Every finding on record at Regency Albany

Based on observation, interview and record review the facility failed to ensure dietary staff wore appropriate hair restraints, stored iced in a sanitary manner and maintained cleanliness for 1 of 1 facility kitchen reviewed for sanitation. This placed residents at risk for cross contamination and food-borne illness. Findings include:1. The facility's 2023 General Sanitation of Kitchen policy stated, Food and nutrition services staff will maintain the sanitation of the kitchen.On 3/23/26 at 10:22 AM during the initial kitchen tour the following was observed:-The grate, drain and plastic outlet tube for the ice machine was covered in a layer of brown debris located at the entrance of the prep kitchen.-Visible red residue covered the lower section of the wall behind the shelf located in the walk-in freezer.-Frozen vegetables were on the floor located in the walk-in freezer.-An open and unsealed package of frozen hamburger patties was located in the walk-in freezer. On 3/23/26 at 10:43 AM Staff 27 (Dietary Manager) stated dietary staff were expected to complete the following cleaning tasks for the kitchen:-Clean the grate, drain and plastic outlet tube for the ice machine on a weekly basis.-Sweep between meals.-Clean food storage areas, which included the walk-in freezer, every evening.-Check the walk-in freezer for open and unsealed foods. On 3/23/26 at 11:11 AM Staff 27 acknowledged the observations made during the kitchen tour. Staff 27 stated the daily and weekly cleaning tasks for the kitchen were not completed as required. Staff 27 stated the open and unsealed package of frozen hamburger patties found in the walk-in freezer were used for the 3/23/26 lunch service but dietary staff were expected to close and seal foods from the walk-in freezer immediately after use. 2. The facility's 2023 Personal Hygiene and Health Reporting policy stated, Hair restraints must be worn around exposed foods, in the kitchen or food service areas.On 3/23/26 at 10:34 AM during the initial kitchen tour Staff 27 (Dietary Manager) entered the prep kitchen and was observed with hair that was approximately one inch long without a hair restraint.On 3/23/26 at 10:35 AM Staff 27 was observed checking the internal temperature of mashed potatoes without a hair restraint. On 3/23/26 at 10:35 AM Staff 27 stated dietary staff were expected to wear hair restraints at all times while working in the kitchen. Staff 27 stated he should have worn a hair restraint before he entered the prep kitchen. 3. The facility's 2023 Production, Storage and Dispensing of Ice policy stated, Ice will be produced, stored and dispensed in a manner to avoid contamination. On 3/23/26 at 10:22 AM during the initial kitchen tour the facility's ice machine was observed in the entrance hallway of the kitchen drained through a white plastic outlet tube into the wall behind the machine.On 3/23/26 at 10:43 AM the plastic outlet tube for the facility's ice machine was observed coiled and in direct contact with the drain located inside the prep kitchen without an air gap. On 3/23/26 at 10:43 AM Staff 27 (Dietary Manager) acknowledged the lack of a required air gap.On 3/25/26 at 11:05 AM the plastic outlet tube for the facility's ice machine was no longer coiled but was observed below the level of the grate for the drain.On 3/26/26 at 8:45 AM Staff 1 (Administrator) and Staff 28 (Regional [NAME] President) confirmed there was no air gap for the ice machine to prevent the risk of contamination from the backflow of water.

Based on observation, interview and record review it was determined the facility failed to follow physician orders for 2 of 4 sampled residents (#s 4 and 7) reviewed for medications and hearing. This placed residents at risk for unmet care needs. Findings include: 1. Resident 4 was admitted to the facility in 12/2025 with diagnoses including diabetes and end stage renal failure. The 3/3/26 MDS indicated Resident 4 had a BIMS score of 12 which indicated Resident 4 was moderately cognitively impaired. a. On 3/25/26 at 8:07 AM, during blood sugar checks, Resident 4 was observed to request a PRN anti-nausea medication from Staff 14 (Agency LPN). Staff 14 checked Resident 4's blood sugar and left her/his room. Staff 14 obtained Resident 4's insulin and administered the insulin, but did not administer PRN anti-nausea medication. The 3/25/26 MAR indicated Staff 14 administered PRN ondansetron (anti-nausea medication) to Resident 4 for nausea symptoms at 10:50 AM (2 hours and 43 minutes after the resident requested the medication). On 3/25/26 at 1:09 PM, Staff 12 (CNA) stated Resident 4 reported nausea at 6:30 AM and requested PRN anti-nausea medication. Staff 12 stated she offered Resident 4 nausea bags and nursing staff were notified of the request. On 3/25/26 at 1:54 PM, Staff 14 acknowledged she did not assess or provide medication for Resident 4's nausea at the time the resident requested PRN anti-nausea medication. Staff 14 stated she assessed the resident's nausea symptoms and administered the medication later in the day. Staff 14 acknowledged the PRN nausea medication was not administered timely. On 3/27/26 at 3:10 PM, Staff 2 (DNS) acknowledged PRN anti-nausea was not administered timely to Resident 4. b. On 3/24/26 at 8:58 AM Resident 4 stated on 2/27/26 she/he did not receive her/his scheduled morning medications prior to leaving the facility for a scheduled dialysis appointment. A review of the 2/2026 Licensed Nurse Admin Record and MAR revealed Resident 4 did not receive the following medications on 2/27/26 and was charted as absent from home: -insulin glargine pen-injector 80 units in the morning at 8 AM for diabetes -insulin aspart flexpen pen-injector 14 units with meals at 8 AM for diabetes -amlodipine 10 MG, one time a day at 8 AM for hypertension -b complex with c, one tablet one time a day in the morning for nutritional supplement -bupropion extended release 150 MG, two tablets one time a day at 8 AM for depression -losartan 25 MG, one tablet one time a day at 8 AM for hypertension -multivitamin, one tablet one time a day in the morning for supplement -sertraline 100 MG, one tablet one time a day at 8 AM for depression -vitamin D3 50 MCG, one tablet one time a day in the morning for supplement -Bumex 2 MG, two tablets two times a day at 8 AM for end stage renal disease -carvedilol 12.5 MG, one tablet two times a day at 8 AM for hypertension -clonidine 0.3 MG, one tablet three times a day at 8 AM for hypertension -sevelamer carbonate 800 MG, three tablets with meals at 8 AM for end stage renal disease A review of the 2/27/26 Progress Notes revealed multiple Medication Administration Notes for the identified medications by Staff 7 (LPN) which indicated Resident 4 was at dialysis and staff were unable to administer the medication. A 2/27/26 at 4:10 PM Progress Note by Staff 7 revealed Resident 4's provider was notified of the missed medication administrations. On 3/27/26 at 11:24 AM Staff 6 (Agency LPN) stated he worked on 2/27/26 but did not recall why Resident 4 did not receive her/his scheduled morning medications. On 3/27/26 at 12:19 PM a call was placed to Staff 7, a voicemail was left and the surveyor did not receive a call back. On 3/27/26 at 3:28 PM Staff 5 (LPN Resident Care Manager) stated she was unsure why Resident 4 did not receive any morning medications on 2/27/26. On 3/27/26 at 4:46 PM Staff 2 (DNS) stated she was not aware Resident 4 missed her/his scheduled AM medications including insulin on 2/27/26 prior to leaving for dialysis. 2. Resident 7 was admitted to the facility on [DATE] with a diagnosis of unspecified hearing loss. A 3/11/26 Quarterly MDS revealed Resident 7 had a BIMS of 14, which indicated the resident was cognitively intact. A provider progress note dated 3/13/26 indicated Resident 7 had impacted ear wax in her/his left ear and the resident requested treatment. The progress note revealed Resident 7 was ordered Debrox (ear drop medication) for both ears. A review of Resident 7's MAR and TAR for 3/2026 revealed no indication of the Debrox order. On 3/24/26 at 9:27 AM Resident 7 stated her/his ears were not cleaned as requested. Resident 7 stated she/he asked assigned CNAs to follow-up with the nurse but did not receive update on when she/he would receive an ear cleaning. On 3/27/26 at 2:51 PM Staff 20 (LPN) stated he was unaware of any hearing or ear concerns for Resident 7. Staff 20 stated he was unaware of a physician order for Debrox and confirmed the Debrox was not administered. On 3/27/26 at 2:14 PM Staff 3 (LPN-RCM/IP) stated providers were able to order new medications and treatments within progress notes. Staff 3 stated he became aware of Resident 7's order for Debrox on 3/26/26. On 3/27/26 at 3:39 PM Staff 2 (DNS) and Staff 26 (Nurse Consultant) stated staff were expected to clarify and implement new physician orders for residents within 3 to 5 days of the date they were issued and staff should have been aware of Resident 7's order for Debrox prior to 3/26/26.

Based on observation, interview and record review it was determined the facility failed to ensure staff used appropriate infection control practices for residents on contact precautions and failed to disinfect glucometers according to manufacturer recommendations for 2 of 3 halls reviewed for infection control and medications. This placed residents at risk for exposure to infections and blood borne pathogens. Findings include: 1. The facility's 10/2017 Use of Blood Glucose Meters Policy indicated Disinfect the meter with an approved disinfecting wipe for blood borne pathogens. Wipe all external areas of the meter including front and back surfaces until wet with solution. A 2023 EvenCare G2 Blood Glucose Monitor manufacturer manual indicated to disinfect the glucometer with an approved disinfecting wipe. Resident 21 was admitted to the facility on [DATE] with diagnoses including diabetes. On 3/26/26 at 11:31 AM, Staff 25 (LPN) entered Resident 21's room to obtain a blood sugar reading using an EvenCare G2 Blood Glucose Monitor (glucometer). When she returned to the medication cart, Staff 25 used an alcohol pad wipe to disinfect the glucometer and placed the glucometer inside the medication cart. On 3/26/26 at 11:35 AM, Staff 25 stated the glucometers were shared. Staff 25 stated she used an alcohol pad to disinfect the glucometer after checking Resident 21's blood sugar. Staff 25 stated an alcohol pad was not an approved disinfectant wipe. On 3/27/26 at 4:23 PM, Staff 3 (LPN Care Manager/IP) stated Staff 26 (Nurse consultant) allowed staff to use an alcohol pad wipe to disinfect the glucometer. On 3/27/26 at 12:10 PM, Staff 2 (DNS) stated staff were expected to use an approved disinfectant wipe to disinfect the glucometers. On 3/27/26 at 4:28 PM, Staff 26 stated the CDC (Center of Disease Control and Prevention) indicated an alcohol pad wipe disinfected the glucometers. Staff 26 proceeded to check the manufacturer guidelines and acknowledged an alcohol pad wipe was not an approved disinfectant wipe. 2. The CDC's 9/24/24 Guideline for Isolation Precautions indicated staff who provided care to residents with a confirmed and symptomatic Respiratory Syncytial Virus (RSV - a common, highly contagious respiratory virus) infection were to wear a gown, gloves and surgical mask if within three feet of the resident. Resident 36 was admitted to the facility on [DATE] with a diagnosis of congestive heart failure. A review of Resident 36's Care Plan revised 3/23/26 indicated she/he was RSV positive and placed on contact precautions. Staff were expected to follow contact and droplet precautions as directed. On 3/25/26 at 8:50 AM Resident 36's room was observed to have contact precautions signage on the door. On 3/25/26 between 8:52 and 8:54 AM Staff 29 (Dietary Aide) was observed as follows: -Entered Resident 36's room with a clipboard without a gown, gloves or surgical mask.-Picked up the resident's tray with partially eaten food, left the room, placed the tray on a cart at the end of the hallway.-Returned to the resident's room without completing hand hygiene.-Re-entered the resident's room without a gown, gloves or surgical mask.-Handed the resident's roommate her clipboard without cleaning the clipboard. On 3/25/26 at 8:56 AM Staff 29 stated she entered Resident 36's room to receive lunch orders. Staff 29 stated she did not need to wear a gown, gloves or surgical mask when she entered the room because she did not provide any direct care to the resident. Staff 29 stated she did not clean the clipboard each time it was held by a resident. Staff 29 confirmed she did not complete hand hygiene after she removed the resident's tray and re-entered her/his room. On 3/25/26 at 1:11 PM Staff 27 (Dietary Manager) stated he did not provide any training to dietary staff on transmission-based precautions. Staff 27 stated he was unaware of any dietary staff who did not follow transmission-based precautions in the facility. On 3/27/26 at 1:57 PM Staff 3 (LPN Care Manager/IP) confirmed all staff needed to wear a gown and gloves before they entered the room of a resident placed on contact precautions. Staff 3 stated all staff needed to wear a surgical mask if they were within a three-foot radius of a resident who was positive for RSV. Staff 3 confirmed all staff needed to complete hand hygiene before they entered or after they exited a resident's room. Staff 3 stated dietary staff were expected to obtain verbal meal orders from residents placed on contact precautions. 3. On 3/25/26 at 5:31 PM a contact precautions sign was observed on the door of room [ROOM NUMBER]. The contact precautions sign directed staff to wear a gown and gloves in the room. Staff 3 (Activities Director) entered room [ROOM NUMBER] with a meal tray and delivered the meal to the resident without donning a gown and gloves. Staff 3 stated she sanitized her hands before entering the room but was unsure if she needed to wear a gown and gloves. On 3/26/26 at 4:43 PM Staff 3 (LPN Care Manager/Infection Preventionist) stated all facility staff were to wear a gown and gloves when they entered rooms of residents on contact precautions.

Based on interview and record review it was determined the facility failed to ensure resident rights to a dignified existence for 1 of 1 sampled resident (#44) reviewed for dignity and respect. This placed residents at risk for diminished quality of life. Findings include: A review of the undated facility Quality of Care Policy stated staff will respect each resident's dignity.Resident 44 admitted to the facility in 2023 with diagnoses including depression and diabetes.A review of the 10/29/25 Annual MDS revealed Resident 44 had a BIMS of 15 indicating she/he was cognitively intact.On 3/23/26 at 10:46 AM Resident 44 stated she/he only wanted female house staff to assist with care. Resident 44 stated Staff 11 (Former DNS) told the resident she/he had to let new CNA staff and male CNA staff care for her/him and this conversation was witnessed by Staff 4 (Activity Director). Resident 44 stated she/he felt her/his feelings were disregarded.On 3/26/26 at 5:08 PM Staff 4 stated Resident 44 requested her to be present during a conversation with Staff 11 in July 2025 about the resident's care preferences. Staff 4 stated Staff 11 spoke to Resident 44 in a rude, condescending and demeaning tone stating to the resident, you will have to let men take care of you. Staff 4 stated Resident 44 was very upset.On 3/26/26 at 7:02 PM Staff 11 stated she had a conversation with Resident 44 about her/his care with Staff 4 as a witness. Staff 11 did not recall speaking to Resident 44 in a rude, condescending or demeaning tone.On 3/27/26 at 5:23 PM Staff 1 stated she expected all staff to speak to residents with dignity, respect and kindness. Staff 1 acknowledged the findings.

Based on observation and interview the facility failed to provide a functional toilet and safe furniture for 3 of 5 sampled residents (#s 31, 38 and 40) reviewed for physical environment. This placed residents at risk for injury and lack of homelike environment. Findings include: 1. Resident 38 was admitted to the facility in 12/2022 with diagnoses including seizures. A 1/9/26 Quarterly MDS indicated Resident 38 had a BIMS score of 15 which indicated Resident 38 was cognitively intact. Resident 40 was admitted to the facility on [DATE] with diagnoses including heart failure.A 3/19/26 Quarterly MDS indicated Resident 40 had a BIMS score of 15 which indicated Resident 40 was cognitively intact. On 3/24/26 at 9:00 AM, Resident 38 and Resident 40 stated the toilet flushed continuously when the toilet was flushed and had been broken for a long time. Resident 38 and 40 stated the toilet was loud and flushed for up to 40 minutes. Resident 38 stated staff called a plumber but the toilet was still broken. On 3/27/26 at 9:19 AM, Staff 12 (CNA) stated the toilet in Resident 38 and Resident 40's flushed continuously after the toilet was flushed. Staff 12 stated Staff 2 (DNS) was notified.On 3/27/26 at 10:08 AM, Staff 23 (CNA) stated the toilet ran continuously when the toilet was flushed. Staff 23 stated she did not notify maintenance or enter a work order because she thought staff were aware. On 3/27/26 at 10:34 AM, Staff 24 (Maintenance Director) indicated he inspected the toilet, and found a damaged part. Staff 24 indicated he had the part on hand and would repair the toilet. 2. Resident 31 was admitted to the facility in 9/2020 with diagnoses including seizures and hemiplegia (paralysis on one side of the body). A 1/14/26 Quarterly MDS indicated Resident 31 had a BIMS score of 14 which indicated Resident 31 was cognitively intact. On 3/27/26 at 9:19 AM, Staff 12 (CNA) stated Resident 31's dresser was hard to open and Resident 31 was not able to open the drawers. On 3/27/26 at 10:08 AM Resident 31 was observed opening her/his dresser and almost fell while trying to open the dresser. Staff 23 (CNA) stated Resident 31 had right sided weakness and pulling the dresser to open the drawer was not safe and was a fall risk for the resident. On 3/27/26 at 10:22 AM, Staff 24 (Maintenance Director) stated Resident 31's dresser drawers were old and were not easily accessible. Staff 24 acknowledged the dresser in Resident 31's room was not safe for the resident to use.

Based on interview and record review it was determined the facility failed to implement a gradual dose reduction of a psychotropic medication in a timely manner for 1 of 6 sampled residents (#42) reviewed for medications. This placed residents at risk for adverse side effects of psychotropic medication. Findings include: Resident 42 was admitted to the facility in 2023 with diagnoses including bipolar disorder and post-traumatic stress disorder.A review of the 3/12/26 pharmacy recommendation indicated Resident 42 was receiving buspirone 10 MG (a psychotropic) twice daily and was due for a gradual dose reduction (GDR) as the resident was not experiencing anxiety. The recommendation was to start buspirone 5 MG twice daily. A further review of the 3/12/26 pharmacy recommendation revealed on 3/13/26 Resident 42's provider agreed to GDR buspirone. A 3/24/26 physician order revealed Resident 42 was to start buspirone 5 MG twice daily. On 3/27/26 at 4:17 PM Staff 5 (LPN Resident Care Manager) acknowledged Resident 42's GDR for buspirone 5 MG twice daily was not implemented timely.

Based on observation, interview and record review it was determined the facility failed to provide personal hygiene for 1 of 2 sampled residents (#9) reviewed for ADLs. This placed residents at risk for lack of personal hygiene. Findings include:Resident 9 was admitted to the facility in 11/2025 with diagnoses including stroke affecting the right side of the body. A 2/11/26 Significant Change MDS indicated Resident 9 had a BIMS score of 9 indicating she/he had moderate cognitive impairment. The MDS indicated Resident 9 depended on staff to complete personal hygiene. The 3/24/26 TAR indicated Staff 18 (LPN) did not perform nail care for Resident 9 because it was not needed. During random observations from 3/23/26 through 3/27/26 from 8:00 AM to 5:00 PM, Resident 8 was observed to have a brown substance in her/his right pointer and ring fingernails. Resident 9's fingernails were not trimmed and were 1/2 to 1/3 inches long. Resident 9 had facial hair on her/his chin and upper lip. On 3/23/26 at 2:15 PM, Resident 9 was observed touching the hair on her/his chin. Resident 9 acknowledged her/his long fingernails. Resident 9 stated she/he allowed staff to provide personal hygiene. On 3/25/26 at 2:35 PM, Staff 15 (CNA) stated Resident 9 required maximum assistance when care was provided. Staff 15 stated Resident 9 on occasion touched her/his soiled brief during continent care. Staff 15 stated she was assigned to Resident 9 that day but did not complete personal hygiene including removing Resident 9's facial hair or cleaning under her/his fingernails. On 3/25/26 at 2:53 PM, Staff 16 (CNA) stated she did not complete personal hygiene including removing Resident 9's facial hair or clean under her/his fingernails after Resident 9's shower the previous day.On 3/25/26 at 4:19 PM, Staff 18 stated Resident 9 required assistance to complete personal hygiene. Staff 18 stated Resident 9's nails looked ok and did not require nail trimming. Staff 18 stated she did not notice Resident 9's hair on her/his chin or upper lip. On 3/26/26 at 2:36 PM, Staff 20 (LPN) stated Resident 9 was diabetic and nail trimming was completed by the nurses. Staff 20 stated CNAs were able to clean under Resident 9's fingernails daily. Staff 9 acknowledged Resident 9 had long fingernails that needed to be trimmed, and a brown substance under her/his fingernails. Staff 20 acknowledged the hair on the resident's upper lip. On 3/27/26 at 12:30 PM, Staff 3 (LPN Care Manager/IP) stated staff were expected to complete personal hygiene daily. Staff 3 stated staff completed nail care and removed facial hair on shower days.

Based on observation, interview and record review it was determined the facility failed to provide equipment and services for 2 of 2 sampled residents (#s 9 and 20) reviewed for mobility. This placed residents at risk for further decrease in range of motion. Findings include: 1. Resident 9 was admitted to the facility in 11/2025 with diagnoses including stroke affecting the right side of the body. A 2/11/26 Significant Change MDS indicated Resident 9 had a BIMS score of 9 which indicated the resident had moderate cognitive impairment. The MDS indicated Resident 9 depended on staff to complete care. A 1/7/26 OT Discharge Summary indicated the following: -Patient will be fitted for elbow orthotic, and tolerate passive stretch, and tone inhibiting techniques to maintain ROM, prevent skin breakdown A 2/17/26 PT Discharge Summary indicated the following: -Continue participation with home exercises and facility directed exercise programs while seated in wheelchair. During random observations from 3/23/26 through 3/27/26 from 8:00 AM to 5:00 PM, Resident 9's right arm had a contracture (joint stiffness). Resident 9's arm was bent towards her/his chest and the right hand was in a fist. Resident 9 was not wearing a splint. The splint was observed on top of Resident 9's dresser. Resident 9 had a home exercise program written on the white board in her/his room. On 3/24/26 at 9:36 AM, Resident 9 was observed multiple times unable to extend her/his right hand. Resident 9 stated she did not complete the home exercises written on the white board in her/his room. Staff 9 stated she did not wear a splint. On 3/25/26 at 9:42 AM, Resident 9 was observed sitting in her/his wheelchair in the dining room for group exercises lead by Staff 22 (Activities Assistance). Resident 9 was observed sleeping the whole time and she/he was not wearing a splint. On 3/25/26 at 2:35 PM, Staff 15 (CNA) stated she was unsure if Resident 9 used a splint and only used a pillow to support her/his right arm. Staff 15 stated she did not perform the home exercises written on the white board in Resident 9's room. On 3/25/26 at 2:53 PM, Staff 16 (CNA) stated she did not perform home exercises written on the white board or ROM exercises with Resident 9. Staff 16 stated she was unsure if Resident 9 was getting restorative services. Staff 16 stated she used a pillow to support Resident 9's right arm. Staff 16 stated Resident 9 used a splint but she did not apply it on her shift. On 3/25/26 at 4:19 PM, Staff 18 (LPN) stated Resident 9 had restorative services to increase her/his mobility and regain strength. Staff 18 stated she was unsure if Resident 9 participated in restorative services. Staff 18 stated Resident 9 did not use a splint or have any interventions related to Resident 9's right hand contracture. On 3/25/26 at 4:56 PM, Staff 19 (Director of Rehab) stated Resident 9's OT Discharge Summary indicated Resident 9 participated in home exercises, group exercises and used a soft splint to prevent further contracture to the right hand. Staff 19 stated Resident 9 did not have a referral to start restorative services and was not enrolled in a restorative program. Staff 19 acknowledged orders did not include a schedule to use the splint. On 3/26/26 at 2:36 PM, Staff 20 (LPN) stated he was not aware Resident 9 used a splint to prevent contractures to her/his right arm. Staff 20 stated Resident 9 did not have orders to start restorative services. Staff 20 stated an OT evaluation order was placed on 3/26/26. On 3/27/26 at 12:30 PM, Staff 3 (LPN Care Manager/IP) stated Resident 9 did not wear a soft splint for contractures and did not have orders to start restorative services. On 3/27/26 at 3:10 PM, Staff 2 (DNS) acknowledged the findings and did not have additional information. 2. Resident 20 was admitted to the facility in 2/2020 with diagnoses including Parkinson's disease. A 2/11/26 Annual MDS revealed Resident 20 had a BIMS of 2, which indicated the resident had severe cognitive impairment, and impairment on both upper extremities. A 3/5/26 OT Discharge Summary indicated Resident 20 required assistance to don and doff a palm protector that was to be worn daily on her/his left hand to decrease the resident's risk of further contractures. Resident 20's Care Plan revised on 3/23/26 revealed she had a palm protector for her/his left hand that was to be applied for up to four hours daily. A review of Resident 20's medical record revealed no evidence to indicate staff offered or assisted the resident to apply her/his left palm protector. On 3/23/26 at 1:44 PM Resident 20 was observed to have a contracture and resting tremor in her/his left hand. Random observations of Resident 20 from 3/23/26 through 3/25/26 between 8:41 AM and 3:46 PM revealed the resident was in her/his room with a sign posted on the wall behind the bed that stated, Please apply L. hand splint. 4 hrs. daily. Need 5-minutes of stretching to open palm. Please stop if she/he reports pain. No palm protector was observed on the resident's left hand. On 3/26/26 at 12:58 PM Staff 30 (CNA) stated she was unaware if Resident 20 had a palm protector for her/his left hand. On 3/26/26 at 2:00 PM Staff 17 (CNA) stated she was aware of Resident 20's palm protector for her/his left hand. Staff 17 stated she attempted to assist the resident to don the palm protector once in 3/2026 but was unsuccessful due to the stiffness in her/his left hand. Staff 17 stated she was unsure how long the resident was required to wear the palm protector. On 3/27/26 at 9:56 AM Staff 31 (OT) stated when a new recommendation was made for a resident to wear a daily palm protector nursing staff received a donning and doffing training and a wear schedule. Staff 31 stated she expected nursing staff to offer and assist Resident 20 to don and doff her/his left palm protector and follow the provided wear schedule daily. On 3/27/26 at 11:15 AM Staff 19 (Director of Rehab) stated therapy staff provided a wear schedule to nursing for Resident 20's left palm protector on 3/5/26. Staff 19 confirmed the sign observed in Resident 20's room was the wear schedule provided to nursing staff. On 3/27/26 at 2:27 PM Staff 3 (LPN Resident Care Manager/IP) stated when a new recommendation was made by OT for a resident to wear a palm protector daily, he was to review and acknowledge the new recommendation. Staff 3 confirmed a training was provided if nursing staff were expected to implement the OT recommendation daily. Staff 3 stated Resident 20 did not have a palm protector for her left hand and nursing staff did not receive a training specific to the resident's palm protector in 3/2026. On 3/27/26 at 4:00 PM Staff 2 (DNS) and 26 (Nurse Consultant) stated nursing staff needed to be aware of and trained on the use of Resident 20's palm protector, and to follow the daily wear schedule.

Based on interview, and record review it was determined the facility failed to protect the resident's right to be free from sexual abuse by another resident for 1 of 3 sampled residents (#101) reviewed for abuse. This placed residents at risk for abuse. Findings include:Based on interview, and record review it was determined the facility failed to provide care and services to ensure the resident's right to be free from sexual abuse by another resident for 1 of 3 sampled residents (#101) reviewed for abuse. This placed residents at risk for abuse. Findings include:Resident 101 was admitted to the facility in 7/2025 with diagnoses including Alzheimer's dementia and stroke.On 9/24/25, Resident 101 had a score of 7 on a BIMS Evaluation which indicated severe cognitive impairment.Resident 101's 8/7/25 MDS CAA for Cognitive Loss/ Dementia indicated the resident had cognitive loss related to a diagnosis of Dementia, aphasia (a disorder that affects your ability to speak, understand, read, and write), a history of a recent stroke and reported inattention. Resident 101 was confused and sometimes struggled with understanding others and making herself/himself understood. Dementia and aphasia impeded the resident's ability to interact with others.A Facility Reported Incident (FRI) dated 9/22/25, indicated Resident 101 was found by Staff 3 (CNA) in the room of Resident 102 and they were having adult relations using Resident 101's hands. Resident 101 was redirected by Staff 3 to her/his room. Resident 101 had no memory of the interaction with Resident 102. Resident 101 has a diagnosis of dementia. On 9/24/25 at 11:34 PM, Resident 101 was interviewed regarding the incident with Resident 102. The resident did not remember the incident.On 9/24/25 at 2:11 PM, Staff 3 (CNA) stated she was Resident 101's CNA on the night of the incident on 9/19/25. Resident 101 was not in her/his room so she went to look and found the resident in Resident 102's room. Staff 3 stated Resident 101 was standing by the bed and her/his hands were on resident 102's private parts. Resident 102 wears adult briefs but he does not wear the briefs taped. Staff 3 stated she was positive what she saw and knew it was not right. Staff 3 said she took resident 101 out of the room and back to her/his own room. Staff 3 also stated when she got the resident back to her/his room Resident 101 was acting differently than normal. Resident 101 would not let her put a new brief on her/him and was going around the room naked, even standing on the bed naked. Staff 3 stated the resident had never behaved like that before and has not done so again since the incident.On 9/24/2025 at 12:47 PM, Resident 102 indicated she/he previously had a room on the 100 Hallway where she/he would see Resident 101 wandering the hallways. Resident 102 stated she/he would try to say hello and wave but Resident 101 did not respond. Resident 102 stated she/he was aware that Resident 101 had mental issues. Resident 102 stated she/he previously had a room on the 100 hallway and one day Resident 101 walked by and Resident 102 asked Resident 101 to come here. Resident 102 stated he was in bed with the door open and asked the resident her/his name but Resident 101 did not answer. Resident 102 went on to say she/he had the covers up to her/his waist and just a brief on. Resident 102 stated she/he was just trying to talk to the resident but could tell something was wrong with Resident 101 mentally. Resident 102 stated Resident 101 did not touch her/him. When asked about the CNA seeing him/her and then quickly trying to cover herself/himself up when she entered the room Resident 102 said she/he was putting her/his urinal in place. Resident 102 stated if anyone wanted to take advantage of me, she/he would let them. A review of Resident 101's medical record including the care plan and nursing progress notes, revealed no interventions were put in place to ensure the resident's safety directly following the incident and no interventions were put in place in the care plan, progress notes or alert charting related to Resident 102's behavior.On 9/25/25 at 1:49 PM, Witness1 (Family Member) stated the incident occurred on Friday evening and she was not informed about it until Monday at 4:00 PM. Witness 1 said she was a retired Nurse Practioner and had just moved to Oregon to be closer to resident 101. Witness 1 also stated Resident 101 had never exhibited any behaviors of a sexual nature, and if the resident got naked after the incident, it was not a behavior she had ever seen or heard about previously. Witness 1 stated her main concern was that this incident should never happen again and her intention was to move the resident to a different facility with a memory unit.On 9/25/25 at 2:04 PM, Staff 1 (Administrator) acknowledged Staff 3 was a witness to the sexual contact between the residents, and Resident 101 did not have the mental capacity to consent to the sexual contact. The facility did not put appropriate interventions in place following the incident because it was not reported to her in a timely manner. On 9/25/25 at 5:32 PM, Staff 2 (LPN) stated when she came to work Resident 101 was already back to her/his room. Staff 3 told her what happened including that Resident 101's hands were on Resident 102's genitals. Staff 2 stated Resident 102 would frequently watch pornography on her/his phone and would make inappropriate comments such as he liked curvy people and watching them bend over. Staff 2 also stated on a recent night shift, although she knocked and announced herself, she had witnessed Resident 102 masturbating while watching pornography, which made her very uncomfortable.

Based on interviews and record review it was determined the facility failed to report an allegation of sexual abuse and an allegation of verbal abuse to the State Survey Agency within two hours of the allegations for 1 of 3 (#101) sampled residents reviewed for abuse. This placed residents at risk for further unreported abuse. Findings include:1.Resident 101's FRI with an allegation of sexual abuse was received by the State Survey Agency on 9/22/25 at 2:51 PM. The incident of alleged sexual abuse occurred on 9/19/25 at 9:30 PM and should have been reported within the two hours of the incident date and time. 2.Resident 101's FRI with an allegation of verbal abuse was received by the State Survey Agency on 7/21/25 at 2:30 PM. The incident of alleged verbal abuse occurred on 7/19/25 at 12:41 PM and should have been reported within two hours of the incident date and time.On 9/25/25 at 2:04 PM, Staff 1 (Administrator) acknowledged the incident of alleged sexual and verbal abuse were not reported to the State Survey Agency in a timely manner.

Based on observation, interview, and record review it was determined the facility failed to ensure transmission based precautions were implemented, to preoprly sanitize resident care equipment and provide wound care in a sanitary manner for 6 of 6 sampled residents (#s 10, 19, 20, 27, 30 and 195) reviewed for clostridium difficile colitis (C-Diff, a bacterium that causes an infection of the colon with symptoms including: inflammation of the colon, diarrhea, and life-threatening damage to the colon), wound care and medication administration. This deficient practice was determined to be an immediate jeopardy (IJ) situation. Resident 30 admitted to the facility with C-Diff, but the facility failed to protect this and other residents and timely implement appropriate contact precautions and properly sanitize once the resident was deemed clear of C-Diff. Findings include: The online reference CDC Preventing C-Diff. revealed the best way to prevent the spread of C-Diff from person to person was for all healthcare workers to wash their hands with soap and water before and after caring for the resident. On 11/5/24 at 4:42 PM the facility administrative staff, including Staff 1 (Administrator), Staff 2 (DNS), Staff 4 (Regional [NAME] President), and Staff 9 (Regional Nurse) were notified of the IJ situation and were provided a copy of the IJ Template related to the facility's failure to ensure transmission-based precautions were implemented timely for Resident 30 related to C-Diff. On 11/6/24 at 12:38 PM an acceptable plan to remove the IJ situation was submitted by the facility. The plan indicated the facility would implement the following actions: -The hydration cart and vital sign equipment was sanitized to prevent the spread of infection. -Current staff on shift were re-educated on transmission-based precautions relative to C-Diff per the CDC guidelines prior to their next scheduled shift. Soap and water were reinforced as the standard for hand hygiene. Additional education was provided to include donning and doffing of PPE. -Nurse management would complete ongoing Infection Control rounds on all three shifts for the next 72 hours, and then conduct random audits on all three shifts for the next 30 days. -New admissions to the facility would be reviewed by the Regional Nurse and IP for the next 30 days to ensure that appropriate Infection Control measures were implemented, and Kardex and Care plans updated. -Resident 30 had completed her/his course of antibiotics and stools were formed. Resident 30 met the CDC criteria and precautions were removed. As of 11/6/24 she/he had her/his room deep-cleaned as well as linens changed. Resident 30 declined a shower but accepted a full bed bath. -Facility staff would be trained on providing hydration while facility residents were on transmission-based precautions including direction to obtain new water pitchers with each hydration pass. -Current residents on transmission-based precautions had donning and doffing procedures added to the signage on the residents' doors for easy staff reference. -Residents on transmission-based precautions were provided individual vital sign equipment while on transmission-based precautions. -The facility IP would complete further training presented by Oregon Care partners on transmission-based precautions no later than end of day on 11/7/24. -Facility equipment for those on transmission-based precautions would be sanitized utilizing the Clorox Bleach Germicidal wipes with a contact time of three minutes. Education was provided to facility staff on cleansing techniques. -The Regional Nurse would review the Infection Control portal three times per week for the next 30 days to ensure that infections were care planned and appropriate precautions were implemented. -A root cause analysis would be completed by the Governing Body and brought to the facility QAPI committee for review. -The facility Executive Director was responsible for ensuring on-going compliance with the plan. -Other residents in the facility with orders for transmission-based precautions were reviewed to validate they were placed on appropriate transmission-based precautions. -Residents admitted to the facility since 11/1/24 were to be reviewed to validate that transmission-based precautions were implemented as appropriate, and PPE was available in the facility. -Findings of the above audits would be reviewed with the medical director. From 11/5/24 through 11/6/24 the IJ removal plan was verified as implemented by the survey team. No additional concerns related to the IJ situation were noted. 1. Resident 30 readmitted to the facility on [DATE] with diagnoses including C-Diff. Resident 30 admitted without special infection control precautions and none were initiated until 11/4/24. On 11/4/24 Resident 30 was placed on enhanced barrier precautions for an open wound. On 11/5/24 at 10:50 AM Staff 2 (DNS) stated Resident 30 was admitted without special infection control precautions and none were initiated until 11/4/24, but for enhanced barrier precautions related to an open wound. Staff 2 stated Resident 30 was positive for C-Diff, but not placed on appropriate transmission-based precautions for C- Diff. A review of the EPA registered antimicrobial products effective against C-Diff spores revealed Mycolio (an alcohol based sanitize wipe), the product in use by the facility, was not an effective product to kill C-Diff spores. On 11/5/24 at 1:36 PM Staff 5 (CNA) entered Resident 30's room, took Resident 30's water cup, left her/his room with the cup and went to the water station with all the hydration supplies in the dining room including: multiple water pitchers, clean cups, and an ice chest with an ice scoop. Staff 5 returned the water to Resident 30 and did not wash her hands. Staff 5 stated she did not remove the hydration station cart from the dining room after filling Resident 30's water cup. On 11/5/24 at 1:52 PM Staff 5 stated management instructed staff PPE was required when coming into physical contact with an applicable resident. Staff 5 stated alcohol-based sanitizer was an acceptable means of hand hygiene after exiting a room with C-Diff precautions. Staff 5 stated the CNA on light duty did the vital sings on the 100 hall, including Resident 30, and used Mycolio disinfectant wipes to disinfect the vital equipment. Staff 5 stated she was told so many different things and she was confused on what the correct procedure was. No interventions were observed to address potential cross-contamination. On 11/5/24 at 1:53 PM Staff 7 (CNA) stated she used the Mycolio disinfectant wipes to disinfect the vital equipment. On 11/5/24 at 1:54 PM Staff 5, Staff 6 (CNA), Staff 7, and Staff 8 (CNA) stated they did not follow transmission-based precautions for C-Diff and furthermore did not demonstrate knowledge of appropriate precautions to prevent the spread of C-Diff. On 11/5/24 at 2:05 PM Staff 3 (Staff Development) provided an 10/2024 training on transmission-based precautions and stated 55% of staff did not complete the training as of 11/5/24. On 11/5/24 at 3:27 PM the front dining room was observed with the soiled water pitchers, cups, ice chest, and ice scoop still in place for residents to use. On 11/6/24 at 9:07 AM Staff 5 stated she gave Resident 30 a bed bath on 11/5/24. Staff 5 stated she washed the resident's hair, changed her/his hospital gown, and changed the bedding. Staff 5 stated she wiped down the resident's bedrail and mattress with Mycolio disinfectant wipes followed by personal wipes. On 11/6/24 at 9:12 AM Staff 41 (Housekeeping Manager) stated he was not informed Resident 30 no longer required transmission-based precautions. Staff 41 indicated a resident's room following C-Diff precautions would have curtains and linens removed and placed in a separate bag and the entire room cleaned and sanitized with bleach. On 11/6/24 at 9:26 AM Staff 2 was asked to identify all tasks completed when a resident was removed from contact precautions. Staff 2 did not include terminal cleaning of the resident's room, or the resident being showered. 2. Resident 10 admitted to the facility in with a Stage 4 (severe damage to the skin, and the surrounding tissue begins to die) pressure ulcer. The 7/22/24 Admission MDS indicated Resident 10 was at high risk for developing another pressure ulcer due to malnutrition, incontinence, functional impairment and cognitive loss. Resident 10 was unable to execute major repositioning independently and relied on staff for assistance. The wound nurse provided wound care to Resident 10's pressure ulcer including measurements, assessment of the wound bed weekly with adjustment to the wound care orders as needed. On 11/6/24 at 9:45 AM Staff 11 (Resident Care Manager-LPN) was observed to perform wound care for Resident 10. During the dressing change the following was observed; -Staff 11 donned a gown and gloves without sanitizing her hands. -Staff 11 placed all clean dressing supplies including bandage scissors on Resident 10's bedside table which had incontinent pads and a urinal on top of the table. Staff 11 began touching drawers of the resident's nightstand to obtain more supplies and did not change her gloves. -Staff 11 then moved the clean supplies to Resident 10's bed on her/his incontinent pad and did not prepare a clean surface. -Staff 11 removed the resident's incontinent brief, removed the wound dressing, and cleansed the wound with her/his soiled gloves. Staff 11 proceeded to open the wound dressing packages with the same gloves, cut the new dressing with the soiled scissors and place the new dressings in the wound with the soiled gloves. Staff 11 used her fingers with donned with the soiled gloves instead of a clean Q-tip to place the dressing inside the wound. -Staff 11 proceeded to open another dressing package, cover the wound, reach into her pocket and obtain a permanent marker, write on the bandage, then place the pen back in her pocket. On 11/6/24 at 10:10 AM Staff 11 acknowledged she did not set-up a clean field for dressing supplies and did not change her gloves and sanitize her hands like she should have. On 11/6/24 at 10:30 AM Staff 9 (Regional Nurse) stated Staff 11 recently finished a wound class and should know to provide a clean area for dressings, change gloves and sanitize hands often when touching dirty dressings and applying clean dressings. 3. Resident 19 admitted to the facility in 2/2022 with diagnoses including respiratory failure. A random observation on 11/8/24 at 8:24 AM revealed Staff 30 (LPN) reached into a resident's medication cup with multiple medications in the cup without sanitizing her hands or donning gloves, obtained a medication capsule from the cup, pulled the capsule apart, and placed the contents of the capsule in pudding. On 11/8/24 at 8:29 AM Staff 30 acknowledged she did not sanitize her hands or don gloves before she touched the resident's medications. 41455 4. Resident 27 admitted to the facility in 10/2023 with diagnoses including infection of the stomach lining and UTI. A 1/3/24 physician order revealed staff were to ensure Resident 27's colostomy (a surgical opening in the abdomen to divert waste out of the body) was emptied daily. An 10/23/24 revised care plan indicated to use enhanced barrier precautions for Resident 27 during high contact care activities including assistance with toileting. On 11/4/24 at 10:15 AM a sign was posted on Resident 27's door which indicated the resident required enhanced barrier precautions and staff were to wear gloves and a gown during high contact care. On 11/4/24 at 10:17 AM Resident 27 stated staff often did not use gloves and gowns to change her/his colostomy bag and the last time PPE was used by staff was a few weeks earlier. No PPE was found near or in Resident 27's room. On 11/4/24 at 10:43 AM Staff 2 (DNS) confirmed PPE was required and not in place for staff to use during Resident 27's care. 42270 5. Resident 195 admitted to the facility in 10/2024 with diagnoses including C-Diff. An 10/26/24 order for Resident 195 revealed she/he received Vancomycin (an antibiotic) four times a day for entercolitiis (inflammation of the digestive track) due to C-Diff. Resident 195's Bowel Movements task revealed the following documented bowel movements: -10/27/24: 1 loose/diarrhea and 2 formed/normal - 10/29/24: 2 loose/diarrhea stool - 10/30/24: 3 loose/diarrhea stool - 10/31/24: 3 loose/diarrhea stool - 11/1/24: 2 loose/diarrhea stool, 1 formed/normal - 11/2/24: 3 loose/diarrhea stool - 11/3/24: 3 loose/diarrhea stool - 11/4/24: 1 loose/diarrhea stool, 1 formed/normal - 11/5/24: 2 loose/diarrhea stool, 1 formed/normal On 11/4/24 at 11:13 AM Resident 195 was observed in her/his room and there were no signs to indicate transmission based precautions or enhanced barrier precautions were needed. On 11/4/24 at 2:54 PM Staff 1 (Administrator) placed a sign on Resident 195's door which indicated she/he was on enhanced barrier precautions, and Staff 1 stated this was due to Resident 195's urostomy. On 11/6/24 at 9:05 AM Staff 2 (DNS) reviewed Resident 195 and stated she/he was not on transmission based precautions for C-Diff due to a negative C-Diff test and soft formed stools. In a joint interview on 11/6/24 at 9:26 AM Staff 2 and Staff 9 (Regional Nurse) were asked to review Resident 195. Staff 2 stated he was unable to access and provide the negative C-Diff test result for Resident 195. Staff 2 was asked to review the bowel records for Resident 195 due to the multiple documented loose/diarrhea stools. Staff 2 stated he would need to follow up with the corporate infection preventionist and the physician regarding the need for contact precautions due to C-Diff and active loose/diarrhea stools. Staff 9 stated the facility would immediately place Resident 195 on contact precautions until a determination was made. 6. Resident 20 admitted to the facility in 10/2019 with diagnoses including diabetes. On 11/4/24 at 11:25 AM Staff 19 (Agency RN) was observed to check Resident 20's CBG (blood sugar measurement) level. After the CBG level was obtained Staff 19 wiped the glucometer with one alcohol prep pad and then placed the glucometer on top of the medication cart. When asked what her process was for cleaning and sanitizing the glucometer Staff 19 stated she cleaned the glucometer between each resident use with alcohol prep pads, as they were the only cleaning product provided. On 11/4/24 at 11:32 AM Staff 2 (DNS) confirmed an alcohol prep pad was not an appropriate method to clean and sanitize the glucometer.

Based on interview and record review it was determined the facility failed to protect residents from verbal abuse by staff for 2 of 2 sampled residents (#s 1 and 18) reviewed for abuse. Resident 18 experienced psychosocial harm. Findings include: 1. Resident 18 admitted to the facility in 2/2022 with diagnoses including anxiety and depression. A 7/28/24 Quarterly MDS revealed Resident 18 was cognitively intact. On 9/3/24 a FRI was received which alleged on 8/31/24 Staff 38 (Former Agency CNA) assisted Resident 18 onto the bed pan. When Resident 18 was finished Staff 38 attempted to assist Resident 18 off the bedpan. Resident 18 was unable to assist with bed mobility and asked Staff 38 to get assistance, but Staff 38 refused. Staff 38 was able to get Resident 18 off the bedpan, but the bedpan spilled onto Resident 18's bed. Resident 18 repeated her/his request for Staff 38 to get assistance. Staff 38 refused to get assistance and proceeded to clean Resident 18 while making comments about the mess in the bed and telling Resident 18 to roll over further. Resident 18 continued to express to Staff 38 she/he was unable to move further without additional assistance. Resident 18 stated she/he felt like Staff 38 stripped [her/him] of [her/his] last ounce of dignity. A 1/28/23 Care Plan revealed Resident 18 was care planned for two-person extensive assistance with bed mobility. On 11/7/24 at 11:07 AM Staff 2 (DNS) stated he was notified of an allegation of abuse involving Staff 38 right after the incident occurred on 8/31/24, and Staff 38 was sent home immediately. Staff 2 stated Resident 18 expressed feeling safe since Staff 38 was sent home. Staff 2 stated the incident was abusive, but Resident 18 was not harmed. Staff 2 acknowledged Resident 18 was not placed on alert for psychosocial harm. On 11/7/24 at 11:24 AM Staff 9 (Regional Nurse) stated it was expected for residents to be placed on alert after an allegation of abuse to monitor for any physical or psychosocial harm. On 11/8/24 at 8:03 AM Resident 18 stated the incident on 8/31/24 with Staff 38 made her/him .feel horrible; less than human. Resident 18 stated she/he still felt .like a piece of meat and to this day [she/he felt] less than a person. On 11/8/24 at 8:27 AM Staff 1 (Administrator) acknowledged the facility failed to place Resident 18 on alert to monitor for any psychosocial harm after the incident on 8/21/24. Staff 1 stated Resident 18 was not harmed, but she/he was stripped of her/his dignity, which is why Staff 38 was removed from the facility. 42270 2. Resident 1 admitted to the facility in 1/2015 with diagnoses including cerebral palsy (a disorder that affects movement, muscle tone, and posture). A 1/22/24 Annual MDS revealed Resident 1 had a BIMS score of 15 which indicated she/he was cognitively intact. A 5/13/24 Grievance form revealed Resident 1 approached Staff 22 (Kitchen Manager) on 5/13/24 after Food Committee to discuss a concern with a previous meal she/he felt caused diarrhea. The grievance revealed Staff 22 became defensive, raised his voice to Resident 1, and said he was not going to let her/him say it was food poisoning. Resident 18, Resident 27, and Staff 21 (Activities Director) were also present in the room. Resident 18 told Staff 22 he should not speak to Resident 1 like that. Resident 27 said he should not raise his voice and condescend Resident 1. A 5/20/24 Resident Council Meeting Notes included the following hand-written statement: We as residents don't feel safe, secure, and safe from all types of abuse, and that is not being addressed. We feel that we can be yelled at in front of a few people. Lots of people thought he [Staff 22] should have been fired on the spot. [Staff 22] thinks [Staff 22] can do whatever he wants to whats next. A 5/20/24 Alleged Abuse Investigation revealed the incident with Resident 1 and Staff 22 was brought up at the 5/20/24 Resident Council and then investigated as abuse. Resident 27 did not feel it was abusive initially, but with further discussion she/he felt the incident was verbal abuse and brought it up in Resident Council. Staff 21 stated Staff 22 spoke to Resident 1 in an elevated tone, but it was not considered abuse. Resident 18 stated she/he told Staff 22 to stop being so rude and she/he felt the interaction could be considered abuse. Resident 1 stated Staff 22 .was not receptive to what [she/he] was saying and began yelling at [her/him]. [Staff 22] would not listen to what [she/he] was saying. [Staff 22] continued to yell and finally just walked away. On 11/4/24 at 10:45 AM Resident 1 stated she/he spoke to Staff 22 about the possibility a meal caused diarrhea. Resident 1 stated Staff 22 got two inches from her/his face and stated Prove it; provide it. multiple times to her/him. Resident 1 stated she/he was taken aback by the entire incident, she/he felt the event would be considered verbal abuse, and it made her/him feel uncomfortable about it. Resident 1 stated Staff 22 got in her/his face for no reason. On 11/6/24 at 11:05 AM Resident 27 stated she/he was present for the incident between Resident 1 and Staff 22 on 5/13/24. Resident 27 stated Staff 22 yelled and it made her/him jump. Resident 27 stated Staff 22 yelled at the top of of his lungs, and every time Resident 1 mentioned fish Staff 22 would say Prove it. Resident 27 stated she/he was appalled, the residents were all bothered that Staff 22 was still at the facility, and she/he definitely felt it was verbal abuse. On 11/6/24 at 11:14 AM Resident 18 stated she/he was present for the incident on 5/13/24, she/he recalled Resident 1 spoke about food, and Staff 22 blew up without any warning and yelled statements repeatedly. Resident 18 stated she/he told Staff 22 he was being inappropriate, and she/he characterized the incident as verbal abuse and Resident 1 was upset afterward. Resident 18 stated Staff 22 tended to raise his voice with residents and it was not appropriate. On 11/6/24 at at 12:25 PM Staff 21 stated she was present for the incident between Resident 1 and Staff 22 on 5/13/24. Staff 21 stated Resident 1 waited until after everyone left the Food Committee meeting and told Staff 22 a fish meal was undercooked. Staff 21 stated Staff 22 basically attacked Resident 1 with accusations and stated there was no way Resident 1 could know if the fish was undercooked. Staff 21 stated anytime Resident 1 tried to speak Staff 22 interrupted her/him and absolutely raised his voice. Staff 21 stated she got between Resident 1 and Staff 22 and attempted to intervene. Staff 21 stated Staff 1 (Administrator) was notified immediately and she felt the interaction was verbal abuse. On 11/6/24 at 1:08 PM Staff 22 stated Resident 1 bought up an issue about residents getting sick from seafood. Staff 22 stated he did not yell at Resident 1, and he was notified when he stood above a resident in a wheelchair his voice could carry and it was about perception. On 11/8/24 at 8:40 AM Staff 1 stated Staff 22 did not respond appropriately to Resident 1, and was unprofessional and defensive. Staff 1 stated at the time there was no indication of verbal abuse, but at the next Resident Council meeting there was a written statement generated regarding abuse after which she immediately started an abuse investigation. Staff 1 stated abuse was ruled out in the investigation, however she confirmed staff raised their voice, talked over a resident, and this could be considered verbal abuse.

Based on observation, interview and record review it was determined facility staff failed to follow professional standards of practice for medication administration and wound care for 4 of 7 sampled residents (#s 9, 10, 19, and 33) reviewed medication administration and wound care. This placed residents at risk for unsafe medication administration and cross contamination. Findings include: 1. Resident 9 admitted to the facility in 2/2017 with diagnoses including heart disease. An 10/1/24 physician order indicated Resident 9 received Cephalexin (antibiotic) BID. An 10/16/24 physician order indicated Resident 9 received Losartan (for high blood pressure) BID. The 11/2024 MAR indicated Resident 9 was to receive her/his medication at 8:00 AM. The facility's standing orders indicated blood pressure parameters included to hold all blood pressure medications for systolic (pressure in your blood vessels when your heart contracts) blood pressure less than 100. On 11/7/24 at 9:45 AM Staff 28 (LPN) administered Resident 9's Losartan at 9:45 AM, one hour and 45 minutes late, but did not check her/his blood pressure prior to administering the medication. On 11/7/24 at 9:50 AM Staff 28 stated when she was running late administering medications she just kept going to hopefully catch-up. Staff 28 stated she spoke with management regarding what the process was when staff are running late passing medications, but did not receive feedback. Staff 28 acknowledged she did not check Resident 9's blood pressure before administering her/his Losartan. 2. Resident 10 admitted to the facility in 7/2024 with a Stage 4 (severe damage to the skin, and the surrounding tissue begins to die) pressure ulcer. The 7/22/24 Admission MDS indicated Resident 10 was at high risk for developing another pressure ulcer due to malnutrition, incontinence, functional impairment and cognitive loss. Resident 10 was unable to execute major repositioning independently and relied on staff for assistance. The wound nurse provided wound care to Resident 10's pressure ulcer including measurements, assessment of the wound bed weekly with adjustment to the wound care orders as needed. On 11/6/24 at 9:45 AM Staff 11 (Resident Care Manager-LPN) was observed to perform wound care for Resident 10. During the dressing change the following was observed; -Staff 11 donned a gown and gloves without sanitizing her hands. -Staff 11 placed all clean dressing supplies including bandage scissors on Resident 10's bedside table which had incontinent pads and a urinal on top of the table. Staff began touching drawers of the resident's nightstand to obtain more supplies and did not change her gloves. -Staff 11 then moved the clean supplies to Resident 10's bed on her/his incontinent pad and did not prepare a clean surface. -Staff 11 removed the resident's incontinent brief, removed the wound dressing, and cleansed the wound with her/his soiled gloves. Staff 11 proceeded to open the wound dressing packages with the same gloves, cut the new dressing with the soiled scissors and place the new dressings in the wound with the soiled gloves. Staff 11 used her fingers with donned with the soiled gloves instead of a clean Q-tip to place the dressing inside the wound. -Staff 11 proceeded to open another dressing package, cover the wound, reach into her pocket and obtain a permanent marker, write on the bandage, then place the pen back in her pocket. On 11/6/24 at 10:10 AM Staff 11 acknowledged she did not set-up a clean field for dressing supplies and did not change her gloves and sanitize her hands like she should have. On 11/6/24 at 10:30 AM Staff 9 (Regional Nurse) stated Staff 11 recently finished a wound class and should know to provide a clean area for dressings, change gloves and sanitize hands often when touching dirty dressings and applying clean dressings. 3. Resident 19 admitted to the facility in 2/2022 with diagnoses including respiratory failure. A random observation on 11/8/24 at 8:35 AM revealed Staff 30 (LPN) reached into a resident's medication cup with multiple medications in the cup without sanitizing her hands or donning gloves, obtained a medication capsule from the cup, pulled the capsule apart, and placed the contents of the capsule in pudding. On 11/8/24 at 8:29 AM Staff 30 acknowledged she did not sanitize her hands or don gloves before she touched the resident's medications. b. A 2/21/22 physician order indicated Resident 19 received Combivent inhaler (for wheezing and shortness of breath) four times a day, and was to rinse her/his mouth after each use. On 11/8/24 at 8:35 AM Staff 30 administered the Combivent inhaler, but did not have Resident 19 rinse her/his mouth. On 11/8/24 at 8:40 AM Staff 30 stated she did not have the resident rinse her/his mouth after she/he received her/his inhaler per the physician order because she forgot and took the resident's water away. Staff 30 did not go back into the resident's room to have her/him rinse her/his mouth. c. A 2/22/24 physician order indicated Resident 19 received Metoprolol ER (extended release for high blood pressure) every morning. The facility's standing orders indicated blood pressure parameters included to hold all blood pressure medications for systolic (pressure in your blood vessels when your heart contracts) blood pressure less than 100. Staff 30 was observed asking CNAs for a blood pressure level for Resident 19 which were obtained at 6:00 AM. On 11/8/24 at 9:37 AM Staff 1 (Administrator) and Staff 9 (Regional Nurse) confirmed touching a resident's medication with bare unsanitary fingers by the staff was unacceptable. Staff 9 stated Staff 30 should not ask CNAs for a blood pressure level obtained hours before administering a medication requiring a blood pressure level check, rather she should have obtained the resident's blood pressure level right before administering Metoprolol. 4. Resident 33 admitted to the facility in 10/2024 with diagnoses including heart disease and thyroid disorder. An 10/4/24 physician order indicated Resident 33 received Apixiban (blood thinner), Carvedilol (for high blood pressure), and Levothyroxine (thyroid medication). An 10/15/24 physician order indicated Resident 33 received Losartan (for high blood pressure). The 11/2024 MAR indicated Resident 33 received her/his medications at 8:00 AM. On 11/7/24 at 9:30 AM Staff 14 (LPN) administered Resident 33's medications, which was one hour and 30 minutes late, and was after Resident 33 consumed her/his breakfast meal. The facility's standing orders indicated blood pressure parameters included to hold all blood pressure medications for systolic (pressure in your blood vessels when your heart contracts) blood pressure less than 100. Staff 14 did not perform a blood pressure check before administering Resident 33's blood pressure medications. Per Drugs.com Levothyroxine should be taken in the morning on an empty stomach, at least 30 to 60 minutes before eating breakfast. On 11/7/24 at 9:40 AM Staff 14 stated he was not told what to do when he was running late administering medications. Staff 14 acknowledged he did not check Resident 33's blood pressure level prior to administering Resident 33's Losartan and Carvedilol.

Based on observation and interview the facility failed to provide a homelike dining environment for 3 of 3 dining rooms reviewed for dining. This placed residents at risk for living in an institutional environment. Findings include: On 11/4/24 at 11:58 AM, while four residents ate in the Middle dining room, their meals were observed left on the delivery tray during the meal. On 11/5/24 at 12:13 PM the Middle dining room was observed. Residents sat at three different tables, one of the tables had a plant, the other tables had no table decoration, and none of the tables had a tablecloth. Five residents ate in the room and all residents' plates were on left on the plate warmer and were left on trays. On 11/5/24 at 12:15 PM the Back dining room was observed. Three residents were at one table in the dining room, no tablecloth was present, and all resident meals were left on trays. On 11/5/24 at 12:18 PM the Front dining room as observed. Two residents were observed eating in the room and both of their meals were left on trays. On 11/5/24 at 12:22 PM Staff 1 (Administrator) stated the facility should make meals feel like home. Staff 1 stated the expectation was for staff to remove the tray and plate warmer unless the resident requested either to remain, and staff were to make it feel like home.

Based on observation, interview, and record review it was determined the facility failed to ensure a medication error rate of less than five percent. There were seven errors out of 37 medication administration opportunities resulting in an 18.92 percent error rate. This placed residents at risk for an ineffective and unsafe medication regimen and risk of administering a BID medication to soon from the first dose Findings include: 1. Resident 9 admitted to the facility in 2/2017 with diagnoses including heart disease. An 10/1/24 physician order indicated Resident 9 received Cephalexin (antibiotic) BID. An 10/16/24 physician order indicated Resident 9 received Losartan (for high blood pressure) BID. The 11/2024 MAR indicated Resident 9 received her/his medications at 8:00 AM. On 11/7/24 at 9:45 AM Staff 28 (LPN) administered Resident 9's medications at 9:45 AM, one hour and 45 minutes late. The facility's standing orders indicated blood pressure parameters included to hold all blood pressure medications for systolic (pressure in your blood vessels when your heart contracts) blood pressure less than 100. Staff 28 did not perform a blood pressure check before administering blood pressure medications. On 11/7/24 at 9:50 AM Staff 28 stated when she was running late administering medications she just kept going to hopefully catch up. Staff 28 stated she spoke with management regarding the procedure if she was running late passing medications, but did not receive feedback. On 11/7/24 at 2:13 PM Staff 9 (Regional Nurse) stated staff should notify management if they are running late administering medications. 2. Resident 19 admitted to the facility in 2/2022 with diagnoses including respiratory failure. a. A random observation on 11/8/24 at 8:24 AM revealed Staff 30 (LPN) reached into a resident's medication cup with multiple medications in the cup without sanitizing her hands or donning gloves, obtained a medication capsule from the cup, pulled the capsule apart, and placed the contents of the capsule in pudding. On 11/8/24 at 8:29 AM Staff 30 acknowledged she did not sanitize her hands or don gloves before she touched the resident's medications. b. A 2/21/22 physician order indicated Resident 19 received Combivent inhaler (for wheezing and shortness of breath) four times a day, and was to rinse her/his mouth after each use. On 11/8/24 at 8:35 AM Staff 30 administered the Combivent inhaler, but did not have Resident 19 rinse her/his mouth. On 11/8/24 at 8:40 AM Staff 30 stated she did not have the resident rinse out her/his mouth after she/he received her/his inhaler per the physician order. On 11/8/24 at 9:37 AM Staff 1 (Administrator) and Staff 9 (Regional Nurse) stated Staff 30 should have donned gloves if she had to touch a resident's medication. 3. Resident 33 admitted to the facility in 10/2024 with diagnoses including heart disease and thyroid disorder. An 10/4/24 physician order indicated Resident 33 received Apixiban (blood thinner), Carvedilol (for high blood pressure), and Levothyroxine (thyroid medication). An 10/15/24 physician order indicated Resident 33 received Losartan (for high blood pressure.) The 11/2024 MAR indicated Resident 33 was to receive her/his medications at 8:00 AM. On 11/7/24 at 9:30 AM Staff 14 (LPN) administered Resident 33's medications, one hour and 30 minutes late, which was after Resident 33 consumed her/his breakfast meal. The facility's standing orders indicated blood pressure parameters included to hold all blood pressure medications for systolic (pressure in your blood vessels when your heart contracts) blood pressure less than 100. Staff 14 did not perform a blood pressure check before administering Resident 33's blood pressure medications. Per Drugs.com Levothyroxine should be taken in the morning on an empty stomach, at least 30 to 60 minutes before eating breakfast. On 11/7/24 at 9:40 AM Staff 14 stated he was not told what to do when he was running late administering medications. Staff 14 acknowledged he did not check Resident 33's blood pressure level prior to administering Resident 33's Losartan and Carvedilol. On 11/7/24 at 2:13 PM Staff 9 (Regional Nurse) stated staff should notify management if they are running late administering medications.

Based on interview and record review it was determined the facility failed to obtain information related to advance directives and health care decisions for 4 of 5 sampled residents (#s 8, 20, 30 and 32) reviewed for advance directives. This placed residents at risk for not having their health care decisions honored. Findings include: 1. Resident 8 admitted to the facility in 9/2024 with diagnoses including a leg fracture. A 9/30/24 Interdisciplinary Care Conference assessment revealed Resident 8 did not have an advance directive, but indicated there was an advance directive in the electronic record. Review of Resident 8's electronic record revealed no advance directive, and further indicated Resident 8 had a POLST (Physician Orders for Life-Sustaining Treatment) which was not signed by the physician. On 11/7/24 at 11:10 AM Staff 24 (Social Service Director) stated she reviewed advance directives at care conferences, and tried to make a note to indicate if an advance directive was provided or not wanted. Staff 24 stated she provided advance directive packets to residents at the care conferences, and if the resident requested assistance she provided it. Staff 24 stated she did not conduct follow up related to provided advance directives. 2. Resident 30 admitted to the facility in 8/2024 with diagnoses including an open wound to the left leg. A 9/18/24 Interdisciplinary Care Conference assessment revealed Resident 30 did not have an advance directive, but an advance directive booklet would be provided for the resident and family to review. A review of Resident 30's Progress Notes from 8/27/24 through 10/5/24 revealed no documentation related to an advance directive. On 11/5/24 at 5:35 PM Staff 24 (Social Service Director) stated she reviewed advance directives in care conferences and tried to make a note to indicate if an advance directive was provided or not wanted. Staff 24 stated she provided advance directive packets to residents in the care conferences and if the resident requested assistance she provided it. Staff 24 stated she did not follow up on provided advance directives. 3. Resident 32 admitted to the facility in 8/2024 with diagnoses including malnutrition. An 8/15/24 Interdisciplinary Care Conference assessment revealed Resident 32's son would bring her/his advance directive to the facility. An 9/15/24 Interdisciplinary Care Conference assessment revealed Resident 32 did not have an advance directive, but an advance directive booklet would be provided for the resident and family to review. A review of Resident 32's Progress Notes from 8/15/24 through 11/4/24 revealed no documentation related to an advance directive. On 11/5/24 at 5:35 PM Staff 24 (Social Service Director) stated she reviewed advance directives in care conferences and tried to make a note to indicate if an advance directive was provided or not wanted. Staff 24 stated she provided advance directive packets to residents in the care conferences and if the resident requested assistance she provided it. Staff 24 stated she did not follow up on provided advance directives. 42270 4. Resident 20 admitted to the facility in 10/2019 with diagnoses including diabetes. A 7/20/24 Quarterly MDS revealed Resident 20 had a BIMS score of 15 which indicated she/he was cognitively intact. A review of Resident 20's medical record revealed no advance directive. A 11/15/23 Interdisciplinary Care Conference assessment revealed Resident 20 did not have an advance directive and there was no indication if one was offered. A 2/7/24 Interdisciplinary Care Conference assessment revealed Resident 20 did not have an advance directive and a copy of an advance directive booklet was provided to Resident 20. A 5/8/24 Interdisciplinary Care Conference assessment revealed Resident 20 did not have an advance directive, there was no indication one was offered, and there was no follow up from the copy provided at the 2/7/24 Interdisciplinary Care Conference. A 7/31/24 Interdisciplinary Care Conference assessment revealed Resident 20 did not have an advance directive and there was no indication one was offered. A review of Resident 20's Progress Notes from 11/2023 through 11/5/24 revealed no documentation related to an advance directive. On 11/5/24 at 5:35 PM Staff 24 (Social Services Director) stated she reviewed advance directives in care conferences and tried to make a note to indicate if an advance directive was provided or not wanted. Staff 24 stated she provided advance directive packets to residents in the care conferences and if the resident requested assistance she provided it. Staff 24 stated she did not follow up on provided advance directives until the next quarterly care conference.

Based on interview and record review it was determined the facility failed to accurately assess 1 of 5 sampled residents (#25) reviewed for discharge. This placed residents at risk for unmet and unidentified needs. Findings include: Resident 25 admitted to the facility in 9/2020 with diagnoses including bipolar disorder. A 9/28/24 Annual MDS indicated Resident 25 did not want to talk to someone about the possibility of leaving the facility and returning to live and receive services in the community. Resident 25 did not want to be asked about returning to the community on all assessments. On 11/4/24 at 10:35 AM Resident 25 stated he wanted to discharge to a home in Corvallis. On 11/5/24 at 1:02 PM Resident 25 stated he wanted to discharge to a home in Corvallis. On 11/6/24 at 11:00 AM Resident 25 stated he wanted to discharge from the facility to either Corvallis or Philomath. On 11/6/24 at 1:37 PM Staff 24 (Social Service Manager) stated Resident 25 wanted to discharge to a home in Corvallis or Philomath. Staff 25 stated the facility was working with Resident 25's case worker to find her/him placement outside the facility. On 11/8/24 at 10:16 AM Staff 37 (Social Service Assistant) stated Resident 25 wanted to go home and the information on the 9/28/24 Annual MDS was incorrect. On 11/8/24 at 11:59 AM Staff 9 (Regional Nurse) acknowledged the 9/28/24 Annual MDS was incorrect, and the facility was making corrections to the MDS.

Based on interview and record review it was determined the facility failed to timely report to the State Survey Agency (SSA) an allegation of abuse for 1 of 2 sampled residents (#18) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 18 admitted to the facility in 2/2022 with diagnoses including anxiety and depression. On 9/3/24 a FRI was received by the SSA reporting an 8/31/24 allegation of abuse. On 11/7/24 at 11:23 AM Staff 1 (Administrator) stated she was unable to recall when the FRI was sent to the SSA. On 11/27/24 at 11:23 AM Staff 2 (DNS) stated the incident occurred on 8/31/24, which was a Saturday, and Monday 9/2/24 was a holiday, so the FRI was sent to the SSA on Tuesday 9/3/24.

Based on observation, interview and record review it was determined the facility failed to assess for and provide an appropriate call light system of 1 of 1 sampled resident (#11) reviewed for hydration. This placed residents at risk for unmet needs and lack of ability to call for assistance. Findings include: Resident 11 admitted to the facility in 2/2020 with diagnoses including Parkinson's disease (progressive disease of the nervous system) and edema (fluid retention). A 11/4/24 revised care plan indicated: - Resident 11 had orders for a diuretic (medication used to assist the removal of extra fluid from the body), fluids were important to the resident, and to encouraged fluids of her/his choice. -Resident 11 had hand contractures and a push pad call light was to be within her/his reach and she/he required maximum assistance for eating. On 11/4/24 at 10:07 AM Resident 11 was observed in bed with her/his hands in a clinched position and she/he was unable to use her/his button call light. On 11/4/24 at 1:39 PM Resident 11 was observed in bed and unable to use her/his push pad call light. Resident 11 stated if she/he was able to use the push pad call light she/he would ask for something to drink because she/he was thirsty. Resident 11 indicated her/his push pad call light was new, but she/he continued to need to yell for assistance. Staff 36 (RA) entered the room and stated the care needs for Resident 11 continued to increase and staff occasionally offered her/him water. On 11/6/24 at 9:48 AM Staff 16 (CNA) confirmed Resident 11 was unable to use the new push pad call light, and her/his care plan had no reference to her/him calling out to obtain assistance or to offer her/him fluids frequently. On 11/6/24 at 12:13 PM Resident 11 stated she/he became frustrated when she/he saw staff in the hallway who did not respond when she yelled for assistance. On 11/7/24 at 11:42 AM Staff 11 (Resident Care Manager-LPN) acknowledged Resident 11 was not assessed prior to the implementation of the new push pad call light, and the resident's care plan required additional interventions to address her/his fluid and call light needs.

Based on interview and record review it was determined the facility failed to ensure residents were treated with respect and dignity for 1 of 3 sampled residents (#1) reviewed for dignity. This placed residents at risk for lack of dignity. Findings include: Resident 1 admitted to the facility in 1/2015 with diagnoses including cerebral palsy (a disorder that affects movement, muscle tone, and posture). A 1/22/24 Annual MDS revealed Resident 1 was able to understand others, was cognitively intact, had no behaviors, and was dependent on staff for toileting. A public complaint was received on 2/6/24 which alleged while providing toileting assistance to Resident 1 two caregivers made fun of her/him and how her/his feces smelled. A review of Resident 1's Progress Notes revealed no documentation of the alleged incident. On 11/4/24 at 10:49 AM Resident 1 stated an agency staff member made a comment about how her/his feces smelled. Resident 1 stated she/he notified Staff 21 (Activities Director), but she/he did not know what happened as a result of that report. Resident 1 stated nobody should experience comments made about their basic bodily functions. On 11/5/24 at 1:40 PM Staff 21 stated, when she was notified by Resident 1 she/he was embarrassed about the comment made by agency staff, she notified the administrator. On 11/6/24 at 3:55 PM Staff 1 (Administrator) stated she was aware of Resident 1's allegation and the facility terminated Staff 31's (Former Agency CNA) contract due to the comment made to Resident 1. Staff 1 stated the comment was inappropriate. On 11/7/24 at 8:44 AM Staff 1 provided an undated and untitled typed statement about the incident with Resident 1. The statement revealed Staff 1 was made aware of Resident 1's concern with Staff 31 on 2/2/24, Staff 31's contract was terminated early, and Resident 1 indicated it was difficult enough to not be able to take care of her/his self to have to depend on other people who are supposed to be caring for me take away more of my dignity. On 11/7/24 at 12:59 PM Staff 25 (CNA) stated she recalled the event. Staff 25 stated she was notified by Resident 1 after the incident occurred. Staff 25 stated Resident 1 reported she/he was shamed for having diarrhea. Staff 25 stated Resident 1 reported feeling embarrassed about the comment. Staff 25 stated other residents reported having issues with the staff involved and the CNA's contract ended early. On 11/8/24 at 8:40 AM Staff 1 reported Staff 31 did not treat Resident 1 with respect and dignity. On 11/8/24 at 12:26 PM Staff 31 (Former Agency CNA) denied she made any comments about Resident 1's feces.

Based on interview and record review it was determined the facility failed to provide timely treatment for [REDACTED].#297) reviewed for hydration and nutrition. Resident 297 experienced a delay in dehydration treatment which resulted in the resident being hospitalized for [REDACTED]. Resident 297 admitted to the facility in 3/2018 post heart-surgery. A care plan dated 3/15/18 indicated the resident was at risk for skin impairment related to immobility, fragile skin and actual skin impairment of multiple surgical incisions. Staff were to encourage good nutrition and hydration in order to promote healthier skin. A Hydration assessment dated [DATE] indicated Resident 297 was not at risk for dehydration. The assessment did not indicate a rationale for why the resident was not at risk for dehydration despite her/his post-heart surgery status. The assessment indicated staff were to offer fluids as requested. According to the Mayo Clinic (https://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/water/art- 256), the average adult requires 2700-3700 cc of fluid per day to maintain adequate hydration. A Fluid Monitor document dated 3/15/18 through 3/27/18 revealed: -3/15/18 at 6:27 PM the resident drank 175 CCs of fluid. -3/16/18 850 cc for all shifts. -3/17/18 690 cc for all shifts. -3/18/18 900 cc for all shifts. -3/19/18 600 cc for all shifts. -3/20/18 680 cc for all shifts. -3/21/18 1320 cc for all shifts. -3/22/18 650 cc for all shifts. -3/23/18 660 cc for all shifts. -3/24/18 390 cc for all shifts. -3/25/18 780 cc for all shifts. -3/26/18 530 cc for all shifts. -3/27/18 day and evening shift 110 cc. A physician order [REDACTED]. A 3/17/18 Alert note indicated the resident was up most the night. The resident had conversations that did not make sense. The resident was alert to self only, was non-compliant with sternal precautions and kept attempting to self-transfer. The resident was very confused and staff would continue to monitor the resident. A 3/18/18 Skilled nursing note indicated the resident was alert and oriented but did seem to have some confusion during the night. A 3/19/18 Skilled nursing note indicated the resident had [MEDICAL CONDITION]. A 3/19/18 Alert note indicated the resident complained of dry mouth and the cardiovascular physician was notified. The 3/22/18 Nutrition CAA indicated Resident 297 had difficulty with swallowing and was cognitively intact upon admission. The 3/22/18 Medication CAA indicated Resident 297 received diuretic medication. An IDT (interdisciplinary team) meeting dated 3/22/18 indicated the resident and family stated there were some issues with CNA attentiveness. Both the resident and her/his family stated the resident was not often checked on. A Dietary Profile dated 3/22/18, indicated the resident received regular food, had dry mouth, received 715 cc daily of fluid and foods did not taste right since surgery. A 3/22/18 physician order [REDACTED]. Lab results from the 3/22/18 BMP included a high BUN (test to check for kidney damage due to dehydration) result of 37 (normal range is 7 to 20). The facility received the results on 3/23/18 and the results were faxed to the physician on 3/23/18. No new orders or reply from the physician was found in the resident's medical record. Documentation of PT notes dated 3/23/18 indicated the resident was having diarrhea and worried about her/his nutrition due to no appetite. PT indicated they worked with the resident in her/his room to be close to the toilet. PT notes indicated nursing staff were made aware of the resident's status. A 3/24/18 skilled nursing note indicated the resident stayed in bed that day and had mild to moderate diarrhea since surgery about an hour after every meal. A 3/25/18 MAR indicated [REDACTED]. A 3/25/18 skilled nursing note indicated the resident worked with OT. Witness 1 (Complainant) stated to staff the resident was continuing to have diarrhea. Staff told the Witness 1 that Immodium had been ordered. Witness 1 also stated the resident was not eating due to very dry mouth and no appetite. A nurse stated she told Witness 1 it could be possible adverse side effects from medication. A 3/26/18 NAR Review indicated the resident had a 9.6 lb weight loss since admission. The resident stated food did not not taste right since surgery and her/his appetite was poor. The resident did have some swelling of the feet on admit that resolved, and that could account for some of the weight loss. The resident's medical record indicated the resident's intake was variable with several refusals. A 3/26/18 skilled nursing note indicated an order for [REDACTED]. A 3/27/18 MAR indicated [REDACTED]. A 3/27/18 Alert note indicated the resident went to a doctor's appointment, then returned to the facility. The resident's [MEDICATION NAME] surgeon called and ordered the resident be hospitalized due to abnormal lab results attained during the appointment. A hospital note dated 3/27/18 indicated the resident was readmitted to the hospital due to weakness, dehydration, diarrhea and acute kidney injury indicative of dehydration with decreased oral intake and increased gastrointestinal losses. In addition, the resident tested positive for [MEDICAL CONDITION] (inflammation of the colon caused by bacteria [MEDICAL CONDITION]). On 4/29/18 at 7:19 PM Witness 1 stated after the resident's surgery the resident was not eating or drinking. The resident drank some fluids brought in by family members, but did not drink much. Witness 1 stated Resident 297 had diarrhea continuously since surgery. Witness 1 stated staff did not check on the resident in order to bring drinks to the resident. Witness 1 asked Staff 45 (RN) if the resident was able to see a doctor and Staff 45 stated the physician had up to 30 days to see a resident after admission to the facility. Witness 1 asked Staff 45 if an IV could be started and Staff 45 stated she would have get a physician order. Witness 1 stated Staff 45 did not call to get the order. Witness 1 stated the resident was constantly complaining of dry mouth and dark colored urine to the nurses when she/he was residing in the facility but the physician was not called. On 4/30/18 at 11:33 AM Staff 2 (DNS) acknowledged progress notes indicated the resident experienced loose stools while in the facility. Staff 2 acknowledged the medical records indicated an inadequate amount of fluids consumed by Resident 297. Staff 2 acknowledged the abnormal lab results from 3/22/18 and indicated the results were faxed to the physician. During an interview on 4/30/18 at 5:30 PM Witness 3 (Complainant) stated the following: Witness 3 told the nurses daily since admission the resident was continuing to have diarrhea and not eating or drinking. Witness 3 tried to get the resident to eat and drink by going to all her/his favorite restaurants to get food. Witness 3 brought in milkshakes for the resident but the resident stated there was a funny taste and got nauseated. Witness 3 stated there was no water or anything for the resident to drink on the bedside table in the mornings and staff did not come in to offer fluids. Witness 3 stated Resident 297 had loose stools and the resident appeared lethargic and pale on 3/18/18. Witness 3 stated the physician was not notified of the resident's condition. Witness 3 stated Resident 297 had loose stools 4-5 times per day. On 5/1/18 at 8:33 AM Staff 18 (CNA) stated she knew the resident was not eating or drinking well and let the nurses know. Staff 18 stated the nurses would have staff get the resident healthshakes but the resident would refuse those too. Staff 18 stated the resident was not good at drinking fluids. Staff 18 stated she reported the resident's loose stools to the nurses. On 5/1/18 at 9:21 AM Staff 17 (OT) stated she remembered the resident complaining of food not tasting right since surgery. On 5/1/18 at 11:01 AM Staff 2 stated it was her expectation when a nurse received an abnormal lab the physician would be called. Staff 2 stated she would expect a response within an hour of a phone call or the nurse should wait on the phone to talk with the physician until the issue was resolved. Staff 2 stated nurses were to keep calling the physician until they got the answers they needed. Staff 2 acknowledged there was no documentation in the medical record to indicate the physician responded regarding abnormal lab results.

1. Based on interviews and record review it was determined the facility failed to follow physician's orders, provide interventions, monitor and contact the physician for episodes of [DIAGNOSES REDACTED] (low blood sugar) and [MEDICAL CONDITION] (high blood sugar) for 4 of 7 sampled residents (#s 2, 3, 4 and 6) reviewed for diabetes management. Resident 4 had a low blood sugar reading, the facility did not recheck the resident's blood sugar and monitor her/his condition. Resident 4 died at the facility. Findings include: The facility's undated hypoglycemic protocol contained instructions to the facility staff to monitor blood glucose (sugar) for resident with diabetes. The record indicated the facility was to document the results of the blood glucose monitoring and if the glucose reading was below 60 the facility was to hold the insulin dose until an order was obtained and to follow the [DIAGNOSES REDACTED] protocol. The protocol indicated if the resident was able to swallow the facility was to provide four ounces of juice, without extra sugar added or provide five packets of sugar in four to six ounces of water, or administer one tube of glucose paste/gel sublingually. The staff were to recheck CBG (Capillary Blood Glucose) in ten to fifteen minutes. If still below 60, repeat the measures. Recheck CBG again in ,[DATE] minutes. If the CBG was still below 60, the facility was to notify MD and call 911 per LN discretion. The facility staff were to document steps taken, resident response, physician notification in a note. There was a [DIAGNOSES REDACTED] protocol if the resident was not able to swallow: the facility was to provide [MEDICATION NAME] 1.0 mg IM (intramuscular). If the resident was in bed the staff were to turn the resident onto their side to prevent aspiration. The facility staff were to recheck the CBG in ten to fifteen minutes. If the CBG was still below 60, the staff were to repeat IM [MEDICATION NAME] and recheck CBG again in ten to fifteen minutes. If the CBG was still below 60 the staff were to notify MD and call 911 per nurse's discretion. The staff were to document steps taken, resident response and MD notification in the record. a. Resident 4 was readmitted to the facility in [DATE] with [DIAGNOSES REDACTED]. The [DATE] physician's orders directed the facility to document the results of the blood glucose monitoring and if the resident's CBG was below 60 the facility was to hold the insulin dose until an order was obtained and to follow the [DIAGNOSES REDACTED] protocol. The [DATE] physician's order was for a scheduled dose of five units of Insulin [MEDICATION NAME] Solution Pen-injection 100 unit ML at 8:00 pm. The physician ordered a sliding scale dose of insulin to be provided according to the CBG reading and was to be administered five to ten minutes prior to the meal. i. The [DATE] Licensed Nurse Administration Record contained no documentation on [DATE] at 5:00 pm of the CBG reading or the sliding scale insulin provided. The record also documented the scheduled dose of insulin at 8:00 pm was not provided. The record documented the information was documented in the progress notes. The resident's progress notes for [DATE] contained no documentation of the resident's blood sugar level at 5:00 pm and sliding scale insulin provided. There was also no documentation regarding the scheduled insulin. The resident's [DATE] meal monitor and fluid monitor documented the resident did not consume a meal for the entire day. The documentation indicated the resident consumed 100 cc of fluids at 11:26 am. The documentation indicated the resident was provided fluids at 6:00 pm and there was no documentation of fluids consumed at 6:00 pm. The [DATE] progress note written at 8:20 pm by Staff 12 (RN) documented the CNA found the resident unresponsive during rounds. The progress note determined the CNA last checked the resident around 7:30 pm and she/he appeared to be resting quietly. Staff 12 documented when the resident was assessed at (8:20 pm) resident was found with no respirations, no apical heart tones, no blood pressure, sallow skin color and cold. On [DATE] Staff 14 (LPN) documented a handwritten progress note as a late entry for [DATE]. Staff 14 documented the resident was lying in bed on the evening of [DATE] and indicated it was unusual for her/him to be in bed. Staff 14 stated she administered Resident 4's medications at 4:45 pm and checked her/his CBG at 5:30 pm and the CBG registered at 61. Staff 14 stated she asked the CNAs to provide the resident with orange juice as she wasn't sure the resident would eat dinner. Staff 14 stated she did not check the resident's CBG at 8:00 pm and did not provide the resident with 5 units of insulin. Staff 14 stated at 8:20 pm it was reported Resident 4 was dead. The undated Event and Occurrence Conclusion Sheet documented Staff 15 (CNA) stated the resident didn't have dinner on [DATE] and recalled the resident received fluids though was not able to remember how much the resident consumed. An interview with Staff 16 (CNA) revealed he picked up the meal tray at 6:20 pm and recalled a cup of orange juice with 100 cc left in the cup. The documentation indicated the resident would have consumed 200 cc of orange juice. The documentation indicated on [DATE] at 6:30 pm Staff 16 (CNA) picked up the resident's meal tray, saw the resident lying in bed mumbling in her/his sleep and moving her/his hands towards her/his mouth in motion. At 8:20 pm Staff 16 (CNA) went into the room and shook the resident's shoulder. Staff 16 noticed the resident was very cold and her/his lips were blue. The facility provided documentation on [DATE] Staff 14 (LPN) was provided with a verbal warning and education. The [DATE] performance documentation indicated Staff 14 failed to recheck the resident's CBG and did not document in a timely manner the nursing interventions implemented. The performance documentation indicated education was provided to improve on documentation and insulin/CBG management. On [DATE] at 1:40 pm Staff 2 (Interim DNS) stated Resident 14 (LPN) did not document the resident's CBG and did not monitor the resident's condition on [DATE]. Staff 2 stated she educated the resident and provided her with a verbal warning. Staff 2 stated she also provided inservice education to all of the licensed nurses about the facility's [DIAGNOSES REDACTED] and [MEDICAL CONDITION] protocol. On [DATE] at 1:50 pm Staff 12 (RNCM) stated she was was working as a charge nurse on the other end of the building on the evening of [DATE]. Staff 12 stated the CNA reported Resident 4 was unresponsive. Staff 12 assessed the resident and determined she/he had been dead for quite awhile. On [DATE] at 2:25 pm Staff 14 (LPN) stated she took the resident's CBG at 5:00 pm and it was 61. She stated she asked the CNAs to provide the resident with orange juice as she was not certain if the resident would eat her/his meal. Staff 14 stated she did not recheck the resident's CBG after 5:00 pm. She stated the CNA reported the resident was unresponsive and Staff 14 stated the resident was dead when she assessed her/him. Staff 14 stated she did not document the CBG at the time it was taken and did not recheck the resident's CBG. On [DATE] at 2:45 pm Staff 15 (CNA) stated she was not assigned to care for Resident 4 and worked on the front part of the hallway. Staff 15 stated it was strange to see Resident 4 lying in bed as she/he usually refused to lie in bed and preferred to sit up in her/his wheelchair. Staff 15 stated she observed the resident from the hallway and she/he appeared to be be sleeping. Staff 15 stated she/he appeared to be as comfortable as she had seen the resident. Staff 15 stated she could not remember if the resident ate the dinner meal or drank orange juice or water. On [DATE] at 3:20 pm Staff 16 (CNA) stated he was assigned to care for Resident 4 on the evening of [DATE]. Staff 16 stated it was abnormal for the resident to be sleeping in bed. Staff 16 stated usually the resident preferred to sit up in her/his wheelchair. Staff 16 stated the resident woke up around 4:30 pm and wanted to go outside to smoke and then complained she/he was too tired and then laid back down in bed to sleep. Staff 16 stated he delivered the resident's meal tray and removed the meal tray from the room. Staff 16 stated he was not able to remember if the resident ate or drank. Staff 16 stated he checked on the resident and she/he appeared to be sleeping. On [DATE] at 12:10 pm Witness 2 (Complainant) stated the facility failed to monitor the resident's condition on [DATE]. Witness 2 stated the resident had a new order for insulin on her/his readmission to the facility and questioned if the facility managed the resident's diabetes. On [DATE] Witness 4 (Pharmacist) provided documentation there was no record the facility returned Resident 4's insulin to the pharmacy. Staff 2 (Interim DNS) provided documentation the facility no longer had the resident's insulin to determine if the resident received a dose of insulin on the evening of [DATE]. On [DATE] at 10:16 am Witness 3 (Physician) stated the facility was to follow hypoglycemic protocol. Witness 3 stated the facility staff needed to document the findings of the resident's CBG when taken. Witness 3 stated it was difficult to determine the accuracy of the CBG reading without documentation at the time it was taken. Witness 3 stated if Staff 14 (LPN) was concerned about the resident's condition and low CBG reading she needed to recheck the resident's CBG. ii. The [DATE] physician's orders directed the facility to document the results of the blood glucose monitoring and if the resident's CBG was below 60 the facility was to hold the insulin dose until an order was obtained and to follow the [DIAGNOSES REDACTED] protocol. The [DATE] physician's order for a scheduled dose of five units of Insulin [MEDICATION NAME] Solution Pen-injection 100 unit ML at 8:00 pm. The physician ordered a sliding scale dose of insulin to be provided according to the CBG reading and was to be administered five to ten minutes prior to the meal. The [DATE] Licensed Nurse Administration Record had an area on the form where the staff were to document food, blood sugars, time of day and the sliding scale insulin provided. The record indicated the resident needed sliding scale insulin on 23 occasions and there were three occasions when there was no documentation food was provided for the resident on [DATE] at 7:00 am, 11:00 am and 5:00 pm. The [DATE] and [DATE] Licensed Nurse Administration Record and progress notes contained no documentation the resident's CBG was checked prior to the scheduled dose of insulin at bedtime on 27 out of 32 occasions. There were 19 occasions Staff 14 (LPN) documented the scheduled insulin was provided and there was no documentation Staff 14 obtained a CBG prior to the scheduled insulin at 8:00 pm. On [DATE] at 2:27 pm Staff 2 (Interim DNS) was asked to provide the facility's policy and procedure regarding CBGs obtained for schedule insulin at bedtime. Staff 2 stated she would expect the facility to follow the [DIAGNOSES REDACTED] and [MEDICAL CONDITION] protocol. On [DATE] at 10:00 am Staff 1 (Administrator) and Staff 2 (Interim DNS) were asked to provide any additional information. No additional information was provided. b. Resident 3 was readmitted in [DATE] with [DIAGNOSES REDACTED]. The [DATE] physician's order was for 6 units of Humalog insulin and 28 units of [MEDICATION NAME] at 7:00 am and 11:00 am. The physician ordered 12 units of Humalog insulin at 5:00 pm. All of the insulin was to be provided within five to ten minutes of a meal. The [DATE] Licensed Nurse Administration Record had an area where the resident's CBG was to be recorded when the insulin was administered. There was no documentation of the resident's CBG recorded at 5:00 pm on [DATE] through [DATE]. There was no documentation of the resident's CBG in the resident's progress notes or in the vitals summary for CBGs. The [DATE] Licensed Nurse Administration Record for [DATE] documented Resident 3's CBG as 57 at 7:00 am. The documentation indicated the resident received 6 units of Humalog and 28 units of [MEDICATION NAME] at 7:00 am. There was a progress notes written at 7:48 am to indicate the resident was provided with eight ounces of orange juice and three sugar packets. The Licensed Nurse Administration Record contained documentation the [DIAGNOSES REDACTED] protocol was effective. The vital summary for blood sugars documented the resident's CBG as 57 at 7:47 am and 7:48 am. There was no documentation the resident's CBG was rechecked until 12:14 pm when the resident's CBG was recorded as 145. The next documentation of a CBG was at 12:20 pm and the CBG was recorded as 119. At 5:00 pm there was no documentation of a CBG recorded on the Licensed Nurse Administration Record, Vitals Summary or progress notes. The documentation on the Licensed Nurse Administration Record indicated the resident received 12 units of Humalog insulin. The [DATE] Meal Monitor contained no documentation the resident received a meal at noon. The documentation at 9:08 pm documented the resident at 50 percent of meal and offered a supplement and refused the supplement. The [DATE] progress notes documented at 7:00 pm Resident 3 was found unresponsive and her/his CBG was 37. The facility staff provided three quarters of a tube of glucose and the CBG registered 189. The documentation indicated five minutes later the resident was unconscious with a CBG of 43. IM [MEDICATION NAME] was provided and the CBG was 44. 911 was called and the resident was transported to the local hospital emergency department. The [DATE] Licensed Nurse Administration Record documented the resident's CBG was 103 at 7:00 am and the resident was provided with 8 units of insulin. The [DATE] progress notes written at 1:16 pm documented the resident was confused and sedated in the morning. Her/his fasting CBG was 52 and glucose was given and following CBG was 51. The progress notes documented the CBG after breakfast was 92. The notes documented the resident ate very little today The [DATE] progress notes written from 5:18 pm through 9:50 pm documented the resident was unresponsive. The [DATE] progress notes written at 11:20 pm indicated the resident's CBG was 49 and was unable to administer medications, food or fluids. The evening insulin was held. There was no documentation the IM [MEDICATION NAME] was provided. The [DATE] progress notes written at 12:22 am documented the resident died at 11:50 pm. On [DATE] at 11:25 am Staff 12 (RNCM) was asked about the resident's CBG recorded at 49 on [DATE] with no documentation IM [MEDICATION NAME] was provided. Staff 12 stated she discussed the incident with Staff 2 (Interim DNS) as there was no documentation written by Staff 7 (LPN). On [DATE] at 3:01 pm Staff 7 (LPN) stated she was the evening shift charge nurse on [DATE] and stated the resident was unresponsive and was unable to swallow. Staff 7 stated she was aware of the [DIAGNOSES REDACTED] protocol and did not provide the resident with the IM [MEDICATION NAME]. Staff 7 stated she thought the resident's low CBG was part of the dying process. On [DATE] at 4:00 pm Staff 2 (Interim DNS) stated she was in the process of conducting an investigation into the incident. The facility's [DATE] Investigation Summary documented the resident was actively dying on the evening shift of [DATE]. The resident had a CBG of 43 and the nurse attempted to administer glucose paste. The nurse did not follow the hypoglycemic protocol to give IM [MEDICATION NAME] and recheck the resident's CBG. The investigation indicated the resident's condition was declining with comfort care measures in place. On [DATE] at 12:20 pm Witness 7 (physician) stated he would expect the facility staff to follow the hypoglycemic protocols when the resident's CBG was 49 and unresponsive even though the resident was on comfort care measures. Witness 7 stated he determined the cause of the resident's death to be due to [MEDICAL CONDITION]. Witness 7 stated it would be difficult to stated the resident's death was due to low CBG. Witness 7 stated Witness 6 (Family member) was concerned the facility provided insulin to the resident when the resident had a low CBG. On [DATE] at 9:30 am Witness 6 (Family member) stated there were occasions when the facility staff gave the resident insulin even though she/he had a low CBG. Witness 6 stated the facility provided the resident with insulin when they did not know how much the resident ate. Witness 6 stated on one occasion the resident's CBG was 32 and the facility gave the resident sugar and the CBG went to 181 through there was nothing in the resident's stomach so the CBG went down again. Witness 6 stated the nurse was scared and sent the resident to the local hospital emergency department. On [DATE] at 2:35 pm Staff 2 (Interim DNS) verified the documentation revealed the resident was provided with insulin on [DATE] at 6:00 am when the resident's CBG was below 60. Staff 2 verified there was no record of the resident's CBG at 5:00 pm. Staff 2 verified on [DATE] Staff 7 (LPN) did not follow the [DIAGNOSES REDACTED] protocol. On [DATE] at 5:08 pm Staff 17 (LPN) stated she was the night shift charge nurse on [DATE]. Staff 17 stated Staff 7 (evening shift charge nurse/LPN) informed her the resident had a low CBG. Staff 17 asked Staff 7 if she followed the [DIAGNOSES REDACTED] protocol and Staff 7 stated she attempted to administer the glucose paste. Staff 17 went to assess the resident and found the resident to be in the active dying process. On [DATE] at 10:00 am Staff 1 (Administrator) and Staff 2 (Interim DNS) were asked to provide any additional information. No additional information was provided. c. Resident 2 was readmitted to the facility in [DATE] with [DIAGNOSES REDACTED]. The facility's undated hyperglycemic protocol contained instructions to the facility staff to monitor blood glucose (sugar) for residents with diabetes. The protocol indicated if the resident's blood glucose was over 400 mg the facility staff were to notify the physician and administer insulin per order. The staff were to recheck the CBG in one hour. Notify the MD if the CBG was still above 400. The [DATE] physician's orders indicated if the resident's CBG was over 400 the facility staff was to contact the physician, administer insulin, recheck CBG in ,[DATE] minutes and notify the physician if CBG remained over 400. The October and [DATE] Licensed Nursing Administration Records, progress notes and vital sign summary of Resident 2's CBGs were reviewed from [DATE] through [DATE]. On [DATE] at 12:00 pm there was no documentation of the resident's CBG. There were thirteen occasions when the resident's CBG was over 400 and the resident's CBG was not rechecked and the physician was not contacted. On [DATE] Resident 2's physician appointment notes indicated the resident did not like how her/his blood sugars were handled at the facility. The resident was discharged to the local hospital on [DATE] and was not readmitted to the facility. On [DATE] at 4:26 pm Witness 1 (Complainant) stated Resident 2 did not want to be readmitted to the facility because the physician's orders were not followed regarding management of her/his insulin. Witness 1 stated the resident was discharged to another local care facility. On [DATE] at 2:00 pm Staff 2 (Interim DNS) stated facility staff were to follow the facility's [MEDICAL CONDITION] protocol. On [DATE] Staff 2 provided documentation to indicate on thirteen occasions when the resident's CBG was over 400 there was no evidence the resident's CBG was rechecked and the physician was contacted. d. Resident 6 was readmitted to the facility in [DATE] with [DIAGNOSES REDACTED]. There was a [DATE] physician's order for the resident to receive 45 units of [MEDICATION NAME] two times a day at 8:00 am and 8:00 pm. The [DATE] progress note written as a late entry at 8:30 pm documented the resident's CBG at HS (hour of sleep or 8:00 pm) was 97. Staff 18 (RN) documented the resident had a history of [REDACTED]. Staff 18 indicated she made a decision to administer Resident 6 half of the insulin dose ordered by the physician and did not inform the resident's physician. The [DATE] progress note written at 7:31 am documented the resident's CBG was 439. The resident required 8 units of sliding scale insulin along with the scheduled dose of 45 units of [MEDICATION NAME]. The notes indicated the resident had no signs or symptoms of [MEDICAL CONDITION]. The resident's physician was contacted. The [DATE] progress note written at 2:23 pm documented on [DATE] at HS it was noted the resident's CBG was 97 and the nurse on duty gave only half of the ordered dose of insulin. The physician was notified of the medication error and the physician changed the order to decrease the dose of insulin by 5 units if the resident's CBG was under 90. The [DATE] Performance Documentation indicated Resident 6's CBG was 97 on the evening of [DATE]. Staff 18 knew the resident had a history of [REDACTED]. Staff 18 received a verbal warning to follow physician's orders and to contact the physician about the resident's condition and obtain new physician's orders as necessary. On [DATE] at 2:35 pm Staff 2 (Interim DNS) verified Staff 18 did not contact the physician about the resident's CBG and obtain new orders to change the amount of insulin provided. Staff 2 stated Staff 18 did not follow physician's orders and did not inform the resident's physician of her decision to provide half of the prescribed insulin. 2. Based on interviews and record review it was determined the facility failed to provide wound care treatments as ordered for 4 of 5 sampled residents (#s 3, 4, 7 and 11) reviewed for non-pressure ulcers. This placed the residents at risk for worsening wounds. Findings include: a. Resident 3 was readmitted in [DATE] with [DIAGNOSES REDACTED]. i. The [DATE] initial skin ulcer assessment documented the presence of a vascular ulcer on the top of her/his left foot to measure 1 cm by 0.5 cm. The physician ordered skin prep to be applied daily. The [DATE] TAR contained no documentation of a treatment for [REDACTED]. The [DATE] TAR contained the [DATE] physician's order for the ulcer to be cleaned with wound cleanser, pat dry gauze, cover over with non-stick pads and kerlix every day and PRN. There was no documentation the resident received a treatment on [DATE] and [DATE]. The weekly skin ulcer measurement wound evaluation completed on [DATE] documented the ulcer measured 1.4 cm by 1.1 cm with non-measurable depth. The [DATE] TAR contained a [DATE] physician's order for the ulcer to be cleaned daily with wound cleanser, was to be patted dry, calcium alginate applied and covered with boarder gauze. There was no documentation the resident received a treatment on [DATE] and [DATE]. The weekly skin ulcer measurement wound evaluation completed on [DATE] documented the ulcer measured 1.2 cm by 0.9 cm with non-measurable depth. The resident died in the facility on [DATE]. On [DATE] at 2:35 pm Staff 2 (Interim DNS) was asked to review the resident's record for additional information. On [DATE] at 10:00 am Staff 1 (Administrator) and Staff 2 (Interim DNS) were asked to provide any additional information. No additional information was provided. ii. The Weekly Non-Pressure Skin Condition Assessment conducted [DATE] indicated the resident had an stasis ulcer on the left lower leg (front) shin and the ulcer was first observed on [DATE]. The measurements were 0.7 cm by 0.9 cm with non-measurable depth. The treatment was described as cleanse with wound cleanser, calcium alginate to wound bed, skin prep periwound, cover with boarder gauze daily. The [DATE] TAR contained no documentation of treatments provided to the resident from [DATE] through [DATE]. The Weekly Non-Pressure Skin Condition Assessment conducted on [DATE] assessed the ulcer to measure 1 cm by 0.8 cm with non-measurable depth. The assessment indicated the facility was to continue with current treatment. The [DATE] TAR contained documentation the resident was provided with one treatment for [REDACTED]. The resident died in the facility on [DATE]. On [DATE] at 2:35 pm Staff 2 (Interim DNS) was asked to review the resident's record for additional information. On [DATE] at 10:00 am Staff 1 (Administrator) and Staff 2 (Interim DNS) were asked to provide any additional information. No additional information was provided. b. Resident 4 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The local hospital discharge summary documented the resident complained of a draining ulcer on her/his left leg. The documentation indicated the resident's left lower extremity ulceration was healing well with granulation tissue. The resident was to have a follow-up appointment for a wound recheck on [DATE]. The local hospital physician's orders were for the resident to have weekly skin checks. The facility's [DATE] Admission Profile documented the resident had a right lower leg dressing in place for stasis ulcer and left knee incision wrapped with ace bandage. There was a [DATE] physician's order for the resident's left lower leg to be cleansed with wound cleanser, xeroform gauze, cover with ABD pad and secure gauze wrap and surginet. The [DATE] TAR contained the physician's order for treatment for [REDACTED]. The documentation indicated treatments were not provided on seven occasions because the resident refused the treatment, two occasions because the resident was sleeping, three occasions the TAR was blank, three occasions the nurse documented the dressing was clean dry and intact and did not indicate the dressing change was completed. The [DATE] progress notes indicated the resident's wound care was not provided as there was a change in the physician's order. There was no documentation of the new physician's order. There was a [DATE] physician's order for unna boots applied to both extremities with kerlix and coban to change every 5 days and PRN every day shift every 5 days for [MEDICAL CONDITION]. The [DATE] TAR contained no documentation the unna boots were changed from [DATE] through [DATE], a period of fourteen days. The [DATE] TAR did not contain the [DATE] physician's order for treatment of [REDACTED]. The TAR documented the resident refused the use of unna boots on [DATE]. There was no documented assessment of the resident's lower extremities from her/his readmission on [DATE] through [DATE]. There was no documentation the resident had a follow-up appointment for a wound recheck on [DATE]. The resident died at the facility on [DATE]. On [DATE] Staff 2 (Interim DNS) provided written documentation there were no skin assessments conducted for Resident 4 from [DATE] through [DATE]. Staff 2 confirmed there was no follow-up appointment for a wound recheck on [DATE]. On [DATE] at 10:00 am Staff 1 (Administrator) and Staff 2 (Interim DNS) were asked to provide any additional information regarding the treatments provided for the resident. No additional information was provided. c. Resident 7 was readmitted to the facility in [DATE] with [DIAGNOSES REDACTED]. The [DATE] progress notes documented the resident was at risk for pressure ulcers due to incontinence, dependent on staff for care and required repositioning schedule to prevent future skin issues. The note indicated the resident had a skin issue which appeared to be due to extended exposure to moisture. Left 1 cm x 1 cm with 2 cm by 2 cm periwound redness. Right 1 cm x 1 cm with 3 cm x 2 cm periwound redness. MD notified via fax with request for [MEDICATION NAME] application. Pending approval The [DATE] incident report documented the resident had skin abrasions of both upper buttocks. There was no documentation the physician was notified of the resident's skin condition. There was no documentation of the treatment of [REDACTED]. The [DATE] Weekly non-pressure skin condition assessment documented the moisture related skin issue for bilateral upper buttocks resolved. On [DATE] Staff 2 (Interim DNS) provided documentation the physician was not notified of the resident's skin condition and [MEDICATION NAME] treatments provided. Staff 2 confirmed the open area on the resident's buttocks resolved. d. Resident 11 readmitted to the facility on [DATE]. The [DATE] progress notes written at 8:45 pm documented the CNA reported new open areas to the resident's buttocks. Barrier cream was applied. There was no documentation of skin assessments or treatments provided to the resident's open areas. The [DATE] progress notes documented the resident had redness to bilateral gluteal fold. The resident also had a shearing wound on her/his left buttock and measured 1.4 cm length by 0.4 cm wide and caused her/him discomfort. The progress notes indicated the wound was cleansed and barrier cream was applied. The progress notes indicated a fax was sent to physician for further wound care orders. There was no documentation of skin assessments or treatments provided to the resident's open areas. Resident 11 died on [DATE]. On [DATE] at 2:00 pm Staff 1 (Administrator), Staff 2 (Interim DNS) and Staff 24 (RN Corporate Consultant) were asked to provide documentation of skin assessment and treatments provided to the resident. On [DATE] Staff 2 (Interim DNS) and Staff 24 (RN Corporate Consultant) indicated there was no follow up for the resident's skin issues. 3. Based on interviews and record review it was determined the facility failed to conduct neurological checks for 3 of 4 sampled residents (#s 3, 4 and 10) reviewed for unwitnessed falls or falls when the residents hit their heads. This placed the residents at risk for unmet needs. Findings include: The facility's [DATE] neurological (neuro) check form indicated neuro checks were to be completed following an unwitnessed fall, witnessed fall with head injury or as needed. The neuro check form indicated the neuro checks were to be done every 15 minutes for four occasions, every hour for four occasions, every four hours for four occasions and every eight hours for six occasions. The facility staff were to document level of consciousness, temperature, heart rate, respiration rate, blood pressure, oxygen saturation rate, pupil size, pupil reactivity, hand grip and additional comments. a. Resident 4 was admitted to the facility in [DATE] with [DIAGNOSES REDACTED]. The [DATE] progress notes documented the resident fell on her/his face. There was no documentation neurological checks were conducted. The progress notes written on [DATE] at 10:40 pm documented Resident 4 had a fall and was found face down on the floor and the resident was assisted off of the floor by the local Emergency Medical Transport Services (EMTs). The documentation indicated neuro checks were started on 10:40 pm. There was no neu (TRUNCATED)

Based on interviews and record review it was determined Staff 14 (LPN) failed to provide resident care according to standards of practice for nurses. Resident 4 had a low blood sugar and the licensed nurse failed to monitor the resident and recheck the resident's CBGs. Resident 4 died at the facility. Findings include: Scope of Practice Standards for All Licensed Nurses: [PHONE NUMBER]-(1) (b) Intervenes on behalf of the client to identify changes in health status to protect, promote and optimize health and alleviate suffering .(5) Standards related to the licensed nurse's responsibility to assign and supervise care. (c) Ensures documentation of the activity .(e) Provides follow-up on problems and intervenes when needed. Resident 4 was readmitted to the facility in [DATE] with [DIAGNOSES REDACTED]. The [DATE] physician's orders [REDACTED]. The facility staff were to follow the [DIAGNOSES REDACTED] protocol. The [DATE] Licensed Nurse Administration Record contained no documentation on [DATE] at 5:00 pm of the CBG reading or the sliding scale insulin provided. The record also documented the scheduled dose of insulin at 8:00 pm was not provided. The record documented the information was documented in the progress notes. The resident's progress notes for [DATE] contained no documentation of the resident's blood sugar level at 5:00 pm and sliding scale insulin provided. There was also no documentation regarding the scheduled insulin. The [DATE] progress note written at 8:20 pm by Staff 12 (RN) documented the CNA found the resident unresponsive during rounds. The progress note determined the CNA last checked the resident around 7:30 pm and she/he appeared to be resting quietly. Staff 12 documented when the resident was assessed at (8:20 pm) resident was found with no respirations, no apical heart tones, no blood pressure, sallow skin color and cold. On [DATE] Staff 14 (LPN) documented a handwritten progress note as a late entry for [DATE]. Staff 14 documented the resident was lying in bed on the evening of [DATE] and indicated it was unusual for her/him to be in bed. Staff 14 stated she administered Resident 4's medications at 4:45 pm and checked her/his CBG at 5:30 pm and the CBG registered at 61. Staff 14 stated she asked the CNAs to provide the resident with orange juice as she wasn't sure the resident would eat dinner. Staff 14 stated she did not check the resident's CBG at 8:00 pm and did not provide the resident with 5 units of insulin. Staff 14 stated at 8:20 pm it was reported Resident 4 was dead. The facility provided documentation on [DATE] Staff 14 (LPN) was provided with a verbal warning and education. The [DATE] performance documentation indicated Staff 14 failed to recheck the resident's CBG and did not document in a timely manner the nursing interventions implemented. The performance documentation indicated education was provided to improve on documentation and insulin/CBG management. On [DATE] at 1:40 pm Staff 2 (Interim DNS) stated Staff 14 (LPN) did not document the resident's CBG and did not monitor the resident's condition on [DATE]. Staff 2 stated she educated Staff 14 and provided her with a verbal warning. Staff 2 stated she also provided inservice education to all of the licensed nurses about the facility's [DIAGNOSES REDACTED] and [MEDICAL CONDITION] protocol. On [DATE] at 1:50 pm Staff 12 (RNCM) stated she was was working as a charge nurse on the other end of the building on the night of [DATE]. Staff 12 stated the CNA reported Resident 4 was unresponsive and Staff 12 assessed the resident and determined the resident had been dead for quite awhile. On [DATE] at 2:25 pm Staff 14 (LPN) stated she took the resident's CBG at 5:00 pm and it was 61. She stated she asked the CNAs to provide the resident with orange juice as she was not certain if the resident was to eat her/his meal. Staff 14 stated she did not recheck the resident's CBG after 5:00 pm. Staff 14 stated a CNA reported the resident was unresponsive. Staff 14 stated she assessed the resident to be dead. Staff 14 stated she did not document the CBG at the time it was taken and did not recheck the CBG. On [DATE] at 12:10 pm Witness 2 (Complainant) stated the facility failed to monitor the resident's condition on [DATE]. Witness 2 stated the resident had a new order for insulin on her/his readmission to the facility and questioned if the facility managed the resident's diabetes. On [DATE] at 10:16 am Witness 3 (physician) stated the facility was to follow hypoglycemic protocol. Witness 3 stated the facility staff needed to document the findings of the resident's CBG when taken. Witness 3 stated it was difficult to determine the accuracy of the CBG reading without documentation at the time it was taken. Witness 3 stated if Staff 14 (LPN) was concerned about the resident's condition and low CBG reading she needed to recheck the resident's CBG. Refer to F-309.

1. Based on interview and record review it was determined the facility failed to assess residents' condition for 2 of 3 sampled residents (#s 2 and 3) reviewed for hospitalization . Resident 3 was hospitalized for [REDACTED]. a. Resident 3 was readmitted to the facility in 2015 with [DIAGNOSES REDACTED]. The resident's [DATE] Medical Clinic note indicated the resident was oriented to person, place and time. The note indicated the resident had surgery on [DATE] to remove hardware from the ankle. The resident had pain and was noted to have [MEDICATION NAME] (narcotic/opioid pain medication) available to treat the pain. The resident's Progress Notes dated [DATE] at 1:45 pm by Staff 5 (LPN) included the resident was very lethargic during the day shift. The note indicated the resident's noon medications were held. The note also indicated the resident talked at times in a low mumble. The resident was observed to bring her/his hand to the resident's mouth when there was nothing in the resident's hand. The resident's temperature was noted to be 100.3. The note also indicated the next shift (evening shift) was informed to monitor the resident. On [DATE] at 1:06 pm Staff 5 (LPN) indicated Resident 3 was normally very independent in the resident's ADLs and was able to ambulate without assistance. The resident was also normally able to sit at the side of the bed to eat. Staff 5 indicated on [DATE] the resident was not the resident's normal self. The resident was very lethargic. The resident was not able to sit up at the side of the bed and this was not normal for the resident. Staff 5 indicated she reported to the oncoming shift the resident's medications were held during the day shift because of the resident's lethargy. Staff 5 stated she informed the evening shift to monitor the resident. The resident's Vital Summary for [DATE] indicated the resident's blood pressure and pulse were obtained once on the evening shift of [DATE] at 3:35 pm. The summary indicated the resident' temperature was not obtained on the evening shift. On [DATE] at 8:30 am Staff 4 (RN) stated she obtained the resident's vital signs at the beginning of the shift but did not obtain additional vital signs until late in the evening shift when the resident was transported to the hospital. The [DATE] Medication Administration Note indicated Staff 2 (CMA) administered [MEDICATION NAME] for the resident's complaint of left leg pain and ankle pain at 3:36 pm and again at 7:53 pm. On [DATE] at 11:07 am Staff 2 (CMA) stated the day shift nurse reported the resident was out of it and the resident's noon medications were held. Staff 2 stated the resident was alert at times. Staff 2 stated the resident requested pain medication and the resident was able to talk so she gave the medication to the resident. Staff 2 indicated she did not ask the nurse to assess the resident prior to the administration of the pain medication because the resident requested the pain medication. Staff 2 indicated a few hours after she administered the second dose of pain medication she walked by Resident 3's room and observed the resident to be completely lethargic. Staff 2 stated she would not have provided the resident pain medication if the resident was not able to talk. On [DATE] at 11:16 am Staff 3 (RN) stated before a CMA provided a PRN medication the LPN or RN was to assess the resident's condition to ensure the PRN medication was appropriate. On [DATE] at 8:30 am Staff 4 (RN) stated she did not recall if Staff 2 administered medication to Resident 3 on [DATE]. Review of the resident's chart revealed there was no assessment of the resident's condition documented after the day shift [DATE] at 1:35 pm note until 10:22 pm. On [DATE] at 8:30 am Staff 4 (RN) stated she assessed the resident at the beginning of the shift on [DATE] and not again until the end of the shift when the resident was transported to the hospital. The resident's Progress Note dated [DATE] at 10:22 pm by Staff 4 (RN) indicated the resident was drowsy but responsive and the resident's speech was incomprehensible. The resident had shallow breathing. The resident was sent to the local hospital for a change in mental status. The resident's [DATE] hospital History and Physical indicated the resident was admitted to the hospital and the resident was very somnolent (sleepy) and woke up after the resident's sternum (breast bone) was rubbed. The resident's [DATE] hospital Discharge Dictation indicated the resident's [DIAGNOSES REDACTED]. On [DATE] at 11:30 am Staff 7 (Corporate RN) Stated the CMA was to have the nurse assess the resident prior to the administration of the PRN pain medication. A request was made to Staff 7 for additional documentation to indicate the resident was monitored. No additional documentation was provided. b. Resident 2 was admitted to the facility in 2014 with [DIAGNOSES REDACTED]. The resident's [DATE] at 9:42 am Progress Note by Staff 8 (LPN) indicated the resident was found on the floor at approximately 8:30 am. The resident was on the left side of the fall mat. The resident denied pain and refused vital signs to be obtained. The resident was noted to be resting in bed, was calm and the resident's respirations were unlabored. There were no documented assessments including neurological checks or vital signs for one hour from 8:30 am until the resident was assessed at 9:30 am. The resident's [DATE] at 12:43 pm Progress Note by Staff 8 (LPN) indicated she checked on the resident at approximately 9:30 am. The note indicated the resident refused to have vital signs obtained and the resident continued to deny pain. There were no documented assessments including neurological checks or vital signs for approximately one and one half hours from 9:30 am until 11:15 pm. The [DATE] at 12:44 pm Progress Note by Staff 8 (LPN) included at 11:15 am a CNA reported the resident was not acting normal. The resident continued to deny pain. Resident 2 was described as anxious, moving around in the bed and the resident reported pain. The resident was unable to identify the location of pain. The resident's blood pressure was identified to be elevated, but the blood pressure reading was not specified in the notes. The resident's oxygen level was unable to be obtained and the resident became unresponsive. The resident was assessed to have no heart rate or respirations. CPR (Cardio-pulmonary resuscitation/heart and lung resuscitation) was initiated and emergency medical services were contacted. CPR for Resident 2 continued until the resident was transported to the local hospital. On [DATE] at 10:50 am Staff 8 (LPN) stated if a resident had an unwitnessed fall, neurological checks and vital signs were to be done. The neurological checks and vital signs were to be completed every 15 minutes for one hour, every 30 minutes for one hour, every hour for four hours then every shift for 24 hours. Staff 8 stated she thought she started a neurological and vital sign assessment sheet. On [DATE] at 11:00 pm Staff 7 (Corporate RN) indicated neurological assessments and vital signs were to be completed on all residents with an unwitnessed fall. A request for documentation was made to Staff 7 to indicate Resident 2's neurological assessment and vital signs were completed from the time of the fall until the resident was transported to the hospital. No additional information was provided. 2. Based on interview and record review it was determined the facility failed to follow physician orders [REDACTED].#s 1 and 3) reviewed for hospitalization . This placed residents at increased risk for unmet needs. Findings include: a. Resident 1 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. The resident's [DATE] hospital Orders at Discharge included the resident was to be administered [MEDICATION NAME] (antibiotic) BID. The resident's [DATE] MAR indicated [REDACTED]. On [DATE] at 11:00 am Staff 9 (Staff Development Coordinator) acknowledged six of seven days from [DATE] through [DATE] the [DATE] MAR indicated [REDACTED]. b. Resident 3 was readmitted to the facility in 2015 with [DIAGNOSES REDACTED]. The resident's [DATE] hospital Discharge Summary included the resident's CBG was to be checked before meals and the resident was to be administered insulin based on a sliding scale. The order indicated if the resident's CBG was greater than 400 the resident's physician was to be notified. The resident's [DATE] Licensed Nurse Administration Record indicated the resident's CBG was greater than 400 on four times from [DATE] through [DATE]. Review of the resident's chart revealed there was no documentation to indicate the resident's physician was notified Resident 3's CBG was greater than 400. On [DATE] at 11:00 am Staff 9 (Staff Development Coordinator) indicated the resident was readmitted to the facility on [DATE] with orders to notify the physician if the resident's CBGs were greater than 400. Staff 9 acknowledged the resident's chart did not include documentation the resident's physician was notified the resident's CBGs were greater than 400.

Based on interview and record review it was determined the facility failed to ensure the CMA (Certified Medication Aid) administered PRN medications within the CMA scope of practice for 1 of 1 CMA staff (Staff 2). Resident 3 was hospitalized for [REDACTED]. 851-063-0070 Authorized Duties and Standards for Certified Medication Aide (CMA) (2) Administration of PRN Medications. A CMA may administer PRN medications (including controlled substances) to stable clients according to physician's or nurse practitioner's orders in the following circumstances: (a) In response to specific client requests: (A) Client request must be reported to licensed nurse; and (B) Client response must be reported to licensed nurse. Resident 3 was readmitted to the facility in 2015 with [DIAGNOSES REDACTED]. The resident's 7/15/15 Medical Clinic note indicated the resident was oriented to person, place and time. The note indicated the resident had surgery on 7/14/15 to remove hardware from the ankle. The resident had pain and had [MEDICATION NAME] (narcotic/opioid pain medication) available to treat the pain. The resident's Progress Notes dated 7/17/15 at 1:45 pm by Staff 5 (LPN) included the resident was very lethargic. The note indicated the resident's noon medications were held. The resident talked at times in a low mumble. The resident was observed to bring her/his hand to the resident's mouth when there was nothing in the resident's hand. The 7/17/15 Medication Administration Note indicated Staff 2 (CMA) administered [MEDICATION NAME] for the resident's complaint of left ankle pain and leg pain at 3:36 pm and 7:53 pm. On 9/25/15 at 1:06 pm Staff 5 (LPN) indicated Resident 3 was normally very independent in the resident's ADLs and was able to sit at the side of the bed to eat. The resident was able to direct care. Staff 5 indicated on 7/17/15 the resident was not the resident's normal self. The resident was very lethargic. The resident was not able to sit at the side of the bed. Staff 5 indicated she reported to the oncoming shift the resident's medications were held during the day shift because of the resident's lethargy. Staff 5 stated she expected the CMA to ask prior to the administration of the PRN narcotic due to the resident's change in condition. On 9/29/15 at 8:30 am Staff 4 (RN) stated Resident 3 was usually alert and able to talk. On 7/17/15 the day shift nurse reported Resident 3 was sleepy and the resident's medications were held. Staff 4 did not recall if Staff 2 (CMA) administered medications to the resident. Staff 4 stated she had to feed the resident because the resident was not able to eat and Staff 4 was concerned because the resident was diabetic. On 9/24/15 at 11:07 am Staff 2 (CMA) stated the day shift nurse reported the resident was out of it on the day shift and the resident's noon medications were held. Staff 2 indicated the day shift nurse indicated the staff were to monitor the resident due to the increased lethargy. Staff 2 stated on 7/17/15 during the evening shift the resident was alert at times. Staff 2 stated the resident requested pain medication and was able to talk so she gave the medication to the resident. Staff 2 indicated she did not ask the licensed nurse to assess the resident prior to the administration of the pain medication since the resident requested it. Staff 2 indicated a few hours later she walked by the resident's room and the resident was completely lethargic and the resident was sent to the emergency room . Staff 2 stated she would not have provided the resident pain medication if the resident was not able to talk. The resident's Progress Note dated 7/17/15 at 10:22 pm by Staff 4 (RN) indicated the resident was drowsy but responsive and the resident's speech was incomprehensible. The resident had shallow breathing. The note indicated the resident was sent to the local hospital for a change in mental status. The resident's 7/18/15 hospital History and Physical indicated the resident was very somnolent (sleepy). The note indicated the resident woke up after the resident's sternum (breast bone) was rubbed. The resident's 7/21/15 hospital Discharge Dictation indicated the resident's [DIAGNOSES REDACTED]. On 7/24/15 at 11:16 am Staff 3 (RN) stated before a CMA provided a PRN medication the LPN or RN were to assess the resident's condition to ensure the PRN medication was appropriate. On 7/24/15 at 11:30 am Staff 7 (Corporate RN) Stated CMAs cannot do an assessment to determine if a PRN medication was needed. The CMA was to notify the LPN or the RN if the resident requested a PRN medication. Refer to F-309

Based on interview and record review it was determined the facility failed to notify the physician of weights, monitor meal intake and implement nutritional interventions to maintain the nutritional status for 1 of 3 sampled residents (#46) reviewed for nutrition. This resulted in a severe weight loss of 19% in three months. Findings include. Resident 46 was admitted to the facility in 2014 for rehabilitation with [DIAGNOSES REDACTED]. Review of a nutritional assessment dated [DATE] revealed the resident was admitted with [DIAGNOSES REDACTED]. The resident's weight was 138 lbs (pounds). The resident was identified as nutritionally at risk due to a meal intake of 25-75% and the resident required assistance with meals. Review of a nutritional care plan dated 6/23/14 revealed the resident was nutritionally at risk due to an altered diet, erratic meal intake, dementia, [MEDICAL CONDITIONS] and [MEDICAL CONDITION]. The resident's care plan goal was to maintain weight within five pounds of 125 pounds. Staff interventions included diet as ordered, NEM (nutritionally enhanced meal), monitor weight, monitor intake and assist with meals as needed. Review of a weight record revealed the resident's weight on 6/23/14 was 133.6 lbs. This indicated the resident lost 4 pounds in two days. Review of a RD (Registered Dietician) assessment dated [DATE] revealed the resident was considered overweight due to a BMI (body mass index) of 28.84. The assessment indicated the resident received a NEM diet due to poor intake and nutritional needs were being met. The assessment did not indicate the resident was expected to lose weight. Review of a Meal Monitor for June 2014 revealed facility staff were to monitor the percentage of every meal consumed and if the resident ate less than 50% of the meal staff were to offer the resident an alternate or supplement. From 6/22/14 through 6/30/14 the resident ate less than 50% of a meal 11 out of 19 documented meals and there was no documentation the resident was offered an alternate or supplement. The meal percentage was not documented 9 out of 27 meals. Review of a weight record revealed the resident weight was 129.6 lbs on 7/3/14 and 122 lbs on 7/13/14. This indicated the resident lost 16 pounds since admission. Review of a NAR (nutritionally at risk) committee note dated 7/16/14 revealed the resident's weight was 122 lbs which was down 11% since admission weight of 138 lbs. The note indicated a recommendation to supplement resident meals with juice and offer Two Cal (high calorie drink to assist with weight gain or maintenance) 90 ml three times a day. The note did not discuss the resident's meal intake or if the resident was expected to lose weight. Review of a physician's orders [REDACTED]. every Wednesday. Review of a July 2014 TAR revealed the resident's weight was documented on 7/17/14 as 122.4 lbs and on 7/21/14 as 126 lbs. The resident was out of the facility from 7/22/14 through 7/26/14. There was no weight documented on 7/19/14, 7/27/14 and 7/29/14 and there was no documentation the resident physician was notified of the resident's weight on 7/30/14. Review of a resident weight record revealed the resident's weight was 126 lbs on 7/20/14. Review of a nurse's note dated 7/21/14 revealed the resident was admitted to the hospital for a right hip prosthetic revision surgery. Review of a nurse's noted dated 7/26/14 revealed the resident was readmitted to the facility post surgery and had 2-3 plus lower extremity [MEDICAL CONDITION]. Review of a nutritional note dated 7/27/14 revealed the resident was readmitted from a local hospital with a weight of 136.8 lbs and 2-3 plus lower extremity [MEDICAL CONDITION]. Review of a Meal Monitor for July 2014 revealed facility staff were to monitor the percentage of every meal consumed and if the resident ate less than 50% of the meal staff were to offer the resident an alternate or supplement. From 7/1/14 through 7/21/14 the resident ate less than 50% in 16 out of 46 documented meals and there was no documentation the resident was offered an alternate or supplement. The meal percentage was not documented 14 out of 62 meals. The resident was out of the facility 7/22/14 through 7/26/14. From 7/27/14 through 7/31/14 the resident ate at least 50% of each meal and the meal intake percentage was not documented 2 out of 15 meals. Review of a fax dated 8/4/14 revealed a physician order [REDACTED]. Review of a August 2014 TAR revealed no documentation the resident weight result was faxed to the resident's physician in three of four opportunities. Review of a nurse's note dated 8/9/14 revealed the resident continued to have lower extremity [MEDICAL CONDITION] and the resident's hip incision was red and swollen. The resident was sent to a local hospital for evaluation and was subsequently admitted . Review of a nurse's note dated 8/15/14 revealed the resident was readmitted from a local hospital with a [DIAGNOSES REDACTED]. Review of a weight record revealed the resident's weight on 8/16/14 was 124.8 lbs. This was 13 lbs less than the resident's admission weight. Review of an RD assessment dated [DATE] revealed the resident's weight was up six pounds since last review and the resident was being treated for [REDACTED]. The note indicated the resident's weight fluctuated with [MEDICAL CONDITION] related to [MEDICAL CONDITION] and nutritional needs appear to be met at this time. The assessment did not include the resident's meal intake or whether the resident was expected to lose weight. Review of a fax to the resident's physician dated 8/19/14 revealed the facility was concerned about the resident's weight gain due to bilateral lower extremity [MEDICAL CONDITION]. The note indicated the resident gained 10 pounds from 8/16/14 through 8/19/14 (125 lbs to 135 lbs). The physician ordered the facility to increase the resident's dose of [MEDICATION NAME] (diuretic) and potassium. Review of a nurse's note dated 8/21/14 at 3:30 pm revealed the resident was sent to a local hospital due to low potassium levels. The resident returned to the facility at 9:00 pm. Review of a Meal Monitor for August 2014 revealed facility staff were to monitor the percentage of every meal consumed and if the resident ate less than 50% of the meal, staff were to offer the resident an alternate or supplement. From 8/1/14 through 8/9/14 the resident ate less than 50% of a meal 3 out of 20 documented meals and there was no documentation the resident was offered an alternate or supplement. The meal percentage was not documented 6 out of 26 meals. The resident was out of the facility 8/10/14 through 8/15/14. From 8/16/14 through 8/31/14 the resident ate less than 50% of each meal 26 out of 40 documented meals and there was no documentation the resident was offered an alternate or supplement on 11 occasions. The meal intake percentage was not documented 7 out of 48 meals. Review of a weight record revealed the resident's weight on 9/1/14 was 126 lbs, on 9/8/14 was 119.6 lbs and 9/9/14 was 117.8 lbs. Review of a September 2014 TAR revealed no documentation the resident's physician was notified of the resident's weight weekly. The TAR indicated the resident's weight on 9/1/14 was 123 lbs and on 9/30/14 was 104 lbs. Review of a RD note dated 9/9/14 revealed the resident's weight loss continued and the resident's weight was 117.8 lbs. The note indicated the resident's average meal intake was 49% and there was no lower extremity [MEDICAL CONDITION]. The note indicated a recommendation to decrease the dose of [MEDICATION NAME] and start [MEDICATION NAME] (antidepressant) to help increase appetite. The use of the [MEDICATION NAME] was declined by the resident's family. The note did not indicate the resident's weight loss was expected. Review of a NAR committee note dated 9/18/14 revealed the resident's weight was up one pound in the past week to 118.8 lbs. The note indicated the resident average meal intake in the past week was 61% and the resident did not have lower leg [MEDICAL CONDITION]. Review of a weight record revealed the resident's weight on 9/28/14 was 110 lbs. Review of a Meal Monitor for September 2014 revealed facility staff was to monitor the percentage of every meal consumed and if the resident ate less than 50% of the meal staff were to offer the resident an alternate or supplement. From 9/1/14 through 9/30/14 the resident ate less than 50% of a meal 30 out of 79 documented meals and the resident was offered a supplement on 6 occasions. The meal intake percentage was not documented 9 out of 90 meals. Review of a RD note dated 10/2/14 revealed the resident was placed on hospice services on 10/1/14 for end of life care. The resident was discontinued from NAR committee monitoring, routine medications and supplements. In an interview on 12/03/14 at 12:39 pm Staff 3 (RN) said the resident was admitted to the facility for rehabilitation for a [MEDICAL CONDITION]. Staff 3 said the resident lost weight while at the facility and could not explain why the resident's weight loss was unavoidable. Staff 3 acknowledged the facility failed to notify the resident's physician of weights, meal intake percentages and if a supplement was offered to the resident. In an interview on 12/03/14 1:17 pm Staff 2 (RNCM) and Staff 21 (Dietary Manager) acknowledged the lack of documentation of the resident's meal intake and if a supplement or alternate was offered to the resident. Staff 2 and Staff 21 also acknowledged the resident's weight loss could have be avoided.

Based on interview and record review it was determined the facility failed to prevent an avoidable pressure ulcer for 1 of 3 sampled residents (#1) reviewed for pressure ulcers. The resident developed a pressure ulcer and required surgical intervention. Findings include: Resident 1 was admitted to the facility in 2013 with [DIAGNOSES REDACTED]. Review of the resident's 11/6/13 hospital Patient Transfer Form and the 11/6/13 hospital Discharge Summary revealed the resident had a Halo brace and vest (A brace keeps the bones in the spine and neck in alignment and allows healing. Halo pin site care was to be performed twice a day. Staff were instructed to call the neurosurgeon for concerns. Review of the Halo Orthosis (medical brace/device) information sheet, provided by Witness 2 (Resident 1's Orthotist-specialist in braces and medical devices) revealed the Halo brace consists of a vest, a halo ring, pins (surgically attaches the halo to the residents skull) and a rigid frame (attaches halo to the vest). Care instructions included to clean each pin twice a day and to examine the skin under the vest daily to ensure pressure ulcers did not develop. Review of the resident's 11/6/13 Bedside Care Plan revealed the staff were to monitor the Halo for proper fit and staff were to notify the licensed nurse if the resident had any pain, redness or skin breakdown. Review of the resident's 11/13/13 Admission CAA revealed the resident had impaired memory and the resident's mental status was potentially impaired due to the use of pain medication. The assessment indicated the resident was able to make her/his needs and preferences known and had good safety awareness. The assessment indicated the resident had a pressure ulcer to the coccyx. The skin assessment did not include the resident was at increased risk for skin breakdown from a device such as the resident's Halo brace and vest. Review of the resident's 11/20/13 Skin at Risk Care Plan revealed the resident was at risk for skin breakdown as evidenced by factors including a current pressure ulcer to the coccyx, immobility, dementia and a Halo device. Interventions included to monitor for redness or the resident's complaint of pain/burning under the Halo. Review of the resident's November 2013 Treatment Records revealed the resident's Halo pins sites were cleaned twice a day and the resident had weekly skin checks. There was no documentation indicating the facility monitored the pressure points under the resident's Halo vest. Review of the resident's Interdisciplinary Progress Notes from 11/6/13 through 11/25/13 revealed the resident's Halo pin sites were assessed at least daily. The notes included the scalp did not have signs or symptoms of infection. The notes did not indicate the skin under the vest was assessed for skin breakdown. Review of the 11/25/13 Physical Therapy Notes revealed the resident's Halo needed adjustment because there was too much space between the resident's shoulders and the shoulder pad of the Halo vest. The note indicated nursing was notified. Review of the 11/25/13 Interdisciplinary Progress Notes revealed the Physical Therapy department notified the nursing staff the resident's Halo vest was loose and the neurosurgeon was notified. Review of the resident's 11/26/13 Neurosurgery Note revealed the resident had pain to the pin sites, an adjustment was made and the resident's skin was tolerating the halo pins. Review of the Interdisciplinary Notes from 11/26/13 through 12/4/13 revealed the resident was assessed at least daily and notes indicated the resident's Halo pin sites were without signs and symptoms of infection. There were no notes indicating the skin under the halo vest was monitored for skin breakdown. Review of the resident's December 2013 TAR revealed the resident's Halo pin sites were cleaned twice a day and the resident had weekly skin checks while in the facility. There was no documentation indicating the skin under the Halo vest was monitored for skin breakdown. The 12/5/13 Physical Therapy Note indicated the resident reported pain to the right clavicle area (collar bone/upper chest region) and the cervical brace was pressing on the area. The patient was repositioned onto her/his back and Witness 7 (PTA/Physical Therapy Assistant) assisted the resident with shoulder rolls to attempt to reduce the pressure. The pressure was not relieved. Witness 7 noted a circular area approximately one half centimeter that was brown and was located below the right clavicle. The brace pad was noted to be stuck to the skin. The note indicated Witness 7 reported the findings to Staff 6 (RNCM), Staff 7 (RN) and Staff 3 (RN), Review of 12/5/13 Interdisciplinary Note written by Staff 3 (RN) revealed the Halo chest harness caused pain to the resident's right clavicle/chest region. Pain medication was offered. There was no assessment documented regarding skin to the right chest region where the resident complained of pain. The note also did not indicate the physician was notified of the pressure from the brace or the resident's complaint of pain. There was no documentation in the Interdisciplinary Progress Notes on 12/6/13, 12/7/13 and 12/8/13. Review of the 12/9/13 Physical Therapy Notes written by Witness 7 (PTA) revealed the resident had pain to the right clavicle region with redness and swelling. Witness 7 felt a "knot" just above the right clavicle. The patient reported the sight was "really painful". The right side of the brace was noted to "dig" into the area below the clavicle. The note indicated Witness 7 notified Staff 2 (RN). Review of the 12/9/13 Interdisciplinary Progress Notes written by Staff 2 (RN) revealed the resident's right chest region was red, swollen and had an open area. The Halo vest was noted to be tight. The neurosurgeon's office was notified and Witness 2 (Orthotist/specialist working with braces and medical devices) would evaluate and adjust the halo brace/vest. The notes indicated the resident was transferred to another local nursing facility for continued care. Review of the 12/9/13 Follow Up or Adjustment Appointments form written by Witness 2 (Orthotist) revealed the resident's right edge of the Halo vest was wedged under the resident's right clavicle and caused pain and skin breakdown. An appointment was made for the resident to be seen by the Neurosurgeon on 12/11/13. Review of the local nursing facility's 12/9/13 Skin Care Progress Sheet revealed the resident had a right upper chest Stage Three pressure ulcer (Full thickness skin loss. Bone, tendon and muscle are not involved. The ulcer can be partially covered with slough/dead tissue). The sheet indicated the ulcer was caused by the chest plate of the Halo brace "pushing" into the the resident's chest. The ulcer was noted to be three centimeters long by one and one half centimeters wide and zero point one centimeters deep. The ulcer had red drainage. The drainage had an odor. Review of the 12/11/13 Neurosurgery Note revealed the resident reported two weeks of right chest wall pain. The note indicated the resident developed skin breakdown to the right side of the chest. The breakdown was red and painful. The resident was admitted to the hospital. Review of the hospital Physician Discharge Summary revealed the resident was admitted to the hospital on [DATE] with a pressure ulcer caused by a Halo brace. The resident ulcer was surgically cleaned and the resident was discharged from the hospital on [DATE]. On 12/31/13 at 10:46 am Witness 2 (Orthotist) stated the resident had the halo brace/vest surgically placed on 10/28/13 at the hospital. Witness 2 stated he provided the hospital with instructions for the care of the Halo brace/vest on 10/28/13. Witness 2 stated he did not see the resident until 12/9/13 when the resident was discharged from the facility. The resident was seen on 12/9/13 and the resident had a pressure ulcer to the right chest region. Witness 2 stated the Halo vest should not cause pressure to the resident's chest and when the brace placed pressure on the resident's chest he should have been notified by the facility but was not. On 12/31/13 at 10:11 am Witness 3 (Neurosurgery Medical Assistant) stated the resident had a Halo brace with vest. Care included to clean the skin under the vest with a soft towel. The skin should be assessed each day for pain and skin breakdown. On 12/31/13 at 1:30 pm and 1/2/14 at 11:13 am Staff 6 (RNCM) stated she did not recall PT reporting the resident had pain and a brown area to the right clavicle region. Staff 6 acknowledged if the brace fit properly it did not put pressure on the skin. If the brace was causing pressure the doctor was notified. Staff 6 stated daily skin checks under the Halo vest should be performed daily to ensure skin breakdown did not occur. Staff 6 acknowledged the resident's Interdisciplinary Progress Notes addressed the pin sites but not the skin under the vest. On 1/2/14 at 10:14 am Witness 7 (PTA) stated on 12/5/13 the resident's vest was putting pressure on the right clavicle region. Witness 7 stated he saw a brown area under the vest but was not for sure if it was debris or skin breakdown. The resident's skin was stuck to the brace. Staff 7 stated he walked to the nurses station and reported the concern to Staff 3 (RN), Staff 7 (RN) and Staff 6 (RNCM). Witness 7 stated he did not work with the resident from 12/5/13 until 12/9/13. On 12/9/13 the resident's brace was "digging" into the resident's right side. Witness 7 stated he informed Staff 2 (RN) the doctor needed to be notified. On 12/31/13 at 1:35 pm Staff 7 (RN/Treatment Nurse) stated he did not recall PT telling him the resident had a possible skin issue on 12/5/13. Staff 7 stated on 12/5/13 he tried to look under the vest near the resident's clavicle but the vest was too tight and he could not visualize the skin under the vest. Staff 7 stated the skin around the brace was not red. Staff 7 stated he was the treatment nurse so he reported the tight vest to Staff 3 (RN/Charge Nurse). Staff 7 stated when he was the treatment nurse he did the resident's pin care but he did not look under the vest. On 12/31/13 at 1:16 pm and on 1/3/14 at 9:25 am Staff 3 (RN/Charge Nurse) stated he worked with the resident on 12/5/13 when the resident complained pain to the right clavicle region. The resident was repositioned in bed and the resident reported the pain was better. Staff 3 stated he did not recall seeing abnormal findings to the resident's right clavicle region. Staff 3 stated he was not able to look under the right side of the vest. The right side of the vest had more pressure than the left side. Staff 3 also stated he did not notify the resident's physician because he did not see any abnormal findings. Staff 3 stated when he was the treatment nurse and he cleaned the resident's pin sites he did not always check the under the vest. Staff 3 stated there was no place in the resident's record to document if the skin under the vest was assessed. The CNA staff provided daily care to the resident and reported new skin issues to the nursing staff if the CNAs discovered new skin issues. On 12/30/13 at 2:45 pm Staff 2 (RN) stated the resident had a halo brace/vest. The pin sites were cleaned twice a day. The resident usually wore a shirt or jacket over the vest. Staff 2 stated she did not provide care under the vest when working with the resident. The resident was only allowed to have showers from the waist down in order to keep the vest dry. The CNA staff assisted the resident with bathing. Staff 2 stated the only day the resident complained of right chest wall pain was on 12/9/13 the day the resident was transferred out of the facility. On 1/3/14 at 8:41 am, Staff 9 (RN) stated she worked with the resident. She assessed and documented on the resident's pin sites. The resident complained of pain to the pin sites and did not complain of pain to the clavicle region. Staff 9 stated she did not look at the residents skin under the vest on a daily bases, just for the weekly body audits. On 1/3/13 at 3:43 pm Staff 4 (LPN) stated the resident did not complain of pain on the night shift. The resident was provided scheduled pain medication on the night shift. The resident was not assessed on the night shift. The resident wore a pajama shirt at night. The CNA staff did not report any skin issues. On 1/3/14 at 8:35 am Staff 8 (CNA) stated she provided Resident 1 one sponge bath. Staff 8 stated she did not clean under the vest and was not able to clean under the clavicle region. Staff 8 stated she did not move the vest. The resident complained of pain to the chest region at times toward the end of the resident's stay at the facility. When the resident complained of pain the nurses were notified and the resident was repositioned. Staff 8 stated she did not recall any redness to the skin that was not covered by the vest. On 1/3/14 at 2:46 pm Staff 10 (CNA) stated he provided ADL care to the resident including bed baths. Staff 10 stated he did not clean under the vest because he was not trained to move the brace. The resident often complained of a headache. Staff 10 stated the last few days the resident was in the facility the resident had redness to the clavicle/chest region and Staff 3 (RN) was notified. Staff 10 stated a few days after the redness developed, Staff 2 (RN) cleaned the clavicle region and then the resident left the facility. On 1/3/14 at approximately 10:00 am Staff 1 (DNS) stated the facility did not have a policy for the care of a Halo brace. The nurse should examined the skin at least once a week and documented findings on the TAR. The CNA staff worked with the resident daily and bathed the resident. The CNA staff reported any abnormal skin issues to the nursing staff. Staff 1 stated the resident was alert and oriented and was able to make his needs know. Staff 1 acknowledged the resident's record did not have documentation to verify the licensed nurses were monitoring the skin under the Halo vest. The Halo vest was one unit and the nurses should have looked under the vest at the same time the staff performed pin site care. Staff 1 stated the staff documented on the resident daily but acknowledged there was no documentation on 12/6/13, 12/7/13 and 12/8/13. Staff 1 also stated this was not the first resident in the facility with a Halo brace.

Based on interview and record review it was determined the facility failed to ensure the resident was provided a mechanically altered diet as prescribed by the physician for 1 of 3 sampled residents (# 2) reviewed for mechanically altered diets. The resident choked on food and was transported to the hospital for treatment. Findings include: Resident 2 was admitted to the facility in 2013 with [DIAGNOSES REDACTED]. Review of the resident's [DATE] Physician's Telephone Orders Audit form revealed the resident's diet included mechanical soft textures (meats are chopped and vegetables/fruit must be cooked or soft). Review of the resident's [DATE] Nutritional Assessment revealed the resident kept food in her/his mouth while eating and needed verbal cues to swallow the food. The assessment indicated the resident was on a mechanical soft diet. Review of the resident's [DATE] Plan of Care revealed the resident's nutritional status was at risk. Risk factors included the resident was on a mechanically altered diet, had difficulty swallowing and retained food in her/his mouth. Interventions included the resident was to be observed during meals to ensure the resident did not retain food in the mouth. Staff were to cue the resident to swallow as needed. Review of the Speech Therapy Treatment Encounter Notes written on [DATE] revealed the resident had severe prolonged chewing when she/he ate a chicken patty. The note also indicated the resident needed cues to clear the food in the resident's mouth. The note indicated the kitchen staff were notified the resident's meats needed to be chopped for the mechanical soft diet. The Speech Therapy note written on [DATE] indicated the resident tolerated a mechanical soft diet with no signs of choking, had excellent intake and was discharged from Speech Therapy services. Review of the resident's [DATE] Witness Report of Resident Occurrence form completed by Witness 4 (Former facility CNA/Certified Nursing Assistant) revealed she/he assisted the resident during the evening meal. The resident was eating too fast and Witness 4 encouraged the resident to eat slower. After the resident started to eat slower, Witness 4 assisted another resident to eat. Witness 4 reported a few minutes passed and Resident 2 dropped some peaches and at this time Witness 4 noticed the resident had difficulty breathing. Witness 4 summoned a nurse for assistance. Review of the [DATE] Incident and Unusual Occurrence Report revealed on [DATE] at 6:10 pm the resident was throwing up in the middle dining room. Staff 4 (LPN) was called to the dining room to assist with the resident. The resident was encouraged to spit out the food that was in her/his mouth and the resident's dentures were removed. The resident continued to have difficulty breathing and was assisted to the resident's room. The report indicated Staff 4 removed two whole chicken nuggets and a large amount of softened food from the resident's mouth. Emergency Medical Services were called to transport the resident to the local hospital. Review of the resident's [DATE] hospital Emergency Department dictation revealed the the resident choked on a chicken nugget at the facility. The dictation indicated when the paramedics arrived at the facility the resident did not have a pulse. The resident received approximately 15 minutes of CPR (Cardio-Pumonary Resuscitation). The paramedics extracted food from the resident's trachea (windpipe) before intubation (artificial airway used to assist with breathing). The resident arrived at the hospital emergency department at 6:50 pm and was comatose (unresponsive to stimulation). Review of the resident's [DATE] Hospitalist History and Physical revealed the resident was without a pulse for approximately 15 minutes The resident developed generalized [MEDICAL CONDITION] after admission to the hospital. Review of the resident's [DATE] hospital Discharge Summary revealed the resident was extubated (removal of artificial airway) and the resident died on [DATE] at 8:08 am. On [DATE] at 8:50 am Staff 5 (Dietary Manager) stated the resident was on a prescribed mechanical soft diet. A mechanical soft diet included ground meat, soft fruit (no melon) and soft cooked vegetables. Chicken nuggets were ground before served to residents on a mechanical soft diet. Staff 5 stated she was not sure why the resident was served whole chicken nuggets instead of ground chicken nuggets. The cook and the dietary aid that worked on [DATE] no longer worked at the facility. On [DATE] at 3:43 pm Staff 4 (LPN) acknowledged she assisted with the resident's choking episode on [DATE]. Staff 4 verified she removed whole pieces of chicken nuggets from the resident's mouth. Staff 4 was unclear why the resident was served whole chicken nuggets. On [DATE] at 10:00 am and [DATE] at 10:00 am phone numbers for Witness 4 (former CNA), Witness 5 (former Cook) and Witness 6 (former Dietary Aide) were requested from Staff 1 (DNS/Director of Nursing Services). No additional information was provided.

Based on interview and record review it was determined the facility failed to obtain treatment orders for a pressure ulcer for 1 of 3 sampled residents (# 65) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers. Findings include: Resident 65 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the resident's 5/18/13 hospital Patient Transfer Form revealed the resident had a stage three coccyx ulcer (Stage three is full tissue loss. Fat may be visible but bone, tendon or muscle were not exposed. Some slough/dead tissue may be present). The Patient Transfer Form also referred the facility to the hospital wound ostomy nurse orders for dressing changes. Review of the resident's 5/18/13 admission Integumentary (skin)/Feet assessment revealed a hand written note dated 5/21/13 written by Staff 16 (RN) indicating the resident had a two mm diameter coccyx pressure ulcer and the ulcer was one mm deep. The ulcer was identified as a possible stage three ulcer. The note indicated the wound was cleaned and a dressing was applied. Review of the resident's 5/21/13 Fax Transmittal revealed Staff 16 requested pressure ulcer treatment orders, three days after the resident was admitted to the facility. The resident's physician signed the orders on 5/22/13. Review of the resident's May 2013 TAR revealed there were no dressing changes per physician orders [REDACTED]. On 7/15/13 at 9:23 am Staff 16 (RN) stated the resident was admitted on [DATE] with an open area to the coccyx. Staff 16 stated it was a stage two ulcer (shallow ulcer with red pink wound bed without slough/dead tissue). Staff 16 stated a dressing change was done on 5/18/13 but was not documented until 5/21/13. Staff 16 stated he did not enter the 5/21/13 hand written note on the admission Integumentary/Feet assessment as a late entry for 5/18/13. Staff 16 stated he did not document the dressing change in any other location in the resident's chart. On 7/15/13 at 9:50 am Staff 2 (DNS) verified the first documented dressing change was on 5/21/13. Staff 2 stated the resident was admitted on a Saturday and was not sure why orders were not requested until Tuesday 5/21/13.

Based on observation, interview, and record review, it was determined the facility failed to prevent the development of pressure ulcers for 1 of 2 residents (#103) who were reviewed for pressure ulcer care. This resulted in the development of 5 unstageable pressure ulcers and 3 additional areas of suspected deep tissue injury on Resident 103's hand. Findings include: The National Pressure Ulcer Advisory Panel defined an unstageable pressure ulcer as one where the depth of the ulcer cannot be determined because slough or eschar (types of dead tissue) obscured the base of the wound bed. If it could be removed, the pressure ulcer would be a Stage III or Stage IV. The National Pressure Ulcer Advisory Panel definition of a suspected deep tissue injury included a purple or maroon localized area of discolored intact skin. These areas may evolve into pressure ulcers even with treatment. The Regency Pacific Clinical Care Guideline for Pressure Ulcer Prevention, adopted 7/2010, identified minimizing pressure as a major area of intervention and included, "For all residents ...monitor skin under medical devices for redness, pain or open sore areas." Resident 103 was admitted on [DATE] after a motor vehicle accident with nerve damage resulting in lack of sensation and movement to the left arm. Resident 103 was also admitted with a compression dressing on the left arm to manage significant [MEDICAL CONDITION]. Resident 103's Resident Admission Profile was completed on 8/23/2013. Resident 103 was documented as having a "Dressing" on the left arm. No wounds were documented. Resident 103's Admission Care Plan dated 8/23/2013 included a care plan for risk for skin breakdown due to decreased mobility. The goal was no development of new areas of skin breakdown and interventions included to monitor skin surfaces for new areas of breakdown during daily care. The admission care plan did not identify the presence of a compression dressing on the left arm, [MEDICAL CONDITION] and lack of sensation to the left arm and hand as risk factors. No specific interventions to address these concerns were included. Resident 103's Temporary Care Plan dated 8/23/2013 included a CMS (Circulation, Movement, and Sensation) assessment of the left hand and arm, however did not include a skin assessment under the compression dressing. A Physical Therapy Evaluation on 8/24/2013 of Resident 103's left arm included motor loss in the arm and total sensory loss below the elbow. There was pronounced [MEDICAL CONDITION] requiring a compression wrap around the arm, hand and fingers and use of a sling. A Braden Scale Assessment for Predicting Pressure Sore Risk was completed on 8/28/2013, and identified that Resident 103 "has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities." physician progress notes [REDACTED]. Resident 103's left fingers were not able to feel a hand squeeze. Circulation was good and skin color was pink and warm. Staff 2, RNCM, completed Resident 103's Admission MDS, assessment reference date 8/30/2013. It identified the resident had limited range of motion to one upper extremity. Through a formal assessment tool and clinical assessment, Resident 103 was determined to be at risk for developing pressure ulcers, but had no pressure ulcers at that time. Staff 2 completed the comprehensive assessment on 9/4/2013. The Pressure Ulcer CAA identified some risk factors and interventions. Weekly skin checks were to be completed by a licensed nurse. The Pressure Ulcer CAA did not include an assessment of the condition of Resident 103's left arm and hand ([MEDICAL CONDITION], lack of sensation, motion, and presence of a compression dressing and sling) and the increased risk they placed on the development of pressure ulcers. No interventions were subsequently described or included on Resident 103's care plan to maintain skin integrity on Resident 103's left arm and hand or manage the dressing and sling. Nursing notes between 8/23/2013 and 9/4/2013 included CMS checks with inconsistent results ranging from "good" to "within normal limits" to noting deficiencies in movement and sensation. Skin checks underneath the dressing were not mentioned and no requests to clarify care and management of Resident 103's left arm were documented. On 9/4/2013, 12 days after admission, physician orders [REDACTED]. The orders included "Remove left arm dressing, provide skin care and hygiene. Then rewrap to prevent [MEDICAL CONDITION] secondary to deinervation (nerve to the arm had been severed) until compression sleeve delivered, (may repeat every 2 days)." The orders were noted and copied to the physical therapy department. On 9/4/2013, the orders were transcribed to a physician telephone order sheet as above and specified, " To: P.T./nursing." The orders were entered onto Resident 103's September 2013 TAR. On 9/5/2013, the initials to document the treatment on the TAR were circled, indicating the treatment was not provided. The next two treatments on 9/7 and 9/9/2013 were not documented. There were no corresponding notes on the TAR or in nurses notes to explain why treatments were not done. A physical therapy note completed by Staff 4, Physical Therapist, on 9/11/2013 stated they started coordinating with nursing to schedule unwrapping Resident 103's pressure bandages and for nursing to check the resident's skin for any wounds and cleaning. The therapist documented removing the dressing and found pressure sores on Resident 103's left fingers. Investigation of the cause of the pressure ulcers included the facility had not followed the 9/4/2013 physician orders. A 9/11/2013 fax to the physician stated that the "dressing (wraps) to left arm were not changed 9/7 and 9/9. When they were removed 9/11, several pressure ulcers were discovered to his left hand (8)." On 9/11/2013, a Weekly Skin Ulcer Measurement Tool was completed on each of the 8 areas of concern. Three areas of facility acquired suspected deep tissue injury were documented on the inner and outer edges of the hand and the inside of the little finger. They ranged from 1.4 to 2.0 cm in length and 0.4 to 0.8 cm in width. Five facility acquired pressure ulcers were documented on each of the inner surfaces of the fingers and were unstageable due to slough. They ranged from 1.3 to 2.2 cm in length and 0.3 to 0.6 cm in width. (One centimeter equals 0.4 inches.) physician progress notes [REDACTED]." In interview on 9/13/2013 at 12:44 pm, Resident 103 stated there was no feeling in the left arm from the elbow down and it lacked any mobility. Resident 103 stated nerves in the neck and shoulder had been torn in the accident. When asked about what happened with the left hand, Resident 103 stated, "They were supposed to take off this wrap, but there was a drop of the ball along the way and so I got sores in between my fingers." Resident 103 stated there was some confusion about who was responsible for providing care to the arm. On 9/13/2013 at 12:44 pm, Resident 103's left arm was observed wrapped in a compression bandage to the fingers and the arm was placed in a sling. The fingers were swollen and dressings for the wounds were noted between the fingers at the knuckles and along both sides of the hand. The dressings were clean, dry and intact. In interview on 9/13/2013 at 1:04 pm, Staff 4 stated Resident 103 was admitted with swelling, lack of mobility, lack of sensation, and compression wraps to the left arm. She had unwrapped and discovered the wounds, which she stated were caused because the compression bandages had been left on too long. Staff 3, Director of Rehab, agreed. Staff 3 stated the order wasn't clear who was responsible for carrying out the physician orders [REDACTED]. The physical therapists were not typically responsible for skin care. In interview on 9/13/2013 at approximately 2:00 pm, Staff 2 acknowledged the comprehensive assessment was incomplete and the care plan lacked interventions to specifically address the care of Resident 103's arm. Staff 2 stated nurses would typically be responsible for carrying out the 9/4/2013 physician orders, however the order was not clear and had not been clarified. She acknowledged the orders had not been followed. In interview on 9/13/2013 at 2:29 pm, Staff 1, DNS, stated the care of Resident 103's arm would be a nursing responsibility, but the orders were not clear. She acknowledged the orders should have been clarified and had not been followed, resulting in the development of the pressure ulcers. She acknowledged Resident 103's comprehensive assessment was incomplete and the only intervention for managing Resident 103's arm was to complete CMS checks. She stated prior to 9/4/2013, they were ordered not to look under the dressing, however the order could not be located. .

Based on interview and record review it was determined the facility failed to document accurate ongoing pressure ulcer assessments, update care plans and to ensure nutritional interventions were followed for 1 of 3 residents (# 1). The resident was admitted to the hospital and required surgery related to the pressure ulcer. Findings include: Resident 1 was admitted to the facility in 2013 with [DIAGNOSES REDACTED]. Review of Resident 1's 2/7/13 Resident Admission Profile revealed the resident was alert and oriented to person, place, time and situation and the resident was not identified with pressure ulcers. Review of the resident's 2/8/13 Admission Care Plan revealed the resident was at risk for skin breakdown and interventions included monitoring skin conditions for complications of healing, and monitoring skin surfaces for new area of breakdown during daily care. Review of the resident's 2/16/13 Incident and unusual Occurrence Report revealed two pressure ulcers were identified. Review of Resident 1's 2/16/13 Weekly Ulcer Measurement Tool identified the left sacrum pressure ulcer was two cm long by two cm wide and less than 0.25 cm deep, had no signs of infection and had a small amount of clear/yellow drainage. The pressure ulcer was identified as an unstageable ulcer (full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough). The coccyx pressure ulcer was identified as one cm long by one cm wide and less than 0.25 cm deep, had a small amount of clear/yellow drainage and did not have of signs of infection. The ulcer was identified as an unstageable ulcer. Both ulcers were noted to have discolored skin around the ulcers. Review of the resident's 2/19/13 Physician's Telephone Orders Audit and 2/19/13 Weekly Medicare Review-Clinical and Social Service form revealed the resident had a Stage two ulcer (Partial thickness loss of skin presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open blister.) on the sacrum/coccyx. On 4/9/13 at 2:38 pm Staff 5 (RNCM) stated the pressure ulcers were unstageable and not stage two ulcers. Review of the February 2013 TAR revealed the dressing was changed on 2/16/13, 2/19/13, 2/21/13, 2/25/13, 2/26/13 and 2/28/13. There was no information on the back of the TAR describing the wounds or on the coinciding Interdisciplinary Progress Notes addressing the the pressure ulcers' characteristics including the stage of the ulcer, size, if there was drainage and or a description of the skin surrounding the ulcers. 4/8/13 at 12:50 pm Staff 6 (RN) stated she did the 2/16/13 Weekly Ulcer Measurement Tool. The skin around the ulcers were discolored but can not say if it was purple or brown but the discoloration was not black. On 4/8/13 Staff 3 (RN) stated she changed the resident's pressure ulcer dressings a few times. Staff 3 stated the resident had three pressure ulcers. The ulcer on the left side of the coccyx and the coccyx ulcer had a white/silvery appearance. The wound on the right side of the coccyx was red. The pressure ulcers did not have black or necrotic (dead ) tissue and did not have an odor. Staff 3 stated on at one point the pressure ulcers worsened. The RNCM was notified and an air mattress was obtained. Staff 3 stated the resident's pressure ulcers stabilized after the air mattress was implemented. On 4/5/13 at 1:50 pm Staff 7 (RN) stated he changed the resident's dressing two or three times. The ulcers were a stage two or three pressure (Full thickness tissue loss; the bone, tendon and muscle are not exposed) ulcer with slough and granulation tissue (healthy new tissue). Staff 7 did not remember the size of the ulcers and stated the RNCMs measured the wounds weekly. On 4/5/13 at 2:15 pm Staff 2 (DNS) stated the weekly assessment of the resident's pressure ulcers were not done on 2/23/13. On 4/5/13 at 1:40 pm and 4/8/13 at 9:30 am Staff 8 (RN) stated she changed the dressing on 2/28/13 at approximately 5:15 am. The resident had two pressure ulcers on each side of the coccyx. The ulcers were black and were approximately 3 cm in diameter. The ulcers were not circular. 4/9/13 at 10:09 am Staff 5 (RNCM) stated pressure ulcers should be measured weekly. Staff 5 acknowledged the initial assessment was 2/16/13. No additional measurements were done after 2/16/13. Review of the 2/16/13 Temporary Care Plan revealed the resident was on alert charting for pressure wounds to the coccyx and sacrum. The temporary care plan was discontinued on 2/22/13. Review of the resident's chart revealed there was no updated care plan for the newly identified pressure ulcers with interventions specific to the ulcers. On 4/10/13 at 8:21 am Staff 5 (RNCM) stated there was no updated care plan addressing the resident's pressure ulcers and the interventions to be implemented. Review of the 2/11/13 Plan of Care revealed the resident was at risk for impaired nutritional status related to risk factors including [MEDICAL TREATMENT] and diabetes. Interventions included supplements as ordered. Review of the 2/14/13 Nutritional Assessment revealed the resident was a high risk for inadequate nutrition and the resident's caloric needs were identified at 1750 calories per day. The resident's interventions included Nepro shakes (nutritional supplement with additional calories/protein) twice a day. Review of the resident's February 2013 MAR indicated [REDACTED]. The resident started refusing the Nepro on 2/16/13. Review of the resident's chart revealed there was no documentation indicating the resident was informed of the increased risk associate with not drinking the shakes and the affect of nutrition as related to pressure ulcer healing. Review of the 2/15/13 Release Against Medical Advice form revealed the resident acknowledged the resident was choosing to not follow the dietary orders and guidelines and was informed of the risks involved . The specific risks and outcomes were not identified on the form. 4/8/13 at 3:11 pm Witness 1 (RD/Registered Dietician) stated at the time of the 2/14/13 Nutritional Assessment the resident did not have a pressure ulcer. The resident was assessed and interventions were recommended that would provide the resident with adequate protein/calories for pressure ulcer healing. The Nepro shakes that were recommended twice a day would provide an additional 40 grams of protein and approximately 1000 extra calories per day for the resident. On 4/9/13 at 10:09 am and 4/10/13 at 1:20 pm Staff 5 (RNCM) stated the resident was not compliant with dietary recommendations. Staff 5 also stated she was not aware the resident refused the Nepro shakes and did not discuss with the resident the risks of inadequate nutritional intake in correlation with pressure ulcer healing. Staff 5 also stated the resident's physician was not notified the resident was refusing the Nepro shakes. On 4/9/13 at 2:38 pm Staff 5 (RNCM) stated she remembered the resident signed a Release Against Medical Advice form on 2/15/13. Staff 5 acknowledged the consent was signed before the resident's pressure ulcers were identified. Staff 5 could not remember the risks discussed with the resident but Staff 5 did not include pressure ulcer healing because the pressure ulcers were not identified at the time the resident signed the form. Staff 5 stated the resident was informed if the resident's diet was not followed it would be harmful to the resident's health. On 2/10/13 at 8:21 am Staff 5 acknowledged the resident started to refuse the Nepro shakes on 2/16/13. Review of the 2/28/13 SBAR (situation/background/assessment/request) revealed the resident had a decreased level of consciousness possibly from a urinary tract infection and the resident was sent to the local hospital at 4:10 pm. Review of the residents's 2/28/13 Consultation Report revealed the resident was admitted to the hospital with [REDACTED]. The assessment of the resident's ulcer included a five by fifteen cm area of black skin and a central tunneled area that was approximately two cm in diameter and extended at least three cm deep. There was approximately five cm of redness in all directions around the wound. Review of the hospital 2/28/13 Operative Report revealed the resident was admitted to the hospital on [DATE] with an infected sacral wound. The post-operative [DIAGNOSES REDACTED]. The wound was surgically cleaned. Review of the 3/2/13 Operative Report revealed the resident returned to surgery for [REDACTED]. Review of the 3/6/13 Discharge Summary revealed the resident was discharged to Hospice.