Every finding on record at Saint Helens Post Acute

Based on interview and record review it was determined the facility failed to transmit resident assessments in the required timeframe for 20 of 20 residents (#s 20, 26, 36, 49, 53, 55, 56, 62, 64, 66, 73, 76, 78, 83, 106, 107, 108, 109, 110 and 111) reviewed for resident assessments. This placed residents at risk for inaccurate records. Findings include:The 4/14/26 Missing OBRA (Omnibus Budget Reconciliation Act of 1987 requiring assessment completion) Assessment Report revealed assessments were not transmitted to CMS in the required timeframe for Resident #s 20, 26, 36, 49, 53, 55, 56, 62, 64, 66, 73, 76, 78, 83, 106, 107, 108, 109, 110 and 111. On 4/24/26 at 10:00 AM Staff 10 (MDS Coordinator) stated she was aware the assessments for these residents were not transmitted to CMS in the required timeframe. Staff 10 stated the facility had a backlog of assessments to transmit when she accepted the position and she did not have adequate knowledge of the system or support to complete the workload in a timely manner.On 4/24/26 at 11:44 AM Staff 1 (Administrator) acknowledged the assessments for these residents were not transmitted to CMS in the required timeframe. Staff 1 stated he expected all assessments to be transmitted per the regulation because this process affects reimbursement and the facility's compliance.

Based on observation, interview and record review it was determined the facility failed to provide an effective pest control program for 1 of 1 facility reviewed for environment. This placed residents at risk for exposure to household pest and increased health risks. Findings include: On 4/22/26 at 9:19 AM Witness 9 (Agency Pest Control) was observed in the facility to place traps for roaches around the facility. AT 9:24 AM Witness 9 stated he came to the facility one time per month per the contract. Witness 9 stated he had not observed evidence of rodents in the facility but observed evidence of roaches for months.Review of the Pest Control Log on 4/22/26 at 1:10 PM revealed sightings of roaches had been reported from 10/2025 to 4/2026.On 4/22/26 at 1:52 PM Witness 9 stated the facility really needed services for two applications per month for pest control to eradicate the roaches.On 4/22/26 at 1:54 PM Staff 1 (Administrator) Staff 1 acknowledged concerns with roaches throughout the facility. Staff 1 stated he had asked Witness 9 to provide more service during his past and recent visits one time per month to control pests, especially roaches. On 4/23/26 at 12:11 PM and 4:45 PM Staff 43 (CNA) and Staff 44 (CNA) both reported sightings of roaches in the facility. Staff 43 and Staff 44 stated sightings were not always written or reported in the Pest Control Log.On 4/24/26 at 8:13 AM Staff 27 (CNA) stated she had observed roaches in the facility and was unaware of a Pest Control Log to report sightings of pests.On 4/27/26 at 9:38 AM Staff 1 confirmed the ongoing issue of roaches, and he expected the facility to be pest free.

Based on interview and record review it was determined the facility failed to ensure CNA staff received 12 hours of annual in-service training for 5 of 5 randomly selected staff members (#s 11, 24, 27, 28 and 29) reviewed for evidence of in-service training. This placed residents at risk for lack of quality care. Findings include: On 4/23/26 at 10:43 AM, Staff 1 (Administrator) provided a list of annual training hours for CNA staff which revealed the following: -Staff 11 CNA: 6 annual training hours;-Staff 24 CNA: 6 annual training hours; -Staff 27 CNA: 6 annual training hours:-Staff 28 CNA: 6 annual training hours and-Staff 29 CNA: 6 annual training hours. On 4/23/26 at 10:43 AM and 4/24/26 at 1:46 PM, Staff 1 confirmed Staff 11, Staff 24, Staff 27, Staff 28 and Staff 29 did not complete the required 12 hours of annual in-service training. Staff 1 stated he expected CNAs to complete the required 12 hours of in-service training.

Based on observation, interview and record review it was determined the facility failed to provide a comfortable and homelike environment for 1 of 1 facility reviewed for environment. This placed residents at risk for an unsatisfying experience and living in an unkept environment. Findings include:Resident 41 was admitted to the facility in 2025 with a diagnoses including anxiety.A 1/28/26 Quarterly MDS assessed Resident 41 as cognitively intact.On 4/19/26 at 10:26 AM room [ROOM NUMBER]'s floor appeared unwashed and dark spots around the toilet and throughout the bathroom.On 4/19/26 at 10:49 AM Resident 41 stated her/his room was not cleaned regularly and had not been cleaned since Friday (4/17/26) because the facility was often short staffed.On 4/19/26 at 10:53 AM Staff 19 (Director of Housekeeping) was the only housekeeping staff observed to work in the facility. Staff 19 confirmed he was the only person working in housekeeping when the survey team entered on 4/19/26.On 4/19/26 at 10:59 AM the shared bathroom for room [ROOM NUMBER] was observed with dark stains in the toilet bowl.On 4/19/26 at 12:03 PM room [ROOM NUMBER] was observed with a dirty floor, debris spread throughout on the floor, dark stains in the toilet bowl and the bathroom smelled of urine.On 4/24/26 at 9:00 AM Staff 19 and Staff 20 (Regional Director of Housekeeping) walked throughout the facility with the surveyor. Staff 19 acknowledged he had scrubbed the resident's toilet bowls on 4/21/26 due to the dark stains. Staff 19 stated due to the older building some stains would not come off several surfaces. Staff 19 and Staff 20 confirmed the following observations:-room [ROOM NUMBER] shared bathroom with dark substance on the toilet seat, handle and tank.-room [ROOM NUMBER] floor baseboards were unclean.-The resident shower rooms on 3 of 3 halls appeared unclean and unkept by items left in the room.On 7/26/23 at 1:12 PM Staff 1 (Administrator) walked through the facility with surveyor. Staff 1 acknowledged he expected the residents' rooms and areas to be clean.

Based on observation, interview and record review it was determined the facility failed to monitor and assess resident skin conditions, administer psychotropic medications and insulin timely for 3 of 5 residents (#s 49, 82 and 94) reviewed for skin conditions, pain and insulin. This placed residents at risk for worsening skin conditions, increased anxiety and complications related to uncontrolled blood sugars. Findings include:1. Resident 49 was admitted to the facility in 9/2025 with diagnoses including diabetes. A 1/9/26 United Wound Healing Note revealed the following:-Resident 49 admitted to the facility with wounds of the bilateral lower extremities and right foot.-Interventions included offloading, repositioning and wound dressings, and the resident's tolerance of the treatment was reported to be good.-All wounds had healed, and treatment recommendations included to monitor for reopening of old wounds and for the presence of new wounds. Resident 49's 4/4/26 Quarterly MDS revealed the resident was severely cognitively impaired, experienced episodes of disorganized thinking (fragmented, illogical or disjointed thoughts often manifesting as incoherence or rapid shifting between unrelated topics) and did not have any ulcers, wounds or skin problems. Resident 49's 4/15/26 Potential for Impaired Skin Integrity and Diabetes Care Plans revealed the following:-Check skin when assisting with ADLs.-Ensure socks/hosiery were clean and absorbent every day.-Avoid constrictive shoes.-Carefully dry between toes but do not apply lotion between toes.-The resident refuses to take off her/his boots. Encourage the resident to remove them at night when in bed.-Inspect feet daily for open areas, sores, pressure areas, blisters, edema or redness. Report any of the above to the provider.-Monitor/document/report to the provider as needed any signs and symptoms of infection.-Refer to foot care nurse/podiatrist. Resident 49's 4/2026 Physician Orders directed the following:-A nurse was to perform a diabetic foot check every week and notify the provider if a skin issue was noted.-A weekly head-to-toe skin inspection was to be completed by the nurse. The resident care manager was to be notified of any new skin issue and if the resident would benefit from a podiatry consult. Any refusals were to be documented in the electronic record. A review of Resident 49's 4/2026 TAR revealed the following:-Staff 17 (LPN) completed the residents' weekly diabetic foot check on 4/6/26 and 4/13/26 and no skin issues were noted.-Staff 15 (LPN) completed the resident's weekly skin inspection on 4/14/26 and no skin issues were noted. A 4/15/26 Nursing Quarterly Evaluation completed by Staff 3 (LPN-Resident Care Manager) indicated Resident 49 did not have any skin integrity concerns. A review of Resident 49's clinical record indicated the resident had routine refusals of all aspects of care. On 4/20/26 at 1:14 PM, Resident 49 was observed in her/his room, sat in her/his wheelchair and wore pants, thick socks and heavy boots. Resident 49 stated she/he was not going to participate in activities on this day as she/he was having trouble with my socks. The resident pulled up her/his right pant leg and revealed a dark red sock covered in flaked skin, and the exposed part of her/his calf was bright red. The resident attempted to pull the right sock away from the skin but was only able to pull away the top part of the sock as the sock stuck to the resident's skin at her/his ankle. A large skin indent was observed where the top part of the sock had been, the skin that was visible underneath was bright red and appeared raw and exuded a malodorous odor. A dirty, blood-tinged bandage was observed underneath the resident's right sock and was stuck to the resident's skin. The resident, unprompted by the state surveyor, removed her/his boots at this time. The resident's socks appeared dirty and were covered in flaked skin. The resident was unable to answer any specific questions related to her/his skin as her/his speech was disorganized (incoherent, illogical or rambling speech) but stated her/his legs were getting more painful and she/he had been in pain for a couple of months because of her/his ankles. On 4/20/26 at 4:18 PM, Resident 49 was observed to ambulate down the hall towards the nurse's station. The resident wore dark red socks and did not wear any shoes or boots. Once at the nurse's station, Resident 49 lifted her/his right pant leg and asked Staff 30 (RN) for some help with this. Resident 49 returned to her/his room and Staff 30 remained at the nurse's station. On 4/21/26 at 11:26 AM, Staff 31 (LPN) stated some of the nurses at the facility do not complete resident skin checks, and they don't even offer. On 4/21/26 at 11:48 AM, Staff 12 (CNA) stated Resident 49 refused to shower, change clothes or remove her/his shoes. Staff 12 stated she had never visualized the resident's legs or feet. On 4/21/26 at 12:32 PM, Staff 15 stated she had never completed a head-to-toe skin inspection for Resident 49 and did not recall completing a skin assessment on 4/14/26. Staff 15 stated she thought she was able to visualize the resident's feet and legs on one occasion but it was not recent. Staff 15 stated she had not reported to the resident's provider her/his refusals of skin inspections. On 4/21/26 at 1:53 PM, Staff 44 (Physician Assistant-Certified) stated she was aware of Resident 49's daily refusals of care, but she would expect to be notified weekly of any refusals of skin inspections. Staff 44 stated she could not recall the last time she was notified Resident 49 refused a skin inspection. On 4/21/26 at 7:22 PM, Staff 17 stated she had never assessed Resident 49's feet. Staff 17 stated her documentation on the resident's TAR on 4/6/26 and 4/13/26 indicated she attempted to complete the resident's diabetic foot check, but the resident refused on both occasions. Staff 17 further stated she had notified the resident's resident care manager of her/his diabetic foot care refusals, but she had not notified the resident's provider. On 4/22/26 at 10:28 AM, Staff 3 stated she was unsure as to when to notify a resident's provider if a resident refused a skin inspection or a diabetic foot check. Staff 3 stated she observed Resident 49's feet on 4/21/26 after the resident had independently removed her/his boots but did not state the last time she had visualized the resident's feet prior to this opportunity. On 4/22/26 at 10:45 AM, Staff 2 (DNS) stated Resident 49's provider should have been notified each time the resident refused a skin inspection or diabetic foot care and confirmed the provider had not been notified. 2. Resident 82 was admitted to the facility in 1/2026 with diagnoses including diabetes requiring hemodialysis (a medical procedure for advanced kidney failure that removes waste products, toxins and excessive fluids from the blood). Physician orders dated 2/20/26 and 3/19/26 indicated Resident 82 was prescribed the following diabetic medications: -Insulin aspart (fast-acting insulin) 2 units with meals, scheduled to be administered at 8:00 AM, 12:00 PM and 5:00 PM. -Insulin aspart before meals and at bedtime according to the prescribed sliding scale (insulin doses adjusted based on pre-meal blood sugars designed to correct high blood sugars), scheduled to be administered at 7:30 AM, 11:30 AM, 4:30 PM and 8:00 PM. A review of Resident 82's 4/1/26 through 4/20/26 DAR (Diabetic Administration Record) revealed the resident's insulin was not administered timely on the following days: -Insulin aspart on 4/2/26 was administered at 7:17 PM and should have been administered at 5:00 PM, 4/3/26 was administered at 6:13 PM and should have been administered at 5:00 PM and 4/7/26 was administered at 2:05 PM and should have been administered at 12:00 PM. -Sliding scale Insulin aspart on 4/3/26 was administered at 10:24 PM, 4/8/26 was administered at 9:36 PM, 4/13/26 was administered at 9:01 PM and 4/19/26 was administered 9:41 PM. These doses should have been administered at 8:00 PM. No evidence was found in Resident 82's clinical record as to why her/his insulin was administered late on the above dates. On 4/19/26 at 10:51 AM and 4/21/26 at 11:25 AM, Resident 82 stated, on many occasions, her/his insulin was not being administered timely. Resident 82 stated she/he was a brittle diabetic (a diabetic that experiences frequent and severe swings in blood sugars) and required hemodialysis so receiving her/his insulin timely to keep her/his blood sugars controlled was very important. Resident 82 stated it was frustrating to receive her/his insulin late and late administration mostly occurred with her/his bedtime insulin. On 4/22/26 at 11:38 AM, Staff 14 (RN) stated Resident 82's blood sugars go low really fast. Staff 14 stated Resident 82 reported to him that her/his nighttime insulin was administered late, at times. Staff 14 stated the night shift nurse (6:00 PM to 6:00 AM) was responsible for administering medications and insulin to residents so they could get busy and might not be able to administer insulin on time. 4/23/26 at 11:54 AM, Staff 3 (LPN-Resident Care Manager) stated when nurses administered insulin late, they were required to write a progress note explaining the reasoning for the late insulin administration. She reported the nighttime nurse could get busy and backed up with medication and insulin administration, resulting in insulin not being administered timely. Staff 3 reviewed Resident 82's 4/2026 DAR and confirmed the resident's insulin was not administered timely on the dates identified. Staff 3 stated it was her expectation that insulin be administered according to the times established on the DAR unless a progress note was written to explain the rationale for late administration. Staff 3 acknowledged the dates identified did not have progress notes written, and Resident 82's insulin was not timely administered. 3. Resident 94 was admitted to the facility on [DATE] with diagnoses including spinal stenosis (a narrowing of spaces within the spine leading to pain), anxiety disorder, panic disorder, and opioid dependence. Resident 94's 2/28/26 admission MDS indicated the resident was cognitively intact. Resident 94's 2/24/26 admission orders included the following:- Lorazepam (a medication used to treat anxiety) 1 mg oral tablet, take 1.5 tablets by mouth two times a day (morning and lunch), and 1 tablet every evening as needed. Resident 94's 2/2026 MAR indicated the following medications were ordered on 2/24/26 at 10:26 AM:1. Lorazepam 1 mg oral tablet - give 1.5 tablets by mouth two times a day related to generalized anxiety disorder.-Scheduled administration times: 8:00 AM and 12:30 PM.-Not administered at either 8:00 AM or 12:30 PM on 2/25/26. 2. Lorazepam 1 mg oral tablet - give 1 tablet by mouth in the evening as needed related to generalized anxiety disorder.-Administered on 2/25/26 at 7:33 AM (not in the evening as ordered). On 4/21/26 at 1:01 PM Staff 33 (LPN) stated they did not recall Resident 94, the admission, or any issues related to the delivery of lorazepam. Staff 33 was unable to provide additional information regarding whether the lorazepam prescription was sent to the pharmacy, or why their was a delay in delivery. No documentation by Staff 33 was identified in the medical record to clarify the events surrounding the lorazepam prescription and its delivery. On 4/21/26 at 6:26 PM Witness 7 (Complainant) stated Resident 94 was admitted to the facility around noon on 2/24/26. Witness 7 stated the admitting nurse advised Resident 94's lorazepam would be delivered to the facility within a few hours of admission. Witness 7 stated at approximately 2:30 AM on 2/25/26 Resident 94 called them upset indicating she/he needed lorazepam, and it was not available. Witness 7 stated they contacted the facility, advised the nurse the resident needed lorazepam and were told the prescription for lorazepam had not been sent to the pharmacy. On 4/27/26 at 12:49 PM Staff 36 (CNA) stated Resident 94 was agitated the night of admission to the facility and the resident requested anti-anxiety medication several times which they reported to the nurse. Staff 36 stated Resident 94 was in distress because her/his lorazepam was not available and upon admission she/he was told it would be. Staff 36 stated the resident also called Witness 7 twice and reported she/he needed her medication and had not received it. On 4/22/26 at 5:24 PM Staff 37 (RN) stated the night of Resident 94's admission they received a call from Witness 7 requesting lorazepam for the resident and upon assessment the resident appeared agitated. Staff 37 stated Resident 94 had admitted to the facility earlier that day with orders for lorazepam 1mg tablet, but the prescription had not been sent to the pharmacy and the resident's medication was not available for administration. Staff 37 contacted the on-call provider and requested a prescription. Staff 37 then requested a pull-code (a code for secure access) from the pharmacy to access the facility's backup supply of lorazepam and was denied because the resident's order was for lorazepam 1mg tablets, whereas the available dose was for 0.5mg tablets. Staff 37 stated they were unable to administer Resident 94 her/his lorazepam. On 4/24/26 at 10:35 AM Staff 3 (LPN-Resident Care Manager) and Staff 4 (RNCM) stated the resident was admitted to the facility from home without a hard copy of the prescription for lorazepam. Staff 4 stated in such cases the admitting nurse should have requested a STAT (immediate) prescription from the on-call provider for Resident 94's lorazepam for delivery as soon as possible and ideally within four hours. Staff 3 and Staff 4 stated there should have been diligent follow-up by the floor nurse and documentation reflecting the cause of any delay and the status of the prescription delivery, especially given Resident 94's diagnoses. Staff 3 acknowledged there was no record of follow-up on the lorazepam prescription in Resident 94's medical record. Staff 3 acknowledged Resident 94 did not receive her/his requested dose of lorazepam the night of admission and did not receive her/his scheduled doses as ordered the following day.

Based on interview and record review it was determined the facility failed to ensure facility staff had the appropriate competencies to work with residents with substance use disorders for 1 of 1 facility reviewed for substance use disorder training. This placed residents at risk for diminished physical, mental and psychosocial well-being. Findings include:Resident 9 was admitted to the facility in 3/2026 with diagnoses including psychoactive substance dependence (a chronic condition where an individual requires a substance, such as alcohol, nicotine or drugs to function normally), other stimulant use (the consumption of illicit, prescription or over-the-counter substances that increase alertness and energy) and sedative, hypnotic or anxiolytic abuse (the misuse of central nervous system depressants for euphoric effects or beyond their prescribed purpose, leading to addiction, coma or death). Resident 9's 3/10/26 Hospital History & Physical revealed the resident had a diagnosis of polysubstance abuse disorder, which included abuse of opioids, benzodiazepines and methamphetamine. The History & Physical revealed the resident reported using each of these drugs daily prior to her/his hospitalization. No evidence was found in Resident 9's 4/2026 Care Plan to indicate she/he had a diagnosis of substance use disorder (SUD) or interventions to help staff identify the signs and symptoms of substance use or how to manage and treat the resident's addiction through individualized and person-centered approaches. A review of the facility's annual nursing department trainings revealed no evidence SUD training was provided to facility staff. On 4/24/26 at 9:09 AM, Staff 12 (CNA) stated she had never received any training on working with residents with SUD, including identifying the signs and symptoms of substance use in a resident with SUD. Staff 12 stated she thought Resident 9 had a drinking problem but was unaware of any additional substance abuse concerns for the resident. Staff 12 stated she thought information about a resident with a known SUD could be found in the resident's care plan. On 4/24/26 at 9:20 AM, Staff 34 (Agency CNA) stated she never received any training on working with residents with SUD, including identifying the signs and symptoms of substance use in a resident with SUD. Staff 34 stated she knew Resident 9 drank alcohol but was unaware of any additional substance abuse concerns for the resident. Staff 34 stated there were times when the resident was so drowsy that she/he could barely wake up. Staff 34 did not indicate an understanding of what she was supposed to do on those occasions when she could not rouse the resident as she stated she was unsure of the resident's baseline. On 4/24/26 at 9:44 AM, Staff 27 (CNA) stated she thought the facility admitted a lot of residents with diagnoses SUDs, but she had not received any training on working with residents with SUDs. Staff 27 stated she was unaware Resident 9 had a diagnosis of SUD. On 4/24/26 at 9:58 AM, Staff 33 (LPN) stated she had not received any training at the facility related to working with residents with SUDs. Staff 33 stated she thought Resident 9 had a diagnosis of SUD and interventions related to the resident's substance use and what staff should be on the lookout for was found in the resident's care plan. On 4/24/26 at 10:54 AM, Staff 6 (Social Services Director) stated she could not remember participating in any trainings at the facility related to SUDs. Staff 6 stated residents who had a diagnosis of SUD should have been care planned regarding SUDs. Staff 6 stated she was unaware Resident 9 had a history of drug abuse. On 4/24/26 at 11:50 AM, Staff 4 (RNCM) stated she had not received or provided any trainings related to residents with a diagnosis of SUD. Staff 4 stated she was unaware of other substance abuse concerns for Resident 9 outside of her/his misuse of diazepam (a prescription benzodiazepine medication). Staff 4 stated residents diagnosed with a SUD should have a care plan in place and confirmed Resident 9 did not have a care plan for SUD. O 4/24/26 at 12:12 PM, Staff 2 (DNS) stated she had not provided any staff training specific to residents with a diagnosis of SUD, including identifying the signs and symptoms of substance use in a resident with SUD. Staff 2 stated all residents with a diagnosed SUD should have a related care plan and confirmed Resident 9 did not have a SUD care plan in place.

Based on observation, interview and record review it was determined the facility failed to provide therapy services as ordered for 4 of 4 sampled residents (#s 8, 50, 82 and 95) reviewed for rehabilitation services. This placed residents at risk for a decline in functional abilities and diminished quality of life. Findings include: Resident 95 was admitted to the facility on [DATE] with a diagnoses including a stroke and a history of falls. The 1/8/26 physician orders prescribed Resident 95 to receive Physical therapy, Occupational therapy and Speech therapy evaluations and treatments as indicated from assessments and evaluations. On 1/9/26 Resident 95 was assessed by Physical therapy to receive therapy five times per week for the certification period of 1/9/26 through 3/9/26. Record review of the Physical therapy records revealed Resident 95 was provided with therapy only four times per week in the following weeks:-2/2/26, 2/3/26, 2/4/26, 2/5/26;-2/9/26, 2/10/26, 2/11/26, 2/12/26;-2/24/26, 2/25/26, 2/26/26 and 2/27/26. On 1/14/26 Resident 95 was assessed for Speech therapy services and not recommended for therapy services at this time. On 1/19/26 Resident 95 was assessed by Speech therapy to require therapy two times per week for the next 60 days. No documentation was provided that indicated Resident 95 was treated by Speech therapy after 1/19/26. Resident 95 was evaluated for Occupational therapy on 2/23/26, 42 days after admission. Record review of the Occupational therapy records revealed Resident 95 was evaluated to need Occupational therapy for five days per week for 60 days. Resident 95 only received Occupational therapy on the following dates: -2/23/26 to 2/27/26 (assessment plus four days);-3/2/26, 3/3/26, 3/4/26 and 3/6/26 (four days);-3/9/26. Resident 95 discharged from the facility on 3/18/26. On 4/24/26 Staff 1 (Administrator) Staff 1 verified Resident 95's therapy services on his computer. Staff 1 confirmed Resident 95 was not provided with therapy services as prescribed. Staff 1 stated he expected Resident 95's Occupational and Speech therapy assessments to be completed in a timely manner and therapy evaluations should have been completed within 48 hours of her/his admission. Staff 1 expected all therapy services provided to residents as often as determined by therapist assessments and signed by the physician. 2. Resident 82 was admitted to the facility in 1/2026, was transferred to the hospital on 2/9/26 and readmitted to the facility on [DATE] with diagnoses including diabetes and mild protein-calorie malnutrition, a form of malnutrition arising from a deficiency of protein, calories and fats necessary to meet bodily needs. Resident 82's 2/13/26 Hospital Discharge and Transfer Orders indicated the resident was prescribed a mechanical soft diet (foods that were chopped, ground, mashed or pureed). Resident 82 was to be evaluated and treated by a SLP. Resident 82's SLP records indicated the resident was not assessed by a SLP until 3/2/26, 17 days after her/his readmission. The resident received mechanical soft diet textures until the SLP assessment was completed. On 4/19/26 at 10:50 AM, Resident 82 stated it took a month to get off puree foods. Resident 82 reported she/he was told the facility needed to hire more SLP staff in order to assess her/him and determine if her/his diet could be changed. On 4/22/26 at 12:16 PM, Staff 9 (Regional Director of Rehabilitation) reviewed Resident 82's SLP documentation and confirmed the resident was not assessed until 3/2/26. Staff 9 was unsure why Resident 82 was not assessed by SLP prior to 3/2/26. On 4/22/26 at 1:00 PM and 4/24/26 at 1:46 PM, Staff 1 (Administrator) acknowledged on 2/13/26 Resident 82 was readmitted to the facility with SLP evaluation and treatment orders and confirmed the resident was not assessed until 3/2/26. Staff 1 stated he expected Resident 82's SLP assessment to be completed in a timely manner and the SLP evaluation should have been completed within 48 hours of her/his readmission. 3. Resident 8 was admitted to the facility in 2/2026 with diagnoses including muscle weakness. Resident 8's 2/12/26 Physician Orders directed the resident to be evaluated and treated by OT (Occupational Therapy). Resident 8's 2/17/26 admission MDS revealed the resident was able to make her/himself understood and understand others without difficulty, and she/he had not received any therapy services in the previous seven days. A 4/20/26 OT Evaluation & Plan of Treatment Form revealed Resident 8 received an initial evaluation by OT on 4/20/26. On 4/19/26 at 1:36 PM, Resident 8 was observed in her/his room and sat in her/his wheelchair. Resident 8 stated she/he did not receive any OT and was interested in participating in any therapy that could help her/him to get out of here. On 4/27/26 between 9:29 AM to 10:10 AM, Staff 27 (CNA), Staff 30 (RN), Staff 34 (Agency CNA) and Staff 35 (CNA) stated they had never observed Resident 8 work with therapy since the resident's admission to the facility. On 4/27/26 at 10:36 AM, Staff 8 (Rehabilitation Director) stated therapy evaluations were typically completed the day of or day after an order for therapy was received. Staff 8 stated Resident 8 had an order for an OT evaluation and treatment from 2/12/26 but the evaluation was not completed until 4/20/26 as he had experienced difficulty maintaining Certified Occupational Therapy Assistants. Staff 8 acknowledged Resident 8's therapy evaluation was not timely. 4. Resident 50 was re-admitted to the facility in 10/2025 with diagnoses including anoxic brain injury (damage to the brain due to a lack of oxygen) and right femur fracture (thighbone fracture). Resident 50's 11/12/25 Orthopedic After Visit Summary included an order for PT (Physical Therapy). A review of the resident's clinical record revealed no evidence the PT order was acknowledged, clarified, or given to the therapy department. On 4/23/26 at 3:24 PM Staff 4 (RNCM) stated the order must have been missed. She confirmed the therapy department was not informed of the order, the therapy order was not clarified, and the resident did not receive therapy services.

Based on observation, interview, and record review it was determined the facility failed to complete an accurate assessment prior to initiating restraint use and did not conduct ongoing assessments for 1 of 1 sampled residents (#50) reviewed for restraints. This placed residents at risk for unnecessary restraint use and reduced self-mobility. Findings include: The facility's 4/2017 Use of Restraints policy listed examples of restraints, which included a Geri-chair (medical chair that is a combination of a wheelchair and recliner chair). The policy instructed the facility:- restraints were only to be used when a resident's specific medical condition that could not be addressed by another less restrictive intervention and a restraint is required to a. treat the medical condition; b. protect the resident's safety; and help the resident attain the highest level of her/his physical or psychological well-being.- to complete a pre-restraining assessment, review the assessment, review the risks verses benefits of the restraint use and obtain consent from the resident and/or representative, and obtain a written physician order before the restraint was used.-re-assessment should be completed at least quarterly for possible reduction or discontinuation.Resident 50 was re-admitted to the facility in 10/2025 with diagnoses including anoxic brain injury (damage to the brain due to a lack of oxygen) and right femur fracture (thighbone fracture), which required use of a knee immobilizer to prevented bending of her/his knee.The 3/24/26 Quarterly MDS revealed the Resident 50's cognition was severely impaired.A review of Resident 50's clinical record revealed no evidence of a pre-restraint use assessment, risks/benefit review, consent, physician order for the use of a Geri-chair, or a care plan regarding the Geri-Chair use. On 4/19/26 at 11:45 AM, 4/19/26 at 1:33 PM, 4/19/26 at 3:38 PM, and 4/21/26 at 11: 54 AM Resident 50 was observed in a Geri-chair with her/his feet elevated and the back of the chair reclined. The resident was observed repeatedly raising and dropping her/his head, moving her/his arms and legs.On 4/21/26 at 12:09 PM Resident 50 was observed in the Geri-chair with the footrest lowered and the back of the chair upright. The resident was repeatedly crossing, uncrossing, bouncing, and kicking her/his feet and legs. On 4/21/26 at 4:35 PM Resident 50 was observed attempting to get out of the Geri-chair, leaning forward. Two staff were attempting to keep Resident 50 in the chair. Staff 23 (CMA) told the two staff to lean Resident 50 back by tilting the chair backwards. Resident 50 was observed pushing the footrest back down after the staff had lifted it up. The staff reclined the chair and elevated the footrest a second time, but the resident lowered the footrest again. The staff were observed holding the resident's legs off the ground and began pushing the resident to her/his room.During interviews on 4/23/26 at 11:05 AM Staff 24 (CNA) and 4/24/26 at 9:24 AM with Staff 28 (CNA) stated Resident 50 had a Tilt-in-space wheelchair (a zero-gravity wheelchair) until sustaining the femur fracture. Staff 24 and Staff 28 stated they requested changing from the Geri chair back to the tilt-in-space wheelchair since Resident 50 could bend her/his knee now. Staff 24 and Staff 28 stated Resident 50 used to propel the wheelchair but cannot propel the Geri-chair. On 4/23/26 at 3:24 PM Staff 4 (RNCM) stated she had not identified the Geri-chair as a restraint because she believed the chair to be a tilt-in-space or reclining wheelchair (wheelchair with a back reclines back) since the Geri-chair reclined back. After looking up the difference between the three types of chairs, Staff 4 acknowledged she had incorrectly identified the chair type; the resident was using a Geri-chair. She confirmed an assessment was not completed, and she had not obtained consent from Resident 50's guardian or an order from the physician before using the Geri Chair.

Based on observation, interview, and record review it was determined the facility failed to provide meaningful activities for dependent residents for 1 of 1 sampled resident (#43) reviewed for activities. This placed residents at risk for lack of social interaction and isolation. Findings include:The facility's Activity Program policy, dated 6/2018, indicated the following: -The Activities Program was provided to support the well-being of residents and to encourage both independence and community interaction.-Activities were based on the comprehensive resident-centered assessment and preferences of each resident. -The Activities Program was ongoing and included facility-organized group activities, independent activities and assisted individual activities. -Activity programs were designed to encourage maximum individual participation and geared to individual resident's needs. Resident 43 was admitted to the facility in 2/2026 with diagnoses including alcoholic cirrhosis of the liver (the final irreversible stage of alcoholic liver disease), encephalopathy (brain dysfunction characterized by altered mental status, confusion and memory loss) and bipolar disorder (a chronic mental health condition characterized by extreme mood swings). Resident 43's 2/25/26 admission MDS indicated the resident had severe cognitive deficits. Resident 43's activity preferences indicated it was very or somewhat important to have newspapers, books and magazines to read, listen to music, do favorite activities, go outside when the weather was good, be around animals, keep up with the news, do things with groups of people and participate in religious services or practices. A 2/26/26 Activities Initial Review revealed Resident 43 enjoyed watching basketball and cooking shows and listening to Rap and metal music. Resident 43 wanted to participate in group, independent and one-on-one activities, including going on facility outings. Resident 43's activities needed to be modified to accommodate the resident's cognitive deficits. Resident 43's 3/4/26 activity care plan indicated the resident had cognitive impairments and required activity engagement to support psychosocial well-being and safe leisure involvement. Activity staff were to: -Offer activities based on Resident 43's interests including video games, basketball viewing, cooking/food shows and music.-Provide access to magazines and encourage reading as a preferred independent activity. -Encourage participation in television programs related to grocery, cooking, sports and educational programming. -Encourage supervised walking within the facility. -Offer conversation and discussion groups related to sports, cooking and television to encourage social interaction. -Provide opportunities for independent leisure such as magazines or TV when Resident 43 did not want to attend group activities. Resident 43's Activity Participation Logs including group, one-on-one and independent activities from 3/20/26 through 4/20/26 revealed: -The resident participated in TV and movies: 4/7/26 and 4/14/26. Resident 43's health record revealed no evidence the resident was provided with magazines, books, newspapers, video games, walks in the facility, educational television programming or music. No evidence was found that Resident 43 was offered or participated in one-to-one visits, group activities of interest to her/him or independent activities from 3/20/26 through 4/20/26 except for a television/movie on 4/7/26 and 4/14/26. Random observations from 4/19/26 through 4/24/26 between the hours of 8:40 AM and 5:04 PM revealed Resident 43 lying on her/his bed wearing a brief, partially covered with a sheet, and the room was typically dark with no stimulation for the resident such as a television show or music playing. The resident often had her/his eyes closed but, at times, was talkative. There were no magazines, newspapers, books, video game equipment, or staff engaging in topics of interest with the resident. Resident 43 was not observed out of her/his bed at any time during the week.On 4/22/26 at 9:09 AM, Staff 11 (CNA) stated most of the time Resident 43 was in bed. She stated she was unable to recall any times when Resident 43 had one-on-one activities provided to her/him. On 4/22/26 at 9:46 AM, Staff 23 (CMA) stated Resident 43 was rarely awake and when awake, she/he had a short attention span. Staff 23 stated Resident 43 loved to walk and eat food. She stated the resident especially enjoyed pumpkin pie and Pepsi.On 4/22/26 at 10:27 AM, Staff 24 (CNA) stated Resident 43 was in bed, a lot and liked video games. She reported occasionally the resident's television was on but not often. Staff 24 stated she did not see any activities occurring with the resident. On 4/23/26 at 11:03 AM, Staff 18 (Activity Director) stated Resident 43 liked to talk and walk in the hallway; otherwise, she did not know much about her/him. Staff 18 stated with residents that had cognitive impairments, she would provide one-on-one activities in the resident's room, bring music to their room, turn on the television to their favorite shows and have conversations or read poems with residents. Staff 18 stated she did not schedule time for one-to-one activities with Resident 43, and there should be things the resident liked in her/his room such as a radio or tablet for music. Staff 18 acknowledged Resident 43 was not being provided with activities of her/his interest or participation level.On 4/23/26 at 4:06 PM, Staff 38 (CNA) stated Resident 43 just lays there. She stated there was no music or television on in the resident's room and five percent of the time she/he might go walking. Staff 38 stated one time she took Resident 43 to the family room where a 90's movie was playing, and the resident enjoyed the movie and was laughing. Staff 38 stated there were no activities or stimulation in Resident 43's room except for a couple of times when the television was on a nature show or soft music was playing. On 4/23/26 at 4:10 PM, Resident 61 (Resident 43's roommate) stated there was no staff interaction or activities occurring with Resident 43 except when staff assisted the resident with eating or changing her/his brief.

Based on observation, interview and record review it was determined the facility failed to implement interventions to prevent skin breakdown for 1 of 4 sampled residents (#8) reviewed for pressure ulcers. This placed residents at risk for the development of pressure ulcers and skin breakdown. Findings include:Resident 8 was admitted to the facility in 2/2026 with diagnoses including muscle weakness. Resident 8's 2/17/26 admission MDS revealed the resident was able to make her/himself understood and understand others without difficulty, was at risk to develop pressure ulcers and was to have a pressure reducing device for her/his chair. The Pressure Ulcer CAA indicated a care plan would be developed to improve continence status and to decrease the risk of pressure ulcers. No evidence was found in Resident 8's 4/2026 Care Plan to indicate she/he was to utilize a pressure reducing device in her/his chair. On 4/19/26 at 1:36 PM, Resident 8 was observed in her/his room and sat in her/his wheelchair. No pressure reducing device was observed in the resident's wheelchair. Resident 8 stated she/he had never been offered a cushion for her/his wheelchair, she/he wanted one, and her/his butt hurt when she/he sat in the wheelchair. Random observations of Resident 8 from 4/20/26 to 4/27/26 between 7:38 AM and 3:43 PM revealed the resident to be in her/his room either in her/his wheelchair or in bed. The resident's wheelchair remained within the resident's reach when she/he was in bed. No pressure reducing cushion or device was observed in the resident's wheelchair. On 4/27/26 at 9:29 AM, Staff 27 (CNA) stated she had never observed Resident 8 to use a cushion in her/his wheelchair. Staff 27 stated she thought therapy had to evaluate a resident for a wheelchair cushion prior to it being used and further stated she did not think Resident 8 had been seen by therapy. On 4/27/26 at 9:39 AM, Staff 30 (RN) stated she had never looked to see if Resident 8 had a cushion in her/his wheelchair. Staff 30 stated information on whether a resident utilized a pressure reducing device, such as a cushion for their wheelchair, could be found in the resident's care plan. Staff 30 reviewed Resident 8's care plan and confirmed it did not indicate the resident was to have a pressure reducing device in her/his wheelchair. On 4/27/26 at 9:59 AM, Staff 34 (Agency CNA) stated Resident 8 spent about two-and-a-half hours during dayshift up in her/his wheelchair. Staff 34 stated she was not sure if Resident 8 had a cushion for her/his wheelchair but thought most residents utilized cushions in their wheelchairs to protect their bottoms. On 4/27/26 at 10:10 AM, Staff 35 (CNA) stated Resident 8 was in her/his wheelchair for meals and whenever her/his family visited. Staff 35 stated he could not recall if the resident had a cushion in her/his wheelchair but thought every resident was supposed to have one. On 4/27/26 at 11:02 AM, Staff 3 (LPN-Resident Care Manager) stated information on the use of pressure reducing devices, such as a cushion for a wheelchair, should be found in a resident's care plan. Staff 3 stated Resident 8 was to have a pressure reducing cushion in her/his wheelchair and confirmed it was not identified in her/his care plan. Staff 3 observed Resident 8's wheelchair and confirmed it did not have a pressure reducing cushion in place.

Based on observation, interview and record review it was determined the facility failed to provide appropriate wheelchair positioning and head/neck support for 1 of 1 sampled resident (#50) reviewed for mobility and positioning. This placed residents at risk for decreased range of motion and pain. Findings include: Resident 50 was re-admitted to the facility in 10/2025 with diagnoses including anoxic brain injury (damage to the brain due to a lack of oxygen) and right femur fracture (thighbone fracture).Resident 50's 12/25/25 Annual and 3/24/26 MDS revealed the resident had a BIMS score of zero, which indicated she/he was severely cognitively impaired, and did not talk. The resident required substantial/maximal assistance and dependence for bed mobility ADLs. The Pressure Ulcer/Injury and Pain CAA identified Resident 50 to have impaired mobility and had chronic pain.Review of the 3/5/26 Nursing Assessment revealed Resident 50 was completely immobile without assistance and maintained good positioning in the chair and bed.Between 4/19/26 through 4/22/26 between the hours of 8:00 AM through 4:00 PM Resident 50 was observed in a Geri-chair with the backrest upright and the footrest raised. While awake Resident 50 repeatedly dropped and snapped their head back. When Resident 50 was asleep, her/his head was bent and rested on their chest. Resident 50 would awaken after a few minutes and abruptly raise and lower her/his head. Staff passed by without intervening or repositioning the resident. Resident 50's 4/20/26 care plan indicated the resident used a Tilt-in-Space (zero gravity-provides advance postural support including headrest, lateral supports, and adjustable features) wheelchair but did not indicate use of the Geri-chair (medical recliner, or positional care recliner), head/neck positioning preferences, or interventions to prevent forward flexion.Review of Resident 50's clinical records revealed there was no evidence of when the resident was switched from the Tilt-in-Space wheelchair (which had head support) to the Geri-chair (which did not). On 4/20/26 at 6:53 PM Witness 6 (Family Member) stated Resident 50 had altered communication abilities and hung her/his head since the resident sustained the anoxic brain injury. Witness 6 stated they were unaware of any interventions to support the resident's head post brain injury. On 4/22/26 at 9:45 AM Staff 11 (CNA) stated the resident had been bending their head forward for a long time, but was not instructed to reposition or recline the resident and stated it looked painful. On 4/24/26 at 9:24 AM Staff 47 (Activity Staff/CNA) stated she was unsure why Resident 50 bent her/his head to her/his chest. She stated the resident did not have any care planned interventions regarding support for the resident's head but used the resident's stuffed animals to support the resident's head. On 4/24/26 at 11:13 AM Staff 28 (CNA) stated when Resident 50 used the Tilt-in-Space wheelchair, the headrest had side panels that supported the resident's head, so she/he kept her/his head in a supported position, which the Geri-chair did not and the resident struggled holding her/his head up. Staff 28 stated she requested to start using the Tilt-in-Space wheelchair with Resident 50 again but was told to continue using the Geri-chair. On 4/23/26 at 3:24 PM Staff 4 (RNCM) stated Resident 50 was moved into the Geri-chair because the resident could not bend her/his knee after the resident broke her/his femur in 10/2025 and remained in the chair because they felt she/he was more comfortable. Staff 4 stated she thought the Geri-chair was considered a Tilt-in-Space chair. She stated she was unsure when Resident 50 was last assessed for head and neck positioning needs. On 4/27/26 at 8:51 AM Staff 8 (Rehabilitation Director) stated there had been no referrals for positioning or therapy assessment when the Geri-chair was introduced and stated he would have wanted to evaluate the resident's positioning needs at that time.

Based on observation, interview and record review it was determined the facility failed to ensure staff followed the care plan related to smoking safety and liquid modifications for 2 of 2 sampled residents (#s 9 and 67) reviewed for smoking and dietary modifications. This placed residents at risk for injury. Findings include:1. The facility's 8/2022 Smoking Policy indicated the following:-Smoking is only permitted in designated resident smoking areas, which are located outside of the building. Smoking is not allowed inside the facility under any circumstances. -Resident smoking status is evaluated upon admission and reevaluated quarterly, upon a significant change and as determined by staff.-Any smoking-related privileges, restrictions and concerns are noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. -The facility may impose smoking restrictions on a resident at any time if it is determined that the resident cannot smoke safely with the available levels of support and supervision. -Residents without independent smoking privileges may not have or keep any smoking items, including cigarettes, tobacco, etc., except under direct supervision. Resident 9 was admitted to the facility in 3/2026 with diagnoses including tobacco use. Resident 9's 3/16/26 Smoking and Safety Evaluation revealed the resident used a vape pen (a battery-powered device that heats a liquid into an aerosol mist to be inhaled and typically contains nicotine, flavorings and other chemicals) and was a supervised smoker as she/he did not follow the smoking protocol. Resident 9's 3/19/26 Smoking and Safety Evaluation revealed the resident used a vape pen and was able to smoke independently. Resident 9's 3/24/26 admission MDS revealed the resident was cognitively intact and did not currently use tobacco. A 4/2/26 Letter to Resident 9 written by Staff 1 (Administrator) revealed the resident was found to smoke in her/his room on two different occasions, and as a result, was determined to require supervision when she/he smoked. Resident 9's 4/8/26 Smoking Care Plan revealed the following:-The resident lost her/his smoking privileges as she/he was observed to smoke/vape inside the facility. -Praise the resident for following safety guidelines.-Support the resident's right to smoke by ensuring and supporting her/him access to the designated smoking area on a supervised schedule. -If concerns or complaints about the new smoking schedule were voiced by the resident, validate her/his feelings.-If the resident demonstrated unsafe smoking behavior, notify Staff 1 and Staff 2 (DNS) immediately, and the nurse was to complete a smoking incident report. On 4/20/26 at 1:02 PM, Resident 9 was observed in her/his room bed. Resident 9 stated she/he did not smoke, vape or maintain any smoking material in her/his room or on her/his person. Resident 9 wore a nicotine patch on her/his right arm and stated she/he was trying to quit smoking. No smoking materials were observed in the resident's room or on the resident's person. On 4/24/26 at 9:09 AM, Staff 12 (CNA) stated she did not think Resident 9 required supervision to smoke. On 4/24/26 at 9:20 AM, Staff 34 (Agency CNA) stated resident smoking at the facility was a free for all. Staff 34 stated she was unsure if Resident 9 smoked or vaped, and she had to ask the facility's resident care managers to find out about a resident's smoking status. Staff 34 stated she was aware the resident was found to vape indoors two-to-three weeks ago but was unaware of any additional vaping incidents. Staff 34 stated she had never seen information on a resident's smoking status and/or abilities in a care plan. On 4/24/26 at 9:44 AM, Staff 27 (CNA) stated Resident 9 was an independent smoker and kept her/his smoking materials on her/his bed or in her/his nightstand. Staff 27 stated she heard the resident was found vaping in her/his room last week, but she had never observed the resident to vape indoors. On 4/24/26 at 9:58 AM, Staff 33 (LPN) stated Resident 9 previously lost her/his privilege to smoke independently but was now back to being independent with regards to smoking. Staff 33 stated it was a grey area as to where the resident's smoking materials were kept because her/his smoking status had changed so much and she was not familiar with the current status. Staff 33 stated Resident 9 had been caught a few times recently vaping indoors. On 4/24/26 at 10:54 AM, Staff 6 (Social Services Director) stated Resident 9 required supervision to smoke and her/his smoking material were to be securely stored at the nurse's station when not in use. On 4/24/26 at 11:50 AM, Staff 4 (RNCM) stated Resident 9 required supervision to smoke and her/his smoking material was to be secured at the nurse's station when not in use. Staff 4 stated she expected staff to be aware of the resident's current smoking status and acknowledged they were not. On 4/24/26 at 12:11 PM, Staff 1 and Staff 2 (DNS) were present for an interview. Staff 1 stated Resident 9 was determined to require supervision when smoking/vaping approximately two and a half weeks ago after the resident was repeatedly observed to vape indoors. Staff 1 stated he was trying to be fair but structured and balancing resident rights along with safety. Staff 2 stated vaping was classified the same as smoking, and she expected staff to supervise the resident was she/he vaped. Neither Staff 1 or Staff 2 expressed awareness of any issues regarding Resident 9 continuing to vape indoors. 2. Resident 67 admitted to the facility in 2/2024 with diagnoses including oropharyngeal phase dysphagia (difficulty swallowing). Review of Resident 67's clinical record revealed the following: - The resident was assessed by the SLP on 10/9/25 and was found to aspirate (when food or fluid enters the windpipe to the lungs instead of the stomach) when she/he drank thin liquids and recommended thickened liquids. - A physician order for mildly thick liquid (nectar) consistency was started on 10/9/25. - The 11/7/25 the SLP's ST discharge summary recommended Resident 67 continue receiving thickened liquids. - The 11/21/25 care plan and current Kardex (CNA care plan) instructed facility staff to provide Resident 67 with mildly thick (nectar) liquids. - The 2/13/26 Quarterly MDS identifies Resident 67's cognition was moderate impairment. - There was no evidence found a risk assessment to deviate from the diet order or an assessment to independently thicken liquids were completed. On 4/19/26 at 9:55 AM Resident 67 was observed with a water pitcher in front of her/him. Two boxes of single serve thickener packets and one box of hot chocolate packets were visible to be within reach of the resident. Witness 11 (Family Member) reported they have found Resident 67 with thin liquids multiple times and brought the boxes of thickening packets so the resident would have thickener available. On 4/20/26 at 2:30 PM Resident 67 was observed with a mug with a chocolate brown liquid that looked thin. Resident 67 stated an unidentified CNA left her/him with thin hot water, so she/he had just added thickening powder themselves but was having a hard time mixing it and demonstrated the difficulty. A two-inch clump was observed in the mug as the resident attempted to mix in into the liquid. On 4/21/26 at 1:10 PM Staff 45 (CNA) was observed providing Staff 23 (CMA) with a water pitcher that she had been observed filling with ice and water. Staff 23 then handed the water pitcher to Resident 67 without adding thickener. The resident drank from the pitcher and coughed but did not choke. On 4/21/26 at 2:00 PM Staff 24 (CNA) stated Resident 67 was usually good with drinking water from the water pitcher but sometimes would cough. Staff 24 stated she noticed Resident 67 had a water pitcher while assisting Resident 67's roommate with eating lunch and removed it as she left the room. Staff 24 stated Resident 67 drank about one quarter of the water and she had not notified the nurse yet. On 4/21/26 at 2:02 PM Staff 45 stated she was aware Resident 67 required liquids to be thickened and confirmed she gave Staff 23 the ice water without thickening it because she assumed Staff 23 would thicken it before giving it to the resident. Staff 23 stated she had not been trained on thickening liquids. On 4/21/26 at 2:05 PM Staff 23 confirmed she gave Resident 67 the water pitcher without thickening the water because she was unaware the resident had an order for thicken liquids. Staff 23 confirmed she should not have provided the water without thickening it after checking Resident 67's physician orders and care plan. Review of a progress note dated 4/21/26 at 7:09 PM revealed Staff 2 (DNS) found Resident 67 with thin water, which she removed. On 4/22/26 at 9:15 AM Staff 2 stated she was unaware Resident 67 had thickener in her/his room. She confirmed Resident 67 should not have been provided with thin liquids, was not assessed to self-thicken liquids, and additionally found thin liquids in Resident 67's room on 4/21/26. On 4/22/26 at 2:58 PM Staff 47 (Speech Language Pathologist) confirmed Resident 67 aspirated on thin liquids while the resident was on services and staff should not provide Resident 67 with thin liquids. Staff 47 stated Resident 67 was not assessed to self-thicken liquids.

Based on interview and record review it was determine the facility failed to ensure residents received appropriate pain management for 1 of 2 sampled residents (#94) reviewed for pain. This placed residents at risk for increased pain. Findings include:Resident 94 was admitted to the facility in 2/2026 with diagnoses including spinal stenosis (a narrowing of spaces within the spine leading to pain), dorsalgia (back pain), anxiety disorder, panic disorder, and opioid dependence. Resident 94's 2/28/26 admission MDS indicated the resident was cognitively intact. Resident 94's 2/24/26 admission orders included the following:Hydrocodone-acetaminophen (an opioid pain reliever) 10 mg - 325 mg oral tablet, give 1 tabs every four hours as needed for pain.Resident 94's 2/2026 MAR indicated the following medication was ordered on 2/24/26 at 10:26 AM:- Hydrocodone-acetaminophen 10 mg - 325 mg oral tablet, give 1 tablet every four hours as needed for pain.- Hydrocodone-acetaminophen 10 mg - 325 mg oral tablet was first administered to the resident on 2/25/36 at 4:25 AM.On 4/21/26 at 1:01 PM Staff 33 (LPN) stated they did not recall Resident 94, the admission, or any issues related to the delivery of hydrocodone-acetaminophen. Staff 33 was unable to provide additional information regarding whether the hydrocodone-acetaminophen prescription was sent to the pharmacy, or why there was a delay in delivery. No documentation by Staff 33 was identified in the medical record to clarify the events surrounding the hydrocodone-acetaminophen prescription and its delivery.On 4/21/26 at 6:26 PM Witness 7 (Complainant) stated Resident 94 was admitted to the facility around noon on 2/24/26. Witness 7 stated the admitting nurse advised Resident 94's hydrocodone-acetaminophen would be delivered to the facility within a few hours of admission. Witness 7 stated at approximately 2:30 AM on 2/25/26 Resident 94 called them in distress indicating she/he was in pain and needed hydrocodone-acetaminophen, and it was not available. Witness 7 stated they contacted the facility, advised the nurse the resident needed pain medication and were told the hydrocodone-acetaminophen prescription had not been sent to the pharmacy. On 4/27/26 at 12:49 PM Staff 36 (CNA) stated Resident 94 was in pain on 2/25/26 and was agitated the night of admission to the facility and the resident requested pain medication several times which they reported to the nurse. Staff 36 stated Resident 94 was upset because her/his hydrocodone-acetaminophen was not available when she/he was told it would be at the time of admission. Staff 36 stated the resident also called Witness 7 twice and reported she/he was in pain and needed her pain medication and had not received it. Staff 36 stated they were unsure what time Resident 94 began requesting pain medication but believed it was early in their shift, which began at 10:00 PM.On 4/22/26 at 5:24 PM Staff 37 (RN) stated the night of Resident 94's admission they received a call from Witness 7 requesting pain medication for the resident reporting she/he had called them from her/his room upset and in pain. Staff 37 stated Resident 94 had admitted to the facility earlier that day with orders for hydrocodone-acetaminophen for pain control, but the prescription had not been sent to the pharmacy, and therefore resident's pain medication was not available for administration. Staff 37 requested a prescription from the on-call provider and a pull-code (a code for secure access) from the pharmacy to access the facility's backup supply of hydrocodone-acetaminophen. Staff 37 administered Resident 94 her/his first dose of hydrocodone-acetaminophen on 2/25/26 at 2:25 AM.On 4/24/26 at 10:35 AM Staff 3 (LPN-Resident Care Manager) and Staff 4 (RNCM) stated the resident was admitted to the facility from home without a hard copy of the hydrocodone-acetaminophen prescription. Staff 4 stated in such cases the admitting nurse should have requested a STAT (immediate) prescription from the on-call provider for Resident 94's hydrocodone-acetaminophen for delivery as soon as possible and ideally within four hours. Staff 3 and Staff 4 stated there should have been diligent follow-up by the floor nurse and documentation reflecting the cause of any delay and the status of the prescription delivery, especially given Resident 94's diagnoses. Staff 3 acknowledged there was no record of follow-up on the hydrocodone-acetaminophen prescription in Resident 94's medical record and the medication was not readily available to the resident upon request.

Based on observation, interview and record review it was determined the facility failed to ensure appropriate provisions for dialysis care were implemented and timely post-dialysis assessments were completed for 1 of 1 sampled resident (#7) reviewed for dialysis. This placed residents at risk for delayed treatment. Findings include:The facility's 2/2023 Hemodialysis Catheters (a flexible, plastic tube inserted into a large vein, typically in the neck, chest or groin used to provide access for filtering blood in patients with kidney failure) - Access and Care of Policy revealed the following:a. Care immediately following dialysis treatment:-The dressing change is done in the dialysis center post-treatment.-If the dressing becomes wet, dirty, or not intact, the dressing shall be changed by a licensed nurse trained in this procedure. -Mild bleeding from the access site can be expected. Apply pressure to the site and contact the dialysis center for instructions.-If there is major bleeding from the site, apply pressure to access site and contact emergency services and dialysis center. b. Documentation is to be completed by the nurse every shift and should include the location of the catheter, condition of the dressing, any interventions needed, if dialysis was done during the shift, any part of the report from the dialysis nurse post-dialysis being given and observations post-dialysis. Resident 7 was admitted to the facility in 3/2026 with diagnoses including dependence on renal dialysis (a life-sustaining medical procedure that acts as an artificial kidney, filtering waste products, excess salt and fluid from the blood when the kidneys have failed). Resident 7's 3/31/26 admission MDS revealed the resident was cognitively intact and received dialysis while a resident at the facility. Resident 7's 3/2026 Physician Orders revealed the following:-Monitor bruit and thrill (signs of turbulent, rushing blood flow, often indicating a narrowed artery or a functioning dialysis fistula [a surgically created connection, typically in the arm or wrist, that joins an artery directly to a vein to provide access for hemodialysis], signs and symptoms of bleeding, hypotension, nausea, chest pain, unsteady gait, fatigue, seizure, leg cramps, fluid imbalance, headache and/or infection. If noted, document in a progress note and notify the physician of abnormalities every shift. -Send vital signs, the MAR and documentation of the time of the last meal consumed with the resident to the dialysis center in the morning every Monday, Wednesday and Friday. A review of Resident 7's 4/2026 TAR and 4/2026 Dialysis Communication Forms revealed the following: -Monitor bruit and thrill, signs and symptoms of bleeding, hypotension, nausea, chest pain, unsteady gait, fatigue, seizure, leg cramps, fluid imbalance, headache and/or infection. If noted, document in progress notes and notify physician of abnormalities every shift: missing day shift documentation on 4/3/26, 4/4/26, 4/5/26, 4/10/26 and 4/11/26.-No evidence was found to indicate the time of the resident's last meal consumed was communicated to the dialysis center. On 4/19/26 at 12:48 PM, Resident 7 was observed to sit on the bed in her/his room. Resident 7 stated not all nurses assessed her/him when she/he returned from dialysis. On 4/20/26 at 4:34 PM, Resident 7 returned to the facility following dialysis. Resident 7 was observed to wheel her/himself to the nurse's station and hand her/his Dialysis Communication Form to Staff 30 (RN). Staff 30 informed the resident she would pass the form to her/his nurse. Resident 7's access site was covered by her/his jacket, and Staff 30 was not observed to perform a post-dialysis assessment of the resident. Resident 7 independently returned to her/his room in her/his wheelchair. Observations on 4/20/26 between 4:34 PM and 5:10 PM revealed a nurse did not complete a post-dialysis assessment of Resident 7 upon her/his return from dialysis. On 4/20/26 at 5:10 PM, Staff 31 (LPN) stated she was the nurse responsible for the care of Resident 7. Staff 31 stated nurses were expected to complete a post-dialysis assessment of Resident 7 as soon as she/he returned from dialysis, but she was unable to do so as she was on break when the resident returned. Staff 31 stated Staff 30 should have completed the assessment when the resident returned from dialysis, but since Staff 30 did not, she would complete Resident 7's post dialysis assessment as soon as she finished checking resident blood sugars. On 4/20/26 at 5:15 PM and 4/27/26 at 9:49 AM, Staff 30 stated post-dialysis assessments should be completed immediately upon a resident's return from dialysis. Staff 30 stated she did not complete a post-dialysis assessment for Resident 7 on 4/20/26 following her/his return from dialysis because these assessments were usually completed by the nurse who was assigned to the resident. On 4/22/26 at 9:40 AM, Staff 32 (LPN) stated he completed resident post-dialysis assessments as soon as possible, which included checking vital signs and the access site to ensure it was not bleeding.On 4/24/26 at 10:47 AM, Staff 33 (LPN) stated she completed resident post-dialysis assessment within the hour of the resident's return from dialysis. Staff 33 reviewed Resident 7's 4/2026 TAR and 4/2026 Dialysis Communication Forms and stated documentation of the time of the resident's last meal was not being communicated to the dialysis center. On 4/24/26 at 11:36 AM, Staff 3 (LPN-Resident Care Manager) stated she was unsure of the timeframe as to when resident post-dialysis assessments should be completed. On 4/24/26 at 12:31 PM, Staff 2 (DNS) stated resident post-dialysis assessments should be completed upon a resident's return from dialysis. Staff 2 stated Resident 7's post-dialysis assessment on 4/20/26 was not timely. Staff 2 further stated she expected staff to follow physician orders with regards to dialysis care and confirmed the time of Resident 7's last meal was not being communicated to the dialysis center, and she could not provide an explanation for the missing documentation on the resident's 4/2026 TAR.

Based on observation, interview and record review it was determined the facility failed to ensure residents who were trauma survivors received trauma-informed care for 3 of 3 sampled residents (#s 8, 41 and 49) reviewed for trauma-informed care. This placed residents at risk for re-traumatization and a decrease in their quality of life. Findings include:The facility's 8/2022 Trauma-Informed and Culturally Competent Care Policy revealed the following: -Universal screening of residents, which includes a brief, non-specialized identification of possible exposure to traumatic events will be performed.-The initial screening will be utilized to identify the need for further assessment and care. -Assessment involves an in-depth process of evaluation of the presence of symptoms, their relationship to trauma, as well as the identification of triggers. -Individualized care plans will be developed that address past trauma in collaboration with the resident and family as appropriate. 1. Resident 8 was admitted to the facility in 2/2026 with diagnoses including PTSD (post-traumatic stress disorder). A 2/4/26 History & Physical Hospital Note revealed Resident 8 had a history of attempted suicide and experienced PTSD as a result of an attempted strangulation by her/his spouse. Resident 8's 2/12/26 Social Services Evaluation indicated the following:-The resident had an experience that was so upsetting that it changed her/him emotionally, spiritually, physically or behaviorally. -A trauma care plan was needed. Resident 8's 2/17/26 admission MDS revealed the resident was able to make her/himself understood and understand others without difficulty. Resident 8's 2/17/26 Care Plan revealed the following:-The resident had a history of physical, emotional or mental distress due to changes in her/his living situation. -Staff were to initiate increased supervision or close visual supervision per policy if the resident exhibited behaviors that presented a significant risk and notify the physician. -The resident's medications were to be reviewed with her/his physician to determine if there was a need to change the current medication regimen. No evidence was found in Resident 8's clinical record to indicate the resident's past history of trauma and/or triggers which could cause re-traumatization were identified or assessed. On 4/19/26 at 1:40 PM, Resident 8 was observed in her/his room and sat in her/his wheelchair. Resident 8 stated she/he experienced trauma but was unable to provide any additional information or details. On 4/27/26 at 9:29 AM, Staff 27 (CNA) stated she was unaware if Resident 8 experienced any trauma or any potential triggers that could cause re-traumatization. Staff 27 stated this information was found in the resident's care plan. On 4/27/26 at 9:32 AM, Resident 8 was observed in her/his room in bed. Resident 8 stated she/he had experienced trauma and religious literature and talks really helped to not dwell on the past. Resident 8 further stated she/he felt more comfortable working with women instead of men but no one at the facility had asked her/him about her/his care preferences. On 4/27/26 at 9:39 AM, Staff 30 (RN) stated she was unaware of any trauma history for Resident 8, but she would look in the resident's care plan to find information on potential trauma triggers. On 4/27/26 at 9:59 AM, Staff 34 (Agency CNA) stated she was unaware if Resident 8 experienced any trauma or of any potential triggers that could cause re-traumatization. Staff 34 further stated she found the resident was more receptive to care when it was provided in a sweet and gentle manner and tasks were thoroughly explained. On 4/27/26 at 10:10 AM, Staff 35 (CNA) stated he was unaware if Resident 8 experienced any trauma or of any potential triggers that could cause re-traumatization. Staff 35 stated the resident did experience episodes of increased anxiety when she/he rubbed her/his hands and complained of not being able to sleep. On 4/27/26 at 10:22 AM, Staff 6 (Social Services Director) stated all residents with a history of trauma should have a trauma-informed care plan in place. Staff 6 stated she was unaware of Resident 8's diagnosis of PTSD or her/his history of trauma. Staff 6 stated she did not reapproach the resident about her/his trauma after her/his initial trauma screen to identify possible trauma triggers, did not talk to the resident's family about her/his trauma history or create a trauma-informed care plan. 2. Resident 49 was admitted to the facility in 9/2025 with diagnoses including schizophrenia (a chronic, severe brain disorder affecting how a person thinks, feels and behaves). Resident 49's 9/23/25 Hospital Psychiatric Evaluation revealed the following:-The resident had a hoarding disorder (a mental health condition characterized by a persistent difficulty discarding possessions, regardless of their actual value, leading to severe clutter that compromises living spaces).-The resident experienced food insecurity, hoarded food, lived in unsanitary conditions and was homeless in the last year. Resident 49's 1/30/26 Social Services Evaluation revealed the following:-The resident had an experience that was so upsetting it changed her/him emotionally, spiritually, physically or behaviorally. -The resident felt angry/had angry outbursts in response to stressful events. -A trauma care plan was not needed. Resident 49's 4/4/26 Quarterly MDS revealed the resident was severely cognitively impaired and experienced episodes of disorganized thinking (fragmented, illogical or disjointed thoughts often manifesting as incoherence or rapid shifting between unrelated topics), inattention and hallucinations. On 4/20/26 at 1:14 PM, Resident 49 was observed in her/his room and sat in her/his wheelchair. The resident had an unpleasant body odor and her/his clothes appeared dirty. The foot of the resident's bed was covered with her/his personal belongings, and the resident wore a necklace of permanent markers that covered the front on her/his chest. The resident was unable to answer any questions related to her/his trauma history as her/his speech was disorganized (incoherent, illogical or rambling speech). On 4/21/26 at 11:56 AM, Staff 27 (CNA) stated she was unsure if Resident 49 had a history of trauma but thought the resident may have been in the military. Staff 27 stated taking things from people was her/his thing, but she was unsure of why the resident took things from others. On 4/21/26 at 1:13 PM, Staff 34 (Agency CNA) stated you can tell [she/he] likes to hoard but was unsure if Resident 49 had a history of trauma. Staff 34 stated the resident was very territorial, refused to change her/his clothes and bathe and was very particular at mealtimes. Staff 34 stated a resident's trauma history and potential trauma triggers were found in the resident's care plan. On 4/21/26 at 7:22 PM, Staff 17 (LPN) stated Resident 49's trauma triggers included being touched or when a person touched any of her/his belongings. Staff 17 further stated information on a resident's trauma history and trauma triggers were found in the resident's care plan. On 4/22/26 at 9:02 AM, Witness 10 (Friend) stated Resident 49 had a history of being homeless, hoarding and living in unsanitary conditions. Witness 10 stated he was unsure if Resident 49 served in the military, but the resident had talked about previous military experiences. On 4/22/26 at 10:28 AM, Staff 3 (LPN-Resident Care Manager) stated she was unaware of Resident 49's history of being homeless but that would actually explain some of the behaviors the resident exhibited at the facility. On 4/22/26 at 11:27 AM, Staff 6 (Social Services Director) stated all residents with a history of trauma should have a trauma-informed care plan in place. Staff 6 stated she was aware of some of Resident 49's past traumas, including food insecurity and being homeless. Staff 6 acknowledged she did not create a care plan specific to trauma-informed care for the resident, and she should have. 3. Resident 41 was admitted to the facility in 7/2025 with diagnoses including PTSD (Post-Traumatic Stress Disorder). Review of the 7/9/25 Social Services Evaluation revealed a trauma care plan was needed because Resident 41 had a trauma history, which included past physical assault, assault with a weapon, and war zone combat trauma and the resident reported having disturbing thoughts, images, or dreams and she/he would avoid certain situations to avoid remembering the traumas. Resident 41's 7/28/25 admission MDS revealed the resident was able to make her/himself understood and understand others without difficulty. Review of Resident 41's 7/21/26 Care Plan revealed no evidence trauma related care planning was completed. On 4/19/26 at 11:09 AM Resident 41 stated that she/he had PTSD bad because of her/his Vietnam War combat and war related injuries. The resident indicated triggers included talking about the trauma, dreams, and pain from injuries sustained during the war, which was why it was important to the resident that pain and psychotropic medications were not reduced or discontinued. Interviews on 4/21/26 at 11:27 AM with Staff 11 (CNA), 4/22/26 at 3:28 PM with Staff 41 (CNA), and 4/23/26 at 11:05 AM with Staff 24 (CNA) stated they were unaware of Resident 41's trauma history. They stated they would look in the care plan but were unaware of Resident 41's signs or symptoms or possible triggers. On 4/23/26 Staff 6 (Social Services Director) stated if a resident admits with a diagnosis of PTSD or has past traumas a trauma care plan was created. She confirmed was aware of the resident's trauma and she did not develop a trauma care plan for Resident 41 but should have.

Based on observation, interview and record review it was determined the facility failed to identify and ensure a resident with a diagnosed substance use disorder and/or mental health disorder received necessary behavioral health care and services for 2 of 2 sampled residents (#s 9 and 49) reviewed for smoking and dementia care. This placed residents at risk for unaddressed behavioral and emotional needs and a decrease in their quality of life. Findings include: 1. Resident 9 was admitted to the facility in 3/2026 with diagnoses including psychoactive substance dependence (a chronic condition where an individual requires a substance, such as alcohol, nicotine or drugs to function normally), other stimulant use (the consumption of illicit, prescription or over-the-counter substances that increase alertness and energy) and sedative, hypnotic or anxiolytic abuse (the misuse of central nervous system depressants for euphoric effects or beyond their prescribed purpose, leading to addiction, coma or death).Resident 9's 3/10/26 Hospital History & Physical revealed the resident had a diagnosis of polysubstance abuse disorder, which included abuse of opioids, benzodiazepines and methamphetamine. The History & Physical further revealed the resident reported using each of these drugs daily prior to her/his hospitalization. No evidence was found in Resident 9's 4/2026 Care Plan to indicate she/he had a diagnosis of substance use disorder (SUD) or interventions to help staff identify the signs and symptoms of substance use or to manage and treat the resident's addiction through individualized and person-centered approaches. On 4/24/26 at 9:09 AM, Staff 12 (CNA) stated she thought Resident 9 had a drinking problem but was not aware of any additional substance abuse concerns for the resident. Staff 12 stated she hoped information about a resident with a known SUD could be found in the resident's care plan. On 4/24/26 at 9:20 AM, Staff 34 (Agency CNA) stated she knew Resident 9 drank alcohol but was unaware of any additional substance abuse concerns for the resident. Staff 34 stated there were times when the resident was so drowsy that she/he could barely wake up. Staff 34 did not indicate an understanding of what she was supposed to do on these occasions when she could not rouse the resident as she stated she was unsure of the resident's baseline. On 4/24/26 at 9:44 AM, Staff 27 (CNA) stated she thought the facility admitted a lot of residents with diagnoses of SUDs, but she was unaware if Resident 9 had a diagnosis of SUD. On 4/24/26 at 9:58 AM, Staff 33 (LPN) stated she thought Resident 9 had a diagnosis of SUD and interventions related to the resident's substance use and what staff should be on the lookout for should be in the resident's care plan. Staff 33 stated there had been instances when she had to hold the resident's scheduled medications because the resident appeared sedated. Staff 33 stated these instances when the resident appeared sedated were observed after the resident returned from being out of the facility. On 4/24/26 at 10:33 AM, Resident 9 was observed in her/his room and sat in her/his wheelchair. Resident 9 stated she/he had a history of substance abuse but did not provide any additional information regarding this topic. Resident 9 stated she/he had been offered treatment and therapy groups, but was not interested. On 4/24/26 at 10:54 AM, Staff 6 (Social Services Director) stated residents who had a diagnosis of SUD should have a care plan in place and further stated she was unware Resident 9 had a history of drug abuse. On 4/24/26 at 12:12 PM, Staff 2 (DNS) stated care plans should include individualized interventions related to the resident's diagnosed conditions, including SUD, and acknowledged Resident 49's care plan lacked behavioral interventions. 2. Resident 49 was admitted to the facility in 9/2025 with diagnoses including schizophrenia (a chronic, severe brain disorder affecting how a person thinks, feels and behaves, causing a disconnection from reality) and dementia.Resident 49's 4/4/26 Quarterly MDS revealed the resident was severely cognitively impaired, exhibited the behavior of rejecting care and experienced episodes of disorganized thinking (fragmented, illogical or disjointed thoughts often manifesting as incoherence or rapid shifting between unrelated topics), inattention and hallucinations. A 4/6/26 Progress Note completed by Staff 44 (Physician Assistant-Certified) indicated the following:-Resident 49 experienced a recent behavioral escalation, which included aggression, paranoia and altercations.-The resident demonstrated significant paranoid ideation and disorganized thought process during her examination of the resident. -The resident required frequent reorientation related to her/his severe dementia. Resident 49's 4/20/26 Care Plan revealed the resident experienced hallucinations, delusions and/or paranoia related to her/his diagnosis of schizophrenia, had hoarder tendencies and stole items from staff and the facility. Interventions included the following:-Document the resident's hallucinations, delusions and paranoia when it occurred.-Listen to the resident when she/he verbalized what occurred.-Consult with family to determine if these experiences were common in the resident's past, and if so, what the treatment was for these perceptions.-Stress reducing interventions included: to take items back that she/he took, example blankets, creams, etc. -The resident needed reassurance and support by staff for all bathing activities. -Monitor the resident's antipsychotic medications.-Psych consult as needed. No evidence was found in Resident 49's clinical record to indicate an individualized and person-centered care plan was developed to support the behavioral health care needs of the resident. On 4/20/26 at 1:14 PM, Resident 49 was observed in her/his room and sat in her/his wheelchair. The resident had an unpleasant body odor and her/his clothes appeared dirty. The foot of the resident's bed was covered with her/his personal belongings, and the resident wore a necklace of permanent markers that covered the front of her/his chest. The resident was unable to answer any questions related to her/his mood or psychosocial well-being as her/his speech was disorganized (incoherent, illogical or rambling). On 4/21/26 at 11:26 AM, Staff 31 (LPN) stated Resident 49 refused care all of the time, but her/his cooperation was dependent upon the way you approach. Staff 31 stated the resident was more likely to refuse care when staff were bossy and/or in a rush. On 4/21/26 at 1:13 PM, Staff 34 (Agency CNA) stated Resident 49 refused to change her/his clothing, and if you pushed the resident a little to change her/his clothes, the resident would yell. Staff 34 stated establishing trust with the resident was very important, and she did not want to agitate the resident or have her/him loose trust in her, so she did not approach the resident to change her/his clothes. Staff 34 stated the resident liked to hoard, and took items that did not belong to her/him, especially pens. Staff 34 stated she did not confront the resident when she/he took items that did not belong to her/him because her/his behaviors worsened. Staff 34 stated a lot of the house staff knew to avoid confrontation with the resident and to remove items that did not belong to her/him from the resident's room when not present. On 4/21/26 at 1:53 PM, Staff 44 (Physician Assistant-Certified) stated Resident 49 had abnormal thought processes and recently experienced an increase in paranoid thinking and behaviors, including hoarding and throwing things at people. Staff 44 stated the resident's behaviors were off and on since her/his admission to the facility, and something would set [her/him] off, and we don't know why. On 4/21/26 at 7:22 PM, Staff 17 (LPN) stated Resident 49 was very particular and felt like building repour and continuity was important when working with the resident. Staff 17 stated the resident refused to change clothes or shower and thought her/his refusals were due to his/her mental illness. Staff 17 stated the resident did not like people messing with her/his stuff, and you can't leave anything out and around or the resident would take it. Staff 17 stated she thought information on the resident's behaviors and related interventions were found in the resident's care plan. On 4/21/26 at 4:43 PM, Staff 40 (CNA) stated Resident 49 got violent if you touched her/his belongings, including items the resident had taken from others. Staff 40 stated the resident took stacks of cups, papers and pens that belonged to the facility staff as well as her/his roommate's belongings, and staff needed to retrieve the items when the resident was not looking. Staff 40 stated she observed staff confront the resident after she/he had taken a pen that did not belong to her/him and the resident went crazy. Staff 40 stated the resident was calm and cooperative when staff didn't have an attitude and took the time to talk to and get to know her/him. Staff 40 stated the care plan should tell us everything about the resident, including behaviors and interventions, but was unsure if Resident 49's care plan contained interventions to help staff with the resident's behaviors. Staff 40 stated Resident 49 did not do well when her/his routine was changed. Staff 40 stated CNAs were constantly changing sections so Resident 49 was always working with different staff, which negatively impacted the resident. On 4/22/26 at 9:02 AM, Witness 10 (Friend) stated Resident 49 hoarded food, stole from others and refused care daily. Witness 10 stated having a consistent routine helped the resident and thought continuity in staff would help to mitigate the resident's behaviors. On 4/22/26 at 9:45 AM, Staff 32 (LPN) stated Resident 49 was verbally and physically aggressive, and her/his behaviors increased when staff directed any accusations towards the resident. Staff 32 stated interventions to address resident behaviors were found in the resident's care plan. Staff 32 stated it would be beneficial for Resident 49 to work with consistent CNAs but currently CNAs rotated sections every day. On 4/22/26 at 10:28 AM, Staff 3 (LPN-Resident Care Manager) and Staff 2 (DNS) were present for an interview. Staff 3 stated Resident 49 had trust issues, refused all personal care, hoarded various items, such as the facility's cups and permanent markers, and became verbally aggressive when repeatedly approached by staff with a question or direction. Staff 3 stated the resident tolerated a few staff and her/his behaviors were improved with certain male staff. Staff 2 (DNS) stated care plans should include individualized interventions to meet the behavioral needs of residents and acknowledged that Resident 49's care plan lacked behavioral interventions.

Based on observation, interview and record review it was determined the facility failed to ensure a medication error rate of less than five percent during medication administration for 2 of 10 sampled residents (#s 74 and 82) reviewed for medication administration. The facility's medication administration error rate was 11.11%. This place residents at risk for subtherapeutic dosing and uncontrolled blood sugars. Findings include: The 2016 insulin aspart (NovoLog) FlexPen manufacturer Guide to Using Your NovoLog FlexPen indicated the insulin pens should be primed with two units of insulin prior to each administration to ensure the correct dose was delivered. 1.Resident 74 was admitted to the facility in 2/2022 with diagnoses including type 2 diabetes mellitus (a chronic condition affecting the body's ability to control blood sugar levels).Resident 74's 6/2024 Physician Orders included the following:- insulin aspart (a rapid acting insulin) 100 unit/ml - give 7 units with meals for type 2 diabetes mellitusOn 4/21/26 at 7:08 AM Staff 31 (LPN) was observed to administer insulin aspart to Resident 74 and did not prime the insulin pen prior to administration. On 4/21/26 at 7:08 AM Staff 31 acknowledged they did not prime the insulin pen and expressed it was not part of their practice. On 4/23/26 at 4:22 PM Staff 2 (DNS) was notified Resident 74's insulin pen was not primed prior to administration. Staff 2 stated they expected all nursing staff to prime insulin pens prior to insulin administration.2. Resident 82 was admitted to the facility in 1/2026 with diagnoses including type 1 diabetes mellitus (a chronic condition in which the body cannot make insulin).Resident 82's 4/2026 Physician Orders indicated the following:1. insulin aspart (a rapid acting insulin) 100 unit/ml - give 3 units with meals related to type 1 diabetes mellitus2. insulin aspart 100 unit/ml - give per sliding scale before meals and at bedtime related to type 1 diabetes mellitus.On 4/21/26 at 7:21 AM Resident 82 was observed leaving the dining room and confirmed she/he had already eaten breakfast.On 4/21/26 at 7:21 AM Staff 31 was observed to administer insulin aspart 6 units (3 units scheduled and 3 units per sliding scale) to Resident 82.On 4/21/26 at 7:21 AM Staff 31 acknowledged Resident 82 received both scheduled and sliding scale doses of insulin aspart after his/her meal.On 4/23/26 at 4:22 PM Staff 2 (DNS) stated insulin was expected to be administered before or with meals as ordered, and acknowledged Resident 82's insulin was not administered in accordance with the ordered timing.

Based on observation and interview it was determined the facility failed to ensure a functional and comfortable environment for 1 of 1 resident rooms reviewed for lighting. This placed residents at risk for diminished quality of life and quality of care. Findings include:The facility's 2/2021 Homelike Environment Policy revealed comfortable and adequate lighting is provided in all areas of the facility to promote a safe, comfortable and homelike environment. The lighting design emphasizes sufficient general lighting in resident-use areas, task lighting as needed and night lighting to promote safety and independence. Resident 9 was admitted to the facility in 3/2026 with diagnoses including quadriplegia (paralysis affecting all four limbs and the torso). Resident 9's 3/24/26 admission MDS revealed the resident was cognitively intact. On 4/23/26 at 7:32 AM, Resident 9 was observed in bed in the room she/he shared with two additional residents. A curtain was pulled to the left of the resident's bed and another one at the foot of the bed to divide the room space and to allow for privacy. No light switch, light fixture or lamp was visible on Resident 9's portion of the room. A light fixture was observed on the ceiling of the room located on the other side of the pulled curtain at the foot of the resident's bed. Resident 9 stated she/he had not had her/his own light since she/he had been in this room, and she/he wanted her/his own light, especially to use at night to be able to watch television and to just be able to have a dim light. Resident 9 further stated it sucks at night because everyone gets woken up because they have to use my roommate's light to change me. On 4/24/26 at 9:20 AM, Staff 34 (Agency CNA) stated all of the CNAs at the facility did not like light situation in Resident 9's room. Staff 34 stated Resident 9 did not have access to a light in her/his portion of the room. Staff 34 further stated she woke up Resident 9's roommates when she turned on the shared light and that was why one of her/his roommates slept with a pillow covering her/his head. On 4/24/26 at 9:44 AM, Staff 27 (CNA) stated Resident 9's room had only one light which was located outside of the resident's portion of the room. Staff 27 stated she felt unsafe when she assisted the resident with transfers or personal hygiene because of the light situation in the room. Staff 27 further stated she frequently woke up one of the resident's roommates and the other roommate slept with a blanket over her/his head because of the lack of lighting in the room. On 4/24/26 at 9:58 AM, Staff 33 (LPN) stated the limited lighting in Resident 9's room posed a safety concern for all three residents who shared the room. On 4/24/26 at 12:03 PM, Staff 1 (Administrator) and Staff 7 (Maintenance Director) were present for an interview. Staff 1 stated each resident was to have their own light that they could independently access. Staff 1 stated Resident 9 was provided with a lamp because of the lighting situation in her/his room. Staff 1 and Staff 7 stated they were unaware the lamp was not available in Resident 9's room.

Based on interview and record review it was determined the facility failed to the ensure the Direct Care Staff Daily Report (DCSDR) postings were accurate and complete for 28 of 49 days reviewed for staffing. This placed residents and the public at risk for inaccurate and incomplete staffing information. Findings include:The facility's Staffing, Sufficient and Competent Nursing Staff policy, dated 8/2022, indicated the direct care daily staffing numbers were posted in the facility for every shift. A review of the facility's DCSDR postings revealed the following: From 3/1/26 through 4/19/26, 49 days were reviewed and revealed 28 days when licensed nurse staff hours were inaccurate or the postings had missing/incomplete information including no census and inaccurate recording of licensed nursing hours on 3/1/26, 3/2/26, 3/3/26, 3/4/26, 3/5/36, 3/6/26, 3/7/26, 3/8/25, 3/9/26, 3/14/26, 3/16/26, 3/17/26, 3/20/26, 3/29/26, 3/30/26, 3/31/26, 4/3/26, 4/5/26, 4/6/26, 4/7/26, 4/11/26, 4/13/26, 4/14/26, 4/15/26, 4/16/26, 4/17/26, 4/18/26 and 4/19/26. On 4/23/26 at 9:40 AM, Staff 22 (Staffing Coordinator) reviewed the 3/1/26 through 4/19/26 DCSDR postings and verified the reports were inaccurate or incomplete on the days identified.

Based on record review and interview the facility failed to report an allegation of abuse and neglect within the required time frame to the State Agency for 2 of 2 sampled residents (#4 and #7) reviewed for abuse and neglect. This placed residents at risk for abuse. Findings include1. Resident 7 was admitted to the facility in 2/2013 with diagnoses including anoxic brain injury (a critical condition that resulted in a lack of oxygen to the brain). Resident 7's 1/12/25 Care Plan indicated the resident had a history of impaired cognitive function with poor impulse control, difficulty in expressing general awareness, decision making, self-expression and mental status. Resident 7's 3/31/25 MDS identified resident with a BIMS score of 0 out 0 which indicated severe cognitive impairment. A 10/23/25 Facility Investigation Report indicated Resident 7 had swelling and bruising on her/his right knee on 10/11/25. An x-ray was ordered on 10/13/25, which identified Resident 7 had a right knee fracture. The facility concluded that the injuries were likely a result of a self-initiated injury from kicking the footboard of the bed. On 3/3/26 at 11:31 AM, Staff 26 (RN) stated she was informed by staff that Resident 7 had noted swelling of the knee. Upon examination of Resident 7, Staff 26 noted significant bruising and swelling around the resident's right knee. Staff 26 stated she ordered an x-ray which revealed the resident had suffered a fracture of the right knee. Staff 26 stated the resident did not know how she/he injured herself/himself and stated she didn't believe Resident 7's injury was self-inflicted. On 3/3/26 at 12:24 PM, Staff 2 (DNS) stated staff initially became aware of Resident 7's swelling of the knee on 10/11/25, but administration did not report it until 10/13/25. Staff 2 stated staff initially became aware of Resident 7's swelling of the knee on 10/11/25. Staff 2 stated she was aware of the incident but had not reported it to the State Agency as staff failed to report this incident to management. On 3/4/26 at 4:49 PM, Staff 11 (LPN) confirmed she was initially made aware of the residents suspected injury on 10/11/25 and did not report it to the facility's administration. Staff 11 stated that she did not report the incident due the assumption the facility was already aware. On 3/9/26 at 12:29 PM, Staff 1 (Administrator) confirmed the facility did not report the incident within the required time. 2. Resident 4 was re-admitted to the facility in 2023 with diagnoses including dementia. The 1/6/25 Annual MDS revealed Resident 4 had a BIMS of 11 (moderately impaired) and was dependent on toileting and personal hygiene. A 3/17/25 Facility Reported Incident revealed on 3/15/25, Staff 6 (CNA) allegedly failed to complete incontinence care for Resident 4 throughout her eight-hour shift. On 3/5/26 at 8:10AM, Staff 2 (DON) confirmed the facility reported the 3/15/25 neglect allegation on 3/17/25 but should have reported the allegation within two hours to the State Agency. On 3/5/26 at 2:12PM, Staff 1 (Administrator) confirmed the facility did not report the 3/15/25 neglect allegation within the required time.

Based on observation, interview and record review it was determined the facility failed to protect the resident's right to be free from physical abuse by Resident 3 for 1 of 5 (#2) sampled residents for abuse. This failure to prevent abuse resulted with Resident 2 experiencing severe pain. Findings include:The facility's abuse policy titled Prevention and Reporting; Resident Mistreatment, Neglect, Abuse, Including Injuries of Unknown Source, and Misappropriation of Resident Property, last update 8/2022, revealed residents has the right to be free from abuse. The policy defined physical abuse as a willful inflection of injury which resulted in physical harm, pain or mental anguish. Willful was defines as the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Resident 2 admitted to the facility in 1/2025 with diagnoses including neuromuscular dysfunction of the bladder and kidney disease. Resident 3 admitted to the facility in 3/11/25 with diagnoses including dementia with agitation and cognitive communication deficit. On 4/5/25 at 7:45 PM a Physical Aggression Received incident report was initiated by Staff 14 (Former LPN) between Resident 3 and Resident 2 which occurred at 7:00 PM. The report revealed Staff 14 was notified Resident 3 pulled on Resident 2's indwelling catheter (tube inserted into bladder through the urethra to allow urine to drain and held in place by tubing called a balloon) while Resident 2 was sleeping in her/his bed. A CNA heard Resident 2 yelling, entered the room and observed Resident 3 holding onto Resident 2's catheter urine collection bag. Resident 3 was noted to be confused and told the CNA she/he thought Resident 2 was going to pull on it' when asked why she/he did it. Staff 14 responded to the room and assessed Resident 2 who was in tears. Resident 2's 4/19/25 and 7/20/225 Quarterly MDS's assessed her/him as cognitively intact and had an indwelling catheter. On 10/14/25 at 1:43 PM Resident 2 recalled the 4/5/25 incident with Resident 3. Resident 2 stated her/his roommate, Resident 3 experienced confusion most of the time. Resident 2 stated on 4/5/25 she/he was sleeping and woke to Resident 3 pulling on her/his catheter tubing. Resident 2 then grabbed the tubing from being pulled out of the tubing entry cite. Resident 2 stated it felt like a game of tug-a-war with Resident 3 pulling on the tubing. Resident 2 stated Resident 3 was confused and when she/he asked Resident 3 what they were doing, she/he said they thought she/he was going to pull on it (catheter tubing). The surveyor observed Resident 2 demonstrate where the catheter tubing broke off when Resident 3 pulled it. Resident 2 stated the catheter tubing did not come all the way out because she/he grabbed it. Resident 2 stated it was painful and it hurt for several days following the incident. On 10/15/25 at 3:34 PM Staff 7 (CNA) stated they recalled the 4/5/25 incident when Resident 3 pulled and broke Resident 2's catheter tubing off. They recalled Resident 2 was definitely in pain for several days after. They recalled Resident 3 was confused. On 10/15/25 at 3:34 PM Staff 11 (CNA) stated they recalled the 4/5/25 incident when Resident 3 pulled and broke Resident 2's catheter tubing off. Staff 11 stated they overheard Resident 2 yelling and went into the room. Staff 11 saw Resident 2 holding her/his groin area and Resident 3 was holding Resident 2's catheter drainage bag. The catheter bag was torn off from Resident 2 and in Resident 3's hand. Staff 11 stated Resident 3 experienced confusion. On 10/15/25 at 4:41 PM Staff 13 (CNA) stated they recalled the 4/5/25 incident when Resident 3 pulled and broke Resident 2's catheter tubing off. Staff 13 stated they sat with Resident 2 for a long time after the incident, until the resident received her/his next scheduled pain medication, held her/his hand and provided an ice pack while Resident 2 cried hard. Staff 13 stated they cried with Resident 2 because it was so painful for the resident. Staff 14, who was the charge nurse that initiated the Physical Aggression Received incident report and responded to the 4/5/25 incident was unavailable for an interview. On 10/17/25 at 12:05 PM Staff 1 (Administrator) stated he expected all residents to be free from abuse while in the facility. Staff 1 acknowledged the 4/5/25 incident between Resident 2 and Resident 3.

1. Based on observation, interview and record review it was determined the facility failed to ensure a safe environment related to smoking for 4 of 4 sampled residents (#s 6, 16, 17 and 36) reviewed for smoking. This deficient practice was determined to be an immediate jeopardy (IJ) situation and placed all residents at risk for serious harm, serious injury or death and constituted substandard quality of care. Findings include: The facility's undated Non-Smoking Policy & Procedure, provided to the survey team on 9/5/23, specified the following: POLICY: - [The] Center does not permit smoking within the Center or on its campus. Smoke, smoking and smoking materials refer to the use of cigarettes, cigars, pipes, tobacco, inhaled tobacco substitutes, matches and lighters. PROCEDURE: - Screen all residents who smoke upon admission, quarterly and with a significant change of condition to determine ability to smoke independently; - Store resident's smoking materials in a secure area at the nurses' station or in a locked box in their room for all residents who desire to smoke off campus. The facility's undated Non-Smoking Agreement specified the facility was a non-smoking facility, a few residents were here prior to becoming non-smoking and the facility was required to let them smoke. The Non-Smoking Agreement included the following requirements [for] which the resident's signature of acknowledgement was required: 1) Not smoke on the campus at any time; 2) Will not be in possession of smoking products. 3) Any violation of this agreement will result in discharge and the decision will be final. Resident 16 was admitted to the facility in 10/2022 with diagnoses including quadriplegia. Resident 16's 10/19/22 Admission MDS indicated the resident was cognitively intact and used tobacco. Resident 16's 5/16/23 Care Plan revealed the resident was at risk for injury when smoking related to her/his diagnoses which included quadriplegia. Resident 16's 5/17/23 Non-Smoking Agreement revealed the resident refused to sign the document. Resident 16's 6/5/23 and 9/6/23 Smoking Evaluations indicated the resident smoked independently. An 8/28/23 Progress Note written by Staff 24 (RN) indicated she called non-emergency police due to a very strong, chemical smoky haze inside [Resident 16's] room which traveled down Hallway A. Resident 6 was admitted to the facility in 3/2020 with diagnoses including atrial fibrillation (irregular heart rhythm). Resident 6's health record revealed a signed 3/3/20 Smoking Agreement. Resident 6's 5/14/23 Quarterly MDS indicated the resident was cognitively intact and used tobacco. Resident 17 was admitted to the facility in 4/2021 with diagnoses including congestive heart failure. Resident 17's health record revealed a signed 1/19/23 Non-Smoking Agreement. Resident 17's 1/26/23 Annual MDS indicated the resident was cognitively intact and used tobacco. Resident 36 was admitted to the facility in 9/2022 with diagnoses including heart failure. Resident 36's health record revealed a signed 9/19/22 Smoking Agreement. Resident 36's 9/19/22 Admission MDS indicated the resident was cognitively intact and used tobacco. A 6/14/23 Progress Note written by Staff 11 (LPN) revealed Resident 36 was caught smoking in her/his bathroom on 6/11/23. On 9/5/23 at 10:44 AM Resident 6 was observed with cigarette butts, electronic cigarettes and rolled cigarettes in her/his sweatshirt pocket. Resident 6 stated she/he preferred to keep smoking materials with him/her and in her/his room. On 9/5/23 at 1:25 PM Resident 36 was observed with a pack of cigarettes and a lighter on her/his bedside table. Resident 36 stated she/he kept smoking materials in her/his room at all times. On 9/6/23 at 9:41 AM Resident 17 stated she/he smoked independently and maintained her/his own smoking materials. Resident 17 stated she/he kept her/his cigarettes and lighter in her/his backpack which hung on the back of her/his wheelchair as well as additional cigarettes in an unlocked drawer of her/his dresser. During the interview, Resident 17 opened her/his dresser drawer which revealed two packages of cigarettes. On 9/6/23 at 10:10 AM Resident 16 stated she/he smoked in the facility in her/his room often because it was [her/his] home and she/he could smoke in [her/his] home anytime [she/he] wanted. Resident 16 stated she/he did not have a lock box in her/his room for smoking materials and stated she/he kept smoking materials in a bag near her/his person. Observations of the contents of Resident 16's bag included a tobacco pipe, cigarette butts and a lighter. A flower pot which contained five lighters was observed on Resident 16's window sill. On 9/6/23 at 11:13 AM Staff 1 (Executive Director) stated the facility had difficulty with Resident 16 and her/his willingness to comply with the facility's Smoking Policy for approximately eight months. Staff 1 stated he had many conversations with Resident 16 about the Smoking Policy but the resident did what she/he wanted to do. Staff 1 stated he received reports of Resident 16, as well as others, smoking in their rooms but staff did not intervene at these times because staff only smelled the smoke and did not actually see residents smoking. Staff 1 stated he was aware Resident 16 as well as other residents maintained their own smoking materials on their person or in other unlocked areas and confirmed the smoking materials should be locked either at the nurses' station or in the residents' rooms when not in use. Staff 1 further stated the facility was in the process of reviewing the entire Smoking Policy as the facility was supposed to be a non-smoking campus. On 9/6/23 at 4:36 PM Witness 1 (Complainant) stated Resident 16 smoked in her/his room frequently and the smoke traveled through the halls and vents of the facility. Witness 1 stated she called 911 one night recently because the smell was so bad and she feared the smoke affected other residents with respiratory illnesses. Witness 1 stated she brought her concerns to management who responded by saying their hands were tied and residents were allowed to smoke in their own home. Witness 1 stated when residents had smoking materials such as cigarettes and lighters in plain view, management directed staff there was nothing they could do and to call the police. Witness 1 stated Resident 36 also smoked in her/his room and it smelled bad in the hallway near her/his room. Interviews from 9/5/23 through 9/6/23 between the hours of 10:07 AM and 3:18 PM with Staff 11 (LPN), Staff 13 (Medical Records), Staff 14 (RN), Staff 15 (Housekeeping), Staff 17 (CNA), Staff 18 (CNA), Staff 19 (CNA), Staff 35 (CNA) and Staff 36 (CNA) revealed Resident 16 smoked in her/his room and bathroom frequently, the smell of smoke was strong throughout the facility, there were smoking materials visible in her/his room and cigarette butts were found in the resident's plastic-lined trash can. Staff stated Resident 36 smoked and kept smoking materials in her/his room. Staff stated there was no system in place to secure smoking materials and no training was provided regarding the facility's Smoking Policy. Staff stated they reported their concerns to management many times, who stated it was the residents' right to smoke and directed staff not to remove smoking materials from residents' rooms. Staff stated they witnessed residents smoking directly outside the facility's front door and not off campus. On 9/6/23 at 2:29 PM Staff 1, Staff 2 (DNS) and Staff 20 (Regional Nurse) were informed of the IJ situation related to the facility's failure to ensure a safe environment regarding smoking. The IJ template was provided and an IJ removal plan was requested. On 9/6/23 at 5:45 PM the facility submitted an IJ removal plan which was approved by the survey team. The IJ removal plan indicated the facility would implement the following actions: - Staff education regarding the facility's Smoking Policy; - Residents identified as smokers would be assessed and care planned for safe smoking practices and educated on the facility Smoking Policy; - Smoking materials secured at the nursing station or in a lockbox in the resident room on a case-by-case basis; - Residents who violate the Smoking Policy will be issued a 30-day notice of discharge for the health and safety of themselves and others; - Establish a designated smoking area with a fire extinguisher, cigarette receptacle, fire blanket and smoking aprons; - Staff will observe the smoking area approximately every two hours to ensure safe smoking practices; - Residents who display any signs of unsafe smoking will be reported to Staff 1 and 2; - Oxygen in use signs shall be used to identify rooms where residents use supplemental oxygen; they should not have roommates that smoke. On 9/7/23 at 11:06 AM Resident 16 stated she/he was provided a lockbox to secure smoking materials in her/his room. On 9/7/23 at 11:46 AM Staff 21 (Assistant DNS) provided documentation which indicated all staff were educated on the Smoking Policy and procedures. On 9/7/23 from 11:06 AM through 12:34 PM interviews were conducted with Resident 16, Staff 13, Staff 14, Staff 15, Staff 16 (CNA), Staff 17, Staff 18, Staff 19, Staff 21 and Staff 36. Staff and Resident 16 confirmed they received education regarding the facility's Smoking Policy and procedures related to the designated smoking area and securing smoking materials. On 9/7/23 at 1:04 PM the designated smoking area was observed with a fire extinguisher and an appropriate cigarette receptacle. On 9/7/23 at 1:14 PM the survey team and Staff 1 verified all elements of the IJ removal plan were completed. 48890 2. Based on observation, interview and record review it was determined the facility failed to assess and care plan for smoking safety for 3 of 7 sampled residents (#s 17, 31 and 36) reviewed for accidents. This placed residents at increased risk for injury related to smoking. Findings include: a. Resident 36 was admitted to the facility in 9/2022 with diagnoses including heart failure. Resident 36's 9/19/22 Admission MDS indicated the resident was cognitively intact and used tobacco. Resident 36's health record revealed a 9/19/22 signed Smoking Agreement. No evidence was found in Resident 36's health record that a Smoking Assessment was completed On 9/8/23 at 11:21 AM Staff 2 (DNS) stated smoking assessments should be completed at least annually and upon readmission. 47000 b. Resident 31 was admitted to the facility in 3/2023 with diagnoses including chronic obstructive pulmonary disease. Resident 31's signed 3/7/23 Non-Smoking Agreement indicated the resident would not be in possession of smoking products while at the facility. Resident 31's 3/13/23 Smoking Evaluation revealed the resident was assessed as safe to smoke independently. Resident 31 discharged from the facility on 8/8/2023 and was readmitted on [DATE]. Resident 31's 9/2023 Physician Orders directed the resident to receive oxygen at three liters via nasal cannula (tube) continuously. No evidence was found in Resident 31's health record that a Smoking Assessment was completed after the resident's readmission to the facility in 8/2023 or a Care Plan was developed related to the resident's smoking abilities and needs. On 9/5/23 at 3:06 PM Resident 31 was observed in bed and used a concentrator (a medical device used to administer oxygen). Resident 31 stated she/he kept her/his cigarettes and lighter in an unlocked drawer in her/his room. On 9/6/23 at 10:07 AM Staff 18 (CNA) stated she found information related to a resident's smoking needs and abilities in the Care Plan. Staff 18 stated smoking materials were supposed to be kept in a lock box at the nurse's station but residents refused to do adhere to this policy so they maintained their own materials. Staff 18 stated Resident 31 smoked independently and she was unsure of where the resident's smoking materials were kept. Staff 18 stated Resident 31 was supposed to leave her/his oxygen at the nurse's station before going outside to smoke. On 9/6/23 at 10:17 AM Staff 19 (CNA) stated Resident 31 maintained her/his own smoking supplies in her/his room and was encouraged to remove her/his oxygen before going outside to smoke. On 9/6/23/at 11:13 AM Staff 1 (Executive Director) acknowledged the findings and confirmed the facility's policy was for resident smoking materials to be secured when not in use. On 9/8/23 at 11:21 AM Staff 2 (DNS) acknowledged the findings and stated smoking assessments should be completed at least annually and upon readmission, and she expected Resident 31 to have a Care Plan for smoking in place. c. Resident 17 was readmitted to the facility in 4/2021 with diagnoses including congestive heart failure. Resident 17's 4/23/21 Smoking Assessment revealed the resident was able to smoke independently without special equipment. Resident 17 discharged from the facility on 7/16/21 and was readmitted on [DATE]. Resident 17's 1/19/23 Non-Smoking Agreement, signed by Resident 17, indicated the resident would not be in possession of smoking products while at the facility. Resident 17's 1/26/23 Annual MDS revealed the resident used tobacco. Resident 17's 6/8/23 Smoking Care Plan revealed the following: - Complete smoking data collection and assessment. - Store smoking materials under lock and key in her/his room. Resident 17's 7/29/23 Quarterly MDS revealed the resident was cognitively intact and was independent with locomotion on-and-off the unit. No evidence was found in Resident 17's clinical record that a Smoking Assessment was completed after 4/23/21, including after her/his readmission to the facility in 7/2021. On 9/6/23 at 9:41 AM Resident 17 stated she/he smoked independently and maintained her/his own smoking materials. Resident 17 stated she/he kept her/his cigarettes and lighter in her/his backpack which hung on the back of her/his wheelchair as well as additional cigarettes in an unlocked drawer of her/his dresser. At this time, Resident 17 opened her/his dresser drawer and revealed two packages of cigarettes. On 9/6/23 at 10:17 AM Staff 19 (CNA) and at 10:31 AM Staff 11 (LPN) stated Resident 17 smoked independently and maintained her/his own smoking materials. Staff 19 and Staff 11 stated they did nothing when unsecured resident smoking supplies were observed because a majority of residents maintained their own smoking materials. On 9/6/23/at 11:13 AM Staff 1 (Executive Director) acknowledged the findings and confirmed the facility's policy was for resident smoking materials to be secured when not in use. On 9/8/23 at 11:21 AM Staff 2 (DNS) acknowledged the findings and stated Smoking Assessments should be completed at least annually and upon readmission. 3. Based on interview and record review it was determined the facility failed to ensure adequate supervision and a safe environment for 2 of 7 sampled residents (#s 1 and 17) reviewed for accidents. This placed residents at increased risk for injuries. Findings include: The facility's 2/3/23 Accidents and Incidents Policy stated the center strived to provide an environment free from hazards over which the center has control and provided supervision and assistance devices to each resident to prevent avoidable accidents. The Policy defined an avoidable accident as an incident that occurred when the center failed to identify environmental hazard and resident risk. The proper action following a fall included the following: -Determined what may have caused the fall. -Address the contributing factors of the fall. -Revise the care plan and/or the centers' practices to reduce the likelihood of another fall. -An evaluation of factors which lead to the residents' fall was necessary to provide appropriate intervention(s) to help prevent future occurrences. a. Resident 17 was readmitted to the facility in 7/2021 with diagnoses including congestive heart failure. Resident 17's 4/28/23 Quarterly MDS revealed the resident was cognitively intact, was independent with locomotion on-and-off the unit and used a wheelchair for mobility. A 6/17/23 Fall Incident Report revealed the following: - Resident 17 and Staff 26 (CNA) were outside of the facility, but on the property, and headed towards the street together to view an accident. - Staff 26 pushed Resident 17 in her/his wheelchair on a gravel road down an incline. - Staff 26 slipped and lost control of Resident 17's wheelchair. - Resident 17 fell out of her/his wheelchair, landed on the ground, sustained abrasions to her/his face, right hand, right arm and bilateral knees. The resident also experienced pain in her/his ribs. A 6/18/23 Progress Note completed by Staff 24 (RN) revealed the following: - Resident 17 fell out of her/his wheelchair when outside with Staff 26. After the fall, Staff 26 pulled [her/him] right up by [her/his] pants and into the chair quickly. - Resident 17 was assisted back to the facility immediately after the fall when a nurse assessment was completed, vitals were taken and wounds were cleaned. A 6/21/23 Witness Statement completed by Staff 26 revealed the following: - Staff 26 was smoking outside of the facility and Resident 17 was present. - Staff 26 asked Resident 17 to accompany her to see an accident up the road. - Staff 26 pushed Resident 17 in her/his wheelchair down a hill. - Staff 26 slipped on rocks and Resident 17 fell out of her/his wheelchair. - Staff 24 was informed of the fall and treated the resident's injuries. On 9/5/23 at 11:34 AM Resident 17 stated she/he recalled the incident that occurred in 6/2023 when she/he fell out of her/his wheelchair outside of the facility. Resident 17 stated Staff 26 pushed her/him in her/his wheelchair in order to see an accident that occurred in the neighborhood. Resident 17 stated along the way, the path changed from paved to gravel, and her/his wheelchair got stuck in the gravel, and she/he flew out of [her/his] wheelchair. Resident 17 stated Staff 26 picked her/him up off the ground by her/his shorts and she/he sustained scratches on her/his right leg and left knee. Resident 17 further stated the gravel tore up her/his hands and she/he had to wear bandages for four or five days. On 9/6/23 at 3:28 PM Staff 11 (LPN) stated she completed the incident report as soon as she was made aware of Resident 11's fall. Staff 11 stated she was informed Staff 26 pushed Resident 17 down a gravel road in her/his wheelchair, Staff 26 slipped and Resident 17 fell out of her/his wheelchair onto the gravel. Staff 11 stated the resident complained of rib pain, an x-ray was obtained and no injury was found. On 9/7/23 at 2:43 PM an attempt was made to interview Staff 26. Staff 26 was unavailable for an interview. On 9/8/23 at 11:21 AM Staff 2 (DNS) stated the incident was an unfortunate accident and was avoidable. 38140 b. Resident 1 was admitted to the facility in 1/2021 with diagnoses including cerebral palsy (impaired muscle coordination). Resident 1's 8/7/23 Quarterly MDS indicated she/he was not able to answer the cognitive questions to assess cognition. An 8/29/23 Progress Note revealed Resident 1 experienced a fall on 8/29/23. Resident 1 was found with her/his face on the floor, lying on her/his left hand, with feet still up on the bed. The resident was lifted back into her/his bed. The RN obtained vitals and made an assessment. The assessment revealed Resident 1's left hand was discolored and light purple in color up to her/his wrist and left temple area was red and slightly swollen. Neurological assessments (evaluation of the nervous system) were initiated. Record review of Resident 1's health record revealed no evidence of an 8/29/23 post fall assessment other than the progress note immediately following the fall. No evidence of neurological assessments, alert charting to follow injuries, evaluation/investigation for the cause of the fall or Care Plan revisions to prevent possible future occurrences were found in the health record for the 8/29/23 fall. On 9/8/23 at 11:14 AM Staff 2 (DNS) confirmed there was no record of Resident 1's 8/29/23 post fall assessments, Care Plan revision, alert charting or neurological assessments completed for the fall. Staff 2 acknowledged no investigation for the cause of the fall was completed and she expected these to be completed after a fall. No further information was provided.

Based on interview and record review it was determined the facility failed to protect a resident's right to be free from physical abuse by a staff member for 1 of 1 sampled resident (#2) reviewed for abuse. This placed residents at risk for physical abuse. Findings include: Resident 2 was admitted to the facility in 11/2022 with diagnoses including kidney injury and congestive heart failure. Resident 2's BIMS from 11/5/22 was 11 which indicates moderate cognitive impairment. An 11/28/22 at 12:21 PM progress note from Staff 11 (Social Services Director) revealed Resident 2 reported she/he had bruises on her/his shoulder, arm and hand after Staff 9 (Former CNA) provided care. According to an 11/30/22 Incident Investigation Report, Resident 2 was observed to be bruised on her/his right hand and left bicep. Staff 9 was immediately suspended and removed from the schedule during the investigation. Resident 2 denied any residual pain from the incident. Resident 2 stated she/he felt safe in the facility after the incident. On 3/1/23 at 11:55 AM Staff 10 (Former CNA) stated she worked with Resident 2 on 11/28/22 and recalled having observed new dark bruising on Resident 2's right hand, right elbow and left shoulder. When asked about the new bruises, Resident 2 stated she/he was treated roughly by Staff 9 during the overnight shift which began on 11/27/22. Resident 2 stated her/his arm was pulled when repositioned in bed which resulted in pain and Staff 9 had not responded to Resident 2's request to stop pulling her/his arm during bed repositioning. On 3/1/23 at 12:04 PM Resident 2 recalled the interaction with Staff 9. Staff 9 grabbed and pulled her/his arm when she/he was repositioned in bed. Resident 2 requested Staff 9 to stop because of pain in her/his right arm, but Staff 9 did not stop and stated Resident 9 could not to tell her what to do. Attempts to contact Staff 9 were unsuccessful. On 3/1/23 at 11:32 AM Staff 11 stated she conducted the facility investigation regarding the incident. Staff 11 stated Resident 2 had bruising and what appeared to have been indentation of finger marks on his right hand and arm when she assessed Resident 2 on 11/29/22. Staff 11 confirmed Resident 2 was physically abused by Staff 9.

Based on interview and record review it was determined the facility failed to ensure staff followed the care plan related to safe transfers and failed to identify risks to prevent a burn injury for 2 of 5 sampled residents (#s 3 and 5) reviewed for accidents. Resident 3 sustained a facial bruise to her/his left jaw, dislocated left greater toe and sustained cuts to the bottom of her/his left foot. Resident 5 sustained a second degree burn on her/his right arm. Findings include: 1. Resident 3 was admitted to the facility in 3/2019 with diagnoses including stroke and depression. A 5/22/21 Significant Change MDS revealed Resident 3's BIMs score was 8 which indicated Resident 3 was moderately cognitively impaired. A comprehensive care plan revised 12/28/20 indicated Resident 3 had an ADL deficit related to stroke, impaired balance and limited mobility. The resident required two person assist with repositioning, turning in bed and was total assistance with personal hygiene care. Resident 3 was incontinent of bladder and received incontinent care every two hours. A 12/26/20 Fall Incident report revealed the following: -Staff 5 (CNA) alerted Staff 11 (LPN) Resident 3 fell out of bed during patient care. Staff 11 entered the room and Resident 3 was laying on her back he assessed Resident 3 and observed a bruise to the left jaw which measured 5 cm x 6 cm and Resident 3 had a cut under her/his third left toe. Resident 3 was a two person assist with patient care and Staff 5 provided patient care by herself. On 12/30/20 interviews were conducted with staff and revealed the following: -Resident 3 complained of pain when Staff 19 (Previous DNS) touched the area close to her/his left toes. Staff 19 assessed the bruise on the left jaw which measured 9 cm x 5 cm was dark bluish purple in color with no open area and Resident 3 denied pain. Resident 3 was on hospice and they were notified. -Staff 5 stated she was changing Resident 3's brief by herself and the resident's left leg was over her/his right and as Staff 5 was cleaning Resident 3's bottom her/his right leg slipped off and Resident 3 rolled off the bed, fell on her/his knees, sustaining a bruise and cuts under her third and fourth left toes. Staff 5 indicated the resident did not hit her/his head. -Upon investigation Resident 3 was turned too far to the side of the bed when Staff 5 was trying to clean the resident's buttocks resulting in the fall. Resident 3 sustained a bruise on the left jaw and cuts under her/his third and fourth toes. Assessment of the toes showed no signs or symptoms of infection, noted minimal bleeding, dislocation was noted on the greater toe of the left leg. Resident 3 was on hospice and hospice declined an x-ray of her/his left lower foot. Abuse and neglect were ruled out. On 7/2/21 at 9:46 AM Staff 6 (CNA) stated she worked on 12/26/20 when Resident 3 fell out of bed and was on her lunch break when the fall occurred. Staff 6 stated Resident 3 was a two person assist with her/his ADL care needs and Staff 5 was providing incontinence care alone. Staff 6 stated Resident 3 had bruised the left side of her/his face and chin and had cuts to her/his left toes. On 7/2/21 at 11:34 AM Staff 5 (CNA) stated on 12/26/20 she went into change Resident 3 and placed Resident 3's left leg over Resident 3's right leg for leverage and the right leg was too far over the edge of the bed and Resident 3 fell out of bed onto her/his knees. Staff 5 stated Resident 3's left toes were bent and were bleeding from being cut. Staff 5 stated she was not sure if Resident 3 hit the left side of her/his chin and face on the air conditioner or the chair on her/his way down. Staff 5 stated she hollered for help and Staff 11 entered the room and assessed the resident and Resident 3 had bruising to her/his left chin and face from the fall. Staff 5 stated Resident 3 did not go to the hospital and did not indicate she/he was in pain. Staff 5 stated she should have had another CNA in the room to assist her when providing incontinence care to Resident 3. On 7/6/21 at 3:12 PM Staff 11 (LPN) stated he worked on 12/26/20 when Resident 3 fell out of bed. Staff 5 hollered for help and he entered the room and Resident 3 was on the floor. Staff 11 stated he assessed the resident and she/he had bruising to the left side of her/his face and her/his left toes were bleeding, and Resident 3 denied any pain or discomfort. Staff 11 stated Staff 5 should have had another CNA assisting with incontinence care for Resident 3. Staff 11 stated he informed Staff 19 of the incident. On 7/6/21 and 7/7/21 attempts were made to reach Staff 19 but were unsuccessful. On 7/9/21 at 10:22 Am Staff 2 (DNS) stated he was not in the building when the 12/26/21 fall occurred but would expect staff to implement and follow the care plan. Resident 3 was a two person assist with incontinent care and Staff 5 provided incontinent care alone. 2. Resident 5 was admitted to the facility in 2012 with diagnoses including stroke and dementia. The 1/2018 Policy and Procedure for hot food and beverage safety indicated: -Attend residents at risk for hot food injury when serving hot food or beverages. -Do not exceed hot food or beverage temperature of 190 degrees on the serving line. -Monitor and record food and beverage serving temperature prior to meal service using Food Temperature Record. The center requires staff supervision of food and beverage service to residents. -Residents at risk for burn injury will be assisted with tray set-up or with eating to prevent spills of hot food or beverage. -Residents at risk for a burn injury include: -Slow response time -Need assistance with eating -Cognitive impairment (dementia). The 1/7/19 Significant Change MDS indicated Resident 5 had a BIMS of 0 which indicated severe impaired cognition. Resident 5's 8/15/16 care plan identified the resident was dependent on one staff for assistance of eating. On 3/24/19 at 7:00 AM an Incident Note indicated the resident was sitting in the dining room in her/his wheelchair at a table waiting for breakfast. Staff 23 (CNA) was pouring coffee for the residents. The coffee was tempt by the kitchen staff at 190 degrees before coming out of the kitchen in a carafe. Staff 23 placed the coffee cup on Resident 5's table out of her/his reach but Resident 5 grabbed the coffee which spilled all over her/his right arm. Staff 23 applied cold water to the arm and alerted the nurse. A 3/24/19 progress note indicated kitchen staff were interviewed and stated hot liquids are tempt when poured into the carafe at a 190 degrees. A 3/27/19 statement from Staff 23 indicated she was in the dining room serving residents drinks when she poured Resident 5 coffee and placed a lid and straw on the cup, set the cup on the table away from the resident's reach because she knew the coffee was too hot and Resident 5 needed assistance with meals and beverages. Staff 23 stated she turned her back when somehow the resident grabbed the coffee and spilled on her/his right arm. A 3/28/19 statement from Staff 18 (RN) indicated Resident 5 obtained a burn to her/his right arm and two small areas to her/his right leg due to spilled coffee. Staff 18 indicated Staff 23 confirmed she poured the coffee, put a lid with a straw on the cup and set the coffee out of reach for Resident 5. Staff 18 indicated it is suspected the resident did reach for the coffee, but resident is not able to state what happened. Staff 18 indicated the resident did have upper extremity weakness and was not able to hold the cup. Resident 5 obtained a second degree burn to her/his arm. On 7/7/21 at 10:23 AM Staff 23 stated it was my fault, I poured Resident 5 a cup of coffee and put the cup in front of her/him on the table and she/he picked the cup up and dropped the cup which burnt her/his right arm and leg. Staff 23 stated she realized what she did when she gave Resident 5 the cup, but it was too late. On 7/7/21 at 11:59 AM Staff 18 stated she could not remember the details but remembered the resident spilled hot coffee on her/him.

1. Based on observation, interview and record review it was determined the facility failed to implement preventative measures to control the spread of COVID-19 during a facility outbreak among residents and staff for 2 of 4 direct care staff (#s 4 and 5) who tested positive for COVID-19 on 12/11/20. Staff 4 and Staff 5 continued to provide direct care to COVID-19 negative residents and interact with COVID-19 negative staff. This failure, determined to be an immediate jeopardy situation, placed all residents and staff at risk of contracting the COVID-19 virus. Findings include: The CDC (Centers for Disease Control and Prevention) 12/14/20 Strategies to Mitigate Healthcare Personnel Staffing Shortages indicated if healthcare personnel (HCP) develop even mild symptoms consistent with COVID-19, they must cease patient care activities and notify their supervisor or occupational health services prior to leaving work. These individuals should be prioritized for testing. If HCP are tested and found to be infected with [DIAGNOSES REDACTED]-CoV-2, they should be excluded from work until they meet all Return to Work Criteria. HCP with suspected [DIAGNOSES REDACTED]-CoV-2 infection should be prioritized for testing, as testing results will impact when they may return to work and for which patients they might be permitted to provide care. The facility's 4/20/20 Cornerstone Contingency Strategies to Mitigate Staffing Shortages Policy and Procedure indicated the following: - Staff with symptoms are to be tested and leave the facility; - If employees are suspected or have actual cases of COVID-19, the employee will not be allowed to work until the following criteria are met: -resolution of fever without the use of fever reducing medications for at least 24 hours; -improvement in (COVID-19) symptoms; -two negative tests at least 24 hours apart. On 12/11/20 at 9:50 AM the facility had a census of 29 residents who resided on three separate units; A, B, and C. Unit A had a total of nine residents, two of whom were COVID-19 negative.Unit B had a total of seven residents, two of whom were COVID-19 negative. Unit C had a total of 13 residents, 10 of whom were COVID-19 negative. On 12/11/20 between the hours of 9:50 AM and 1:16 PM observations were conducted of facility staff. During those observations, Staff 4 (CNA), Staff 5 (CNA) and Staff 10 (CNA) provided direct resident care across all three units and to residents who were negative for COVID-19. Staff 4 and Staff 5 were observed to work in close proximity to Staff 10 (CNA). In an interview on 12/11/20 at 1:16 PM Staff 5 (CNA) stated she started work in the facility on 12/11/20 at 6:00 AM and reported not feeling well to Staff 1 (Administrator). Staff 5 stated Staff 7 (Medical Records) conducted a rapid test for COVID-19 at 8:10 AM and the results were positive. Staff 5 stated Staff 1 asked her to stay on shift to help out. Staff 5 stated she was providing direct care to COVID-19 positive and negative residents. During the interview, Staff 5 appeared pale, sweaty, flushed and fatigued. In an interview on 12/11/20 at 1:18 PM Staff 4 (CNA) stated she started her shift on 12/11/20 at 6:00 AM, was not feeling well and reported not feeling well to Staff 1 (Administrator). Staff 4 stated a rapid test for COVID 19 was conducted at 8:00 AM and the results were positive. Staff 4 stated she was told by Staff 1 she could stay in the facility to work. Staff 4 confirmed she was providing direct care to COVID-19 positive and negative residents. During the interview, Staff 4 appeared pale and fatigued. On 12/11/20 at 1:22 PM the findings of this investigation were discussed with Staff 1. Staff 1 confirmed Staff 4 and Staff 5 tested positive for COVID-19 on the morning of 12/11/20. Staff 1 stated they were desperate and thought it was ok for COVID-19 positive staff to work with COVID-19 positive residents. Staff 1 confirmed Staff 4 and Staff 5 were assigned to provide direct care to residents who were COVID-19 negative and COVID-19 positive. On 12/11/20 at 2:30 PM Staff 8 (HR/Staffing Coordinator) provided two COVID-19 rapid test [MEDICATION NAME] (Ag) cards which indicated positive test results. The COVID-19 rapid test Ag cards were labeled with Staff 4 and Staff 5's initials. On 12/11/20 at 3:30 PM Staff 1 and Staff 2 (DNS) were informed of the immediate jeopardy (IJ) situation related to the facility's failure to mitigate and prevent the spread of the COVID-19 virus to residents and staff by allowing COVID-19 positive staff to provide direct care to COVID-19 negative residents and interact with COVID-19 negative staff. On 12/11/20 at 3:37 PM IJ templates were provided to Staff 1 and an immediate IJ removal plan was requested. On 12/11/20 at 7:31 PM the facility submitted a removal plan which was accepted and approved by the survey team. The IJ Removal Plan indicated the facility would implement the following actions: - Residents identified as COVID-19 positive will be cohorted on A unit on 12/11/20; - Signage for appropriate precautions will be placed for COVID-19 positive residents on 12/11/20; - Nursing staff, department heads, housekeeping and dietary staff will be educated on required PPE use and precautions for COVID-19 positive residents by 9:00 PM on 12/11/20; - Staff testing COVID-19 positive or become symptomatic at work will be sent home. On 12/11/20 at 7:34 PM surveyors verified all elements of the IJ removal plan were implemented and no COVID-19 positive staff were working in the facility. 2. Based on observations, interviews and record review it was determined the facility failed to maintain appropriate infection control practices to prevent the potential spread of the COVID-19 virus and other infectious diseases for 3 of 3 units reviewed. This placed residents at risk for the exposure and contraction of the COVID-19 virus and other infectious diseases. Findings include: a. 1. The Centers for Disease Control (CDC) Coronavirus 2019 (COVID-19), last revised 11/20/20, instructed healthcare workers to perform hand hygiene before and after all patient contact, before and after removing PPE (Personal Protective Equipment), including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process. The facility's 1/2017 Hand Hygiene Policy and Procedure outlined hand hygiene is the most important procedure for preventing Healthcare Associated Infections. Observations were conducted from 12/11/20 through 12/22/20 between the hours of 9:50 AM and 7:30 PM. During these observations staff were observed to not perform hand hygiene appropriately to prevent the spread of the COVID-19 virus. Examples included: - Staff 17 (LPN) was observed on the designated COVID-19 unit with her face mask tucked under her chin and her face shield placed on the desk without a barrier. After the surveyor entered the unit, Staff 17 donned her mask and shield and did not perform hand hygiene between or after the process. - An unidentified maintenance staff entered the designated COVID-19 unit PPE storage area and placed his tool bag and tools on the floor. The maintenance personnel then donned his face mask and face shield, picked up his tool bag and tools and exited the storage area without performing hand hygiene before, during or after the process. - Staff 24 (District Manager) touched and adjusted her face mask and shield multiple times and did not perform hand hygiene. - Staff 6 (Regional RN) adjusted and touched her face mask and shield on multiple occasions without completing hand hygiene, potentially contaminating the immediate environment she subsequently touched including the medication cart and nursing station. Staff 6 did not perform hand hygiene during the donning, doffing and disinfection process of her mask and face shield in the PPE storage and disinfecting area. - An unidentified staff entered the PPE storage and disinfecting area and retrieved a reused face shield and face mask from a bag, donned the items and did not perform hand hygiene before or during the process. - Staff 4 (HR/Staffing Coordinator) was observed in her office without face PPE donned. A face mask and face shield was observed on her desk. When the surveyor entered Staff 4's office, Staff 4 donned the face mask and face shield and did not perform hand hygiene before, during or after the process and touched items in her immediate environment; - An unidentified staff entered the facility with a face mask donned and entered the PPE storage and disinfection area. The staff doffed her face mask, placed it in a paper bag, retrieved a face mask from a different bag and donned the mask. No hand hygiene was performed between the donning and doffing process. - Staff 14 (CMA) doffed her face shield and face mask, placed both pieces in a storage bag, and did not perform hand hygiene before, during or after the process and did not perform hand hygiene before exiting the area. - Staff 10 (CNA) donned her reused face mask and face shield without performing hand hygiene before, during or after the process. b. The CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, revised 11/20/20 instructed facilities to ensure environmental cleaning and disinfection procedures were followed consistently and correctly. The facility's 3/4/20 COVID-19 Environmental Cleaning and Disinfection Policy and Procedures instructed staff to wear appropriate Personal Protective Equipment (PPE) when performing cleaning procedures and follow manufacturer's instructions for use to determine dwell times of (product) being used to ensure disinfection has occurred. Observations were conducted from 12/11/20 through 12/22/20 between the hours of 9:50 AM and 7:30 PM. During these observations staff were observed to not adhere to or have knowledge of appropriate disinfection processes or dwell/contact times to ensure disinfection. Examples included: - Staff 23 (Director of Rehabilitation) was observed disinfecting shared resident equipment with a disinfecting wipe and stated she was not aware of the product's contact time. - Staff 18 (CNA) stated she thought the contact time for the [MEDICAL CONDITION] Solution she used was four minutes. The EPA N Disinfectant Results indicated the contact time was one minute. - Staff 6 (Regional RN) was observed to spray her face shield with the [MEDICAL CONDITION] Solution and after three seconds, Staff 6 wiped the face shield dry. Staff 6 did not adhere to the one minute contact time. - Staff 14 (CMA) was observed to doff her face shield and place it into a bag. Staff 14 did not disinfect her face shield after the doffing process and before storage. - Staff 8 (CNA) was observed to exit the designated COVID-19 unit with her face shield and mask donned. Staff 8 did not disinfect her shield upon exit or re-entering the COVID-19 unit. - Staff 10 (CNA) was observed to spray her face shield with the [MEDICAL CONDITION] Solution. Staff 10 immediately and vigorously wiped the back and front of the shield repeatedly with a paper towel while holding the shield against her pant leg. c. The OHA 5/9/20 Provisional Guidance: Clinical Care and Healthcare Infection Prevention and Control for COVID-19 Recommendations for Aerosol-Generating Procedures (AGPs) instructed when conducting (or assisting with) AGPs for patients with fever or respiratory symptoms, or with known or suspect COVID-19, HCP should utilize standard, contact, and airborne precautions, including: -ensure staff wear N95 masks, face shields, gowns and gloves during AGPs; -only one staff member present during the procedure; -door closed during the procedure and for two hours afterwards. On 12/12/20 at 10:40 AM Resident 2 was observed in her/his room with an AGP in progress with the resident's door fully open. At 11:04 AM Staff 18 (CNA) and Staff 19 (LPN) were observed entering Resident 2's room wearing N95 masks, face shields and gloves. No gowns were worn. On 12/12/20 at 10:41 AM Staff 19 stated he was not aware of any specific guidance regarding AGPs. On 12/14/20 at 10:14 AM Resident 2 was observed in her/his room with an AGP in progress with the resident's door fully open. Staff 18 was observed to enter the resident's room wearing an N95 mask, face shield and gloves. No gown was worn. d. The 12/13/20 OHA recommendations regarding isolation gowns instructed gowns should not be reused (i.e. removed and put back on) and should be doffed in the room after each resident contact. On 12/14/20 at 12:45 PM Staff 2 (DNS) was observed in the designated COVID-19 unit donning and doffing PPE as she walked through the hallways. At 12:56 PM Staff 2 entered room five without a gown or gloves donned. Staff 2 stated she was reusing gowns on the COVID-19 unit and entered room five expecting to find her reused gown there. Staff 2 stated she thought gowns could be reused and hung inside resident rooms for use at a later time. e. The 10/25/20 CDC Coronavirus 2019 (COVID-19) Strategies for Optimizing the Supply of Eye Protection indicated if a disposable face shield is reprocessed, it should be reprocessed whenever it is visibly soiled or removed, such as when leaving an isolation area, prior to putting it back on. OHA recommendations regarding face shield storage directed facilities to organize face shield storage area so face shields are not touching each other. Staff should place face shields apart from each other in labeled, clear plastic bags so there is no risk of touching or having staff touch the bag of another staff 's face shields. Observations were conducted from 12/11/20 through 12/22/20 between the hours of 9:50 AM and 7:30 PM of the facility staff reusable PPE storage and disinfecting area. The observations revealed the storage room disorganized and in disarray. Examples included: - multiple clear, open plastic ziplock bags and paper bags which contained face shields and masks pinned on twine touching each other; - multiple clear, open plastic ziplock bags which contained more than one reused face shield folded over onto each other; - multiple clear plastic bags which contained face shields and N95s stored together and touching each other; - multiple clear plastic bags which contained face shields lying on the floor and on the fireplace hearth; - two trash receptacles over-flowing with discarded used PPE and paper towels; - [MEDICAL CONDITION] Solution disinfectant spray bottles on the disinfection table with the incorrect information of 2 minute dwell time handwritten on the bottle; - A box of unused procedure masks opened with the masks spilled out of the box and onto the disinfection table. On 12/22/20 at 10:30 AM the findings of this investigation were discussed with Staff 1 (Administrator) and Staff 2 (DNS). Staff 2 stated continuing education would be provided regarding appropriate hand hygiene and her expectation of staff included washing hands with soap and water or alcohol based hand rub before and after cares and resident contact and after touching the PPE or face. Staff 2 incorrectly stated all disinfectants in the facility had a dwell time of two minutes and staff should know the dwell times for the disinfectants. Staff 2 stated the door should be closed for AGPs and stated staff should know not to reuse isolation gowns unless the facility was in a crisis mode. Staff 1 and Staff 2 did not provided additional information or explanation regarding the condition of the PPE storage and disinfection area.

Based on interview and record review it was determined the facility failed to ensure Staff 5 (LPN), Staff 12 (LPN), Staff 13 (RN), Staff 23 (CNA), Staff 24 (CNA) met professional standards of care for 4 of 8 sampled residents (#s 2, 4, 6 and 10) reviewed for change of condition and discharge. As a result of this deficient practice this was determined to be an Immediate Jeopardy situation as the deficiencies resulted in a delay in Resident 6's treatment for [REDACTED]. Findings include: Oregon Administrative Rules (OARs) Board of Nursing [PHONE NUMBER] Conduct Derogatory to the Standards of Nursing Defined (3) Conduct related to the client's safety and integrity: (b) Failing to take action to preserve or promote the client's safety based on nursing assessment and judgment; (4) Conduct related to communication: (f) Failing to communicate information regarding the client's status to members of the health care team in an ongoing and timely manner as appropriate to the context of care. Board of Nursing [PHONE NUMBER] Scope of Practice Standards for Registered Nurse (3) Standards related to the RN's responsibility for nursing practice. Through the application of scientific evidence, practice experience, and nursing judgment, the RN shall: (a) Conduct comprehensive assessments by: (A) Collecting data from observations, examinations, interviews, and records in an accurate and timely manner as appropriate to the client's needs and context of care; (C) Distinguishing abnormal from normal data, sorting, selecting, recording, evaluating, synthesizing and communicating the data; (E) Identifying signs and symptoms of deviation from current health status; (c) Develop a client-centered plan of care based on analysis of the client's problems or risks that: (A) Establishes priorities in the plan of care; (C) Includes nursing interventions to address prioritized diagnostic statements or reasoned conclusions. (5) Standards related to the RN's responsibility for client advocacy. The RN shall: (a) Advocate for the client's right to receive appropriate care, including client-centered care and end-of-life care, that is respectful of the client's needs, choices and dignity; (b) Intervene on behalf of the client to identify changes in health status, to protect, promote and optimize health, and to alleviate suffering. Board of Nursing [PHONE NUMBER] Conduct Unbecoming a Nursing Assistant A CNA, regardless of job location, responsibilities, or use of the title CNA, whose behavior fails to conform to the legal standard and accepted standards of the nursing assistant profession, or who may adversely affect the health, safety or welfare of the public, may be found guilty of conduct unbecoming a nursing assistant. Such conduct includes but is not limited to: (3) Conduct related to client safety and integrity: (a) Failing to take action to preserve or promote a person's safety based on nursing assistant knowledge, skills, and abilities . (c) Failing to report changes in a person's status from the last assessment made by the registered nurse; (4) Conduct related to communication: (f) Failing 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 1. Resident 6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 6's 11/2018 Quarterly MDS revealed a Brief Interview of Mental Status score of 14 out of 15 (cognitively intact). A 10/17/18 neurology Progress Note revealed in 8/2018 Resident 6 had a hemorrhagic stroke from high blood pressure. Resident 6's goal for controlling her/his blood pressure was a systolic (pressure in the blood vessel when a heart beats and the top number of a blood pressure reading) blood pressure less than 140. The 1/2019 Physician's Orders revealed if there was a severe condition change in Resident 6 and there was not a timely response from the on-call provider, please send to the emergency department. A 1/21/19 at 10:35 PM Blood Pressure Summary revealed Staff 13 (RN) documented Resident 6's blood pressure was 162/100. The 1/21/19 emergency response report and Prehospital Care report revealed the following: -At 10:44 PM there was a call to emergency services; -At 10:50 PM the ambulance arrived at the facility; -Family and staff stated the resident became slow to respond to them approximately 30 minutes prior to calling. Upon arrival the resident was unresponsive. The 1/21/19 at 11:27 PM hospital Consultation revealed Resident 6 was noted to be unresponsive at the facility late in the evening on 1/21/19. The resident had a left thalamic and [MEDICATION NAME] hematoma (type of bleeding stroke). The resident was intubated (tube placed for breathing) and was essentially in a coma. A 1/22/19 at 6:48 AM Progress Note, written by Staff 13 (RN), revealed at approximately 10:40 PM (on 1/21/19) Resident 6's family member reported the resident was not responding. Resident 6 was evaluated and was found to be alert but was not tracking as well and was unable to answer simple questions like what her/his name was or where she/he was at. When asked how many fingers were in front of the resident, the resident stuttered two. The resident's blood pressure was high 162/100 and 166/102. The resident had no shortness of breath or restlessness. The resident shook her/his head no when asked if she/he was in pain. The resident's chart was reviewed, and papers were prepared for the emergency transport to the hospital. 911 was called and the resident was transferred to the hospital. The resident's spouse was at the bedside and was aware of the incident. The physician was called and informed of the incident and okayed the transfer to the hospital for evaluation and treatment. In an interview on 3/8/19 at 11:16 AM Witness 9 (Family) stated Resident 6 was left for approximately 40 minutes while having a stroke and Staff 13 did call the ambulance timely. In an interview on 3/20/19 at 12:10 AM Staff 13 (RN) stated Witness 10 (Family) reported there was something wrong with Resident 6. Staff 13 stated she took the resident's vital signs, asked the resident her/his name and she/he responded with the correct name. Staff 13 stated she asked how many fingers she was holding up and the resident correctly stated two. Resident 6 was alert and did not stutter at all and the resident's vitals were fine. When asked why the resident needed sent out urgently if Staff 13 had no concerns, Staff 13 stated Resident 6 was slow to respond, and Witness 9 kept asking her to send the resident out. Staff 13 stated she was going to call the physician and Witness 9 stated she needed to hurry. Staff 13 stated instead of calling the physician she called the ambulance and provided them an assessment of the resident. When asked how long it took between when Staff 13 assessed the resident and when the resident was sent out, Staff 13 stated she did not know but Staff 13 stated she helped another resident prior to helping Resident 6. Staff 13 stated she was uncertain on how long it took her to call 911 but it was less than one hour. When asked to clarify Staff 13's 1/22/19 at 6:48 AM Progress Note (see above) about Resident 6's inability to say her/his name and where she/he was, Staff 13 stated she meant she was slow to respond not that she/he was unable to state her/his name or location. When asked why Staff 13 stated Resident 6's vitals were fine but documented high blood pressures, Staff 13 acknowledged the blood pressures were high. Staff 13 stated the resident's symptoms of slow speech and high blood pressures were not a trigger for Resident 6 to be sent out. Staff 13 did know of Resident 6's 8/2018 hemorrhagic stroke. In an interview on 3/21/19 at 5:22 AM Staff 21 (CNA) stated Staff 13 was the RN on shift on 1/21/19. Staff 21 stated Witness 10 (Family) reported to Staff 13 that Resident 6 was not responding to her. Staff 21 stated she went to Resident 6's room and Resident 6 had a blank look on her/his face and was not responding. Staff 21 stated Witness 9 entered the room and demanded Resident 6 be sent to the hospital. Staff 13 stated she had to get a physician's order prior to sending Resident 6 out to the hospital. In an interview on 3/27/19 at 1:45 PM Witness 10 (Family) stated at approximately 10:23 PM on 1/21/19 she went in to say goodnight to Resident 6 and noticed the call light was on the floor. Witness 10 stated she left the room and told Staff 13 about the call light and returned to Resident 6's room. Witness 10 stated when she returned to the room Resident 6 could not respond. Resident 6's eyes were glazed over, could not respond and barely could speak. Witness 10 stated she immediately got Staff 13 and Staff 13 told her to stay out of the room while completing an assessment but mentioned the blood pressure was high like 185/118. Witness 10 stated when Staff 13 exited the room, she shrugged her shoulders and said Resident 6 was having a mini-stroke and she would call the physician and send the resident to the hospital. Witness 10 went outside and got Witness 9 who was waiting for her in the car. Witness 10 stated there was no one in the room and no one was monitoring Resident 6 for signs and symptoms of a stroke when they returned. Witness 10 stated she and Witness 9 thought Staff 13 called 911. When 15-20 minutes passed Witness 9 asked Staff 13 why she did not call 911 and Staff 13 responded because she needed a physician's order to send Resident 6 out of the facility and could not reach the physician. Witness 10 stated Witness 9 called 911 and while he was on the phone dispatch said the facility nurse was on the line. Witness 10 stated it took approximately 30-40 minutes before Resident 6 was in the care of emergency services because Staff 13 did not call 911 timely. Refer to F684, example 1 On 3/21/19 at 2:31 PM the facility was notified of the immediate jeopardy (IJ) situation related to the facility's failure to meet professional standards for documenting assessments and monitoring, following physician orders, appropriate response to change of conditions and reporting incidents timely. As a result there was a delay in Resident 6's treatment for [REDACTED]. On 3/21/19 at 4:54 PM an acceptable facility plan to remove the IJ situation was submitted by the facility. The plan indicated the facility would implement the following actions: -The DNS or designee will review every critical lab for the last 30 days, to be done by the end of the day Friday, 3/22/19. The interdisciplinary team (IDT) will continue to review 24 hour alert charting on a weekly, Monday through Friday basis. The RN in question has already been re-educated and disciplinary action was taken on 3/20/19. -The educator or designee will educate all nursing staff on the procedures involving critical labs. Education will also be done on episodic documentation which includes the following: documenting vitals signs, physical assessments, resident response, low level of consciousness and symptoms, and notifying the physician and documenting the time of all notifications. Staff will also be educated on whom they can call with questions during the night. All education will be done before a nurse works their next shift. Records of education given, with signatures and dates of the nurses receiving the education will be kept in the nurse's files. -The IDT will monitor night nurse activities and adherence to regulations by incorporating a new self-reporting tool to be developed by the end of the day Friday, 3/22/19, which will be filled out twice during the night shift and will include indication of any labs received with instructions on critical pathways and guidelines to follow if labs are indicated to be critical. -All monitoring tools will be collected by the day shift nurses who review and sign off on it. IDT will collect and review in the morning meetings, Monday through Friday, and reports will be made at the monthly QAPI meeting as needed. Resident council notes will continue to be reviewed to monitor resident satisfaction. On 3/21/19 at 5:00 PM the IJ removal plan was verified through interview and review of education for licensed staff. 2. Resident 10 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 2/18/19 at 2:21 PM outside provider email from Witness 6 (Outside Provider RN) to an outside provider physician documented Staff 12 (LPN) reported Resident 10 felt ill. Resident 10 did not come in for a PICC (peripherally inserted central catheter, a form of intravenous access for treatment such as [MEDICAL CONDITION]) dressing change as the resident refused to get out of bed. The outside provider RN encouraged Staff 12 to ask the facility physician to order CBC (Complete Blood Count) and CMP (Comprehensive Metabolic Panel) labs since the resident was one week post [MEDICAL CONDITION]. The outside provider physician responded the resident was post [MEDICAL CONDITION] and was at risk of infection,[MEDICAL CONDITION], and other complications, and if not improved, the resident should be transported to the ED (Emergency Department) for evaluation. The 2/18/19 lab order documented Witness 5 (Physician) ordered the CMP and CBC labs with a duplicate copy of the report being sent to the outside provider. There was no documentation by Staff 12 in the clinical record regarding Resident 10's 2/18/19 change of condition, including assessment of the resident's status, vital signs, and the need to order labs. The 2/18/19 lab report documented Resident 10 had a critical lab value of 0.48 (reference range of 4.0 to 10.0) for the white blood count (indicating risk of infection) and a critical lab value of 12 (reference range of 140 to 440) for platelets (blood cells that form clots to stop bleeding). The lab report documented the critical lab values were reported to Staff 13 (RN)with read back verification done on 2/18/19 at 11:33 PM and 11:34 PM. There was no documentation by Staff 13 in the clinical record on 2/18/19 regarding Resident 10's critical lab values, including following up with the physician and assessment of the resident's status. On 2/19/19 there was no documentation by Staff 12 in the clinical record regarding an assessment of the resident's status, including vital signs. The 2/19/19 at 11:11 AM Progress Note documented the resident had a critical white blood count, the physician was notified, and the resident was sent to the hospital. The 2/19/19 Hospital Records documented Resident 10 arrived at 8:06 AM, approximately eight and a half hours after the critical lab notification. The Emergency Department Encounter notes documented the resident reported having upper respiratory symptoms over the past three to four days and woke up with a fever. The facility had a current outbreak of influenza and the resident was still receiving [MEDICAL CONDITION]. Resident 10 was noted as oriented to person, place, and time. The Discharge Summary noted [DIAGNOSES REDACTED]. On 3/6/19 at 1:07 PM Resident 10 stated regarding the 2/18/19 labs she/he was sick and had no energy so labs were ordered, which revealed her/his white and red blood counts were really low. Resident 10 stated she/he was ill at least a day before going to the hospital which the resident reported to staff, you could tell by looking at me I was sick. The lack of documented assessments related to Resident 10's 2/18/19 to 2/19/19 change of condition were discussed with Staff 2 on 3/15/19 at 3:13 PM. Staff 2 stated there was no indication Resident 10 was ill on 2/18/19 and the staff did a good job sending the resident out to the hospital on [DATE]. On 3/20/19 at 8:27 AM Staff 2 stated staff were expected to call the physician right away when they received reports of critical lab values. On 3/15/19 at 8:00 AM Staff 12 (LPN) initially stated Resident 10 exhibited no changes in condition on 2/18/19, the resident and her/his vital signs were fine, and the resident had nausea from [MEDICAL CONDITION]. On the morning of 2/19/19 Staff 12 obtained the resident's vital signs for her own monitoring of the resident's status and the resident had a temperature of 102 degrees. Staff 12 stated she did not document the resident's vital signs. On 3/18/19 at 8:38 AM Staff 12 stated she did not recall speaking with the outside provider on 2/18/19 regarding the resident's status. On 3/19/19 Staff 12 provided a written statement that documented Staff 12 did speak with the outside provider regarding Resident 10 and was directed to inform the physician if the resident presented with any symptoms of illness, .which (Resident 10) didn't. The blood draw that day was a routine one. On 3/18/19 at 10:01 AM Staff 4 (RN) stated on 2/18/19 there was [MEDICAL CONDITION] in the facility, the resident recently completed [MEDICAL CONDITION], and Resident 10 did not feel well. The outside provider asked Witness 5 to order the labs which Staff 4 obtained. When Staff 5 obtained the lab the resident was lying in bed with a blanket over her/his head and the resident did not want to be bothered. Staff 4 stated she was not the floor nurse that day and the floor nurse was responsible for completing alert charting and resident assessments. The outside provider called back later and directed staff to send the resident to the hospital. On 3/18/19 at 10:30 AM Witness 5 (Physician) stated if Resident 10 had a temperature of 102 degrees the resident should have been sent to the hospital. On 3/18/19 at 6:38 PM Staff 13 (RN) stated no staff nor the resident reported a change of condition during the 2/18/19 to 2/19/19 night shift. Staff 13 stated she was not aware of a change of condition for the resident. On 3/20/19 at 12:21 AM Staff 13 stated she thought she passed the critical lab information to the oncoming nurse. Staff 13 did not recall who she reported the labs to, nor did she recall notifying the physician. On 3/19/19 at 8:36 AM Witness 6 (Outside Provider RN) stated she spoke with Staff 12 (LPN) on 2/18/19, who reported Resident 10 felt sick, nauseated, had abdominal pain, and did not come in for the scheduled dressing change as the resident refused to get out of bed due to not feeling good. Witness 6 asked Staff 12 to have the facility physician order labs due to the resident being a week post [MEDICAL CONDITION] and not feeling well. The outside provider received the lab results the next day, the resident was neutropenic (abnormally low level of white blood cells), and the facility was called right away and directed to send the resident to the hospital as she/he was high risk of being septic. Witness 6 stated she was concerned about the facility's critical lab response as it was documented on the lab report the critical labs were reported to Staff 13 (RN) on 2/18/19 at 11:33 PM. On 3/19/19 at 4:10 PM Witness 8 (Lab Client Services Rep) stated the lab was required to document who they reported critical labs to, the staff member's job title, what time they spoke with the staff member, and the staff member had to read the results back to the lab. On 3/21/19 at 2:31 PM the facility was notified of the immediate jeopardy (IJ) situation related to the facility's failure to meet professional standards for documenting assessments and monitoring, following physician orders, appropriate response to change of conditions and critical lab values, and reporting incidents timely. As a result there was a delay in the treatment for [REDACTED]. On 3/21/19 at 4:54 PM an acceptable facility plan to remove the IJ situation was submitted by the facility. The plan indicated the facility would implement the following actions: -The DNS or designee will review every critical lab for the last 30 days, to be done by the end of the day Friday, 3/22/19. The interdisciplinary team (IDT) will continue to review 24 hour alert charting on a weekly, Monday through Friday basis. The RN in question has already been re-educated and disciplinary action was taken on 3/20/19. -The educator or designee will educate all nursing staff on the procedures involving critical labs. Education will also be done on episodic documentation which includes the following: documenting vitals signs, physical assessments, resident response, low level of consciousness and symptoms, and notifying the physician and documenting the time of all notifications. Staff will also be educated on whom they can call with questions during the night. All education will be done before a nurse works their next shift. Records of education given, with signatures and dates of the nurses receiving the education will be kept in the nurse's files. -The IDT will monitor night nurse activities and adherence to regulations by incorporating a new self-reporting tool to be developed by the end of the day Friday, 3/22/19, which will be filled out twice during the night shift and will include indication of any labs received with instructions on critical pathways and guidelines to follow if labs are indicated to be critical. -All monitoring tools will be collected by the day shift nurses who review and sign off on it. IDT will collect and review in the morning meetings, Monday through Friday, and reports will be made at the monthly QAPI meeting as needed. Resident council notes will continue to be reviewed to monitor resident satisfaction. On 3/21/19 at 5:00 PM the IJ removal plan was verified through interview and review of education for licensed staff. 3. Resident 2 was admitted to the facility with [DIAGNOSES REDACTED]. The 1/1/19 ADL Care Plan noted Resident 2 required a two person, sit to stand lift transfer. The 2/22/19 at 6:43 AM Progress Note disclosed Resident 2 reported bad pain in the left hip with any movement. The resident reported during a 2/21/19 transfer in the sit to stand she/he and the caregivers heard a pop. An x-ray was ordered. The 2/22/19 Radiology Report documented the resident sustained [REDACTED]. The 2/22/19 at 3:39 PM Progress Note disclosed the resident was sent to the hospital for follow up. The facility's 2/21/19 investigation noted during a transfer on 2/21/19 between 2:30 PM and 3:00 PM Staff 23 (CNA) and Staff 24 (CNA) transferred the resident to the bathroom with the sit to stand lift. While placing an incontinence brief on the resident staff heard a loud pop. Staff 23 documented they placed the resident in bed then notified the nurse. Staff 24 documented after the resident used the bathroom the resident stood while staff placed a new incontinence brief then the resident's hip popped loudly. Staff sat the resident back down, fixed the brief, placed the resident back into bed, then the nurse was notified of the situation. Both staff documented the resident felt sick and weak. The facility's investigation disclosed Staff 5 (LPN) did not report the incident to the physician nor was the incident documented in the clinical record. On 3/5/19 at 10:47 AM Resident 2 was observed lying in bed with her/his feet elevated. The resident stated the fracture occurred during a transfer and both the resident and staff present heard the snap. A nurse evaluated her/his leg and the resident reported having pain to the nurse. On 3/13/19 at 11:42 AM Staff 24 stated she and Staff 23 assisted the resident to the toilet with the sit to stand. After the resident was done with toileting she/he was placed back in the sit to stand lift. While placing an incontinence brief on the resident her/his hip made a loud popping noise. The resident stated she/he had pain and they sat the resident back down on the toilet. Staff 24 stated they did not get the nurse at that time because the resident wanted off the toilet and back in bed. On 3/14/19 at 8:55 AM Staff 5 stated on 2/21/19 CNAs reported to her they heard a sound from the resident's hip while the resident was in the sit to stand lift. Staff 5 stated she evaluated the resident who reported she/he was not in any more pain than normal, the hip was not red or swollen, and the resident could move the hip. Staff 5 stated she did not contact the physician as nothing looked abnormal to her and the resident's pain was at her/his baseline. Staff 5 stated she reported the incident to Staff 8 (LPN) but forgot to document the incident. On 3/14/19 at 12:51 PM Staff 2 (DNS) stated when staff and the resident heard a pop and the resident complained of pain the CNAs should have informed the nurse. Staff 2 stated CNAs reported they heard the resident's hip pop while they were transferring the resident back to bed and she was not told the incident occurred while the resident was still in the bathroom, was transferred back to the toilet, then to bed. Staff 2 stated Staff 5 should not have made her own decision there was no injury and should have notified the physician when staff and the resident heard a pop. Staff 5 did not report the incident to the next shift. On 3/15/19 at 4:59 AM Staff 8 (LPN) stated Staff 5 did not report the 2/21/19 incident to her. Staff 8 stated Resident 2's cognition was intact and reported the incident to Staff 8. On 3/15/19 at 9:55 AM Staff 23 (CNA) initially stated they assisted Resident 2 to the toilet with the sit to stand lift. After toileting the resident staff assisted her/him back in the sit to stand, they heard a loud pop, then placed the resident in bed and informed the nurse. When asked about assisting the resident back to the toilet after hearing the popping sound Staff 23 stated the resident had pain, felt weak and dizzy, the resident could not stand on her/his own by holding herself/himself up in the sit to stand, and they placed the resident back on the toilet. After the resident felt better and was able to transfer in the sit to stand lift they assisted the resident from the toilet then transferred the resident back to bed. After the resident was in bed they informed the nurse about the incident. 4. Resident 4 was admitted to the facility in 12/2018 with [DIAGNOSES REDACTED]. The 12/2018 to 2/2019 Physician Orders did not include the administration of [MEDICATION NAME] (a narcotic medication). The 1/31/19 Discharge Orders did not include discharging the resident to home with narcotic medications. The 2/8/19 at 10:55 AM Progress Note Staff 5 (LPN) documented Resident 4 was discharged from the facility to home with a family member. The facility's 2/8/19 investigation documented Resident 4 was discharged to home on 2/8/19 at 8:30 AM with medications and the pharmacy medication list. On 2/9/19 at 10:45 AM the resident's family and friend returned to the facility and gave the nurse a medication card with [MEDICATION NAME] 50 mg tablets with another resident's name on the card. The nurse looked in the Narcotic Book and noted at the time the card was signed out on 2/8/19 there were nine tablets and there were only four tablets left when the card was returned on 2/9/19. The facility determined the discharge orders were not accurately compared with current orders and with the orders sent with the resident. On 3/14/19 at 8:55 AM Staff 5 (LPN) stated on 2/8/19 it was a very, very busy morning as she had another discharge to do during medication pass, she put aside all of Resident 4's medications and did not realize when she signed out all of the medications one did not belong to Resident 4. Staff 5 stated at discharge she gave Resident 4 another resident's [MEDICATION NAME].

Based on observation, interview and record review it was determined the facility failed to evaluate, assess, and ensure a timely response to changes in condition and ensure timely response to critical lab values for 3 of 4 sampled residents (#s 2, 6, and 10) reviewed for changes in condition. As a result this deficient practice was determined to be an Immediate Jeopardy situation and the deficiencies resulted in a delay in treatment in Resident 6's treatment for [REDACTED]. Findings include: 1a. Resident 6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 6's 11/2018 Quarterly MDS revealed a Brief Interview of Mental Status score of 14 out of 15 (cognitively intact). A 10/17/18 neurology Progress Note revealed in 8/2018 Resident 6 had a hemorrhagic stroke from high blood pressure. Resident 6's goal for controlling her/his blood pressure was a systolic (measure of the pressure in the blood vessel when a heart beats and the top number of a blood pressure reading) blood pressure less than 140. The 1/2019 physician's orders [REDACTED]. A 1/21/19 at 10:35 PM Blood Pressure Summary revealed Staff 13 (RN) documented Resident 6's blood pressure was 162/100. A 1/21/19 at 10:45 PM Nursing Home to Hospital Transfer Form completed by Staff 13 revealed the following: -Blood pressure was 162/100. -The reason for transfer was altered mental status. -Mental status was alert, disoriented but cannot follow simple instructions. -Not ambulatory. -Risks were anticoagulation, falls, swallowing precautions and aspiration. -Impaired speech and paralysis. -This report was sent after the transfer on 1/22/19 at 4:42 AM. The 1/21/19 emergency response report and Prehospital Care report revealed the following: -At 10:44 PM there was a call to emergency services; -At 10:50 PM the ambulance arrived at the facility; -Family and staff stated the resident became slow to respond to them approximately 30 minutes prior to calling. Upon arrival the resident was unresponsive. The resident's eyes were open with a left sided gaze and would not respond when spoken to by emergency services. The family reported the resident was able to speak and follow commands until this evening. The resident was placed in the stroke position where she/he had no improvement. The hospital was advised of stroke activation; -At 11:25 PM the ambulance arrived at the hospital. The 1/21/19 at 11:27 PM hospital Consultation revealed Resident 6 was noted to be unresponsive at the facility late in the evening on 1/21/19. The resident had a left thalamic and [MEDICATION NAME] hematoma (type of bleeding stroke). The resident was intubated (tube placed for breathing) and was essentially in a coma. A 1/22/19 at 6:48 AM Progress Note, written by Staff 13 (RN), revealed at approximately 10:40 PM (on 1/21/19) Resident 6's family member reported the resident was not responding. Resident 6 was evaluated and was found to be alert but was not tracking as well and was unable to answer simple questions like what her/his name was or where she/he was at. When asked how many fingers were in front of the resident, the resident stuttered two. The resident's blood pressure was high 162/100 and 166/102. The resident had no shortness of breath or restlessness. The resident shook her/his head no when asked if she/he was in pain. The resident's chart was reviewed, and papers were prepared for the emergency transport to the hospital. 911 was called and the resident was transferred to the hospital. The resident's spouse was at the bedside and was aware of the incident. The physician was called and informed of the incident and okayed the transfer to the hospital for evaluation and treatment. In an interview on 3/8/19 at 11:16 AM Witness 9 (Family) stated Resident 6 was left for approximately 40 minutes while having a stroke and Staff 13 did not call the ambulance timely. Witness 9 stated approximately 80 minutes passed from the time Resident 6 had symptoms of a stroke until she/he got treatment at the hospital. Witness 9 stated Resident 6 could self-propel in a wheelchair and talk, but now was paralyzed, had a [MEDICAL CONDITION] (tube placed through an opening in the throat to provide an airway) and can no longer talk. In an interview on 3/20/19 at 12:10 AM Staff 13 (RN) stated Witness 10 (Family) reported there was something wrong with Resident 6. Staff 13 stated she took the resident's vital signs, asked the resident her/his name and she/he responded with the correct name. Staff 13 stated she asked how many fingers she was holding up and the resident correctly stated two. Resident 6 was alert and did not stutter at all and the resident's vitals were fine. When asked why the resident needed sent out urgently if Staff 13 had no concerns, Staff 13 stated Resident 6 was slow to respond, and Witness 9 (Family) kept asking her to send the resident out. Staff 13 stated she was going to call the physician and Witness 9 stated she needed to hurry. Staff 13 stated instead of calling the physician she called the ambulance and provided them an assessment of the resident. When asked how long it took between when Staff 13 assessed the resident and when the resident was sent out, Staff 13 stated she did not know but Staff 13 stated she helped another resident prior to helping Resident 6. Staff 13 stated she was uncertain on how long it took her to call 911 but it was less than one hour. When asked to clarify Staff 13's 1/22/19 at 6:48 AM Progress Note (see above) about Resident 6's inability to say her/his name and where she/he was, Staff 13 stated she meant she was slow to respond not that she/he was unable to state her/his name or location. When asked why Staff 13 stated Resident 6's vitals were fine but documented high blood pressures, Staff 13 acknowledged the blood pressures were high. Staff 13 stated the resident's symptoms of slow speech and high blood pressures were not a trigger for Resident 6 to be sent out. Staff 13 did know of Resident 6's 8/2018 hemorrhagic stroke. In an interview on 3/21/19 at 5:22 AM Staff 21 (CNA) stated Staff 13 was the RN on shift on 1/21/19. Staff 21 stated Witness 10 (Family) reported to Staff 13 that Resident 6 was not responding to her. Staff 21 stated she went to Resident 6's room and Resident 6 had a blank look on her/his face and was not responding. Staff 21 stated when she spoke Resident 6 moved her/his hand in front of her/his face. Staff 21 stated she took Resident 6's vitals and they were high. Staff 21 stated Witness 9 entered the room and demanded Resident 6 be sent to the hospital. Staff 13 stated she had to get a physician's orders [REDACTED]. Staff 21 stated she believed Resident 6 needed to be sent to the hospital immediately because this was a significant change for Resident 6. Staff 21 provided Witness 9 the address of the facility and he called 911. In an interview on 3/27/19 at 1:45 PM Witness 10 (Family) stated at approximately 10:23 PM on 1/21/19 she went in to say goodnight to Resident 6 and noticed the call light was on the floor. Witness 10 stated she left the room and told Staff 13 about the call light and returned to Resident 6's room. Witness 10 stated when she returned to the room Resident 6 could not respond. Resident 6's eyes were glazed over, could not respond and barely could speak. Witness 10 stated she immediately got Staff 13 and Staff 13 told her to stay out of the room while completing an assessment but mentioned the blood pressure was high like 185/118. Witness 10 stated when Staff 13 exited the room, she shrugged her shoulders and said Resident 6 was having a mini-stroke and she would call the physician and send the resident to the hospital. Witness 10 went outside and got Witness 9 who was waiting for her in the car. Witness 10 stated there was no one in the room and no one was monitoring Resident 6 for signs and symptoms of a stroke when they returned. Witness 10 stated she and Witness 9 thought Staff 13 called 911. When 15-20 minutes passed Witness 9 asked Staff 13 why she did not call 911 and Staff 13 responded because she needed a physician's orders [REDACTED]. Witness 10 stated Witness 9 called 911 and while he was on the phone dispatch said the facility nurse was on the line. Witness 10 stated it took approximately 30-40 minutes before Resident 6 was in the care of emergency services because Staff 13 did not call 911 timely. On 3/21/19 at 2:22 PM the facility was notified of the immediate jeopardy (IJ) situation related to the facility's failure to document assessments and monitoring, follow physician orders, appropriately respond to changes of conditions and report incidents timely. As a result there was a delay in Resident 6's treatment for [REDACTED]. On 3/21/19 at 4:54 PM an acceptable facility plan to remove the IJ situation was submitted by the facility. The plan indicated the facility would implement the following actions: -The DNS or designee will review every critical lab for the last 30 days, to be done by the end of the day Friday, 3/22/19. The interdisciplinary team (IDT) will continue to review 24 hour alert charting on a weekly, Monday through Friday basis. The RN in question has already been re-educated and disciplinary action was taken on 3/20/19. -The educator or designee will educate all nursing staff on the procedures involving critical labs. Education will also be done on episodic documentation which includes the following: documenting vitals signs, physical assessments, resident response, low level of consciousness and symptoms, and notifying the physician and documenting the time of all notifications. Staff will also be educated on whom they can call with questions during the night. All education will be done before a nurse works their next shift. Records of education given, with signatures and dates of the nurses receiving the education will be kept in the nurse's files. -The IDT will monitor night nurse activities and adherence to regulations by incorporating a new self-reporting tool to be developed by the end of the day Friday, 3/22/19, which will be filled out twice during the night shift and will include indication of any labs received with instructions on critical pathways and guidelines to follow if labs are indicated to be critical. On 3/21/19 at 5:00 PM the IJ removal plan was verified through interview and review of education for licensed staff. b. A 10/17/18 neurology clinic Progress Note revealed the neurologist recommend a cardiac Holter monitor for four weeks to evaluate for a-fib burden. The neurologist will consider Eliquis (anticoagulant medication) at the next visit based on the results of the Holter monitor. The resident had some a-fib and thus will evaluate with a 30-day Holter monitor prior to starting an anticoagulant being the resident's blood pressure was still high and the history of a hemorrhagic stroke. The neurologist will communicate this to the skilled nursing facility. A 10/17/18 Physician Documentation Note revealed the physician ordered recommended Holter monitor for one month. Physician ordered return to neurologist clinic in three months. The resident did not return with the Holter monitor but the physician would put in an order for [REDACTED].>A 10/17/18 Report of Consultation from the neurology clinic to the facility revealed Resident 6 was seen for blood pressure management. The neurologist recommend a Holter monitor for one month. A 10/17/18 Progress Note completed by Witness 11 (Nurse Practitioner, NP) revealed per the neurology visit an order for [REDACTED]. A 10/30/18 Physician Documentation note completed by Witness 11 revealed per the neurology appointment Resident 6 was to wear a heart monitor for one month and follow up in three months. Requested facility to contact neurology clinic clarify start date for heart monitor. On 10/30/18 the Physician's Telephone Orders revealed an order to follow up with neurology to clarify the start date for heart monitoring. A 10/31/18 physician's orders [REDACTED]. A message was left at the neurology clinic to clarify and waiting to hear back. The 10/2018 MAR indicated [REDACTED] -Holter monitor 1 month with a start date of 10/17/18. (A line was drawn across the administration boxes); -Schedule follow-up with neurology. Clarify start date for heart monitoring with a start date of 10/30/18. A 11/1/18 neurology clinic Progress Note revealed the facility called regarding the cardiac heart monitoring orders. A late entry Physician's Documentation note with an effective date of 11/2/18 revealed per the neurology appointment Resident 6 was to wear a heart monitor for one month and follow up in three months. Requested the facility to contact neurology clinic clarify start date for heart monitor. A 11/9/18 Progress Note revealed the facility called the neurology clinic and left a message to call back with an order for [REDACTED]. A 11/15/18 Progress Note revealed the facility called the neurology clinic and left a message about Resident 6 and was waiting for a call back. A 12/15/18 an untitled document noted a concern from Resident 6 and her/his family requested follow-up on the heart monitor that was recommended and felt the heart monitor would be beneficial to Resident 6's health and further treatment. On 12/20/18 the physician's reply stated, okay I will have to send to a cardiologist to see next steps. A 12/17/18 neurology clinic Progress Note revealed Staff 2 (DNS) called the clinic and stated the facility did not have anyone that could order the Holter monitor and requested if the neurologist wanted the Holter monitor ordered then could he please order it. A 12/20/18 Progress Note completed by Staff 2 (DNS) revealed there were calls to the neurology department regarding the recommended heart monitor as noted on the report of consultation. Neurology staff stated they did not order it but recommended it to the family on the visit. Neurology staff stated they would speak to the physician and call back. On 12/18/18 Staff 2 (DNS) called back and was told they would not order the heart monitor and the primary care physician needed to order it. Staff 2 spoke to the facility physician and he would provide a cardiology referral. A 12/20/18 Physician Document note revealed when Resident 6 was an impatient in the hospital (8/2018) there was a recommendation for a Holter monitor. The neurology department suggested ordering one. On discharge to the facility the resident did not get a Holter monitor as ordered as she/he did not follow up with cardiology. The resident's spouse was upset this was not ordered after leaving the hospital. Discussed with Resident 6 about getting a Holter monitor and she/he felt stable and did not want additional testing. Will refer to a cardiologist if Resident 6 changes her/his mind. Per neurology appointment the resident was to wear a Holter monitor for one month. The resident would need a cardiology appointment in order to get the Holter monitor organized. The resident would like to hold off until she/he follows up with the neurologist. In an interview on 3/22/19 at 9:17 AM Witness 12 (Neurologist Office Assistant) stated the neurologist's documentation stated to discuss the heart monitor with the resident's primary care physician (PCP) to order the heart monitor. The notes indicate the facility was to follow-up with the resident's PCP to get the order to start the Holter monitor. In an interview on 3/29/19 at 12:17 PM Witness 11 (NP) stated based on the neurologist's report the neurologist wanted Resident 6 to wear the heart monitor to see if Resident 6 was still having [MEDICAL CONDITION]-fibrillation. Witness 11 stated she was going off the neurology recommendation to order the Holter monitor. Witness 11 stated she did not know if the Holter monitor was ever ordered. Witness 11 stated she left working at the facility in 12/2018 and as far as she knew the monitor was never implemented. c. Resident 6's 8/22/18 Inpatient Stroke Discharge Summary revealed the following: -In 8/2018 Resident 6 had a hemorrhagic stroke from hypertension (high blood pressure). -Resident 6's goal for controlling her/his blood pressure was a systolic blood pressure (pressure in the blood vessel when a heart beats and is the top number of a blood pressure reading) less than 140. -Follow up with the neurology clinic in one month, scheduled for 10/17/18. -No anticoagulation on discharge given intraparenchymal hematoma (ICH, brain bleed). -Will consider starting Eliquis (anticoagulant) 5mg BID in one month if blood pressures are well controlled. This will be discussed at the neurology follow up visit. An 8/28/18 Physician Documentation completed by Witness 11 (NP, Nurse Practitioner) revealed the following: -Chronic a-fib, start Eliquis in one month if blood pressure was controlled; -IHC control with blood pressure and follow up with neurology in one month; -Hypertension controlled with the systolic blood pressure less than 140 and consider [MEDICATION NAME] (antihypertensive medication) if above the goal. The 9/2018 MAR indicated [REDACTED]. A 9/6/18 Physician Documentation note completed by Witness 11, revealed Resident 6's blood pressure was in the 150's and considering the resident's history of IHC will need improved control of hypertension (high blood pressure). Add [MEDICATION NAME] 5mg daily. The 10/1/18 through 10/10/18 MAR indicated [REDACTED]. A 10/10/18 Physician Documentation note completed by Witness 11 revealed Resident 6's blood pressure was controlled. The resident had a neurology follow up on 10/17/18. Discussed with Resident 6 the need to start Eliquis considering her/his [DIAGNOSES REDACTED]. Resident 6 seemed to understand the necessity of the recommendation and was agreeable. Resident 6 had lots of questions regarding starting a blood thinner and they were answered during the visit. A 10/10/18 Progress Note revealed Eliquis 5mg BID for [MEDICAL CONDITION]-fibrillation was ordered. On 10/15/18 a concern was noted that on 10/15/18 the resident continued to have elevated blood pressures and the blood pressure was 154/68. The physician responded, will see patient today. A 10/17/18 neurology clinic Progress Note revealed the following: -Continue strict blood pressure control with systolic pressure less than 140. -If Systolic pressures are greater than 140 for three readings recommend [MEDICATION NAME] 15 mg daily. -Will consider starting Eliquis on the next visit based on the results of the heart monitoring. -The resident had some a-fib and thus will evaluate with a 30-day Holter monitor prior to starting an anticoagulant being the resident's blood pressure was still high and the history of a hemorrhagic stroke. -Will communicate this to the skilled nursing facility. A 10/17/18 Physician Documentation note, completed by Witness 11 (NP) revealed Resident 6's blood pressure has been controlled. The resident's blood pressure was elevated at the neurology appointment and new orders to increase [MEDICATION NAME] to 10mg daily. A 10/17/18 physician's orders [REDACTED]. On 10/27/18 a concern was noted on 10/27/18 the resident's blood pressure was 150/100 and a recheck was 140/90. The physician replied with an increase of [MEDICATION NAME] to 20mg daily. On 10/30/18 the Physician's Telephone Orders revealed an order to increase [MEDICATION NAME] to 20mg daily. The 10/2018 MAR indicated [REDACTED] -On 10/11/18 through 10/31/18, 12 of 42 systolic blood pressures were at or above 140. -On 10/11/18 Eliquis 5mg BID was started. -On 10/18/18 [MEDICATION NAME] increased to 10mg daily. -On 10/31/18 [MEDICATION NAME] increased to 20 mg daily. The 11/2018 MAR indicated [REDACTED]. The 12/2018 MAR indicated [REDACTED]. The 1/2019 MAR indicated [REDACTED]. In an interview on 3/22/19 at 9:17 AM Witness 12 (Neurologist Office Assistant) stated she/he did not see any communication from the facility about starting Resident 6 on Eliquis on 10/10/18. In an interview on 3/29/19 at 12:17 PM Witness 11 (NP) stated from the note she read from the neurologist she believed the neurologist wanted Eliquis started in one month if Resident 6's blood pressure was stable. When asked about the direction Eliquis would be considered at the 10/17/18 neurology appointment and if she clarified this prior to starting Eliquis, Witness 11 stated from her understanding the neurologist wanted the Eliquis started if blood pressure was stable. Witness 11 stated Resident 6's blood pressure was stable based on her review of the MARs. When asked if the neurologist knew or had concerns about the Eliquis started prior to their follow up, Witness 11 stated she did not recall if the neurologist had any concerns with Eliquis being started. 2. Resident 10 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 2/18/19 at 2:21 PM outside provider email from Witness 6 (Outside Provider RN) to an outside provider physician documented Staff 12 (LPN) reported Resident 10 felt ill. Resident 10 did not come in for a PICC (peripherally inserted central catheter, a form of intravenous access for treatment such as [MEDICAL CONDITION]) dressing change as the resident refused to get out of bed. Witness 6 encouraged Staff 12 to ask the facility physician to order CBC (Complete Blood Count) and CMP (Comprehensive Metabolic Panel) labs since the resident was one week post [MEDICAL CONDITION]. The outside provider physician responded the resident was post [MEDICAL CONDITION] and was at risk of infection,[MEDICAL CONDITION], and other complications, and if not improved, the resident should be transported to the ED (Emergency Department) for evaluation. The 2/18/19 lab order documented Witness 5 (Physician) ordered the CBC and CMP labs with a duplicate copy of the report being sent to the outside provider. There was no documentation in the clinical record regarding Resident 10's 2/18/19 change of condition, including assessment of the resident's status, vital signs, or the need to order labs. The 2/18/19 lab report documented Resident 10 had a critical lab value of 0.48 (reference range of 4.0 to 10.0) for the white blood count (risk of infection) and a critical lab value of 12 (reference range of 140-440) for platelets (blood cells that form clots to stop bleeding). The lab report documented the critical lab values were reported to Staff 13 (RN) with read back verification done on 2/18/19 at 11:33 PM and 11:34 PM. There was no documentation in the clinical record on 2/18/19 regarding Resident 10's critical lab values, including following up with the physician and assessment of the resident's status. On 2/19/19 the clinical record lacked documented assessment of the resident's status, including vital signs. The 2/19/19 at 11:11 AM Progress Note documented the resident had a critical white blood count and was sent to the hospital. The 2/19/19 Hospital Records documented Resident 10 arrived at 8:06 AM, approximately eight and a half hours after the critical lab notification. The Emergency Department Encounter notes documented the resident reported having upper respiratory symptoms of cough and congestion over the past three to four days and woke up with a fever. The facility had a current outbreak of influenza and the resident was still receiving [MEDICAL CONDITION]. Resident 10 was noted as oriented to person, place, and time. The Discharge Summary noted [DIAGNOSES REDACTED]. On 3/6/19 at 1:07 PM Resident 10 stated regarding the 2/18/19 labs she/he was sick and had no energy so labs were ordered, which revealed her/his white and red blood counts were really low. Resident 10 stated she/he was ill at least a day before going to the hospital which the resident reported to staff, you could tell by looking at me I was sick. On 3/7/19 at 3:20 PM Staff 2 (DNS) stated she spoke with Witness 5 (Physician) who stated the 2/18/19 lab was a routine lab completed by the outside provider and was not ordered by Witness 5. The lack of documented assessments related to Resident 10's 2/18/19 to 2/19/19 change of condition was discussed with Staff 2 on 3/15/19 at 3:13 PM. Staff 2 stated there was no indication Resident 10 was ill on 2/18/19 and the staff did a good job sending the resident out to the hospital on [DATE]. On 3/20/19 at 8:27 AM Staff 2 stated staff were expected to call the physician right away when they received reports of critical lab values. On 3/15/19 at 8:00 AM Staff 12 (LPN) initially stated Resident 10 exhibited no changes in condition on 2/18/19, the resident and her/his vital signs were fine, and the resident had nausea from [MEDICAL CONDITION]. On the morning of 2/19/19 Staff 12 obtained the resident's vital signs for her own monitoring of the resident's status and the resident had a temperature of 102 degrees. Staff 12 stated she did not document the resident's vital signs. On 3/18/19 at 8:38 AM Staff 12 stated she did not recall speaking with the outside provider on 2/18/19 regarding the resident's status. On 3/19/19 Staff 12 provided a written statement that documented Staff 12 did speak with the outside provider regarding Resident 10 and was directed to inform the physician if the resident presented with any symptoms of illness, .which (Resident 10) didn't. The blood draw that day was a routine one. On 3/15/19 at 8:50 AM Staff 17 (CNA) stated her shift started at 6:00 AM and on the morning of 2/19/19 Resident 10 was lying in bed and reported she/he was not okay. Staff 17 reported the resident's status to the nurse who asked her to obtain the resident's vital signs. Staff 17 could not recall the vital signs but thought they were normal and the resident was later sent out to the hospital. On 3/18/19 at 10:01 AM Staff 4 (RN) stated on 2/18/19 there was [MEDICAL CONDITION] in the facility, the resident recently completed [MEDICAL CONDITION], and Resident 10 did not feel well. The outside provider asked Witness 5 to order the labs which Staff 4 obtained. When Staff 4 obtained the lab the resident was lying in bed with a blanket over her/his head and the resident did not want to be bothered. Staff 4 stated she was not the floor nurse that day and the floor nurse was responsible for completing alert charting and resident assessments. The outside provider called back later and directed staff to send the resident to the hospital. On 3/18/19 at 10:30 AM Witness 5 (Physician) stated if the 2/18/19 labs were routine the outside provider would have ordered the lab themselves. Witness 5 could not recall if he ordered the 2/18/19 labs and if Resident 10 had a temperature of 102 degrees the resident should have been sent to the hospital. On 3/18/19 at 6:38 PM Staff 13 (RN) stated no staff nor the resident reported a change of condition during the 2/18/19 to 2/19/19 night shift. Staff 13 stated she was not aware of a change of condition for the resident. On 3/20/19 at 12:21 AM Staff 13 stated she thought she passed the critical lab information to the oncoming nurse. Staff 13 did not recall who she reported the labs to, nor did she recall notifying the physician. On 3/19/19 at 8:36 AM Witness 6 (Outside Provider RN) stated she spoke with Staff 12 (LPN) on 2/18/19, who reported Resident 10 felt sick, nauseated, had abdominal pain, and did not come in for the scheduled dressing change as the resident refused to get out of bed due to not feeling good. Witness 6 asked Staff 12 to have the facility physician order [REDACTED]. The outside provider received the lab results the next day, the resident was neutropenic (abnormally low level of white blood cells), and the facility was called right away and directed to send the resident to the hospital as she/he was high risk of being septic. Witness 6 stated she was concerned about the facility's critical lab response as it was documented on the lab report the critical labs were reported to Staff 13 (RN) on 2/18/19 at 11:33 PM. On 3/19/19 at 4:10 PM Witness 8 (Lab Client Services Rep) stated the lab was required to document who they reported critical labs to, the staff member's job title, what time they spoke with the staff member, and the staff member had to read the results back to the lab. On 3/21/19 at 2:22 PM the facility was notified of the immediate jeopardy (IJ) situation related to the facility's failure to document assessments and monitoring, follow physician orders, appropriately respond to changes of conditions and critical lab values, and report incidents timely. As a result there was a delay in treatment for [REDACTED]. On 3/21/19 at 4:54 PM an acceptable facility plan to remove the IJ situation was submitted by the facility. The plan indicated the facility would implement the following actions: -The DNS or designee will review every critical lab for the last 30 days, to be done by the end of the day Friday, 3/22/19. The interdisciplinary team (IDT) will continue to review 24 hour alert charting on a weekly, Monday through Friday basis. The RN in question has already been re-educated and disciplinary action was taken on 3/20/19. -The educator or designee will educate all nursing staff on the procedures involving critical labs. Education will also be done on episodic documentation which includes the following: documenting vitals signs, physical assessments, resident response, low level of consciousness and symptoms, and notifying the physician and documenting the time of all notifications. Staff will also be educated on whom they can call with questions during the night. All education will be done before a nurse works their next shift. Records of education given, with signatures and dates of the nurses receiving the education will be kept in the nurse's files. -The IDT will monitor night nurse activities and adherence to regulations by incorporating a new self-reporting tool to be developed by the end of the day Friday, 3/22/19, which will be filled out twice during the night shift and will include indication of any labs received with instructions on critical pathways and guidelines to follow if labs are indicated to be critical. On 3/21/19 at 5:00 PM the IJ removal plan was verified through interview and review of education for licensed staff. 3. Resident 2 was admitted to the facility in 2014 with [DIAGNOSES REDACTED]. The 1/1/19 ADL Care Plan noted Resident 2 required a two person, sit to stand lift transfer. The 2/22/19 at 6:43 AM Progress Note disclosed Resident 2 reported bad pain in the left hip with any movement. The resident reported during a 2/21/19 transfer in the sit to stand she/he and the caregivers heard a pop. An x-ray was ordered. The 2/22/19 Radiology Report documented the resident sustained [REDACTED]. The 2/22/19 at 3:39 PM Progress Note disclosed the resident was sent to the hospital for follow up. The facility's 2/21/19 investigation noted during a transfer on 2/21/19 between 2:30 PM and 3:00 PM Staff 23 (CNA) and Staff 24 (CNA) transf

Based on interview and record review it was determined the facility failed to consult with the physician for changes in condition and critical labs for 2 of 4 sampled residents (#s 2 and 10) reviewed for physician notification. This resulted in a delay in treatment for [REDACTED]. 1. Resident 10 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 2/18/19 at 2:21 PM outside provider email from Witness 6 (Outside Provider RN) to an outside provider physician documented Staff 12 (LPN) reported Resident 10 felt ill. Resident 10 did not come in for a PICC (peripherally inserted central catheter, a form of intravenous access for treatment such as [MEDICAL CONDITION]) dressing change as the resident refused to get out of bed. The outside provider RN encouraged Staff 12 to ask the facility physician to order CBC (Complete Blood Count) and CMP (Comprehensive Metabolic Panel) labs since the resident was one week post [MEDICAL CONDITION]. The outside provider physician responded the resident was post [MEDICAL CONDITION] and was at risk for infection,[MEDICAL CONDITION], and other complications, and if not improved, the resident should be transported to the ED (Emergency Department) for evaluation. The 2/18/19 lab order documented Witness 5 (Physician) ordered the CBC and CMP labs with a duplicate copy of the report being sent to the outside provider. The 2/18/19 lab report documented Resident 10 had a critical lab value of 0.48 (reference range of 4.0 to 10.0) for the white blood count (indicating at risk for infection) and a critical lab value of 12 (reference range of 140-440) for platelets (blood cells that form clots to stop bleeding). The lab report documented the critical lab values were reported to Staff 13 (RN) with read back verification done on 2/18/19 at 11:33 PM and 11:34 PM. There was no documentation in the clinical record on 2/18/19 regarding Resident 10's critical lab values, including consultation with the physician. The 2/19/19 at 11:11 AM Progress Note documented the resident had a critical white blood count and was sent to the hospital. The 2/19/19 Hospital Records documented Resident 10 arrived at 8:06 AM, approximately eight and a half hours after the critical lab notification. The discharge summary noted [DIAGNOSES REDACTED]. On 3/6/19 at 1:07 PM Resident 10 stated regarding the 2/18/19 labs she/he was sick and had no energy so labs were ordered, which revealed her/his white and red blood counts were really low. On 3/19/19 at 8:36 AM Witness 6 (Outside Provider RN) stated they received the critical lab values on 2/19/19. The resident was neutropenic (abnormally low level of white blood cells) and the facility was called right away and directed to send the resident to the hospital as she/he was high risk of being septic. Witness 6 stated she was concerned about the facility's critical lab response as it was documented on the lab report the critical labs were reported to Staff 13 (RN) on 2/18/19 at 11:33 PM. On 3/19/19 at 4:10 PM Witness 8 (Lab Client Services Rep) stated the lab was required to document who they reported critical labs to, the staff member's job title, what time they spoke with the staff member, and the staff member had to read the results back to the lab. On 3/20/19 at 12:21 AM Staff 13 stated she did not recall if she notified the physician regarding the critical labs. On 3/20/19 at 8:27 AM Staff 2 (DNS) stated staff were expected to call the physician right away when they received reports of critical lab values. Refer to F658 and F684. 2. Resident 2 was admitted to the facility in 2014 with [DIAGNOSES REDACTED]. The 1/1/19 ADL Care Plan noted Resident 2 required a two person, sit to stand lift transfer. The 2/22/19 at 6:43 AM Progress Note disclosed Resident 2 reported bad pain in the left hip with any movement. The resident reported during a 2/21/19 transfer in the sit to stand she/he and the caregivers heard a pop. An x-ray was ordered. The 2/22/19 Radiology Report documented the resident sustained [REDACTED]. The facility's 2/21/19 investigation noted the incident occurred during a sit to stand transfer. Staff 5 (LPN) was notified of the situation, however, she did not report the incident to the physician. On 3/5/19 at 10:47 AM Resident 2 stated the fracture occurred during a transfer and both the resident and staff present heard the snap. A nurse evaluated her/his leg and the resident reported having pain to the nurse. On 3/14/19 at 8:55 AM Staff 5 stated on 2/21/19 CNAs reported to her they heard a sound from the resident's hip while the resident was in the sit to stand lift. Staff 5 stated she evaluated the resident who reported she/he was not in any more pain than normal, the hip was not red or swollen, and the resident could move the hip. Staff 5 stated she did not contact the physician as nothing looked abnormal to her and the resident's pain was at baseline. On 3/14/19 at 12:51 PM Staff 2 (DNS) stated Staff 5 should not have made her own decision there was no injury and should have notified the physician when staff and the resident heard a pop. Refer to F658 and F684.

Based on interview and record review it was determined the facility failed to develop and implement a baseline care plan related to fall risk for 1 of 5 sampled residents (#1) reviewed for accidents. This failure, determined to be an immediate jeopardy situation, resulted in Resident 1 having a fall with a head injury with bleeding and transfer to the hospital where the resident died ; and placed other residents at risk for falls. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A hospital History and Physical dated [DATE] indicated Resident 1 fell at home when she/he got up from a chair to a standing position. The resident was found on the floor three hours later and was sent to the hospital. The resident appeared emaciated and suggestive of severe volume depletion (fluid loss which can cause symptoms including dry mucous membranes, rapid heart rate, and low blood pressure on standing). A Hospital to SNF/ALF/Home Health/Hospice Transfer Form dated [DATE] indicated Resident 1 was a fall risk and was weak but called (for assistance) appropriately. The resident required assistance with ambulation and two person assistance with transfers. An Admission assessment dated [DATE] indicated Resident 1 required extensive two person assistance with transfers and bed mobility. A Fall Risk assessment dated [DATE] indicated Resident 1 had a history of [REDACTED]. Resident 1's Care Delivery Guide (a brief care plan used by direct care staff for the provision of care) dated [DATE] indicated the resident required one to two person assistance with a gait belt for transfers. The only safety devices noted were Bolsters on bed (raised padding around the perimeter of the mattress to assist residents in being able to define where the edges of the bed were and does not restrict the resident's movement). The resident was identified as a fall risk and instructed staff call light in reach - resident may forget to use. Fall risk interventions such as fall mats, a low bed or frequent visual checks were not on the Care Delivery Guide. A Progress Notes dated [DATE] at 2:24 AM by Staff 7 (LPN) indicated Resident 1 was admitted to the facility with [DIAGNOSES REDACTED]. The resident used the call light for assistance using a urinal because she/he was too weak to sit up at the side of the bed or position the urinal independently. The resident's safety judgement was impaired as she/he was observed to raise the bed to an unsafe height and attempted to place her/his feet on the floor which would have resulted in a fall. The note did not indicate if the resident was provided education related to the risks of attempting to self-transfer, or the implementation of any fall risk interventions such as fall mats, a low bed or frequent visual checks. A Progress Notes dated [DATE] at 6:27 AM by Staff 7 indicated Resident 1 did not use the call light for assistance and staff were to ensure all her/his needs were met. A Progress Notes dated [DATE] indicated the resident was confused with poor safety awareness and attempted to get out of bed without assistance. Frequent visual checks. A Progress Notes dated [DATE] indicated the resident was alert but confused with poor safety awareness and was compulsive. A Physician's Telephone Orders dated [DATE] indicated Resident 1 was ordered [MEDICATION NAME] (anticoagulant medication which increases the risk of bleeding or delayed stopping of bleeding) daily at bedtime. A Progress Note dated [DATE] by Staff 8 (LPN) indicated Resident 1 was alert and responsive on night shift. The resident fell from bed to the floor which resulted in a head injury which was open and bleeding. The resident also had a bleeding skin tear to the elbow (side not indicated). The resident was unresponsive to verbal commands and her/his pupils were pinpoint and fixed. 911 was called and the resident left the facility at 12:20 AM. An incident investigation dated [DATE] indicated Resident 1 fell out of bed on the morning of [DATE] incurring a bleeding head injury and was unresponsive. 911 was called and the resident was sent to the hospital. On [DATE] the facility was notified the resident had died and the resident's family retrieved her/his belongings. The investigation concluded Resident 1 was provided care consistent with standards of practice and the Care Delivery Guide was in place. The investigation failed to address the resident's fall risk designation, history of falls, lack of fall risk intervention in place, documented evidence of the resident's poor safety awareness or speak to specific interventions on the Care Delivery Guide pertinent to the resident's risk for falls. An undated Nursing Admission Checklist indicated the nurse conducting a resident admission was to initiate a Fall/Injury Assessment: Prevention and Management Plan of Care. The form indicated the checklist was to be completed and provided to the RNCM within 24 hours of a resident admission. A review of Resident 1's clinical record revealed no Nursing Admission Checklist. Resident 1's hospital records were requested from the hospital but were not received in time for this report. On [DATE] at 10:23 AM Staff 8 (LPN) stated at about 11:45 PM (on [DATE]) the call light for Resident 1's room came on and she went to answer the call light. At that time she found Resident 1 on the floor. Resident 6 (Resident 1's roommate) had turned on the call light for her/his own needs and was not aware Resident 1 had fallen and was on the floor. She stated the resident was on the floor face down parallel to the bed with her/his head toward the foot of the bed. She stated the resident was not responsive with a large bleeding lump on the forehead. Staff 8 stated she knew the resident was taking an anticoagulant medication. The resident's pulse was thready (weak and barely perceptible) and pupils were non-responsive. Staff 8 stated there were only two CNAs on the shift that night and they were both on other halls taking resident vitals. She stated the resident was only wearing a gown and brief at the time, the bed was in the low position, there were no fall mats or bed bolsters in place. On [DATE] at 10:37 AM Staff 9 (CNA) stated she was assigned to half of Resident 1's hall on the night the resident fell . She stated Staff 10 (CNA) and herself were the only CNAs on duty and they were taking resident vitals on their main halls when Resident 1 was found on the floor. She stated the resident was a fall risk and on many occasions had found the resident attempting to get up without assistance. She did not recall if there were floor mats or bed bolsters in place but stated the bed was in the low position. She stated all the staff knew to check on the resident a lot. She stated they were understaffed that night and had not gotten to Resident 1's hall yet. On [DATE] at 11:16 AM Resident 6 (Resident 1's roommate) stated she/he woke up and turned on her/his call light for assistance with toileting and when staff came into the room they found Resident 1 on the floor. Resident 6 stated she/he had seen Resident 1 attempt to get up without assistance and an unnamed nurse told her/him the resident frequently attempted to get up. Resident 6 stated staff were frequently reminding the resident to use the call light. On [DATE] at 12:06 PM Staff 10 (CNA) stated he was on another hall when Staff 8 (LPN) came and got him to assist her and it was urgent. Staff 8 told him to grab the crash (emergency) cart which he did. He stated Resident 1 was prone on the floor and unresponsive. The resident was bleeding from the forehead and her/his eyes were unresponsive. Staff 10 stated he was never assigned to care for the resident but heard the resident was a fall risk. Staff 10 stated the resident's bed was a little higher than it should have been, part way up. Staff 10 was unsure what bed bolsters were and stated there were no fall mats in place. On [DATE] at 12:53 PM Staff 2 (Assistant Director of Nursing/RNCM) stated when Resident 1 was admitted to the facility she was working on admitting another resident and was not very familiar with Resident 1. Staff 2 did not recall if she developed the resident's care plan and was unaware the resident was attempting to self-transfer. She was unable to recall if the resident had any fall risk precautions in place. On [DATE] at 1:18 PM, 1:29 PM and 1:43 PM Staff 4 (Acting DNS) stated she was not aware Resident 1 was attempting to self-transfer. She said the facility did not use tab alarms and was unable to answer as to why there were no fall mats in place. She stated if a resident was exhibiting unsafe behavior the expectation was for that information to be documented on the 24 hour report so the resident could be assessed and interventions put in place. She acknowledged there was no documentation on the 24 hour report related to Resident 1's attempts to self-transfer. Staff 4 stated Staff 7 was the nurse who initiated Resident 1's admission Fall Risk Assessment and she was responsible for completing the care planning section of the assessment. Staff 4 acknowledged it was not completed. She stated it was the expectation for nurses to assess residents and use their judgement to at least put minimal fall risk interventions in place such as a low bed, fall mats or move the resident closer to the nurses' station. On [DATE] at 2:01 PM Staff 7 (Agency LPN) stated she was unfamiliar with the resident admission process and her understanding was that as an agency nurse she did not work on the care plan and care plan development was the responsibility of the RNCM. She stated Staff 2 and a corporate nurse were present when Resident 1 was admitted to the facility. She stated she did not think the resident would use the call light and told the aides to anticipate the resident's needs. She stated she was not aware there were no fall mats in place. On [DATE] at 10:49 AM Staff 1 (Administrator) acknowledged Resident 1 was a fall risk on admission to the facility and minimal fall risk interventions such as fall mats, frequent visual checks and a low bed should have been care planned. She stated she was not aware the resident was attempting to self-transfer. On [DATE] at 12:45 PM and 1:50 PM Staff 1 acknowledged the Care Delivery Guide was used by staff to provide care for residents. Refer to F-689

Based on interview and record review it was determined the facility failed to ensure staff adhered to professional standards of practice for 1 of 5 sampled residents (#1) reviewed for accidents. This failure, determined to be an immediate jeopardy situation, resulted in Resident 1 having a fall with a head injury with bleeding and transfer to the hospital where the resident died ; and placed other residents at risk for falls. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A hospital History and Physical dated [DATE] indicated Resident 1 fell at home when she/he got up from a chair to a standing position. The resident was found on the floor three hours later and was sent to the hospital. The resident appeared emaciated and suggestive of severe volume depletion (fluid loss which can cause symptoms including dry mucous membranes, rapid heart rate, and low blood pressure on standing). A Hospital to SNF/ALF/Home Health/Hospice Transfer Form dated [DATE] indicated Resident 1 was a fall risk and was weak but called (for assistance) appropriately. The resident required assistance with ambulation and two person assistance with transfers. An Admission assessment dated [DATE] indicated Resident 1 required extensive two person assistance with transfers and bed mobility. A Fall Risk assessment dated [DATE] indicated Resident 1 had a history of [REDACTED]. Resident 1's Care Delivery Guide (a brief care plan used by direct care staff for the provision of care) dated [DATE] indicated the resident required one to two person assistance with a gait belt for transfers. The only safety devices noted were Bolsters on bed (raised padding around the perimeter of the mattress to assist residents in being able to define where the edges of the bed were and does not restrict the resident's movement). The resident was identified as a fall risk and instructed staff call light in reach - resident may forget to use. Fall risk interventions such as fall mats, a low bed or frequent visual checks were not on the Care Delivery Guide. A Progress Notes dated [DATE] at 2:24 AM by Staff 7 (LPN) indicated Resident 1 was admitted to the facility with [DIAGNOSES REDACTED]. The resident used the call light for assistance using a urinal because she/he was too weak to sit up at the side of the bed or position the urinal independently. The resident's safety judgement was impaired as she/he was observed to raise the bed to an unsafe height and attempted to place her/his feet on the floor which would have resulted in a fall. The note did not indicate if the resident was provided education related to the risks of attempting to self-transfer, or the implementation of any fall risk interventions such as fall mats, a low bed or frequent visual checks. A Progress Notes dated [DATE] at 6:27 AM by Staff 7 indicated Resident 1 did not use the call light for assistance and staff were to ensure all her/his needs were met. A Progress Note dated [DATE] by Staff 8 (LPN) indicated Resident 1 was alert and responsive on night shift. The resident fell from bed to the floor which resulted in a head injury which was open and bleeding. The resident also had a bleeding skin tear to the elbow (side not indicated). The resident was unresponsive to verbal commands and her/his pupils were pinpoint and fixed. 911 was called and the resident left the facility at 12:20 AM. An incident investigation dated [DATE] indicated Resident 1 fell out of bed on the morning of [DATE] incurring a bleeding head injury and was unresponsive. 911 was called and the resident was sent to the hospital. On [DATE] the facility was notified the resident had died and the resident's family retrieved her/his belongings. An undated Nursing Admission Checklist indicated the nurse conducting a resident admission was to initiate a Fall/Injury Assessment: Prevention and Management Plan of Care. The form indicated the checklist was to be completed and provided to the RNCM within 24 hours of a resident admission. A review of Resident 1's clinical record revealed no Nursing Admission Checklist. Resident 1's hospital records were requested from the hospital but were not received in time for this report. On [DATE] at 12:53 PM Staff 2 (Assistant Director of Nursing/RNCM) stated when Resident 1 was admitted to the facility she was working on admitting another resident and was not very familiar with Resident 1. Staff 2 did not recall if she developed the resident's care plan and was unaware the resident was attempting to self-transfer. She was unable to recall if the resident had any fall risk precautions in place. On [DATE] at 1:18 PM, 1:29 PM and 1:43 PM Staff 4 (Acting DNS) stated if a resident was exhibiting unsafe behavior the expectation was for that information to be documented on the 24 hour report so the resident could be assessed and interventions put in place. She acknowledged there was no documentation on the 24 hour report related to Resident 1's attempts to self-transfer. Staff 4 stated Staff 7 was the nurse who initiated Resident 1's admission Fall Risk Assessment and she was responsible for completing the care planning section of the assessment. Staff 4 acknowledged it was not completed. She stated it was the expectation for nurses to assess residents and use their judgement to at least put minimal fall risk interventions in place such as a low bed, fall mats or move the resident closer to the nurses' station. On [DATE] at 2:01 PM Staff 7 (Agency LPN) stated she was unfamiliar with the resident admission process and her understanding was that as an agency nurse she did not work on the care plan and care plan development was the responsibility of the RNCM. She stated Staff 2 and a corporate nurse were present when Resident 1 was admitted to the facility. She stated she did not think the resident would use the call light and told the aides to anticipate the resident's needs. She stated she was not aware there were no fall mats in place. On [DATE] at 10:49 AM Staff 1 (Administrator) acknowledged Resident 1 was a fall risk on admission to the facility and minimal fall risk interventions such as fall mats, frequent visual checks and a low bed should have been care planned. She stated she was not aware the resident was attempting to self-transfer. Refer to F-689

Based on interview and record review it was determined the facility failed to evaluate and analyze fall risks, implement fall risk interventions and provide adequate supervision to prevent accidents for 4 of 5 sampled residents (#s 1, 2, 3 and 4) reviewed for accidents. This failure, determined to be an immediate jeopardy situation, resulted in Resident 1 having a fall with a head injury with bleeding and transfer to the hospital where the resident died ; and placed other residents at risk for falls. Findings include: 1. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A hospital History and Physical dated [DATE] indicated Resident 1 fell at home when she/he got up from a chair to a standing position. The resident was found on the floor three hours later and was sent to the hospital. The resident appeared emaciated and suggestive of severe volume depletion (fluid loss which can cause symptoms including dry mucous membranes, rapid heart rate, and low blood pressure on standing). A Hospital to SNF/ALF/Home Health/Hospice Transfer Form dated [DATE] indicated Resident 1 was a fall risk and was weak but called (for assistance) appropriately. The resident required assistance with ambulation and two person assistance with transfers. An Admission assessment dated [DATE] indicated Resident 1 required extensive two person assistance with transfers and bed mobility. A Fall Risk assessment dated [DATE] indicated Resident 1 had a history of [REDACTED]. Resident 1's Care Delivery Guide (a brief care plan used by direct care staff for the provision of care) dated [DATE] indicated the resident required one to two person assistance with a gait belt for transfers. The only safety devices noted were Bolsters on bed (raised padding around the perimeter of the mattress to assist residents in being able to define where the edges of the bed were and does not restrict the resident's movement). The resident was identified as a fall risk and instructed staff call light in reach - resident may forget to use. Fall risk interventions such as fall mats, a low bed or frequent visual checks were not on the Care Delivery Guide. A Progress Notes dated [DATE] at 2:24 AM by Staff 7 (LPN) indicated Resident 1 was admitted to the facility with [DIAGNOSES REDACTED]. The resident used the call light for assistance using a urinal because she/he was too weak to sit up at the side of the bed or position the urinal independently. The resident's safety judgement was impaired as she/he was observed to raise the bed to an unsafe height and attempted to place her/his feet on the floor which would have resulted in a fall. The note did not indicate if the resident was provided education related to the risks of attempting to self-transfer, or the implementation of any fall risk interventions such as fall mats, a low bed or frequent visual checks. A Progress Notes dated [DATE] at 6:27 AM by Staff 7 indicated Resident 1 did not use the call light for assistance and staff were to ensure all her/his needs were met. A Progress Notes dated [DATE] indicated the resident was confused with poor safety awareness and attempted to get out of bed without assistance. Frequent visual checks. A Progress Notes dated [DATE] indicated the resident was alert but confused with poor safety awareness and was compulsive. A Physician's Telephone Orders dated [DATE] indicated Resident 1 was ordered [MEDICATION NAME] (anticoagulant medication which increases the risk of bleeding or delayed stopping of bleeding) daily at bedtime. A Progress Note dated [DATE] by Staff 8 (LPN) indicated Resident 1 was alert and responsive on night shift. The resident fell from bed to the floor which resulted in a head injury which was open and bleeding. The resident also had a bleeding skin tear to the elbow (side not indicated). The resident was unresponsive to verbal commands and her/his pupils were pinpoint and fixed. 911 was called and the resident left the facility at 12:20 AM. An incident investigation dated [DATE] indicated Resident 1 fell out of bed on the morning of [DATE] incurring a bleeding head injury and was unresponsive. 911 was called and the resident was sent to the hospital. On [DATE] the facility was notified the resident had died and the resident's family retrieved her/his belongings. The investigation concluded Resident 1 was provided care consistent with standards of practice and the Care Delivery Guide was in place. The investigation failed to address the resident's fall risk designation, history of falls, lack of fall risk intervention in place, documented evidence of the resident's poor safety awareness or speak to specific interventions on the Care Delivery Guide pertinent to the resident's risk for falls. An undated Nursing Admission Checklist indicated the nurse conducting a resident admission was to initiate a Fall/Injury Assessment: Prevention and Management Plan of Care. The form indicated the checklist was to be completed and provided to the RNCM within 24 hours of a resident admission. A review of Resident 1's clinical record revealed no Nursing Admission Checklist. Resident 1's hospital records were requested from the hospital but were not received in time for this report. On [DATE] at 10:23 AM Staff 8 (LPN) stated at about 11:45 PM (on [DATE]) the call light for Resident 1's room came on and she went to answer the call light. At that time she found Resident 1 on the floor. Resident 6 (Resident 1's roommate) had turned on the call light for her/his own needs and was not aware Resident 1 had fallen and was on the floor. She stated the resident was on the floor face down parallel to the bed with her/his head toward the foot of the bed. She stated the resident was not responsive with a large bleeding lump on the forehead. Staff 8 stated she knew the resident was taking an anticoagulant medication. The resident's pulse was thready (weak and barely perceptible) and pupils were non-responsive. Staff 8 stated there were only two CNAs on the shift that night and they were both on other halls taking resident vitals. She stated the resident was only wearing a gown and brief at the time, the bed was in the low position, there were no fall mats or bed bolsters in place. On [DATE] at 10:37 AM Staff 9 (CNA) stated she was assigned to half of Resident 1's hall on the night the resident fell . She stated Staff 10 (CNA) and herself were the only CNAs on duty and they were taking resident vitals on their main halls when Resident 1 was found on the floor. She stated the resident was a fall risk and on many occasions had found the resident attempting to get up without assistance. She did not recall if there were floor mats or bed bolsters in place but stated the bed was in the low position. She stated all the staff knew to check on the resident a lot. She stated they were understaffed that night and had not gotten to Resident 1's hall yet. On [DATE] at 11:16 AM Resident 6 (Resident 1's roommate) stated she/he woke up and turned on her/his call light for assistance with toileting and when staff came into the room they found Resident 1 on the floor. Resident 6 stated she/he had seen Resident 1 attempt to get up without assistance and an unnamed nurse told her/him the resident frequently attempted to get up. Resident 6 stated staff were frequently reminding the resident to use the call light. On [DATE] at 12:06 PM Staff 10 (CNA) stated he was on another hall when Staff 8 (LPN) came and got him to assist her and it was urgent. Staff 8 told him to grab the crash (emergency) cart which he did. He stated Resident 1 was prone on the floor and unresponsive. The resident was bleeding from the forehead and her/his eyes were unresponsive. Staff 10 stated he was never assigned to care for the resident but heard the resident was a fall risk. Staff 10 stated the resident's bed was a little higher than it should have been, part way up. Staff 10 was unsure what bed bolsters were and stated there were no fall mats in place. On [DATE] at 12:53 PM Staff 2 (Assistant Director of Nursing/RNCM) stated when Resident 1 was admitted to the facility she was working on admitting another resident and was not very familiar with Resident 1. Staff 2 did not recall if she developed the resident's care plan and was unaware the resident was attempting to self-transfer. She was unable to recall if the resident had any fall risk precautions in place. On [DATE] at 1:18 PM, 1:29 PM and 1:43 PM Staff 4 (Acting DNS) stated she was not aware Resident 1 was attempting to self-transfer. She said the facility did not use tab alarms and was unable to answer as to why there were no fall mats in place. She stated if a resident was exhibiting unsafe behavior the expectation was for that information to be documented on the 24 hour report so the resident could be assessed and interventions put in place. She acknowledged there was no documentation on the 24 hour report related to Resident 1's attempts to self-transfer. Staff 4 stated Staff 7 was the nurse who initiated Resident 1's admission Fall Risk Assessment and she was responsible for completing the care planning section of the assessment. Staff 4 acknowledged it was not completed. She stated it was the expectation for nurses to assess residents and use their judgement to at least put minimal fall risk interventions in place such as a low bed, fall mats or move the resident closer to the nurses' station. On [DATE] at 2:01 PM Staff 7 (Agency LPN) stated she was unfamiliar with the resident admission process and her understanding was that as an agency nurse she did not work on the care plan and care plan development was the responsibility of the RNCM. She stated Staff 2 and a corporate nurse were present when Resident 1 was admitted to the facility. She stated she did not think the resident would use the call light and told the aides to anticipate the resident's needs. She stated she was not aware there were no fall mats in place. On [DATE] at 10:49 AM Staff 1 (Administrator) acknowledged Resident 1 was a fall risk on admission to the facility and minimal fall risk interventions such as fall mats, frequent visual checks and a low bed should have been care planned. She stated she was not aware the resident was attempting to self-transfer. On [DATE] at 12:45 PM and 1:50 PM Staff 1 acknowledged the Care Delivery Guide was used by staff to provide care for residents. Staff 1 acknowledged the incident investigation failed to determine the root cause of the resident's fall. On [DATE] at 1:17 PM Staff 1 (Administrator) was notified the failure to provide fall risk interventions for Resident 1 was determined, in consultation with survey management, to be an immediate jeopardy situation. An acceptable plan to abate the immediate jeopardy situation was submitted by the facility on [DATE] at 3:25 PM. The plan indicated the facility would implement the following actions to address the immediate concerns related to baseline care plan, accidents, assessments and professional standards: 1. Residents in the facility would be audited for current fall risk assessments. Those without assessments since their most recent MDS, fall or change in condition would be updated. 2. Residents in the facility would have their care plans and care guides reviewed for current fall prevention interventions and updated as needed. 3. Residents who were admitted to the facility within the previous 21 days would be reviewed for baseline and/or comprehensive care plans which would be updated as needed. 4. Licensed nurses would be educated related to completing a fall risk assessment at the time of admission, upon incident and as needed to include implementing interventions as appropriate based upon assessments and updating the care plan and care guide. Licensed nurses would be educated regarding the requirement of developing a baseline care plan at the time of admission. 5. Licensed nurses would be educated on their responsibilities regarding implementing immediate interventions when a resident had an accident to minimize the risk of injury on reoccurrence. The education would include documentation of interventions on the care plan and care delivery guide. On [DATE] at 8:22 PM it was verified the facility had audited the residents in the facility to determine who were fall risks, recent admissions and what fall risk interventions were currently in place in resident rooms. The Care Delivery Guides for all identified residents were reviewed and updated as needed. Licensed nurses were in-serviced regarding fall risk assessment, care planning and the implementation of interventions. A tour of the facility revealed residents appeared safe and their needs were being met. At that time it was deemed the facility had sufficiently implemented their plan to remove the immediate jeopardy and ensure immediate resident safety regarding fall risks and the facility was notified the immediate jeopardy situation was removed. 2. Resident 2 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Resident 2's Care Delivery Guide initiated on [DATE] indicated the resident was a fall risk due to non-weight bearing status on the left side. Safety devices included bolsters and enabler bars. The resident also had a transfer pole to aide in transfers. Resident 2's Falls CAA dated [DATE] indicated the resident was at risk for falls related to weakness, infection and heel pressure ulcer. The resident required extensive assistance with transfers and ambulation. Environmental factors included the bed kept at sitting height or lower with wheels locked, call light in reach and pathways clear and well lit. The care plan was to address potential risk factors of falls such as weakness, cognitive issues and pain. A review of Resident 2's clinical record revealed no comprehensive fall risk care plan. On [DATE] at 3:25 PM Resident 2 was observed in bed, the bed height was above sitting level, with a call light within reach, a transfer pole, wheelchair at bedside with brakes locked, bed mobility bars and uncluttered floors. An incident investigation dated [DATE] indicated during an assisted transfer and with the use of the transfer pole, the resident had difficulty moving her/his feet, was unable to complete the transfer and was assisted to the floor by the aide. The resident was assessed and no injuries were found. The investigation indicated the resident's care plan was reviewed. The investigation failed to analyze the incident to determine if this was an isolated incident or if the resident had a decline in ability which may have warranted changes in the resident's transfer status and develop a plan to prevent a reoccurrence. On [DATE] at 10:36 AM Staff 1 (Administrator) and Staff 6 (RN Director of Education and Training) acknowledged Resident 2 did not have a fall risk care plan and the incident investigation did not identify the root cause of Resident 2's fall or a plan to prevent a reoccurrence. On [DATE] at 12:45 PM Staff 1 acknowledged the Care Delivery Guide was used by staff to provide care for residents. 3. Resident 3 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Resident 3's Care Delivery Guide initiated on [DATE] indicated the resident was a high fall risk due to left sided weakness and required two person assistance with ambulation and transfers. No fall risk interventions or safety devices were noted. The guide indicated the resident was continent of bladder but did not indicate the use devices or amount of staff assistance required for toileting. Resident 3's Falls CAA dated [DATE] indicated the resident had a history of [REDACTED]. The assessment included Continued monitoring by staff and reeducation and indicated a care plan would be developed for falls. A review of Resident 3's clinical record revealed no comprehensive fall risk care plan. An incident investigation dated [DATE] indicated Staff 11 (Physical Therapist) went to the resident's room to see her/him for therapy and the resident stated she/he needed to use the urinal. Staff 10 provided the resident with the urinal and offered assistance which the resident declined. Staff 10 stepped out of the room to provide the resident with privacy. While outside the room Staff 10 asked the resident several times if she/he needed assistance and on the last time the resident stated she/he was on the floor. The investigation indicated the resident's wheelchair brakes were not locked and as the resident repositioned to the front of the seat to use the urinal the wheelchair did scoot out from behind her/him. The investigation indicated it was an unpredicted accident that was not for(e)seen. The investigation did not address the appropriateness of the resident using a urinal unsupervised while in a wheelchair with the brakes unlocked, the failure of the Care Delivery Guide to indicate the use of a urinal and fall risk interventions, the lack of a fall risk care plan or a plan to prevent reoccurrence. On [DATE] at 3:29 PM Resident 3 was observed in bed. The bed was in the low position, the call light was in reach and textured traction strips on the floor at the bedside. On [DATE] at 10:44 AM Staff 1 (Administrator) and Staff 6 (RN Director of Education and Training) acknowledged there were no fall risk interventions on the Care Delivery Guide, there was no comprehensive fall risk care plan and the incident investigation did not address the root cause of the fall or a plan to prevent reoccurrence. On [DATE] at 12:45 PM Staff 1 acknowledged the Care Delivery Guide was used by staff to provide care for residents. 4. Resident 4 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The resident no longer resided in the facility. Resident 4's fall risk care plan revised on [DATE] included: Anticipate and meet needs, call light in reach, cue signs to encourage the resident to use the call light, fall mat on the right side of the bed, change positions slowly, needed items in reach and clear pathways. Resident 4's Care Delivery Guide updated [DATE] indicated the resident was a fall risk but did not include any of the fall risk interventions from the [DATE] care plan. An incident investigation dated [DATE] indicated on [DATE] Resident 4 was found on the floor of her/his room and no injuries were noted. The investigation failed to indicate if the resident's call light was in reach, cue signs were posted and fall mat were in place. The investigation indicated the care plan was reviewed but did not address the failure of the Care Delivery Guide to have the fall risk interventions noted. On [DATE] at 10:44 AM Staff 1 (Administrator) and Staff 6 (RN Director of Education and Training) acknowledged there were no fall risk interventions on the Care Delivery Guide. On [DATE] at 12:45 PM Staff 1 acknowledged the Care Delivery Guide was used by staff to provide care for residents.

Based on interview and record review it was determined the facility failed to ensure Staff 7 (LPN) had the appropriate skills and competencies necessary to care for resident needs related to fall risk for 1 of 5 sampled residents (#1) reviewed for accidents. This failure, determined to be an immediate jeopardy situation, resulted in Resident 1 having a fall with a head injury with bleeding and transfer to the hospital where the resident died ; and placed other residents at risk for falls. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A hospital History and Physical dated [DATE] indicated Resident 1 fell at home when she/he got up from a chair to a standing position. The resident was found on the floor three hours later and was sent to the hospital. The resident appeared emaciated and suggestive of severe volume depletion (fluid loss which can cause symptoms including dry mucous membranes, rapid heart rate, and low blood pressure on standing). A Hospital to SNF/ALF/Home Health/Hospice Transfer Form dated [DATE] indicated Resident 1 was a fall risk and was weak but called (for assistance) appropriately. The resident required assistance with ambulation and two person assistance with transfers. An Admission assessment dated [DATE] indicated Resident 1 required extensive two person assistance with transfers and bed mobility. A Fall Risk assessment dated [DATE] indicated Resident 1 had a history of [REDACTED]. Resident 1's Care Delivery Guide (a brief care plan used by direct care staff for the provision of care) dated [DATE] indicated the resident required one to two person assistance with a gait belt for transfers. The only safety devices noted were Bolsters on bed (raised padding around the perimeter of the mattress to assist residents in being able to define where the edges of the bed were and does not restrict the resident's movement). The resident was identified as a fall risk and instructed staff call light in reach - resident may forget to use. Fall risk interventions such as fall mats, a low bed or frequent visual checks were not on the Care Delivery Guide. A Progress Notes dated [DATE] at 2:24 AM by Staff 7 (LPN) indicated Resident 1 was admitted to the facility with [DIAGNOSES REDACTED]. The resident used the call light for assistance using a urinal because she/he was too weak to sit up at the side of the bed or position the urinal independently. The resident's safety judgement was impaired as she/he was observed to raise the bed to an unsafe height and attempted to place her/his feet on the floor which would have resulted in a fall. The note did not indicate if the resident was provided education related to the risks of attempting to self-transfer, or the implementation of any fall risk interventions such as fall mats, a low bed or frequent visual checks. A Progress Notes dated [DATE] at 6:27 AM by Staff 7 indicated Resident 1 did not use the call light for assistance and staff were to ensure all her/his needs were met. An incident investigation dated [DATE] indicated Resident 1 fell out of bed on the morning of [DATE] incurring a bleeding head injury and was unresponsive. 911 was called and the resident was sent to the hospital. On [DATE] the facility was notified the resident had died and the resident's family retrieved her/his belongings. The investigation concluded Resident 1 was provided care consistent with standards of practice and the Care Delivery Guide was in place. The investigation failed to address the resident's fall risk designation, history of falls, lack of fall risk intervention in place, documented evidence of the resident's poor safety awareness or speak to specific interventions on the Care Delivery Guide pertinent to the resident's risk for falls. An undated Nursing Admission Checklist indicated the nurse conducting a resident admission was to initiate a Fall/Injury Assessment: Prevention and Management Plan of Care. The form indicated the checklist was to be completed and provided to the RNCM within 24 hours of a resident admission. A review of Resident 1's clinical record revealed no Nursing Admission Checklist. Resident 1's hospital records were requested from the hospital but were not received in time for this report. On [DATE] at 1:18 PM, 1:29 PM and 1:43 PM Staff 4 (Acting DNS) stated if a resident was exhibiting unsafe behavior the expectation was for that information to be documented on the 24 hour report so the resident could be assessed and interventions put in place. She acknowledged there was no documentation on the 24 hour report related to Resident 1's attempts to self-transfer. Staff 4 stated Staff 7 was the nurse who initiated Resident 1's admission Fall Risk Assessment and she was responsible for completing the care planning section of the assessment. Staff 4 acknowledged it was not completed. She stated it was the expectation for nurses to assess residents and use their judgement to at least put minimal fall risk interventions in place such as a low bed, fall mats or move the resident closer to the nurses' station. On [DATE] at 2:01 PM Staff 7 (Agency LPN) stated she was unfamiliar with the resident admission process and her understanding was that as an agency nurse she did not work on the care plan and care plan development was the responsibility of the RNCM. She stated Staff 2 and a corporate nurse were present when Resident 1 was admitted to the facility. She stated she did not think the resident would use the call light and told the aides to anticipate the resident's needs. She stated she was not aware there were no fall mats in place. On [DATE] at 10:49 AM Staff 1 (Administrator) acknowledged Resident 1 was a fall risk on admission to the facility and minimal fall risk interventions such as fall mats, frequent visual checks and a low bed should have been care planned. She stated she was not aware the resident was attempting to self-transfer. On [DATE] at 12:45 PM and 1:50 PM Staff 1 acknowledged the Care Delivery Guide was used by staff to provide care for residents. On [DATE] at 9:40 AM Staff 6 (RN Director of Education and Training) stated agency nurses were provided with a training program or training in the facility's resident admission process. She stated there was a checklist for nurses to follow for the admission of a resident. Refer to F-689

Based on interview and record review it was determined the facility failed to ensure the resident's safety for 1 of 3 sampled residents (#1) reviewed for falls. Resident 1 fell and sustained a fractured nose. Findings include: Resident 1 was admitted to the facility in 2016 with [DIAGNOSES REDACTED]. The 10/2016 Fall Care Plan noted Resident 1 was at risk for falls related to weakness, left leg above the knee amputation, and refusal to follow the non-smoking policy. The care plan lacked documented interventions related to the resident's risk of falls while smoking. The 4/11/17 at 1:29 pm Progress Note disclosed Resident 1 fell and sustained injuries. The facility's correlating investigation revealed a visitor found the resident face down in the facility parking lot on 4/11/17 at 9:20 am. The resident was visually observed at 9:00 am, however, there was no documentation as to what the resident was doing at that time nor what supervision was in place when the resident went out to smoke. The resident reported dropping a lighter and fell out of her/his wheelchair while bending over to pick it up. The resident sustained [REDACTED]. The investigation noted this was the second injury of this type. The 4/12/17 and 4/21/17 Smoking Assessments noted Resident 1 fell out of the wheelchair on numerous occasions while attempting to pick up dropped objects. Due to the resident's left leg amputation she/he could not stop herself/himself when falling forward. The resident fell twice incurring multiple facial contusions when her/his head hit the pavement of off-site smoking area. The resident was assessed as a dependent smoker. There was no update to the resident's 10/2016 Fall Care Plan related to the resident's continued fall risk while smoking. The 6/1/17 at 10:00 am Progress Note disclosed Resident 1 fell out of the wheelchair while in the parking lot, bleeding from the nose and the right side of her/his face. The resident was sent to the hospital for evaluation. The facility's correlating investigation noted on 6/1/17 at 10:00 am Resident 1 fell from her/his wheelchair while smoking in the facility parking lot. The resident was visually observed at 9:30 am, however, there was no documentation as to what the resident was doing at that time nor what supervision was in place when the resident went out to smoke. The resident reported she/he dropped the lighter, was reaching for it and fell landing on her/his face. The 6/2/17 Hospital Discharge Summary noted the resident sustained [REDACTED]. There was no update to the resident's 10/2016 Fall Care Plan related to the resident's continued fall risk while smoking. The 6/2/17 Progress Note disclosed the resident was readmitted to the facility. The 6/30/17 Discharge Planning Note revealed Resident 1 was discharged from the facility on 6/19/17. During interview with Staff 1 (Administrator), Staff 2 (DNS), and Staff 5 (RNCM) on 6/27/17 at 10:30 am it was stated they were a non-smoking facility. Staff 1 stated residents assessed as dependent required a visitor with them when smoking. Staff 2 stated staff did not supervise residents during smoking and the residents were to smoke off of facility grounds. Staff 2 stated staff were aware Resident 1 smoked while in the facility parking lot. In interview with Staff 2 (DNS) and Staff 3 (Director of Operations) on 6/27/17 at 11:45 am Staff 3 stated the facility should have increased the resident's supervision and ensured her/his safety. In interview on 7/12/17 at 9:50 am Staff 17 (CNA) stated prior to the 6/1/17 fall the resident had falls while smoking in the facility parking lot. Staff 17 stated if the resident leaned forward she/he fell out of the wheelchair. Per facility policy the resident was to smoke off property and staff were aware the resident went outside to smoke, however, staff did not go out with the resident. Staff 17 stated regarding the 6/1/17 fall he did not know if staff were aware Resident 1 went out to smoke prior to the fall. The resident was found on the ground in the middle of the facility parking lot. In interview on 7/12/17 at 10:37 am Staff 20 (LPN) stated regarding the 4/11/17 and 6/1/17 Resident 1 falls staff were aware the resident went outside to smoke as she/he reported it to CNA staff. The resident had falls related to dropping items. Per the facility policy staff were not to go out with the resident and assist with smoking. In interview on 7/12/17 at 2:43 pm Staff 21 (CNA) stated the resident's routine included getting up in the wheelchair and out of her/his room. Being assigned residents on different halls at the same time made it difficult to keep an eye on Resident 1. Staff 21 stated he did not know the resident was going out to smoke prior to the 4/11/17 fall. In interview on 7/12/17 at 4:21 pm Staff 12 (RN) stated Resident 1 had several falls when going to the facility parking lot to smoke and would drop her/his lighter and fall. Staff 12 stated staff were aware the resident went out to smoke but could not assist. In interview on 7/13/17 at 11:50 am Staff 10 (CNA) stated the resident's morning routine included placing the resident at the nurse's station so she/he could then move about the building. Staff 10 stated she was not aware of staff monitoring the resident for going outside to smoke. Staff 10 stated Staff 2 (DNS) told her Resident 1 could not go outside to smoke due to it being unsafe and the resident did not tell staff when going outside.

Based on observation, interview and record review it was determined the facility failed to develop and follow up on fall interventions in a timely manner and ensure proper positioning to prevent aspiration for 2 of 4 sampled residents (#s 2 and 3) reviewed for safety. Resident 2 sustained multiple injuries including hematomas and a laceration that required sutures. Resident 3 was at risk for aspiration. Findings include: 1. Resident 2 was admitted to the facility in 2014 with [DIAGNOSES REDACTED]. The 4/2016 Cognitive Loss, ADL and Falls CAAs noted Resident 2 was cognitively impaired, had unsteady gait and weakness and required extensive one to two person assistance with transfers. Staff were directed to monitor the resident every two hours and as needed and to maintain an appropriate position for the resident. The 2/2016 Care Delivery Guide noted Resident 2 required two person sit to stand transfers. The resident had poor safety awareness and a history of falls. The 10/5/16 at 2:44 pm and 10/6/16 at 9:56 am Progress Notes disclosed Resident 2 had falls. The 10/6/16 Fax to the physician noted Resident 2 had two falls in two days, will collect urine to r/t (rule out) UTI (urinary tract infection). There was no documented follow up on the unrinanalysis. The 11/4/16 Therapy to Nursing Communication noted the resident's positioning in the wheelchair was assessed. A pommel cushion (assists with positioning) was recommended as this may prevent slipping forward out of the wheelchair. There was no documented follow up of the therapy recommendation. The 11/15/16 facility fall investigation disclosed Resident 2 was found on the floor in the hallway. The resident used the wheelchair at the time of the fall. The resident sustained [REDACTED]. The resident was sent to the hospital for evaluation. The 11/15/16 Emergency Department notes documented Resident 2 sustained a large hematoma to the left forehead and superficial abrasions around the left eye. No new interventions to prevent further falls were identified until 11/21/16 when Staff 2 (DNS) requested anti roll back brakes be installed to the resident's wheelchair. The anti roll back brakes were not installed until 11/23/16, eight days after the 11/15/16 fall. The 11/22/16 facility fall investigation documented Resident 2 fell in her/his room. The resident was found on the floor with the wheelchair behind her/him and sustained a hematoma to the left forehead. Resident 2 stated she/he tried to pick something off the floor. The resident's physician was faxed regarding the fall with a hematoma, to which the physician responded .Accidents with injury should always be called to the attending Dr. Please educate staff! The 11/24/16 at 12:14 am Progress Note disclosed Frequent visual checks . as the resident used the call light at times .anticipating res (resident) needs to try and decrease risk of injury. There was no documented follow up for the use of frequent checks as a fall intervention. The 11/30/16 at 2:09 pm Progress Note revealed Resident 2 fell , sustained a large laceration to the forehead and was sent to the hospital. The correlating facility investigation noted the fall occurred at 9:25 am in the resident's room. The investigation documented the resident was last visually observed at 8:45 am (40 minutes before the fall). However, there were discrepancies in the investigation as to when the resident was last toileted/observed, noting the resident was toileted at 8:20 am (approximately an hour before the fall). The resident was found lying face down with a large pool of blood. When rolled to her/his back a large laceration to the forehead was observed. Staff placed pressure on the forehead until EMTs (Emergency Medical Technicians) arrived. The resident was transported to the hospital. The 11/30/16 Emergency Department Notes and discharge instructions noted Resident 2 sustained a 5 cm laceration to the left upper forehead that required sutures. The 12/2/16 at 10:50 am Progress Note disclosed Resident 2 changed rooms for safety and will be checked more frequently . The 12/7/16 at 7:35 pm Progress Note documented Frequent visual checks as res is high fall risk. The 12/22/16 facility fall investigation noted at 12:40 pm Resident 2 slid out of the wheelchair, fell to the floor and bumped her/his head on the wall. Staff 8 (CNA) documented she unsuccessfully attempted to reach Resident 2 as the resident slid out of the wheelchair. Staff 11 (NA) documented prior to the fall Resident 2 was sliding out of chair all day long. The investigation noted Staff is noted to be checking on (Resident 2) often . Prior to the fall Resident 2 had dycem (anti-slip material) in place under the wheelchair cushion. After the fall the use of dycem was added to the top of the cushion, which was added to the care plan. There was no documented evidence the resident's sliding out of the wheelchair was reported to the LN prior to the resident's fall. On 12/28/16 at 11:35 am and 12:58 pm Resident 2 was observed self-propelling in the wheelchair in the dining room and her/his room. At 2:44 pm dycem was observed in place on top and underneath the wheelchair cushion. Resident 2's falls were discussed with Staff 2 (DNS) in interviews on 1/3/17 at 8:37 am, 1/5/17 at 12:46 pm and 1/9/17 at 10:23 am. Staff 2 stated if a fall resulted in injury nursing staff were to call the physician. Staff 2 provided no documented follow up for the 10/6/16 urinanalysis. Staff 2 initially stated there was no defined time for how often frequent checks were completed, they were not necessarily a 15 minute check and could not state how often staff were to check on Resident 2. In subsequent interview Staff 2 stated frequent checks were done every 15 minutes as staff were up and down the halls. Staff 2 stated he would not care plan for frequent checks to continue as it would not work in the facility. Staff 2 stated the timeframe for checking Resident 2 prior to the 11/30/16 fall was appropriate. In interview on 1/3/17 at 1:36 pm Staff 29 (Maintenance Manager) stated on 11/21/16 he received the request for placing the anti roll back brakes on Resident 2's wheelchair. The brakes did not fit, he located another wheelchair for the resident and installed the brakes on either 11/23/16 or 11/24/16. In interview on 1/5/17 at 10:50 am Staff 24 (CNA) stated Resident 2 was a fall risk and staff tried to check the resident as they could. In interview on 1/5/17 at 11:45 am Staff 31 (PT) stated regarding the pommel cushion recommendation, once the recommendation was given it was up to nursing staff to follow through. In interview on 1/5/17 at 1:58 pm Staff 23 (CNA) stated on 11/22/16 she found Resident 2 lying on the floor. The resident was seen in the wheelchair eating dinner approximately 15 minutes before the fall. The resident sustained [REDACTED]. In interview on 1/5/17 at 12:20 pm Staff 8 (CNA) stated on 11/30/16 she could not recall if she observed Resident 2 a half an hour or an hour prior to the fall. On 12/22/16 Staff 8 walked down the hall and observed Resident 2 sliding out of the wheelchair but did not get to the resident in time and the resident fell . Staff 8 stated she did not know if the resident had problems with sliding out prior to that fall. In interview on 1/5/17 at 11:10 am Staff 26 (LPN) stated on 12/22/16 she received no reports of the resident sliding out of the wheelchair prior to the fall. In interview on 1/6/17 at 7:25 am Staff 11 (NA) stated prior to the resident's fall on 12/22/16 Resident 2 slid forward in the wheelchair multiple times during lunch and required repositioning. Staff 11 stated she did not report the change in the resident's positioning to the LN prior to the resident's fall. Resident 2 was left in her/his room while Staff 11 located the sit to stand machine to transfer the resident to bed. As Staff 8 (CNA) went to the resident's room to assist with the transfer Resident 2 fell . In interview on 1/5/17 at 11:21 am Staff 3 (RNCM) stated she was not aware of Resident 2 sliding out of the wheelchair prior to the fall on 12/22/16. Staff 3 stated if she had known she would have done something to address the resident's positioning. Regarding frequent checks for Resident 2, Staff 3 stated it was mentioned in the morning meetings to check on Resident 2 but Staff 3 could not recall specific details. Refer to F225 2. Resident 3 was admitted to the facility in 2016 with [DIAGNOSES REDACTED]. The 3/2016 Cognitive Loss CAA noted Resident 3 was cognitively impaired. The updated 10/16/16 Care Delivery Guide noted Resident 3 required aspiration precautions. The 12/8/16 SBAR (Situation, Background, Assessment and Request) form revealed Resident 3 vomited while lying flat in bed then was assessed with [REDACTED]. The physician ordered an x-ray to rule out aspiration, which was negative. In interview on 12/28/16 at 11:46 am Staff 28 (CNA) stated Resident 3 was in bed flat on her/his back and reported being nauseous (could not recall the date). Resident 3 was cognitively impaired and could not tell someone if she/he needed to sit up. Staff 10 (CNA) stated to Staff 28 she gave the resident a basin. Resident 3 called for help and had vomited. Staff 28 observed Resident 3 lying flat on her/his back holding the basin to her/his chest and the emesis was on the resident's face, in her/his nose, everywhere. Staff 28 rolled Resident 3 to her/his side and obtained assistance from the LN due to the resident's history of aspiration. In interview on 1/5/17 at 1:39 pm Staff 10 (CNA) stated she assisted Resident 3 to bed between breakfast and lunch (could not recall the date). The resident reported being nauseous and Staff 10 gave the resident a basin but forgot to raise up the head of the bed. Staff 10 checked on Resident 3 multiple times and approximately an hour later Resident 3 vomited. The resident was not completely flat in bed but the head of bed was only raised a little, not enough to assist the resident. Staff 10 stated she was trained to ensure residents sat up completely when nauseous but forgot. In interview on 1/6/16 at 8:44 am Staff 33 (RN) stated on 12/8/16 Resident 3 reported being nauseous to her/his aide (could not recall the name) and the aide gave the resident a basin. About a half an hour later Staff 33 went into the resident's room and found the resident had vomited. The aide had not raised the head of the bed when the resident was transferred to bed nor when provided the basin. The resident was a high aspiration risk, staff were informed regarding the resident's positioning related to that risk and the head of the bed was always raised. Refer to F226, F281

Based on interview and record review it was determined facility staff failed to ensure professional standards of practice were followed regarding medication administration for 1 of 4 sampled residents (#1) reviewed for medication administration. Resident 1 did not receive medications as ordered, including [MEDICATION NAME] (a corticosteroid) and was hospitalized . Findings include: Division 45 Standards and Scope of Practice for Licensed Practical Nurses 851-045-0050 (2)(d)(A) "The Board recognizes that the scope of practice for the Licensed Practical Nurse encompasses a variety of roles, including but not limited to: Implement the plan of care by: Implementing treatment and therapy appropriate to the context of care, including but not limited to, medication administration..." Division 45 Standards and Scope of Practice for Registered Nurses 851-045-0060 (2)(d)(A) "The Board recognizes that the scope of practice for the Registered Nurse encompasses a variety of roles, including but not limited to: Implement the plan of care by: Implementing treatment and therapy appropriate to the context of care, including ... medication administration..." Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1 was admitted with physician orders [REDACTED]. Additionally, Resident 1 had physician orders [REDACTED]. 25 mg from 8/16 to 8/18/13 20 mg from 8/18 to 8/21/13 17.5 mg from 8/22 to 8/26/13 16.25 mg from 8/27 to 8/31/13 15 mg from 9/1 to 9/5/13 12.5 mg from 9/6 to 9/10/13 10 mg daily starting 9/11/13 On 8/17/13 the physician ordered the resident could receive his/her morning medications upon return from [MEDICAL TREATMENT]. It was noted on the August 2013 MAR "Ok to give AM meds late when resident returns from [MEDICAL TREATMENT] on Monday, Wednesday and Friday." On 8/21/13, 8/23/13, 8/28/13 and 8/30/13 it was documented the resident was "OOF" (out of facility) and did not receive morning medications of [MEDICATION NAME], Aspirin, [MEDICATION NAME] and Nephro-Vite. According to the facility's Drug Handbook, 2014 Lippincott's Nursing Drug Guide, regarding [MEDICATION NAME], "Taper doses when discontinuing high-dose or long-term therapy to avoid [MEDICAL CONDITION]." It was noted on the August 2013 MAR "[MEDICATION NAME] taper continues 9/1 *See physician's orders [REDACTED]. A 9/2/13 [MEDICAL TREATMENT] Center Communication Record documented the resident had a low blood pressure at [MEDICAL TREATMENT], which was treated with fluids. Upon return to the facility, staff were unable to get vital signs, blood sugar was 124 and the resident was "very incoherent, having hallucinations." A correlating 9/2/13 Progress Note indicated Resident 1 returned from [MEDICAL TREATMENT] in "poor condition." The resident was diaphoretic (excessive sweating), "not well." 911 was called and the resident was sent to the hospital. According to the 9/2/13 hospital records, facility staff reported the resident complained of nausea prior to [MEDICAL TREATMENT]. Upon return from [MEDICAL TREATMENT], the resident was noted to have [MEDICAL CONDITION] of the right upper extremity and altered mental status. At the hospital, the resident reported he/she "feels terrible" but was unable to give any more details of specific symptoms. He/she appeared confused, lethargic, responses to questions were very slow and he/she was disoriented. "Cognition and memory are impaired." The resident was found to have a blood sugar of 79 and was given juice and the resident improved. The physician noted the altered mental status was likely due to [DIAGNOSES REDACTED] and was resolved. However, the hospital records lacked documented evidence the hospital had been informed the resident had previously received [MEDICATION NAME] prior to the hospitalization . A 9/2/13 Progress Note indicated Resident 1 returned back to the facility and complained of feeling "weak." A 9/5/13 Day Progress Note revealed Resident 1 had emesis in the morning, which was treated with medication. Facility staff documented on a 9/6/13 [MEDICAL TREATMENT] Center Communication Record the resident complained of nausea and loss of appetite, which was treated with medication prior to going to [MEDICAL TREATMENT]. Upon return from [MEDICAL TREATMENT], Resident 1 was identified as having fatigue and [MEDICAL CONDITION]. A 9/6/13 3:50 pm Progress note documented the resident was out to [MEDICAL TREATMENT] and returned at approximately 11:20 am with a low blood pressure of 88/42. When the resident's blood pressure was rechecked after being given medications and fluids, it was 90/44. The facility nurse practitioner was notified of the low blood pressure and staff were advised to recheck to make sure it was coming up. At approximately 12:30 pm, the resident was sent to a nephrology (renal) appointment. The 9/6/13 hospital History and Physical and Emergency Department Notes revealed Resident 1 went to see Witness 2, Physician, who noted the resident had a systolic blood pressure of 70. Witness 2 informed the hospital physician the resident had not received the [MEDICATION NAME] doses. The resident was described as fatigued and was admitted for evaluation of generalized weakness, dizziness and poor appetite. The resident was started on [MEDICATION NAME] "years ago but unable to discontinue them completely." The resident had been hospitalized three times in the last few months and required "stress dose steroids...It was confirmed that (Resident 1) had not been receiving (Resident 1's) steroids for the week leading up to (Resident 1's) admission." After getting [MEDICATION NAME] IV in the Emergency Department, the resident "felt better" and his/her systolic blood pressure went into the 100's. Additionally, in regards to the need for [MEDICATION NAME], it noted in the 9/6/13 hospital records the resident's [MEDICAL CONDITION] happened more frequently with [MEDICAL TREATMENT] and limited the amount of fluid that could be removed, so he/she was started on [MEDICATION NAME]. The facility's investigation noted the [MEDICATION NAME] was not given from 9/1/13 to 9/6/13 due to the medication was not on the September 2013 physician orders [REDACTED]. The investigation did not address the 8/2013 medication errors. In interview on 10/11/13 at 1:50 pm, Resident 1 stated he/she was very sick and had an appointment with Witness 2, Physician. "I was getting sicker and sicker...they could have killed me." The physician saw that he/she was sick, he/she had a blood pressure of 70/40 and was sent to the hospital right away. The physician called the facility and was told the resident had not received the [MEDICATION NAME] for six days. Resident 1 stated he/she could not just stop the medication as he/she had been on it for about seven and a half years. The resident stated while at the hospital they gave him/her IV steroids,"it helped me a lot." In interview on 10/10/13 at 12:45 pm, Staff 2, RNCM, stated she had completed the August to September 2013 recaps. "It was my error, it appeared to me the order ended and the pharmacy did not add it to the new MAR." In reviewing the 8/2013 MAR, Staff 2 stated she had overlooked the statement to carry over the [MEDICATION NAME] to September 2013. Staff 2 stated it was not caught during the first Emergency Department visit, but rather at the physician's office. In interviews on 10/10/13 at 3:22 pm and 10/11/13 at 11:58 am, Staff 1, DNS, stated it was noted on the August 2013 MAR to give the resident his/her morning medications after returning from [MEDICAL TREATMENT]. Staff 1 stated she had not reviewed the August 2013 MAR as part of her investigation and was not aware the medication had not been administered as ordered when the resident returned from [MEDICAL TREATMENT]. Regarding the [MEDICATION NAME] not being transcribed on the MAR, Staff 1 stated pharmacy should have caught it, "but we are the double-check." In interview on 10/11/13 at 10:55 am, Staff 7, LPN, stated regarding the missed doses on 8/23/13, she was not aware the resident had physician orders [REDACTED]. Staff 7 stated she had not administered the resident's medications upon return to the facility. In interview on 10/14/13 at 9:06 am, Staff 4, RN, stated regarding the 8/28/13 and 8/30/13 medication administration, it was noted in the chart the resident could take his/her morning medications upon return to the facility. Staff 4 stated it was hard for her to recall if she had administered the morning medications after the resident returned. In interview on 10/15/13 at 9:25 am, Witness 2, Physician, stated the resident had been discharged from the hospital to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 9/6/13 the resident was in his office, complained of feeling lousy, "he was terrible" and had a blood pressure of 76/64. Witness 2 called the facility and learned the resident had not received the [MEDICATION NAME]. He sent the resident to the hospital and he/she was admitted from 9/6/13 to 9/9/13. Witness 2 stated he was "convinced" the resident's symptoms were due to not receiving the [MEDICATION NAME]. While in the hospital, the resident was treated with steroids and was much better. The resident stated to him, "Thank you for saving my life, I feel like a different person."

Based on interview and record review it was determined the facility failed to follow physician orders [REDACTED]. Resident 1 did not receive [MEDICATION NAME] (a corticosteroid) as ordered and was hospitalized . Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1 was admitted with physician orders [REDACTED]. Additionally, Resident 1 had physician orders [REDACTED]. 25 mg from 8/16 to 8/18/13 20 mg from 8/19 to 8/21/13 17.5 mg from 8/22 to 8/26/13 16.25 mg from 8/27 to 8/31/13 15 mg from 9/1 to 9/5/13 12.5 mg from 9/6 to 9/10/13 10 mg daily starting 9/11/13 On 8/17/13 the physician ordered the resident could receive his/her morning medications upon return from [MEDICAL TREATMENT]. It was noted on the August 2013 MAR "Ok to give AM meds late when resident returns from [MEDICAL TREATMENT] on Monday, Wednesday and Friday." On 8/21/13, 8/23/13, 8/28/13 and 8/30/13 it was documented the resident was "OOF" (out of facility) and did not receive morning medications including [MEDICATION NAME] and [MEDICATION NAME]. According to the facility's Drug Handbook, 2014 Lippincott's Nursing Drug Guide, regarding [MEDICATION NAME], "Taper doses when discontinuing high-dose or long-term therapy to avoid [MEDICAL CONDITION]." It was noted on the August 2013 MAR "[MEDICATION NAME] taper continues 9/1 *See physician's orders [REDACTED]. A 9/2/13 [MEDICAL TREATMENT] Center Communication Record documented the resident had a low blood pressure at [MEDICAL TREATMENT], which was treated with fluids. Upon return to the facility, staff were unable to get vital signs, blood sugar was 124 and the resident was "very incoherent, having hallucinations." A correlating 9/2/13 Progress Note indicated Resident 1 returned from [MEDICAL TREATMENT] in "poor condition." The resident was diaphoretic (excessive sweating), "not well." 911 was called and the resident was sent to the hospital. According to the 9/2/13 hospital records, facility staff reported the resident complained of nausea prior to [MEDICAL TREATMENT]. Upon return from [MEDICAL TREATMENT], the resident was noted to have [MEDICAL CONDITION] of the right upper extremity and altered mental status. At the hospital, the resident reported he/she "feels terrible" but was unable to give any more details of specific symptoms. He/she appeared confused, lethargic, responses to questions were very slow and he/she was disoriented. "Cognition and memory are impaired." The resident was found to have a blood sugar of 79 and was given juice and the resident improved. The physician noted the altered mental status was likely due to [DIAGNOSES REDACTED] and was resolved. However, the hospital records lacked documented evidence the hospital had been informed the resident had previously received [MEDICATION NAME] prior to the hospitalization . A 9/2/13 Progress Note indicated Resident 1 returned back to the facility and complained of feeling "weak." A 9/5/13 Day Progress Note revealed Resident 1 had emesis in the morning, which was treated with medication. Facility staff documented on a 9/6/13 [MEDICAL TREATMENT] Center Communication Record the resident complained of nausea and loss of appetite, which was treated with medication prior to going to [MEDICAL TREATMENT]. Upon return from [MEDICAL TREATMENT], Resident 1 was identified as having fatigue and [MEDICAL CONDITION]. A 9/6/13 3:50 pm Progress note documented the resident was out to [MEDICAL TREATMENT] and returned at approximately 11:20 am with a low blood pressure of 88/42. When the resident's blood pressure was rechecked after being given medications and fluids, it was 90/44. The facility nurse practitioner was notified of the low blood pressure and staff were advised to recheck to make sure it was coming up. At approximately 12:30 pm, the resident was sent to a nephrology (renal) appointment. The 9/6/13 hospital History and Physical and Emergency Department Notes revealed Resident 1 went to see Witness 2, Physician, who noted the resident had a systolic blood pressure of 70. Witness 2 informed the hospital physician the resident had not received the [MEDICATION NAME] doses. The resident was described as fatigued and was admitted for evaluation of generalized weakness, dizziness and poor appetite. The resident was started on [MEDICATION NAME] "years ago but unable to discontinue them completely." The resident had been hospitalized three times in the last few months and required "stress dose steroids...It was confirmed that (Resident 1) had not been receiving (Resident 1's) steroids for the week leading up to (Resident 1's) admission." After getting [MEDICATION NAME] IV in the Emergency Department, the resident "felt better" and his/her systolic blood pressure went into the 100's. Additionally, in regards to the need for [MEDICATION NAME], it noted in the 9/6/13 hospital records the resident's [MEDICAL CONDITION] happened more frequently with [MEDICAL TREATMENT] and limited the amount of fluid that could be removed, so he/she was started on [MEDICATION NAME]. The facility's investigation noted the [MEDICATION NAME] was not given from 9/1/13 to 9/6/13 due to the medication was not on the September 2013 physician orders [REDACTED]. The investigation did not address the 8/2013 [MEDICATION NAME] and [MEDICATION NAME] medication errors. In interview on 10/11/13 at 1:50 pm, Resident 1 stated he/she was very sick and had an appointment with Witness 2, Physician. "I was getting sicker and sicker...they could have killed me." The physician saw that he/she was sick, he/she had a blood pressure of 70/40 and was sent to the hospital right away. The physician called the facility and was told the resident had not received the [MEDICATION NAME] for six days. Resident 1 stated he/she could not just stop the medication as he/she had been on it for about seven and a half years. The resident stated while at the hospital they gave him/her IV steroids,"it helped me a lot." In interview on 10/10/13 at 12:45 pm, Staff 2, RNCM, stated she had completed the August to September 2013 recaps. "It was my error, it appeared to me the order ended and the pharmacy did not add it to the new MAR." In reviewing the 8/2013 MAR, Staff 2 stated she had overlooked the statement to carry over the [MEDICATION NAME] to September 2013. Staff 2 stated it was not caught during the first Emergency Department visit, but rather at the physician's office. In interviews on 10/10/13 at 3:22 pm and 10/11/13 at 11:58 am, Staff 1, DNS, stated it was noted on the August 2013 MAR to give the resident his/her morning medications after returning from [MEDICAL TREATMENT]. Staff 1 stated she had not reviewed the August 2013 MAR as part of her investigation and was not aware the medication had not been administered as ordered when the resident returned from [MEDICAL TREATMENT]. Regarding the [MEDICATION NAME] not being transcribed on the MAR, Staff 1 stated pharmacy should have caught it, "but we are the double-check." In interview on 10/11/13 at 10:55 am, Staff 7, LPN, stated regarding the missed doses on 8/23/13, she was not aware the resident had physician orders [REDACTED]. Staff 7 stated she had not administered the resident's medications upon return to the facility. In interview on 10/14/13 at 9:06 am, Staff 4, RN, stated regarding the 8/28/13 and 8/30/13 medication administration, it was noted in the chart the resident could take his/her morning medications upon return to the facility. Staff 4 stated it was hard for her to recall if she had administered the morning medications after the resident returned. In interview on 10/15/13 at 9:25 am, Witness 2, Physician, stated the resident had been discharged from the hospital to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 9/6/13 the resident was in his office, complained of feeling lousy, "he was terrible" and had a blood pressure of 76/64. Witness 2 called the facility and learned the resident had not received the [MEDICATION NAME]. He sent the resident to the hospital and he/she was admitted from 9/6/13 to 9/9/13. Witness 2 stated he was "convinced" the resident's symptoms were due to not receiving the [MEDICATION NAME]. While in the hospital, the resident was treated with steroids and was much better. The resident stated to him, "Thank you for saving my life, I feel like a different person."

Based on interviews and record review it was determined facility staff failed to implement care planned interventions and provide necessary supervision to prevent injury for 1 of 3 residents (# 1) who were at significant risk for falls. Resident 1 sustained a left arm fracture. Findings include: Review of the Oregon State Board of Nursing, Authorized Duties and Standards for Certified Nursing Assistants [PHONE NUMBER] revealed, (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 admitted to the facility in 5/2011 with [DIAGNOSES REDACTED]. According to a comprehensive admission assessment the resident had short and long-term memory loss and had "Severe Cognitive Impairment." The resident was identified as a fall risk due to impaired balance and multiple falls in the past. The assessment narrative indicated "resident is to be in a visible area when in (wheelchair), and not to be alone in room." According to the in-room care plan the resident required a pressure alarm when in bed and wheelchair. The resident was not to be left alone on the commode or in a wheelchair in her/his room, "must be in a visible location." The care plan also indicated the resident required two-person assist for transfers using a Hoyer lift. According to a 5/16/11 Therapy ADL's care plan under the section "Toileting/Showering," "Commode" was checked with instructions "requires assist/supv. At all times (due to decreased) cognition." According to an Incident Report on 5/20/11 at 10:35 pm Staff 1, CNA, assisted the resident to the bathroom toilet in the room by herself and left her/him with the call light within reach. Staff 1 returned to the bathroom and found the resident on the floor. Resident 1 sustained a skin tear to the left eye brow. On the morning of 5/21/11 the resident's left shoulder was noted to be swollen. The physician was called and the resident was transported to the hospital and diagnosed with [REDACTED]. According to a written statement dated 5/24/11, Staff 1 indicated she had not been assigned to the resident's room. Staff 1 heard the resident's alarm go off so she went into the resident's room to check on her/him. The resident was attempting to get out of bed. The resident did not tell Staff 1 what she/he needed but Staff 1 assumed the resident needed to go to the bathroom. Staff 1 transferred the resident to the wheelchair without using the Hoyer lift and then to the bathroom toilet. Staff 1 oriented the resident to the call light. Staff 1 was gone approximately two minutes. When Staff 1 returned to the bathroom the resident was on the floor. In an interview on 6/8/11 at 12:30 pm Staff 3, DNS, stated Staff 1 transferred the resident to the toilet by herself and left her/him alone in the bathroom. Staff 3 stated Staff 1 knew where resident care plans were located but had not looked at Resident 1's care plan before transferring her/him to the toilet. In an interview on 9/8/11 at 10:00 am Staff 3, DNS, stated it was a facility policy that residents who needed alarms to prevent falls, needed supervision when on the toilet in the bathroom or in any other situation where an alarm cannot be feasibly used. Staff 3 stated this policy is disseminated to staff verbally and she felt certain Staff 1 knew this policy as she had worked with the resident at least one time before. Refer to F-323.

Based on interviews and record review it was determined the facility failed to implement care planned interventions and provide necessary supervision to prevent injury for 1 of 3 residents (# 1) who were at significant risk for falls. Resident 1 sustained a left arm fracture. Findings include: Resident 1 was admitted to the facility in 5/2011 with [DIAGNOSES REDACTED]. According to a comprehensive admission assessment the resident had short and long-term memory loss and had "Severe Cognitive Impairment." The resident was identified as a fall risk due to impaired balance and multiple falls in the past. The assessment narrative indicated "resident is to be in a visible area when in (wheelchair), and not to be alone in room." According to the in-room care plan the resident required a pressure alarm when in bed and wheelchair. The resident was not to be left alone on the commode or in a wheelchair in her/his room, "must be in a visible location." The care plan also indicated the resident required two-person assist for transfers using a Hoyer lift. According to a 5/16/11 Therapy ADL's care plan under the section "Toileting/Showering," "Commode" was checked with instructions "requires assist/supv. At all times (due to decreased) cognition." According to facility incident reports the following events occurred: - On 5/10/11 the resident was found on the floor in her/his room; the resident had attempted to go to the bathroom without assistance. - On 5/18/11 the resident was found on the floor in her/his room; the resident had attempted to go to the bathroom without assistance. - On 5/19/11 staff discovered the resident attempting to get out of bed unassisted. According to nurse's notes on the 5/20/11 evening shift the resident was noted to be confused and had attempted to get out of bed unassisted. The resident was transferred to a wheelchair. The resident attempted to get out of the wheelchair multiple times without assistance. The nurse's notes indicated "CNA notified to watch (resident) closely." The resident was transferred back to bed at 10:00 pm According to an Incident Report on 5/20/11 at 10:35 pm Staff 1, CNA, assisted the resident to the bathroom toilet in the room by herself and left her/him with the call light within reach. Staff 1 returned to the bathroom and found the resident on the floor. Resident 1 sustained a skin tear to the left eye brow. On the morning of 5/21/11 the resident's left shoulder was noted to be swollen. The physician was called and the resident was transported to the hospital and diagnosed with [REDACTED]. According to a written statement dated 5/24/11, Staff 1 indicated she had not been assigned to the resident's room. Staff 1 heard the resident's alarm go off so she went into the resident's room to check on her/him. The resident was attempting to get out of bed. The resident did not tell Staff 1 what she/he needed but Staff 1 assumed the resident needed to go to the bathroom. Staff 1 transferred the resident to the wheelchair without using the Hoyer lift and then to the bathroom toilet. Staff 1 oriented the resident to the call light. Staff 1 was gone approximately two minutes. When Staff 1 returned to the bathroom the resident was on the floor. Multiple attempts to contact Staff 1 were unsuccessful. In an interview on 6/8/11 at 10:15 am Staff 2, Administrator stated Staff 1 had been terminated from employment. In an interview on 6/8/11 at 12:30 pm Staff 3, DNS, stated Staff 1 transferred the resident to the toilet by herself and left her/him alone in the bathroom. Staff 3 stated Staff 1 knew where resident care plans were located but had not looked at Resident 1's care plan before transferring her/him to the toilet. In an interview on 9/8/11 at 10:00 am Staff 3, DNS, stated it was a facility policy that residents who needed alarms to prevent falls, needed supervision when on the toilet in the bathroom or in any other situation where an alarm cannot be feasibly used. Staff 3 stated this policy is disseminated to staff verbally and she felt certain Staff 1 knew this policy as she had worked with the resident at least one time before.

Based on observation, interview and record review it was determined the facility failed to provide adequate care and services in the area of pain management for 1 of 1 sampled resident (#1) reviewed for pain management. Due to not developing and implementing interventions for situations when pain could be anticipated, the resident experienced significant, episodic pain. Findings include: Resident 1 was admitted to the facility in 11/2009 with [DIAGNOSES REDACTED]. The 5/2010 Quarterly Review for pain revealed at times staff had to "guestimate" the resident's pain level based on the resident's expressions due to the resident's frequent inability to rate pain. The resident was described as having frequent episodes of spasm type pains in both legs, and spurring of the spine, which created painful episodes for the resident. The goal was to do everything possible to relieve as much pain as possible. The 8/2010 Quarterly MDS coded the resident as having cognitive impairment and moderate pain daily. There was no documented evidence the updated quarterly pain review had been completed. A 9/9/10 entry on the Plan of Care: Pain Management noted x-ray results indicated a suspected subacute right [MEDICAL CONDITION] without displacement. Staff were directed to use caution with the resident's right leg. The 9/29/10 physician's note revealed the resident was being seen for pain. The resident was described as in the wheelchair and crying in pain. The resident complained of back pain, was uncomfortable no matter how staff had positioned the resident and did not want to be in bed. The physician changed the routine medication from [MEDICATION NAME] to [MEDICATION NAME] 15 mg every 12 hours for pain and continued the [MEDICATION NAME] 0.25 to 0.5 ml every four hours as needed for pain and Tylenol 500 1 tablet twice daily as needed for pain. On 10/21/10 at 7:47 am, the resident was observed to be in bed, crying and wanted to get up into the wheelchair. The resident complained of leg pain. Staff 2, RN was in the room at the time of the observation and left the room, stating she would get the resident some pain medication. Staff 1, CMA obtained the assistance of a second staff member and then provided incontinence care and dressed the resident, with the resident continuing to cry. The resident was transferred to the wheelchair and complained of pain when the right leg was moved onto the leg rest and when a pillow was placed under the leg. Once in the wheelchair, the resident continued to have a pained facial expression. In an interview directly after the observation, Staff 1 stated the resident cried most mornings, wanted out of bed and had pain in the right leg, which had problems with swelling. Staff 1 stated she was waiting for Staff 2 to bring the resident pain medication and probably should have waited to provide care until the medication had been given. In an interview on 10/21/10 at 8:33 am, Staff 2 stated she gave the pain medication to the resident at approximately 30 minutes after observing the resident in pain. Staff 2 stated she realized she "should have stayed focused" and given the resident the pain medication before staff dressed and transferred the resident out of bed into the wheelchair. On 10/21/10 at 11:08 am, the resident was observed to be comfortable in the wheelchair. The resident smiled in response to questions and stated the pain was better. In interviews on 10/21/10 at 10:20 am and 11:47 am, Staff 3, RNCM stated she had not completed the current pain assessment for the resident. Staff 3 described the resident as having multiple spurs in the back, which was very painful for the resident and the resident wanted to be in the chair for pain relief. Staff 3 acknowledged that the resident should have been given pain medication prior to cares being provided.