Every finding on record at Regency Redmond Rehabilitation and Nursing Center

Based on observation, interview, and record review it was determined the facility failed to ensure a resident was assisted to with grooming for 1 of 2 sampled residents (#5) reviewed for ADLs. This placed residents at risk for unmet grooming care needs. Findings include: Resident 5 was admitted to the facility in 11/2022 with a diagnosis of pain. Resident 5's 11/14/25 Annual MDS revealed she/he had severe dementia; it was important to her/him to make choices about bathing and required extensive assistance of one staff for hygiene. Resident 5's current Care Plan indicated she/he required extensive assistance by one staff with personal hygiene. The facility's 11/21/25 shower schedule revealed Resident 5 was to be showered on Mondays and Thursdays. Resident 5's 1/12/26 Skin Monitoring: Comprehensive CNA Shower Review Sheet revealed Staff 9 (CNA) assisted the resident with a shower on 1/12/26. On 1/12/26 at 1:33 PM and 1/13/26 at 12:56 PM, Resident 5 was observed to have long facial hair. Resident 5 stated she /he preferred to shave daily but staff did not offer to assist her/him. On 1/13/26 at 1:57 PM, Staff 9 stated she assisted Resident 5 with a shower but did not offer her/him to shave. Staff 9 stated Resident 5 had an electric shaver and would ask if she/he wanted to shave. On 1/14/26 at 8:15 AM, Resident 5 was observed to have a razor on her/his bedside table. Resident 5 was in her/his wheelchair but was not able to reach the electric shaver due to the room layout. Resident 5 stated she/he was not shaved for weeks. Witness 6 (Spouse) stated Resident 5 was not able to shave by her/himself. On 1/15/26 at 1:24 PM, Staff 3 (RNCM) stated Resident 5 preferred to shave daily and wanted to be offered to shave. Staff 3 indicated the care plan did not reflect Resident 5's shaving preference.

Based on observation, interview, and record review it was determined the facility failed to ensure a resident was assessed prior to use of a potential restraint for 1 of 1 sampled resident (#17) reviewed for hospice. This placed residents at risk for limited mobility. Findings include: Resident 17 was admitted to the facility in 8/2024 with a diagnosis of dementia. The facility's Enabler Restraint Policy and Procedure revised 10/2022 revealed the facility was to evaluate and routinely review residents prior to the use of enablers or restraints to ensure less restrictive measures were attempted and how the device(s) enabled the resident to function at their highest practical level. An Enabler/Restraint Evaluation and Consent was to be completed prior to implementation of a device to ensure less restrictive measures were attempted and the device enabled a resident to function at their highest practical level. Resident 17's 8/12/25 Annual MDS revealed she/he had severe dementia and was a severe fall risk. The assessment indicated Resident 17's behaviors and memory were becoming worse. The MDS did not indicate Resident 17 had a restraint. Resident 17's 11/10/25 Quarterly MDS revealed she/he did not have a restraint when out of bed. Resident 17's Care Plan last revised on 1/13/26 revealed no interventions related to the use of a pommel cushion (specialized cushion with a raised center [pommel] that separated the thighs, preventing forward sliding). On 1/14/26 at 10:05 AM Resident 17 was observed in bed with her/his eyes shut. A pommel cushion was observed in Resident 17's wheelchair. A review of Resident 17's clinical record found no documented evidence an assessment was completed prior to the use of a potential restraint. On 1/15/26 at 3:55 PM Staff 12 (CNA) stated Resident 17 had a pommel cushion for a few months. Staff 12 indicated Resident 17's pommel cushion was implemented after a fall because she/he slid out of her/his wheelchair. On 1/15/26 at 1:21 PM Staff 3 (RNCM) stated if a resident was to use a potential restraint PT was to evaluate the resident and a restraint assessment was to be completed prior to initiation. Staff 3 stated she was not aware Resident 17 had a pommel cushion.

Based on observation, interview, and record review it was determined the facility failed to ensure fall interventions were followed and ensured medications were not left at a resident's bedside for 3 of 5 sampled residents (#s 5, 8, and 17) reviewed for accidents, hospice and ADLs. Findings include: 1. Resident 17 was admitted to the facility in 8/2024 with a diagnosis of dementia. Resident 17's 8/10/25 Annual MDS revealed she/he had severe dementia, received hospice services, required extensive assistance with propelling a wheelchair, and was assessed to be a severe fall risk. Resident 17 had falls while residing in the facility. Resident 17's Care Plan revised on 9/20/24 revealed she/he was not to be left unattended while in a wheelchair related to elopement risk and high risk for falls related to self-transferring. Resident 17's 12/2025 MAR revealed she/he had PRN orders for the following pain medications: -Tylenol (over the counter pain medication) and was administered zero doses. -Morphine Sulfate (narcotic pain medication) and was administered zero doses. -Oxycodone (narcotic pain medication) and was administered zero doses. -Diclofenac sodium (nonsteroidal anti-inflammatory medication) external gel and was administered zero doses. Resident17's Fall investigation revealed on 1/11/26 at 9:10 AM staff observed Resident 17 on the ground as well as an empty unlocked wheelchair in another resident's room. Resident 17 was found on the floor on her/his back. Staff assessed Resident 17 then assisted the resident back into the wheelchair. The investigation indicated staff last saw Resident 17 approximately 10 minutes prior to the fall and Resident 17 likely self-propelled into the other resident's room and self-transferred. Resident 17's 1/2026 MAR revealed she/he had PRN and scheduled orders for the following pain medications: --Diclofenac sodium external gel and was administered zero doses. -Oxycodone PRN and 17 doses were administered from 1/11/26 through 1/15/26. -Tylenol PRN and was administered two times on 1/12/26 -Morphine and was administered two doses on 1/14/26 -Fentanyl patch (narcotic pain medication) scheduled to be applied every three days and was initiated 1/14/26. On 1/14/26 at 9:30AM, 9:57 AM, and 10:05 AM, Resident 17 was observed in bed. On 1/15/26 at 8:54 AM Staff 6 (RN) stated Resident 17 fell on 1/11/26. Staff 6 stated Resident 17 was able to propel a wheelchair and on 1/11/26 she/he propelled her/himself to another residents' room and was found on the floor. Resident 17 may have fractured a hip but after extensive conversations with hospice and Resident 17's family, the choice was to not send Resident 17 to the hospital for evaluation and treatment. Staff 6 stated the facility was assisting Resident 17 with pain control. Prior to the fall Resident 17 was up for all meals. On 1/15/26 at 9:00 AM Staff 11(CNA) stated before Resident 17 fell on 1/11/26 she/he was up for all meals but was now assisted to eat while in bed. Staff 11 stated after the 1/11/26 fall Resident 17 had increased pain. On 1/15/26 at 3:55 PM Staff 29 (CNA) stated Resident 17 slid out of her/his wheelchair and a pommel cushion was used to help prevent falls. Staff 29 stated on 1/11/26 Resident 17 was placed by the nurse's station and she/he must have propelled to the other resident's room and fell. On 1/16/26 at 9:15 AM Staff 10 (CNA) stated on 1/11/26 she was assigned to care for Resident 17. Staff 10 stated Resident 17 was to be supervised when up in a wheelchair. Staff 10 stated after breakfast she assisted Resident 17 to the nurse's station where a CNA and nurse were present to observe her/him. Staff 17 stated she left the area to assist another resident and left Resident 17 at the nurse's station. Staff 17 stated she did not recall if she informed the staff at the nurse's station to monitor Resident 17. Staff 10 stated Resident 17 must have propelled from the nurse's station to the other resident's room and self-transferred. Staff 10 stated prior to the fall Resident 17 may have had a little pain, but the pain was now worse. On 1/16/26 at 12:14 PM Staff 26 (Corporate RN) stated Resident 17 had a care plan for supervision when up in a wheelchair, but believed it was for her/his elopement risk. 2. Resident 5 was admitted to the facility in 11/1/22 with a diagnosis of encephalopathy (altered brain function). Resident 5's 11/5/25 Annual MDS revealed she/he had severe dementia. Resident 5's 1/2026 MAR revealed she/he had orders for PRN Tums (antacid) and was administered Tums on 1/9/26 on the evening shift. On 1/12/26 at 1:40 PM Resident 5 was observed sitting in her/his wheelchair in front of a bedside table and one large pink tablet was observed in a medication cup on her/his table. Staff 28 (RN) sated Resident 5 had an order for Tums (pink large tablet) but did not have an order to keep medications at the beside or to self-administer the medication. On 1/12/2026 at 1:46 PM Staff 27 (RN) stated medications were not to be kept at the beside without an order. On 1/15/26 1:36 PM Staff 2 (DNS) stated residents were not to have medications at the bedside with an assessment, physician orders, and locked storage. 3. Resident 8 was admitted to the facility in 7/2025 with diagnoses including cognitive decline and repeat falls. A 10/27/25 Fall Investigation revealed Resident 8 had no socks or shoes on when the resident fell during an attempt to self-transfer from her/his bed to a wheelchair. The 11/2/25 Quarterly MDS indicated Resident 8 had a BIMS assessment score of nine (moderately cognitively impaired), had one fall during the previous assessment period, and required partial assistance by staff for transfers, dressing and toileting hygiene. A 12/14/25 Fall investigation revealed Resident 8 had one sock on and did not use her/his call light when the resident fell during an attempt to self-transfer from her/his wheelchair to the bed. A 1/7/26 revised care plan indicated Resident 8 was at risk or falls; staff were to ensure the resident's call light was within reach and wear non-slip socks while in bed or when footwear was unavailable. On 1/13/26 at 1:22 PM, Resident 8 was observed resting on her/his bed while wearing plain white socks on both of her/his feet. On 1/13/26 at 1:28 PM and 1/14/26 at 1:03 PM, Staff 16 (CNA) and Staff 6 (RN) stated Resident 8 was able to use her/his call light successfully to ask for assistance and non-slip socks were not in place as expected. On 1/13/26 at 3:26 PM, Staff 19 (CNA) stated regular white socks were provided to Resident 8 when non-slip socks were unavailable. On 1/15/26 at 12:49 PM, Resident 8 was observed in her/his room in a wheelchair near the foot of her/his bed as Staff 20 (CNA) assisted a roommate. Staff 20 left the room, Resident 8 confirmed she/he was unable to reach for her/his call light which was near the head of the bed and out of reach for the resident due to the location of the resident's bedside table. On 1/15/26 at 1:08 PM, Staff 6 observed Resident 8 in her/his room and confirmed the resident's call light was not within reach as expected. On 1/15/26 at 1:15 PM, Staff 20 stated she did not bring Resident 8 into her/his room after lunch and assumed the resident's call light was within reach when she left. On 1/15/26 at 3:33 PM, Staff 12 (CNA) stated that she recalled Resident 8 was not wearing non-slip socks at the time of her/his fall on 10/27/25. Staff 12 stated Resident 8 was asked if she/he preferred to wear non-slip socks in bed and this option continued to be offered to the resident. On 1/16/26 at 9:14 AM, Staff 11 (CNA) stated that on 1/15/25, she returned Resident 8 to the entrance of her/his room after a meal and acknowledged she did not ensure the resident's call light was within reach before she left the resident. On 1/16/26 at 11:29 AM, Staff 2 (DNS) expected Resident 8's call light to be within reach and staff to follow the care plan to ensure non-slip socks were in place.

Based on interview and record review it was determined the facility failed to implement trauma informed care interventions for 1 of 5 sampled residents (#2) reviewed for medications. This place residents at risk for re-traumatization. Findings include:Resident 2 was admitted to the facility in 12/2025 with diagnoses including PTSD (Post-Traumatic Stress Disorder) and depressive episodes. The 12/9/25 admission MDS indicated Resident 2 had a BIMS assessment score of 14 (cognitively intact) and she/he received an antidepressant for mood and sleep. A 12/26/25 Encounter Note indicated Resident 2 recently had an episode of nightmares when she/he was choking a person and woke up from sleep acting out the dream. Resident 2 was concerned about the nightmare because she/he received medication for sleep. Review of Resident 2's clinical record revealed no assessment or care plan interventions related to her/his PTSD. On 1/14/26 at 8:38 AM, Resident 2 acknowledged there was danger for staff if she/he was woken from sleep because of her/his PTSD. On 1/14/26 at 11:35 PM, Staff 6 (RN) stated he was aware Resident 2 had a stressful situation during sleep but was unaware of any details. On 1/14/26 at 11:46 AM, Staff 13 (Social Services) stated he was not aware of concerns related to Resident 2's PTSD and contacted a psychologist to address the resident's psychological needs. On 1/14/26 at 11:59 AM, Staff 2 (DNS) stated the facility was aware of Resident 2's nightmare and confirmed there was no follow up with the resident. Staff 2 acknowledged a thorough PTSD assessment was not conducted. Staff 2 expected an updated care plan and staff education to address Resident 2's PTSD triggers.

Based observation, interview, and record review it was determined the facility failed administer oxygen for 1 of 1 sampled resident (# 26) reviewed for respiratory care. This placed residents at risk for respiratory distress. Findings include: Resident 26 admitted to the facility in 6/2025 with diagnoses including hypoxemia (low levels of oxygen), acute respiratory distress (severe difficulty breathing due to lack of oxygen) and was on hospice. The 10/28/25 Care Plan revealed Resident 26 required 2-3 litters of continuous oxygen. The 11/18/25 Physician Order instructed staff to deliver 2 litters of oxygen per minute for comfort. On 1/12/26 at 11:02 AM, Resident 26 was observed seated in her/his wheelchair and was not interviewable. Resident 26's oxygen tubing was positioned along the side of the resident's face. Resident 26's portable oxygen tank gauge was observed in the red, indicating the tank was empty. On 1/12/26 at 12:37 PM, Resident 26's portable oxygen tank gauge was observed in the red, indicating the tank was empty. On 1/12/26 at 1:32 PM, Resident 26 remained seated in her/his wheelchair and the portable oxygen tank remained empty. On 1/12/26 at 1:57 PM, Staff 4 (RN) stated Resident 26 required oxygen. Staff 4 stated Resident 26's portable oxygen tank should be changed every two hours and confirmed the tank was empty. Staff 4 checked Resident 26's oxygen saturation which was 95 percent. Staff 4 stated she would ask a CNA to replace the portable oxygen tank. On 1/12/26 at 3:03 PM, Staff 30 (CNA) stated she was assigned resident 26 and was not informed of the portable oxygen tank was empty. Staff 30 confirmed the tank gauge was in the red and stated this meant the tank was low and that she would check the tank after assisting another resident. On 1/13/26 at 11:39 AM, Resident 26 was sitting in her/his wheelchair. Resident 26's oxygen tubing was wrapped behind her/his wheelchair and lying on the floor, the resident was not wearing the oxygen tubing. On 1/13/26 at 11:51 AM, Staff 9 (CNA) stated hospice staff assisted Resident 26 out of bed at approximately 9:40 AM. Staff 9 stated she normally checked the resident every two hours and confirmed the resident was not wearing her/his oxygen. Staff 9 stated she believed hospice staff did not apply to oxygen tubing aftercare and reported this to the nurse. On 1/13/26 at 12:00 PM, Staff 4 confirmed hospice staff assisted Resident 26 with care, and they did not apply the resident's oxygen tubing. Staff 4 stated from approximately 9:40 AM to 11:51 AM resident was not wearing oxygen. Resident 26's oxygen saturation was reported as 90 percent. On 1/13/26 at 10:30 AM, Staff 2 (DNS) stated Resident 26 had oxygen orders for comfort, however the care plan indicated continuous oxygen at 2 to 3 L. Staff 2 expected staff to ensure the oxygen tank was full, oxygen was in place, and oxygen saturation were maintained above 91 percent.

Based on observation, interview, and record review it was determined the facility failed to ensure assessed and preferred activities were provided for 2 of 2 sampled residents (#s 2 and 17) reviewed for activities. This placed residents at risk for decreased quality of life. Findings include: 1. Resident 2 was admitted to the facility in 12/2025 with diagnoses including orthopedic surgery aftercare, PTSD (Post-Traumatic Stress Disorder), and depressive episodes. Resident 2's Activities Initial Review dated 12/8/25 indicated Resident 2 played games on her/his phone and it was very important for the resident to get outside and get fresh air when the weather was good. The 12/9/25 admission MDS indicated Resident 2 had a BIMS assessment score of 14 (cognitively intact) and the resident required extensive assistance by staff to maneuver in her/his wheelchair due to weakness and poor coordination. The 1/12/26 revised Care Plan indicated Resident 2 was at risk for little or no activity due to her/his right rotator cuff repair and staff was to provide in-room visits and one on one activities for the resident. The care plan did not indicate the resident had any interest in outdoor activities. On 1/12/26 at 9:39 AM, Resident 2 was observed with her/his right shoulder in a sling and stated there was no follow up on a request to get outside. Resident 2 stated she/he felt confined to her/his room because of her/his right shoulder. On 1/13/26 at 2:24 PM, Staff 17 (CNA) stated she recalled Resident 2's request to go outside over a week ago and worked with Staff 18 (LPN) to achieve that goal. Staff 17 stated she was unsure if Resident 2's request was granted. On 1/13/26 at 2:50 PM, Staff 8 (Activities) stated she was not aware Resident 2 requested to go outside and acknowledged she was aware it was important for the resident to go outside when the weather was good. Staff 8 stated it was possible communication fell through the cracks since activity requests of residents were verbal. On 1/16/26 at 11:49 AM, Staff 1 (Administrator) and Staff 2 (DNS) expected verbal communication to occur between staff to accomplish the activity requests of residents and acknowledged the activity participation goal for Resident 2 was not met. 2. Resident 17 was admitted to the facility in 8/2024 diagnosis of dementia. Resident 17's 8/9/24 admission MDS revealed she/he expressed it was very important to participate in her/his favorite activities. Resident 17 also reported it was very important to her/him to be outside. Resident 17's Care Plan revised on 8/9/24 revealed she/he was at risk for decreased activity involvement. Care Plan interventions included staff were to open Resident 17's curtains so she/he could enjoy watching birds and people outdoors. The care plan did not include a stuffed animal. Resident 17's 8/10/25 Annual MDS revealed she/he had severe dementia. For activities Resident 17 was assessed to not like group activities, liked to be in bed, and snack. Resident 17's 11/5/25 Interdisciplinary Care Conference form revealed Resident 17's family member requested her/his bed be moved next to the window so she/he could get sunshine. Resident 17's 11/6/25 Customary Activities Quarterly Participation Review form revealed staff identified Resident 17 preferred independent activities and if staff asked her/him questions she/he would answer. Resident 17's favorite activity was identified to be a nap. Staff were to inquire if Resident 17 wanted a stuffed animal companion. On 1/12/26 at 9:23 AM, 1/13/26 at 1:58 PM, and 1/14/26 at 10:05 AM, Resident 17 was observed in bed. Resident 17's eyes were shut. Resident 17's bed was positioned with a window behind her/his head of the bed and if Resident 17 looked forward she/he looked at a privacy curtain. On 1/15/26 11:12 AM, Staff 8 (Activities Director) stated she completed resident's activity assessment by speaking with residents or residents' families. Staff 8 stated she visited with each resident daily. Residents were provided an activity calendar. Resident 17 liked to observe when in the facility public sitting areas, loved to eat, and liked to go outside when the weather was warmer. Staff 8 stated Resident 17 had a stuffed dog and had a beautiful view of the rose garden from her/his window. Staff 8 acknowledged the intervention for a stuffed animal was not placed on the care plan and Resident 17 would not be able to look out her/his window with the resident's current bed placement.

Based on observation and interview review it was determined the facility failed to follow therapeutic diets for 1 of 1 kitchen. This placed residents at risk for lack of nutritional interventions. Findings include: On 8/15/24 at 11:06 AM Staff 14 (Cook) was observed to prepare lunch for residents and did not utilize recipes or therapeutic diet spread sheets for portion control or meal substitution for any resident who received a therapeutic diet. Staff 14 stated she had no training on the use of diet spread sheets since she was hired almost a year ago. Staff 14 also stated when a NEM (Nutritionally Enhanced Meal) was ordered for a resident, their foods were not nutritionally enhanced but rather nutritional supplements were ordered by the RD and provided. Staff 13 (Dietary Manager) stated any recipe used in the kitchen was obtained through a generic search of the Internet since no recipes were provided by the facility. On 8/15/24 at 11:16 AM and 12:16 PM Staff 15 (RD) stated her audits of the facility kitchen did not include verification that diet spread sheets and system recipes were utilized. Staff 15 acknowledged system recipes with therapeutic diet spread sheets were to be utilized and foods were to be daily enhanced with extra calories to meet the expectations of a NEM diet order.

Based on observation, interview and record review it was determined the facility failed to staff a registered nurse for eight consecutive hours per day seven days per week for nine out of 60 days reviewed for staffing. This placed residents at risk for unmet assessment needs. Findings include: A review of the Direct Care Staff Daily Reports and payroll records dated 2/1/24 through 3/31/24 revealed nine days without eight consecutive hours of registered nurse coverage on any shift in a 24 hour period. On 8/15/24 at 12:04 PM and 8/16/24 at 10:32 AM Staff 1 (Administrator) confirmed on the dates of 2/3/24, 2/10/24, 2/17/24, 2/24/24, 3/2/24, 3/9/24, 3/16/24, 3/23/24 and 3/30/24 there were no RNs in the building as required and a corrective action plan was in place since 4/1/24 to address RN staffing. On 8/19/24 at 3:24 PM Staff 1 provided the following written documentation of the corrective action: an 4/1/24 short-term action plan was implemented to ensure RNs reallocated their hours to ensure the requirements for RN coverage was met until new RNs were hired and trained. The committee members met quarterly to evaluate progress which included the use of hosting nursing clinics and increased recruitment. The facility's implementation of corrective actions were verified through the survey process. Observations of RN coverage from 8/12/24 through 8/16/24 and record review of Direct Care Staffing Report from 7/14/24 through 8/12/24 revealed no concerns with RN coverage for eight consecutive hours in a 24 hour period for any of these shifts .

Based on observation, interview and record review it was determined the facility failed to accurately assess, investigate, and care plan pressure ulcers for 3 of 4 sampled residents (#s 15, 27 and 28) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers. Findings include: A Skin at Risk Program Overview Policy revised on 4/2018 revealed the following: -Residents who enter the facility without a significant wound do not develop wounds unless their clinical condition demonstrates the wound was unavoidable. -The initial ulcer assessment will be initiated for each new ulcer (pressure, venous stasis, arterial or diabetic) identified, and wound monitoring order added to the resident treatment record as appropriate. -Pressure ulcers will be reviewed weekly during wound rounds. -Weekly measurements for pressure ulcers will be documented on the weekly ulcer evaluation following completion of the initial ulcer assessment. Documentation includes length, width, depth, undermining, tunneling, pain, amount and type of drainage, condition of the wound bed and wound edges. -Development of a stage 2 (partial-thickness loss of skin with exposed dermis) or greater pressure ulcer will be documented on an incident report and investigated per protocol. 1. Resident 15 admitted to the facility in 12/2023 with diagnoses including depression and diabetes. A 12/23/23 Admission MDS and Pressure Ulcer and Injury CAA indicated Resident 15 was at risk for skin breakdown due to decreased mobility and her/his need for extensive assistance with toileting. Resident 15 did not have any pressure ulcers and staff were to notify nursing with any signs of skin breakdown. An 4/28/24 Skin Check and Body Diagram revealed there was a scab on the right ankle prominence boney area fell off, float heel and off load to relieve any pressure to avoid skin break down, No new skin issues. The 5/2024 TAR indicated on 5/31/24 Resident 15 started to receive wound treatments with iodine to both of her/his outer ankles every shift and a foam dressing was to be applied for protection. A 6/8/24 Skin and Wound Evaluation (first wound evaluation) indicated Resident 15 had a Stage 2 pressure ulcer on her/his left [NAME] (ankle) on her/his amputation site (Resident 15 did not have an amputation site) and the wound was in the middle. The form indicated the wound was new. A 6/11/24 SOAP (Subjective, Objective, Assessment, Plan) provider note indicated an air mattress for Resident 15 was discussed becaused the resident laid in her/his bed frequently on her/his sides which caused pressure ulcers on the outside of Resident 15's ankles. A 7/13/24 Skin and Wound Evaluation indicated Resident 15 had a Stage 2 pressure ulcer to her/his right Lateral Malleolus (boney joint on the outside of the ankle) and the origin was unknown. A 7/24/24 revised care plan included Resident 15 had the potential for skin breakdown, encourage the resident to float heels and reposition and she/he used body positioning pillows to decrease pressure. On 8/12/24 11:30 AM and 1:18 PM Resident 15 was observed in bed sleeping and no body pillow was used or heels floated to protect her/his ankles. On 8/13/24 at 2:25 PM Resident 15 was observed sitting in her/his wheelchair with foam dressing attached to both of her/his outer ankles. Staff 34 (NA) stated she often assisted Resident 15 and was not aware the resident had any pressure ulcers or what care was necessary to address the needs of her/his ankles. On 8/14/24 at 10:06 AM and 10:49 AM Staff 16 (Regional Nurse) and Staff 30 (LPN-Resident Care Manager) stated when the wounds on Resident 15's ankles were first discovered the wounds were believed to be skin tears. The 6/8/24 wound assessment first identified the wounds as Stage 2 pressure ulcers based on a physician's observation and recommendation. Staff 30 stated she believed Resident 15's ankle wounds were caused when Resident 15 hit her/his ankles against her/his wheelchair foot rests. On 8/14/24 at 1:29 PM Staff 16 acknowledged, based on the data presented and available documentation, there was no initial investigation and appropriate follow-up of the wounds to Resident 15's ankles as expected to understand the root cause of the wounds and the wound assessments were inaccurate once the wounds were identified as pressure ulcers. 50928 2. Resident 27 admitted to the facility on ,d+[DATE] with diagnoses including stroke and diabetes. A 12/19/23 Admission Profile assessment indicated Resident 27 had pressure to the coccyx (tailbone). The pressure area was described as purple, non-blanchable, and not currently open. Calazime (a skin protectant) cream was to be applied during skin checks. No wound measurements were obtained. A 12/29/23 Pressure Ulcer CAA indicated resident 27 was at risk for skin breakdown and pressure injury due to decreased mobility and the need for extensive assistance with toileting. Staff were to provide prompt peri-care for toileting and to notify a nurse of any skin breakdowns or injuries. The CAA did not include any information regarding the pressure to Resident 27's tailbone. A review of Resident 27's clinical record from 12/30/23 through 4/3/24 (106 days), revealed the following: -No weekly wound round assessments were initiated. -The Weekly Skin Check Body Diagram and the TARs had no information or monitoring of Resident 27's coccyx pressure ulcer. An 4/3/24 Pressure Injury investigation revealed Resident 27 reported pain and discomfort to his/her buttock region. The resident exhibited dark purple discoloration on both bilateral buttocks and tailbone; wound measurements were completed. Staff 3 (LPN) notified Staff 30 (LPN Resident Care Manager) the wound nurse. An 4/3/24 Initial Skin Ulcer/Injury Measurement and Evaluation completed by Staff 30 revealed the resident had a facility-acquired DTPI (deep tissue pressure injury [persistent non-blanchable deep red, maroon or purple discoloration]) to the bilateral buttocks. The suspected DTPI had multiple, purple/maroon localized areas of discolored intact skin from pressure and/or shearing with repositioning or transfers. Wound measurements were obtained and treatment was initiated. Weekly wounds rounds and treatments were implemented on 4/4/24. On 7/6/24 a Wound Evaluation assessment indicated Resident 27 had a Stage 2 (partial-thickness loss with exposed dermis) pressure ulcer. The pressure ulcer measured 2.8 cm in length x 1.95 cm in width, with an overall area of 3.68 cm, and no signs or symptoms of infection. The assessment did not identify the location of the wound and indicated it was present on admission. A physician order with a start date of 7/10/24 and discontinued on 7/23/24 instructed staff to cleanse with wound Dakins (a solution to treat wound infections), pat to dry, apply Santyl ointment (helps remove dead tissue) to the wound bed, sprinkle Flagyl (an antibiotic) on the wound bed for odor control, pack with Maxorb AG ribbon (a calcium alginate to treat moderate to heavy draining wounds), apply calazime ointment, cover with a dressing and keep clean and dry every day and evening shift for wound care to left buttocks. A 7/13/24 and 7/20/24 Wound Evaluation assessment indicated Resident 27 had a Stage 3 (full-thickness skin loss) pressure ulcer. The pressure ulcer measured 2.68 cm in length x 1.38 cm in width, with an overall area of 2.41 cm. The assessment indicated the resident's wound had a suspected infection but was improving. A 7/23/24 Wound Clinic document revealed Resident 27 had a Stage 4 (full-thickness skin and tissue loss, undermining and/or tunneling often occur) pressure injury over the left iliac crest (hip bone) as well as the following: -The resident's left iliac crest foam dressing was 100% saturated, and the drainage was purulent (thick milky fluid which oozes from a wound that is not healing properly) and yellow with no odor. -The wound measured 2.8 cm in length x 1.6 cm in width x 2.4 cm in depth with a wound surface of 4.48 cm. The wound had significant depth/tunneling, extending to 7.5 cm. -During the wound debridement three pieces of packing were found in the wound and subsequently removed. -A new order directed staff to change the dressing PRN for saturation of the foam dressing at three to four corners of the foam dressing, remove the packing and heavily irrigate the wound using wound cleanser spray or pressure nozzle wound cleanser, pat the wound dry and fill the wound with ONE continuous piece of silver hydrofiber (soft sterile wound care product) packing. -It was emphasized to ensure ALL packing was removed from the wound before filling the wound with one continuous piece of packing, leaving a three-inch tail for retrieval. In an interview on 8/12/24 at 11:23 AM and 8/14/24 at 11:10 AM Resident 27 stated she/he had a sore on her/his buttocks and was receiving treatment in the facility. Resident 27 stated she/he recently was sent to a wound clinic due to the wound not improving. The resident stated during the wound clinic appointment, the wound nurse discovered old packing deep within the wound, which she had to remove before cleaning and packing the wound. Resident 27 stated this caused her/him extreme pain. In an observation and interview on 8/15/24 at 9:40 AM Staff 3 (LPN) was observed performing wound care for Resident 27. Staff 3 removed the dressing from the resident's left buttock, removed the packing from the wound, discarded her gloves, sanitized her hands, and donned clean gloves. Staff 3 cleansed the wound with a spray, changed her gloves, and applied packing to the inside of the wound. Staff 3 stated the tunneling extended all the way up the left buttock, close to the lower back. Staff 3 placed a dressing over the wound and applied ointment to reddened area around the buttocks. Staff 3 stated she was aware of the wound when it was a stage 2, and staff applied Flagyl due to the wound developing an odor. Staff 3 stated she heard about the wound clinic discovering packing left in Resident 27's wound. Staff 3 stated she did not apply packing into the wound until after the wound clinic appointment. Staff 3 indicated Resident 27 stated it was the worst pain she/he ever had. In an interview on 8/15/24 at 12:44 PM Staff 3 stated the weekly Skin Body Diagram was completed by Staff 30. These diagrams involved a full body scan to ensure no skin breakdown occurred. Staff 3 stated recently the weekly skin checks were reassigned to nurses on the floor. Staff 3 stated she recalled first noticing the wound on Resident 27's buttocks approximately three months ago during a weekly skin check, but she could not recall to whom she reported the concern. The wound care orders directed staff to pack the wound, treat the wound with Santyl ointment, place AG rope on top of the resident's wound, and apply Flagyl for odor control. Staff 3 stated she placed the AG rope on top of the wound because she/he was unaware of any tunneling and indicated she never packed the wound. Staff 3 stated packing a wound meant folding the dressing in half and placing it on top of the wound. Staff 3 stated she only began packing the wound after Resident 27 was seen by the wound specialist on 7/23/24. In an interview on 8/15/24 at 3:34 PM Staff 8 (LPN) stated weekly skin checks were conducted by Staff 30 which involved an entire head-to-toe body check to identify any skin breakdown or wounds. Staff 8 stated recently the weekly skin checks were reassigned to nurses on the floor. Staff 8 did not recall any reports of Resident 27's buttocks until a few months ago. During that time the wound was not open, but resembled a discolored scab without any signs or symptoms of infection. Staff 8 confirmed the wound care orders prior to Resident 27's wound clinic visit instructed staff to pack the wound. Staff 8 explained the term packing referred to covering the site to facilitate absorption, as there was no tunneling to the wound to Staff 8's knowledge. Staff 8 denied packing Resident 27's wound. Staff 8 stated Resident 27 was seen by a wound specialist in 7/2024 and packing was found inside the wound, possibly remaining from previous dressing changes. Staff 8 stated Staff 30 completed weekly wound assessments which involved measurements and a description of the wound, including measuring the length, width, and depth. Interviews conducted on 8/16/24 at 9:28 AM revealed the following: -Staff 4 (RNCM) stated she completed the Admission Profile assessment for Resident 27 on 12/19/23 but did not identify the stage of the wound to the tailbone region. Staff 4 sated she was supposed to report her finding to Staff 30 to initiate wound care orders and treatment for Resident 27's pressure to the tailbone. -Staff 30 stated she completed the MDS and the 12/29/23 Pressure Ulcer CAA for Resident 27. Staff 30 stated she reviewed hospital records and spoke with the resident. Staff 30 stated she intended to review the Admission Profile Skin assessment, which Staff 4 completed, however Staff 30 acknowledged there was no information about the resident's pressure ulcer on the CAA because she missed reviewing the Admission Profile Skin assessment on 12/19/23. Staff 30 stated when she reviewed the 12/30/23 Skin Check Body Diagram there was no information regarding Resident 27's wound to the buttocks, leading her to assume the wound was resolved. - Staff 16 (Regional Nurse) stated Resident 27 had a DTPI, and weekly wound assessments should have been initiated along with monitoring of the wound. Staff 16 acknowledged the three-month delay for monitoring of the DTPI. -Staff 16 and Staff 30 stated Resident 27 showed no signs or symptoms of infection until 7/8/24. The wound culture was negative, and Staff 30 stated to her knowledge there was no noticeable tunneling. On 7/23/24 Resident 27 was sent to the wound specialist where the wound was debrided, tunneling was noted, and old packing was found in the wound. Staff 16 acknowledged the wound orders for Resident 27 instructed staff to pack the wound. Staff 16 explained packing a wound referred to laying a pad across the wound, even if the wound was crater-like, to assist with granulation (development of new tissue). -Staff 30 stated she completed weekly wound assessment and used a sterile cotton swab to measure the deepest point, and monitored the tunneling of the wound. Staff 30 and Staff 16 acknowledged there was no documentation regarding Staff 30 measuring the wound for tunneling. -When asked about current wound care orders for Resident 27, Staff 16 confirmed the order instructed staff to heavily irrigate the wound with cleanser. Staff 16 stated the method of heavy irrigation could vary depending on the specific order. When asked if spraying a wound with wound cleanser constituted heavily irrigated, Staff 16 stated she would clarify the wound order. Staff 16 acknowledged there were significant issues and concerns with wound care. -No information was provided if the wound care order was clarified. 34703 3a. Resident 28 admitted to the facility in 2/2024 with diagnoses including bilateral aka (above the knee) amputations and pressure ulcers. The 6/2/24 Admission MDS indicated Resident 28 required assistance with bed mobility and was at risk for pressure ulcers to deteriorate and to develop more. Resident 28's skin was monitored for signs of newly developing skin issues. The care plan dated 7/28/24 indicated Resident 28 had excoriation and an open area to the right buttock. An 8/2/24 Skin Ulcer/Injury Measurement and Evaluation Note indicated Resident 38 had a Stage 3 (full-thickness skin loss) pressure ulcer to her/his left buttocks. An 8/12/24 Skin and Wound Evaluation Note indicated Resident 28 had a Stage 2 (partial-thickness skin loss) pressure ulcer to her/his left buttocks. On 8/15/24 at 4:33 PM Staff 16 (Regional Nurse) acknowledged staff assessed the wound inaccurately; Resident 28 had a Stage 2 pressure ulcer not a Stage 3. b. On 8/9/24 a Skin Monitoring Comprehensive CNA Shower Review indicated the resident had no skin issues. The 8/2024 Documentation Survey Report indicated Resident 28 had a skin observations performed on 8/12/24 and 8/13/24 on all shifts, and no skin concerns were observed. On 8/12/24 at 1:27 PM Resident 28 was is observed to have an open area approximately the size of a nickel on the right stump underneath the leg prosthesis and a small scab. Resident 28 stated she/he had open areas to the right thigh, but staff did not place dressings over the wounds. On 8/14/24 at 1:39 PM Staff 16 (Regional Nurse) observed multiple blisters (Stage 2 pressure ulcers) to Resident 28's right thigh and acknowledged there was no documentation in Resident 28's medical record to identify the blisters to the resident's right thigh.

Based on interview and record review it was determined the facility failed to suction a resident safely, and failed to follow diabetic orders for 2 of 9 sampled residents (#s 7 and 85) reviewed for accidents and medications. This placed residents at risk for injury and delayed treatment. Findings include: 1. Resident 7 admitted to the facility in 7/2020 with a diagnosis of diabetes. A 7/2024 Diabetic Administration Record (DAR) revealed staff were to implement the hypoglycemic protocol (provide juice, sugar or medication to increase a resident's low blood sugar level) if Resident 7's CBG level was less than 60. The DAR revealed on 7/16/24 at 7:00 AM Resident 7's CBG was 48. The Diabetic Administration Record did not indicate the hypoglycemic protocol was implemented. A 7/16/23 Progress Note contained no information staff provided interventions when Resident 7's CBG level was 48. On 8/1/24 at 9:09 AM Staff 4 (RNCM) stated if a CBG level was less than 60 staff should have provided interventions, re-checked the CBG level after interventions were provided, and documented in the resident's clinical record. Staff 4 verified the resident's record did not indicate the hypoglycemic protocol was followed. 2. Resident 85 admitted to the facility in 1/2013 with a diagnosis of stroke. A Care Plan initiated 12/2014 revealed Resident 85 was at times resistive to care and had a communication deficit due to a stroke. If the resident bats away staff or pushes them away it indicated Resident 85 did not want to participate in something. Staff were to allow Resident 85 to make choices. A Progress Note by Staff 20 (Agency LPN) dated 7/31/23 revealed the nurse on the previous shift reported she may have inserted the suction tip too far into Resident 85's throat to suction secretions and blood was observed in the suction tubing. A 7/31/23 hospice Staff Progress Notes revealed facility staff reported Resident 85 was suctioned too deep by facility staff and she/he had dried blood in her/his mouth. The note indicated Resident 26 did not appear to be actively bleeding. On 8/13/24 at 6:07 PM Witness 4 (Anonymous Staff) stated she heard the nurse give report that a CNA held Resident 85's hands down while a nurse suctioned the resident and the resident bled. On 8/13/24 at 3:25 PM Staff 2 (Assistant DNS) stated she did not recall an incident related to Resident 85's care.

Based on interview and record review it was determined the facility failed to develop a person-centered care plan for 1 of 1 sampled resident (#30) reviewed for tube feeding. This placed residents at risk for lack of identified needs. Findings include: Resident 30 admitted to the facility in 3/15/24 with diagnoses including brain damage, quadriplegia (paralysis of all four extremities), and a feeding tube. An 3/15/24 Care Plan indicated the following for Resident 30: -Toilet use: the resident was independent or had toileting deficits due to quadriplegia and brain damage. The interventions included toilet use, dependant on one staff. Resident 30 was incontinent and did not use the toilet. -Bowel incontinence: the resident will have less than two episodes of incontinence per day. Assess pattern of incontinence and indicate toileting schedule if indicated. -Transfers: the resident was independent or had transferring performance deficits due to quadriplegia and brain damage. Interventions were three or more staff assistance with slide transfer to bed and wheelchair. Resident 30 used a mechanical lift for transferring. -Eating: The resident was independent or had eating performance deficits due to quadriplegia and brain damage. The goal included the resident will be able to eat in the highest practical level for their current condition. Resident 30 received nourishment and medications through her/his feeding tube. -Dressing: the resident was independent or had dressing performance deficits due to quadriplegia and brain damage. Interventions included to assist the resident to choose simple comfortable clothing that enhanced the resident's ability to dress her/himself, and to make sure shoes were comfortable and not slippery. On 8/15/24 at 11:57 AM Staff 7 (RNCM) acknowledged Resident 30's care plan was not individualized or person-centered and should have been.

Based on interview and record review it was determined the facility failed to ensure allegations of abuse were reported to administration for 1 of 5 sampled residents (#85) reviewed for accidents. This placed residents at risk for abuse. Findings include: Resident 85 admitted to the facility in 1/2013 with a diagnosis of stroke. A 7/31/23 Progress Noted by Staff 20 (Agency LPN) revealed the nurse on the previous shift (not identified) reported she may have placed the suction tip too far into the resident's throat to suction secretions and blood was observed in the suction tubing. On 9/23/24 Witness 2 (Complainant) reported to the state agency facility staff were aware of an incident when a CNA held Resident 85's hands down in order for the nurse to suction the resident's secretions. On 8/13/24 at 5:40 PM Staff 32 (Former CNA) stated she heard another CNA held down Resident 85's hand while the nurse suctioned the resident. On 8/13/24 at 6:07 PM Witness 4 (Anonymous Staff) stated she was aware of a situation when the night nurse had a CNA hold down Resident 85's hand so the nurse could suction the resident. Witness 4 stated she reported to Witness 3 (Anonymous Staff) On 8/13/24 at 7:51 PM Witness 3 stated a CNA reported to her, during Resident 85's care, another CNA held the resident's hands down. Witness 3 directed the CNA to report the concern to administration. On 8/14/24 at 3:12 PM Staff 16 (Regional Nurse) stated if staff had any concern that another staff member held down a resident's hands during care, it was to be reported and an investigation would be initiated. On 8/14/24 at 3:30 PM Staff 1 (Administer) stated she was just made aware of the allegation a CNA held down Resident 85's hands therefore a FRI was not submitted at the time of the 7/31/23 incident.

Based on interview and record review it was determined the facility failed to address a grievance for 1 of 4 sampled residents (#20) reviewed for ADLs. This placed residents at risk for unresolved grievances. Findings include: Resident 20 admitted to the facility in 6/2021 with a diagnosis of a stroke. A 11/20/23 Interdisciplinary Conference form revealed Resident 20 reported she/he requested assistance from a CNA and the CNA refused to assist. The form indicated the resident care manager was to follow up with the concern. On 8/15/24 at 8:35 AM Staff 9 (Social Services Director) stated if a resident voiced a concern at a care conference staff were to follow-up with the concern. Staff 9 stated Staff 28 (Staffing) was to review the schedule and determine the CNA who worked with the resident. Staff 9 stated she maintained all the grievances and she did not have a grievance for Resident 20's 11/20/23 concern. On 8/15/24 at 9:47 AM Staff 28 stated if a resident voiced a concern a grievance was to be initiated. Depending on the situation, she or nursing staff would address the resident concern and follow-up with the resident. Staff 28 stated she did not recall Resident 20's grievance. On 8/16/24 at 9:23 AM Staff 4 (RNCM) stated she did not recall the 11/20/23 grievance.

Based on interview and record review it was determined the facility failed to ensure call lights were in reach for 1 of 3 sampled residents (#287) reviewed for environment. This placed residents at risk for unaddressed individual needs. Findings include: Resident 287 was admitted to the facility in 8/2024 with diagnoses including palliative care and diabetes. A 8/5/24 care plan indicated staff were to respond immediately to Resident 287's need for pain relief. On 8/13/24 at 1:45 PM Resident 287 was observed in bed and her/his call light was not within reach. On 8/13/24 at 2:11 PM Staff 35 (CNA) stated she neglected to ensure Resident 287's call light was within reach after she provided her/his care around noon. On 8/14/24 11:37 AM Staff 4 (RNCM) stated Resident 287 was able to use her/his call light and expected the resident's call light would be within reach when she/he was alone in her/his room. Staff 4 stated staff would be re-educated to ensure Resident 287's call light was within reach. On 8/15/24 at 2:09 PM Resident 287 was observed in bed and her/his call light was not within reach. On 8/15/24 at 2:10 PM Staff 4 was notified Resident 287 did not have her/his call light within reach and confirmed her/his call light should be within her/his reach.

Based on interview and record review it was determined the facility failed to ensure flu and pneumonia vaccines were provided for 2 of 5 sampled residents (#s 7 and 15) reviewed for immunizations. This placed residents at risk for respiratory infections. Findings include: 1. Resident 7 admitted to the facility in 4/2017 with a diagnosis of diabetes. A Consent For Annual Flu, Pneumonia, and Covid Vaccines form revealed on 5/4/24 Resident 7 consented to have a pneumonia vaccine administered. Resident 7's record did not have documentation to indicate she/he received the vaccine. On 8/14/24 at 2:33 PM Staff 30 (IP) verified Resident 7 consented to the pneumonia vaccine but staff did not administer it. 2. Resident 15 admitted to the facility in 12/19/23 with a diagnosis of diabetes. A Consent For Annual Flu, Pneumonia, and Covid Vaccines form revealed on 12/19/23 Resident 15 consented to have a flu vaccine administered. Resident 15's record did not have documentation to indicate she/he received the vaccine. On 8/14/24 at 2:33 PM Staff 30 (IP) verified Resident 15 consented to the flu vaccine but staff did not administer it.

Based on interview and record review it was determined the facility failed to monitor side effects of psychotropic medications for 1 of 5 sampled residents (#7) reviewed for medications. This placed residents at risk for adverse medication reactions. Findings include: Resident 7 was admitted to the facility in 5/2017 with chronic mental health diagnoses. Resident 7's 7/2024 and 8/2024 MARs and TARs revealed she/he was administered scheduled olanzapine (antipsychotic), valproic acid (mood stabilizer), and clonazepam (treats anxiety). There was no indication the side effects of the psychotropic medications were monitored. On 8/14/24 at 10:01 AM Staff 3 (LPN) stated staff were to document on the TAR if a resident had side effects of psychotropic medications. If there were side effects staff were also to document in the Progress Notes. On 8/14/24 at 2:15 PM Staff 4 (RNCM) stated the psychotropic medication side effects were to be entered as a scheduled nursing task. Staff 4 stated the order was entered as PRN and therefore the system did not alert staff to monitor and document if the resident had any medication side effects.

Based on observation, interview and record review it was determined the facility failed to assess and implement trauma informed care interventions for 1 of 5 sampled residents (#15) reviewed for medications. This placed residents at risk for re-traumatization. Findings include: Resident 15 admitted to the facility in 12/2023 with diagnoses including PTSD (Post Traumatic Stress Disorder) and anxiety. A 12/22/23 Psychosocial History and Discharge Plan assessment indicated Resident 15 had no trauma, mood or behavior issues. A 7/18/24 revised care plan indicated staff were to notify Staff 9 (Social Services Director) with changes in mood or behaviors and Resident 15's psychosocial well-being problem was related to a recent hospitalization (in 2023). No focus or interventions related to Resident 15's PTSD were found. On 8/12/24 11:30 AM and 1:18 PM Resident 15 was observed in bed sleeping with the door open and no blankets or clothing were observed to cover her/him. On 8/13/24 at 9:34 AM Resident 15 was observed in bed sleeping. Staff 6 (RN) stated Resident 15 usually was awake most of the night and woke for the day by 3:00 PM. On 8/14/24 at 11:17 AM Staff 6 stated she was only aware of Resident 15's PTSD because she spoke with the resident and believed her/his withdrawn behavior and anxiety at night was also related to her/his PTSD. Staff 6 stated other staff would benefit to know how to approach Resident 15 because she/he only accepted or spoke with select staff. Staff 6 expressed concerns there were no monitors in place related to Resident 15's PTSD. On 8/14/24 at 11:41 AM and 12:48 PM Staff 9 stated she was recently informed of issues at night for Resident 15 and stated her/his baseline behavior was long hours of sleep and ignoring people. Staff 9 acknowledged Resident 15's psychosocial assessment was inaccurate because she was not aware of her/his PTSD diagnosis at admission. Staff 9 also acknowledged Resident 15's care plan was not specific to her/his behaviors and interventions for her/his PTSD were needed.

Based on interview and record review it was determined the facility failed to ensure staff followed the care plan related to fall safety and ascertain post-fall injuries for 2 of 4 sampled residents (#s 10 and 26) reviewed for accidents. This placed resident placed at risk for lack of supervision and falls. Findings include: 1. Resident 26 admitted to the facility in 9/2022 with a diagnosis of a stroke. a. A Fall investigation dated 5/14/24 revealed Resident 26 had an unwitnessed fall on 5/14/24 at 12:35 AM. Progress Notes from 5/14/24 to 6/4/24 revealed the following: -5/14/24 Resident 26 fell and neurological assessments were initiated. -5/15/24 Resident 26 was assessed to not have an injury from her/his fall. There were no additional post fall assessments after 5/15/24. A Neurological Check form (assessment for head injury) initiated 5/14/24 revealed staff were to assess Resident 26 every 15 minutes for one hour, every one hour for four hours, every four hours for 16 hours, and every eight hours for 24 hours, a total of 19 assessments. The assessment included vital signs, pupil size, and strength of arms and legs. A complete neurological assessment was not completed for any of the scheduled times. On 8/15/24 at 8:30 AM Staff 4 (RNCM) stated staff were to assess and document in the Progress Notes for 72 hours after a resident fall. Staff 4 acknowledged the neurological assessments and charting was not done for Resident 26's 5/14/24 fall. b. A Fall investigation dated 6/4/24 revealed Resident 26 had an unwitnessed fall on 6/4/25 at 6:13 AM. The investigation indicated neurological assessments were completed. Review of Resident 26's clinical record revealed no Neurological Check form (assessment for head injury). Progress notes from 6/4/24 to 6/7/24 revealed no notes related to Resident 26's fall. On 8/15/24 at 8:30 AM Staff 4 (RNCM) stated staff were to assess and document in the Progress Notes for 72 hours after a fall. On 8/15/24 at 9:51 AM Staff 33 (LPN) stated neurological assessments were to be completed at scheduled times for unwitnessed falls. On 8/15/24 at 12:24 PM and 8/15/24 at 12:45 PM a request was made to Staff 16 (Regional Nurse) for assessments after Resident 26's 6/4/24 fall. No additional information was provided. c. A Fall investigation dated 6/26/24 revealed Resident 26 had an unwitnessed fall on 6/26/24 at 4:39 AM. Resident 26 sustained a hematoma (collection of blood under the skin) and was sent to the emergency room for evaluation. Resident 26 was assessed to not have a head injury. The investigation also indicated neurological assessments were completed. A Neurological Check form (assessment for head injury) initiated 6/26/24 revealed staff were to assess Resident 26 every 15 minutes for one hour, every one hour for four hours, every four hours for 16 hours, and every eight hours for 24 hours, a total of 19 assessments. The assessment included vital signs, pupil size, and strength of arms and legs. Complete neurological assessments were completed six times in the first 24 hours. Assessments were not completed for the remaining 32 hours. On 8/15/24 at 9:51 AM Staff 33 (LPN) stated neurological assessments were to be completed at scheduled times for unwitnessed falls. On 8/15/24 at 8:30 AM Staff 4 (RNCM) acknowledged the neurological assessments and charting was not completed after Resident 26's 6/26/24 fall. 36494 2. Resident 10 admitted to the facility on ,d+[DATE] with diagnoses including Parkinson's disease and repeated falls. A care plan initiated on 7/1/21 revealed Resident 10 was a fall risk and required a one-person assist with toileting. A revision dated 5/6/22 revealed Resident 10 was not to be left alone when using the restroom. A FRI dated 1/25/24 revealed the following: - Resident 10 was found on the floor in the north common bathroom by Staff 18 (Former CNA) and Staff 26 (Former CNA) after they heard a thud. - Staff 4 (RNCM) assessed Resident 10 who was unable to describe the incident due to being non-verbal, but was able to shake her/his head yes or no. The resident denied pain. Staff 4 indicated the resident sustained a hematoma (an abnormal collection of blood outside of a blood vessel or body space) measuring approximately three inches. - Staff 17 (Former CNA) indicated she placed Resident 10 on the toilet and left the restroom to allow her/him privacy. Staff 17 indicated during shift change she reported to Staff 18 Resident 10 was on the toilet. Staff 17 assumed Staff 18 was going to assist Resident 10 off of the toilet, so Staff 17 left the facility. - Staff 18 indicated she received report during shift change from Staff 17 and was informed Resident 10 was on the toilet, but assumed Staff 17 was going to complete caring for Resident 10 and assist her/him off of the toilet. However, Staff 17 left the facility after shift change. -The miscommunication resulted in Resident 10 being left on the toilet unattended in the bathroom and she/he subsequently fell off the toilet. -It was determined there was poor communication between Staff 17 and Staff 18 during shift change and Staff 17 did not follow the care plan, which indicated Resident 10 was not to be left alone when using the toilet. On 8/12/24 and 8/13/24 attempts to contact Staff 17 were unsuccessful. On 8/13/24 at 12:54 PM and 3:09 PM Staff 23 (CNA) and Staff 19 (CNA) stated on 1/25/24, during shift change, Staff 17 was assigned to Resident 10 and indicated she placed the resident on the toilet in the bathroom, after which Staff 17 left the facility. Staff 23 stated she entered the bathroom after hearing a loud noise and found Resident 10 on the floor. Staff 23 stated she ran for additional help because other staff were already in the bathroom. Staff 23 and Staff 19 stated Resident 10 was a fall risk and was not to be left alone when she/he was in the bathroom. On 8/15/24 at 9:13 AM Staff 18 stated on 1/25/24, during shift change, Staff 17 told Staff 18 she placed Resident 10 on the toilet but then left the facility. Staff 18 stated she thought Staff 17 was going to assist the resident off of the toilet before she left the facility after her shift ended, but that did not occur. Staff 18 stated she heard a thud and found Resident 10 on the floor in the bathroom unattended. The resident looked bewildered but was smiling. Staff 18 stated Resident 10 was not to be left unattended in the bathroom and there was a miscommunication between her and Staff 17. On 8/15/24 at 1:51 PM Staff 4 stated the 1/25/24 incident occurred during shift change and there was poor communication between staff. Additionally, Resident 10 was not to be left alone when she/he was placed on the toilet. Staff 4 stated Staff 17 did not follow the care plan which resulted in Resident 10 falling off of the toilet. Staff 4 stated Resident 10 obtained a hematoma with pain to the head, but once back in her/his wheelchair the resident was back to her/his baseline. On 8/15/24 at 2:10 PM Staff 2 (acting DNS) stated she was aware of the incident on 1/25/24, acknowledged Staff 17 did not follow the care plan, and there was poor communication during shift change. Staff 2 stated Resident 10 was not sent out to the hospital because she/he was comfort care measures only. Staff 2 stated staff initiated neurological checks and monitored her/him appropriately for pain and discomfort after the fall.

Based on interview and record review it was determined the facility failed to ensure residents were free from significant medications errors for 1 of 6 sampled residents (#131) reviewed for medication. Resident 131 received an excessive dose of morphine (opioid pain medication) which resulted in hospitalization . Findings include: Resident 131 was admitted to the facility on [DATE] with diagnoses including femur fracture and respiratory failure. The 3/30/22 hospital physician orders indicated Resident 131 was to receive the following: -morphine 10 mg/5 ml take 2 ml in the morning and 1 ml in the afternoon; -morphine concentrate 10 mg/0.5 ml concentrated solution take 0.1 ml (2 mg total) PO TID PRN air hunger for up to three days. The Omnicell (automated medication dispensing system used when medication is not otherwise available) indicated on 3/30/22 at 6:42 PM Staff 6 (LPN) and Staff 18 (Former Staff/LPN) pulled one bottle of morphine sulfate 20 mg/ml solution 30 ml for Resident 131. The 3/31/22 Medication Administration Audit Report indicated Resident 131 was to receive Morphine Sulfate Solution 10 MG/5 ML Give 2 ml by mouth in the morning related to chronic respiratory failure with hypoxia; chronic obstructive pulmonary disease. Watch dosages = two different concentrations ordered. The report indicated Staff 15 (CMA) administered the medication on 3/31/22 at 8:04 AM. The 4/5/22 FRI indicated on 3/31/22 Resident 131 received 2 ml of 20 mg/1 ml giving 40 mg of morphine and the error was immediately noted. An order was received by the provider to administer 0.4 mg of Narcan (opioid antidote medication) as needed for hypoxia (lack of oxygen in the body), decreased respiratory status and unresponsiveness. If the resident was non-responsive, or hypoxic call 911. The provider reviewed the record and made the decision to send Resident 131 to the emergency room due her/his comorbidities, respiratory illness, for monitoring and appropriate dosing of Narcan as needed. The provider indicated the resident may need more Narcan than the amount available in the Omnicell. Resident 131 was calm, had no pain and no respiratory difficulty. The note further indicated staff sat with the resident and frequently monitored respiration/pulse/cognition until EMTs arrived. The resident went out to the ER via EMT. The resident received Narcan on the way to the ED. The resident discharged from the ED to home per the resident's choice and did not return to the facility. The 3/31/22 hospital records indicated Resident 131 was brought in after an accidental opiate overdose. She/he was getting morphine for pain and was accidentally given 40 mg instead of 3 mg at 8:45 AM on 3/31/22 . The mistake was identified, and EMS was called. The patient became drowsy and was given 2 mg of Narcan by EMS. The resident was alert and awake and complaining of hip and total body pain. She/he was upset and demanding to be discharged home, refusing to go back to rehab. She/he denied feeling drowsy at the time. She/he was observed for two hours post Narcan with no evidence of somnolence or respiratory depression. She/he was referred to home health and discharged home. On 4/5/23 at 3:28 PM Staff 15 stated she did not compare the MAR to the bottle of morphine which resulted in the medication error on 3/31/22 which resulted in the administration of Narcan by EMS and hospitalization . On 4/7/23 at 9:50 AM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged Resident 131 had an order for 4 mg of morphine and the resident received 40 mg of morphine on 3/31/22 resulting in the administration of Narcan by EMS and hospitalization .

Based on interview and record review it was determined the facility failed to ensure Staff 15 (CMA) administered medications per the current standard of practice. This resulted in Resident 131 experiencing adverse medication consequences and being sent to the hospital for treatment and observation. Findings include: Resident 131 was admitted to the facility on [DATE] with diagnoses including femur fracture and respiratory failure. The 3/30/22 hospital physician orders indicated Resident 131 was to receive the following: -morphine 10 mg/5 ml take 2 ml in the morning and 1 ml in the afternoon; -morphine concentrate 10 mg/0.5 ml concentrated solution take 0.1 ml (2 mg total) PO TID PRN air hunger for up to three days. The Omnicell (automated medication dispensing system used when medication is not otherwise available) indicated on 3/30/22 at 6:42 PM Staff 6 (LPN) and Staff 18 (Former Staff/LPN) pulled one bottle of morphine sulfate 20 mg/ml solution 30 ml for Resident 131. The 3/31/22 Medication Administration Audit Report indicated Resident 131 was to receive Morphine Sulfate Solution 10 MG/5 ML Give 2 ml by mouth in the morning related to chronic respiratory failure with hypoxia; chronic obstructive pulmonary disease. Watch dosages = two different concentrations ordered. The report indicated Staff 15 (CMA) administered the medication on 3/31/22 at 8:04 AM. The 4/5/22 FRI indicated on 3/31/22 Resident 131 received 2 ml of 20 mg/1 ml giving 40 mg of morphine and the error was immediately noted. An order was received by the provider to administer 0.4 mg of Narcan (opioid antidote medication) as needed for hypoxia (lack of oxygen in the body), decreased respiratory status and unresponsiveness. If the resident was non-responsive, or hypoxic call 911. The provider reviewed the record and made the decision to send Resident 131 to the emergency room due her/his comorbidities, respiratory illness, for monitoring and appropriate dosing of Narcan as needed. The provider indicated the resident may need more Narcan than the amount available in the Omnicell. Resident 131 was calm, had no pain and no respiratory difficulty. The note further indicated staff sat with the resident and frequently monitored respiration/pulse/cognition until EMTs arrived. The resident went out to the ER via EMT. The resident received Narcan on the way to the ED. The resident discharged from ED to home per the resident's choice and did not return to the facility. The 3/31/22 hospital records indicated Resident 131 was brought in after an accidental opiate overdose. She/he was getting morphine for pain and was accidentally given 40 mg instead of 3 mg at 8:45 AM on 3/31/22 . The mistake was identified, and EMS was called. The patient became drowsy and was given 2 mg of Narcan by EMS. The resident was alert and awake and complaining of hip and total body pain. She/he was upset and demanding to be discharged home, refusing to go back to rehab. She/he denied feeling drowsy at the time. She/he was observed for two hours post Narcan with no evidence of somnolence or respiratory depression. She/he was referred to home health and discharged home. On 4/5/23 at 3:28 PM Staff 15 stated she did not compare the MAR to the bottle of morphine which resulted in the medication error on 3/31/22 which resulted in the administration of Narcan by EMS and hospitalization . On 4/7/23 at 9:50 AM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged Resident 131 had an order for 4 mg of morphine and the resident received 40 mg of morphine on 3/31/22 resulting in the administration of Narcan by EMS and hospitalization .

Based on interview and record review it was determined the facility failed to ensure an anticoagulant medication was adequately monitored for 1 of 3 sampled residents (#6) reviewed for medication. Resident 6 was diagnosed with an intracranial bleed (brain bleed) and required ongoing care at a hospital. Findings include: Resident 6 was admitted to the facility in 12/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] requires monitoring of INR (International Normalized Ratio) due to a potential for abnormal bleeding. On 12/7/20 a physicians order included the following: [MEDICATION(S)] 7.5 mg one tablet PO once a day four days a week. [MEDICATION(S)] 7.5 mg one-half tablet PO once a day on the remaining three days of the week. Documentation on the facility's INR record dated 12/7/20 showed the resident's INR was 1.7 and 12/11/20 was the next scheduled INR. There was no INR result entered on the resident's INR record after 12/7/20. On 12/16/20 a physicians order included the following: [MEDICATION(S)] 7.5 mg one tablet PO once a day four days a week. [MEDICATION(S)] 7.5 mg 1/2 tab PO on the remaining three days of the week. The 12/16/20 [MEDICATION(S)] order was not transcribed on the resident's MAR. The MARs dated 12/2020, 1/2021 and 2/2021 showed [MEDICATION(S)] was administered according to the 12/7/20 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The progress notes dated 2/8/21 documented the laboratory reported the resident had a critically high potassium level and the facility received an order to send the resident to the Emergency Department (ED). The ED record dated 2/8/21 revealed the resident had additional laboratory tests drawn in the ED and the resident's INR was a critically elevated result of greater than 9. The resident's head CT (Computerized Tomography) done during the ED visit on 2/8/21 showed evidence of an intracranial bleed (brain bleed). A Facility Reported Incident (FRI) dated 2/10/21 indicated the State agency was notified after the facility became aware of the critical INR on 2/8/21 and the lack of anti-coagulant monitoring for Resident 6 during the prior two months. On 6/9/21 at 2:30 PM the facility's [MEDICATION(S)] logbook was reviewed. The residents' [MEDICATION(S)] doses, INR results and the next scheduled INR were documented. In an interview on 6/9/21 at 2:45 PM Staff 1 (Administrator) stated the facility did not ensure the resident's INRs were done 12/11/20 through 2/8/21 and the facility administered the resident's [MEDICATION(S)] 12/11/20 through 2/8/21. In an interview on 6/10/21 at 12:00 PM Witness 5 (Physician) said INRs were supposed to be done when a resident took [MEDICATION(S)]. Witness 5 said the resident was seen in the ED in 2/2021 after a laboratory test showed an abnormally high potassium result. He indicated the same day the resident had a critically high INR which was treated in the ED and the resident's head CT showed a small brain bleed. Witness 5 said the next day the resident's INR was within normal range.

Based on observation, interview and record review it was determined the facility failed to administer the correct medications for 1 of 3 sampled residents (#5) reviewed for safe medication administration. Resident 3 experience unmanaged pain for a prolonged period. Findings include: Resident 5 admitted to the facility in 11/2020 with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A 11/2020 MAR indicated [REDACTED]. Additionally, two nurses were required to observe the removal of the old patch, placement of the new patch and document disposal via the narcotic log book. Two staff were to date and sign the new patch when applied and remove the old patch per schedule. A 11/21/20 Medication Error Report revealed the following error on 11/21/20: -A 25 mcg [MEDICATION NAME] was placed on Resident 5 at 12:36 PM instead of a 100 mcg [MEDICATION NAME]. -The wrong dosage was discovered on 11/21/20 at 10:15 PM and the correct 100 mcg [MEDICATION NAME] was placed on Resident 5. - Staff 12 (LPN) an agency nurse asked Staff 8 (RN) if she needed a second nurse for visual placement and dose check of the [MEDICATION NAME] prior to placing on Resident 5 and Staff 8 replied to go ahead because she did not have time. -The impact of the error on the resident included Resident 5 being very painful all evening. Random observations on 1/13/21 through 1/14/21 revealed Resident 5 asleep in bed, lying on her/his side, with a nasal cannula and an oxygen concentrator running. Resident 5 was not interviewable and was asleep in bed anytime time observations and interviews were attempted. On 1/14/21 at 1:25 PM Staff 8 indicated she recalled the medication error related to Resident 5, however did not believe she worked that day. On 1/14/21 at 2:44 PM Staff 7 (LPN) stated she worked the evening shift on 11/21/20 and recalled Resident 5 was more painful than usual, she/he was agitated, grimacing and kept trying to get up out of bed. Staff 7 stated the resident was administered additional [MEDICATION NAME] (a narcotic pain medication for moderate to severe pain) every two hours. Staff 7 stated CNA staff reported throughout the entire evening shift that anytime they attempted to move Resident 5 in bed she/he would scream ouch, ouch, grimace and wince. Staff 7 stated the [MEDICATION NAME] could only be administered every two hours and CNA staff reported to her that Resident 5 continued to struggle with pain in between the two hour window of Diludid administration. Staff 7 stated she and Staff 14 (LPN) discovered the medication error during shift change when they were counting the narcotics. Staff 7 and Staff 14 assessed Resident 5 and discovered a 25 mcg [MEDICATION NAME] was on the resident's back instead of a 100 mcg [MEDICATION NAME]. Staff 7 stated the 25 mcg patches were taped up and were not to be used and were delivered by hospice by mistake. Staff 7 stated two nurses were to be present to verify the correct [MEDICATION NAME]es being placed, the old [MEDICATION NAME] being removed, two signatures on the new patch and both nurses were to sign the narcotic log. Staff 7 stated this did not occur during the day shift on 11/21/21 and Resident 5 was more painful than usual the entire evening shift due to the incorrect [MEDICATION NAME]; a period of approximately nine and a half hours until the error was discovered. On 1/15/21 at 9:53 AM Staff 11 (Pharmacist Consultant) stated Resident 5's medication error related to the reduction of the [MEDICATION NAME] could impart the resident's pain level because Resident 5 could develop a tolerance and dependence upon the 100 mcg [MEDICATION NAME]. On 1/25/21 at 2:36 PM Staff 12 stated she did not work in the building often, however she worked on 11/21/21 on day shift. She vaguely remembered placing a [MEDICATION NAME] on Resident 5. Staff 12 stated because she did not work regularly in the building she asked Staff 8 if she needed to have a witness prior to applying the [MEDICATION NAME] and Staff 8 replied there was nothing special regarding placement of the [MEDICATION NAME]. Staff 12 stated she removed the old [MEDICATION NAME] and replaced with a new one and dispose of the old patch. Staff 8 stated she did not recall the 25 mcg [MEDICATION NAME]es being taped up, but she recalled them being in a box and she pulled out a single [MEDICATION NAME]. Staff 12 stated she applied the patch to Resident 5 and signed and dated the [MEDICATION NAME]. Staff 12 further stated she did not recall if Resident 5 was painful or not. In an interview on 1/14/21 at 2:15 PM and 1/25/21 at 1:45 PM Staff 2 (DNS) stated she was aware of the medication error on 11/21/20 and Resident 5 being more painful than usual during evening shift. Staff 2 stated she expected two nurses to witness when [MEDICATION NAME]es were being applied to ensure the correct dosage, application and disposal of the [MEDICATION NAME] was. Staff 2 stated the 25 mcg [MEDICATION NAME]es were delivered by hospice, which was the wrong dose for Resident 5. The 25 mcg [MEDICATION NAME]es should have been destroyed and not in the medication cart, however they were taped up and placed in the narcotic drawer. Staff 2 stated due to the lower dosage being placed on Resident 5 she/he was painful the entire evening until the error was discovered at the end of evening shift change by Staff 7 and Staff 14.

Based on interview and record review it was determined the facility failed to ensure a resident's alarm was in place as care planned prior to a fall and that appropriate transfer assistance was provided for 2 of 7 sampled residents (#s 2 and 3) reviewed for incidents. Resident 2 sustained a hip fracture after a fall. Findings include: 1. Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's temporary care plan dated 2/8/17 indicated the resident was a fall risk with safety interventions of a low bed, frequent visual checks, remind the resident to use the call light and wait for assistance and offer frequent toileting or check and change often. The resident's comprehensive care plan dated 2/8/17 indicated the resident was a fall risk with poor safety awareness. The resident required extensive assistance of two staff for transfers, toileting and bed mobility. The resident's care plan reflected safety interventions including frequent visual checks, low bed and mat at the bedside. There was no information regarding a bed alarm on the care plan. The care plan reflected updates/revisions through 4/5/17. A signed physician order [REDACTED]. A hospice visit note dated 3/13/17 indicated a pressure alarm for the resident's bed was requested and the order was placed. Care plan detail and history reports showed an order for [REDACTED]. The resident's Kardex (CNA Care Plan) was updated after a fall on 4/4/17. A copy of the Kardex that was in place prior to the resident's fall was not located. Nursing progress notes dated 2/8/17 through 2/10/17 indicated the resident required frequent reminders to use the call light and wait for assistance. Frequent visual checks were done to ensure resident safety as the resident attempted to get up to the restroom on her/his own. Nursing progress notes dated 2/11/17 through 3/22/17 contained no information on self-transfer attempts by the resident. The resident's vital signs were noted within normal limits for the resident. The next nursing note dated 4/2/17 at 8:30 pm indicated the resident was found on the ground on her/his right side calling for help outside the resident's bedroom door. The resident's hip was assessed for injury and a small abrasion was noted. The resident's hip/leg did not show any deformity or shortening. The resident was placed on alert, neurological checks were initiated and the resident was medicated for pain. An additional nursing progress note on 4/2/17 at 10:56 pm indicated the resident had no visible sign of injury but complained of right hip pain. The resident was medicated for pain and continued on alert. At 12:55 am the resident was soundly sleeping and again assessed for injury. There was no visible injury noted, no shortening of the leg, no bulge on the hip, no swelling, no bruising and no redness. A nursing progress note dated 4/3/17 at 9:07 am showed the resident expressed increased pain with movement. The resident grimaced and yelled out in pain with even slight movement of the right leg. A bulge on the right hip was noted. Hospice was notified of the resident's condition, paramedics were called and the resident was transported to the hospital for evaluation. The resident returned to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident passed away on 4/8/17. A facility incident investigation dated 4/2/17 indicated the resident was found on the floor in the hallway outside her/his room. The resident was on her/his right side and complained of right hip plain. The resident was heard calling for help, the call light was not on and no alarm was sounding. Interviews conducted 5/9/17 through 5/11/17 between 9:15 am and 3:00 pm showed: Staff 3 (RN) indicated she was working in a CNA capacity at the time of the fall. She was in a room with another resident at the time of the fall. When she left the room Resident 2 was on the ground in the hallway. Staff 3 stated the call light was not on and there was no alarm sounding. She had seen the resident approximately ten minutes prior in bed. Staff 3 stated there was no alarm on the resident when she saw her/him in bed. She did not receive any information regarding alarm placement on the resident. Staff 3 stated the resident was alert and oriented with some confusion. She was assigned to the resident that evening but was not the staff member who assisted the resident to bed after dinner. Staff 18 (CNA) indicated he was not at the facility at the time the resident fell . Staff 18 worked with the resident earlier in the day and noticed the alarm was not working. He took the alarm box to Staff 21 (RA/CNA) and she replaced the batteries. The resident had the alarm in place on her/his wheelchair at dinner. Staff 18 stated the resident was to have the pressure alarm in the wheelchair and in bed. The resident had good days and bad days when she/he was sometimes more alert. Staff 18 indicated the resident could turn the alarm off but was not really aware of the alarm so did not often try to disable it. Staff 18 stated he did not lay the resident down after dinner and was not sure who did but the alarm was in place and working the last time he saw the resident. Staff 21 (RA/CNA) indicated she was working as RA at the time of the fall on 4/2/17. Staff 18 brought her the alarm box from Resident 2's pressure alarm because it wasn't working. Staff 21 replaced the batteries and tested the alarm. The alarm was working properly and was placed back onto the resident. Staff 21 indicated a little later the resident attempted to toilet herself/himself and the alarm sounded. Staff 21 intervened, assisted the resident to the restroom, put the resident back into the wheelchair and verified the alarm was on. The resident was taken to the dining room. Staff 21 further indicated the resident was alert and confused. The resident normally did not touch the alarm but would get up quickly/spontaneously and go without asking for assistance. Staff 21 was unsure who put the resident into bed after dinner but the last she saw the resident the alarm was on and functioning. Staff 5 (LPN) indicated the resident should have had a pressure alarm in place at the time of the fall on 4/2/17. The resident had some confusion but did not normally try to disable the alarm. Staff 5 stated when he arrived at the resident's room the resident was already on the ground. The resident was painful, an assessment was completed with no visible signs of injury other than a small abrasion. Staff 5 stated there was no alarm visible in the resident's room or on the resident at the time of the fall. The physician and hospice were notified. Staff 5 indicated the resident was monitored for changes and was sent to the hospital for evaluation the following day when there was visible deformity of the hip and the resident had complaints of increased pain. Staff 2 (DNS) indicated she was unable to determine what happened to the resident's alarm prior to the fall on 4/2/17. There was no additional information to provide. 2. Resident 3 was admitted to the facility in February 2017 with [DIAGNOSES REDACTED]. The resident's admission profile dated 2/27/17 indicated the resident required limited assistance with bed mobility, transfers, bathing, toilet use, dressing and was independent with locomotion, eating and personal hygiene. The resident was noted to have amputations, but there was no specific information regarding the type or location of the amputations. The resident had a stage 2 pressure ulcer on his buttocks, multiple scabs/sores to the arms, legs, back, chest, head and abdomen and yeast rash to the groin. The resident's Kardex (CNA Care Plan) dated 2/27/17 indicated the resident required extensive assistance of two staff for transfers and bed mobility. The Kardex contained no information regarding how the resident transferred or if he required a mechanical lift. The resident's temporary care plan dated 3/2/17 indicated the resident required limited assistance for transfers and was a fall risk. The temporary care plan contained no information on how the resident transferred or if he required a mechanical lift. The resident's comprehensive care plan dated 3/2/17 indicated the resident required extensive assistance of two staff for transfers and bed mobility and extensive assistance of one staff for bathing, dressing, personal hygiene and toilet use. The care plan contained no information regarding what method the resident used for transfers and if he required a mechanical lift. The resident's admission MDS dated [DATE] indicated the resident had a score of 15/15 on the brief interview for mental status. The resident required extensive assistance of two staff for transfers and bed mobility, the remaining ADLs required extensive assistance of one staff. The resident had no falls noted and had fluctuating inattention with some altered level of consciousness continuously present. Nursing progress notes dated 2/27/17 through 3/9/17 showed the resident transferred with one staff assistance but did not mention any mechanical lift or device used. The resident was noted on a few occasions to be itching and picking at sores on his skin. There was no information related to any sores on the resident's scrotum or penis. Nursing progress notes dated 3/10/17 through 3/12/17 indicated the scab on the penis was intact. Nurses Notes on 3/14/17 indicated the resident was sent to the emergency room from dialysis due to left testicular pain. The resident returned with new orders for antibiotics and pain medication. Hospital emergency department notes, obtained from nursing facility records, dated 3/14/17 indicated the resident stated increased pain to the tip of his penis as well in the scrotum. The resident stated the pain was getting progressively worse. The resident was provided a testicular ultrasound which showed no evidence of testicular disease or neoplasm with no other findings to suggest trauma. The resident stated his penis was smashed while transferring from bed to wheelchair approximately three days ago. The physician noted the pain was likely secondary to injury. The resident was discharged with antibiotics, pain medication and was to follow up with a urologist. Nursing progress notes dated 3/15/17 through 4/5/17 contained no information on sores to the resident's penis or scrotum or concerns regarding a transfer. On 4/7/17 indicated the resident was out of the facility at a urology appointment, was sent to the hospital and did not return to the facility. Hospital emergency department notes obtained from the nursing facility records dated 4/7/17 indicated the resident was referred from a local urologist with severe 10/10 scrotal pain since a crush injury about 3 weeks ago. Per medical records, the patient was seen in the ED on 3/14/17 after his genitalia was crushed during a transfer. A circular black lesion on the penis which measured approximately 1.5 cm and two ovoid lesions to the left scrotum each approximately 1.5 cm x 4.0 cm were noted. Summary of the visit indicated an acute scrotal abscess, acute pelvic osteo[DIAGNOSES REDACTED] and acute severe necrotizing soft tissue infection. A hospital discharge summary obtained from the nursing facility records dated 4/7/17 indicated the resident was being seen status [REDACTED]. The physician additionally was concerned the resident showed symptoms of a potential infection in his bones. Interviews conducted 5/3/17 through 5/9/17 between 8:30 am and 5:45 pm showed: Witness 1 (Family) indicated the resident was having intense groin pain and could not sit still while at dialysis. The resident was sent by dialysis to the hospital to be evaluated. Witness 1 indicated the resident stated he was injured during a transfer with the slide board. Witness 1 stated the resident was too weak to use a slide board and should have only been a Hoyer (a mechanical lift that fully supports the residents' weight in a sling). The resident did not provide her with any timeframes on when the injury occurred. Witness 2 (Family) indicated she was notified by another family member the resident was being sent to the hospital on [DATE]. The resident was very uncomfortable, could not be still while at dialysis and was sent to the hospital for evaluation of pain to his testicles. Witness 2 indicated the resident stated he informed a nurse at the facility about the injury to his testicle. The resident stated his testicle was smashed during a transfer, she assumed it was related to the Hoyer lift but the resident mentioned a slide board. Witness 2 stated the pain the resident experienced to his testicles was severe and something caused that injury. Witness 3 (Dialysis Clinical Manager/RN) indicated the resident had long term skin issues due to his kidney disease. They were instructed since at least October 2016 not to use any slide board with the resident due to wounds he had to the scrotum in the past and current breakdown to his bottom. A Hoyer lift was the only way the resident was transferred while at dialysis. Witness 3 stated as far as she knew the sores to the scrotum were resolved but the slide board was not to be used due to the risk for injury. The resident could be very sleepy and difficult to stay awake but was alert, oriented and directed his own care. On 3/14/17 the resident could not get comfortable and was yelling out in pain. The resident indicated pain to his testicles and wanted to go to the hospital. Witness 3 stated they called non-emergent transport to take the resident. The resident did not typically have scrotal pain but first expressed discomfort a few days prior to the hospital transport on 3/14/17. On 3/14/17 the resident stated he could not stand the scrotal pain any longer and requested to go to the hospital. Staff 13, 19 and 22 (CNAs) indicated the resident used a slide board with two staff assistance for a short while at the start of his most recent stay. The staff could not give any specific time frames. The staff indicated the resident was very weak and not as successful with slide board transfers so a Hoyer transfer was initiated. Staff 13 stated he attempted a one-person transfer with a slide board but the resident could not move his body at all. Staff 13 stopped the transfer and left to get another staff member to help. Staff 13, 19 and 22 were unaware of any specific injuries or problems related to a transfer. Staff 18 (CNA) indicated he only assisted the resident with Hoyer transfers. There were a few occasions the resident yelled out about being pinched. They would stop the transfer to lower and readjust the resident which seemed to help. Staff 18 stated if the resident was already up in the air they might finish the transfer to the bed/wheelchair and then adjust the resident once he was lowered. He was not aware of any injuries during a transfer. Staff 15 (CNA) indicated the resident used a slide board early on in his stay and was changed to a Hoyer lift at some point. The resident's amputations and weakness made a slide board transfer difficult. Staff 15 stated there were two occasions the resident complained of pain and being pinched when using the Hoyer lift. One occasion the resident said his scrotum was pinched during the transfer and on another occasion it was the resident's thigh. Staff 15 further indicted the resident was not comfortable in the Hoyer especially when his scrotum was more swollen towards the end of his stay. They attempted to readjust the sling as they could, finished the transfer and checked the resident. Staff 15 reported the resident's complaints to the nurse. Staff 5 (LPN) indicated he did not discover the scabbed area to the penis. He was told by the previous shift and did not complete an investigation. The resident first mentioned his genitals being pinched during a previous transfer on 3/23/17. Staff 5 did a skin audit at that time but did not complete an investigation because the resident was seen by the physician a few days prior. Staff 5 had no additional information to provide. Staff 8 (LPN) indicated the resident was alert and oriented but difficult to keep awake on some occasions. The resident directed her/his own care. Staff 8 completed the admission assessment and initial care plan. The resident probably should have been a Hoyer all along but the resident preferred to transfer on his own and would scoot across the wheelchair surface to the bed. Staff 8 stated the staff stood by and assisted the resident as he needed; the type of transfer assistance and the use of any kind of mechanical lift should be documented on the care plan. Staff 23 (PTA) indicated during the resident's most current stay he was a Hoyer lift for transfers. The resident's strength was greatly diminished from his previous stays. Staff 23 stated the resident had only one leg and the resident could not maintain a standing position without the knee buckling. The Hoyer lift was the only thing that could be done safely with the presence of two staff. Staff 2 (DNS) indicated limited assistance of one staff was not an appropriate transfer status for the resident primarily due to the resident's hand and leg amputations. As far as Staff 2 knew a Hoyer lift was the only way the resident was transferred on his most recent stay. Staff 2 had no additional information to provide related to the scab on the resident's penis and scrotum or his statements of injury during a transfer.

Based on interviews and record review it was determined the facility failed to ensure a resident was transported with sufficient interventions to prevent the resident's leg from being pulled under the wheelchair for 1 of 3 sampled residents (#1). Resident 1 sustained a suspected hairline tibial fracture with delayed treatment of [REDACTED]. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's care plan dated 9/6/12 indicated the resident was to wear a "3D boot" on the right foot at all times. The resident was noted to be alert and oriented with impaired decision making. On 9/14/12 the care plan noted additions of a knee brace to the right leg at all times and staff were to make sure wheelchair foot rests were in place at all times. A facility investigation dated 9/14/12 indicated on 9/13/12 the resident was being propelled in the wheelchair back to her/his room with no footrests in place. The resident's right foot came down onto the floor and pulled the right leg under the wheelchair. The resident had her/his 3D boot in place on the right foot at the time of the incident. The resident denied pain or discomfort at the time of the occurrence and was transferred with one person into bed without any problem. On 9/14/12 the resident had increased pain to the right leg/knee and when the area was assessed it showed increased swelling, was warm and painful to the touch. The resident showed increased pain with transfers and weight bearing. The resident's family and physician were notified the evening of 9/14/12. The interdisciplinary team conclusions/follow up indicated the resident was unable to hold right leg off the floor/elevated enough during transport. The 3D boot became stuck to the carpet and the resident's leg was bent under the wheelchair as a result. The resident's "leg rests not applied to w/c. Leg rests to be on w/c at all times as resident does not have ability to elevate leg to avoid catching on floor." An orthopedic consult dated 9/19/12 indicated there was no definite fracture but possibly as she/he was osteopenic. The resident had a previous knee replacement, hip, femur and heel fracture. The resident was in a boot for the heel fracture and required skin precautions. The physician ordered a brace for treatment of [REDACTED]. The resident's September 2012 MAR showed PRN pain medication was administered 1-2xs a day with three occasions when three doses of pain medication were administered, from 9/6/12 to 9/12/12. The remainder of the month the resident requested pain medications 1-2xs a day with six occasions when three doses of pain medication were administered to the resident. NNs dated 9/6/12 through 9/12/12 showed daily complaints of sternal pain treated with PRN Norco, narcotic pain medication, with good relief. On 9/13/12 at 2:30 pm the resident was out to dialysis, pleasant affect and pain medication sent with the resident to dialysis. On 9/15/12 at 3:00 pm it was noted the resident expressed right knee pain during therapy. The resident was assessed while lying in bed with no indication of discomfort and no visual signs of injury. A NN at 9:20 pm indicated when the resident's knee was assessed at 6:00 pm the knee was swollen, warm to the touch, painful when touched and with movement. An X-ray was ordered and completed on 9/15/12 at the resident's preference. The resident was medicated twice during the shift for right knee pain with good affect. Upon investigation it was determined the resident's leg was bent under the wheelchair the previous day, 9/13/12. NNs dated 9/14/12 through 9/19/12 showed the resident had ongoing pain to the right leg and knee. The resident's PRN pain medications provided good relief as did rest. The resident's pain continued to be present but improved slightly after an orthopedic consult was obtained. On 9/19/12 a knee brace was put in place to treat the injured area and the resident was ordered to stay off of the leg. In an interview on 11/6/12 at 8:25 am Staff 8 (CNA) indicated on 9/13/12 while pushing the resident to her/his bedroom the resident's foot dropped to the floor, the boot caught the carpet, the wheelchair abruptly stopped and the resident's leg was pulled under the wheelchair. Staff 8 stated the resident "said ouch that hurt," but did not really complain of any other pain. The resident was transferred into bed with a stand pivot transfer as was the usual. Staff 8 did not report the incident to the nurse because the resident did not say she/he had any pain. Staff 8 did not think the resident was hurt. On 9/14/12 Staff 8 heard the resident was injured and had increased pain so she talked with the charge nurse about the incident from the day before. Staff 8 further indicated she normally put the footrests on the wheelchair and should have had them in place on 9/13/12. In an interview on 11/7/12 at 3:30 pm Staff 4 (LPN) indicated she was unaware of the incident on 9/13/12. She was told during shift report on 9/14/12 the resident had increased pain to the knee/leg. The resident was normally painful but did not have a lot of complaints. However, the area the resident stated was painful was not an area she/he normally complained of pain. Staff 4 assessed the resident and found no noticeable bruising but there was increased swelling and pain. The resident stated her/his foot was twisted under the wheelchair on 9/13/12. Staff 4 then interviewed the aide from 9/13/12 (Staff 8, CNA), started the investigation/incident report, notified the physician and family and counseled the aide involved. The incident should have been reported immediately. Staff 4 stated the resident could hold the foot with the boot up to some degree, but not for long. The resident was often tired from dialysis and weak. Staff 4 indicated on the occasions she saw the resident being transported around the facility the footrests were normally in place. In interviews on 11/6/12 and 11/7/12 between 9:40 am and 2:00 pm Staff 5, 6 and 10 (CNAs) indicated the resident was alert and oriented with some confusion. The resident could express pain but did not like to bother people so would rarely ask for what she/he needed. The staff stated they had to anticipate the resident's needs and if they asked her/him specific questions then she/he would answer. The staff further indicated the resident had a very difficult time lifting/holding up her/his right foot because of the boot for her/his heel fracture and weakness. The staff stated when pushing the resident in the wheelchair they always had the footrests in place to help support the resident's foot. The staff were unsure if the use of footrests was on the care plan prior to the incident on 9/13/12. The staff stated after the resident's leg was pulled under the wheelchair she/he was much more painful and did not bear weight. The resident had a knee brace in place at all times after she/he was injured as well. In an interview on 11/7/12 at 8:55 am Staff 9 (RNCM) indicated Staff 8 (CNA) did not believe the resident was injured during the occurrence on 9/13/12 so she did not report it to any of the nursing staff. Staff 9 did not recall that the resident pushed herself/himself in the wheelchair and could not say how well or how long the resident could hold up the right leg with the 3D boot. Staff 9 stated the resident had increased pain and no longer bore any weight after the fracture occurred. After the incident on 9/13/12 the resident's care plan was updated to have footrests on at all times effective 9/14/12.

Based on interviews and record review it was determined Staff 8 (CNA) failed to ensure a resident was transported with sufficient interventions to prevent the resident's leg from being pulled under the wheelchair. The incident was not reported to the charge nurse for 1 of 3 sampled residents (#1). Resident 1 sustained a suspected hairline tibial fracture with delayed treatment of [REDACTED]. According to Oregon Standards and Authorized Duties for Certified Nurses Assistants [PHONE NUMBER] (6)(d) the CNA shall consistently follow the care plan as directed by the licensed nurse and [PHONE NUMBER] Conduct Unbecoming a Nursing Assistant (3)(g) Failing to communicate information regarding the client's status to the supervising nurse or other appropriate person in a timely manner. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's care plan dated 9/6/12 indicated the resident was to wear a "3D boot" on the right foot at all times. The resident was noted to be alert and oriented with impaired decision making. On 9/14/12 the care plan noted additions of a knee brace to the right leg at all times and staff were to make sure wheelchair foot rests were in place at all times. A facility investigation dated 9/14/12 indicated on 9/13/12 the resident was being propelled in the wheelchair back to her/his room with no footrests in place. The resident's right foot came down onto the floor and pulled the right leg under the wheelchair. The resident had her/his 3D boot in place on the right foot at the time of the incident. The resident denied pain or discomfort at the time of the occurrence and was transferred with one person into bed without any problem. On 9/14/12 the resident had increased pain to the right leg/knee and when the area was assessed it showed increased swelling, warm to the touch and painful to the touch. The resident showed increased pain with transfers and weight bearing. The resident's family and physician were notified the evening of 9/14/12. The interdisciplinary team conclusions/follow up indicated the resident was unable to hold right leg off the floor/elevated enough during transport. The 3D boot became stuck to the carpet and the resident's leg was bent under the wheelchair as a result. The resident's "leg rests not applied to w/c. Leg rests to be on w/c at all times as resident does not have ability to elevate leg to avoid catching on floor." In an interview on 11/6/12 at 8:25 am Staff 8 (CNA) indicated on 9/13/12 while pushing the resident to her/his bedroom the resident's foot dropped to the floor, the boot caught the carpet, the wheelchair abruptly stopped and the resident's leg was pulled under the wheelchair. Staff 8 stated the resident "said ouch that hurt," but did not really complain of any other pain. The resident was transferred into bed with a stand pivot transfer as was the usual. Staff 8 did not report the incident to the nurse because the resident did not say she/he had any pain. Staff 8 did not think the resident was hurt. On 9/14/12 Staff 8 heard the resident was injured and had increased pain so she talked with the charge nurse about the incident from the day before. In an interview on 11/7/12 at 3:30 pm Staff 4 (LPN) indicated she was unaware of the incident on 9/13/12. She was told during shift report on 9/14/12 that the resident had increased pain to the knee/leg. The resident was normally painful but did not have a lot of complaints. However, the area the resident stated was painful was not an area she/he normally complained of pain. Staff 4 assessed the resident and found no noticeable bruising but there was increased swelling and pain. The resident stated her/his foot was twisted under the wheelchair. Staff 4 then interviewed the aide from 9/13/12 (Staff 8, CNA), started the investigation/incident report, notified the physician and family and counseled Staff 8 involved. The incident should have been reported immediately. Staff 4 stated the resident could hold the foot with the boot up to some degree, but not for long. The resident was often tired from [MEDICAL TREATMENT] and weak. Staff 4 indicated on the occasions she saw the resident being transported around the facility the footrests were in place. Refer to F-323

Based on interviews and record review it was determined the facility failed to ensure a resident's care plan reflected sufficient interventions to safely support the resident's legs when transported in the wheelchair for 1 of 3 sampled residents (#1). Resident 1 was transported in the wheelchair with no footrests in place which resulted in her/his leg being caught/pulled under the wheelchair and injured. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's care plan dated 9/6/12 indicated the resident was to wear a "3D boot" on the right foot at all times. The resident was noted to be alert and oriented with impaired decision making. On 9/14/12 the care plan noted additions of a knee brace to the right leg at all times and staff were to make sure wheelchair foot rests were in place at all times. A facility investigation dated 9/14/12 indicated on 9/13/12 the resident was being propelled in the wheelchair back to her/his room with no footrests in place. The resident's right foot came down onto the floor and pulled the right leg under the wheelchair. The resident had her/his 3D boot in place on the right foot at the time of the incident. The interdisciplinary team conclusions/follow up indicated the resident was unable to hold right leg off the floor/elevated enough during transport. The 3D boot became stuck to the carpet and the resident's leg was bent under the wheelchair as a result. The resident's "leg rests not applied to w/c. Leg rests to be on w/c at all times as resident does not have ability to elevate leg to avoid catching on floor." In an interview on 11/6/12 at 8:25 am Staff 8 (CNA) indicated on 9/13/12 while pushing the resident to her/his bedroom the resident's foot dropped to the floor, the boot caught the carpet, the wheelchair abruptly stopped and the resident's leg was pulled under the wheelchair. Staff 8 stated the resident "said ouch that hurt," but did not really complain of any other pain. The resident was transferred into bed with a stand pivot transfer as was the usual. Staff 8 did not report the incident to the nurse because the resident did not say she/he had any pain. Staff 8 did not think the resident was hurt. On 9/14/12 Staff 8 heard the resident was injured and had increased pain so she talked with the charge nurse about the incident from the day before. Staff 8 further indicated she normally put the footrests on the wheelchair and should have had them in place on 9/13/12. In an interview on 11/7/12 at 3:30 pm Staff 4 (LPN) indicated she was unaware of the incident on 9/13/12 until the following day. Staff 4 assessed the resident and found no noticeable bruising but there was increased swelling and pain. The resident stated her/his foot was twisted under the wheelchair. Staff 4 stated the resident could hold the foot with the boot up to some degree, but not for long. The resident was often tired from [MEDICAL TREATMENT] and weak. Staff 4 indicated on the occasions she saw the resident being transported around the facility the footrests were normally in place. In interviews on 11/6/12 and 11/7/12 between 9:40 am and 2:00 pm Staff 5, 6 and 10 (CNAs) indicated the resident was alert and oriented with some confusion. The staff stated they had to anticipate the resident's needs and if they asked her/him specific questions then she/he would answer. The staff further indicated the resident had a very difficult time lifting/holding up her/his right foot because of the boot for her/his heel fracture and weakness. The staff stated when pushing the resident in the wheelchair they always had the footrests in place to help support the resident's foot. The staff were unsure if the use of footrests was on the care plan prior to the incident on 9/13/12. In an interview on 11/7/12 at 8:55 am Staff 9 (RNCM) indicated it was reasonable for any resident who received therapy to have footrests off to allow them to use their legs for mobility and increase strength. The use of footrests was individualized based on resident need; Staff 9 indicated she had not thought about the resident's fracture boot and the ability to hold her/his legs up. Staff 9 did not recall if the resident pushed herself/himself in the wheelchair and could not say how well or how long the resident could hold up the right leg with the 3D boot. After the incident on 9/13/12 the resident's care plan was updated to have footrests on at all times effective 9/14/12. Refer to F-323