. The resident's pain increased on 9/23/12 with assessment showing no bruising, swelling or rotation of either of the resident's legs. No nursing staff were aware of the resident's fall on 9/21/12 until the afternoon of 9/24/12 when Staff 3 reported the incident. The resident's physician was contacted, X-rays were obtained and the resident was sent to the hospital for evaluation of a hip fracture on 9/26/12. The September 2012 Medication Administration Record (MAR) showed the resident received Tylenol for complaints of leg/hip pain 3xs on 9/23/12, once daily on 9/24/12, refused offer of medication once on 9/25/12 and received Tylenol 2xs on 9/26/12. The resident was sent to the hospital for evaluation on 9/26/12. There were no NN's documented between 9/19/12 and 9/23/12. NN's dated 9/24/12 at 4:22 am indicated the resident complained of pain in the left hip joint. The resident was administered PRN Tylenol and stated relief was provided. The resident was noted to be calling out in pain especially with movement. The left leg was not turned outward or shorter than the right leg. There was no bruising noted and the resident was able to feel sensation on the bottom of the left foot and was monitored for further changes. NN's on 9/24/12 at 5:13 pm indicated orders were received for a pelvic X-ray for left hip pain, no pelvic fracture was found but osteopenia (bone loss) was present. An additional X-ray was completed on 9/26/12 of the left hip which showed a fracture and the resident was sent to the hospital for evaluation. A hospital discharge summary dated 9/26/12 indicated the resident had a fractured left hip which was pinned on 9/29/12. The resident was discharged back to the nursing facility on 10/1/12. Interviews conducted on 10/10/12 between 10:30 am and 12:00 PM showed: Staff 3 (CNA) indicated she knew the resident required two staff and a gait belt for all transfers. She thought she could transfer the resident quickly to the wheelchair for dinner but the resident's legs buckled and she had to lower the resident to the floor. The resident was lowered "very gently" onto her/his right side. Staff 3 got another aide to help lift the resident back into the wheelchair. Staff 3 did not tell the charge nurse the resident was put on the floor and the resident was not assessed by the nurse. Staff 3 further indicated the resident did not complain of pain and seemed her/his usual self through dinner. Staff 3 stated she spent the weekend worried about what had happened and when she came to work on Monday 9/24/12 she went to Staff 2 (RNCM) and reported the incident. Staff 3 further indicated the nurse should have been told as soon as the fall occurred. Staff 4 (CNA) indicated he was assisting his assigned residents when Staff 3 (CNA) came and asked for help with an emergency. Staff 4 went to the resident's room and saw the resident was on the floor on her/his side. He assisted Staff 3 to lift the resident up and into the wheelchair. Staff 4 assumed the nurse had already been informed, assessed and cleared the resident for transfer. Staff 4 indicated the resident did not complain of pain at the time he assisted the resident into the wheelchair. The resident required two staff for all transfers due to her/his height and weakness on the left side. Staff 4 indicated the resident's care plan reflected two staff for transfers and had for several months. Staff 5 and Staff 6 (RNs) indicated the resident required two staff assistance for all transfers. The resident was alert and oriented with some confusion but she/he could make needs known. Staff 5 worked with the resident on the evening of 9/21/12 and their were no complaints of pain. The resident's behaviors were within her/his norm. Staff 5 further indicated she was not told by any of the staff on 9/21/12 the resident had fallen. Staff 5 did not assess the resident related to the fall. When Staff 5 returned to work a few days later the resident had increased complaints of pain but no physical indications of injury. Staff 6 (RN) indicated she worked with the resident on 9/24/12 and was told the resident had some hip pain. Staff 6 assessed the resident, gave medications for pain and monitored for further changes. There was no indication of an injury. The resident's lower extremities showed no signs of bruising, rotation, swelling or shortening of either leg. Staff 6 stated she received no information the resident had fallen on 9/21/12. Towards the end of the shift on 9/24/12 Staff 2 (RNCM) received information the resident had previously fallen. The physician was notified and X-rays were requested to rule out a fracture. Staff 2 (RNCM) indicated the resident's care plan required two staff to assist with transfers due to the resident's height and left sided flaccidity. Staff 2 was told on 9/24/12 the resident was transferred on 9/21/12 with only one staff assisting (Staff 3), which resulted in the resident being lowered to the floor. Staff 2 indicated Staff 3 was a long term, skilled aide with no similar problems ever reported. The interviews Staff 2 conducted during the incident investigation showed nursing staff were not informed of the resident's fall at the time of the occurrence. The resident had increased pain during 9/22/12 and 9/23/12 and was later found to have a hip fracture.

Based on interviews and record reviews, it was determined the facility failed to follow the care plan for a resident transfer with two CNAs and a sliding board for 1 of 4 sampled residents (#1). Resident 1 sustained a fractured humerus. Findings include: The State Board of Nursing Authorized Duties and Standards for Certified Nursing Assistants states at [PHONE NUMBER] (5) (d) Follow the care plan as directed by the licensed nurse. Resident 1 was admitted in in 2003 with [DIAGNOSES REDACTED]. The 1/9/12 in-room and chart care plans indicated Resident 1 was to be transferred by two CNAs with the use of a sliding board or a sheet under the resident's thighs. The 3/20/12 quarterly MDS indicated the resident was assessed to require the extensive assistance of a two people for transfers. A 6/4/12 Nursing Facility Incident Self-Report Form indicated Resident 1 was found on 6/1/12 with swelling and bruising to her/his right arm. The resident's physician was contacted, a portable X-ray was taken and the resident was sent to the local hospital emergency department for observation. The resident was diagnosed with [REDACTED]. The facility's investigation indicated Staff 3 (RNCM) interviewed Staff 4 (RN) on 6/1/12. Staff 4 indicated she was the charge nurse on the evening shift of 5/31/12 when Staff 9 (CNA) reported he heard a "pop" sound when the resident was transferred into bed. Staff 4 (RN) stated she assessed the resident on 5/31/12 and found no visible sign of injury. Staff 4 worked the evening shift of 6/1/12 when the resident's arm was observed to be bruised and swollen. On 6/1/12, Staff 3 (RNCM) asked Staff 9 (CNA) how he transferred the resident on 5/31/12. Staff 9 stated he transferred the resident with the assistance of Staff 7 (CNA) and a pillow case under the resident's thighs. Staff 9 stated he was on the resident's right side and Staff 7 was on the resident's left side. Staff 3 (RNCM) had Staff 9 recreate the transfer on two occasions and Staff 9 provided the same information on both occasions. On 6/1/12, Staff 3 (RNCM) interviewed Staff 7 (CNA) and Staff 7 stated she was preparing the resident for the transfer when Staff 9 (CNA) picked Resident 1 up from the wheelchair in a "bear hug" and lifted her/him into bed. On 6/4/12, Staff 1 (SSD) and Staff 3 (RNCM) interviewed Staff 4 (RN). Staff 4 indicated Staff 9 (CNA) told her the CNAs heard a "pop" from under the resident's right upper arm area during a two person transfer. Staff 4 indicated on 6/1/12 at 7:15 pm she was notified by a CNA the resident's arm was observed to be swollen above the right elbow and a bruise on her/his arm. On 6/5/12, Staff 2 (DNS) interviewed Staff 7 (CNA) and Staff 7 stated she did not know why Staff 9 (CNA) transferred the resident alone. Staff 7 stated she had the resident all set up for the transfer and Staff 9 just picked the resident up and transferred her/him. Staff 7 stated this was completed before she could say anything to stop him. On 6/5/12, Staff 2 (DNS) interviewed Staff 9 (CNA) and Staff 9 stated "we were getting (her/him) transferred and heard a snap. We called (Staff 4) to look and nothing seemed wrong. Nothing was noticed until the next day." Staff 9 was asked how Resident 1 was transferred and he stated "well to be honest, I transferred (her/him) on my own. I wasn't honest at first. I gave (her/him) a big hug and picked (her/him) up. Staff 7 (CNA) was just there, but it was all me. I don't know what I wasn't honest; I guess I was just scared." Staff 9 was asked if he felt anything in the resident's arms when he transferred her/him and he stated "No, didn't feel anything, jut heard a snap. It sounded like the button on (her/his) gown coming unsnapped." An interview on 6/20/12 at 11:00 am with Staff 2 (DNS) revealed she had no additional information from the investigation of Resident 1's injury. Staff 2 verified Staff 9 (CNA) was no longer working at the facility and was reported to the state board of nursing because he failed to accurately report the transfer of the resident and failure to follow the resident's care plan for the use of a sliding board or a sheet under the resident's thighs and two CNAs. An interview on 6/20/12 at 11:32 am with Staff 3 (RNCM) revealed she had no additional information from the investigation of Resident 1's injury. An interview on 6/20/12 at 2:07 pm with Staff 7 (CNA) revealed Staff 9 (CNA) transferred the resident by himself on 5/31/12. Staff 7 stated she was preparing the resident for the transfer and Staff 9 (CNA) picked up the resident with a big hub and transferred the resident by himself. Staff 7 stated when the resident was in "mid-air" the CNAs heard a loud "pop." Staff 9 (CNA) went to tell Staff 4 (RN) of the incident who assessed the resident. Staff 7 stated the resident was not in any pain, swelling or bruising of her/his arm during the rest of the evening shift. Staff 7 stated she reported Staff 9 transferred the resident by himself and was not aware Staff 9 stated a two person transfer had been done. Staff 7 was asked if she was aware of any instance when Staff 9 failed to follow residents' care planned approaches of a two person transfer. Staff 7 stated she observed Staff 9 transferring Resident 1 by himself on one other occasion. Staff 7 was not able to state the exact date of the observation. Staff 7 stated Resident 4 required the transfer assistance of two and Staff 9 was observed to transfer the resident by himself. Staff 7 was not able to state the exact date of the observation. Staff 7 was asked if she told anyone of her observations. Staff 7 stated she told Staff 3 (RNCM). Resident 4 was admitted to the facility in 2010 with [DIAGNOSES REDACTED]. The resident's 5/30/12 quarterly MDS, nursing assessment record and progress notes contained no documentation was no evidence the resident had sustained an injury or a fall during a transfer. Attempts to interview Staff 9 (CNA) on 6/20/12 and 6/21/12 were unsuccessful. Refer to F-323.

Based on interviews and record review it was determined the facility failed to provide adequate supervision to ensure care planned interventions for a two person transfer and the use of a sliding board or a sheet under the resident's thighs for 1 of 4 sampled residents (#1). Resident 1 sustained a fractured humerus and received treatment at the local hospital emergency department. Findings include: Resident 1 was admitted in in 2003 with [DIAGNOSES REDACTED]. The 1/9/12 in-room and chart care plans indicated Resident 1 was to be transferred by two CNAs with the use of a sliding board or a sheet under the resident's thighs. The 3/20/12 quarterly MDS indicated the resident was assessed to require the extensive assistance of a two people for transfers. A 6/4/12 Nursing Facility Incident Self-Report Form indicated Resident 1 was found on 6/1/12 with swelling and bruising to her/his right arm. The resident's physician was contacted, a portable X-ray was taken and the resident was sent to the local hospital emergency department for observation. The resident was diagnosed with [REDACTED]. The facility's investigation indicated Staff 3 (RNCM) interviewed Staff 4 (RN) on 6/1/12. Staff 4 indicated she was the charge nurse on the evening shift of 5/31/12 when Staff 9 (CNA) reported he heard a "pop" sound when the resident was transferred into bed. Staff 4 (RN) stated she assessed the resident on 5/31/12 and found no visible sign of injury. Staff 4 worked the evening shift of 6/1/12 when the resident's arm was observed to be bruised and swollen. On 6/1/12, Staff 3 (RNCM) asked Staff 9 (CNA) how he transferred the resident on 5/31/12. Staff 9 stated he transferred the resident with the assistance of Staff 7 (CNA) and a pillow case under the resident's thighs. Staff 9 stated he was on the resident's right side and Staff 7 was on the resident's left side. Staff 3 (RNCM) had Staff 9 recreate the transfer on two occasions and Staff 9 provided the same information on both occasions. On 6/1/12, Staff 3 (RNCM) interviewed Staff 7 (CNA) and Staff 7 stated she was preparing the resident for the transfer when Staff 9 (CNA) picked Resident 1 up from the wheelchair in a "bear hug" and lifted her/him into bed. On 6/4/12, Staff 1 (SSD) and Staff 3 (RNCM) interviewed Staff 4 (RN). Staff 4 indicated Staff 9 (CNA) told her the CNAs heard a "pop" from under the resident's right upper arm area during a two person transfer. Staff 4 stated she immediately assessed the resident to determine the resident's ROM. When the resident's arm was raised above her/his head the resident began to say "no, no, no" which was common for the resident to say. Staff 4 indicated there was no evidence of swelling, bruising and signs of pain. Staff 4 wrote a report of the incident on the 24 hour board for the next shift to observe the resident. Staff 4 indicated she worked the evening shift of 6/1/12 and there had been no reports from the night and day shift staff of problems with the resident's arm. Staff 4 indicated on 6/1/12 at 7:15 pm she was notified by a CNA the resident's arm was observed to be swollen above the right elbow and a bruise on her/his arm. On 6/5/12, Staff 2 (DNS) interviewed Staff 7 (CNA) and Staff 7 stated she did not know why Staff 9 (CNA) transferred the resident alone. Staff 7 stated she had the resident all set up for the transfer and Staff 9 just picked the resident up and transferred her/him. Staff 7 stated this was completed before she could say anything to stop him. On 6/5/12, Staff 2 (DNS) interviewed Staff 9 (CNA) and Staff 9 stated "we were getting (her/him) transferred and heard a snap. We called (Staff 4) to look and nothing seemed wrong. Nothing was noticed until the next day." Staff 9 was asked how Resident 1 was transferred and he stated "well to be honest, I transferred (her/him) on my own. I wasn't honest at first. I gave (her/him) a big hug and picked (her/him) up. Staff 7 (CNA) was just there, but it was all me. I don't know what I wasn't honest; I guess I was just scared." Staff 9 was asked if he felt anything in the resident's arms when he transferred her/him and he stated "No, didn't feel anything, jut heard a snap. It sounded like the button on (her/his) gown coming unsnapped." An interview on 6/20/12 at 11:00 am with Staff 2 (DNS) revealed she had no additional information from the investigation of Resident 1's injury. Staff 2 verified Staff 9 (CNA) was no longer working at the facility and was reported to the state board of nursing because he failed to accurately report the transfer of the resident and failure to follow the resident's care plan for the use of a sliding board or a sheet under the resident's thighs and two CNAs. Staff 2 was not aware of any other incidents when the care planned approaches for a two person transfer and a sliding board had not been followed. An interview on 6/20/12 at 11:32 am with Staff 3 (RNCM) revealed she had no additional information from the investigation of Resident 1's injury. Staff 3 stated she was not aware of any other occasions when Staff 9 (CNA) independently transferred residents assessed to require the assistance of two CNAs. An interview on 6/20/12 at 1:25 pm with Staff 4 (RN) revealed Staff 9 (CNA) reported to her of a loud "pop" heard when Resident 1 was transferred on the evening shift of 5/31/12. Staff 4 stated she assessed the resident and determined there had been no injuries sustained by the resident. Staff 4 stated she alerted the night shift of the incident on the 24 hour board to be observant for any changes in the resident. Staff 4 stated Staff 9 (CNA) told her the resident was transferred by two CNAs. Staff 4 was not aware of any incidents when the care plan approaches for a two person transfer was not being followed. An interview on 6/20/12 at 2:07 pm with Staff 7 (CNA) revealed Staff 9 (CNA) transferred the resident by himself on 5/31/12. Staff 7 stated she was preparing the resident for the transfer and Staff 9 (CNA) picked up the resident with a big hub and transferred the resident by himself. Staff 7 stated when the resident was in "mid-air" the CNAs heard a loud "pop." Staff 9 (CNA) went to tell Staff 4 (RN) of the incident who assessed the resident. Staff 7 stated the resident was not in any pain, swelling or bruising of her/his arm during the rest of the evening shift. Staff 7 stated she reported Staff 9 transferred the resident by himself and was not aware Staff 9 stated a two person transfer had been done. Staff 7 was asked if she was aware of any instance when Staff 9 failed to follow residents' care planned approaches of a two person transfer. Staff 7 stated she observed Staff 9 transferring Resident 1 by himself on one other occasion. Staff 7 was not able to state the exact date of the observation. Staff 7 stated Resident 4 required the transfer assistance of two and Staff 9 was observed to transfer the resident by himself. Staff 7 was not able to state the exact date of the observation. Staff 7 was asked if she told anyone of her observations. Staff 7 stated she told Staff 3 (RNCM). Resident 4 was admitted to the facility in 2010 with [DIAGNOSES REDACTED]. The resident's 5/30/12 quarterly MDS, nursing assessment record and progress notes contained no documentation was no evidence the resident had sustained an injury or a fall during a transfer. On 6/20/12 at 2:30 pm, Staff 3 (RNCM) was asked if Staff 7 (CNA) informed her of the observations of Staff 9 (CNA) not following the residents' care plans regarding two person transfers. Staff 3 stated she had been told of the observations just before Staff 7 (CNA) was interviewed by the surveyor. Staff 3 stated she would expect the CNA staff to inform the supervisory nursing staff when care plans were not being followed. On 6/20/12 at 2:35 pm, Staff 2 (DNS) was informed of the surveyor's findings. Staff 2 stated she was in the process of conducting CNA meetings to address issues regarding following care plans, and the need to report problems. Staff 2 stated she would be conducting additional inservices for all of the staff. On 6/20/12 at 2:40 pm, Staff 8 (Administrator) was informed of the surveyor's findings. Staff 8 provided documentation of a CNA meeting held on 6/11/12 to address bedside care plans, reporting unsafe workplace, transfers and behavior monitoring. Staff 8 indicated there would be additional trainings provided so all of the staff were trained. Attempts to interview Staff 9 (CNA) on 6/20/12 and 6/21/12 were unsuccessful.

Based on interview and record review it was determined the facility failed to follow care planned interventions to prevent falls for 1 of 4 sampled residents (#2) who experienced falls. Resident 2 fell , sustained a fracture and was hospitalized . Findings include: The Oregon State Board of Nursing (OSBN) Scope of Practice for Licensed Practical Nurses [PHONE NUMBER] (2)(d) Implement the plan of care by: (A) Implementing treatments and therapy. Resident 2 was admitted on [DATE] following a surgical hip repair. The resident was readmitted to the facility on [DATE] with a shoulder repair following a stroke. The Resident's Active Care Plan dated 5/17/11 indicated the resident was at risk for falls related to recent surgery. Approaches to prevent falls included to assist to the toilet if resident wakes during the night to avoid self transfers. The Bedside Care Plan dated 6/13/11 related to Safety, indicated the resident was not to be left unattended on the side of the bed or on the commode. Interdisciplinary Notes dated 7/12/11 indicated the resident fell in the bathroom at 12:40 am and was sent to the hospital for an X-ray of the left hip. The investigation of the 7/12/11 fall indicated that Staff 5, LPN found the resident sitting on the edge of the bed, and the resident indicated a need to use the bathroom. Staff 5 assisted the resident to the bathroom, and then left the resident on the toilet while changing linens on the resident's bed. Staff 5 saw the resident stand up, and he told the resident to wait, but the resident fell . When the resident got back in bed, Staff 5 found a difference in the length of the resident's legs and suspected a [MEDICAL CONDITION]. "911" was activated and the resident was sent to the hospital. The resident sustained [REDACTED]. Interdisciplinary Notes dated 7/14/11 indicated the resident was in ICU following surgery. On 7/21/11 at 2:50 pm Staff 5, LPN confirmed he had left Resident 2 on the toilet while he went to the bed to change some linens. Staff 5 stated the care plan indicated the resident was not to be left alone anywhere outside the bed, and he had left the resident in the bathroom alone. Refer to F 323

Based on interview and record review it was determined the facility failed to follow care plan interventions to prevent a fall for 1 of 4 sampled residents (#2) reviewed for falls. Resident 2 fell and sustained a fracture with hospitalization . Findings include: Resident 2 was admitted on [DATE] following a surgical hip repair. The resident was readmitted to the facility on [DATE] with a shoulder repair following a stroke. The Resident's Active Care Plan dated 5/17/11 indicated the resident was at risk for falls related to recent surgery. Approaches to prevent falls included to assist to the toilet if resident wakes during the night to avoid self transfers. The Bedside Care Plan dated 6/13/11 related to Safety, indicated the resident was not to be left unattended on the side of the bed or on the commode, and floor pads were to be kept beside the bed. Interdisciplinary Notes dated 7/12/11 indicated the resident fell in the bathroom at 12:40 am and was sent to the hospital for an X-ray of the left hip. The investigation of the 7/12/11 fall indicated that Staff 5, LPN found the resident sitting on the edge of the bed, and the resident indicated a need to use the bathroom. Staff 5 assisted the resident to the bathroom, and then left the resident on the toilet while changing linens on the resident's bed. Staff 5 saw the resident stand up, and he told the resident to wait, but the resident fell . When the resident got back in bed, Staff 5 found a difference in the length of the resident's legs and suspected a hip fracture. "911" was activated and the resident was sent to the hospital. The resident sustained [REDACTED]. Interdisciplinary Notes dated 7/14/11 indicated the resident was in ICU following surgery. On 7/21/11 at 2:50 pm Staff 5, LPN confirmed he had left Resident 2 on the toilet while he went to the bed to change some linens. Staff 5 stated the care plan indicated the resident was not to be left alone anywhere outside the bed, and he had left the resident in the bathroom alone.

Based on interview and record review it was determined the facility failed to provide sufficient fluids for 1 of 4 sampled residents (#3) reviewed for dehydration. Resident 3 was sent to the emergency room and was diagnosed with [REDACTED]. Resident 3 was admitted on [DATE] with [DIAGNOSES REDACTED]. A Nutrition Risk Assessment identified abnormal lab test results completed on 7/1/11, which included a high BUN of 42, (an indicator of insufficient fluid). There was no assessment of the high BUN, and no Registered Dietitian's assessment of the resident's fluid needs. Interdisciplinary Notes on 7/18/11 indicated the resident had "3 loose stool this a.m. Appears to be mucousy ... resident very confused, diaphoretic and pale ... (BP 80/50, Pulse 80, afebrile, Respirations 18)." Fasting blood sugar was 205. The physician was notified who ordered the resident to be sent to the emergency department. Interdisciplinary Notes on 7/18/11 at 7:24 pm indicated the resident returned from the hospital with [DIAGNOSES REDACTED]. emergency room instructions regarding Dehydration in the Elderly included warning signs of "severe dehydration" as rapid, weak pulse (more than 100 at rest), cold hands and feet, loss of ability to sweat in spite of heat and temperature, rapid breathing, blue lips and confusion, lethargy (sleepy and difficult to awaken) and difficult to arouse. It was specified "To treat dehydration, you must first find and treat the cause. In the elderly, lack of fluid intake is a common cause of dehydration ...". The care plan was updated on 7/19/11 to include "Potential for dehydration related to recent onset of diarrhea." The care plan did not include signs or symptoms of rapid, weak pulse, rapid breathing, lethargy or weakness. Low blood pressure, a symptom of dehydration was not included in the care plan, even though the resident had [MEDICAL CONDITION] prior to going to the hospital. There was no evidence staff had considered causes and symptoms other than diarrhea, as factors in the resident's dehydration. On 7/21/11 at 2:20 pm Resident 3 stated fluid intake was not a problem. On 7/21/11 at 2:15 pm Staff 2 RNCM acknowledged the assessment for dehydration was not comprehensive to include fluid needs, or the causal factors of dehydration and the care plan had not been individualized with the resident's symptoms of dehydration.