Every finding on record at Rose Haven Nursing Center

Based on observation, interview, and record review it was determined the facility failed to follow proper infection control techniques for urinary catheter bags containing bodily fluid for 2 of 2 sampled residents (#s 2 and 54), failed to perform proper use of PPE when administering medications for 2 of 31 sampled residents (#s 17 and 27) reviewed for medication administration and ensure proper hand hygiene was completed during a dressing change for 1 of 2 sampled residents (#35). This placed residents at risk for cross-contamination and infection. Findings include: 1. Resident 2 was admitted to the facility in 4/2026 with diagnoses including flaccid bladder (a condition where the bladder cannot contract, leading to an inability to urinate) and ulcerative colitis (inflammatory bowel disease). A 10/9/25 Care Plan revealed Resident 2 had a catheter with interventions to include position catheter bag and tubing below the level of the bladder and away from the door entrance. Resident 2 also had a rectal tube bag with interventions to include ensure patency (preventing obstruction) of the tube by repositioning her/him. Random observations from 6/1/26 at 11:44 AM through 6/2/26 at 11:49 AM on day and evening shifts revealed Resident 2's catheter bag and rectal tube bag drains touched the floor. On 6/4/26 at 12:35 PM, Staff 14 (CNA) and Staff 15 (CNA) stated any bag drains with bodily fluids should not touch the floor due to infection control protocol. On 6/4/26 at 5:14 PM, Staff 3 (Unit Manager/RN) stated all bag drains with bodily fluids must never touch the floor due to infection control and cross contamination. On 6/5/26 at 1:09 PM, Staff 1 (Administrator) and Staff 5 (Regional Nurse) stated all bag with drains containing bodily fluids must always be off the ground. 2. Resident 54 was admitted to the facility in 11/2025 with diagnoses including bladder neck obstruction, MRSA (methicillin-resistant staphylococcus aureus bacteria that has developed resistance to many common antibiotics), and EBP (Enhanced Barrier Precautions). An 11/20/25 revised Care Plan indicated Resident 54 will be free from acute infection in spite of colonization of MRSA and observe standard precautions for infection control.Observations revealed:- On 6/1/26 at 10:18 AM Resident 54's catheter bag drain was hanging off her/his wheelchair and touched the floor.-On 6/2/26 at 9:45 AM Resident 54 was escorted to activities in her/his wheelchair with her/his catheter bag drain dragging on the floor underneath her/his wheelchair.-On 6/3/26 at 12:53 PM Resident 54's catheter bag drain was laying on the floor in her/his room under her/his wheelchair.On 6/4/26 at 12:35 PM, Staff 14 (CNA) and Staff 15 (CNA) stated any bags containing bodily fluids should not touch the floor due to infection control protocol. Staff 14 went into Resident 54's room and grabbed the catheter bag from under the resident's wheelchair and stated, the bag is full of urine. Staff 14 proceeded to grab the urinal to empty the catheter bag. Staff 14 was not wearing any PPE including gloves. Staff 15 stopped Staff 14 and Staff 14 donned full PPE before emptying Resident 54's catheter bag. On 6/4/26 at 5:14 PM, Staff 3 (Unit Manager/RN) stated all bag drains with bodily fluids must never touch the floor due to infection control and cross contamination. On 6/5/26 at 1:09 PM, Staff 1 (Administrator) and Staff 5 (Regional Nurse) stated all bag with drains containing bodily fluids must always be off the ground. 3. Resident 17 was admitted to the facility in 7/2025 with diagnoses including depression and diabetes. On 6/3/26 at 1:05 PM, Staff 6 (RN) was observed to perform a CBG for Resident 17. Staff 6 did not sanitize his hands before entering the room and donned one glove to his left hand. Staff 6 proceeded to poke Resident 17's finger with a lancet (tiny needle to draw blood), squeezed the blood out, and placed the blood on a test strip. Staff 6 stated there was not enough blood, so he went back to the treatment cart to get more test strips. Staff 6 returned to the room and proceeded two more times to get a blood sample from the resident with success on the second try. Staff 6 disposed of the test strips which contained blood and the lancet and threw them into a regular garbage can, not into a sharps hazard material container. Staff 6 stated he was not aware he disposed of the test strips and the lancet in the regular garbage can. On 6/5/26 at 1:17 PM, Staff 1 (Administrator) and Staff 5 (Regional Nurse) stated they expected staff to wear gloves and gowns and never throw lancets or test strips in a regular garbage can. Hazardous materials must be disposed of in a sharps hazard material container. 4. Resident 27 was admitted to the facility in 4/2026 with diagnoses including abscess of the abdominal wall and vascular dementia. A 4/21/26 Care Plan indicated Resident 27 was on EBP (Enhanced Barrier Precautions) due to chronic wounds, a surgical wound, and IV (intravenous) placement and staff were to don gowns and gloves during high-contact care activities including providing care/hygiene, changing briefs, or assisting with toileting. On 6/3/26 at 7:50 AM, Staff 7 (RN) was observed to administer medication to Resident 27. Staff 7 did not sanitize her hands or don gloves before entering the room. Resident 27 was lying on her/his side low in the bed. Staff 7 did not reposition her/him before administering medication to avoid choking. Staff 7 placed Resident 27's medication from a medication cup into the resident's hand and gave her/him a cup of water. Resident 27 put the handful of medication into her/his mouth. Some pills fell out of her/his mouth onto her/his shirt and bed. Staff 7 picked up the medication with no gloves and gave the medication back to her/him. Resident 27 placed the medication back in her/his mouth. After medications were administered, Resident 27 indicated to Staff 7 she/he needed to use the bathroom. Staff 7 did not sanitize her hands but proceeded to don gloves. Staff 7 did not don a gown and proceeded to open the resident's brief and assist with a urinal. Staff 7 stated the brief was already soiled, so she would call a CNA. Staff 7 touched the call light with dirty gloves. On 6/3/26 at 8:10 AM, Staff 7 stated she sanitized her hands when she left the room but did not see a problem when she picked up the medication with her bare hands off the bed and the resident's shirt when medication fell out of her/his mouth. On 6/5/26 at 1:12 PM, Staff 1 (Administrator) and Staff 5 (Regional Nurse) stated staff were to sanitize their hands and don gowns and gloves before they enter a room depending on the precautions. Staff 5 stated her expectation was for Staff 7 to don gloves and a gown before she went into Resident 27's room to administer medications. Staff 5 noted Staff 7 should have had gloves on when the pills dropped out of her/his mouth, and those pills should have been disposed of. Staff 5 stated Staff 7 should have sanitized her hands, donned gloves and a gown before she assisted Resident 27 with her/his brief. Staff 5 stated a lot of infection control practices were broken. 5. Resident 35 was admitted to the facility in 5/2026 with diagnoses including diabetes and bullous pemphigoid (an autoimmune disease-causing fluid-filled blisters). A 5/27/26 Wound Care Evaluation indicated Resident 35 had multiple blisters to her/his labia, left hand, left leg, right leg, right foot, left foot, right thumb, and left gluteal fold. On 6/3/26 at 1:45 PM, an observation of Resident 35's dressings was completed before the dressings were changed. The observation revealed both lower extremities had wraps around them with bright red blood breaking through the dressings. Resident 35's toes had dark purple/black spots, which appeared to be blood blisters, on the bottom, top, and in-between her/his toes. There was blood on the blanket on her/his bed. On 6/3/26 at 2:00 PM, Staff 21 (RN) and Staff 22 (LPN) were observed to perform dressing changes for Resident 35's multiple wounds. Staff 21 did not prepare a clean barrier for supplies. Staff 21 brought in a basin of packaged dressings and sat them directly on the resident's bedside table which contained a television remote, paperwork, and a water cup. Staff 21 removed the wrap from the resident's right leg and proceeded to grab a wound cleanser bottle off the bedside table, sprayed the abdominal wound pads on the wounds due to the pads sticking to the wounds, removed the dressings, and set them on the bed with the wound cleaner. Staff 22 held Resident 35's leg when Staff 21 cleaned the wound to the right leg. Staff 21 and Staff 22 were stopped due to not washing their hands and changing their gloves before cleaning the wounds. Staff 21 and Staff 22 changed their gloves and proceeded to clean the wounds. Staff 21 reached into her pocket to grab her cell phone to take photos with measurements of the wounds. Staff 21 then grabbed dirty dressing packages from the dressing basin and placed them on the bed. Staff 21 and Staff 22 were stopped again due to touching the cell phone and dirty dressing wrappers. Staff 21 washed her hands and donned clean gloves. Staff 22 went to change her gloves at this time but did not sanitize her hands and was stopped. Staff 22 washed her hands and donned clean gloves. Staff 21 placed open dressing packages on the bed and garbage bags for the old dressings. Staff 21 and Staff 22 were unaware a bed could not be used as a clean barrier because the bed was dirty. Staff 21 and Staff 22 stated they realized they made multiple mistakes while changing the wound dressings. On 6/5/26 at 1:21 PM, Staff 1 (Administrator) and Staff 5 (Regional Nurse) stated staff are to follow all infection control procedures for wound care. Staff 5 acknowledged the dressing change should have been completed with more infection control practices being followed.

Based on observation, interview, and record review it was determined the facility failed to ensure staff adhered to professional standards related to medication administration and non-pressure wound care for 4 of 4 licensed nurses Staff 6 (RN), Staff 7 (RN), Staff 21 (LPN), and Staff 22 (RN) reviewed for medication administration and non-pressure wound care. This placed residents at risk for cross contamination. Findings include: Per OAR [PHONE NUMBER] Scope of Practice Standards for All Licensed Nurses(1) Standards related to the licensee's responsibility for safe nursing practice. The licensee shall:(A) Adhere to professional practice and performance standards;Per OAR [PHONE NUMBER] Conduct Derogatory to the Standards of Nursing Defined:Conduct that adversely affects the health, safety, and welfare of the public, fails to conform to legal nursing standards, or fails to conform to accepted standards of the nursing profession, is conduct derogatory to the standards of nursing. Such conduct includes, but is not limited to:(2) Conduct related to achieving and maintaining clinical competency:(a) Failing to conform to the essential standards of acceptable and prevailing nursing practice. Actual injury need not be established;(3) Conduct related to the client's safety and integrity:(a) Developing, modifying or implementing policies that jeopardize client safety;1. Resident 17 was admitted to the facility in 7/2025 with diagnoses including depression and diabetes. On 6/3/26 at 1:05 PM, Staff 6 (RN) was observed to perform a CBG for Resident 17. Staff 6 did not sanitize his hands before entering the room and donned one glove to his left hand. Staff 6 proceeded to poke Resident 17's finger with a lancet (tiny needle to draw blood), squeezed the blood out, and placed the blood on a test strip. Staff 6 stated there was not enough blood, so he went back to the treatment cart to grab more test strips. Staff 6 returned to the room and proceeded two more times to get a blood sample from the resident with success on the second try. Staff 6 disposed of the test strips which contained blood and the lancet and threw them into a regular garbage can, not into a sharps hazard material container. Staff 6 stated he was not aware he disposed of the test strips and the lancet in the regular garbage can. On 6/5/26 at 1:17 PM, Staff 1 (Administrator) and Staff 5 (Regional Nurse) stated they expected staff to wear gloves and gowns and never throw lancets or test strips in a regular garbage can. Hazardous materials must be disposed of in a sharps hazard material container.2. Resident 27 was admitted to the facility in 4/2026 with diagnoses including abscess of the abdominal wall and vascular dementia. A 4/21/26 care plan indicated Resident 27 was on EBP (Enhanced Barrier Precautions) due to chronic wounds, surgical wounds, and IV placement. Staff were to don gowns and gloves during high contact care activities including providing care/hygiene, changing briefs, and assisting with toileting. On 6/3/26 at 7:50 AM, Staff 7 (RN) was observed to administer medication to Resident 27. Staff 7 did not sanitize her hands or don gloves before entering the room. Resident 27 was laying on her/his side low in the bed. Staff 7 did not reposition her/him before administering medication to avoid choking. Staff 7 placed Resident 27's medication from a medication cup into the resident's hand and gave her/him a cup of water. Resident 27 put the handful of medication in her/his mouth. Some pills fell out of her/his mouth onto her/his shirt and the bed. Staff 7 picked up the medication with no gloves and gave it to her/him. Resident 27 placed the medication back in her/his mouth. After medications were administered, Resident 27 indicated to Staff 7 she/he needed to use the bathroom. Staff 7 did not sanitize her hands but proceeded to don gloves. Staff 7 did not don a gown and proceeded to open the resident's brief and assist with a urinal. Staff 7 stated the brief was already soiled, so she would call a CNA. Staff 7 touched the call light with dirty gloves. On 6/3/26 at 8:10 AM, Staff 7 stated she sanitized her hands when she left the room but did not see a problem when she picked up the medication with her bare hands off the bed and the resident's shirt when medication fell out of her/his mouth.On 6/5/26 at 1:12 PM, Staff 1 (Administrator) and Staff 5 (Regional Nurse) stated staff are to sanitize their hands, don gowns and gloves, before they enter a room depending on the precautions. Staff 5 stated her expectation was for Staff 7 to don gloves and a gown before she went into the room but definitely should have had gloves on when the pills dropped out of the resident's mouth, and those pills should have been disposed of. Staff 5 stated Staff 7 should have sanitized her hands, donned gloves and a gown before she assisted the resident with her/his brief. 3. Resident 35 was admitted to the facility in 5/2026 with diagnoses including diabetes and bullous pemphigoid (an autoimmune disease-causing fluid-filled blisters). A 5/27/26 Wound Care Evaluation indicated Resident 35 had multiple blisters to her/his labia, left hand, left leg, right leg, right foot, left foot, right thumb, and left gluteal fold. On 6/3/26 at 1:45 PM, an observation of Resident 35's dressings was completed before the dressings were changed. The observation revealed both lower extremities had wraps around them with bright red blood breaking through the dressings. Resident 35's toes had dark purple/black spots, which appeared to be blood blisters, on the bottom, top, and in-between her/his toes. There was blood on the blanket on her/his bed. On 6/3/26 at 2:00 PM, Staff 21 (RN) and Staff 22 (LPN) were observed to perform dressing changes for Resident 35's multiple wounds. Staff 21 did not prepare a clean barrier for supplies. Staff 21 brought in a basin of packaged dressings and sat them directly on the resident's bedside table which contained a television remote, paperwork, and a water cup. Staff 21 removed the wrap from the resident's right leg and proceeded to grab a wound cleanser bottle off the bedside table, sprayed the abdominal wound pads on the wounds due to the pads sticking to the wounds, removed the dressings, and set them on the bed with the wound cleaner. Staff 22 held Resident 35's leg when Staff 21 cleaned the wound to the right leg. Staff 21 and Staff 22 were stopped due to not washing their hands and changing their gloves before cleaning the wounds. Staff 21 and Staff 22 changed their gloves and proceeded to clean the wounds. Staff 21 reached into her pocket to grab her cell phone to take photos with measurements of the wounds. Staff 21 then grabbed dirty dressing packages from the dressing basin and placed them on the bed. Staff 21 and Staff 22 were stopped again due to touching the cell phone and dirty dressing wrappers. Staff 21 washed her hands and donned clean gloves. Staff 22 went to change her gloves at this time but did not sanitize her hands and was stopped. Staff 22 washed her hands and donned clean gloves. Staff 21 placed open dressing packages on the bed and garbage bags for the old dressings. Staff 21 and Staff 22 were unaware a bed could not be used as a clean barrier because the bed was dirty. Staff 21 and Staff 22 stated they realized they made multiple mistakes while changing the wound dressings. On 6/5/26 at 1:21 PM, Staff 1 (Administrator) and Staff 5 (Regional Nurse) stated nursing staff were to follow all infection control procedures for wound care.

Based on observation, interview and record review it was determined the facility failed to accurately assess 3 of 5 sampled residents (#s 6, 34, and 103) reviewed for unnecessary medications. This placed residents at risk for unassessed needs. Findings include:1. Resident 6 was admitted to the facility in 3/2026 with diagnoses including Cerebrovascular Accident with hemiplegia and hemiparesis (stroke with weakness and paralysis). Resident 6's MDS Section C (BIMS assessment) dated 5/1/26 indicated the resident was rarely or never understood with a score of 99 (unable to assess). On 6/3/26 at 5:35 PM, Staff 15 (CNA) stated she understood Resident 6 when she/he expressed her/his needs. On 6/3/26 at 5:49 PM, Staff 16 (LPN) stated she understood Resident 6 when she/he told her what her/his needs were. On 6/5/26 at 1:45 PM, Staff 13 (MDS Coordinator) stated if a resident was able to make herself/himself understood at least 50% of the time, Section C should be completed. Staff 13 stated if the resident refused to respond, the assessor should try again later or ask another staff member to assist with the assessment. On 6/5/26 at 2:07 PM, Staff 4 (Social Services Assistant) stated she was trained a BIMS assessment could not be completed when a resident was rarely or never understood or if a resident declined to respond. On 6/5/26 at 2:15 PM Staff 1 (Administrator) stated she expected the MDS to be completed accurately. 2. Resident 34 was admitted to the facility in 2/2025 with diagnoses including Cerebrovascular Accident (CVA). Resident 34's 3/2026 Annual MDS Assessment did not list CVA in Section I. On 6/5/26 at 1:45 PM, Staff 13 (MDS Coordinator) stated the diagnosis CVA was not listed in Section I for Resident 34. Staff 13 stated it should be in the MDS. On 6/5/26 at 2:15 PM Staff 1 (Administrator) stated she expected the MDS to be completed accurately. 3. a. Resident 103 admitted to the facility on [DATE] with diagnoses including osteomyelitis (bone infection) and muscle weakness. A 5/27/26 Physician order directed staff to change Resident 103's PICC (Peripherally Inserted Central Catheter) line and dressing. A 5/27/26 physician order directed staff to administer meropenem (antibiotic) 2 grams intravenously three times a daily for the treatment of osteomyelitis. The 5/29/26 admission MDS indicated Resident 103 did not receive intravenous antibiotic therapy. On 6/1/26 at 12:51 PM, Resident 103 stated she/he received IV therapy for an infection. On 6/5/26 at 8:40 AM, Staff 13 (MDS Coordinator) acknowledged Resident 103's MDS was inaccurate. b. A 5/28/26 Smoking Screen indicated Resident 103 smoked tobacco products two to five times per day. The 5/29/26 admission MDS indicated Resident 103 was cognitively intact and did not use tobacco products. On 6/1/26 at 12:51 PM, Resident 103 stated she/he smoked cigarettes and the facility assessed her/him for smoking. On 6/5/26 at 8:40 AM, Staff 13 (MDS Coordinator) acknowledged Resident 103's MDS was inaccurate.

Based on observation, interview, and record review it was determined the facility failed to ensure catheter bags and rectal tube bags were covered for 1 of 2 sampled residents (# 2) reviewed for dignity. This placed residents at risk for a loss of dignity. Findings include:Resident 2 was admitted to the facility in 4/2026 with diagnoses including flaccid bladder (a condition where the bladder cannot contract, leading to an inability to urinate) and ulcerative colitis (inflammatory bowel disease). A 10/9/25 care plan revealed Resident 2 had a urinary catheter with interventions including position catheter bag and tubing below the level of the bladder and away from the door entrance. Resident 2 also had a rectal tube bag with interventions including ensuring patency (preventing obstruction) of the tube by repositioning her/him. Random observations from 6/1/26 at 11:44 AM through 6/2/26 at 11:49 AM on day and evening shifts revealed Resident 2's urinary catheter bag and rectal tube bag were hanging off the side of the bed uncovered. On 6/4/26 at 12:35 PM, Staff 14 (CNA) and Staff 15 (CNA) stated urinary catheter bags must be covered for dignity. Staff 15 stated Resident 2's rectal tube bag must also be covered. On 6/4/26 at 5:14 PM, Staff 3 (Unit Manager/RN) stated all bags with bodily fluids must be covered for dignity. On 6/5/26 at 1:09 PM, Staff 1 (Administrator) and Staff 5 (Regional Nurse) stated all bags with bodily fluids must always be covered.

Based on observation, interview, and record review it was determined the facility failed to accurately complete a comprehensive admission assessment to include dentures for 1 of 1 sampled resident (#34) reviewed for dental. This placed residents at risk for unmet dental needs. Findings include:Resident 34 was admitted to the facility in 2/2025 with diagnoses including stroke and dysphagia (swallowing difficulty).The 2/19/25 Nursing admission Evaluation and Inventory of Resident Personal Items revealed Resident 34 had no dental appliances.The 2/25/26 Annual MDS revealed Resident 34 had a BIMS score of 12 (moderately cognitively impaired). No concerns related to dentures were identified. A 3/30/26 progress note revealed an appointment was scheduled for Resident 34 to obtain dentures. The revised Care Plan dated 5/11/26 revealed Resident 34 was at risk for alterations in dentition, one staff member was to assist with the set-up of the resident's oral hygiene and provide supplies for tooth brushing.On 6/1/26 at 3:41 PM, Resident 34 stated her/his dentures were lost. No dentures were observed in the resident's mouth.On 6/4/26 at 12:42 PM, Staff 12 (CNA) stated she setup oral hygiene supplies for Resident 34 and was unaware the resident had dentures. On 6/4/26 at 12:48 PM, Staff 10 (CNA) stated she was aware Resident 34 had dentures. Staff 10 reported when she returned to the facility after an absence, she observed the resident's dentures in a cup and not in her/his mouth.On 6/4/26 at 1:17 PM, Staff 6 (RN) stated he did not recall his observations during the admission assessment of Resident 34 and acknowledged Resident 34 recently reported oral concerns.On 6/4/26 at 1:54 PM, Resident 34 was observed with upper dentures in her/his mouth and stated she/he possessed a complete set of dentures in 2000. On 6/4/26 at 1:55 PM, Staff 11 (CNA) stated Resident 34 frequently refused assistance with dental care and independently brushed her/his own teeth. Staff 11 stated she was unaware Resident 34 had dentures. On 6/4/26 at 2:18 PM, Staff 3 (Unit Manager-LPN) stated she was aware Resident 34 had upper dentures. Staff 3 acknowledged Resident 34's initial nursing assessment was incomplete and failed to include accurate information regarding the resident's dentures. Staff 3 acknowledged the resident's baseline care plan did not accurately reflect the resident's dental care needs and required revision.On 6/4/26 at 4:50 PM, Staff 5 (Regional Director of Clinical) acknowledged the initial inventory assessment for Resident 34 was incomplete, inaccurate, and omitted the resident's dentures. Staff 5 stated the facility audits were incomplete and needed revision.

Based on observation, interview, and record review it was determined the facility failed to address behavioral health needs timely for 1 of 1 sampled resident (#69) reviewed for mood and behavior. This placed residents at risk for lack of behavioral health care. Findings include: Resident 69 was admitted to the facility in 10/2019 with diagnoses including chronic pain and major depressive disorder. The 10/29/25 Annual MDS revealed Resident 69 had minimal depressive symptoms. The 4/28/26 IDT (Interdisciplinary Team) Care Plan Conference Evaluation revealed Witness 1 (Family Member) was not present. The 5/1/26 Quarterly MDS revealed Resident 69 had a PHQ-9 (Patient Health Questionnaire) assessment score of 13 (moderate depression) and a BIMS score of 15 (cognitively intact). The 5/1/26 Social Services Quarterly and Annual Evaluation revealed an increased PHQ-9 score from minimal to moderate and psychological services were needed. A 5/20/26 revised Care Plan directed staff to arrange for psychological consultations for Resident 69 when indicated, provide opportunities for the resident to express concerns, and encourage Witness 1 to visit often. On 6/2/26 at 9:22 AM, Resident 69 was observed in bed and fixated on the placement of her/his incontinence brief. Resident 69 stated no staff had discussed these concerns with her/him, Witness 1 visited less frequently, and staff spoke with her/him less often. Resident 69 stated she/he was willing to consider counseling services if offered. On 6/3/26 at 12:50 PM, Staff 21 (CNA) stated she believed Resident 69's mood remained consistent and the resident relied on Witness 1 and others for emotional support. On 6/4/26 at 10:26 AM, Staff 3 (Unit Manger-LPN) stated she did not observe any recent changes in Resident 69's mood and relied on Social Services staff to address Resident 69's mood-related concerns. On 6/4/26 at 11:22 PM, Staff 4 (Social Services Assistant) acknowledged Resident 69 experienced a change in mood during the most recent care conference and quarterly review. Staff 4 acknowledged Witness 1 had personal issues at home and was unable to visit as frequently. On 6/4/26 at 11:49 AM, Staff 12 (CNA) stated Resident 69's behaviors remained consistent and she only documented changes in resident behaviors. Staff 12 stated Resident 69 continued to exhibit agitation when care was not provided according to the resident's preferences. On 6/4/26 at 6:27 PM, Staff 20 (CNA) stated Resident 69 became frustrated with newly hired staff and staff who did not provide care according to the resident's expectations. On 6/5/26 at 11:29 AM, Staff 1 (Administrator) acknowledged she was responsible to refer residents for psychological services, but no email notification was received to indicate Resident 69 needed a psychological referral. Staff 1 stated she expected an email notification immediately after staff identified Resident 69 required psychological services.

Based on observation, interview, and record review it was determined the facility failed to thoroughly assess a resident after an unwitnessed fall for 1 of 2 sampled residents (#34) reviewed for accidents. This placed residents at risk for unassessed injuries. Findings include:Resident 34 was admitted to the facility in 2/2025 with diagnoses including cardiovascular accident with hemiplegia and hemiparesis. Resident 34's clinical record revealed the resident had a BIMS of 12 (moderate impairment).Resident 34's clinical record revealed an unwitnessed fall with no injuries was reported on 5/27/26. On 6/1/26 at 3:45 PM, Resident 34 stated she/he fell in her/his room and skinned her/his knees. Resident 34 was observed to have healing scabs below her/his right knee. On 6/4/26 at 6:34 PM, Staff 16 (LPN) stated on 5/27/26 she found Resident 34 after the fall. Staff 16 stated she did not remove Resident 34's clothing to assess for injuries after the resident's fall. On 6/4/26 at 7:07 PM, Staff 6 (RN) stated he completed a skin check on 6/3/26 for Resident 34. Staff 6 stated he did not know how he would have missed injuries on Resident 34's legs. On 6/5/26 at 9:26 AM, Staff 3 (Unit Manager/LPN) stated she expected nursing staff to complete a full-body skin assessment of a resident after a fall and record weekly skin checks. Staff 3 also stated a CNA told her on 6/1/26 Resident 34 had abrasions from a fall the previous week and did not assess Resident 34. On 6/5/26 at 10:00 AM, Staff 19 (LPN) completed an assessment of Resident 34's legs and identified two small, healing abrasions on Resident 34's right knee and one small, healing abrasion on the left knee. On 6/5/26 at 10:00 AM, Resident 34 stated she/he received the injuries on her/his legs when she/he fell out of her/his wheelchair the previous week. On 6/5/26 at 1:12 PM, Staff 2 (DNS) stated Staff 3 should have done an assessment of Resident 34 after being told of her/his injuries. Staff 2 stated she expected nursing staff to complete full-body assessments of residents after falls or during weekly skin checks and for them to record their finding in the clinical record. Staff 2 stated the DNS and the wound nurse needed to be notified when a resident had injuries so wounds could be assessed and monitored.

Based on observation, interview and record review it was determined the facility failed to ensure residents remained free from accident hazards for 2 of 3 sampled residents (#s 25 and 283) reviewed for accidents. Due to Staff 42 (CNA) not following the care plan, Resident 25 fell and broke her/his hip which required surgery. Findings include: 1. Resident 25 was admitted to the facility on ,d+[DATE] with acute embolism of the right lower extremity and difficulty walking. A 10/2019 Annual MDS revealed Resident 25 had a BIMS score of 7. She/he was not able to provide an interview due to impaired cognition. A review of the comprehensive care plan revised 2/3/25, indicated the resident's bed was to be in a lowered position due to her/his documented fall risk. A 7/26/24 incident investigation revealed: -Resident 25 had a fall with injury. -Resident 25 required an x-ray of her/his spine due the fall. -Resident 25 was crying out in pain complaining of her/his right buttock/hip hurting. No visible signs of bruising were noted. Resident 25 was unable to tolerate any range of motion of her/his right lower extremity. - RN on duty medicated Resident 25 with two narcotics per orders. - X-ray results revealed Resident 25 had a broken hip and was transferred to Emergency Department for surgical evaluation. A 7/31/24 History and Physical Summary indicated Resident 25 had a right femoral neck fracture. An 8/1/24 Operate Report revealed Resident 25 received surgery for her/his hip fracture and was taken to the post anesthesia care unit in stable condition. In an interview on 2/25/25 at 11:47 AM, Staff 42 (CNA) stated Resident 25 needed a bed change, she left the room to try and get help, and told her/him to roll onto her/his back. Staff 42 heard the resident fall, got the nurse, did her vitals, a neuro check, and completed the bed change. Staff 42 said she called the DNS and found out Resident 25 broke her hip. Staff 42 stated I know [the resident] was a two person everything. On 2/25/25 at 11:17 AM, Staff 1 (Administrator) acknowledged the resident was unsupervised, fell , and required surgery for a broken hip. 41455 2. Resident 283 was admitted to the facility in 2/2025 with diagnoses including nicotine dependence and paraplegia (paralysis of the legs). A 2/14/25 Nursing Smoking Screen indicated Resident 283 smoked five to 10 times each day, had a history of using her/his smoking equipment in non-designated areas, was unable to demonstrate safe smoking practices and was to utilize her/his electronic cigarettes during monitored smoke breaks. A 2/15/25 care plan indicated Resident 283 signed a facility smoking agreement and the resident's smoking materials were to be stored at the nurses station. On 2/23/25 at 2:13 PM Resident 283 said she/he did not sign any safety agreement related to smoking at the time of her/his admission and continued to use her/his electronic cigarettes outside at various places during the day and night. On 2/24/25 at approximately 9:40 AM Resident 283 was observed seated in a non-smoking area on the grounds of the facility. Resident 283 stated this is where I sit when she/he was outside for fresh air and to smoke. Electronic cigarettes were observed with Resident 283. Resident 283 stated staff were aware of the use of her/his electronic cigarettes at the observed location and assisted her/him in and out of the building. On 2/24/25 at 4:15 PM Staff 27 (CNA) stated Resident 283 smoked independently and often went outside on her/his own to use her/his electronic cigarettes. On 2/25/25 at 12:25 PM Staff 1 (Administrator) acknowledged the facility's Smoking Contract was not clear about electronic cigarette safety and the Smoking Contract and Smoking Fire Hazard Awareness Form applied to both smoking and electronic cigarettes. On 2/25/25 at 1:06 PM Staff 2 (DNS) acknowledged smoking contracts were needed and not completed timely for Resident 283 to ensure smoking safety.

Based on observation, interview and record review it was determined the facility failed to follow infection control standards for 4 of 4 halls observed and 2 of 4 sampled residents (#77 and 43) reviewed for pressure ulcers. This placed residents at risk for exposure and contraction of infectious diseases. Findings include: 1. Resident 77 was admitted to the facility in 2/2025 with diagnoses including necrotizing fasciitis (flesh eating disease), utilized a wound vac (vacuum assisted closure for healing of wounds) and a colostomy ( a surgical opening in the abdominal wall to divert stool). The CDC indicated EBP (enhanced barrier precautions) involve gown, and gloves during high contact resident care. Resident 77 was not on EBP. On 2/24/25 at 8:30 AM Staff 41 (RN/Unit Manager) stated the resident should be on EBP due to the resident's wound and colostomy. Staff 41 observed the opened dressing packages in the resident's dresser drawer and stated the dressings have to be thrown away if they are all the way opened and need to be dated and these dressings were not. On 2/23/25 at 2:40 PM a dressing change for Resident 77 was performed by Staff 40 (LPN). -Staff 40 washed her hands and donned gloves but no gown. -Staff 40 placed all clean dressing supplies including bandage scissors on Resident 77's bed which had a dirty blanket and sheets. Staff 40 began touching dressing packages. -Staff 40 removed the resident's wound vac dressing and wiped wound and surrounding area with wound cleanser. -Surveyor reminded Staff 40 to change her gloves but she did not. -Staff 40 opened black sponge for the wound vac and began cutting the sponge with scissors on the resident's bed. -Staff 40 inserted the black sponge into the resident's wound but did not change gloves or sanitize hands. -Staff 40 grabbed the tape to seal the wound with dirty gloves. -Staff 40 continued to touch the inside of the large wound along with the resident's genitals trying to get the black sponge into the wound. -Staff 40 held the black sponge in the wound while reaching for the tape to cover the black sponge with dirty gloves. -Staff 40 finished dressing change and wiped blood from between the resident's legs. -Staff 40 placed dirty dressings containing blood and left them in the garbage can by the resident's bed. On 2/23/25 at 3: 30 PM Staff 40 stated she should have donned a gown, set-up a clean field for the dressing change, change her gloves and sanitize her hands like she should have. On 2/23/25 at 3:45 PM Staff 41 stated she had gone over how to complete the dressing change with Staff 40 and told her to make sure she had a clean field for the dressings and change her gloves. 40774 2. On 2/23/25 at 10:47 AM Staff 33 (Agency CNA) was observed in the 300 Hall entering a room with signage on the door indicated Enhanced Barrier Precautions (EBP) and Droplet Precautions, with specific instructions for PPE use. Staff 33 did not sanitize her hands before donning gloves then proceeded to enter the room. Staff 33 left the room without sanitizing her hands or removing her face mask and walked to the linen closet to retrieved towels without sanitizing her hands beforehand. Staff 33 then delivered the towels and a cup of coffee to the same room while still not sanitizing her hands prior to donning PPE. Additionally, Staff 33 continued to enter other resident rooms and the linen closet without proper hand hygiene. On 2/23/25 at 11:17 AM Staff 34 (CNA) was observed in the 300 Hall entering a room without sanitizing her hands. Staff 34 closed the door and later exited with a bag of soiled linen, which she transported down the hall. Staff 34 did not sanitize her hands after handling the bag of soiled linen. On 2/23/25 at 12:30 PM Resident 43 was observed in the 500-dining room eating her/his lunch. An unidentified staff member was observed taking Resident 43's blood sugar at the table. Resident 43 stated she/he had previously expressed discomfort with staff multiple times about taking her/his blood sugar in the dining room. Resident 43 further stated it grossed her/him out thinking about blood near her/his food. On 2/26/25 at 9:02 AM Staff 35 (Agency LPN) entered a room on the 400 Hall that was on Enhanced Barrier Precautions. The room had signage posted on the door indicating EBP with specific instructions for PPE use. Staff 35 did not don a gown before touching the residents tube feeding supplies. Staff 2 (DNS) was standing next to Staff 35 and instructed Staff 35 to don a gown before providing care. On 2/26/25 at 5:57 PM Staff 35 was asked about the process for (EBP) prior to providing care related to resident on a feeding tube. Staff 35 stated she was confused about the process, and she did not notice the signage posted on the resident's door before entering the room and did not know she was supposed to wear a gown. On 2/27/25 at 10:33 AM Staff 2 was informed of the above staff observations, and she confirmed staff were expected to follow proper infection control precautions before and after entering resident rooms and before and after handling clean linen. Staff 2 also confirmed staff should have been aware of the infection control expectations prior to handling resident feeding tubs and obtaining blood sugars. 41455 3. On 2/24/25 at 8:38 AM a sign on the door of room [ROOM NUMBER] indicated Enhanced Barrier Precautions (EBP) were in place in the room. Staff were directed to perform hand hygiene before entering, when leaving the room and to wear gloves and gowns during direct care or contact with the resident. On 2/24/25 at 8:39 AM Staff 11 (CNA) entered room [ROOM NUMBER] from another room with EBP and did not perform hand hygiene prior to the donning of gloves and gown. Staff 11 transferred the resident while in the room. On 2/24/25 at 8:49 AM Staff 11 confirmed hand hygiene was not performed as needed prior to the resident's transfer in room [ROOM NUMBER]. On 2/24/25 at 9:21 AM Staff 7 (LPN) was observed to enter room [ROOM NUMBER] with only gloves when a pain patch was applied to the skin of the resident. Staff 7 stated he was not aware room [ROOM NUMBER] was on EBP. On 2/26/25 at 3:35 PM Staff 10 (IP) confirmed staff should perform hand hygiene prior to the donning of gowns and gloves and wear gowns and gloves during close contact of residents on EBP. 49676 4. On 2/26/25 at 9:41 AM, Staff 24 (Housekeeping) was observed cleaning residents' rooms. Staff 24 took off PPE after cleaning room with signage indicating enhanced barrier precautions and placed the soiled gown into the bottom of the plastic bin outside the residents' room mixing it with clean gowns. When asked where he should remove the gown Staff 24 stated he gets confused and doesn't know which one is clean or dirty. I've only worked here two weeks. On 2/26/25 at 10:43 AM, Staff 25 (Housekeeping Manager) stated staff receive training online and are also trained by a seasoned housekeeper. All gowns when removed are placed in a plastic bin inside residents' rooms and do not get placed in plastic bin outside residents' room. On 2/26/25 at 10:20 AM, Staff 10 (Infection Preventionist) Stated the brown inside residents' room with blue liner inside is where staff are to discard gown and should never come out of resident room with gown on. On 2/27/25 at 10:42 AM, Staff 1 (Administrator) stated staff are supposed to wear PPE appropriately and discard of it in the resident's room. Staff should also not put soiled gown in the plastic three drawer bin outside residents' room with clean PPE.

Based on interview and record review it was determined the facility failed to ensure narcotic drug records were in order, accurate, and maintained for all controlled drugs for 5 of 5 medication carts reviewed for medication administration and failed to provide accurate and timely pharmaceutical services for 2 of 2 sampled residents (#s 77 and 131) reviewed for medications and pressure wounds. This placed residents at risk for drug diversion and unmet pharmaceutical needs. Findings include: The 3/2023 the Reconciliation and Destruction of Controlled Substances Policy Statement indicated The facility regularly reconciles controlled substances and conducts thorough investigation of identified irregularities. Controlled substances are disposed of in a manner that reduces the risk of exposure, ingestion, misuse, abuse, or diversion. 1. On 2/25/25 at 8:00 AM the 100 hall medication cart narcotic log book for 1/2025 through 2/2025 revealed the facility staff did not sign the log book to verify the narcotic count was accurate for 44 out of 336 counting opportunities. On 2/25/25 at 8:15 AM the 200 hall medication cart narcotic log book for 2/25/25 revealed facility staff did not sign the log book to verify the narcotic count was accurate for 17 out of 144 counting opportunities. On 2/25/25 at 8:30 AM the 300 hall medication cart narcotic log book for 1/2025 through 2/24/25 revealed facility staff did not sign the log book to verify the narcotic count was accurate for 62 out of 336 counting opportunities. On 2/25/25 at 8:40 AM the 400 hall medication cart narcotic log book for 1/2025 through 2/24/25 revealed facility staff did not sign the log book to verify the narcotic count was accurate for 65 out of 330 counting opportunities. On 2/25/25 at 8:55 AM the 500 and 700 hall medication cart narcotic log book for 1/2025 through 2/24/25 revealed facility staff did not sign the log book to verify the narcotic count was accurate for 58 out of 330 counting opportunities. On 2/25/25 at 9:05 AM Staff 2 (DNS) acknowledged two staff members needed to count the narcotics, sign the log books and verify the narcotic count was correct. Staff 2 verified the missing signatures and stated the narcotic count was not correct. 2. Resident 77 was admitted to the facility in 2/2025 with diagnoses including depression. A 2/6/25 Care plan indicated Resident 77 had depression and insomnia with interventions which included to administer antidepressant medications as ordered by the physician. A 2/2025 MAR instructed staff to administer Burpropion and Lexapro once a day for depression with a start date of 2/12/25. On 2/21/25, 2/22/25, 2/23/25, and 2/24/25 at 8:00 AM the MAR referred the reader to review Progress Notes. The Progress Notes indicated Burpropion and Lexapro were not administered to Resident 77 because the medications were unavailable. On 2/27/25 at 11:45 AM Staff 2 (DNS) acknowledged Resident 77 did not receive her/his antidepressants for the above dates and staff should have alerted her the medication was unavailable. 3. Resident 131 was admitted to the facility in 2/2024 with diagnoses including Stage 4 pressure wound, Unstageable left heel wound, Unstageable buttocks wound and infection. A 8/20/24 Care Plan indicated Resident 131 had a nutritional problem or potential nutritional problem related to pressure injuries with increased demand for wound healing. Interventions included to administer medications by the physician. A 8/2024 MAR instructed staff to administer B-Complex-C (supplement) once a day and Juven (supplement) two times a day for wound healing with a start date of 8/21/24. The MAR referred the reader to review Progress Notes. The Progress Notes indicated B-Complex-C was unavailable from 8/25/25 through 8/30/24 and Juven was unavailable from 8/22/24 through 8/27/24 and 8/31/24 and were not administered to Resident 131. On 2/27/25 at 11:45 AM Staff 2 (DNS) acknowledged Resident 131 did not receive her/his B-Complex-C and Juven for the above dates and staff should have alerted her the medication was unavailable.

Based on observation, interview, and record review it was determined the facility failed to provide care and services for a fall, infection, and skin wound for 4 of 11 residents (#6, 35, 55, and 77) reviewed for skin, accidents, medications. This placed residents at risk for delayed treatment and unmet needs. Findings include: 1. A review of the facility's Skin and Wound Management Guidelines revealed the following: The following alterations in skin integrity would be assessed, measured, photographed, and documented in the Skin and Wound Module: -All vascular-related wounds, venous or arterial. -Scabs which have not healed for four weeks. Resident 6 was admitted to the facility in 4/2021 with diagnoses including heart failure, and chronic kidney disease. A 1/29/25 Wound Evaluation indicated Resident 6 had a venous wound on the left lateral calf. The Area was 1.02 cm, with a length of 1.84 cm and a width of .83 cm. There was a light amount of exudate serous with progress of resolved. The photo on the evaluation showed a red area with two dark scabbed areas and two small, scabbed areas. No documentation was found in Resident 6's clinical record of any additional Wound Evaluations of her/his left lateral calf venous wound. A 2/2025 TAR instructed staff to treat Resident 6's venous wound to the left outer leg area by applying skin prep over the area every day shift on Monday, Wednesday, and Friday, with a start date of 12/20/24. On 2/26/25 at 12:23 PM, Resident 6 was sitting in her/his wheelchair in her/his room. On Resident 6's left lateral calf, a scabbed area approximately the size of a nickel was observed. On 2/27/24 at 7:22 AM, Staff 22 (LPN Unit Manager) stated the facility did not complete evaluations on scabs until they fell off. In an interview on 2/27/25 at 10:03 AM with Staff 1 (Administrator), Staff 2 (DNS), and Staff 12 (Regional Care Nurse). Staff 2 confirmed Resident 6's wound should continue to have weekly wound assessments when the wound was not fully healed. 2. Resident 35 was readmitted to the facility in 8/2021 with diagnoses including stroke, muscle weakness, and difficulty walking. A review of Nursing Notes revealed the following occurred with Resident 35: -2/2/25 at 3:25 PM was found sitting on the floor beside her/his bed. Resident 35's vitals were completed. -2/3/25 at 9:13 PM vitals monitored with no signs or symptoms of pain or discomfort regarding this mornings fall. -2/4/23 at 3:41 PM vitals were monitored at 3:32 PM -2/4/25 at 3:32 PM vitals monitored. -2/6/25 at 3:09 PM vitals monitored. -2/7/25 at 12:12 PM vitals monitored. -2/9/25 at 11:24 PM vitals monitored. -2/11/25 at 1:56 PM vitals monitored. -2/12/25 at 5:25 PM was found sitting on the floor beside the bed. At 6:25 PM, vitals were monitored. -2/13/25 at 5:24 PM vitals monitored. -2/14/25 at 11:37 AM vitals monitored. -2/15/25 at 5:15 PM vitals monitored. -2/16/25 at 1:33 AM vitals monitored. -2/16/25 at 5:06 PM vitals monitored. -2/18/25 at 10:45 AM vitals monitored. -2/21/25 at 10:42 PM fell in the dining area. -2/25/25 at 2:29 PM vitals monitored. A review of Neurological Observation reports revealed the following for Resident 35: -2/2/25 at 3:53 PM for unwitnessed fall 15-minute check number one was completed with no concerns documented. -2/3/25 at 9:21 PM for unwitnessed fall four-hour check number four was completed with no concerns documented. -2/12/25 at 5:28 PM for unwitnessed fall initial check. On 2/27/25 at 8:04 AM, Staff 18 (RN) stated after a resident sustained an unwitnessed fall, the staff should complete neurological checks every 15 minutes three times, then every 30 minutes two times, then every hour four times, then every four hours four times then every eight hours three times and document in the resident's clinical records. In an interview on 2/27/25 at 10:03 AM with Staff 1 (Administrator), Staff 2 (DNS), and Staff 12 (Regional Care Nurse), Staff 2 confirmed no documentation was found for additional neurological checks for Resident 35 after her/his unwitnessed falls. 34703 3. Resident 77 was admitted to the facility in 2/2025 with diagnoses including necrotizing fasciitis (flesh eating disease) and utilized a wound vac (vacuum assisted closure for healing of wounds). The 2/2025 MAR indicated for staff to premedicate the resident with diazepam (for anxiety) and percocet (narcotic pain medication) one hour prior to the resident's dressing change. On 2/23/25 Resident 77 was administered percocet and diazepam at 2:00 PM. Resident 77's dressing change was completed at 2:40 PM, less than an hour after the prescribed medication was administered. Resident 77 was observed moaning and making painful expressions during the dressing change. On 2/27/25 at 11:52 AM Staff 2 (DNS) acknowledged Resident 77 was not premedicated one hour prior to the 2/23/25 dressing change and should have been due to the large wound and pain. 41455 4. Resident 55 was admitted to the facility in 5/2024 with diagnoses including severe obesity and diabetes. A 2/6/25 Quarterly MDS revealed Resident 55 was cognitively intact. A 2/14/25 revised care plan indicated Resident 55 had the potential for impaired skin integrity related to impaired mobility and other conditions. Resident 55 was to avoid scratching and keep her/his body parts from excessive moisture. A 2/18/25 Nursing Note indicated Resident 55 complained of severe itching in her/his genital area. The area was very red and itchy with heavy, clumpy, yellow discharge. The provider was notified with a request for new orders. A 2/18/25 Nurse/MD Request sent to Resident 55's provider indicated fluconazole (yeast infection treatment) was ordered and to wait for urine results if the resident had UTI symptoms. The orders were acknowledged and entered on 2/25/25 (seven days after symptom onset). A 2/21/25 Nursing Note indicated Resident 55 had a red area on her/his right thigh area as well as redness to her/his abdominal folds and antifungal cream was applied. The 2/2025 TAR indicated Resident 55 required a urine sample starting on 2/21/25 and to attempt during each shift until the specimen was collected. The final nursing entry was documented on 2/24/25 during the evening shift (three days after the order was received). A 2/22/25 Late Entry Note indicated an attempt to obtain a urine sample from Resident 55 was unsuccessful and the oncoming nurse would attempt again. The 2/2025 TAR did not indicate orders were in place for any topical antifungal treatment for Resident 55. On 2/23/25 at 12:56 PM and 2/27/25 at 8:15 AM Resident 55 stated over the last week she/he felt like something was eating her/him from the inside and only the topical antifungal treatment provided some relief which was inconsistently provided. Resident 55 indicated staff even tried pillowcases to absorb moisture a few times but the attention to her/his care related to skin moisture and itching was inconsistent. Resident 55 stated the staff excuse for the lack of care and treatment was because she/he did not use the facility provider. On 2/24/25 at 3:19 PM Staff 1 (Administrator) stated Resident 55's use of antifungal cream was ineffective and Staff 3 (Unit Manager-LPN) reported to Staff 1 the use of pillowcases around Resident 55's skin to keep her/him dry. On 2/25/25 at 3:05 PM Staff 38 (CNA) indicated Resident 55 needed assistance for proper daily hygiene, Staff 38 acknowledged Resident 55 had a yeast infection and Staff 38 used antifungal cream on Resident 55's skin because the resident had no other option for relief or treatment. Staff 38 stated updates for Resident 55's care were verbally communicated between CNAs because the resident's care plan was not accurate. On 2/26/25 at 7:58 AM Staff 6 (LPN) stated she was aware of Resident 55's yeast infection and that a second urine catch was completed for Resident 55, but no information or results were found. Staff 6 stated she often called providers within hours of sent communication to ensure a resident's treatment was not delayed and acknowledged Resident 55 had ongoing issues with delay in her/his treatment. On 2/26/25 at 3:42 PM Staff 3 acknowledged follow-up by nursing to ensure timely treatments and implementation of physician orders for Resident 55's yeast infection was lacking and confirmed there was an opportunity for improved yeast infection management for Resident 55. Staff 3 confirmed orders for the antifungal powder Resident 55 needed were not in place and orders for fluconazole started on 2/25/25. On 2/27/25 at 10:53 AM Staff 2 (DNS) stated Resident 55's change of condition communication to Staff 2 related to her/his yeast infection should have occurred earlier than 2/27/25. Staff 2 stated standing orders for antifungal powder were available for Resident 55 but not implemented timely.

Based on observation, interview, and record review, it was determined the facility failed to provide physician-ordered respiratory care for 1 of 1 sampled resident (#6) reviewed for respiratory services. This placed residents at risk for unmet respiratory needs. Findings include: Resident 6 was admitted to the facility in 4/2021 with diagnoses including heart failure and chronic obstructive pulmonary disease (a lung condition caused by damage to the lungs). A review of Resident 6's Vitals Report for oxygen (O2) saturation levels (how much oxygen was in the lungs) indicated on 9/4/24 and 9/5/24 her/his O2 levels were received while she/he was on a continuous positive airway pressure ((CPAP) takes room air then filters and pressurizes it and delivers it through a tube to a facial mask to keep a continuous flow of air). A 9/6/24 signed physician order instructed staff to provide Resident 6 with a bilevel positive airway pressure (BiPAP), a non-invasive ventilation therapy used to treat sleep apnea, respiratory failure, and other breathing disorders. It delivers two levels of pressure, a higher pressure during inhalation to support breathing) with five liters of oxygen with a start date of 12/19/23. A 9/22/24 Nursing Note indicated Resident 6's oxygen saturation was 63 percent, and when she/he was switched from a CPAP mask to a nasal cannula, oxygen saturations increased to 95 percent. On 10/14/24, the State Survey agency received a public complaint that indicated Resident 6 had orders for a BiPAP machine since her/his admission. Around 10/1/24, Resident 6 was discovered to have a CPAP machine instead of a BiPAP machine. A 12/13/24 Annual MDS revealed Resident 6's BIMs was 15, indicating she/he was cognitively intact. The MDS also indicated Resident 6 was on a non-invasive mechanical ventilator but did not indicate if it was a BiPAP or CPAP. On 2/24/25 at 5:50 AM, 7:00 AM, and on 2/26/25 at 8:00 AM, Resident 6 was observed in bed with a facial mask with tubing going to a small machine on the bedside table. On 2/25/25 at 8:19 AM, Witness 4 (Complainant) stated Resident 6 had the wrong equipment and was on a CPAP instead of a BiPAP. On 2/26/25 at 8:52 AM, Staff 20 (RN) stated Resident 6 had a CPAP and was switched to a BiPAP. On 2/26/25 at 12:23 PM, Resident 6 stated she/he did have the CPAP for a while and believed when she /he was readmitted to the facility from the hospital, they gave her/him the wrong machine. In an interview on 2/27/25 at 10:03 AM with Staff 1 (Administrator), Staff 2 (DNS), and Staff 12 (Regional Care Nurse), Staff 2 stated the respiratory company delivered a CPAP instead of a BiPAP, so Resident 6 had the wrong machine.

Based on interview and record review it was determined the facility failed to provide adequate indication for use of medications for 2 of 4 sampled residents (#s 6 and 131) reviewed for pressure ulcers. This placed residents at risk for unnecessary medications. Findings include: 1. Resident 6 was admitted to the facility in 4/2021 with diagnoses including heart failure and shortness of breath. A 9/23/24 physician order instructed staff to administer Doxycycline Hyclate (an antibiotic to treat various conditions, including UTI, sinus infection, and acne) two times a day for infection for 10 days. A review of signed physician orders dated 9/29/24 instructed staff to administer Augmentin (an antibiotic to treat bacterial infections) twice a day. No diagnosis was documented for the Augmentin on the physician's orders. A 9/2024 MAR instructed staff to administer the following: -Augmentin two times a day for ABX (medical abbreviation for antibiotics) with a start date of 9/29/24. -Doxycycline Hyclate two times a day for infection with a start date of 9/23/24. A 10/31/24 physician order instructed staff to administer Linezolid (an antibiotic that stops the growth of bacteria) every 12 hours for infection with a start date of 10/31/24. A 10/2024 MAR instructed staff to administer Linezolid every 12 hours for infection with a start date of 10/31/24. No documentation was found in Resident 6's clinical record for the indication for use for Augmentin, Doxycycline Hyclate, and Linezolid. In an interview on 2/27/25 at 10:03 AM with Staff 1 (Administrator), Staff 2 (DNS), and Staff 12 (Regional Care Nurse), Staff 2 stated the expectation was to have the diagnosis documented for the use of antibiotics. 34703 2. Resident 131 was admitted to the facility in 8/2024 with diagnoses including Stage 4 pressure wound, Unstageable left heel wound, and Unstageable buttocks wound. The August 2024 MAR indicated Cephalexin (an antibiotic) was given for antibiotic. No diagnostic indication of use was documented. On 2/27/25 at 12:02 Staff 2 (DNS) acknowledged the Cephalexin did not have a documented indication of use.

Based on interview, and record review, it was determined the facility failed to provide care and services for dementia for 1 of 5 sampled residents (#35) reviewed for medications. This placed residents at risk for unmet needs. Findings include: Resident 35 was readmitted to the facility in 12/2024 with diagnoses including dementia and borderline personality disorder. A 12/26/24 Admission MDS revealed Resident 35 was rarely understood. Resident 35 did not have any physical, verbal, or behavioral symptoms. Resident 35 had rejection of care behavior. A 1/28/25 care plan indicated Resident 35 had the potential to be physically and verbally aggressive. Interventions included administering medications as ordered, anticipating her/his needs, and providing physical and verbal cues to communicate. Give Resident 35 as many choices as possible about care and activities. Monitor, document, and report if she/he was posing a danger to self or others. When Resident 35 was agitated, intervene before the agitation escalates. A Documentation Survey Report from 2/1/25 through 2/25/25 revealed Resident 35 demonstrated the following behavioral symptoms: -Two times on day shift rejection care, yelling, and kicking or hitting. -Three times on evening shift yelling, kicking of hitting, and abusive language. -Three times on night shift rejection of care, abusive language, and kicking or hitting. A review of the TAR from 2/1/25 through 2/25/25 instructed staff to complete a progress note regarding behaviors, including but not limited to rejection of cares, abusive or inappropriate language, kicking or hitting, and yelling. The TAR referred the reader to progress notes 14 times on the evening shift and five times on the night shift. A review of Nursing Notes revealed the following occurred with Resident 35: -2/4/25 at 3:41 PM anxious, frustrated, cursing, and hitting out at nursing staff at times. -2/10/25 at 9:03 AM today cheerful but mood and reality changes quickly. No documentation was found in Resident 35's clinical record to indicate what interventions to reduce her/his behaviors were attempted or if the intervention attempts were successful. On 2/26/25 at 9:33 AM, Staff 16 (CNA) stated Resident 35 had behaviors; if she/he was incontinent, she/he may grab the blanket. Resident 35 usually liked to sleep until lunchtime and had behaviors if woken up when she/he wanted to sleep in. On 2/26/25 at 12:37 PM, Staff 23 (CNA) stated Resident 35 had behaviors when she/he was incontinent and she/he would get irritated. Staff 23 stated when she spoke to her/him, she/he started to calm down. In an interview on 2/27/25 at 10:03 AM with Staff 1 (Administrator), Staff 2 (DNS), and Staff 12 (Regional Care Nurse), Staff 2 confirmed staff needed to offer and document interventions provided for the behaviors of Resident 35.

Based on interview and record review the facility failed to accurately assess pain, develop person centered plans and provide pain medications as ordered for 2 of 3 sampled residents (#s 24 and 55) reviewed for pain management. This placed residents at risk for increased pain. Findings include: 1. Resident 24 was admitted to the facility in 1/2025 with diagnoses including chronic pain and fusion of the spine. A 1/23/25 Admission MDS indicated Resident 24's pain was frequent, occasionally impacted her/his sleep and therapy, and her/his pain reached a level of 10 (worse pain imagined) on a scale of of one through 10 during the last five days. A 1/20/25 Nursing Pain Evaluation for Resident 24 revealed her/his pain was best managed by repositioning and receiving scheduled pain medications. A 1/21/25 revised care plan indicated to anticipate Resident 24's need for pain relief and respond immediately to any complaint of pain. The 2/2025 MAR indicated Resident 24 was to receive gabapentin (nerve pain treatment) twice during the day and once at bedtime for the relief of pain to her/his spinal region: -On 2/14/25 at 10:00 PM the facility was waiting for delivery of the medication and the medication was not provided. -On 2/15/25 at 7:00 AM the facility was waiting for the delivery of the medication and the medication was not provided. -On 2/19/25 and 2/22/25 at 10:00 PM the medication was not provided and no nursing notes were found. The 2/2025 TAR indicated to apply Biofreeze (topical menthol pain relief) once every four hours for Resident 24's pain relief. Resident 24 was not provided the medication as ordered because she/he was sleeping during the following times: -2/3/25 at 10:00 PM -2/12/15 at 2:00 AM -2/16/25 at 10:00 AM as documented by Staff 19 (RN) -2/16/25 at 10:00 PM On 2/24/25 at 9:08 AM Resident 24 stated her/his Biofreeze was a big solution for her/his pain management. Resident 24 indicated she/he believed at times her/his Biofreeze was unavailable because of the lack of consistent application of the medication. On 2/25/25 at 3:38 PM Staff 4 (Medication Tech) stated he was aware Resident 24 did not receive her/his Biofreeze as ordered. On 2/26/25 at 4:27 PM Staff 3 (Unit Manager-LPN) confirmed Resident 24's pain medication should be administrated as ordered even if the resident was asleep and the physician should be notified if orders were not followed. On 2/26/25 at 4:40 PM Staff 9 (LPN) confirmed Resident 24's missed gabapentin medication was not available in the reserve medication system on 2/14/25. The pharmacy indicated the medication was in the building on 2/15/25. Staff 9 indicated Staff 19 was the nurse on duty on 2/14/25. On 2/26/25 at 12:14 PM and 2/27/25 at 10:38 AM attempts to reach Staff 19 were unsuccessful. On 2/27/25 at 10:53 AM Staff 2 (DNS) stated a system change to improve missed or lacking medications for Resident 24 was necessary. 2. Resident 55 was admitted to the facility in 5/2024 with diagnoses including diabetes with neuropathy (nerve pain) and kidney disease. A 5/6/24 Admission MDS indicated Resident 55 was at risk to decline due to frequent levels of moderate to severe pain. Staff were to assess Resident 55's pain, treat the resident's pain as ordered and provide non-pharmacological pain interventions. The 2/2025 MAR indicated Resident 55 received oxycodone-acetaminophen (opioid pain medication) as needed for pain every six hours. From 2/1/25 through 2/24/25 Resident 55 was administered the medication 44 times with no pain level indicated. The 2/2025 MAR indicated Resident 55 received acetaminophen as needed every six hours for pain. From 2/1/25 through 2/23/25 Resident 55 was administered the medication 20 times with no pain level indicated. A 2/5/24 Progress Note indicated Resident 55's pain was managed through the use of PRN pain medications. A 2/6/25 Quarterly MDS did not indicate Resident 55 received opioid medications. A 2/14/25 revised care plan indicated Resident 55 had low back pain, was administered pain medication and staff were to monitor for side effects of the medication. The care plan did not indicate any non-pharmacological pain interventions. Review of Resident 55's clinical record revealed no monitor for the use of pain medication side effects. On 2/25/25 at 3:05 PM Staff 38 (CNA) reviewed Resident 55's care plan, indicated the resident's care plan lacked details related to her/his pain management, and the resident had pain everywhere. On 2/26/25 at 7:58 AM Staff 6 (LPN) stated Resident 55's PRN pain medications were to have her/his pain levels documented at the time the pain medication was administered. On 2/26/25 at 12:33 PM Resident 55 indicated her/his pain rarely went below a pain level of three on a pain scale of zero to 10 (highest pain level imagined). On 2/26/25 at 3:42 PM Staff 3 (Unit Manager-LPN) confirmed Resident 55's pain care plan lacked details especially for non-pharmacological interventions. The PRN pain medication monitor and side effect monitor were also not in place as expected.

Based on observation, interview and record review it was determined the facility failed to monitor, assess and document signs and symptoms of dehydration for 1 of 1 sampled resident (#21) reviewed for limited range of motion and depression. This placed residents at risk for dehydration. Findings include: Resident 21 was admitted to the facility in 2019 with diagnoses including a stroke affecting her/his left side, muscle weakness, and dysphagia (difficulty swallowing). A 7/25/23 diet order indicated Resident 21 received regular liquids and required a two-handled cup with all meals. Resident 21's 11/26/24 annual MDS indicated the resident was cognitively intact, she/he was at risk for malnutrition and had dysphagia. No CAAs were documented related to dehydration/fluid maintenance. A 12/22/24 Nutritional Evaluation indicated Resident 21 was on a regular diet and fluids. Staff were to provide Resident 21 with a two-handed cup. Resident 21's estimated daily fluid requirements were 1450 to 1550 cc. Resident 21's goal was to maintain or improve nutritional status. Staff were to ensure Resident 21 met her/his nutritional intake and maintained adequate hydration status with no signs/symptoms of dehydration. A 2/17/25 revised care plan indicated Resident 21 would be hydrated and nourished as her/his condition allowed. Resident 21 had potential for decline in daily fluid intake related to impaired mobility, relying upon staff to provide her/him with fluids. Staff were to ensure Resident 21 was free of symptoms of dehydration, maintained moist mucous membranes, and had good skin turgor. Resident 21's Fluid Monitor dated 1/30/25 through 2/27/25 revealed:the resident's fluid intake fell below the registered dietitian's fluid recommendation for 26 out of 29 days: 1/30/25-917 cc for all shifts 1/31/25-1060 cc for all shifts 2/1/25-1030 cc for all shifts 2/2/25-507 cc for all shifts 2/3/25-1000 cc for all shifts 2/4/25-860 cc for all shifts 2/5/25-910 cc for all shifts 2/6/25-1210 cc for all shifts 2/7/25-1620 cc for all shifts 2/8/25 830 cc for all shifts 2/9/25-1270 cc for all shifts 2/10/25-1200 cc for all shifts 2/11/25-960 cc for all shifts 2/12/25-1227 cc for all shifts 2/13/25-910 cc for all shifts 2/14/25-1865 cc for all shifts 2/15/25-740 cc for all shifts 2/16/25-450 cc for all shifts 2/17/25-1250 cc for all shifts 2/8/25-1100 cc for all shifts 2/19/25-1055 cc for all shifts 2/20/2 5-1230 cc for all shifts 2/21/25-720 cc for all shifts 2/22/25-865 cc for all shifts 2/23/25-1340 cc for all shift 2/24/25-1350 cc for all shifts 2/25/25-2610 cc for all shifts 2/26/25-1330 cc for all shifts 2/27/25-960 cc for all shifts On 2/23/25 at 2:18 PM Resident 21 was sitting upright in bed with a two-handed cup of water on her/his bed side table. The resident exhibited signs of dry mouth, dry lips, and had difficulty speaking. The resident's face appeared pale and gray in color. The resident's tongue was coated with a white film residue. Resident 21 stated multiple times that she/he was thirsty and asked for water. On 2/24/25 between 7:48 AM and 2:42 PM Resident 21 was observed multiple times sitting upright in bed with little to no fluid in her/his two-handed cup. At times, the resident was unable to speak when spoken to. On 2/24/25 at 2:47 PM Staff 28 (CNA) indicated Resident 21 was dependent on staff for care and stated she checked on the resident every hour to ensure fluids were available at her/his bedside table. Resident 21 stated they wanted water. Staff 28 was unsure how to determine if the resident's mouth was dry. Staff 28 did not return to provide fluids at any time in the next hour. On 2/24/25 at 4:11 PM Staff 29 (LPN) assessed Resident 21 and stated the residents mouth looked better than yesterday, and her/his mouth appeared dry. Staff 29 stated she was not concerned about the layer of white, chunky film on her/his tongue. Staff 29 stated Resident 21's skin tone was fair. Resident 21 again stated that she/he was thirsty and asked for water. Staff 29 stated she was not concerned about the resident's hydration status. On 2/25/25 at 8:06 AM Staff 30 (CNA) stated his shift started at 6:00 AM and Resident 21 was dependent on staff for care. He reported providing water every two hours and the resident required a special cup but he had not seen the cup since the start of his shift, assuming the kitchen was washing it. Staff 30 stated Resident 21 expressed thirst and requested water 45 minutes earlier and noted 45 minutes was a long wait for water, the resident's mouth appeared dry, and if the wait continued, he would request the resident's two-handed cup from the kitchen. He also stated Resident 21 typically drank a lot of water during the day and did not usually have a dry mouth. Resident 21 was observed on 2/25/25 9:01 AM sitting up in bed with three empty cups on her/his bed side table. Resident 21 asked for more water. Resident 21's tongue appeared dry and was covered in a white film. On 2/25/25 at 9:05 AM Staff 18 (RN) was asked to assess Resident 21 for concerns related to hydration. Staff 18 performed a skin turgor test on Resident 21 and her/his skin stayed tented. Staff 18 stated this was indicative of dehydration. Staff 18 confirmed Resident 21's mouth had build up and had three empty cups on her/his bedside table. Resident 21 told Staff 18 that she/he was thirsty and asked for water. A Nursing Note dated 2/25/25 at 11:50 AM indicated Resident 21 exhibited signs of dehydration, including dry mouth, dry lips, and poor skin turgor. A 2/25/25 at 2:38 PM Administration Note revealed the resident's doctor requested a full assessment, instructed staff to encourage fluids, and Resident 21 did not void during the shift. On 2/26/25 at 8:33 AM Resident 21 was observed sitting upright in bed with three half empty cups sitting on her/his bedside table. Resident 21 stated she/he was thirsty, and her/his mouth and lips appeared dry. On 2/26/25 at 8:35 AM Staff 39 (CNA) stated Resident 21 did not void during the last shift. Staff 39 stated Resident 21 did not typically ask for fluids, but staff offer and provide fluids every couple hours. Staff 39 stated Resident 21 usually drank six to eight cups of fluid during a shift. On 2/27/25 at 8:23 AM Staff 22 (LPN/UM) confirmed Resident 21 was placed on alert charting on 2/25/25 for five days related to signs and symptoms of dehydration. Staff 22 confirmed the required documentation was not completed as expected. Staff 22 further stated I would definitely show that to the DNS. On 2/27/25 at 8:58 AM Staff 36 (Facility Nurse Practitioner) stated Resident 21 had mild skin turgor. Staff 36 noted Resident 21 did not like water and that he did not believe it was uncommon for Resident 21 to go eight hours without voiding. He indicated concerns would arise only if the resident went longer than eight hours without voiding. On 2/27/25 at 9:48 AM Staff 2 (DNS) confirmed the facility failed to thoroughly monitor, assess and document signs and symptoms of dehydration for Resident 21.

Based on observation, interview and record review it was determined the facility failed assess, implement, follow and maintain pressure ulcer treatments and care plans for 1 of 4 sampled residents (# 3) reviewed for pressure ulcers. Findings include: Resident 3 was admitted to the facility in 2/2025 with diagnoses including pressure ulcer and paraplegia. The 2/2/25 Admission Assessment revealed Resident 3 had a coccyx (tailbone) pressure wound and a wound to the left gluteal fold, but did not mention the purple area to the resident's right anterior ankle. The 2/13/25 care plan revealed Resident 3 had two Stage IV (full thickness tissue loss which extend to muscle, tendon, or bone) pressure ulcers to the sacrum (triangle shaped bone at the base of the spine) and left ischial tuberosity (lower part of the pelvis) but did not mention the wound to the right anterior ankle. On 2/17/25 Staff 2's (DNS) Progress Note revealed Resident 3 was admitted to the facility with a red/purple discoloration to both ankles. On 2/19/25 the 2/2025 TAR revealed Resident 3's right anterior ankle wound opened and treatment was intiated. A 2/21/25 Skin and Wound Evaluation indicated Resident 3 had a Stage 2 pressure wound to the right medial malleolus (bony prominence to the side of the ankle). On 2/27/25 at 8:53 AM Staff 2 acknowledged the pressure wound to the right anterior ankle was not captured on the Admission Assessment, and was not treated until 2/19/25 when the wound opened.

Based on interview and record review it was determined the facility failed to develop an individualized plan of care for 1 of 1 sampled resident (#77) reviewed for medications. This placed residents at risk for unmet care planned needs. Findings include: Resident 77 was admitted to the facility in 2/2025 with diagnoses including colostomy (opening in large intestine to divert stool from the colon to an external bag), necrotizing fasciitis (flesh eating disease) and utilized a wound vac (vacuum assisted closure for healing of wounds). Resident 77's care plan last revised 2/10/25 did not address Resident 77's care and services for her/his colostomy or wound vac. On 2/25/25 at 10:10 AM Staff 11 (CNA) stated she was not aware of care and services for the colostomy or the wound vac, and acknowledged this was not on the care plan. On 1/25/25 at 12:03 PM Staff 30 (CNA) stated he was not aware of what care and service he was to provide for the resident's colostomy or wound vac. Staff 30 acknowledged care and services for both were not on the care plan. On 2/27/25 at 11:51 AM Staff 2 (DNS) acknowledged Resident 77's care plan needed more on the care plan related to the colostomy and the wound vac. Staff 2 acknowledged the care plan was not person centered.

Based on interview, and record review the facility failed to ensure resident's pain was managed appropriately for 2 of 6 sampled residents (#s 212 and 262) reviewed for pain management. Resident 212 experienced severe pain. Findings include: 1. Resident 212 admitted to the facility in 2021 with diagnoses including anxiety and osteoarthritis of the knee. An 8/17/21 care plan indicated Resident 212 had pain due to impaired mobility, osteoarthritis and chronic conditions with interventions which included to monitor, record and report to the nurse Resident 212's complaints of pain or requests of pain treatment. A 7/23/22 Pain evaluation indicated Resident 212 was able to verbalize her/his pain and took pain medications. Resident 212 had pain during the evaluation, during the previous five days and had a history of chronic pain. Resident 212's pain was full body pain. The current pain level numeric pain scale, what made the pain better, what made pain worse and all methods of alleviating pain and their effectiveness were blank with no documentation. On 9/26/22 a public complaint was received which indicated on 9/24/22 Resident 212 returned from an outing and requested oxycodone pain medication for her/his knee pain between 5:00 PM and 5:30 PM and did not receive her/his pain medication for hours and was in a lot of pain. Resident 212 stated by the time she/he received her/his pain medication her/his pain level was a level 10 on a pain scale of one to 10. A 9/2022 MAR instructed staff to administer oxycodone every four hours as needed for pain and to use the medication for a pain level of six or higher and to not give for a pain level of zero. Staff were to offer non-pharmacological relief. On 9/24/22 Resident 212 received oxycodone at 1:00 AM with a pain level of zero, at 5:20 AM with a pain level of zero and at 8:21 PM with a pain level of nine. A 9/2022 Documentation Survey Report indicated on 9/24/22 on evening shift Staff 11 (CNA) documented Resident 212 complained of pain. An 10/26/22 Resident Council Minutes revealed night shift nurses were not attentive when residents asked for PRN medications. On 10/17/23 at 8:22 AM Resident 212 confirmed she/he did not receive her/his pain medications timely on 9/24/22 and was in a lot of pain. On 10/19/23 at 10:12 AM Staff 14 (CMA) stated Resident 212 needed her/his PRN medication often. Resident 212 complained to her often that some of the regular staff did not provide her/his medications timely. On 10/19/23 at 10:41 AM Staff 11 indicated she remembered Resident 212 as she saw her/him when she/he had uncontrollable pain. Resident 212 was crying a lot and called and told Staff 11 she/he was hurting bad and kept calling and asked for her/his pain medication. It took an hour or two and Staff 11 had to beg the medication aide and nurses to provide her/him pain medications. Resident 212 would bawl and bawl, and bawl and kept saying not controlled, not controlled Staff 11 stated her opinion was Resident 212's pain was either an eight or nine on a one to 10 pain scale. On 10/20/23 at 10:10 AM in an interview Staff 1 (Administrator), Staff 2 (DNS) and Staff 24 (Regional Director of Clinical) stated if a resident needed PRN pain medication and the medication aide did not administer the medication then the CNA staff should find a nurse and inform them of the need. 2. Resident 262 admitted to the facility in 2023 with a diagnosis of open wound to the abdominal wall. An 10/6/23 Pain Evaluation indicated Resident 262 was able to verbalize pain, and was taking pain medications. Resident 262 had pain in the last five days and did not have chronic pain. The following areas were blank on the evaluation with no documentation: - If Resident 262 had pain - Physical location of pain - Numeric pain scale on zero through 10 pain scale - What made pain better or worse - What negatively impacted her/his pain, and - All methods of alleviating pain and their effectiveness An 10/6/23 care plan indicated Resident 262 had pain (no documentation of source of pain). Interventions included to evaluate the effectiveness of pain interventions every shift, review for compliance, alleviating of symptoms, dosing schedules, resident satisfaction with results and impact on functional ability. To monitor and document probable cause for each pain episode. An 10/9/23 Admission MDS indicated Resident 262 was cognitively intact, she/he did not receive scheduled pain medications, received PRN pain medications and non-medication interventions for pain. Resident 262 had pain frequently with an intensity of eight which occasionally affected sleep and interfered with therapy and day to day activities. The Pain CAA was blank with no documentation. On 10/17/23 at 7:41 AM and 10/18/23 at 8:07 AM Resident 262 stated she/he was trying to keep up with pain relief. Resident 262 reported the week of 10/9/23 she/he had to wait seven hours and another day she/he waited twelve hours to receive her/his PRN pain medication after requesting the medication. Resident 262 stated the medication aide at night had to administer medications between two halls and at times it took hours to get her/his pain medications and she/he got frustrated and angry because of the pain. Resident 262 stated on 10/16/23 the facility stated they ran out of her/his pain medication and she/he waited from 4:00 AM until 2:30 PM to get her/his medications. On 10/18/23 at 9:18 AM Staff 15 (CNA) stated she saw Resident 262 in pain. Resident 262 asked for her/his PRN pain medications whenever they were due. At times she/he waited and she/he was in pain. Staff 15 checked with the medication aide and see how many other residents were in line in front of Resident 262 to get their medications. If the medication aide was too busy, she found a nurse. An 10/2023 MAR instructed staff to administer Resident 262 oxycodone (for pain) one tablet by mouth every four hours as needed for moderate pain. The MAR revealed the following: -10/9/23 administered 3:39 AM pain level seven, 7:23 AM pain level five and 8:34 PM pain level eight. -10/16/23 Resident 262 received oxycodone at 12:12 AM with pain level of eight, 4:15 AM pain level of seven, 2:24 PM pain level eight. On 10/19/23 at 6:20 AM Staff 19 (Agency LPN) stated at times she needed to administer medications on two halls. Staff 19 stated typically the CNAs documented a resident needed PRN pain medications on a note and placed it on the medication cart. If Staff 19 was charting, she did not check the cart all the time and did not see the note until later. On 10/19/23 at 9:10 AM Staff 21 (CNA) stated the medication aides worked two halls and when the aide left Resident 262's hall she was supposed to let the nurses know when a resident requested a pain medication. Staff 21 stated one nurse did not administer pain medication and she needed to find the medication aide to administer the medication. On 10/18/23 the medication aide was off the hall, she told the nurse and left a note. Resident 262 came out of her/his room, inquired about her/his pain medications and she/he was not happy. Later Resident 262 came out of her/his room again to inquire and again went back into her/his room not happy. On 10/19/23 at 10:02 AM Staff 16 (CNA) stated he observed Resident 262 request her/his pain medications multiple times. In an interview on 10/20/23 at 10:11 AM Staff 1 (Administrator), Staff 2 (DNS), and Staff 24 (Regional Director of Clinical) stated the expectation was if a medication aide was not available the CNA was to inform the nurse and not leave a note on the medication cart.

Based on observation and interview it was determined the facility failed to ensure Ombudsman contact and complaint filing information were posted in the facility for 1 of 1 facility reviewed for required postings. This placed residents at risk for lack of advocacy information. Findings include: During the recertification survey contact information for the Ombudsman's office and complaint reporting could not be located in a prominent and accessible location in the facility. On 10/20/23 at 9:34 AM Staff 1 (Administrator) was asked about required postings for the Ombudsman and complaint reporting information. Staff 1 stated the Ombudsman's information was removed as it was inaccurate and the complaint reporting information was on the 400 hall, but it was also removed due to inaccurate information.

Based on interview and record review the facility failed to ensure a resident did not develop an avoidable pressure ulcer for 1 of 3 sampled residents (#25) reviewed for pressure ulcers. This resulted in Resident 25 developing an avoidable unstageable pressure ulcer. Findings include. Resident 25 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Admission MDS dated [DATE] revealed Resident 25's BIMS score was 14 which indicated she/he was cognitively intact. Resident 25 required two-person extensive assist with all her/his ADL care needs and she/he did not admit with any pressure ulcers. An investigation regarding an incident that occurred on 9/20/21 revealed the following: -Resident 25 had a BIMS score of 14 which indicated cognitively intact but she/he had confusion at times. -At approximately 12:00 PM on 9/20/21 a wound nurse performed wound rounds on Resident 25 and noted a bed pan, upside down underneath her/him. When the nurse inquired why the bed pan was upside down underneath her/him Resident 25 reported the bedpan was underneath her/him since the night of 9/19/21 around 9:00 PM when she/he had surgery. -Resident 25 had a 1.0 x 2.0 cm filled blister lateral to her/his right gluteal fold with blanchable [CONDITION(S)] (redness of the skin caused by hyperemia [increase blood flow] that occurs with any skin injury, infection or inflammation). -The area was cleaned with normal saline and zinc-based cream applied. treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . -All residents on the COVID unit had a thorough skin assessment conducted and no further skin issues were identified. -Care plan interventions were in place at the time of the incident. Resident 25 was repositioned frequently related to skin integrity and comfort, weekly skin checks were in place per protocol, staff monitored her/his weight and nutritional status to prevent malnutrition and to promote skin integrity. -The incident was avoidable however; care plan interventions were followed. -On the spot education was completed with CNAs and nursing staff including the importance of repositioning. -Conclusion: Upon investigation abuse and neglect was ruled out as Resident 25 was monitored, repositioned and checked on by staff throughout the shift. However, with the resident's size and no significant body positional changes, the bedpan was not noted by staff. Resident 25 confirmed that staff checked and monitored throughout the night shift and the following morning. Resident 25 was confused about the foley insertion on 9/19/21, stating she had surgery and did not realize she/he was still on the bed pan and verified she/he did not report to any staff the presence of the bedpan or discomfort or pain. The 1.0 x 2.0 cm blister had dissolved and was continually improving. The Document Report Survey dated 9/19/21 and 9/20/21 reviewed for bed mobility and bladder elimination revealed the following: -Resident 25 required two-person extensive assistant with bed mobility. -On 9/19/21 on evening and night shift no documentation was completed. -On 9/20/21 during days shift Resident 25 was provided one-person limited assist with bed mobility. Bladder Elimination revealed: -On 9/19/21 on evening and night shift no documentation was completed. -On 9/20/21 on day and night shift no documentation was completed. Progress Notes dated 9/19/21 at 8:27 PM and 8:28 PM revealed Staff 36 (LPN) attempted to place an indwelling catheter for Resident 25 which was unsuccessful and a second attempt by another nurse Staff 37 was successful. A Progress Note dated 9/20/21 at 3:20 PM revealed Witness 29 noted she was going to perform wound care for Resident 25 and when she turned her/him she noticed a bedpan under her/him, placed upside down. Witness 29 noted the area of skin that was on the bedpan was red and there was a ring on her/his skin where the bed pan was placed under her/him the night of 9/19/21 when the nurse was attempting to insert a foley catheter. Witness 29 completed wound care to the area. Review of medical records revealed on 9/20/21 wound care was initiated for Resident 25's in-house acquired unstageable (full thickness tissue loss covered by slough [yellow, tan, gray, green or brown] and or eschar [tan, brown or black] in the wound bed) pressure ulcer to the coccyx (tail bone) region. On 3/16/22 at 2:35 PM Witness 24 (Former CNA) stated he worked on the COVID unit on 9/20/21 and was informed by another staff Resident 25 was left on a bedpan for hours and had skin breakdown. Witness 24 was not present or working when the incident occurred. On 3/18/22 at 10:42 AM Staff 37 (LPN) stated he recalled the incident on 9/19/21 because he stayed late to assist with medication administration. Staff 37 stated Staff 36 attempted to insert a foley catheter for Resident 25 but was unsuccessful and Staff 37 entered the room, inserted the foley catheter for Staff 36 and then he left the room. Staff 37 indicated on his next shift he was told Resident 25 was left on the bedpan from the 9/19/21 foley catheter insertion and when he saw her/his buttocks there was redness and bruising. On 3/18/22 at 12:19 PM Staff 36 (LPN) stated he worked with Resident 25 and remembered the incident on 9/19/21. Staff 36 stated he attempted to insert a foley catheter for Resident 25 and was taught to use a bedpan to adjust her/his hips to make the foley catheter insertion easier. Staff 36 stated he was unsuccessful with the insertion of the foley catheter and left the room to retrieve another foley catheter, when he came back into the room the foley catheter procedure was completed. Staff 36 stated when he went back into the room everything was cleaned up and Resident 25 stated the procedure was completed and she/he was okay so he left the room. Staff 36 stated he was spoken to by Staff 2 (DNS) on his next shift because Resident 25 was left on the bedpan all night. Staff 36 further stated Resident 25 was pissed and she/he had a mark from where the bed pan was placed. On 3/21/22 at 12:25 PM Witness 30 (Former LPN) stated she did not work when the 9/19/21 incident occurred regarding Resident 25 being on a bedpan for hours resulting in an injury. Staff 30 stated she worked with Resident 25 after the incident and Resident 25 reported to her that she/he kept telling staff that something was under [her/his] bottom [on 9/19/21], was very upset and was crying but no one checked on [her/him]. Witness 30 stated Resident 25 was dependent on staff and was to be checked on every couple of hours. On 3/21/22 at 1:00 PM Witness 29 stated Resident 25 was alert and oriented but was totally dependent on staff. Witness 29 stated he did not work on 9/19/21 when the bedpan incident occurred but Resident 25 spoke with him regarding the incident. Staff 29 stated she/he was upset and when staff came in to assist her/him the next day (9/20/21) they found the bed pan under her/him and she/he went the entire night with the bedpan under [her/him]. Witness 29 stated she/he was crying and upset and indicated she had increased buttocks and lower back pain from the incident. On 3/21/22 at 1:08 PM Witness 28 (Former RN) stated she was not present regarding the bedpan incident but saw Resident 25's wound after the 9/19/21 incident and it was reddish and she could see the edges or line from the bedpan on [her/his] buttocks. Witness 28 stated she was not sure how long Resident 25 was left on the bedpan. On 3/21/22 at 1:21 PM Resident 25 stated she/he remembered the incident regarding the bedpan. Staff 36 was changing her/his foley catheter, placed a bedpan underneath her/his bottom during the procedure but could not get the foley catheter inserted. Another staff member she/he thought was Staff 37 completed the procedure. Resident 25 stated she/he was left on the bedpan for approximately 12 hours, was very upset and was in so much pain. Resident 25 indicated no staff checked on her/him that night and they did not reposition her/him either. Resident 25 stated using the call lights for assistance was worthless and staff might not show up for two hours. Resident 25 indicated the next day a staff member was getting her/his medications and discovered the bedpan underneath her/him because she/he was complaining of intense pain in [her/his] low back and butt. Resident 25 stated the nurse could see the bedpan and she/he had an imprint/dent from it grinding into her/his butt. Resident 25 further stated she/he felt humiliated by the incident because staff took pictures and everyone new about the bed pan incident. Resident 25 stated she had a permanent scar from the bedpan injury. On 3/23/22 at 11:43 AM Witness 31 (Former CNA) stated he believed he worked on 9/19/21 but was working a different hall than Resident 25 and the next day worked with Resident 25. Witness 31 stated she/he expressed to him she/he was very angry, upset and very painful because of the bedpan being under her/him for so long. Witness 31 stated she/he had a huge red deep bruise on [her/his] buttocks, markings from the bedpan and a blister. Witness 31 stated she/he was to be repositioned and changed every two hours. On 3/25/22 at 11:43 AM Staff 1 (Administrator) and Staff 2 (DNS) were present for an interview. Staff 2 stated the 9/19/21 bedpan incident was an unfortunate accident and oversight by staff regarding the use of the bed pan during the foley catheter insertion procedure. Staff 2 indicated Resident 25 was a larger person, staff repositioned her/him with pillows during the night but would not necessarily perform incontinence care during the middle of the night and the bedpan was not noticeable to staff.

Based on observation, interview and record review it was determined the facility failed to accurately assess and revise the plan of care for 2 of 2 sampled residents (#s 22 and 57) reviewed for pressure ulcers. Resident 22 experienced a worsening of a pressure ulcer from Stage 3 to Stage 4, and Resident 57 developed a Deep Tissue Pressure Injury. Findings include: Stage 1 pressure injuries are defined as intact skin with a localized area of non-blanchable [DIAGNOSES REDACTED] (redness). Stage 2 pressure ulcers are defined as partial-thickness skin loss with exposed dermis presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. Stage 3 pressure ulcers are defined as full-thickness skin loss in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. Stage 4 pressure ulcers are defined as full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed. Epibole (rolled edges), undermining and/or tunneling often occur. Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. 1. Resident 22 was readmitted to the facility in 2/2018 with [DIAGNOSES REDACTED]. The 12/30/17 Annual MDS indicated the resident had two unhealed Stage 3 pressure ulcers. The 12/30/17 Pressure Ulcer CAA indicated the resident was at risk for pressure ulcers and skin issues related to her/his history of pressure ulcers, medications, decreased mobility, incontinence, and disease process. The care plan was updated on 4/3/18 and identified the resident's risk for skin breakdown and reflected a Stage 3 coccyx pressure ulcer. The care planned interventions included use of a speciality mattress, draw sheet or lifting device to move the resident and use of a wheelchair cushion. A care plan intervention dated 8/23/17 also directed staff to report abnormalities, failure to heal, signs and symptoms of infection and maceration to the doctor. The facility's Wound Assessment Details from 12/26/17 to 4/3/18 were reviewed and included pictures of Resident 22's coccyx pressure ulcer. The weekly Wound Assessment Details indicated the coccyx pressure ulcer was facility acquired and identified on 2/25/17. The pictures were inconsistent and were captured from various vantage points. On 2/7/18 the coccyx wound was described by Staff 16 (RN) as a Stage 3 and was 1.5 cm x 0.8 cm and 0.9 cm depth. On 2/14/18 the coccyx wound was described as a Stage 3 and was 1.48 cm x 0.7 cm with an unknown depth. The Wound Assessment Details picture indicated the wound changed from the previous week and had thickened rolled white edges and was elongated in shape. On 2/22/18 the wound appearance changed again and the picture showed a visible mass in the center of the wound with thickened rolled white edges. On 3/27/18 the assessment indicated the wound was a Stage 2, measured 2.0 cm x 3.75 cm and was 0.23 cm in depth. The Wound Assessment Details picture contained a centimeter measuring device next to the wound which visually indicated the wound was 4.5 cm in length and the rolled edges were white in color and larger than 0.23 cm. The wound bed was not visible in the picture. Review of the 2/2018, 3/2018 and 4/2018 TARs indicated in 2/2018 the resident's wound treatment was to clean with saline, coat with non-sting barrier, fill with calcium alginate and cover with a foam dressing daily and as needed. The TAR indicated the treatment was started on 3/22/17 and the treatment was not changed when the wound appearance changed on 2/14/18 or 2/22/18. The treatment remained unchanged as of 4/4/18. On 4/3/18 at 3:50 PM Staff 16 (RN) stated the coccyx pressure ulcer had no odor, was a Stage 3 and was now a Stage 2. On 4/3/18 at 6:21 PM Staff 1 (DNS) reviewed the Wound Assessment Details pictures of Resident 22's coccyx wound and verified on 2/22/18 the wound appeared to be a Stage 4 pressure ulcer and the mass appeared to be exposed muscle in the wound. Staff 1 verified the pressure ulcer edges where white and rolled, the pictures were inconsistent and Staff 16's assessment of the coccyx wound as a Stage 2 ulcer was inaccurate. On 4/4/18 at 7:30 AM the physician progress notes [REDACTED]. There was no evidence the resident was seen by the physician or wound specialist related to pressure ulcers. The physician notes did not indicate the physician was aware of the resident's coccyx pressure ulcer. On 4/4/18 at 8:08 AM Staff 19 (LTC Unit Resident Assessment Coordinator) verified the resident's coccyx pressure ulcer was inaccurately staged and measured. Staff 19 verified the wound worsened in 2/2018 and there was no change in the treatment or referral to a wound specialist. 2. Resident 57 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Resident 57's 2/28/18 Pressure Ulcer CAA indicated the resident was at increased risk for pressure ulcers due to limitations in mobility and incontinence. CNAs and staff were to report changes to the Charge Nurse. The Charge Nurse was to follow facility skin protocol, document findings and report changes to the Physician for follow up, referrals and orders. The Charge Nurse was to also notify the resident's family of any changes or injuries. A Wound Assessment Detail documentation dated 3/5/18 indicated the resident had a facility acquired deep tissue injury to the right heel which measured 3.00 centimeters in length, 2.30 centimeters in width and and covered an area of 6.90 centimeters. A Wound Assessment Detail documentation dated 3/13/18 indicated the wound measurements were 3.00 cm in length, 2.30 cm in width and an area of 6.90 cm. A Wound Assessment Detail documentation dated 3/20/18 indicated the wound measurements were 3.00 cm in length, 3.30 cm in width and an area of 9.30 cm. A Wound Assessment Detail documentation dated 3/29/18 indicated the wound measurements were 3.80 cm in length, 3.30 cm in width and an area of 12.54 cm. Progress Notes dated 3/5/18 through 4/2/18 did not indicate the resident had a deep tissue injury or the Physician or family were notified of the resident's wound. In an observation on 3/29/18 at 10:30 AM Staff 6 (Skilled Unit Resident Assessment Coordinator) performed a wound assessment to the resident's right heel. The resident's wound covered the bottom and up the back of the right heel. The wound was dark maroon with dry edges of yellowish skin and lighter purple around the edges outside the wound. In an interview on 4/3/18 at 3:54 PM Staff 2 (Skilled Unit Manager) acknowledged the progress notes should include documentation of the resident's wound and Physician and family notification of the wound. Staff 2 also acknowledged preventative measures should have been in place and no investigation was completed for the resident's wound. In an interview on 4/2/18 at 4:10 PM Staff 7 (Admission Coordinator) stated the resident came from the hospital with dressings on both heels. She stated the hospital applied dressings to prevent injuries. Staff 7 stated the resident did not have a deep tissue injury at admission but both heels were soft and boggy (tissue that is mushy). Staff 7 acknowledged no preventative measures were in place to avoid the deep tissue injury. In an interview on 4/2/18 at 4:22 PM Staff 1 (DNS) acknowledged no preventative measures were put in place to avoid the deep tissue injury and no investigation was completed.

Based on interview and record review it was determined the facility failed to operate a mechanical lift according to manufactures recommendations during a transfer for 1 of 3 sampled residents (#3) reviewed for falls. Facility staff failed to appropriately secure a sling to the mechanical lift, Resident 3 slipped out of the mechanical lift sling and Resident 3 suffered a head injury which required hospitalization . Findings include: Resident 3 was admitted to the facility in 2017 with [DIAGNOSES REDACTED]. Review of a care plan dated 6/15/17 revealed the resident required the use of a mechanical lift with the assistance of two people for transfers. Review of a nurse's note dated 7/29/17 at 6:47 pm revealed Resident 3 fell from a mechanical lift during a transfer from bed to a chair. The note indicated the resident fell and had an open injury to the back of the resident's head. The note indicated paramedics were called and the resident was transferred to a local hospital for evaluation. Review of the mechanical lift user manual (Lumex LF1090) revealed the mechanical lift spreader bar had six hooks for the lift sling. There were three hooks on each side of the spreader bar for attachment of the sling loops. The manual indicated a four or six loop sling could be used with the mechanical lift. The manual had several warnings to the user which included: 1. Use only Lumex slings specifically designed for the LF1090 bariatric patient lift and; 2. Ensure that the lifting sling loops are correctly attached to the hooks to prevent the patient from sliding of falling out of the sling, which could result in personal injury. Review of a fall investigation by Staff 1 (DNS) dated 8/2/17 revealed the cause of the fall was a mechanical sling loop catching on one of the hooks of the mechanical lift causing it to be off balance and pulling the sling out from under the resident. The investigation was complete and indicated no abuse or neglect was suspected. Review of a fall investigation by Staff 1 dated 8/7/17 revealed the resident's fall was caused by the mechanical lift crossbar swiveling and turning upside down which caused the sling loops to come off the hook. The investigation indicated the accident was not avoidable and facility staff would be re-educated on the use of the mechanical lift. Review of a form Internal Investigation for Incident on 7/29, undated and completed by Staff 1, indicated Staff 2 (CNA) and Staff 3 (CNA) placed the resident in the mechanical lift sling and attached three sling loops on each side to the center hooks on the mechanical lift spreader bar. The form indicated the resident came out of the sling and hit head on the mechanical lift which caused a laceration. The resident was sent to a local hospital and was diagnosed with [REDACTED]. This included instructing staff not to place all loops on the center hooks. Review of a hospital note dated 7/29/17 revealed the resident was diagnosed with [REDACTED]. The resident received x-rays, a brain scan and a dressing was applied to the resident's head. Review of an inservice attendance record for 8/2/17 and 8/3/17 revealed facility CNAs were trained on the use of the Lumex six point mechanical lift on the proper sling placement. In an interview on 11/1/17 at 11:06 am Staff 2 (CNA) said on 7/29/17 she and Staff 3 attempted to transfer Resident 3 from the bed to a wheelchair. Staff 2 said one of the loops on the lift sling fell off the hook and the resident slipped out of the sling and hit her/his head on the metal lift. Staff 2 said the resident was transferred using a Lumex mechanical lift and a six loop sling. Staff 3 said three sling loops were placed on the middle hook of each side of the lift's spreader bar. Staff 2 said this was the way she was trained to use to sling on the mechanical lift. Staff 2 said she did not know all six hooks on the spreader bar were to be used until Staff 1's inservice. Staff 2 acknowledged the lift sling was not applied correctly to the mechanical lift. In an interview on 11/1/17 at 12:44 pm Staff 4 (Central supply/Staffing Coordinator) said she did not know only Lumex slings were to be used with the Lumex mechanical lifts. Staff 4 said the facility did not have any Lumex slings in the building. In an interview on 11/1/17 at 1:06 pm Staff 3 (CNA) said on 7/29/17 she and Staff 2 used a Lumex mechanical lift to transfer Resident 3. Staff 3 acknowledged the sling loops were all placed on the center hooks of the lift spreader bar. Staff 3 said the resident slipped out of the sling and fell to the floor. Staff 3 said an inservice was conducted after the incident on how to correctly attach the lift sling to the Lumex mechanical lift. In an interview on 11/2/17 at 12:34 pm Witness 4 (Lumex Representative) said the Lumex LF1090 mechanical lift had six hooks on the spreader spreader bar. Witness 4 said when staff use a six loop sling to transfer a resident there should be one loop placed on each of the six hooks. Witness 4 also recommended the facility only use Lumex slings with this mechanical lift. In an interview on 11/3/17 at 8:45 am Staff 1 (DNS) acknowledged Resident 3 fell from the mechanical lift because facility staff incorrectly attached the lift sling to the lift.

Based on interview and record review it was determined the facility failed to report to the State Survey Agency a fall with injury for 1 of 3 sampled residents (#3) reviewed for falls. Facility staff failed to appropriately secure a sling to a mechanical lift, Resident 3 slipped out of the mechanical lift sling and Resident 3 suffered a head injury which required hospitalization . Findings include: Resident 3 was admitted to the facility in 2017 with [DIAGNOSES REDACTED]. Review of a nurse's note dated 7/29/17 at 6:47 pm revealed Resident 3 fell from a mechanical lift during a transfer from bed to a chair. The note indicated the resident fell and had an open injury to the back of the resident's head. The note indicated paramedics were called and the resident was transferred to a local hospital for evaluation. Review of a form Internal Investigation for Incident on 7/29, undated and completed by Staff 1, indicated Staff 2 (CNA) and Staff 3 (CNA) placed the resident in the mechanical lift sling and attached three sling loops on each side to the center hooks on the mechanical lift spreader bar. The form indicated the resident came out of the sling and hit head on the mechanical lift which caused a laceration. The resident was sent to a local hospital and was diagnosed with [REDACTED]. This included instructing staff not to place all loops on the center hooks. Review of a hospital note dated 7/29/17 revealed the resident was diagnosed with [REDACTED]. The resident received x-rays and a brain scan and was diagnosed with [REDACTED]. In an interview on 11/3/17 at 8:45 am Staff 1 (DNS) acknowledged Resident 3 fell from the mechanical lift because facility staff incorrectly attached the lift sling to the lift. Staff 1 also acknowledged the incident was not reported to the State Survey Agency. See F323

Based on interview and record review it was determined facility staff failed to meet standards of care for following a care plan and timely reporting of an incident for 1 of 3 sampled residents (#1) reviewed for accidents. Resident 1 sustained a femur (upper leg) fracture. Findings include: Per OAR [PHONE NUMBER](4)(f) it is conduct unbecoming a CNA to fail to communicate information regarding a person's status to the supervising nurse or other appropriate member of the healthcare team in an on-going and timely manner and as appropriate to the context of care. Resident 1 resided in the facility for several years with [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed the resident required extensive assistance of two staff for bed mobility and transfers. The Care Plan dated 9/20/16 indicated the resident had left-sided weakness, was at risk for falls and two staff were needed to transfer the resident. The Incident Report dated 10/24/16 documented at approximately 5:15 pm on 10/24/16 Staff 1 (CNA) transferred the resident by herself, the resident's left leg was giving out, she lowered the resident to the floor, she left the room and asked Staff 2 (Graduate Nursing Assistant, GNA) for help. The documentation revealed the resident's left knee was bent, the resident was sitting on her/his left heel and the resident's right leg was straight out in front of the resident. The report revealed the incident was not reported to a nurse before Staff 1 and Staff 2 transferred the resident into a wheelchair from the floor. The Departmental Notes dated 10/24/16 indicated at approximately 6:00 pm Staff 3 (LPN) assessed the resident who reported 8 out of 10 pain and had a swollen left knee. The facility received orders to send the resident to the Emergency Department (ED), the paramedics arrived at 6:30 pm and they brought the resident to the ED. The hospital's History and Physical dated 10/25/16 documented the resident was hosptalized on [DATE] and diagnosed with [REDACTED]. The Investigative report dated 10/25/16 revealed Resident 1 indicated a female aide was present when her/his left knee gave out on 10/24/16, the female aide went out and got a male aide and they both got her/him off the floor. The report revealed Staff 1 (CNA) acknowledged she did not look at Resident 1's care plan before she transferred the resident by herself on 10/24/16 and she did not use a gait belt. The resident's left knee gave out during the transfer, Staff 1 lowered the resident to the floor, she left the room and got another nursing assistant to help transfer the resident into a wheelchair. On 11/14/16 at 3:30 pm Staff 3 (LPN) stated she was the charge nurse on 10/24/16, Staff 1 (CNA) told her about the resident's incident after two nursing assistants transferred the resident from the floor and into a wheelchair. She stated the resident should not have been moved until a nurse did an assessment. On 11/15/16 at 10:15 am Staff 4 (DNS) stated the situation was reported to the local APS unit, Staff 1 was suspended and she was reported to the State Board of Nursing. She indicated standards of practice were not followed when Staff 1 did not read the resident's transfer status on the in-room care plan and she neglected to use a gait belt for the resident's transfer. On 11/15/16 at 11:30 am Resident 1 indicated she/he could not remember how her/his left leg was injured on 10/24/16. On 11/15/16 at 2:50 pm Witness 1 (Family) stated the resident was supposed to have two staff for transfers, the facility told her/him the resident was transferred with one staff and the resident was sent to the hospital with a broken leg on 10/24/16. On 11/15/16 at 3:05 pm Staff 1 (CNA) stated she did not look at the resident's care plan before she stood the resident up without a gait belt and without another staff member on 10/24/16. Staff 1 indicated the resident was lowered to the floor after the resident told her/him a knee was giving out and that was about half-way to standing up. Staff 1 stated she and a male nursing assistant transferred the resident into a wheelchair after they checked the resident's legs and she informed the charge nurse about the incident after they transferred the resident into a wheelchair. She stated the nurse did an assessment and sent the resident to the hospital. On 11/16/16 at 8:45 am Staff 5 (Administrator) stated Staff 1 was reported to the State Board of Nursing and she no longer worked at the facility. Staff 1 indicated Staff 2 had not become a CNA and he no longer worked at the facility. Refer to F323.

Based on interview and record review the facility failed to follow the care plan for 1 of 3 sampled residents (#1) who had a fall. Resident 1 sustained a femur (upper leg) fracture. Findings include: Resident 1 resided in the facility for several years with [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed the resident required extensive assistance of two staff for bed mobility and transfers. The Care Plan dated 9/20/16 indicated the resident had left-sided weakness, was at risk for falls and two staff were needed to transfer the resident. The Incident Report dated 10/24/16 documented at approximately 5:15 pm on 10/24/16 Staff 1 (CNA) transferred the resident by herself, the resident's left leg was giving out, she lowered the resident to the floor, she left the room and asked Staff 2 (Graduate Nursing Assistant, GNA) for help. The documentation revealed the resident's left knee was bent, the resident was sitting on her/his left heel and the resident's right leg was straight out in front of the resident. The report revealed the incident was not reported to a nurse before Staff 1 and Staff 2 transferred the resident into a wheelchair from the floor. The Departmental Notes dated 10/24/16 indicated at approximately 6:00 pm Staff 3 (LPN) assessed the resident who reported 8 out of 10 pain and had a swollen left knee. The facility received orders to send the resident to the Emergency Department (ED), the paramedics arrived at 6:30 pm and they brought the resident to the ED. The hospital's History and Physical dated 10/25/16 documented the resident was hosptalized on [DATE] and diagnosed with [REDACTED]. The Investigative report dated 10/25/16 revealed Resident 1 indicated a female aide was present when her/his left knee gave out on 10/24/16, the female aide went out and got a male aide and they both got her/him off the floor. The report revealed Staff 1 (CNA) acknowledged she did not look at Resident 1's care plan before she transferred the resident by herself on 10/24/16 and she did not use a gait belt. The resident's left knee gave out during the transfer, Staff 1 lowered the resident to the floor, she left the room and got another nursing assistant to help transfer the resident into a wheelchair. On 11/14/16 at 3:30 pm Staff 3 (LPN) stated she was the charge nurse on 10/24/16, Staff 1 (CNA) told her about the resident's incident after two nursing assistants transferred the resident from the floor and into a wheelchair. She stated the resident should not have been moved until a nurse did an assessment. On 11/15/16 at 10:15 am Staff 4 (DNS) stated the situation was reported to the local APS unit, Staff 1 was suspended and she was reported to the State Board of Nursing. She indicated standards of practice were not followed when Staff 1 did not read the resident's transfer status on the in-room care plan and she neglected to use a gait belt for the resident's transfer. On 11/15/16 at 11:30 am Resident 1 indicated she/he could not remember how her/his left leg was injured on 10/24/16. On 11/15/16 at 2:50 pm Witness 1 (Family) stated the resident was supposed to have two staff for transfers, the facility told her/him the resident was transferred with one staff and the resident was sent to the hospital with a broken leg on 10/24/16. On 11/15/16 at 3:05 pm Staff 1 (CNA) stated she did not look at the resident's care plan before she stood the resident up without a gait belt and without another staff member on 10/24/16. Staff 1 indicated the resident was lowered to the floor after the resident told her/him a knee was giving out and that was about half-way to standing up. Staff 1 stated she and a male nursing assistant transferred the resident into a wheelchair after they checked the resident's legs and she informed the charge nurse about the incident after they transferred the resident into a wheelchair. She stated the nurse did an assessment and sent the resident to the hospital. On 11/16/16 at 8:45 am Staff 5 (Administrator) stated Staff 1 was reported to the State Board of Nursing and she no longer worked at the facility. Staff 1 indicated Staff 2 had not become a CNA and he no longer worked at the facility.

Based on interview and record review it was determined the facility failed to meet the standards of clinical practice for 1 of 3 sampled residents (#1). Findings include: The Division 63 Standards and Authorized Duties for Certified Nursing Assistants and Certified Medication Aides "851-063-0030 Authorized Duties and Standards for Certified Nursing Assistants (6) Standards of Care for Certified Nursing Assistants. In the process of client care the CNA shall consistently: (d) Follow the care plan as directed by the licensed nurse;" Resident 1 was readmitted to the facility 1/13/11. The resident's [DIAGNOSES REDACTED]. The Resident Care Plan (in-room care plan) dated 4/14/11 included: "Fall risk. Alarm in place in bed and wheelchair at all times." A personal alarm sounds when a resident attempts a self-transfer. Resident 1's care plan included the use of a low bed and floor mats beside the resident's bed. The Comprehensive Care Plan dated 4/25/11 indicated the "resident is unavoidable for falls, r/t impaired cognitive abilities, frequent attempts to self-transfer, non-compliance with transfer needs and inability to make immediate needs known." The care plan included the following approaches: personal alarm attached to the resident's wheelchair and bed, low bed, non-skid floor mat by the bed and prompt call light response. The Comprehensive Care Plan directed staff to "follow in-room care plan for direct safety instructions." On 6/28/11 at 3:10 pm Staff 2 (DNS) stated on 5/14/11 Staff 5 (assigned CNA) revealed he did not attach an alarm on Resident 1's wheelchair prior to the resident's fall with an injury. The DNS stated Staff 5 admitted he did not read the resident's care plan. On 7/11/11 at 8:00 am Staff 5 (CNA) stated he was assigned to Resident 1's care during the evening of 5/14/11. He indicated he returned from a break and Staff 6 (CNA) told him Resident 1 fell onto the floor. Staff 5 stated "I don't remember order for wheelchair alarm. (Resident 1) never did have alarm on (her/his) wheelchair...Other CNAs did not know about wheelchair alarm either...Care plan had two orders in one sentence and it wasn't clearly stating there was a wheelchair alarm. I didn't realize alarm was supposed to be on the wheelchair and there wasn't one there." Staff 5 indicated about six months ago, the RNCMs reviewed the resident care plans with the CNAs and it was a good system. Refer to F323

Based on record review and interview it was determined the facility failed to implement an assistive device for 1 of 3 sampled residents (#1) who were care planned for the use of personal alarms. Resident 1 fell and sustained a right hip fracture. Findings include: Resident 1 was readmitted to the facility 1/13/11. The resident's [DIAGNOSES REDACTED]. The Resident Care Plan (in-room care plan) dated 4/14/11 directed staff to attach and activate Resident 1's bed and wheelchair personal alarms. A personal alarm sounds when a resident attempts to self-transfer. The resident's care plan included the use of a low bed and floor mats placed by the resident's bed. The Comprehensive Care Plan dated 4/25/11 indicated the "resident is unavoidable for falls, r/t impaired cognitive abilities, frequent attempts to self-transfer, non-compliance with transfer needs and inability to make immediate needs known." The care plan included the following approaches: personal alarm attached to the resident's wheelchair and bed, low bed, non-skid floor mat by the bed and prompt call light response. The Comprehensive Care Plan directed staff to "follow in-room care plan for direct safety instructions." The resident's May, 2011 ADL record revealed Resident 1 required two staff to provide extensive assistance during transfers. The Resident Incident Report dated 5/14/11 indicated the resident's roommate called for help when Resident 1 fell to the floor. The report revealed Staff 6 (CNA) found the resident lying on the floor near the wheelchair. The incident report indicated the resident's "tab alarm was not in place." The NNs dated 5/14/11 indicated after the resident fell that evening, Staff 7 (LPN) assessed the resident's complaint of significant right hip pain. The NNs indicated 911 was called and the resident was transported to the emergency room . The hospital's emergency room Report dated 5/14/11 revealed Resident 1's [DIAGNOSES REDACTED]. Staff 3's (RNCM) investigation dated 5/19/11 revealed the events surrounding Resident 1's fall with a fracture on 5/14/11. Staff 3 wrote the "CNA reports hearing resident call out and alarm was not sounding when (Resident 1) was discovered on the floor." An unidentified CNA interview was included in Staff 3's investigation. Staff 3 indicated resident 1 was care planned for both bed and wheelchair personal alarms. Staff 3's investigation concluded with the statement: "no abuse or neglect suspected, as care plan was followed correctly." On 6/28/11 at 11:50 am Resident 1 was observed lying in bed with a personal alarm in place and a floor mat was next to the bed. On 6/28/11 at 12:00 pm Staff 5 (assigned CNA) stated Resident 1's bed alarm was activated and she read the in-room care plan. On 6/28/11 at 3:00 pm Staff 3 (RNCM) was shown the copy of her investigation regarding Resident 1's fall on 5/14/11. The investigative documentation included the statement "no abuse or neglect suspected, as care plan was followed correctly." On 6/28/11 at 3:10 pm Staff 2 (DNS) stated Staff 5 (CNA) was assigned to Resident 1's care at the time of the resident's fall on 5/14/11. The DNS stated Staff 5 notified her that he did not read the resident's care plan and did not place an alarm on Resident 1's wheelchair prior to the resident sustaining a hip fracture. The DNS stated Staff 5 no longer worked at the facility. On 7/5/11 at 1:15 pm Staff 7 (LPN) stated the the staff informed her of the resident's fall on 5/14/11. Staff 7 stated Resident 1 was lying on the floor and exhibited significant pain with ROM. On 7/5/11 at 3:45 pm Staff 6 (CNA) stated other staff members informed her of the resident's fall while she was at work near Resident 1's room. Staff 6 stated she was not assigned to the resident's care at that time and went in with the other staff to help. On 6/28/11 at 4:00 pm Staff 1 (Administrator) was made aware at the time of Resident 1's fall on 5/14/11, the wheelchair alarm was care planned and not in place. Staff 1 revealed Staff 5 (CNA) no longer worked at the facility. No further information was provided. On 7/11/11 at 8:00 am Staff 5 (CNA) stated he was assigned to Resident 1's care during the evening of 5/14/11. He indicated he returned from a break and Staff 6 (CNA) told him Resident 1 fell onto the floor. Staff 5 stated "I don't remember order for wheelchair alarm. (Resident 1) never did have alarm on (her/his) wheelchair...Other CNAs did not know about wheelchair alarm either...Care plan had two orders in one sentence and it wasn't clearly stating there was a wheelchair alarm. I didn't realize alarm was supposed to be on the wheelchair and there wasn't one there." Staff 5 indicated about six months ago, the RNCMs reviewed the resident care plans with the CNAs and it was a good system. On 7/11/11 at 2:40 pm Staff 8 (CNA) indicated she utilized the resident's bed pressure alarm at night. Staff 8 stated she had not observed Resident 1 in a wheelchair. Staff 8 stated she reviewed the assigned residents' care plans. On 7/11/11 at 2:50 pm Staff 9 (CNA) stated he remembered the resident was care planned for both a bed and a wheelchair alarm. Staff 9 stated "we had to take the bed alarm off and attach it to the wheelchair. I remember the resident's wheelchair alarm was used." On 7/11/11 at 3:15 pm Staff 10 (CNA) indicated she recalled Resident 1 was care planned for a wheelchair and bed alarm. On 7/11/11 at 3:45 pm Staff 6 (CNA) stated she remembered there was no alarm was on (Resident 1's) wheelchair when the resident fell on [DATE]. Staff 6 indicated the resident was care planned for a bed and wheelchair alarm.