Every finding on record at Milton Freewater Health and Rehabilitation

Based on interview and record review it was determined the facility failed to prevent drug diversion for 2 of 2 residents (#s 29 and 38) reviewed for misappropriation. This placed residents at risk for misappropriation of personal medications. Findings include:A facility policy regarding misappropriation dated 3/2025 stated the following:Each resident has the right to be free from misappropriation of resident property.Misappropriation of resident property includes diversion of a resident's medications for staff use or personal gain.1. Resident 38 was admitted to the facility in 2/2025 with diagnoses including loss of a lower extremity below the knee as result of frost bite.A 10/22/25 Physician Order stated hydrocodone-acetaminophen 5-325 mg to be provided as needed to address Resident 38's pain.An 11/11/25 Quarterly MDS revealed Resident 28 had normal cognitive function.Review of Resident 38's 11/2025 MAR revealed Resident 38 was documented as having received four doses of hydrocodone-acetaminophen at the following times on 11/20/25: 1:38 AM, 6:56 AM, 7:00 PM, and 11:30 PM.An 11/21/25 Grievance Form completed by Resident 38 stated her/his pain was managed by receiving one dose of her/his pain medication in the morning and one in the evening. Resident 38 stated, I don't ever ask for an extra [pain pill] because I know eventually they wont work for me anymore. Even if I need an extra, I distract myself until it is time for the regular dose.An 11/26/25 Incident Report stated Resident 38 was approached by Staff 17 (CMA) on 11/21/25 to determine if her/his pain had been reduced after she/he had received hydrocodone at 11:30 PM on 11/20/25. Resident 38 stated she/he had not requested or received additional hydrocodone medication outside of her/his normal routine on 11/20/25. After Staff 17 was provided this information, Staff 2 (DNS) was notified of the discrepancy of records and Resident 38's report and reviewed medication administration records for all residents from 10:00 PM on 11/20/25 to 3:30 AM on 11/21/25 and identified eight total residents who were reported to have requested and received PRN hydrocodone which was outside of their normal routine. Six of the eight residents were reported to be mostly non-verbal and did not have a history of requesting PRN pain medications.Attempts to interview Resident 38 were unsuccessful as Resident 38 no longer lived in the facility and did not respond to phone calls.Attempts to interview Staff 18 (RN) were unsuccessful as Staff 18 no longer worked at the facility and did not respond to phone calls. On 1/13/26 at 11:40 AM Staff 17 (CMA) stated she recalled two days when Resident 38's medication records indicated she/he required additional doses of hydrocodone which were not received by Resident 38. Staff 17 stated Resident 38 did not have any cognitive deficiencies had a routine of requesting PRN hydrocodone which was around 7:00 AM and around 7:00 PM. Staff 17 stated she notified the charge nurse and DNS after records conflicted with Resident 38's statements and routine of requesting medications.On 1/13/26 at 12:08 PM Staff 2 stated Staff 17 reported concerns of drug diversion on 11/21/25. Staff 2 stated upon review of the Controlled Substance Record Book and Resident 38's MAR, there was a discrepancy in the typical routine of medication administration for Resident 38 as well as seven additional residents. Staff 2 stated Resident 38 was asked about pain levels on the morning of 11/21/25 because records indicated she/he had requested hydrocodone-acetaminophen twice outside of her/his normal routine. Staff 2 reported Resident 38 stated she/he did not request additional medications on 11/20/25 or 11/21/25.On 1/13/26 at 12:23 PM Staff 1 (Administrator) and Staff 3 (Regional RN) confirmed misappropriation of Resident 38's medications occurred by Staff 18 on at least three administrations of pain medications. Staff 3 stated upon review of the records of eight residents, including Resident 38, a pattern of documented administration of hydrocodone-acetaminophen during the night to residents who had not requested these medications was found. Staff 1 and Staff 3 confirmed this when Resident 38 was questioned about her/his pain levels by Staff 17, and Resident 38 reported he did not request or receive additional hydrocodone on 11/20/25 or 11/21/25 from Staff 18.On 11/26/25, the deficient practice was identified by the facility and was corrected when the facility completed a root cause analysis of the incident and determined there was a pattern of drug diversion. The Plan of Correction included: 1. Staff 18 was immediately suspended and then terminated. 2. The Staff 2 and Staff 3 reviewed medication administration records for all residents to determine the pattern of drug diversion. 3. Nurses and new hires were educated about drug diversion and how to follow-up with concerns related to resident concerns with not receiving pain medications. 4. Staff 2 and Staff 4 (RNCM) monitored PRN pain medications daily to determine potential diversion. 5. Medication administration of narcotics were reviewed for non-use and discontinued medications when appropriate.2. Resident 29 was admitted in 4/2025 with diagnoses including hemiplegia (loss of motor and/or sensory function of one side of the body).A 9/30/25 Annual MDS revealed Resident 29 had normal cognitive function.An 11/4/25 Physician Order stated 5-325 mg of hydrocodone-acetaminophen was to be provided to Resident 29 as needed ever four hours to reduce her/his pain.Review of Resident 29s 11/2025 MAR revealed Resident 29 was documented to have received hydrocodone-acetaminophen on 11/21/25 at 3:36 AM from Staff 18 (RN).An 11/21/25 Grievance Form completed by Resident 29 stated Resident 29 was unable to receive a pain medication when requested on 11/21/25 around 6:30 AM. Resident 29 complained that she/he had requested a pain medication in the morning on 11/20/25 and 11/21/25 and was told it was too early. Resident 29 stated she/he usually slept through the night and would have remembered waking up during the middle of the night and requesting to receive a pain medication. Resident 29 also stated she/he would have remembered tasting the hydrocodone-acetaminophen.A 11/26/25 Incident Report stated Resident 29 requested a pain medication after she/he had woken up at 6:15 AM on 11/21/25. Resident 29 was told she/he had received this medication at 3:36 AM and was unable to receive the medication until 7:36 AM. Resident 29 stated she/he did not receive the medication at 3:36 AM and stated she/he would just have to suffer until then. Staff 17 (CMA) stated this information sounded unusual.On 1/13/26 Staff 17 stated she worked on 11/21/25 when Resident 29 requested a pain medication and Staff 18 overheard the request and chimed in stating it was too early. Staff 17 stated this was unusual. Staff 17 stated after another resident was asked about her/his pain level due to having received pain medication outside of her/his routine, she suspected potential drug diversion.On 1/13/26 at 12:08 PM Staff 2 (DNS) stated Staff 17 reported concerns of drug diversion on 11/21/25. Staff 2 stated upon review of the Controlled Substance Record Book and Resident 29's MAR, there was a discrepancy in the typical routine of medication administration for Resident 29 as well as seven additional residents. Staff 2 stated Resident 29 had requested a pain pill on 11/21/25 and was told she/he had already received one a couple hours earlier. Staff 2 stated Resident 29 stated she/he had not received a dosage of pain medication around 3:00 AM.On 1/13/26 at 12:23 PM Staff 1 (Administrator) and Staff 3 (Regional RN) confirmed misappropriation of Resident 38's pain medications occurred on 11/21/25. Staff 3 stated when drug diversion was suspected, a review of medication administration was performed for all residents and was determined to have occurred by Staff 18 on 11/21/25. Upon review of the records of eight residents, including Resident 29, a pattern of documented administration of hydrocodone-acetaminophen to residents who do not request this medication during the middle of the night was found.The deficient practice was identified as Past Noncompliance based on the following:On 11/26/25, the deficient practice was identified by the facility and was corrected when the facility completed a root cause analysis of the incident and determined there was a pattern of drug diversion. The Plan of Correction included: 1. Staff 18 was immediately suspended and then terminated. 2. The Staff 2 and Staff 3 reviewed medication administration records for all residents to determine the pattern of drug diversion. 3. Nurses and new hires were educated about drug diversion and how to follow-up with concerns related to resident concerns with not receiving pain medications. 4. Staff 2 and Staff 4 (RNCM) monitored PRN pain medications daily to determine potential diversion. 5. Medication administration of narcotics were reviewed for non-use and discontinued medications when appropriate.

Based on interview and record review it was determined the facility failed to follow physician orders for 1 of 1 sampled residents (#1) reviewed for medication administration. This placed residents at risk for adverse side effects. Findings include:Resident 1 was admitted to the facility in 9/2023 with diagnoses including pneumonia (an infection of the lungs) and unspecified convulsions.Resident 1's 11/24/25 Annual MDS indicated the resident was cognitively intact.Resident 1's 10/2025 MAR indicated the resident was to have levetiracetam (an anticonvulsant) twice a day for unspecified convulsions. Review of Resident 1's medical record revealed the following laboratory order:- 10/4/25 levetiracetam level for two days, must be done before resident takes morning dose. Review of Resident 1's 10/2025 MAR revealed she/he did not receive levetiracetam on 10/4/25, 10/5/25 and 10/6/25. Medication administration resumed on 10/7/25.The Facility's investigation dated 10/6/25 included the following:- On 10/6/25 it was noted Resident 1's levetiracetam was not active on her/his MAR.- Resident 1 was reported to have had mild seizure activity on 10/4/25 and 10/5/25 but did not require emergency treatment or hospitalization.- It was determined Staff 9 (RN) discontinued Resident 1's levetiracetam administration order on 10/3/25, the same day a laboratory order was received to check the resident's levetiracetam level.- Staff 10 (Medical Director) was notified and Resident 1's levetiracetam administration order was reinstated.- Resident 1 was placed on a 72-hour assessment alert, and no further seizure activity was observed or reported.On 1/12/26 at 10:35 AM Resident 1 stated she/he recalled having seizures in 10/2025 of last year. Resident 1 stated her/his whole body shook for several minutes, but denied experiencing any pain, distress or injury because of the seizures. The resident stated she/he was not aware of missing any doses of levetiracetam. On 1/13/26 at 1:15 PM Staff 7 (RN) stated they were notified by Staff 13 (CNA), they observed Resident 1 having a seizure. Resident 1 was assessed and found to have no adverse effects resulting from the seizure. Following Resident 1's seizure Staff 7 reviewed the MAR and found her/his levetiracetam was discontinued. Staff 7 notified both Staff 10 and Staff 2 (DNS), and Staff 10 gave verbal orders to reinstate the resident's medication order.On 1/13/26 at 1:35 PM Staff 13 stated she observed Resident 1 having a seizure while in her/his room and notified Staff 7. Staff 13 denied Resident 1 showed any signs of pain, distress, injury or lasting effects of the seizure.On 1/14/26 at 1:30 PM Staff 2 stated they investigated the incident, and it was discovered Staff 9 (RN) discontinued Resident 1's levetiracetam rather than place it on hold for a levetiracetam level blood draw as ordered. Staff 2 acknowledged the medication administration error and stated a corrective plan was immediately implemented. Multiple attempts were made to reach Staff 9 for interview but were unsuccessful. The deficient practice was identified as Past Noncompliance based on the following:On 10/6/25 the deficient practice was identified by the facility and corrected with the following actions:- One-on-one training with Staff 9 was provided on accurately entering orders into the electronic medical record.- All other residents with seizure diagnoses were reviewed and verified there were no changes to their seizure medications.- All nursing staff were provided with education on accurately entering orders into the electronic medical record. - A two-step verification process to ensure all orders were entered accurately in the electronic medical record was implemented. - The medication error was reviewed at the facility's QAA (Quality Assessment and Assurance) meeting, and no additional trends were identified.

Based on observation, interview and record review the facility failed to ensure 1 of 2 sampled residents (#13) reviewed for urinary catheter received appropriate services when staff failed to ensure catheter tubing did not touch the floor. This failure placed residents at increased risk for urinary tract infections (UTIs) and its associated complications. The Centers for Disease Control and Prevention (CDC) website's 6/27/25 Catheter-associated Urinary Tract Infection (CAUTI) Basics revealed a CAUTI occurs when germs enter the urinary tract through a urinary catheter and cause infection. Heathcare workers and facilities can prevent CAUTIs and protect patients with proper infection control processes. The CDC's undated Indwelling Urinary Catheter Insertion and Maintenance Guide instructed urine bags to be kept off the floor and for staff to incorporate observation of urinary catheter and bag into routine rounds. Resident 13 was admitted to the facility in 6/2023 with diagnoses including presence of urogenital implants (having artificial devices in the urinary or reproductive organs, often to restore function like urinary control or erectile function) and obstructive and reflux uropathy (a urinary system problem where urine flow is blocked and/or flows backward toward the kidneys). Resident 13's 11/18/25 Quarterly MDS revealed the resident was moderately cognitively impaired and had an indwelling catheter and UTI in the past 30 days.Resident 13's 11/25/25 Care Plan indicated the following:-The resident had a superpubic catheter (a tube inserted directly into the bladder through a small incision in the lower abdomen, above the pubic bone, to drain urine when normal urination is difficult or impossible). -Staff were to position the resident's catheter bag and tubing below the level of the bladder and away from entrance to the room.-Staff were to check for a catheter strap or securement device (used to hold an indwelling catheter tube or a drainage leg bag securely against the skin).A 12/20/25 Resident Infection Report indicated Resident 13 had a UTI with an Indwelling Catheter. On 1/12/26 at 7:52 AM, Resident 13 was observed in her/his room asleep in a recliner chair. The catheter tubing that extended out from the resident's leg and connected to the catheter bag that hung on the resident's walker at the end of the recliner chair was observed to be on the floor. On 1/12/26 at 9:30 AM, Resident 13 was observed in her/his wheelchair in her/his room. Resident 13 stated she/he had a UTI about a month ago and staff told her/him it was caused by the catheter. On 1/13/26 from 9:50 AM to 10:07 AM, Resident 13 was observed in her/his wheelchair in the hallway. The resident's catheter tubing was filled with clear yellow urine and observed on the floor. At 10:01 AM, an unidentified staff member provided the resident a cup of coffee and Staff 14 (CNA) was observed in the hallway at this time and entered the room next to the resident. Neither staff assisted the resident to secure her/his catheter tubing off of the floor. On 1/13/26 at 11:23 AM, Resident 13 was observed in her/his wheelchair in her/his room and the resident's catheter tubing was on the floor. At 11:25 AM, Staff 2 (DNS) entered the resident's room and assisted her/him with her/his oxygen concentrator. At 11:27 AM, Staff 14 entered the resident's room, placed the resident's meal tray on an overbed table and exited the room. At 11:32 AM, Staff 2 exited the room. Staff 2 observed the resident's catheter tubing from the hallway outside of the resident's room, confirmed it was on the floor and stated it should not be. Staff 2 stated the tubing may have become loose when we were moving around, but Staff 2 did not confirm secure placement of the tubing before she exited the room. On 1/14/26 at 3:27 PM, Resident 13 was observed in her/his room in her/his wheelchair. The resident's catheter tubing was filled with clear yellow urine and observed on the floor. On 1/15/26 at 10:22 AM, Staff 7 (RN) stated catheter tubing should never be on the floor as it placed residents at risk for infection. On 1/15/26 at 11:04 AM, Staff 5 (RN) stated Resident 13 had a superpubic catheter and she/he had been diagnosed with a couple of UTIs recently. Staff 5 stated she had observed the resident's catheter tubing on the floor during transfers and when the resident was in her/his recliner chair. Staff 5 stated staff were expected to keep catheter tubing off of the floor as it placed residents at risk for infection. On 1/15/26 at 11:16 AM, Staff 16 (CNA) stated it was not okay for catheter tubing to be on the floor, and she observed Resident 13's catheter tubing to be on the floor at least once a week. On 1/15/26 at 11:25 AM, Staff 15 (CNA) stated Resident 13 had experienced multiple UTIs lately. Staff 15 stated the resident never refused catheter care and was always concerned with the placement of her/his catheter tubing. Staff 15 stated Resident 13 required frequent checking and fixing of her/his catheter tubing. Staff 15 further stated the resident's tubing should never be on the floor as it placed her/him at risk for infection.On 1/15/26 at 12:22 PM, Staff 4 (RNCM) stated Resident 13 got UTIs too much, roughly every couple of months. Staff 4 stated Resident 13's catheter tubing was supposed to be off of the floor at all times because tubing on the floor placed the resident at increased risk of infection. On 1/15/26 at 12:39 PM, Staff 6 (IP) acknowledged the findings of this investigation and stated he expected Resident 13's catheter tubing to be off of the floor at all times and for staff to ensure proper placement of the catheter tubing with each resident interaction.

Based on observation, interview and record review it was determined the facility failed to ensure sufficient staffing to meet resident care needs for 3 of 3 residents (#s 1, 8 and 22) reviewed for sufficient and competent staffing. This placed residents at risk for delayed and unmet care needs. Findings include:1. Resident 8 was admitted to the facility in 12/2025 with diagnoses including colon cancer. Resident 8's 12/25/25 admission MDS revealed the resident was cognitively intact.Resident 8's 1/12/26 Care Plan indicated the resident was to be offered a shower each day during dayshift and she/he required assistance from two staff for showers. A review of Resident 8's Bathing Task Log from 12/20/25 to 1/13/26 revealed bathing activity did not occur on 12/20/25, 12/28/25, 1/2/26, 1/4/26, 1/6/26, 1/12/26 and 1/13/26. On 1/13/26 at 11:13 AM, Staff 14 (CNA) stated she worked dayshift at the facility, and they were short-staffed during her shift today. Staff 14 stated on days when they were short staffed, she was not able to complete all of her assigned responsibilities, including resident showers. On 1/13/26 at 1:08 PM, Staff 13 (CNA) stated she worked dayshift at the facility, and they were short-staffed during her shift today. Staff 13 stated when the facility was short-staffed, resident care was rushed and resident showers were especially impacted. Staff 13 stated today has been overwhelming and showers were not happening because we were so busy. On 1/13/26 at 1:23 PM, Staff 11 (CNA) stated when the facility was short-staffed, like today, it is really hard and 'there are things that don't get done, including showers. On 1/13/26 at 3:00 PM, Staff 19 (CNA) stated the facility was short-staffed all of the time which made it difficult to complete resident showers. On 1/14/26 at 10:42 AM, Staff 5 (RN) stated the facility was short a CNA at least weekly and the biggest area of resident care that was impacted was residents not getting showers. Staff 5 further stated when staff were unable to assist a resident with a shower or bed bath on the resident's scheduled day, the resident had to wait until their next scheduled day to receive a shower or bed bath. On 1/14/26 at 12:48 PM, Staff 11 (CNA) stated when she marked a bathing activity did not occur on a resident's Bathing Task Log that indicated she did not have time and could not complete the task. On 1/14/26 at 12:52 PM, Resident 8 was observed in her/his room in bed. Resident 8 stated she/he was scheduled to receive a bed bath on 1/13/26 but she/he was not offered one. Resident 8 further stated she/he received bed baths once a week but preferred to have them more often. On 1/14/26 at 1:08 PM, Staff 14 (CNA) stated she marked a bathing activity did not occur on a resident's Bathing Task Log when the facility was short-staffed and there was not time to offer a shower or bed bath to a resident. On 1/14/26 at 3:12 PM, Staff 8 (RN) stated resident showers were the biggest thing affected when the facility was short-staffed. Staff 8 further stated when staff were unable to assist a resident with a shower or bed bath on the resident's scheduled day, the resident had to wait until their next scheduled day to receive a shower or bed bath. On 1/15/26 at 1:21 PM, Staff 2 (DNS) acknowledged Resident 8 did not receive her/his showers as indicated in her/his care plan, and she expected resident showers to be completed even when the facility was short-staffed. Staff 2 further stated she expected residents to be offered a shower or bed bath the next shift or the next day if staff were unable to complete them as scheduled. 2. Resident 22 was admitted to the facility in 12/2025 with diagnoses including lymphedema (chronic swelling from a buildup of lymph fluid in soft tissues, usually the arms or legs).Resident 22's 12/11/25 admission MDS revealed the resident was cognitively intact.Resident 22's 1/13/26 Care Plan indicated the following:-The resident preferred a shower or a bed bath.-The resident's scheduled bathing days were dayshift on Tuesdays and evening shift on Fridays. A review of Resident 22's Bathing Task Log from 12/15/25 to 1/13/26 revealed a bathing activity did not occur on 12/30/25, 1/3/26 or 1/13/26.On 1/13/26 at 11:13 AM, Staff 14 (CNA) stated she worked dayshift at the facility, and they were short-staffed during her shift today. Staff 14 stated on days when they were short staffed, she was not able to complete all of her assigned responsibilities, including resident showers. On 1/13/26 at 1:08 PM, Staff 13 (CNA) stated she worked dayshift at the facility, and they were short-staffed during her shift today. Staff 13 stated when the facility was short-staffed, resident care was rushed and resident showers were especially impacted. Staff 13 stated today has been overwhelming and showers were not happening because we were so busy. On 1/13/26 at 1:23 PM, Staff 11 (CNA) stated when the facility was short-staffed, like today, it is really hard and 'there are things that I don't get done, including showers. On 1/13/26 at 2:06 PM, Resident 22 was observed in her/his room in her/his wheelchair. Resident 22 stated the facility was short-handed so she/he did not always receive her/his scheduled showers or bed baths. Resident 22 stated she was scheduled to receive a shower today and she/he wanted one. On 1/13/26 at 3:00 PM, Staff 19 (CNA) stated the facility was short-staffed all of the time which made it difficult to complete resident showers. On 1/14/26 at 8:51 AM, Resident 22 stated she/he did not receive either a shower or bed bath on 1/13/26 nor was she/he offered one. On 1/14/26 at 10:42 AM, Staff 5 (RN) stated the facility was short a CNA at least weekly and the biggest area of resident care that was impacted was residents not getting showers. Staff 5 further stated when staff were unable to assist a resident with a shower or bed bath on the resident's scheduled day, the resident had to wait until their next scheduled day to receive a shower or bed bath. On 1/14/26 at 12:48 PM, Staff 11 (CNA) stated when she marked a bathing activity did not occur on a resident's Bathing Task Log that indicated she did not have time and could not complete the task. On 1/14/26 at 1:08 PM, Staff 14 (CNA) stated she marked a bathing activity did not occur on a resident's Bathing Task Log when the facility was short-staffed and there was not time to offer a shower or bed bath to a resident. On 1/14/26 at 3:12 PM, Staff 8 (RN) stated resident showers were the biggest thing affected when the facility was short-staffed. Staff 8 further stated when staff were unable to assist a resident with a shower or bed bath on the resident's scheduled day, the resident had to wait until their next scheduled day to receive a shower or bed bath. On 1/15/26 at 1:21 PM, Staff 2 (DNS) acknowledged Resident 22 did not receive her/his showers as scheduled, and she expected resident showers to be completed even when the facility was short-staffed. Staff 2 further stated she expected residents to be offered a shower or bed bath the next shift or the next day if staff were unable to complete them as scheduled. 3. Resident 1 was admitted to the facility in 9/2023 with diagnoses including hemiplegia (total paralysis on one side of the body) and hemiparesis (partial weakness on one side) following a stroke. Resident 1's 11/24/25 Annual MDS revealed the resident was cognitively intact and dependent on the assistance from staff for all bathing activities. Resident 1's 12/18/25 Care Plan revealed the resident was to receive a bed bath or shower twice weekly on Tuesdays and Fridays. A review of Resident 1's Bathing Task Log from 12/15/25 to 1/13/26 revealed a bathing activity did not occur on 1/13/26. On 1/13/26 at 11:13 AM, Staff 14 (CNA) stated she worked dayshift at the facility, and they were short-staffed during her shift today. Staff 14 stated on days when they were short staffed, she was not able to complete all of her assigned responsibilities, including resident showers. On 1/13/26 at 1:08 PM, Staff 13 (CNA) stated she worked dayshift at the facility, and they were short-staffed during her shift today. Staff 13 stated when the facility was short-staffed, resident care was rushed and resident showers were especially impacted. Staff 13 stated today has been overwhelming and showers were not happening because we were so busy. On 1/13/26 at 1:23 PM, Staff 11 (CNA) stated when the facility was short-staffed, like today, it is really hard and 'there are things that I don't get done, including showers. On 1/13/26 at 3:00 PM, Staff 19 (CNA) stated the facility was short-staffed all of the time which made it difficult to complete resident showers. On 1/14/26 at 10:42 AM, Staff 5 (RN) stated the facility was short a CNA at least weekly and the biggest area of resident care that was impacted was residents not getting showers. Staff 5 further stated when staff were unable to assist a resident with a shower or bed bath on the resident's scheduled day, the resident had to wait until their next scheduled day to receive a shower or bed bath. On 1/14/26 at 12:48 PM, Staff 11 (CNA) stated when she marked a bathing activity did not occur on a resident's Bathing Task Log that indicated she did not have time and could not complete the task. On 1/14/26 at 1:08 PM, Staff 14 (CNA) stated she marked a bathing activity did not occur on a resident's Bathing Task Log when the facility was short-staffed and there was not time to offer a shower or bed bath to a resident. On 1/14/26 at 2:43 PM, Resident 1 was observed in her/his room in bed. Resident 1 stated she/he was scheduled to receive a bed bath on 1/13/26 but she/he was not offered one. Resident 1 stated she/he would have liked to have had one yesterday and will have to wait to receive one until her/his next scheduled day. On 1/14/26 at 3:12 PM, Staff 8 (RN) stated resident showers were the biggest thing affected when the facility was short-staffed. Staff 8 further stated when staff were unable to assist a resident with a shower or bed bath on the resident's scheduled day, the resident had to wait until their next scheduled day to receive a shower or bed bath. On 1/15/26 at 1:21 PM, Staff 2 (DNS) acknowledged Resident 1 did not receive her/his showers as scheduled, and she expected resident showers to be completed even when the facility was short-staffed. Staff 2 further stated she expected residents to be offered a shower or bed bath the next shift or the next day if staff were unable to complete them as scheduled. Refer to M185.

Based on observation, interview and record review it was determined the facility failed to ensure residents were free from unnecessary antibiotic medications for 1 of 5 sampled residents (#22) reviewed for unnecessary medications. This placed residents at risk for the development of antibiotic-resistant organisms and other serious infections. Findings include: The facility's 3/2018 Antimicrobial Stewardship Program Policy directed the following:-Applicable SBAR (Situation, Background, Assessment and Recommendation, a structured communication tool used by healthcare professionals to quickly and effectively convey critical patient information) tools are utilized to guide clinicians in the evaluation of clinical signs and symptoms potentially indicative of infection. -The clinical rationale to support the use of antibiotics, if using outside current clinical guidelines, is to be documented.-Communication with the resident and/or resident representative regarding the treatment plan and appropriate use of antibiotics is to be documented. -The DNS or IP is to collaborate with providers and Medical Director regarding resident clinical status and current treatment, communicating inappropriate treatment and need for alternative as needed.-Antibiotics are to be stopped when not pertinent or appropriate. Resident 22 was admitted to the facility in 12/2025 with diagnoses including congestive heart failure. Resident 22's 12/11/25 admission MDS revealed the resident was cognitively intact.A 12/26/25 Progress Note revealed Resident 22 was placed on alert charting related to the resident's complaint of a nonproductive cough. A review of Resident 22's clinical record from 12/26/25 to 1/4/26 revealed the resident received Mucinex (an over-the-counter medicine used for cough, cold and flu symptoms) for cough congestion each day. The clinical record further indicated she/he was afebrile (without fever), not short of breath and not observed to cough. A 1/4/26 Progress Note written by Staff 9 (RN) revealed Staff 10 (Medical Director) was notified of the following:-Resident 22 informed Staff 9 she/he had been coughing since 12/5/25 and the cough medicine she/he received was ineffective.-Resident 22 reported she/he had been coughing up brown sputum (mucus coughed up from the lungs and lower airways).-Wheezing was noted in the resident's lungs.-The resident's vital signs were stable and the resident did not have a fever.-The resident requested antibiotics. Resident 22's 1/2026 MARs revealed the resident received doxycycline (a broad-spectrum antibiotic) twice daily from 1/5/26 to 1/10/26 for MD ordered for 5 days. On 1/14/26 at 8:51 AM, Resident 22 was observed in her/his room in bed. Resident 22 stated Staff 10 prescribed her/him an antibiotic a few weeks ago per her/his request. On 1/14/26 at 10:13 AM and 1:14 PM, Staff 5 (RN) stated Staff 10 ordered doxycycline for Resident 22 due to the resident's complaints of a cough and not feeling well. Staff 5 stated she recalled the resident to have a dry and non-productive cough with stable vital signs at the time the antibiotics were prescribed. On 1/14/26 at 10:52 AM, Staff 10 stated he prescribed doxycycline to Resident 22 because staff reported to him the resident was short of breath, had sputum production and had a fever. Staff 10 stated in the absence of these symptoms, he still would have prescribed the resident the antibiotic if she/he had diagnoses of asthma, COPD (Chronic Obstructive Pulmonary Disease) or something like that. Staff 10 further stated it would be a little more iffy to prescribe an antibiotic to a resident without either of these diagnoses and the only observed symptom being a non-productive cough. No evidence was found in Resident 22's clinical record to indicate she/he had diagnoses of asthma or COPD. On 1/14/26 at 1:03 PM, Staff 11 (CNA) stated she did not recall Resident 22 to cough or complain of a cough. Staff 11 further stated the resident always seemed like her/himself since her/his admission to the facility, and she did not recall any concerns with the resident's vital signs. On 1/14/26 at 2:50 PM Staff 8 (RN) stated she recalled Resident 22 to have a cough in 12/2025 but it seemed to get better. Staff 8 stated the resident was worried about a cough and requested to be on an antibiotic. Staff 8 further stated the resident's vital signs were within normal limits and she/he did not have a fever at the time the doxycycline was prescribed. On 1/14/26 at 3:52 PM, Staff 12 (CNA) stated she had never observed Resident 22 to cough.On 1/15/26 at 9:06 AM, Staff 9 (RN) stated Resident 22 reported to her on 1/4/26 she/he had been coughing stuff up and it was brown. Staff 9 stated the resident's vitals were fine, she had only observed Resident 22 to have a dry cough, and when she listened to the resident's lungs on 1/4/26, she did not hear any crackles (popping, bubbling, or rattling sounds that often signal fluid in the lungs, pneumonia or bronchitis), just some wheezing. Staff 9 further stated she did not use any type of clinical tool to gather and report symptoms to Staff 10, and Resident 22 received an order for the doxycycline because she/he asked for it. On 1/15/26 at 11:50 AM, Staff 4 (RNCM) stated she was unsure if nurses utilized a tool to evaluate clinical signs and symptoms to indicate a possible respiratory infection when providing a report of a resident's clinical status to their medical provider. Staff 4 stated the criteria for prescribing an antibiotic for a respiratory infection included a fever, low oxygen saturations, results from an x-ray that indicated pneumonia and overall risk of symptoms to the resident. Staff 4 stated the only indication for Resident 22's antibiotic prescription was a cough. On 1/15/26 at 12:30 PM, Staff 6 (IP) stated Resident 22 received an order for doxycycline because she/he requested the antibiotic, and a cough was not a sufficient indication for its' use. Staff 6 stated an x-ray should have been ordered, facility staff should have followed up with Staff 10 to challenge the antibiotic order and education should have been provided to the resident regarding the use of antibiotics unnecessarily.

Based on interview and record review, it was determined the facility failed to follow care planned interventions related to transfers for 1 of 3 sampled residents (#13) reviewed for safety. As a result, Resident 13 experienced an injury of unknown origin and internal bleeding, which required hospitalization and a blood transfusion. Findings include: Resident 13 was admitted to the facility in 4/2025 with diagnoses including acute post-hemorrhagic anemia (a condition where a person experiences a rapid decrease in red blood cells and hemoglobin due to significant blood loss) and dysphagia (difficulty swallowing). Resident 13's MDS Quarterly dated 7/7/25 revealed a BIMS score of 4, indicating severe cognitive impairment. Resident 13's care plan dated 7/13/25 revealed she/he was completely dependent for transfers and required a two person assist with a mechanical lift (Hoyer sling). On 7/29/25 and 7/30/25, two public complaints were received by the State Survey Agency (SSA) which stated Resident 13 received an injury of unknown origin on her/his chest area and the resident experienced significant bruising and swelling at the chest area. On 8/5/25 at 5:14 PM, Witness 1 (Complainant) stated paramedics were called to the facility on 7/29/25, where the facility reported Resident 13's hemoglobin level was low and the resident was lethargic. Witness 1 was told the resident was involved in a Hoyer accident on 7/24/25 and sustained bruising on her/his arm. Witness 1 stated no other information was provided by staff. When Resident 13 arrived at the ED, Witness 1 stated he observed the resident had significant bruising across her/his chest, upper abdomen and back, the bruises on the resident's upper abdominal area were black, dark purple and blue and wrapped around to the resident's back. Witness 1 stated the injuries looked like an injury where someone was hit by a car.if there's any sort of trauma and someone's on a blood thinner, she/he needed to go out when it happened. You don't know what's going on internally, she/he could have had significant injury to her/his organs. On 8/6/25 at 8:45 AM, Witness 2 (Complainant) stated nursing staff at the facility observed Resident 13 on 7/26/25 after the day shift nurse came on and received report from the NOC nurse. Witness 2 stated the nurses observed the resident's left breast area to be swollen almost four times the size the area normally was, the whole area was black and blue and bruising was observed down to mid rib on the resident's back. The resident appeared to be in severe pain, so the day shift nurse immediately asked another nurse (Staff 4 - RN) to examine Resident 13. Staff 4 examined the resident's injuries, stated the resident looked as if she/he had fallen and should be sent out. Witness 2 stated Staff 2 (DNS) and Staff 3 (RNCM) were notified, examined Resident 13 but decided not to send her/him to the hospital. Witness 2 stated the resident was given ice packs for the swelling and scheduled pain medication. Witness 2 later learned Resident 13's blood test/lab results indicated Resident 13's hemoglobin and hematocrit counts were at critically low levels, requiring hospitalization and blood transfusions. On 8/6/25 at 11:45 AM, Staff 11 (CNA) stated she provided care for Resident 13 several times. She stated the resident was totally dependent for everything and had been care planned as a two person Hoyer transfer for about two weeks. Prior to that, staff used a sit to stand lift for the resident. Staff 11 stated she had worked the day shift on 7/24/25 and assisted Resident 13 to get up and dressed for breakfast. She recalled she and another CNA used the Hoyer because the resident appeared weak and in pain. She stated the resident did not have any injuries that morning and was certain because she had changed the resident's shirt.On 8/6/25 at 12:31 PM, Staff 4 (RN) stated he came to work for day shift on 7/25/25. He stated another nurse asked him to examine Resident 13's left breast area and stated the resident's left breast area was swollen to three times the size of the right breast, was engorged and hard to palpate. He noticed a lump on the size of the breast that was firm to the touch and stated the resident had bruising on the left side of her/his abdomen. Staff 4 stated he was told the resident was transferred with the sit to stand, screamed while being transferred and the incident was reported to the evening shift nurse. Staff 4 stated at that point, Staff 1, Staff 2 and Staff 3 took it from there. On 8/6/25 at 3:06 PM, Staff 13 (CNA) stated on 7/24/25 she assisted Staff 14 with transferring Resident 13 using the sit to stand a little before 5:00 PM. She recalled the resident was placed in the sit to stand, the straps were on, the resident's feet were positioned correctly and the resident grabbed the bar. Staff 13 and Staff 14 stood Resident 13 up and the resident stated shit loudly, which was unusual for the resident. Staff 13 stated she noticed the resident was already tired when they transferred her but did not notice anything else. On 8/6/25 at 4:17 PM Staff 5 (LPN) confirmed she worked the evening shift on 7/24/25. She stated she wasn't made aware of the resident's injury until the CNAs told her the resident was transferred into her/his chair and to bed when they noticed the significant bruising. Staff 5 stated the CNAs stated the resident stated ouch when she/he was getting ready for dinner and later was seen leaning to the left side. She stated the bruise was already a deep, dark color, the whole left side flank from [her/his] armpit to the belly button and around to the back, almost to the spine. The breast was huge, hard and had and dark blue bruise. Staff 5 stated she decided to use the hoyer to put the resident in bed, turned her/him to the right side and used ice for the injury. She stated the injury was reported to NOC shift who passed it on to day shift on 7/25/25. Efforts to contact Staff 14 on 8/6/25 and 8/7/25 were unsuccessful. On 8/7/25 at 10:45 AM, Staff 1 (Administrator) stated on 7/25/24 he, Staff 2 and the CNAs re-enacted what happened and they thought the harness in the sit to stand might have caught the resident's left breast when she/he was transferred for dinner and the injury was exacerbated by the blood thinner. On 8/7/25 at 10:45 AM, Staff 2 stated when she examined Resident 13 on 7/25/25, the bleeding had spread below the resident's breast area. She and Staff 3 examined the resident and did not feel the resident sustained a deep tissue injury. A 7/25/24 at 9:23 AM progress note written by Staff 3 stated reported that during sit to stand transfer last evening that the resident called out in pain. On exam no injury was noted at that time, night RN was notified. On RN exam this am the resident was noted to have large area of bruising, swelling and discomfort to left breast extending under left arm/lateral chest. The note further stated the facility provider was notified and the recommendation was to discontinue the anticoagulant and use ice packs on the affected area. No nursing notes were written on 7/26/25; notes from 7/27/25 through 7/29/25 revealed the swelling to the affected area continued, the resident was painful and nursing staff continued to hold the anticoagulant and apply ice packs. No provider notes were observed in the resident's chart during the time frame. On 7/29/25 at 2:06 PM, a nursing note revealed the facility was contacted by laboratory staff, who informed staff the resident's hematocrit (the percentage of red blood cells in a blood sample) and hemoglobin (proteins in red blood cells that carry oxygen throughout the body) levels were critically low. The facility's provider was contacted and recommended the resident be sent to the ED. Hospital ED records dated 7/29/25 diagnosed Resident 13 with acute blood loss anemia from left side torso hematoma/contusion exacerbated by anticoagulant use for secondary stroke prevention with possible splenic infarct (a condition in which blood flow supply to the spleen is compromised and can cause tissue death in the spleen). Two units of PRBC (packed red blood cells) were ordered and transfused. Resident 13 was discharged from the hospital on 7/31/25 and returned to the facility. She/he was observed on 8/6/25 at 11:33 AM but was not interviewed due to her/his cognitive status. A large green colored bruise was observed on the resident's left upper arm area. On 8/7/25 at 10:45 AM, Staff 1, Staff 2 and Staff 3 were informed of the findings of staff not following Resident 13's care plan for transferring a resident with a Hoyer lift instead of a sit to stand.

Based on interview and record review it was determined the facility failed to protect the resident's right to be free from abuse for 1 of 4 sampled residents (#11) reviewed for abuse. This placed residents at risk for abuse and psychosocial harm. Findings include: The facility's Abuse Policy, updated in 3/2025, defined abuse as the willful infliction of injury with resulting physical harm, pain or mental anguish. Physical abuse was defined as hitting, slapping, punching, choking, pinching, biting, kicking, throwing objects, grabbing and shoving.Resident 10 admitted to the facility in 2018 with diagnoses including stroke and dysphagia (inability to swallow). Resident 10's MDS Quarterly dated 11/7/24 revealed a BIMS score of 99, indicating the assessment could not be completed. Resident 10's Care Plan revised on 12/29/24, revealed she/he had verbal and physical aggression toward others and behaviors such as pulling or knocking things off walls and counters and unsafe behaviors during mealtime. Care plan interventions included providing distractions, to monitor and cue the resident at all times during meals. Resident 11 admitted to the facility in 2023 with diagnoses including hypertension and atrial fibrillation (an irregular, fast heartbeat).Resident 11's MDS Quarterly dated 8/23/24 revealed a BIMS score of 14, indicating no cognitive impairment. The MDS indicated Resident 11 had no behavioral issues. On 9/23/24, the State Survey Agency (SSA) received a FRI which indicated on 9/22/24, Resident 10 grabbed a beverage bottle from Resident 11's cup holder and threw it at Resident 11. The bottle struck Resident 11 in the face, hit the resident's eyeglasses and she/he sustained a small cut on the bridge of her/his nose. The report indicated all staff were in resident rooms providing care to other residents. On 8/6/25 at 2:53 PM, Staff 12 (CNA) stated she remembered Resident 10 and Resident 11 had several altercations because Resident 10 accused Resident 11 of stealing her/his wallet and wanted to fight. She stated the incidents went from bad to worse and at some point Resident 10 was placed on one on one supervision but did not recall when that occurred. She recalled Resident 10 assaulted people, tried to run over staff's toes, turned hall lights off and on and threw things. On 8/7/25 at 9:08 AM, Staff 15 (RN) stated Resident 10 was aggressive, knocked pictures and objects off the walls, cursed at residents and was sexually inappropriate with staff. She stated she witnessed interactions between Resident 10 and Resident 11 where they cursed and threatened each other. She stated after the 9/22/24 incident, Resident 10 was placed on one on one supervision. Residents 10 and 11 were not interviewed due to their discharge from the facility. A risk management report was initiated by nursing staff on 9/22/24 which noted Resident 11 was observed to have a cut on her/his nose and first aid was provided. Review of Resident 10's nursing notes from 6/2024 through 9/2024 revealed she/he initiated several incidents with Resident 11 and other residents at the facility, including throwing punches at Resident 11 and staff. No physical harm to residents was determined in each of the incidents. On 8/7/25 at 11:05 AM, Staff 1 (Administrator) confirmed the incident occurred on 9/22/24.

Based on interview and record review it was determined the facility failed to report an injury of unknown origin to the appropriate State agency within state mandated timelines for 1 of 3 sampled residents (#13) reviewed for accidents and falls. Findings include: Resident 13 was admitted to the facility in 4/2025 with diagnoses including acute post-hemorrhagic anemia (a condition where a person experiences a rapid decrease in red blood cells and hemoglobin due to significant blood loss) and dysphagia (difficulty swallowing). Resident 13's MDS Quarterly dated 7/7/25 revealed a BIMS score of 4, indicating severe cognitive impairment. Resident 13's care plan dated 7/13/25 revealed she/he was completely dependent for transfers and required a two person assist with a Hoyer sling. On 7/29/25 and 7/30/25, two public complaints were received by the State Survey Agency (SSA) which stated Resident 13 had received an injury of unknown origin on her/his chest area and the resident experienced significant bruising, swelling at the chest area and was not sent to the hospital for several days after the injuries were apparent.NO FRI's were received by the SSA regarding the injury. On 8/6/25 at 12:31 PM, Staff 4 (RN) stated he came to work for day shift on 7/25/25. He stated another nurse asked him to examine Resident 13's chest area, and stated the resident's left breast area was swollen to three times the size of the right breast, was engorged and hard to palpate. He noticed a lump on the side of the breast that was firm to the touch and stated the resident had bruising on the left side of her/his abdomen. Staff 4 stated he was told the resident was transferred with the sit to stand, screamed while being transferred and the incident was reported to the evening shift nurse. At that point Staff 4 stated he went to his office and sent a note to Staff 1 (Administrator) and Staff 2 (DNS) because he thought the injury should be reported. Staff 4 stated at that point Staff 1, Staff 2 and Staff 3 (RNCM) took it from there. On 8/7/25 at 10:45 AM, Staff 1 (Administrator), Staff 2 (DNS) and Staff 3 (RCM) were notified of the findings they did not report Resident 13's injury of unknown origin to the SSA.

Based on interview and record review, it was determined the facility failed to respond to a change of condition related to anticoagulant use for 1 of 3 sampled residents (#13) reviewed for change of condition. This placed residents at risk for adverse side effects of anticoagulant use. Findings include: According to Drugs.com https://www.drugs.com/, serious side effects of anticoagulant medication include bleeding, with common adverse reactions including anemia, hemorrhage, and nausea.Resident 13 was admitted to the facility in 4/2025 with diagnoses including acute post-hemorrhagic anemia (a condition where a person experiences a rapid decrease in red blood cells and hemoglobin due to significant blood loss) and dysphagia (difficulty swallowing). Resident 13's MDS Quarterly dated 7/7/25 revealed a BIMS score of 4, indicating severe cognitive impairment. Resident 13's care plan dated 7/13/25 revealed she/he was completely dependent for transfers and required a two person assist with a mechanical lift (Hoyer sling). The care plan also indicated the resident received an anticoagulant (blood thinner) for her/his anemia. On 7/29/25 and 7/30/25, two public complaints were received by the State Survey Agency (SSA) which stated Resident 13 had received an injury of unknown origin on her/his chest area and the resident experienced significant bruising, swelling at the chest area and was not sent to the hospital for several days after the injuries were apparent. Both complainants stated the resident was on anticoagulant medication (blood thinner) and should have been sent to the hospital immediately after the significant bruising was discovered. On 8/5/25 at 5:14 PM, Witness 1 (Complainant) stated paramedics were called to the facility on 7/29/25 and the facility reported Resident 13's hemoglobin level was low and the resident was lethargic. Witness 1 was told the resident was involved in a Hoyer accident on 7/24/25 and sustained bruising on her/his arm. Witness 1 stated no other information was provided by staff. When Resident 13 arrived at the ED, Witness 1 stated he observed the resident had significant bruising across her/his chest, upper abdomen and back, the bruises on the resident's upper abdominal area were black, dark purple and blue and wrapped around to the resident's back. Witness 1 stated the injuries looked like an injury where someone was hit by a car.if there's any sort of trauma and someone's on a blood thinner, she/he needed to go out when it happened. You don't know what's going on internally, she/he could have had significant injury to her/his organs. On 8/6/25 at 8:45 AM, Witness 2 (Complainant) stated nursing staff at the facility observed Resident 13 on 7/26/25 immediately after the day shift nurse came on and received report from the NOC nurse. Witness 2 stated the nurses observed the resident's left breast area to be swollen almost four times the size the area normally was, the whole area was black and blue and bruised down to mid rib on the resident's back. The resident appeared to be in severe pain, so the day shift nurse immediately asked another nurse (Staff 4 - RN) to examine Resident 13. Staff 4 examined the resident's injuries, stated the resident looked as if she/he had fallen and should be sent out. Witness 2 stated Staff 2 (DNS) and Staff 3 (RNCM) were immediately notified, examined Resident 13 but decided not to send her/him to the hospital. Witness 2 stated the resident was given ice packs for the swelling and scheduled pain medication. Witness 2 later learned Resident 13's blood test results revealed critical levels, requiring hospitalization and blood transfusions. On 8/6/25 at 12:31 PM, Staff 4 stated he came to work for day shift on 7/25/25. He stated another nurse asked him to examine Resident 13's chest area, and stated the resident's left breast area was swollen to three times the size of the right breast, was engorged and hard to palpate. He noticed a lump on the size of the breast that was firm to the touch and stated the resident had bruising on the left side of her/his abdomen. Staff 4 stated he was told the resident was transferred with the sit to stand, screamed while being transferred and the incident was reported to the evening shift nurse. Staff 4 then saw Staff 1 (Administrator) and told Staff 1 he thought Resident 13 should be sent out due to the resident's bruising and pain. Staff 4 stated at that point Staff 1, Staff 2 and Staff 3 took it from there.On 8/6/25 at 4:17 PM. Staff 5 (LPN) confirmed she worked the evening shift on 7/24/25. She stated she wasn't made aware of the resident's injury until the CNAs told her the resident was transferred into her/his chair and to bed when they noticed the significant bruising. Staff 5 stated the CNAs stated the resident stated ouch when she/he was getting ready for dinner and later was seen leaning to the left side. She stated the bruise was already a deep, dark color, the whole left side flank from her/his armpit to the belly button and around to the back, almost to the spine. The breast was huge, hard and had a dark blue bruise. Staff 5 stated I should have sent [her/him] out when she observed the resident's injury. On 8/7/25 at 10:45 AM, Staff 2 (DNS) stated when she examined Resident 13 on 7/25/25, the bleeding had spread below the resident's breast area. She and Staff 3 examined the resident and did not feel the resident sustained a deep tissue injury.A 7/25/25 at 9:23 AM progress note written by Staff 3 stated reported that during sit to stand transfer last evening that the resident called out in pain. On exam no injury was noted at that time, night RN was notified. On RN exam this am the resident was noted to have large area of bruising, swelling and discomfort to left breast extending under left arm/lateral chest. The note further stated the facility provider was notified and the recommendation was to discontinue the anticoagulant and use ice packs on the affected area. The facility provided documentation those orders were followed. There was no documented evidence in Resident 13's nursing notes the injury was monitored or assessed on 7/26/25.On 7/28/25 at 11:18 AM an order was input for a comprehensive metabolic panel (CMP) test to be completed due to the resident's infection at the site of an IV line in her/his arm. No nursing notes were observed to contain any further communication with the facility provider until 7/29/25.On 7/29/25 at 2:06 PM, a nursing note revealed the facility was contacted by laboratory staff, who informed staff the resident's hematocrit (the percentage of red blood cells in a blood sample) and hemoglobin (proteins in red blood cells that carry oxygen throughout the body) levels were critically low. The facility's provider was contacted and recommended the resident be sent to the ED.Hospital ED records dated 7/29/25 diagnosed Resident 13 with acute blood loss anemia from left side torso hematoma/contusion exacerbated by anticoagulant use for secondary stroke prevention with possible splenic infarct (a condition in which blood flow supply to the spleen is compromised and can cause tissue death in the spleen). Two units of PRBC (packed red blood cells) were ordered and transfused. On 8/7/25 at 10:45 AM, Staff 1, Staff 2 and Staff 3 were informed of the findings of staff not responding to a resident's change of condition related to anticoagulant use.

Based on observation, interview and record review it was determined the facility failed to ensure there was sufficient nursing staff available to provide the necessary care and services to meet residents' needs in 1 of 1 facility reviewed for staffing. This placed residents at risk for unmet care needs. Findings include: On 6/23/24 the facility had a census of 26 residents. On 6/27/24, Staff 2 (DNS) provided a list of residents who: -Required two-person mechanical lift transfers: 13; -Required one or two-person extensive or total assistance for bathing: 21; -Required one or two-person extensive or total assistance for toileting: 18; -Required one or two-person extensive or total assistance for dressing: 22; -Required two person assistance at all times for all care: 3; -Had behavioral healthcare needs which required monitoring: 19; -Were at risk for elopement: 5. Observations from 6/23/24 through 6/27/24 between the hours of 8:00 AM and 11:15 PM revealed multiple times when no CNA staff were visualized in the hallways for up to 30 minutes. On 6/23/24 at 12:34 PM, Resident 2 stated there were staffing issues on evening and night shift. Resident 2 stated, at times, there was only one nurse and one CNA scheduled which resulted in long call light response times. On 6/23/24 at 1:35 PM, Resident 27 stated the facility was often short staffed, especially at night. Resident 27 stated recently it took staff so long to answer her/his call light, she/he began crying. Resident 27 stated she/he was incontinent and often waited up to 30 minutes to have her/his brief changed. Resident 27 stated she/he no longer used the call light because the wait was so long and she/he got up by herself/himself even though she/he was not supposed to. On 6/23/24 at 2:16 PM, Resident 10 stated evening and night shift staffing was not good. Resident 10 stated she/he waited up to 30 minutes for her/his call light to be answered, at times. On 6/23/24 at 3:13 PM, Resident 26 stated she/he did not typically require pain medication but on this date she/he had pain and requested pain medication. Resident 26 stated it took one hour and five minutes before pain medication was administered. On 6/24/24 at 1:33 PM, Witness 1 (Complainant) reported staffing was a consistent problem for a long time. Witness 1 stated there were times when only one nurse and one CNA worked the entire facility. Witness 1 stated the facility continued to admit residents even though they were unable to properly staff CNAs to meet the residents' needs. On 6/24/24 at 2:08 PM, Staff 4 (CNA) stated the facility recently had rough times regarding staffing. Staff 4 stated when the facility was short CNA staff, call lights were not answered timely, CNAs were unable to complete all of the residents' care and showers did not get completed. Staff 4 stated all shifts were impacted by a lack of staffing but evening and night shift were impacted the most. On 6/25/24 at 9:32 AM, Staff 10 (CMA) stated medications were administered to residents late. Staff 10 indicated it was hard to get medications administered to all residents timely as ordered. On 6/25/24 at 9:48 PM, Staff 5 (CNA) stated the facility had high acuity residents including many residents with dementia. Staff 5 stated nearly one-half of the residents required two person assistance for transfers using a mechanical lift and three residents required two person care at all times. Staff 5 stated there was one resident who was aggressive and could not be properly monitored when staffing was low and the resident wandered into everyone's room and started fights. Staff 5 stated some shifts were one to two CNAs short which resulted in an increase in falls and residents being upset due to long call light response times. Staff 5 stated at times she was assigned 13 to 14 residents which was a very heavy load. On 6/26/24 at 12:25 PM, Staff 9 (CMA) stated the morning medications were not all administered timely due to staffing. On 6/26/24 at 2:14 PM, Staff 2 (DNS) stated there were concerns with low staffing and low staffing could be mentally draining for staff. Staff 2 stated staff felt stressed there won't be enough staff. Staff 2 acknowledged there were multiple shifts that lacked adequate CNA coverage. On 6/26/24 at 4:45 PM, Staff 1 (Administrator) stated the facility was not doing well with staffing and acknowledged there were multiple shifts that lacked adequate CNA coverage.

Based on interview and record review it was determined the facility failed to protect the residents' right to be free from physical abuse by another resident for 2 of 3 sampled residents (#s 7 and 17) reviewed for abuse. This placed residents at risk for abuse. Findings include: 1. Resident 7 was admitted to the facility in 6/2018, with diagnoses including dementia with behavior disturbances. Resident 7's 9/1/23 Care Plan indicated she/he had physical and verbal aggressive behaviors with instructions to intervene if this behavior escalated. Resident 17 was admitted to the facility in 3/2023, with diagnoses including hemiplegia (limited motor control of one side of the body). A 9/21/23 BIMs indicated Resident 17 had normal cognitive function. Resident 17 exhibited physical and verbal aggressive behaviors as indicated by her/his 9/1/23 care plan. Interventions included to intervene when the resident displayed these behaviors. On 11/3/23 a FRI was received by the State Survey Agency (SSA) which reported Resident 7 disturbed Resident 17's personal item which resulted in Resident 17 punching Resident 7. Immediate intervention was required to separate Resident 7 and Resident 17. The incident investigation from 11/3/23 included Resident 17 stating we were both hitting each other at first and then I hit him, I punched him in the face so he would stop. A 11/3/23 Progress Note stated Resident 17 and Resident 7 were witnessed by Staff 19 (RN) hitting each other. On 6/26/24 at 10:33 AM, Resident 17 stated she/he hit [Resident 7] in the face so [she/he] would stop bothering me and my things. [Resident 7] kept doing it. I figured if I kept hitting [Resident 7], they would stop. On 6/27/24 at 11:45 AM, Staff 19 stated she witnessed Resident 17 and Resident 7 yelling at each other and striking each other on 11/3/23. On 6/27/24 at 10:12 AM, Staff 2 (DNS) stated Resident 7 knew exactly how to push Resident 17 buttons which resulted in both residents hitting each other. Staff 2 confirmed Resident 7 and Resident 17 were involved in an incident of physical abuse on 11/3/23. 2. Resident 7 was admitted to the facility in 6/2018, with diagnoses including dementia with behavior disturbances. Resident 7's 9/1/23 Care Plan indicated she/he had physical and verbal aggressive behaviors with instructions to intervene if this behavior escalated. Resident 17 was admitted to the facility in 3/2023 with diagnoses including hemiplegia (limited motor control of one side of the body). A 9/21/23 BIMs indicated Resident 17 had normal cognitive function. Resident 17 exhibited physical and verbal aggressive behaviors as indicated by her/his 9/1/23 care plan. Interventions included to intervene when the resident displayed these behaviors. On 11/6/23 a FRI was received by the State Survey Agency (SSA) which reported Resident 7 had disturbed Resident 17's personal item which resulted in Resident 17 approaching Resident 7, yelling at Resident 7 and attempting to strike Resident 7. The incident investigation included Resident 17 stating, I looked and saw [Resident 7] sitting at my doorway. I yelled at [her/him] to leave my stuff alone and hurried over. I do not deny, I stood up from my wheelchair and hit [Resident 7] on the right side of [her/his] face. On 6/24/24 at 1:06 PM, Staff 4 (CNA) stated she did not recall the specific dates of the incidents she had witnessed, but stated she witnessed Resident 7 and Resident 17 striking each other on 3 separate incidents during 2023. On 6/27/24 at 9:48 AM, Staff 18 (Housekeeping Manager) stated on 11/6/23 she heard an argument in the hallway and witnessed Resident 7 and Resident 17 yelling at each other, pushing each other and throwing punches at each other. Staff 18 stated immediate intervention was required to separate Resident 7 and Resident 17. On 6/27/24 at 10:12 AM, Staff 2 (DNS) stated Resident 7 knew exactly how to push Resident 17 buttons which resulted in both residents hitting each other. Staff 2 confirmed Resident 7 and Resident 17 were involved in an incident of physical abuse on 11/6/23.

Based on interview and record review it was determined the facility failed to ensure residents were given the right to participate in the development of their person-centered care plan for 1 of 1 sampled resident (#2) reviewed for care planning. This placed residents at risk for not being involved in the care planning process. Findings include: Resident 2 was admitted to the facility in 4/2023 with diagnoses including major depression and repeated falls. A review of Resident 2's health record revealed Resident 2 had not had a care conference completed since 11/9/23. A review of Resident 2's care plan revealed on 2/7/24, 3/5/24, 3/6/24 and 5/10/24, Resident 2's care plan was updated. On 6/23/24 at 12:36 PM, 6/24/24 at 11:55 AM, and 6/26/24 at 9:09 AM, Resident 2 stated with dissatisfaction, her/his most recent care conference was sometime last year. Resident 2 stated it was important for her/him to be involved in her/his care planning process and other residents participated regularly in care conferences so she/he did not understand why she/he had not had a care conference since last year. On 6/25/24 at 9:14 AM, Staff 8 (SSD) stated, due to changes in staff, it was difficult to get a team together in order to conduct care conferences. Staff 8 confirmed Resident 2 did not have a care conference since 11/9/23 and she expected residents to be offered care conferences at least quarterly. Staff 8 stated Resident 2 always participated in her/his care conferences and one should have been scheduled since 11/9/23.

Based on interview and record review it was determined the facility failed to accurately assess residents for falls for 1 of 1 sampled resident (#6) reviewed for falls. This placed residents at risk for inaccurate assessments and unmet care needs. Findings include: Resident 6 was admitted to the facility in 10/2023 with diagnoses including dementia. The 3/28/24 Quarterly MDS indicated Resident 6 had one fall with major injury since her/his prior MDS assessment on 1/3/24. On 6/24/24 at 2:57 PM Staff 2 (DNS) stated Resident 6 had no falls since her/his prior MDS assessment on 1/3/24 and the resident's 3/28/24 Quarterly MDS, fall section, was inaccurate.

Based on interview and record review it was determined that facility failed to develop and provide a summary of the baseline care plan for 3 of 8 sampled residents (#s 25, 26 and 180) reviewed for pain, nutrition and ADLs. This placed residents at risk for being uninformed of their plan of care. Findings include: 1. Resident 25 was admitted to the facility in 5/2024, with diagnoses including dementia without behavioral disturbances. Review of the Resident 25's health record indicated no evidence the facility provided a written summary of the baseline care plan to the resident or their representative. During an interview with Staff 2 (DNS) on 6/27/24 at 4:23 PM, she stated she did not know if a summary of the baseline care plan was provided to the resident. 2. Resident 180 was admitted to the facility in 6/2024, with diagnoses including compression fracture (occurs when one or more bones in the spine weaken and crumple). Review of Resident 180's health record indicated that a baseline care plan was not developed within 48 hours of admission and did not include resident centered pain interventions. There was no evidence the baseline care plan was provided to the resident. Interview with Staff 2 (DNS) on 6/27/24 at 4:23 PM, she stated the baseline care plan should be completed with 48 hours and did not know if a summary of the baseline care plan was provided to with the resident. 50927 3. Resident 26 was admitted to the facility on [DATE], with diagnoses including depression. Review of the medical record revealed Resident 26 was not provided with a written summary of her/his basline care plan. On 6/25/24 at 1:54 PM, Staff 3 (Divisional Director of Clinical Operations) verified there was no documentation to indicate the baseline care plan was discussed with Resident 26 or a written summary was offered. Staff 3 further indicated there was no system in place to provide a baseline care plan to residents and their representatives.

Based on observation, interview and record review it was determined the facility failed to assist in vision care needs for 1 of 1 sampled resident (#2) reviewed for vision. This placed residents at risk for impaired vision. Finding include: Resident 2 was admitted to the facility in 4/2023 with diagnoses including major depression and repeated falls. A 12/6/23 Physician Order indicated Resident 6 was referred for an eye examination due to visual changes and double vision. The 5/1/24 Quarterly MDS indicated Resident 2 had no impaired cognitive functioning and the resident wore glasses. A review of Resident 2's heath record revealed no evidence an eye examination was discussed with the resident, scheduled or completed. Observations from 6/23/24 through 6/27/24 between the hours of 8:00 AM and 4:30 PM revealed Resident 2 was not wearing glasses. On 6/23/24 at 12:40 PM, Resident 2 stated she/he was supposed to wear glasses and asked for glasses several months ago but nobody followed up. On 6/27/24 at 10:50 AM, Staff 2 (DNS) confirmed there was no evidence in Resident 2's health record that an eye examination was discussed with Resident 2 or completed.

Based on observation, interview and record review it was determined the facility failed to provide appropriate treatment and services to maintain and prevent a potential decrease in mobility for 1 of 2 sampled residents (#5) reviewed for rehabilitation services. This placed residents at risk for loss of mobility. Findings include: Resident 5 was admitted to the facility in 12/2022 with age-related debility (weakness). Resident 5's 6/14/24 PT Discharge Summary indicated the resident was discharged from PT services on 6/14/24. Resident 5's current Walk Daily Program task indicated Resident 5 was to be walked by CNA staff from her/his room to the nursing station and back using a front wheeled walker every day before lunch. A review of Resident 5's health record revealed no evidence the resident was walked by staff from her/his room to the nursing station and back on any days since Resident 5 was discharged from PT services. Observations from 6/23/24 through 6/27/24 between the hours of 8:00 AM and 11:15 PM revealed no observations of Resident 5 being walked by staff. On 6/23/24 at 1:28 PM, Resident 5 stated she/he was discharged from PT services earlier this month and was supposed to walk everyday with staff. Resident 5 stated she/he had not walked for at least the past two weeks. Resident 5 stated it was very important for her/him to keep up with her/his walking or she/he would lose her/his walking abilities and become weak. On 6/25/24 at 10:00 AM, Staff 11 (PTA) stated Resident 5 was discharged from PT services on 6/14/24 and was supposed to be walked by staff everyday. Staff 11 stated Resident 5 had not been walked since her/his discharge from PT services. On 6/25/24 at 11:00 AM and 6/26/24 at 8:52 AM, Staff 12 (CNA) and Staff 7 (CNA) stated no CNAs walked Resident 5. Staff 7 stated she saw Resident 5's Walk Daily Program on the resident's Kardex (a care plan that gives a brief overview of the resident's care needs) but she did not have time to walk Resident 5 given the number of residents assigned to her. On 6/26/24 at 1:19 PM, Staff 2 (DNS) stated CNAs were expected to complete Resident 5's Walk Daily Program and acknowledged Resident 5's Walk Daily Program was not being completed.

Based on interview and record review it was determined the facility failed to ensure records were accurate for 2 of 5 sampled residents (#s 6 and 10) reviewed for unnecessary medications. This placed residents at risk for inaccurate treatment. Findings include: 1. Resident 6 was admitted to the facility in 10/2023 with diagnoses including hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone). Resident 6's 10/3/23 Physician Order indicated the resident was to receive levothyroxine (medication to treat hypothyroidism) one time a day to be given alone before breakfast. Resident 6's 5/2024 MAR revealed no documentation the resident's levothyroxine was administered on 5/6 and 5/30. On 6/26/24 at 1:53 PM, Staff 2 (DNS) stated the same nurse worked on 5/6/24 and 5/30/24 and the nurse administered Resident 6's levothyroxine on both days but did not document that he administered the medication because he was distracted during change of shift. 2. Resident 10 was admitted to the facility in 8/2021 with diagnoses including stomach ulcer. Resident 10's 12/28/22 Physician Order indicated the resident was to receive Protonix (a medication to treat stomach ulcers) one time a day, 30 minutes before meals. Resident 10's 5/2024 MAR revealed no documentation the resident's Protonix was administered on 5/6 and 5/30. On 6/27/24 at 11:00 AM, Staff 2 (DNS) stated the same nurse worked on 5/6/24 and 5/30/24 and the nurse administered Resident 10's Protonix on both days but did not document that he administered the medication because he was distracted during change of shift.

Based on interview and record review it was determined the facility failed to ensure care conferences were documented for 4 of 7 sampled residents (#s 10, 13, 20 and 21) reviewed for behaviors, unnecessary medications, care planning and nutrition. This placed residents at risk for incomplete records. Findings include: 1. Resident 13 was admitted to the facility in 2020 with diagnoses including chronic lung disease. A 2/16/23 Care Conference Form revealed the resident's weight was filled out and the resident's activity status was addressed. The sections of the form to indicate if the resident or resident's responsible party attended or was invited, who attended from the facility and if there were any identified concerns from the resident or responsible party were blank. The nursing summary, dietary summary, social services summary, therapy summary and follow up sections were also blank. On 4/6/23 at 10:31 AM Staff 6 (Social Services) stated the resident's care conference was done but she did not yet transcribe all the notes into the resident's record. 27792 2. Resident 10 was admitted to the facility in 11/2017 with diagnoses including stroke. Review of Resident 10's medical record revealed her/his 2/9/23 Care Conference document was incomplete. The only section completed was for activities. On 4/5/23 at 5:08 PM Staff 6 (Social Services) acknowledged Resident 10's 2/9/23 Care Conference document in her/his medical record was not complete. She stated a care conference was held but the information was not added to the document. She stated a busy workload and time constraints caused her to fall behind on completing the resident's 2/9/23 Care Conference document. 3. Resident 20 was admitted to the facility in 6/2022 with diagnoses including depression. Review of Resident 20's medical record revealed her/his 2/16/23 Care Conference document was incomplete. The only section completed was for activities. On 4/5/23 at 5:08 PM Staff 6 (Social Services) acknowledged Resident 20's 2/16/23 Care Conference document in her/his medical record was not complete. She stated a care conference was held but the information was not added to the document. She stated a busy workload and time constraints caused her to fall behind on completing the resident's 2/16/23 Care Conference document. 4. Resident 21 was admitted to the facility in 9/2022 with diagnoses including depression. Review of Resident 21's medical record revealed her/his 3/10/23 Care Conference document was incomplete. The document was missing information on social services, therapy and discharge. On 4/5/23 at 5:08 PM Staff 6 (Social Services) acknowledged Resident 21's 3/10/23 Care Conference document in her/his medical record was not complete. She stated a care conference was held but the information was not added to the document. She stated a busy workload and time constraints caused her to fall behind on completing the resident's 3/10/23 Care Conference document.

Based on observation, interview and record review it was determined the facility failed to ensure misappropriation of medications for 2 of 2 sampled residents (#s 12 and 13) reviewed for misappropriation. This placed residents at risk for lack of medications. Findings include: Resident 12 was admitted to the facility in 2021 with diagnoses including diabetes. Resident 13 was admitted to the facility in 2020 with diagnoses including an irregular heart beat. Resident 3 was admitted to the facility in 2019 with diagnoses including diabetes and a history of blood clots. Review of a 2/24/23 FRI and associated investigation revealed on 2/24/23 the facility identified Resident 3 did not have her/his apixaban (blood thinner) or metformin (treats diabetes) available in the medication cart. Residents with the same medications and dosages were identified. The pharmacy ran a report and the facility determined Resident 12 was short one metformin and Resident 13 was short one apixaban. The facility provided Resident 12 and Resident 13 a full 30 day supply of medications and ordered Resident 3 her/his medications on a stat [urgent] delivery. It was determined Staff 13 (CMA) used Resident 12's metformin and Resident's 13's apixaban for Resident 3. Resident 3's, 12's and 13's 2/2023 MARs revealed there were no missed medication administrations. On 4/4/23 at 7:52 AM Staff 13 stated on one occasion she borrowed medications from other residents when Resident 3 ran out of her/his medications. She did not recall who she borrowed the medications from but stated it was the same medication with the same dosage. Staff 13 also stated it only happened on one day. Staff 13 stated the facility provided education on how to order medications. Staff 13 was able to verbalize the facility medication re-ordering process. On 4/4/23 at 10:18 AM Staff 1 (Interim Administrator) stated during a routine Quality Assurance (QA) audit they discovered Resident 3's apixaban and metformin were not available in the medication cart, but the resident was still administered the medication. During the investigation it was determined Staff 13 was the staff involved with the misappropriation. Staff 1 indicated Staff 13 did not recall from whom she borrowed the medication. The facility worked with the pharmacy to determine who was on the same medications, when the medications were last filled and how many doses should have been used to date. It was determined one of Resident 12's metformin was missing and one of Resident 13's apixaban was missing. Resident 12 and 13 were reimbursed a 30 day supply of the medication. Staff 1 stated education was provided to all staff who administered medication and routine medications were now on auto-refill. Continued education will be provided to staff at all staff meetings on abuse which includes misappropriation. Staff 1 stated the facility will continue to check the medication carts as part of the QA process on a quarterly basis. During medication administration observation residents had medications available. On 3/3/23, the Past Noncompliance was corrected when the facility completed an investigation of Resident 3's lack of available metformin and apixaban. The Plan of Correction included: 1. Staff education on Medication Cart Organization Technique, Pharmacy Delivery, Medication Re-ordering and Rights of Medication Administration.

Based on interview and record review it was determined the facility failed to complete quarterly care conferences and include residents and their representatives in their care planning process for 1 of 3 sampled residents (#22) reviewed for behaviors. This placed residents and their representatives at risk for not making their care needs and health care decisions known. Findings include: Resident 22 was admitted to the facility in 9/2022 with diagnoses including dementia and anxiety. Review of Resident 22's medical record revealed the resident's last care conference was completed on 11/10/22. There was no indication a care conference was held between 12/2022 and 4/2023. On 4/5/23 at 5:08 PM Staff 6 (Social Services) acknowledged Resident 22 and her/his representative did not have a care conference since November of 2022. She stated a busy workload and time constraints caused her to fall behind on scheduling and completing resident care conferences.

Based on interview and record review it was determined the facility failed to ensure care planned interventions were followed for 1 of 3 sampled residents (#1) reviewed for falls and failed to prevent elopement for 1 of 1 sampled resident (#4) reviewed for elopement. As a result of facility staff not following the care planned interventions, Resident 1 fell and sustained a [CONDITION(S)]. Findings include: 1. Resident 1 admitted to the facility in 2013 with diagnoses including hypertension and depression. Resident 1's care plan in 2/2022 directed staff to provide two person extensive assist to turn, reposition and to provide care with bed mobility. Record review revealed a progress note on 2/21/22 Staff 5 (Former LPN) reported around 6:30 PM Staff 3 (Former CNA) provided care to Resident 1 and failed to comply with the plan of care. Staff 3 assisted Resident 1 in bed with only herself and not two people as directed in the care plan. Resident 1 fell from bed, was sent to the hospital and was diagnosed with a hip fracture. A 2/28/22 facility investigation revealed, on 2/21/22 Resident 1 fell from bed to the floor while Staff 3 rendered care as a one-person assistance when Resident 1's care planned directed two-person assistance. Resident 1 sustained a fracture to her/his left hip. Staff 3 was interviewed by Staff 2 (Former DNS) and Staff 4 (Former RN). The report indicated Staff 3 reenacted how she did not use another staff to assist with care and stated she was aware she needed another person, but she did not want to wait for assistance. On 2/21/22 Resident was sent by ambulance to the hospital where she/he was diagnosed with a left closed [CONDITION(S)] which was moderately displaced. On 7/13/22 at 10:07 AM attempts were made to contact Staff 3. No return call was received. On 7/14/22 at 12:37 PM Staff 1 (Regional RN/Interim DNS) acknowledged the accident for Resident 1 on 2/21/22, which resulted in a [CONDITION(S)]. Staff 1 stated Staff 3's employment was terminated for not following the plan of care. 2. Resident 4 admitted to the facility in 2019 with diagnoses including [CONDITION(S)] disorder (psychotic disorder with delusions). Resident 4's 2/10/20 Significant Change MDS revealed a BIMS score of 99 (not able to participate and staff need to assess cognition). Staff assessed Resident 4 with the following: short term memory problems; long term memory problems; was not able to recall she/he was in a nursing facility; cognitive skills were severely impaired. Resident 4's care planned identified her/him as an elopement risk. Resident 4 was care planned to have a wanderguard on her/his wheelchair to alert staff if the resident was exiting the facility. A 3/10/20 progress note revealed Staff 6 (Former DNS) documented police officers came to the facility to report they found Resident 4 at a local store. Two CNAs left to bring Resident 4 back to the facility. All the doors were checked and found to be secure. Resident 4's wander guard was not located on the resident or on her/his wheelchair. On 3/11/20 Staff 7 (Former Executive Director) submitted a FRI to the SA reporting Resident 4 had eloped from the facility and returned safely. On 7/14/22 at 12:37 PM Staff 1 (Regional RN/Interim DNS) confirmed Resident 4's elopement from the facility on 2/10/20.

Based on observation, interview and record review it was determined the facility failed to implement infection control practices to prevent the spread of the COVID-19 virus from 6/30/20 through 7/1/20 for 1 of 1 RN Staff (Staff 2) reviewed for infection control. This failure, determined to be an immediate jeopardy situation, resulted from Staff 2's improper use of PPE (personal protective equipment), Staff 2 not performing hand hygiene appropriately and staff not following infection control policies and procedures exposed residents to the risk of contracting the highly communicable COVID-19 virus. Findings include: The Facility Policy COVID-19 Crisis Strategy for PPE - Cloth/Non-Surgical Masks, reference number 8832, last revised 4/16/20 instructed for the duration of the state of emergency in their State, all long-term care facility personnel should wear a facemask while they are in the facility. The Facility Policy Request for PPE reference number 8798, last revised 4/30/20, instructed to Do NOT TOUCH the front of the respirator! It may be contaminated. Centers for Disease Control (CDC), page last updated 6/19/20, refers to the facility to implement Universal Source Control which refers to facemasks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are talking, sneezing or coughing. Because of the potential for asymptomatic and pre-symptomatic transmission, source control measures are recommended for everyone in a healthcare facility, even if they do not have symptoms of COVID-19. Staff should wear a facemask at all times while they are in the healthcare facility, including spaces where they might encounter co-workers. Staff should be aware about the importance of performing hand hygiene immediately before and after any contact with their facemask or cloth face covering. Do not wear respirator/facemask under (the) chin or store in scrubs pocket between patients. On 7/1/20 the Oregon Health Authority reported Umatilla County had 492 positive COVID-19 cases, 155 people recovered and 4 deaths. The Umatilla Case County per 10,000 people was 60.6, the third highest rate in the state. The facility is located in Umatilla County. Technical assistance was provided by the State Survey Agency on prior Infection Control Surveys and Weekly State Monitoring on-site visits from 5/15/20 through 6/23/20. The technical assist was related to multiple observations of Staff 2 in the facility either without a mask while at the nurse's station and hallway, with the mask tucked under her chin or hanging from one ear and coming within six feet of care staff without a mask. On 6/30/20 at 1:45 PM, Staff 2 (RN) was observed standing behind the medication cart at the nurse's station without a mask on her face. After seeing the surveyor, Staff 2 quickly put a mask on, touched the front of mask and continued working without performing hand hygiene. On 6/30/20 at 2:13 PM, Staff 2 was observed to walk down the hall towards the front exit door. Staff 2 was observed to raise both her arms and remove her mask into her left hand. Staff 2 put her mask back on and then touched the keypad and door to exit without performing hand hygiene. On 6/30/20 at 3:56 PM, Staff 2 wore a mask looped on one ear while sitting at the nurse's station. Staff 1 (Executive Director) was standing opposite of Staff 2 at the nursing station counter and Staff 1 and Staff 2 were engaged in conversation. Staff 1 did not cue Staff 2 to wear the mask appropriately. On 7/1/20 at 8:36 AM, Staff 2 was observed standing at the nurse's station without a mask. After greeting the surveyor, Staff 2 reached in her bag and put on a mask quickly. On 7/1/20 at 9:14 AM, Staff 2 was observed at the nurse's station looking at a medication book on the treatment cart with a mask hanging from her left ear and not covering her face. Staff 2 put the mask on and touched the front of her mask. Staff 2 then touched the medication book, then sat in a chair at the nursing station and touched a black pen, computer keyboard and medication book again with no hand hygiene. On 7/1/20 at 9:17 AM, Staff 2 reported she understood she could take the mask off when she was in the bathroom or taking a drink of coffee. She stated she was always to wear a mask while in the facility. Staff 2 reported she tried to limit the amount of the hand sanitizer on her skin due to a sensitive skin condition. On 7/1/20 at 10:55 AM, Staff 3 (CNA) and Staff 4 (CNA) stated it was a requirement to wear a mask at all times while in the facility. Staff 3 and Staff 4 stated masks should cover their mouth and nose and should not be worn under their chin or hanging from one ear. Staff 3 and Staff 4 stated if they adjusted their mask or inadvertently touched the front of the mask, hand hygiene should be performed immediately after. Staff 3 and Staff 4 stated Staff 1 stated masks could only be removed in the breakroom for meals and provided daily education to staff regarding the requirement to wear a mask at all times. On 7/1/20 at 11:12 AM, (Witness 1) reported she/he observed Staff 2 to not wear a mask while in the facility. Witness 1 reported Staff 2 often had her mask under her chin, hanging off her ear or not on at all. Witness 1 stated it was standard practice for Staff 2 to not wear a mask while near the nurse's station. On 7/1/20 at 12:27 PM, Staff 2 stated it was facility protocol to wear a mask at all times but it was a tricky topic. Staff 2 stated she should wear a mask when in direct contact with a resident and stated she should not have to wear a mask while at the nurse's station. Staff 2 stated the nursing station was her space and if residents were six feet away, she should not have to wear a mask. Staff 2 stated she should wear a mask while preparing medications at the medication cart. Staff 2 stated she should be able to pull the mask down or aside to get sips of coffee and water and it was ok for the mask to hang from the ear strap to take a break and get some fresh air. Staff 2 stated she was counseled by Staff 1 several times regarding proper use of the mask and was told to wear the mask at all times. On 7/1/20 at 12:44 PM, Staff 1 stated every staff member was required to wear a mask at all times while in the facility. Staff 1 stated staff could only remove the mask while social distancing in the breakroom for meals. Staff 1 stated masks could not be removed in any area of the facility including the nursing station, the hallways, the medication cart and resident rooms. Staff 1 acknowledged Staff 2 was not wearing her mask appropriately during their conversation at the nurse's station on 6/30/20 and did not direct Staff 2 to wear her mask as required at that time. Staff 1 specified staff who were working in the facility could not remove the mask to sip water or coffee unless they were in the breakroom and stated hand hygiene should be performed after adjusting the mask or touching the front of the mask. Staff 1 confirmed Staff 2 was considered direct care staff as she was the only licensed nurse working in the facility and was responsible for all the residents. Staff 1 confirmed Staff 2 had been counseled on multiple occasions over the past month regarding not wearing her mask appropriately. On 7/1/20 at 3:40 PM, the facility was informed of the immediate jeopardy situation for failing to implement infection control practices to prevent the spread of the highly communicable COVID-19 virus from 6/30/20 through 7/1/20. A plan to abate the immediate jeopardy situation was requested. On 7/1/20 at 7:45 PM, the abatement plan for the immediate jeopardy was approved. The plan included the following: -Screening of residents and staff for symptoms of COVID-19; -Staff 2 was reeducated on infection control practices for mask use and hand hygiene; -Staff 2 remained supervised by Staff 1 for the duration of her final 7/1/20 shift; Staff 2 was terminated on 7/1/20. -Education and training regarding proper mask use and hand hygiene with all staff; completed by 7/4/20 at 6:00 PM and ongoing; -Housekeeping completed and ongoing for thorough disinfection of entire nursing station, handrails, facility door knobs, medication carts, computers, key boards, phone and counters; -Ongoing audits and observations of mask use and hand hygiene compliance. On 7/2/20 at 8:45 AM the immediate jeopardy removal plan was verified based on observations of Staff 2 not in the facility and no longer employed. Observations conducted showed all facility staff with masks worn appropriately and performed hand hygiene as required. Staff were interviewed and confirmed education was provided regarding mask use and hand hygiene. On 7/2/20 at 10:00 AM the immediate jeopardy was abated.

Based on observation, interview and record review it was determined the facility failed to ensure appropriate information was communicated to the receiving health care institution for 1 of 3 sampled residents (#10) reviewed for facility transfers. As a result, Resident 10 experienced unnecessary, invasive diagnostic procedures and the failure placed residents at risk for unsafe transition of care. Findings include: Resident 10 was admitted to the facility in 2/2019 with [DIAGNOSES REDACTED]. Resident 10's 10/22/19 Quarterly MDS Section C: Cognitive Patterns indicated the resident was severely cognitively impaired with a BIMS of 7 and exhibited inattention and disorganized thinking. Resident 10's 10/22/19 Quarterly MDS Section E: Behaviors indicated the resident experienced hallucinations and delusions. Review of Resident 10's medical record revealed an 11/21/19 MDS Discharge Assessment to an acute care hospital. Resident 10's medical record contained no discharge summary or the reason for discharge on 11/21/19. Resident 10's medical record lacked information such as a physical assessment, psychosocial assessment, vital signs, reason for discharge, incident summary, paperwork sent with Resident 10, mode of transport, physician notification and family notification. Resident 10's 11/21/19 Hospital Admission Record indicated the following physician and nurse summarization: (Resident 10) is rambling and quite agitated on arrival. Apparently a resident of an extended care facility .a van dropped (her/him) off at the hospital to have her/him checked for a UTI although we never received any contact from the facility. The (resident) is not sure why she/he is here. (She/he) denies urinary frequency or urgency or dysuria (painful urination) .states (she/he) was treated for [REDACTED]. (She/he) has no specific complaints other than wanting to go back to the living facility. (Resident) arrived for 'urine problem' dropped off by friend. (She/he) is alert and responsive, quite agitated and combative and does not wish us to do anything. Contacted the resident's living facility and the night shift supervisor refuses to take the resident back. Resident 10''s 11/21/19 Hospital Admission Record indicated the following diagnostic procedures were performed: - Urine was obtained via catheterization (tube inserted through the urethra to reach bladder for urine) and a urinalysis completed; - Head CT Scan was completed; no findings. - Blood was obtained intravenously; no findings. Resident 10's 11/21/19 Hospital Admission Record included an 11/22/19 mental health assessment. The 11/22/19 Lifeways Crisis Contact Note revealed Resident 10 was not an imminent risk for suicide or homicide. She/he is easily redirectable when angry and lacks the strength or mobility to be dangerous. On 12/17/19 at 9:55 AM Resident 10 was observed sitting in a chair in her/his room. Resident 10 presented alert, confused and rambled unintelligibly. In an interview on 12/17/19 at 12:02 PM Staff 1 (Administrator) stated on 11/21/19 Resident 10 struck another resident. Staff 1 stated he contacted police who told him to take Resident 10 to a hospital for a psychiatric hold. Staff 1 stated he and Staff 5 (NA) assisted Resident 10 into the facility van and took her/him to the hospital. Staff 1 stated he, Staff 5 and Resident 10 physically walked into the Emergency Department and he handed a paperwork packet that contained a transfer/discharge report to the ER Registrar. Staff 1 stated he used the bathroom and then asked the Registrar (admitting clerk) if she needed anything else. Staff 1 stated the Registrar said no and he and Staff 5 left the hospital. Resident 10 was left in the emergency department waiting room. Review of the 11/21/19 Facility Transfer/Discharge Report revealed the following information: - Resident personal information such as name, date of birth and insurance details; - allergies [REDACTED].> - Primary Contact information; - Primary Physician; - List of Diagnoses; - Vital signs taken on 10/13/19. The Transfer/Discharge Report lacked pertinent information such as medical concerns to warrant the emergency room visit, recent vital signs, current medication list, current treatments and pertinent progress notes to reflect Resident 10's current medical and psychosocial status. In an interview on 12/17/19 at 12:21 PM Witness 1 (Complainant) stated she was contacted by Witness 2 (Hospital Case Manager RN) who reported Resident 10 was dropped off at the emergency room with no pertinent information provided, no pertinent paperwork and no facility staff escort. In an interview on 12/17/19 at 3:03 PM Witness 2 (Hospital Case Manager RN) stated Resident 10 was dropped off in the emergency room waiting area. Witness 2 stated it was reported to her by the admitting clerk that Staff 1 told the clerk Resident 10 had a urine problem, handed the paperwork to her and then left. Witness 2 stated Resident 10 was confused, agitated, combative and unable to provide accurate medical history or a reason for being in the emergency room . Witness 2 stated because Staff 1 told the admitting clerk Resident 10 had a urine problem and there was no other medical history provided, Resident 10 was subjected to a urethral catheterization to obtain urine, a CT scan (X-ray imaging), and intravenous laboratory screening (blood draw) in an attempt to determine Resident 10's medical status. Witness 2 stated during these procedures Resident 10 was observed to become increasingly agitated, yelled and screamed, and required her/his legs held down and restrained during the catheritization. Witness 2 stated the hospital staff later obtained medical history and it was discovered Resident 10 was diagnosed with [REDACTED]. Witness 2 stated the catheterization, CT scan and blood draw tests were a violation of Resident 10's privacy and body and could have been avoided if the facility provided Resident 10's medical history, accurate medical status, medication list to include the antibiotics for UTI, pertinent information and the specific reason(s) for the emergency room visit. Witness 2 stated the facility clinical staff should have called the ER and provided an accurate medical report on Resident 10 and stated the resident should not have been left in the ER without a facility staff escort to speak on her/his behalf. Witness 2 stated there was no clinical rationale to admit Resident 10 to the hospital on [DATE], notified the facility multiple times to pick up the resident and the facility refused. Witness 2 reported Resident 10 stayed in an ER room from 11/21/19 through 11/25/19 and was fearful, confused, agitated and wanted to return back to the nursing facility. Witness 2 stated the hospital arranged transportation and Resident 10 was sent back to the facility since the facility would not provide transportation for the resident to leave the emergency room . On 1/6/20 at 11:07 AM Staff 1 was notified of the findings of this investigation related to the facility's failure to ensure a safe transition of care which resulted in Resident 10 experiencing unnecessary invasive procedures. Staff 1 did not provide additional information but did state the right paperwork should have been provided.

Based on interview and record review, it was determined the facility failed to implement care planned interventions for 1 of 3 sampled residents (#1) who had a fall. The resident fell and sustained a fracture. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/28/15 a Fall Evaluation identified the resident was at high risk for falls related to mental status, ambulation/toileting status, gait/balance problems, medications, and the need for safety reminders. The resident's 5/28/15 Care Directive identified the resident needed one person assistance for transfer and ambulation. On 5/29/15 the care plan was undated to include non-skid socks for safety. On 5/30/15 at 2:20 am a nursing note identified Resident 1 was found on the floor lying on the left side. The note indicated the resident stated she/he slipped and fell after using the restroom. The resident was wearing regular socks at the time. The note identified Resident 1 complained of hip pain. On 5/30/15 at 2:50 am a nursing note indicated the resident was sent to the hospital due to unbearable hip pain. On 5/30/15 an Event Investigation Final Summary identified night staff reported Resident 1 had been assisted in and out of her/his wheelchair to and from the bed and bathroom on 5/29/15-5/30/15. The resident was last checked on at 1:55 am on 5/30/15 and was found at 2:20 am on the floor between the sink and her/his bed. The resident revealed she/he was coming back from the bathroom and slipped and fell to the floor. The resident complained of left hip pain and was transferred to the hospital. Hospital reports indicated the resident had osteopenia and a non-displaced fracture. Witness statements dated 5/30/15 from Staff 4, LPN, Staff 6, CNA, and Staff 7, CNA identified Resident 1 was wearing regular socks at the time of the incident. In interviews on 8/19/15 at 10:19 and at 10:56 am Staff 2, DNS, reported she added non-skid socks to Resident 1's care plan on 5/29/15 after reviewing the resident's fall assessment at the morning clinical meeting. In interview on 8/19/15 at 10:58 am and on 8/25/15 at 10:07 am Staff 3, RNCM, reported Staff 2 added non-skid socks as a safety intervention onto Resident 1's care plan on 5/29/15 during the morning clinical meeting, which ran from 8:30 am to approximately 9:45 am. She stated the intervention was added because the resident scored as a high risk for falls on her/his fall assessment. Staff 3 reported at the end of the meeting (at approximately 9:45 am) she gave a copy of the updated care plan to the nurse to alert CNAs of the update and place the revised copy of the plan in the resident's closet. She stated newly admitted residents received packets of supplies which included non-skid socks and reported the socks should have been in Resident 1's room on 5/29/15. Staff 3 stated it was the CNAs responsibility to view the residents' care plan every day prior to performing care. Staff 3 reported Resident 1 could have slipped either way however, wearing non-skid sock was a safer option. In interview on 8/24/15 at 11:27 am Staff 4, LPN reported she and Staff 6 heard someone yelling and found Resident 1 lying on the floor on the way to the restroom. Resident 1 stated she/he was trying to go to the bathroom. Staff 4 stated the resident complained of left hip pain and was sent out to the hospital for evaluation. Staff 4 reported the resident was wearing regular socks, not non-skid as was care planned for. In interview on 8/25/15 at 1:32 pm Staff 6, CNA, reported she and Staff 4 heard a resident yelling for help and found Resident 1 lying on the floor. She stated the resident reported she/he had slipped on the way to use the bathroom. Staff 6 reported the floor was dry and the resident's pants were wet as if she/he urinated after the fall. Staff 6 stated the resident was wearing regular socks. In interview on 8/26/15 at 8:10 am Staff 6, CNA, who was assigned to Resident 1 during the night on 5/29/15-5/30/15, reported she did not check the resident's care plan that night. She stated she doesn't read them every night and nurses or CNAs passed on updated care plan information. Staff 6 denied viewing Resident 1's feet/socks prior to the fall on 5/30/15 at 2:20 am. She reported there were no non-skid socks observed lying around the resident's room during the night of 5/29/15-5/30/15. In interview on 8/26/15 at 10:08 am Staff 2, DNS, confirmed Resident 1 did not have non-skid socks on at the time of the fall. She reported the socks help grip the floor and she didn't know why they weren't on the resident on 5/30/15.

1. Based on interview and record review it was determined the facility failed to ensure residents' changes in condition were identified and responded to in a timely fashion for 5 of 12 sampled residents (#s 5, 6, 8, 9 and 11). Residents 8 experienced ongoing pain, vomiting, black stool and further decline in condition. Resident 9 experienced prolonged abdominal pain and further decline in condition. Resident 11 was left unresponsive for approximately five hours before emergency measures were initiated. Findings include: a. Resident 11 was a long time resident of the facility with [DIAGNOSES REDACTED]. The resident's quarterly MDS dated [DATE] and quarterly nursing summary dated [DATE] indicated the resident was alert and oriented with a brief interview for mental status score of ,[DATE]. The resident was able to complete a large portion of her/his ADLs with supervision or set up assistance as needed. The resident was independent with mobility but utilized supervision for mobility, hygiene and meals. The resident was continent of bowel and bladder with minimal assistance required for toileting. The resident's quarterly nursing summary additionally indicated the resident's code status was full code-attempt CPR, full medical treatment, use antibiotics if medically indicated and long-term artificial nutrition by tube if medically necessary. The resident's care plan dated [DATE] indicated the resident had clear speech, could make needs known, was alert and oriented. The resident was independent for toileting and transfers and required supervision with cueing for ambulation/mobility, bed mobility, meals and grooming. Staff were to notify the licensed nurse if the resident had any complaints of pain or non-verbal signs of pain. NNs dated [DATE] indicated a late entry from [DATE]. The resident had slipped to the floor, she/he stated "I lost my balance" while ambulating in the main dining room. The resident had a small abrasion to the right elbow. The resident had an additional fall in room as she/he slid from the bed onto the floor on [DATE]. The resident was noted to have normal ADL function. A portable X-ray was going to be scheduled at the family's request to rule out any additional injury. A NN dated [DATE] at 11:30 am indicated the portable X-ray company was in and completed X-rays, results available in approximately two hours. Witness 5 (Former Facility RN) noted a phone call was made to the family to inform them of the resident's status today: "resident has been sleeping, unable to be awakened-has remained in bed-O2 via non-breather applied d/t (due to) labored breathing." The resident's oxygen saturation levels were unable to be obtained and respirations were shallow, O2 sats now at 88 with resident on oxygen 4L/min. The resident's blood pressure at 9:00 am ,[DATE], at 11:00 am it was ,[DATE]. The administrator and DNS were informed and stated to call 911. An additional NN at 12:00 pm indicated the ambulance assessed and transported the resident to the emergency room . Attempts continued to reach the resident's family. A NN dated [DATE] at 11:40 am indicated Witness 6 (Former Facility DNS) went to the resident's room to assess the resident. The resident's respirations were at 12 and shallow, the pulse was 54. Witness 6 received no response from the resident to verbal stimuli or painful stimuli. The right pupil was dilated and non-reactive, the left pupil was reactive to light and the resident's extremities were flaccid. Witness 6 ran out and told the resident's nurse, Witness 5 (Former Facility RN), to call 911 and get the resident to the hospital. Witness 5 contacted 911 and asked Staff 14 (Social Services) to contact the resident's family. An Event Investigation Final Summary dated [DATE] indicated the resident slept through most of the night and toileted self sometime between 2:30 and 4:30 am on [DATE]. At 6:00 am the resident appeared to be sleeping, at 6:45 am Staff 20 (CNA) changed and dressed the resident but the resident did not respond during the process. Staff 20 stated he reported to the nurse, Witness 5, that the resident was unresponsive. Witness 5 stated she checked on the resident several times and the resident appeared to be sleeping and snoring. Oxygen was applied at approximately 9:00 am. The Event Summary further indicated mobile X-rays were completed around 10:00 am. Witness 5 checked the resident at 10:20 am and the resident appeared comfortable. Witness 5 left a message for the resident's family at 11:00 am. At 11:20 am Witness 5 notified Witness 6 (Former Facility DNS) and Staff 3 (Administrator) of a suspected change in condition. The resident left with EMTs at 12:00 pm. Interviews conducted [DATE] through [DATE] between 8:20 am and 5:20 pm showed: Witness 2 (Complainant) indicated the resident was normally up and around the facility on her/his own. The resident had good cognition and could make needs known. Witness 2 stated he was not informed the resident had two falls until the care conference meeting on [DATE]. Witness 2 frequently talked to the resident on the phone and over the last week or so the resident had not seemed herself/himself. The resident participated in the care conference and did not sound right either. Witness 2 told multiple staff including Witness 6 (Former Facility DNS) that there was something wrong with the resident. The following day on [DATE] Witness 2 received a phone call around 12:45 pm that the resident was unresponsive and sent to the hospital. Witness 2 received no prior information that the resident had spent hours unresponsive. When Witness 2 got home he had a voicemail from Witness 5 (Former Facility RN) that the resident took a turn for the worse and they were sending to the hospital. Witness 2 was told by Witness 5 the resident was verbally unresponsive, had missed breakfast and that she applied oxygen. The resident was sent to the hospital several hours later. Witness 2 stated the hospital physician believed the resident had a catastrophic stroke and possibly a [MEDICAL CONDITION]. Staff 20 (CNA) indicated the resident was fairly independent and was usually up and at least partially dressed to go to breakfast. The resident rarely ever missed a meal and would walk down on her/his own sometimes with a standby staff. Staff 20 stated he went in to the resident's room at 6:30 am or so to make sure the resident was ready, as he usually would. The resident was on her/his back in a totally relaxed position and snoring. Staff 20 stated the resident's positioning was out of the norm as she/he typically slept on her/his side curled up under a blanket. Staff 20 called the resident's name, touched her/his hands, tapped/shook the resident's shoulder but the resident would not wake or respond. Staff 20 proceeded to get the other resident in the room ready then tried again to wake Resident 11 with no success. Staff 20 reported to the nurse, Witness 5, the resident was not responding to any attempts to awaken her/him. Staff 20 was told the resident had a fall and a rough night and to let the resident rest. Staff 20 continued his rounds, delivered trays and answered lights but periodically attempted to wake the resident with no response to any of his attempts. Staff 20 again reported to Witness 5 there was something wrong and the resident would not respond. Staff 20 was told Witness 5 would check the resident after medication pass. Staff 20 attempted to wake the resident again after breakfast with no success and was told by Witness 5 a portable X-ray was coming and he was to assist. Staff 20 stated he assisted to sit the resident up into a full sitting position, roll side to side, place slides and lay the resident back down again. Staff 20 stated the resident did not open her/his eyes, show signs of pain, made no sounds and made no movement during the X-ray process, but was breathing. Staff 20 again went to the nurse, expressed concerns with the resident's abnormal behavior and demanded she check the resident. Witness 5 went to the resident's room and took an oxygen concentrator with. Staff 20 indicated the resident was still unresponsive and he was preparing to report to another supervisor either the RCM or DNS when Witness 5 said she was sending the resident to the hospital. Two attempts were made to reach Witness 6 (Former Facility DNS), no return call was received. Four attempts were made to reach Witness 5 (Former Facility RN), no return call was received. Staff 17 (LPN) indicated the resident was alert, oriented and directed her/his own care. The resident was pretty independent for all ADL care. Staff 17 stated the resident did not require much assistance unless she/he was feeling weaker. The resident was up and around the facility frequently with meals in the dining rooms. Staff 8 (CNA) stated the resident directed her/his own care but did not require much assistance from staff. The resident had weaker days and took her/his time moving but did very well on her/his own. Staff 19 (CNA) indicated the resident was alert, oriented and directed her/his own care. The resident could complete most of her/his ADLs independently. The resident typically would get up a few times in the night to urinate then go back to bed. The resident usually slept curled up and cocooned into the blankets on her/his side. Witness 11 (Physician) indicated the resident was to receive full treatment and CPR if needed. The resident had a complicated medical history which limited some treatments. However, the resident should have been sent to the hospital as soon as it was determined she/he had a decline/was unresponsive. b. Resident 8 was a long time resident of the facility with [DIAGNOSES REDACTED]. The resident's quarterly nursing assessment dated [DATE] indicated the resident required extensive to dependent assistance with ADLs related to progressive dementia and limitations in range of motion. The resident's Physician order [REDACTED]. When pulse and breathing present the resident was to receive full treatment including intubation, advanced airway interventions and mechanical ventilation. NNs dated [DATE] indicated the resident had a coffee ground emesis (vomit with the appearance of coffee grounds due to clotted blood in the vomit indicative of a [MEDICAL CONDITION]). The on call physician was notified and ordered the resident out to the hospital. The resident returned the same evening with [DIAGNOSES REDACTED]." NNs dated [DATE] indicated the resident had a large semi-liquid bowel movement following night shift enema. The resident was noted as resting comfortably. NNs dated [DATE] at 6:30 pm indicated no emesis but a small dark, black, sticky stool was noted. The physician was notified. A fax dated [DATE] at 6:28 pm was sent to the physician regarding the dark black stool. The physician responded on [DATE] at 9:11 am with "noted." Additional NNs on [DATE] at 7:30 pm indicated the resident had small brown emesis with food chunks. There was no indication the physician was notified. No fax was located regarding the brown emesis on [DATE]. At 8:15 pm the resident had a large brown emesis with food chunks. The resident was gurgling, having trouble breathing. The resident had a medium black tarry stool, aids changed the resident and sat her/him up in the chair. The resident had a firm distended abdomen with hyperactive bowel tones. Vital signs were pulse 114, respirations 28 and blood pressure ,[DATE]. "Notified (RCM) and (physician) will evaluate in the am." No fax was located to show the physician was notified of the emesis, tarry stool and difficulty breathing. NNs on [DATE] at 12:47 pm indicated no emesis this shift, will continue to monitor. At 10:00 pm no emesis noted this shift, lungs clear, ate 100% at dinner. NNs dated [DATE] at 4:30 am indicated emesis x 1 early in night shift, moderate amount, dark brown in color. Head of bed elevated to 45 degrees, in no distress at the present time. Will continue to monitor. There was no indication the physician was notified. NNs dated [DATE] at 6:00 am indicated emesis x1 on night shift, keep head of bed at 45 degrees at all times, will continue to monitor. There was no indication the physician was notified. Additional NNs at 9:10 am indicated the resident had a large coffee ground emesis. The resident was dusky in color, respirations were audible and shallow. Resident vomited again and 911 was called. At 9:20 am EMTs arrived and facility staff were performing CPR on the resident. EMTs took over CPR but the resident did not regain function and resident passed away at 9:45 am. Review of physician visit logs and physician visit notes showed the resident was last seen by the physician on [DATE]. Interviews conducted [DATE] through [DATE] between 7:55 am 5:30 pm showed: Witness 7 (Former Facility RN) indicated she knew something was wrong with the resident. She wanted to send the resident out to the hospital again but she was "told not to and just monitor," so she did not send out. Witness 7 indicated Staff 5 (RNCM) and Witness 6 (Former Facility DNS) told her to monitor. The resident had been to the hospital few days prior with [DIAGNOSES REDACTED]." Witness 7 stated she was a new nurse, knew now to send a resident to the hospital if needed regardless if she was told no by a superior. Two attempts were made to reach Witness 6 (Former Facility DNS), no return call was received. Staff 5 stated if a resident required hospital treatment they would be sent out. Staff 5 could not recall any conversation with Witness 7 to withhold care of the resident. Staff 16 (RN) indicated nothing stood out in his mind about the resident. He could only say that whatever was documented in his NNs was what happened. Staff 16 stated he would not necessarily contact the physician each time a resident vomited and could not remember if he contacted the physician about this resident. Staff 16 stated when any resident vomits the important part was to ensure a proper airway. He offered no other information. Staff 17 (LPN) indicated she remembered the resident but could not recall any specifics. She was not sure if she had contacted the physician about the resident, it would be in her NNs. Staff 25 (Corporate RN) indicated there was no additional documentation of faxes after the initial [DATE] contact and no documented physician visits after [DATE]. Three attempts were made to reach Witness 9 (Former Facility LPN), with no return call received. Witness 11 (Physician) indicated he should have been notified of the resident's ongoing problems with vomiting and black stool. The resident was full treatment and CPR. Witness 11 stated the facility should have been sent out to the hospital in response to continued changes and ongoing emesis. c. Resident 9 was admitted to the facility in [DATE] with [DIAGNOSES REDACTED]. The resident's POLST dated [DATE] indicated the resident was not to receive CPR if there was no pulse or breathing present. The resident was to receive limited additional interventions to provide basic medical treatments and transfer to the hospital if indicated. The resident's initial CAA summary dated [DATE] indicated the resident was admitted to the facility after hospitalization for respiratory distress with copious secretions. The resident had recent [MEDICAL CONDITION] activity with a history of stroke, anxiety and [MEDICAL CONDITION]. The resident was noted to have chronic pai[DIAGNOSES REDACTED] which was treated with narcotic pain medications and repositioning. The resident's 14 day MDS assessment dated [DATE] indicated the resident understands others and can make herself/himself understood. The resident was dependent for her/his ADLs with a tube feeding in place for all nutrition. The resident's care plan dated [DATE] indicated the resident had clear communication and was Spanish speaking only. The resident was noted to have some confusion, was dependent for care and the head of the bed was to be elevated greater than 35 degrees. NNs dated [DATE] indicated the resident was sent to the hospital around 10:00 pm related to projectile vomiting and abdominal pain. The resident returned to the facility in the early morning on [DATE] with [DIAGNOSES REDACTED]. NNs dated [DATE] at 3:00 pm indicated the resident complained of nausea with upset stomach and was crying out in pain. The resident was treated with PRN [MEDICATION NAME] (narcotic pain medication) and stomach residuals showed 90 ml of formula remained. The resident's tube feeding was held for two hours, when the residual was at 5 ml feeding was restarted with no additional stomach pain. NNs dated [DATE] at 4:00 am indicated the resident was crying out in pain and was medicated with PRN [MEDICATION NAME]. NNs dated [DATE] at 3:00 pm indicated the resident was crying out in pain with increased anxiety. The resident was medicated with PRN [MEDICATION NAME] (antianxiety) and [MEDICATION NAME]. At 9:00 pm the resident was crying, pointed to her/his abdomen and stated in Spanish "tiene dolor" (have pain). The resident was medicated with PRN [MEDICATION NAME] and [MEDICATION NAME]; the resident was calmer and resting. NNs dated [DATE] indicated the resident slept without incident. The resident received PRN [MEDICATION NAME] x3 during the night for pain, will continue to monitor. NNs dated [DATE] indicated the resident was awake and crying much of night, no changes noted. The resident was medicated for pain x3 during the night, will continue to monitor. There was no indication the physician was notified. NNs dated [DATE] at 2:20 pm indicated the resident was medicated with PRN [MEDICATION NAME] x2 for generalized pain. At 7:00 pm PRN [MEDICATION NAME] was given for pain, [MEDICATION NAME] given for anxiety and vital signs were noted within normal limits. NNs dated [DATE] at 6:00 am indicated the resident continued to be awake and crying loudly most of night shift despite comfort measures and [MEDICATION NAME] administration. At 2:10 pm PRN [MEDICATION NAME] was given for pain. There was no indication the physician was notified. NNs dated [DATE] at 4:00 am indicated the resident cried off and on through the shift, PRN [MEDICATION NAME] was given with some success. NNs dated [DATE] at 5:00 am indicated no changes to the resident's physiological condition. The resident received PRN [MEDICATION NAME] x3 for pain, resident yelling and screaming loudly during the night. NNs at 2:10 pm indicated the resident continued to be confused with periods of yelling and moaning, no complaints of pain. PRN [MEDICATION NAME] was provided with good effect. At 4:00 pm confusion continues, [MEDICATION NAME] used with good results. There was no indication the physician was notified. NNs dated [DATE] at 3:00 pm indicated the resident had large amount of projective vomiting this am. The resident complained of pain to the right face radiating to the left face. The resident stated through a translator that she/he wanted to go to the emergency room . The resident was taken to the hospital and returned at 5:30 pm with new [DIAGNOSES REDACTED]. Pancreatitis is inflammation of the pancreas. The most common symptom is mild to severe abdominal pain that may begin or worsen after eating. People with acute pancreatitis usually feel very sick. Besides pain symptoms may also include nausea, fever, chills, swollen abdomen and a rapid heartbeat. Review of the physician visit log and the physician progress notes [REDACTED]. Review of faxes sent to the physician between [DATE] and [DATE] showed contact was made on [DATE] regarding nausea and upset stomach, [DATE] to restart feedings and [DATE] regarding severe facial pain and transport to the hospital. No additional documentation was found to show the physician was informed of ongoing pain issues and increased abdominal pain for the resident. Interviews conducted [DATE] through [DATE] between 7:55 am 4:09 pm showed: Staff 16 (RN) indicated he could not remember any specifics on the resident or her/his condition. Staff 16 did not recall contacting the physician about any particular issue. Staff 16 stated the information in his NNs was all he could accurately provide. Staff 17 (LPN) indicated she had to suction the resident on a few occasions because the resident could not handle the secretions. She did not recall specific contacts to the physician, whatever was documented in her NNs was accurate. Staff 17 stated the resident had some confusion but could make most of her/his needs known. Staff 21 (RN) indicated the resident did not come to the facility in good shape, had some on going pain issues and spoke Spanish. The resident had some confusion but could answer questions about pain, how feeling and some other needs with an interpreter. Staff 21 could not remember any specifics about changes in the resident's condition or physician notification. The information he documented in the NNs was all he could confirm now. Witness 7 (Former Facility RN) indicated the resident came to the facility in very bad shape, was sent back to the hospital the same day and returned to the facility a few hours later. Witness 7 could not remember any specifics about the resident's condition or ongoing problems. Witness 7 stated she documented any physician contacts or new orders in her NNs, she could not recall any additional information. Witness 11 (Physician) indicated the resident was at the end of her/his life and he was concerned with maintaining resident comfort. Witness 11 was aware of the vomiting. He should have been informed of the abdominal pain and increased pain as it was out of the resident's norm and a more profound change. d. Resident 5 was admitted to the facility [DATE] with [DIAGNOSES REDACTED]. The resident's quarterly nursing summary and care plan dated [DATE] indicated the resident was oriented with intermittent confusion. The resident required extensive assistance with ADLs. The resident's current treatment was focused on comfort care due to a [MEDICAL CONDITION] [DIAGNOSES REDACTED]. NNs dated [DATE] through [DATE] indicated the resident was alert, oriented and pleasant. The resident had intermittent complaints of pain and was medicated with narcotic pain medications with some relief noted. NNs dated [DATE] at 1:00 pm indicated at the beginning of the shift the resident's oxygen saturations were 42% on room air, fingernails were blue, cold to the touch, audible gurgling with a decreased level of consciousness. The resident's respirations were ,[DATE], blood pressure ,[DATE] and oxygen was applied with saturation levels increased to ,[DATE]%. Suctioning was initiated every two hours for increased secretions. The resident's family was informed and the physician was notified of the change. The physician stated he would see the resident later that day at rounds. A fax was sent to the physician on [DATE] at 8:27 am which indicated the resident had a change in condition, decreased level of consciousness, respirations ,[DATE], and increased respiratory secretions. The physician responded at 11:32 am that he would check the resident later that day. NNs dated [DATE] at 3:15 pm indicated the physician was in to assess the resident and an order was given for [MEDICATION NAME] ([MEDICATION NAME]) 0.8 mg now (medication used to counteract narcotic medication effects). [MEDICATION NAME] was administered in the resident's left deltoid, at 3:15 pm the resident's vital signs were pulse 73, respirations 17 and blood pressure ,[DATE]. The resident was awake, opened eyes on command and was verbally responsive. An emergent physician visit dated [DATE] indicated the resident had end stage [MEDICAL CONDITION] of the liver and [MEDICAL CONDITION]. The resident was primarily comfort care and had some increasing shoulder pain. The resident received several doses of [MEDICATION NAME] and [MEDICATION NAME] last night. The resident was quite sedated since then and showed some respiratory depression which could be related to the narcotics or a progression of her/his [MEDICAL CONDITION]. The physician ordered a trial of [MEDICATION NAME] and if no response will continue with comfort measures. In an interview on [DATE] at 4:09 pm Witness 7 (Former Facility RN) indicated the resident received multiple doses of her/his PRN narcotic medications on the evening of [DATE]. The resident was in extreme pain. The resident was up walking around and was verbal. Witness 7 stated the resident was her/his usual self except for the increased pain. The resident eventually started to show some relief and rested. Witness 7 indicated there was no indication the resident was over sedated and she saw no reason to notify the physician about the resident's pain. In an interview on [DATE] at 12:25 pm Staff 17 (LPN) stated she went in to check the resident early in the shift 6:30 or 7:00 am. She saw the resident had declined and contacted the physician who said he would see the resident later that day. Staff 17 was not given any additional instructions or orders. Staff 17 did not make any additional notifications to the physician after the initial contact. She continued to check on the resident but otherwise waited for the physician to arrive. Staff 17 stated the physician came in to see the resident that afternoon and [MEDICATION NAME] was administered. In an interview on [DATE] at 1:50 pm Staff 5 (RNCM) indicated the physician came to assess the resident in the afternoon on [DATE] and ordered a dose of [MEDICATION NAME]. Staff 5 administered the dose as soon as the physician ordered it. The resident opened her/his eyes pretty quickly after the medication was given and began conversing with her/his significant other who was at the bedside. During the night the resident began to decline again and passed away. e. Resident 6 was admitted to the facility in [DATE] with [DIAGNOSES REDACTED]. The resident's POLST dated [DATE] indicated if no pulse and no breathing then attempt resuscitation/CPR; if pulse and/or breathing was present provide full treatment including hospital transfer if indicated. The resident's CAA summary dated [DATE] indicated the resident had a full code status with full treatment. The resident had a history of [REDACTED]. The resident was noted to be a fall risk due to a history at home as well as impaired mobility and medication usage. The resident was alert, oriented, refused care and self isolated with agitated behaviors towards staff. The resident's care plan dated [DATE] indicated the resident was alert and oriented with clear speech. The resident required extensive to total assistance with ADLs. Staff were to notify the licenses nurse if there was any verbal complaints of pain or non-verbal signs/symptoms of pain such as facial grimacing, guarding or changes in behavior. The care plan further indicated the resident often refused cares and treatment. The resident ate meals in her/his room. NNs dated [DATE] at 12:30 pm indicated the resident showed a decline in level of consciousness. The resident did respond to voice, blood pressure medications were held with a blood pressure of ,[DATE]. The resident refused meals, took 120 ml of fluids with some coaching. The physician was faxed. A fax was sent to the physician on [DATE] at 12:33 am which indicated the resident's blood pressure medications were held due to a low blood pressure. The resident refused other medications and meals. The resident showed a decline in level of consciousness since two days ago. The physician responded on [DATE] at 9:05 am "noted." NNs dated [DATE] at 1:00 am indicated the resident requested and received PRN pain medication early in the shift. The resident continues to be oriented and aware of surroundings although the resident's level of consciousness "continues to be diminished." The resident's temperature 96 degrees, pulse 116, respirations 28 and blood pressure ,[DATE]. There was no indication the physician was notified. NNs dated [DATE] at 10:45 am indicated the resident was found unresponsive when approached for morning blood sugars. The resident did not respond to any stimulus, pupils were fixed and not responsive to light. The resident's blood pressure was ,[DATE], pulse 53 and respirations 30. The resident was sent to the hospital via emergency transport and the physician was notified. A fax was sent to the physician on [DATE] at 8:39 am which indicated the resident was observed non-responsive at 8:00 am. The resident's pupils were fixed, not blinking, no response to any stimulus. The resident was sent to the emergency room via ambulance. The physician responded shortly thereafter that the resident had expired. Interviews conducted [DATE] through [DATE] between 7:55 am and 4:09 pm showed: Staff 21 (RN) indicated the resident was compliant with some things and refused others. The resident rarely left her/his room. Staff 21 stated there had been some adjustments to the resident's medication times so that she/he would not be bothered early in the morning. The resident was alert and oriented but "disgruntled with life" which affected her/his decisions. Staff 21 stated the first low blood pressure on [DATE] was not profound and the resident was still verbal and expressing some needs so he did not feel the physician needed to be notified. On [DATE] he went in later in the morning to check the resident's blood sugars and found she/he was not verbal or interacting. Staff 21 had not seen the resident prior to this and received no reports that the resident had a decline or was not responding appropriately. The resident was sent out to the hospital and the physician was notified. Staff 16 (RN) indicated he remembered the resident but did not remember much about [DATE] or [DATE]. Staff 16 could not say if he contacted the physician or if he thought it was necessary at the time. Staff 16 stated his NNs were accurate at the time. Staff 16 stated the resident was alert, oriented x4 and refused multiple medications, treatments and cares. Witness 11 (Physician) indicated the resident was a full code with full medical treatment. The resident had some good recovery potential but her/his choices and refusals got in the way. Witness 11 expected to be informed of unexpected changes in level of consciousness and changes in condition. He would come and see the resident if needed or have the facility send the resident to the hospital. Witness 11 indicated the resident likely should have been seen at the first decline in level of consciousness by himself or at the hospital. 2. Based on interviews and record review it was determined the facility failed to follow physician's orders [REDACTED].#s 9 and 10) reviewed for bowel care. Resident 10 was admitted to the local hospital with a fecal impaction. Findings include: The facility's [DATE] Bowel Care Policy and Procedure indicated the resident was to be provided Milk of Magnesia (MOM) after three days of no bowel movement. If the resident did not have a bowel movement during the following shift the resident was to be given a suppository. If the resident did not have a bowel movement during the following shift the resident was to be given an enema. If small bowel movements were not the baseline, the resident was to be assessed for constipation. If the resident had bouts of diarrhea or loose stools the resident was to be assessed for constipation/impaction. If the resident did not have a bowel movement after four days the physician was notified for

Based on interviews and record reviews it was determined the facility failed to provide pressure relieving devices, arrange for a podiatry appointment, conduct consistent pressure ulcer assessments, follow physician's orders [REDACTED].#s 10, 14 and 16) reviewed for pressure ulcer care. Resident 10 was admitted with a Stage I (an observable pressure related alteration of intact skin) coccyx ulcer which deteriorated to Stage III (full thickness tissue loss). Findings include: The facility's February 2000 policies and procedures for skin integrity indicated the facility was to have a systematic approach and monitoring process for evaluating and documenting the skin integrity and promote healing of skin ulcers/pressure ulcer/wounds 1. Resident 10 was admitted to the facility in July 2014 with [DIAGNOSES REDACTED]. a. The 7/1/14 physician's orders [REDACTED]. The 7/1/14 and 7/3/14 Wound/Skin evaluation and documentation form indicated the resident's Stage II pressure ulcer on her/his coccyx measured 3.5 cm by 1.75 cm by 0.5 cm. There was no documentation on the Wound/Skin evaluation and documentation form of an assessment of the resident's coccyx pressure ulcer from 7/3/14 through 7/21/14. There was documentation on 7/7/14 regarding the pressure ulcer though there were no measurements and description of the ulcer. The 7/21/14 Wound/Skin evaluation and documentation form indicated the resident's coccyx ulcer measured 2 cm by 1.25 cm by 0.4 cm. The 7/29/14 Wound/Skin evaluation and documentation form indicated the resident's coccyx ulcer "improved" and measured 1.0 cm by 0.75 cm and 0.3 cm. There was no documented assessment of the resident's coccyx pressure ulcer from 7/29/14 until a 9/2/14 NN indicated physician was "faxed regarding coccyx wound that appears to be larger per NOC (night) shift report; requested eval (evaluation) by Witness 10 (Advanced Practice Nurse Practitioner)." Witness 10 (Advanced Practice Nurse Practitioner) assessed the resident's coccyx ulcer on 9/4/14 and described the ulcer as non-stageable (pressure ulcers are unstageable when the tissue at the base of the ulcer is covered by dead skin that is yellow, tan, green or brown) and measured 2.7 cm by 1.7 cm by 0.1 cm. The treatment orders were for the coccyx ulcer to have santyl ointment with dry gauze dressing changed daily. The September 2014 TAR documented on 9/6/14 the santyl cream was not applied. There was a note on the front of the TAR to indicate the resident requested not to be "jostled around tonight." On 9/7/14 there was a circle around the nurse's initial to indicate the santyl cream was not applied. There was a note on the front of the TAR to indicate "santyl cream missing." Resident 10 was hosptalized on [DATE] and was assessed by the local hospital wound care nurse to have a Stage III coccyx ulcer measuring 3 cm by 2 cm by 0.4 cm. The resident was readmitted to the facility on [DATE]. On 10/29/14 the physician's orders [REDACTED]. The October 2014 TAR was not updated to reflect the 10/29/14 physician's orders [REDACTED]. The resident was discharged to the local hospital on [DATE]. The hospital assessed the resident to have a Stage III coccyx decubitus ulcer which was 2 cm in diameter and was "deep." On 11/28/14 the resident returned to the facility. Witness 10's 12/15/14 assessment indicated the resident's Stage III coccyx ulcer with "deterioration." The treatment orders were for santyl ointment to be applied to coccyx daily and cover with dry gauze. The December 2014 TAR contained no documentation the coccyx dressings were done on 12/16/14 and 12/17/14. On 1/6/15 at 3:00 pm Witness 1 (family member) stated Resident 10 was admitted to the facility with pressure ulcers though the pressure ulcers deteriorated because the facility failed to provide the pressure ulcer treatments as ordered by the physician. On 1/14/15 at 11:00 am Staff 5 (RNCM) had no explanation why the resident's ulcer had not been assessed from 7/29/14 through 9/2/14. Staff 5 verified the treatment orders were not followed. On 1/15/15 at 11:15 am and 1/27/14 at 4:00 pm Staff 22 (LPN) and Staff 16 (RN) had no explanation why the resident's treatment orders were not followed. On 1/28/15 at 10:00 am Staff 25 and Staff 26 (Corporate Consulting RNs) were asked about the assessment of the resident's coccyx ulcer and the treatments provided. On 1/29/15 Staff 25 indicated the santyl cream was not applied as ordered. There was no documentation the resident's request to have her/his santyl cream on coccyx changed from nights to days. Staff 25 indicated treatment orders were not followed as ordered. On 2/4/15 at 9:40 am Witness 10 (Advanced Practice Nurse Practitioner) stated she would expect the wound care orders to be followed. Witness 10 stated she conducted the assessments of the pressure ulcers and did not review the TARs to determine if the treatment orders were carried out. b. The 6/30/14 local hospital Discharge to FACILITY Physician order [REDACTED]." There was no documentation the resident was seen by the podiatrist until 8/19/14. On 1/28/15 at 10:00 am Staff 25 and Staff 26 (Corporate Consulting RNs) were asked if the podiatry appointment had been arranged for the resident upon admission. On 1/29/15 Staff 25 provided podiatry notes prior to the resident's hospitalization and during hospitalized from [DATE] through 6/30/14. The 6/30/14 podiatry notes recommended the foot ulcer sites were to be cleansed with [MEDICATION NAME] and dressed with [MEDICATION NAME] gauze and dry gauze dressings, covered with kerlix roll. The podiatrist recommended use of SCDs (sequential compression devices-to reduce numbness and swelling), continued daily wound cleansing and dressing changes. There was no documentation a podiatry appointment was made after the resident was admitted to the facility. There was no documentation the SCDs were provided for the resident from 7/1/14 until the resident was provided with TED hose on 7/11/14. On 1/29/15 at 3:00 pm Staff 25 (Corporate Consulting RN) verified SCDs were provided for the resident. c. The 7/1/14 physician's treatment orders for Resident 10's bottom of right great toe, bottom of left heel, left heel and right heel was to cleanse with hibicleans 4%-apply [MEDICATION NAME] petroleum gauze and kerlix and change every day. The facility's 7/1/14 Wound/Skin evaluation and documentation form indicated the resident was admitted with a Stage II pressure ulcer on the left heel measuring 1 cm by 0.5 cm by 0.1 cm, a Stage II pressure ulcer on the bottom of the left heel measuring 2.5 cm by 1.5 cm by 0.1 cm, a Stage II pressure ulcer on the bottom of the right great toe and an unstageable right heel ulcer 3 cm by 2.75 cm by 0 cm. The 7/1/14 and 7/10/14 Bedside Care Plan indicated the resident had pressure ulcers on coccyx and feet. The approaches indicated the resident was to have a foot cradle, was to be turned every one to two hours at night, low air mattress. There was no documentation in the care plan to provide the resident with heel protectors when in bed. There was no documentation of an assessment of the ulcers on the bottom of the left heel, left heel, bottom of the right great toe, right heel from 7/7/14 through 7/21/14. The 7/31/14 wound/skin evaluation and documentation form indicated the resident's right heel ulcer resolved. The 8/4/14 wound/skin evaluation and documentation form indicated the resident's left heel ulcer resolved. The August 2014 TAR continued to document the treatments were done for all of the pressure ulcers including the resident's right and left heel ulcers which had been identified as resolved. The wound skin evaluation and documentation form contained no documentation the bottom of the resident's left heel was assessed from 7/29/14 until the resident was seen by the podiatrist on 8/19/14. The 8/19/14 podiatrist notes indicated the resident was assessed due to concerns of possible infection. The podiatrist documented the plan for "ulcer sites cleansed with chlorexidine, debrided and dressed with xeroform gauze and dry gauze dressings. Recommend continuing with current wound care, no apparent infection noted bilateral foot. " On 9/4/14 Witness 10 (Advanced Practice Nurse Practitioner) assessed the resident's left heel as non-stageable and measured 0.9 cm by 1.5 cm, left plantar ulcer non-stageable measured 1.5 cm by 0.9 cm by 1.5 cm and right heel non-stageable measured 3 cm by 4 cm. The assessment determined the resident needed bilateral leg "[MEDICAL CONDITION] wraps from foot to upper thighs with change of dressing every 2 days (3 layer wraps)." Right, left heels and left plantar ulcers were to have transparent dressings to "debride" changed with [MEDICAL CONDITION] wraps. The left leg wound was to have a thin [MEDICATION NAME] dressing to be changed with [MEDICAL CONDITION] wraps. There were orders for the resident to have heel protectors provided. The September 2014 TAR contained no documentation the leg wraps were in place when ordered on [DATE]. On 9/7/14 there was a circle around the nurse's initials to indicate the leg wraps were not in place. There was a note on the back of the TAR "[MEDICAL CONDITION] wraps not available yet." The TAR had a written note to indicate the facility used ace wraps on bilateral lower extremities and the ace wraps were to be discontinued when "[MEDICAL CONDITION] wraps here." There was no documentation the [MEDICAL CONDITION] wraps were provided for the resident from 9/4/14 through 9/10/14. There was documentation the resident was provided with ace wraps from 9/4/14 through 9/10/14 when the resident was discharged to the local hospital. The local hospital wound care nurse assessment indicated the resident had a Stage II pressure ulcer on the right and left heels. The resident was readmitted to the facility on [DATE]. On 9/22/14 the treatment orders changed to include bilateral heel ulcers were to have a foam dressing with alginate and was to be changed every five days with compressions wraps. The 9/28/14 physician's orders [REDACTED]. The September 2014 TAR contained no documentation both of the heel dressings were done on 9/29/14 and 9/30/14. The October 2014 TAR was not updated to reflect the 9/28/14 order for both of the heel dressings to be done daily. The TAR continued with the 9/22/14 order for the bilateral heel foam dressings with alginate and to change every 5 days with compression wraps. The TAR contained the discontinuation of the compression wraps. The TAR documented treatments were done on 10/2/14, 10/5/15, 10/7/14, 10/9/14, 10/12/14 and 10/13/14. There was no documentation the dressing changes had been done from 10/13/14 through 10/16/14 when the resident was hospitalized . On 10/25/14 the resident was readmitted to the facility with treatment orders for the facility to use [MEDICATION NAME] dressings on the resident's heels and they were to be changed every three days. On 10/29/14 the treatment orders were changed to include dry dressings only to heels with change every two days. The October 2014 TAR was not updated on 10/29/14 to reflect the treatment orders. The TAR continued with the 10/25/14 orders. The November 2014 TAR was updated to reflect the 10/29/14 treatment orders. The resident was discharged to the local hospital on [DATE] and was readmitted to the facility on [DATE] with the previous wound care orders. On 12/15/14 the resident's left heel was assessed to be resolved and skin was intact. The treatment orders for the resident's right heel was changed to daily moist [MEDICATION NAME] dressing. The December 2014 TAR contained no documentation the right heel dressing was done on 12/16/14 and 12/17/14. Resident 10 was hosptalized on [DATE] and did not return to the facility. On 1/14/15 at 11:00 am Staff 5 (RNCM) had no explanation why the resident's ulcers had not been consistently assessed. Staff 5 verified the treatment orders were not always updated on the TARs and the treatment orders followed. Staff 5 verified the resident did not have heel protectors in place until 9/4/14. On 1/15/15 at 10:40 am Staff 6 (CNA) stated the resident had heel protectors when she/he was in bed though could not remember when they were first used. On 1/15/15 at 11:15 am and 1/27/14 at 4:00 pm Staff 22 (LPN) and Staff 16 (RN) had no explanation why the resident's treatment orders were not followed. On 1/28/15 at 10:00 am Staff 25 and Staff 26 (Corporate Consulting RNs) were asked about the assessment of the resident's ulcers, treatments provided and pressure relieving devices used. On 1/29/15 Staff 25 provided written documentation to indicate the facility could not find documentation heel dressings and leg compression wraps were provided as ordered. Staff 25 could not locate documentation orders for change in treatments were carried over and treatments provided as ordered. No additional information was provided to indicate heel protectors were used for the resident until 9/4/14. On 2/4/15 at 9:40 am Witness 10 (Advanced Practice Nurse Practitioner) stated when a resident was admitted to the facility with heel ulcers she would expect the facility to provide the resident with heel protectors. Witness 10 stated she would expect the wound care orders to be followed. Witness 10 stated she conducted the assessments of the pressure ulcers and did not review the TARs to determine if the treatment orders were carried out. d. The 7/1/14 physician's treatment orders for the resident's right medial malleolus pressure ulcer (bony prominence on the inner side of the ankle). The facility's 7/1/14 and 7/7/14 wound/skin evaluation and documentation form identified the ulcer as a Stage II pressure ulcer. The next documented assessment was on 7/21/14 and the wound/skin evaluation and documentation form identified the ulcer as a right lateral malleolus (prominence on the outer side of the ankle). The last documented assessment of the resident's malleolus was on 7/29/14 when it was described as the right lateral malleolus and measured 2 cm by 1.25 cm by 0.1 cm. On 9/4/14, Witness 10 (Advanced Practice Nurse Practitioner) assessed the resident's right medial malleolus to be an unstageable pressure ulcer measured 2 cm by 1 cm. On 1/14/15 at 11:00 am Staff 5 (RNCM) verified the assessment changed from the right medial to right lateral malleolus and there was no documented assessment of the right medial malleolus from 7/29/14 until Witness 10's assessment on 9/4/14. On 1/26/15 at 1:00 pm Staff 25 (Corporate Consulting RN) verified there was no assessment of the right medial malleolus after 7/7/14. Staff 25 stated the assessments documented the ulcer was on the right lateral malleolus and there was no documented assessment after 7/29/14. e. On 7/2/14 the physician ordered the resident to receive protein powder three times a day for wound healing. The July 2014 MAR indicated [REDACTED]. The August 2014 MAR indicated [REDACTED]. On the back of the MAR for three of the occasions the documentation indicated the facility was "out of protein powder." On 9/16/14 the physician order [REDACTED]. The September 2014 MAR indicated [REDACTED]. On 10/3/14 the physician ordered the resident to receive protein powder three times a day with medication pass. The October 2014 MAR indicated [REDACTED]. On 1/14/15 at 11:00 am Staff 5 (RNCM) verified the protein powder and Juven powder were not provided as ordered. On 1/28/15 at 10:00 am Staff 25 and 26 (Corporate Consulting RNs) were asked about the provision of protein powder. On 1/29/15 Staff 25 provided written documentation to indicate protein powder was not given and unable to locate documentation the protein powder was provided. Staff 25 indicated the licensed nurses had been instructed to notify the DNS or the Executive Director immediately so the supplement or medication could be obtained. 2. Resident 14 was admitted to the facility in 2010 with [DIAGNOSES REDACTED]. Periodic observations of Resident 14 were made on 1/12/15 at 3:00 pm through 1/16/15 at 8:00 am and from 2/2/15 at 1:00 pm through 2/4/15 at 9:00 am. The resident was observed to be seated on a Star/Roho cushion (multi-cellular, air-filled design adjusts to the contours of the resident in the wheelchair) when seated in her/his wheelchair for meals. The resident was observed to be repositioned every two hours. Resident 14 was observed to be laid down in bed after meals with heel protectors on and had an air mattress in place. The 12/11/13 CAAs identified the resident was at risk for developing pressure ulcers. The resident was assessed to require assistance in bed mobility, repositioning and transfers. Resident 14 was repositioned to prevent pressure to localized areas. A pressure-relieving mattress was utilized continuously. The 5/26/14 Skin Integrity Evaluation documented the resident was at risk for skin breakdown and had no areas of skin breakdown. The 10/3/14 physician's 30 day visit documented the resident "no longer uses her/his powered wheelchair however since it is needing repairs and her/his (family member) is having difficulty getting the company to do the warranty repairs. She/he does however get up in a wheelchair and is wheeled to meals ...." The 10/19/14 NN documented the resident had a Stage II pressure ulcer (partial thickness skin loss) measuring 1 by 1 by 0.25 cm on her/his coccyx and a Stage I (an observable, pressure related alteration of intact skin) 1 by 1 cm pressure ulcer on her/his right buttocks. The documentation indicated the nurse applied barrier cream and faxed the physician. The 10/19/14 fax to the physician described the resident's skin condition and asked the physician for any additional orders. On 10/20/14 the physician responded with no additional orders. On 10/29/14 the coccyx pressure ulcer was assessed to have increased in size and measured 1.5 by 0.5 by 0.1 cm. On 10/30/14 the physician ordered the facility to "cleanse coccyx with normal saline. Apply dry gauze dressing, cover with [MEDICATION NAME]. Change every shift." The October 2014 TAR contained no documentation the dressing changes were made on 10/30/14 and 10/31/14. There was a circle around the initials for the night shift of 10/30/14. The back of the TAR indicated the treatment was not provided on the night of 10/30/14 because the resident refused. There was no documentation to indicate the dressing change had been conducted on the night of 10/31/14. There was no documentation on the back of the TAR to indicate the reason why the treatment had not been provided. The November 2014 TAR indicated there was a circle around the nurse's initials to indicate the treatments were not provided on the night shift of 11/1/14, 11/2/14 and 11/3/14. There was no documentation the treatments were provided on the evening shift of 11/2/14 and 11/3/14. There was no documentation to indicate the reason why the treatments were not provided as ordered. On 11/4/14 Witness 10 (Advanced Practice Nurse Practitioner) assessed the resident. The assessment indicated the resident recently "developed an open coccyx ulcer that had not responded to wound care." Witness 10 assessed the ulcer to be non-stageable and measured 1.9 by 1.2 by 0.8 cm. The treatment orders were changed to include cleansing the coccyx ulcer, apply wound gel, cover with 3 by 3 foam dressing and change every two days. Witness 10 indicated the resident was to be on a turn schedule when in bed, was to have a wheelchair cushion evaluation and was to be laid down for two hours after meals. The November 2014 TAR indicated there was no documentation the dressing was changed on 11/20/14. There was no documentation why the treatment was not provided. On 11/21/14 Witness 10 evaluated the resident and indicated there was a "deterioration of unstageable wound." The treatment orders were changed to cleansing the coccyx ulcer, pack with moist [MEDICATION NAME] gauze, cover and change twice a day. The 11/21/14 Annual Nursing CAAs indicated pressure ulcers were triggered due to her/his development of a pressure ulcer in her/his coccyx area. The assessment indicated the resident was a diabetic and her/his nutritional status had declined which played a contributing factor to her/his skin issues. The November 2014 TAR contained no documentation the dressings were changed during the day shift from 11/26/14 through 11/30/14. There was no documentation on the TAR to indicate the dressing changes had been done during the evening shift of 11/25/14, 11/26/14 and 11/30/14. There was no documentation why the treatments were not done. The November 2014 TAR contained information for the staff to include "limit time up in chair to 1-2 hours. Turn every 2 hours and HOB (head of bed) up at 30 degrees." On 11/28/14 Witness 10 evaluated the resident's ulcer increased in size to 3.5 by 3.5 by 3 cm and needed to be surgically debrided. On 12/10/14 the treatment orders were changed to cleanse coccyx ulcer, pack with [MEDICATION NAME], gauze cover every shift and PRN. The December 2014 TAR contained no documentation the treatment was done on the day shift of 12/12/14 and the evening shift of 12/13/14, 12/14/14 and 12/15/14. There was no documentation why the treatments were not provided. On 12/16/14 the treatment orders were changed to wet to dry, normal saline and gauze changed every 12 hours. The December 2014 TAR contained no documentation the dressing changes were conducted on 12/18/14. There was no documentation why the treatments were no provided. On 12/19/14 the treatment orders were changed to [MEDICATION NAME] gauze with 4 by 4 cover with film dressing to be changed BID. The December 2014 TAR contained no documentation the dressing change were conducted on the evening shift of 12/20/14. There was no documentation why the treatment was not provided. On 1/9/15 the physician noted the resident was to have a debridement of the necrotic tissue of the coccyx ulcer. On 1/28/15 Witness 10 indicated after the ulcer debridement the coccyx ulcer was assessed to be a Stage IV (full thickness tissue loss with exposed bone, tendon, or muscle). On 1/15/15 at 11:15 am and 1/27/14 at 4:00 pm Staff 22 (LPN) and Staff 16 (RN) had no explanation why the resident's treatment orders were not followed. On 1/15/15 at 3:18 pm Staff 5 (RNCM) stated there was no documentation the treatment orders were consistently provided. On 2/3/15 at 9:15 am Staff 31 (Occupational Therapist/OT) indicated she did not document a wheelchair cushion evaluation had been done though she stated she provided the resident with a Star/Roho cushion after Witness 10's request for a cushion to be in place. Staff 31 stated she periodically checked to ensure the Star/Roho cushion was properly inflated. Staff 31 stated there had not been no problems with the cushion. On 2/4/15 at 9:40 am Witness 10 (Advanced Practice Nurse Practitioner) stated she would expect the wound care orders to be followed. Witness 10 stated she conducted the assessments of the pressure ulcers and did not review the TARs to determine if the treatment orders were carried out. Witness 10 was asked about the development of Resident 14's pressure ulcer. Witness 10 stated she felt the resident's pressure ulcer was unavoidable. On 2/4/15 at 10:15 am Staff 25, 26 and Staff 27 (Corporate Consulting RNs) were asked to provide any additional information regarding the failure of Resident 14's pressure ulcer treatment. No additional information was provided. 3. Resident 16 was admitted to the facility in October 2014 with [DIAGNOSES REDACTED]. There was no indication the resident had any skin breakdown during the month of October 2014. a. The 11/5/14 Weekly Skin Evaluation indicated the resident had a laceration of her/his right lower leg which measured 2 cm by 1 cm by 0.25 cm. The 11/5/14 physician's orders [REDACTED]." The November 2014 TAR documented the dry gauze dressing was applied to the right lower leg from 11/5/14 through 11/19/14. The 11/19/14 NN indicated the resident's right leg wound "has gotten larger in volume. Additional small wounds have developed ...." The 11/21/14 Weekly Skin evaluation indicated the resident's right leg wound was a Stage 2 pressure ulcer which measured 4 cm by 2.5 cm by 0.2-0.3 cm. The 11/21/14 physician's note indicated the resident was to have had a follow up appointment with orthopedist on 11/20/14 though the appointment was canceled due to poor road conditions. The physician indicated the resident developed a pressure ulcer on the right lower leg from the brace. On 11/21/14 Witness 10 (Advanced Practice Nurse Practitioner) assessed the resident's right leg ulcer was due to "pressure from her/his splint staged at Stage 3 ...." The 11/21/14 treatment order indicated the facility was to cleanse the right leg wound apply [MEDICATION NAME], cover with thin foam and change every three days. On 11/24/14 the resident was assessed by the orthopedist and determined the resident continued to need the knee immobilizer on at all times. The November 2014 TAR contained no documentation any dressings were applied until 11/29/14. On the back of the November 2014 TAR there was documentation the "[MEDICATION NAME] dressing was not available" on 11/23/14, 11/24/14 and 11/25/14. On 12/12/14 the treatment orders were changed to include the addition of alginate when the dressing was changed every three days. The December 2014 TAR indicated the order to change the dressings every three days was discontinued on 12/12/14. The TAR indicated the ulcer was to have alginate under the dressing. There was no indication on the TAR when the dressing changes were to occur. The TAR indicated alginate with dressing changes were provided on 12/12/14, 12/15/14 and daily from 12/19/14 through 12/31/14. The January 2015 TAR contained the 12/12/14 treatment orders to cleanse right leg wound, apply [MEDICATION NAME], add small amount of alginate just enough to cover wound-cover with thick foam dressing and change every three days. The January 2015 TAR contained documentation the treatments were provided as ordered. Witness 10's 1/2/15 and 1/14/15 notes indicated the resident's right lower leg ulcer was resolving. On 1/15/15 at 11:15 am and 1/27/14 at 4:00 pm Staff 22 (LPN) and Staff 16 (RN) had no explanation why the resident's treatment orders were not followed. On 1/15/15 at 3:18 pm Staff 5 (RNCM) stated there was no documentation the treatment orders were provided. On 2/4/15 at 9:40 am Witness 10 (Advanced Practice Nurse Practitioner) stated she would expect the wound care orders to be followed. Witness 10 stated she conducted the assessments of the pressure ulcer and did not review the TARs to determine if the treatment orders were carried out. Witness 10 was asked about the development of Resident 16's pressure ulcer. Witness 10 stated she felt the resident's pressure ulcer was unavoidable. Witness 10 stated the ulcer was resolving. On 2/4/15 at 10:15 am Staff 25, 26 and Staff 27 (Corporate Consulting RNs) were asked to provide any additional information regarding Resident 14's pressure ulcer treatment. No additional information was provided. b. The 11/21/14 Weekly Skin Evaluation and Wound consult note indicated the resident had a Stage II pressure ulcer on her/his left heel measuring 1.4 cm by 1.5 cm by 0.01 cm. The 11/21/14 treatment order indicated a thin [MEDICATION NAME] dressing on her/his left heel and the dressing was to be changed every four days. The November 2014 TAR had circles around the nurse's initials to indicate the dressing had not been done from 11/22/14 through 11/25/14. On the back of the TAR it indicated [MEDICATION NAME] dressing was not available. There was no documentation the left heel dressing was changed from 11/25/14 through 11/30/14. The 11/28/14 treatment orders indicated a small amount of Alginate "just enough to cover heel ulcer under the dressing during each dressing change ...." The November 2014 TAR contained no documentation the Alginate was provided during the month of November 2014. The December 2014 TAR indicated the left heel wound dressing was changed on 12/3/14, 12/7/14 and 12/11/14. There was no documentation Alginate was applied to the left heel ulcer when the dressing was changed on 12/3/14 and 12/7/14. On 12/12/14 the treatment orders were changed to the left heel ulcer to be cleansed and covered with a moist [MEDICATION NAME] dressing and was to be changed daily. The December 2014 TAR contained the order for the daily dressing change for the left heel ulcer though the TAR did not discontinue the prior order for the dressing change every four days. The TAR contained documentation the resident continued to receive the left heel ulcer dressing every four days from 12/14/14 through 12/19/14. There was no documentation the resident received the daily wound dressing on 12/12/14 through 12/14/14 and 12/16/14 through 12/18/14. On 1/2/15 Witness 10 assessed the resident's left heel ulcer to be resolving. On 1/15/15 at 11:15 am and 1/27/14 at 4:00 pm Staff 22 (LPN) and Staff 16 (RN) had no explanation why the resident's treatment orders were not followed. On 2/4/15 at 9:40 am Witness 10 (Advanced Practice Nurse Practitioner) stated she would expect the wound care orders to be followed. Witness 10 stated she conducted the assessments of the pressure ulcer and did not review the TARs to determine if the treatment orders were carried out. Witness 10 was asked about the development of Resident 16's pressure ulcer. Witness 10 stated she felt the resident's pressure ulcer was unavoidable Witness 10 stated the resident's ulcer was resolving. On 2/4/15 at 10:15 am Staff 25, 26 and Staff 27 (Corporate Consulting RNs) were asked to provide any additional information regarding Resident 16's pressure ulcer treatment. No additional information was provided.

Based on interview and record review it was determined the facility failed to ensure changes in condition were reported to residents' families and physician for 7 of 17 sampled residents (#s 6, 7, 8, 9, 11, 14 and 16). This put residents at risk for extended delays in treatment, unaddressed declines in health and potentially avoidable pain and discomfort. Resident 11 was left unresponsive for approximately five hours before emergency measures were initiated. Findings include: 1. Resident 11 was a long time resident of the facility with [DIAGNOSES REDACTED]. The resident's quarterly nursing summary additionally indicated the resident's code status was full code-attempt CPR, full medical treatment, use antibiotics if medically indicated and long-term artificial nutrition by tube if medically necessary. The resident's care plan dated [DATE] indicated the resident had clear speech, could make needs known, was alert and oriented. The resident was independent for toileting and transfers and required supervision with cueing for ambulation/mobility, bed mobility, meals and grooming. a. A NN dated [DATE] at 11:30 am indicated the portable X-ray company was in and completed X-rays, results available in approximately two hours. Witness 5 (Former Facility RN) noted a phone call was made to the family to inform them of the resident's status today: "resident has been sleeping, unable to be awakened-has remained in bed-O2 via non-breather applied d/t (due to) labored breathing." The resident's oxygen saturation levels were unable to be obtained and respirations were shallow, O2 sats now at 88 with resident on oxygen 4L/min. The resident's blood pressure at 9:00 am ,[DATE], at 11:00 am it was ,[DATE]. The administrator and DNS were informed and stated to call 911. An additional NN at 12:00 pm indicated the ambulance assessed and transported the resident to the emergency room . Attempts continued to be made to reach the resident's family. An Event Investigation Final Summary dated [DATE] indicated the resident slept through most of the night and toileted self sometime between 2:30 and 4:30 am on [DATE]. At 6:00 am the resident appeared to be sleeping, at 6:45 am Staff 20 (CNA) changed and dressed the resident but the resident did not respond during the process. Staff 20 stated he reported to the nurse, Witness 5, the resident was still unresponsive. Witness 5 stated she checked on the resident several times and the resident appeared to be sleeping and snoring. Oxygen was applied at approximately 9:00 am. The Event Summary further indicated mobile X-rays were completed around 10:00 am. Witness 5 checked the resident at 10:20 am and the resident appeared comfortable. Witness 5 left a message for the resident's family at 11:00 am. At 11:20 am Witness 5 notified Witness 6 (Former Facility DNS) and Staff 3 (Administrator) of a suspected change in condition. The resident left with EMTs at 12:00 pm. Interviews conducted [DATE] through [DATE] between 8:20 am and 5:20 pm showed: Witness 2 (Complainant) indicated the resident was normally up and around the facility on her/his own. The resident had good cognition and could make needs known. Witness 2 frequently talked to the resident on the phone and over the last week or so the resident had not seemed herself/himself. The resident participated in the care conference on [DATE] and did not sound right. Witness 2 told multiple staff including Witness 6 (Former Facility DNS) there was something wrong with the resident. The following day on [DATE] Witness 2 received a phone call from the facility to his cell phone around 12:45 pm that the resident was unresponsive through the morning and was sent to the hospital. Witness 2 received no prior information the resident had spent hours unresponsive. Witness 2 headed to the hospital to see the resident, when Witness 2 arrived home the evening of [DATE] he had a voicemail from Witness 5 (Former Facility RN) that the resident took a turn for the worse and they were sending the resident to the hospital. Witness 2 was told by Witness 5 the resident was verbally unresponsive, had missed breakfast and that she applied oxygen. The resident was sent to the hospital several hours later. Staff 20 (CNA) indicated the resident was fairly independent and was usually up and at least partially dressed to go to breakfast. The resident rarely ever missed a meal and would walk down on her/his own sometimes with a staff. Staff 20 stated he went into the resident's room at approximately 6:30 am or so to make sure the resident was ready, as he usually would. The resident was on her/his back in a totally relaxed position and snoring. Staff 20 stated the resident's positioning was out of the norm as she/he typically slept on her/his side curled up under a blanket. Staff 20 called the resident's name, touched her/his hands, tapped/shook the resident's shoulder but the resident would not wake or respond. Staff 20 proceeded to get the other resident in the room ready then tried again to wake Resident 11 with no success. Staff 20 reported to the nurse, Witness 5, the resident was not responding to any attempts to awaken her/him. Staff 20 was told the resident had a fall and a rough night and to let the resident rest. Staff 20 continued his rounds, delivered trays and answered lights but periodically attempted to wake the resident with no response to any of his attempts. Staff 20 again reported to Witness 5 there was something wrong and the resident would not respond. Staff 20 was told Witness 5 would check the resident after medication pass. Staff 20 attempted to wake the resident again after breakfast with no success and was told by Witness 5 a portable X-ray was coming and he was to assist. Staff 20 stated he assisted to sit the resident up into a full sitting position, roll side to side, place slides and lay the resident back down again. Staff 20 stated the resident did not open her/his eyes, show signs of pain, made no sounds and made no movement during the X-ray process, but was breathing. Staff 20 again went to the nurse, expressed concerns with the resident's abnormal behavior and demanded she check the resident. Witness 5 went to the resident's room and took an oxygen concentrator with. Staff 20 indicated the resident was still unresponsive and he was preparing to report to another supervisor either the RCM or DNS when Witness 5 said she was sending the resident to the hospital. Two attempts were made to reach Witness 6 (Former Facility DNS), no return call was received. Four attempts were made to reach Witness 5 (Former Facility RN), no return call was received. Witness 11 (Physician) indicated the resident was to receive full treatment and CPR if needed. The resident had a complicated medical history which limited some treatments. Witness 11 stated he should have been notified as soon as it was determined the resident was unresponsive. The resident should have been sent to the hospital as soon as it was determined she/he had a decline and was unresponsive. b. NNs dated [DATE] indicated a late entry from [DATE]. The resident had slipped to the floor, she/he stated "I lost my balance" while ambulating in the main dining room. The resident had a small abrasion to the right elbow. The resident had an additional fall on [DATE] in her/his room as she/he slid from the bed onto the floor. The resident was noted to have normal ADL function. A portable X-ray was going to be scheduled at the family's request to rule out any additional injury. A care conference note dated [DATE] at 11:30 am indicated the resident's falls were discussed with the resident's family. Witness 5 (Former Facility RN) explained to the resident's family the falls that occurred on [DATE] and [DATE]. In an interview on [DATE] at 10:42 am Witness 2 (Complainant) indicated he was the resident's designated contact and he was not informed the resident had a fall on [DATE] and [DATE] until the care conference meeting on [DATE]. Witness 2 stated he was supposed to be contacted right away with any changes to the resident. The resident did not normally have falls and sustained an injury. In an interview on [DATE] at 1:15 pm Staff 7 (RNCM) and 1:50 pm Staff 5 (RNCM) indicated they did not contact Witness 2 regarding the resident's falls prior to the care conference. Refer to F-309 2. Resident 8 was a long time resident of the facility with [DIAGNOSES REDACTED]. The resident's quarterly nursing assessment dated [DATE] indicated the resident required extensive to dependent assistance with ADLs related to progressive dementia and limitations in range of motion. NNs dated [DATE] at 6:30 pm indicated no emesis but a small dark, black, sticky stool was noted. The physician was notified. A fax dated [DATE] at 6:28 pm was sent to the physician regarding the dark black stool. The physician responded on [DATE] at 9:11 am with "noted." Additional NNs on [DATE] at 7:30 pm indicated the resident had small brown emesis with food chunks. There was no indication the physician was notified. No fax was located regarding the brown emesis on [DATE]. At 8:15 pm the resident had a large brown emesis with food chunks. The resident was gurgling, having trouble breathing. The resident had a medium black tarry stool; aids changed the resident and sat her/him up in the chair. The resident had a firm distended abdomen with hyperactive bowel tones. Vital signs were pulse 114, respirations 28 and blood pressure ,[DATE]. "Notified (RCM) and (physician) will evaluate in the am." No fax was located to show the physician was notified of the emesis, tarry stool and difficulty breathing. NNs dated [DATE] at 4:30 am indicated emesis x 1 early in night shift, moderate amount, and dark brown in color. Head of bed elevated to 45 degrees, in no distress at the present time. Will continue to monitor. There was no indication the physician was notified. NNs dated [DATE] at 6:00 am indicated emesis x1 on night shift, keep head of bed at 45 degrees at all times, will continue to monitor. There was no indication the physician was notified. Interviews conducted [DATE] through [DATE] between 7:55 am 4:09 pm showed: Witness 7 (Former Facility RN) indicated she contacted the physician on [DATE] regarding the dark, black stool. Witness 7 did not re-contact the physician about subsequent issues that she could recall. Staff 17 (LPN) indicated she remembered the resident but could not recall any specific issues. She was not sure if she had contacted the physician about the resident, it would be in her NNs. Staff 25 (Corporate RN) indicated there was no additional documentation of faxes after the initial [DATE] contact and no documented physician visits after [DATE]. Witness 11 (Physician) indicated he should have been notified of the resident's ongoing problems with vomiting and black stool. The resident was full treatment and CPR. Witness 11 stated the resident should have been sent out to the hospital in response to continued changes and ongoing emesis. The facility did not need to wait for Witness 11 to give the okay for transport; they could notify him after the fact if a resident needed immediate evaluation. 3. Resident 9 was admitted to the facility in [DATE] with [DIAGNOSES REDACTED]. NNs dated [DATE] at 4:00 am indicated the resident was crying out in pain and was medicated with PRN [MEDICATION NAME]. There was no indication the physician was notified. NNs dated [DATE] at 3:00 pm indicated the resident was crying out in pain with increased anxiety. The resident was medicated with PRN [MEDICATION NAME] (antianxiety) and [MEDICATION NAME]. At 9:00 pm the resident was crying, pointed to her/his abdomen and stated in Spanish "tiene dolor" (have pain). The resident was medicated with PRN [MEDICATION NAME] and [MEDICATION NAME]; the resident was calmer and resting. There was no indication the physician was notified. NNs dated [DATE] indicated the resident slept without incident. The resident received PRN [MEDICATION NAME] x3 during the night for pain, will continue to monitor. NNs dated [DATE] indicated the resident was awake and crying much of night, no changes noted. The resident was medicated for pain x3 during the night, will continue to monitor. There was no indication the physician was notified. NNs dated [DATE] at 6:00 am indicated the resident continued to be awake and crying loudly most of the night shift despite comfort measures and [MEDICATION NAME] administration. At 2:10 pm PRN [MEDICATION NAME] was given for pain. There was no indication the physician was notified. NNs dated [DATE] at 4:00 am indicated the resident cried off and on through the shift, PRN [MEDICATION NAME] was given with some success. There was no indication the physician was notified. NNs dated [DATE] at 5:00 am indicated no changes to the resident's physiological condition. The resident received PRN [MEDICATION NAME] x3 for pain, resident "yelling and screaming loudly" during the night. NNs at 2:10 pm indicated the resident continued to be confused with periods of yelling and moaning, no complaints of pain. PRN [MEDICATION NAME] was provided with good effect. At 4:00 pm confusion continues, [MEDICATION NAME] used with good results. There was no indication the physician was notified. NNs dated [DATE] at 3:00 pm indicated the resident had large amount of projective vomiting this am. The resident complained of pain to the right face radiating to the left face. The resident stated through a translator that she/he wanted to go to the emergency room . The resident was taken to the hospital and returned at 5:30 pm with new [DIAGNOSES REDACTED]. Interviews conducted [DATE] through [DATE] between 7:55 am 4:09 pm showed: Staff 16 (RN) indicated he did not recall contacting the physician about any particular issue. Staff 16 stated the information in his NNs was all he could accurately provide at this time. Staff 17 (LPN) indicated she did not recall specific contacts to the physician, whatever was documented in her NNs was accurate at that time. Staff 21 (RN) could not remember any specifics about changes in the resident's condition or physician notification. The information he documented in the NNs at the time was all he could confirm now. Witness 11 (Physician) indicated the resident was at the end of her/his life and he was not particularly concerned with abnormal vital signs but maintaining resident comfort. Witness 11 was aware of the vomiting. He should have been informed of the abdominal pain and increased pain as it was out of the resident's norm and a more profound change. 4. Resident 6 was admitted to the facility in [DATE] with [DIAGNOSES REDACTED]. NNs dated [DATE] at 1:00 am indicated the resident requested and received PRN pain medication early in the shift. The resident continued to be oriented and aware of surroundings although the resident's level of consciousness "continues to be diminished." The resident's temperature 96 degrees, pulse 116, respirations 28 and blood pressure ,[DATE]. There was no indication the physician was notified. Interviews conducted [DATE] through [DATE] between 7:55 am and 4:09 pm showed: Staff 16 (RN) indicated he remembered the resident but did not remember much about [DATE] or [DATE]. Staff 16 could not say if he contacted the physician or if he thought it was necessary at the time. Witness 11 (Physician) indicated the resident was a full code with full medical treatment. Witness 11 expected to be informed of unexpected changes in level of consciousness and changes in condition. He would come and see the resident if needed or have the facility send the resident to the hospital. Witness 11 indicated the resident likely should have been seen at the first sign of a decline. 5. Resident 7 was a long term resident of the facility. NNs dated [DATE] at 12:30 pm indicated the resident's oxygen saturation levels were 87% on 3L of oxygen, increased to 4L and sats went up to 90%. The resident was noted to use accessory muscles while breathing. The resident was unable to take food, fluids or medications. Lemon swabs used every two hours to help with mouth dryness. The resident had a decline in level of consciousness. Vitals monitored on flow sheet and physician was notified. A fax was sent to the physician on [DATE] at 1:20 pm which indicated the resident had a decline in level of consciousness, refused all meals and liquids. The resident was unable to take medications. Will continue to monitor. The physician responded on [DATE] at 3:57 pm with "noted." There was no indication notification was made to the physician for approximately an hour from when the resident's decline was first documented. No additional contacts were made to the physician during the 2.5 hours between when the first fax was sent and a response was received. In an interview on [DATE] at 8:45 am Staff 17 (LPN) indicated the resident was usually pretty active around the facility. Staff 17 reviewed her NNs and did not remember anything additional about the resident's decline. Staff 17 believed she discovered the resident's decline early in the shift. She stated for a big change like was documented she would probably have called and faxed the physician. 6. Resident 14 was admitted to the facility in 2010 with [DIAGNOSES REDACTED]. The [DATE] NN documented the resident had a Stage II pressure ulcer (partial thickness skin loss) measuring 1 by 1 by 0.25 cm on her/his coccyx and a Stage I (an observable, pressure related alteration of intact skin) 1 by 1 cm pressure ulcer on her/his right buttocks. The documentation indicated the nurse applied barrier cream and faxed the physician. There was no documentation the resident's responsible family member had been informed of the resident's pressure ulcer. On [DATE] at 11:00 am Staff 5 (RNCM) was asked to provide documentation the family member was notified. On [DATE] at 10:00 am Staff 25, 26 and 27 (Corporate Consulting RNs) were asked to provide documentation the family member was been notified. No additional information was provided. 7. Resident 16 was admitted to the facility in [DATE] with [DIAGNOSES REDACTED]. The [DATE] Weekly Skin Evaluation indicated the resident had a laceration of her/his right lower leg which measured 2 cm by 1 cm by 0.25 cm. There was no documentation the resident's responsible family member had been informed of the right leg laceration. On [DATE] at 11:00 am Staff 5 (RNCM) was asked to provide documentation the family member was notified. On [DATE] at 10:00 am Staff 25, 26 and 27 (Corporate Consulting RNs) were asked to provide documentation the family member was notified. No additional information was provided.

Based on interview and record review it was determined the facility failed to ensure nurses (Witness 5, 7 and 9 and Staff 16) acted within professional standards of practice by responding timely to resident changes in condition and to ensure accurate documentation was placed in the resident record for 4 of 17 sampled residents (#s 5, 8, 9 and 11). Residents 8 experienced ongoing pain, vomiting, black stool and further decline in condition. Resident 9 experienced prolonged abdominal pain and further decline in condition. Resident 11 was left unresponsive for approximately five hours before emergency measures were initiated. Findings include: Oregon State Board of Nursing Division 45 standards of practice OAR [PHONE NUMBER] indicated Scope of Practice Standards for All Licensed Nurses "...(1) ...(b) Intervenes on behalf of the client to identify changes in health status, to protect, promote and optimize health, and to alleviate suffering ..." AND OAR [PHONE NUMBER] Scope of Practice Standards for Registered Nurses ..."(2)... (a) ... (D) Anticipating and recognizing changes or potential changes in client status; Identifying signs and symptoms of deviation from current health status; and ...(d) (A) Implementing treatments and therapy, appropriate to the context of care, including emergency measures, interpretation of medical orders, medication administration ...(B) Documenting nursing interventions and responses to care in an accurate, timely, thorough, and clear manner." 1. Resident 11 was a long time resident of the facility with [DIAGNOSES REDACTED]. The resident's Physician order [REDACTED]. If the resident had a pulse or was breathing then full medical treatment, including hospital transportation should be utilized. The resident's care plan dated [DATE] indicated the resident had clear speech, could make needs known, was alert and oriented. The resident was independent for toileting and transfers and required supervision with cueing for ambulation/mobility, bed mobility, meals and grooming. A NN dated [DATE] at 11:30 am indicated a phone call was made to the family to inform them of the resident's status today: "resident has been sleeping, unable to be awakened-has remained in bed-O2 via non-breather applied d/t (due to) labored breathing." The resident's oxygen saturation levels were unable to be obtained and respirations were shallow, O2 sats at 88% with resident on oxygen 4L/min. The resident's blood pressure at 9:00 am was ,[DATE], at 11:00 am it was ,[DATE]. A NN dated [DATE] at 11:40 am indicated Witness 6 (Former Facility DNS) went to the resident's room to assess the resident in response to Witness 5's (Former Facility RN) statements. The resident's respirations were at 12 and shallow, her/his pulse was 54. Witness 6 received no response from the resident to verbal stimuli or painful stimuli. The right pupil was dilated and non-reactive, the left pupil was reactive to light and the resident's extremities were flaccid. Witness 6 ran out and told the resident's nurse, Witness 5 (Former Facility RN), to call 911 and get the resident to the hospital. An Event Investigation Final Summary dated [DATE] indicated the resident slept through most of the night and toileted self sometime between 2:30 and 4:30 am on [DATE]. At 6:00 am the resident appeared to be sleeping, at 6:45 am Staff 20 (CNA) changed and dressed the resident but the resident did not respond during the process. Staff 20 stated he reported to the nurse, Witness 5, that the resident was unresponsive. Witness 5 stated she checked on the resident several times and the resident appeared to be sleeping and snoring. Oxygen was applied at approximately 9:00 am. The Event Summary further indicated mobile X-rays were completed around 10:00 am. Witness 5 checked the resident at 10:20 am and the resident appeared comfortable. Witness 5 left a message for the resident's family at 11:00 am. At 11:20 am Witness 5 notified Witness 6 (Former Facility DNS) and Staff 3 (Administrator) of a suspected change in condition. The resident left with EMTs at 12:00 pm. Interviews conducted [DATE] through [DATE] between 8:20 am and 5:20 pm showed: Witness 2 (Complainant) indicated the resident was normally up and around the facility on her/his own. The resident had good cognition and could make needs known. Witness 2 frequently talked to the resident on the phone and over the last week or so the resident had not seemed herself/himself. Witness 2 told multiple staff including Witness 6 (Former Facility DNS) there was something wrong with the resident. The following day on [DATE] Witness 2 received a phone call around 12:45 pm the resident was unresponsive and sent to the hospital. Witness 2 received no prior information the resident had spent hours unresponsive. When Witness 2 got home he had a voicemail from Witness 5 (Former Facility RN) that the resident took a turn for the worse and they were sending to the hospital. Witness 2 was told by Witness 5 the resident was verbally unresponsive, had missed breakfast and that she applied oxygen. The resident was sent to the hospital several hours later. Staff 20 (CNA) indicated the resident was fairly independent and was usually up and at least partially dressed to go to breakfast. The resident rarely ever missed a meal and would walk down on her/his own sometimes with a staff. Staff 20 stated he went in to the resident's room at 6:30 am or so to make sure the resident was ready, as he usually would. The resident was on her/his back in a totally relaxed position and snoring. Staff 20 stated the resident's positioning was out of the norm as she/he typically slept on her/his side curled up under a blanket. Staff 20 called the resident's name, touched her/his hands, tapped/shook the resident's shoulder but the resident would not wake or respond. Staff 20 reported to the nurse, Witness 5, the resident was not responding to any attempts to awaken her/him. Staff 20 was told the resident had a fall and a rough night and to let the resident rest. Staff 20 continued his rounds, delivered trays and answered lights but periodically attempted to wake the resident with no response to any of his attempts. Staff 20 again reported to Witness 5 there was something wrong and the resident would not respond. Staff 20 was told Witness 5 would check the resident after medication pass. Staff 20 attempted to wake the resident again after breakfast with no success and was told by Witness 5 a portable X-ray was coming and he was to assist. Staff 20 stated he assisted to sit the resident up into a full sitting position, roll side to side, place slides and lay the resident back down again. Staff 20 stated the resident did not open her/his eyes, show signs of pain, made no sounds and made no movement during the X-ray process, but was breathing. Staff 20 again went to the nurse, expressed concerns with the resident's abnormal behavior and demanded she check the resident. Witness 5 went to the resident's room and took an oxygen concentrator to the room. Staff 20 indicated the resident was still unresponsive and he was preparing to report to another supervisor either the RCM or DNS when Witness 5 said she was sending the resident to the hospital. Two attempts were made to reach Witness 6 (Former Facility DNS), no return call was received. Four attempts were made to reach Witness 5 (Former Facility RN), no return call was received. Witness 11 (Physician) indicated the resident was to receive full treatment and CPR if needed. The resident had a complicated medical history which limited some treatments. However, the resident should have been sent to the hospital as soon as it was determined she/he had a decline/was unresponsive. Refer to F-309 2. Resident 8 was a long time resident of the facility with [DIAGNOSES REDACTED]. The resident's Physician order [REDACTED]. When pulse and breathing present the resident was to receive full treatment including intubation, advanced airway interventions and mechanical ventilation. NNs dated [DATE] at 6:30 pm indicated no emesis but a small dark, black, sticky stool was noted. The physician was notified. A fax dated [DATE] at 6:28 pm was sent to the physician regarding the dark black stool. The physician responded on [DATE] at 9:11 am with "noted." Additional NNs on [DATE] at 7:30 pm indicated the resident had a small brown emesis with food chunks. There was no indication the physician was notified. No fax was located regarding the brown emesis on [DATE]. NNs dated [DATE] at 8:15 pm indicated the resident had a large brown emesis with food chunks. The resident was gurgling, having trouble breathing. The resident had a medium black tarry stool, aids changed the resident and sat her/him up in the chair. The resident had a firm distended abdomen with hyperactive bowel tones. Vital signs were pulse 114, respirations 28 and blood pressure ,[DATE]. "Notified (RCM) and (physician) will evaluate in the am." No fax was located to show the physician was notified of the emesis, tarry stool and difficulty breathing. NNs on [DATE] at 12:47 pm indicated no emesis this shift, will continue to monitor. At 10:00 pm no emesis noted this shift, lungs clear, ate 100% at dinner. NNs dated [DATE] at 4:30 am indicated emesis x 1 early in night shift, moderate amount, dark brown in color. Head of bed elevated to 45 degrees, in no distress at the present time. Will continue to monitor. There was no indication the physician was notified. NNs dated [DATE] at 6:00 am indicated emesis x1 on night shift, keep head of bed at 45 degrees at all times, will continue to monitor. There was no indication the physician was notified. Additional NNs at 9:10 am indicated the resident had a large coffee ground emesis. The resident was dusky in color, respirations were audible and shallow. Resident vomited again and 911 was called. At 9:20 am EMTs arrived and facility staff were performing CPR on the resident. EMTs took over CPR but the resident did not regain function and resident passed away at 9:45 am. Review of physician visit logs and physician visit notes showed the resident was last seen by the physician on [DATE]. Interviews conducted [DATE] through [DATE] between 7:55 am 5:30 pm showed: Witness 7 (Former Facility RN) indicated she knew something was wrong with the resident. She wanted to send the resident out to the hospital again but she was "told not to and just monitor," so she did not send out. Witness 7 indicated Staff 5 (RNCM) and Witness 6 (Former Facility DNS) told her to monitor. The resident had been to the hospital a few days prior with [DIAGNOSES REDACTED]." Two attempts were made to reach Witness 6 (Former Facility DNS), no return call was received. Staff 5 stated if a resident required hospital treatment they would be sent out. Staff 5 could not recall any conversation with Witness 7 to withhold care of the resident. Staff 16 (RN) indicated nothing stood out in his mind about the resident. He could not remember if he contacted the physician about the resident. Staff 17 (LPN) indicated she remembered the resident but could not recall any specific issues. She was not sure if she had contacted the physician about the resident, it would be in her NNs. Staff 25 (Corporate RN) indicated there was no additional documentation of faxes after the initial [DATE] contact and no documented physician visits after [DATE]. Three attempts were made to reach Witness 9 (Former Facility LPN), with no return call received. Witness 11 (Physician) indicated he should have been notified of the resident's ongoing problems with vomiting and black stool. The resident was full treatment and CPR. Witness 11 stated the resident should have been sent out to the hospital in response to continued changes and ongoing emesis. Refer to F-309 3a. Resident 9 was admitted to the facility in [DATE] with [DIAGNOSES REDACTED]. The resident's POLST dated [DATE] indicated the resident was not to receive CPR if there was no pulse or breathing present. The resident was to receive limited additional interventions to provide basic medical treatments and transfer to the hospital if indicated. The resident's care plan dated [DATE] indicated the resident had clear communication and was Spanish speaking only. The resident was noted to have some confusion, was dependent for care and the head of the bed was to be elevated greater than 35 degrees. NNs dated [DATE] indicated the resident was sent to the hospital around 10:00 pm related to projectile vomiting and abdominal pain. The resident returned to the facility in the early morning on [DATE] with [DIAGNOSES REDACTED]. NNs dated [DATE] at 3:00 pm indicated the resident complained of nausea with upset stomach and was crying out in pain. The resident was treated with PRN [MEDICATION NAME] (narcotic pain medication) and stomach residuals showed 90 ml of formula remained. The resident's tube feeding was held for two hours, when the residual was at 5 ml feeding was restarted with no additional stomach pain. The physician was notified. NNs dated [DATE] at 4:00 am indicated the resident was crying out in pain and was medicated with PRN [MEDICATION NAME]. There was no indication the physician was notified. NNs dated [DATE] at 3:00 pm indicated the resident was crying out in pain with increased anxiety. The resident was medicated with PRN [MEDICATION NAME] (antianxiety) and [MEDICATION NAME]. At 9:00 pm the resident was crying, pointed to her/his abdomen and stated in Spanish "tiene dolor" (have pain). The resident was medicated with PRN [MEDICATION NAME] and [MEDICATION NAME]; the resident was calmer and resting. There was no indication the physician was notified. NNs dated [DATE] indicated the resident slept without incident. The resident received PRN [MEDICATION NAME] x3 during the night for pain, will continue to monitor. There was no indication the physician was notified. NNs dated [DATE] indicated the resident was awake and crying much of night, no changes noted. The resident was medicated for pain x3 during the night, will continue to monitor. There was no indication the physician was notified. NNs dated [DATE] at 2:20 pm indicated the resident was medicated with PRN [MEDICATION NAME] x2 for generalized pain. At 7:00 pm PRN [MEDICATION NAME] was given for pain, [MEDICATION NAME] given for anxiety and vital signs were noted within normal limits. NNs dated [DATE] at 6:00 am indicated the resident continued to be awake and crying loudly most of night shift despite comfort measures and [MEDICATION NAME] administration. At 2:10 pm PRN [MEDICATION NAME] was given for pain. There was no indication the physician was notified. NNs dated [DATE] at 4:00 am indicated the resident cried off and on through the shift, PRN [MEDICATION NAME] was given with some success. There was no indication the physician was notified. NNs dated [DATE] at 5:00 am indicated no changes to the resident's physiological condition. The resident received PRN [MEDICATION NAME] x3 for pain, resident yelling and screaming loudly during the night. NNs at 2:10 pm indicated the resident continued to be confused with periods of yelling and moaning, no complaints of pain. PRN [MEDICATION NAME] was provided with good effect. At 4:00 pm confusion continues, [MEDICATION NAME] used with good results. There was no indication the physician was notified. NNs dated [DATE] at 3:00 pm indicated the resident had large amount of projective vomiting this am. The resident complained of pain to the right face radiating to the left face. The resident stated through a translator that she/he wanted to go to the emergency room . The resident was taken to the hospital and returned at 5:30 pm with new [DIAGNOSES REDACTED]. Pancreatitis is inflammation of the pancreas. The most common symptom is mild to severe abdominal pain that may begin or worsen after eating. Interviews conducted [DATE] through [DATE] between 7:55 am 4:09 pm showed: Staff 16 (RN) indicated he could not remember any specifics on the resident or her/his condition. Staff 16 did not recall contacting the physician about the resident. Staff 17 (LPN) indicated she had to suction the resident on a few occasions because the resident could not handle the secretions. She did not recall specific contacts to the physician, whatever was documented in her NNs was accurate. Staff 21 (RN) indicated the resident did not come to the facility in good shape, had some on going pain issues and spoke Spanish. The resident had some confusion but could answer questions about pain, how feeling and some other needs with an interpreter. Staff 21 could not remember any specifics about changes in the resident's condition or physician notification. Witness 7 (Former Facility RN) indicated she documented any physician contacts or new orders in her NNs, she could not recall anything additional at this time. Witness 11 (Physician) indicated the resident was at the end of her/his life and he was concerned with maintaining resident comfort. Witness 11 was aware of the vomiting. He should have been informed of the abdominal pain and increased pain as it was out of the resident's norm. Refer to F-309 b. Oregon State Board of Nursing Division 45 standards of practice OAR [PHONE NUMBER] Scope of Practice Standards for Registered Nurses indicated " ...(2) ... (a) ...(C)Detecting potentially inaccurate, incomplete or missing client information and reporting as needed ... " A PT/INR stands for [MEDICATION NAME] Time and International Normalized Ratio. This lab is used to monitor the effectiveness of anticoagulant medication. [MEDICATION NAME] Time is also used to help [DIAGNOSES REDACTED]. An INR normal/goal range can vary from 2XXX,[DATE].5 depending on the medications an individual is taking and current clot risk. NNs for Resident 9 dated [DATE] at 3:00 am indicated the lab called with two critical lab values. [MEDICATION NAME] 78.2, INR 11.5. Will pass on to day shift. No additional information was noted regarding the critical lab until the following night shift. NNs dated [DATE] at 11:00 pm indicated the physician was notified of critical values on PT/INR. A fax was sent, unknown time and date, to the physician stating the critical lab values. The physician responded on [DATE] at 1:09 pm "is (she/he) on [MEDICATION NAME] (anticoagulant medication)?" A reply was sent to the physician on [DATE] at 12:09 am "resident is not on [MEDICATION NAME], MAR indicated [REDACTED]. Review of the resident's [DATE] through [DATE] MARs showed no anticoagulant medication such as [MEDICATION NAME]. The resident had no previous PT/INR labs completed or monitoring of bleeding. In a group interview on [DATE] at 3:15 pm Staff 25 and 26 (Corporate RNs) indicated the hospitals and laboratories the facility utilized were contacted regarding the critical lab value and no PT/INRs were located for Resident 9. The resident was not taking any blood thinners presently or in the recent past. Staff 26 reviewed all the discharged residents from the time of the lab as well as record review for current residents. No critical lab was located for any resident on anticoagulants. Staff 25 and 26 believe the lab erroneously reported the critical result to the facility. Staff 26 supplied multiple PT/INR labs for review with no critical values noted. Staff 25 and 26 could not say who the lab may have belonged to or if it even belonged to the facility. Staff 16 (RN) could not recall any information about the critical lab value he noted. 4. Resident 5 was admitted to the facility [DATE] with [DIAGNOSES REDACTED]. The resident's quarterly nursing summary and care plan dated [DATE] indicated the resident was oriented with intermittent confusion. The resident's current treatment was focused on comfort care due to a [MEDICAL CONDITION] diagnosis. NNs dated [DATE] through [DATE] indicated the resident was alert, oriented and pleasant. The resident had intermittent complaints of pain and was medicated with narcotic pain medications with some relief noted. NNs dated [DATE] at 1:00 pm indicated at the beginning of the shift the resident's oxygen saturations were 42% on room air, fingernails were blue, cold to the touch, audible gurgling with a decreased level of consciousness. The resident's respirations were ,[DATE], blood pressure ,[DATE] and oxygen was applied with saturation levels increased to ,[DATE]%. Suctioning was initiated every two hours for increased secretions. The resident's family was informed and the physician was notified of the change. The physician stated he would see the resident later that day at rounds. A fax was sent to the physician on [DATE] at 8:27 am which indicated the resident had a change in condition, decreased level of consciousness, respirations ,[DATE], and increased respiratory secretions. The physician responded at 11:32 am that he would check the resident later that day. NNs dated [DATE] at 3:15 pm indicated the physician was in to assess the resident and an order was given for [MEDICATION NAME] ([MEDICATION NAME]) 0.8 mg now (medication used to counteract narcotic medication effects). [MEDICATION NAME] was administered in the resident's left deltoid, at 3:15 pm the resident's vital signs were pulse 73, respirations 17 and blood pressure ,[DATE]. The resident was awake, opened eyes on command and was verbally responsive. In an interview on [DATE] at 4:09 pm Witness 7 (Former Facility RN) indicated the resident received multiple doses of her/his PRN narcotic medications on the evening of [DATE] due to extreme pain. The resident was up walking around and was verbal. Witness 7 stated the resident was her/his usual self except for the increased pain. The resident eventually started to show some relief and rested with no indication the resident was over sedated. She saw no reason to notify the physician about the resident's pain. In an interview on [DATE] at 12:25 pm Staff 17 (LPN) stated she went in to check the resident early in the shift 6:30 or 7:00 am. She saw the resident had declined and contacted the physician who said he would see the resident later that day. Staff 17 was not given any additional instructions or orders. Staff 17 did not make any additional notifications to the physician after the initial contact. She continued to check on the resident but otherwise waited for the physician to arrive. Staff 17 stated the physician came in to see the resident that afternoon and [MEDICATION NAME] was administered. In an interview on [DATE] at 1:50 pm Staff 5 (RNCM) indicated the physician came to assess the resident in the afternoon on [DATE] and ordered a dose of [MEDICATION NAME]. Staff 5 administered the dose as soon as the physician ordered it. The resident opened her/his eyes pretty quickly after the medication was given and began conversing with her/his significant other who was at the bedside. During the night the resident began to decline again and passed away. Refer to F-309

Based on interview and record review it was determined the facility failed to provide care and services in a timely manner for identification and treatment of [REDACTED].#s 3 & 5) reviewed for UTIs. Residents 3 and 5 did not receive treatment in a timely manner and Resident 3 experienced a change of condition and subsequent decline. Findings include: 1. Resident 3 was admitted to the facility in 2012 with [DIAGNOSES REDACTED]. The [DATE] POLST (Physician order [REDACTED]. An [DATE] Progress Note disclosed the physician was faxed, notifying the physician the resident's urine was foul smelling that day. An [DATE] Progress Note revealed the physician ordered for staff to obtain a UA (urinalysis) by straight catheterization. The [DATE] 9:30 am Progress Note indicated the UA was obtained per the physician's orders [REDACTED]. At the time of the survey, there was no documented evidence in the clinical record that addressed why there was a delay in obtaining a UA specimen, nor of staff follow up when the physician did not respond timely to the [DATE] fax. The [DATE] 9:45 pm Progress Note disclosed the resident had "dark brown liquid emesis....Will continue to monitor for any change in condition." The [DATE] 4:30 am Progress Note revealed Resident 3 had "emesis x 1 - black in color." A Urine Culture and Susceptibility Report was faxed to the facility on [DATE]. The report identified organisms of Escherichia Coli and Streptococcus anginosus. The [DATE] 4:00 pm Progress Note indicated the UA lab results were faxed to the physician. At the time of the survey, there was no documented evidence in the clinical record why there was a delay in notifying the physician of the lab results. According to the ,[DATE] and ,[DATE] MARs, Resident 3 had not refused medications until [DATE]. The [DATE] 1:00 pm Progress Note documented "Resident showing noted change in condition, shaking, not eating, awake but unresponsive to staff." Vital signs included a pulse of 126. The physician was called and notified of lab results showing a positive UTI. A [DATE] physician progress notes [REDACTED]. (Resident 3) also has been passing some foul urine. A urinalysis was obtained which was consistent with a urinary tract infection." The physician [MEDICATION NAME] treat the UTI. The [DATE] 6:00 pm Progress Note indicated the resident had decreased responsiveness and would not take anything by mouth. Due to the resident being DNR (do not resuscitate) the resident remained at the facility. Progress notes dated [DATE] and [DATE] noted the resident refused to eat or drink and refused medications. A [DATE] 12:20 am Progress Note revealed Resident 3 passed away. In response to the survey, a [DATE] Physician's Note documented Resident 3 was diagnosed with [REDACTED]. The resident was started [MEDICATION NAME] [DATE] and refused all medication. The physician noted the resident had a history of [REDACTED]. It was the opinion of the physician the resident "expired as a result of (Resident 3's) age, advanced dementia and comorbidities." The resident was identified with signs and symptoms of a UTI on [DATE], with physician orders [REDACTED]. The UA was not collected until [DATE], five days later. The facility received lab results that was positive for a UTI on [DATE], however, treatment orders were not obtained until [DATE], which was 16 days after the resident was initially identified with a possible UTI. In interview on [DATE] at 7:09 am, Staff 9, LPN, stated one of the CNAs informed her the resident had a urine odor. Staff 9 stated she went to the resident's room and observed the resident had odor and discharge. Staff 9 stated the physician was faxed for obtaining a UA and she did not know why it took so long to get it done. Staff 9 stated she looked in the lab book and realized the UA had not been done and obtained it. In interview on [DATE] at 2:35 pm, Staff 7, RN, stated she remembered staff stating during report they needed a UA for the resident. When asked about the delay in obtaining the specimen, Staff 7 stated she thought there was no order for a straight catheterization at that time. Staff 7 stated she did not follow up on the UA because she didn't know it wasn't done during the day shift. Staff 7 stated she did not recall any changes for the resident, "I was surprised (Resident 3) was gone." In interview on [DATE] at 11:00 am, Staff 4, LPN, stated she thought the day shift staff had obtained the resident's UA specimen. The resident had a positive UA and they were waiting for antibiotics for treatment. Staff 4 stated towards the end she noticed a change in the resident, but could not recall the date. Staff 4 stated it was always difficult to get the resident to take medications or eat but staff could usually get the resident to do so. The last time she worked with the resident ([DATE]), the resident was more shaky and was not eating. In interview on [DATE] at 9:10 am, Staff 8, RN, stated she noticed a change in Resident 3's condition starting [DATE]. It was harder to get the resident to take medications, the resident was more lethargic, slower and eating less. Staff 8 stated they received an order for [REDACTED]. In interview on [DATE] at 9:47 am, Staff 11, LPN, stated the resident was difficult and liked to kick, hit and scream. Staff 11 stated she attempted to obtain a UA via straight catheterization but did not do it because of the resident's kicking and screaming. Staff 11 did not recall the date when she attempted to obtain the UA, however, it had been ordered for several days and had not been done." Staff 11 stated she did not know if the physician had been informed that the UA had not been obtained. When asked if other staff had been informed that she was unable to obtain the UA, Staff 11 stated "assuming we discussed it" at report. Staff 11, who worked with Resident 3 on dates including [DATE] to [DATE] and [DATE] to [DATE], stated she "did not see anything negative", "no deterioration" and did not see any change with the resident. In interview on [DATE] at 8:56 am, Staff 3, RNCM, stated she was aware the resident had a UTI, but she was not aware of any delay in obtaining the UA. Staff 3 stated she did not recall details about the resident's decline. 2. Resident 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An [DATE] 1:55 pm Progress Note indicated a physician's orders [REDACTED]." A Urine Culture and Susceptibility Report was faxed to the facility on [DATE]. The report identified an organism of Proteus mirabilis. According to the [DATE] Progress Note, the lab results were faxed to the physician. The [DATE] 7:00 pm Progress Note indicated a call from the physician's office disclosed the results for the UA were positive for a UTI and the physician's office would fax over a prescription for an antibiotic. An [DATE] 24 Hour Report entry indicated the physician was called regarding the UTI lab results. At the time of the survey, there was no documented evidence in the clinical record of staff follow up on [DATE], [DATE] or [DATE] when the physician did not respond to the fax or give orders for treatment of [REDACTED]. An [DATE] Progress Note indicated the physician was called for follow up for the resident's UTI. "Order has not been received at this time." An [DATE] Progress Note disclosed the physician ordered an antibiotic to treat the resident's UTI. According to the [DATE] MAR, the resident started receiving the prescribed antibiotic on [DATE], 11 days after the resident initially exhibited signs and symptoms of a UTI and eight days after the facility received lab results which were positive for a UTI. In interview on [DATE] at 10:40 am with Staff 1, Executive Director, Staff 2, DNS and Staff 15, Nurse Consultant, it was stated staff should have followed up on the 24 hour report and contact the the facility's medical director when physicians did not respond timely. In interview on [DATE] at 7:09 am, Staff 9, LPN, stated she did not recall contacting the resident's physician regarding the resident's UA results. In interview on [DATE] at 8:56 am, Staff 3, RNCM, stated nurses did not report to her they were not getting responses back from the physician or she would have followed up on it and it was a long period to not follow up on. In interview on [DATE] at 9:47 am, Staff 11, LPN, stated she did not try to contact the physician about the lab results. In interview on [DATE] at 2:05 pm, Staff 8, RN, stated she did not follow up on the lab results when she worked with the resident because there had already been previous faxes or calls about it and she thought there was already some follow up done. In interview on [DATE] at 2:35 pm, Staff 7, RN, stated she was not aware the resident had a UTI and needed follow up with the physician.