Every finding on record at Mt Angel Health and Rehabilitation

Based on interview and record review it was determined the facility failed to ensure CNA staff annual performance reviews were completed for 3 of 3 sampled CNA staff (#s 11, 12, 23) reviewed for sufficient and competent nurse staffing. This placed residents at risk for a lack of competent staff. Findings include: A review of personnel records on 6/5/26 indicated the following employees did not receive their annual performance evaluations: -Staff 11 (CNA), hire date was 12/2019 and a performance review was not completed.-Staff 12 (CNA), hire date was 8/2013 and a performance review was not completed.-Staff 13 (CNA), hire date was 1/2019 and a performance review was not completed. On 6/4/26 at 4:00 PM, Staff 1 (Administrator) and Staff 2 (DNS) confirmed annual performance reviews were not completed for Staff 11, Staff 12 and Staff 13.

Based on observation, interview and record review it was determined the facility failed to properly disinfect a shared glucometer for 1 of 3 facility staff (#5) reviewed for infection control. This placed residents at risk for exposure to blood-borne pathogens. Findings include: The 12/2025 facility Glucometer Disinfection Policy indicated to disinfect after each individual patient use with EPA disinfectant wipes. A 2017 Evencare G2 glucometer Manufacturer Manual indicated, Disinfect common use glucometers with the use of approved disinfectant wipes. The glucometer was to be wiped with the disinfecting wipe and left wet for two minutes to ensure disinfection. Resident 81 was admitted to the facility in 11/2025 with diagnoses including diabetes.On 6/3/26 at 11:33 AM, Staff 5 (LPN Resident Care Manager) was observed to return to the medication cart after checking Resident 81's CBG, and place the glucometer in the drawer. Staff 5 did not disinfect the glucometer. On 6/3/26 at 11:51 AM, Staff 5 stated she used alcohol pad wipes to clean the glucometers after she checked residents CBG. Staff 5 stated EPA disinfectant wipes were harsh on the glucometer and she preferred to use alcohol pad wipes to clean the glucometers. Staff 5 stated she occasionally worked on all units within the facility. On 6/3/26 at 12:39 PM, Staff 2 (DNS) stated staff were to use approved EPA disinfectant wipes to disinfect the glucometers.

Based on interview and record review it was determined the facility to revise a resident's care plan for 1 of 1 sampled resident (#3) reviewed for hospice. This placed residents at risk for unmet hospice needs. Findings include: Resident 3 was admitted to the facility 2024 with diagnoses including dementia, bipolar and heart failure.The 8/14/25 Significant Change MDS indicated Resident 3 was on hospice status.Review of Resident 3's care plan referred to hospice and/or end of life in the following manner:-For ADL care hospice helped with bathing, dated 2/13/26. -For psychosocial well-being hospice was identified as one service to provide consultation, date initiated 7/3/25. -For activities, hospice was identified and indicated the resident often declined, date initiated 2/19/26. -Use of anti-anxiety medication related to end of life, dated 9/12/25. The Care Plan did not indicate Resident 3's terminal illness as a focus area with interventions including hospice services or interventions related to end of life.On 6/4/26 at 9:30 AM Staff 2 (DNS) stated her expectation was for a terminal illness to be captured with interventions including hospice services on a resident's care plan. Staff 2 acknowledged Resident 3's care plan was not revised to reflect her/his terminal illness and hospice status.

Based on interview and record review it was determined the facility failed to implement bowel care interventions for 2 of 5 sampled residents (#s 12 and 19) reviewed for medications. This placed residents at risk for constipation. Findings include: 1. Resident 12 admitted to the facility in 2025 with diagnoses including chronic pain and heart failure. The facility's revised 3/31/26 bowel care policy indicated the following for patients not on a daily senna bowel medication: -If no BM in two days, Miralax was to be given. -If no BM on day three, Miralax was to be repeated, and provider was to be notified. -If no BM on day four, suppository was to be administered, and provider was to be notified. -Results from all treatment were to be monitored and recorded. Review of Resident 12's 5/26/26 physician orders indicated the following bowel medications: -Lactulose as needed for constipation -Bisacodyl suppository as needed for constipation -Milk of Magnesia as needed for constipation -Docusate as needed for constipation -Senna as needed for constipation -Miralax as needed for no BM in 2 days and repeated if no BM in 3 days and notify provider. -Fleet enema as needed for constipation. Review of Resident 12's bowel records indicated the resident did not have a bowel movement from 5/28/26 through 6/1/26 (five days). Review of Resident 12's May 2026 MAR indicated Docusate was administered on 5/31/26 and was noted as ineffective. No other ordered bowel medication was noted as administered or attempted to be administered. On 6/3/26 at 9:36 AM Staff 2 (DNS) acknowledged Resident 3 did not receive bowel care interventions in a timely manner and went five days without a bowel movement. 2. Resident 19 was admitted to the facility in 5/2026 with diagnoses including kidney failure. A review of Resident 19's physician orders indicated the following bowel medications: -Miralax, one scoop every Tuesday, Thursday, Saturday and Sunday for constipation. -Senna, one tablet every Tuesday, Thursday, Saturday and Sunday for constipation. -Docusate Sodium, one tablet every Tuesday, Thursday, Saturday and Sunday for constipation. -Milk of Magnesia as needed for constipation. -Fleet enema, one application every 24 hours as needed for constipation. -Bisacodyl rectal suppository, one application as needed for constipation. If no BM (bowel movement) on day four notify the provider. A review of Resident 19's bowel records indicated the resident did not have a bowel movement from 5/10/26 through 5/20/26 (11 days) and 5/28/26 through 6/3/26 (7 days). A review of Resident 19's 5/2026 MAR revealed the resident received milk of magnesia on 5/16/26 (day 7) and one suppository on 5/21/26 (day 12) and no additional PRN bowel medication was provided. A review of Resident 19's 6/2026 MAR revealed the resident received milk of magnesia on 6/2/26 (day 5) and no additional PRN bowel medication was provided. On 6/2/26 at 9:17 AM Resident 19 stated she/he had not had a bowel movement in over seven days which caused discomfort in her/his abdomen. On 6/4/26 at 9:28 AM Staff 7 (CNA) stated Resident 19 went 22 shifts without a bowel movement. On 6/4/26 at 9:53 AM Staff 6 (LPN) stated Resident 19 was often on alert for not having a bowel movement. Staff 6 stated Resident 19 was on a scheduled bowel care regimen. Staff 6 was not able to provide additional information related to the lack of PRN bowel medications provided to the resident. On 6/4/26 at 11:58 AM Staff 2 (DNS) acknowledged Resident 19 did not receive bowel care interventions in a timely manner and went 11 and 7 days without having a bowel movement.

Based on observation, interview and record review it was determined the facility failed to provide services to prevent further decrease in ROM for 1 of 2 sampled residents (#17) reviewed for positioning. This placed residents at risk for decrease in range of motion. Findings include:Resident 17 was admitted to the facility in 2/2018 with diagnoses including osteomyelitis (inflammation in the bones).The 2/18/26 Quarterly MDS indicated the resident had a BIMS score of 00 indicating Resident 17 was severely cognitively impaired. The MDS indicated Resident 17 was unable to make daily decisions and was dependent on staff to complete daily activities including to apply splints. The MDS indicated Resident 17 had bilateral upper and lower ROM impairments. The 3/19/26 Care Plan indicated Resident 17 wore a left-hand carrot splint and a right-hand palm guard. During interviews on 6/3/26 at 11:24 AM and 6/4/26 at 10:56 AM, Resident 17's hands were observed to be curled up into a fist. Resident 17 was unable to extend her hand. Resident 17 was not wearing her/his hand splint and the splint was observed on top of the resident's bedside table. Resident 17 stated she allowed staff to apply the splint. On 6/4/26 at 12:54 PM, Staff 8 (CNA) stated Resident 17's hand contractures were stiff and difficult to manage. Staff 8 stated Resident 17 allowed staff to apply the hand splint. Staff 8 stated she did not offer to apply the brace during her shift because she forgot. On 6/5/26 at 9:28 AM, Staff 9 (LPN) stated Resident 17 used bilateral hand splints to prevent further decrease to range of motion. Staff 9 stated Resident 17 tolerated the splint and allowed staff to apply the hand splints. Staff 9 stated staff did not tell her they were unable to apply the hand splint during the day. On 6/5/26 at 10:13 AM, Staff 10 (RN Resident Care Manager) stated he was unsure of why Resident 17 did not wear the hand splint consistently and acknowledged the splints should be worn.

Based on interview and record review it was determined the facility failed to protect residents' right to be free from misappropriation of property by staff for 1 of 1 sampled resident (#4) reviewed for misappropriation of property. This placed residents at risk for financial loss. Findings include: Resident 4 admitted to the facility in 3/2024 with diagnoses including diabetes. A 5/22/25 Facility Reported Incident revealed Resident 4 was admitted to the hospital on [DATE] and passed away at the hospital on 5/21/25. On 5/21/25 Staff 7 (RN) locked up Resident 4's personal belongings including credit cards and debit cards in the narcotic box in the medication cart. On 5/22/25 Staff 7 discovered Resident 4's credit and debit cards were no longer in the medication cart. A 5/29/25 Investigation Report revealed: -Staff 7 wrapped Resident 4's six bank, credit, and debit cards in a piece of notepad paper and placed them in the very back of the narcotic lock box on 5/21/25. -Staff 6 (Former LPN) replaced Staff 7 at 4:00 PM on 5/21/25. Staff 7 stated she notified Staff 6 of the cards in the medication cart. -Staff 6 reportedly behaved odd throughout the shift. -On 5/22/25 Staff 7 returned to work and discovered Resident 4's six cards were no longer in the medication cart. -Staff 6 did not report to work after 5/21/25 and did not respond to contact attempts from the facility. -Local law enforcement were notified on 5/22/25 of Resident 4's missing credit and debit cards. On 6/16/25 at 1:57 PM Staff 7 stated when she was notified Resident 4 passed away, she had another staff join her to pick up some items from Resident 4's room including credit cards, bank cards, and electronics. Staff 7 reported she wrapped the cards in an envelope and placed them in the narcotic box in the medication cart. The next nurse, Staff 6, arrived at 4pm and Staff 7 notified Staff 6 the cards were in the medication cart. Staff 7 stated the next time she was in the facility she noticed the credit and bank cards were no longer in the medication cart and notified the DNS. On 6/17/25 at 3:05 PM Staff 8 (LPN) stated she worked on 5/21/25 on a different hall and noticed Staff 6 was struggling during the shift to give medications, so she administered the evening medications and was unaware of the cards locked in the medication cart. Staff 8 stated Staff 6 was very scattered and had a difficult time accomplishing tasks during the shift. On 6/18/25 at 9:57 AM Witness 3 (Power of Attorney) stated the facility notified her Resident 4's credit and debit cards were stolen by a facility staff member. Witness 3 confirmed none of Resident 4's friends or family picked up the cards. On 6/18/25 at 11:19 AM Staff 9 (CNA) indicated she worked with Staff 6 on 5/21/25. Staff 9 stated she helped Staff 7 take things out of Resident 4's room but did not see the credit and debit cards. Staff 9 stated on 5/21/25 Staff 6 did not do her job, was found sitting in front of the medication cart going through the medications instead of administering them, and went in and out of the unit. Staff 9 stated she did not see Staff 6 take Resident 4's credit and debit cards. On 6/20/25 at 2:34 PM Staff 6 confirmed she worked on 5/21/25 but denied taking anything from the facility and stated she was unaware of Resident 4's locked up credit and debit cards. On 6/20/25 at 9:54 AM Staff 1 (Administrator) confirmed Resident 4's credit and debit cards were missing from the facility and were not found. The deficient practice was identified as Past Noncompliance based on the following: On 5/22/25 the deficient practice was identified by the facility and corrected when the facility audited the hall, and provided education to licensed nurses. No further instances of misappropriation were identified by the facility.

Based on interview and record review it was determined the facility failed to ensure physician orders were followed for 1 of 6 sampled residents (#10) reviewed for medications. This placed residents at risk for adverse medication side effects. Findings include: Resident 10 readmitted to the facility in 2023 with diagnoses including dementia and schizoaffective disorder. a. The 3/6/24 medication error investigation indicated the following: -On 3/6/24 at 4:32 PM Staff 14 (RN) administered the following medications (in error) to Resident Resident 10: -clonazepam 0.5 mg (anticonvulsant medication) -Depakote 200 mg (anticonvulsant medication) -docusate sodium 100 mg (bowel medication) -gabapentin 400 mg (mood stabilizer medication) -metoprolol 12.5 mg (blood pressure medication) -levothyroxine 200 mcg (thyroid medication) -clozapine 100 mg (antipsychotic medication) On 3/6/24 the physician was notified of the medication error. On 2/13/25 at 10:18 AM Staff 14 stated she worked on 3/6/24. She stated she prepared another resident's medications and administered them to Resident 10 by mistake. Staff 14 was unable to recall the name of the resident whose medications were accidentally administered to Resident 10 and did not recall the medications that were administered. Staff 14 stated the physician was notified of the medication error. On 2/13/25 at 12:21 PM Staff 16 (RNCM) acknowledged on 3/6/24 Staff 14 administered the identified medications to Resident 10 in error. b. The 10/5/24 medication error investigation indicated the following: -On 10/5/24 at 11:26 AM Staff 15 (LPN) administered the following medications (in error) to Resident Resident 10. -clonazepam 2 mg (anticonvulsant medication) -Clozaril 100 mg (antipsychotic medication) -lamotrigine 200 mg (anticonvuslant medication) -furosemide 40 mg (diuretic medication) -levothyroxine 200 mcg (thyroid medication) On 10/5/24 the physician was notified of the medication error. On 2/13/25 at 10:04 AM Staff 15 acknowledged she administered the identified medications to Resident 10 on 10/5/24 and the medication was intended for Resident 23. On 2/13/25 12:21 PM Staff 16 (RNCM) acknowledged on 10/5/24 Staff 15 administered the identified medications to Resident 10 in error.

Based on interview and record review it was determined the facility failed to provide residents with a written bed hold notification at the time of transfer to the hospital for 2 of 2 sampled residents (#s 30 and 38) reviewed for hospitalization . This placed residents at risk for lack of knowledge regarding their choices and potential financial responsibilities. Findings include: 1. Resident 30 was admitted to the facility in 1/2023 with diagnoses including depression and diabetes. A review of Resident 30's health record revealed she/he was discharged to the hospital on three separate occasions: 3/19/24, 4/22/24, and 7/8/24. No evidence was found in Resident 30's health record to indicate written notice of the facility's bed hold policy was provided to the resident or her/his representative when she/he was transferred to the hospital on 3/19/24, 4/22/24, and 7/8/24. On 2/13/25 at 3:50 PM Staff 2 (DNS) confirmed a written bed hold policy was not provided to Resident 30 or their representative when the resident was transferred to the hospital on the identified dates. 2. Resident 38 was admitted to the facility in 8/2022 with diagnoses including anxiety and diabetes. A review of Resident 38's health record revealed she/he was discharged to the hospital on three separate occasions: 2/27/24, 3/7/24, and 8/14/24. No evidence was found in Resident 38's health record to indicate written notice of the facility's bed hold policy was provided to the resident or her/his representative when she/he was transferred to the hospital on the identified dates. On 2/13/25 at 3:50 PM Staff 2 (DNS) confirmed a written bed hold policy was not provided to Resident 38 or their representative when the resident was transferred to the hospital on the identified dates.

Based on interview and record review the facility failed to prevent an avoidable fall related to fall safety for 1 of 3 sampled residents (#1) reviewed for accidents. Resident 1 fell out of bed and sustained a right shoulder fracture. Findings include: Resident 1 was admitted to the facility in 7/2024 with diagnoses including quadriplegia (paralysis that affects all a person's limbs and body from the neck down) and a Stage 4 (full thickness skin loss) pressure injury. The Admission MDS dated [DATE], revealed Resident 1 was cognitively intact. A care plan dated 7/25/24, revealed Resident 1 was limited in performing ADLs and was encouraged to perform as much of her/his ADLs as their condition allowed. Staff were to follow the most recent instructions and posted wall signs for mobility, transfers, exercises, and restorative programs. A revision on 7/27/24, revealed Resident 1 had half siderails on both sides of her/his bed to assist with repositioning and bed mobility. Two undated bedside care plans revealed the resident required the assistance of one or two people to roll from side to side in bed and required the assistance of two-people for scooting and repositioning. The resident had a Foley catheter and was incontinent of bowel. A Fall Investigation dated 8/22/24 revealed the following: -Staff 6 (Agency CNA) had multiple interactions with Resident 1 throughout her shift on 8/17/24 and followed the care plan. However, when she recognized the resident's positioning was possibly unsafe, she did not request a second staff person to assist with repositioning the resident prior to providing incontinent care. This created additional risk, contributing to Resident 1's fall. Staff 6 acknowledged Resident 1's positioning in bed led to her/his fall. -Resident 1 stated Staff 6 was going to provide cares and she/he was supposed to roll to the left side. Resident 1 indicated she/he was close to the edge of the mattress and the CNA pushed me too far over. When Staff 6 realized she/he was too close to the edge of the mattress, Resident 1 fell off the bed. -Staff 2 (DNS) determined and indicated Staff 6 recognized the potential safety issue with Resident 1's positioning but did not seek peer assistance. While this was a safety risk that led to an injury, it was not a willful infliction of injury or failure to provide a necessary service. However, the fall was an avoidable situation. On 9/16/24 at 5:18 PM, Resident 1 stated on 8/17/24, Staff 6 was going to provide care and had her/him too close to the edge of the bed, causing her/him to fall out of the bed. Resident 1 stated her/his right arm caught in the bed railing, resulting in a fractured right shoulder. Resident 1 stated she/he was a quadriplegia and needed assistance with cares and most of the time two staff would assist her/him with repositioning and care. On 9/17/24 at 1:43 PM Staff 8 (Physical Therapist) stated Resident 1 was able to use her/his arms and required one staff person to assist with rolling in bed but required two staff to reposition her/him in bed. Staff 8 stated the resident had a care plan in her/his room and pictures on the wall to ensure staff assisted the resident appropriately. On 9/18/24 at 9:58 AM, Staff 6 stated she worked on 8/17/24 which was her first time working at the facility. Staff 6 stated she received a report from a male nurse who indicated Resident 1 required one-person assistance for all her/his ADL care needs. Staff 6 stated she did not review or have access to the care plan. Staff 6 stated she did not know where the bedside care plan was located for Resident 1. Staff 6 stated she interacted with Resident 1 throughout the shift because the resident used her/his call light often. Staff 6 stated the resident was close to the edge of the bed but indicated the resident refused to be repositioned prior to providing incontinence care. Staff 6 stated when she went to gather supplies in the room for incontinent care, Resident 1 slid out of bed but did not fall. Staff 6 stated Resident 1's right arm was stuck in the side rail. Staff 6 stated she called for assistance, and a nurse entered the room to assess and help get the resident back into bed. Staff 6 further stated the resident did not report any pain or discomfort in the right shoulder. On 9/18/24 at 2:14 PM, Staff 3 (Agency RN) stated on 8/17/24, Staff 6 alerted her that Resident 1 was too close to the edge of the bed and had slid out of bed, legs first. Staff 3 stated when she entered the room, the resident was holding onto the side rail with her/his right arm and said, get me up. Staff 3 stated she assessed the resident, who was able to move both her/his arms and denied any pain to her/his right arm or shoulder area. Staff 3 stated the resident was put back into bed. On 9/18/24 at 2:27 PM, Staff 4 (LPN) stated she was aware Resident 1 fell out of bed on 8/17/24, and her/his right arm was caught in the bed rail, but the resident did not complain of any pain to the right shoulder until 8/20/24, which an X-ray was ordered. However, the resident was out to an appointment when the technician arrived on 8/20/24. Staff 4 stated Resident 1 was sent out to the hospital on 8/21/24, due to a critical lab result, and an X-ray of the right shoulder was obtained and revealed a fractured right shoulder. On 9/19/24 at 10:40 AM Staff 2 stated she completed the investigation regarding Resident 1's fall out of bed on 8/17/24. Staff 2 confirmed Resident 1 was too close to the edge of the bed, causing the resident to fall and fracture her/his right shoulder. Staff 2 stated the fall was avoidable. Staff 2 stated during shift change, she expected CNAs to have a peer-to-peer report, review the care plan and communicate with the nurses regarding care needs for all residents.

Based on interview and record review it was determined the facility failed to identify and reflect risk factors in the care plan related to pressure ulcers for 1 of 3 sampled residents (#2) reviewed for pressure ulcers. This placed residents at risk for pressure injuries and skin breakdown. Findings include: Resident 2 admitted to the facility in 8/2023 with diagnoses including a colostomy (redirects the colon to an opening in the abdominal wall, called a stoma, which is attached to a colostomy bag to collect bowel movements) and cellulitis of the abdomen. The Admission MDS dated [DATE], revealed Resident 2 was cognitively intact. A care plan dated 8/8/23, revealed Resident 2 had a colostomy, impaired skin integrity, a wound around the stoma, nonhealing skin graft to the buttocks, and history of pressure injury. Staff were to monitor the ostomy appliance and belt for moisture and tightness twice daily, encourage the resident to loosen her/his belt when lying down, and monitor for signs and symptoms of infection. The care plan did not identify Resident 2 had a history of skin breakdown from the ostomy belt or that Resident 2 refused ADL and ostomy cares. A review of Resident 2's clinical record from 7/1/24 through 9/19/24, revealed the resident refused ADL care and ostomy care, but no evidence was found a risk verses benefit form was completed. A 7/24/24 Facility Reported Incident revealed the following: -Resident 2 had a Stage 3 (full thickness loss of skin that exposes subcutaneous fat) pressure injury from her/his ostomy belt. The wound was measured, cleansed, and treatment orders were put into place. -Resident 2 had a pattern and long history of refusals, poor hygiene, and poor safety insight. Resident 2's care was mostly independent. -Resident 2 was seen at the wound clinic on 7/17/24, with no identified skin issues. The wound potentially developed between 7/17/24 and 7/24/24. -Staff 10 (LPN), Staff 9 (Agency RN), and Staff 11 (RN) all indicated they worked with Resident 2 prior to and upon discovery of the wound, and Resident 2 refused ostomy changes and skin assessments. Staff 10 indicated Resident 2 refused more care than she/he allowed. -It was determined due to Resident 2's wound history, medical background, refusals of care, wound care clinic visits and interviews, neglect was not substantiated. On 9/17/24 at 11:01 AM and 2:26 PM, Resident 2 stated she/he had her/his ostomy bag for [AGE] years and I know how to change it. Resident 2 stated she/he allowed staff to change her/his ostomy bag at times but changed the ostomy bag on her/his own. Resident 2 stated when staff came to change or look at her/his ostomy bag, it was not always a convenient time because she/he was in the middle of watching a movie. Resident 2 stated she/he had a sore from the ostomy belt but had not worn the belt since the wound was discovered. On 9/17/24 at 11:17 AM, Staff 14 (CNA) and Staff 15 (CNA) and at 12:08 PM, Staff 13 (CNA) stated Resident 2 was alert and oriented, hard of hearing, and became anxious easily. Staff 14 and Staff 15 stated Resident 2 refused care, including changing her/his soiled clothing or removing her/his ostomy belt for showers. Staff 14 and Staff 15 stated the resident had a history of skin breakdown under and around the ostomy belt due its tightness around Resident 2's waist and the resident's refusal of care. Staff 14, Staff 15, and Staff 13 stated they did not recall seeing any wounds around the resident's ostomy belt when assisting with ADL cares. On 9/18/24 at 10:41 AM Staff 9 stated Resident 2 was particular with her/his colostomy care and staff were to place pads under the ostomy belt to reduce friction and sheering of the skin, although this was not always successful. Staff 9 stated when attempting to assess or change the colostomy bag the resident would refuse, say it was fine, ask Staff 9 to come back later because she/he was watching a movie. Staff 9 stated they educated the resident but was unsure if the resident had completed a risk verses benefit form due to Resident 2's refusals. On 9/18/24 at 11:52 AM, Staff 10 stated Resident 2 admitted with a history of skin breakdown around the ostomy belt, a history of non-compliance related to her/his ostomy care, and refusal to allow staff to assess or change her/his ostomy belt and ostomy bag. This resulted in the ostomy bag leaking, causing bowel movements to run underneath the resident's ostomy belt. Staff 10 stated the resident was seen regularly at the wound clinic for her/his ostomy care and skin breakdown. Staff 10 stated after the wound was found, the resident no longer used the ostomy belt and new orders were received from the wound clinic. An observation on 9/18/24 at 1:16 PM revealed Resident 2's right hip wound was completely healed, with no open areas observed. However, the resident's skin was red, dry, and flaky. Resident 2's ostomy bag was in place, without an ostomy belt and the resident indicated her/his skin felt much better. On 9/19/24 at 9:50 AM Staff 11 stated Resident 2 was non-compliant with her/his ostomy care. Staff 11 stated a CNA alerted her on 7/27/24 about a wound on the resident's right hip caused by the ostomy belt. Staff 11 stated the ostomy belt was digging into the resident's skin and the wound was deep. Staff 11 stated she cleansed the wound, orders were initiated, and Staff 2 (DNS) was informed of the incident. Staff 11 stated she could not speak to a risk verses benefit form. On 9/19/24 at 11:11 AM, Staff 2 stated she was informed and visualized the wound on 7/27/24. Staff 2 stated the resident was non-complaint with her/his ostomy care and the ostomy belt was a false sense of security for the resident. Staff 2 stated CNA staff were expected to do a full head to toe assessment when providing ADL care two times daily and report any skin breakdown to the nurses. Staff 2 acknowledged the care plan did not include Resident 2's refusal of care or identify her/his history of skin breakdown related to the use of the ostomy belt. Staff 2 stated a risk verses benefit form should have been completed and would have been beneficial for Resident 2. On 9/19/24 at 2:56 PM Witness 17 (Wound Clinic RN) stated she saw Resident 2 at the wound clinic for her/his ostomy care and indicated the resident's ostomy belt was always too tight and digging into her/his belly. Staff 17 stated she saw the resident on 7/17/24 and did not visualize a wound to the resident's right hip. Staff 17 stated she/he was seen again on 7/25/24 and the resident was no longer wearing the ostomy belt.

Based on observation, interview, and record review it was determined the facility failed to protect the resident's right to be free from sexual abuse by another resident for 1 of 2 sampled residents (#1) reviewed for sexual abuse. This resulted in Resident 1 experiencing psychosocial harm and increased distress. Findings include: Resident 1 was admitted to the facility in 3/2024 with diagnoses including dementia, mood disturbance, anxiety and developmental disorder of speech and language. A 3/22/24 Cognitive Loss and Dementia CAA revealed Resident 1 required one-step cueing for tasks, time to process cues and communication, and 24-hour supervision for safety. Resident 1 required a floor alarm because the resident did not remember to use the call light. Staff were to provide simple direct communication and interpret Resident 1's tone of voice and facial expressions. Resident 2 was admitted to the facility in 3/2024 with diagnoses including stroke and encephalopathy (damage or disease that affects the brain). Resident 2's care plan, initiated on 3/26/24, revealed Resident 2 had a stroke with left-sided weakness, was Spanish speaking only, had impaired eyesight and impaired cognition. A revision on 3/27/24 revealed Resident 2 had inappropriate physical behaviors and spoke inappropriately towards female caregivers. The resident was to be continuously supervised when in a public space, was impulsive and left her/his room independently. The staff were to provide care in pairs and remind Resident 2 what appropriate behavior and language were. Staff were to draw appropriate verbal and physical boundaries. Progress Notes revealed the following: -3/27/24 at 3:39 PM Staff 10 (Pastoral Care) visited Resident 2 but was unable to complete the assessment due to a language barrier. Resident 2 attempted inappropriate touch, which Staff 10 deflected. -3/27/24 at 6:08 PM Three CNAs reported Resident 2 grabbed and touched them during their shift, and made inappropriate remarks towards staff. Resident 2 was placed at a table away from other female residents. Staff 3 (LPN-Agency) spoke with Resident 2, with assistance from a Spanish-speaking CNA, and informed Resident 2 she/he was not allowed to touch staff inappropriately. -3/30/24 at 2:49 AM Staff 4 (LPN) revealed Resident 2 exposed herself/himself earlier in the shift, while a resident was outside of Resident 2's room. It was unclear if the exposure was intentional or not as Resident 2 made prior gestures to use her/his urinal. -3/30/24 [recorded as Late Entry on 4/2/24 at 10:15 AM] Staff 2 (DNS) was notified Resident 1 was inappropriately touched by Resident 2. The touch was unsolicited and not consensual. Staff were instructed to monitor Resident 2 and keep Resident 2 distanced from other patients for safety. Resident 2 was sent to the hospital at approximately 4:55 PM for nonemergent care related to inappropriate sexual behaviors. Random observations from 4/2/24 through 4/3/24 revealed Resident 1 was either in her/his room in bed, or up in her/his wheelchair out in the hallway, and was able to self-propel up and down the halls. Resident 2 was no longer in the building. On 4/2/24 at 11:07 AM Witness 10 (Police Officer) was interviewed and stated the following: -Witness 10 received a call from Staff 2 to report Resident 2 touched Resident 1 in an inappropriate sexual manner during breakfast on 3/30/24. -Witness 10 arrived at the facility and interviewed all parties involved. -Witness 10 stated Staff 5 (CNA) witnessed Resident 2 and Resident 1 move around the breakfast table toward one another when Staff 5 noticed Resident 2 started rubbing Resident 1's thigh in a sexual manner. Staff 5 moved Resident 2 out to the hallway, left both residents for approximately 90 seconds and returned with Staff 3. Resident 2 approached Resident 1 again and rubbed Resident 1's private area. Staff 3 and Staff 5 stopped Resident 2 and took Resident 2 back to her/his room. -Staff 5 reported Resident 2 attempted to touch her inappropriately when she took her/his blood sugar measurement, but was able to move out of the way. - Staff 3 reported Resident 2 was zeroing in on Resident 1 but did not give specific details as to what zeroing in meant. -Witness 10 interviewed Resident 1 but the resident was unable to recall what occurred. Resident 1 was upset, and stated to be nice because Resident 2 was her/his friend. -Witness 10 interviewed Resident 2, who denied touching Resident 1 in an inappropriate sexual manner. Resident 2 was able to carry a full conversation in Spanish with Witness 10 and understood Staff 5 told Resident 2 to go back to her/his room. -Witness 10 asked Resident 2 about sexually inappropriate behavior towards staff, such as offering money to staff for sexual favors. Resident 2 stated she/he did not have any money and then indicated she/he offered the nurse some money for the shower she/he received. On 4/2/24 at 11:35 AM Resident 1 stated she/he did not know how long she/he was at the facility. When asked if she/he recalled being inappropriately touched by another resident, Resident 1 replied, I don't remember, and mentioned she/he had difficulty remembering things. Resident 1 stated she/he had a bit of a headache. On 4/2/24 at 11:52 AM Staff 3 (LPN-Agency) stated she was familiar with Resident 1 and Resident 2. Staff 3 stated Resident 2 was Spanish-speaking but was able to communicate her/his needs. Resident 2 was impulsive and was sexually inappropriate towards staff. Resident 1 was pleasantly confused, impulsive and easily redirected. Staff 3 stated on 3/30/24 Resident 1 and Resident 2 were in the North Hall dining room, both within eyesight of staff. Staff 3 stated Staff 5 approached Staff 3 and indicated she needed assistance because Resident 2 rubbed Resident 1's leg and knee, and Staff 5 wheeled Resident 2 to the nurses station. Staff 3 entered the dining area with Staff 5, where they observed Resident 2 back at the dining table with Resident 1. Resident 2's hand was between Resident 1's legs, and Resident 2 was rubbing Resident 1's private area over Resident 1's brief and pants. Staff 3 stated she immediately wheeled Resident 2 away from Resident 1, and firmly stated, No, you can't touch people like that. Resident 2 understood the word no and Staff 3 escorted Resident 2 to her/his room. Staff 3 stated Resident 1 was initially upset when Resident 2 was removed from the area. Staff 3 stated Resident 1 was unable to answer questions and did not recall the incident. Later, Resident 1 requested to lay down for the day, which was uncharacteristic behavior. Resident 1 also expressed concern, stating, Don't let anyone sneak into my room. Staff 3 stated she believed Resident 1 had some awareness of what happened but was unable to voice it due to her/his dementia. On 4/2/24 at 1:22 PM Staff 5 (CNA) stated she worked with Resident 2 prior to the incident on 3/30/24. Resident 2 exhibited sexual behavior towards staff but not toward residents. Resident 2's care plan required two staff members in the room when interacting with Resident 2. Staff 5 recalled she heard about one incident when Resident 2 attempted to entice Resident 1 out of her/his room by flashing money. Resident 1 did not witness the behavior. Staff 5 stated during breakfast on 3/30/24 at approximately 8:30 AM Resident 1 and Resident 2 were seated across from each other in the dining room area. A nurse was at the nurses station and the residents were visible from the nurses station. Staff 5 stated she avoided an attempt by Resident 2 to inappropriately touch her when she checked Resident 2's blood sugar. Resident 1 and Resident 2 received their breakfast trays and as Staff 5 emerged from a room around the corner she observed Resident 1 and Resident 2 scooted closer to one another. Resident 2 was rubbing Resident 1's leg and knee back and forth. In response to the situation, Staff 5 promptly wheeled Resident 2 to the nurses station and sought assistance from Staff 3, urgently stating, I need you right now. Staff 5 and Staff 3 rushed to the dining area. Resident 2, who was able to self-propel, approached Resident 1 and grabbed Resident 1's private area over Resident 1's brief and pants. Resident 2 glanced around to ensure no one was watching. Staff 3 firmly told Resident 2, No, no, and Resident 2 raised her/his hands in response. Staff 3 wheeled Resident 2 back to her/his room. Staff 5 stated Resident 1 initially indicated Resident 2 did not harm her/him and Resident 2 was a friend. Resident 1 later became upset and reacted negatively. Approximately an hour afterward, Resident 1 expressed fatigue and a desire to rest her/his legs. Resident 1 stated, Hopefully I could get some sleep and no one will sneak in my room. Staff 5 stated she noticed Resident 1 seemed unusually agitated during the day shift, as her/his typical baseline behavior was pleasantly confused. When Staff 5 checked on Resident 1, she/he firmly stated, Don't touch me, and I don't want anything from you. On 4/2/24 at 1:59 PM and 4/3/24 at 12:14 PM Staff 4 (LPN) stated she worked with Resident 2, who was Spanish speaking. Staff 4 stated in the early AM hours prior to 8:30 AM on 3/30/24 Resident 2 was in bed with her/his genitalia exposed. Staff 4 believed the exposure was directed at Resident 1, although Resident 1 did not observe it. Staff 4 stated she was uncertain whether Resident 2 intentionally exposed herself/himself or needed to use the urinal. Staff 4 stated Resident 1 was confused at baseline and on 3/31/24 expressed concern and asked if, that man was still there. Staff 4 reassured Resident 1 no one was in her/his room. On 4/2/24 at 3:27 PM Witness 11 (Family Member) stated she received a call on 3/30/24 regarding Resident 1. Witness 11 stated another resident maneuvered to the opposite side of the table while Resident 1 was having breakfast and the resident engaged in inappropriate sexual behavior, touching Resident 1's private area. Witness 11 stated a staff member witnessed the incident, intervened, and separated the residents. Witness 11 stated staff retrieved assistance and when the staff returned the resident made her/his way back to Resident 1 and was rubbing Resident 1's private area, necessitating a second separation. Witness 11 stated she was upset about the incident and Resident 1, who lacked awareness of the situation, couldn't recall her/his own name, or effectively communicate. Witness 11 was uncertain whether the touching occurred over or under Resident 1's clothing, but regardless, such behavior should not have occurred. On 4/3/24 at 8:52 AM Staff 8 (CNA) stated she was not present on 3/30/24, when Resident 2 inappropriately touched Resident 1. Staff 8 stated Resident 2 was Spanish-speaking only, and she assisted with Resident 2's admission due to the language barrier. Resident 2 reported a sexually inappropriate act to her, when Resident 2 became aroused by a staff member at the hospital. Staff 8 stated she reported the conversation to Staff 9 (RN) who was in the room. Staff 9 indicated Resident 2 made inappropriate sexual comments at the hospital. Staff 8 stated she worked with Resident 1 on multiple occasions and the resident was pleasantly confused. Staff 8 stated she worked with Resident 1 on 3/31/24, the day after the incident with Resident 2. During charting, Resident 1 was in her/his wheelchair, lifted her/his shirt, exposing her/his breast. Staff 8 addressed the unusual behavior and was concerned. Staff 8 stated later in the evening, during her shift, Staff 8 assisted Resident 1 to bed. Resident 1 immediately called and asked if someone was in her/his room and Resident 1 asked, is that guy still there? Staff 8 assured Resident 1 there was no one in her/his room. Approximately five minutes later, around 9:30 PM Staff 8 returned to Resident 1's room, and Resident 1 again asked if that man was still out there. Staff 8 reassured Resident 1 once more. Staff 8 stated she reported her concern to Staff 4 (LPN) and she charted the incident. Staff 8 further stated she was fairly certain she knew Resident 1 was referring to Resident 2. On 4/3/24 at 1:29 PM Staff 9 (RN) stated she assessed Resident 2 upon admission to the facility. Staff 9 stated Resident 2, who spoke only Spanish, received assistance from Staff 8, who was also fluent in Spanish, for communication. Staff 9 stated Resident 2 had confusion, and Staff 8 relayed Resident 2 stated he experienced a sexual incident at the hospital and became aroused. Staff 9 stated she stepped out of the room with Staff 8 and shared hospital records indicated Resident 2 made inappropriate sexual comments to staff during her/his hospitalization . Staff 9 stated on one occasion Resident 2 offered staff money for sexual favors, but staff members firmly declined. Staff 9 stated Resident 2 put the money away, and Staff 9 believed this was an isolated occurrence. Staff 9 stated the money incident occurred prior to the 3/30/24 incident, during which Staff 9 was not present. Staff 9 stated upon returning to work, Resident 2 was no longer in the building. The 4/3/24 Investigation Summary Abuse Allegation revealed Resident 2 exhibited inappropriate behaviors while at the hospital, but no known knowledge of sexual assault. After admission to the facility, Resident 2 demonstrated growing behavioral concerns, prompting appropriate response from staff. Resident 2's care plan was updated to include increased behavior monitoring, two-person cares, redirection and setting appropriate boundaries. On 3/30/24 Staff 5 was assigned to Resident 2 and brought Resident 2 to the common area for breakfast, placing Resident 2 across the table from Resident 1. A nurse was at the nurses station and the residents were visible from the nurses station. At approximately 8:30 AM, Staff 5 delivered a meal tray down the hall. Upon returning, Resident 2 and Resident 1 both came around the table and met. Resident 2 was looking around while also reaching to rub Resident 1's thigh. Staff 5 intervened and expressed Resident 2's behavior was not appropriate. Staff 5 indicated despite the language barrier, Resident 2 indicated understanding and played it off with hand signals, suggesting Resident 2 was not doing anything wrong. Resident 1 expressed confusion and reported Resident 2 was my friend. Staff 5 moved Resident 2 into a separate hall and then sought help. Staff 5 returned in less than a minute with Staff 3. Resident 2 returned to the table and was witnessed rubbing between Resident 1's thighs and on her/his groin area. Staff 5 and Staff 3 separated Resident 1 and Resident 2, emphasizing Resident 2's behavior was not acceptable. Staff 5 indicated Resident 1 expressed frustration regarding their separation and Resident 2 was being nice. Staff 5 educated Resident 1 regarding the inappropriate touch. Resident 1 was agitated and in a poor mood for the remainder of the shift and requested to lie down because she/he was tired. After laying Resident 1 down, Resident 1 told Staff 5, Don't let anyone sneak into my room. Reassurance was offered. Although Resident 1 remained agitated into the evening, Resident 1 returned to her/his baseline according to Staff 5. The encounter between Resident 2 and Resident 1 on 3/30/24 was documented as unavoidable. Staff monitored Resident 2 and kept Resident 2 separated from other residents to the best of their ability. Resident 2 was sent to the hospital at approximately 4:55 PM for further evaluation due to her/his behavioral concerns. Resident 1 experienced a temporary change in her/his mood but returned to her/his baseline; no long-term harm occurred. Resident to resident sexual abuse was substantiated. On 4/3/24 at 2:18 PM Staff 2 (DNS) stated she initiated an investigation and concluded Resident 1 was sexually abused by Resident 2 based on her interviews and record review. The incident on 3/30/24 was witnessed by staff, and Resident 2 engaged in inappropriate sexual touch which was not consensual with Resident 1, as Resident 1 was unable to consent due to her/his cognition.

Based on interview and record review it was determined the facility failed to ensure physician orders were followed for 1 of 3 sampled residents (#3) reviewed for medication administration. This placed residents at risk for adverse side effects of medications. Findings include: Resident 3 admitted to the facility on [DATE] with diagnoses including femur fracture. The 11/27/23 physician orders indicated Resident 3 was to receive aspirin 81 mg BID for 23 days (until 12/19/23) and then stop. The 11/2023 and 12/2023 MARs indicated Resident 3 received aspirin once daily from 11/28/23 through 12/8/23. The 12/8/23 physician order indicated to discontinue aspirin. On 3/22/24 at 9:15 AM Staff 2 (DNS) acknowledged Resident 3 did not receive aspirin as ordered from 11/28/23 through 12/8/23.

Based on interview and record review it was determined the facility failed to ensure a resident was free from verbal abuse for a resident-to-resident altercation for 1 of 4 sampled residents (#8) reviewed for abuse. This placed residents at risk for isolation. Findings include: Resident 8 admitted to the facility in 2021 with diagnoses including depression. Resident 6 admitted to the facility in 2022 with diagnoses including bipolar and personality disorder. On 11/29/23 a facility investigation indicated an incident of resident-to-resident verbal abuse. Resident 6 came out of her/his room into the common area after Resident 8 arrived for breakfast. Resident 6 directed her/his attention to Resident 8 and stated, It stinks in here. Resident 8 stated it was not nice to make the statement and Resident 6 responded, Who cares? A verbal argument developed, and staff intervened. However, Resident 6 continued to make unpleasant comments to Resident 8. Resident 8 indicated Resident 6 made comments in the past which led Resident 8 to isolate in her/his room. Verbal abuse was substantiated by the facility and both residents' care plans were updated to reflect the altercation with interventions in place. On 3/20/24 at 1:23 PM Resident 6 stated on 11/29/24 she/he made a statement about the smell in the common area but denied it was made toward Resident 8. On 3/21/24 at 9:52 AM Resident 8 stated Resident 6 told her/him that she/he did not like her/him. Resident 8 stated he was devastated by Resident 8's comments. Resident 8 stated after the incident on 11/29/23 she/he ate meals in her/his room until recently. Resident 8 stated she/he now came out of her/his room more and Resident 6 was no longer a factor. On 3/21/24 at 10:08 AM Staff 4 (LPN) stated on 11/29/23 Resident 6 came out to the common area for breakfast and stated it smelled. Staff 4 stated she knew Resident 6 was talking about Resident 8. Staff 4 stated Resident 8 told Resident 6, It was not nice to say that. Staff 4 stated Resident 6 proceeded to self-propel her/himself away to a different area. Staff 4 further stated Resident 6 made previous comments about Resident 8 including calling her/him a pig. On 3/21/24 at 2:47 PM Staff 11 (CNA) stated Resident 6 made comments about Resident 8 smelling bad and had a history of making comments about Resident 8 including calling her/him a [NAME], fat ass and disgusting. Staff 11 stated Resident 8 was a good sport about it. Staff 11 stated they encouraged Resident 8 to not engage when Resident 6 made comments and staff tried to deescalate the situation. On 3/22/24 at 10:13 AM Staff 2 (DNS) confirmed Resident 6 verbally abused Resident 8.

Based on observation, interview and record review it was determined the facility failed to protect resident identifiable information and ensure resident records were accurate for 1 of 1 facility and for 1 of 2 sampled residents (#466) reviewed for record management and insulin. This placed residents at risk for unauthorized use of their personal information and inaccurate medical records. Findings include: 1. A review of the facility's undated Safeguarding Resident Identifiable Information policy indicated the facility was to adhere to HIPAA (Health Insurance Portability and Accountability Act) compliant practices by placing any printed material with residents' personal or medical information in a secure disposal container to be shredded. On 9/21/23 at 11:31 AM resident identifiable information including resident name, room number, discharge date and those who were on hospice care, was observed inside recycle bins located outside of the facility next to the garbage compactor. This list also indicated certain residents who had requested their identifiable information not to be released to any inquirers and it stated all visitors must check in at the nurses' station before visiting a resident. On 9/21/23 at 11:50 AM Staff 1 (Administrator) observed the recycle bins that contained resident identifiable information and acknowledged resident identifiable information was not to be placed in any recycle bin. Staff 1 stated the expectation was for staff to place any paper material with resident identifiable information in a secure confidential shred bin located inside the facility. 2. Resident 466 admitted to the facility in 9/2023 with diagnoses including diabetes with diabetic neuropathy (nerve damage). Resident 466's electronic health record indicated she/he had an allergy to gabapentin (a medication for nerve pain). Resident 466 had an active physician order to receive gabapentin three times a day. On 9/20/23 at 9:55 AM Resident 466 confirmed she/he was not allergic to gabapentin and was on the medication for approximately two years. On 9/20/23 at 4:00 PM Staff 2 (DNS) confirmed Resident 466 did not have an allergy to gabapentin and the resident's electronic health record was inaccurate.

Based on observation and interview it was determined the facility failed to ensure resident rooms, bathrooms, ceiling fans, toilets/commodes and floor mats were sanitized and cleaned timely for 10 of 11 sampled residents (#s 3, 24, 27, 32, 35, 40, 46, 47, 51 and 52) and 2 of 4 halls (Harmony and Cedar) reviewed for environment. This placed residents at risk for an unsanitary environment. Findings include: On 9/18/23 and 9/19/23 the following observations were made: -room [ROOM NUMBER]: The resident stated she/he used the bathroom and stated she/he was unsure when it was last cleaned. The bathroom was observed to have black splatters across the inside of the bowl and on the back of the toilet seat. -room [ROOM NUMBER]: The resident stated she/he used the bathroom and shared it with residents in room [ROOM NUMBER] who also both used the bathroom. Resident 47 stated she/he was not sure how often the bathroom was cleaned. The toilet was observed to have black residue, dust, and debris around the back of the seat. The toilet was visibly unclean with a dark ring around the inside of the toilet bowl. -room [ROOM NUMBER]: The bathroom floor around the toilet had water stains and a thick layer of dust with dust particles. The toilet was dirty with fecal matter under the toilet seat and around the rim. Next to the toilet on the floor was a bedside commode bucket with fecal matter splattered on it. -room [ROOM NUMBER]: The resident stated the bathroom was disgusting and the fan in the bathroom was dirty and broken for some time. Resident 46's bathroom fan had a thick layer of fuzz/lint build up (approximately half an inch) and the fan did not work. The floor under the sink and adjacent to the sink had large moldy/water stains and a thick layer of dust on the floor around the sink and the toilet. The toilet was dirty with fecal matter in and around the toilet bowl. The floor around the toilet had dust particles and moldy/water stains. -room [ROOM NUMBER]: The bathroom fan had a thick layer of fuzz/lint build up (approximately half an inch) and the fan did not work. The floor under the sink and adjacent to the sink had large moldy/water stains and a thick layer of dust and dust particles on the floor around the sink and the toilet. -room [ROOM NUMBER]: The bathroom had a toilet riser over the toilet and the backside of the toilet riser had fecal matter along the backside of the rim and the water in the toilet was dark brown. The sink adjacent to the toilet had moldy/water stains under the sink and the floor had visible dust particles. -room [ROOM NUMBER]: The resident was asleep in bed and a floor mat was on the floor left of with multiple food crumbs and debris. The food crumbs were scattered on the mat and the floor on the left side of her/his bed. -room [ROOM NUMBER]: The bathroom fan had a thick layer of fuzz/lint buildup. The toilet riser over the toilet had smeared fecal matter in the front of the seat and the toilet had splatters of fecal matter in the toilet bowl and on top of the seat area. There was a large reddish orange area of discoloration on the back corner of the toilet. On 9/19/23 at 11:00 AM Staff 22 (Maintenance Director) stated he maintained repairs for the entire campus and repaired any items not functioning in the building or resident rooms. Staff 22 stated he was not aware of any fans that were not functional in resident rooms. Staff 22 stated housekeeping was responsible for cleaning the residents rooms and Staff 1 (Administrator) was in charge of housekeeping. On 9/19/23 at 11:10 AM Staff 1 observed and acknowledged the 10 identified rooms were not cleaned appropriately including the dirty and non-functioning fans, dirty floors, toilets and toilet risers. Staff 1 stated housekeepers were expected to complete daily cleaning for each resident rooms and they utilized a check off sheet to ensure all tasks were completed.

Based on observation, interview and record review it was determined the facility failed to provide an emergency kit in the resident's for 1 of 1 sampled resident (#317) reviewed for dialysis. This placed the resident at risk for complications related to dialysis. Findings include: Resident 317 admitted to the facility in 8/2023 with diagnoses including end stage renal disease and diabetes. Resident 317's 9/4/23 Admission MDS indicated the resident was cognitively intact. Resident 317's 9/9/23 Admission Care Plan revealed the resident received dialysis (a procedure to remove waste products from the blood when the kidneys stop working) three times a week at a clinic outside the facility. On 9/20/23 at 9:46 AM observations made in Resident 317's room revealed no emergency kit in the room. On 9/21/23 at 10:00 AM Staff 22 (CNA) stated he would call the nurse if he noticed any bleeding from the resident's dialysis site. Staff 22 was unable to locate dressings, bandages or an emergency supply kit in the room if needed for an emergency. On 9/21/23 at 10:14 AM Staff 23 (Agency LPN) stated in his experience, there would be an emergency kit with dressings or Kerlix (a type of gauze bandage) in Resident 317's room for any dialysis bleeding emergencies. Staff 23 acknowledged there was not an emergency kit in the room. On 9/21/23 at 2:39 PM Staff 2 (DNS) stated she expected an emergency supply kit to be in Resident 317's room.

Based on observation, interview and record review it was determined the facility failed to provide appropriate foot care for 1 of 1 sampled resident (#21) reviewed for foot care. This placed residents at risk for lack of nail care and infections. Findings include: Resident 21 admitted to the facility in 12/2022 with diagnoses including peripheral vascular disease (blood circulation disorder) and chronic heart failure. Resident 21's 9/2023 TAR revealed nail care was provided every week on Saturdays on her/his scheduled shower days. Staff initialed they provided weekly nail care on 9/2/23, 9/9/23 and 9/16/23. On 9/20/23 at 9:52 AM Resident 21 stated she/he requested an appointment in 7/2023 to have her/his toenails trimmed because the facility did not provide toenail care. Resident 21 stated the left toenails were a concern because the second toenail on her/his left foot was pressing into the left big toe and was kind of uncomfortable. On 9/20/23 at 9:55 AM Resident 21's toes were observed with all toenails discolored, deformed, thickened (half-an-inch) and longer than one inch. Resident 21's left large toenail was black and the nail vertically extended above the face of the nail bed over one inch. The left second toenail was pressing into the left big toe. On 9/20/23 at 10:41 AM Staff 17 (CNA) stated she thought Resident 21 was a diabetic and nurses were to trim Resident 21's nails. Staff 17 stated Resident 21's toenails were thick, long and dark in color. On 9/21/23 at 9:37 AM Staff 19 (LPN) stated weekly skin checks were completed and Resident 21's toenails were thick, long and extended beyond the nail bed. Staff 19 state she thought a podiatry appointment was made for Resident 21. On 9/21/23 at 10:34 AM Staff 20 (CNA) stated when showers were provided for Resident 21 she checked her/his toenails and if unable to trim the resident's toenails she reported this to the charge nurse. Staff 20 stated she could not recall if the resident's nails needed trimmed. On 9/21/23 at 1:14 PM Staff 2 (DNS) observed Resident 21's toenails and acknowledged her/his toenails were thick, long and not adequately tended to. Staff 2 stated she expected staff to complete weekly toenail care and if unable to trim the nails to make a podiatry appointment.

Based on observation, interview and record review it was determined the facility failed to provide care and services to maintain good grooming and personal hygiene for 2 of 7 sampled residents (#s 21 and 41) reviewed for ADLs. This placed residents at risk for skin breakdown and quality of care. Findings include: 1. Resident 21 admitted to the facility in 12/2022 with diagnoses including peripheral vascular disease (blood circulation disorder) and chronic heart failure. Resident 21's care plan, initiated on 12/19/22, identified the resident was at risk for skin breakdown related to peripheral vascular disease, respiratory failure and local edema. The care plan indicated staff were to apply dressings, creams, or ointments as prescribed. Resident 21's 9/2023 TARs revealed Aquaphor (a thick ointment effective at protecting dry skin) was to be applied to Resident 21's lower leg extremities twice daily. On 9/20/23 at 9:52 AM Resident 21 stated staff applied lotion to her/his legs but had not applied lotion to her/his feet in some time. On 9/20/23 at 9:55 AM Resident 21's feet were observed and the skin on her/his feet was cracked, dry and flaky. On 9/21/23 at 9:37 AM Staff 19 (LPN) stated lotion was applied to Resident 21's lower legs but could not recall how often this was completed. On 9/21/23 at 10:34 AM Staff 20 (CNA) stated she applied lotion to Resident 21's legs but not to her/his feet. On 9/21/23 at 1:14 PM Staff 2 (DNS) observed Resident 21's feet and acknowledged her/his feet were cracked, dry and had flaky skin. Staff 2 stated she expected staff to implement and follow the care plan. 48820 2. Resident 41 was admitted to the facility in 10/2021 with diagnoses of diabetes, anxiety disorder and morbid obesity. The care plan dated 5/27/23 indicated I may refuse cares and treatments as a way of maintaining my autonomy and controlling my situation and directed staff to re-approach when the resident refused care and to inform the nurse of refusals. A review of the Quarterly MDS dated [DATE] revealed the resident was cognitively intact and she/he required extensive assistance for personal hygiene. On 9/18/23 at 11:06 AM Resident 41 stated she/he asked staff to brush or wash her/his hair, but staff did not follow up with her/him. An observation of Resident 41's hair on 9/18/23 at 11:06 AM revealed her/his entire head of hair was entangled and unkempt including a large clump of hair with white dander and the entire backside of her/his hair was matted to her/his scalp. A review of clinical care records dated 7/13/23 to 9/19/23 indicated no evidence Resident 41 refused hair hygiene care. On 9/20/23 at 9:41 AM Staff 14 (CNA) stated Resident 41 consistently refused to allow any staff to brush or wash her/his hair, and the nurses knew about the condition of Resident 41's hair. On 9/20/23 at 9:54 AM Staff 15 (RN) stated Resident 41 was not always compliant with personal hygiene care. Staff 15 stated CNAs offered personal hygiene care and when the resident refused, the RN's spoke with the resident and Resident 41 consistently refused care from the RN's when offered. On 9/20/23 at 10:43 AM Staff 2 (DNS) observed the resident and acknowledged Resident 41's hair and scalp needed to be attended to. Staff 2 stated she was unaware Resident 41 refused hair hygiene care and expected staff to re-approach Resident 41 if she/he refused ADL care, and document the activity.

Based on observation, interview and record review it was determined the facility failed to implement a person-centered care plan for 1 of 1 sampled resident (#21) reviewed for foot care. This placed residents at risk for skin breakdown. Findings include: 1. Resident 21 admitted to the facility in 12/2022 with diagnoses including peripheral vascular disease (blood circulation disorder) and chronic heart failure. Resident 21's care plan, initiated on 12/19/22, identified the resident was at risk for skin breakdown related to peripheral vascular disease, respiratory failure and local edema. Staff were to offload Resident 21's heels when in bed. On 9/20/23 at 9:52 AM Resident 21 stated she/he preferred to stay in bed and staff did not always place pillows under her/his feet. On 9/20/23 and 9/21/23 random observations revealed Resident 21's heels were not offloaded while in bed. On 9/21/23 at 10:45 AM Staff 14 (CNA) acknowledged Resident 21's heels were not offloaded and her/his heels were to be offloaded while the resident was in bed. Staff 14 stated staff were expected to follow the care plan. On 9/21/23 at 9:37 AM Staff 19 (LPN) stated Resident 21 refused to get out of bed and her/his feet were offloaded with pillows when in bed. Staff 19 stated she thought the resident refused at times to have her/his heels offloaded. On 9/21/23 at 10:34 AM Staff 20 (CNA) stated she was not sure if Resident 21's heels needed to be offloaded while in bed. Staff 20 stated care plans were located in the room for staff to use as a reference. On 9/21/23 at 1:14 PM Staff 2 (DNS) stated Resident 21 was often compliant with her/his ADL care. Staff 2 stated staff were expected to review, implement and follow the care plan and Resident 21's heels were to be offloaded when she/he was in bed.

Based on interview and record review it was determined the facility failed to ensure staff treated residents with dignity and respect for 1 of 1 sampled resident (#56) reviewed for abuse. This placed residents at risk for lack of dignity. Findings include: Resident 56 was admitted to the facility in 4/2023 with chronic kidney disease. A 5/1/23 FRI revealed Staff 16 (CNA) told Resident 56 to shut up while assisting with ADL care. On 9/18/23 at 11:10 AM Resident 56 stated she/he did not recall the incident. On 9/20/23 at 5:33 PM Staff 16 stated she was assisting Resident 56 with ADLs and became frustrated. Staff 16 stated she told Resident 56 to shut up and immediately apologized for her mistake. On 9/21/23 at 3:14 PM Staff 2 (DNS) acknowledged the incident occurred and described it as a mistake. The findings were determined to be Past Noncompliance, as the facility identified and corrected the deficient practice prior to the survey. The deficient practice was corrected on 5/6/23 when the plan of corrected was fully implemented. The Plan of Correction included: 1. A facility incident report which determined Resident 56 was not treated in a dignified manner by Staff 16. 2. Staff 16 was immediately suspended from work until she completed in-service training. 3. Staff education was provided on 5/6/23.

Based on observation, interview and record review it was determined the facility failed to ensure pressure injury wounds were appropriately assessed, monitored and treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . This placed residents at risk for inaccurate wound assessments and worsening wounds. Resident 18 had a coccyx wound that worsened from Stage 2 to Stage 4. Findings include: 1. Resident 18 was admitted to the facility in 2/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/25/22 initial assessment of Resident 18's Stage 2 sacral pressure injury indicated the wound was 1.2 cm in length and 0.6 cm in width, with epithelial tissue (thin protective layer), well-defined edges, no drainage, no odor and the skin surrounding the wound was dark purple or rusty discoloration. The assessment identified the wound as stable and present on admit with the surrounding skin blanchable (becomes lighter when pressed). The family indicated the wound was much more open and has been healing. The wound was covered with Allevyn (foam) dressing for protection. A photo provided by the facility of the area, from 2/25/22, showed an area of deep red to purple with a defined darker area in the center over the resident's coccyx. The wound appeared to have a shallow open area in the center, although there was also a deep purple area within the border. The facility classified the wound as a Stage 2 pressure ulcer. However, the appearance of the wound, including the area surrounding the center in the photo was consistent with a description of Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration over intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. The wound may evolve rapidly to reveal the actual extent of the pressure injury. The resident's 2/25/22 Care Plan revealed the following information regarding her/his pressure ulcer: The resident had impaired skin integrity related to Stage 2 pressure injuries (on heels) and unstageable-S4 on her/his coccyx/sacrum; care approaches include: wound care to coccyx per current orders, ensure her/his special mattress was operational, regular diet per SLP services, general mulitivitamin with minerals and vitamin C for healing, supplements including Boost mixed with ice cream to help with providing extra protein for healing, minimize layers between her/his skin/wounds and mattress, assist her/him to reposition frequently and float heels while in bed. Will need to help reposition the bed or devices as well so she/h can see her/his tablet/TV and reach her/his call light straw with her/his lips and alert the nurse of any skin changes. The following wound care orders for Resident 18's sacral/coccyx wound were located in her/his medical record: -2/25/22 discharge orders from the physician at the hospital: Use liquid/spray skin protectant, cover with foam dressing, adhesive, change every two days or PRN if soiled. -2/25/22, Staff 38 (Medical Director): Change Allevyn dressing to coccyx two times per week and PRN. There was no documentation in the medical record to indicate the wound care orders were reviewed to determine which one was appropriate. Resident 18's MARs revealed wound care was provided to her/his coccyx two times a week from 2/27/22 through 3/15/22. On 3/18/22 Staff 38 discontinued the Allevyn dressing and provided new orders to apply moisture barrier cream to the coccyx every shift and ensure the resident was turned and off-loaded from her/his coccyx. A 3/18/22 Wound Management Detail Report indicated the wound measured 1.2 cm in length and 0.7 cm in width, had light exudate (drainage) and granulation tissue (healing) and was noted to be improving. On 3/27/22 the wound status was documented as 2.8 cm in length and 0.3 cm in width, declining, larger in size and open more than before. On 4/7/22 the hospital physician provided new wound orders for the resident's sacrum: Use liquid/spray skin protectant and cover with foam dressing, adhesive and change every two days. Special instructions included to wake the resident to do the dressing. There was no documented evidence the 4/7/22 orders were implemented on the 4/2022 MAR. The previous orders from Staff 38 on 3/18/22 were continued through 4/15/22 when Resident 18 was admitted to the hospital. Resident 18 was discharged from the hospital on 4/18/22 with wound care information and orders completed by the wound/ostomy RN: -Wound Assessment: Sacrum: 4 cm by 3 cm by 1 cm, Stage 3 (Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by location; Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage or bone is not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.) pressure injury; community acquired. Surrounding skin indicates the wound started as a deep tissue injury and has now demarcated (formed defined edges) to reveal pink, moist tissue with slough or [MEDICATION(S)] in the base. The resident has had a pressure injury in the same spot and is now at higher risk for continued breakdown. The wound/ostomy RN's 4/18/22 recommendations for wound care: Wound gel to the wound bed, followed by silicone foam dressing; change every two days. The resident will need aggressive turning and repositioning continuously to help heal the wound and prevent further breakdown. The plan for the wound at discharge was a referral for outside wound care support. There was no documentation the resident's care plan was updated to reflect aggressive turning and repositioning to help heal the wound. Resident 18's 4/18/22 hospital discharge orders also included a second set of coccyx wound orders: Stage 2 pressure injury at coccyx: clean with normal saline and place protective dressing PRN. The medical record revealed on 4/18/22 Staff 42 (RN) initiated the resident's pre-hospitalization coccyx wound orders for use of moisture barrier cream and ensure the resident was floated, turned and off-loaded from her/his coccyx. The treatment was documented from 4/18/22 through 4/30/22. In addition, on 4/19/22, Staff 38 ordered a sacral wound treatment to cleanse the wound, apply [MEDICATION(S)] or Iodosorb (iodine-based) ointment to wound bed, cover with Allevyn dressing and change three times per week. There was no documentation in the resident's medical record to demonstrate the multiple wound orders on 4/18/22 and 4/19/22 were reviewed to determine which were appropriate for the resident's wound care. The hospital wound care orders were not added to the 4/2022 MAR. A Wound Management Detail Report on 5/6/22 revealed the resident's sacral wound was 7 cm in length and 5 cm in width with a moderate amount of seropurulent (watery, pus-like) drainage. The skin surrounding the wound was dark purple or rusty discoloration; blanchable. It was noted the wound looked much worse than the previous week. The 5/2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/19/22 a new treatment was implemented with the use of iodine on a yeast rash on the buttocks and in the gluteal cleft, use of Santyl (removes dead tissue from wounds) in coccyx wound if open and draining, cover with Allevyn dressing and change every other day. On 5/26/22 packing the wound with gauze was added to the wound care treatment and the wound care was changed to daily. A 5/26/22 Wound Management Detail Report revealed the resident's coccyx wound was 5 cm in length, 6 cm in width, with a depth of 2 cm. The wound was noted to now be a Stage 4 (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the wound bed, it is an unstageable PU/PI.), with mild odor, necrotic tissue and declining in healing status. The wound was described to have multiple areas of undermining and tunneling, with the surrounding skin dark red/purple around wound, warm to touch and blanching. There was no documentation in the medical record of a thorough assessment to describe how the coccyx wound progressed from a Stage 2 to Stage 4 wound, including what factors caused it to worsen or what new interventions were implemented. On 6/7/22 wound care orders were implemented to include the use of cacium alginate dressing with silver (absorbs wound fluids) and cover the wound with ABD dressing (highly absorbent). 6/13/22 Progress Notes indicated the resident's family notified facility staff one of the wound consultant physicians wanted Resident 18 to be seen at the ED (Emergency Department) for bacteria in her/his wound, surgical debridement of the wound and imaging. The resident was transported to the ED via EMS (emergency medical services). According to hospital medical records from 6/13/22 through 6/22/22 the resident required IV (intravenous) antibiotics for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The 6/22/22 Hospital Discharge Summary indicated Resident 18 was diagnosed with a worsening Stage 4 pressure wound with multiple contibutors including: [CONDITION(S)], nutrition, hard wheelchair/cushions, local wound care, potentially under-treated muscle [CONDITION(S)]. Plastic surgery would not recommend a flap until these factors were remediated. The Discharge Summary included further recommendations: Every two hour turns: turn side to side, NO TIME on back; needs a specialized wheelchair cushion, [MEDICATION(S)] 10 mg BID to treat [CONDITION(S)] and plastic surgery follow-up in three months. The 6/22/22 Discharge Summary included new coccyx wound treatment orders: Cleanse and irrigate wound with normal saline, paint peri-wound skin with [MEDICATION(S)] skin prep (ultra-thin skin barrier) moisten kerlix gauze with Dakin's solution (wound cleanser), loosely fill wound with Dakin's moistened gauze - ensure all undermined areas of wound are loosely filled; cover with ABD pad and secure with mesh underwear or minimal tape, twice daily. On 7/25/22 at 2:20 PM this surveyor observed Resident 18 and Witness 5 (Family), in the resident's room. The resident was alert, oriented and talked freely about her/his medical needs and care at the facility. Witness 5 stated there was almost always a family member here with the resident for support and to ensure care was given correctly. Witness 5 indicated the resident had an open area on her/his coccyx that was infected. The resident was observed on a specialized fluid immersion simulation bed and Witness 5 stated it was their own bed and they brought it into the facility for the resident to use. On 7/26/22 at 11:36 AM Witness 4 (Family) was visiting Resident 18 and Witness 4 voiced concern because staff told them pressure sores were not preventable. Both the resident and Witness 4 told this surveyor the resident was not always turned every two hours as required. During the interview at 12:00 PM two CNAs entered the resident's room to reposition her/him. After the CNAs left the room Witness 4 stated she had been there all morning and the last time the resident was turned or repositioned was at 9:00 AM. On 7/27/22 at 5:39 PM Witness 3 (complainant) stated he observed Resident 18's sacral wound during her/his hospitalization in 6/2022 when he took care of the resident's medical needs. Witness 3 stated the Stage 4 pressure injury was quite deep and due to the resident's inability to care for herself/himself, staff were responsible for most of her/his needs and ensuring pressure relief was provided appropriately. Witness 3 indicated the resulting wound was likely the result of neglect due to lack of enough position changes. Witness 3 stated he discussed his concerns regarding the sacral wound with the resident's family. On 8/1/22 at 10:26 AM Staff 32 (RN) stated she was part of the staff who participated in Resident 18's initial admission and her/his wound was pretty minor at that time. Staff 32 stated the wound was a Stage 2 on admit. Staff 32 revealed the resident was turned every two hours and required two staff to do so. Staff 32 indicated the completion of the resident's turning schedule was documented on the TAR and by the CNAs, plus they give shift-to-shift report when the last time the resident was repositioned. Staff 32 stated the resident's wound had worsened around the end of May of this year when there was a staffing decrease. Staff 32 indicated after the wound worsened it required surgical debridement in the hospital. On 8/1/22 at 1:22 PM Staff 42 (CNA) stated the resident's transfers or position changes were always two-person and they used a transfer blanket for him/her which was very helpful. Staff 42 stated they tried to do at least every two hour position changes and the resident was very alert and patient during her/his care. On 8/1/22 at 1:22 PM Staff 33 (CNA) stated they used a draw-sheet type blanket to move the resident to assist with changing her/his position. Staff 33 stated the resident got out of bed sometimes and she/he liked to get a shower at least once a week. In an interview on 8/1/22 at 4:17 PM Staff 34 (RN/Infection Preventionist) stated she had previously seen the resident's wound and written some wound care orders in her capacity as a wound care nurse. Staff 34 stated the wound was a Stage 2 when the resident was admitted , then it became unstageable and was now a Stage 4 wound. During interviews on 8/2/22 at 9:28 AM and 11:11 AM Staff 2 (DNS) and this surveyor reviewed Resident 18's coccyx wound care information. Staff 2 stated the resident's wound care orders came from multiple sources including: Staff 34, Staff 38, doctors at the wound clinic and hospital orders. Staff 2 indicated she did not know specifically how the wound progressed from Stage 2 to a Stage 4, but stated the facility provided multiple things including changing treatments, outside consults, dietary consults. Staff 2 stated she did not feel they caused the resident's coccyx wound to worsen because they were changing orders all the time and trying to find something that worked. Staff 2 indicated she did not see the 4/18/22 referral from the hospital wound nurse regarding wound care. On 8/4/22 at 8:40 AM, Staff 38 (Medical Director) acknowledged he treated Resident 18's sacral wound and stated there were multiple reasons why wounds worsen. Staff 38 indicated pressure injury wounds were difficult to care for and there were many challenges involved, including staffing at the time. Staff 38 indicated many were involved with the care of the resident's wound including outside wound care. Staff 38 stated he was not sure how worsening of the wound could have been avoided. Staff 38 indicated pressure ulcers still happen even when people are getting good care it was difficult to prevent them. 2. Resident 3 admitted to the facility in 2016 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Pressure Ulcer Injury CAA dated 2/12/22 revealed Resident 3 was at risk for skin breakdown, especially related to pressure. Resident 3 had minimal position changes in a day, poor perfusion due to multiple comorbidities, and had generalized weakness. Resident 3 had a right leg fracture and had a brace on the right leg. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A 2/16/22 Occupational and Physical Therapy Note revealed Resident 3 was working with Staff 6 (Occupational Therapy) and Staff 7 (Physical Therapy) in therapy. Resident 3's brace was discontinued per physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . In an attempt to don socks Resident 3 reported pain to the right ankle and Staff 6 noticed a wound near the right lower extremity on the ankle which was approximately 4 cm's in size. Staff 6 reported the finding to nursing staff. A 2/16/22 Progress note revealed therapy was working with Resident 3 and noted an open area to her/his right lateral malleolus (ankle). Resident 3 had been wearing a knee brace (immobilizer) until 2/16/22. Resident 3's right ankle bent in a way that her/his right foot faced inward at baseline. The open area was located at the area where the metal portion of the immobilizer was resting. The wound was a Stage 2 (partial thickness skin loss, a shallow open ulcer with a red, pink wound bed) pressure injury with a red wound bed. There was also one small area that was yellow/brown. A review of Resident 3's clinical record revealed on 2/16/22 treatment was initiated to address the new Stage 2 pressure ulcer. No documentation was found in the clinical record regarding an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A Observation Detail List Report dated 2/16/22 revealed Resident 3 had a Stage 2 pressure ulcer. The wound to the right lateral ankle was red in color with one small area containing yellow and brown. The wound measured 4.6 cm x 3.0 cm and 0.1 cm, drainage was serosanguineous (watery fluid that is red to pink in color), no odor and the condition around the wound bed was pink with skin intact and was newly noted. No information regarding if Resident 3 had pain or discomfort to the area. A Observation Detail List Report dated 3/3/22 (15 days later) revealed Resident 3 had a Stage 2 pressure ulcer. The wound to the right lateral ankle measured 5.0 cm x 0.8 cm the wound color was black/brown eschar (dead tissue) and no drainage. The wound was scabbed with a completely healed area in the 5 cm length. No drainage or tenderness. No information regarding if Resident 3 had pain or discomfort to the area. A Observation Detail List Report dated 3/9/22 (six days later) revealed Resident 3 had a Stage 2 pressure ulcer. The wound to the right lateral ankle measured 3.0 cm x 0.8 cm the wound color was black/brown eschar and no drainage, odor or open skin, healing in progress. No information regarding if Resident 3 had pain or discomfort to the area. A Wound Management Detail Report dated 3/23/22 (20 days later) revealed the wound measured 1.5 cm x 1 cm, no drainage and the tissue type was closed/resurfaced. The wound had well defined wound edges and the skin surrounding the wound was pink/normal and was improving. No information regarding if Resident 3 had pain or discomfort to the area. A Wound Management Detail Report dated 3/30/22 (seven days later) revealed the wound measured 1.3 cm x 1.3 cm with light serosanguineous exudate, well defined wound edges and the skin surrounding the wound was pink/normal and was noted as declining. No information regarding if Resident 3 had pain or discomfort to the area. A Wound Management Detail Report dated 4/20/22 (31 days later) revealed the wound measured 4.5 cm x 1.0 cm was a Stage 2 pressure ulcer and the tissue type was closed/resurfaced with well-defined wound edges and the skin surrounding the wound was pink/normal and was noted as improving. No information regarding if Resident 3 had pain or discomfort to the area. A Wound Management Detail Report dated 5/27/22 (37 days later) revealed the wound measured 4.5 cm x 1.0 cm was a Stage 2 pressure ulcer and the tissue type was closed/resurfaced with well-defined wound edges and the skin surrounding the wound was pink/normal and was noted as improving. No information regarding if Resident 3 had pain or discomfort to the area. A Wound Management Detail Report dated 6/3/22 revealed the Stage 2 pressure ulcer was healed but with a slight red scar to the area. On 7/28/22 at 7:32 AM Staff 3 (LPN) and Staff 5 (RN) both stated Resident 3 acquired a pressure injury to her/his right ankle because of how her/his ankles rolled outward at rest but could not recall the leg brace. On 8/1/22 at 11:36 AM Staff 6 stated she worked with Resident 3 on 2/16/22 and removed the brace from her/his right leg and was donning a sock to the right foot and Resident 3 stated ouch that is really painful. Staff 6 stated she could see a wound to the area which was roughly 4 cm's around and appeared it was caused by the brace rubbing on the right ankle. Staff 6 stated she alerted nursing staff to assess the wound. On 8/1/22 at 1:57 PM Staff 7 indicated she worked with Resident 3 after she/he had fractured her/his right leg and returned from the hospital in 2/2022. Staff 7 stated on 2/16/22 it was ok to remove the right leg immobilizer and attempted to place a sock on her/his right foot when Resident 3 said ouch when lifting up her/his foot. Staff 7 stated she could see a wound to the right ankle from the immobilizer. Staff 7 stated therapy was stopped and a nurse was notified. On 8/1/22 at 11:18 AM and 7/29/22 at 12:00 PM Staff 2 (DNS) stated Resident 3 returned from the hospital on 2/3/22 with a right leg immobilizer, however there was not an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff 2 stated the investigation into the Stage 2 pressure ulcer to the right ankle was documented in the 2/16/22 progress note. Staff 2 stated she did not find documentation from 2/3/22 through 2/16/22 of a staff assessment of Resident 3's skin integrity to the right lower leg to ensure there were no wounds under the right leg immobilizer. Staff 2 stated staff initiated weekly observational forms to monitor the Stage 2 pressure ulcer and additionally utilized the wound management detail report. Staff 2 further stated weekly assessments should be completed by staff.

Based on interview and record review it was determined the facility failed to re-evaluate a resident injury after the resident reported additional symptoms for 1 of 4 sampled residents (#3) reviewed for accidents. Resident 3 experienced pain from an undiagnosed leg fracture. Findings include: Resident 3 admitted to the facility in 2016 with diagnoses including right leg fracture, stroke and diabetes. A 1/13/22 Progress Note revealed Resident 3 was found on the floor by staff in the early morning. Resident 3 used the commode without calling for assistance and when attempting to get back in her/his recliner slipped down to the floor and landed on her/his buttocks. An assessment was completed with ROM which was within normal limits and at the time of the fall the resident had no complaints of pain however later during the shift Resident 3 complained of right calf pain and discomfort. A Late Progress Note entry on 1/14/22 (for 1/13/22) revealed a request was made on 1/13/22 for an X-ray of Resident 3's right foot and ankle but a technician was unable to get to the facility due to staff shortages and the X-ray would not be completed until 1/14/22. Resident 3 complained of foot and ankle pain and Staff 3 (LPN) noticed dark purple bruising around her/his right ankle and Resident 3 stated the pain was 10 out of 10. Results of the right ankle/foot X-ray was negative for a fracture. Progress Notes from 1/15/22 through 1/18/22 revealed Resident 3's right ankle was swollen; bruising had lessened and Resident 3 complained of pain off and on. Resident 3 did report her/his ankle was painful with touch. Pain medications were given and at times were effective. Resident 3 was being assisted with use of mechanical lift for toileting because she/he could not bear weight to her/his right lower ankle. A Physical Therapy Note dated 1/18/22 revealed Resident 3 was agreeable to physical therapy but reported she/he was unable to move her/his RLE since her/his fall and was not open to Staff 7 (Physical Therapist) touching her/his leg due to fear of pain. Resident 3 was unwilling to allow Staff 7 to move her/his RLE with her hands or use a sheet (due to hypersensitivity of skin per Resident 3's report). Resident 3 responded It will move when it moves. I'm not going to let people force it. Resident 3 declined transfer reporting that she/he was voiding in her/his brief to avoid transfers and was only agreeable to move her/his leg, once she/he felt it was ready and did not want to be pushed with activity. Prior to her/his fall she/he was able to use a front wheeled walker and transfer with assistance to a bed side commode. A Occupational Therapy Note dated 1/19/22 revealed Resident 3 was seen by Staff 6 (Occupational Therapist) and she/he complained of 10/10 foot pain. Resident 3 declined standing or attempts to transfer out of her/his recliner. Resident 3 declined occupational therapy treatment due to fear of standing and did not want to use her/his power scooter. A 1/19/22 Progress Note revealed Resident 3 was painful, fearful of more pain with touch, moving or weight bearing and declined to stand or attempt to transfer out of her/his recliner in her/his room. A Physical Therapy Note dated 1/20/22 revealed Resident 3 declined treatment due to pain in RLE. There was no documented evidence the physician was notified of Resident 3's inability to participate in therapy due to increased pain. A 1/25/22 Progress Note revealed Resident 3 complained of severe pain during care. Nursing staff assessed Resident 3 and she/he stated the pain was from her/his right knee to her/his right hip while laying on her/his right side. There was no redness, swelling or bruising noted to the right hip or knee area but the extremity was slightly warm. The physician was notified would assess the resident on 1/26/22. A Physical Therapy Note dated 1/26/22 revealed Resident 3 reported to nursing staff significant pain in RLE from hip to foot with rolling and a hip X-ray was requested. CNA staff were assisting Resident 3 with ADL care in bed and Staff 7 provided breathing techniques to help decrease complaints of pain because she/he was yelling in pain with attempts to roll her/him to the left side. Resident 3 required two or three staff to roll partially to the left with Resident 3 complaining of significant right hip pain. Resident 3 continued to experience and report high levels of RLE pain. A Progress note dated 1/27/22 revealed an X-ray of the right hip and knee was completed. 18 days after the fall on 1/13/22. A Progress note dated 1/28/22 revealed the X-ray results verified Resident 3 had a distal right femur fracture with significant displacement. Witness 1 (Family Member) and physician were notified and Resident 3 was sent to the hospital. On 7/28/22 at 11:46 AM Staff 5 (RN) stated she was not present for the fall but on 1/14/22 she assessed Resident 3 and she/he had faint bruising on the right knee and she/he complained of ankle pain but could move her toes and lift her/his right leg a little bit. Staff 5 stated by evening shift Resident 3 had bruising and swelling around the ankle and was complaining of more pain to the ankle. An X-ray was completed and indicated she/he did not fracture her/his ankle or foot. Staff 5 stated as time went by Resident 3 refused to stand or transfer due to her/his pain and discomfort and was provided ADL care with use of a mechanical lift to get her/him on the bedside commode because she/he refused to use a bed pan due to pain and discomfort. Staff 5 stated roughly a few days prior to the resident being sent out to the hospital she/he started screaming and had increased pain when ADL care was provided. An stat X-ray was ordered and confirmed Resident 3 fractured her/his right leg and she/he was sent out to the hospital. On 7/28/22 at 1:07 PM Staff 9 (CNA) stated Resident 3 had on-going pain after the 1/13/22 fall and was painful with repositioning or during ADL care. Staff 9 stated Resident 3 would grimace and moan with any sort of touch to her/his RLE not just her/his ankle. On 7/28/22 at 1:29 PM Staff 6 (Occupational Therapist) and Staff 7 (Physical Therapist) were present for an interview. Staff 6 stated she completed an evaluation on 1/19/22 (six days after the fall) but Resident 3 was very painful to her/his RLE and declined standing, transfers and did not want to use her/his power chair. Staff 7 stated she completed an evaluation on 1/18/22 (five days after the fall) and stated Resident 3 did not appear in pain at rest but would not bear weight to her/his right leg, would not allow her/his leg to be touched. On 7/28/22 at 7:32 PM and 3:03 PM Staff 3 (LPN) stated she worked evening shift on 1/13/22 and after the fall noticed some bruising and swelling to the right ankle and Resident 3 was complaining of pain. Resident 3 was able to move her/his toes, ankle and lift her leg slightly. Resident 3 complained of severe pain when CNAs provided incontinence care in bed. Staff 3 stated the resident was screaming and when she assessed her/him there was no bruising or swelling in her/his right leg but Resident 3 refused care and did not want to move the right leg. Staff 3 confirmed an X-ray of Resident 3's ankle was obtained. On 7/29/22 at 10: 11 AM Staff 37 (LPN) stated she was not present for the 1/13/22 fall but two days after the fall Resident 3 was in a lot of pain to her/his entire right leg and any type of movement caused her/him severe pain. Prior to the fall she/he was a one-person assist with a front wheeled walker from her/his recliner to the bedside commode. Staff 37 stated she had been concerned with Resident 3's continued severe pain and was not sure how helpful her/his pain medications were. The physician was not notified of Resident 3's increased pain and decrease in her/his ADL status. On 7/29/22 at 2:37 PM Staff 38 (Medical Director) stated regarding the right femur fracture he covered for Staff 39 (Physician) and determined the right leg fracture was not identified timely. Staff 38 stated he did not believe Resident 3 complained of pain but was not sure. On 7/29/22 at 10:39 AM Resident 3 stated she had a fall earlier in the year and had ongoing pain to her/his RLE which hurt with movement. Resident 3 stated she/he was frustrated because staff did not listen to me! On 8/1/22 at 12:48 Staff 2 (DNS) stated Resident 3 self-transferred on 1/13/22 which resulted in her/his fall but Resident 3 only complained of right foot and ankle pain. Staff 2 indicated the facility obtained an X-ray to the area which was negative. Staff 2 stated Resident 3 had increased pain a few days prior to being sent out to the hospital on 1/28/22. Staff 2 stated if Resident 3 had increased pain and was not participating in therapies it would be expected for staff to notify the physician. Staff 2 stated Staff 39 ordered an X-ray of the entire right leg and she was shocked that she/he had a fractured right leg because Resident 3 had no swelling or bruising other than the ankle area. There was no documented evidence the physician was notified until 1/25/22 (12 days after Resident 3's fall) regarding Resident 3's increased pain and her/his inability to participate in ADL's.

Based on observation, interview and record review it was determined the facility failed to timely assess, intervene, or reassess 1 of 8 sampled residents (#s 7) with weight loss. Resident 7 experienced severe weight loss. Findings include: Resident 7 was admitted to the facility in July 2010 with [DIAGNOSES REDACTED]. Review of the Weight Graph revealed on 7/13/10 the resident weighed 198 pounds when wearing the prosthetic leg. The resident was weighed daily without the prosthetic leg on 7/14/10 through 7/20/10 with an average weight of 191.8 pounds. Based on these weights, the weight of the prosthetic leg was approximately six pounds. An undated facility policy and procedure for weighing residents indicated CNAs were to weigh residents by the 10th of each month. They were to follow weighing instructions that included information regarding the weight of the wheelchair, if leg rests or other attachments were on the wheelchair, if the resident was weighed in a shower chair, the presence of a blanket, the time of day, etc. CNAs were to " compare with last weight on graph. If there is more than 4 lbs. (pounds) difference, check that you followed the weighing instructions and reweigh the resident to assure the weight is accurate. " Review of the Weight Graph from August to December 2010 revealed the resident weighed: 195.4 pounds on 8/1/10, 187.4 pounds in September 2010 (no specific date), 185.6 pounds on 10/3/10 with prosthesis on, 182.4 pounds on 11/4/10 and 166.4 pounds on 12/1/10. The presence or absence of the prosthesis was noted only on the 10/3/10 weight. The Dietary assessment dated [DATE] indicated the resident was "eating (and) drinking well" and had a current weight of 195.5 pounds. The Nutrition Prescription was CCHO (controlled carbohydrate diet), Choice Menus in the dining room and supplements of multivitamins and Vitamin C. The Interdisciplinary Focus dated 10/15/10 indicated the resident's weight was 185.6 pounds, a weight loss of 12.4 pounds in three months, representing a 6.2 percent weight loss. Staff 11 (Registered Dietitian/RD) wrote the resident had a urinary tract infection with decreased oral intake. The resident's diet was altered to change two percent milk to whole milk, increase bacon to four to six slices per day according to the resident's choice and to offer a meal replacement after dinner. Review of the Progress Notes (PN) dated 11/20/10 from 4:00 pm through 5:30 pm revealed the resident fell , experienced a scalp laceration and a "tiny hemmoragic (sic) contusion on the brain" and was kept overnight at the hospital for observation. PN dated 11/23/10 at 4:00 pm indicated the resident had decreased alertness and a low grade temperature and was sent to the emergency department. PN dated 11/24/10 at 7:00 am indicated the resident returned to the facility and PN the same date at 11:30 am indicated the resident had a "superficial stage 2 open area noted to coccyx." (A stage II pressure ulcer is a partial thickness skin loss and presents clinically as an abrasion, blister or shallow crater.) The Skin Wound Flow Sheet dated 11/24/10 indicated the resident had a Stage II pressure ulcer of the coccyx that measured 1 cm by 0.5 cm and was 1 millimeter deep. A portion of the form indicating "Nutrition: date dietician notified" was dated 11/24/10. PN dated 11/26/10 at 5:05 pm indicated the resident refused lunch and PN at 7:25 pm indicated the resident had an x-ray of the lungs that was positive for pneumonia. Multiple PN from 11/27/10 through 12/20/10 indicated the resident had a poor appetite or ate poorly. PN dated 12/29/10 indicated Staff 11 (RD) did a Nutrition and Weight Review of the resident. Staff 11 documented the resident's weight was 166.2 pounds, a decrease of 16.2 pounds or 8.8 percent in one month and a decrease of 20 pounds or 11.1 percent in three months. Staff 11 calculated the resident's average meal intake from the first through the tenth of December 2010 as 35 percent with an increase to 77 percent the week before her review. "Would expect Jan (January) wt (weight) to improve (with increased oral intake), however Res (resident) at nut'l (nutritional) risk." The plan was to offer either 2cal (nutritionally dense liquid supplement) or health shake in morning coffee. In an interview on 1/11/11 at 3:02 pm Staff 14 (RNCM) stated the resident had a significant change in condition. The resident had been "really sick" with pneumonia, a bladder infection and a fall with an injury. The resident had lost weight but had rebounded some. At 3:25 pm Staff 11 (RD) joined the interview and stated she charted on weights monthly and by the time she got around to looking at Resident 7, the resident's oral intake was improving. Staff 14 stated CNAs were responsible for weighing residents and a change of four pounds up or down meant the CNA automatically should reweigh the resident and report to the charge nurse. In an interview on 1/11/11 at 4:00 pm Staff 11 stated when residents developed pressure ulcers, the nurse would inform her and she would proceed to do a chart and nutrition review of the resident. Staff 11 stated she did not chart on Resident 7's skin condition in November and did not include the skin condition in the analysis of the resident's weight loss in the 12/29/10 note. In an interview on 1/11/11 at 4:20 pm Staff 14 (RNCM) stated Staff 11 was contacted for consults for residents with pressure ulcers. In an interview on 1/12/11 at 9:50 am Staff 14 and Staff 11 provided a copy of a nurse's "cheat sheet" (nurse's list of residents' conditions, things to do, note or chart on for that shift) dated 12/6/10 that indicated the resident weighed 175.2 pounds. Staff 14 and Staff 11 stated that the weight taken on 12/6/10 was a reweigh of the 12/1/10 weight. Review of the clinical record revealed the weight on the nurse's cheat sheet had not been documented in the resident's chart nor was it documented on the monthly weight log for all residents on the unit. The weight did not indicate if the resident wore his leg prosthesis. Observations on 1/12/11 at 7:59 am, 11:20 am, 12:00 pm and 2:45 pm revealed the resident in bed. In an interview on 1/12/11 at 2:45 pm Staff 15 (RN) stated the resident was still recovering from pneumonia and had good days and off days. The resident was having an off day and had not gotten out of bed. Staff 15 stated staff encouraged the resident to eat and drink a health shake with coffee. In an interview on 1/12/11 at 3:00 pm Staff 12 (Administrator) and Staff 13 (DNS) agreed Resident 7 was a compromised resident with new problems of pneumonia, a fall, a pressure ulcer and weight loss. The lack of ongoing assessments, interventions, monitoring of effectiveness of interventions and revising the interventions after continued weight loss was discussed. Review of a document provided by the facility on 1/13/11 at 10:50 am revealed the resident had "a bladder infection (for most of October), [MEDICAL CONDITION], had a change in cognition resulting in hospitalization , and eventually developed pneumonia (in November)." The resident "has lost small amounts of weight each month, but did not lose enough to be considered significant." The resident was "assessed by our dietitian in August, September, October and December, with recommended changes made in October and December." In an interview on 1/13/11 at 10:50 am Staff 12 (Administrator), Staff 13 (DNS), Staff 11 (RD) and Staff 14 (RNCM) acknowledged the resident ' s health was compromised by his many diagnoses, and from mid October through December 2010, he had the additional stressors of a urinary tract infection, a fall with injury, a pressure ulcer and pneumonia. Staff 11 stated she had not evaluated the resident's nutritional status or needs between 10/15/10 and 12/29/10 when the resident lost 19.2 pounds.