Every finding on record at Oregon Veterans Home

Based on observation, interview and record review it was determined the facility failed to protect the resident's right to be free from physical abuse for 1 of 10 sampled residents (#26) reviewed for abuse. This placed residents at risk for physical harm. Findings include:The facilities Resident Freedom from Abuse Policy revised 10/7/24 stated the following:-The facility would prevent and prohibit abuse and ensure residents were provided with a safe environment.-Resident-to-Resident abuse included the willful or non-willful infliction of injury resulting in physical harm.Resident 26 was admitted to the facility in 6/2023 with diagnoses including depression.Resident 26's 11/30/25 Annual MDS revealed she/he had a BIMS of 14, which indicated the resident was cognitively intact. Resident 7 was admitted to the facility in 5/2025 with diagnoses including post-traumatic stress disorder and depression.Resident 7's 4/24/26 Annual MDS revealed she/he had a BIMS of 14, which indicated the resident was cognitively intact. A Facility Reported Incident dated 4/27/26 indicated a physical altercation occurred in the facility's smoking area between Resident 7 and Resident 26, which resulted in a bodily injury. Resident 26 received a laceration on her/his scalp from the physical altercation, which required the resident to be sent to the hospital.An Emergency Department Encounter dated 4/27/26 revealed Resident 26 was struck over the head with a cane and had a 1 cm laceration on her/his scalp, which required the placement of three staples. Resident 26 was discharged on 4/27/26 at 7:05 PM.A facility investigation dated 5/4/26 stated video footage was reviewed to determine the sequence of events of the physical altercation between Resident 7 and Resident 26. On 4/27/26 at 4:40 PM Resident 26 entered the facility's smoking area alone and Resident 7 entered afterward. Resident 7 proceeded to move within a foot of Resident 26 and attempted to strike Resident 26's right arm. During the physical altercation, Resident 7 struck Resident 26 in the head with a cane, which caused Resident 26 to bleed. At 4:51 PM, Staff 3 (RN) escorted Resident 26 out of the smoking area.The 5/4/26 facility investigation of the physical altercation stated the following:-Resident 7 was ordered bupropion (an antidepression medication) on 4/17/26 with a potential side effect of agitation. The medication was discontinued on 4/28/26. -Review of the video footage indicated Resident 7 acted with intent to cause physical harm to Resident 26.-Verbal provocation between Residents 7 and 26 was undetermined. -The investigative conclusion was Resident 7's actions appeared willful.On 6/23/26 at 10:23 AM, Resident 7 confirmed she/he was in a physical altercation with Resident 26. Resident 7 stated she/he caused Resident 26 to bleed. Resident 7 stated she/he had a tendency to fight in response to interpersonal conflict. Resident 7 acknowledged she/he made a mistake and stated, I should have turned around and walked out.On 6/23/26 at 11:10 AM, Resident 26 confirmed she/he was in a physical altercation with Resident 7. Resident 26 stated she/he was unaware why Resident 7 struck her/him with a cane. Resident 26 stated she/he was unable to recall if a verbal altercation preceded the physical altercation with Resident 7. On 6/24/26 at 2:00 PM, Resident 26 was observed in the dining room of [NAME] Unit with a small scar on her/his forehead. On 6/24/26 at 2:16 PM, Staff 3 (RN) confirmed he intervened in the physical altercation between Resident 7 and Resident 26. Staff 3 stated there were no other staff or residents who witnessed the physical altercation. Staff 3 stated Resident 26 did not have a history of physical altercations with other residents in the facility.On 6/25/26 at 2:11 PM, Staff 13 (RNCM) stated Resident 26 did not have a history of verbal altercations with other residents in the facility. On 6/26/26 at 10:52 AM, Staff 14 (RNCM) confirmed she reviewed the video footage of physical altercation between Resident 7 and Resident 26. Staff 14 stated Resident 26 was alone for a few minutes before Resident 7 entered the smoking area on 4/27/26. Staff 14 stated Resident 7 did not sustain any injuries from the physical altercation.On 6/26/26 at 11:12 AM, Staff 2 (Assistant DNS), Staff 13 and Staff 14 confirmed they were involved in the completion of the 5/4/26 facility investigation. Staff 2, Staff 13 and Staff 14 indicated Resident 7 acted willfully to inflict harm to Resident 26 on 4/27/26. Staff 2, Staff 13 and Staff 14 confirmed physical harm occurred to Resident 26 on 4/27/26 as a result of Resident 7's actions. The deficient practice was identified as Past Noncompliance based on the following:On 4/28/26, the deficient practice was identified by the facility and was corrected when the facility implemented a plan of correction. The Plan of Correction included the following:1. Resident 7 and Resident 26 were required to be supervised for all smoking activities until the facility was able to determine there was no potential for future occurrences.2. Resident 7's cane was removed and not returned until the facility was able to determine there was no potential for future occurrences.3. Staff were educated to provide increased monitoring for Resident 7 and 26 to ensure the safety of themselves and other residents.

Based on interview and record review it was determined the facility failed to administer medications according to physician orders and failed to notify the physician of continued missed medication for 2 of 5 sampled residents (#s 62 and 115) reviewed for medications. This placed residents at risk for adverse side effects of medications and worsening medical conditions. Findings include: 1. Resident 62 was admitted to the facility in 11/2023 with diagnoses including dementia with behavioral disturbances. Resident 62's 6/5/26 care plan indicated to administer medications as ordered, and document for effectiveness or side effects. Resident 62's 5/2026 and 6/2026 signed physician's orders included the following:-Duloxetine (a depression medication) 60mg daily for depression.-Eliquis (an anticoagulant medication) 5mg two times daily for stroke.-Olanzapine (an antipsychotic medication) 5mg two times daily for agitation and hallucinations. Resident 62's 5/2026 and 6/2026 MAR revealed the following:-Duloxetine was not given on 5/4, 5/5, 5/10, 5/19, 6/18, 6/19, or 6/21.-Eliquis was not given on 5/4, 5/5, 5/10, 5/19, 6/18, 6/19, or 6/21.-Olanzapine was not given during morning medication pass on 5/4, 5/5, 5/10, 5/19, 6/18, 6/19 or 6/21. A review of Resident 62's medical record revealed no evidence the facility notified the physician of the resident's missed medications. On 6/24/26 at 9:38 AM, Staff 5 (CMA) stated it was common for Resident 62 to miss her/his morning medications, as the resident preferred to sleep in and would often refuse to get up to take her/his pills. Staff 5 stated if the resident slept through morning medication pass, she would document the information into the resident's chart and notify the nurse in charge. On 6/25/26 at 8:17 AM, Staff 10 (RN) stated she was unaware Resident 62 missed any medications. Staff 10 stated if staff were unable to administer medication to a resident for any reason, the provider would be notified. On 6/25/26 at 8:22 AM, Staff 11 (RNCM) acknowledged Resident 62's 5/2026 and 6/2026 MAR indicated the resident did not receive multiple medications on multiple days. Staff 11 could not provide any additional information related to the resident's medical provider being informed of the missed medication. On 6/26/26 at 9:21 AM, Staff 2 (Assistant DNS) confirmed Resident 62 had missed multiple medications throughout 5/2026 and 6/2026 and acknowledged the facility should have notified the provider to ensure the resident was receiving medications as ordered. 2. Resident 115 was admitted to the facility in 3/2026 with diagnoses including Parkinson's disease (a progressive brain disorder that occurs when nerve cells in the brain die or become impaired, resulting in a drop in dopamine) and dementia with Lewy Bodies. The 3/30/26 admission MDS revealed Resident 115 had a BIMS score of 3 indicating she/he had severe cognitive impairment. The 4/2/26 care plan revealed Resident 115 was to receive medications for Parkinson's disease as ordered and staff were to monitor, document, and report any signs or symptoms of medication side effects. The 6/8/26 physician orders revealed orders to start on 3/24/26 for carbidopa-levodopa (a medication to treat Parkinson's disease) 25-100 MG TID (8 AM, 12 PM and 8 PM) and carbidopa-levodopa extended release 50-200 MG QID (8 AM, 12 PM, 4 PM and 8 PM). Resident 115's 6/2026 MAR indicated she/he was sleeping or refused and missed carbidopa-levodopa 25-100 MG and carbidopa-levodopa extended release 50-200 MG on the following dates/times: -On 6/1/26, both doses for 8 AM administration. -On 6/2/26, both doses for 8 AM and 8 PM administration. -On 6/4/26, both doses for 8 AM administration. -On 6/5/26, both doses for 8 AM administration. -On 6/7/26, both doses for 8 AM and 12 PM administration, and 4PM administration of carbidopa-levodopa extended release 50-200 MG. -On 6/8/26, both doses for 8 AM administration. -On 6/9/26, both doses for 8 AM administration. -On 6/10/26, both doses for 8 AM and 12 PM administration. -On 6/11/26, both doses for 8 AM administration. -On 6/12/26, both doses for 8 AM administration. -On 6/13/26, both doses for 8 AM administration and 4PM administration of carbidopa-levodopa extended release 50-200 MG -On 6/14/26, both doses for 8 AM administration. -On 6/15/26, both doses for 8 AM administration. -On 6/16/26, both doses for 8 AM and 12 PM administration. -On 6/18/26, both doses for 8 AM administration. -On 6/19/26, All medication administration of both doses, 8 AM, 12 PM, 4 PM, and 8 PM. -On 6/20/26, both doses for 8 AM administration. -On 6/21/26, both doses for 8 AM administration and 4PM administration of carbidopa-levodopa extended release 50-200 MG -On 6/22/26, both doses for 8 AM administration. -On 6/24/26, both doses for 8 AM, 12 PM, 8 PM administration. A review of Resident 115's medical record revealed no evidence the facility notified the physician of the continued missed doses of both carbidopa-levodopa medications until 6/24/26. A review of the 6/24/26 fax to Resident 115's physician from Staff 13 (RNCM) revealed Resident 115 missed multiple doses of carbidopa-levodopa 25-100 MG and carbidopa-levodopa extended release 50-200 MG over the last month primarily during morning medication pass at 8 AM and some at the 12 PM and 4 PM medication pass due to the resident either sleeping or was combative. Staff 13 noted that was a change from Resident 115's first couple months at the facility. On 6/25/26 Resident 115's physician responded to the fax acknowledging it. On 6/24/26 at 1:45 PM, Staff 15 (CMA) stated Resident 115 was often asleep during the 8 AM medication pass and was not woken up as the resident would try to bite her. Staff 15 stated she would reapproach the resident a second time but if the resident was still asleep, she documented in the MAR as 'sleeping' and notified the nurse of the missed dose of medication. Staff 15 stated there were no interventions in place related to the resident's continued missed doses. On 6/24/26 at 3:35 PM, Staff 16 (RN) stated when the CMA communicated to her that Resident 115 was asleep during medication pass, she would attempt to wake up the resident, but the resident often refused and continued to sleep. Staff 16 stated she then notified Staff 13 (RNCM) and it was up to Staff 13 whether to notify the provider. On 6/24/26 at 3:57 PM, Staff 17 (CMA) stated Resident 115 was often awake during the afternoon and evening medication pass and accepted her/his medications. Staff 17 stated if Resident 115 was having behaviors of agitation he would reapproach the resident and notify the nurse if Resident 115 missed any doses. On 6/25/26 at 11:54 AM, Staff 18 (CMA) stated Resident 115 had several behaviors of biting, grabbing, and kicking staff members and often was asleep during medication pass which had increased in the last month. Staff 18 stated she would reapproach the resident, but the resident often stayed asleep or refused medications. Staff 18 stated she would report to the nurse of any missed medications. On 6/25/26 at 3:26 PM, Staff 13 (RNCM) stated over the last three to four weeks Resident 115 had an increase in behaviors and missed medications including both doses of carbidopa-levodopa. Staff 13 stated he was aware of the missed medication but did not know the frequency of missed medications until yesterday, 6/24/26 when he completed a quarterly review of Resident 115's medications. Staff 13 stated the physician would be notified every quarter or sooner, dependent on the severity of the situation. Staff 13 also stated Resident 115's physician made some medication changes related to the increase in behaviors, but it was never communicated to the physician of the multiple missed doses of carbidopa-levodopa until 6/24/26. On 6/26/26 at 11:54 AM, Staff 2 (Assistant DNS) acknowledged Resident 115 had multiple occurrences of missed medication due to the resident refused or was sleeping and no notification to the physician until 6/24/26. Staff 2 stated she would expect the nurse or the RNCM to notify the physician, especially after the Resident 115 missed the 8 AM administration of both doses of carbidopa-levodopa from 6/7/26 to 6/17/26.

Based on observation, interview, and record review it was determined the facility failed to ensure proper labeling of biologicals for 2 of 7 treatment carts and failed to ensure treatment carts were properly secured during observations. This placed residents at risk for receiving medications with reduced efficacy and unauthorized access to medications. Findings include:1. On 6/24/26 at 12:27 PM, one open Lantus insulin pen was observed in the [NAME] Unit treatment cart, it was not labeled with an open date.On 6/24/26 at 12:27 PM, Staff 3 (RN) acknowledged the insulin pen was open and not labeled with an open date.On 6/26/26 at 9:30 AM, Staff 2 (Assistant DNS) stated the expectation was for open insulin to be labeled with an open date.2. On 6/24/26 at 10:44 AM, one open Lantus insulin pen was observed in the Delta Unit treatment cart, it was not labeled with an open date.On 6/24/26 at 10:44 AM, Staff 6 (RN) acknowledged the insulin pen was open and not labeled with an open date.On 6/26/26 at 9:30 AM, Staff 2 (Assistant DNS) stated the expectation was for open insulin to be labeled with an open date.3. On 6/22/26 from 12:37 PM to 12:42 PM and from 2:59 PM to 3:01 PM, the [NAME] Unit treatment cart was observed to be unlocked and unattended. On 6/22/26 at 12:42 PM and 3:01 PM, Staff 3 (RN) acknowledged the treatment cart was left unlocked and unattended. On 6/26/26 at 9:31 AM, Staff 2 (Assistant DNS) stated the expectation was for treatment carts to be locked when unattended.

Based on interview and record review it was determined the facility failed to ensure flu and pneumonia vaccines were provided for 3 of 5 sampled residents (#s 2, 3 and 66) reviewed for immunizations. This placed residents at risk for illness. Findings include:A review of the facility's 10/2019 Pneumococcal Vaccine policy stated residents will be offered pneumococcal vaccines within 30 days of admission to the facility unless medically contraindicated.1. Resident 2 was admitted to the facility in 5/21/26 with diagnoses including a stroke. Resident 2's clinical record revealed she/he was eligible but not offered a pneumococcal vaccine. On 6/5/26 at 4:24 PM, Staff 2 (Assistant DNS) and Staff 12 (RN) stated eligible residents were administered pneumococcal vaccines within seven to ten days of admission to the facility.On 6/25/26 at 4:43 PM, Staff 2 and Staff 12 verified Resident 2 consented to and was eligible for a pneumococcal vaccine on 5/21/26. Staff 2 and Staff 12 stated there was no documentation in the resident's clinical record to indicate the pneumococcal vaccine was offered, administered or refused between 5/28/26 and 5/31/26 (seven to ten days after admission). 2. Resident 3 was admitted to the facility in 11/17/25 with diagnoses including congestive heart failure. Resident 3's clinical record revealed she/he was eligible but not offered a pneumococcal vaccine. On 6/5/26 at 4:24 PM, Staff 2 (Assistant DNS) and Staff 12 (RN) stated eligible residents were administered pneumococcal vaccines within seven to ten days of admission to the facility.On 6/25/26 at 4:41 PM, Staff 2 and Staff 12 verified Resident 3 consented to and was eligible for a pneumococcal vaccine on 11/17/25. Staff 2 and Staff 12 stated there was no documentation in the resident's clinical record to indicate the pneumococcal vaccine was offered, administered or refused between 11/24/25 to 11/27/25 (seven to ten days after admission). 3. A review of the facility's 10/2019 Influenza Vaccine policy stated all residents without medical contraindications were offered the influenza vaccine annually between October 1 and March 31. Resident 66 was admitted to the facility in 9/2025 with diagnoses including Alzheimer's Disease. Resident 66's clinical record revealed she/he was eligible but not offered an influenza vaccine. On 6/25/26 at 4:30 PM, Staff 2 (Assistant DNS) and Staff 12 (RN) verified Resident 66 consented to the influenza vaccine on 9/2/25. Staff 2 and Staff 12 stated there was no documentation in the resident's clinical record to indicate the influenza vaccine was offered, administered or refused between 10/1/25 and 3/31/26.

Based on interview and record review it was determined the facility failed to offer Covid-19 vaccines for 3 of 5 sampled residents (#s 2, 3 and 155) reviewed for vaccines. This placed residents at risk for respiratory illness. Findings include: A review of the facility's 11/2021 COVID-19: Vaccination of Residents policy stated, each resident is offered the COVID-19 vaccine unless the immunization is medically contraindicated.1. Resident 2 was admitted to the facility in 5/2026, with diagnoses including a stroke. Resident 2's clinical record revealed she/he was eligible but not offered a COVID-19 vaccine. On 6/25/26 at 4:34 PM, Staff 2 (Assistant Director of Nursing) and Staff 12 (RN) verified Resident 2 consented to and was eligible for a COVID-19 vaccine on 5/21/26. Staff 2 and Staff 12 stated there was no documentation in the resident's clinical record to indicate the COVID-19 vaccine was offered, administered or refused. 2. Resident 3 was admitted to the facility in 11/2025, with diagnoses including congestive heart failure. Resident 3's clinical record revealed she/he was eligible but not offered a COVID-19 vaccine. On 6/25/26 at 4:30 PM, Staff 2 (Assistant DNS) and Staff 12 (RN) verified Resident 3 consented to and was eligible for a COVID-19 vaccine on 11/17/25. Staff 2 and Staff 12 stated there was no documentation in the resident's clinical record to indicate the COVID-19 vaccine was offered, administered or refused.3. Resident 155 was admitted to the facility in 3/2026 with diagnoses including Parkinson's Disease. Resident 155's clinical record revealed she/he was eligible but not offered a COVID-19 vaccine. On 6/25/26 at 4:37 PM, Staff 2 (Assistant DNS) and Staff 12 (RN) verified Resident 155 consented to and was eligible for a COVID-19 vaccine on 3/20/26. Staff 2 and Staff 12 stated there was no documentation in the resident's clinical record to indicate the COVID-19 vaccine was offered, administered or refused.

Based on interview and record review it was determined the facility failed to accurately code MDS assessments for 5 of 5 sampled residents (#s 10, 23, 84, 97, and 103) reviewed for use of anticoagulants. This placed residents at risk for inaccurate medication assessments. Findings include: 1. Resident 10 admitted to the facility in 2018 with diagnoses including dementia and anxiety. The 10/29/24 and 1/21/25 Quarterly MDSes indicated Resident 10 received an anticoagulant medication. No evidence was found in Resident 10's clinical record to indicate she/he received an anticoagulant medication. On 3/14/25 at 9:40 AM, Staff 6 RNCM and at 11:15 AM, Staff 2 (DNS) were interviewed. Staff 6 stated she completed portions of the the MDS, including section N for medications. Staff 6 acknowledged Resident 10 was not on an anticoagulant and the 10/29/24 and 1/21/25 Quarterly MDS entries were inaccurate. Staff 2 (DNS) acknowledged Resident 10 was not on an anticoagulant medication. 2. Resident 23 admitted to the facility in 2024 with diagnoses including dementia and heart failure. The 11/30/24 and 2/3/25 Quarterly MDSes indicated Resident 23 received anticoagulant medication. No evidence was found in Resident 23's clinical record to indicate she/he received anticoagulant medication. On 3/14/25 at 9:40 AM, Staff 6 RNCM and at 11:15 AM, Staff 2 (DNS) were interviewed. Staff 6 stated she completed portions of the the MDS, including section N for medications. Staff 6 acknowledged Resident 23 was not on an anticoagulant and the 11/30/24 and 2/3/25 Quarterly MDSes were inaccurate. Staff 2 (DNS) acknowledged Resident 10 was not on an anticoagulant medication. 3. Resident 84 admitted to the facility in 2023 with diagnoses including dementia and a stroke. The 10/4/24 and 12/25/24 Quarterly MDSes indicated Resident 84 received anticoagulant medication. No evidence was found in Resident 84's clinical record to indicate she/he received an anticoagulant medication. On 3/14/25 at 9:40 AM, Staff 6 RNCM and at 11:15 AM, Staff 2 (DNS) were interviewed. Staff 6 stated she completed portions of the the MDS, including section N for medications. Staff 6 acknowledged Resident 84 was not on an anticoagulant and the 10/4/24 and 12/25/24 Quarterly MDSes were inaccurate. Staff 2 (DNS) acknowledged Resident 10 was not on an anticoagulant medication. 4. Resident 97 admitted to the facility in 2024 with diagnoses including a stroke. The 10/9/24 and 1/3/25 Quarterly MDS indicated Resident 97 received anticoagulant medication. No evidence was found in Resident 97's clinical record to indicate she/he received an anticoagulant medication. On 3/14/25 at 9:40 AM, Staff 6 RNCM and at 11:15 AM, Staff 2 (DNS) were interviewed. Staff 6 stated she completed portions of the the MDS, including section N for medications. Staff 6 acknowledged Resident 97 was not on an anticoagulant and the 10/9/24 and 1/3/25 Quarterly MDSes were inaccurate. Staff 2 (DNS) acknowledged Resident 10 was not on an anticoagulant medication. 5. Resident 103 admitted to the facility in 2/2025 with diagnoses including dementia and anxiety. The 2/20/25 Admission MDS indicated Resident 103 received anticoagulant medication. No evidence was found in Resident 103's clinical record to indicate she/he received an anticoagulant medication. On 3/14/25 at 9:40 AM, Staff 6 RNCM and at 11:15 AM, Staff 2 (DNS) were interviewed. Staff 6 stated she completed portions of the the MDS, including section N for medications. Staff 6 acknowledged Resident 103 was not on an anticoagulant and the 2/20/25 Admission MDS was inaccurate. Staff 2 (DNS) acknowledged Resident 10 was not on an anticoagulant medication.

Based on interview and record review, it was determined the facility failed to report an allegation of sexual abuse to the State Survey Agency for 2 of 3 residents (#s 54 and 307) reviewed for sexual abuse. This placed residents at risk for a lack of protective measures to prevent further abuse. Findings include: 1. Resident 54 admitted to the facility in 4/2021 with diagnoses including diabetes and a leg fracture. Resident 108 admitted to the facility in 11/2022 with diagnoses including diabetes and PTSD. Resident 54's 9/16/24 St. Louis University Mental Status (SLUMS) Examination indicated the resident had a score of 16/30, indicating cognitive impairment or possible dementia. On 1/8/25 a public complaint was received indicating Resident 108 was known to inappropriately touch female residents during activities. Witness 2 (Complainant) stated Resident 108 put her/his hand up their shirts or down their pants. Witness 2 stated Resident 108 put her/his hand up Resident 54's shirt five or six months ago. There was no further information provided. On 3/11/25 at 1:19 PM and 3/13/25 at 9:42 AM Staff 17 (Activities) stated she witnessed Resident 108 grab Resident 54's breast over the resident's shoulder during an activity. Staff 17 stated the incident occurred months ago. At the time of the incident, Staff 17 separated the residents and reported the incident to Staff 23 (Former RNCM). No evidence was found to indicate the incident was reported to the State Survey Agency. On 3/12/25 at 2:17 PM and on 3/13/25 at 10:18 AM attempts were made to contact Staff 23, but calls were not returned. On 3/13/25 at 12:09 PM Staff 1 (Administrator) stated she was not aware of the concerns regarding Resident 108 touching Resident 54's breast. Staff 1 acknowledged the incident was not reported to the State Survey Agency and stated she expected this type of incident to be reported. 2. Resident 307 admitted to the facility in 1/2024 with diagnoses including dementia and vascular Parkinsonism. Resident 307 passed away on 2/8/25. Resident 108 admitted to the facility in 11/2022 with diagnoses including diabetes and PTSD. Resident 307's 9/3/24 Annual MDS indicated the resident had moderately impaired cognition. The resident's 9/5/24 care plan indicated the resident had impaired cognitive function or impaired thought process related to the dementia diagnosis. On 1/8/25 a public complaint was received and the complainant (Witness 2) reported Resident 108 was known to inappropriately touch female residents during activities. Witness 2 stated Resident 108 put her/his hand up their shirts or down their pants. On 3/11/25 at 1:19 PM and 3/13/25 at 9:42 AM Staff 17 (Activities) stated months ago she witnessed Resident 108 touch Resident 307's breast during an activity. Staff 17 stated Resident 307 would encourage the behavior, but Resident 307 could not consent to the contact. Staff 17 stated she reported the incident to Staff 18 (Activities) and Staff 28 (Activities Director). No evidence was found to indicate the incident was reported to the State Survey Agency. On 3/13/25 at 12:09 PM Staff 1 (Administrator) stated she was not aware of the concerns regarding Resident 108 touching Resident 307's breast and acknowledged it was not reported to the State Survey Agency.

Based on interview and record review it was determined the facility failed to protect the resident's right to be free from physical abuse by Resident 76 for 1 of 3 sampled residents (#106) reviewed for physical abuse. This placed residents at risk for physical, mental, or psychosocial harm. Findings include: Resident 106 admitted to the facility in 2/2024 with diagnoses including heart failure and dementia. Resident 106 passed away on 11/2/24. Resident 76 admitted to the facility in 1/2023 with diagnoses including dementia and anxiety disorder. Resident 76's, Behavior Care Plan dated 4/24/23 indicated the resident expressed agitation with others, typically related to noise. Staff were to encourage Resident 76 to go to her/his room or another quiet area if there was music playing and she/he was getting agitated. A 9/17/24 Resident to Resident Conflict report indicated that day an altercation occurred in the residents' shared room. The report stated Resident 106 was choked by Resident 76. Staff reported hearing yelling coming from the room and when they arrived, they observed Resident 76 with both her/his arms around Resident 106's neck from behind. Resident 106's glasses were knocked off during the altercation. Staff separated the residents. The investigation indicated Resident 76 also struck a staff member across the face after being pulled away from Resident 106. Per resident interviews, Resident 76 asked resident 106 to turn off her/his radio, and Resident 106 told Resident 76 to Shut the hell up. Resident 76 did not recall the incident, but when details were provided, she/he did recall placing her/his hands on Resident 106. Resident 106 stated, I just wanted to listen to my radio. I try not to bother anyone. Resident 106 further stated Resident 76 was, going to kill me and [Resident 76] had [her/his] finger in my mouth then covered my nose and mouth with [her/his] hand. Resident 106 denied feeling afraid of Resident 76, but stated, I feel mad at [her/him]. Resident 106 sustained temporary redness to the back of her/his neck due to the incident. A 9/17/24 Wound Evaluation with a photo documented as Bruise indicated a reddened area to Resident 106's neck. A 9/18/24 nursing note completed by Staff 12 (RN) indicated Resident 106 no longer had a bruise on her/his neck. A 9/21/24 Wound Evaluation note with photo documented as Bruise indicated measurements of .27 cm x 1.47 cm x 0.2 cm and indicated Resident 106's bruise resolved. On 3/12/25 at 10:12 AM Staff 12 stated she was not the nurse on duty for the 9/17/24 incident as the nurse no longer worked at the facility. Staff 12 stated she did alert charting after the incident and would consider the incident abuse. Staff 12 stated there were no further incidents between the residents. On 3/13/25 at 11:47 AM Staff 25 (CNA) stated she did not witness the 9/17/24 incident but heard the residents yelling and assisted after the incident. Staff 25 stated Resident 106 responded to the incident like what the heck just happened? On 3/13/25 at 8:46 AM Staff 6 (RNCM) stated Resident 106 was playing music on the boombox and which triggered Resident 76. Resident 106 was on her/his side of the room with her/his back to Resident 76 who was upset Resident 106 was not turning the music down. Resident 76 came up behind Resident 106 and wrapped her/his arm around Resident 106's neck. Resident 106 told Staff 6, [Resident 76] put [her/his] fingers in my mouth and reported that [woman/man] tried to kill me! Resident 106 sustained a red area behind her/his neck because Resident 76 was holding her/him close. Staff 6 stated the reddened area resolved on 9/21/24. Resident 106 reported some pain after the incident, but it was not long lasting. Survey determined the Past Noncompliance was corrected on 9/23/24 when the facility identified deficient practice and initiated corrections with no further incidents. The Plan of Action included; 1. Resident 76 was placed on 1:1 observation for 24 hours after the incident. 2. A room change was completed for Resident 106 on 9/17/24, down a different hall. 3. A room change to a private room was completed for Resident 76 on 9/23/24 4. Monitoring of both residents was immediately initiated. 5. The facility updated both resident care plans to prevent a re-occurence on 9/23/24.

Based on interview and record review it was determined the facility failed to ensure physician orders related to bowel care were followed for 1 of 5 sampled residents (#79) reviewed for unnecessary medications. This placed residents at risk for adverse side effects of medications. Findings include: Resident 79 was admitted to the facility in 5/2023 with diagnosis including dementia and diabetes. A 7/16/24 physician order indicated Resident 79 was to receive a bowel care medication, Lactulose, once a day for constipation and the medication was to be held if the resident had two loose stools the day prior. A review of the 1/2025, 2/2025, and 3/2025 bowel records revealed the resident had two or more loose stools on the following dates: 1/3/25, 1/4/25, 1/10/25, 2/25/25, and 3/4/25. A review of the 1/2025, 2/2025, and 3/2025 MARs revealed Resident 79 was administered Lactulose on days it was to be held per the physician order on the following dates: 1/4/25, 1/5/25, 1/11/25, 2/26/25, and 3/5/25. On 3/13/25 at 2:39 PM Staff 4 (CMA) stated Resident 79 was consistent with having loose stools and she was aware of the physician order to hold the medication, Lactulose, for two loose stools the day prior. Staff 4 confirmed her initials on the MAR and acknowledged she administered Lactulose to the resident when it was to be held. On 3/13/25 at 3:01 PM Staff 5 (CMA) stated she was aware of Resident 79's physician order to hold Lactulose if the resident had two loose stools the day prior. Staff 5 stated at the start of her shift a report was run to identify Resident 79's bowel consistency and if the daily Lactulose physician order should be held. Staff 5 confirmed her initials on the MAR and acknowledged she administered Lactulose to the resident when it was to be held. On 3/14/25 at 9:43 AM and at 10:50 AM Staff 3 (RNCM) acknowledged Resident 79 was administered Lactulose on the identified dates and the dose should have been held. Staff 3 stated her expectation was for all staff to follow the resident's physician orders.

Based on interview and record review, it was determined the facility failed to thoroughly investigate an allegation of abuse for 3 of 6 sampled residents (#s 54, 106, and 307) reviewed for abuse. This placed residents at risk for lack of protective measures to prevent a reoccurrence. Findings include: The facility's 10/7/24 Freedom from Abuse and Abuse Investigation Policy stated, The facility will investigate all charges of abuse and report findings to the appropriate local and state agencies. 1. Resident 54 admitted to the facility in 4/2021 with diagnoses including diabetes and a leg fracture. Resident 108 admitted to the facility in 11/2022 with diagnoses including diabetes and PTSD. Resident 54's 9/16/24 St. Louis University Mental Status (SLUMS) Examination indicated the resident had a score of 16/30, indicating cognitive impairment or possible dementia. On 1/8/25 a public complaint was received indicating Resident 108 was known to inappropriately touch female residents during activities. Witness 2 (Complainant) stated Resident 108 would put her/his hand up their shirts or down their pants. Witness 2 stated five-six months prior, Resident 108 put her/his hand up Resident 54's shirt. There was no further information provided. On 3/11/25 at 1:19 PM and 3/13/25 at 9:42 AM Staff 17 (Activities) stated she witnessed Resident 108 grab Resident 54's breast over the resident's shoulder during an activity. Staff 17 stated the incident occurred months ago. At the time of the incident, Staff 17 moved Resident 108 away and reported the incident to Staff 23 (Former RNCM) who she believed talked with Resident 108 about the incident. On 3/13/25 at 12:09 PM Staff 1 (Administrator) stated she was not aware of the concerns regarding Resident 108 touching Resident 54's breast and this incident was not investigated prior to 3/13/25. 2. Resident 307 admitted to the facility in 1/2024 with diagnoses including dementia and vascular Parkinsonism. Resident 307 passed away on 2/8/25. Resident 307's 9/3/24 Annual MDS indicated the resident had moderately impaired cognition. Resident 108 admitted to the facility in 11/2022 with diagnoses including diabetes and PTSD. On 3/11/25 at 1:19 PM and 3/13/25 at 9:42 AM Staff 17 (Activities) stated she witnessed Resident 108 touch Resident 307's breast during an activity. Staff 17 stated Resident 307 would encourage the behavior, but the resident could not consent to the contact. The incident was reported to Staff 18 (Activities) and Staff 28 (Activities Director). On 3/13/25 at 12:09 PM Staff 1 (Administrator) stated she was not aware of the concern regarding Resident 108 touching Resident 307's breast and this incident was not investigated prior to 3/13/25. 3. The facility's 10/7/24 Freedom from Abuse and Abuse Investigation Policy, Abuse Investigation Guidelines stated, RCM (Resident Care Manager) will complete a full comprehensive and thorough investigation, including follow-up interviews with witnesses or persons involved. Resident 106 admitted to the facility in 2/2024 with diagnoses including heart failure and dementia. Resident 106 passed away on 11/2/24. Resident 76 admitted to the facility in 1/2023 with diagnoses including dementia and anxiety disorder. Resident 76's Behavior Care Plan dated 4/24/23 (prior to the incident), indicated the resident expressed agitation with others, typically related to noise. Staff were to encourage Resident 76 to go to her/his room or another quiet area if there is music playing and she/he is getting agitated. A facility reported incident dated 9/17/24 indicated an altercation occurred in the residents' shared room. Staff reported hearing yelling coming from the room and when they arrived, they observed Resident 76 with her/his arms around Resident 106's neck. Resident 76 asked Resident 106 to turn off her/his radio, and Resident 106 told Resident 76 to Shut the hell up. Resident 106 was sitting in her/his wheelchair with her/his back to Resident 76's side of the room when Resident 76 came up behind Resident 106 and wrapped her/his arms around Resident 106's neck. Resident 76 did not recall the incident, but when details were provided, she/he did recall placing her/his hands on Resident 106. Resident 106 stated Resident 76 was, going to kill me. [Resident 76] had [her/his] hand in my mouth then covered my nose and mouth with [her/his] hand. The investigation did not indicate if abuse was ruled out or verified. The investigation did not include staff or other witness statements prior to 3/14/25. On 3/13/25 at 8:46 AM Staff 6 (RNCM) stated she completed the investigation for the 9/17/24 incident. Staff 6 stated she normally interviewed staff as part of an investigation, but not including them was my mistake. When asked if abuse was determined to have occurred, Staff 6 stated it was determined the action was intentional from Resident 76. Staff 6 acknowledged the investigation required a determination to be documented.

Based on interview and record review it was determined the facility failed to ensure residents were assessed after significant weight loss was identified for 2 of 3 sampled residents (#s 62 and 74) reviewed for weight loss. This placed residents at risk for severe weight loss. Findings include: 1. Resident 62 was admitted to the facility in 2/2023 with diagnoses including end stage renal disease. The 2/20/23 Admission MDS indicated Resident 62 had no weight loss and was on a therapeutic diet. The resident's Care Plan for risk for altered nutritional status, revised on 2/24/23, indicated a goal of maintaining weight and did not indicate the resident had any weight loss. Resident's 62's weight records indicated the following (weight in pounds): - 2/20/23: 142 - 9/12/23: 136 - 9/28/23: 125 - 10/5/23: 127 - 10/23/23: 125 The weight loss of 11 pounds from 9/12/23 to 9/28/23 indicated a significant weight loss of 8% in 16 days. A review of the resident's clinical record revealed no evidence Resident 62's weight loss was assessed and no indication new interventions were put in place to address the resident's weight loss. On 10/31/23 at 1:07 PM Staff 6 (RN) indicated Resident 62's weight was pretty stable, and the resident had not lost a significant amount of weight. Staff 6 stated Resident 62 was not on alert charting for weight loss. On 10/31/23 at 1:29 PM Staff 18 (CNA) indicated Resident 62's weight was stable. On 10/31/23 at 1:38 PM Staff 3 (RNCM) indicated Resident 62's weight was down a little bit but the resident did not lose a significant amount of weight. On 11/1/23 at 10:13 AM these findings were shared with Staff 2 (DNS). Staff 2 stated she thought Resident 62 lost weight because the resident received hemodialysis treatment (a process of artificially removing toxins from the blood using an external filtering system). Staff 2 was asked to provide an assessment of the resident's weight loss. No assessment was provided. 2. Resident 74 was admitted to the facility in 2022 with diagnoses including Parkinson's disease. The Care Plan for risk for altered nutritional status, initiated on 9/12/22 indicated a goal of no significant weight changes. The 5/24/23 Quarterly MDS indicated Resident 74 did not have any significant weight loss. Resident 74's weight records indicated the following (weight in pounds): - 7/1/23: 181 - 8/3/23: 168 - 9/4/23: 157 - 10/7/23: 155 - 10/27/23: 153 The weight loss of 13 pounds from 7/1/23 to 8/3/23 indicated a significant weight loss of 7.2% in 33 days. A review of the resident's clinical record revealed no evidence Resident 74's weight loss was assessed until 8/18/23 (15 days after the resident's significant weight loss was identified) and no new interventions were put in place to address the weight loss until 8/22/23 when an additional calorie supplement was ordered. Resident 74's Care Plan for nutrition was updated on 10/4/23 to include a goal of comfort measures for nutrition. The goal of no significant weight changes was discontinued. On 10/30/23 at 5:54 PM Staff 19 (Infection Preventionist/RNCM) indicated weight loss showed up in the facility's electronic dashboard and the RNCM and dietitian were notified. Staff 19 stated she expected weight loss to be addressed right away. On 10/30/23 at 4:45 PM and 10/31/23 at 10:15 AM these findings were discussed with Staff 1 (Administrator), Staff 2 (DNS), and Staff 19. Staff 2 acknowledged Resident 74's significant weight loss and stated the weight loss was expected. Staff 2 acknowledged there was no evidence in the clinical record to indicate the weight loss was expected. Staff 2 stated Resident 74 was referred to the NAR (Nutritionally At Risk) committee on 8/14/23. Staff 2 was asked to provide evidence of an assessment of the resident's weight loss prior to 8/18/23 or evidence of new interventions put in place when the resident's weight loss was identified on 8/3/23 and prior to 8/22/23. No assessment and no evidence of additional interventions were provided.

Based on observation, interview and record review it was determined the facility failed to obtain a physician's order for supplemental oxygen, ensure oxygen tubing was changed and oxygen equipment was maintained for 1 of 1 sampled resident (#25) reviewed for respiratory care. This placed residents at risk for respiratory complications. Findings include: Resident 25 was admitted to the facility in 2022 with diagnoses including obstructive sleep apnea (Pauses in breathing during sleep due to airway blockage). The facility's 2012 Oxygen Administration Procedure related to Physician's Orders and equipment maintenance included the following: - Check the Physician's Order for oxygen liter flow and method of administration. - Check and clean oxygen equipment and change oxygen tubing at regular intervals. On 10/31/23 at 8:41 AM Resident 25 was observed to have an oxygen concentrator (machine that filters air into purified oxygen) in her/his room. The oxygen concentrator had dust accumulation on the top of the concentrator and concentrator filter. The humidification bottle and oxygen tubing were not dated or initialed to indicate when they were last changed. On 10/31/23 at 9:19 AM Resident 25 stated she/he wears oxygen at night at 4 liters per minute. The resident stated staff changed the oxygen tubing and the humidification water about once a month. Resident 25's 10/2023 Physician Orders and 10/2023 TAR revealed no order for oxygen, oxygen tubing changes or oxygen concentrator maintenance and cleaning frequency. Resident 25's 10/13/23 Care Plan did not contain information or interventions for oxygen therapy. On 10/31/23 at 2:09 PM Staff 6 (RN) stated Resident 25 used oxygen at night when sleeping. Staff 6 stated she believed Resident 25 had a Physician's Order for oxygen at 2 liters per minute. Staff 6 confirmed after review of the resident's clinical record the resident did not have an order for oxygen. Staff 6 stated routine care of the oxygen concentrator for a resident who received oxygen therapy included cleaning the filters and concentrator. Staff 6 stated oxygen tubing and humidification water for a resident with an oxygen order was to be changed at least weekly. On 10/31/23 at 2:21 PM Staff 3 (RCM) confirmed Resident 25 did not have an order for oxygen, oxygen tubing changes, or maintenance of the concentrator. Staff 3 confirmed the oxygen concentrator was dirty and the tubing and humidification water were not dated and initialed by staff to indicate when they were last changed. On 11/02/23 at 3:18 PM Staff 2 (DNS) stated her expectation was for residents to have a Physician's Order to administer oxygen therapy, and for tubing changes and oxygen concentrator maintenance to be in place.

Based on observation, interview and record review it was determined the facility failed to ensure care and services were in place to treat an emergency related to a resident's dialysis port for 1 of 1 sampled resident (#62) reviewed for dialysis. This placed residents at risk for blood loss. Findings include: Resident 62 was admitted to the facility in 2/2023 with diagnoses including end stage renal disease. Resident 62's Care Plan, revised on 3/6/23, indicated the resident received hemodialysis (a process of artificially removing toxins from the blood using an external filtering system) via a port in the resident's chest. The care plan did not include any interventions related to emergent blood loss from the port. On 10/30/23 at 2:23 PM no emergency supplies were observed in Resident 62's room. On 10/31/23 at 1:07 PM Staff 6 (RN) stated she was not sure what she would do if Resident 62 was bleeding from the port. On 10/31/23 at 1:38 PM Staff 3 (RNCM) stated if Resident 62 was bleeding from the port she would try to stop it and call 911. When asked if the facility had supplies on hand to stop the bleeding from the port, Staff 3 stated she was not sure. Staff 3 stated she needed to contact the hemodialysis provider to determine what was needed to stop the port from bleeding.

Based on interview and record review it was determined the facility failed to provide ROM and RA services for 4 of 4 sampled residents (#s 7, 72, 83 and 85) reviewed for positioning and mobility. This placed residents at risk for a decline in mobility. Findings include: 1. Resident 7 was admitted to the facility in 2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Facility Restorative Care Referral form (generated by the therapy department PT) dated 1/17/22 indicated the resident was to have an RA walking program to maintain mobility. The resident was a contact guard assist (CGA) with walking and needed cues for balance, steering her/his front wheel walker (FWW) and safety. Special instructions included walking to the bathroom, dining room or activities. Resident 7's care plan dated 1/25/22 indicated the resident had limited physical mobility related to [CONDITION(S)], chorea movements (involuntary, irregular, unpredictable muscle movements) and dementia. The goal was for the resident to maintain current level of mobility with CGA from staff and use of a FWW on the unit as the resident desired, requested and allowed. The resident was at low risk for pressure ulcers related to impaired mobility, varied oral intake and required reminders and cuing for position changes in her/his wheelchair. A Social Services Summary note dated 9/23/22 indicated Resident 7's willingness to engage in activities varied but recently she/he had been more involved and active. On 10/4/22 at 11:56 AM Witness 3 (Family Member) indicated Resident 7 had a rough year but was currently doing better. He felt the resident was better able to participate and cooperate when he wanted to take her/him for an outing or have a visit. Witness 3 stated he felt the resident would benefit from a ROM and RA program but did not believe the resident was currently participating. He stated the resident could be very moody but would participate if it was presented nicely. On 10/6/22 at 2:42 PM Staff 4 (RNCM) indicated the resident had some decline this past year due to being on Hospice. Last year Resident 7 was not able to feed herself/himself, was bedbound and participated in PT with improvement. Resident 7 graduated from therapy just when the RA gym was closed because of COVID-19. Staff 4 (RNCM) further stated RA was important because conistency was required to prevent decline. On 10/7/22 at 8:59 AM Staff 18 (CNA/RA) indicated she did not know why the resident was not participating in the RA program. Resident 7 liked routine and perhaps due to RA staff not always being available it prevented the resident from participating. They had a referral for the resident dated 1/2022. There was no documentation provided to indicate the resident had worked with RA since the referral. On 10/7/22 at 3:00 PM Staff 2 (DNS) stated she understood the benefits of an RA program and was not sure why the residents were not getting the service. They had an RA program set up. No additional documentation was provided. 2. Resident 83 was admitted to the facility in 2021 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident resided in the memory care unit of the facility. Resident 83's care plan dated 7/1/21 indicated the resident had an ADL deficit due to: diagnoses, medications, impaired mobility, advanced age, fracture, cognition and impulsivity. The resident self-propelled in a wheelchair using her/his heels and was an extensive assist with transfers but frequently self-transferred. Resident 83 was also an elopement risk and wanderer and staff were to try and identify the pattern of wandering such as: aimless, escapist, looking for something, or indicating the need for more exercise. Resident 83 enjoyed activities such as working out, gardening and active games. Additionally, the resident was at risk for pressure ulcer development related to dehydration, disease process and immobility. There was no documentation for ROM or RA services. An MDS Indicator Facility Rate Report dated through 10/31/22 indicated the facility had 31 residents identified as having limited ROM and were not receiving services. Resident 83 was one of the residents not receiving services. On 10/4/22 at 3:16 PM Staff 4 (RNCM) indicated the resident would be a candidate for the RA program and the reason she/he was not on it was due to the COVID 19 lock down. Staff 4 stated the RA staff were pulled to work on the floor often and were not available on a regular enough schedule to be the most beneficial for residents with memory issues. The resident was not receiving ROM or RA services. On 10/7/22 at 11:15 AM Staff 18 (CNA/RA) and Staff 19 (CNA/RA) indicated they had not received a referral for Resident 83 but all of the residents with ROM limitations could benefit from RA services. Staff 18 and Staff 19 indicated they did get pulled to work on the floor often which made it hard to maintain scheduled RA services and residents were upset when they had to close the gym. Staff 18 and Staff 19 further stated an additional barrier to providing services was related to the CNAs not having residents ready to go when it was time for RA and not assisting with bringing residents to the RA gym as needed. This was particularly true regarding the memory care unit residents. On 10/7/22 at 11:30 AM a review of the RA staff's calendar revealed the following days either one or both staff were pulled off RA duties to perform CNA duties: 8/2022: 8/1, 8/4, 8/5, 8/8, 8/12 and 8/25. 9/2022: 9/12, 9/16, 9/19, 9/20, 9/21, 9/22, 9/27. 10/2022: (partial month 10/3-10/7) 10/3, 10/4, 10/5, 10/6. On 10/7/22 at 3:00 PM Staff 2 (DNS) stated she understood the benefits of an RA program and was not sure why the residents were not getting the service. They had an RA program set up. No additional documentation was provided. 3. Resident 72 admitted to the facility in 2012 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan dated 1/25/18 revealed Resident 72 had a contracture of the left hand and nursing staff were to clean and place a rolled washcloth in her/his contracted hand daily. Random observation from 10/3/22 through 10/6/22 revealed Resident 72 did not have a rolled washcloth in her/his left hand and both hands were contracted. Resident 72's left hand was in a fist and her/his right fingers were curled towards the palm of her/his hand. On 10/6/22 at 11:44 AM Staff 13 (CNA) stated Resident 72 was totally dependent on staff for all her/his ADL care needs and had washcloths to help with both of her/his contracted hands but they did not always get placed in Resident 72's hands. On 10/6/22 at 3:57 PM Staff 12 (RN) stated during the day Resident 72 was to have washcloths in both of her/his hands due to Resident 72's bilateral contractures. On 10/7/22 at 10:16 AM Staff 3 (RCM) stated she observed Resident 72 had a washcloth in her/his left hand on 10/7/22. When asked what the expectation was for staff regarding Resident 72's contractures Staff 3 stated she expected staff to implement and follow the care plan. On 10/7/22 at 11:51 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 7 (Infection Preventionist) were present for an interview. Staff 1 and Staff 2 stated they expected staff to implement and follow the care plan regarding Resident 72's contracted hands. 4. Resident 85 was admitted to the facility in 5/2001 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/9/22 Annual MDS indicated Resident 85 was extensive assistance for ADLs but should be encouraged to participate in her/his own personal cares physically as she/he was able. The 9/9/22 revised care plan indicated Resident 85 had impaired physical function related to [CONDITION(S)] and was to participate in open gym as desired. On 10/4/22 at 10:54 AM Resident 85 stated she/he was going to the open gym three times a week before the pandemic. Resident 85 stated it was over a year since she/he received ROM in the gym. The resident stated the exercises helped her/his arm strength and she/he looked forward to it. Resident 85 stated she/he was told she/he would have to perform exercises on her/his own due to no RA program. Resident 85 stated she/he spoke with staff but did not hear any response. Resident 85 stated her/his ROM decreased due to the inability to use the exercise bike and have staff work with her/his ROM. On 10/7/22 at 9:33 AM Staff 18 (CNA/RA) and Staff 19 (CNA/RA) stated they worked with Resident 85 awhile ago when there was open gym and performed ROM but the RAs were pulled from RA duties to CNA duties due to staff shortages. Staff 18 stated Resident 85 would benefit from ROM daily due to her/his disease process. On 10/7/22 at 9:53 AM Staff 5 (RCM) stated the RA program was not occurring due to COVID-19 restrictions and staff shortages. Staff 5 stated Resident 85 would benefit from the RA program due to her/his disease process. On 10/7/22 at 3:00 PM Staff 2 (DNS) stated she understood the benefits of an RA program and was not sure why the residents were not getting the service. They had an RA program set up. No additional documentation was provided.

Based on observation, interview and record review it was determined the facility failed to handle and utilize PPE and clean reusable equipment between uses according to CDC guidelines for 1 of 1 facility, ensure AGP procedures were adhered to for 1 of 4 sampled residents (#68) reviewed for infection control, and ensure catheters were properly contained for 2 of 3 sampled residents (#s 55 and 81) reviewed for urinary catheters. This placed residents at risk for infection. Findings include: 1. A review of the undated Policy and Procedure for AGP (Aerosol-generating procedures) revealed the following: -AGP included [CONDITION(S)] (continuous positive airway pressure). -When conducting AGP for patients suspected or known exposure to COVID-19, health care personnel should utilize PPE for special contact droplet precautions. -Staff are to wear N95, eye protection, gown and gloves. -When conducting AGP staff to provide a private room for residents who utilized AGP and close off room where procedure took place for two hours after completion of the procedure. Resident 68 was admitted to the facility in 3/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A comprehensive care plan dated 3/10/22 revealed Resident 68 had ineffective gas exchange related to CHF, chronic respiratory failure, and utilized a [CONDITION(S)] machine each night when she/he slept. Resident 68 was positive for [CONDITION(S)] ([CONDITION(S)]-resistant staphylococcus aureus, a bacterium with antibiotic resistance) and staff were directed to wear gown and a mask when providing care for Resident 68. Upon entering the facility on 10/3/22 the survey team was notified the facility had an active COVID-19 outbreak in the building. Random observations on 10/3/22 from 1:30 PM through 3:30 PM revealed Resident 68 did not have PPE supplies and no contact or AGP precautions were posted outside her/his room. On 10/4/22 at 8:56 AM an observation revealed Staff 14 (CNA) and Staff 15 (CNA) donned PPE from the room adjacent to Resident 68's room and placed a surgical mask over their N95 masks prior to entering Resident 68's room. Resident 68 did not have PPE supplies or signs posted outside her/his room. Upon exiting the room both had doffed in the room and had removed the surgical mask and were in the hallway with the same N95 masks on. On 10/4/22 at 9:06 AM Staff 14 and Staff 15 stated Resident 68 was on contact precautions related to [CONDITION(S)] in her/his urine and they always placed a surgical mask over their N95 mask prior to entering Resident 68's room. Both staff stated they would remove the surgical mask inside the room just prior to exiting. Staff 14 and Staff 15 stated they were not aware of any additional precautions related to the use of Resident 68's [CONDITION(S)] machine. On 10/5/22 at 8:16 AM Resident 68 had a PPE cart outside her/his room along with contact precautions signs but no signage indicating use of AGP precautions. On 10/6/22 at 3:34 PM Staff 12 (RN) stated Resident 68 used a [CONDITION(S)] machine at night. Staff 3 stated she was not aware AGP precautions were required for Resident 68's [CONDITION(S)] machine use. On 10/7/22 at 10:13 AM Staff 3 (RCM) stated she was not sure why Resident 68 did not have PPE supplies outside of her/his room and when asked about the AGP procedure/process she indicated she would have to speak with Staff 7 (Infection Preventionist). On 10/7/22 at 11:51 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 7 were present for an interview. Staff 7 acknowledged there was not a PPE cart outside of Resident 68's room with appropriate signage for [CONDITION(S)] and AGP procedures. Staff 7 stated staff were not supposed to put a surgical mask over the N95s when entering Resident 68's room but were expected to follow appropriate PPE procedures. 2. Upon entering the facility on 10/3/22 the survey team was notified the facility had an active COVID-19 outbreak in the building. On 10/4/22 at 7:30 AM and 10/5/22 at 7:45 AM the survey team entered the building and proceeded to self-screen themselves for COVID-19, completed the appropriate form and checked their temperatures with the thermometer, however there were no disinfecting supplies available from the facility to disinfect the used thermometer. On 10/5/22 at 7:45 AM Staff 17 (Receptionist) acknowledged they did not have appropriate disinfecting supplies available to disinfect the thermometer in between each use. On 10/7/22 at 11:51 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 7 (Infection Preventionist) were present for an interview. Staff 1, Staff 2 and Staff 7 were not aware appropriate disinfecting supplies were not available to disenfect the thermometer in between use for COVID-19 self-screening. 3. On 10/5/22 at 10:53 AM Staff 7 (Infection Preventionist) was observed in the facility between the front door and the conference room wearing a gown, face shield and N95 mask. Staff 7 then removed the gown, disposed of it in an uncovered garbage can and performed hand hygiene. Staff 7 stated she was just outside and had performed a COVID-19 test outside on a staff member who was symptomatic for COVID-19. Staff 7 stated after completing the COVID-19 test she entered the facility and disposed of the dirty PPE inside the open nook between the front door and the conference room. The used gown was observed in an uncovered trash can, partially dangling out of the garbage can. In an interview on 10/6/22 at 4:35 PM Staff 7 stated she should have disposed of the PPE worn for COVID-19 testing outside where the test occurred. On 10/3/22 at 3:41 PM Staff 7 stated staff were required to sanitize face shields after leaving resident rooms who were on precautions but staff were not expected to replace face shields before going into other resident rooms. Staff 7 further stated staff were not required to change N95 masks after leaving a COVID-19 positive room. On 10/3/22 at 4:18 PM the [NAME] Hall entry door had signs posted that indicated a COVID-19 exposure and N95 masks were required before entry. On 10/4/22 at 7:56 PM Staff 3 (Agency LPN) was observed on the [NAME] Hall in direct contact with a COVID-19 positive resident. Staff 3 stated he spent the past hour with the resident. At 8:15 PM before Staff 3 left [NAME] Hall he acknowledged there was no PPE cart or garbage can nearby. Staff 3 opened the doors to leave [NAME] Hall to locate a PPE cart without doffing his PPE and performing hand hygiene. Staff 3 acknowledged he did not follow infection control measures. On 10/5/22 at 8:22 AM Staff 3 was observed entering a resident's room who was on precautions. Staff 3 was wearing an N95 mask, face shield, and gloves. Staff 3 did not wear a gown. Staff 3 confirmed he was not wearing appropriate PPE. On 10/6/22 at 9:12 Staff 22 (Dietary Aid) was observed on [NAME] Hall pushing a food cart. Staff 22 was not wearing an N95 mask. Staff 22 confirmed he should have been wearing an N95 mask. On 10/6/22 at 12:55 PM Staff 26 (Housekeeper) was observed in [NAME] Hall spraying disinfectant on hand rails. Staff proceeded to wipe off the disinfectant within a few seconds. Staff 26 stated she was supposed to wait the appropriate contact time of 60 seconds before she wiped off the disinfectant but did not. Staff 26 continued to spray the disinfectant on the hand rails and repeated wiping off the disinfectant within a few seconds. On 10/6/22 at 4:35 PM Staff 7 was informed of the above surveyor observations. Staff 7 acknowledged staff failed to follow and implement infection control measures. 4. On 10/4/22 at 6:00 PM Resident 81 was observed sitting in her/his wheelchair in the dining room. Resident 81's catheter bag was hanging from the bottom of her/his wheelchair touching the floor. On 10/5/22 at 10:19 AM Resident 81 was observed lying in bed and the bed was in the lowest position. The resident's catheter bag was sitting on floor. On 10/5/22 at 8:18 AM Resident 55 was observed sitting in her/his wheelchair in her/his room. The resident's catheter bag was dragging on her/his floor. On 10/5/22 at 8:36 AM Resident 55 was observed in her/his power wheelchair in the hallway going outside to smoke. The resident's catheter bag was dragging on the floor. On 10/7/22 at 12:17 PM Resident 55 was observed sitting in her/his power wheelchair. The resident stated she/he was going to the dining room to eat lunch. The resident's catheter bag was dragging on the floor. On 10/5/22 at 1:43 PM Staff 21 (CNA) confirmed Resident 55 had a catheter and staff assisted the resident with catheter care. Staff 21 stated catheter bags were supposed to be attached to the bottom of the resident's wheelchairs so they did not come in contact with the floor. On 10/6/22 at 11:20 AM Staff 25 (CNA) confirmed Resident 55 had a catheter bag and staff were required to secure it properly so that it did not drag on the floor. On 10/5/22 at 2:08 PM Staff 5 (RCM) stated staff were expected to ensure Resident 55's catheter bag did not drag on the floor. Staff 5 was informed of the above observations and confirmed staff failed to implement infection control measures.

Based on observation, interview and record review it was determined the facility failed to ensure gradual dose reductions (GDRs) were attempted for residents on [CONDITION(S)] medications for 1 of 5 sampled residents (# 87) reviewed for unnecessary [CONDITION(S)] medications. This placed residents at risk for receiving unnecessary medications. Findings include: Resident 87 was admitted to the facility in 2018 with diagnoses including Alzheimer's dementia and Post-Traumatic Stress Disorder ([CONDITION(S)]). A review of Resident 87's MAR/TAR for 9/2022 and 10/2022 revealed the resident was on a number of [CONDITION(S)] and opioid medications: [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], trazadone, [MEDICATION(S)], [MEDICATION(S)] sprinkle and [MEDICATION(S)] scheduled and PRN . Four of the medications were Central Nervous System Drugs: [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)]. Two were antidepressants: [MEDICATION(S)] and [MEDICATION(S)]. Eight of the resident's medications had major drug interaction warnings. The 10/2022 MAR also contained the following order: [MEDICATION(S)] 4 mg actuation spray. One spray in alternating nostrils as needed for Narcotic Overdose-Order Date 10/18/21. Observations between 10/3/22 through 10/6/22 of Resident 87 revealed the resident participated in no activities except sitting in front of the TV in the common room. The resident was not interacting with staff or other residents. During two meal observations the resident allowed staff to assist her/him with eating but did not attempt conversation or reply to attempted conversation. The resident was observed a few times up in a wheelchair wearing a blanket over her/his head and upper body and wearing sunglasses. The resident appeared to be asleep anytime she/he was not actively eating. No behaviors were observed during any observation. On 10/4/22 at 10:31 AM Staff 22 (Pharmacist) indicated he had concerns related to the facility and the Provider not doing gradual dose reductions (GDRs) for medications of residents with multiple [CONDITION(S)] and narcotic medications. On 3/8/21 a GDR was recommended by the Pharmacist as follows: The resident was receiving the antipsychotic medication [MEDICATION(S)] 2.5 mg every morning and 5 mg at bedtime since 6/2019 for dementia with physically aggressive behaviors. It was recommended that a GDR in [CONDITION(S)] medication be attempted periodically. A GDR was a good tool to help assess if medication was still necessary, if it was at the lowest effective dose, and also to help limit side effects of long-term use. Since a GDR to find the lowest effective dose was not attempted in quite some time, please consider a trial reduction in an attempt to use the lowest possible effective dose and reduce the risk of possible side effects. On 9/17/21 GDR and medication changes were recommended as follows: an interim medication regimen review was requested due to the following change in condition: severe pain, possibly headache. The patient was nonverbal due to advanced Alzheimer's, but frequently grabbed her/his head and cried out in pain. The following recommendation was based on the resident's active prescription profile. The resident was not currently receiving medication known to significantly increase the risk of severe headache. The resident's blood pressure and heart rate, per electronic records, were stable, and significant blood pressure swings were unlikely causing the headaches. This resident had several diagnoses, which may increase headache risk: Alzheimer's disease, [CONDITION(S)], depression, and [CONDITION(S)]. Resident 87 was on the following medications that should reduce headache pain: [MEDICATION(S)] 100 mg for [CONDITION(S)] (may reduce neuropathic pain) [MEDICATION(S)] 50 mg for depression (may reduce neuropathic pain) [MEDICATION(S)] 5 mg for dementia with physical aggression (sedating) [MEDICATION(S)] 5 PRN and 10 mg PO every 8 hours for pain [MEDICATION(S)] 12 mcg/hr patch every 72 hours for pain Please consider the following: - Headaches can be associated with opioid over use. If the patient suffered from migraines, Routine use of opioids for migraine treatment often leads to more frequent and severe headaches, and detoxifying from opioid dependency wasn't always enough to undo that damage. For many residents, overuse of opioids can trigger the transition from episodic migraine to chronic migraine. per the American Headache Society. - Please consider titrating off of [MEDICATION(S)] and on to [MEDICATION(S)] for depression and pain. [MEDICATION(S)] is better for treating neuropathic pain and possibly headaches. - Consider a trial of [MEDICATION(S)] PRN, in case the resident is experiencing migraines, which are common for people with a diagnosis of Alzheimer's disease or depression. - Consider daily aspirin or some form of anticoagulation in case the patient is experiencing TIA. On 6/9/22 a GDR was requested by the Pharmacist as follows: The resident was currently receiving the atypical antipsychotic [MEDICATION(S)] 2.5 mg every morning and 5 mg every evening for dementia with physically aggressive behaviors since 11/16/21. Secondary to the resident's advanced age and the length of time receiving this medication, and in an attempt to minimize the potential for falls, would this resident be a good candidate for a trial GDR in an attempt to maintain the lowest possible effective dose? Recommend decreasing to [MEDICATION(S)] 2.5 mg twice daily. On 10/6/22 at 3:11 PM Staff 4 (RNCM) stated no GDRs were done for Resident 87 since she started working at the facility in 11/2020. There may have been some changes in medications in 2019 but no recent GDRs until the request for [MEDICATION(S)] to be reduced this month. On 10/7/22 at 9:28 AM Staff 22 (Pharmacist) stated some residents had many medications and he had mentioned it to the providers. He asked them to switch medications and they would forget to remove the initial medication so the resident ended up with more medications. The providers met with Staff 22 and told him the residents' had a history of behaviors and the risk was too much for a GDR. Staff 22 stated he continued to make recommendations according to the guidelines but the providers would not budge, even when the staff at the facility agreed the GDRs should be done. Resident 87's medications were very complex and staff stated the resident was stable but by definition they should try a reduction. Staff 22 stated many times the issues facility staff were mentioning as reasons not to try a GDR were very historical and may no longer be pertinent. Staff 22 further stated the 3/8/21, 9/17/21 and 6/9/22 pharmacy requests were denied without appropriate rationale. In an interview on 10/6/22 at 12:28 PM with Staff 1 (Administrator) and Staff 2 (DNS) they acknowledged they needed to improve their tracking of GDRs, provide better documentation from the [CONDITION(S)] meetings and have the physician provide appropriate risk and benefit analysis related to denial of GDRs.

Based on observation, interview and record review it was determined the facility failed to ensure dependent residents were provided services to maintain hygiene for 2 of 4 sampled residents (#s 55 and 84) reviewed for ADLs. This placed residents at risk for unmet needs. Findings include: Resident 55 was admitted to the facility in 2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A 1/13/22 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/12/22 Quarterly MDS indicated Resident 55 required extensive one person assist with personal hygiene. Resident 55's 6/29/18 care plan indicated the resident was at risk for impaired ADL function related to impaired mobility and weakness and required extensive assistance with all hygiene. On 10/5/22 at 8:18 AM and 10/7/22 at 12:17 PM Resident 55 was observed sitting in her/his wheelchair. The resident's fingernails were long, uncut and appeared dark brown in color. Resident 55 stated she/he was not able to trim her/his fingernails for a few years. Resident 55 stated she/he preferred her/his fingernails cut short, but staff did not cut them as often as she/he would like. On 10/7/22 at 12:23 PM Staff 9 (LPN) verified Resident 55 was dependent on staff for ADL care, and the fingernails needed trimmed. 2. Resident 84 was admitted to the facility in 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The 9/5/22 Significant Change in Condition MDS indicated Resident 84 required extensive one person assist with personal hygiene. Resident 84's 8/18/20 care plan indicated the resident had an ADL care deficit and required extensive assistance for ADL care due to weakness. On 10/4/22 at 11:52 AM Resident 84 was observed sitting in her/his wheelchair in the dining room. The resident had unshaven facial hair approximately 1/2 inch in length and her/his fingernails were long and uncut. Resident 84 stated she/he needed staff to help her/him shave her/his facial hair and trim her/his fingernails, but staff did not ask if she/he needed the assistance. On 10/6/22 at 12:12 PM Staff 21 (CNA) stated Resident 84 was dependent on staff for ADL care. On 10/7/22 at 12:23 PM Staff 9 (LPN) verified Resident 84 was dependent on staff for ADL care, and verified Resident 84's fingernails needed trimmed.

Based on interviews and record reviews it was determined the facility failed to ensure residents consistently received restorative services for 2 out of 4 sampled residents (#s 9 and 13) reviewed for restorative services. This placed residents at risk for a decline in strength and range of motion. Findings include: The facility's policy implemented in 4/2019 for their Restorative Nursing Program stated: It was the policy of the facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. a. Resident 9 was admitted ,d+[DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 6/5/21 annual MDS indicated the resident was cognitively intact. The 10/8/18 Therapy Restorative Care Referral form indicated Resident 9 was to receive leg strengthening on an exercise bike assisted by the restorative aide (RA) three times per week. The exercises were to improve and/or maintain leg strength for transfer purposes. On 8/3/21 at 10:47 AM Resident 9 stated she/he was going to the gym three times a week before the pandemic. Resident 9 reported it had been a year since she/he had received exercises in the gym. The resident stated the exercises helped her/his leg strength and they looked forward to it. Resident 9 reported her/his legs had become weaker due to the inability to use the exercise bike. The annual MDS dated [DATE] revealed Resident 9's transfer status as a one person assist with lift. The 6/5/21 annual MDS revealed Resident 9's transfer status as a two -person to total dependence with lift. b. Resident 13 was readmitted ,d+[DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/11/21 Therapy Restorative Care Referral form indicated Resident 13 was referred to receive upper extremity exercise with the use of the manual arm bike assisted by the RA three times per week. The exercise was to increase and/or maintain upper body strength and range of motion. On 8/4/21 at 12:36 PM Resident 13 reported she/he had not received the RA referred program. Resident 13 stated it defeated the purpose of getting stronger and that she/he had become weaker with the loss of exercise. Resident 13 stated it was important to her/him to receive exercise. The admission MDS dated [DATE] revealed Resident 13 was a two person assist for dressing. The Occupational Therapy (OT) evaluation on 4/29/21 reported impaired strength and limitations with mobility in the bilateral upper body. On 8/3/21 at 8:36 AM, Staff 12 (PTA) stated there was a lack of staff for the RA program in the gym. On 8/3/21 at 10:10 AM and 8/9/21 at 3:27 PM Staff 9 (RA/CNA) stated there was no RA program in the gym due to COVID-19 restrictions. Staff 9 reported the RA's had been pulled from RA duties to CNA duties due to staff shortages. On 8/3/21 at 1:44 PM Staff 5 (Rehabilitation Director) stated residents were upset with the lack of RA services and no use of the gym. On 8/4/21 at 8:45 AM Staff 3 (RNCM) stated the RA program was not occurring in the gym currently because of COVID-19 restrictions and staff shortages. Staff 3 reported residents on the RA program were upset as they are unable to go to the gym. On 8/4/21 at 11:06 AM Staff 10 (CNA) stated the RA program in the gym was closed due to COVID-19 restrictions. On 8/12/21 at 2:01 PM Staff 13 (Assistant Director of Nursing) stated the gym had been closed for the RA program. Staff 13 stated residents benefited from the RA program and use of the gym equipment to maintain their level of function and to have different interactions with other residents/people. Staff 13 stated there could be a potential decline for residents if the RA program and exercise equipment were not available.

Based on interview and record review it was determined the facility failed to protect residents from resident-to-resident verbal and physical abuse for 6 of 7 sampled residents (#s 16, 18, 20, 21, 23 and 26) reviewed for abuse. This placed residents at risk for abuse. Findings included: 1. The facility's Freedom from Abuse Policy and Procedures revised 8/21/19 stated the facility would prohibit and prevent abuse, neglect and exploitation of residents and misappropriation of resident property. -Resident-to-Resident Abuse included willful or non-willful infliction of injury and included instances of abuse of all residents irrespective of any mental or physical condition. Resident 16 was admitted to the facility in 10/2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident 17 was admitted to the facility in 10/2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A Facility Incident Report dated 1/19/20 indicated Resident 17 had a physical altercation with Resident 16. The facility's video footage showed Resident 16 made her/his way down the hallway and she/he may have bumped Resident 17's foot or wheelchair which protruded into the hallway. Resident 17 grabbed and hit Resident 16's arm. Staff reported Resident 16 yelled out, it hurts and required a [MEDICATION(S)] patch as the arrn was red and the resident complained of pain. An RCM Incident Note dated 1/24/20 included witness statements by Staff 34 (CMA) who indicated she saw Resident 17 hit Resident 16's arm and by Staff 35 (CNA) who indicated she heard a hitting sound and saw Resident 17 hit Resident 16 three or four times before staff separated them. The note indicated Resident 16 was not the aggressor during the incident and made no attempt to retaliate and no appropriate new interventions were implemented for the resident following the incident. A facility investigation dated 1/24/20 included information Resident 17 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 17 would yell at other residents, staff and visitors and had additional physical and verbal resident-to-resident events on 1/3/19, 7/15/19, 1/10/20 and 3/23/20. On 8/13/21 at 12:16 PM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged Resident 16 and Resident 17 had a physical altercation on 1/19/20. Resident 16's arm had redness with pain and required a [MEDICATION(S)] patch. 2. Resident 18 was admitted to the facility in 9/2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident 17 was admitted to the facility in 10/2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A Facility Incident Report dated 3/23/20 revealed Staff 31 reported Resident 17 was using foul language and was aggressive towards Resident 18. Resident 18 was on the phone speaking with family when Resident 17 came up from behind her/him, called the resident a [OBSCENITY] and pulled on a bag which was hanging around Resident 18's neck. The incident was unprovoked. Staff 29 (CMA), Staff 31 (CNA) and Staff 36 (CNA) witnessed the incident and concurred with the events in the report. Resident 18 had no physical injury but was frightened by the incident. The facility Investigation Report conducted 3/27/20 included information Resident 17 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 17 would yell at other residents, staff and visitors and had additional physical and verbal resident-to-resident events on 1/3/19, 7/15/19, 1/10/20 and 1/19/20. On 8/13/21 at 12:16 PM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged Resident 17 and Resident 18 had a verbal and physical altercation on 3/23/20. Resident 18 had been frightened by the incident. No further information was provided. 3. Resident 20 was admitted to the facility in 9/2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident 19 was admitted to the facility in 11/2015 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility Investigation Report dated 6/22/20 indicated a Social Services assessment dated [DATE] found Resident 20 had an extensive history of inappropriate behaviors in other care settings. With a previous history of behavior issues, in addition to behaviors which occurred in the current facility, the resident had a care plan for behaviors. A Facility Reported Incident dated 6/22/20 stated the incident was not witnessed but there was video footage. The video footage showed Resident 19 approached Resident 20 in the dining room and had a verbal argument. Resident 19 slapped Resident 20 in the back of the head and the residents swung at each other several times with arm to arm contact occurring. Resident 19 stated she/he was pissed off at Resident 20 for being in the bathroom an extended time and leaving a mess. Resident 20 could not remember the incident when later questioned. On 8/13/21 at 12:16 PM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged Resident 19 and Resident 20 had a verbal argument and physical argument. Resident 20 was the aggressor and slapped Resident 20 in the back of the head. No further information was provided. 4. Resident 21 was admitted to the facility in 11/2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident 22 was admitted to the facility in 10/2016 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Facility Reported Incident dated 6/26/20 indicated Staff 32 (CMA) heard shouting at the end of the North Hall and witnessed Resident 22 swinging an object at Resident 21. Interviews with staff determined Resident 22 had been striking Resident 21 with a plastic coathanger and additionally striking her/him with a bag of metal objects (nuts, washers and a watch) which caused a bruise on the left knee of Resident 21. On 8/12/21 at 3:11 PM Staff 32 (CMA) indicated he saw Resident 22 swinging something at Resident 21. He ran up to the room and saw it was a plastic hanger. Staff 32 stated neither resident was usually aggressive but Resident 22 was paranoid and did accuse others, including Resident 21, of stealing her/his things. On 8/13/21 at 12:16 PM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged Resident 21 and Resident 22 had a physical altercation witnessed by staff. Resident 21 was found on the ground at the scene and had a bruise to the left knee. No further information was provided. 5. Resident 16 was admitted to the facility in 10/2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident 25 was admitted to the facility in 4/2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Facility Reported Incident dated 10/6/20 indicated Resident 25 came out of her/his room and hit Resident 16 without any prior warning. Staff separated the residents and returned Resident 25 back to her/his room and moved Resident 16 to another area of the dining room but while staff were assisting another resident, Resident 25 came back out of her/his room and hit Resident 16 again. Staff assisted Resident 16 with an ice pack on the neck/shoulder area where the resident was struck. Staff 25 (CNA) and Staff 36 (Activities Coordinator) both witnessed the incident. Resident 25 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/3/21 at 2:34 PM Staff 24 (CNA) and Staff 25 both stated Resident 25 regularly targeted Resident 16 for verbally and physically aggressive behaviors. Resident 17 also targeted Resident 16. On 8/3/21 at 3:17 PM Staff 26 (RNCM) acknowledged Resident 25 did target Resident 16 and indicated they did not always have enough staff to fully monitor the behaviors of residents. The memory unit had a high number of residents with behaviors and a high number of residents who required assistance with eating. This left less time for staff to monitor and prevent behaviors. Staff 26 had requested an additional CNA for evening shift and an additional CNA for the overnight shift. Resident 25's current Care Plan indicated the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 16's current Care Plan contained no care plan interventions or goals related to resident-to-resident aggression. Care Plan Meeting notes dated 8/11/21 indicated Resident 16 was the victim of resident-to-resident incidents by the same aggressor (Resident 25) four times over the last year (2020). On 8/13/21 at 12:16 PM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged Resident 16 and Resident 25 had two physical altercations on 10/6/20. Staff 1 and Staff 2 acknowledged even with interventions in place they had been unable to stop Resident 25 from verbally and physically targeting Resident 16. No further information was provided. 6. Resident 23 was admitted to the facility in 6/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 24 was admitted to the facility in 2/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A Facility Reported Incident dated 7/10/21 indicated Resident 24 was agitated and aggressive and when Resident 23 attempted to use a shared bathroom. Resident 24 struck her/him on the right forearm and knocked the walking cane out of her/his hand. Resident 23 stated she/he was struck twice but only hurt on the right forearm. Resident 23 told staff she/he was pushed down after being struck on the arm and may have hurt her/his left knee trying to crawl away. It was determined from documentation, witness reports and resident reports that Resident 24 was the aggressor and physically assaulted Resident 23. Resident 23 was assisted up from the ground and ice administered to her/his forearm. On 8/13/21 at 12:16 PM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged Resident 23 and Resident 24 had a physical altercation and per the facility investigation Resident 24 was the aggressor and physically assaulted Resident 23. No further information was provided. 7. Resident 16 was admitted to the facility in 10/2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident 25 was admitted to the facility in 4/2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A Facility Reported Incident dated 11/6/20 indicated Resident 16 was sitting at a table in the dining room drinking coffee. Resident 25 was sitting at a table with other residents, got up and walked towards the lounge, stopped near Resident 16's chair and hit her/him. Resident 16 sustained scratch abrasions to the neck, injury to the inside right surface of the mouth and a skin tear on the right outer forearm. Video surveillance was reviewed by the RCM and revealed the incident was unprovoked and Resident 25 hit Resident 16 four to five times before they were separated. The facility Investigation Report dated 11/9/20 indicated Resident 16 remembered the event and being hit. The resident stated, she/he attacked me. Resident 16 also stated that it hurt and my arm bled a little. Resident 16's Care Plan contained no care plan interventions or goals related to resident-to-resident aggression. Resident 25 was care planned for physical aggression to other residents if they enter her/his room, for staff during cares, for verbal aggression and agitation, wandering, exit seeking and rummaging in other's belongings. Care Plan Meeting notes dated 8/11/21 indicated Resident 16 was the victim of resident-to-resident incidents by the same aggressor (Resident 25) four times over the last year (2020). On 8/13/21 at 12:16 PM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged Resident 16 and Resident 25 had a physical altercation on 11/6/20. Resident 16 sustained injuries from the altercation. No additional information was provided. 8. Resident 26 was admitted to the facility in 12/2018 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Resident 12 was admitted to the facility in 4/2016 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A Facility Reported Incident received 1/7/21 for an incident which occurred on 1/6/21 indicated Resident 26 and Resident 12 were sitting next to each other in the dining room when Resident 12 punched Resident 26 in the right cheek. Video surveillance of the incident was reviewed and documented by Staff 26 (RNCM) and revealed Resident 12 made physical contact six times, five times to the right side of Resident 26's body and one time to the resident's face. Resident 12's actions were seen as unprovoked. Staff 24 (CNA) documented she heard raised voices, looked up, saw Resident 12 punch Resident 26 on the right cheek. Staff 24 reported she heard Resident 12 call Resident 26 an[OBSCENITY] and said [OBSCENITY] you to the back of Resident 26's head prior to the altercation. During an interview with Staff 26 (RNCM) Resident 12 made statements such as, she/he knew she/he was not supposed to do that (hit anyone) but no one would put her/him to bed and she/he was aware she/he was wrong but she/he wanted attention. The facility Investigation Report dated 1/7/21 revealed Resident 12's behaviors had increased and she/he was verbally aggressive toward staff, made racial slurs, cursed at staff and hit a staff member. Despite staff attempts to intervene, Resident 12 continued to make verbally aggressive comments toward staff, was physically more aggressive toward other residents and made sexually inappropriate comments toward female residents. On 8/13/21 at 12:16 PM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged Resident 12 and Resident 26 had a physical altercation. The incident was unprovoked, Resident 12 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interviews and record review it was determined the facility failed to ensure adequate supervision to prevent falls for 1 of 1 resident (#15) reviewed for accidents. This placed resident at increased risk for injury related to falls. Findings include: Resident 15 was admitted ,d+[DATE] with diagnoses of repeated falls. Resident 15's comprehensive care plan dated 12/27/16 revealed Resident 15 was at risk for falls due to history of falls prior to admit. Resident 15's annual MDS dated [DATE] indicated Resident 15 was severely cognitively impaired for daily decision making. The annual Nurses Comprehensive assessment dated [DATE] revealed Resident 15 was dependent for a two-person staff assistance with positioning in bed. Progress notes and Nursing Facility Reported Incident Form (FRI) report dated 6/17/21 and 6/18/21 revealed Resident 15 had a fall caused by Witness 5 (former contracted CNA) not following the care plan which included a two-person assistance for positioning in bed. As a result of the fall, Resident 15 sustained a laceration to the back of her/his head. On 8/10/21 at 12:40 PM, Staff 20 (RN) confirmed Resident 15 required a two-person staff assistance with positioning in bed. Staff 20 stated Witness 5 had completed orientation on Resident 15's unit which included; shadowing Staff 21 (CNA) and the facility's procedures and responsibilities related to residents' care plans. Staff 20 stated Resident 15's care plan was posted in her/his closet and Witness 5 was oriented to the location of residents' care plans. Staff 20 stated Witness 5 should have requested assistance for positioning Resident 15 in bed.

Based on observation, interview and record review it was determined the facility failed to have emergency equipment and supplies readily accessible for 5 of 5 residents (#s 2, 3, 9, 10 and 11) who were positive for COVID-19 and who resided in a unit separate from the facility. This failure, determined to be an immediate jeopardy situation, placed residents with COVID-19 at risk for delayed emergency interventions, serious harm and/or death in the event of rapid physical deterioration related to the COVID-19 disease progression. Findings include: The CDC Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease (COVID-19) outlined clinicians should be aware of the potential for some patients with COVID-19 to rapidly deteriorate about one week after illness onset. Age is a strong risk factor for severe illness, complications and death. On 12/3/20 at 3:45 PM a tour of the COVID-19 unit was conducted. The unit was a portable building located in the facility's parking lot and was separate from the facility. There were five residents observed on the unit who were positive for COVID-19. No emergency equipment and supplies such as a suction machine (an appliance used to remove mucus and saliva from a person's airway), collection canisters, connecting tubing, suction catheters, saline solution, oxygen tanks, oxygen concentrators, oxygen tubing and oxygen cannulas were in the unit. Staff 4 (RN) stated she was the nurse on duty for the COVID-19 unit and no emergency equipment or supplies were stored and accessible on the unit. Staff 4 stated all supplies were kept inside the facility and if emergent equipment and supplies were needed, she called staff inside the facility's Alpha Wing and staff would deliver the items to the portable COVID-19 unit. On 12/3/20 at 5:35 PM surveyors assessed the route from the COVID-19 unit to the entrance of the facility's Alpha Wing. Surveyors briskly walked the route between the portable COVID-19 unit and the closest facility entrance. From the exit of the COVID-19 unit, brisk walking was two minutes one way to reach the doors of the Alpha Wing. The route was an irregular and uneven walkway and was partially graveled with no outdoor lighting. Once inside the facility doors, the emergency equipment and supplies were located on a cart 50 feet down the hallway. On 12/3/20 at 5:45 PM Staff 14 (Agency RN) stated she was the nurse on the Alpha Wing. Staff 14 stated she did not know the location of the emergency equipment and supplies cart and was unsure of the procedure for delivering those items to the COVID-19 unit. On 12/3/20 at 7:03 PM Staff 1 (Administrator) and Staff 2 (DNS) were informed of the immediate jeopardy (IJ) situation related to the facility's failure to have emergency equipment and supplies readily accessible on the COVID-19 unit in the event of residents' rapid physical deterioration. The IJ template was provided and an immediate IJ removal plan was requested. On 12/3/20 at 8:26 PM the facility submitted a removal plan which was accepted and approved by the survey team. The IJ Removal Plan indicated the facility would implement the following actions: - The COVID-19 unit RN was notified to immediately call the Alpha Wing nurse if emergency supplies were needed. - The Alpha Wing RN was educated on the procedure and the location of the emergency equipment and supplies cart. - An inventory of necessary emergency equipment and supplies would be completed. - Full oxygen tanks would be supplied on the COVID-19 unit. - An emergency equipment and supplies cart with the necessary items would be placed on the COVID-19 unit. On 12/4/20 at 10:31 AM surveyors verified all elements of the IJ removal plan were completed and emergency equipment and supplies were readily accessible on the COVID-19 unit.

Based on observation, interview and record review it was determined the facility failed to comprehensively evaluate and track wounds, obtain and follow wound treatment physician orders, follow up on a surgical wound consultation, complete alert charting, and communicate changes in condition to the physician for 4 of 4 sampled residents (#s 1, 2, 3 & 4) reviewed for wounds. Resident 1's wounds worsened, her/his change of condition was not addressed in a timely manner, and the resident was hospitalized . Resident #s 2, 3, & 4 were at risk of unmet care needs. Findings include: 1. Resident 1 was admitted to the facility in 2013 with [DIAGNOSES REDACTED]. The [DATE] Fax to the physician noted Resident 1 had multiple areas of skin breakdown on both legs and feet. Wounds included an abrasion on the top of the right foot and skin breakdown between the 4th and 5th right foot toes and the left heel. The [DATE] Fax to the physician nor the Skin Conditions report identified the type of wounds found between the right foot toes and the left heel. There was no documented comprehensive evaluation of those wounds. The Skin Condition report noted on [DATE] the resident had excoriation on the coccyx and scrotum, including measurements for both open areas. There was no further documentation of the coccyx skin breakdown, no additional measurements of the scrotal wound until [DATE], nor was there an evaluation of the wounds other than noting improved or same. The Skin Condition report noted on [DATE] the skin breakdown between the 4th and 5th right foot toes was noted as same. However, the [DATE] at 12:22 pm Progress Note disclosed the physician was faxed regarding the resident's wound status. The area between the 4th and 5th right foot toes worsened and appeared necrotic (dead tissue) with a foul odor and some drainage. On [DATE] the physician ordered daily whirlpool treatments for the lower extremity skin breakdown. The [DATE] at 3:11 pm Progress Note and [DATE] Physician Visit Notes disclosed the wound between the resident's toes did not improve, was dark in color, and had a large amount of drainage with very strong foul odor. Staff requested a treatment change to calcium alginate (a type of wound treatment), which the physician ordered. The [DATE] at 2:22 pm Progress Note revealed the wound between the 4th and 5th right foot toes did not improve. The foot was red, swollen and painful when touched. The [DATE] Physician Notes disclosed the resident's foot ulcer between the 4th and 5th right foot toes was deep, much slower to heal and had a great deal of necrotic tissue that remained despite treatment. The ulcer was in need of debridement and the foot showed signs of [MEDICAL CONDITION] (a bacterial infection) developing. The physician ordered antibiotics and a surgical consultation for wound debridement. There was no documented evidence the surgical consultation referral was completed. The Skin Condition Report noted on [DATE] the resident had two new areas of skin breakdown on the right side of the coccyx, side by side that measured 1.6 cm x 1 cm and 1.2 cm x 0.3 cm. There was no further evaluation of the wound including the type of wound. There were no physician orders to treat the new areas of skin breakdown. The Skin Condition report noted on [DATE] the resident's wound between the right foot toes deteriorated with no further description of how the wound worsened, nor were there documented measurements of the wound. The abrasion to the top of the right foot was documented as deterioration open. The [DATE] Physician Visit Notes disclosed Resident 1 declined during the previous weeks after developing ulcerations on the right foot. The [DATE] surgical consultation referral was apparently never submitted or entered. The wound between the 4th and 5th right foot toes was described as a deep ulceration with eschar (dead tissue). The resident had a large new area of skin and tissue death on the bottom of the foot by the 2nd and 4th toes. The new area had drainage with a necrotic odor and mild redness surrounding the area. The physician noted Multiple ulcers, R (right) foot, with new deep ulcer recently developed. All of them need surgical debridement. We will take action to expedite this .If [DIAGNOSES REDACTED] (redness) increases at all in the next day or two (Resident 1) will need antibiotics again . There was no documented identification or comprehensive evaluation of the new wound identified by the physician. There was no documented evidence the previously identified wound between the right foot toes had increased in size. On [DATE] the physician changed wound treatments including the application of calcium alginate to open areas on the bilateral lower extremities. When the physician's order was transcribed onto the ,[DATE] TAR the application of calcium alginate was not included for treatment of [REDACTED]. The [DATE] at 6:17 am Progress Note disclosed during the [DATE] physician visit Resident 1 had an elevated temperature of 100.0 degrees. Resident uncommonly lethargic. Not replying to questions, fixated stares . Resident 1 was placed on the facility's Alert Monitoring Record for a change of condition on [DATE]. The alert monitoring did not include monitoring the resident for increased lethargy and staff were directed to complete alert charting every shift. The [DATE] at 2:02 am Progress Note (for the [DATE] 12 hour evening/night shift) disclosed the resident was lethargic and the whirlpool treatment for [REDACTED]. The [DATE] Daily Vital Signs report noted during the day shift Resident 1 had a temperature of 99.0 and a blood pressure of ,[DATE]. During the evening shift the resident had a blood pressure of ,[DATE], which was significantly lower from the day shift finding and the resident's baseline for ,[DATE]. There was no documented evidence the physician was contacted regarding the continued lethargy and changes in vital signs on [DATE]. There was no documented alert charting for the [DATE] day/evening 12 hour shift regarding the resident's change of condition including the lethargy and elevated temperature. The [DATE] at 12:16 am Progress Note did not address the resident's lethargy. The Skin Condition report noted on [DATE] the abrasion to the top of the right foot and the left heel wound showed deterioration. There was no further description of how the wounds worsened. The wound between the right foot toes showed no increase in size from the last documented measurement on [DATE]. The [DATE] at 3:42 pm Progress Note disclosed the physician was contacted due to the desecration of resident wounds and was sent to the ED (Emergency Department) for evaluation, treatment, surgical consultation for wound debridement, and antibiotics. The [DATE] ED Report noted Resident 1 presented with a right foot diabetic ulcer with swelling, redness and increased warmth. The resident appears to have a significantly infected [MEDICAL CONDITION] with possible osteo[DIAGNOSES REDACTED] (an infection in the bone). A pressure ulcer was also identified with no location noted. The resident was dehydrated, treated with antibiotics and fluids and was admitted to the hospital. The [DATE] Hospital History and Physical noted the resident had severe dementia with increasing [DIAGNOSES REDACTED] to the right foot, consistent with [MEDICAL CONDITION]. The physical examination revealed the resident had [DIAGNOSES REDACTED] up to the shin on the right leg with the greatest amount over the 2nd and 3rd digit of the right foot. There was a 4 cm x 4 cm eschar on the top of the right foot, very foul-smelling and a stage II ulcer on the coccyx. X-rays of the foot revealed findings consistent with [MEDICAL CONDITION] and osteo[DIAGNOSES REDACTED]. The [DATE] Hospital physician progress notes [REDACTED]. The [DATE] Hospital Discharge Summary noted a decision was made to place the resident on comfort measures and not perform the amputation. The resident was discharged from the hospital to a different facility and a hospice referral. In interview on [DATE] at 10:58 am Witness 1 (Complainant) stated due to the foot infection that went to the bone the physician initially wanted to amputate the residents leg. Later the physician decided the resident would not survive the surgery and the resident was discharged from the hospital. The resident was placed on hospice then passed away. In interview on [DATE] at 1:39 pm Witness 2 (Family) reported Resident 1 had multiple foot wounds. The facility told Witness 2 the resident was receiving wound care, however, Witness 2 did not know how badly the wounds were infected. When in the hospital the wound infection treatment options included continued antibiotic treatment for [REDACTED]. Witness 2 observed the resident's wounds and the resident had other areas of skin breakdown including a wound on the buttocks. In interviews on [DATE] at 1:26 pm and [DATE] at 11:19 am Staff 14 (LPN) stated there was a binder at the nurse's station that directed staff on alert charting and she could not recall any details regarding the lack of alert charting on [DATE]. Resident 1 only had excoriation on the buttocks with no open areas. Staff 14 stated when she sent Resident 1 to the hospital on [DATE] there was an area underneath the foot that required [MEDICATION NAME], the foot looked swollen, red and was warm to touch. The area between the right foot toes had granulating tissue. In interview on [DATE] at 10:25 am Staff 1 (Administrator) stated she reviewed the resident's care and noted the [DATE] surgical consult was not followed up on by nursing staff. In interview on [DATE] at 12:50 pm Staff 2 stated the [DATE] physician's finding of a new skin breakdown on the bottom of resident's foot was not new, it started off small then increased in size. Staff 2 provided no additional documentation regarding that wound. Staff 2 stated the facility needed to tighten their system regarding wound documentation and acknowledged the lack of comprehensive wound evaluation. In interview on [DATE] at 11:08 am Witness 3 (Physician) stated he could not recall observing skin breakdown on the resident's buttocks as he focused on the resident's legs and feet. On [DATE] the ulceration between the right foot toes was deeper, not improving, and started to look infected so he requested a surgical consultation for debridement. The facility did not follow up on the surgical consultation and the foot wound .worsened substantially because the debridement was delayed. Witness 3 stated on [DATE] he found a new area of skin breakdown on the right foot. Per Witness 3 facility staff normally informed him of new areas of skin breakdown, however, he was not notified of a skin breakdown in that area of the foot. Witness 3 stated he was not informed of the resident's changes in condition until [DATE] and there was a delay of sending the resident to the hospital by at least one or two days. In interview on [DATE] at 2:13 pm Staff 10 (Former LPN) stated on [DATE] and [DATE] Resident 1 had an area of friction/abrasion on the buttocks and the resident required more assistance with eating, which was new for the resident. Staff 10 stated the resident's foot wounds looked terrible, necrotic and never got better. Per Staff 10 there was a deep tissue area on the ball of the foot. Staff 10 stated she didn't know the facility's policy for what was required for alert charting with changes in condition. In interview on [DATE] at 2:49 pm Staff 27 (CNA) stated on [DATE] Resident 1 slumped over which was not normal for the resident. The resident stated she/he did not feel well, was tired and did not want to eat dinner. The resident's vital signs were obtained and the blood pressure was low. Staff 27 reported the findings to a nurse (could not recall the name). The resident had some skin breakdown on the buttocks which was treated with a cream. In interview on [DATE] at 2:56 pm Staff 11 (Former LPN) stated during the [DATE] physician rounds the resident was lethargic and exhibited a lack of responsiveness, which she reported to the physician. Staff 11 directed staff to not provide the whirlpool bath as it was not safe. Staff 11 stated she did not recall details regarding skin breakdown on the resident's buttocks. In interview on [DATE] at 5:21 am Staff 9 (LPN) stated per report from other nursing staff the resident stayed continuously lethargic since the initial report to the physician. On [DATE] Resident 1 fell asleep in the chair, would not stay awake and Staff 9 did not feel comfortable putting the resident in the whirlpool. Staff 9 stated she did not notify the physician regarding the continued lethargy as the previous staff had already contacted the physician. The wounds on the feet were dark in color and had a strong odor to them. Staff 9 stated facility staff had previously contacted the physician about possible infection, the legs were warm to touch and she thought the resident was already on antibiotics. Staff 9 stated she was not aware of any skin breakdown on the buttocks. In interview on [DATE] at 10:39 am and [DATE] at 3:28 pm Staff 6 (RNCM) stated the [DATE] surgical consultation order was not done. Staff 6 stated prior to the [DATE] hospitalization the resident had excoriation on the buttocks. The [DATE] and [DATE] Skin Condition reports for skin breakdown on the coccyx and scrotum was discussed with Staff 6, no additional documentation was provided. Staff 6 stated she was unable to determine if the left lower extremity had any open areas that required treatment with calcium alginate. Regarding the new wound identified by Witness 3 (Physician) on [DATE] Staff 6 stated it was connected to the initial wound between the right foot toes and was just larger. Staff 6 acknowledged the lack of documentation for any increase in size for the initial wound between the right foot toes. Staff 6 stated she expected staff to document a description for any new wounds including the measurement and if there were any changes in the wound. If the wound deteriorated staff were to document if there was a change in size, drainage or odor. Regarding the resident's [DATE] to [DATE] changes in condition Staff 6 stated she expected staff to notify the physician regarding the resident's changes and document assessments. Refer to F157 2. Resident 2 was admitted to the facility in [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 9:23 am Resident 2's wounds and ordered treatments were observed by an RN surveyor and facility staff. In addition to the initial areas of concern a 1.8 cm x 1.8 cm wound on the right gluteal fold that was red, granulated and bleeding was identified. There were no physician treatment orders at the time of the observation and a dressing was applied to the wound. Staff thought the area was new and was from shearing during repositioning. In interview on [DATE] at 11:25 am Staff 5 (RNCM) was asked about physician orders to treat the right gluteal fold wound and any documented follow up of the wound. Staff 5 stated he was unaware of the skin breakdown on the gluteal fold and would obtain treatment orders. No additional documentation was provided. 3. Resident 3 was admitted to the facility in 2016 with [DIAGNOSES REDACTED]. The [DATE] physician order directed staff to apply [MEDICATION NAME] ointment to the buttocks twice a day for wound care until resolved. The ,[DATE] to ,[DATE] TARs documented the [MEDICATION NAME] was applied as ordered. The clinical record lacked documented identification or evaluation of skin breakdown on the buttocks. The [DATE] physician progress notes [REDACTED]. The physician ordered staff to apply xeroform gauze (a type of wound treatment) to the front of the right leg daily and Santyl (a [MEDICATION NAME] ointment) twice a day to the posterior leg ulcer. There was no documented evidence the [DATE] physician orders were transcribed onto the ,[DATE] TAR and administered as ordered. On [DATE] new physician treatment orders were obtained. The [DATE] at 9:27 am Progress Note disclosed the posterior right lower leg ulcer was larger and deeper, had a tear drop formation on part of the wound, and the wound bed was all eschar (dead tissue). The [DATE] physician progress notes [REDACTED]. The Skin Condition report noted on [DATE] the posterior right lower leg wound was worse. There was no further evaluation of the wound including a description of how the wound had worsened. The [DATE] at 1:02 pm Progress Note disclosed Resident 3 was admitted to the hospital. The [DATE] Hospital Records noted the right leg wound was deep with tunneling. On [DATE] at 12:50 pm Resident 3 was observed sitting in a wheelchair in her/his room. The resident had a left leg [MEDICAL CONDITION] and a partial amputation of the right foot. On [DATE] at 9:46 am Staff 7 (RNCM) stated regarding the [MEDICATION NAME] treatment for [REDACTED]. why the treatment was not discontinued. Staff 7 stated she didn't know why the [DATE] physician order was not transcribed onto the TAR. Staff 7 stated regarding the [DATE] right lower leg wound documentation she expected staff to document what was worse about the wound. Staff 7 stated nurses documented wound status weekly on the Skin Condition report, which was sent to Staff 37 (RNCM) for review. In interview on [DATE] at 11:12 am Staff 37 (RNCM) stated nurses completed the Skin Condition records. Staff 37 stated the residents' RNCM reviewed the skin reports and he used the information to create a weekly unit report. 4. Resident 4 was admitted to the facility in 2016 with [DIAGNOSES REDACTED]. The [DATE] Pressure Ulcer CAA noted Resident 4 had multiple admissions to the hospital for diabetic foot wounds and subsequent toe amputations for osteo[DIAGNOSES REDACTED]. The [DATE] at 9:47 am Progress Note disclosed Resident 4 sustained two abrasions on the left foot third toe. The [DATE] at 2:30 pm Progress Note revealed Resident 4 was seen at a toenail clinic due to concerns for the two wounds on the top of the toe. The physician classified the wounds as pressure ulcers. The [DATE] at 9:21 am Progress Note disclosed the physician changed the wound classification to [MEDICAL CONDITION]. The [DATE] at 1:30 pm Progress Note revealed the physician ordered [MEDICATION NAME] (an antibiotic) 100 mg twice a day for seven days for continued redness to the left foot third toe. The [DATE] Nurse Practitioner Visit Note indicated the [MEDICATION NAME] was continued for an additional 10 days. The [DATE] Nurse Practitioner Visit Note disclosed a culture was obtained from the base of the toe. The nurse practitioner ordered staff to continue the [MEDICATION NAME] until the culture results were received. The [DATE] order to continue the [MEDICATION NAME] was not transcribed onto the ,[DATE] MAR. On [DATE] a new antibiotic was ordered and administered. The Skin Condition record lacked documented evaluation and tracking of the toe wounds between [DATE] and [DATE]. On [DATE] and [DATE] the wounds were noted as deteriorated' with no further description of how the wound had worsened. In interviews on [DATE] at 11:12 am and [DATE] at 10:40 am Staff 37 (RNCM) stated he relied on weekly Skin Condition reports for documentation on the resident's wound status and any time a wound is documented as worse the nurse should document why it's worse. The [DATE] order to continue the [MEDICATION NAME] was not done and was written up as a medication error.

Based on interview and record review it was determined the facility failed to consult with the physician and notify responsible family members in a timely manner for changes in condition for 1 of 3 sampled residents (#1) reviewed for notification of changes. This placed the resident at risk for delay in treatment and lack of family involvement. Findings include: Resident 1 was admitted to the facility in 2013 with [DIAGNOSES REDACTED]. The resident's Admission Record listed two family members as responsible parties for Resident 1. The [DATE] Fax to the physician disclosed Resident 2 developed multiple areas of skin breakdown on both feet and legs, including a wound between the 4th and 5th toes on the right foot. There was no documented evidence the responsible parties were contacted regarding the resident's skin breakdown at that time. The facility's correlating investigation documented a family member was notified regarding the new onset of skin breakdown on [DATE], four days after the wounds were identified. On [DATE] the physician ordered daily whirlpool treatments for the skin breakdown. The [DATE] at 3:11 pm Progress Note and [DATE] at 4:46 pm Physician Visit Note disclosed the physician was updated regarding the resident's wounds. The wound between the 4th and 5th toes on the right foot did not improve, the wound was dark in color with a large amount of fluid and had a strong foul odor. The facility requested a treatment change to the wound due to the drainage and smell, which the physician ordered. The [DATE] at 2:22 pm Progress Note revealed the wound between the 4th and 5th toes on the right foot did not improve and the foot red, swollen and painful when touched. The [DATE] at 3:54 pm Physician Visit Note disclosed the foot ulcer needed debridement and showed signs of [MEDICAL CONDITION] (a bacterial infection) developing. The physician ordered antibiotics and a surgical consultation for wound debridement. There was no documented evidence the resident's responsible parties were notified of the resident's worsening skin breakdown, the change in treatments to the wound including antibiotics nor of the surgical consultation. There was no documented evidence the surgical consultation was followed up on by nursing staff. The [DATE] Physician Visit Notes disclosed Resident 1 had a large new deep area of skin and tissue death on the bottom of the right foot. The [DATE] surgical debridement was not followed up on and multiple areas of skin breakdown needed surgical debridement. We will take action to expedite this. The physician noted if redness increased in the next day or two the resident would require antibiotics. The [DATE] at 6:17 am Progress Note disclosed during the [DATE] physician visit Resident 1 had an elevated temperature of 100.0 degrees. Resident uncommonly lethargic. Not replying to questions, fixated stares . The [DATE] at 2:02 am Progress Note disclosed the resident was lethargic and the whirlpool treatment for [REDACTED]. The [DATE] Daily Vital Signs report noted during the day shift Resident 1 had a temperature of 99.0 and a blood pressure of ,[DATE]. During the evening shift the resident had a blood pressure of ,[DATE], which was significantly lower from the day shift finding and the resident's baseline for ,[DATE]. There was no documented evidence the resident's responsible parties were notified of the [DATE] to [DATE] changes in condition nor continued worsening of skin breakdown. There was no documented evidence the physician was consulted regarding the continued lethargy and changes in vital signs. The [DATE] at 3:42 pm and 5:04 pm Progress Notes disclosed the physician was contacted regarding the worsening of her/his wounds and the physician gave orders to send the resident to the ED (Emergency Department) for evaluation, treatment, surgical consultation and antibiotics. In interview on [DATE] at 10:48 am Witness 1 (Complainant) stated the facility was to inform him of the resident's wound status, however, staff did not inform him until the resident was sent to the hospital. In interview on [DATE] at 1:39 pm Witness 2 (Family) stated the facility told her the resident received wound care but she did not know how long the resident had the wounds and how badly they were infected. In interview on [DATE] at 10:25 am Staff 1 (Administrator) stated she reviewed the resident's care at the facility and noted there was a lack of documented communication with the resident's family. In interview on [DATE] at 11:08 am Witness 3 (Physician) stated he was not informed of the resident's changes in condition until [DATE] and there was a delay of sending the resident to the hospital by at least one or two days. The lack of consulting with the physician regarding the changes in condition was discussed with Staff 2 (DNS) on [DATE] at 10:04 am. No additional documentation was provided. The lack of consulting with the physician regarding the changes in condition was discussed with Staff 6 (RNCM) on [DATE] at 10:39 am. Staff 6 stated she expected nursing staff to notify the resident's physician regarding the changes in lethargy and vital signs. Refer to F309, example 1.

Based on observation, interview and record review it was determined that the facility failed to provide adequate supervision for 1 of 7 sampled residents (# 7) who experienced recurrent falls. The plan of care was not followed, the resident's fall resulted in a fractured hip. Findings include: Resident 7 had been admitted to the facility in 3/2009. [DIAGNOSES REDACTED]. On 3/8/10 the resident was hospitalized for [REDACTED]. On 7/16/10 the resident was hospitalized for [REDACTED]. A 3/24/10 assessment indicated the resident had been readmitted after receiving treatment for [REDACTED]. The resident was described as having short and long term memory problems, moderately impaired decision making skills, and did not recognize safety limitations well. The resident was identified to need extensive assistance for transfers, dressing and toileting. Fall review/investigations indicated that after the 3/8/10 fall/fracture the resident experienced additional falls on 3/26, 5/17, 5/21, 6/6, 6/15, and 6/18/10. The 6/18/10 fall review/ investigation indicated the resident's cognition was worsening, that the resident did not fully recognize his physical limitations, had poor safety awareness, was very quick to maneuver and it was difficult to reach him in time to intervene or assist for transfers. The care plan updated 6/23/10 indicated the resident had impaired cognition related to a CVA, seizures, dementia, and had impaired decision making skills. The care plan also indicated the resident was "At risk for injuries from falls r/t high risk, recent multiple falls and injury with fall." A corresponding intervention, dated 2/18/10 indicated "Follow (Resident 7) if he leaves the dining area". The resident's Safety Alert Fall Risk Form updated 6/23/10 indicated "Follow (Resident 7) if leaves DR (dining area)." A fall review/investigation indicated that on 7/16/10 the resident fell which resulted in a fractured left hip. The review/investigation indicated that the resident had an extensive history of falls prior to admission and during the past year while at the facility. The resident was described as " ... independent with the use of his wheelchair making it necessary for staff to monitor his whereabouts. He at times will wander in his wheelchair to the main lobby near the fireplace." The fall review/investigation indicated that the resident had eaten dinner in the dining room. When staff was ready to put him in bed it was noticed he was not in the dining room. It had been about 15-20 minutes since the staff person had seen the resident. The resident was found outside the building, on the ground, next to his wheelchair. The fall resulted in a left hip fracture which required treatment at the hospital. In interview on 11/4/10 at 2:00 pm Staff 3, CNA reported that the resident had been in the dining room for dinner and that she had been busy assisting other residents with dinner and picking up the dinner trays. Staff 3 realized she had not seen the resident for 15-20 minutes, and the search for the resident began. The 6/23/10 updated care plan and Safety Alert Fall Risk care plan that was in effect at the time of the fall was reviewed with Staff 3. The Safety Alert Fall Risk form and 6/23/10 updated care plan indicated "Follow (Resident 7) if leaves DR (dining room)." Staff 3 reported that meant that staff were to go with the resident, find the resident, follow the resident, be with the resident if /when the resident left the dining area. Staff 3 reported that the resident had been wandering off the unit not every evening, but frequently, and 1 to 2 times an evening when he did wander away from the unit . On 11/4/10 at 2:40 pm the 7/16/10 fall review/investigation was reviewed with Staff 2, RNCM. It was acknowledged the updated 6/23/10 care plan and Fall Alert had been current at the time of the 7/16/10 fall, that the resident had left the dining area, and that it had been 15-20 minutes since staff had seen the resident before the search for him began. On 11/4/10 at 3:15 pm the resident's 7/16/10 fall review/ investigation and care plan was reviewed with Staff 1, ADON. Staff 1 acknowledged it had been 15- 20 minutes before staff were aware the resident was missing, and that the Fall Alert Form and care planned intervention to follow the resident if he left the dining room had not occurred. In addition, Resident 7's current care plan indicated the resident required extensive assistance for transferring and that 1 person assistance was needed. On 11/4/10 at 9:20 am, after breakfast, the resident was observed to self propel in his wheelchair down the hall, from the dining room area, to his room. The resident had already begun self transferring into bed before Staff 4, CNA reached the resident's room to assist the resident. .