Every finding on record at Regency Care of Rogue Valley

Based on interview and record review, it was determined the facility failed to provide required communication and documentation for 2 of 3 sampled residents (#s 49 and 51) reviewed for hospitalization and discharge. This placed residents at risk for unsafe discharge. Findings include: The 8/2024 Facilities Bed Hold Policy and Agreement Form indicated a resident who was temporarily absent from the facility because of a Break in Services (defined under Oregon law as a hospitalization or leave of absence) may apply for a bed hold to ensure her/his bed was preserved for her/his anticipated return. The policy indicated at the time of discharge to the hospital; the discharging nurse would give the residents and representatives a copy of the Bed Hold Policy and Agreement.1.Resident 51 was admitted to the facility on [DATE] with diagnoses including muscle weakness and stroke.On 1/18/26, Resident 51 left for a physician appointment. After the appointment, Resident 51 went home with Witness 1 (Family Member). On 1/18/26 at 10:37 PM, Staff 5 (RN) spoke with Witness 1 on the phone. Witness 1 indicated Resident 51 fell asleep and would not return to the facility that night but would return the following day.On 3/24/26 at 1:33 PM, Witness 1 stated Resident 51 returned to the facility the following day, but when she/he arrived, the facility had discharged the resident. Witness 1 stated there was no notification the resident would be discharged and the resident was not offered a bed hold. On 3/25/26 at 12:17 PM, Staff 3 (Social Services) stated she oversaw discharges but if a resident went home for an overnight visit, the RCM or DNS oversaw the leave. Staff 3 stated when a resident went out overnight her/his bed was held and they were not charged.On 3/25/26 at 12:53 PM, Staff 6 (RNCM) stated Resident 51 returned to the facility after 24 hours and management decided she/he would be discharged . Staff 6 stated the overnight visit was a therapeutic leave and Resident 51's bed should have been held for his/her return. Staff 6 acknowledged staff did not call the spouse in the morning to discuss what time the resident would return, no documentation was sent to the resident or spouse regarding discharge or bed hold, and Resident 51 should not have been discharged .On 3/25/26 at 1:54 PM, Staff 3 stated Resident 51 went to her/his appointment and did not return by midnight and the IDT considered her/him leaving the facility AMA (against medical advice). Staff 3 stated Resident 51 and Witness 1 should have been called regarding return to the facility and they were not. Staff 3 acknowledged no discharge documentation or bed hold information was sent to Resident 51 or Witness 1.On 3/26/26 at 10:28 AM, Staff 1 (Administrator) acknowledged Resident 51 did not receive documentation regarding a discharge, was not offered a bed hold, and was not assessed for a safe discharge. Staff 1 stated Resident 51's discharge was unplanned and unsafe.2. Resident 49 was admitted to the facility in 12/2025 with diagnoses including respiratory failure and kidney disease.A progress note dated 1/4/26 indicated Resident 49 had oxygen saturation of 52% on room air, secretions in her/his lungs which could not be cleared with suctioning (removal of airway secretions), and respirations were labored. Staff 3 (LPN) provided oxygen, contacted the family who agreed to send the resident to the hospital, and called emergency transport.On 3/25/26 at 12:15 PM, Witness 3 (POA) stated when Resident 49 was sent to the hospital she/he was not offered a bed hold for her/his return.On 3/25/26 at 12:17 PM, Staff 3 (Social Services) stated she oversaw discharges and provided bed holds for residents or their POAs. Staff 3 stated she did not provide a bed hold for Resident 49 or her/his POA.On 3/26/26 at 10:46 AM, Staff 1 (Administrator) acknowledged residents or their POAs needed to be offered a bed hold when they were discharged to the hospital or on leave of absence from the facility.

Based on observation, interview and record review it was determined the facility failed to ensure concerns regarding proper food temperatures were addressed for Resident Council and 2 of 5 sampled residents (#s 9 and 25) reviewed for food. This placed residents at risk for food that was not palatable. Findings include: A 9/9/24 computer dashboard communication revealed CNAs were provided a reminder to not reheat anything for a resident in a microwave oven because resident safety and staff licenses were at risk. Staff were given the following direction: Coffee-offer to get them a new cup. Food-ask the kitchen to reheat the food. 1. On 11/20/24 at 11:00 AM nine residents attended a Resident Council meeting. A majority of the residents in attendance agreed staff were not allowed to warm or address cold food concerns when a resident stated she/he was concerned about cold food. On 11/20/24 at 8:04 AM Staff 11 (Dietary Manager) stated the kitchen had one additional meal available if a resident requested warmer food during a meal service. Staff 11 stated food handled by a resident could not be reheated in the kitchen due to cross-contamination. Staff 1 (Administrator) stated she was not aware of reports related to residents' cold food and acknowledged staff education was necessary to address residents' cold food concerns. 2. Resident 9 admitted to the facility in 2020 with diagnoses including chronic pain and dementia. A 9/19/24 Annual MDS indicated Resident 9 had mild cognitive impairment. On 11/20/24 at 12:06 PM Resident 9 was observed in her/his room eating lunch with frozen strawberries on her/his plate. Resident 9 stated she/he was waiting for the strawberries to thaw before she ate them and indicated staff did not know how to address issues with cold food. Resident 9 stated she/he was mobile and routinely went to the kitchen to directly address concerns regarding cold food. On 11/20/24 at 8:04 AM Staff 11 (Dietary Manager) stated the kitchen had one additional meal available if a resident requested warmer food during a meal service. Staff 11 stated food handled by a resident could not be reheated in the kitchen due to cross-contamination. Staff 1 (Administrator) acknowledged staff education was necessary to address residents' cold food concerns. 3. Resident 25 admitted to the facility in 6/2023 with diagnoses including stroke and malnutrition. The 8/9/23 Orders Details for Resident 25's diet indicated she/he received regular nutritionally enhanced meals. A 5/31/24 revised care plan indicated Resident 25 had poor intake and to encourage and offer alternatives with respect to her/his preferences. On 11/18/24 at 12:10 PM Resident 25 stated she/he ate meals slowly and staff did not reheat her/his meals or beverages to accommodate her/his needs. Resident 25 stated she/he would eat more if her/his food was warmed including fruit. On 11/19/24 at 12:48 PM Staff 17 (CNA) stated staff were not allowed to reheat residents' food once a meal was touched by a resident. Staff 17 stated Resident 25 complained about cold food about 25 percent of the time, but nothing could be done to address Resident 25's concerns. On 11/19/24 at 3:39 PM Staff 18 (CNA) stated staff were not allowed to reheat residents' food, but the kitchen was to provide new servings of the meal if a resident requested warmer food. On 11/20/24 at 8:04 AM Staff 11 (Dietary Manager) stated the kitchen had one additional meal available if a resident requested warmer food during a meal service. Staff 11 stated food touched by a resident could not be reheated in the kitchen due to cross-contamination. Staff 1 (Administrator) acknowledged staff education was necessary to address residents' cold food concerns.

Based on observation, interview and record review it was determined the facility failed to maintain water temperatures for 2 of 6 sampled residents (#s 27 and 88) reviewed for environment and accidents. This placed residents at risk for burns. Findings include: 1. Resident 27 admitted to the facility 10/2024 with a diagnosis of a wedge compression fracture. An 10/2024 admission MDS revealed Resident 27 was cognitively intact. Resident 27 resided in Birch Hall. On 11/19/24 at 10:54 AM Resident 27 stated on one occassion she/he used the sink to wet her/his hair. On 11/19/24 at 10:56 AM Staff 6 (Maintenance Director) used a digital thermometer to test the hot water temperature at the tap of the sink in Resident 27's room. The thermometer indicated the hot water temperature was 125 degrees F. Staff 6 acknowledged the temperature of the hot water in Resident 27's room needed to be dialed down. 26991 2. Resident 88 admitted to the facility 11/2024 with a diagnosis of hip surgery. A 11/14/24 admission MDS revealed Resident 88 was cognitively intact. Resident 88 resided in Cedar Hall. On 11/18/24 at 2:59 PM te hot water at the tap of the sink in Resident 88's bathroom was hot to touch when checked by the surveyor. On 11/19/24 at 9:30 AM Resident 88 stated the water was very hot if she/he was not careful, but she was able to adjust the temperature. On 11/19/24 at 9:51 AM Staff 6 (Maintenance Director) measured the temperature of the hot water in Resident 88's bathroom and it was observed to be 126 degrees F. Staff 6 stated the hot water heater was in a room adjacent to Resident 88's bathroom. On 11/19/24 at 2:21 PM Staff 6 stated he performed weekly water temperature checks in random resident rooms. Staff 6 indicated his goal was to keep the water temperature between 113 and 118 degrees F. Staff 6 stated no one reported concernsregarding excess water temparature in resident rooms.

Based on observation, interview, and record review it was determined the facility failed to provide a meaningful activity program for 1 of 1 sampled resident (#3) reviewed for activities. This placed residents at risk for lack of social engagement. Findings include: Resident 3 admitted to the facility in 8/2023 with a diagnosis of paralysis. A 7/23/24 annual MDS revealed Resident 3 was cognitively impaired, preferred to stay in bed, and required assistance with ADLs. When interviewed, Resident 3 indicated choosing activities was very important. Activities important to Resident 3 included interaction with pets and reading. A care plan initiated on 8/23/23 and revised on 10/7/24 indicated Resident 3 was at risk for little activity involvement related to physical mobility, decreased ROM, impaired motor skills, and deficits in judgement. Activities to offer included to invite Resident 3 to group activities, provide 1:1 visits, and to provide reading material. An 10/23/24 Activities Quarterly Participation Review form indicated Resident 3 preferred to self-direct her/his own activities, did not want to participate in group activities, and 1:1 visits were acceptable. The form indicated there was only one 1:1 activity provided during the previous quarter. Resident 3's favorite activities included reading the bible, looking out her/his window, napping, and visits with family and her/his roommate. An Activity Participation log from 10/22/24 through 11/16/24 indicated Resident 3 participated in independent activities. The activity identified was snack offered. No 1:1 visits were provided, no reading, and no other visits occurred. On 11/18/24 at 12:30 PM Resident 3 stated there was not much to do for activities. Resident 3 was not able to articulate what she/he wanted to do. On 11/19/24 at 2:45 PM Staff 8 (CNA) stated Resident 3 did not like television, but enjoyed talking and joking. Staff 8 stated staff offered Resident 3 group activities, but she did not like group activities. Observations revealed: -On 11/18/24 at 12:30 PM Resident 3 was in bed, awake, window blinds closed, and there was no television or music playing in the background. -On 11/19/24 at 10:18 AM Resident 3 was observed in bed with her/his eyes shut, there was no music or television playing in the background. -On 11/20/24 at 8:51 AM Resident 3 was observed in bed with her/his eyes shut and her/his window blinds closed. -On 11/20/24 at 9:22 AM Resident 3 was in bed, awake, and her/his blinds were shut. On 11/20/24 at 8:27 AM Staff 3 (Activity Supervisor) stated both she and her/his assistant provided 1:1 visits with residents. If a visit was provided it was documented in the resident's clinical record. Staff 3 stated the facility had a volunteer with a dog visit the facility, but it was very infrequent. Staff 3 acknowledged Resident 3 liked pets and there were some facility staff who had pets in the facility which Resident 3 may enjoy. Staff 3 stated Resident 3 slept a lot but was awake for meals and showers. Staff 3 indicated 1:1 visits could be scheduled during the times Resident 3 was awake. Staff 3 stated she was not sure if Resident 3 was able to read and stated the facility had an audible book player, but did not offer it to Resident 3. Staff 3 acknowledged the resident only had snacks as documented activities and family did not come in very often. On 11/20/24 at 9:21 AM Staff 7 (CMA) stated Resident 3's blinds were often shut, but Resident 3, on occasion, asked staff to open her/his blinds.

Based on interview and record review it was determined the facility failed to notify a resident prior to change of administration of medication for 1 of 1 sampled resident (#139) reviewed for informed consent. This placed residents at risk for lack of informed consent. Findings include: Resident 139 admitted to the facility in 2024 with diagnoses including depression. A 3/26/24 Admission MDS indicated Resident 139 was cognitively intact. Admission orders signed 3/28/24 revealed Citalopram (an anti-depressant) 60mg at bedtime and Imipramine (an anti-depressant) 50mg at bedtime for depression. An 4/9/24 provider order specified Citalopram 20mg at bedtime and Imipramine 25mg at bedtime for depression. An 4/18/24 provider note indicated the provider spoke with Resident 139 and she/he had no unaddressed concerns. A review of Resident 139's chart revealed no documentation to indicate Resident 139 was notified of the changes to her/his medications. On 11/18/24 at 2:49 PM Resident 139 stated she/he was taking Citalopram 60mg and Imipramine 50mg at bedtime as a successful depression treatment for years. She/He stated the facility reduced her/his medications without her/his knowledge or consent. On 11/20/24 at 12:10 PM Staff 23 (Social Services Director/Admissions) verified no other information was present in Resident 139's chart regarding notification of medication changes.

Based on interview and record review it was determined the facility failed to monitor a resident's thyroid hormone level for 1 of 5 sampled residents (#1) reviewed for medications. This placed residents at risk for a non-therapeutic medication regimen. Findings include: Resident 1 admitted to the facility in 8/2021 with a diagnosis of obesity. A 9/20/24 Order Summary Report revealed Resident 1 was administered Synthroid (hormone to increase thyroid levels). The start date was 10/9/21. Resident 1's clinical record revealed her/his last TSH (thyroid stimulating hormone; monitors thyroid function) test was obtained on 11/20/22 and the results were within therapeutic range. No additional TSH test results were in the clinical record. On 11/19/24 at 2:00 PM Staff 10 (LPN IP) stated TSH levels were usually checked annually. A request was made to Staff 10 to provide documentation a TSH level was obtained yearly after 2022 or a rationale was in the resident's record indicating it was not required. No additional information was provided. On 11/19/24 at 5:00 PM in interview with Staff 4 (RN Patient Care Coordinator) and Staff 2 (DNS), Staff 2 stated stated the pharmacy reported the TSH was usually checked annually.

Based on interview and record review it was determined the facility failed to ensure respiratory treatments were implemented timely and diagnostic results were available in the medical record timely for 1 of 1 sampled resident (#1) reviewed for respiratory care. This placed residents at risk for respiratory complications. Findings include: Resident 1 admitted to the facility in 8/2021 with a diagnosis of a stroke. Progress Notes revealed: -10/8/24 Resident 1 was assessed by her/his NP for shortness of breath and orders were placed for a PRN nebulizer (machine which turns liquid medicine into a mist that can be inhaled to treat lung conditions). The note was not signed by the NP as completed until 10/26/24. -10/10/24 Resident 1 had shortness of breath, wheezing, and the physician was faxed to obtain an order for a nebulizer. -10/11/24 Resident 1 had chest pain with deep breaths, an order for a chest x-ray was obtained, and staff were waiting for results. -10/17/24 staff called radiology for x-rays obtained on 10/11/24. -10/21/24 staff confirmed radiology was completed on 10/11/24. Resident 1's 10/2024 MAR revealed her/his nebulizer was started on 10/10/24 and not started on 10/8/24 when prescribed by the NP. Resident 1's record indicated the x-ray ordered on 10/11/24 was faxed to the facility on [DATE]. On 11/19/24 at 2:00 PM Staff 4 (RN Patient Care Coordinator) stated when a medical provider assessed residents they communicated their findings with facility staff, or wrote orders. Staff 4 stated if an x-ray was ordered and obtained, the results were usually in the chart within one week. If the results were not in the record staff called for the results. Staff 4 acknowledged the x-ray was not faxed to the facility until 10/28/24. Staff 4 was not sure the reason why the nebulizer was not started on the day the NP assessed Resident 1.

Based on interview and record review it was determined the facility failed to ensure a resident was provided an RA program for 1 of 1 sampled resident (#3) reviewed for mobility. This placed residents at risk for increased weakness. Findings include: Resident 3 admitted to the facility in 8/2023 with a diagnosis of paralysis. A 7/23/24 annual MDS indicated Resident 3 had impaired cognition, was bed bound, required a mechanical lift for transfers, and assistance with ADLs. An 8/3/24 PT Discharge Summary revealed Resident 3 was provided therapy services to assist her/him with increased independence with bed mobility, sitting balance while in a wheelchair, and improve ROM to her/his legs. The benefit of therapy was to prevent contractures and muscle wasting. Discharge recommendation included a RA program. The RA program was for ROM for feet mobility and leg rotation. The RA program was also to assist in maintaining the resident's ability to sit at the side of the bed, transfer to the wheelchair, and participate in bed mobility. A care plan revised on 10/30/24 revealed Resident 3 had a walking deficit and impaired bed mobility due to decreased ROM, decreased cognition, impaired balance, and weakness. Interventions indicated therapy was to be provided as needed, but she/he had poor therapy participation. The care plan indicated Resident 3 did not walk and she/he was dependent on one staff to assist with turning and sitting up in bed. The care plan did not include a RA program. Review of Resident 3's clinical record did not include documentation to indicate a RA program was implemented. On 11/19/24 at 4:09 PM Staff 22 (Therapy Director) verified Resident 3 participated in therapy from 6/25/24 to 8/3/24 for leg ROM. Staff 22 verified a RA program was established. If RA was determined to be appropriate the RA staff would be trained in the program and then the program would be implemented. Staff 22 stated she did not see a RA program in the RA book. On 11/19/24 at 4:42 PM Staff 5 (RA) stated he worked in the facility for many years and never worked with Resident 3. On 11/19/24 at 4:55 PM Staff 4 (RN Patient Care Coordinator) stated if therapy recommended a RA program, they set up the exercises and provided a copy of the referral to her. She then ensured the resident was provided restorative services. After a period of time if the resident did not participate the RA program would be re-reevaluated and determined if it should continue or discontinue. Staff 4 stated Resident 3 historically refused therapy. Staff 4 stated she was never provided a RA referral to implement for Resident 3.

Based on interview and record review it was determined the facility failed to properly assess a pressure ulcer and revise treatments for 1 of 1 sampled resident (#5) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers. Findings include: Resident 5 admitted to the facility in 3/2017 with diagnoses including dementia and failure to thrive. An 4/11/24 Annual Pressure Ulcer CAA indicated Resident 5 was at risk for pressure ulcers, was unable to make position changes independently, and had recurrent MASD (Moisture Associated Skin Damage). A 7/4/24 Unavoidable Pressure Injury Evaluation indicated Resident 5 had MASD which resulted in a pressure injury due to fragile skin and impaired skin integrity despite pressure injury interventions. An 10/2/24 Quarterly MDS indicated Resident 5 had a facility acquired Stage 3 (full thickness tissue loss) pressure ulcer. An 10/12/24 physician order indicated Resident 5 was to receive wound care to her/his coccyx (tailbone) every evening which included to cover the wound bed with calcium alginate (dressing to treat wounds with moderate to heavy drainage), apply marathon (wound protective layer) to the peri-wound (tissue surrounding the wound) and cover the wound with a foam dressing. An 10/29/24 Wound Evaluation revealed Resident 5's Stage 3 coccyx wound was improving, the peri-wound area was denuded (surface area removed), the wound exudate (fluid) was moderate and measured 0.51 cm x 0.76 cm and was 0.1 cm in depth. The progress notes indicated the wound was healing and current treatment continued. A 11/4/24 Wound Evaluation revealed Resident 5's wound was deteriorating, the exudate was light and bloody, and the wound measured 1.71 cm x 3.89 cm and it was 0.1 cm in depth. Progress notes indicated the current treatment continued. A 11/15/24 Wound Evaluation revealed Resident 5's wound continued to deteriorate, the exudate was light and bloody, and the wound measured 7.67 cm x 14.69 cm and it was 0.1 cm in depth. Progress notes indicated the wound size greatly increased due to the adhesive from the dressing which irritated the skin, but the pressure injury was nearly resolved. No new notes related to wound treatment were found. On 11/19/24 at 5:14 PM Staff 14 (LPN) stated she completed Resident 5's wound treatment weekly, the wound was improving but the surrounding area around the wound appeared to worsen. Staff 14 stated Staff 4 (RN-Patient Care Coordinator) assessed Resident 5's wound weekly and determined what treatments were necessary. On 11/20/24 at 1:46 PM Staff 15 (LPN) stated a few weeks earlier she observed two to three new red spots near Resident 5's coccyx wound that remained closed but wanted to open (indication of a Stage 1 pressure ulcer when the skin is intact and appears red). Staff 15 stated Resident 5's entire coccyx wound area appeared worse compared to prior observations and Staff 4 was aware. On 11/20/24 at 3:28 PM Staff 4 stated she believed Resident 5's coccyx wound was healing and wanted to focus on the coccyx wound before the surrounding skin issue was addressed. Staff 4 stated she did not consider an alternative to the residents' current wound treatment despite the changes observed to the surrounding skin. At 11/20/24 at approximately 3:30 PM Staff 2 (DNS) reviewed the wound documentation and acknowledged Resident 5's wound should be assessed as two separate wounds with a new treatment regimen considered at the time the surrounding skin area of the initial wound deteriorated.

Based on interview and record review it was determined the facility failed to ensure resident records were complete and accurate for 2 of 6 sampled residents (#s 1 and 11) reviewed for pressure ulcers and change of condition. This placed residents at risk for inaccurate clinical records. Findings include: 1. Resident 1 was admitted to the facility in 1/2021 with diagnoses including diabetes. A 2/24/22 Weekly Non-Pressure Skin Condition Assessment revealed Resident 1 had what started as superficial wounds on the gluteal cleft and bilateral buttocks area. The wound bed was red and the Periwound was macerated. The measurement of the wound was 2 cm length by 1 cm width, and a depth of 0.28 cm, with a small amount of serous exudate (clear, thin and watery discharge). Wound bed granulation tissue was present which was pale pink to beefy red in color, and the surrounding skin was bright red and blanchable. The progress of the wound was noted as improved but fragile, and the treatment of calcium alginate on the open and moist wounds would continue. A 3/2/22 Hospital Wound Care Progress Note revealed Resident 1 had a Stage 2 sacrum pressure ulcer which was present on admission. A 3/7/22 Admission Profile for readmission revealed Resident 1 had non-pressure skin conditions which were present on admission. The profile indicated Resident 1 did not have a pressure ulcer, venous stasis, arterial or diabetic ulcers. Resident 1 had an open area to the sacrum and right buttock with no measurements of the wounds. No other information was provided about the sacrum or right buttock wounds. A 3/7/22 Skin Condition assessment sheet with body diagrams indicated an open area to Resident 1's sacrum area and right buttock. A 3/15/22 Wound Clinic Progress Notes revealed Resident 1 had a diagnosis of a Stage 2 pressure ulcer to the sacral region. The wound measured 2 cm in length by 0.5 cm in width with a depth of 0.1 cm, and an area of 1 cm2. A 3/18/22 Weekly Non-Pressure Skin Assessment revealed Resident 1 had superficial wounds to the gluteal cleft with a length of 2 cm by width of 1 cm and a depth of .28 cm. No documentation was found in clinical records for a pressure ulcer assessment of Resident 1's sacrum Stage 2 pressure ulcer. On 12/22/22 at 10:05 AM Staff 1 (Administrator) and Staff 2 (DNS) stated when Resident 1 first developed the wound on her/his buttocks it was determined to be moisture associated skin damage. When Resident 1 discharged to the hospital the wound presented as a pressure ulcer and the hospital did not see the wound in its initial stages. The hospital provided their determination to the wound clinic and the facility did not agree with the staging of the wound and felt it was a moisture associated wound. 2. Resident 11 was admitted to the facility in 11/2022 with diagnoses including hip dislocation. A 12/2022 TAR instructed staff to administer Thera Worx Relief (topical solution to relieve muscle spasms) topically every four hours PRN for spasms. It was documented Resident 11 was administered Thera Worx on 12/3/22 and 12/7/22 at 9:24 AM. On 12/7/22 at 11:53 AM Resident 11 was screaming and requesting the blue thing to be removed from between her/his legs as it was causing her/him pain. On 12/8/22 at 9:29 AM Staff 8 (LPN) stated she administered the Thera Worx to Resident three instances on 12/7/22 and she forgot to document the second two administrations on the TAR. Staff 8 stated the blue wedge was in between Resident 11's legs so her/his hip would not become dislocated. On 12/9/22 at 9:37 AM Resident 11 stated the muscle spasms she/he was having the last few days caused her/him to scream out in pain as she/he could not move to relieve the pain. On 12/22/22 at 10:45 AM Staff 1 (Administrator) and Staff 2 (DNS) stated each time a PRN medication was used it should be documented on the TAR.

Based on interview and record review it was determined the facility failed to provide appropriate care and treatment, and failed to follow physician orders for 1 of 1 sampled resident (#1) reviewed for injury of unknown origin. This placed residents at risk for injuries and lack of physician oversight. Findings include: Resident 1 was admitted to the facility in 1/2021 with multiple fractures of ribs. a. A 12/15/21 revised care plan revealed Resident 1 had moderate to severe calcific tendinitis (calcium deposits form in the tendon) to her/his hands. Interventions for Resident 1 were described as areas of pain to the left shoulder, left knee pain and right wrist/hand. A 1/10/22 Incident Note indicated Resident 1 was noted to have blisters on her/his abdominal area. Resident 1 was unable to describe how they occurred. Resident 1 was placed on alert charting. A 1/10/22 at 11:38 AM New Skin Issue investigation indicated Resident 1 was found to have intact blisters on her/his lower abdominal area during cares. Resident 1 was unaware of the blistering. The injury location was indicated as the front right and left iliac crest (the three most significant bones that make up the hip bone). The blisters were around the umbilical area from three o'clock to seven o'clock. There was a total of three blisters around her/his belly button with the larger blister measuring five cm by six cm. There was some pale and blanchable redness around the large blister. A hot water bottle was not found in Resident 1's room and was ruled out as a contributing factor during the investigation. After the investigation was completed, it was determined the hot water bottle was not used for more than 12 hours. The last use was on the prior evening shift and was placed on Resident 1's hand with a pillowcase over the water bottle to prevent direct contact with her/his skin. Resident 1 indicated the hot water bottle was used on her/his hand and the way she/he sat up in her/his chair if the water bottle rolled out of place or got dropped it would land on her/his upper abdomen and not where the blisters were located. The hot water bottle was removed from her/his room to prevent potential future skin issues and Resident 1 was aware of the removal. An undated handwritten statement by Staff 12 (CNA) indicated she bought hot packs for Resident 1 earlier in 12/2021 and was informed the hot packs were allowed because they did not require to be microwaved. The hot packs were bladder bags which were filled with warm tap water. On 1/9/22 before Resident 1 presented with blisters, when staff put her/him into bed, Resident 1 liked a large pillow under each arm and rested her/his hands on those pillows. Resident 1's hot packs were placed on the top of the pillows and did not meet her/his skin on her/his abdomen. The hot packs were only for her/his hands because she/he had pain. Staff placed them into a pillowcase or placed a towel over them so there was no direct contact to her/his skin. No documentation was found in clinical records that Resident 1 was care planned or had a physician order for treatment or intervention using hot packs, hot water bottles or warm rags to be placed on her/his hands. A 3/15/22 Wound Clinic Progress Notes indicated Resident 1 presented with an open wound to the abdomen caused by a hot water bottle. The burn wound was debrided, the history came from the family and Resident 1's medical records. The age of the wounds was 10 weeks and they measured 9.5 cm by 8.5 cm by 0.1 cm, with a total wound area of 80.75 cm2. There was subcutaneous (beneath all layers of skin) eschar (dead tissue which is cast off from the surface of the skin, particularly after a burn injury but also can be seen in gangrene, ulcer, fungal infections, and bite wounds), granulation (new connective tissue which forms on the surface of a wound during healing process) was 10 percent, slough (necrotic tissue which needs to be removed) was 30 percent, unstable eschar was 50 percent, stable eschar was 10 percent, and serosanguineous (both blood and liquid part of the blood which is yellowish in color) drainage was present. The pain level was noted at five out of 10 since the last visit. Resident 1 was diagnosed with a burn of the abdomen with an unspecified burn degree. A 9/19/22 Significant Change MDS indicated Resident 1 had a BIMS of 9 indicating moderate cognitive impairment. On 12/8/22 at 7:59 AM Witness 1 (Complainant) stated the physicians who saw Resident 1's blisters indicated it was caused from burning to the skin. Witness 1 stated she was first told by the facility it was from a medication reaction, but never heard what medication. She was then informed it was from Resident 1's incontinent brief which caused the blisters on her/his abdomen. Witness 1 stated she believed the CNAs were trying to help Resident 1 with her/his cold hands when placing the hot water bottle. On 12/8/22 at 10:10 AM Resident 9 stated she/he was Resident 1's roommate in 1/2022 and she/he saw staff using a hot water bottle on Resident 1 once or twice and heard a conversation that they could no longer use the hot water bottle for Resident 1 anymore. On 12/13/22 at 10:30 AM Witness 7 (Wound Clinic Family Nurse Practitioner) stated she did not believe the wounds on Resident 1's abdomen were caused by an incontinent brief. Witness 7 stated her assessment was the wounds were burns caused by the hot water bottle as the wounds were in the shape of a hot water bottle. On 12/14/22 at 12:38 PM Staff 2 (DNS) stated she knew the hospital and the wound clinic described Resident 1's abdominal wounds as burns and that is what the family believed. Staff 2 stated she believed that was why the hospital and wound clinic documented the wounds as burns. Staff 2 stated Staff 3 (RNRCM) ruled out the wounds as burns and the investigation found the blisters were caused from Resident 1's incontinent briefs which developed eschar as they evolved. On 12/16/22 at 9:51 AM Staff 31 (RN) stated she observed the hot water pack in Resident 1's room and she removed it from the room. On 12/16/22 at 10:59 AM Staff 10 (CNA) stated she used warm rags which she put in a pillowcase for Resident 1 but she did not use a hot water packs. Staff 10 stated someone gave Resident 1 a water bag thing but she never saw any one use it. Staff 10 stated she saw the wounds on Resident 1's abdomen and they were above her/his belly button. Staff 1 stated Resident 1's brief went below her/his belly button for comfort. Staff 10 stated there were two to three wounds in one area and one was bigger and they were not all the same size. Staff 10 stated since working as a CNA for [AGE] years she never saw a brief cause wounds like Resident 1 had on her/his abdomen. Staff 19 stated she did not see burns on a resident in her [AGE] years working as a CNA. On 12/20/22 at 12:23 PM Staff 12 (CNA) stated she was the staff member who purchased the hot packs for Christmas in 12/2021 for Resident 1's hands. Staff 12 described the hot pack as an old-fashioned pack which was balloon shaped, was made of rubberized material, and it was pleated from the base to the top which had the lid in which to put in either cold or warm water. Staff 12 stated she spoke to the RCM before purchasing the hot packs to make sure it was okay to use. Staff 12 stated she used warm tap water in the pack and either placed them into a pillowcase or placed a towel on top of the pack before placing on Resident 1's hands. On 12/21/22 at 9:33 AM Staff 38 (Nurse Practitioner) stated she believed the abdominal blisters could have been caused by the brief from the plastic fold and from the brief being too small on Resident 1. Staff 38 stated it was also possible the blisters could have been caused from a burn. On 12/22/22 at 10:01 AM Staff 1 (Administrator) and Staff 2 (DNS) confirmed Resident 1 did not have physician orders and was not care planned for the use of a hot water packs. b. A 1/10/22 Incident Note indicated Resident 1 had blisters to her/his abdominal area. Resident 1 was unable to describe how they occurred. Resident 1 was placed on alert charting. A revised 2/1/22 care plan indicated Resident 1 required one staff for incontinent care, she/he may use two staff for comfort, and she/he was totally incontinent of bowel. Resident 1 used bariatric size disposable incontinent briefs. A 1/10/22 at 11:38 AM New Skin Issue investigation indicated Resident 1 was found to have intact blisters on her/his lower abdominal area during cares. Resident 1 was unaware of the blistering. Notes written on 1/11/22 indicated staff noted multiple fluid fill blisters on Resident 1's abdomen. The blisters were around the belly button area from three o'clock to seven o'clock. There was a total of three blisters around her/his belly button and the larger blister measured five cm by six cm. There was some pale and blanchable redness around the large blister. Staff indicated they used a different size incontinent brief as the bariatric brief normally used for Resident 1 was on back-order and was out of stock at the facility. The staff used a brief which was one size smaller on Resident 1. Staff stated the brief was a bit snugged on her/him and might have caused compression and friction creating the blisters on her/his lower abdomen and belly button area. An undated handwritten statement by Staff 12 (CNA) indicated she was assisting Resident 1 into bed and her/his brief was not the right size because they were not available. Staff 12 noticed a small open area on her/his left side where the brief was fastened and mentioned the briefs were too small. Staff 12 proceeded to fasten the brief as loose as possible so it was not cutting into her/his skin. A 1/14/22 Physician/ARNP/PA Note indicated Staff 38 (Nurse Practitioner) indicated Resident 1 was evaluated for a large fluid filled blister to lower abdomen. Staff 38 wrote CAN believe blister came with using different adult briefs causing reaction, and recommended to allow the blister fluid to reabsorb into Resident 1's body. On 12/8/22 at 7:59 AM Witness 1 (Complainant) stated she was first told by the facility the blistering was from a reaction to medication, but never heard what medication, and she was then informed it was from Resident 1's brief which caused the blisters on her/his abdomen. On 12/14/22 at 12:38 PM Staff 2 (DNS) stated Staff 3 (RNRCM) ruled out the abdominal wounds as burns and the investigation found the blisters were caused from Resident 1's incontinent briefs which developed eschar as they evolved. On 12/20/22 at 12:23 PM Staff 12 (CNA) stated she had to use smaller size briefs for a while as the facility was out of stock for Resident 1's size. Staff 12 stated the brief fit under Resident 1's abdominal fold and Staff 12 usually placed a pillowcase in Resident 1's abdominal fold for comfort. Staff 12 stated the brief was not touching the area of the abdominal wounds and she did not know how the wounds occurred. Staff 12 stated it was super random. On 12/21/22 at 9:33 AM Staff 38 (Nurse Practitioner) stated she believed the blisters could have been caused by the brief from the plastic fold and from the brief being too small on Resident 1. On 12/22/22 at 10:01 AM Staff 1 (Administrator) and Staff 2 (DNS) stated when the facility became aware Resident 1's brief size was out of stock and on back-order the facility placed an order with a different company. Staff 2 stated if a smaller size brief had to be used on a resident it was suggested not to attach the tabs. c. A 1/20/21 Admission Profile revealed Resident 1 had ace wraps on both lower legs and usually wore stockings at home which would be on during the day and off during the night. Resident 1 used the ace wraps 24 hours a day seven days a week since she/he went to the hospital. Lotion was applied to Resident 1's legs and the wraps were put back into place. A review of Resident 1's clinical medical records revealed no physician order for the leg wraps to be applied on 1/20/21. On 12/22/22 at 10:23 AM Staff 1 (Administrator) and Staff 2 (DNS) stated it was expected of staff to reach out to a physician for an order if Resident 1 insisted on having the leg wraps be put on.

Based on record review and interview it was determined the facility failed to complete a discharge summary which included a recapitulation of stay and a final summary of resident status for 1 of 3 sampled residents (#1) reviewed for a discharge summary. This placed residents at risk for unmet needs post discharge. Findings include: Resident 1 was admitted to the facility in 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a Discharge Summary dated 2/3/21 revealed Resident 1 was discharged to a local Adult Foster Home (AFH). The Discharge summary did not include a recapitulation of Resident 1's course of illness or treatment at the facility. The summary also did not include the resident's status on discharge including functional status, diet limitations, skin condition, equipment discharged with the resident and prognosis. In an interview on 6/4/21 at 10:23 AM Staff 1 (DNS) acknowledged Resident 1's discharge summary did not include a recapitulation of the resident's stay at the facility and the resident's status upon discharge from the facility. In an interview on 6/4/21 at 11:18 AM Witness 5 (AFH Provider) said the facility did not send a Discharge Summary to the AFH with a recapitulation of the resident's stay and the resident's status on discharge from the facility when the resident was admitted to the AFH.

Based on interview and record review, the facility failed to ensure the Infection Preventionist (IP), completed specialized training in infection control prevention, which had the potential to affect 38 of 38 residents residing in the facility. Findings include: On 12/10/20 at 10:03 AM, an interview in the conference room with the Infection Preventionist, indicated she had not completed specialized training for infection control. The IP revealed she had started the training, but that she had gotten too busy at work to complete the program. On 12/10/20 at 10:30 AM, an interview with the Administrator indicated the facility's IP had not had infection control specialized training because they have been busy with COVID-19 related issues. The Administrator revealed the IP should have specialized training and it will be completed as soon as possible. On 12/11/20 at 10:20 AM, an interview in the conference room with the Director of Nursing Services (DNS) revealed the IP had been in her position since early June and the IP had not had time to complete infection prevention specialized training. The DNS indicated she was aware of the mandatory infection control training and that the facility's IP should have specialized training in infection control. On 12/11/20 at 3:00 PM, in the conference room, the DNS provided the policy entitled, Infection Preventionist, dated 1/10 and revised 10/17. The DNS revealed this is the policy the facility follows regarding the Infection Preventionist's roll. The policy was reviewed at this time and revealed no guidance on required training for Infection Preventionists.

Based on observation, interview and record review it was determined the facility failed to provide therapeutic heart healthy diets for 1 of 1 kitchens reviewed for dining. This placed residents at risk for worsening health conditions. Findings include: On 1/15/20 at 7:22 AM Staff 5 (Cook) was observed during the breakfast meal portioning hot food according to a typed document posted on the wall near the kitchen steam table titled Portion Sizes and Diets. The document included the following statements: -CCHO (Controlled Carbohydrate) diets-regular protein, regular vegetables, half serving starch, half serving desserts or diabetic dessert. -Heart Healthy-Regular Portions??? Small serving of desserts. On 1/15/20 at 8:10 AM Staff 4 (Dietary Manager) indicated she was not aware of the Portion Sizes and Diet document posted on the kitchen wall. Staff 4 confirmed staff were to follow therapeutic diets as order by the physician for each resident and provide portion sizes and food restriction of therapeutic diets according spreadsheets provided by the Registered Dietitian. Staff 4 also confirmed the posted document did not have the correct portions sizes or food restrictions of a heart healthy therapeutic diet. On 1/15/20 at 2:17 PM Staff 8 (RD) stated she was not aware of the Portion Sizes and Diets document and staff were to follow the therapeutic diet spreadsheets provided. On 1/15/20 at 4:23 PM Staff 11 (RNCM) provided documentation indicating six residents had orders for a heart healthy therapeutic diet at the time of the survey. On 1/16/20 at 9:32 AM Staff 9 (RD) indicated the last kitchen assessment she completed was during the summer when she observed staff following the therapeutic diet spreadsheets. Staff 9 also stated she was not aware of the Portion Sizes and Diets document. On 1/16/20 at 12:16 PM Staff 2 (DNS) stated the kitchen was to provide therapeutic diets as ordered.

Based on interview and record review it was determined the facility failed to ensure narcotic drug records were in order and an account of all controlled drugs was maintained for 3 of 4 medication carts reviewed for medication storage. This placed residents at risk for drug diversion. Findings include: On 1/14/20 at 9:45 AM the D hall medication cart Narcotic log book revealed 24 times out of 107 counting opportunities the facility staff did not sign verification the narcotic count was accurate. On 1/14/20 at 10:30 AM the A hall medication cart Narcotic log book revealed 27 times out of 107 counting opportunities the facility staff did not sign verification the narcotic count was accurate. On 1/14/20 at 11:00 AM the B hall medication cart Narcotic log book revealed 17 times out of 109 counting opportunities the facility staff did not sign verification the narcotic count was accurate. On 1/14/20 at 10:22 AM Staff 2 (DNS) verified the missing signatures in the Narcotic books. Staff 2 acknowledged the Narcotic book always needed to be signed by two nurses to verify the count was accurate.

Based on observation and interview it was determined the facility failed to provide dignity during dining for 1 of 1 sampled dining rooms observed for dining assistance. This placed residents at risk for an undignified dining experience. Findings include: On 1/13/20 at 6:10 PM Staff 10 (CNA) was observed standing and assisting two residents with dining during the evening meal. On 1/14/20 at 12:30 PM and 1/15/20 at 12:23 PM Staff 6 (CNA) was observed standing while assisting two residents with dining during the afternoon meal. On 1/15/20 at 4:12 PM Staff 2 (DNS) stated she expected staff to interact with residents during meals and not stand over them.

Based on observation, interview and record review it was determined the facility failed to prevent the development of pressure ulcers for 1 of 3 sampled residents (#36) reviewed for pressure ulcers. This resulted in the development of a Stage 3 and an additional Stage 2 pressure ulcer for Resident 36 and increased the risk of complications associated with pressure ulcers. Findings include: CMS Appendix PP defined the following pressure ulcer stages: - Stage 1 Pressure Injury: Non-blanchable [DIAGNOSES REDACTED] of intact skin Intact skin with a localized area of non-blanchable [DIAGNOSES REDACTED] (redness). In darker skin tones, the PI may appear with persistent red, blue, or purple hues. The presence of blanchable [DIAGNOSES REDACTED] or changes in sensation, temperature, or firmness may precede visual changes. Color changes of intact skin may also indicate a deep tissue PI (see below). - Stage 2 Pressure Ulcer: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. This stage should not be used to describe moisture associated skin damage including incontinence associated [MEDICAL CONDITION], intertriginous [MEDICAL CONDITION] (inflammation of skin folds), medical adhesive related skin injury, or traumatic wounds (skin tears, burns, abrasions). - Stage 3 Pressure Ulcer: Full-thickness skin loss Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the wound bed, it is an Unstageable PU/PI. - Unstageable Pressure Ulcer: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) should only be removed after careful clinical consideration and consultation with the resident's physician, or nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws. If the slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer will be revealed. If the anatomical depth of the tissue damage involved can be determined, then the reclassified stage should be assigned. The pressure ulcer does not have to be completely debrided or free of all slough or eschar for reclassification of stage to occur. Resident 36 was admitted to the facility in 3/2018 with [DIAGNOSES REDACTED]. A 3/25/18 Progress Note revealed the resident had a neck brace on with a wash cloth under the brace to avoid abrasions on the chest. A 3/26/18 Progress Note included the neck brace was to be worn at all times. The resident's family had expressed it was very important the facility call family for any problems, questions or changes. A Pressure Ulcer CAA dated 4/1/18 indicated Resident 36 had a decline in ADL and functional status related to a fall with resulting injuries including a neck fracture. No existing pressure ulcers were present. The resident was at risk for skin breakdown and falls and staff were to monitor her/his skin. The 4/2018 TAR contained the following: monitor skin under the Aspen cervical collar, report skin breakdown to MD every day and evening shift for skin management (have another person steady the resident's head). The start date for the treatment order was 3/27/18. The 4/2018 TAR indicated no treatments ordered for the clavicle pressure ulcer, first identified on 4/8/18, were done on 4/9, 4/10, 4/11 or 4/13. The 4/2018 TAR also instructed staff to check the resident's skin and indicate + if new condition present, - if no new skin condition. If new skin condition present, document a progress note and initiate skin documentation form, every shift for prevention of skin breakdown. The start date was 3/26/18. No skin issues were checked with a + on either 4/8/18 when the initial pressure ulcer was found or on 4/23/18 when the second pressure ulcer was found. Staff initialed three times a day on day, evening and night shift that skin was checked but did not identify the new skin issues. On 4/8/18 at 5:20 AM an Incident Progress Note indicated the resident was noted to have an open area on her/his left clavicle neck area. An LPN noticed a sore about the size of a nickel with slight yellow bed to it, mostly pink bedded with some cream colored discharge noted on the brace. The area was cleansed and a dry dressing applied. On 4/13/18 a revised care plan indicated the resident had developed a Stage 3 pressure ulcer on her/his left clavicle area related to the neck brace as of 4/8/18. The care plan contained no documentation or instructions to staff on how to care for the brace, how to clean the brace, what to monitor, potential issues related to the use of the brace or how to safely remove the brace to complete skin assessments. A 4/13/18 Skin/Wound Progress Note indicated the resident's skin treatment was done to the right neck area (Stage 3). Witness 3 (family) was present for the wound care. The neck brace was opened while the resident was lying flat in bed to view the full neck area for any other skin concerns (none were found). The 4/23/18 Incident Report for the pressure ulcer found on 4/8/18 was provided but was not complete. The Injury Type was not specified nor was the location of the ulcer. The Nursing Description section stated the resident had a sore on the left clavicle area about nickel size but contained no further information or description. The Predisposing Situation Factors section had the comment the patient wears a collar for a neck fracture but contained no explanatory information on the impact of the brace on development of the pressure wound. No incident summary was provided, no witnesses were found and the family was not notified according to the form. A 4/23/18 progress note revealed Resident 36 had a new sore under her/his chin from the cervical collar. On 4/26/18 at 2:30 PM surveyors were present for a dressing change of Resident 36's clavical/neck wound and observed a quarter size Stage 3 pressure ulcer with a reddish wound bed with slough over one third of the area. A second nickle size Stage 2 pressure ulcer was noted under the resident's chin on the left side. The Stage 2 wound was open and with red tissue present. A third area of concern located directly at the base of the jaw was open and moist. On 4/27/18 at 9:21 AM Staff 12 (LPN) stated the resident had two pressure ulcers. One was on the resident's clavicle and the other was under the resident's chin. Staff 12 stated when the resident first admitted to the facility she would not remove the brace but would try to look underneath the brace to assess the skin. The resident did not want the brace removed unless a family member was present. Staff 12 indicated she did not remove the brace to view the skin during the day and the dressing changes were done on the evening shift only. On 4/27/18 at 9:46 AM Resident 36 stated the staff did not initially look under the brace when she/he admitted to the facility and the sore was located under the brace. It felt scratchy like a bad sunburn and was very irritating. When the staff finally opened up the brace the wound was already there. Resident 36 stated there was no runny stuff but the sore was painful and itchy. Resident 36 also stated the staff did not check under the brace in the mornings only in the evenings, they did not clean under the brace during bed baths and they did not look at the skin during bath time either. The resident further stated, I got a new brace and that's when I got the other sore under my chin. The new brace has a bar that goes under my chin and when I talk or chew it rubs across that area. On 4/27/18 at 10:08 AM Staff 10 (CNA) stated she worked during day shifts and had never assisted with removing the brace for any reason. On 4/27/18 at 11:04 AM Staff 6 (RNCM) indicated staff had not completed the 4/2018 TAR accurately and there was no documentation to indicate staff had been monitoring the skin under the cervical collar in 4/2018. On 4/30/18 at 3:13 PM Witness 3 (family) revealed she was in the room for the resident's initial intake and assessment and the staff did not take the brace off for the skin assessment, they looked up under it. Witness 3 stated she believed no one took the brace off until the staff popped it open on 4/8/18 and saw the wound. Witness 3 also revealed the resident had been hesitant to have the brace removed and preferred to have family present when it was removed. Witness 3 stated she lived very close to the facility and was always available to be there if needed. Witness 3 indicated staff had not called and notified her of the second ulcer, the resident had told her about it. On 5/1/18 at 7:45 AM Staff 11 (CNA) stated he worked with the resident the first week she/he admitted to the facility and then sporadically from then on. Staff 11 stated he was never asked to assist with helping to remove the neck brace for nursing to do any treatments or to look at the skin at any time. On 4/27/18 at 11:11 AM Staff 6 (RNCM) acknowledged the sore under the brace was a Stage 3 facility acquired pressure ulcer. The initial Aspen collar (neck brace) was changed to a Miami J brace but there was no documentation found regarding the change. Additionally, there was nothing on the care plan for managing the neck brace or documentation that nursing staff were given any information about the brace. Staff 6 acknowledged the Incident Report for the wound was incomplete. Upon review of the 4/2018 TAR Staff 6 acknowledged there was no documentation on the TAR to indicate the treatments ordered for 4/9, 4/10. 4/11 or 4/13 were done. Regarding the newer Stage 2 pressure ulcer discovered on 4/23/18 under resident's chin Staff 6 (RNCM) initially indicated the wound was only an abrasion. On 4/27/18 at 12:04 PM a dressing change was completed for Resident 36 and the chin was observed by two surveyors including an RN and Staff 6. Staff 6 acknowledged it was a Stage 2 pressure ulcer not an abrasion.

Based on observation and interview it was determined the facility failed to ensure proper labeling and storage of biologicals for 1 of 4 medication carts and 1 of 1 medication rooms. This placed residents at risk for receiving expired and unsafe medications. Findings include: On [DATE] at 6:49 AM the medication cart for B hall was observed to contain an unlabeled medication syringe with a clear substance inside of it. On [DATE] at 7:12 AM the medication room contained a [MEDICATION NAME] vial with no open date and a [MEDICATION NAME] (long acting insulin) pen with no open date. On [DATE] at 6:49 AM and 7:12 AM Staff 3 (LPN) acknowledged the medication syringe with clear liquid was unlabeled, the [MEDICATION NAME] had no open date and the [MEDICATION NAME] vial had no open date.

Based on interview and record review it was determined the facility failed to ensure accurate assessments for 4 of 11 sampled residents (#s 14, 19, 21 and 37) reviewed for accidents, nutrition, catheter care and unnecessary medications. This placed residents at risk for inaccurate assessments. Findings include: 1. Resident 14 was admitted to the facility in 11/2017 with [DIAGNOSES REDACTED]. Resident 14's 11/27/17 Admission MDS Section J - Health Conditions revealed the pain assessment was not completed and was coded resident rarely/never understood. On 4/27/18 at 11:46 AM Staff 12 (LPN) stated Resident 14 was able to verbalize her/his needs including complaints of pain. In an interview on 4/30/18 at 3:34 PM Staff 6 (RNCM) acknowledged the pain assessment in Section J was not completed and stated she was unable to remember why she did not do the interview because Resident 14 was interviewable. 2. Resident 19 was admitted to the facility in 1/2018 with [DIAGNOSES REDACTED]. Resident 19's 1/15/18 Admission MDS Section I - Active [DIAGNOSES REDACTED]. The resident's 1/15/18 Admission MDS Section J - Health Conditions indicated Resident 19 had a condition or chronic disease with a life expectancy of less than six months. During an interview on 4/24/18 at approximately 12:15 PM Resident 19 indicated she/he was not on hospice. On 5/1/18 at 8:13 AM Staff 4 (RNCM) acknowledged the MDS was not coded accurately regarding the resident's active medical [DIAGNOSES REDACTED]. 3. Resident 21 was admitted to the facility in 3/2018 with [DIAGNOSES REDACTED]. According to 2/23/18 hospital records Resident 21 experienced a fall at home prior to transport to the hospital. Resident 21's 3/12/18 Admission MDS Section J - Health Conditions was not coded to reflect the resident's fall within the last month prior to entry to the facility. The (MONTH) (YEAR) MAR indicated [REDACTED]. The 3/12/18 Admission MDS Section N - Medications indicated Resident 21 received an anticoagulant (decreases blood's clotting ability) during the look back period (3/6/18 through 3/12/18). The RAI Manual current guidance indicated antiplatelet medications are not coded as anticoagulants. During interviews on 4/24/18 at 3:38 PM and 5/1/18 at 9:44 AM Staff 6 (RNCM) acknowledged the coding for Resident 21's fall history and [MEDICATION NAME] use was inaccurate. 4. Resident 37 was admitted to the facility in 3/2018 with [DIAGNOSES REDACTED]. Resident 37's 3/28/18 Admission MDS Section N - Medications indicated the resident received an anticoagulant (decreases blood's clotting ability) during the seven day look back period (3/22/18 through 3/28/18). The (MONTH) (YEAR) MAR indicated [REDACTED]. The RAI Manual current guidance indicated antiplatelet medications are not coded as anticoagulants. During an interview on 4/26/18 at 3:38 PM Staff 4 (RNCM), Staff 6 (RNCM) and Staff 2 (DNS) acknowledged [MEDICATION NAME] was not an anticoagulant and the MDS was coded inaccurately.

Based on observation, interview and record review it was determined the facility failed to ensure comprehensive assessments were completed for falls and pain for 2 of 8 sampled residents (#s 14 and 21) reviewed for accidents and unnecessary medications. This placed residents at increased risk for pain and falls with injury. Findings include: 1. Resident 14 was admitted to the facility in 11/2017 with [DIAGNOSES REDACTED]. Resident 14's 11/20/17 admission orders [REDACTED]. On 4/26/18 at 6:50 PM Witness 4 (Family) revealed Resident 14 had experienced pain issues for years and her/his pain continued to worsen due to the resident's recent fall and arthritis. Resident 14's 11/27/17 Admission MDS did not include a Pain CAA. On 4/30/18 at 11:15 AM Staff 7 (RNCM) acknowledged a Pain CAA was not completed for Resident 14 upon admission. 2. Resident 21 was admitted to the facility in 3/2018 with [DIAGNOSES REDACTED]. Resident 21's 2/23/18 hospital record revealed she/he experienced a fall at home prior to transport to the hospital. The resident's 3/12/18 Admission MDS Falls CAA indicated she/he had weakness and was at risk for falls but did not include Resident 21's history of falls. In an interview on 5/1/18 at 9:44 AM Staff 6 (RNCM) stated she missed the documentation regarding Resident 21's fall at home and did not include it in the Fall CAA.

Based on observation, interview and record review it was determined the facility failed to ensure care planned fall interventions were followed for 1 of 3 sampled residents (#1) reviewed for falls. Resident 1 sustained a fracture. Findings include: Resident 1 was admitted to the facility in November, 2012 with [DIAGNOSES REDACTED]. The resident sustained [REDACTED]. The In-Room Care Plan dated 11/4/12 indicated the resident had poor safety awareness and was a high fall risk. The care plan directed staff turn on the resident's bed motion sensor alarm (sounds an alarm if a self transfer is attempted). The Fall Risk Evaluation dated 11/29/12 documented the resident's high fall risk. The Resident Incident Investigation Report dated 12/30/12 indicated at 2:30 am staff heard a noise in the resident's room and saw the resident lying on her/his back on the floor. The report documented the resident had self transferred out of bed to use the restroom and fell after an attempt to return to bed. The documentation revealed the resident reported significant left hip pain. The Investigation and Findings report dated 12/30/12 revealed the resident's In-Room care plan dated 11/4/12 included the use of a motion alarm. The investigation concluded Staff 3 (LPN) had not seen an alarm in the resident's room when she assisted the resident into bed 30 minutes prior to the resident's fall. The report revealed Staff 3 thought the resident's motion alarm was discontinued. The Witness Report dated 12/30/12 indicated Staff 4 (CNA) saw the resident lying on the floor near the restroom and the resident's walker was within reach. The hospital's Radiology Report dated 12/30/12 revealed the resident sustained [REDACTED]. The hospital's Discharge Summary dated 1/4/13 indicated the resident underwent [REDACTED]. On 1/11/13 at 12:00 pm Staff 1 (Administrator) stated Staff 3 (LPN) indicated she transferred Resident 1 into bed, did not see a bed sensor alarm in the resident's room and Staff 3 indicated she was not aware the device was to be utilized. On 1/11/13 at 1:30 pm Resident 1 was observed lying in bed. There was a fall mat and an activated bed sensor alarm in use at the resident's bedside. The resident indicated s/he could not recall the details of the fall on 12/30/12. On 1/11/3 at 1:40 pm Staff 2 (RNCM) stated the resident was assessed as a high fall risk and the resident often attempted self transfers. Staff 2 stated the resident was care planned for a bed motion sensor alarm when the resident fell on [DATE]. On 1/11/13 at 1:45 pm Staff 5 (CNA) stated the resident often attempted self transfers and a bed motion sensor alarm was included on the resident's In-Room Care Plan. On 1/11/13 at 1:55 pm Staff 3 (LPN) indicated she transferred Resident 1 into bed around 2:00 am on 12/30/12. Staff 3 stated at 2:30 am staff heard a noise, found the resident lying on her/his back on the floor. Staff 3 indicated she was not aware the resident was care planned for a bed sensor alarm. Staff 3 stated the resident reported significant left leg pain during gentle ROM and the resident was sent to the local hospital. On 1/11/13 at 4:30 am Staff 4 (CNA) indicated the resident often hid the motion sensor, she checked the resident frequently and she was aware the resident's care plan included the use of a bed sensor alarm. Staff 4 indicated she did not see the resident from the time Staff 3 transferred the resident into bed and when she saw the resident lying on the floor on 12/30/12. On 1/15/13 at 12:00 pm Staff 1 (Administrator) indicated Staff 3 (LPN) admitted she did not see a bed sensor alarm in Resident 1's room when she transferred the resident into bed prior to the resident's fall on 12/30/12. Staff 1 concluded Staff 3 was not aware of the resident's care planned bed sensor alarm and agreed staff should review a resident's care plan prior to the provision of care.

Based on observation, interview and record review it was determined the facility failed to ensure staff professional standards of practice were followed related to care planned fall interventions for 1 of 3 sampled residents (#1) who had a fall. Resident 1 sustained a fracture. Findings included: Division 45 Scope of Practice Standards for All Licensed Nurses 851-045-0040 (1) Standards related to the licensed nurse's responsibilities for client advocacy. The licensed nurse: (b) Intervenes on behalf of the client to identify changes in health status, to protect, promote and optimize health, and to alleviate suffering... Resident 1 was admitted to the facility in November, 2012 with [DIAGNOSES REDACTED]. The In-Room Care Plan dated 11/4/12 indicated the resident had poor safety awareness and was a high fall risk. The care plan directed staff turn on the resident's bed motion sensor alarm (sounds an alarm if a self transfer is attempted). The Fall Risk Evaluation dated 11/29/12 documented the resident's high fall risk. The Resident Incident Investigation Report dated 12/30/12 indicated at 2:30 am staff heard a noise in the resident's room and saw the resident lying on her/his back on the floor. The report documented the resident had self transferred out of bed to use the restroom and fell after an attempt to return to bed. The documentation revealed the resident reported significant left hip pain. The Investigation and Findings report dated 12/30/12 revealed the resident's In-Room Care Plan dated 11/4/12 included the use of a motion alarm. The investigation concluded Staff 3 (LPN) had not seen an alarm in the resident's room when she assisted the resident into bed 30 minutes prior to the resident's fall. The report revealed Staff 3 thought the resident's motion alarm was discontinued. The Witness Report dated 12/30/12 indicated Staff 4 (CNA) saw the resident lying on the floor near her/his restroom and the resident's walker was within reach. The hospital's Radiology Report dated 12/30/12 revealed the resident sustained [REDACTED]. The hospital's Discharge Summary dated 1/4/13 indicated the resident underwent [REDACTED]. On 1/11/13 at 12:00 pm Staff 1 (Administrator) stated Staff 3 (LPN) indicated she transferred Resident 1 into bed, did not see a bed sensor alarm in the resident's room and Staff 3 indicated she was not aware the device was to be utilized. On 1/11/13 at 1:30 pm Resident 1 was observed lying in bed. There was a fall mat and an activated bed sensor alarm in use at the resident's bedside. The resident indicated s/he could not recall the details of the fall on 12/30/12. On 1/11/3 at 1:40 pm Staff 2 (RNCM) stated the resident was assessed as a high fall risk and the resident often attempted self transfers. Staff 2 stated the resident was care planned for a bed motion sensor alarm when the resident fell on [DATE]. On 1/11/13 at 1:45 pm Staff 5 (CNA) stated the resident often attempted self transfers and a bed motion sensor alarm was included on the resident's in-room care plan. On 1/11/13 at 1:55 pm Staff 3 (LPN) indicated she transferred Resident 1 into bed around 2:00 am on 12/30/12. Staff 3 stated at 2:30 am staff heard a noise, found the resident lying on her/his back on the floor. Staff 3 indicated she was not aware the resident was care planned for a bed sensor alarm. Staff 3 stated the resident reported significant left leg pain during gentle ROM and the resident was sent to the local hospital. On 1/11/13 at 4:30 am Staff 4 (CNA) indicated the resident often hid the motion sensor, she checked the resident frequently and she was aware the resident's care plan included the use of a bed sensor alarm. Staff 4 indicated she did not see the resident from the time Staff 3 transferred the resident into bed and when she saw the resident lying on the floor on 12/30/12. On 1/15/13 at 12:00 pm Staff 1 (Administrator) indicated Staff 3 (LPN) admitted she did not see a bed sensor alarm in Resident 1's room when she transferred the resident into bed prior to the resident's fall on 12/30/12. Staff 1 concluded Staff 3 was not aware of the resident's care planned bed sensor alarm and Staff 1 agreed staff should review a resident's care plan prior to the provision of care. Refer to F323