Every finding on record at Regency Prineville Rehabilitation and Nursing Cent

Based on observation, interview and record review it was determined the facility failed to ensure supervision and safety interventions were in place for 1 of 1 sampled resident (#2) reviewed for smoking safety. This placed residents at risk smoking related injuries. Findings include:The facility's 4/2018 Smoking Policy indicated the following:-Residents were able to smoke tobacco only in designated areas on the premises.-If the facility had supervised smoking, times would be posted on the facility's nursing units and provided for residents who smoke. Smoking periods were limited to 15 minutes at the designated times.-The schedule for smoke breaks was Monday-Sunday at 6:45 AM, 9:45 AM, 12:45 PM, 3:45 PM, 6:45 PM, and 9:30 PM.-It was recommended residents were supervised when they were smoking although there may be some residents assessed to be independent. Resident 2 was admitted to the facility in 10/2024 with diagnoses including chronic obstructive pulmonary disease (a lung disease that blocks airflow). A 10/24/25 Annual MDS indicated Resident 2 was cognitively intact. A 10/25/25 Care Plan indicated Resident 2 was assessed to be an independent smoker and had to store her/his smoking supplies at the nurse's station. A 1/12/26 Smoking Safety Evaluation indicated Resident 2 had poor judgement and decision-making skills related to smoking. The resident was to be supervised during smoking periods and return all smoking supplies to the nurse's station at the end of each designated smoke period. Resident 2 was observed outside smoking without supervision on the following occasions:-1/13/26 at 12:44 PM-1/13/26 at 1:02 PM-1/14/26 at 2:40 PM-1/15/26 at 10:15 AMNo evidence was found in Resident 2's clinical record to indicate the resident had any smoking related accidents or injuries.On 1/14/26 at 9:04 AM Staff 9 (CNA) stated Resident 2 required supervision for smoking and required staff to obtain her/his smoking items from the nurse's station and accompany her/him to the designated smoking area. Staff 9 stated a staff member had to be with the resident during the entire smoking period and was to collect the resident's smoking items and return them back to the secured cupboard at the nurse's station after the resident was finished smoking. On 1/14/26 at 9:40 AM Staff 4 (LPN) stated Resident 2 required supervision for smoking and she/he was found outside on multiple occasions, smoking without staff present. On 1/15/26 at 10:02 AM Staff 2 (DNS) stated Resident 2 was assessed as requiring supervision for smoking due to her/him being impulsive when it involved making decisions related to smoking. Staff 2 stated the resident was recently reviewed for her/his quarterly Smoking Safety Evaluation and the care plan was not updated to reflect the change of smoking privilege status until 1/15/26. Staff 2 indicated Resident 2 did not have any smoking related accidents or injuries. On 1/15/26 at 10:21 AM Staff 1 (Administrator) and the surveyor observed Resident 2 smoking outside without supervision and Staff 1 acknowledged Resident 2 required supervision while smoking.

Based on interview and record review it was determined the facility failed to follow physician orders for 1 of 3 sampled residents (#1) reviewed for medication. This placed residents at risk for behaviors. Findings include: Resident 1 admitted to the facility in 2024 with diagnoses including depressive disorder. The 12/27/24 physician order indicated Resident 1 was to receive Zyprexa (antipsychotic) 2.5 mg at bedtime. The 12/2024 MAR indicated Resident 1 did not start taking Zyprexa until 12/31/24. On 5/13/25 at 12:08 PM Witness 2 (Pharmacy Technician) stated the pharmacy did not receive an order for Zyprexa until 12/31/24. On 5/13/25 at 1:19 PM Staff 2 (DNS) acknowledged Resident 1 had an order for Zyprexa on 12/27/25 and the order was not implemented until 12/31/24 (4 days later).

Based on interview it was determined the facility failed to ensure mail was delivered to residents on Saturdays for 1 of 1 facility reviewed for resident council. This placed residents at risk for lack of timely written communication. Findings include: During the resident council meeting on 8/14/24 at 2:30 PM residents stated their mail was not delivered to them on Saturdays. On 8/15/24 at 2:12 PM Staff 3 (Activities Director) stated mail was delivered to the facility Monday through Saturday, and she passed out mail to the residents Monday through Friday. She verified mail was not delivered to residents on Saturdays. On 8/16/24 at 10:35 AM Staff 1 (Administrator) stated mail was previously passed out to residents on Saturdays by housekeeping or activities staff, but this practice was currently on hold. He verified mail was not delivered to residents on Saturdays.

Based on interview and record review it was determined the facility failed to follow physician's orders for blood sugar parameters for 1 of 5 sampled residents (#6) reviewed for unnecessary medications. This placed residents at increased risk for hyperglycemia. Findings include: Resident 6 admitted to the facility in 2017 with diagnoses including diabetes. A 6/23/23 physician order indicated Resident 6's insulin aspart 100 units before meals parameters to hold for blood sugar less than 120. A review of Resident 6's MAR revealed the following: -On 5/8/24 a blood sugar of 143 at 7:00 AM and the insulin aspart was withheld by Staff 4 (LPN). -On 5/11/24 a blood sugar of 148 at 7:00 AM and the insulin aspart was withheld by Staff 4. -On 6/4/24 a blood sugar of 137 at 7:00 AM and the insulin aspart was withheld by Staff 4. -On 7/11/24 a blood sugar of 148 at 5:00 PM and the insulin aspart was withheld by Staff 4. -On 7/19/24 a blood sugar of 132 at 7:00 AM and the insulin aspart was withheld by Staff 4. -On 7/24/24 a blood sugar of 146 at 5:00 PM and the insulin aspart was withheld by Staff 4. -On 8/7/24 a blood sugar of 143 at 7:00 AM and the insulin aspart was withheld by Staff 4. -On 8/7/24 a blood sugar of 137 at 5:00 PM and the insulin aspart was withheld by Staff 4. On 8/15/24 at 10:03 AM Staff 4 stated Resident 6's blood sugars were checked three times per day before meals and if blood sugars were below 110, the insulin was withheld. The surveyor requested Staff 4 to review Resident 6's insulin aspart orders. Staff 4 stated Resident 6's previous orders indicated to hold if blood sugar was less than 150. Staff 4 stated she forgot the order changed recently. On 8/15/24 at 1:56 PM Staff 2 (DNS) stated it was her expectation that nurses read the physician orders when administering medications every time. Staff 2 acknowledged the insulin aspart was withheld from Resident 6 when it should have been administered per physician orders.

Based on interview and record review it was determined the facility failed to follow up on advance directives for 3 of 4 sampled residents (#s 12, 13 and 20) reviewed for advance directives. This placed residents at risk for receiving care in conflict with their health care wishes. Findings include: A 5/2023 review of Resident 12, 13 and 20's clinical records revealed the residents did not have advance directives, but information was provided. There was no additional information to indicate whether the residents or their representatives executed an advance directive or declined to do so. On 5/17/23 at 8:58 AM Staff 3 (Social Services Director) stated she was not aware of the requirements regarding advance directives and was not consistent with following up to ensure advance directives were reviewed or received. On 5/18/23 at 8:36 AM Staff 1 (Administrator) confirmed advance directives were not followed up on for Residents 12, 13 and 20.

Based on interview and record review the facility failed to protect the resident's right to be free from verbal abuse by a staff member for 1 of 2 sampled residents (#34) reviewed for abuse. This placed residents at risk for psychosocial harm. Findings include: Resident 34 admitted to the facility in 3/2022 with diagnoses including diabetes, obesity and polyosteoarthritis. A 3/10/22 Quarterly MDS indicated Resident 34's BIMS score was 11 which indicated moderate cognitive impairment. A Abuse Incident Report dated 5/5/22 and completed on 5/10/22 revealed the following: - Witness 1 (Family Member) reported to Staff 1 (Administrator) that Resident 34 was verbally abused by Staff 14 (CNA) and indicated Staff 14 used foul language, was disrespectful and demeaned Resident 34. -Resident 34 stated Staff 14 entered her/his room multiple times and did not assist with care but turned her/his call light off and did not leave the room. At one point Staff 14 entered the room and was smoking something at her/his window and then blew smoke into her/his face. Resident 34 indicated Staff 14 told her/him you stink, you are morbid, everyone can't stand you, you fucking stink so bad. Resident 34 stated Staff 8 (CNA) overheard comments that Staff 14 made to her/him and told Staff 14 she could not talk that way to residents and Staff 14 left the room. -Staff 8 indicated she asked for assistance with Resident 34 and Staff 14 assisted. Staff 8 indicated while performing ADL care to Resident 34 Staff 14 told her/him to shut the fuck up, stop whining, complaining, and told Resident 34 she/he was lazy, smelled and no one wanted to care for her/him. Staff 8 finished ADL care for Resident 34 and told Staff 14 to stop talking to Resident 34 in an inappropriate way. Staff 8 indicated both of them left the room but Staff 14 continued to be loud in the hallways and curse. Staff 8 indicated Staff 14's behavior was totally out of character and something she had not witnessed before. -Staff 6 (CNA) indicated when she started her shift at 6:00 AM Staff 14 was talking very loudly throughout the halls and was acting out of character. -Staff 3 (Social Service Director) stated staff reported to her, the early morning of 5/5/22 Staff 14 was acting out of character, yelling and cussing in the hallways. Witness 2 (Family Member) indicated she spoke with Resident 34 who reported Staff 14 told Resident 34 to stop using her/his call light, took up too much time and you [Resident 34] fucking stink and would be the last to receive any care. -Staff 14 indicated she was not assigned to Resident 34 that night but assisted Staff 8 with Resident 34's ADL care needs and told Staff 8 it would be a good idea to have two staff in when providing ADL care. Staff 14 indicated Resident 34 refused ADL care and had behaviors on 5/3/22, became upset with her and did not want her to provide ADL care or be in Resident 34's room alone. On 5/8/22 Staff 14 submitted her resignation letter. -It was determined based off the 5/5/22 facility reported incident verbal abuse occurred and Staff 14 made disparaging remarks and cruel comments to Resident 34. Staff 14 was to be terminated from employment however, on 5/8/22 the facility received a resignation letter from Staff 14 which was accepted. On 5/15/23 at 4:57 PM Witness 1 (Family Member) stated he remembered the incident on 5/5/22 and Staff 14 was screaming and used vulgar language towards Resident 34. Witness 1 stated Resident 34 indicated Staff 14 was smoking something in her/his room and blew smoke into her/his face. Witness 1 stated Resident 34 initially was very upset and crying when he arrived at the facility that morning because the event had only occurred a couple hours prior. Witness 1 stated Staff 14 was no longer in the building when he arrived. Witness 1 further stated he reported his concerns to Staff 1 (Administrator) and was satisfied with the outcome regarding the incident. Witness 1 stated Resident 34 had no long-term side effects from the incident but was a little taken back by the incident. On 5/16/23 at 11:43 AM Staff 3 stated she arrived to work and staff reported Staff 14 was acting funny that night and was verbally abusive towards Resident 34. Staff 3 indicated Staff 14 told Resident 34 she/he smelled bad and used vulgar language. Staff 3 stated Staff 14 was not in the building when she arrived and Staff 1 and Staff 2 (DNS) were looking into the incident. On 5/16/23 at 12:49 PM Witness 2 stated Resident 34 spoke with Witness 2 the morning of 5/5/22 and indicated Staff 14 was blowing smoke in her/his face with a vape pen, told her/him to stop putting her/his call light on and used vulgar language towards Resident 34 which was verbally demeaning. Witness 2 stated Resident 34 was initially upset but was back to her/his baseline and felt safe at the facility. On 5/16/23 at 2:08 PM Staff 7 (LPN) stated she worked with Staff 14 when the incident occurred on 5/5/22 with Resident 34 and noticed Staff 14 was not her normal self but thought it was just because she was busy. Staff 7 stated Witness 1 reported his concerns to Staff 7 towards the end of her shift regarding the disparaging comments towards Resident 34 and she was going to report the incident to Staff 1 but he was already aware of the incident. On 5/17/23 at 6:42 PM Staff 8 (CNA) stated she witnessed Staff 14 being verbally abusive to Resident 34 the morning of 5/5/22. Staff 8 stated Staff 14 assisted with ADL care and she flipped out on Resident 34 and stated that she/he stunk and used vulgar language. Staff 8 intervened and told Staff 14 that behavior was inappropriate and needed to stop and Staff 14 left the room. Staff 8 stated Resident 34 indicated Staff 14 came back into her/his room and was smoking and blew smoke into her/his face. Staff 14 stated when she checked on Resident 34 after the incident she/he was not crying but a little bit taken back over the incident and seemed to be back to her/his baseline. On 5/18/23 at 1:30 PM Staff 1 and Staff 2 (DNS) were present for an interview. Staff 1 stated he was alerted of the 5/5/22 incident that morning by Witness 1 and initiated the investigation and determined verbal abuse occurred. Staff 1 and Staff 2 stated Resident 34 initially was upset about the incident but had no long-term psychosocial effects from the verbal abuse. Staff 1 stated they suspended Staff 14 and she turned in her resignation letter on 5/8/22, which the facility accepted. On 5/10/22, the Past Noncompliance was corrected when the facility completed a root cause analysis of the incident and determined there was verbal abuse. The Plan of Correction included: 1. A facility incident report which determined Resident 34 was verbally abused by Staff 14. 2. Staff 14 no longer worked for the facility after the 5/5/22 incident. 3. Staff were educated and completed abuse in-service training. 4. Continued education regarding abuse training occurred at all staff meetings.

Based on interview and record review it was determined the facility failed to ensure a resident's care plan reflected the needs of the resident for 1 of 3 sampled residents (#19) reviewed for accident. This placed residents at risk for unmet needs. Findings include: Resident 19 was admitted to the facility in 2021 with diagnoses including adult failure to thrive and dysphagia (difficulty swallowing). A review of Resident 19's Care Plan initiated on 2/15/21 revealed Resident 19 required 100% supervision for all meals. On 5/16/23 at 8:05 AM resident 19 was observed alone in her/his room eating toast and drinking milk through a straw. On 5/16/23 at 8:20 AM Staff 9 (CNA) walked by, looked at Resident 19 and kept walking while Resident 19 drank liquid through a straw. On 5/16/23 at 8:21 AM Staff 9 stated Resident 19 ate on her/his own and staff would help a little. Staff 9 stated Resident 19 ate slowly and had not witnessed her/him having difficulty with consuming meals. On 5/16/23 at 8:31 AM Staff 11 (RNCM) stated when Resident 19 was ill she/he required assistance with eating and drinking but if Resident 19 was well she/he did not require assistance with meals. On 5/16/23 at 8:35 AM Staff 2 (DNS) confirmed Resident 19's care plan did not reflect her/his current needs.

Based on interview and record review it was determined the facility failed to administer diabetic and bowel medication according to physician orders for 1 of 5 sampled residents (#13) reviewed for medications. This placed residents at risk for low blood sugar and complications of constipation. Findings include: Resident 13 was admitted to the facility in 2019 with diagnoses including Type 2 diabetes and constipation. a. Resident 13's current care plan for diabetes indicated a focus for unstable blood sugar. Resident 13's 4/2023 physician orders included the following order: - Novolog (fast-acting) insulin three times a day with meals. The insulin was to be held for a blood sugar less than 150. A review of the 4/2023 DAR (Diabetic Administration Record) indicated Resident 13's Novolog insulin was not held on the following dates and times for levels under 150: - 4/8/23 7:00 AM blood sugar 135 - 4/16/23 5:00 PM blood sugar 141 - 4/30/23 7:00 AM blood sugar 114 On 5/18/23 at 11:17 AM Staff 2 (DNS) confirmed Resident 13's Novolog insulin was not held according to the physician ordered parameters on the identified dates. b. Resident 13's 4/2023 and 5/2023 physician orders included the following medications: - Bisacodyl (laxative) tablet prn daily for constipation - Bisacodyl suppository prn daily if no results from the prn Bisacodyl tablet Resident 13's bowel movement records from 4/18/23 through 5/17/23 indicated the resident did not have a bowel movement on the following dates: - 4/24/23 through 4/28/23 (five days) - 5/2/23 through 5/6/23 (five days) - 5/9/23 through 5/12/23 (four days) - 5/14/23 through 5/17/23 (four days) A review of the 4/2023 and 5/2023 MARs indicated Resident 13 was administered a Bisacodyl tablet on 4/26/23, 4/27/23, 4/28/23, 5/4/23, 5/5/23, 5/6/23, and 5/11/23. No evidence was found in the residents clinical record to indicate the Bisacodyl suppository was administered. On 5/18/23 at 10:54 AM Staff 13 (LPN) stated she expected staff to offer the Bisacodyl suppository if the tablet was not effective. On 5/18/23 at 11:17 AM Staff 2 (DNS) confirmed the Bisacodyl suppository was not administered to Resident 13 as ordered when the Bisacodyl tablet was not effective.

Based on interview and record review it was determined the facility failed to conduct routine reviews of care plans to include the resident or resident representative on a quarterly basis for 4 of 7 sampled residents (#s 3, 7, 15 and 172) reviewed for skin conditions and medications. This placed residents at risk for not participating in their plan of care. Findings include: 1. Resident 3 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The medical record for Resident 3 indicated care plan reviews were completed on 6/2017, 9/2017, and 1/2018. No additional documentation was found for care plan reviews by the interdisciplinary care team or coordination to include the resident or resident representative were found in Resident 3's medical record. On 3/22/19 at 10:30 AM Staff 3 (RNCM) stated she had no additional information of care plan reviews for Resident 3. 2. Resident 7 was admitted to the facility in 2014 with [DIAGNOSES REDACTED]. The medical record for Resident 7 indicated care plan reviews were completed on 3/2017, 6/2017, and 10/2017. No additional documentation was found for care plan reviews by the interdisciplinary care team or coordination to include the resident or resident representative were found in Resident 7's medical record. On 3/22/19 at 10:49 AM Staff 3 (RNCM) stated she had no additional information of care plan reviews for Resident 7. 3. Resident 15 was readmitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Resident 15's medical record indicated the last care plan review was completed 11/2017. No additional documentation was found for care plan reviews by the interdisciplinary care team or coordination to include the resident or resident representative were found in Resident 15's medical record. On 3/22/19 at 10:49 AM Staff 2 (DNS), Staff 3 (RNCM) and Staff 13 (Regional Director of Clinical Operations) stated they had no additional information of care plan reviews for Resident 15. 4. Resident 172 was readmitted to the facility in 10/2018 with [DIAGNOSES REDACTED]. The medical record revealed Resident 172's indicated the last care plan review was completed 6/2018. No additional documentation was found for care plan reviews by the interdisciplinary care team or coordination to include the resident or resident representative were found in Resident 172's medical record. On 3/22/19 at 10:49 AM Staff 2 (DNS), Staff 3 (RNCM) and Staff 13 (Regional Director of Clinical Operations) stated they had no additional information of care plan reviews for Resident 172.

Based on observation and interview it was determined the facility failed to ensure 1 of 1 ice machines was plumbed correctly to prevent backflow of contaminated matter into the ice machine. This placed residents at risk for foodborne illness. Findings include: On 3/20/19 at 2:50 PM the facility ice machine was observed to have 2 small drainage pipes lying horizontally on the floor under the machine near the sewage drain. The ends of the drainage pipes had gray and black matter around the ends of the pipes and the floor around the drain was stained with rust and wet from draining water. On 3/21/19 at 12:45 PM Staff 5 (Maintenance Director) acknowledged the two small drainage pipes were lying horizontally on the floor, they were dirty and had black and gray matter around the ends of the drainage pipes.

Based on interview and record review it was determined the facility failed to document and inform residents of their right to execute an advance directive and failed to maintain copies of advance directives for 3 of 4 sampled residents (#s 7, 20 and 21) reviewed for advance directives. This placed residents at risk for not having their health care decisions honored. Finding include: 1. Resident 7 was readmitted to the facility in 2019 with [DIAGNOSES REDACTED]. On 3/20/19 at 10:45 AM Staff 4 (Social Service Director) stated conversations with residents about advance directives were documented on the Initial Psychosocial History and Discharge Plan. The Initial Psychosocial History and Discharge Plan dated 3/13/19 indicated Resident 7 had an advance directive. The medical record for Resident 7 did not have a copy of an advance directive. On 3/20/19 at 3:36 PM Staff 4 confirmed there was no advance directive for Resident 7. 2. Resident 20 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. On 3/20/19 at 10:45 AM Staff 4 (Social Service Director) stated conversations with residents about advance directives were documented on the Initial Psychosocial History and Discharge Plan. The Initial Psychosocial History and Discharge Plan dated 9/1/17 for Resident 20 did not include information for an advance directive. There was no information located related to advance directive for Resident 20 in her/his medical record. On 3/20/19 at 3:36 PM Staff 4 confirmed there was no advance directive for Resident 20. 3. Resident 21 was admitted to the facility in 2/2019 with [DIAGNOSES REDACTED]. The Resident Admission Policy revealed if the resident had an advance directive, the resident must make it known to the facility's representative to be reviewed and made a part of the resident's medical record. A hospice Consent and Benefit Election dated 12/18/18 indicated Resident 21 completed an advance directive and provided it to the hospice agency. An Initial Psychosocial History and Discharge Plan dated 3/4/19 revealed Resident 21 had an advanced directive and was satisfied with it. On 3/19/19 at 3:13 PM Resident 21 acknowledged she/he had an advance directive and hospice had a copy. In an interview on 3/21/19 at 3:08 PM Staff 4 (Social Services Director) confirmed Resident 21 had a current advance directive but refused to provide a copy to the facility. On 3/22/19 at 10:05 AM Staff 2 (DNS) and Staff 13 (Regional Director of Clinical Operations) indicated a copy of Resident 21's advance directive should have been obtained from hospice for the facility record.

Based on interview and record review it was determined the facility failed to ensure a thorough investigation was completed for 1 of 2 sampled residents (#172) reviewed for skin conditions. This placed residents at risk for experiencing further injuries. Findings include: Resident 172 was admitted to the facility in 10/2018 with [DIAGNOSES REDACTED]. A Weekly Non-Pressure Skin Condition Assessment completed on 10/19/18 revealed a wound on Resident 172's left calf was cleansed and a dressing applied. On 11/6/18 Resident 172 was sent to the hospital for an unrelated health issue. According to an Incident Description/Investigation dated 11/7/18 Witness 1 (Social Worker) contacted the facility to report Resident 172 was found to have a dressing on her/his left calf dated 10/19/18 (19 days prior) that hasn't been changed. The 11/7/18 Incident Description/Investigation did not include Resident 172's mental or physical status or note her/his predisposing factors including current infection and admission to the facility within the past 72 hours. There was no information regarding situational factors pertaining to the wound or witness statements from staff responsible for provision of wound treatments. The investigation did not describe corrective actions to minimize the reoccurrence of further incidents. On 3/20/19 at 7:10 PM Staff 8 (LPN) stated she was directed to initiate the incident form by management so that wound care education for staff could be started as soon as possible. In an interview on 3/22/19 at 9:37 AM Staff 2 (DNS), Staff 3 (RNCM) and Staff 13 (Regional Director of Clinical Operations) acknowledged the investigation regarding Resident 172's left calf dressing was incomplete.

Based on interview and record review it was determined the facility failed to ensure the MDS assessment was accurate for 2 of 7 sampled residents (#s 15 and 21) reviewed for hospice and medications. This placed residents at risk for unmet needs. Findings include: 1. Resident 21 was admitted to the facility in 2/2019 on hospice with [DIAGNOSES REDACTED]. Resident 21's medical record and current hospice orders dated 2/22/19 indicated she/he had the following [DIAGNOSES REDACTED]. The resident also had a urinary tract infection and received antibiotics from 3/2/19 through 3/7/19. Resident 21's 3/4/19 Admission MDS did not identify any of the resident's active diagnoses. On 3/22/19 at 10:01 AM Staff 2 (DNS), Staff 3 (RNCM) and Staff 13(Regional Director of Clinical Operations) acknowledged the 3/4/19 Admission assessment was not accurate and did not include all of the resident's active diagnoses. 2. Resident 15 was readmitted to the facility in 5/2017 with [DIAGNOSES REDACTED]. Resident 15's medical record indicated she/he had a history of [REDACTED]. The 3/2019 MAR indicated [REDACTED]. Resident 21's 5/23/18 Annual MDS and 2/23/19 Quarterly MDS did not identify [MEDICAL CONDITION] as an active diagnosis. On 3/22/19 at 10:01 AM Staff 2 (DNS), Staff 3 (RNCM) and Staff 13 (Regional Director of Clinical Operations) acknowledged the 5/23/18 and 2/23/19 assessments were not accurate and did not include the [MEDICAL CONDITION] diagnoses.

Based on interview and record review it was determined the facility failed to ensure a skin injury was treated and monitored for 1 of 2 sampled residents (#172) reviewed for skin conditions. This placed residents at risk for injury and infection. Findings include: Resident 172 was admitted to the facility in 10/2018 with [DIAGNOSES REDACTED]. A 10/18/18 Admit Nursing Report indicated a dressing to the left calf was changed today. A 10/18/18 Admission Profile revealed Resident 172 had a left lower leg (rear) skin tear. A Weekly Non-Pressure Skin Condition Assessment was completed on 10/19/18 and revealed the area on Resident 172's left calf was first observed on 10/18/18. The area measured 2.1 cm by 0.7 cm by 0.1 cm deep with a scant amount of serous exudate (clear thin drainage) and the wound bed was covered in adherent yellow slough (dead tissue) with no infection noted. The wound was cleansed and a dressing applied. TARs from 10/19/18 through 11/6/18 (19 days) revealed no documentation of wound care or monitoring of Resident 172's left calf wound. On 11/6/18 Resident 172 was sent to the hospital for evaluation of an unrelated health issue. According to an incident description/investigation dated 11/7/18 Witness 1 (Social Worker) contacted the facility to report Resident 172 was found to have a dressing on her/his left calf dated 10/19/18 that hasn't been changed. On 3/20/19 at 7:10 PM Staff 8 (LPN) stated she did not see the wound on Resident 172's left calf. Staff 8 indicated the resident's legs were elevated on pillows with protective boots on at all times and the dressing could have been overlooked because the resident refused care a lot. On 3/21/19 at 2:33 PM Staff 7 (RN) stated she recalled Resident 172 and she initially observed the left calf wound when the resident was admitted on [DATE]. Staff 7 further stated the left calf wound was a small open area like a small Stage 2 (partial thickness pressure ulcer) and there could have been a simple dressing covering the area. Staff 7 indicated the resident wore bilateral pressure relief boots at all times. In an interview on 3/22/19 at 8:15 AM Witness 1 stated after Resident 172 was admitted to the hospital on [DATE] the dressing with the 10/19/18 date was discovered by nursing and she was notified. Witness 1 indicated she contacted the facility after the dressing was found and notified nursing of her concerns. On 3/22/19 at 9:37 AM Staff 2 (DNS), Staff 3 (RNCM) and Staff 13 (Regional Director of Clinical Operations) acknowledged Resident 172's left calf wound was not monitored or treated from 10/19/18 through 11/6/18 and the dressing was left on for 19 days. Staff 13 stated there was no treatment order initiated for the left calf wound after the first treatment was provided.

Based on interview and record review the facility failed to ensure consultant pharmacist recommendations were followed for 1 of 5 sampled residents (#15) reviewed for medications. This placed residents at risk for adverse medication side effects. Findings include: Resident 15 was readmitted to the facility in 5/2017 with [DIAGNOSES REDACTED]. Physician orders [REDACTED]. A 10/23/18 Pharmacist Consultant Report recommended a reduction in the dose of [MEDICATION NAME] to once daily. The recommendation indicated if the physician chose to keep the [MEDICATION NAME] at the higher dose, documentation of an assessment of the risk versus benefit was required. This was a repeat recommendation from 9/10/18. The physician responded with need to discuss (symptoms with patient). Current signed physician orders [REDACTED]. Resident 15's medical record revealed no documentation of a consult with the resident or an assessment of the risk versus benefit regarding the use of the [MEDICATION NAME]. Resident 15's medical record revealed she/he received the following [MEDICAL CONDITION] medications: [REDACTED] - [MEDICATION NAME] (antidepressant) started in 1/2018. - [MEDICATION NAME] (antidepressant) started in 5/2018. - [MEDICATION NAME] (antidepressant) started in 1/2018. A Pharmacist Consultation Report dated 11/12/18 included information from the facility interdisciplinary team (IDT): No GDR (gradual dose reduction) because (resident) is still depressed. The pharmacist recommended the physician perform an updated GDR assessment. The physician responded by accepting the IDT's recommendation and provided no further information. There was no documentation of an assessment by the physician of the [MEDICAL CONDITION] medication regimen, including the risk versus benefit of the continued use of three antidepressants. A Pharmacist Consultation Report dated 12/10/18 and repeated reports on 1/7/19 and 2/11/19 revealed Resident 15's TSH ([MEDICAL CONDITION] stimulating hormone) was 99.15 (normal range: 0.30-4.20) on 10/24/18. The pharmacist recommended lab testing of Resident 15's TSH and free T4 ([MEDICAL CONDITION] hormone level) each time. The physician signed the recommendation on 2/28/19 and the lab testing was completed on 3/4/19 (86 days after the first request). During interviews on 3/21/19 at 3:12 PM and 3/22/19 at 10:06 AM Staff 2 (DNS), Staff 3 (RNCM) and Staff 13 (Regional Director of Clinical Operations) acknowledged the consultant pharmacist's recommendations were not followed up on in a timely manner and requested assessments were not completed.

Based on interview and record review it was determined the facility failed to ensure a resident's [MEDICAL CONDITION] medication regimen was reviewed for risks and benefits, a rationale was documented for duplicate therapy and the accurate dose was administered for 1 of 5 sampled residents (#15) reviewed for medications. This placed residents at risk for adverse medication side effects. Findings include: Resident 15 was readmitted to the facility in 5/2017 with [DIAGNOSES REDACTED]. Resident 15's medical record revealed she/he received the following [MEDICAL CONDITION] medications: [REDACTED] - [MEDICATION NAME] (antidepressant) started in 1/2018. - [MEDICATION NAME] (antidepressant) started in 5/2018. - [MEDICATION NAME] (antidepressant) started in 1/2018. A Medical Visit Report on 11/14/18 indicated Resident 15's physician ordered an increase in the [MEDICATION NAME] dose from 30 mg daily to 40 mg daily for three months (until 2/15/19) then return to 30 mg daily. There was no documentation of a clinical rationale for the increased dose of [MEDICATION NAME]. A [MEDICAL CONDITION] Medication Review on 11/30/18 listed the three antidepressants and there was no history of gradual dose reductions (GDRs) or contraindications for GDRs listed for each medication. The summary of the review noted Resident 15's mood and affect were stable and no GDR was recommended for any of the three medications. The review did not include the risk versus benefit or clinical rationale for continued duplicate therapy (use of multiple medications from the same class) or a rationale for the increased dose of [MEDICATION NAME] on 11/14/18. Resident 15's medical record did not include a physician order [REDACTED]. The 3/2019 MAR indicated [REDACTED]. During interviews on 3/21/19 at 3:12 PM and 3/22/19 at 10:06 AM Staff 2 (DNS), Staff 3 (RNCM) and Staff 13 (Regional Director of Clinical Operations) confirmed GDRs were not attempted for the three antidepressants. Staff 3 indicated there was no documentation of the rationale for not conducting GDRs or the risk versus benefits for duplicate therapy. Staff 2 and Staff 3 acknowledged the [MEDICATION NAME] dose was not decreased to 30 mg on 2/15/19 as ordered.

Based on observation, interview and record review it was determined the facility failed to provide care and services in a manner that maintained and promoted dignity for 4 of 8 sampled residents (#s 43, 73, 75 and 79) reviewed for dignity and medications. This placed residents at risk for lack of dignity. Findings include: 1. Resident 73 admitted on ,[DATE] with [DIAGNOSES REDACTED]. The Cognitive Loss CAA dated 10/6/17 indicated the resident had communication impairments related to [MEDICAL CONDITION] and dysphasia (loss of the ability to understand or express speech, caused by brain damage) following a stroke. Resident 73 could sometimes make herself/himself understood with the use of hand gestures and communication with a picture board. The care plan revised on 10/10/17 directed staff to anticipate needs by checking on Resident 73 for safety and toileting needs every hour. On 11/1/17 observations from 7:25 am through 9:26 am revealed the following: - 7:25 am Resident 73 was awake, this surveyor attempted to speak to the resident but all she/he replied was mmmm. The room had a foul smell of bowel movement (BM). Her/his commode lid was up and the surveyor could see the BM inside the commode. -7:40 am the resident was still in the room with the privacy curtain drawn closed , and the foul smell was present in the hallway. -7:55 am Staff 8 (Licensed Practical Nurse) entered the room with this surveyor, the foul smell was present and staff 8 noticed her/his commode lid was up and she closed the lid. -8:14 am a foul smell was present in the room and hallway. Resident 73's door was wide open and the privacy curtain drawn closed. Staff 14 (CNA) and Staff 9 (CNA) passed by the resident's room multiple times, but did not enter the room. -8:34 am this surveyor checked in Resident 73's room and the commode was still not emptied. The foul smell was present in the room and out in the hallway. -8:58 am a second surveyor reported the odor outside Resident 73's room. -9:00 am Resident 73 was in her/his room with a surveyor. While in the room Staff 8 (LPN) entered briefly and Staff 15 (Activities Manager) came in and delivered the activities schedule. She placed the schedule on Residents 73's board/wall. The commode lid was raised. -9:07 am a third Surveyor observed medication pass for Resident 73 in her/his room. The surveyor noted a fecal odor permeating the room. -9:26 am Resident 73 was still in her/his room, the privacy curtain was drawn closed. The smell was present in the hallway and room. A surveyor entered the room and the commode lid was in the up position with bowel movement/feces present. On 11/1/17 interviews conducted from 9:00 am through 10:14 am revealed the following: -At 9:00 am Resident 73 used the communication board and circled the answer no if any staff person had come in and serviced her/his commode that morning. -At 9:42 am Staff 9 (CNA) stated Resident 73 was capable of using her/his bedside commode on her/his own. She further stated that she checked on her/him probably once every hour. -At 10:14 am Staff 2 (RNCM) acknowledged that staff should have checked on Resident 73 every hour and the commode should have been cleaned. 2. Resident 75 was admitted to the facility in 10/2017 with [DIAGNOSES REDACTED]. Resident 75's 10/27/17 admission orders [REDACTED]. On 10/30/17 at 9:32 am the catheter drainage bag and its contents were observed in plain view from the hall hanging on the bed frame without a cover. Subsequent observations of Resident 75's catheter drainage bag on 10/30/17 at 10:40 am, 12:19 pm and 1:13 pm revealed it remained uncovered and visible from the hall. On 10/30/17 at 1:13 pm Staff 16 (CNA) was observed emptying the catheter drainage bag. On 10/31/17 at 11:16 am Resident 75's catheter drainage bag was partially visible from the hall and lying on the floor under the bed. There was no cover on the bag and the tubing was also in contact with the floor. On 10/31/17 at 11:22 am Staff 16 stated catheter drainage bags were checked and emptied at least one time per shift. Staff 16 further stated blue covers were available for the drainage bags and she did not think Resident 75's catheter bag had one on it when she emptied it on 10/30/17. Staff 16 indicated Resident 75 had been in her/his room since admission and if she/he came out of the room they would put a cover on the drainage bag. At 11:26 am on 10/31/17 Staff 2 (RNCM) was informed of the status of Resident 75's catheter drainage bag including the lack of a dignity cover and being found on the floor. Staff 2 and the surveyor went to the resident's room and Staff 2 acknowledged the drainage bag needed a cover and should never be on the floor. 3. Resident 43 was admitted to the facility in 11/2016 with [DIAGNOSES REDACTED]. Resident 43's care plan dated 11/17/16 included to maintain dignity at all times and use a leg strap and bag cover for the catheter. On 10/30/17 at 11:18 am Resident 43's catheter bag was uncovered while the resident was in bed and could be observed from hallway. On 11/2/17 at 1:00 pm Staff 2 (RNCM) confirmed Resident 43's catheter bag should be covered at all times. 4. Resident 79 was admitted to the facility on ,[DATE] with [DIAGNOSES REDACTED]. On 10/29/17 at 5:45 pm Resident 79 and her/his family members were in the resident's room. They expressed concern the resident was not being dressed. The resident was observed to be wearing a blue T-shirt and adult briefs only. The resident stated she/he understood it was easier for staff to change her/him without pants on but a person should have their pants on during the day. On 11/02/17 at 8:18 am Resident 79 was observed in bed watching TV after eating breakfast. The resident was in a T-shirt and adult brief and verified staff were not putting her/his pants on. The resident stated she/he was not sure why she/he still did not have pants on but stated she/he had plenty of clothes to wear as her/his family had brought clothing in, including pants. On 11/02/17 at 8:25 am Staff 10 (CNA) stated Resident 79 was getting skilled therapy so the therapy department would get the resident dressed. Staff 10 stated We don't do things for the resident until therapy okays it. On 11/02/17 at 8:28 am Staff 17 (Physical Therapy Assistant) was in Resident 79's room but indicated she was not there to dress resident. She stated the CNAs get the residents dressed. On 11/02/17 at 8:31 Staff 11 (Therapy Manager) stated she had not scheduled an appointment to get the resident up and dressed. The CNAs were to get residents up and dressed for the day. On 11/02/17 at 8:37 am Staff 1 (DNS) acknowledged the CNA should get the resident up and dressed for the day.

Based on interview and record review it was determined the facility failed to ensure use of the services of an RN for at least eight consecutive hours a day, seven days a week for 17 of 32 days reviewed for RN staffing coverage. This placed residents at risk for unmet assessment and care needs. Findings include: Direct Care Staff Daily Report postings and facility Direct Care Nursing reports were reviewed from 10/1/17 through 11/1/17. The facility failed to provide RN coverage on the following days: * 10/1/17; * 10/6/17; * 10/8 and 10/9/17; * 10/11/17; * 10/15, 10/16, 10/17, 10/18/17; * 10/22, 10/23, 10/24, 10/25/17; * 10/29, 10/30, 10/31, 11/1/17. On 11/3/17 at 7:38 am and 9:02 am Staff 1 (DNS) acknowledged the lack of RN coverage for the 17 days from 10/1/17 through 11/1/17. Staff 1 stated they did not have enough staff and utilized an agency or reached out to sister facilities for staffing assistance.

1. Based on observation and interview it was determined the facility failed to store food in a sanitary manner for 1 of 1 refrigerators and 1 of 1 dry storage rooms reviewed during kitchen tour. This placed residents at risk for possible food contamination. Findings include: On 10/29/17 at 5:31 pm during initial kitchen tour the following dates on food were found: Refrigerator: -Turkey marked with an open date of 10/25/17. -Soup marked with an open date of 10/23/17. -Meat marked with an open date of 10/19/17. Dry Storage: -Corn meal expiration date of 11/5/16. On 10/29/17 at 5:45 pm Staff 5 (helper) stated foods opened in refrigerator should be thrown out after three days. On 11/2/17 at 11:56 am Staff 4 (Dietary Manager) stated food should be thrown out after three days. She confirmed the above foods should have been thrown away. 2. Based on observation and interview it was determined the facility failed to serve food in a sanitary manner in 1 of 2 dining rooms and 2 of 2 halls observed during meal service. This placed residents at risk for cross contamination. Findings include: a. During dining observation on 10/29/17 from 5:47 through 5:54 pm in the dining room across the hall from the kitchen, Staff 6 (CNA) was observed with gloved hands to retrieve a food tray from the kitchen and deliver it to a female resident. Staff 6 then, without changing gloves or sanitizing her hands, assisted a male resident and touched the resident's arm with her gloved hands. Staff 6 then went back to the kitchen, picked up another tray, delivered it to another female resident and opened her yogurt with the same gloved hands. Staff 6 then went to a drawer, picked up a straw and assisted a resident with placing the straw into a cup. Staff 6 then took off her gloves and without sanitizing her hands and went into room 16. On 10/29/17 at 5:55 pm Staff 6 stated she did not notice she had touched the male resident's arm. On 11/2/17 at 8:11 am Staff 1 (DNS) stated she would expect hand washing in-between glove usage and moving from dirty to clean space. Staff 1 stated it is ok to wear gloves, but staff should be washing hands appropriately in between contact of surfaces and people. b. During observations on 10/29/17 from 6:00 pm through 6:14 pm the following events occurred: - 6:00 pm Staff 7 (CNA) was observed wearing gloves and returned a tray to the East hall cart. She then knocked, entered room 12 and then came back out with the same gloves on. -6:05 pm Staff 7 proceeded to the West hall, placed her hands on a wheel chair and pushed a resident down the hall back to room 30. She came out of room 30, knocked on room 27, grabbed the door knob and entered the room wearing the same pair of gloves. -6:12 pm Staff 7, still wearing the same pair of gloves, came out of a work room, and then entered the administrators office and removed her gloves. On 11/2/17 at 8:11 am Staff 1 (DNS) stated she would expect hand washing in between glove usage and moving from dirty to clean space. Staff 1 stated it is ok to wear gloves, but staff should be washing hands appropriately in between contact of surfaces and people.

Based on interview and record review it was determined the facility failed to notify the physician for refusals of an ordered treatment for 2 of 5 sampled residents (#s 14 and 73) reviewed for medications. This placed residents at risk for unmet needs. Findings include: 1. Resident 73 admitted on ,[DATE] with [DIAGNOSES REDACTED]. A physician order [REDACTED]. The October 2017 MARS disclosed Resident 73 refused the [MEDICATION NAME] 23 times. Review of medical records revealed no notification to the physician regarding the 23 refusals. On 11/2/17 at 7:37 am Staff 2 (RNCM) and Staff 1 (DNS) would expect staff to document the reason for the refusals and the physician should have been notified. 2. Resident 14 was admitted to the facility in 2/2015 with [DIAGNOSES REDACTED]. Physician orders [REDACTED]. The 10/2017 MAR indicated [REDACTED]. There was no evidence in the medical record Resident 14's physician was contacted in regard to the refusals. On 11/2/17 at 12:52 pm Staff 2 (RNCM) confirmed the physician was not notified of Resident 14's refusal of medication.

Based on interview and record review it was determined the facility failed to follow the care plan to prevent a fall for 1 of 2 (#2) sampled residents who fell in the facility. Resident 2 sustained a hip fracture during a fall and required surgery. Findings include: Resident 2 was admitted to the facility in November, 2007 with [DIAGNOSES REDACTED]. The resident was readmitted following right hip fracture surgery in February, 2011. The resident was re-hospitalized and no longer resided at the facility. The resident's Comprehensive Care Plan dated 1/12/11 indicated the resident high fall risk potential with the intervention to "maintain tabs alarm placement at all times." A tab alarm is a device attached to the resident's clothing that sounds during an attempt to rise out of bed or a chair. Resident 2's care plan directed one staff member to use a gait belt while assisting the resident with walking. The MDS dated [DATE] indicated the resident required the extensive assistance of one staff during the performance of the resident's mobility ADLs. The Physical Restraint/Device Record of Informed Consent dated 1/27/11 revealed Resident 2 required a tab alarm at all times. The Fall Risk assessment dated [DATE] indicated the resident scored at a high risk for falls, due to poor standing and walking balance. The RNCM's Quarterly Report dated 1/29/11 revealed the resident "remained a high risk for falls r/t medications, cognition and mobility issues...No changes to prevention measures..." The Nurse's Notes dated 2/11/11 revealed Resident 2 had experienced an unwitnessed fall at 2:15 pm that afternoon. The notes indicated the resident was independently ambulating in the facility's memory care hallway. The Resident Incident Report dated 2/11/11 documented Staff 8 (CNA) and Staff 11 (CNA) found the resident lying on her/his back in the hall and the resident had been unable to fully extend both legs. The facility's Witness Report Of Resident Occurrence indicated at 2:07 pm at 2/11/11 , Staff 11 (CNA) just worked the day shift, walked out of the nursing station and heard Resident 2 "yell out help." The report indicated Staff 7 (RN) assessed the resident, the physician was notified and the resident was sent to the hospital. The Incident Investigation dated 2/11/11 documented before the resident fell that day, Resident 2 was walking unassisted in the hallway and staff heard a "screeching sound" from the resident at the time of the fall. The report indicated there was no known cause for the resident's fall, the environment was clean and no obstacles were found. Documentation at the end of the Incident Investigation report revealed the note: "fall noted-tab alarm care planned to be in place at all times. Staff aware of fall potential." The hospital emergency room records dated 2/11/11 indicated the resident's X-ray showed the resident had sustained a new right hip fracture. The hospital's History and Physical (H&P) dated 2/11/11 contained the physician's assessment note: "ground level fall, unsure how this was done...patient with known fall history...on multiple agents that can cause dizziness...The patient should not be walking on (their) own and should always have a stand-by assist." On 3/8/11 at 4:00 pm Staff 7 (RN) stated on 2/11/11, at change of shift, Staff 8 (CNA) and Staff 11 (CNA) informed her the resident fell and was lying on the floor of the memory care unit. Staff 7 stated she assessed the resident, notified the physician and the resident was sent to the hospital. On 3/9/11 at 1:00 pm Staff 1 (DNS) stated the resident ambulated freely without a gait belt or a personal alarm prior to the resident's fall on 2/11/11. Staff 1 stated she could not locate the resident's CNA care plan, in use on 2/11/11. On 3/9/11 at 5:00 pm Staff 8 (CNA) stated he came on duty, got report from (Staff 11) and was told the resident had been walking all day without the assistance of staff. Staff 8 stated he and Staff 11 heard the resident yell out help when the resident fell and they walked around the corner from the nursing station and saw Resident 2 lying on the hallway floor. Staff 8 stated the nurse was alerted and assessed the resident immediately. On 3/24/11 at 12:00 pm Staff 11 (CNA) stated the resident had been doing well before the resident fell and fractured a hip. Staff 11 stated the resident did not have TAB alarms in use at the time of the resident's fall. Staff 11 stated the resident had gotten in and out of the wheelchair all day, while the resident was in the hallway . Staff 11 stated the resident walked without assistance on the day s/he fell in the hallway of the memory care unit.