Every finding on record at Pioneer Nursing Home

Based on interview and record review it was determined the facility failed to ensure PRN psychotropic medication orders had an end date and failed to ensure a clinical rationale was obtained to extend the use of PRN psychotropic medications beyond 14 days for 1 of 5 sampled residents (#4) reviewed for medications. This placed residents at risk for adverse side effects of psychotropic medication. Findings include: Resident 4 was admitted to the facility on [DATE] with diagnoses including adult failure to thrive, depression and anxiety. A review of the 2/27/26 admission MDS revealed Resident 4 had a BIMS score of 14 indicating she/he was cognitively intact. The MDS also indicated Resident 4 received hospice services. The care plan related to the use of anti-anxiety medication, initiated on 2/24/26, revealed Resident 4's PRN medication use was to be reviewed by day 14. The physician would be notified for a face-to-face visit to address the need to renew the PRN order. A 2/20/26 physician order revealed an order for lorazepam (anti-anxiety) oral concentrate two mg/ml; give 0.25 ml every four hours PRN for anxiety and agitation. No end date was documented. A 4/7/26 physician order revealed an order for lorazepam oral concentrate two mg/ml; give 0.25 ml every four hours PRN for anxiety and agitation. No end date was documented. A review of the February 2026 MAR revealed Resident 4 received PRN lorazepam for a total of five days. A review of the March 2026 MAR revealed Resident 4 received PRN lorazepam for a total of 29 days; including 24 days of consecutive use. A review of the April 2026 MAR revealed Resident 4 received PRN lorazepam for a total of ten days. A 3/13/26 at 9:40 AM Progress Note by Staff 2 (DNS) revealed Resident 4 had continued anxiety with non-pharmacological interventions and PRN lorazepam. Staff 2 noted Resident 4 might benefit from scheduled anxiety medication and messaged the physician. A 3/13/26 at 1:04 PM Progress Note revealed a new order for clonazepam (anti-anxiety) 0.25 MG one tablet BID for anxiety. There was no mention about an end date for PRN lorazepam or the continued use beyond 14 days. On 4/23/26 at 12:25 PM and at 1:31 PM Staff 2 stated she communicated to Resident 4's hospice physician about the need for evaluation after 14 days for the PRN lorazepam and left it up to the physician to decide. Staff 2 acknowledged the facility did not ensure an end date for Resident 4's PRN lorazepam and did not receive a clinical rationale from the physician for the continued use of PRN psychotropic medication.

Based on interview and record review it was determined the facility failed to ensure the resident environment remained free of accident hazards including failure to secure the resident's wheelchair during transport in the facility van for 1 of 3 sampled residents (#1) reviewed for falls. The facility's failure was determined to be an immediate jeopardy situation. The fall resulted in a cervical spine (neck) fracture and spinal cord injury requiring hospitalization and emergency surgical intervention. According to hospital records the resident died on [DATE] as a result of this fall. Findings include: The facility's undated Transport Van Driver policy and procedure revealed transport drivers will receive a documented initial and annual orientation for each vehicle prior to being approved as a transport driver. This orientation will include in-person training by a qualified individual including return demonstration. The policy indicated residents might be vulnerable to injuries when there was rapid acceleration or deceleration, turning too fast, changing lanes, swerving and stopping. The policy did not identify any guidance or information for provision of emergency care to residents in the event of an accident or other incident with injuries. Resident 1 was admitted to the facility in ,d+[DATE] with diagnoses including schizophrenia (serious brain condition that causes abnormal interpretation of reality) and depression. Resident 1's [DATE] care plan indicated Resident 1 required the stand-by assistance of one person for ambulation with a walker. During interviews on [DATE] at 3:45 PM and [DATE] at 10:04 AM Witness 10 (CNA) described what occurred on [DATE] when she transported Resident 1 in the facility transport van. Witness 10 stated she prepared the resident for transport and buckled the back two buckles to the wheelchair and put on the resident's seatbelt. Witness 10 stated she was stopped at a stop sign and when she drove forward the resident's wheelchair tipped backwards, so she pulled over immediately. Witness 10 indicated she attempted to get the resident's wheelchair uprighted but was unable to do so. Witness 10 stated she called Staff 2 (DNS) at the facility, explained to her what happened and asked what she should do. Staff 2 directed her to return to the facility. Witness 10 revealed after they returned to the facility Resident 1 told staff her/his neck hurt. Witness 10 stated training for transport drivers was completed with a checklist that included checking the status of the van and completing a mileage log. Hospital Notes on [DATE] revealed the resident's medical diagnoses included: fracture of the sixth cervical vertebrae (caused by a sudden, forceful injury resulting in severe pain in the back, legs and arms), central cord syndrome (commonly caused by hyperextension - to extend a body part beyond the normal range of motion) of the neck during a traumatic event that results in impaired ability to transmit messages to or from the brain) and spinal cord injury (damage to the spinal cord resulting from trauma). On [DATE] the facility investigation report of Resident 1's fall on [DATE] in the facility transport van was requested. At 1:55 PM Staff 2 provided a copy of a Corrective Action Form which included a description of the incident and witness statements by staff who were present. The form included a Facts section which revealed Resident 1 fell backwards during the trip and required assistance from staff upon return to the facility. The report indicated the front straps used to secure the wheelchair were not applied because Witness 10 did not think they were needed. On [DATE] at 2:30 PM and [DATE] at 12:55 PM current and initial training records for all transport drivers were received. The training records revealed multiple staff from the Nursing Facility and ALF (Assisted Living Facility) were trained as transport van drivers. The Transport Van Driver Safety Training included instruction for the following: -How to safely use seatbelts, wheelchair tie-downs and straps. -How to secure residents and prevent wheelchair and resident movement inside the vehicle while it is in operation. -Wheelchairs must be secure if the vehicle is in motion. There was no evidence of training provided to drivers for what to do in the event of an emergency. On [DATE] at 3:00 PM and [DATE] at 12:55 PM Staff 1 (administrator) provided the following documentation of transport van driver training for Nursing Facility and ALF staff: -Staff 8 (Medical Records): Initial [DATE], Retrained [DATE]. -Staff 9 (Activities): Trained [DATE]. -Staff 10 (Maintenance): Trained [DATE]. -Staff 11 (Maintenance): Trained [DATE]. -Witness 5 (ALF Administrator/Driver Trainer): Initial [DATE]; Retrained [DATE]. -Witness 7 (ALF Activities): Initial [DATE], Retrained [DATE]. -Witness 8 (ALF Resident Care Coordinator): Initial [DATE], Retrained [DATE]. -Witness 9 (ALF Human Resources): Initial [DATE]. -Witness 11 (ALF Caregiver): Trained [DATE] The training records provided by Staff 1 did not include documentation of driver training for Witness 10. During interviews on [DATE] at 3:00 PM and [DATE] at 12:55 PM Staff 1 revealed there were no specific qualifications for who received driver training and stated experience would be the qualification. Staff 1 stated he assumed staff would call the facility before calling 911 and whether or not they would do so depended on the issue. Staff 1 acknowledged the driver training did not address what staff were to do in an emergency. Staff 1 also acknowledged there was no documented driver training for Witness 10. On [DATE] at 1:45 PM Staff 1 was notified Resident 1's fall during transport in the facility van on [DATE] was an Immediate Jeopardy (IJ) situation and was provided with a copy of the IJ template related to the facility's failure to ensure residents are secured appropriately while being transported. An IJ immediacy removal plan was requested. On [DATE] at 4:43 PM the facility submitted a final acceptable immediacy removal plan which would abate the IJ situation. The IJ immediacy removal plan included: The facility will keep residents free from accidents/hazards (specifically head and neck injuries) as evidenced by: 1. Immediate action taken on Thursday, [DATE] with past facility transport drivers (current ALF Administrator) and the current facility administrator with all facility drivers to ensure proper use of wheelchair secure straps, wheelchair positioning and overall van mechanics (lifts, doors, etc.) 2. Providing all current facility drivers and any future facility drivers with training upon hire and annually that will focus on what to do in the event of an injury or suspected injury (with emphasis on head and neck injuries). The initial training will be provided by an offsite transport consultant who will train the trainer as the facility is currently looking for a new transport driver. This will take 5 business days to locate an offsite transport consultant. 3. Facility administrator and DNS will review any current policies and procedures dealing with transportation and will revise or develop new policies to include handling resident emergencies while on a transport vehicle including, but not limited to: head and neck injuries, spinal injuries, pelvic injuries, injuries to arms/hands/fingers, injuries to legs/feet/toes, respiratory emergencies, cardiac emergencies, skin tears/abrasions/burns/lacerations, fall from seats, fall from wheelchair, wheelchair tipping backward/sideways/forwards. These policies will be given to all facility drivers and competency checks will be given upon hire and annually per facility transport driver (once they complete driver training). It will take 5 business days to review and/or develop policies. It will take 1 day to present, review and competency check all facility drivers once policies are in place. 4. Policies will address when it is appropriate to call 911/EMS, following DNS clinical consultant training to ensure that proper understanding is in place to avoid any future accidents/hazards. *F689 will be reviewed in QAPI to ensure that all team members have input and suggestions to better improve facility standards. On [DATE] the immediacy for F689 was removed based on the implementation of the IJ immediacy removal plan confirmed through staff interviews for verification of provided training. During interviews on [DATE] staff confirmed they received the required training.

Based on interview and record review it was determined the facility failed to ensure 2 of 2 staff (RNs) adhered to professional standards of nursing practice related to the provision of care for a resident after a fall with potential neck and back injuries. This was determined to be an immediate jeopardy situation which resulted from a lack of assessment of the resident and provision of appropriate neck and spine precautions for 1 of 1 sampled resident (#1) who was injured in a fall resulting in blunt trauma to the back of the resident's head, complaints of neck pain and inability to move extremities. The fall resulted in a cervical spine (neck) fracture and spinal cord injury requiring emergency surgical intervention. According to hospital records the resident died on [DATE] as a result of this fall. Findings include: The Oregon State Board of Nursing and the Oregon Nurse Practice Act include the following information: Division 45 - Standards and Scope of Practice for the [NAME] [DATE] Scope of Practice Standards for Registered Nurses and Licensed Practical Nurses. 2) Standards related to the RN's responsibility for ethical practice, accountability for services provided, and competency. The RN shall: (a) Base RN practice on current and evolving nursing science, other sciences, and the humanities; (b) Be knowledgeable of the professional nursing practice and performance standards and adhere to those standards; (c) Be knowledgeable of the Oregon statutes and regulations governing RN practice and practice within those legal boundaries; (d) Demonstrate honesty, integrity and professionalism in the practice of registered nursing; (e) Be accountable for individual RN actions; (f) Maintain competency in one's RN practice role; (g) Maintain documentation of the method that competency was acquired and maintained; (h) Accept only RN assignments that are within one's individual scope of practice; (i) Recognize and respect a client's autonomy, dignity and choice; (j) Accept responsibility for notifying employer of an ethical objection to the provision of a specific nursing intervention; (k) Ensure unsafe nursing practices are addressed immediately; (l) Ensure unsafe practice and practice conditions are reported to the appropriate regulatory agency; and (m) Protect confidential client information and only share information in a manner that is consistent with consistent with current law. The Mayo Clinic provided the following guidance (dated ,d+[DATE]) for a suspected spinal injury: Do not move the affected person. Permanent paralysis and other serious complications can result. Assume a person has a spinal injury if: -There's evidence of a head injury with an ongoing change in the person's level of consciousness. -The person complains of severe pain in her/his neck or back. -An injury has exerted substantial force on the back or head. -The person complains of weakness, numbness, or paralysis or lacks control of her/his limbs, bladder or bowels. The neck or body is twisted or positioned oddly. If you suspect someone has a spinal injury: -Get help. Call 911 or emergency medical help. -Keep the person still. Place heavy towels or rolled sheets on both sides of the neck or hold the head and neck to prevent movement. -Avoid moving the head or neck. Resident 1 was admitted to the facility in ,d+[DATE] with diagnoses including schizophrenia (serious brain condition that causes abnormal interpretation of reality) and depression. Resident 1's [DATE] care plan revealed Resident 1 required the stand-by assistance of one person for ambulation with a walker. Staff 2's (DNS) [DATE] at 12:44 PM progress note revealed while being transported by Witness 10 (ALF [Assisted Living Facility] CNA), Resident 1 tipped backward in her/his wheelchair and hit the back of [her/his] head and neck on the wheelchair ramp and remained in that position for approximately ,d+[DATE] minutes. Staff 2 indicated she observed the resident in the wheelchair tipped backward on the van floor and she/he was in a position which caused the resident's neck to be folded with [the] chin tucked to [her/his] chest. The resident was moved to an upright position by four facility staff and was noted to have a quarter sized abrasion to the back of the head. The resident reported neck pain and having difficulty moving all of her/his extremities. The resident was noted to be able to lift her/his hands/arms and feet/toes. The resident asked to go to the ER (emergency room ) for evaluation. Staff 2 notified the resident's family and primary care physician. There was no documentation in the resident's record that neck and spine precautions were put in place when she/he complained of neck pain. An [DATE] Oregon EMS (Emergency Medical Services) Patient Care Report indicated an ambulance was dispatched at 1:05 PM and arrived at the facility at 1:07 PM. The EMS report revealed facility staff reported Resident 1 fell backwards in the wheelchair onto the floor of the facility transport van and landed on her/his back and neck. Resident 1 reported she/he had sharp pain in her/his neck and pain and tingling in all extremities. The resident stated when she/he fell backwards in the wheelchair she/he thought she/he felt something in her/his neck pop. The report indicated facility staff assisted with transferring the resident to an EMS gurney and c-spine (cervical spine: first seven vertebrae or bones in the spine) precautions were implemented. The report revealed the cervical collar available [on the ambulance] did not fit the resident and a pillow and multiple towel rolls were used to support the resident's neck. The closest time given since the injury was approximately one hour. EMS observations revealed Resident 1 was breathing at a normal rate and with quality circulation. The ambulance departed from the facility at 1:17 PM and arrived at the ED (Emergency Department) at 1:40 PM. ED notes revealed: Resident 1 was admitted on [DATE] at 1:43 PM and indicated the resident had constant moderate to severe pain that worsened with movement or touch; she/he could not feel her/his abdomen/arms or wiggle her/his toes since the fall, which was unusual for her/him. The notes revealed a c-collar (supportive neck brace) was applied and c-spine precautions were maintained. Results of diagnostic imaging at 2:04 PM and 3:07 PM revealed there was a fracture of the spine through the c-,d+[DATE] level. At 3:02 PM the ED physician documented the resident had a diagnosis of fracture of the sixth cervical vertebrae and indicated a trauma surgeon at another hospital agreed to see Resident 1 for evaluation and treatment. Hospital Notes: -On [DATE] the resident was transferred to the other hospital via Life Flight (helicopter) and was admitted to the Neuro Trauma Intensive Care Unit at 7:51 PM. The resident's medical diagnoses included: fracture of the sixth cervical vertebrae, caused by a sudden, forceful injury resulting in severe pain in the back, legs and arms, central cord syndrome (impaired ability to transmit messages to or from the brain) and spinal cord injury (damage to the spinal cord resulting from trauma). -On [DATE] at 6:11 PM hospital notes revealed Resident 1 had additional diagnostic testing to confirm the diagnosis of a cervical spine injury. On [DATE] the resident had spinal fusion surgery (surgical procedure to join two or more bones of the spine together permanently) to treat the cervical spine fracture and spinal cord injury. Hospital notes indicated the resident's status remained serious and she/he died on [DATE]. A witness statement signed by Staff 2 on [DATE] revealed Witness 10 contacted her on [DATE] at 12:32 PM while she was transporting Resident 1. Witness 10 reported Resident 1's fall in the facility van and her attempt to push the resident back to an upright sitting position but was not able to do so. Staff 2 instructed Witness 10 to return to the facility as safely as she could. Staff 2 indicated she observed the resident in the wheelchair tipped backward on the van floor in a position which caused her/his chin to be tucked into [her/his] chest. Staff 2 noted Resident 1 was awake, talking, complained of neck and back pain and had a quarter sized abrasion to the back of her/his head. Staff 2 documented four facility staff raised the resident and the wheelchair to an upright position and she tried to secure/stabilize the resident's neck from behind. While staff were removing Resident 1 from the transport van, Staff 2 stated as Witness 10 was wheeling the resident into the facility Staff 2 held up her/his feet using the bottom of her/his pants because there were no foot pedals and she/he could not lift her/his feet. Staff 2 indicated she completed a neurological assessment that revealed PERRLA (pupils equal, round and reactive to light and accommodation). Staff 2 documented the resident had weak grip strength and would not vs could not move [her/his] feet/legs. The resident stated she/he wanted to go to the hospital and EMS was contacted for transport. There was no documented evidence that the resident was provided with continuous support for her/his neck. A witness statement signed by Witness 10 on [DATE], revealed while transporting Resident 1 she moved away from a stop sign about a block away from the facility and the resident's wheelchair tipped backwards. Witness 10 indicated she stopped and was unable to get [Resident 1's] chair back up. Witness 10 documented she called the facility and Staff 2 told her to return to the facility because they were fairly close by. When she arrived at the facility there were other employees who helped get [the resident] and [her/his] chair tipped back upwards. During interviews on [DATE] at 3:45 PM and [DATE] at 10:04 AM Witness 10 stated she pulled the van over and attempted to get the wheelchair upright and was unable to do so. She called Staff 2 (DNS) at the facility, explained what happened and asked what she should do. Staff 2 directed her to return to the facility because she was close by. Witness 10 stated the resident seemed calm, alert and was still talking to her. When they arrived at the facility there were multiple people who came out to help. They uprighted the wheelchair and got the resident out of the van. Resident 1 was still talking and she/he told staff her/his head and neck hurt. Witness 10 stated she did not implement protective measures in the van because Resident 1 did not verbalize pain to her. During an interview on [DATE] at 6:00 PM Witness 1 (Complainant) indicated he went to the facility on [DATE] for an emergency that involved a resident who fell in the transport van. Witness 1 observed Resident 1 in the facility, seated in a wheelchair with no neck support in place. Witness 1 stated he observed the resident's head down with her/his chin on her/his chest. Witness 1 asked staff how the resident was injured and no response was given. Witness 1 requested to speak to Witness 10, who was present at the time of the fall. Staff 2 indicated Witness 10 was unavailable. Witness 1 stated he and facility staff used his lifting strap to get the resident from the wheelchair to the gurney and secured and loaded her/him onto the ambulance. Witness 1 observed marks on Resident 1's shoulders and neck and a red abrasion on the back of her/his head. Witness 1 asked Resident 1 what happened and she/he did not provide any information at that time. Witness 1 was familiar with Resident 1 and said she/he used a walker and was able to move independently with minimal assistance. Enroute to the hospital, the resident said her/his arms and legs were tingling and burning and she/he could not move her/his fingers on either hand normally. Witness 1 stated the resident tried to move her/his arms but was weak and had uncoordinated movements. Resident 1 stated she/he fell over backwards in the wheelchair and landed on her/his neck and back. Witness 1 indicated the resident stated she/he felt something pop in her/his neck and he immediately initiated cervical spine precautions. Witness 1 asked how long it had been since injury and the resident said it was quite awhile. Witness 1 reported when he was dispatched around 1:00 PM, facility staff would not provide a specific time when the incident took place. On [DATE] at 11:06 AM Witness 6 (ALF Caregiver) revealed she was present when Witness 10 and Resident 1 returned to the facility on [DATE] after her/his fall in the transport van. Witness 6 stated the resident was very quiet but she/he said she/he had pain in her/his neck and back. Witness 6 stated she checked the resident's vital signs and asked her/him what her/his pain level from one to ten and the resident replied it was a ten. Witness 6 stated the resident was usually able to assist with transfers but was she/he was unable to assist when transferring from the wheelchair to the EMT's (Emergency Medical Technician's) gurney. On [DATE] at 1:55 PM Staff 3 (RNCM) stated she was present after Resident 1's fall in the facility van and observed Staff 2 (DNS) attempt to stabilize the resident's head. Staff 3 stated she observed the resident's head was against the raised wheelchair ramp and her/his chin was pressed to her/his chest. When Staff 3 was asked whether the resident's status was assessed prior to moving her/him she stated she did not check the resident. Staff 3 stated she did not think about calling 911 prior to moving the resident because she/he needed to get out of that position. Staff 3 indicated after she and the other staff got [Resident 1] up, she exited the van and assisted with the van lift to help the resident out of the van. During an interview on [DATE] at 2:35 PM Staff 2 stated Witness 10 told her she went around a corner and the resident tipped back in the wheelchair. Staff 2 stated she asked Witness 10 where they were and was informed they were close by and they arrived at the facility within a minute. In response to how the resident was lifted and removed from the van, Staff 2 stated she/he was difficult to move and they did not have extra cervical collars available for emergencies. When Staff 2 was asked whether she considered instructing Witness 10 to call 911 from the site of the incident, she stated no because they were so close to the facility. The surveyor asked Staff 2 if she considered waiting for EMTs before moving the resident and she stated no because she was concerned about the resident's breathing. On [DATE] at 12:55 PM Staff 1 (administrator) stated he assumed staff would call the facility before calling 911 and whether or not they would do so, depended on the issue. On [DATE] at 1:45 PM Staff 1 was notified Resident 1's fall during transport in the facility van on [DATE] was an Immediate Jeopardy (IJ) situation and was provided with a copy of the IJ template regarding the facility's failure to ensure residents received care according to accepted nursing standards of practice. An IJ immediacy removal plan was requested. On [DATE] at 4:43 PM the facility submitted a final acceptable immediacy removal plan which would abate the IJ situation. The IJ immediacy removal plan included: The facility will take immediate corrective actions to ensure care and services provided by the facility are provided according to accepted standards of clinical practice as evidenced by: 1. Training the DNS with use of a clinical consultant to ensure the DNS has full understanding of current practices and accepted standards. This will require at least 5 business days to locate and secure a clinical consultant. 2. DNS will be validated and competency checked by an outside clinical consultant as per their protocols to ensure full understanding of emergency situations, with specific reference to suspected head and neck injuries as well as other emergency situations. 3. DNS will develop and/or review facility policies and procedures with the facility administrator to ensure policies and procedures reflect current practices and accepted standards. This requires a review of current policies and procedures as well as possible development of new policies and procedures. This will require 5 business days following completion of DNS consultant training. 4. DNS and facility administrator will provide all staff training to every department in the facility including nursing department to address policy updates, changes and any new policies that are developed following DNS training and policy review with facility administrator. This will take 1 business day to provide all staff training. 5. All facility staff will be provided with a competency quiz following training to ensure that all facility staff understand what to do in the event of a clinical emergency based on the policy updates, changes or new policies presented. 6. All facility staff will be provided with training upon hire and annually to ensure understanding of current practices and accepted standards during emergencies. Training will be provided by the DNS. *F685 will be reviewed in QAPI to ensure that all team members have input and suggestions to better improve facility standards. On [DATE] the immediacy was removed based on implementation of the IJ immediacy removal plan confirmed through staff interviews for verification of provided training and review of facility documentation. During interviews on [DATE] staff confirmed they received the required training.

Based on interview and record review it was determined the facility failed to have a system in place to ensure CNA staff received 12 hours of required in-service training annually for 4 of 5 sampled CNAs (#s 12, 13, 14, 15) and failed to ensure 2 of 2 ALF (Assisted Living Facility) CNAs (#s 12 and 13) received training prior to working in the Nursing Facility reviewed for required in-service training for CNAs. This placed residents at risk for lack of competent staff. Findings include: Review of the facility's CNA staff training records on 12/9/23 at 4:20 PM revealed the following: -Staff 12 (CNA), hired 8/19/21, had three hours of documented training from 8/19/22 through 8/19/23. -Staff 13 (CNA), hired 2/2/11, had six hours of documented training from 2/2/22 through 2/2/23. -Staff 14 (CNA, hired 11/28/22 had no hours of documented training from 11/28/22 through 11/28/23. -Staff 15 (CNA), hired 10/16/20, had five hours of documented training from 10/22/22 through 10/22/23. During interviews on 12/9/23 at 4:20 PM and 12/10/23 at 11:00 AM and 2:35 PM Staff 1 (Administrator) stated he was unable to find the inservice binder and unable to locate additional training records for CNAs. Staff 1 indicated the nursing facility and ALF training was rolled into one and there was a flood in the ALF where the human resources office maintained records for both facilities. Staff 1 acknowledged the CNA training was incomplete. On 12/10/23 at 4:00 PM Staff 1 revealed two ALF CNAs were currently working in the Nursing Facility. Staff 1 stated there was no documented training for Witness 12 (ALF CNA) and Witness 13 (ALF CNA).

Based on interview and record review it was determined the facility failed to conduct and complete a comprehensive facility wide assessment for 1 of 1 sampled facility. This placed residents at risk for lack of quality of care and reduced quality of life. Findings include: On 12/7/23 at 1:30 PM Staff 1 (Administrator) provided a copy of the facility's assessment. The assessment lacked evaluation and information for the following areas: -There was no identification or evaluation of the specific diseases, conditions or physical and cognitive disabilities of the current resident population. -The was no description or evaluation of training programs for staff, including nursing, food service, maintenance or administrative areas. -Observations and interviews revealed the use of agency staff and staff from the attached ALF (Assisted Living Facility). The facility assessment did not provide a description or evaluation of the use of those staff. -The facility currently has three bariatric (BMI: body mass index of 35 or greater with specific significant health problems) residents. The facility assessment did not include a description of care needs, staffing or other requirements for these residents. -Information regarding all personnel, including managers, staff (contract, volunteers) including their education, training and competencies related to resident care. -Listing of contracts, memorandums of understanding and other agreements with third parties who provide services or equipment to the facility during both normal operations and emergencies. -A facility-based and community-based risk assessment was not identified in the plan and there was no assessment or plan to address continuity of care during an emergency. -Infection Control lacked specific information related to current infection control standards, evaluation of the provision of services related to communicable diseases, including Covid-19 or a plan to ensure immunizations are provided timely. The lack of a comprehensive facility assessment was reviewed with Staff 1 on 12/10/23 at 2:20 PM. Staff 1 acknowledged the assessment did not include all the required information.

Based on interview and record review it was determined the facility failed to follow pharmacy recommendations in a timely manner for 1 of 5 sampled residents (#11) reviewed for medications. This placed residents at risk for unmet diabetic needs. Findings include: Resident 11 admitted to the facility in 2018 with diagnoses including diabetes. The 9/18/23 pharmacy recommendation indicated Resident 11 received insulin and needed an A1C (a blood test that measures the average blood sugar levels over the past three months) to be completed. There was no indication in the clinical record to indicate Resident 11 had an A1C completed. On 10/19/23 at 10:11 AM Staff 2 (DNS) stated she thought Resident 11 had all recommended labs scheduled including the A1C and acknowledged the 9/18/23 pharmacy recommendation for Resident 11's A1C was not completed as of 10/19/23 and was not timely.

Based on observation, interview and record review it was determined the facility failed to ensure the medication error rate was less than 5%. There were 30 medication administration opportunities with 2 errors resulting in an error rate of 6%. This placed residents at risk for adverse medication side effects. Findings include: Resident 3 readmitted to the facility in 2022 with diagnoses including diabetes. The 10/6/23 physician order indicated Resident 3 was to receive insulin lispro (fast-acting insulin) 12 units once daily. On 10/18/23 at 10:37 AM Staff 5 (LPN) administered 12 units of insulin lispro to Resident 3. Continuous observations revealed Resident 3 was not served food until her/his lunch tray arrived on 10/18/23 at 12:02 PM (1 hour and 25 minutes after she/he received insulin). On 10/18/23 at 11:26 AM Staff 5 used the facility 2023 Drug Handbook and referenced insulin lispro. Staff 5 stated the drug guide indicated insulin lispro should be given within 15-30 minutes of a meal. Staff 5 acknowledged she administered insulin lispro at 10:37 AM and Resident 3 was not served lunch until 12:02 PM. On 10/18/23 at 1:09 PM Staff 2 (DNS) stated the expectation was for staff to follow manufacturer's recommendations for insulin administration. 2. Resident 1 admitted to the facility in 2018 with diagnoses including diabetes. The 10/6/23 physician order indicated Resident 3 was to receive insulin lispro (fast-acting insulin) 50 units before meals. On 10/18/23 at 11:04 AM Staff 5 (LPN) administered 50 units of insulin lispro to Resident 1. Continuous observations revealed Resident 1 was not served food until her/his lunch tray arrived on 10/18/23 at 11:49 AM (45 minutes after she/he received insulin). On 10/18/23 at 11:26 AM Staff 5 used the facility 2023 Drug Handbook referenced insulin lispro. Staff 5 stated the drug guide indicated insulin lispro should be given within 15-30 minutes of a meal. Staff 5 acknowledged she administered insulin lispro at 11:04 AM and Resident 3 was not served lunch until 11:49 AM. On 10/18/23 at 1:09 PM Staff 2 (DNS) stated the expectation was for staff to follow manufacturer's recommendations for insulin administration.

Based on interview and record review it was determined the facility failed to ensure dialysis services were in place including monitoring and communication with the dialysis provider for 1 of 1 sampled resident (#11) reviewed for dialysis. This placed residents at risk for dialysis complications. Findings include: Resident 11 readmitted to the facility on [DATE] with diagnoses including end stage renal disease. a. The 9/13/23 physician order indicated Resident 11 was to receive dialysis on Monday, Wednesday, and Friday. On 10/18/23 at 1:38 PM Staff 4 (RN) stated the dialysis communication forms were to be completed by the facility and sent with Resident 11 to dialysis. She stated upon return the facility staff scanned the information into the clinical record. Staff 4 was asked to provide a copy of the form for the visit on 10/18/23. Staff 4 stated she was unsure if the communication form was sent to dialysis with the resident and acknowledged there was no communication form in the resident's dialysis folder that she/he took to and from dialysis. Staff 4 stated the only dialysis communication form found in the clinical record was from 10/9/23. The 10/9/23 dialysis communication form was reviewed and indicated the facility was to fill out the sections for vital signs, medications, time of last meal and any alerts. The dialysis center was to fill out the sections for discharge time, pre and post dialysis weights, fluid removed, vital signs, labs, medications given at dialysis, tolerance to procedure, follow up orders, appointments made and any problems. The clinical record was reviewed and there was no documentation found to indicate communication with the dialysis center was completed on dialysis days from 9/13/23 through 10/18/23. On 10/18/23 at 2:01 PM Staff 2 (DNS) was asked to provide dialysis communication forms from 9/13/23 through 10/18/23. On 10/18/23 at 2:51 PM Staff 2 stated one dialysis communication form dated 10/9/23 was the only form completed from 9/13/23 through 10/18/23 and acknowledged the resident received dialysis three times per week. b. On 10/17/23 at 10:47 AM Resident 11 stated her/his dialysis site was on her/his chest and the dressing around it was changed by dialysis staff. Resident 11 indicated she/he did not have issues with the dialysis site. On 10/18/23 at 1:38 PM Staff 4 (RN) stated the resident had a dialysis port and dialysis staff changed the dressings around the port and the facility staff did not do anything with the dialysis site. On 10/18/23 the clinical record was reviewed and there was no indication the facility monitored the resident's dialysis site. On 10/18/23 at 2:51 PM Staff 2 (DNS) stated Resident 11 readmitted to the facility on [DATE] and as of 10/18/23 there was no monitoring for her/his dialysis site. Staff 2 stated the expectation was for staff to monitor the dialysis site every shift for pain, redness and swelling.

Based on interview and record review it was determined the facility failed to ensure residents received bowel care as ordered for 2 of 5 sampled residents (#s 10 and 14) reviewed for medications. This placed residents at risk for constipation. Findings include: 1. Resident 14 admitted to the facility in 2023 with diagnoses including chronic pain and dementia. The 8/17/23 MDS indicated Resident 14 was cognitively impaired. Review of the 8/16/23 physician orders indicated Resident 14 was to receive the following: - Milk of Magnesia (MOM) as needed for constipation after two days of no bowel movement (BM). - bisacodyl as needed after two days of no BM. -docusate sodium enema as needed for constipation after four days of no BM. Review of bowel records indicated Resident 14 did not have a bowel movement from 9/29/23 through 10/4/23 (6 days). Review of Resident 14's 9/2023 and 10/2023 MAR indicated the following: - MOM was not administered on any occasion during time frame. - Bisacodyl was not administered until 10/4/23. - Docusate sodium enema was not administered until 10/5/23. On 10/18/23 at 12:55 PM Staff 2 (DNS) acknowledged Resident 14 had no BM from 9/29/23 through 10/4/23 and did not receive bowel medications as ordered by the physician. 48830 2. Resident 10 was admitted to the facility in 10/2018 with diagnoses including dementia, depression, and chronic pain. A review of Resident 10's medical records revealed from 10/2/23 through 10/4/23 (three days) and from 10/10/23 through 10/12/23 (three days) the resident did not have a bowel movement (BM). Review of Resident 10's care plan, dated 9/7/23, revealed the resident was at risk for constipation from daily use of olanzapine (an antipsychotic medication), sertraline (an antidepressant medication), and Baclofen (a pain medication). Interventions included to monitor for side effects such as constipation. Review of the 9/15/23 physician orders indicated Resident 10 was to receive the following: -polyethylene glycol as needed daily for constipation. -prune juice as needed after one day of no BM. -bisacodyl as needed after two days of no BM. -Milk of Magnesia as needed after two days of no BM. -Dulcolax suppository as needed after three days of no BM. A review of Resident 10's 10/2023 MAR revealed bowel care medications were not administered on any occasion during the time frame. On 10/19/23 at 10:39 AM Staff 2 (DNS) acknowledged Resident 10 did not have a BM from 10/2/23 through 10/4/23 and from 10/10/23 through 10/12/23. Staff 2 acknowledged the physician orders were not followed and bowel care was not provided when it should have been.

Based on interview and record review it was determined the facility failed to implement a discharge plan of care regarding discharge medications for 1 of 3 sampled residents (#9) reviewed for safe discharge. This placed residents at risk for unsafe discharge. Findings include: Resident 9 was admitted to the facility in 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Pioneer Nursing Home Health District Order Summary Report dated 3/8/22 revealed the resident's medications were reconciled prior to discharge. The 3/8/22 Physician Discharge Fax Form indicated the services needed on discharge included: Home Health nursing and the medications the resident needed filled post discharge could be sent to a local pharmacy. The plan was for the resident to be discharged with a family member and a home health agency nurse would visit the resident at home. There were no indications in the 3/8/22 discharge records or the 3/8/22 Progress Notes that the medication prescriptions were called in or faxed to the local pharmacy. Resident 9 signed the discharge paperwork from the facility. In an interview on 4/26/22 at 9:39 AM Witness 1 (Complainant) stated they were unable to pick up the prescriptions at the pharmacy, the prescriptions were not there. Witness 1 stated they called the pharmacy and the facility every day for five days after discharge and attempted to get the prescription medications. Witness 1 contacted the home health agency scheduled to see Resident 9. Witness 8 (Home Health Nurse) stated she/he called the pharmacy and the facility, and it was determined the prescription medications remained at the facility. Witness 8 drove to the facility and obtained Resident 9's prescriptions. On 4/27/22 at 1:41 PM Staff 7 (SSD) stated Resident 9's insurance allowed her/his medications to be sent home with the resident. On 4/28/22 at 10:30 AM Staff 2 (DNS) had no further information or documentation about Resident 9's prescription medications being faxed to the pharmacy. In an interview on 4/29/22 at 2:32 PM Staff 1 (Interim Administrator) and Staff 3 (RNCM) stated when Resident 9 discharged from the facility, the medications should have gone home with her/him.

Based on interview and record review it was determined the facility failed to ensure skin treatment was implemented for 1 of 1 sampled resident (#39) reviewed for pressure ulcers. This placed residents at risk for worsening wounds. Findings include: Resident 39 was admitted to the facility in 2016 with [DIAGNOSES REDACTED]. The 9/30/16 Admit/quarterly assessment indicated Resident 39 had maceration (softening of the skin due to exposure to moisture) to the coccyx region and did not have a pressure ulcer. The 10/7/16 weekly skin assessment indicated Resident 39 had a pressure ulcer to the coccyx. The area was described to be red/purple, blanchable and had a three cm by four cm open area. The 10/8/16 Progress Note indicated barrier cream was applied to the red/purple area to the resident's buttock region. The 10/10/16 Progress Note indicated the resident had three open areas to the buttock region. The note indicated the physician was notified and the area was cleaned and a foam dressing was applied. The fax sent to Resident 39's physician on 10/10/16 included the 10/10/16 Progress Note including the application of a foam dressing to the buttock region. The associated Physician's Telephone Orders response was OK. The orders did not include the frequency the foam dressing was to be changed. The October 2016 TAR did not include documentation to indicate a foam dressing was provided to Resident 39 after the 10/10/16 physician order [REDACTED]. The 10/11/16 night shift Progress Note indicated the resident had a dressing to the coccyx. The note did not indicate the dressing was changed. The 10/14/16 and 10/16/16 day shift Progress Note indicated barrier cream was applied to the resident's coccyx region. The notes did not indicate a foam dressing was applied. The 10/16/16 evening shift note indicated barrier cream was applied to the resident's coccyx region and an island dressing (absorbent dressing with an adhesive border, used to absorb light drainage) was applied. The 10/17/16 day notes indicated the resident had three open areas and a foam dressing was applied. On 2/15/17 at 2:06 pm Staff 1 (RNCM) acknowledged the 10/10/16 Progress Note indicated a foam dressing was applied to the resident's buttock region. A request was made to Staff 1 to provide documentation to indicate how often the foam dressing was to be applied and if the dressing changes were provided when not addressed in the progress notes. No additional information was provided. Resident 39's 10/17/16 Medical Visits and Orders form indicated the staff requested the physician to assess the resident's wounds to the coccyx area. The form included directions from the physician for staff to apply magic butt cream. The form did not include how often the cream was to be applied. The 10/17/16 Progress Note indicated Resident 39 was seen at the physician office and magic butt cream was to be applied. The October 2016 TARs did not have documentation to indicate the magic butt cream was applied after the 10/17/16 physician office visit. On 2/15/17 at 2:11 pm Staff 1 (RNCM) indicated magic butt cream was mixed at the facility and was a combination of an antibacterial cream, vitamin based cream, zinc oxide (barrier cream) and [MEDICATION NAME] (antacid). A request was made to Staff 1 to provide documentation to indicate staff applied the magic butt cream after the 10/17/16 physician visit. No additional information was provided. The 10/18/17 Progress Note by Staff 2 (DNS) indicated Resident 39's skin to the buttock region worsened despite barrier cream and new treatment was implemented. The new treatment included the skin was to be cleaned, calcium alginate (seaweed based absorbent material) was to be applied and then covered with a dressing. The note indicated the suggested change was forwarded to the physician for order approval. The Physician's Telephone Orders indicated the new treatment with calcium alginate was authorized by the physician on 10/19/16. The 10/19/16 night shift Progress Note indicated a dressing was present and the buttock wounds were not able to be visualized. The 10/22/16 day shift Progress Note indicated a dressing was removed and barrier cream was applied. The note did not indicate calcium alginate was reapplied. The October 2016 TAR did not have documentation to indicate the new orders with the application of calcium alginate and a foam dressing was provided to Resident 39. On 2/15/17 at 2:13 pm Staff 2 (DNS) indicated Resident 39 did not have a pressure ulcer. The resident had significant swelling to the buttock region and the resident was frequently incontinent. The skin was macerated with an open area. Staff 2 acknowledged she recommended the resident's buttock region be treated with calcium alginate on 10/18/16. Staff 2 indicated the dressings did not stay on because the resident was frequently incontinent. A request was made to Staff 2 to provide documentation to indicate the staff implemented the calcium alginate dressing changes. No additional information was provided. The 10/27/16 Weekly Skin assessment indicated Resident 39 buttocks were red and had a superficial open area to the left buttock. The note indicated cream was applied. Resident 39 was discharged from the facility 10/31/16.

Based on observation, interview and record review it was determined the facility failed to review and revise a care plan for a resident's use of an alarm when in a recliner for 1 of 1 sampled resident (#17) reviewed for restraints. This placed residents at risk for falls. Findings include: Resident 17 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. The resident's 6/2016 annual MDS and associated CAAs indicated the resident was at risk for falls and required assistance for transfers. The 12/14/16 Care Plan indicated Resident 17 was at risk for falls and interventions included the resident was to have an alarm in the wheelchair and bed. The care plan also indicated the resident was to be in supervised areas when the resident sat in the wheelchair. The care plan did not address if the resident was to have an alarm when the resident sat in a recliner. On 2/14/17 at 9:54 am Resident 17 was observed to sit in a recliner by the nurses station. The recliner foot rests were elevated. An alarm was not observed to be attached to the recliner to notify staff if Resident 17 attempted to stand. The resident's wheelchair was adjacent to the recliner and the wheelchair had an alarm. On 2/16/17 at 8:45 am Staff 11 (CNA) indicated at times Resident 17 was tired, did not want to go to bed but if the resident fell asleep in the wheelchair the resident was at risk to fall forward. Staff 11 indicated he assisted the resident to the recliner on 2/14/17 for comfort and indicated the resident did not use an alarm when the resident sat in the recliner. Staff 11 indicated the resident did not usually attempt to stand from the recliner but it was possible the resident might attempt to stand. On 2/15/17 at 10:10 am Staff 6 (CNA) indicated Resident 17 had an alarm when in bed. Staff 6 was not sure if he could stand from the recliner. On 2/15/17 at 10:11 am Staff 8 (RA) indicated at times the resident was able to stand with staff assistance. Staff 8 indicated she was not sure if Resident 17 was capable to stand or if the resident attempted to stand from the recliner. On 2/15/17 at 11:12 am Staff 9 (CNA) indicated Resident 17 sat in the recliner at least twice a week. Staff 9 indicated Resident 17 was able to stand with staff assistance but she was not sure if the resident was able to stand from the recliner without staff assistance. On 2/16/17 at 10:04 am Staff 12 (CNA) indicated for at least the past two months Resident 17 periodically sat in the recliner. Staff 12 indicated when Resident 17 sat in the recliner staff did not place an alarm. On 2/16/17 at 9:47 am Staff 2 (DNS) indicated Resident 17 had a history of [REDACTED]. Staff 2 indicated the resident did not have good safety awareness and did not use the call light to request assistance to stand. Staff 2 indicated the resident used an alarm in the wheelchair and bed to alert staff if the resident attempted to stand. Staff 2 indicated Resident 17 could attempt to stand when in the recliner. Staff 2 acknowledged the care plan was not updated to direct staff to use or not use the alarm when the resident sat in the recliner.

Based on interview and record review it was determined the facility failed to develop a comprehensive care plan for a resident's use of [MEDICATION NAME] (blood thinner/anticoagulant) for 1 of 5 sampled residents (#51) reviewed for medications. This placed residents at risk for medication side effects. Findings include: Resident 51 was admitted to the facility in 2017 with [DIAGNOSES REDACTED]. The 2/7/17 comprehensive admission MDS indicated the resident was administered an anticoagulant. The February 2017 MAR indicated [REDACTED] Resident 51's comprehensive care plan initiated on 2/7/17 did not identity Resident 51's use of [MEDICATION NAME] and did not have measurable objectives and interventions developed to ensure the resident did not have side effects from the anticoagulant. On 2/15/17 at 1:59 pm Staff 1 (RNCM) acknowledged Resident 51 was on and continued to receive [MEDICATION NAME]. Staff 1 acknowledged a comprehensive care plan for the use of [MEDICATION NAME] was not developed after the comprehensive assessment was completed.

Based on interview and record review it was determined the facility failed to ensure completion of thorough incident investigations for 1 of 2 sampled residents (# 26) reviewed for accidents. This put residents at risk for unaddressed abuse and neglect. Findings include: Resident 26 was a long term resident of the facility with [DIAGNOSES REDACTED]. The resident's care plan with an initiation date of 6/3/15, indicated the the resident had multiple safety interventions in place including a low bed, fall mat next to the bed, a pressure alarm when in bed, a tab alarm in place when up in the wheelchair, offer toileting when resident was agitated or restless, when the resident was up in the wheelchair she/he was to be in common areas where staff could see the resident and staff were to provide a prompt response to the resident's requests for assistance. The resident could be alert and confused with hallucinations that made it difficult to redirect the resident. Nursing progress notes dated 12/24/16 indicated the resident was found on her/his left side on the fall mat next to the bed. The resident stated she/he was trying to put (her/his) call light back on the bed and slipped out of (her/his) chair. The resident denied pain or hitting her/his head. No injuries were noted and the resident was assisted into the wheelchair. A 12/26/16 note indicated the resident had a tab alarm to the wheelchair and a pressure alarm to the bed. The resident could push her/his wheelchair short distances around the facility. A facility investigation dated 12/24/16 at 2:11 pm indicated a CNA responded to the call light and the resident was found laying on her/his left side on the fall mat next to the bed. The resident stated she/he slipped out of the chair. No injuries were noted. The investigation contained no information to determine where and when the resident was last seen, the last time the resident was toileted, if the resident was in the wheelchair or in bed prior to the fall, if the alarm was in place and sounding, the names and statements from the CNA who found the resident and the CNA who was assigned to work with the resident at the time of the fall and if any care plan updates were made after the fall. Nursing progress notes dated 1/21/17 indicated kitchen staff entered the dining room and found the resident on the floor. The resident stated she/he slid out of the wheelchair while trying to pick up a newspaper from the floor. No injuries were noted. A facility investigation dated 1/21/17 at 7:38 pm indicated kitchen staff found the resident in the dining room on the floor. The resident stated she/he slid out of the wheelchair while trying to pick up a newspaper off the floor. The investigation contained no information to determine where and when the resident was last seen prior to the fall, the last time the resident was toileted, the names of the staff that found the resident, statements from the staff who found the resident and the CNA who was assigned to the resident at the time of the fall, if there were any other staff or residents in the dining room at the time of the fall and if any care plan updates were made after the fall. Nursing progress notes dated 1/24/17 indicated the resident was found on the floor near her/his bed with the alarm sounding. The resident was confused but no injury was noted. The resident was noted to be incontinent and her/his clothing was soaked through with urine. The resident was cleaned up and the bed was changed. The resident's spouse and physician were notified of the fall. A facility investigation dated 1/24/17 at 2:15 am indicated the resident's alarm was sounding and staff responded quickly to the room. The resident was found on the fall mat next to the night stand. The bed was in the lowest position and the resident's clothes were soaked through with urine. The resident had no injury, was assisted back to bed, the resident's clothes and bedding were changed. The investigation contained no information to determine where and when the resident was last seen prior to the fall, when the resident was last toileted, the names and statements from CNA staff involved with the fall and assigned to the resident and if there were any updates to the care plan after the fall. On 2/15/17 at 3:25 pm Staff 2 (DNS) indicated she had no additional information related to the investigations. She noticed the missing information regarding the alarms but there was no additional follow up at the time. Staff 2 only had documentation of the charge nurse involved, there was no information on the other staff involved with the falls. She did not recall any specific updates to the care plan as a result of the three falls in question. On 2/15/17 at 3:32 pm with Staff 1 (RNCM) stated she did not participate in the investigations. Staff 1 had no additional information to provide regarding the specific staff involved with the falls, the resident's location prior to the falls or what interventions were actually in place at the time of the fall. Staff 1 stated the resident could be alert and confused so her/his statements of what happened could be true or the resident could be confused or hallucinating. The resident's tab alarm was discontinued not long after the 12/24/16 fall because it caused the resident increased agitation. Staff 1 had no additional information regarding specific care plan updates as a result of the falls.

Based on interview and record review it was determined the facility failed to comprehensively assess pressure ulcers for 1 of 1 sampled residents (#10), activities preferences and needs for 1 of 2 sampled residents (#56) and use of psychopharmacological medications for 2 of 5 (#'s 9, 27) residents reviewed for comprehensive assessment and the RAI process. This placed residents at risk for unassessed needs. Findings include: 1. Resident 10 was admitted in 9/15 with [DIAGNOSES REDACTED]. A weekly pressure observation worksheet dated 10/7/15 indicated resident had a Stage 2 right buttocks pressure ulcer. Resident 10's care plan dated 9/29/15 indicated resident had a pressure ulcer to bilateral buttocks folds. Review of the Pressure Ulcer CAA dated 10/6/15 revealed resident had a Stage 2 pressure ulcer. The CAA did not include location of the pressure ulcer, analysis of causes or contributing factors related to the pressure ulcer or treatments and interventions for the pressure ulcer. On 12/2/15 at 1:15 pm Staff 1 (DNS) and Staff 3 (RNCM) confirmed Resident 10's Pressure Ulcer CAA was not comprehensive. 2. Resident 27 was readmitted in 5/2015 with [DIAGNOSES REDACTED]. The November MAR indicated [REDACTED]. Review of the [MEDICAL CONDITION] Drug Use CAA dated 12/19/14 revealed Resident 10 was on Risperdone for agitation and behaviors and Velafaxine for depression. The CAA did not specify the resident's behaviors, contributing factors related to the behaviors and depression, non-pharmacological interventions used or analysis of effectiveness or supporting documentation of potential adverse side consequences related to the medications. On 12/2/15 at 1:15 pm Staff 1 (DNS) and Staff 3 (RNCM) confirmed Resident 27's [MEDICAL CONDITION] Drug Use CAA was not comprehensive. 3. Resident 56 was admitted to the facility in 11/2015 with [DIAGNOSES REDACTED]. The resident's 11/17/15 Admission MDS Section F Preferences for Customary Routine and Activities indicated the resident told staff it was very Important for her/him to keep up with the news and to go outside when the the weather was good. The CAA indicated the resident had anxiety and did not enjoy group activities. There was no assessment of the impact the resident's anxiety placed on the resident for attending activities or identification of the resident activity preferences. The resident's participation in rehabilitation therapies was not identified. On 12/2/15 at 10:00 am Staff 3 (RNCM) confirmed the assessment was not comprehensive for Resident 56's activities. 4. Resident 9 was admitted in 9/2014 with [DIAGNOSES REDACTED]. The Annual MDS [MEDICAL CONDITION] Drug Use CAA dated 10/4/15 analysis identified [MEDICATION NAME] and [MEDICATION NAME] (antidepressant medications) were utilized for signs and symptoms of depression. There was no assessment and no evidence of any non-pharmacological interventions that had been tried or used. There was no comprehensive assessment of behavior or mood interventions, or of side effects or adverse consequences that might be related to the resident's medication regimen. A review of the [MEDICAL CONDITION] Medication Management Tool dated 10/7/15 indicated Resident 9's expressions of distress included aggression, agitation, repetitive speech, delusions and yelling at staff with name calling. Recommendations included to continue current [MEDICAL CONDITION] medications. Resident 9's behaviors or moods had not been included in the Annual [MEDICAL CONDITION] Drug Use CAA. In interview on 12/2/15 at 1:42 pm, Staff 1 (DNS) acknowledged the assessment for the [MEDICAL CONDITION] Drug Use CAA was not comprehensive.

Based upon observation, interview and record review it was determined the facility failed to ensure a medication error rate of less than 5 %. There were two errors observed during 28 opportunities which resulted in a 7.1 % error rate. The failure to administer medications according to recommended standards placed resident's at risk for decreased medication efficacy and/or side effects. Findings include: 1. In observation and interview on 11/30/15 at 4:48 pm, Staff 5 (LPN) administered KCL (Potassium Chloride) ER (extended release) 20 meq to Resident 26. The coated extended release tablet was crushed and administered in pudding. When asked whether the ER tablet was crushable, Staff 5 stated, she won't take it any other way. During interviews with Staff 2 (RN Supervisor) and Staff 4 (LPN) on 12/2/15 between 7:19 and 7:44 am, they stated [MEDICATION NAME] coated and extended release tablets should not be crushed and Resident 26 was capable of taking the medication whole. On 12/2/15 at 7:50 am a Medications Not To Be Crushed list was provided by facility staff upon request. KCL was identified as a non-crushable medication. The 2015 Davis Drug Guide for Nurses emphasized Do not chew or crush [MEDICATION NAME]-coated or extended-release tablets. Crushing EC & ER tablets increased the risk for GI irritation. 2. In observation on 12/1/15 at 4:39 pm Resident 57 was administered QVAR (a corticosteroid inhalant). The medication was administered using a metered dose inhaler. There was no delay between the two inhalation doses and the resident was instructed by Staff 6 (LPN) to quickly inhale each dose. The 2015 Davis Drug Guide for Nurses emphasized allowing 1-2 minutes between inhalations to maximize effectiveness of the medication. During interview with Staff 6 on 12/2/15 between 3:30 pm and 4:00 pm Staff 6 acknowledged she used an incorrect technique to administer the inhaled medication.

Based on observation, interview, and record review it was determined the facility failed to ensure utensils were clean under sanitary conditions and to store foods in a sanitary manner in one of one facility kitchens. This is placed residents at risk for food borne illness. Findings include: On 10/9/14 during the noon meal preparation and meal service the following were observed: 1. The dishwasher manufacturer's label indicated the wash temperature should be greater than 150 degrees and the rinse cycle temperature greater than 180 degrees. The dishwasher temperature logs for 9/14 and 10/14 had 30, out of 79, wash/rinse cycle required temperature quality checks, were missing and undocumented. 2. At 11:45 am a cart of desserts were in the walk in refrigerator. The top level was covered with clear plastic wrap but the other levels were uncovered. On 10/9/14 at 12:10 Staff 9, Dietary Service Manager, verified the dishwasher temperatures were not recorded and the need to cover all foods to prevent cross contamination.

Based on interview and record review it was determined the facility failed have a Quality Assessment and Assurance committee that met at least quarterly and failed to identify deficiencies with systems related to restorative services. This placed residents at risk of unidentified issues with the facility's systems. Findings include: On 10/7/14 at 8:25 am Staff 3, Administrator, stated the Quality Assessment and Assurance (QAA) committee consisted of the Administrator, DNS, RNCM, Social Service Director, Maintenance, Medical Director, and the Pharmacist. On 10/10/14 at 2:00 pm Staff 3 stated the QAA committee reviewed trends for falls, pressure ulcers, weight loss, and infection control and focused on assessments, hiring policies and human resources, dining room sanitation, and facility policies. Staff 3 provided evidence the QAA committee had met in 4/2014 and 5 months later on 9/10/14. Staff 3 was unaware residents had not received restorative services and verified the facility had not held QAA meetings on a quarterly basis.

Based on observation, interview, and record review the facility failed to provide pharmacy services and to establish systems to enable accurate reconciliation, storage, and disposal of all controlled drugs in accordance with accepted professional principles for one of one medication storage areas reviewed. This placed residents at risk for potential drug diversion and nonavailability. Findings include: On 10/9/14 at 10:30 am Staff 1, DNS, stated controlled medications were to be disposed of by at least one RN and another licensed nurse. On 10/9/14 the facility's Drug Disposal Form for the months of Sept and October 2014 indicated 6 out of 8 occurrences when controlled medications were disposed, the form had been signed by two LPN's. On 10/9/14 at 10:35 am Staff 1 verified the facility did not follow the disposal protocol. On 10/9/14 at 11:30 am Staff 12 stated the pharmacy would not allow the facility to return unused controlled medications to the pharmacy but was unaware of the facility's specific system for disposal of controlled substances. Staff 12 thought the facility might incinerated the medications or put them in a "undesirable mix". On 10/9/14 at 12:05 pm Staff 1 entered the soiled utility room and showed the surveyor a blue plastic, non-locking box on the floor at the back wall of the utility room. Staff 1 slid the top of the box off. The box contained a large glass jar with dark brown contents and a bright colored top. Staff 1 stated the jar contained wasted narcotics mixed in used coffee grounds and that the biohazard company picked them up. Staff 1 verified the box and jar were not a secure waste system.

Based on observation, interview, and record review it was determined the facility failed to provide restorative services to maintain or prevent loss of range of motion for four of five sampled residents (#'s 1,7, 9, and 10) reviewed for restorative range of motion program. As a result Resident 10 had decline in strength and range of motion and it placed other resident's at risk for decline. Findings include: 1. Resident 10 was admitted to the facility in 2008 with [DIAGNOSES REDACTED]. The resident's annual MDS dated [DATE] identified the resident had impaired functional limitation of range of motion (ROM) of both upper and lower extremities on one side and was identified to be on a restorative program for ROM. The resident required one person extensive physical assist with ADLs, transfer, and bed mobility. On 10/6/14 at 7:00 pm Resident 10 was observed sitting in a wheelchair with her/his neck/head tilted towards their left shoulder. On 10/07/14 at 8:55 am Resident 10 was observed in their room sitting in a recliner with her/his neck tilted to the left and both hands were contracted ( held in a fixed flexed position.) Resident 10's July 2014 restorative program revealed the resident was to receive active range of motion (AROM) on the "right side" for 15 minutes with a goal to maintain ROM to prevent contractures. There was no direction of how often the AROM was to be provided. During July 2014 the resident was offered restorative services 16 days. In August 2104 the resident's restorative services goal and plan remained the same. The resident was offered restorative services only seven days during the month. The restorative services progress notes revealed Staff 5, Restorative Aide, (RA) worked the "floor" 14 days and did not provide Resident 10's restorative program as directed on those 14 days. In [DATE] the resident's restorative services goal and plan remained the same. The resident was offered restorative services 17 days and the progress notes notes indicated "RA working floor" six days and did not provide Resident 10's restorative services program as directed on those days. The October 2014 restorative services program, as of 10/9/14, contained the same goal and plan. Resident 10 had not received restorative services seven of the nine days. On 10/9/14 at 2:40 Staff 4, RN Restorative Services Supervisor, was questioned about who provided restorative services when Staff 5 worked as a CNA on the floor and not as an RA. Staff 4 stated "it doesn't get done" and that "nobody" completed any of the facility resident's restorative services program on those days. On 10/10/2014 at 3:28 pm Staff 5 indicated the restorative services program was five days per week, Monday through Friday. Staff 5 verified there had been no changes in the restorative services program for Resident 10. Staff 5 verified when the program was attempted in October 2014, it was more difficult to perform Resident 10's ROM and Resident 10 strength has decline. 2. Resident 7 was admitted to the facility in 2009 and had a [DIAGNOSES REDACTED]. The Restorative Plan revealed Resident 7 was referred to the restorative program on 3/19/14. The 6/24/14 Quarterly MDS indicated the resident did not walk, required extensive physical assistance of two persons for transfers, and was totally dependent for locomotion. The Care Plan, last reviewed on 7/12/14, noted the resident required one to two person extensive assistance daily as desired or tolerated and referred to the restorative plan. The goal listed on the August 2014, September 2014 and October 2014 Restorative Care Flow Records was to maintain strength for ambulation. The Flow Records indicated the resident was to be ambulated as tolerated and to respect the resident's right to refuse. The 2014 Restorative Care Flow Records revealed the following: -August: 15 dates when the Restorative Aide (RA) was pulled to work on the floor as a CNA. There was no documentation Resident 7 refused or received restorative services on those dates. -September: nine dates the resident did not refuse and did not receive restorative services when the RA was working as a CNA. -October: Resident 7 was ambulated daily. On 10/10/14 at 1:39 pm, Staff 2, RNCM, stated she was unaware Resident 7's RA services were not provided regularly. On 10/10/14 at 1:48 pm, Staff 7, CNA, stated Resident 7's balance was shaky but did well once she/he was up and had the walker. Staff 7 said if the RA was pulled to work as a CNA, the CNA in charge of the resident's section was supposed to provide restorative services to the resident. On 10/10/14 at 4:10 pm, Staff 4, RN Restorative Services Supervisor, stated Resident 7 was referred to the restorative program from therapy. Staff 4 said she was unaware the resident was not receiving regular restorative services. According to Staff 4, if Resident 7 did not receive the restorative services or only received them erratically, Resident 7 would get weak and continue to deteriorate. 3. Resident 9 was admitted to the facility in 2012 with a [DIAGNOSES REDACTED]. The Restorative Plan revealed Resident 9 was referred to restorative services on 2/19/13. The 5/5/14 and 7/30/14 Quarterly MDSs revealed the resident required extensive physical assistance of one person with transfers, walking and ambulation and used a walker and wheelchair for mobility. The resident's care plan listed the restorative program as an area of focus. The goal was to maintain the resident's ROM in upper/lower extremities and maintain ambulation ability. Staff were to provide active ROM to all extremities and ambulate Resident 9 with one person assistance and a walker at least 100 feet as tolerated up to five times weekly for 15 minutes. The 2014 Restorative Care Flow Records revealed: -August: 11 dates the RA was pulled to work as a CNA and no evidence Resident 9 refused or received restorative services on those dates. A telephone order, dated 8/8/14, discontinued restorative services for Resident 9. On 10/10/14 at 2:34 pm, Staff 8, CNA, stated if the Restorative Aide was pulled to work as a CNA, the CNA assigned to that area was to provide restorative services to the residents. On 10/10/14 at 4:05 pm, Staff 4, RN Restorative Services Supervisor, indicated she was unaware the resident was not receiving regular restorative services during August 2014. Staff 4 stated if the facility was short of CNAs, the RA was pulled to work the floor as a CNA. Staff 4 said if that happened, the CNAs were to provide restorative services to the residents.

Based on interview and record review it was determined that the facility failed to revise and implement nutritional interventions to prevent weight loss for 1 of 3 residents (# 1) reviewed for weight loss. Resident 1 experienced a severe weight loss of greater than 10% in less than a 3 month period. Findings include: Resident 1 was admitted to the facility in June 2013 with [DIAGNOSES REDACTED]. and was identified to be independent with eating on the Nursing Assistant Care Sheet. On 6/18/13 Staff 3, Registered Dietitian, documented in an assessment progress note the resident received a Diabetic Mechanical soft diet, his/her meal intake was 66%, and weight was down 3.8% in 7 days to 273 lbs. The resident was identified to be at risk for inadequate energy intake related to altered mental status. The nutritional goal was to increase the resident's meal intake to greater than 90%. The interventions identified to achieve the goal were to continue the current diet orders, encourage meal and fluid intake and monitor the resident's weight. On 7/3/13 the resident's weight was 263.4 lbs which indicated a significant (5.7%) weight loss of 16.6 lbs, in less than 30 days since admission. The record did not contain documentation from dietary, dietary management, or nursing regarding a review of the weight loss. The record lacked documentation the MD had been notified of the significant weight loss. The facility had a Nutrition at Risk Review (NARR) meeting in 7/2013. Even though Resident 1 had a severe weight loss of over 5% in less than 30 days, the resident was not reviewed by the NARR committee . The resident's care plan dated 7/22/13 identified the need for diabetic management and directions for a dietary consult for nutritional regime and for staff to observe compliance with diet. There was no identification of Resident 1's severe weight loss or care planned interventions to prevent weight loss. On 8/6/13 a dietitian progress note indicated on 8/3/13 the resident continued to lose weight and weighed 261.0, a 6.6% weight loss from the admission weight. The note indicated the resident's meal intake was up 23%, snacks up 9% and fluids up 23% since 6/13. The plan was to continue to monitor. A progress note dated 8/30/13 indicated the resident's family had called the facility and asked the facility about a trial of a pureed diet. In response to the family's request, the facility planned to provide a moist mechanical soft diet with supplements, if meal intake was low, before advancing to a pureed diet. On 8/31/13 the resident's weight of 249 lbs was recorded as a 10% weight severe loss. There was no documented evidence the facility had attempted further diet interventions or had evaluated the potential relationship of the resident's medication regime to the resident's severe weight loss. The change in diet texture did not occurred before the resident was transferred out of the facility on 9/2/13. On 10/17/13 at 12:30 pm, in interview with Staff 1, DNS, Staff 1 stated both nursing and dietary monitored residents weights for any significant changes. Staff 1 stated a weight gain/loss of greater than 3 lbs would be identified, verified, discussed and the doctor would be notified of the significant weight change. If the resident weight change met the Nutrition at Risk Review (NARR) threshold, the resident would be reviewed monthly at that meeting. At 1:00 pm on 10/17/13 Staff 4, Dietary Manager, was interviewed. The dietary manager acknowledged that both nursing and dietary monitor residents weights for change. Staff 4 stated that they would look at a 5% weight loss and that dietary would review for NARR. If the weight loss was verified, then the MD would be notified. The dietary manager acknowledged Resident 1's severe weight loss and that the resident had not been referred to NARR for focused review. On 10/18/13 at 7:46 am in interview with Staff 3, RD, explained that residents were weighed daily for the first week after they were admitted , along with food intake recorded. Staff 3 completed a questionnaire/interview on appetite, weight loss, and food preferences and would evaluate how it compared with the resident's baseline. If a resident experiences a 5-10% weight loss, the resident would be put on NARR. Staff 3 stated they don't wait for nursing to notify them of resident weight loss because they monitor the computer record themselves. Staff 3 acknowledged they could have done more to prevent this resident's weight loss, that the MD was not notified of the weight change, and that they did not follow their Nutrition and Hydration policy on NARR referral. Staff 3 acknowledged Resident 1 should have been referred to NARR for multidisciplinary review and monitoring.

Based on observation, interview, and record review it was determined the facility failed to implement interventions and thoroughly investigate causative factors or antecedents to prevent falls for 1 of 3 residents (#1) reviewed for falls. As a result the resident fell and sustained a fractured hip. Findings include: Resident 1 was admitted to the facility 6/2013 with [DIAGNOSES REDACTED]. The resident's admission temporary care plan identified the resident required assistance with wheelchair mobility and was dependent on staff for ambulation and transfers. The Nursing Assistant Care Sheet dated 6/8/13 identified the resident was a fall risk. The safety interventions included bed alarms, chair alarm, and a low bed. On 6/12/13 the Nursing Assistant Care Sheet was updated to include bed check, bed exit, and floor mat both sides of bed. On 6/13/13 at 1:45 am the resident was found on the floor of her/his room next to the bed. The nursing progress notes and the facility's investigation included no evidence of a nursing assessment of injury or notification of the doctor or the family. There was no identification of what the resident's activity had been before the fall, when they were last toileted, or when the resident was last visualized by staff. The facility's follow-up corrective action plan for the fall was dated 6 days later on 6/19/13 and included to have a floor mat on the right side of bed, soft bumpers, bed check, and a bed exit alarm. The Nursing Assistant Care sheet was updated on 6/13/13 to include bolsters on both side of the bed. At 6:15 am on 6/13/13 the resident's bed alarm was heard and the resident was found by staff on the floor lying on his/her stomach next to their bed. The nursing progress notes and the facility's investigation report contained no identification of times of the resident's last meal, last time toileted, whether or not the resident was wearing glasses, the floor was clean, or the room lights were off or on. The corrective action plan and follow up investigation was dated 11 days later on 6/24/13 and identified the same plan as written on 6/19/13 for a floor mat on the right side of bed, soft bumpers, bed check, and a bed exit alarm. At 8:45 pm on 6/13/13 at the resident was found on the bedroom floor, again. The corrective action plan and follow up investigation was dated 6/24/13 and identified the same plan as written on 6/19/13 for a floor mat on the right side of bed, soft bumpers, bed check, and a bed exit alarm. There were no new interventions initiated at the time of the incidents and the corrective action plan that had been identified on 6/19/13, 6 days after the fall, was repeated on 6/24/13, 11 days after the incidents. The resident's care plan dated 7/22/13 identified the resident was a high risk for falls. The interventions included use of electronic alarms in chair/bed check and exit alarm. The care plan did not include the interventions listed with the fall investigations of floor mats or soft bumpers. On 8/16/13 at 9:50 pm the resident was observed by facility staff to stand independently from his/her wheelchair and start to fall. Resident 1 was assisted by staff to the floor. There were no nursing progress notes until 8/17/13 at 2:37 pm regarding the fall. The investigation and follow-up corrective action was dated 8/20/13 and directed staff to toilet the resident before and after meals, place in a recliner chair between meals and in the evening, ensure the tab alarm was on and working at all times. On 8/21/13 the care plan was updated to reflect those interventions and on 8/23/13 the staff was directed in a Staff Communication note to toilet all residents before and after meals and/or activities. On 9/2/13 at "approx" 6:50 pm the resident had an unwitnessed fall and was found laying on their back with his/her head against a chair in the facility's lobby. The Nursing Progress notes indicated the resident was questioned about level of pain but there was no documented assessment of injury. The resident was transported to the hospital at 7:40 pm with left hip pain. The incident investigation did not indicate when the resident had last been toileted or visualized by staff. The investigation report indicated the resident had been in a wheelchair and not in a recliner chair as per the care plan. On 10/15/13 at 8:30 am Resident 1 was observed in bed with his/her eyes closed, supine, and with the head of the bed slightly elevated. The bed was lowered, against the wall on the right side, and there was a floor mat on the left side of the bed. A bed exit alarm and left side turn bar were in place. On 10/15/13 at 2:45 pm the investigations of the three falls on 6/13/13, the fall on 8/16/13, and one on 9/2/13 were reviewed with Staff 1, DNS. Staff 1 verified the same interventions were listed on the three 6/13/13 investigations and no changes were made to prevent further falls at that time. Staff 1 verified that after the resident's fall on 8/16/13, the resident was to be in a recliner and to be toileted after meals. Staff 1 stated the fall on 9/2/13 happened in the facility's TV room and the resident fell out of his/her wheelchair. Staff 1 verified the care plan interventions were not being followed at the time of the 9/2/13 fall and the investigation for the 9/2/13 event was incomplete. Staff 1 verified the investigation lacked description of the resident's status before the fall and identification of the last time the resident had been toileted.