Every finding on record at Nehalem Valley Care Center

Based on observation, interview and record review it was determined the facility failed to ensure sufficient nursing staff were available to meet resident needs for 3 of 3 resident halls reviewed for staffing. This placed residents at risk for lack of timely assistance and unmet care needs. Findings include: On 9/3/26 the facility provided lists of residents who:-Required assistance with transfers: 10-Required a mechanical lift with transfers: 10- Required one or two-person assistance with bathing: 21-Required one or two-person assistance with toileting: 20-Required assistance with personal hygiene and dressing: 21These residents resided on all three facility halls. a. A review of public complaints received by the State Agency revealed the following:-On 6/11/26 a public complaint was received alleging resident call lights were not answered in a timely manner leaving residents to wait for a long time before receiving help and the facility staff were overworked as there were not enough staff.-On 7/8/26 a public complaint was received alleging the facility scheduled CNA staff using the state minimum staffing ratios and did not consider resident acuity to determine adequate staffing needs. b. Grievances from 8/1/26 through 8/31/26 indicated the following concerns:-8/14/26: medications were administered late and snacks were not provided.-8/25/26: medications were administered late.-8/26/26: medications were administered late.-8/31/26: consistently waited long periods of time for toileting which caused anxiety and urgency. Call light log times were attached to the grievance and revealed call light wait times of 25 to 55 minutes on multiple occasions in four days.c. Resident Council Meeting Minutes from 5/2026 through 7/2026 revealed the following:-5/2026: Residents stated call lights were left on and CNAs stated they would be right back but don't come back.-6/2026: Residents stated care plans were not followed.-7/2026: Residents stated CNAs got residents half ready, said they would be back but never came back, and residents experienced long call light wait times. d. A review of Resident Call Light Logs from 6/1/26 through 6/15/26 and from 8/1/26 through 9/1/26 revealed the following instances of residents waiting 30 minutes or longer for assistance. -6/1/26: Resident 3, 51 minutes.-6/1/26: Resident 24, 39 minutes.-6/2/26: Resident 3, 42 minutes.-6/2/26: Resident 8, 35 minutes.-6/4/26: Resident 3, 38 minutes.-6/6/26: Resident 8, 34 minutes.-6/8/26: Resident 3, 35 minutes, 40 minutes 11 seconds, and 40 minutes 42 seconds.-6/9/26: Resident 3, 46 minutes.-6/9/26: Resident 24, 32 minutes.-6/12/26: Resident 24, 41 minutes.-6/13/26: Resident 24, 36 minutes.-6/14/26: Resident 24, 30 minutes 37 seconds and 30 minutes 52 seconds.-6/14/26: Resident 3, 31 minutes and 45 minutes.-6/15/26: Resident 3, 31 minutes and 41 minutes.-8/9/26: Resident 25, 30 minutes, 32 minutes, and 34 minutes.-8/13/26: Resident 25, 39 minutes.-8/17/26: Resident 2, 53 minutes.-8/18/26: Resident 25, 34 minutes.-8/25/26: Resident 2, 34 minutes.-8/26/26: Resident 25, 39 minutes.-8/27/26: Resident 25, 1 hour 9 minutes.-8/31/26: Resident 25, 35 minutes.e. Observations and Interviews with residents and witnesses revealed the following concerns:-On 8/31/26 at 11:31 AM Resident 2 stated call light response times were typically around 30 minutes; however, on one occasion she/he had to wait over 45 minutes to use the bathroom, yelled for assistance three times and ultimately was incontinent in bed. Resident 2 stated she/he felt humiliated.-On 8/31/26 at 12:38 PM Resident 18 stated there was a slow response from staff to answer her/his call light and sometimes she/he had to yell for help to come.-On 8/31/26 at 12:50 PM Resident 8 stated evening time was difficult to have her/his call light answered by staff and frequently had to wait 30 minutes or longer for help to come.-On 9/2/26 at 1:18 PM during the Resident Council meeting, residents stated call light wait times ranged from 15 minutes to two hours. Some residents stated they took themselves to the bathroom and did not wait for help. Other residents stated they were incontinent from having to wait for assistance, which was embarrassing. -On 9/2/26 at 3:40 PM Witness 3 (Family Member) stated she observed staff rushing around on the evening shifts and the facility did not staff to resident acuity. -On 9/3/26 at 10:43 AM and at 10:48 AM the surveyor was in the hallway and Staff 12 (Agency CNA) asked if the surveyor saw another CNA recently as she needed assistance with a hoyer lift transfer and could not find help.-On 9/3/26 at 1:11 PM the surveyor was in the hallway and observed a resident yelling for help to get into bed. A CNA checked on this resident and stated to her/him, I have two other people I have to help right now, one to get back in bed and then get someone off the toilet too. The resident was observed to continue to yell for help.-On 9/3/26 at 2:31 PM Resident 25's call light was observed to be on for 40 minutes. On 9/3/26 at 2:35 PM Resident 25 stated the call light was on because the resident needed to use the bathroom, but the resident already went to the toilet by her/himself because she/he was unable to wait any longer. Resident 25 stated she/he was supposed to wait for help but got frustrated when help did not arrive timely.f. Interviews with staff revealed the following concerns:-On 9/2/26 at 9:53 AM and on 9/3/26 at 10:14 AM Staff 13 (Agency CNA) stated evening shift was the hardest; there was a continuous struggle for CNA staff to answer call lights in a timely manner and provide quality care for the residents. Staff 13 stated she typically did not receive a lunch break on the evening shift due to the acuity of the residents and not enough CNA staff to cover the call lights while on lunch break. Staff 13 stated she saw call light times over 45 minutes daily on day and evening shift.-On 9/2/26 at 12:37 PM and at 12:53 PM Staff 12 stated she could not get to resident call lights in a timely manner due to the acuity of the residents and it was hard to receive help from co-workers as they were busy answering call lights. Staff 12 stated she could not get to her scheduled breaks and lunch, tasks like resident weights were often missed and with newer agency staff working, who were unfamiliar with the residents, Staff 12 felt like she and the other CNAs were drowning. -On 9/2/26 at 1:17 PM Staff 10 (CNA) stated the number of CNAs was limited based on the census, and the facility needed another CNA as it was difficult to answer call lights and complete tasks. -On 9/2/26 at 3:19 PM Staff 7 (RN) stated she was the only nurse working the floor during her shift and it was intense and almost impossible at times to complete all the required tasks and treatments for the residents. Staff 7 stated there were several residents in the facility that required a lot of assistance and CNA staff tried their hardest to answer call lights in a timely manner, but it was hard.-On 9/3/26 at 1:00 PM Staff 14 (CNA) stated it was difficult to get to call lights during evening shift as the acuity was insane. Staff 14 stated when there were only three CNA staff working the evening shift, two were busy assisting a resident with a hoyer lift transfer which left one CNA to answer call lights and often Staff 14 did not receive scheduled breaks and lunch. Staff 14 stated some charge nurses assisted with call lights and transfers, but administrative staff did not assist and did not like to hear about staffing complaints from staff.On 9/4/26 at 9:43 AM Staff 4 (Human Resources Director) stated the facility followed the state minimum staffing ratios for CNA staffing. Staff 4 stated the facility had increased staffing for acuity when the facility had a Covid-19 outbreak but did not consider resident acuity recently. Staff 4 stated she was not aware of any complaints from residents or staff about staffing at the facility.On 9/4/26 at 8:56 AM and at 10:54 AM Staff 2 (DNS) stated she expected staff to answer resident call lights within five to seven minutes; she did not like to see call lights on for 20 minutes and she stated it was unacceptable for residents to wait longer than 30 minutes. Staff 2 stated she currently was working on a PIP (Performance Improvement Plan) for call light wait times. Staff 2 stated audits of call lights and staff education were completed monthly as part of the ongoing PIP.On 9/4/26 at 11:04 AM Staff 1 (Administrator) stated usually the state minimum ratios for CNA staffing met the needs of the residents, but the facility staff reviewed acuity at their morning meeting. Staff 1 stated if the facility had more than one admission, they staffed another nurse to assist. Staff 1 stated they reviewed grievances for staffing complaints, and the interdisciplinary team was hands on with the residents and conducted audits of call lights. Staff 1 stated he was not aware of any complaints about staffing from residents and was not aware of complaints from staff about acuity. Staff 1 provided no additional information.

Based on observation and interview it was determined the facility failed to ensure food storage and transportation devices were clean for 1 of 1 portable cooler and cart reviewed for sanitation. This placed residents at risk for food-related illness. Findings include:On 9/1/26 at 10:28 AM, a portable cooler containing ice was positioned on a cart in the entryway of the facility. A staff member pushed the cart past the nurses station and into a nearby closet. The exterior of the cooler had visible dark brown to black discoloration. The attached black mesh had slimy, moldy residue. The cart used to transport the cooler had visible dirt and black residue on it.On 9/1/26 at 10:33 AM, Staff 15 (CMA) stated the cooler stored on the cart contained ice, which was served to residents. On 9/1/26 at 10:41 AM, Staff 1 (Operations Manager) stated the black substance on the outside of the cooler was not acceptable and the cooler would be replaced immediately.

Based on interview and record review the facility failed to report allegations of neglect to the state survey agency within the required timeframe for 1 of 1 sampled resident (#24) reviewed for neglect. This placed residents at risk for continued neglect. Findings include:Resident 24 was admitted to the facility in 10/2025 with diagnoses including cirrhosis of the liver (a long-term scarring of the liver that prevents it from working properly) and type 2 diabetes mellitus (a long-term condition in which the body does not use insulin properly). Resident 24's 10/24/25 Care Plan indicated the resident was incontinent of bladder and was to be offered position changes while in bed approximately every two hours. The 7/17/26 Quarterly MDS revealed Resident 24 had a BIMS score of 15, indicating the resident was cognitively intact. The facility's FRI report, received by the State Survey Agency on 4/21/26 at 4:30 PM, revealed Resident 24 alleged neglect on 4/17/26 between 12:00 PM and 1:00 PM. Resident 24 reported to Staff 13 (CNA) she/he did not receive a brief change since approximately 5:30 AM and did not receive a position change during the day shift. The report indicated Staff 13 reported the allegation to Staff 2 (DNS) at 2:25 PM on 4/17/26.On 9/3/26 Staff 2 stated she was aware there was a timeframe for reporting allegations of neglect but was unable to recall the specific timeframe. Staff 2 acknowledged the facility did not complete the FRI report for alleged neglect within the mandated 24-hour timeframe.

Based on observation, interview and record review it was determined the facility failed to provide a splint device to prevent further decrease in ROM for 1 of 2 sampled residents (#14) reviewed for positioning. This placed residents at risk for decrease in range of motion. Findings include:Resident 14 admitted to the facility in 2014 with diagnoses including hemiplegia (one-sided weakness).The 4/4/26 Care Plan indicated to encourage Resident 14 with the use of supportive devices of splints/braces as recommended and as allowed.A 6/18/26 physician order indicated the use of a splint/brace on Resident 14's right hand while in the wheelchair as tolerated for contractures.On 8/31/26 at 1:28 PM Resident 14 was observed with no brace on her/his right hand. Resident 14 acknowledged she/he did not have the brace on. Resident 14 stated she/he did not know where the brace was, and it was up to the CNAs to know where the brace was and to place the brace on her/him.Continued observations on 9/1/26 at 11:31 AM and 9/2/26 at 10:49 AM were made of Resident 14 in her/his wheelchair in the dining room and participating in activities. No brace was observed in place on the resident's right hand.On 9/1/26 Staff 9 (CNA) stated Resident 14 used to wear a brace on her/his right hand and did now know why the resident no longer wore it. Staff 9 stated it was up to the resident to ask staff to place the brace on her/him. Staff 9 stated nursing staff did not verify with her if Resident 14 was wearing the brace.Review of the 8/2026 and 9/2026 TARs indicated the use of the splint/brace on Resident 14's right hand when in the wheelchair. Treatment was checked off as completed by Staff 7 (RN) including on 9/2/26 and by Staff 8 (RN) including on 9/1/26.On 9/1/26 at 12:47 PM Staff 8 stated Resident 14's use of a brace was on the TAR. Staff 8 stated a check mark on the TAR indicated if the brace was observed on the resident or not. Staff 8 stated she checked it off on the TAR if the resident had the brace on or should be wearing the brace. Staff 8 stated she was not sure if Resident 14 had the brace on and acknowledged she checked it off as completed on the TAR for 9/1/26.On 9/2/26 at 12:30 PM Staff 10 (CNA) stated she was not aware of a brace that Resident 14 was supposed to wear.On 9/2/26 at 1:51 PM Staff 7 stated Resident 14 was to wear a brace when she was in her/his wheelchair but rarely saw the resident in the wheelchair. Staff 7 stated if the resident was up in her/his wheelchair no one told her, so the brace could be placed. Staff 7 stated CNAs were to place the brace on Resident 14. Staff 7 further stated a check mark on the TAR meant she actually did something. Staff 7 acknowledged she checked it off on the TAR as completed for 9/2/26.On 9/3/26 at 10:08 AM Staff 1 (Administrator) and Staff 2 (DNS) stated staff were to offer to assist Resident 14 with wearing the brace when she/he was in the wheelchair. Both Staff 1 and Staff 2 acknowledged the findings with no further information provided.

Based on observation, interview and record review it was determined the facility failed to ensure staff followed contact precautions for 1 of 1 sampled resident (#4) reviewed for contact precautions. This placed residents at risk for exposure and contraction of infectious diseases. Findings include:According to the CDC website (https://www.cdc.gov/mrsa/hcp/infection-control/index.html andhttps://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html): CDC recommends the use of Contact Precautions for Methicillin-resistant Staphylococcus aureus (MRSA) colonized or infected patients. Use PPE appropriately including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. The facility's Transmission-Based Precautions Policy revised 8/2019 stated the following: When transmission-based precautions are implemented, the infection preventionist determines the appropriate notification on the room entrance door. The signage on the room entrance door informs staff of the type of CDC precautions and instructions for use of PPE.Resident 4 was admitted to the facility in 6/2026 with diagnoses including osteomyelitis (an infection of the bone usually caused by bacteria) and colostomy (a surgical opening in the abdomen that allows stool to leave the body). Resident 4's 6/10/26 Care Plan indicated contact precautions were to be implemented. Resident 4's 8/7/26 hospital discharge orders indicated the resident was placed on antibiotic treatment for MRSA in a wound. On 8/31/26 at 12:02 PM Staff 10 (CNA) was observed entering Resident 4's room to deliver a lunch tray without donning a gown and gloves. A CDC contact precautions sign was prominently displayed on the exterior of the room door and specifically instructed staff to don a gown and gloves prior to room entry. Staff 10 stated she did not don PPE to enter the resident's room, because she did not perform a high-contact task. Staff 10 acknowledged she did not don the appropriate PPE in accordance with contact precautions protocol when entering Resident 4's room. On 8/31/26 at 12:04 PM Staff 8 (RN) was observed in Resident 4's room wearing gloves but no gown to perform a blood sugar check. Staff 8 acknowledged the CDC contact precautions sign displayed on the resident's room door and stated she did not don both gown and gloves because she believed the level of care did not require it. Staff 8 acknowledged she did not don the appropriate PPE in accordance with contact precautions protocol.On 8/20/26 Staff 2 (DNS) stated staff were expected to use appropriate PPE when providing care for residents on contact precautions, regardless of the task, and acknowledged both gloves and gown should have been worn to deliver meal trays and perform blood sugar checks.

Based on interview and record review it was determined the facility failed to provide incontinent and repositioning assistance to a dependent resident in a timely manner for 1 of 3 sampled residents (#2) reviewed for ADLs. This placed residents at risk for unmet ADL needs. Findings include: Resident 2 admitted to the facility in 2025 with diagnoses including cancer and hospice. The 8/14/25 care plan indicated Resident 2 had mixed bladder incontinence and was dependent on staff for toileting needs. Interventions included for staff to provide check and change during repositioning and as needed. Staff were to check throughout the shift as required for incontinence. The care plan also indicated the resident had a pressure injury to the coccyx and staff were to provide turn/repositioning assistance at least every two hours, and more often as needed. A 9/5/25 facility investigation indicated it was reported Staff 8 (CNA) did not provide incontinent care or repositioning to Resident 2 during a span of seven hours during her shift. When Staff 8 was asked about the incident, Staff 8 indicated she had not changed the resident (time was 1:11 PM) during her shift and only checked [her/his] brief. When Staff 8 was asked if she provided repositioning during her shift, Staff 8 indicated no. Staff 8 was removed from the floor and placed on suspension. Based on staff interviews the facility determined Staff 8 was untruthful about the care she presumably provided during the first seven hours of her shift. Resident 2 was unable to provide any information due to her/his cognition. Resident 2 passed away on 9/6/25 and Staff 8 was terminated on 9/8/25. The investigation indicated Resident 2's care plan was updated and education was provided to staff regarding the importance of timely care. The facility Investigation included the following statements:Staff 4 (LPN Resident Care Manager) indicated at 12:40 PM Staff 6 (CNA) and Staff 5 (CNA) reported they were going to provide Resident 2 a bed bath. Staff 6 reported that Staff 8 made a comment alluding to the fact she had not changed Resident 2 and needed to check to make sure the resident's bedding was not wet before Staff 4 went into the room. Staff 4 indicated she and Staff 7 (HR) spoke with Staff 8 regarding what was reported. Staff 8 indicated she went into the resident's room around 7:15 AM and changed Resident 2's brief. Staff 8 was asked if the resident's brief was wet or not and she indicated, oh well I looked at [her/his] brief and it looked dry, so I left it. Staff 8 was asked if she repositioned the resident as she/he was supposed to be repositioned every two hours per the care plan. Staff 8 indicated she pulled on her/his [NAME] pad and grimaced so she did not turn the resident. Staff 8 acknowledged she did not change or reposition Resident 2 during the previous seven hours. Staff 5 indicated Staff 8 was aware Staff 4 was about to complete wound care on Resident 2. Staff 4 indicated at 1:00 PM Staff 8 quickly rushed to change Resident 2's brief and reposition her/him as she did not do so prior in the day. On 2/18/26 at 1:23 PM and 2/19/26 at 9:47 AM Staff 5 was attempted to be contacted for this investigation. No return call was received. On 2/18/26 at 1:27 PM Staff 3 (RN) stated she was the charge nurse on 9/5/25. Staff 3 stated it was almost the end of the shift when she became aware Staff 8 did not provide any care to Resident 2 the entire shift. Staff 3 asked other CNA staff to assist with completing cares for the resident. Staff 3 stated the staff indicated it was obvious Resident 2 had not been changed.On 2/18/26 at 2:34 PM Staff 4 stated when she was notified of Resident 2 not being assisted with incontinence care or repositioning, she questioned Staff 8. Staff 4 stated Staff 8 confirmed she did not change or reposition Resident 2 in seven hours. Staff 4 stated it was a standard of practice to complete cares including incontinence care and repositioning at least every two hours or according to the care plan. Staff 4 stated there was no negative outcome to Resident 2.On 2/19/26 at 9:51 AM Staff 6 stated Staff 8 wrote a note on the CNA message board indicating to not let Staff 4 go into Resident 2's room because she did not yet change the resident. Staff 6 stated she showed Staff 4 the message written by Staff 8. Staff 6 stated she made a comment to Staff 5 about not providing incontinent care to Resident 2. Staff 6 stated as a standard of care CNA staff were to check on residents and provide incontinence care and repositioning according to the care plan.On 2/19/26 at 10:14 AM Staff 8 stated she worked in the facility for approximately ten years. Staff 8 stated she asked other CNAs to assist her with Resident 2, but the other staff were busy, and she was unable to get help for seven hours. Staff 8 stated she did not change Resident 2's brief or provide incontinence care because she/he was dry for seven hours. Staff 8 further stated she also did not reposition the resident due to the resident's pain, but spoke with the staff about pain medication and was working on it when Staff 4 questioned her. Staff 8 acknowledged her statement to Staff 4 was correct and she did not provide incontinent care, change resident 2's brief or reposition her/him for seven hours.On 2/19/26 at 10:28 AM Staff 1 (Administrator) acknowledged the incident occurred on 9/5/25 and Resident 2 was not provided ADL assistance by Staff 8 for a prolonged period of time.On 9/10/25 the facility provided information to indicate an action plan to prevent further occurrences was completed, staff education and audits were completed related to providing ADL assistance timely. The deficient practice was determined to be past non-compliance, corrected on 9/5/25.

Based on interview and record review it was determined the facility failed to ensure sufficient nursing staff to meet resident care needs in a timely manner for 3 of 3 resident halls reviewed for staffing. This placed residents at risk for lack of timely assistance and unmet care needs. Findings include: Resident Council Notes indicated the following: -3/25/25: Showers were not being done. -4/30/25: CNAs were not getting residents to activities in a timely manner and meal service was late. A review of the facility's Direct Care Staff Daily Reports from 2/11/25 through 2/18/25 and 5/23/25 through 6/23/25 revealed the facility had insufficient CNA staff, according to state minimum staffing requirements, for one or more shifts on the following dates: -5/30/25 -6/2/25 -6/7/25 -6/9/25 -6/11/25 -6/19/25 Interviews with residents revealed the following concerns: -On 6/22/25 at 11:59 PM Resident 28 stated on 6/22/25 at 8:20 PM she/he pushed her/his call light and staff did not answer her/his light until 9:15 PM. -On 6/22/25 at 12:12 PM Resident 231 stated at night it took up to an hour for the call light to be answered. -On 6/22/25 at 12:34 PM Resident 21 stated she/he received late showers related to the facility's staffing issues. -On 6/22/25 at 12:54 PM Resident 15 stated call lights took up to 45 minutes to be answered and meals were delivered late. -On 6/22/25 at 2:40 PM Resident 9 stated it took up to an hour for staff to answer her/his call-light and at times she/he had to go into the hall to find help and often nobody was around. Interviews with staff revealed the following concerns: -On 6/23/25 at 9:30 AM Staff 25 (Agency CNA) stated the facility was short staffed and she was often rushed to complete her basic tasks which included resident showers and answering call lights. -On 6/24/25 at 9:40 AM Staff 16 (CNA) stated all shifts, both weekdays and weekends, had staffing issues. Staff 16 stated she was usually assigned to 8-12 residents which made it hard to answer call-lights and provide resident care timely. -On 6/24/25 at 10:55 AM Staff 24 (CNA) stated it was often hard to get basic tasks done timely and she often felt rushed. -On 6/24/25 at 11:25 AM Staff 15 (CNA) stated it was normal for staff to be rushed and not have enough time to provide showers. Staff 15 stated answering call lights timely was a constant challenge. -On 6/25/25 at 11:25 AM Staff 26 (Agency CNA) stated the facility was always short staffed and it was common for residents to wait over 20 minutes for call lights to be answered. On 6/26/25 at 11:27 AM Staff 1 (Administrator) acknowledged the staffing concerns related to timely assistance and confirmed the staffing shortages.

Based on interview and record review it was determined the facility failed to ensure RN coverage for eight consecutive hours per day for 3 of 43 days reviewed for staffing. This placed residents at risk for unassessed needs and lack of care. Findings include: Review of the Direct Care Staff Daily Reports from 2/11/25 through 2/18/25 and 5/23/25 through 6/23/25 indicated there was no RN coverage for eight consecutive hours on 2/13/25, 2/15/25, and 6/20/25. On 6/26/22 at 10:17 PM Staff 1 (Administrator) and Staff 3 (Regional Nurse) acknowledged the facility lacked RN coverage on the identified days.

Based on observation, interview and record review the facility failed to ensure proper hand hygiene during meals and failed to use proper PPE for contact-based precautions for 1 of 1 dining room and 2 of 2 of sampled residents (#s 8 and 12) reviewed for dining and infection control. This placed residents at risk for cross contamination. Findings include: According to the Centers for Disease Control and Prevention (CDC) website (https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html): · Use Contact Precautions for patients with known or suspected infections that present an increased risk for contact transmission. · Use personal protective equipment (PPE) appropriately including gloves and gown. · Wear a gown and gloves for all interactions that may involve contact with the patient or patient's environment. · Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. · If common use of equipment for multiple patients is unavoidable, clean and disinfect such equipment before use on another patient. The facility's Standard Precautions policy revised September 2022 stated the following: · Hand hygiene is performed with Alcohol-Based Hand Rub (ABHR) or soap and water: before and after contact with the resident. · Gloves are worn when in direct contact with a resident who is infected or colonized with organisms that are transmitted by direct contact. · Reusable equipment is not to be used for the care of more than one resident until it has been appropriately cleaned and reprocessed. 1. On 6/23/25 at 9:10 AM Staff 22 (CNA) entered Resident 12's room who was on Contact Precautions. Prior to entering the room, Staff 22 did not don PPE. Staff 22 exited the resident's room without performing hand hygiene. A CDC Contact Precautions sign was prominently displayed on the room door. On 6/23/25 at 9:20 AM Staff 22 returned to Resident 12's room with a cup of coffee and again entered without donning PPE. No hand hygiene was observed upon exiting the room. On 6/23/25 at 9:23 AM Staff 22 acknowledged the resident was on Contact Precautions, and that she/he did not don PPE upon entering the room or perform hand hygiene upon exiting. On 6/25/25 at 2:22 PM Staff 2 (DNS) and Staff 3 (Regional RN) acknowledged staff were to use appropriate PPE for residents on Contact Precautions. Staff 2 and Staff 3 indicated some staff were confused about the difference between Enhanced Barrier Precautions and Contact Precautions. 2. On 6/23/25 at 9:24 AM Staff 23 (LPN) entered Resident 8's room who was on Contact Precautions. Staff 23 did not don PPE and used a reusable blood pressure device to take a reading on the resident. Staff 23 exited the resident's room and placed the blood pressure device on top of a medication cart without putting down a barrier first. Staff 23 returned to the resident's room to administer medications and did not don PPE before she/he entered. A CDC Contact Precautions sign was prominently displayed on the room door. On 6/23/25 at 9:29 AM Staff 23 acknowledged the resident was on Contact Precautions and that she/he did not don PPE before entering the resident's room. Staff 23 acknowledged she did not clean the reusable blood pressure cuff after using it on the resident. On 6/25/25 at 2:22 PM Staff 2 (DNS) and Staff 3 (Regional RN) acknowledged staff were to use appropriate PPE for residents on Contact Precautions. Staff 2 and Staff 3 indicated some staff were confused about the difference between Enhanced Barrier Precautions and Contact Precautions. Based on observation, interview and record review it was determined the facility failed to ensure proper hand hygiene was implemented during meals and failed to use proper PPE for contact-based precautions for 1 of 1 dining room and 2 of 2 of sampled residents (#s 8 and 12) reviewed for dining and infection control. This placed residents at risk for cross contamination. Findings include: On 6/23/25 from 12:22 PM to 12:42 PM, Staff 22 was observed assisting residents to dine in the main dining room wearing the same gloves and without hand hygiene. Staff 22 was observed to: On 6/23/25 at 12:22 PM Staff 22 (CNA) was observed wearing gloves while serving a resident her/his meal tray in the main dining room. Staff 22 took off plastic wrap from resident's fruit bowl using gloves while touching every surface of the bowl including the fruit, this was repeated with at least three residents. On 6/23/25 at 12:39 PM Staff 22 (CNA) was observed handling his phone with the same gloves on, he then provided beverages to residents with the same gloves on. Staff 22 (CNA) then assisted a resident with getting food and uncovering the food with the same gloves. Staff 22 (CNA) poured more beverages for residents with the same gloves on. On 6/23/25 at 12:42 PM Staff 22 (CNA) pushed a resident closer to the table with the same gloves on, then poured more beverages and opened creamers to put into coffee with the same gloves on. Staff 22 then finally removed the soiled gloves, but did not perform hand hygiene. On 6/23/25 at 12:56 PM Staff 22 (CNA) stated he usually performed hand hygiene and glove changes only twice during meal service. When Staff 22 was asked about glove changes after touching his phone he noted he took the gloves off right away but should have performed hand hygiene. On 6/26/25 at 11:20 AM Staff 3 (Regional RN) stated staff were expected to perform hand hygiene in between helping residents in the dining room.

Based on observation, interview, and record review it was determined the facility failed to ensure pureed foods were prepared using methods that conserved nutritive value and flavor for 2 of 2 meals served to residents requiring pureed diets. This placed residents at risk for consuming unpalatable, nutritionally compromised food. Findings include: The facility's dining menu on 6/25/25 indicated the entrée for the lunch meal was roasted salmon. The facility's recipe for preparation of pureed food indicated to add hot cooking liquid and/or hot broth and food thickener to the roasted salmon while it was being processed to the puree texture. On 6/25/25 at 11:58 AM Staff 28 (Cook) was observed adding approximately 6-8 ounces of clear liquid to the salmon puree as it was being processed. Staff 28 stated he was preparing the salmon for one resident tray. Staff 28 confirmed the clear liquid was water. On 06/25/25 at 02:47 PM Staff 7 (Dietary Manager) stated water was not be used to prepare a pureed meal. Instead, a liquid with more nutritional value was to be added.

Based on observation and interview it was determined that the facility failed to ensure a dignified dining experience for 2 of 5 sample residents (#s 8 and 20) reviewed for dining. This placed residents at risk for decreased quality of life. Findings include: On 6/23/25 at 12:39 PM two meal trays were observed in the dining room with black plastic garbage bags over the trays. Each tray had the main meal served in a disposable clamshell container, the fruit was served in a disposable paper soup cup and there were plastic utensils for residents to utilize. Staff 22 (CNA) provided the meal trays to Residents 8 and 20 who were sitting at a communal table with three other residents. On 6/24/25 at 11:42 AM Staff 27 (Cook) stated the plastic covered trays with disposable containers and utensils were for people on precautions. On 6/25/25 at 03:17 PM Staff 3 (Regional Nurse) stated the plastic bag covering the tray and the use of the clamshell, disposable soup cups and utensils were not part of the protocol for residents on contact precautions. On 6/26/25 at 11:33 AM Resident 20 stated she/he preferred to have a normal tray if the disposable tray was not required for safety. On 6/26/25 at 11:37 AM Resident 8 stated she/he wanted to be like everyone else and have the same tray.

Based on observation, interview and record review it was determined the facility failed to ensure residents with diagnoses of dementia were free from unnecessary use of antipschotic medication for 1 of 5 sampled residents (#7) reviewed for medications. This placed residents at risk for adverse side effects of antipsychotic medication. Findings include: Resident 7 was admitted to the facility in 11/2023 with diagnoses including a stage four pressure ulcer and dementia. The following psychoactive medications were ordered on Resident 7's 6/2025 MAR: · quetiapine (an antipsychotic) · trazodone (an antidepressant) · venlafaxine (an antidepressant and antianxiety agent) · Namenda (an anti-Alzheimer ' s agent) · hydroxyzine (an antianxiety agent) On 5/15/24 Resident 7's Abnormal Involuntary Movement Scale (AIMS) total score was 7 indicating the symptoms/side effects of psychoactive medication use were present. On 2/4/25 the facility notified Resident 7's physician that she/he was experiencing symptoms including sweating, and involuntary smiling and grimacing. The physician ordered a reduction of Resident 7's venlafaxine dose, but did not address the resident's use of quetiapine. The 3/31/25 Psychotropic Committee Meeting Review form indicated no additional GDRs were ordered, and there was nothing to indicate Resident 7's use of antipsychotic medication despite the presenece of adverse side effects was assessed. On 4/24/25 Resident 7's AIMS total score was 9 indicating worsening symptoms/side effects of antipsychotic medication were present. A review of the resident's clinical record from 5/2025 through 6/2025 indicated staff were to monitor for calling out behaviors. The document indicated the behavior did not occur. On 6/22/25 at 12:28 PM, 6/24/25 at 12:48 PM, and 6/25/25 at 10:31 AM Resident 7 was observed in her/his room and interacted with staff with no negative behaviors or signs of distress noted. On 6/24/25 at 12:30 PM Staff 4 (LPN) stated Resident 7's calling out behaviors lessened in the past several months and she/he was able to express her/his wants and needs. On 6/24/25 at 2:56 PM Staff 29 (NA) stated Resident 7 was able to express her/his needs and did call out for things like a pillow or pain medication, but denied the resident exhibited signs of distress. On 6/25/25 at 3:15 PM Staff 6 (LPN Resident Care Manager) stated the facility did not assess Resident 7 for antipsychotic medication use, but rather they relied on the pharmacist reviews and recommendations. On 6/26/25 at 10:30 AM Staff 2 (DNS) and Staff 3 (Regional RN) acknowledged antipsychotic medication was prescribed to address Resident 7's calling out behaviors that were disturbing to those around her/him, but did not seem to cause distress to the resident. Staff 3 further acknowledged a comprehensive risk/benefit assessment should have been completed to determine if continued use of the medication was appropriate despite the presence of adverse side effects.

Based on interview and record review it was determined the facility failed to use the services of a registered nurse for at least eight consecutive hours a day for 41 out of 99 days reviewed for staffing. This placed residents at risk for unmet assessment needs. Findings include: 1. A review of the Direct Care Staff Daily Reports dated 8/1/24 through 11/7/24 revealed there were 41 days without eight consecutive hours of registered nurse coverage in a 24-hour period. The identified dates included: - 8/12/24, 8/19/24, 8/20/24, 8/21/24, 8/22/24, 8/23/24, 8/26/24, 8/27/24, 8/28/24. - 9/2/24, 9/3/24, 9/4/24, 9/5/24, 9/6/24, 9/8/24, 9/13/24, 9/14/24, 9/16/24, 9/17/24, 9/18/24, 9/25/24, 9/26/24, 9/27/24. - 10/7/24, 10/9/24, 10/10/24, 10/11/24, 10/15/24, 10/17/24, 10/18/24, 10/19/24, 10/20/24, 10/21/24, 10/25/24, 10/26/24, 10/27/24, 10/28/24, 10/31/24. - 11/1/24, 11/3/24, 11/5/24. On 10/29/24 at 10:03 AM Staff 1 (Administrator) confirmed the identified days were missing RN coverage. 2. Based on observation and interview it was determined the facility failed to designate a registered nurse to serve as the director of nursing on a full time basis for 1 of 1 facility reviewed for nurse staffing. This placed residents at risk for lack of nursing oversight. Findings include: During the survey conducted from 11/7/24 through 11/12/24, no DNS was observed in the facility. On 11/7/24 at 9:15 AM Staff 2 (CNA) stated it had been 2-3 months since the last DNS was in the building. Staff 2 stated everything felt more chaotic. On 11/7/24 at 9:25 AM Staff 3 (CNA) stated it had been 3-4 months since the last DNS was in the building. Staff 3 stated it was difficult to know who was in charge and staff didn't have a higher up to go to when there was a problem. During interviews with Staff 2 (CNA), Staff 3 (CNA), Staff 4 (CNA), Staff 5 (CNA), Staff 7 (LPN), Staff 8 (CNA), and Staff 9 (CNA) from 11/7/24 through 11/12/24 the staff reported the previous DNS left in October of 2024 and there was no full-time DNS in the facility since that time. The staff reported Staff 10 (RN Consultant) was designated as the DNS, but she did not work in the facility. Staff 8 stated it was rough not having a DNS. Staff 4 stated there was no one to go to for clinical questions. On 11/12/24 at 11:00 AM Staff 12 (Therapy Staff Member) stated the facility struggled with higher level recommendations for clinical needs and concerns. Staff 12 stated resident information was provided to the charge nurses, but it was clear they didn't always know what to do with the information. On 11/12/24 at 11:35 AM Staff 1 (Administrator) confirmed Staff 10 was working remotely as the DNS. Staff 1 confirmed there was no full time RN serving as Director of Nursing in the facility.

Based on observation, interview and record review it was determined the facility failed to maintain comfortable temperatures, clean resident personal care items and provide a clean resident room for 1 of 1 dining room and 1 of 2 sampled residents (#22) reviewed for environment. The placed residents at risk for unhome like conditions. Findings include: 1. Resident 22 admitted to the facility in 2023 with diagnoses including anxiety and muscle weakness. a. On 3/3/24 at 2:25 PM Witness 1 (Family) stated Resident 22 informed her that her/his floors were hardly cleaned and had stains from the previous week. On 3/3/24 at 2:50 PM Resident 22 was observed to be in bed. The resident's floor was observed to be dirty with large dried spills and several strands of floss throughout the room. Resident 22 stated the floor had not been cleaned for a long time. Review of the February 2024 Resident Council Minutes indicated multiple residents stated their rooms were not cleaned in two weeks. On 3/5/24 a housekeeping form entitled, Rooms Cleaned indicated Resident 22's room was not cleaned from 3/1/24 to 3/5/24. On 3/5/24 at 9:20 AM Staff 5 (Housekeeping) stated resident rooms were cleaned at a minimum of twice a week. Staff 5 stated cleaning of rooms included sweeping and mopping the floors. On 3/5/24 at 9:30 AM Staff 4 (Maintenance Manager) stated Resident 22's room was not cleaned since Thursday (2/29/24). Staff 4 acknowledged Resident 22's floors were dirty and needed to be cleaned. b. The 11/26/23 Care Plan indicated Resident 22 required assistance with grooming/hygiene and oral hygiene was to be encouraged. On 3/3/24 at 2:50 PM Resident 22 she/he preferred to brushed her/his teeth once a week due to difficulty getting to the sink. Resident 22 state she/he used the toothbrushes located in the basins sitting on the counter. Resident 22 was observed to have two toothbrush basins; each basin contained a toothbrush. The basins were both dirty with dried and crusty white toothpaste throughout. The toothbrushes were also observed to have dried and crusty toothpaste on the handles. On 3/5/24 at 9:35 AM Staff 6 (NA) stated Resident 22 brushed her/his teeth independently and only required assistance with getting to the sink. Staff 6 stated CNAs were responsible for cleaning and wiping down the toothbrushes and basins. Staff 6 acknowledged Resident 22's toothbrushes and basins were dirty and needed to be replaced. On 3/7/24 at 9:27 AM Staff 2 (DNS) acknowledged the identified findings for Resident 22. 2. Review of the February 2024 Resident Council Minutes indicated residents stated there was no heat in the dining room. On 3/5/24 at 10:22 AM during a Resident Council interview Resident 4, Resident 10 and Resident 23 stated the dining room was cold and residents were unable to enjoy their food during meals. The residents stated some of the residents wrapped themselves in blankets while they ate, which was not comfortable, or went back to their rooms early and were not able to finish their meals due to being too cold. The residents further stated the issue was brought up before and the residents were told, They were working on it. On 3/5/24 at 10:43 AM Staff 4 (Maintenance Director) was asked to take a temperature reading of the dining room. The dining room temperature indicated the outer wall (adjacent to the outside window) was 63.5 degrees, the inner wall was 65.5 degrees and the kitchen wall (middle) was 67 degrees. Staff 4 stated the dining room heating system broke in November of 2023 and they were waiting for a replacement part.

Based on observation, interview and record review it was determined the facility to provide sufficient nursing staff to ensure residents attained their highest practicable psychosocial well-being for 1 of 1 facility reviewed for staffing. This placed residents at risk for unmet needs. Findings include: On 3/5/24 a list was requested for residents who required the following care. The facility provided lists of residents who: -Required assistance with eating: 7. -Required two-person assistance with transfers: 5. -Required a mechanical lift with transfers: 8. -Required assistance with dressing: 25. -Required assistance with bathing: 26. -Required assistance with toileting: 18. -Residents who were incontinent: 17. -Residents with wandering behaviors: 3. -Residents with behavioral healthcare needs: 18. Review of Resident Council Meeting notes revealed the following staffing concerns: - November 2023: residents indicated there was not enough staff and call lights were too long. - December 2023: residents indicated they could not find staff on the floor especially at night. Call light wait times were, still too long. - January 2024: residents indicated meals arrived late. - Febuary 2024: residents indicated trays were not being picked up and showers were not done or were missed. Interviews with residents revealed the following concerns: - On 3/3/24 at 3:33 PM Resident 6 stated she/he had to wait up to 45 minutes for assistance after pushing the call light. -On 3/6/24 at 12:07 PM Resident 4 stated she/he had to wait for a half hour for the call light to be answered when she/he needed to use the bed pan. Resident 4 stated once she/he was on the bed pan it took staff an additional 30 minutes to take her/him off the bed pan. Resident 4 further stated she/he normally got up and went to the dining room for lunch, but because it took staff so long to assist her/him and she/he required a mechanical lift to get up for lunch, she/he did not go to the dining room today (3/6/24), and was, a little upset. Observations and interviews revealed the following concerns: -On 3/3/24 at 12:10 PM observations by the survey team revealed residents eating in the dining room. Staff 7 (RN) stated the facility was short staffed and Staff 13 (CMA) had to work as a CNA which left all resident medications and treatments for Staff 7 to administer. Staff 7 was observed to administer morning medications as late as 1:32 PM. Insulins due prior to lunch were observed to be administered to residents as late at 1:17 PM. Staff 7 was observed rushing around and was not able to administer medications and treatments timely. -On 3/6/24 at 11:12 AM Staff 19 (CNA) stated staffing was hit and miss and the facility would benefit from additional staff to help with nail care and showers. Staff 19 stated if the facility was short staffed he was not able to take breaks. Staff 19 stated care was rushed when they were short staffed and staff were not able to give person-centered care to residents. -On 3/6/24 at 11:59 AM Staff 11 (CNA) stated the acuity level of the residents was high and today she did not have time to get Resident 4 out of bed and down to the dining room, per the resident's preference. Staff 11 stated Resident 4 required a two-person sit to stand lift and staff did not have time to get the resident up because several residents were incontinent that morning. Staff 11 stated a lot of residents required two-person transfer assistance and assistance with eating; and some residents had behaviors that needed to be addressed. Staff 11 stated the facility was short-staffed about once a week. -On 3/6/24 at 2:27 PM Staff 10 (CNA) stated there were a lot of residents who required higher acuity including mechanical lifts. Staff 10 stated when the facility was short-staffed, staff were unable to complete nail care, showers, and restorative therapy. Staff 10 stated he was not able to take lunches and breaks when the facility was short-staffed. On 3/5/24 at 9:10 AM and on 3/7/24 at 6:26 AM Staff 18 (Staffing Coordinator) stated it was difficult to fill shifts due to lack of staff and agency staff availability and the facility was short-staffed about once a week. Staff 18 further stated the facility had high acuity residents who required incontinence care and two-person assistance due to resident behaviors. Staff 18 stated incontinence care and showers were not always completed when the facility was short staffed. Staff 18 acknowledged the facility was short staffed on 3/3/24 and there was only one RN completing treatments and medications for the entire facility.

Based on interview and record review it was determined the facility failed to use the services of a Registered Nurse for at least eight consecutive hours a day, seven days a week for 3 of 28 days reviewed for RN staffing coverage. This placed residents at risk for lack of RN oversight including resident assessment, care and services. Findings include: A review of the Direct Care Staff Daily Reports from 2/2/24 through 3/1/24 revealed the following days with no RN coverage: -2/10/24 -2/11/24 -3/1/24 On 3/5/24 at 9:10 AM Staff 18 (Staffing Coordinator) acknowledged the facility lacked RN coverage on the identified dates.

Based on observation, interview and record review it was determined the facility failed to maintain a medication error rate of less than 5 percent. There were six errors in 27 opportunities resulting in a 22 percent error rate. This placed residents at risk for adverse medication side effects. Findings include: 1. Resident 14 admitted to the facility in 2022 with diagnoses including stroke. The 2/23/24 physician order indicated Resident 14 was to receive Eliquis (anticoagulant medication) 2.5 mg once daily. The 3/2024 MARs indicated Eliquis was to be administered in the morning. On 3/3/24 at 12:34 PM Staff 7 (RN) was observed to administer the morning dose of Eliquis. Staff 7 acknowledged the medication was administered late as she was still passing morning medications. 2. Resident 2 admitted to the facility in 2015 with diagnoses including chronic pain and opioid dependence. The 2/4/24 physician order indicated Resident 2 was to receive methadone (opioid medication) twice daily for opioid dependence. The 3/2024 MARs indicated methadone was scheduled at 9:30 AM and 9:30 PM. On 3/3/24 at 12:52 PM Staff 7 (RN) was observed to administer the 9:30 AM dose of methadone 20 mg to Resident 2 (3 hours and 22 minutes after it was due). Staff 7 stated the previous dose of methadone was administered on the evening of 3/2/24 and acknowledged the methadone was administered late, as she was still passing morning medications. 3. Resident 13 admitted to the facility in 2019 with diagnoses including diabetes. The 2/27/24 physician order indicated Resident 13 was to receive Admelog insulin 16 units before meals. The manufacturer instructions for Admelog insulin pen indicated to prime the pen with two units of insulin prior to administering the insulin dose. On 3/3/24 at 1:03 PM Staff 7 (RN) was observed to administer 16 units of Admelog insulin to Resident 13. Staff 7 did not prime the insulin pen with the two units recommended by the manufacturer prior to administering the Admelog insulin. On 3/3/24 at 1:03 PM and 2:26 PM Staff 7 stated she was not aware insulin pens needed to be primed prior to administration and acknowledged the insulin was not administered before lunch as ordered. 4. Resident 7 admitted to the facility in 2014 with diagnoses including diabetes. The 2/27/24 physician order indicated Resident 7 was to receive Novolog insulin 15 units before meals. The manufacturer instructions for Novolog insulin pen indicated to prime the pen with two units of insulin prior to administering the insulin dose. On 3/3/24 at 1:11 PM Staff 7 (RN) was observed to administer 15 units of Novolog insulin to Resident 7. Staff 7 did not prime the insulin pen with the two units recommended by the manufacturer prior to administering the Novolog insulin. On 3/3/24 at 1:11 PM and 2:26 PM Staff 7 stated she was not aware insulin pens needed to be primed prior to administration and acknowledged the insulin was not administered before lunch as ordered. 5. Resident 16 admitted to the facility in 2023 with diagnoses including diabetes. The 2/27/24 physician order indicated Resident 16 was to receive 18 units of Humalog before meals. The 3/2024 MARs indicated Resident 16 was to receive 15 units of Humalog before meals. The start date was 2/6/24. The manufacturer instructions for Humalog insulin pen indicated to prime the pen with two units of insulin prior to administering the insulin dose. On 3/3/24 at 1:17 PM Staff 7 (RN) was observed to administer 15 units of Humalog insulin to Resident 16. Staff 7 did not prime the insulin pen with the two units recommended by the manufacturer prior to administering the Humalog insulin. On 3/3/24 at 1:17 PM and 2:26 PM Staff 7 stated she was not aware insulin pens needed to be primed prior to administration and acknowledged the insulin was not administered before lunch as ordered. On 3/4/24 at 12:33 PM Staff 3 (LPN Resident Care Manager) stated the correct order for Resident 16's Humalog insulin was 15 units before meals. Staff 3 provided a copy of the signed clarification of Humalog orders dated 3/4/24 and acknowledged the discrepancy. 6. Resident 11 admitted to the facility in 2023 with diagnoses including chronic obstructive pulmonary disease (COPD). The 2/27/24 physician orders indicated Resident 11 was to receive Advair Diskus one puff twice daily related to COPD and to rinse the mouth with water and spit after each inhalation. The 3/2023 MARs indicated Advair Diskus was due at 8:00 AM. On 3/3/24 at 1:32 PM Staff 7 (RN) was observed to give Resident 11 the Advair Diskus for administration (five hours and 32 minutes after it was due). Staff 7 did not ask Resident 11 to rinse her/his mouth and spit. On 3/3/24 at 1:32 PM and 2:26 PM Staff 7 stated she did not instruct Resident 11 to rinse and spit after the use of the Advair Diskus and acknowledged it was given late as she was still passing morning medications as of 1:32 PM.

Based on observation, interview, and record review it was determined the facility failed to ensure medications were secured and failed to ensure proper labeling of biologicals for 1 of 1 facility reviewed for safe medication storage. This placed residents at risk for receiving medications with reduced efficacy and unauthorized access to potentially harmful medications. Findings include: 1. On 3/3/24 at 12:10 PM Staff 7 (RN) was observed standing at a medication cart in the dining room preparing medications. There were several resident medication cards containing medication, and a cup that contained one white pill sitting on top of the cart. Staff 7 walked down the hall and left the medication cart unlocked and unattended with the medications sitting on top of the cart. There were several residents in the dining room. On 3/3/24 at 12:13 PM Staff 7 returned to the medication cart and acknowledged the top of the cart had resident medication cards, as well as a pill in a cup, resident medications were inside the cart and the cart was left unlocked and unattended. 2. On 3/3/24 at 1:03 PM an open and undated Admelog insulin pen was observed in the treatment cart. On 3/3/24 at 1:03 Staff 7 (RN) acknowledged the Admelog insulin pen was open and not labeled with an open date. 3. On 3/3/24 at 1:11 PM an open and undated Novolog Flex insulin pen and an open and undated Basalgar insulin pen were observed in the treatment cart. On 3/3/24 at 1:11 PM Staff 7 (RN) acknowledged the Novolog Flex insulin pen and the Basalgar insulin pen were open and not labeled with open dates.

Based on observation and interview it was determined the facility failed to ensure the dietary manager met the required qualifications for 1 of 1 kitchen reviewed for competent staffing. This placed residents at risk for unmet nutritional needs. Findings include: On 3/6/24 at 2:31 PM Staff 14 (Dietary Manager) was observed to direct staff while working in the kitchen. Staff 14 stated he worked in the kitchen for three years and was employed as the dietary manager for two years. Staff 14 stated he was not a certified dietary manager and did not take the classes to become a dietary manager. On 3/7/24 at 8:57 AM Staff 1 (Administrator) acknowledged Staff 14 did not meet the qualifications for the Dietary Manager position.

Based on observation and interview it was determined the facility failed to ensure foods and bulk ingredients were labeled and stored in a way to minimize food spoilage, failed to maintain a clean and sanitary environment for storage of kitchen equipment and cookware and failed to wear hair restraints in 1 of 1 kitchen reviewed for sanitary conditions. This placed residents at risk for foodborne illness. Findings include: 1. On [DATE] at 12:19 PM the walk-in refrigerator in the facility's kitchen was observed to contain the following improperly stored items: -two moldy bell peppers stored in a bag, undated. -a half gallon of unopened whip cream with a use by date of [DATE]. -slices of white cheese - three different bundles - no label and undated. On [DATE] at 12:30 PM in the prep area, the surveyor observed two opened 50-pound bags, one bag of bread crumbs was rolled down closed, the second bag of all-purpose flour was torn open and the flour open to the air under a prep table. In the prep area, a five-gallon bucket was positioned on the floor under an open drop ceiling tile with water dripping from the ceiling. The bucket contained a brownish liquid. The bucket was between the prep table with the open flour bag and bread crumbs and a storage rack which contained a deli slicer machine and two large clear plastic drink dispensers. Staff 15 (Dietary Aide) stated the water heater pipe burst about a week or two ago which caused the pipe to leak. On [DATE] at 12:40 PM Staff 15 acknowledged the expired and undated items in the refrigerator and stated he was unsure how the items in the refrigerator were missed. Staff 15 stated he was unaware they could not store the bread crumbs and flour in bags and had to be in covered containers. On [DATE] at 2:31 PM Staff 14 (Dietary Manager) acknowledged the items found in the refrigerator were not disposed of timely. Staff 14 acknowledged the flour and bread crumbs should be in covered containers. 2. On [DATE] at 12:40 PM the surveyor requested Staff 15 (Dietary Aide) test the bleach buckets for correct chemical solution concentration. Staff 15 stated he had not tested the bleach buckets all day and was unable to find the test strips to test the chemical solution concentration. Staff 15 and Staff 16 (Cook/Dietary Aide) searched for the test strips and stated they were out of test strips for the past couple of days. On [DATE] at 2:31 PM Staff 14 (Dietary Manager) stated he expected staff to test the bleach buckets at least once before each meal and when the bleach needed to be replaced. 3. On [DATE] at 12:19 PM Staff 15 (Dietary Aide) was observed without a hairnet and beard covering while assisting with tray line. Staff 16 (Cook/Dietary Aide) was observed plating the food and was not wearing a beard covering. On [DATE] at 11:57 AM Staff 17 (Dietary Aide) was observed during tray line to use her gloved hands to rearrange her clothing, adjust her eyeglasses then touched several food items on a tray. On [DATE] at 11:58 AM Staff 17 the surveyor intervened and Staff 17 acknowledged she touched her clothing and glasses and should have completed hand hygiene before touching the food tray. On [DATE] at 10:48 AM Staff 14 (Dietary Manager) was observed not wearing a beard covering while preparing sides for the lunch meal. The surveyor requested Staff 14 test the bleach buckets. Staff 14 used gloved hands to the bleach bucket, and then proceeded to pour barbecue sauce into individual containers. On [DATE] at 10:50 AM the surveyor intervened and Staff 14 acknowledged he should have removed his gloves, washed his hands and put on a new pair of gloves before pouring the barbecue sauce. On [DATE] at 2:31 PM Staff 14 stated he expected staff to always follow hand hygiene and to wear hairnets and beard coverings when in the kitchen.

Based on interview and record review it was determined the facility failed to address residents' change of condition timely and provide medication as ordered for 4 of 6 sampled residents (#s 3, 6, 7 and 10) reviewed for a change in condition and pain medication. This placed residents at risk for a decline and increased pain and resulted in hospitalization for Resident 7. Findings include: 1. Resident 7 was admitted to the facility in 2015 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] -11/2/21 Resident 7 had jaundice and elevated liver enzymes. An ultrasound and abdominal CT scan were ordered and the resident declined to go the emergency department. -11/5/21 Resident 7 was seen for a follow up for jaundice. The ultrasound and CT scan could not be done until the end of the month and a message was left to see if she/he could get in sooner. The resident declined to go the emergency room and her/his abdomen was distended but soft and no pain was noted. -11/12/21 Radiology called after Resident 7's CT today [11/12/21] and reported multiple gallstones and recommended a GI [gastrointestinal] consult and EGD [upper endoscopy]. The GI provider was contacted and indicated they were unable to do outpatient ERCPs [a procedure to diagnose and treat problems in the liver, gallbladder, bile ducts and pancreas]. Resident 7 initially declined to go to the emergency department, but then decided she/he would like an urgent evaluation but only if she/he did not have to wait a long time and could have the procedure soon. The emergency department was contacted and indicated they do not do ERCPs on the coastand could not facilitate a transfer but suggested the resident go to the Portland emergency department by private car. The social worker was not able to arrange for transportation and the resident's family was unable to take her/him as the resident would have a very difficult time in the car and could not stand or transfer independently, was dependent on oxygen and was anxious about her/his breathing. A plan was made to re-evaluate next week and if she/he developed worsening liver function and/or [CONDITION(S)] staff were to call 911. -11/16/21 discussed with the resident in order to have the procedure done to remove the gallstone blockage she/he needed to go to Portland by private car and insurance did not pay for medical transport that far away. The resident did not feel she/he was able to go by car and she/he really [wasn't] feeling bad lately so [she/he] did not want to pursue this. -12/2/21 Resident 7 was seen for follow up after an emergency department visit on 12/1/21 for jaundice secondary to obstruction. The resident was sent to the hospital where it was recommended semi-urgently send to a clinic for cholelithiasis [gallstones] and she/he was scheduled to see a physician on 12/7/21 regarding a consult to see if she/he could have an ERCP. Today [12/2/21] the resident reported feeling weak and complained of abdominal pain. At around 1:00 PM she/he vomited bile and was sent to the emergency department. Advocated for admission and a hospital to hospital transfer as this would be safer for the resident. On 12/14/21 at 7:35 PM Staff 13 (RN) stated Resident 7 started turning yellow and had a blockage and needed surgery. Staff 13 stated the facility was working to get [her/him] in for the surgery [she/he] needed. Staff 13 further stated staff were directed to send the resident to the emergency department if there were any changes and she/he was sent out after she/he started vomiting. On 12/21/21 at 9:19 AM Witness 12 (Family Member) stated in 10/2021 Resident 7 saw a physician regarding a feeding tube and it was noted the resident had jaundice. Witness 12 stated the resident had a blockage and she was told the resident needed to go to have a procedure done by private car. She stated two weeks later she visited the resident and she/he was so yellow and the facility continued to do testing and the resident was sent back to the hospital because her/his stomach was distended and she/he had pain. Witness 12 stated the resident was hospitalized and had been in and out of ICU. Witness 12 stated the facility failed to make the appointment for the surgery timely and did not coordinate transportation for the procedure. On 12/22/21 at 1:09 PM Staff 2 (DNS) acknowledged Resident 7 was noted to have jaundice on 11/2/21 and on 11/12/21 it was recommended the resident have a surgical procedure. Staff 2 acknowledged the facility failed to coordinate care for the ERCP appointment timely. The resident was sent to the hospital on 12/1/21 and returned to the facility. On 12/2/21 the resident had abdominal pain and vomited during lunch and was sent to the emergency room for her/his worsening condition. 2. Resident 10 was admitted to the facility in 2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Progress notes indicated the following for Resident 10: -6/1/21 at 6:39 PM the resident was complaining of lower back pain, vomited and had a temperature of 99F. The physician was notified and new orders were received. -6/2/21 at 7:50 AM the resident was not feeling well yesterday [6/1/21] and she/he was worse and new orders were sent. An indwelling catheter was suggested to measure urine output since she/he was voiding scant amounts and now had back pain. -6/2/21 at 8:25 AM the resident had altered mental status and was unable to hold utensil and difficult to wake. Will notify provider. -6/2/21 at 9:01 AM orders for a shot of [MEDICATION(S)] (antibiotic), blood work and UA. The resident was given a shot of [MEDICATION(S)] 1 gram to right buttock, tolerated well. -6/2/21 at 6:46 PM Resident was not coherent this shift. A Foley (catheter) was placed without difficulty, resident complained of pain during procedure. Dark tea colored urine, UA was sent along with labs. She/he was more interactive and ate dinner with assistance. The physician orders indicated the following: -undated and untimed order 6/ [date was incomplete] to push fluids, draw CBC and BMP, monitor for changes. -6/4/21 [MEDICATION(S)] (antibiotic) 500 mg every eight hours for five days for [CONDITION(S)]. -no physician order was located for the [MEDICATION(S)] injection that was administered on 6/1/21. The lab results indicated labs were drawn on 6/2/21 and the results were received on 6/3/21. The resident had elevated white blood cells of 24.7 (normal range is 3.4 - 10.8). On 12/17/21 at 12:56 PM Staff 2 (DNS) acknowledged on 6/1/21 Resident 10 had an elevated temperature, back pain and vomiting. Staff 2 acknowledged there was no physician order located in the resident's electronic health record for [MEDICATION(S)] that was administered on 6/1/21. Staff 2 acknowledged on 6/2/21 the resident had altered mental status and was difficult to wake. Staff 2 further acknowledged the undated and untimed physician orders indicated labs were to be completed for the resident and labs were not completed until 6/2/21 and lab results were not received until 6/3/21. Staff 2 further acknowledged the resident had altered mental status on 6/2/21. Staff 2 acknowledged the [MEDICATION(S)] order did not start until 6/5/21. 3. Resident 6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A 4/20/21 Physician Order indicated Resident 6 was to receive a calcium alginate dressing change to the right hip once daily. The 4/2021 TAR indicated the treatments did not start until 4/23/21 and Resident 6 did not receive dressing changes on 4/26/21 and 4/30/21. Progress notes indicated the following: -4/22/21 6:26 PM Resident 6 had an open area near her/his incision, draining thick green purulent drainage with odor, culture obtained and redressed. -4/23/21 5:49 PM Resident 6's right hip continued to have thick green drainage. -4/26/21 1:20 PM Resident 6 had a wound culture to the right hip and indicated staph aureus [infection]. The provider was updated. A 4/26/21 Physician Order indicated Resident 6 was to receive [MEDICATION(S)] (antibiotic) four times daily. The 4/2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/17/21 at 12:58 PM Staff 2 (DNS) acknowledged Resident 6 had green drainage and a wound culture on 4/22/21, physician orders for [MEDICATION(S)] were received on 4/26/21 and did not start until noon on 4/29/21. Staff 2 acknowledged orders for daily treatments were received on 4/20/21, treatments did not start until 4/23/21 and the resident did not receive wound care on 4/26/21 and 4/30/21. Staff 2 acknowledged there was no indication the wound was measured. 4. Resident 3 admitted to the facility in 2010 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 11/11/21 Annual MDS indicated Resident 3 was cognitively intact and the resident had occasional 3/10 pain on the pain scale during the lookback period. On 12/13/21 at 2:39 PM Witness 1 (Family Member) stated there was an incident when the facility ran out Resident 3's pain patch medication. An 8/13/21 Physician Order indicated Resident 3 was to receive a 72-hour [MEDICATION(S)] (pain medication) patch once a day every three days. The 9/2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] *The [MEDICATION(S)] patch was administered on 9/10/21. *The 9/13/21 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . *The [MEDICATION(S)] patch was last observed on Resident 3 on 9/14/21. *The 9/16/21 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] The 9/2021 Narcotic Log indicated Resident 3's [MEDICATION(S)] patch was last placed on 9/10/21 and another was not placed until 9/18/21. The 9/15/21 Emergency Kit Sign-Out Record indicated a [MEDICATION(S)] patch was pulled for Resident 3 at 11:45 PM. There was no pain level monitoring indicated in the medical record for Resident 3. On 12/13/21 at 1:20 PM Resident 3 stated there was a time she/he was without her/his pain patch but stated there was no outcome she/he could recall. On 12/15/21 at 11:45 AM Staff 2 (DNS) verified Resident 3 was without her/his [MEDICATION(S)] patch from 9/13/21 until 9/15/21 and there was no evidence as to why the [MEDICATION(S)] patch order was not filled or pulled from the emergency kit prior to 9/15/21. Staff 2 further verified there was no pain monitoring in the medical record for Resident 3.

A. Based on observation, interview and record review it was determined the facility failed to report a resident's potential injury and new onset of pain to the physician in a timely manner for 1 of 1 sampled residents (#6) reviewed for fractures. This resulted in a delay in Resident 6 had a delay in treatment and pain management when she/he sustained a fracture. Findings include: The Facility's Policy for Changes In Resident Condition included: "it will be the policy...to notify physician of any resident change in condition such as...Resident's deteriorating in health, mental or psychosocial status...A need to alert treatment significantly..." The Acute Condition Changes-Clinical Protocol included: "...the Nurse shall assess and document/report the following baseline information...Current level of pain, and any recent changes in pain level...Before contacting a physician about someone with an acute change of condition the nursing staff will make detailed observations and collect pertinent information to report to the physician." The Change In A Resident's Condition or Status included: "The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been...an accident or incident involving the resident..." Resident 6 was admitted to the facility in 2012 with [DIAGNOSES REDACTED]. The 3/19/15 In Room Plan Of Care noted Resident 6 required two person Hoyer lift transfers and used the beside commode for toileting. Resident 6 had physician orders [REDACTED]. The 3/28/15 7:30 am Progress Note documented Resident 6 was observed with no complaints of left arm pain or left arm difficulty. The resident was visualized in the shower chair by Staff 16, LPN between 6:00 am and 7:30 am with no left arm pain/guarding observed. The 3/28/15 7:52 pm Progress Note only noted Resident 6 was "quite painful" after a shower and toileting, but did not specifically document left arm/shoulder pain. The 3/28/15 7:52 pm Progress Note indicated Staff 3, LPN noted redness and irritation inside the left elbow, which was reported to the physician. The 3/28/15 Fax to the physician only noted that redness and irritation was found to the inside of the left elbow. There was no mention of left arm/shoulder pain. The 3/29/15 3:26 am Progress Note disclosed Resident 6 complained of left arm and shoulder pain. The 3/30/15 9:42 am Progress Note revealed the resident cried or yelled out if anyone attempted to move the resident's arm. The left upper arm from just above the elbow to the shoulder was swollen, warm to touch and possible bruising was noted. An x-ray was obtained. The 3/30/15 x-ray report revealed Resident 6 sustained a fractured arm with displacement. The 3/2015 MAR indicated [REDACTED]. The 3/30/15 After Visit Summary included new physician orders [REDACTED]. The 4/2015 MAR indicated [REDACTED]. The facility's investigation disclosed on 3/301/5 Staff 6, DNS received report from Staff 1, RNCM Resident 6 was complaining of left shoulder pain and the resident was sent out for x-rays for a possible fracture. It was learned that on 3/28/15 Staff 23, CNA reported she and Staff 3, LPN transferred the resident to the toilet with the Hoyer lift at around 10:00 am to 10:20 am. Staff 3, LPN stated she was providing other resident's care at that time, denied assisting the resident to the toilet and stated the resident was only careplanned for the use of the bedside commode. Per Staff 23, Resident 6 complained of discomfort during the transfer and wanted off the toilet within two seconds. Staff 23 reported she walked out of the bathroom into the resident's room meaning to grab the Hoyer but accidentally grabbed the sit to stand machine. Staff 7, CNA heard Resident 6 yelling and screaming very loudly at around 10:30 am. She checked on the resident and observed her/him sitting on the toilet with the sit to stand sling in place and the sit to stand machine in front of the resident. Staff 23 reported to Staff 7 the resident's arm flung backwards in the "Hoyer" sling, "I think I may have hurt (Resident 6)." Staff 23 removed the sit to stand sling and asked Staff 7 to get the Hoyer sling and machine. The Hoyer machine was down the hall. Staff 7 and 23 transferred Resident 6 with the Hoyer lift from the toilet to bed and she/he stated "My arm hurts!" The facility determined the care plan was not followed regarding the type of machine used in the transfer, only one staff transferred the resident as opposed to two and the resident was placed on the toilet instead of the bedside commode. The characteristics of the resident's bruising coincided with the sit to stand sling placement and abrupt leaning into the sling itself and the fracture most likely occurred during the transfer with a sit to stand machine. There was no documented evidence in the clinical record of the investigation being initiated until 3/30/15, two days after the incident occurred. On 4/15/15 at 3:11 pm and 4/17/15 at 7:45 am Resident 6 was observed sitting in a wheelchair with her/his left arm in a sling. The resident refused to be interviewed. In interview on 4/17/15 at 9:31 am Staff 23, CNA stated Resident 6 was careplanned for either the bedside commode or bedpan for toileting but insisted on using the toilet. She and Staff 3, LPN transferred the resident with the Hoyer lift and she removed the sling. The resident's arm was already hurting from a previous fracture and Staff 23 thought she may have put the resident's arm too far back in the Hoyer sling. The resident was screaming to get off the toilet and "was really abusing" her. Staff 23 stated she grabbed the sit to stand machine in error but did not use it. Staff 7 and 23 transferred the resident from the toilet. The resident was in more pain than usual, complaining of shoulder pain prior to a shower earlier that morning and while on the toilet, "whining and crying." Staff 23 stated she did not inform the charge nurse of the resident's pain until after the resident was transferred back to bed from the toilet. When asked what she would have done differently, Staff 23 stated she would have made sure the resident's arms were where they should be. Staff 23 described Resident 6 as "mentally wearing her out" because of her/his behaviors and stated it was a "hard morning for both of us." In interview on 4/16/15 at 10:26 am Staff 7, CNA stated on 3/28/15 at around 10:30 am she was charting and could hear Resident 6 screaming. She went to check on the resident and observed her/him on the toilet. Staff 23 was with the resident, the sit to stand sling was around the resident and the sit to stand machine was in front of the resident but not hooked up to the sling. Staff 7 stated Resident 6 required a Hoyer lift for transfers. Staff 23 asked her to get the Hoyer sling from the resident's drawer. Staff 23 removed the sit to stand sling and placed the Hoyer sling on the resident and she/he was transferred off the toilet. Per Staff 7, with the resident present, Staff 23 stated she was going to lose her job, she "f***** up." While the resident was still on the toilet, Staff 23 reported a possibly injury to the resident and demonstrated the resident's left arm went backwards during the transfer onto the toilet with the sit to stand machine. Staff 7 and Staff 23 transferred the resident off of the toilet. Afterwards Staff 23 and Staff 11, CMA informed the nurse but Staff 7 did not know what was reported. Staff 7 stated she did not report Resident 6's possible injury to the charge nurse as she thought Staff 23 had already done so. She learned the next day (3/29/15) what was told to the charge nurse was not accurate, however, she did not report the incident until 3/30/15. Per Staff 7 the left arm was the resident's bad arm to begin with, but the severity of her/his pain was new. When asked what she would have done differently, Staff 7 stated she would have gone to the nurse right away. Interviews on 4/16/15 at 9:31 am, 10:55 am and 2:15 pm and on 4/17/15 at 12:36 pm Staff 3, LPN (Day Shift Charge Nurse) stated on 3/28/15 Staff 23, CNA and Staff 11, CMA informed her Resident 6 was crying and hurting. Staff 23 informed Staff 3 she placed the resident in bed after toileting. Staff 23 was afraid there was something wrong with the resident's shoulder and the resident was really hurting. Staff 3 did as much of an assessment as the resident allowed, the resident screamed in pain when she touched the resident's shoulder, but did the same when touching other areas on the resident's body. The left shoulder pain was different for the resident as she/he previously only reported pain with the right shoulder. During the assessment the resident was very painful, which increased when she opened the resident's arm and she observed a red spot on the resident's left inner elbow. The resident was more agitated and was in more pain than usual, which she thought was due to the red spot she had observed and with having to straighten the resident's arm. There was no other redness or swelling and when the resident was repositioned in bed she/he did not make a sound. On 3/29/15 she assessed the resident's arm again and she still did not see anything. However, the resident complained again of left shoulder pain. Staff 3 stated she did not recall Staff 20, RN informing her Resident 6 requested an x-ray. Staff 3 stated no staff informed her that an incident occurred that might have caused an injury and if they had she would have handled it differently and would have sent the resident out for an evaluation. In interview on 4/16/15 at 11:49 am Staff 11, CMA stated on 3/28/15 Staff 23, CNA reported Resident 6 voiced complaints of arm pain and Staff 23 checked to see if the resident could have some pain medication. The resident was already in bed and at that time all the resident had for pain management was Tylenol. The medication did not help her and she did not see any difference in treating the resident's pain. The resident always reported shoulder pain, however, this time the resident was literally screaming, which was different, it was a more intense complaint of pain. Staff 23 did not report an incident and she did not hear what Staff 23 reported to Staff 3, LPN. The resident previously had an order for [REDACTED]. In interview on 4/16/15 at 2:22 pm, Staff 14, CNA stated when she received report on 3/28/15, Staff 23, CNA told her Resident 6's arm got twisted up with her/his arm behind the back during toileting. Staff 23 initially stated she used the sit to stand machine for the transfer then later stated it was the Hoyer lift. Staff 14 stated she did not know what Staff 23 reported to the nurse but she informed the day charge nurse (Staff 3) what she was told about the resident's arm being twisted around. Staff 14 stated the resident's pain was different than normal, was lot worse and the resident screamed more than normal. In interviews on 4/16/15 at 10:00 am and 12:00 pm, Staff 20, RN (Night Shift Charge Nurse) stated on 3/28/15 the resident complained her/his arm hurt and was given Tylenol. She directed staff to be careful of the resident's arm when they were rolling her/him and told them not to roll the resident on the left side and to protect it. Staff 20 stated a staff member (could not recall who) reported the resident's arm went backwards during a transfer and somehow got twisted behind the resident's back in the sling and there was some type of injury to the resident's arm. The arm did not look swollen and there was no bruising and Staff 20 thought the resident pulled some muscles. The resident usually complained of pain with the right shoulder but this time it was on the left. Staff 20 stated she thought the resident's pain was reported to the physician. The resident requested an x-ray on Sunday and she told the resident the clinic was closed and she/he would have to wait until Monday when the clinic was opened. Per Staff 20, the resident's request for an x-ray most likely occurred during the 3/28/15 - 3/29/15 night shift at 2:00 am, which she reported to either Staff 3, LPN or Staff 4, RN. In interview on 4/16/15 at 1:26 pm Staff 21, CNA stated she worked with Resident 6 on 3/29/15. At 6:00 am the resident was screaming, stating "I can't stand this pain anymore. I need to get up." Something was definitely different with the resident and not right about the arm. As she was trying to find out what happened, a former CNA told her that on 3/28/15 something happened to the resident's arm during a transfer for toileting. Staff 21 stated she reported the resident's pain to Staff 20, RN and asked for the resident to be checked. When Staff 20 told her there was no bruising, she told Staff 20 there was something definitely wrong. Staff 21 stated the resident's arm normally was very stiff from contracture and she could barely lift it while dressing the resident. On 3/29/15 the arm was a little more pliable while dressing the resident, which she reported to Staff 20. Staff 21 stated she also reported her concerns to Staff 3, LPN and kept reporting the resident was in a lot of pain and she knew something was wrong. One of the nurses (could not recall who) stated to her the shoulder might have come out of the socket and went back in place and they would play it out and see how it goes. In interviews on 4/17/15 at 10:12 am and 4/20/15 at 8:18 am Staff 4, RN stated on 3/30/15 she was told the resident had arm pain and may have gotten the arm caught during a transfer. Staff 4 stated Staff 20, RN did not inform her the resident requested an x-ray, only that the resident's arm was hurt and requested she check the resident's shoulder. Staff 4 assessed the arm and noted bruising and swelling from the shoulder area and down the arm. She called the physician and sent the resident out for an x-ray. In interviews on 4/14/15 at 8:05 am and 4/17/15 at 8:04 am Staff 1, RNCM stated Staff 23, CNA used the sit to stand to transfer Resident 6 with toileting. Staff 23 should have either used the Hoyer lift or provided incontinence care. The bruising was from the sit to stand sling, which was observed in place by another staff member. The facility attributed the fracture to the use of the sit to stand. Staff 1 stated if there was a new onset of pain, something different for the resident the physician should have been notified. Per Staff 1 the physician should have been notified of the resident's pain on 3/28/15. In interview on 4/17/15 at 10:47 am with Staff 6, DNS and Staff 17, Administrator, they acknowledged the incident was not reported timely. Staff 6 reviewed the 3/28/15 Fax to the physician and stated the physician was not notified about the resident's pain, stating it was "black and white", the physician should have been notified on 3/28/15. B. Based on interview and record review it was determined the facility failed to follow physician orders [REDACTED].# 23) reviewed for comfort care. This placed residents at risk for unmet needs. Findings include; Resident 23 was admitted to the facility in 2011 with a [DIAGNOSES REDACTED]. On 2/6/15 the physician signed comfort care orders which included to discontinue routine medications. The resident's February 2015 MARs indicated the facility administered four routine medications to the resident without physician orders [REDACTED]. [MEDICATION NAME] (an antianxiety medication) 0.25 mg daily at 9:00 am and 0.5 mg every day at 5:00 pm, [MEDICATION NAME] (an anti-Alzheimer's medication) 10 mg every evening, and [MEDICATION NAME] ( an antipsychotic medication) 25 mg twice daily. On 2/16/15 the physician signed new orders for the [MEDICATION NAME] and [MEDICATION NAME] but not for the [MEDICATION NAME] or [MEDICATION NAME]. The March 2015 MAR indicated [REDACTED]. On 4/17/15 at 3:00 pm Staff 6 (DNS) and Staff 1 (RNCM) verified the physician discontinued the medications on 2/6/15 and the facility continued to administer the medications without orders until 3/19/15.

Based on observation, interview and record review it was determined the facility failed to implement their written policies to ensure the resident was free from neglect of care during a transfer for 1 of 1 sampled residents (#6) reviewed for fractures. Resident 6 sustained a fracture. Findings include: The facility's Abuse Policy and Procedures defined abuse, including "Failure to provide basic care to resident resulting in physical harm, unreasonable discomfort or loss of dignity." Their Abuse Prohibition Policy included: "Purpose: To assure that all residents receive professional, humane, and [MEDICATION NAME] services that include a safe and secure environment. To facilitate that environment, this facility will identify and investigate all reported or alleged incidents of physical, emotional, verbal, sexual, and psychological abuse or neglect...Neglect means failure to provide goods and services necessary to avoid physical harm..." Resident 6 was admitted to the facility in 2012 with [DIAGNOSES REDACTED]. In Room Plan Of Care dated 3/19/15 Resident 6 required two person Hoyer lift transfers and used the beside commode for toileting. On 3/28/15 at 7:52 pm Progress Note indicated Resident 6 was "quite painful" after a shower and toileting, but did not specifically document left arm/shoulder pain. On 3/29/15 at 3:26 am Progress Note indicated Resident 6 complained of left arm and shoulder pain. On 3/30/15 at 9:42 am Progress Note revealed the resident cried or yelled out if anyone attempted to move the resident's arm. The resident's left upper arm from just above the elbow to the shoulder was swollen, warm to touch and possible bruising was noted. An x-ray was obtained, which revealed Resident 6 sustained a fractured arm with displacement. The facility's investigation summary dated 3/30/15 disclosed Staff 23, CNA, on 3/28/15 reported she and Staff 3, LPN transferred the resident to the toilet with the Hoyer lift between 10:00 am and 10:20 am. Staff 3, LPN investigation statement indicated she was providing another resident's care at that time, denied assisting the resident to the toilet and stated the resident was only care planned for the use of the bedside commode. Staff 23 indicated Resident 6 complained of discomfort during the transfer and wanted off the toilet within two seconds. Staff 23 walked out of the bathroom into the resident's room meaning to grab the Hoyer but accidentally grabbed the sit to stand machine. Staff 7's, CNA, investigation statement indicated she heard Resident 6 yelling and screaming very loudly at around 10:30 am. She checked on the resident and observed her/him sitting on the toilet with the sit to stand sling in place and the sit to stand machine in front of the resident. Staff 23 reported to Staff 7 the resident's arm flung backwards in the "Hoyer" sling, "I think I may have hurt (Resident 6)." Staff 23 removed the sit to stand sling and asked Staff 7 to get the Hoyer sling and machine. The Hoyer machine was down the hall. Staff 7 and 23 transferred Resident 6 with the Hoyer lift from the toilet to bed and Resident 6 stated "My arm hurts!" The facility determined the care plan was not followed regarding the type of machine used in the transfer, only one staff transferred the resident as opposed to two and the resident was placed on the toilet instead of the bedside commode. The characteristics of the resident's bruising coincided with the sit to stand sling placement and abrupt leaning into the sling itself and the fracture most likely occurred during the transfer with a sit to stand machine. On 4/15/15 at 3:11 pm and 4/17/15 at 7:45 am Resident 6 was observed sitting in a wheelchair with her/his left arm in a sling. The resident refused to be interviewed. In interview on 4/17/15 at 9:31 am Staff 23, CNA stated Resident 6 was care planned for either the bedside commode or bedpan for toileting but insisted on using the toilet. She and Staff 3, LPN transferred the resident with the Hoyer lift and she removed the sling. The resident's arm was already hurting from a previous fracture and Staff 23 thought she may have put the resident's arm too far back in the Hoyer sling. The resident was screaming to get off the toilet and "was really abusing" her. Staff 23 stated she grabbed the sit to stand machine in error but did not use it. Staff 23 and Staff 7, CNA transferred the resident from the toilet. The resident was in more pain than usual, complaining of shoulder pain prior to a shower earlier that morning and while on the toilet, "whining and crying." Staff 23 stated she did not inform the charge nurse of the resident's pain until after the resident was transferred back to bed from the toilet. When asked what she would have done differently, Staff 23 stated she would have made sure the resident's arms were where they should be. Staff 23 described Resident 6 as "mentally wearing her out" because of her/his behaviors and stated it was a "hard morning for both of us." In interview on 4/16/15 at 10:26 am Staff 7, CNA stated on 3/28/15 at around 10:30 am she was charting and could hear Resident 6 screaming. She went to check on the resident and observed her/him on the toilet. Staff 23 was with the resident, the sit to stand sling was around the resident and the sit to stand machine was in front of the resident but not hooked up to the sling. Staff 7 stated Resident 6 required a Hoyer lift for transfers. Staff 23 asked her to get the Hoyer sling from the resident's drawer. Staff 23 removed the sit to stand sling and placed the Hoyer sling on the resident and she/he was transferred off the toilet. Per Staff 7, with the resident present, Staff 23 stated she was going to lose her job, she "f***** up." While the resident was still on the toilet, Staff 23 reported a possibly injury to the resident and demonstrated the resident's left arm went backwards during the transfer onto the toilet with the sit to stand machine. Staff 7 and Staff 23 transferred the resident off of the toilet. Afterwards Staff 23 and Staff 11, CMA informed the nurse but Staff 7 did not know what was reported. Staff 7 stated she did not report Resident 6's possible injury to the charge nurse as she thought Staff 23 had already done so. She learned the next day (3/29/15) what was told to the charge nurse was not accurate, however, she did not report the incident until 3/30/15. Per Staff 7 the left arm was the resident's bad arm to begin with, but the severity of her/his pain was new. When asked what she would have done differently, Staff 7 stated she would have gone to the nurse right away. In interview on 4/16/15 at 9:31 am Staff 3, LPN stated Staff 23, CNA and Staff 11, CMA informed her Resident 6 was crying and hurting. Staff 23 informed Staff 3 she placed the resident in bed after toileting. Staff 23 was afraid there was something wrong with the resident's shoulder and the resident was really hurting. Staff 3 stated she was not informed that something occurred that might have caused an injury In interview on 4/16/15 at 2:22 pm, Staff 14, CNA stated when she received report on 3/27/15, Staff 23, CNA told her Resident 6's arm got twisted up with her/his arm behind the back during toileting. Staff 23 initially stated she used the sit to stand machine for the transfer then later stated it was the Hoyer lift. Staff 14 stated she did not know what Staff 23 reported to the nurse but she informed the day charge nurse (Staff 3) what she was told about the resident's arm being twisted around. Staff 14 stated the resident's pain was different than normal, was a lot worse and the resident screamed more than normal. In interview on 4/14/15 at 8:05 am Staff 1, RNCM stated Staff 23, CNA used the sit to stand to transfer Resident 6 with toileting. Staff 23 should have either used the Hoyer lift or provided incontinence care. The bruising was from the sit to stand sling, which was observed in place by another staff member. The facility attributed the fracture to the use of the sit to stand.

Based on observation, interview and record review it was determined the facility failed to implement their written policies for reporting possible neglect of care and resident injury in a timely manner for 1 of 1 sampled residents (#6) reviewed for fractures. Resident 6 sustained a fracture and had a delay in pain management and treatment. Findings include: The facility's Abuse Policies and Procedures defined abuse including "Failure to provide basic care to resident resulting in physical harm, unreasonable discomfort or loss of dignity...Because YOU work in a nursing home, YOU are required by law to report any actual or suspected abuse...Immediately notify the Administrator of Director of Nursing. If not available, notify Social Services..." The policy for Report of Events Assessing for Abuse/Neglect included "Any event resulting in injury to the resident mandates an investigation...The DNS & Administrator must be notified whenever there is an injury to a resident...Unusual behavior or statements by the resident should be reported to the Charge Nurse and a determination made whether to initiate an investigation....Staff to resident abuse/neglect allegations: upon report...The Charge Nurse will initiate an investigation, collecting statements from staff, residents and family members..." Resident 6 was admitted to the facility in 2012 with [DIAGNOSES REDACTED]. The 3/19/15 In Room Plan Of Care noted Resident 6 required two person Hoyer lift transfers and used the beside commode for toileting. The 3/28/15 7:30 am Progress Note documented Resident 6 was observed with no complaints of left arm pain or left arm difficulty. The resident was visualized in the shower chair by Staff 16, LPN between 6:00 am and 7:30 am with no left arm pain/guarding observed. The 3/28/15 7:52 pm Progress Note only noted Resident 6 was "quite painful" after a shower and toileting, but did not specifically document left arm/shoulder pain. The 3/29/15 3:26 am Progress Note disclosed Resident 6 complained of left arm and shoulder pain. The 3/30/15 9:42 am Progress Note revealed the resident cried or yelled out if anyone attempted to move the resident's arm. There left upper arm from just above the elbow to the shoulder was swollen, warm to touch and possible bruising was noted. An x-ray was obtained. The 3/30/15 x-ray report revealed Resident 6 sustained a fractured arm with displacement. The facility's investigation disclosed on 3/301/5 Staff 6, DNS received report from Staff 1, RNCM Resident 6 was complaining of left shoulder pain and the resident was sent out for x-rays for a possible fracture. It was learned that on 3/28/15 Staff 23, CNA reported she and Staff 3, LPN transferred the resident to the toilet with the Hoyer lift at around 10:00 am to 10:20 am. Staff 3, LPN stated she was providing other resident's care at that time, denied assisting the resident to the toilet and stated the resident was only careplanned for the use of the bedside commode. Per Staff 23 Resident 6 complained of discomfort during the transfer and wanted off the toilet within two seconds. Staff 23 reported she walked out of the bathroom into the resident's room meaning to grab the Hoyer but accidentally grabbed the sit to stand machine. Staff 7 heard Resident 6 yelling and screaming very loudly at around 10:30 am. She checked on the resident and observed her/him sitting on the toilet with the sit to stand sling in place and the sit to stand machine in front of the resident. Staff 23 reported to Staff 7 the resident's arm flung backwards in the "Hoyer" sling, "I think I may have hurt (Resident 6)." Staff 23 removed the sit to stand sling and asked Staff 7 to get the Hoyer sling and machine. The Hoyer machine was down the hall. Staff 7 and 23 transferred Resident 6 with the Hoyer lift from the toilet to bed and she/he stated "My arm hurts!" The facility determined the care plan was not followed regarding the type of machine used in the transfer, only one staff transferred the resident as opposed to two and the resident was placed on the toilet instead of the bedside commode. The characteristics of the resident's bruising coincided with the sit to stand sling placement and abrupt leaning into the sling itself and the fracture most likely occurred during the transfer with a sit to stand machine. There was no documented evidence in the clinical record of the investigation being initiated until 3/30/15, two days after the incident occurred. On 4/15/15 at 3:11 pm and 4/17/15 at 7:45 am Resident 6 was observed sitting in a wheelchair with her/his left arm in a sling. The resident refused to be interviewed. In interview on 4/17/15 at 9:31 am Staff 23, CNA stated Resident 6 was careplanned for either the bedside commode or bedpan for toileting but insisted on using the toilet. She and Staff 3, LPN transferred the resident with the Hoyer lift and she removed the sling. The resident's arm was already hurting from a previous fracture and Staff 23 thought she may have put the resident's arm too far back in the Hoyer sling. The resident was screaming to get off the toilet and "was really abusing" her. Staff 23 stated she grabbed the sit to stand machine in error but did not use it. Staff 23 and Staff 7 transferred the resident from the toilet. The resident was in more pain than usual, complaining of shoulder pain prior to a shower earlier that morning and while on the toilet, "whining and crying." Staff 23 stated she did not inform the charge nurse of the resident's pain until after the resident was transferred back to bed from the toilet. When asked what she would have done differently, Staff 23 stated she would have made sure the resident's arms were where they should be. Staff 23 described Resident 6 as "mentally wearing her out" because of her/his behaviors and stated it was a "hard morning for both of us." In interview on 4/16/15 at 10:26 am Staff 7, CNA stated on 3/28/15 at around 10:30 am she was charting and could hear Resident 6 screaming. She went to check on the resident and observed her/him on the toilet. Staff 23, CNA was with the resident, the sit to stand sling was around the resident and the sit to stand machine was in front of the resident but not hooked up to the sling. Staff 7 stated Resident 6 required a Hoyer lift for transfers. Staff 23 asked her to get the Hoyer sling from the resident's drawer. Staff 23 removed the sit to stand sling and placed the Hoyer sling on the resident and she/he was transferred off the toilet. Per Staff 7 with the resident present, Staff 23 stated she was going to lose her job, she "f***** up." While the resident was still on the toilet, Staff 23 reported a possibly injury to the resident and demonstrated the resident's left arm went backwards during the transfer onto the toilet with the sit to stand machine. Staff 7 and Staff 23 transferred the resident off of the toilet. Afterwards Staff 23 and Staff 11, CMA informed the nurse but Staff 7 did not know what was reported. Staff 7 stated she did not report Resident 6's possible injury to the charge nurse as she thought Staff 23 had already done so. She learned the next day (3/29/15) what was told to the charge nurse was not accurate, however, she did not report the incident until 3/30/15. Per Staff 7 the left arm was the resident's bad arm to begin with, but the severity of her/his pain was new. When asked what she would have done differently, Staff 7 stated she would have gone to the nurse right away. Interviews on 4/16/15 at 9:31 am, 10:55 am and 2:15 pm and on 4/17/15 at 12:36 pm Staff 3, LPN (Day Shift Charge Nurse) stated on 3/28/15 Staff 23, CNA and Staff 11, CMA informed her Resident 6 was crying and hurting. Staff 23 informed Staff 3 she placed the resident in bed after toileting. Staff 23 was afraid there was something wrong with the resident's shoulder and the resident was really hurting. Staff 3 did as much of an assessment as the resident allowed, the resident screamed in pain when she touched the resident's shoulder, but did the same when touching other areas on the resident's body. The left shoulder pain was different for the resident as she/he previously only reported pain with the right shoulder. During the assessment the resident was very painful, which increased when she opened the resident's arm and she observed a red spot on the resident's left inner elbow. The resident was more agitated and was in more pain than usual, which she thought was due to the red spot she had observed and with having to straighten the resident's arm. There was no other redness or swelling and when the resident was repositioned in bed she/he did not make a sound. On 3/29/15 she assessed the resident's arm again and she still did not see anything. However, the resident complained again of left shoulder pain. Staff 3 stated she did not recall Staff 20, RN informing her Resident 6 requested an x-ray. Staff 3 stated no staff informed her that an incident occurred that might have caused an injury and if they had she would have handled it differently and would have sent the resident to an urgent care clinic for an evaluation. In interview on 4/16/15 at 11:49 am Staff 11, CMA stated on 3/28/15 Staff 23, CNA reported Resident 6 voiced complaints of left arm pain and Staff 23 checked to see if the resident could have some pain medication. The resident was already in bed and at that time all the resident had for pain management was Tylenol. The medication was not effective. The resident always reported shoulder pain, however, this time the resident was literally screaming, which was different, it was a more intense complaint of pain. Staff 23 did not report an incident and she did not hear what Staff 23 reported to Staff 3. The resident previously had an order for [REDACTED]. In interview on 4/16/15 at 2:22 pm, Staff 14, CNA stated when she received report on 3/28/15, Staff 23, CNA told her Resident 6's arm got twisted up with her/his arm behind the back during toileting. Staff 23 initially stated she used the sit to stand machine for the transfer then later stated it was the Hoyer lift. Staff 14 stated she did not know what Staff 23 reported to the nurse but she informed the day charge nurse (Staff 3, LPN) what she was told about the resident's arm being twisted around. Staff 14 stated the resident's pain was different than normal, was a lot worse and the resident screamed more than normal. In interviews on 4/16/15 at 10:00 am and 12:00 pm, Staff 20, RN (Night Shift Charge Nurse) stated on 3/28/15 the resident complained her/his arm hurt and was given Tylenol. She directed staff to be careful of the resident's arm when they were rolling her/him and told them not to roll the resident on the left side and to protect it. Staff 20 stated a staff member (could not recall who) reported the resident's arm went backwards during a transfer and somehow got twisted behind the resident's back in the sling and there was some type of injury to the resident's arm. The arm did not look swollen and there was no bruising and Staff 20 thought the resident pulled some muscles. The resident usually complained of pain with the right shoulder but this time it was on the left. Staff 20 stated she thought the resident's pain was reported to the physician. The resident requested an x-ray on Sunday and she told the resident the clinic was closed and she/he would have to wait until Monday when the clinic was opened. Per Staff 20, the resident's request for an x-ray most likely occurred during the 3/28/15 - 3/29/15 night shift at 2:00 am, which she reported to either Staff 3, LPN or Staff 4, RN. In interview on 4/16/15 at 1:26 pm Staff 21, CNA stated she worked with Resident 6 on 3/29/15. At 6:00 am the resident was screaming, stating "I can't stand this pain anymore. I need to get up." Something was definitely different with the resident and not right about the arm. As she was trying to find out what happened, a former CNA told her that on 3/28/15 she was informed something happened to the resident's arm during a transfer for toileting. Staff 21 stated she reported the resident's pain to Staff 20, RN and asked for the resident to be checked. When Staff 20 told her there was no bruising, she told Staff 20 there was something definitely wrong. Staff 21 stated the resident's arm normally was very stiff from contracture and she could barely lift it while dressing the resident. On 3/29/15 the arm was a little more pliable while dressing the resident, which she reported to Staff 20. Staff 21 stated she also reported her concerns to Staff 3, LPN and kept reporting the resident was in a lot of pain and she knew something was wrong. One of the nurses (could not recall who) stated to her the shoulder might have come out of the socket and went back in place and they would play it out and see how it goes. In interviews on 4/17/15 at 10:12 am and 4/20/15 at 8:18 am Staff 4, RN stated on 3/30/15 she was told the resident had arm pain and may have gotten the arm caught during a transfer. Staff 4 stated Staff 20, RN did not inform her the resident requested an x-ray, only that the resident's arm was hurt and requested she check the resident's shoulder. Staff 4 assessed the arm and noted bruising and swelling from the shoulder area and down the arm. She called the physician and sent the resident out for an x-ray. In interview on 4/14/15 at 8:05 am Staff 1, RNCM stated Staff 23, CNA used the sit to stand to transfer Resident 6 with toileting. Staff 23 should have either used the Hoyer lift or provided incontinence care. The bruising was from the sit to stand sling, which was observed in place by another staff member. The facility attributed the fracture to the use of the sit to stand. In interview on 4/17/15 at 10:47 am with Staff 6, DNS and Staff 17, Administrator, they acknowledged the incident was not reported timely.

Based on interview and record review it was determined 4 staff (#s 3, LPN, 7, CNA, 20, RN and 23, CNA) failed to provide care in a manner that met professional standards of quality. As a result, Resident 6 sustained a fracture and did not receive pain management and treatment in a timely manner. Findings include: DIVISION 45 STANDARDS AND SCOPE OF PRACTICE FORTHE LICENSED PRACTICAL NURSE AND REGISTERED NURSE 851-045-0040 Scope of Practice Standards for All Licensed Nurses (1) Standards related to the licensed nurse ' s responsibilities for client advocacy. The licensed nurse: (b) Intervenes on behalf of the client to identify changes in health status, to protect, promote and optimize health, and to alleviate suffering; DIVISION 63 STANDARDS AND AUTHORIZED DUTIES FOR THE CERTIFIED NURSING ASSISTANT AND CERTIFIED MEDICATION AIDE 851-063-0090 Conduct Unbecoming a Nursing Assistant A CNA, regardless of job location, responsibilities, or use of the title "CNA" whose behavior fails to conform to the legal standard and accepted standards of the nursing assistant profession, or who may adversely affect the health, safety or welfare of the public, may be found guilty of conduct unbecoming a nursing assistant. Such conduct includes but is not limited to: (1) Conduct, regardless of setting, related to general fitness to perform nursing assistant authorized duties: (a) Demonstrated incidents of violent, abusive, neglectful or reckless behavior; or (b) Demonstrated incidents of dishonesty, misrepresentation, or fraud. (3) Conduct related to client safety and integrity: (a) Failing to take action to preserve or promote a person's safety based on nursing assistant knowledge, skills, and abilities; (b) Failing to implement the plan of care developed by the registered nurse; (c) Failing to report changes in a person's status from the last assessment made by the registered nurse; (d) Jeopardizing the safety of a person under the CNA's care; (h) Failing to report actual or suspected incidents of abuse, neglect, or mistreatment; (4) Conduct related to communication: (c) Entering inaccurate, incomplete, falsified or altered documentation into a health record or into agency records. This includes but is not limited to: (f) Failing to communicate information regarding a person's status to the supervising nurse or other appropriate member of the healthcare team in an on-going and timely manner and as appropriate to the context of care; or (g) Failing to communicate information regarding the person's status to individuals who are authorized to receive the information and need to know. Resident 6 was admitted to the facility in 2012 with [DIAGNOSES REDACTED]. The 3/19/15 In Room Plan Of Care noted Resident 6 required two person Hoyer lift transfers and used the beside commode for toileting. Resident 6 had physician orders [REDACTED]. The 3/28/15 7:30 am Progress Note documented Resident 6 was observed with no complaints of left arm pain or left arm difficulty. The resident was visualized in the shower chair by Staff 16, LPN between 6:00 am and 7:30 am with no left arm pain/guarding observed. The 3/28/15 7:52 pm Progress Note only noted Resident 6 was "quite painful" after a shower and toileting, but did not specifically document left arm/shoulder pain. The 3/28/15 7:52 pm Progress Note indicated Staff 3, LPN noted redness and irritation inside the left elbow, which was reported to the physician. The 3/28/15 Fax to the physician only noted that redness and irritation was found to the inside of the left elbow. There was no mention of left arm/shoulder pain. The 3/29/15 3:26 am Progress Note disclosed Resident 6 complained of left arm and shoulder pain. The 3/30/15 9:42 am Progress Note revealed the resident cried or yelled out if anyone attempted to move the resident's arm. The left upper arm from just above the elbow to the shoulder was swollen, warm to touch and possible bruising was noted. An x-ray was obtained. The 3/30/15 x-ray report revealed Resident 6 sustained a fractured arm with displacement. The 3/2015 MAR indicated [REDACTED]. The 3/30/15 After Visit Summary included new physician orders [REDACTED]. The 4/2015 MAR indicated [REDACTED]. The facility's investigation disclosed on 3/301/5 Staff 6, DNS received report from Staff 1, RNCM Resident 6 was complaining of left shoulder pain and the resident was sent out for x-rays for a possible fracture. It was learned that on 3/28/15 Staff 23, CNA reported she and Staff 3, LPN transferred the resident to the toilet with the Hoyer lift at around 10:00 am to 10:20 am. Staff 3, LPN stated she was providing other resident's care at that time, denied assisting the resident to the toilet and stated the resident was only careplanned for the use of the bedside commode. Per Staff 23, Resident 6 complained of discomfort during the transfer and wanted off the toilet within two seconds. Staff 23 reported she walked out of the bathroom into the resident's room meaning to grab the Hoyer but accidentally grabbed the sit to stand machine. Staff 7, CNA heard Resident 6 yelling and screaming very loudly at around 10:30 am. She checked on the resident and observed her/him sitting on the toilet with the sit to stand sling in place and the sit to stand machine in front of the resident. Staff 23 reported to Staff 7 the resident's arm flung backwards in the "Hoyer" sling, "I think I may have hurt (Resident 6)." Staff 23 removed the sit to stand sling and asked Staff 7 to get the Hoyer sling and machine. The Hoyer machine was down the hall. Staff 7 and 23 transferred Resident 6 with the Hoyer lift from the toilet to bed and she/he stated "My arm hurts!" The facility determined the care plan was not followed regarding the type of machine used in the transfer, only one staff transferred the resident as opposed to two and the resident was placed on the toilet instead of the bedside commode. The characteristics of the resident's bruising coincided with the sit to stand sling placement and abrupt leaning into the sling itself and the fracture most likely occurred during the transfer with a sit to stand machine. There was no documented evidence in the clinical record of the investigation being initiated until 3/30/15, two days after the incident occurred. In interview on 4/17/15 at 9:31 am Staff 23, CNA stated Resident 6 was careplanned for either the bedside commode or bedpan for toileting but insisted on using the toilet. She and Staff 3, LPN transferred the resident with the Hoyer lift and she removed the sling. The resident's arm was already hurting from a previous fracture and Staff 23 thought she may have put the resident's arm too far back in the Hoyer sling. The resident was screaming to get off the toilet and "was really abusing" her. Staff 23 stated she grabbed the sit to stand machine in error but did not use it. Staff 7 and and Staff 23 transferred the resident from the toilet. The resident was in more pain than usual, complaining of shoulder pain prior to a shower earlier that morning and while on the toilet, "whining and crying." Staff 23 stated she did not inform the charge nurse of the resident's pain until after the resident was transferred back to bed from the toilet. When asked what she would have done differently, Staff 23 stated she would have made sure the resident's arms were where they should be. Staff 23 described Resident 6 as "mentally wearing her out" because of her/his behaviors and stated it was a "hard morning for both of us." In interview on 4/16/15 at 10:26 am Staff 7, CNA stated on 3/28/15 at around 10:30 am she was charting and could hear Resident 6 screaming. She went to check on the resident and observed her/him on the toilet. Staff 23 was with the resident, the sit to stand sling was around the resident and the sit to stand machine was in front of the resident but not hooked up to the sling. Staff 7 stated Resident 6 required a Hoyer lift for transfers. Staff 23 asked her to get the Hoyer sling from the resident's drawer. Staff 23 removed the sit to stand sling and placed the Hoyer sling on the resident and she/he was transferred off the toilet. Per Staff 7, with the resident present, Staff 23 stated she was going to lose her job, she "f***** up." While the resident was still on the toilet, Staff 23 reported a possibly injury to the resident and demonstrated the resident's left arm went backwards during the transfer onto the toilet with the sit to stand machine. Staff 7 and Staff 23 transferred the resident off of the toilet. Afterwards Staff 23 and Staff 11, CMA informed the nurse but Staff 7 did not know what was reported. Staff 7 stated she did not report Resident 6's possible injury to the charge nurse as she thought Staff 23 had already done so. She learned the next day (3/29/15) what was told to the charge nurse was not accurate, however, she did not report the incident until 3/30/15. Per Staff 7 the left arm was the resident's bad arm to begin with, but the severity of her/his pain was new. When asked what she would have done differently, Staff 7 stated she would have gone to the nurse right away. Interviews on 4/16/15 at 9:31 am, 10:55 am and 2:15 pm and on 4/17/15 at 12:36 pm Staff 3, LPN (Day Shift Charge Nurse) stated on 3/28/15 Staff 23, CNA and Staff 11, CMA informed her Resident 6 was crying and hurting. Staff 23 informed Staff 3 she placed the resident in bed after toileting. Staff 23 was afraid there was something wrong with the resident's shoulder and the resident was really hurting. Staff 3 did as much of an assessment as the resident allowed, the resident screamed in pain when she touched the resident's shoulder, but did the same when touching other areas on the resident's body. The left shoulder pain was different for the resident as she/he previously only reported pain with the right shoulder. During the assessment the resident was very painful, which increased when she opened the resident's arm and she observed a red spot on the resident's left inner elbow. The resident was more agitated and was in more pain than usual, which she thought was due to the red spot she had observed and with having to straighten the resident's arm. There was no other redness or swelling and when the resident was repositioned in bed she/he did not make a sound. On 3/29/15 she assessed the resident's arm again and she still did not see anything. However, the resident complained again of left shoulder pain. Staff 3 stated she did not recall Staff 20, RN informing her Resident 6 requested an x-ray. Staff 3 stated no staff informed her that an incident occurred that might have caused an injury and if they had she would have handled it differently and would have sent the resident out for an evaluation. In interview on 4/16/15 at 11:49 am Staff 11, CMA stated on 3/28/15 Staff 23, CNA reported Resident 6 voiced complaints of arm pain and Staff 23 checked to see if the resident could have some pain medication. The resident was already in bed and at that time all the resident had for pain management was Tylenol. The medication did not help her and she did not see any difference in treating the resident's pain. The resident always reported shoulder pain, however, this time the resident was literally screaming, which was different, it was a more intense complaint of pain. Staff 23 did not report an incident and she did not hear what Staff 23 reported to Staff 3, LPN. The resident previously had an order for [REDACTED]. In interview on 4/16/15 at 2:22 pm, Staff 14, CNA stated when she received report on 3/28/15, Staff 23, CNA told her Resident 6's arm got twisted up with her/his arm behind the back during toileting. Staff 23 initially stated she used the sit to stand machine for the transfer then later stated it was the Hoyer lift. Staff 14 stated she did not know what Staff 23 reported to the nurse but she informed the day charge nurse (Staff 3, LPN) what she was told about the resident's arm being twisted around. Staff 14 stated the resident's pain was different than normal, was a lot worse and the resident screamed more than normal. In interviews on 4/16/15 at 10:00 am and 12:00 pm, Staff 20, RN (Night Shift Charge Nurse) stated on 3/28/15 the resident complained her/his arm hurt and was given Tylenol. She directed staff to be careful of the resident's arm when they were rolling her/him and told them not to roll the resident on the left side and to protect it. Staff 20 stated a staff member (could not recall who) reported the resident's arm went backwards during a transfer and somehow got twisted behind the resident's back in the sling and there was some type of injury to the resident's arm. The arm did not look swollen and there was no bruising and Staff 20 thought the resident pulled some muscles. The resident usually complained of pain with the right shoulder but this time it was on the left. Staff 20 stated she thought the resident's pain was reported to the physician. The resident requested an x-ray on Sunday and she told the resident the clinic was closed and she/he would have to wait until Monday when the clinic was opened. Per Staff 20, the resident's request for an x-ray most likely occurred during the 3/28/15 - 3/29/15 night shift at 2:00 am, which she reported to either Staff 3, LPN or Staff 4, RN. In interview on 4/16/15 at 1:26 pm Staff 21, CNA stated she worked with Resident 6 on 3/29/15. At 6:00 am the resident was screaming, stating "I can't stand this pain anymore. I need to get up." Something was definitely different with the resident and not right about the arm. As she was trying to find out what happened, a former CNA told her that on 3/28/15 she was informed something happened to the resident's arm during a transfer for toileting. Staff 21 stated she reported the resident's pain to Staff 20, RN and asked for the resident to be checked. When Staff 20 told her there was no bruising, she told Staff 20 there was something definitely wrong. Staff 21 stated the resident's arm normally was very stiff from contracture and she could barely lift it while dressing the resident. On 3/29/15 the arm was a little more pliable while dressing the resident, which she reported to Staff 20. Staff 21 stated she also reported her concerns to Staff 3, LPN and kept reporting the resident was in a lot of pain and she knew something was wrong. One of the nurses (could not recall who) stated to her the shoulder might have come out of the socket and went back in place and they would play it out and see how it goes. In interviews on 4/17/15 at 10:12 am and 4/20/15 at 8:18 am Staff 4, RN stated on 3/30/15 she was told the resident had arm pain and may have gotten the arm caught during a transfer. Staff 4 stated Staff 20, RN did not inform her the resident requested an x-ray, only that the resident's arm was hurt and requested she check the resident's shoulder. Staff 4 assessed the arm and noted bruising and swelling from the shoulder area and down the arm. She called the physician and sent the resident out for an x-ray. In interviews on 4/14/15 at 8:05 am and 4/17/15 at 8:04 am Staff 1, RNCM stated Staff 23, RNCM used the sit to stand to transfer Resident 6 with toileting. Staff 23 should have either used the Hoyer lift or provided incontinence care. The bruising was from the sit to stand sling, which was observed in place by another staff member. The facility attributed the fracture to the use of the sit to stand. Staff 1 stated if there was a new onset of pain, something different for the resident the physician should have been notified. Per Staff 1 the physician should have been notified of the resident's pain on 3/28/15. In interview on 4/17/15 at 10:47 am with Staff 6, DNS and Staff 17, Administrator, they acknowledged the incident was not reported timely. Staff 6 reviewed the 3/28/15 Fax to the physician and stated the physician was not notified about the resident's pain, stating it was "black and white", the physician should have been notified on 3/28/15.

Based on observation, interview, and record review it was determined the facility failed to prevent weight loss for 1 of 3 sampled residents (#10) reviewed for nutrition. This resulted in the resident sustaining a severe weight loss of 9.2% in a three month period and placed the resident at risk for continued weight loss. Findings include: Resident 10 was admitted to the facility in 7/2014 with [DIAGNOSES REDACTED]. On 12/18/14 the resident weighed 109.4 lbs (pounds) and the Dietary Progress Notes indicated the resident's average diet intake was 35%. On 12/18/14 the NAR (Nutrition at Risk) committee notes, signed by the RD (Registered Dietician) , identified the resident weighed 109.4 lbs and had a 10.8 lb weight loss in one month related to a urinary tract infection. The resident received CCHO (controlled carbohydrate) regular texture diet with finger foods and NEM (Nutritional Enhanced Meals) along with 4 oz of 2.0 calorie supplement twice daily. The note identified the resident "loves hi cal supplement" and recommendations were to change to 6 oz of NSA (No Sugar Added) 1.7 calorie supplement three times daily. The resident's full care plan dated 12/23/15 identified a significant weight loss. The approaches included a controlled carbohydrate, regular texture diet with thin liquids and 180 mls (6 oz) of NSA 1.7 calorie supplement three times daily. There was no indication of the resident's food or fluid preferences. The next NAR committee note dated 1/8/15 indicated the resident had gained weight to 115.2 lbs. On 2/18/15 the NAR note indicated the resident weighed 107.2 lbs , a 6.9% weight loss since 1/8/15. The resident was not on comfort care but the resident's continued weight loss was attributed to her/his [DIAGNOSES REDACTED]." The resident was noted as able to chew regular finger foods textures. There was no assessment of the resident's nutritional calorie or fluid needs. No further dietary interventions were identified and the previous diet and supplement were continued. The resident's quarterly MDS dated [DATE] indicated the resident did not have a swallowing disorder, received a therapeutic diet, and had a weight loss. On 3/16/15 the NAR note, signed by the RD, identified the resident had lost two more pounds and weighed 107.2 lbs. The note included information about attempting to discuss with the resident's family and possible lab work but no new dietary interventions were identified and the previous diet and supplement were continued. The resident was referred to speech therapy on 3/27/15 due to onset of weight loss. The speech therapist evaluated the resident's swallowing ability with diet textures and recommended the resident remain on regular texture finger foods with thin liquids by a cup and provided no further diet recommendations. The resident's April 2015 physician orders [REDACTED]. The orders also included No Sugar Added (NSA) 1.7 cal supplement three times daily. On 4/13/15 the NAR notes, signed by the RD, revealed the resident lost additional weight and weighed 104.6 lbs. The note indicated, as of 4/13/15, the resident had a severe weight loss of 9.2% in three months and 14.5% in six months. The documentation included lab work results from the previous month, the speech therapy treatment, and referred to a mental health evaluation performed in 2/2015 for change in antidepressant medications. There was no identification of the resident's percentage of meals and fluids consumed and no assessment of the resident's nutritional caloric or fluid requirements/needs. No further dietary interventions were identified and the previous diet and supplement were continued. The resident's in room care plan dated 4/14/15 indicated the resident was on a controlled carbohydrate regular texture diet with finger foods and NEMS. There were no directions to staff of the resident's food or fluid preferences. On 4/13/15 at 5:58 pm Resident 10 was observed in the dining room during the evening meal. Staff 2 (CNA) was assisting, and cueing the resident to eat. The resident independently held a cup and consumed fluids. Staff 2 stated the resident "does best with fluids." On 4/17/15 at 8:40 am the resident was sitting in the dining room. Staff 5 (CNA) was encouraging her/him to drink fluids. Staff 5 stated the resident drank "anything" they gave her/him. The resident's April 2015 meal monitor flow sheet between 4/1/15 and 4/17/15 indicated the resident consumed the majority of the her/his fluids but frequently consumed less than 50% of her/his meal. The resident's April 2015 MAR indicated [REDACTED]. Between 4/1/15 and 4/17/15 the resident refused the supplement only once. On 4/21/15 at 11:43 am Staff 1 (RNCM) verified the resident's significant to severe weight loss since 12/2014 and verified the only dietary intervention attempted since 12/2014 was to change the supplement in 12/2014. Staff 1 stated the resident usually drank fluids offered to her/him. Staff 1 verified the facility made no attempt to liberalize the resident's diet or to increase the amount of fluid calories the resident received.

Based on observation, interview and record review it was determined the facility failed to follow care planned interventions and ensure residents' safety for 3 of 6 sampled residents (#s 1, 2 & 6) reviewed for falls. Resident 2 sustained a fracture and Residents 1 & 6 were at risk for continued falls. Findings include: 1. Resident 2 was admitted to the facility in 1999 with [DIAGNOSES REDACTED]. The current care plan noted Resident 2 was at risk for falls due to a stroke with left sided [DIAGNOSES REDACTED] and impaired decision making skills. The goal noted the resident "will not receive harm from falls." The 4/14/14 6:05 pm Progress Note indicated while on an outing the resident slipped out of the wheelchair while on the bus. The resident had a small abrasion but no complaints of pain at that time. The 4/15/14 7:43 am and 10:17 am Progress Notes disclosed Resident 2 had pain with cares during the night. At shift change the resident was unable to transfer out of bed and her/his leg appeared turned outward more than noted earlier in the night. The resident had pain upon palpation of the left hip. The physician was contacted and the resident was sent to the emergency room . The facility's correlating investigation noted Staff 7, Activities Director/CNA, transferred Resident 2 into a seat on the bus and left to address another resident and their spouse. Staff 7 reported she did not realize Resident 2 was not seat belted in and while going around a corner, the resident slipped out of the seat and struck her/his left leg on an unknown object. Staff 7 then transferred Resident 2 back into the seat and returned to the facility, where nursing staff assessed the resident for injury. Staff 7 acknowledged she failed to secure the resident with the seat belt before driving the bus. The 4/15/14 hospital x-ray report identified Resident 2 had a left hip fracture. The 4/18/14 6:18 pm Progress Note indicated Resident 2 returned to the facility and "has a lot of pain from (Resident 2's) procedure. The left hip was swollen and the resident did not like anyone to get near or touch her/his leg and was anxious when staff were near the leg. The resident rated her/his pain at 10 out of 10. Progress Notes dated 4/19/14 and 4/20/14 indicated the resident continued to have increased pain. On 4/20/14 the physician was contacted, who changed the resident's pain management. On 4/29/14 at 9:30 am, Resident 2 was observed lying in bed and appeared comfortable. When asked about the incident, Resident 2 stated she/he was normally seat belted into the bus, but was not on the day of the incident. Resident 2 stated she/he fractured her/his hip as a result. Staff 1, Administrator, and Staff 7, Activities Director/CNA, were interviewed on 4/29/14 at 10:57 am. Staff 7 stated at the end of the outing on 4/14/14, residents were getting "antsy" and wanted to leave. She transferred Resident 2 into the bus seat but did not put the seat belt in place. Staff 7 assisted another resident and their spouse with getting on the bus but did not go back to ensure Resident 2 was seat belted in. Per Staff 7, "...the way everything got rushed and everyone was getting agitated and wanted to leave" it was an oversight on her part. Staff 7 reported while driving, she was turning the corner going around 30 miles an hour and the resident slid out and landed in the middle of the aisle. She pulled the bus over and got the resident's legs free, as one leg was underneath the seat in front of the resident and the other leg was in the aisle. When asked if she had contacted the facility regarding the incident prior to transferring the resident back to the seat and returning to the facility, Staff 7 stated "No, I just reacted to get (Resident 2) off the floor..." Staff 1, Administrator, stated Staff 7 should have called the facility when the incident occurred to have a nurse come out to assess the resident prior to returning to the facility. On 4/29/14 at 11:20 am, the facility's bus was observed. All bus seats were observed to have seat belts in place. 2. Resident 1 was admitted to the facility with [DIAGNOSES REDACTED]. The Updated 12/16/13 In Room ADL Plan of Care noted the resident was to wear non-skid footwear when out of bed and use a bed alarm. The 12/19/13 Progress Note indicated Resident 1 fell while transferring herself/himself to the bathroom. The CNA stated she forgot to re-arm the resident's alarm. The correlating facility investigation noted the CNA was counseled for leaving the alarm off. The Assigned Care-Staff/Witness Report signed by Staff 10, CNA, noted the resident was found sitting on the floor in front of the bathroom. The alarm did not sound at the time of the fall. In interview on 5/15/14 at 3:21 pm, Staff 10, CNA, stated she did not recall working with Resident 1, did not get counseled regarding the resident's fall and did know anything about her/his falls. In interview on 5/15/14 at 3:25 pm, Staff 2, DNS, stated Staff 10, CNA, was assigned to Resident 1 when he/she fell on [DATE]. The 1/27/14 updated In Room ADL Plan of Care noted Resident 1 was to be monitored for wandering, redirected away from front doors and use a wanderguard (an alarm system to prevent residents from exiting a door). For safety, the resident was to have non-skid footwear on when out of bed, frequent checks and a pressure alarm to the wheelchair. The 2/20/14 9:45 am Progress Note indicated Resident 1 was up in the hallway in the wheelchair. Staff 17, RN, heard the resident fall. The correlating facility investigation noted the resident had on regular socks that were not non-skid. The alarm was marked as "N/A" and did not sound. In interviews on 5/15/14 at 3:51 pm and 5/16/14 at 11:51 am, Staff 17, RN, stated she was unsure of the status of the alarm when the resident fell on [DATE]. Staff 17 stated the resident would dress herself/himself and staff would follow up to ensure the use of non-skid socks. In interview on 5/16/14 at 11:55 am, Staff 4, CNA, stated she did not recall details regarding the 2/20/14 fall due to the resident having so many falls. In interview on 5/19/14 at 11:42 am, Staff 2, DNS, stated after review of the updated care plans, the resident was care planned to have an alarm in place when the resident fell on [DATE]. The 3/12/14 Progress Note revealed Resident 1 went outside in the courtyard that was full of gravel and was found on the ground. Resident 1 "has been exit seeking all day." The correlating facility investigation indicated the closed garden was replaced with gravel. At 2:00 pm, the resident was trying to go out the front door. At 2:25 pm, the resident was sitting in the wheelchair in front of the nurse's station. The doorway to the courtyard was not secured, the resident exited the doorway and at 2:30 pm, the resident was found down in the graveled courtyard without injury. In interview on 5/15/14 at 2:24 pm, Staff 9, Business Office Manager, stated on 3/12/14 she observed Resident 1 on the ground in the courtyard and alerted nursing staff. In interview on 5/15/14 at 8:52 am, Staff 18, RN, stated she did not witness the fall on 3/12/14, but the resident was found in the gravel. Staff 18 stated the doors to the garden area could be opened and the resident managed to get outside, go off the sidewalk into the gravel and tip her/his wheelchair over. In interview on 5/15/14 at 2:45 pm, Staff 11, CNA, stated Resident 1 was known to exit seek. On 3/12/14, Resident 1 had wandered into the exercise gym, he moved the resident out of the gym and left the resident next to nurse's station. Staff 11 stated he left to answer a call light on another hall and upon return, Staff 9, Business Office Manager, informed him about the incident. The resident was in the courtyard, in the gravel and he assisted the resident back into the wheelchair and into the building. At the time of the survey, Resident 1 no longer resided in the facility. On 4/29/14 at 9:10 am, there was an unlocked door that opened to an enclosed patio, just off of the nurse's station. 3. Resident 6 was admitted to the facility in 1/2014 and readmitted in 2/2014 with [DIAGNOSES REDACTED]. The 3/17/14 In Room ADL Plan Of Care noted interventions including: "KEEP IN SUPERVISED AREAS WHEN IN W/C (WHEELCHAIR)" and the use of non-skid footwear when out of bed. The 4/14/14 6:41 pm Progress Note disclosed Resident 6 was found on the floor of her/his room, next to her/his wheelchair. The correlating facility investigation noted the resident was out of bed for one to two hours prior to the fall and was not wearing proper footwear. The investigation did not address the lack of supervision when the resident was in the wheelchair. When asked about the 4/14/14 fall in interview on 5/15/14 at 2:04 pm, Staff 21, CNA, stated Resident 6 was in the dining area and therapy asked her to keep the resident there until they came to get the resident for therapy. Per Staff 21, she had other residents assigned to her as well as residents in the common area and she stepped out of the room, however, there was another staff member in the room when she left. Resident 6 left the cafe and went back to her/his room, however, she assumed therapy staff had taken the resident for therapy. When asked about the resident's supervision, Staff 21 stated "when (Resident 6) left the room it slipped our attention." The 2/11/14 Chart Care Plan continued the intervention of keeping the resident in supervised areas when in the wheelchair, however, that intervention was not included on the 4/17/14 In Room ADL Plan of Care. The 4/17/14 In Room Plan of Care directed staff to monitor the resident in her/his wheelchair for self propelling out of the cafe and into her/his room. The resident was to be laid down soon after meals. The use of non-skid footwear continued to be noted as an intervention. The 4/22/14 8:14 pm Progress Note disclosed at 7:00 am Resident 6 was found on the floor in her/his room with the wheelchair behind the resident. At 11:45 am, the resident was found on the floor in the cafe. The correlating 7:00 am facility investigation revealed Resident 6 was observed in the cafe, sitting in her/his wheelchair five minutes before the fall. One of the resident's shoes was off under the table where her/his feet were located. The resident was found on the floor in her/his room, lying on her/his back, with the wheelchair behind the resident and the left shoe was off. The resident asked to be put back to bed. The plan to prevent reoccurrences included not leaving the resident in the wheelchair unsupervised and to be the last resident up for meals. The correlating 11:45 am facility investigation disclosed Resident 6 was sitting on the floor in the cafe, in front of her/his wheelchair. The resident was in the dining room, "lights were on, other residents were there" and the CNA was assisting other residents at the time of the fall. Staff 19, CNA, documented on the Assigned Care-staff/Witness Report she left to assist another resident, heard Resident 6's alarm and found the resident on the floor. The 4/22/14 7:00 am and 11:45 am fall investigations did not address the lack of supervision at the time of the falls. In interview on 5/16/14 at 10:50 am, Staff 19, CNA, stated on 4/22/14 she took Resident 6 to the cafe in her/his wheelchair. Staff 19 stated she had other residents to get up that were not in the same hallway as the cafe and she did not have eye contact on the resident at all times. Per Staff 19, while she was assisting other residents, other staff were in and out of the dining room assisting other residents as well. Staff 19 stated she did not believe the resident required constant supervision. The 4/24/14 8:22 am indicated Resident 6 was "found on floor of room in front of w/c." The correlating facility investigation noted Resident 6 was found on the floor in her/his room. The resident was last laid down in bed before breakfast and had been out of bed since breakfast. The external risk factor that could have contributed to the resident's fall was the resident was left unsupervised in the cafe. The investigation did not address the resident not being laid down after breakfast, as care planned. In interview on 5/15/14 at 8:52 am, Staff 18, RN, stated when the resident fell on [DATE], she did not think the resident was left unsupervised for very long. Per Staff 18, the assigned CNA may have left the area to take another resident back to their room. Staff 18 acknowledged Resident 6 was not in a supervised area if the staff member left to provide care for another resident. In interview on 5/15/14 at 9:30 am, Staff 5, CNA, stated he was around the corner from the resident, busy with another resident in the hallway and not in the dining room when the resident fell on [DATE]. In interview on 5/16/14 at 12:45 pm with Staff 2, DNS and Staff 3, RNCM, Staff 3 stated she expected staff to be in the dining room and keep an eye on Resident 6 so the resident did not climb out of the wheelchair. Staff 3 stated due to the resident wheeling herself/himself back to her/his room, on 4/22/14 she added interventions such as lying the resident down after meals. On 4/29/14 at 11:35 am, Resident 6 was observed in bed conversing with visitors. The resident was observed to be severely cognitively impaired.

Based on observation, interview and record review it was determined facility staff failed to ensure professional standards were met regarding safety for 1 of 1 sampled resident (#2) with falls during transport. As a result Resident 2 sustained a fracture. Findings include: DIVISION 63 STANDARDS AND AUTHORIZED DUTIES FORCERTIFIED NURSING ASSISTANTS AND CERTIFIED MEDICATION AIDES 851-063-0090 Conduct Unbecoming a Nursing Assistant "A CNA, regardless of job location, responsibilities, or use of the title " CNA," who, in the performance of nursing related duties, may adversely affect the health, safety or welfare of the public, may be found guilty of conduct unbecoming a nursing assistant. Conduct unbecoming a nursing assistant includes but is not limited to: (1) Conduct related to the client ' s safety and integrity: (e) Neglecting a client. The definition of neglect includes but is not limited to unreasonably allowing a client to be in physical discomfort or be injured; (g) Failing to communicate information regarding the client's status to the supervising nurse or other appropriate person in a timely manner. (6) Conduct related to achieving and maintaining clinical competency: (a) Failing to competently perform the duties of a nursing assistant; (b) Performing acts beyond the authorized duties for which the individual is certified" Resident 2 was admitted to the facility in 1999 with [DIAGNOSES REDACTED]. The current care plan noted Resident 2 was at risk for falls due to a stroke with left sided [MEDICAL CONDITION] and impaired decision making skills. The goal noted the resident "will not receive harm from falls." The 4/14/14 6:05 pm Progress Note indicated while on an outing the resident slipped out of the wheelchair while on the bus. The resident had a small abrasion but no complaints of pain at that time. The 4/15/14 7:43 am and 10:17 am Progress Notes disclosed Resident 2 had pain with cares during the night. At shift change the resident was unable to transfer out of bed and her/his leg appeared turned outward more than noted earlier in the night. The resident had pain upon palpation of the left hip. The physician was contacted and the resident was sent to the emergency room . The facility's correlating investigation noted Staff 7, Activities Director/CNA, transferred Resident 2 into a seat on the bus and left to address another resident and their spouse. Staff 7 reported she did not realize Resident 2 was not seat belted in and while going around a corner, the resident slipped out of the seat and struck her/his left leg on an unknown object. Staff 7 then transferred Resident 2 back into the seat and returned to the facility, where nursing staff assessed the resident for injury. Staff 7 acknowledged she failed to secure the resident with the seat belt before driving the bus. The 4/15/14 hospital x-ray report identified Resident 2 had a left [MEDICAL CONDITION]. The 4/18/14 6:18 pm Progress Note indicated Resident 2 returned to the facility and "has a lot of pain from (Resident 2's) procedure. The left hip was swollen and the resident did not like anyone to get near or touch her/his leg and was anxious when staff were near the leg. The resident rated her/his pain at 10 out of 10. Progress Notes dated 4/19/14 and 4/20/14 indicated the resident continued to have increased pain. On 4/20/14 the physician was contacted, who changed the resident's pain management. On 4/29/14 at 9:30 am, Resident 2 was observed lying in bed and appeared comfortable. When asked about the incident, Resident 2 stated she/he was normally seat belted into the bus, but was not on the day of the incident. Resident 2 stated she/he fractured her/his hip as a result. Staff 1, Administrator, and Staff 7, Activities Director/CNA, were interviewed on 4/29/14 at 10:57 am. Staff 7 stated at the end of the outing on 4/14/14, residents were getting "antsy" and wanted to leave. She transferred Resident 2 into the bus seat but did not put the seat belt in place. Staff 7 assisted another resident and their spouse with getting on the bus but did not go back to ensure Resident 2 was seat belted in. Per Staff 7, "...the way everything got rushed and everyone was getting agitated and wanted to leave" it was an oversight on her part. Staff 7 reported while driving, she was turning the corner going around 30 miles an hour and the resident slid out and landed in the middle of the aisle. She pulled the bus over and got the resident's legs free, as one leg was underneath the seat in front of the resident and the other leg was in the aisle. When asked if she had contacted the facility regarding the incident prior to transferring the resident back to the seat and returning to the facility, Staff 7 stated "No, I just reacted to get (Resident 2) off the floor..." Staff 1, Administrator, stated Staff 7 should have called the facility when the incident occurred to have a nurse come out to assess the resident prior to returning to the facility. On 4/29/14 at 11:20 am, the facility's bus was observed. All bus seats were observed to have seat belts in place.

Based on observation, interview and record review, it was determined the facility failed to provide the necessary care and services related to changes in condition for 1 of 8 sampled residents (#5) reviewed for changes in condition. Resident 5 was hospitalized with [MEDICAL CONDITION] secondary to presumed GI blood loss; [MEDICAL CONDITION] secondary to [MEDICAL CONDITION] and [DIAGNOSES REDACTED]. Findings include: Resident 5 was admitted on [DATE] with [DIAGNOSES REDACTED]. A hospital physician's note dated 7/4/11 indicated the resident had [MEDICAL CONDITION], and hemoglobin was low at 9.6 and hematocrit was low at 30.3. Nurse's Notes dated 7/8/11 indicated the resident had [MEDICAL CONDITION] relieved by [MEDICATION NAME]. There was no evidence of a nursing assessment of the [MEDICAL CONDITION], including vital signs, duration and intensity of the [MEDICAL CONDITION]. Nurse's Notes indicated [MEDICAL CONDITION] continued on 7/19/11, when the resident had two [MEDICAL CONDITION] attacks, and some bright red frank blood in stool; and on 7/23/11. On 8/4/11 the resident's blood pressure dropped after [MEDICATION NAME] was given. Nurse's Notes dated 8/5/11 at 8:35 am indicated the resident was feeling weak. Blood pressure was 98/42 and pulse 58. There was no [MEDICAL CONDITION] or chest pain. On 8/6/11 at 4:30 am the resident complained of right arm numbness and requested to go to the hospital. The resident was sent to the hospital at 5:00 am. A hospital report "Addendum" dated 8/6/11 indicated the resident had [MEDICAL CONDITION] secondary to presumed GI blood loss, [MEDICAL CONDITION] secondary to [MEDICAL CONDITION], and [DIAGNOSES REDACTED]. Laboratory work showed hemoglobin decreased to 6 from 9 in early July. "Other values are stable including renal function." On 8/9/11 physician's orders [REDACTED]. physician's orders [REDACTED]." On 8/11/11 at 4:00 pm Staff 9, RNCM acknowledged that [MEDICAL CONDITION] (low hemoglobin/hematocrit) could cause chest pain related to low oxygen levels to the heart. Staff 9 confirmed from 7/8/11 to 8/5/11 the resident had chest pain, an episode of rectal bleeding and a positive hemoccult (a test for blood in stool). Staff 9 stated the bloody stools were reported to the physician, but no hemoglobin/hematocrit was done to rule out internal bleeding and/or [MEDICAL CONDITION]. At the hospital the resident was anemic, requiring 4 units of blood. On 9/14/11 at 10:45 am, the resident was observed lying in bed. Resident 5 stated there was no further bleeding, and no abdominal pain or chest pain. The resident had not had therapy for 2 - 3 days due to weakness.

Based on interview and record review it was determined the facility failed to competently administer medications for 1 of 1 sampled resident (#9) reviewed for use of potassium ER (extended release) medication. Resident 9 had nausea/vomiting with severe weight loss, and hospitalization for dehydration. Findings include: The Oregon State Board of Nursing (OSBN) Standards and Authorized Duties for Certified Nursing Assistants and Certified Medication Aides: Authorized Duties and Standards for Certified Medication Aides [PHONE NUMBER](9)Standards of Care for Certified Medication Assistants (b) Maintain competency as a CMA. Resident 9 was admitted on [DATE] with [DIAGNOSES REDACTED]. Nurse's Notes dated 6/2/11 indicated the resident was vomiting in the morning and prior to eating lunch, which was "likely pre meal meds." At 10:00 pm there was emesis again. On 6/20/11 the CMA reported that vomiting often occurred after medications were given. Nurse's Notes on 7/1/11 and 7/4/11, indicated the resident had nausea/vomiting. [MEDICATION NAME] and [MEDICATION NAME] were both given. On 7/8/11 there was no nausea/vomiting "since taking pills whole." Nurse's Notes dated 7/14/11, 7/26/11 and 7/27/11, indicated the resident was nauseated and vomiting and ate no lunch. The RD (Registered Dietitian) notified the physician on 8/4/11 of a severe weight loss of 27 pounds in 3 months. Nurse's Notes from 8/3/11 to 8/7/11 indicated the resident had continued constipation, was refusing meals, took small amounts of fluid, and had nausea/vomiting. From 8/8/11 to 8/10/11 [MEDICATION NAME] and [MEDICATION NAME] were given for nausea/vomiting. On 8/10/11 at 9:00 am, the resident's POA (power of attorney) stated CMAs recently reported they were crushing all medications, including potassium, which the CMAs thought might be causing nausea/vomiting. On 8/12/11 at 9:30 am Resident 9 was observed in bed with the head of the bed raised at about 45 degrees. Staff 7, CMA was observed crushing the resident's medications and putting them in pudding, according to a physician's orders [REDACTED]. Previously the resident had potassium 10 mEq, smaller pills that could be crushed. Staff 7 stated the crushed potassium caused the resident to have nausea/vomiting. Staff 7 reported to the RNCM, and the physician, but no alternative form of the medication had been ordered. After discussion with the surveyor, Staff 7 held the potassium ER and notified the charge nurse, Staff 4, LPN. On 8/12/11 at 10:05 am there was a physician's orders [REDACTED]. The order indicated the resident had nausea/vomiting from the crushed potassium ER. On 8/15/11 at 5:00 pm Staff 4, LPN stated prior to 8/12/11, no one reported they were crushing the ER potassium, that liquid potassium could have been thickened. Staff 4 stated if the physician ordered to crush all medications, the CMAs probably had crushed the ER potassium. On 9/13/11 at 4 pm, Staff 11, CMA stated she had broken the potassium ER in half and put it in plain pudding for the resident. The pill was so big the resident could not swallow it whole. Staff 11 did not know that breaking the pill would release more of the medication into the resident's system at one time. Staff 11 stated an inservice had been given recently to nursing staff regarding ER and EC ([MEDICATION NAME] coated) medications not being crushed. On 9/14/11 at 12:10 pm, Staff 12, CMA stated she had crushed the potassium ER, even though she knew it should not be crushed, because the pill was too big for the resident to swallow. Staff 12 thought all the CMAs had crushed the potassium ER. The resident was observed on 9/14/11 at 11:00 am lying in bed. The resident stated she/he had no pain, appetite good, not sick to stomach, no constipation and that she/he "feels pretty good." Refer to F329.

Based on interview and record review it was determined the facility failed to comprehensively assess health conditions for 1 of 1 sampled resident (# 5) whose comprehensive assessment was reviewed. Resident 5 was hospitalized with [MEDICAL CONDITION] secondary to presumed GI blood loss; [MEDICAL CONDITION] secondary to [MEDICAL CONDITION] and [DIAGNOSES REDACTED]. Findings include: 1. Resident 5 was admitted on [DATE] with [DIAGNOSES REDACTED]. A hospital physician's note dated 7/4/11 indicated the resident had [MEDICAL CONDITION], with low hemoglobin of 9.6 and hematocrit of 30.3. Nurse's Notes dated 7/8/11 indicated the resident had [MEDICAL CONDITION] relieved by [MEDICATION NAME]. There was no evidence of a nursing assessment of the [MEDICAL CONDITION], including vital signs, duration and intensity of the [MEDICAL CONDITION]. The Care Area assessment dated [DATE] did not include an assessment of the [MEDICAL CONDITIONS] or chest pain. Nurse's Notes indicated [MEDICAL CONDITION] continued on 7/19/11, when the resident had two [MEDICAL CONDITION] attacks, and some bright red frank blood in stool; on 7/23/11 when [MEDICATION NAME] was given three times; and on 8/4/11 when the resident's blood pressure dropped after [MEDICATION NAME] was given. Nurse's Notes dated 8/5/11 at 8:35 am indicated the resident was feeling weak. Blood pressure was 98/42 and pulse 58. There was no [MEDICAL CONDITION] or chest pain. Nurse's Notes dated 8/6/11 at 4:30 am indicated the resident complained of right arm numbness and requested to go to the hospital. A hospital report "Addendum" dated 8/6/11 indicated the resident had [MEDICAL CONDITION] secondary to presumed GI blood loss, [MEDICAL CONDITION] secondary to [MEDICAL CONDITION], and [DIAGNOSES REDACTED]. Laboratory work showed hemoglobin decreased to 6 from 9 in early July. "Other values are stable including renal function." On 8/9/11 physician's orders [REDACTED]. physician's orders [REDACTED]." On 8/11/11 at 4:00 pm Staff 9, RNCM acknowledged that [MEDICAL CONDITION] (low hemoglobin/hematocrit) could cause chest pain related to low oxygen levels to the heart. Staff 9 was unable to provide evidence of a comprehensive assessment of [MEDICAL CONDITION], chest pain, and [MEDICAL CONDITION]. Refer to F309.

Based on observation, interview and record review it was determined the facility failed to provide medications with adequate indications for use, and gave medications in the presence of adverse consequences for 2 of 2 sampled residents (#s 1 & 9) whose medication regimens were reviewed. Resident 1 had [MEDICAL CONDITION], abdominal pain and GI bleed with hospitalization for ischemic [MEDICAL CONDITION]; and nausea/vomiting and anorexia with significant weight loss. Resident 9 had nausea/vomiting with severe weight loss, was hospitalized for [REDACTED]. Findings include: 1. Resident 1 was admitted on [DATE] with diagnoses which included [MEDICAL CONDITIONS] and hypertension. A hospital medication transfer list dated 12/30/11, included [MEDICATION NAME] mg, oral, sustained release [MEDICATION NAME] (an opioid medication) twice daily, [MEDICATION NAME]-[MEDICATION NAME] ([MEDICATION NAME], an opioid medication) every 6 hours if needed for pain, [MEDICATION NAME] ([MEDICATION NAME], an anti-emetic medication) every 6 hours as needed for nausea/vomiting, and [MEDICATION NAME] (opiate [MEDICATION NAME]) 5 - 10 mg every 4 hours as needed for pain. A Pain assessment dated [DATE] indicated the resident had pain related to a [MEDICAL CONDITION]. [MEDICATION NAME] ER 15 mg every eight hours was given for pain. The pain assessment did not include the type, duration or intensity of the pain, or the use of non-pharmacological pain relief measures. On 3/1/11 a note from the pharmacist to the physician indicated that [MEDICATION NAME] (anticonvulsant) was given without a [DIAGNOSES REDACTED]. According to the MAR indicated [REDACTED]. There was no [DIAGNOSES REDACTED]. A psychoactive drug review dated 3/17/11 indicated [MEDICATION NAME] (antipsychotic medication) was given for opioid induced nausea with a start date of 1/26/11. The resident had a "very poor appetite" with 20 - 40 % of meals eaten. The resident "... is going to need a G.I. workup. Will add [MEDICATION NAME] (anti-ulcer medication) & re-eval 2 - 3 (days)." Nurse's Notes from 2/19/11 to 3/31/11 did not include any references to the resident's nausea/vomiting, and no evidence of a GI work-up. MARs dated 3/2011 included the following medications given routinely: [MEDICATION NAME] ER 15 mg every 8 hours, and [MEDICATION NAME] 1 mg daily. [MEDICATION NAME] for complaints of "upset GI" was given three times. A pharmacist's "Note to Attending Physician Prescriber" dated 3/19/11, indicated there was no rationale/reason for use of [MEDICATION NAME] for opioid induced vomiting. The physician was asked to reassess the risk/benefit or document the clinical rationale to support [MEDICATION NAME] use. The physician indicated Resident 1's [MEDICAL CONDITION] problems remained undiagnosed , the resident was nauseated, and that Hospice literature clearly supported [MEDICATION NAME] to address opioid induced nausea. The physician added [MEDICATION NAME]. There was no evidence the resident was on hospice, and no risk/benefit was found for the use of [MEDICATION NAME]. On 3/21/11 another pharmacist's note to the physician indicated the resident was receiving [MEDICATION NAME] 1 mg daily for opioid induced nausea/vomiting. The staff reported the resident had decreased appetite completing approximately 20% of meals. In addition the resident was complaining of headaches which might be caused by arm spascity. The physician was asked to consider discontinuing the [MEDICATION NAME] and starting [MEDICATION NAME] 2.5 mg twice daily for appetite stimulation and opioid induced nausea/vomiting; and initiating [MEDICATION NAME] 10 mg twice daily for spascity. On 3/23/11, the physician disagreed. There was no risk/benefit found, and no assessment of the resident's arm spascity. Care Plans and Temporary Care Plans indicated the resident had H. pylori oral thrush on 3/16/11 and 5/16/11, and took fluconazole ([MEDICATION NAME], systemic antifungal medication). A fax to the physician dated 4/20/11 indicated the resident had continued anorexia with weight loss of 5.2 % in one month. [MEDICATION NAME], medication to stimulate the appetite was ordered. Opioids and [MEDICATION NAME] were continued without further assessment in relation to the weight loss. Nurse's Notes dated 5/1/11 indicated the use of [MEDICATION NAME] to increase the resident's appetite was discussed with the resident's family. On 5/4/11 there were orders for [MEDICATION NAME] ES and [MEDICATION NAME]. There was no information related to when [MEDICATION NAME] had been discontinued (from 4/2011), or if there was a change in the dosage of [MEDICATION NAME]. There was no risk/benefit found for the use of [MEDICATION NAME] for appetite stimulation. Nurse's Notes dated 5/17/11 indicated the resident's weight had increased and "thrush treated (with) [MEDICATION NAME]." A Consultant Pharmacist Medication Regimen Review summary dated 5/19/11 indicated the resident was receiving [MEDICATION NAME] for thrush and was on [MEDICATION NAME] inhaler. An AIMS (Abnormal Involuntary Movement Scale) related to [MEDICATION NAME] use was suggested. On 8/8/11 at 3:25 pm Staff 6, DNS stated the resident had some chest pain from working with therapy. [MEDICATION NAME] was given for chest pain. The resident was a "failure to thrive" with no appetite, and was given antibiotics for H. pylori thrush. An AIMS evaluation was found dated 8/10/11 which did not identify any abnormal involuntary movements. There was no reason given for the delay in obtaining the AIMS, or evidence the arm spascity was assessed. MARs dated 6/2011, 7/2011 and 8/2011 included the following medications that were continued throughout that time period: [MEDICATION NAME] ER 15 mg every 8 hours, [MEDICATION NAME] 0.5 mg once daily for opioid induced nausea, [MEDICATION NAME] ([MEDICATION NAME]) 20 mg before am and pm meals. [MEDICATION NAME] was given from 5/4/11 to 6/3/11, from 6/4/11 to 7/3/11, from 7/7/11 to 7/11/11 and from 8/3/11 to 8/11/11, without an indication for it's use. Nurse's Notes dated 7/3/11, indicated Resident 1 had chest pain, on 7/13/11 had severe abdominal pain with a large incontinent BM and on 7/14/11 had bright red bleeding in stool, and was sent to the emergency room . The hospital Discharge Summary dated 7/17/11 indicated the resident had ischemic [MEDICAL CONDITION]. On 7/22/11 the resident complained of chest pain. Three days later, on 7/25/11 Staff 4, LPN noted what appeared to be a [MEDICAL CONDITION] about 60 seconds. The resident was sent to the hospital. On 7/27/11, hospital discharge instructions indicated the resident had aspiration pneumonia. On 8/10/11 at 2:08 pm, Staff 3, Therapy staff stated the resident had been sent to the hospital that day (8/10/11) after the resident complained of severe headache and right arm numbness while in therapy. Hospital Discharge Instructions dated 8/10/11, indicated the resident had "brief" chest pain (non-specific). According to Mosby's Nursing Drug Reference, [MEDICATION NAME] and [MEDICATION NAME] both include side effects of [MEDICAL CONDITIONS], respiratory depression, nausea/vomiting, headache and anorexia. Contraindications for [MEDICATION NAME] include hemorrhage. [MEDICATION NAME] has common side effects which include headache, abdominal pain, vomiting, nausea, and acid regurgitation. [MEDICATION NAME] and [MEDICATION NAME] inhaler, both corticosteriods, are contraindicated for use in the presence of fungal infections. [MEDICATION NAME] includes side effects of fungal infections, and GI hemorrhage. [MEDICATION NAME] includes [MEDICAL CONDITION] as a side effect. On 8/12/11 at 11:40 am Staff 5, RNCM was unable to provide further information about the continued use of opioids with nausea/vomiting, whether there were attempts to taper the [MEDICATION NAME], or the continued use of [MEDICATION NAME] without a risk/benefit. There was no information provided that staff had considered medication side effects as factors in the resident's thrush, anorexia, weight loss, GI bleed, [MEDICAL CONDITION], nausea/vomiting, or chest pain. During observations on 8/3/11 at 3:30 pm, and 8/12/11 at 9:30 am, the resident was observed sleeping in bed, and was not awakened for an interview. 2. a. Resident 9 was admitted on [DATE] with diagnoses which [MEDICAL CONDITION] anxiety. A Physician Communication form dated 4/12/11 included a family request for scheduled Tylenol in lieu of scheduled [MEDICATION NAME] (opiate [MEDICATION NAME]) with PRN [MEDICATION NAME] available. The family felt the resident was overmedicated and that new orders including [MEDICATION NAME] 5 mg every 4 hours, along with [MEDICATION NAME] (anti-anxiety medication) 1 mg TID might oversedate the resident at times. The physician ordered [MEDICATION NAME] 1 mg in the evening and BID PRN anxiety, and [MEDICATION NAME] 5 mg every 8 hours. No Tylenol was ordered. There was no evidence of a pain assessment related to oversedation or the use of Tylenol for pain control. MARs dated 5/2011 included [MEDICATION NAME] 5 mg every 8 hours started on 4/13/11 for pain, and BID PRN. The scheduled [MEDICATION NAME] was given, with additional PRN [MEDICATION NAME] given three times. There was no Tylenol listed on the MAR. Nurse's Notes from 5/17/11 to 5/22/11 indicated the resident had some nausea/vomiting related to opioid use. On 6/3/11 a Nursing Quarterly Summary indicated the resident had pain in the right lower extremity. [MEDICATION NAME] PRN for pain appeared to be effective. There was no assessment related to how often the resident was using [MEDICATION NAME], it's effectiveness or side effects; or if Tylenol had been considered. The MARs dated 6/2011 included Tylenol 325 mg, two tablets one hour prior to PT (Physical Therapy) with a start date of 6/15/11. It was given one time on 6/20/11. [MEDICATION NAME] 5 mg every 8 hours was given with the exception of 17 doses circled as not given. Nurse's Notes dated 6/23/11 indicated the resident was sent to the emergency room for impaction concerns. The hospital Discharge Summary dated 6/28/11 indicated the resident was admitted for difficulty swallowing and dehydration. The resident received IV fluids for 48 hours. A note to the physician dated 6/29/11 requested scheduled [MEDICATION NAME] 5 mg every 8 hours be discontinued and changed to PRN. The family indicated Tylenol given in the hospital was effective for pain control. On 6/30/11 the physician agreed to that request. MARs dated 7/2011 indicated Tylenol 325 mg, 2 tablets were ordered for one hour prior to PT. For the month of 7/2011 Tylenol was given twice, and [MEDICATION NAME] 5 mg was given 9 times. There was no Tylenol listed for routine use for pain control. [MEDICATION NAME] for nausea/vomiting was given 10 times; four of those times correlated with administration of [MEDICATION NAME]. Nurse's Notes on 7/1/11 and 7/4/11, indicated the resident had nausea/vomiting. [MEDICATION NAME] and [MEDICATION NAME] were both given. Nurse's Notes dated 7/13/11, indicated a large fecal impaction was removed. On 7/14/11, 7/26/11 and 7/27/11, the resident was nauseated and vomiting and ate no lunch. Nurse's Notes from 7/27/11 to 8/3/11, indicated the resident had constipation, even though the bowel protocol was followed. Nausea was sporadic during that time period and it was noted that [MEDICATION NAME] was given for pain. The resident also was refusing meals. The RD (Registered Dietitian) notified the physician on 8/4/11 of a severe weight loss of 27 pounds in 3 months. Nurse's Notes from 8/3/11 to 8/7/11 indicated the resident had continued constipation, was refusing meals, took small amounts of fluid, and had nausea/vomiting. From 8/8/11 to 8/10/11 [MEDICATION NAME] and [MEDICATION NAME] were given for nausea/vomiting. There was a physician's orders [REDACTED]. Mosby's Nursing Drug Reference includes [MEDICATION NAME] side effects of vomiting, anorexia, sedation and constipation. Side effects of [MEDICATION NAME] include constipation. [MEDICATION NAME] includes a side effect of increased appetite, as well as nausea/vomiting and constipation. On 8/10/11 at 9:00 am, the resident's POA (power of attorney) stated the resident's pain medication ([MEDICATION NAME]) caused constipation and impaction. The resident's weight loss was attributed to vomiting. On 8/12/11 at 9:30 am Resident 9 was observed in bed with the head of the bed raised. Staff 7, CMA stated the resident had trouble swallowing, and was frequently nauseated after taking medication. The resident was observed to swallow the medication in pudding. On 8/12/11 at 11:40 am Staff 5, RNCM stated the most recent pain assessment was done in 3/2011, and that [MEDICATION NAME] had been changed to PRN recently. Staff 5 was unable to provide evidence of follow-up to concerns regarding [MEDICATION NAME] causing oversedation, constipation, anorexia, nausea/vomiting, and weight loss. There was no evidence provided that Tylenol given routinely was attempted for pain control. On 8/16/11 a Medication Review signed by Staff 5 indicated the resident was sensitive to narcotics and when taking [MEDICATION NAME] there was a correlation with nausea/vomiting. The resident preferred Tylenol for pain which the resident stated provided pain relief without nausea/vomiting. There was no further information provided that constipation, impaction, dehydration, nausea/vomiting, anorexia and weight loss were assessed as side effects/adverse consequences of medications. 2. b. Nurse's Notes dated 6/2/11 indicated Resident 9 was vomiting in the morning and prior to eating lunch, which was "likely pre meal meds." At 10:00 pm there was emesis again. On 6/20/11 the CMA reported that vomiting often occurred after medications were given. Nurse's Notes on 7/1/11 and 7/4/11, indicated the resident had nausea/vomiting. [MEDICATION NAME] and [MEDICATION NAME] were both given. On 7/8/11 there was no nausea/vomiting "since taking pills whole." Nurse's Notes dated 7/14/11, 7/26/11 and 7/27/11, indicated the resident was nauseated and vomiting and ate no lunch. Nurse's Notes from 8/3/11 to 8/7/11 indicated the resident had continued constipation, was refusing meals, took small amounts of fluid, and had nausea/vomiting. From 8/8/11 to 8/10/11 [MEDICATION NAME] and [MEDICATION NAME] were given for nausea/vomiting. On 8/10/11 at 9:00 am, the resident's POA (power of attorney) stated CMAs recently reported they were crushing all medications, including potassium, which the CMAs thought might be causing nausea/vomiting. On 8/12/11 at 9:30 am Resident 9 was observed in bed with the head of the bed raised at about 45 degrees. Staff 7, CMA was observed crushing the resident's medications and putting them in pudding, according to a physician's orders [REDACTED]. Previously the resident had potassium 10 mEq, smaller pills that could be crushed. Staff 7 stated the crushed potassium caused the resident to have nausea/vomiting. Staff 7 reported to the RNCM, and the physician, but no alternative form of the medication had been ordered. After discussion with the surveyor, Staff 7 held the potassium ER and notified the charge nurse, Staff 4, LPN. On 8/12/11 at 10:05 am there was a physician's orders [REDACTED]. The order indicated the resident had nausea/vomiting from the crushed potassium ER. On 8/15/11 at 5:00 pm Staff 4, LPN stated previous to 8/12/11, no one reported they were crushing the ER potassium. There was no evidence nursing staff assessed the resident's nausea/vomiting after medication was administered. The resident was observed on 9/14/11 at 11:00 am lying in bed. The resident stated she/he had no pain, appetite good, not sick to stomach, no constipation and that she/he "feels pretty good."

Based on interviews and record review, it was determined the facility failed to provide the necessary care and services for 1 of 6 sampled residents (#1). Resident 1's right leg was observed to be in contact with the baseboard heater at 11:35 pm on 2/26/11 and was not provided with emergency medical treatment until 11:00 am on 2/27/11. The local hospital emergency room diagnosed the resident with second and third-[MEDICAL CONDITION] transferred the resident to a burn unit. Findings include: Scope of Practice State Standards for All Licensed Nurses [PHONE NUMBER] (1) (b) Intervenes on behalf of the client to identify changes in health status, to protect, promote and optimize health, and to alleviate suffering. Scope of Practice Standards for Registered Nurses [PHONE NUMBER] (2) (a) Conduct and document initial and ongoing comprehensive and focused nursing assessments of the health status of clients by: (A) Collecting objective and subjective data from observations, examinations, interviews, and written records in an accurate and timely manner as appropriate to the client's health care needs and context of care; (D) Anticipating and recognizing changes or potential changes in client status: identifying signs and symptoms of deviation from current health status; and (E) Validating data by utilizing available resources, including interactions with the client and health team members. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was only one NN written during the night shift of 2/27/11. Staff 10 (RN) wrote the NN (no specific time) and it indicated "resident was found with right leg resting on heater beside bed. CNA stated she had looked in minutes prior; resident was sleeping in bed then. At 0030 (12:30 am) what appears to be a broken blister located on right leg. Dry gauze dressing applied-FYI (For Your Information) to Dr (physician). Family will be notified in am. Resident does not appear to be in pain. Bed moved away from heater." The resident's February 2011 MAR indicated [REDACTED]. The FYI or Physician Communication Form written on 2/27/11 by Staff 10 (RN) (no specific time) indicated the concern was the resident's right lower leg "appeared to have a broken blister. An hour prior the resident was found with leg on heater." The other objective assessment written by Staff 10 indicated the resident needed pain medication increased as well. There was no documentation of an ongoing assessment of the condition of the resident's leg during the night shift. There was no documentation of the effectiveness of the Tylenol provided at 1:45 am. There was no documentation of an ongoing pain assessment of the resident during the night shift. The 2/27/11 NN written at 10:15 am by Staff 6 (RNCM) as an RN assessment of the resident's blisters to right leg and heel. The resident's anterior (front) ankle had a 3.5 by 4.5 (cm) clear fluid-filled blister. The right inner ankle blister measured 2 by 2 cm; heel blister measured 13 by 13 (cm) and wrapped around the resident's entire heel. Staff 6 wrote that she was unable to visualize the wound bed though described it as light pink, light purple and white. The resident's ankle was described as having slight [MEDICAL CONDITION]. There was a broken blister along the resident's calf with the pink wound bed measuring 6 by 6 cm. The redness in the area was described as 18 inches by 4 cm. The resident was medicated with [MEDICATION NAME] (narcotic pain medication). The physician observed the resident's wounds and new orders received. On 2/27/11 Witness 2 (physician) wrote a note on the FYI or Physician Communication Form to indicate the resident's bed was next to baseboard heater and the resident's right leg was in contact with the heater. Witness 2 assessed the resident to have second-[MEDICAL CONDITION] lateral (the side of) calf. Witness 2 indicated the area of white along the resident's lateral foot and ankle "may be deeper." Witness 2 indicated there was some blistering on the heel. Witness 2 assessed the resident to have second-[MEDICAL CONDITION] possibly third-[MEDICAL CONDITION] the right foot. Witness 2's written plan was to dress the wounds with Hydrogel, observe for further progression and provide [MEDICATION NAME] for pain control. The 2/27/11 local hospital emergency department assessment of Resident 1's injuries indicated the resident sustained [REDACTED]. Third-[MEDICAL CONDITION] the resident's lateral (side) foot measured 15 cm by 4 cm and 4 cm by 2 cm on the right lateral calf. A second-degree burn on right anterolateral (front side) lower leg measuring 8 cm by 8 cm, several intact blisters, extensive first-[MEDICAL CONDITION] the resident's knee to the right foot; extensive second-degree laterally and most of the heel. The resident was transferred to a burn unit for treatment. An interview on 3/9/11 at 5:38 pm with Staff 10 (RN) and Staff 2 (DNS) revealed Staff 10 was informed by Staff 11 (CNA) on 2/27/11 at 12:30 am there was a wet spot on the resident's bed sheets from an opened blister on the resident's right lower calf. Staff 10 stated she applied a dry sterile dressing to the resident's right leg and wrote an FYI or Physician's Communication Form. Staff 10 was asked if the resident's physician was contacted regarding the resident's injury and obtained an order for [REDACTED]. Staff 10 stated the resident's burn did not appear serious and a physician's orders [REDACTED]. Staff 10 indicated that it was appropriate to apply a dry dressing on an open burn blister. Staff 10 indicated she administered Tylenol to the resident on 2/27/11 at 1:45 am and assessed the resident at 3:00 am. Staff 10 indicated the resident did not appear to be in pain during the night shift. An interview on 3/9/11 at 6:00 pm with Staff 2 (DNS) revealed that Staff 2 felt a dry dressing was appropriate to protect the resident's burn from infection. Staff 2 indicated it was appropriate to place a dry dressing on the leg without a physician's orders [REDACTED]. An interview on 3/9/11 at 1:08 pm and 3/10/11 at 8:00 am with Staff 6 (RNCM) revealed she arrived at the facility at 5:45 am on 2/27/11. Staff 6 stated it was reported to her that Resident 1 had a burn blister on his/her right leg. Staff 6 indicated the resident's right leg was wrapped with a dry gauze dressing from the calf to the middle of the foot. Staff 6 indicated when the dry gauze dressing was removed it was not wet and there were areas of skin that was removed when the dressing was removed. Staff 6 stated she had no experience in [MEDICAL CONDITION] indicated the resident's physician needed to be notified when the burn was identified and treatment orders obtained before the placement of a dry dressing on a burn blister. An interview with Staff 5 (LPN) on 3/9/11 at 12:08 pm revealed she was the charge nurse on the day shift of 2/27/11. Staff 5 stated Staff 10 (RN) informed her that Resident 1 had a blister on her/his right leg. Staff 5 stated the resident had a dressing on her/his right leg from her calf and down to the middle of the foot. Staff 5 stated the dressing remained intact until the resident was assessed by the physician on 2/27/11. Staff 5 indicated the resident had no signs and symptoms of pain. Staff 5 stated she did not know the severity of the resident'[MEDICAL CONDITION] she removed the dressing. An interview on 3/9/11 at 4:09 pm with Witness 2 (Resident 1's physician) revealed Staff 10 (RN) needed to contact Witness 2 when she observed that the resident's burn blister opened. Witness 2 indicated a dry gauze dressing was not an appropriate treatment and Staff 10 needed a physician's orders [REDACTED]. Witness 2 stated that initially he didn't think [MEDICAL CONDITION] severe though when he saw there were areas of white he indicated the resident needed to be seen at the local hospital emergency room . On 3/9/11 the surveyor reviewed the Mayo Clinic website entitled Burns: First Aid. The website indicated when the first layer of skin had been burned through and the second layer of skin (dermis) also was burned, the injury was called a second-degree burn. Blisters developed and the skin would have an intense reddened, splotchy appearance. If the second degree burn was larger than 3 inches (7.6 centimeters) or on the feet, the burn was to be treated as a major burn and medical help was needed immediately. Major burn treatment was defined as a call to 911 or emergency medical help. Until emergency unit arrived the burned area was to be covered with cool, moist, sterile bandage; clean moist cloth; or moist towels. On 3/10/11 at 7:46 am Staff 2 (DNS) reviewed the Mayo Clinic website and confirmed there was no documentation of the size and condition of the resident's burn during the night shift of 2/27/11. Staff 2 confirmed the use of dry gauze was not an appropriate intervention and the resident required emergency treatment at the time the burn blister was first identified. Staff 2 confirmed there was no documentation of the effectiveness of the pain medication provided and ongoing pain assessment during the night shift of 2/27/11. Refer to F-323.

Based on observations, interviews and record review it was determined the facility failed to provide an environment free of a burn hazard from the room baseboard heater for 1 of 6 sampled residents (#1). Resident 1 sustained second and third-degree burns The resident was transferred to a burn center. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 2/16/11 facility physical therapy notes indicated the resident required maximum assistance with bed mobility. The 2/16/11 In Room ADL Plan of Care indicated the resident was dependent with bed mobility and needed to be turned every two hours. The 2/23/11 MDS assessed the resident was totally dependent on the assistance of one for bed mobility. On 3/9/11 at 10:45 am, the following observations were made during a tour of the facility with Staff 1 (Administrator): all resident rooms were private rooms, the baseboard heaters were observed to be attached to the wall under the room windows, the thermostats for the baseboard heaters were in a locked case on the wall opposite of the windows and there were mesh screens attached along the bottom of the heaters. The 2/27/11 NN written during the night shift (no specific time) by Staff 10 (RN) indicated "resident was found with right leg resting on heater beside bed. CNA stated she had looked in minutes prior, resident was sleeping in bed then. At 0030 (12:30 am) what appears to be a broken blister located on right leg. Dry gauze dressing applied-FYI (For Your Information) to Dr (physician). Family will be notified in am. Resident does not appear to be in pain. Bed moved away from heater." The 2/27/11 NN written at 10:15 am by Staff 6 (RNCM) as an RN assessment of the resident's blisters to right leg and heel revealed the resident's anterior (front) ankle had a 3.5 by 4.5 (cm) clear fluid-filled blister. The right inner ankle blister measured 2 by 2 cm; heel blister measured 13 by 13 (cm) and wrapped around the resident's entire heel. Staff 6 wrote that she was unable to visualize the wound bed though described it as light pink, light purple and white. The resident's ankle was described as having slight edema. There was a broken blister along the resident's calf with the pink wound bed measuring 6 by 6 cm. The redness in the area was described as 18 inches by 4 cm. The resident was medicated with Oxycodone (narcotic pain medication). The physician observed the resident's wounds and new orders received. Witness 2 (physician) wrote a 2/27/11 note on the FYI or Physician Communication Form to indicate the resident's bed was next to baseboard heater and the resident's right leg was in contact with the heater. Witness 2 assessed the resident to have second-degree and possible third-degree burns to the resident's right foot, calf, ankle and heel. The 2/27/11 NN written at 11:00 am by Staff 5 (LPN) indicated the facility called Witness 3 (the resident's family member) and the resident was sent to the local hospital emergency room for treatment. The next NN written for the day shift indicated the resident was transferred to the local burn unit. The NN written at 5:00 pm indicated Witness 3 called and wanted to know how the incident occurred. Staff 5 indicated Staff 1 (Administrator) and Staff 2 (DNS) would be conducting an investigation and would follow up with Witness 3. Staff 5 informed Witness 3 the resident was found with leg on the heater. The 2/27/11 local hospital emergency department assessment of Resident 1's injuries indicated the resident sustained [REDACTED]. Third-degree burns on the resident's lateral foot measured 15 cm by 4 cm and 4 cm by 2 cm on the right lateral calf. A second-degree burn on right anterolateral lower leg measuring 8 cm by 8 cm, several intact blisters, extensive first-degree burns from the resident's knee to the right foot; extensive second-degree laterally and most of the heel. The resident was transferred to a local burn unit for treatment. The Incident/Accident Report Witness Report written by Staff 11 (CNA) indicated on 2/26/11 at 11:30 pm Staff 11 found Resident 1 with his/her left leg on the heater. Staff 11 indicated the resident had a popped blister, skin discoloration and wrote a statement of "possibly a burn" and had a question mark after the statement. Staff 11 indicated Staff 10 (RN) checked the resident and the instructions given to Staff 11 were to "roll the resident on his/her right side." An interview on 3/10/11 at 6:55 am with Staff 11 (CNA) and Staff 2 (DNS) revealed the resident never moved when in bed. Staff 11 indicated the resident was a one person assist for bed mobility. Staff 11 indicated on 2/26/11 at 11:30 pm, the resident was pulling on the assist rail on the upper portion of the bed in an attempt to get out of bed. Staff 11 stated she saw the resident going toward the baseboard heater and never saw the resident's foot on the heater. Staff 11's Witness Report was read to her regarding her statement that she found the resident's left foot on the baseboard heater. Staff 11 stated that was an error and she had written an addendum to indicate she never the saw the resident's foot touch the baseboard heater. Staff 11 was shown there was no documentation of an addendum included in the Incident/Accident report. Staff 11 indicated she assisted the resident back into bed and lowered the bed. Staff 11 demonstrated the height of the resident's bed when she observed the resident trying to get out of bed. Staff 11 indicated the bed was not in a low position and was at mid-height. Staff 11 indicated she saw the resident's leg was midway down the mattress and the resident's foot was approximately 12 inches higher than the baseboard heater. Staff 11 indicated the side of the resident's bed was located within six inches of the side of the baseboard heater. Staff 11 stated there were no other preventative approaches used to protect the resident from the baseboard heater. Staff 11 did not indicate the resident's bed was moved away from the baseboard heater. Staff 11 stated on 2/27/11 at 12:30 am, she noticed a wet spot on the bed sheet and noticed a popped blister on the resident's leg. Staff 11 indicated she informed Staff 10 (RN) that the resident was crawling out of bed and the open blister on the resident's leg. Staff 11 and Staff 2 indicated the resident had socks on the night of 2/27/11 and there were no burn marks on the resident's right sock. An interview on 3/10/11 at 7:46 am with Staff 2 (DNS) verified that Staff 11 (CNA) stated she had not seen the resident's foot on the baseboard heater though this was what was written in the Witness Report. Staff 2 confirmed Staff 11's Witness Report indicated the resident's left leg was involved instead of the resident's right leg. Staff 2 also verified that Staff 11 did not state the resident's bed had been moved away from the heater when the resident was observed to attempt to crawl out of bed. The Incident/Accident Report completed by Staff 10 (RN) indicated Staff 11 (CNA) was checking on the resident at 11:25 pm and the resident put his/her right leg on the heater. Staff 10 wrote that the immediate response to the incident was that the resident's bed was moved away from the heater. Staff 10 indicated there had been no injury during transfer. An interview on 3/9/11 at 5:38 pm with Staff 10 (RN) and Staff 2 (DNS) revealed Staff 10 could not remember the placement of the resident's bed before 12:30 am on 2/27/11. Staff 10 stated at 12:30 am on 2/27/11 Staff 11 (CNA) informed her there was a wet spot on the resident's bed from the opened blister on the resident's right lower calf and at 11:25 pm Staff 11 (CNA) observed Resident 1 trying to crawl out of bed and the resident placed his/her right foot on the baseboard heater. Staff 10 stated that Staff 11 informed her that the bed was moved away from the heater after 11:25 pm. Staff 10 stated she observed the resident's bed had been moved away from the baseboard heater at 12:30 am. Staff 10 stated that she had never seen or heard of the resident attempting to crawl out of bed prior to 2/26/11. An interview on 3/15/11 at 11:00 am with Witness 3 (Resident 1's family member) revealed Witness 3 and other family members where at the facility the evening of 2/26/11 until 8:00 pm. Witness 3 stated the resident's bed was less than six inches from the baseboard heater on the outside wall and was concerned about the resident's blankets near the heater. Witness 3 stated the baseboard heater was cold to the touch. Witness 3 stated when she arrived at the facility on 2/26/11; the resident's bed was low to the floor. Witness 3 estimated the bed was 18 inches or less off of the floor. Witness 3 stated the resident was cared for by Staff 12 (CNA) and did not see the location of the bed after Staff 12 cared for the resident after 8:00 pm. Witness 3 stated the resident was not able to get out of bed on his/her own and needed assistance to sit up in bed. Witness 3 stated the resident was not capable of independently getting into a sitting position. An interview on 3/15/11 at 4:37 pm with Staff 12 (CNA) revealed Staff 12 was "75 percent" sure that Resident 1's bed was placed in a low position off of the floor. Staff 12 estimated the bed was positioned at twelve to eighteen inches off of the floor. Staff 12 indicated when the resident was placed in bed the resident would have been three to five inches higher than the baseboard heater. Staff 12 stated the resident was last observed by Staff 12 at 9:45 pm and the resident was located in the middle of the resident's bed. Staff 12 stated before the incident with Resident 1 the facility had the majority of the residents' beds against the baseboard heaters. Staff 12 was not aware of any prior incidents of residents being burned by the baseboard heater. Staff 12 stated the baseboard heater had not been touched by Staff 12 to determine if it was hot. The resident's care plan did not indicate the resident's bed needed to be located away from the baseboard heater or the height of the resident's bed. An interview with Staff 5 (LPN) on 3/9/11 at 12:08 pm revealed she was the charge nurse on the day shift of 2/27/11. Staff 5 indicated the resident required a total assistance with bed mobility and was never observed to move in bed. An interview on 3/9/11 at 1:46 pm with Staff 7 (CNA) stated she worked with the resident and indicated the resident never moved around in bed and needed the total assistance of one CNA for bed mobility. An interview on 3/9/11 at 1:51 pm with Staff 8 (CNA) stated she worked with the resident and indicated the resident stayed in the exact same spot in the bed when she was assisted into bed. The 2/27/11 Incident Follow-Up written by Staff 6 (RNCM) indicated the resident had [DIAGNOSES REDACTED]. Staff 6 indicated Staff 11 (CNA) stated the resident was restless and was seen attempting to "get out of bed" at approximately 11:30 pm on 2/26/11 and the resident's right leg was found resting on the floor baseboard heater. Staff 6 indicated the resident's bed was not in a low position. An interview on 3/9/11 at 1:08 pm with Staff 6 (RNCM) revealed Resident 4 sustained a burn on his/her foot from the baseboard heater four years prior to 2011. Staff 6 stated at that time the facility's policy was that the residents beds were not to be placed in the low position near the baseboard heaters. Staff 6 stated there had been no facility policy to place the residents' beds away from the baseboard heaters until after the incident involving Resident 1. Resident 4's 11/25/06 NN indicated at 5:00 am CNA found resident with his/her feet over edge of bed on the baseboard heater. The resident had also been rubbing his/her foot back and forth on the wall. The resident's left foot had an open area on the end of great toe and several blisters underneath his/her toes and his/her smaller toes. The resident's great toe on the right foot had a blister down the outside of the toe and several blisters under the smaller toes. The resident's bed was turned to other side of the room and away from the heater. The resident's physician examined the resident at 3:00 pm and obtained orders for Silvadene for the resident's blistered feet. An interview on 3/9/11 at 10:14 am with Staff 3 (CNA) revealed there had been incidents in the past when a resident who had Alzheimer's disease placed his/her feet under the baseboard heater to warm their toes and sustained a burn. Staff 3 stated the facility placed a metal strip underneath all of the baseboard heaters so the residents were no longer able to place their feet under the baseboard heater. On 3/9/11 at 8:00 am Witness 4 (Management Representative) indicated the facility had a change of management companies on 1/1/11. On 3/10/11, Witness 4 provided written information regarding the baseboard heaters. On 1/18/11, a preliminary investigation was done by Witness 4 to determine the history of the baseboard heaters. The previous Maintenance Director indicated the baseboard heaters had "governors" installed on the heaters to restrict them from getting too hot. In addition, lock boxes were put over the individual thermostats to prevent the continual adjustment to the heat in the resident rooms. To further prevent the heating of the baseboard units, there was also secondary heat in the hallways provided through a boiler system. On 2/1/11, the Health District CEO informed Witness 4 that a metal strip had been placed under the baseboard heaters so that "extremities" could not get under the heater units. This was a perforated metal to continue to allow air flow to the unit. On 2/7/11, infrared thermometers were located and were to be used to check the temperature of the baseboard heaters. There was an e-mail from the previous management company regarding the baseboard heaters. The previous management company indicated in March 2010 the company researched the possibility of replacing the baseboard heaters and indicated there hadn't been any issues with the baseboard heaters. An interview on 3/10/11 at 11:00 am with Witness 4 (Management Representative), Staff 1 (Administrator) and Staff 2 (DNS) revealed Witness 4 had used the infrared thermometer to check 70 percent of the room baseboard heaters after 2/7/11. Witness 4 stated there was no written documentation of the temperatures of the baseboard heaters and indicated there had not been any concerns regarding the temperatures taken. Witness 4 indicated there was no information provided by the previous management company regarding the monitoring of the baseboard heaters. Witness 4, Staff 1 and Staff 2 were asked to provide a policy and procedure regarding the baseboard heaters. There was no evidence the facility had a policy and procedure regarding the baseboard heaters until after the incident involving Resident 1 on 2/26/11 and 2/27/11. An interview on 3/15/11 at 4:00 pm with Staff 1 (Administrator) revealed the thermostats had been locked prior to 2/26/11 and the charge nurses had a key to open the thermostat.