Every finding on record at Stanley Post Acute

Based on interview and record review it was determined the facility failed to implement care plan interventions to prevent a fall for 1 of 3 sampled residents (#2) reviewed for falls. As a result, Resident 2 suffered bilateral femur fractures. Findings include:Resident 2 admitted to the facility in 2015 with diagnoses of diabetes and urinary incontinence.Resident 2's 1/9/26 MDS assessment indicated Resident 2 was dependent on staff for ADLs including bed mobility and toileting.Resident 2's Care Plan documented Resident 2 required two-person assistance and was dependent on staff for ADLs including toileting and bed mobility. Resident 2's Progress Notes documented:-At 7:40 PM on 2/7/26, Staff 3 (LPN) charted Resident was transferred to the hospital after a witnessed fall at 4:40 PM.-At 10:30 AM on 2/8/26, Staff 7 (RN) charted that a hospital social worker called to report Resident 2 required surgery on her/his legs.A 2/7/26 Fall Report initiated by Staff 3 on 2/7/26 at 6:50 PM documented:-Staff 5 (CNA) left the resident's room to request barrier cream from Staff 3, leaving Staff 4 (CNA) with Resident 2.-Resident 2 was left on her/his side.-While outside Resident 2's room, Staff 5 heard Staff 4 yell, Help! Help!-Staff 5 and Staff 3 found Resident 2 on the floor.-Staff 4 stated she had gotten a washcloth from Resident 2's drawer and wet it in the sink. Resident 2 suddenly yelled that she/he was rolling.-Staff 4 yelled for help and Staff 5 and Staff 3 came into the room.-On 2/9/26, the fall report was updated to reflect Resident 2 sustained bilateral femur fractures.In a written statement signed on 2/7/26, Staff 4 stated she was the only person in the room when Resident 2 fell.On 2/18/26 at 11:51 AM, Staff 3 stated Resident 2 required assistance of two staff for all ADL care including bed mobility and incontinence care for the duration of cares. She stated that on 2/7/26 around 6:30 PM, Staff 4 and Staff 5 were assisting Resident 2 with incontinence care. Staff 5 exited the room to request barrier cream from Staff 3, leaving Staff 4 alone with Resident 2. Staff 3 stated another CNA notified her of the fall. Staff 3 stated Resident 2 looked injured and she called 911. She stated Resident 2 sustained femur fractures as a result of the fall.On 2/19/26 at 2:22 PM, Staff 5 stated Resident 2 was unable to perform any bed mobility for her/himself. Staff stated Resident 2 was on her/his side when Staff 4 left the room to get barrier cream. Staff 5 stated she was ringing out a washcloth while Resident 2 remained on her/his side when she heard the resident say, Oh, I'm falling.On 2/19/26 at 2:38 PM, Staff 4 stated she and Staff 5 were in the middle of changing Resident 2's brief and Resident 2 was on her/his side when Staff 4 left the room to get barrier cream. Staff explained Resident 2 required assistance of two people for bed mobility and incontinence care and that Resident 2 was dependent and unable to roll her/himself in bed independently. Staff 4 stated Resident 2 should have been rolled onto her/his back before she left the room. On 2/20/26 at 7:37 AM, Staff 8 (CNA) stated Resident 2 required assistance from two staff for bed mobility including rolling and for incontinence care. Staff 8 stated two staff were required to remain with Resident 2 for the duration of care or the resident should be rolled onto her/his back before staff left the room.On 2/20/26 at 7:42 AM, Staff 7 (RN) stated two-person dependent meant two staff must assist at all times during bed mobility and when changing Resident 2's brief.On 2/20/26 at 7:49 AM, Staff 18 (CNA) stated two-person dependent required two staff to assist Resident 2 for the duration of incontinence care and bed mobility, with one staff supporting Resident 2 on her/his side while the second staff completed care.On 2/20/26 at 9:01 AM, Staff 21 (LPN/Care Manager) stated Resident 2 was fully dependent on staff for all cares and required two-person assistance for bed mobility and toileting. She stated if a care plan documented two-person dependent, then two staff must remain with the resident throughout the care and should not leave the resident on her/his side unattended to prevent falling. On 2/20/26 at 9:13 AM, Staff 2 (DNS) stated for a two-person dependent resident, both staff must remain through the care and reposition the resident onto her/his back before leaving.

Based on observation, interview and record review it was determined the facility failed to use appropriate disinfection practices for reusable medical equipment, failed to ensure the community use CBG glucometer was properly cleaned and sanitized between resident use, and failed to ensure hand hygiene was completed for 1 of 4 halls reviewed for infection control and meal service, and 1 of 1 sampled resident (#44) reviewed during medication pass. This placed all residents who required CBG checks at risk for exposure to infections including bloodborne illness and placed residents at risk for cross contamination. Findings include:The facility policy Guidelines for Cleaning and Disinfection of Non-Critical Resident Care Items dated 9/1/24 indicated: Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment). 1.On 9/4/25 at 6:59 AM, Staff 4 (CNA) was observed exiting room [ROOM NUMBER] with a rolling vitals cart which contained reusable vitals equipment without cleaning the reusable vitals equipment. Staff 4 walked across the hall to room [ROOM NUMBER] and began to enter the room with the vitals cart without cleaning the vital equipment. Staff 4 stated she did not clean the vitals equipment because room [ROOM NUMBER] did not have wipes, so she was going to clean the vitals equipment at the next resident's bedside with their wipes. Staff 4 walked across the hall to a precautions cart which had a package of FitRight Wet Wipes (personal care wipes) and used the personal care wipes to clean the vitals equipment. Staff 4 stated she was to use the purple alcohol wipes (Super Sani-Cloth wipes), but CNAs no longer had access to them, so she used the resident personal care wipes to clean the reusable vitals equipment. Staff 4 stated the personal care wipes were used to clean the residents, so it was okay to clean the vitals equipment. On 9/4/25 at 8:19 AM, Staff 2 (DNS) stated the facility staff were to clean the reusable vitals equipment between each resident with the Super Sani-Cloth wipes and stated the personal care wet wipes were not acceptable because it did not have the appropriate germicide. 2. The blood glucose monitoring system manufacturer instructions indicated to disinfect the meter with EPA-registered wipes. The 8/1/24 facility policy and procedure indicated to clean glucometers according to manufacturer’s recommendation using EPA approved disinfectants to protect residents from cross contamination of blood-borne pathogens. On 9/4/25 at 7:00 PM Staff 3 (LPN) was observed to check Resident 44’s CBG using a community use glucometer. Staff 3 exited the room and set the glucometer on the cart without cleaning it. At 7:23 PM Staff 3 proceeded to enter Resident 40’s room using the same glucometer. The State Surveyor intervened, and Staff 3 went back to the treatment cart and used and EPA approved wipe to clean the glucometer. Staff 3 acknowledged she did not clean the community use glucometer between resident use and stated she usually cleans the glucometer but “it slipped my mind. On 9/4/25 at 8:11 PM Staff 2 (DNS) stated staff were expected to clean community use glucometers using EPA approved wipes and ensure the two-minute dwell time was reached in between resident use. 3. During 9/2/25 lunch meal service, the following was observed on the Northwest unit hallway: -On 9/2/25 at 12:00 PM Staff 8 (NA) carried a tray with partially eaten food out of room [ROOM NUMBER] and then delivered a tray to room [ROOM NUMBER] without completing hand hygiene. -On 9/2/25 at 12:03 PM Staff 8 left room [ROOM NUMBER] and delivered a tray to room [ROOM NUMBER] without completing hand hygiene. -On 9/2/25 at 12:04 PM Staff 8 left room [ROOM NUMBER] and passed a drink to a family member of a resident in room [ROOM NUMBER] without completing hand hygiene. On 9/2/25 at 12:10 Staff 8 stated they did not perform hand hygiene after leaving resident rooms during meal service. On 9/5/25 at 12:19 PM Staff 5 (LPN Resident Care Manager) stated staff were expected to perform hand hygiene after leaving a resident room during meal service.

Based on interview and record review it was determined the facility failed to inform the resident of the risks and benefits of a psychotropic medication for 1 of 5 sampled residents (#37) reviewed for unnecessary medications. This placed residents of risk of being uninformed. Findings included: Resident 37 admitted to the facility in 2025 with diagnoses including insomnia and depression. A 6/11/25 physician order indicated 25mg quetiapine fumarate (antipsychotic) related to insomnia for Resident 37. An updated 7/10/25 physician order indicated an increase of the quetiapine fumarate to 50mg related to depression. Review of Resident 37's medical record revealed no indication the resident was informed of the risks and benefits of the use of quetiapine fumarate.On 9/4/25 at 2:00 PM Staff 2 (DNS) acknowledged there was no evidence in Resident 37's medical record a risk and benefits of the quetiapine fumarate was completed.

Based on interview and record review it was determined the facility failed to ensure resident advance directives were available for 2 of 4 sampled residents #s 46 and 96) reviewed for advance directives. This placed residents at risk for not having their end of life preferences honored. Findings include:The facility's 9/2024 Advance Directive policy indicated residents were to be asked about, and provided with information about, advance directives upon admission and quarterly thereafter.1.Resident 46 admitted to the facility in 2021 with diagnoses including diabetes.A 12/2023 POLST (Physician Order for Life Sustaining Treatment) indicated Resident 46's family member was the medical power of attorney.Resident 46's care plan, revised on 8/14/25, indicated the resident had an advance directive. The resident's advance directive was to be honored and kept in the medical record at all times.A review of Resident 46's medical record revealed neither the medical power of attorney form nor the advance directive were on file.On 9/3/25 at 12:36 PM Resident 46 stated she/he completed an advance directive with her/his family.On 9/3/25 at 1:42 PM Staff 12 (Social Services) was asked about Resident 46's advance directive and indicated a POLST (Physician Orders for Life Sustaining Treatment) was on file. Staff 12 indicated she was not familiar with the difference between a POLST and an advance directive and used the terms interchangeably. Staff 12 acknowledged Resident 46's advance directive was not in the resident's clinical record.2. Resident 96 readmitted to the facility in 4/2025 with diagnoses including multiple sclerosis. The resident's care plan, updated 6/3/25, indicated Resident 96 had an advance directive. The advance directive was to be honored.A review of the resident's clinical record revealed the advance directive was not on file. On 9/3/25 at 12:31 PM Resident 96 indicated she/he completed an advance directive while residing in the facility. On 9/3/25 at 1:42 PM Staff 12 (Social Services) was asked about Resident 96's advance directive and indicated a POLST (Physician Orders for Life Sustaining Treatment) was on file. Staff 12 indicated she was not familiar with the difference between a POLST and an advance directive and used the terms interchangeably. Staff 12 acknowledged Resident 96's advance directive was not in the resident's clinical record.

Based on interview and record review it was determined the facility failed to consistently provide restorative services to maintain range of motion for 1 of 1 sampled resident (#96) reviewed for mobility. This placed resident at risk for decreased range of motion. Findings include:Resident 96 was admitted to the facility in 8/2022 with a diagnosis of multiple sclerosis. A 3/18/2025 Restorative Nursing Referral revealed Resident 96 was to receive passive ROM exercises for her/his right and left lower extremities. Resident 96's 7/31/25 Annual MDS revealed she/he was cognitively intact, had ROM impairment on both sides of her/his lower extremities and received no passive ROM during the seven-day look back period. Resident 96's Comprehensive Care Plan last revised on 8/18/25 included a restorative nursing program to address her/his risk for decreased range of motion which included bilateral knee and right hip passive ROM exercises. A review of Resident 96's ROM Program Task tracking form from 8/5/25 through 9/3/25 and a restorative nursing services binder revealed no documentation of restorative services were provided for Resident 96. The restorative nursing binder indicated Resident 96 was to receive ROM to her/his lower extremities. On 9/3/25 at 2:35 PM Resident 96 stated staff no longer provided ROM exercises for her/his legs. On 9/4/25 at 11:47 AM Staff 6 (CNA) stated the restorative nursing services binder indicated to staff which residents were supposed to be offered exercises but was unaware if Resident 96 received restorative services. On 9/4/25 at 1:30 PM Staff 7 (CNA) stated she did not provide passive ROM exercises to Resident 96's lower extremities when she worked with her/him. On 9/5/25 at 11:43 AM and 11:46 AM Staff 5 (LPN Resident Care Manager) stated Resident 96 had a restorative program to address her/his risk for contractures. Staff 5 stated the facility previously had a designated restorative aide, but CNAs were currently responsible to provide restorative services to residents. Staff 5 stated she expected staff to provide Resident 96 passive ROM exercises for her/his lower extremities as indicated in her/his care plan.

Based on observation, interview, and record review it was determined the facility failed to ensure proper labeling of biologicals for 1 of 2 treatment carts reviewed for medication storage. This placed residents at risk for reduced efficacy of medication. Findings include:On 9/4/25 at 7:00 PM Staff 3 (LPN) was observed to prepare insulin glargine for Resident 44, there was no open date on the insulin vial. The manufacturer's instructions indicated the medication was to be discarded 28 days after opening.On 9/4/25 at 7:00 PM Staff 3 acknowledged the insulin glargine vial was open with no open date.

Based on interview and record review it was determined the facility failed to assist a resident with obtaining dentures for 1 of 2 sampled residents (#3) reviewed for dental care. This placed residents at risk for decreased quality of life. Findings include:Resident 3 admitted to the facility in 1/2025 with diagnoses including blindness. A 2/1/25 admission MDS indicated Resident 3 had no dental concerns. A 7/8/25 progress note indicated a physician ordered new bottom dentures for Resident 3. A 7/8/25 physician order indicated a new bottom denture was to be fabricated. No further information related to the new lower denture was found in the resident's clinical record. On 9/2/25 Resident 3 stated she/he had a dental appointment two months ago and was supposed to receive a new lower denture, but she/he did not receive anything and was unsure why. On 9/3/25 at 1:42 PM Staff 12 (Social Services) stated she was typically involved with assisting residents acquiring dentures but she was unaware of Resident 3's new order for a new lower denture. On 9/3/25 at 3:16 PM Staff 5 (LPN Resident Care Manager) indicated she was unaware of the resident's order for a new lower denture. Staff 5 acknowledged no follow-up was completed regarding the order since the appointment two months ago.

Based on interview and record review it was determined the facility failed to ensure staff followed the care plan related to toileting for 1 of 1 sampled resident (#7) reviewed for accidents. This placed residents at risk for injuries. Findings include:Resident 7 was admitted to the facility in 9/2015 with diagnoses including multiple sclerosis and overactive bladder.The 5/15/25 Quarterly MDS revealed Resident 7 had a BIMS score of 15, which indicated the resident was cognitively intact, and dependent for toilet hygiene.A review of the 9/14/24 Care Plan revealed Resident 7 required two-person assistance for toileting.A 2/4/25 facility investigation revealed Resident 7 fell out of bed when Staff 5 (Agency CNA) was providing toileting care and did not have a second person assisting.On 8/25/25 at 12:12 PM Resident 7 stated the staff member rolled her/him off the bed while providing care because the CNA stated she could provide the care herself and did not need another person to assist.On 8/28/25 at 1:16 PM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged Resident 7's care was not followed when the fall occurred.

Based on record review and interview it was determined the facility failed to complete a discharge summary which included a recapitulation of stay and a final summary of the resident's status for 1 of 3 sampled residents (#1) reviewed for a discharge summary. This placed residents at risk for unmet needs post discharge. Findings include: Resident 1 admitted to the facility in 4/2024, with diagnoses including hip fracture and congestive heart failure. On 7/1/24, the State Agency received a public complaint which alleged Resident 1 was discharged home and the facility did not refer Resident 1 to her/his long standing home health agency. Witness 1 (Complainant) stated she made multiple phone calls to the facility in order to ensure Resident 1 received continuity of care with her/his home health agency upon her/his discharge. Witness 1 stated the facility referred Resident 1 to a different home health agency and the other home health agency never made a home visit. Review of the Discharge Summary dated 6/25/24 revealed that Resident 1 was discharged home. The Discharge Summary did not include a nursing or physician recapitulation of Resident 1's diagnosis, course of illness or treatment at the facility, pertinent home health agency or contact information, prognosis or condition on discharge. On 2/12/25 at 11:02 AM, Staff 3 (Social Services Director) stated it was an expectation that a resident discharge summary contain information about resident diagnoses, course of illness or treatment at the facility, prognosis or condition on discharge and home health agency and contact information. She further stated the facility typically referred discharged residents to their previous home health agency unless the agency was unable to resume services.

Based on interview and record review it was determined the facility failed to follow physician orders for 1 of 3 sampled residents (#4) reviewed for medication administration. This placed residents at risk for unmet medication needs. Findings include: Resident 4 admitted to the facility in 8/2024, with diagnoses including End Stage Renal Disease (ESRD) and clavicle fracture. Resident 4's initial care plan dated 8/24/24 revealed she/he received medications for pain and End Stage Renal Disease and attended dialysis two times per week. Physician orders dated 8/24/24 revealed Resident 4 was to receive Gabapentin (a medication for nerve pain), 100 mg capsule TID, and Sodium Zirconium Cyclosilicate, 1 packet QD for hyperkalemia (a condition where the potassium level in the blood is too high) on the resident's non dialysis days. Review of Resident 4's 9/2024 MAR revealed she/he was not administered Sodium Zirconium Cyclosilicate on 9/12/24 and 9/14/24 and was not administered Gabapentin on 9/24/24, 9/25/24 and 9/26/24. Progress notes reviewed from 9/12/24 through 9/26/24 did not provide an explanation as to why the medication was not administered. On 2/14/25 at 1:00 PM, Staff 1 (Administrator) and Staff 2 (DNS) were notified of the investigative findings regarding missed medications and provided no additional information.

Based on interview and record review it was determined the facility failed to comprehensively assess 8 of 14 sampled residents (#s 25, 26, 32, 36, 52, 55, 57 and 114) reviewed for medications, pressure ulcers, ADLs, pain and nutrition. This placed residents at risk for unassessed needs. Findings include: 1. Resident 57 was admitted to the facility on ,d+[DATE] with diagnoses including chronic heart failure and diabetes. The 4/25/24 Admission MDS indicated Resident 57 received an antidepressant medication. The Psychotropic Drug Use CAA associated with the 4/25/24 MDS indicated psych meds per physician orders. The CAA did not indicate a description of the problem, causes and contributing factors or how the resident's symptoms manifested or whether the medication was effective. On 5/20/24 at 8:58 AM Staff 16 (MDS Coordinator) stated she was responsible for completing the MDS assessment and CAAs for all residents. Staff 16 stated she worked remotely and reviewed resident electronic medical records to complete the CAA section. On 5/20/24 at 1:13 PM Staff 2 (DNS) stated she was unfamiliar with the process of completing the CAAs. Staff 2 stated Staff 16 was responsible for the MDS and CAA assessments, and there was daily communication regarding residents' assessments. Staff 1 (Administrator) and Staff 2 acknowledged the CAA was not comprehensive. 2. Resident 55 was admitted to the facility on ,d+[DATE] with diagnoses including a Stage 3 (full thickness tissue loss) pressure ulcer to the tailbone. The Pressure Ulcer CAA dated 4/22/24 indicated Resident 55 needs assist with adls and transfers, has pressure injury to buttocks. The CAA did not include a description of the problem, causes and contributing factors, any alternatives discussed or tried or an overall analysis of the pressure ulcer. On 5/20/24 at 8:58 AM Staff 16 (MDS Coordinator) stated she was responsible for completing the MDS assessment and CAAs for all residents. Staff 16 stated she worked remotely and reviewed resident electronic medical records to complete the CAA section. On 5/20/24 at 1:13 PM Staff 2 (DNS) stated she was unfamiliar with the process of completing the CAAs. Staff 2 stated Staff 16 was responsible for the MDS and CAA assessments, and there was daily communication regarding residents' assessments. Staff 1 (Administrator) and Staff 2 acknowledged the CAA was not comprehensive. 3. Resident 36 was admitted to the facility on ,d+[DATE] with diagnoses including arthritis and polyneuropathy (nerve pain). The 11/17/23 Significant Change MDS and the 2/15/25 Quarterly MDS indicated Resident 36 received scheduled and PRN pain medication. The Pain CAA associated with the 11/17/23 MDS indicated no change to plan of care. The CAA did not include a description of, how the resident displayed pain symptoms or whether the medications and any other interventions were effective. On 5/20/24 at 8:58 AM Staff 16 (MDS Coordinator) stated she was responsible for completing the MDS assessment and CAAs for all residents. Staff 16 stated she worked remotely and reviewed resident electronic medical records to complete the CAA section. On 5/20/24 at 1:13 PM Staff 2 (DNS) stated she was unfamiliar with the process of completing the CAAs. Staff 2 stated Staff 16 was responsible for the MDS and CAA assessments, and there was daily communication regarding residents' assessments. Staff 1 (Administrator) and Staff 2 acknowledged the CAA was not comprehensive. 4. Resident 114 was admitted to the facility on ,d+[DATE] with diagnoses including end stage renal disease and depression. The 2/20/24 Admission MDS indicated Resident 57 received an antidepressant medication and was occasionally incontinent of urine and frequently incontinent of bowel. The CAAs associated with the 2/20/24 MDS revealed the following: -The Psychotropic Drug Use CAA indicated takes anti-depressants per physician orders. The CAA did not indicate a description of the problem, causes and contributing factors, how the resident's symptoms manifested or whether the medications were effective. -The Urinary Incontinence and Indwelling Catheter CAA indicated has occasional incontinence and requires assistance with toileting. The CAA did not indicate a description of the problem, causes or contributing factors. On 5/20/24 at 8:58 AM Staff 16 (MDS Coordinator) stated she was responsible for completing the MDS assessment and CAAs for all residents. Staff 16 stated she worked remotely and reviewed resident electronic medical records to complete the CAA section. On 5/20/24 at 1:13 PM Staff 2 (DNS) stated she was unfamiliar with the process of completing the CAAs. Staff 2 stated Staff 16 was responsible for the MDS and CAA assessments, and there was daily communication regarding residents' assessments. Staff 1 (Administrator) and Staff 2 acknowledged the CAA was not comprehensive. 47005 5. Resident 25 admitted to the facility in 6/2022 with diagnoses including falls and chronic pain syndrome. The 6/20/23 Annual MDS indicated Resident 25 received scheduled and PRN pain medication. The Pain CAA associated with the 6/20/23 MDS indicated Resident 25 had pain that affected sleep, day-to-day activities and almost constant pain. The CAA did not include a location of the pain, how the resident displayed pain symptoms or whether the medications and other pain interventions were effective. On 5/20/24 at 8:58 AM Staff 16 (MDS Coordinator) stated she was responsible for completing the MDS assessment and CAAs for all residents. Staff 16 stated she worked remotely and reviewed resident electronic medical records to complete the CAA section. Staff 16 further stated she communicated as needed with the Resident Care Managers and the IDT (Interdisciplinary Team). On 5/20/24 at 1:13 PM Staff 2 (DNS) stated she was unfamiliar with the process of completing the CAAs. Staff 2 stated Staff 16 was responsible for the MDS and CAA assessments, and there was daily communication regarding residents' assessments. 6. Resident 32 admitted to the facility in 3/2024 with diagnoses including right lower extremity cellulitis and diabetes. The 3/26/24 Admission MDS indicated Resident 32 received an antidepressant medication. The Psychotropic Drug Use CAA associated with the 3/26/24 MDS indicated antidepressant use per physician orders. The CAA did not indicate a description of the problem, causes and the contributing factors, how the resident's symptoms manifested, or whether the medication was effective. On 5/20/24 at 8:58 AM Staff 16 (MDS Coordinator) stated she was responsible for completing the MDS assessment and CAAs for all residents. Staff 16 stated she worked remotely and reviewed resident electronic medical records to complete the CAA section. Staff 16 further stated she communicated as needed with the Resident Care Managers and the IDT (Interdisciplinary Team). On 5/20/24 at 1:13 PM Staff 2 (DNS) stated she was unfamiliar with the process of completing the CAAs. Staff 2 stated Staff 16 was responsible for the MDS and CAA assessments, and there was daily communication regarding residents' assessments. 48830 7. Resident 26 was admitted to the facility in 1/2024 with diagnoses including glaucoma and depression. The 1/15/24 Admission MDS indicated Resident 26 had adequate vision and received an antidepressant medication. The CAAs associated with the 1/15/24 MDS revealed the following: -The Visual Function CAA indicated has glaucoma. No further information was provided specific to the resident's current visual functioning, use of visual appliances, or other treatments in place. -The Psychotropic Drug Use CAA indicated takes antidepressants for depression. The CAA did not indicate a description of the problem, causes and contributing factors or how the resident's symptoms manifested or whether the medication was effective. On 5/20/24 at 8:58 AM Staff 16 (MDS Coordinator) stated she was responsible for completing the MDS assessment and CAAs for all residents. Staff 16 stated she worked remotely and reviewed resident electronic medical records to complete the CAA section. On 5/20/24 at 1:13 PM Staff 2 (DNS) stated she was unfamiliar with the process of completing the CAAs. Staff 2 stated Staff 16 was responsible for the MDS and CAA assessments, and there was daily communication regarding residents' assessments. Staff 1 (Administrator) and Staff 2 acknowledged the CAAs were not comprehensive. 8. Resident 52 was admitted to the facility in 4/2024 with diagnoses including depression. The 4/10/24 Admission MDS indicated Resident 52 received an antidepressant medication. The Psychotropic Drug Use CAA associated with the 4/10/24 MDS indicated received antidepressant per physicians orders. The CAA did not indicate a description of the problem, causes and contributing factors or how the resident's symptoms manifested or whether the medication was effective. On 5/20/24 at 8:58 AM Staff 16 (MDS Coordinator) stated she was responsible for completing the MDS assessment and CAAs for all residents. Staff 16 stated she worked remotely and reviewed resident electronic medical records to complete the CAA section. On 5/20/24 at 1:13 PM Staff 2 (DNS) stated she was unfamiliar with the process of completing the CAAs. Staff 2 stated Staff 16 was responsible for the MDS and CAA assessments, and there was daily communication regarding residents' assessments. Staff 1 (Administrator) and Staff 2 acknowledged the CAA was not comprehensive.

Based on interview and record review it was determined the facility failed to ensure CNAs received annual performance reviews for 4 of 5 randomly selected CNAs (#s 15, 23, 24, and 25) reviewed for staff performance reviews. This placed residents at risk for lack of care by competent staff. Findings include: On 5/17/24 at 9:58 AM a review of facility personnel records with Staff 31 (Human Resource Director) indicated the following: - Staff 15 (CNA) was hired on 8/17/22; no annual performance review was completed. - Staff 23 (CMA) was hired on 8/31/20; no annual performance reviews were completed. - Staff 24 (CNA) was hired on 6/16/16; no annual performance reviews were completed. - Staff 25 (CNA) was hired on 4/11/16; no annual performance reviews were completed. On 5/17/24 at 4:04 PM Staff 1 (Administrator) stated it was his expectation the annual performance reviews were completed annually. Staff 1 confirmed the annual performance reviews were not completed for Staff 15, Staff 23, Staff 24, or Staff 25.

Based on interview and record review it was determined the facility failed to ensure a resident was treated in a dignified manner for 1 of 4 sampled residents (#114) reviewed for dignity. This placed residents at risk for lessened quality of life. Findings include: Resident 114 was admitted to the facility on ,d+[DATE] with diagnoses including end stage renal disease and depression. A 3/20/24 Mistreatment Investigation revealed the following: * Staff 2 (DNS) was informed on 2/27/24 Resident 114 had a concern regarding her/his care. Staff 2 spoke with Resident 114, who indicated the incident occurred roughly one week prior. During the night shift, a female staff member entered the resident's room because she/he had a bowel movement in bed. The staff person stated, Oh, you shit the bed. Resident 114 did not feel abused, but stated the staff person was rude. Resident 114 stated other staff assisted with cleaning her/him up. *Staff 2 determined Staff 26 (Former RN) worked with Resident 114 on 2/19/24 during the night of the incident. *Staff 26 recalled the incident and stated Resident 114 had a bowel movement, and poop was everywhere. Staff 26 denied making a derogatory comment towards Resident 114. Staff 26 stated she had a CNA and another nurse provide ADL care and clean the bed/bedding. Resident 114 was assisted back to bed. *Staff 21 (LPN) reported Staff 26 worked the night shift on 2/19/24. While the CNA assigned to Resident 114 was on break, Resident 114's roommate peaked her/his head out and indicated they needed help in the room. Staff 26 went into the room and immediately came back to the nurses' station and stated, [She/He] shit everywhere, [she/he's] wiping it everywhere. Staff 26 asked Staff 21 to assist in cleaning Resident 114 up. The bedding was changed, and Resident 114 received a shower before being situated back in bed. *Conclusion: Mistreatment was ruled out. Staff 26 provided all necessary cares at the time of the incident and denied speaking to Resident 114 in the alleged manner. No other resident concerns were reported. Staff 26 received education regarding customer service in the workplace. On 5/13/24 at 2:07 PM Witness 1 (Complainant) stated Resident 114 reported a bowel incident which occurred roughly in the middle of 2/2024. Witness 1 stated during the night, Resident 114 had a bowel movement, and a staff person entered the resident's room, saying, You shit all over yourself and the bed. Witness 1 stated Resident 114 was embarrassed and did not want to talk about the incident. Witness 1 stated the facility investigated the incident but Witness 1 was unsure of the outcome. On 5/14/24 at 10:57 AM Resident 114 stated she/he recalled the incident, which happened during night shift. Resident 114 stated she/he had an accident (bowel movement) in bed. Staff 26 entered her/his room and stated, You shit all over the place. Resident 114 stated Staff 26 berated her/him and the incident was embarrassing. Resident 114 stated two other staff members assisted in cleaning her/him up. Attempts were made on 5/15/24 and 5/16/24 to reach Staff 26, but were unsuccessful. On 5/16/24 at 2:25 PM Staff 21 (LPN) stated she recalled the incident on 2/19/24 with Resident 114. Staff 26 approached the nurses' station and reported the resident, had shit everywhere. Staff 21 stated she and another CNA, along with Staff 26, cleaned up the resident and her/his bedding. On 5/17/24 at 2:50 PM Staff 2 (DNS) stated she initiated and completed the investigation. Staff 26 denied she made derogatory comments towards Resident 114 and assisted in cleaning her/him. Staff 2 stated education was provided to Staff 26, and she did not return to the building after the 2/19/24 incident. On 3/3/24, the Past Noncompliance was corrected when the facility completed the following: 1. Performed a thorough investigation of the incident and submitted a FRI on 2/27/24. 2. Interviewed Resident 114 and other residents in the facility and asked about care concerns. 3. Interviewed staff involved in the incident. 4. Educated Staff 26 and she did not return or work for the facility after 2/19/24 incident.

Based on observation, interview and record review it was determined the facility failed to assess self-administration of a medication for 2 of 3 sampled residents (#s 8 and 26) reviewed for self-administration of medication. This placed residents at risk for unsafe medication administration. Findings include: The facility's Self-Administration Medication policy last revised on 3/2020, specified the following: -Upon admission the resident's desire to self-administer is ascertained. -During the 14-day admission assessment period the RCM (Resident Care Manager) evaluates the resident's ability to self-administer medications. -If the resident has the cognitive, physical, and emotional ability to self-administer their own medications in a safe and prudent manner a plan for self-administration is established with the resident. -A physician order is obtained indicating the specific medications that the resident is able to self-administer. -The self-administration is on the resident's care plan to include location of drugs, documentation procedure, place of administration and specific medications. -The resident is reevaluated for continued ability to self-administer their medications annually and with significant change in condition. 1. Resident 8 was admitted to the facility in 4/2024 with diagnoses including a stroke and heart disease. A Physician Order dated 4/29/24 revealed Resident 8 was to receive Artificial Tears ophthalmic solution and to instill one drop in both eyes as needed for dry eyes daily. A 4/30/24 Admission MDS indicated Resident 8 had a BIMS score of 14 and she/he was cognitively intact. A review of Resident 8's clinical record revealed no evidence that a self-administration of medication assessment was completed. Random observations from 5/13/24 through 5/16/24 revealed Resident 8 was in bed, and a small green bottle labeled Artificial Tears was on her/his bedside table. On 5/14/24 at 10:40 AM Resident 8 stated the eye drops were for her/his eyes and she/he self-administered the eye drops. On 5/16/24 at 11:42 AM Staff 6 (CNA) stated Resident 8 was confused at baseline. Staff 6 stated she did not notice the eyedrops on the resident's bedside table, but Resident 8 required assistance from a nurse in administering the eye drops. On 5/16/24 at 2:39 PM and 3:20 PM Staff 12 (LPN-Resident Care Manager) stated she was unaware Resident 8 had eye drops accessible at her/his bedside table and thought maybe a family member brought the eye drops in. Staff 12 removed the eye drops from the resident's bedside table. Staff 12 stated the resident was not to self-administer eye drops unless a self-medication assessment was completed. 48830 2. Resident 26 was admitted to the facility in 1/2024 with diagnoses including paraplegia. The 1/15/24 Admission MDS revealed Resident 26 was cognitively intact. On 5/17/24 at 10:42 AM Resident 26 stated she/he kept a prescription medication, ipratropium bromide nasal spray (used for rhinitis), at her/his bedside in a locked box. Resident 26's comprehensive care plan, last revised on 3/25/24, revealed the resident self-administered certain prescription medications including ipratropium bromide nasal spray. A review of Resident 26's health record indicated a self-administration of medication evaluation was completed on 2/23/24, however, Resident 26 was not assessed to self-administer ipratropium bromide nasal spray. On 5/17/24 at 11:14 AM Staff 36 (Agency RN) stated Resident 26 had self-administered ipratropium bromide nasal spray and reported to the charge nurse when she/he self-administered the medication and if the dose was effective. Staff 36 stated he then documented in the resident's medical record of the administration and the result. On 5/20/24 at 1:57 PM Staff 12 (LPN Resident Care Manager) confirmed the resident was not assessed to self-administer ipratropium bromide nasal spray.

Based on observation, interview and record review it was determined the facility failed to ensure resident personal property was identified upon admission, and clothing was retained and accessible for 2 of 4 sampled residents (#s 20 and 57) reviewed for personal property. This place residents at risk for loss of personal property. Findings include: The facility's Resident Personal Items Safekeeping policy, last revised 4/2023, specified the following: -All personal items, including but not limited to clothing, dentures, glasses, and hearing aids must be marked with the resident's name upon admission. -The facility designee will assist residents and families with marking the personal belongings. -On admission and thereafter each time a resident's personal possession is brought into the facility, the item will be recorded on the resident's inventory record by designated staff and signed by the resident or responsible party. -If any personal items is lost during a resident's stay, an investigation will be completed by the facility and the results will be communicated to the resident and/or family. -The Administrator/designee will discuss the method of replacement for lost items with the resident and/or family. 1. Resident 57 was admitted to the facility in 4/2024 with diagnoses including chronic heart failure and diabetes. The Annual MDS dated [DATE] revealed Resident 57 had a BIMS score of 15 and was cognitively intact. Resident 57's Inventory Record dated 4/19/24 revealed the resident had one pair of black shoes, navy blue sleeping shorts, a black pair of slacks and a black t-shirt. On 5/13/24 at 11:40 AM, the resident was observed in bed wearing a facility nightgown. Resident 57 stated she/he wanted to be dressed in her/his own clothing but it was hit or miss if this was offered by staff. The resident stated she/he was uncertain of the location of her/his clothes. Random observations from 5/14/24 through 5/17/24 revealed Resident 57 was either in bed wearing a facility nightgown or in bed with no nightgown on, with her/his chest exposed. On 5/14/24 at 7:22 PM Staff 15 (CNA) and on 5/16/24 at 12:53 PM Staff 14 (CNA) stated Resident 57 requested to be dressed, but the resident did not have appropriate clothing to wear. Staff 14 and Staff 15 were unsure where the resident's clothes were, which was why Resident 57 was consistently in her/his nightgown. Staff 15 stated he reported the resident's lack of clothing to a nurse. On 5/17/24 at 4:01 PM Staff 9 (RNCM) entered the room with the surveyor and located Resident 57's black shoes, a pair of shorts and a black jacket. None of the items had Resident 57's name on them. Staff 9 reviewed Resident 57's Inventory Record and acknowledged the resident admitted with a pair of slacks and a T-shirt, which were not found in her/his room. Staff 9 stated no missing form was completed or missing items were reported to her regarding Reident 57's missing clothing items. Staff 9 stated Resident 57's clothing items were to be labeled, and any missing clothing items were to be reported. Staff 9 further stated the resident was to be dressed per her/his request. 48830 2. Resident 20 was admitted to the facility in 2020 with diagnoses including depression and anxiety. The 4/2/24 Annual MDS indicated Resident 20 was cognitively intact. On 5/14/24 at 2:43 PM during a resident group meeting, respect of resident's personal possessions was discussed. Resident 20 stated she/he submitted a grievance form in 3/2024 regarding missing and broken personal property, but was not reimbursed. On 5/15/24 at 11:34 AM two submitted grievance forms, dated 3/21/24, were reviewed. One grievance form indicated the resident was missing several clothing items. The second grievance form indicated a staff member pulled down and damaged hanging lights in the resident's room. Both grievance forms indicated a reimbursement was approved by Staff 1 (Administrator) on 3/25/24. A copy of the receipt for reimbursement was requested on 5/15/24 by the survey team. On 5/16/24 at 11:00 AM two cash disbursement vouchers were provided and revealed a cash reimbursement for Resident 20's missing clothing and broken personal property was issued on 5/15/24. On 5/16/24 at 3:04 PM Staff 3 (Corporate Social Service Director) confirmed the resident's request for reimbursement for personal possessions was not completed timely.

Based on interview and record review it was determined the facility failed to ensure a written summary of a baseline care plan was reviewed and provided to residents within 48 hours of admission for 2 of 3 sampled residents (#s 4 and 44) reviewed for care planning. This placed residents at risk for being uninformed about their plan of care. Findings include: 1. Resident 4 was admitted to the facility in 2022 with diagnoses including paralysis of left side and osteoporosis. On 5/14/24 Resident 4's clinical record was reviewed. No record was found that Resident 4 had a baseline care plan reviewed or provided to her/him. On 5/16/24 at 12:33 PM Staff 3 (Corporate SSD) confirmed no baseline care plan was discussed or provided to Resident 4. 2. Resident 44 was admitted to the facility in 2/2024 with diagnoses including heart failure and chronic kidney disease. Resident 44's 2/2024 Admission MDS indicated she/he was cognitively intact. On 5/14/24 Resident 44's clinical record was reviewed. No record was found that Resident 44 had a baseline care plan reviewed or provided to her/him. On 5/16/24 at 12:33 PM Staff 3 (Corporate SSD) confirmed no baseline care plan was discussed or provided to Resident 44.

Based on interview and record review it was determined the facility failed to follow physician orders and provide bowel medication in a timely manner for 1 of 6 sampled residents (#57) reviewed for medications. This placed residents at risk for medical complications from constipation. Findings include: The facility's Bowel Care Protocol Policy last revised on 2/2019, specified the following: -At beginning of each shift the nurse will pull the bowel care report and identify residents that have not had a BM (Bowel Movement) for 3 days. -Residents who have not had a BM in three days will be given MOM (Milk of Magnesia). -If no BM by the following shift, a Dulcolax suppository is given. -If resident continues without BM by the next shift a Fleets enema will be given. -Residents who are noted as having small bowel movement will be assessed for constipation. -If resident exceeds four days without a BM, the nurse will complete an abdominal assessment and the physician will be notified for further orders. Resident 57 was admitted to the facility in 4/2024 with diagnoses including chronic heart failure and diabetes. Resident 57's BM documentation from 4/19/24 through 5/9/24 revealed the following: -4/26/24 through 5/1/24 (six days) Resident 57 did not have a BM. -5/3/24 through 5/8/24 (six days) Resident 57 did not have a BM. Resident 57's Physician Order Report signed by the physician on 4/22/24 included an order for polyethylene glycol packet. Staff were to administer 17 grams by mouth one time daily as needed for bowel care. Resident 57's 5/2024 MAR revealed the polyethylene glycol packet was administered on 5/8/24 and was marked as U (unknown). A Nutrition assessment dated [DATE] revealed Resident 57 had constipation and was placed on the bowel protocol with no BM for the prior week. Resident 57 had a large BM on 5/9/24. A review of the resident's clinical record revealed no documentation bowel care was implemented timely or an abdominal assessment was completed. On 5/16/24 at 10:53 AM Staff 4 (LPN) stated Resident 57 struggled with constipation and was frequently on the bowel list. Staff 4 stated she followed bowel protocol: if Resident 57 had no BM after three days, the resident was administered MiraLAX (a laxative) during the morning shift. If there was still no BM by the following shift, the resident received Senna (a laxative). If these measures yielded no results, Staff 4 stated she contacted the provider for a possible enema. On 5/17/24 at 4:01 PM Staff 9 (RNCM) stated Resident 57 had problems with BMs and was frequently on the bowel list. Staff 9 stated residents did not have standing PRN bowel orders and depended on the doctor. Staff 9 acknowledged the findings and stated Resident 57's bowel protocol needed to be initiated due to her/his constipation. On 5/20/24 at 1:13 PM Staff 2 (DNS) stated staff were expected to implement and adhere to the bowel protocol. Additionally, if a resident had no BM by day four staff were to contact the physician and conduct a bowel assessment.

Based on observation, interview and record review it was determined the facility failed to provide appropriate foot care for 3 of 3 sampled residents (#s 26, 41 and 57) reviewed for foot care. This placed residents at risk for lack of nail care and infections. Findings include: 1. Resident 41 was admitted to the facility on ,d+[DATE] with diagnoses including diabetes. A Physician Order dated 3/27/24 directed a licensed nurse to check Resident 41's fingernails and toenails once a week on bath day. The order indicated to trim as needed every day shift on Wednesdays for diabetic nail checks. Staff were directed to document (+) if the nails were trimmed and (-) if nail trimming was not needed. A review of the LN Task from 3/2024 through 5/2024 revealed the following: -3/27/24 nails did not need trimmed. -4/3/24, 4/10/24 and 4/17/24 nails did not need trimmed. 4/24/24 Resident 41 refused nail care. -5/1/24 nails did not need trimmed. 5/8/24 Resident 41 refused nail care. A Progress Note dated 5/9/24 revealed Staff 9 (RNCM) entered Resident 41's room to offer toenail care. Resident 41 initially stated she would allow toenail care without clippers only for toenails to be filed down. Resident 41 allowed Staff 9 to file three out of 10 toenails and then declined to have the rest of the toenails trimmed. On 5/13/24 at 10:44 AM Resident 41 stated she/he was a diabetic for [AGE] years and needed her/his toenails treated by a podiatrist which was not scheduled. Resident 41 indicated staff were unable to cut her/his thick toenails and made her/him uncomfortable when staff attempted to complete the nail care. Random observations from 5/13/24 through 5/16/24 revealed Resident 41 was in bed and her/his toes were observed with all toenails discolored, deformed, thickened (half-an-inch) and longer than one inch. Resident 41's right large toenail was brownish/black. On 5/14/24 at 6:46 PM Staff 32 (CNA) and on 5/16/24 at 11:42 AM Staff 6 (CNA) entered the room with the surveyor and acknowledged Resident 41's toenails were long, thick, discolored and indicated the toenails were, awful. Staff 32 stated she noticed the resident's long and discolored toenails. Staff 6 stated nail care was provided by the nursing staff because Resident 41 was diabetic. Staff 6 and Staff 32 stated the resident occasionally declined showers due to anxiety but accepted a bed bath. On 5/16/24 at 9:47 AM Staff 11 (LPN) stated nurses were responsible for diabetic nail care. Staff 11 stated Resident 41's toenails were thick, long, and difficult to trim and needed to be addressed. Staff 11 stated nurses completed weekly skin checks which included observing finger and toenails. On 5/16/24 at 2:54 PM Staff 9 (RNCM) stated nurses were expected to complete nail care for diabetic residents. Staff 9 stated Resident 41 was a brittle diabetic, who occasionally declined nail care. Staff 9 stated she attempted to file Resident 41's toenails but the resident did not allow Staff 9 to complete the task. When asked about a podiatry appointment, Staff 9 stated LTC (Long Term Care) residents were placed on the in-house podiatry list. Staff 9 stated the care managers assisted with appointments, including podiatry outside of the facility. 2. Resident 57 was admitted to the facility in 4/2024 with diagnoses including chronic heart failure and diabetes. The Annual MDS dated [DATE] revealed Resident 57 had a BIMS score of 15 and was cognitively intact. A Physician Order dated 4/24/24 directed a licensed nurse to check fingernails and toenails once a week on bath day. The order indicated to trim as needed every day shift every Wednesday for diabetic nail checks. Staff were directed to document (+) if nails were trimmed and (-) if nail trimming was not needed. A review of the LN Task from 4/2024 through 5/2024 revealed the following: - On 4/24/24, 5/1/24, 5/8/24 and 5/15/24 nails did not need trimmed. On 5/13/24 at 11:40 AM and 5/16/24 at 11:16 AM the resident stated her/his toenails were long, thick, and needed to be trimmed. Random observations from 5/13/24 through 5/16/24 revealed Resident 57 was in bed and her/his toes were observed with all toenails longer than one inch, and his second toenails were deformed, thickened (half-an-inch) and discolored. On 5/16/24 at 10:53 AM Staff 4 (LPN) stated Resident 57 was diabetic and nurses were responsible for addressing all nail care. Staff 4 stated she was not sure if the resident's toenails were long, but if she was unable to address Resident 57's nail care then she reported it to the care manager to schedule a podiatry appointment. On 5/16/24 at 2:54 PM and 5/17/24 at 4:01 PM Staff 9 (RNCM) stated nurses were expected to provide nail care for diabetic residents. If staff were unable to perform diabetic nail care, staff were expected to report this to her. Staff 9 entered the room with the surveyor and acknowledged Resident 57's toenails were long and were not treated appropriately. 48830 3. Resident 26 was admitted to the facility in 1/2024 with diagnoses including paraplegia. The 1/15/24 Admission MDS revealed Resident 26 was cognitively intact. On 5/13/24 at 2:18 PM Resident 26 stated her/his toenails were long, thick, and caught on the inside of her/his socks. Resident 26 stated she/he wanted her/his toenails trimmed and voiced her/his concern to staff, but no one followed up with her/him. Resident 26's toenails were observed to be long in length, thick, fungal, and jagged. On 5/16/24 at 10:34 AM Resident 26 stated she/he had a bath on 5/15/24 and requested her/his toenails to be trimmed or at least filed and the CNA stated they would let the nurse know. The resident stated the nurse did not talk with her/him. On 5/16/24 at 11:16 AM Staff 12 (LPN Resident Care Manager) stated toenail care was provided on bath days for the resident and Staff 12 expected it to be completed. On 5/16/24 at 2:57 PM Staff 3 (Corporate Social Services Director) stated the facility had a podiatrist that rounded every three months and podiatry services were offered to all residents. Staff 3 stated the podiatrist could not see every resident on the list, so a rotation was completed. Staff 3 stated Resident 26 was on the podiatrist's list to be seen on the next rotation.

Based on observation, interview, and record review it was determined the facility failed to ensure interventions were in place to prevent smoking related accidents for 1 of 2 sampled residents (#32) reviewed for accidents. This placed residents at risk for smoking-related accidents. Findings include: The facility's 10/2023 Smoking Policy and Procedure indicated the following: -Residents who wish to smoke are evaluated for their ability to smoke safely. A smoking evaluation is completed at admission or at the time they decided to smoke, to evaluate their ability to smoke safely. -Definition of Smoking Materials: Cigarettes, Cigars, Pipes, Novelties - E-Cigarettes, Vapor Devices, Ignition Sources. -Residents who do not adhere to the smoking policies are subject to revocation of their ability to smoke while a resident at the facility. Resident 32 admitted to the facility on [DATE] with diagnoses including right lower extremity cellulitis and diabetes. A 4/28/24 progress note revealed a fire alarm was triggered when Resident 32 stated she/he burned papers in her/his room which caused the room to fill with smoke and Resident 32 was found in possession of a torch lighter. A 5/9/24 progress note revealed Resident 32 was smoking in her/his room. Staff reviewed the smoking policy with the resident. Lighters and smoking materials were removed from the resident's room. Resident 32's smoking care plan was initiated on 5/13/24 which revealed the resident was an unsupervised smoker. The care plan did not include safe storage of the smoking paraphernalia and interventions to regarding previous smoking incidents that occurred in the resident's room. On 5/15/24 at 10:36 AM Staff 28 (CNA) stated Resident 32 was a smoker who smoked in her/his room and did not smoke in the designated smoking area. Staff 28 stated Resident 32 was supposed to keep her/his smoking paraphernalia in a lockbox in her/his room. On 5/16/24 at 10:59 AM Resident 32 was observed seated at the edge of the bed with a four-inch green tubular-shaped canister with a pink bejeweled handle. Resident 32 stated it was her/his blow torch lighter and demonstrated that the lighter was operational. Resident 32 stated the facility kept taking her/his lighters and she/he kept replacing them. Resident 32 stated she/he was allowed to keep lighters in her/his lockbox. On 5/16/24 at 1:40 PM Staff 23 (CMA) stated she had seen Resident 32 with smoking paraphernalia in her/his room but was not sure what rules Resident 32 was supposed to follow. Staff 23 stated Resident 32 had been caught smoking in her/his room several times but was still allowed to keep her/his smoking paraphernalia in her/his room. Staff 23 stated she informed the charge nurse of the smoking paraphernalia. On 5/16/24 at 3:06 PM Staff 35 (LPN) stated she considered Resident 32 a smoker and all her/his smoking paraphernalia including marijuana, cigarettes and lighters were in a lockbox in her/his room. Staff 35 stated Resident 32 had smoking paraphernalia confiscated the previous week due to smoking in her/his room and staff were told to do a visual sweep of Resident 32's room whenever staff went into the resident's room. A SNF Smoking Safety Evaluation completed on 5/16/24 revealed Resident 32 was a supervised smoker, was not receptive to supervision, was unwilling to store her/his smoking items with the facility and continued to make unsafe smoking choices. On 5/20/24 at 10:42 AM Staff 2 (DNS) acknowledged the safety concerns associated with Resident 32's possession of incendiary devices in the facility, and history of unsafe behaviors including smoking in her/his room. Staff 2 acknowledged a smoking assessment was not completed until 5/16/24, and the care plan was not updated regarding the safety concerns.

Based on observation, interview, and record review it was determined the facility failed to maintain oxygen equipment and ensure oxygen was administered as ordered for 1 of 2 sampled residents (#46) reviewed for oxygen therapy. This placed residents at risk for increased risk for respiratory failure. Findings include: Resident 46 was admitted to the facility in 2/2024 with diagnoses including acute and chronic respiratory failure with hypoxia (not enough oxygen in the blood) and hypercapnia (buildup of carbon dioxide in the bloodstream). The 2/9/24 Admission MDS indicated Resident 46 was cognitively intact. The 5/13/24 physician order for Resident 46 revealed the resident used continuous oxygen with a flow rate of two liters since 4/25/24. On 5/13/24 at 12:04 PM Resident 46 was observed to use an oxygen concentrator with a flow rate of three liters. The external filter on the oxygen concentrator was observed to have a layer of dust when touched with a finger. The resident stated she/he used oxygen most of the time but could not state how many liters were prescribed. On 5/16/24 at 11:21 AM Staff 12 (LPN Resident Care Manager) observed the resident and equipment. Staff 12 acknowledged the physician's order was not followed regarding the oxygen flow rate and the external filter of the oxygen concentrator was not clean.

Based on observation interview and record review it was determined the facility failed to administer medications and treatments as ordered for 4 of 6 sampled residents (#s 10, 11, 17 and 27) reviewed for medications and catheter care. This placed residents at risk for adverse side effects of medication, worsening skin conditions and hospitalization . Findings include: 1. Resident 17 admitted to the facility in 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The revised 1/19/22 care plan indicated Resident 17 was diabetic and was to receive diabetic medications as ordered by the physician. The residents care plan also indicated she/he went to [CONDITION(S)] three days a week (Monday, Wednesday and Friday). Resident 17's 12/2021 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] - insulin [MEDICATION(S)] 8 units before meals. - insulin [MEDICATION(S)] sliding scale insulin before meals. - CBGs checked twice a day before breakfast and before bed. The 1/2022 and 2/2022 Diabetic Administration Record indicated the following: -1/3/22, 1/5/22, 1/28/22 and 1/31/22 insulin was not administered and morning CBG was not checked. -2/2/22 and 2/4/22 insulin was not administered and morning CBG was not checked. Review of Resident 17's progress notes indicated on 1/3/22, 1/5/22, 1/28/22, 1/31/22, 2/4/22 and 2/6/22 insulin was not administered and CBG's was not checked due to the resident being at [CONDITION(S)]. Review of Resident 17's medical record revealed no indication the physician was notified of the missed insulin and CBG checks. On 2/17/22 at 12:40 PM Staff 10 (LPN) stated Resident 17 she did not administer insulin and CBG was not checked because the resident was at [CONDITION(S)] and did not document if the physician was notified. On 2/18/22 at 1:30 PM Staff 15 (LPN) confirmed she did not administer Resident 17's insulin or check CBG's due to the resident being at [CONDITION(S)] and could not verify if the physician was notified. On 2/18/22 at 2:00 PM Staff 2 (DNS) confirmed Resident 17 was not given insulin per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Resident 27 admitted to the facility in 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/27/21 revised care plan indicated Resident 27 used a G tube (Gastronomy tube that brings nutrition directly to the stomach) and all ordered medications were administered through the G tube. The 2/2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] - famotidine (antacid) BID - [MEDICATION(S)] sulfate supplement (dietary supplement) BID - frozen supplement (nutritional supplement) BID - [MEDICATION(S)] (diabetic medication) BID - [MEDICATION(S)] (antipsychotic) BID - [MEDICATION(S)] (antipsychotic) BID - [MEDICATION(S)] (medication used to treat dry mouth) BID - [MEDICATION(S)] (antipsychotic) TID Review of the 2/22 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] - famotidine - [MEDICATION(S)] sulfate liquid supplement - frozen supplement - [MEDICATION(S)] - [MEDICATION(S)] - [MEDICATION(S)] - [MEDICATION(S)] dry mouth liquid - [MEDICATION(S)] A progress note dated 2/9/22 indicated the resident's provider was notified of the missed dose of medication on 2/8/22. There was no other progress note that indicated the physician was notified of the 2/12/22 missed medications. A 2/9/22 Medication Error report indicated Resident 17 did not receive her/his afternoon medications on 2/8/22 as ordered. The provider was not notified until 2/9/22. A witness statement indicated the nurse got busy with treatments and blood sugars and missed administering the residents medications. No negative outcome was reported. On 2/23/22 at 9:08 AM and 9:24 AM Staff 19 (LPN Resident Care Manager) stated the missed medication on 2/8/22 was done by an agency staff. She stated the staff person forgot to give Resident 17 her/his medications via the G tube. Staff 19 confirmed she was not aware of the missed medications on 2/12/22 and stated the physician was not notified. 3. Resident 11 admitted to the facility in 11/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/1/22 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/2022 Diabetic Administration Record indicated Resident 11 did not receive insulin [MEDICATION(S)] as ordered on 2/9/22, 2/11/22 and 2/16/22. On 2/17/22 at 11:22 AM Resident 11 stated she/he often did not receive insulin prior to [CONDITION(S)] and it caused her/him to have high CBGs. A review of progress notes from 2/1/22 through 2/17/22 and indicated there was no adverse outcomes to the resident regarding her/his CBGs. On 2/23/22 at 11:23 AM Staff 23 (LPN) stated she was Resident 11's nurse on 2/11/22 and 2/16/22 and did not administer [MEDICATION(S)] insulin to Resident 11 because the resident went to [CONDITION(S)] before she was able to administer insulin. On 2/23/22 at 11:44 AM Staff 24 (LPN) stated she was Resident 11's nurse on 2/9/22. Staff 24 stated she did not administer [MEDICATION(S)] insulin to Resident 11 because the resident went to [CONDITION(S)] and it was supposed to be completed by the prior shift. On 2/23/22 at 1:19 PM Staff 25 (Physician Assistant) acknowledged Resident 11 did not receive [MEDICATION(S)] insulin before [CONDITION(S)] as ordered on 2/9/22, 2/11/22 and 2/16/22. 4. Resident 10 admitted to the facility in 11/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The 1/5/22 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -Right lower leg- remove all dressings and replace xeroform over graft, cover with ABD (absorbent dressing) and kerlix (woven gauze), secure with ACE wrap or coban. -Change the dressing on the right thigh once daily and PRN soiling. Leave vaseline gauze on unless it comes off, dress with vaseline gauze adaptec or xeroform (non-adherent wound dressing), pad with ABD pads, skin prep surrounding tissue and adhere with tape. The 2/22 TAR indicated the following: -Resident 10 did not receive a dressing change to the right thigh on 2/7/22. -Resident 10 did not receive a dressing change to the right lower leg on 2/7/22. On 2/16/22 at 10:35 AM Resident 10 stated staff did not complete dressing changes to her/his right leg and thigh on 2/15/22. Resident 10 further stated staff do not complete dressing changes daily and missed completing dressing changes approximately twice a week. On 2/16/22 at 10:35 AM Staff 9 (LPN) was observed to complete a dressing change to the Resident 10's right lower leg and the right thigh. Both areas were covered with dressings dated 2/14/22 (indicating that was the last date the dressings were changed). Staff 9 acknowledged both dressings were dated 2/14/22 and confirmed the dressings were not changed on 2/15/22. The TAR indicated Staff 4 (LPN) completed a dressing change on 2/15/22. On 2/16/22 at 1:57 PM Staff 4 indicated she documented she completed both dressing changes for Resident 10 on 2/15/22 but did not complete the dressing changes. Staff 4 stated she got distracted and did not amend the documentation. On 2/17/22 at 2:49 PM Staff 2 (DNS) acknowledged Resident 10 did not receive dressing changes as ordered on the identified dates.

Based on observation, interview and record review it was determined the facility failed to ensure appropriate infection control measures were followed related to disinfection of common use glucometers, hand hygiene during meal service and wound care, and use of hand sanitizing solution for 2 of 2 resident units reviewed for infection control. The failure to utilize appropriate disinfection practices for common use glucometers constituted an immediate jeopardy situation. Findings include: Manufacturer instructions for disinfecting common use glucometers indicated the use of EPA approved sanitizing wipes (SaniCloth). The glucometer was to be wiped with the SaniCloth wipe and left wet for two minutes to ensure disinfection. On [DATE] at 8:10 AM Staff 19 (LPN) completed a fingerstick blood glucose test on Resident 34 and proceeded to the next room to perform a finger stick blood glucose test on Resident 30. Staff 19 entered Resident 30's room, removed her gloves and did not disinfect her hands before putting on new gloves. She continued to prepare the common resident use glucose monitor which was not cleaned after use on Resident 34. The surveyor intervened and stopped Staff 19 who confirmed she was going to perform a fingerstick blood glucose test on Resident 30 without disinfecting after use on Resident 34. When asked about the process of cleaning the glucometer, Staff 19 stated she usually cleaned the glucometer with alcohol (non-approved cleaning agent) but forgot to clean the glucometer. The surveyor also discussed with Staff 19 that a manufacturer approved disinfecting wipe (SaniCloth) was indicated for cleaning the glucometer between all resident use and hands were to be disinfected after removing contaminated gloves before placing new gloves on hands. On [DATE] at 9:20 AM Staff 40 (RN) stated her process to disinfect the glucometer was to use the SaniCloth but sometimes also used an alcohol wipe. During interviews on [DATE] at 9:22 AM and 10:58 AM Staff 17 (LPN) stated she used a common use glucometer to check resident capillary blood sugar. Staff 17 stated she used alcohol prep pads to clean the glucometer between resident uses. Staff 17 stated disinfecting wipes were supposed to be used but she used the alcohol pads, because it is fast. Staff 17 stated the alcohol evaporated immediately, but the sanitizing wipe took about three times longer. Staff 17 did not express awareness of proper sanitizing practice including the required two minutes to ensure the glucometer was disinfected. On [DATE] at 11:00 AM Staff 19 (LPN) stated she typically used alcohol pads to clean the glucometers, but when she used the sanitizing wipes she waited about a minute for the glucometer to dry. Staff 19 did not express awareness of proper sanitizing practice including the required two minutes to ensure the glucometer was disinfected. On [DATE] at 11:12 AM Staff 2 (DNS) stated all glucometers used in the facility were multi resident use. She further stated the disinfection process to sanitize the meter between resident use called for using Sanicloth wipes and to allow the glucometer to sit wet for two minutes and then be allowed to dry for two minutes. Staff 2 indicated facility nurses had competencies/skills checks which included the process for disinfecting glucometers. She stated she had no indication the nurses were not disinfecting glucometers correctly. When asked if any residents who received CBG checks had infections diseases, Staff 2 stated Resident 6 received CBG checks with the common use glucometers and had an active [DIAGNOSES REDACTED]. Review of facility records indicated there were 16 residents who received daily CBG checks. On [DATE] at 12:30 PM Staff 1 (Administrator) and Staff 2 were informed the failure to ensure appropriate disinfection of glucometers prior to resident use constituted an immediate jeopardy situation. An immediate plan of correction was requested. On [DATE] at 3:00 PM a plan of correction was received. The plan indicated all licensed nurses on duty were in-serviced regarding proper disinfection of glucometers and all oncoming licensed nurses were to be in-serviced prior to their next shift. The physician for each resident who was placed at risk for infection as a result of the deficient practice was contacted and any needed treatment was initiated. On [DATE] at 4:25 PM Staff 17 was observed performing a finger stick glucose test and used appropriate technique and maintained good disinfection of the glucometer. Staff 17 stated she had a review of the training for cleaning of the glucometer by Staff 2 today, and a discussion about purchasing another treatment cart so nurses did not need to share or carry everything with them. On the evening of [DATE] and the morning of [DATE] additional nurses were observed to properly disinfect glucometers. On [DATE] in-service training records were reviewed. The records indicated all licensed nurses received training regarding the proper disinfection of glucometers, and it was determined the immediate jeopardy situation was removed. 2. On [DATE] at 9:29 AM a bottle of hand sanitizer was observed on each desk in the Resident Care Managers' office. The bottles were observed to have an expiration of ,[DATE]. Staff 4 (RNCM) stated she and the other Resident Care Managers used the bottles for hand sanitizing. Staff 4 acknowledged the hand sanitizer expired approximately 18 months prior. 3. On [DATE] from 12:17 PM through 12:20 PM Staff 16 (CNA) was observed passing meal trays to residents. Staff 16 was observed to assist a resident with meal setup. Staff 16 touched the resident and various items in the resident's room. Staff 16 exited the room and proceeded to the meal cart without performing hand hygiene. Staff 16 removed a tray and took it to a resident in a different room and assisted the resident with meal setup without performing hand hygiene. Staff 16 returned to the cart and pushed it down the hall. Staff 16 was observed to touch her hair and then opened the cart without performing hand hygiene. Staff 16 began to remove a meal tray from the cart when a surveyor intervened. On [DATE] at 12:21 PM Staff 16 acknowledged she did not sanitize her hands between assisting residents with meal setup or after touching her hair. Staff 16 acknowledged she needed to sanitize her hands in between assisting residents and after touching her hair. On [DATE] at 1:00 PM these findings were shared with Staff 2 (DNS) who acknowledged hand hygiene was to be performed between assisting residents with meal setup. 4. On [DATE] at 3:00 PM Resident 32's coccyx wound care was observed. Staff 17 changed gloves between cleaning and redressing the coccyx wound but did not disinfect her hands. Staff 17 was reminded to disinfect her hands after glove removal and before donning new gloves. On [DATE] at 3:10 PM Staff 17 acknowledged she did not disinfect her hands between glove changes during wound care.

Based on observation, interview and record review it was determined the facility failed to ensure pressure injury wounds were appropriately assessed, monitored and treated for [REDACTED].#32) reviewed for pressure ulcers. This failure resulted in Resident 32 experiencing a worsening pressure ulcer. Findings include: The facility's skin at risk/skin breakdown policy, dated 3/2019 included: upon discovery of new skin impairment the nurse will- -document size, color, odor and drainage. -complete an incident report. -document findings on skin grid form. -implement interventions. -initiate alert charting. -evaluate interventions implement new if needed. -notify the director of nursing who will notify the administrator. -RCM conduct a review of records and document. Weekly rounds by DNS, RCM. If the wound fails to improve after two weeks of treatment or the condition of the wound deteriorates the physician will be notified. Federal regulations define a Stage 3 pressure ulcer as: Full-thickness skin loss Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the wound bed, it is an Unstageable PU/PI. Federal regulations define an unstageable pressure ulcer as: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) should only be removed after careful clinical consideration and consultation with the resident's physician, or nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws. If the slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer will be revealed. If the anatomical depth of the tissue damage involved can be determined, then the reclassified stage should be assigned. The pressure ulcer does not have to be completely debrided or free of all slough or eschar for reclassification of stage to occur. Resident 32 was admitted to the facility in 4/2019 with [DIAGNOSES REDACTED]. Resident 32's clinical record indicating the following: *Hospice care plans dated 5/6/19-11/19/19 included altered skin integrity due to her/his bed-bound status and developed skin breakdown of the sacral area. Interventions included the facility was to apply barrier paste and foam dressing to sacral area every three days or more frequently if needed. *MACC (tool used to document new skin conditions) dated 5/28/19 indicated new redness to buttocks with interventions to monitor for skin breakdown, frequent brief checks and frequent repositioning. No additional MACC forms were found for Resident 32 to indicate ongoing monitoring or assessments of the wound. *Comprehensive care plan initiated 6/22/19, updated on 10/10/19 and 12/9/19 for potential/actual impairment to skin integrity related to incontinence with interventions of air mattress, keep skin clean and dry, assist to change positions frequently, barrier cream, turn every two hours to off load coccyx and other bony prominences. The goal was to be free from skin break down with good skin integrity. The skin was to be checked on bath days and during daily cares. The care plan also indicated to follow facility policy/protocol for prevention and treatment of [REDACTED]. The care plan also included weekly treatment documentation to include measurement of each area of skin breakdown, width, length, depth, type and drainage. *Progress notes regarding the resident's skin breakdown from 4/30/19 through 12/11/19 included: -4/30/19 No redness on bottom. -5/28/19 redness to right and left buttock near tailbone, area blanchable. -5/29/19 continued blanchable redness to buttock. -6/1/19 skin prep to redness on buttocks with no new issues noted. -6/5/19 bottom continues to have redness, applying barrier cream for protection, no skin breakdown. -6/12/19 resident on alert for new redness to buttocks, no redness noted removed from alert, continue to be monitored with daily cares. - 9/1/19 redness to middle back on bony prominence, MACC sheet started for observation. -11/21/19 bandage applied to cover area, coccyx is now open and weeping clear fluids. -11/27/19 stage two on coccyx, wound is static at this time, treatment in place. -12/11/19 coccyx wound re-assessed wound is stage three (3.0cm length, 2.0 cm width, 0.7 cm depth. No drainage, wound bed color-yellow, no odor, appearance of wound is 100% slough, wound cleaned with wound cleanser, Santyl applied with boarder foam dressing. Hospice notified, waiting for a call back from Hospice and new wound order request to include Santyl. *Treatment Administration records indicated weekly skin checks were completed. New skin impairment was identified on 8/20/19 and 9/1/19, but no corresponding assessments of the new identified skin impairments were found. *A 10/21/19 incident investigation indicated a sacral pressure ulcer, but no details were noted on the form. *A 10/21/19 physician order [REDACTED]. No documentation of wound treatment was found in the resident's clinical record prior to 11/29/19. *10/26/19 skin grid documentation sheet identified the partial thickness coccyx wound was red and was 60 cm in length and 30 cm in width. No additional skin grid documentation forms were found for Resident 32. *The 11/5/19 Quarterly MDS indicated Resident 32 had mild cognitive impairment and required two person assistance with bed mobility. On 12/9/19 at 3:00 PM Resident 32's coccyx wound care was observed. Staff 17 (LPN) removed a [MEDICATION NAME] dressing (non-foam adhesive dressing) over the entire coccyx area that was dated 11/8. When the existing dressing was removed there was drainage that was thick and yellow tinged. Staff 17 cleansed the wound with saline and gauze. Staff 17 measured the coccyx wound and stated the wound was a stage three (full thickness skin loss) pressure ulcer that measured 1.5 cm x 2 cm. Staff 17 stated the wound showed some slough (dead tissue) in the center with a pink border and there was no odor. After the wound was cleaned, Solosite wound gel was applied and the wound was covered with a foam bandage. On 12/9/19 at 3:20 PM Staff 17 stated nurses did skin checks on all residents weekly. She further stated Resident 32's coccyx wound worsened from redness to a stage three and she did not think barrier cream, which was the current wound care order, should have been used and chose to apply Solosite wound gel instead because she thought it would work better. On 12/11/19 at 2:03 PM Staff 21 (CNA) stated the last time Resident 32 was turned and repositioned was 10:30 AM due to being short a nurses aide today which gave the remaining CNAs extra residents to assist. Staff 21 stated her goal was to turn Resident 32 every 30 minutes. On 12/12/19 at 1:05 PM Staff 10 (RN) stated Resident 32's wound worsened and was upgraded to stage three. Staff 10 stated she applied Santyl (medicated wound treatment gel) to the wound yesterday because Staff 4 (RNCM) directed her to do so and told her to later call Hospice for an order. Staff 10 stated on the day of the interview barrier cream was used for the wound care because hospice did not approve the Santyl for wound care and ordered a wound consult instead. On 12/16/19 at 11:50 AM Staff 4 (RNCM) acknowledged wound observation sheets were not completed weekly for Resident 32 and the change in the wound since onset of stage one to the now stage three was not addressed and the physician was not notified. She stated the expectation is for all wounds to be monitored closely and interventions put in place to prevent worsening. Staff 4 also stated she did not instruct Staff 10 to apply a non-ordered treatment to the wound and only ordered treatments were to be used. She further indicated if staff did not have time to turn a resident they needed to report to the charge nurse. On 12/16/19 at 12:15 PM Staff 2 denied knowing Resident 32's pressure ulcer progressed from stage one to stage three. She further acknowledged that it was her expectation to be notified and the wound was to be managed and monitored to prevent worsening. Staff 2 acknowledged Resident 32's wound worsened. Staff 2 also indicated it was not acceptable for staff to apply a wound care treatment without an order from the physician. She further indicated if staff did not have time to turn a resident the expectation was to report to her for additional help.

Based on interview and record review it was determined the facility failed to provide pain management to 1 of 3 sampled residents (#97) reviewed for pain. This failure resulted in Resident 97 experiencing unrelieved severe pain. Findings include: Resident 97 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/12/19 Resident 97 began to receive hospice services. Resident 97's physician's orders [REDACTED]. On 6/19/19 a complaint was received to indicate Resident 97 did not receive scheduled pain medication on 6/17/19. Resident 97 was found by Witness 18 (Complainant) at 8:45 AM in bed crying out in great pain. The 6/17/19 MAR and information in the narcotic administration book for 6/17/19 revealed Resident 97 did not receive the 00:00 AM (midnight) and 4:00 AM doses of [MEDICATION NAME] because she/he was sleeping. In addition, the 8:00 AM dose was administered at 11:00 AM (three hours late). The last time the resident received pain medication was on 6/16/19 at 8:00 PM, which indicated Resident 97 went 15 hours without receiving [MEDICATION NAME] for pain. No evidence was found to indicate hospice was contacted or the resident was assessed for needed PRN pain medication in between the scheduled doses. A 6/17/19 progress note by Resident 97's physician stated Resident 97 missed a few doses of [MEDICATION NAME] .and was in a great deal of pain. On 12/16/19 at 9:38 AM Staff 2 (DNS) confirmed the missed and late doses of [MEDICATION NAME] and was not able to provide further documentation to indicate Resident 97's pain was assessed and hospice was contacted for further pain management direction.

Based on observation and record review it was determined the facility failed to assess and revise the care plan for new and increased behaviors and agitation for 1 of 3 sampled residents (#1) reviewed for behaviors. The resident was distressed and sustained multiple injuries. Findings include: Resident 1 was admitted to the facility in 3/2018 with [DIAGNOSES REDACTED]. The 5/10/18 at 11:50 AM Progress Note disclosed a CNA observed the resident wrapping a call light cord around her/his neck. Staff 4 (SSD, Social Services Director) immediately followed up and observed the cord was wrapped around the resident's arms. Through the use of a communication board the resident reported pain in her/his legs and arms. Staff 4 completed a Suicide Assessment Risk assessment, the resident denied making a suicide attempt, and it was determined the behavior was caused by the extremity pain. The 5/11/18 Behavioral Symptoms Comprehensive Care Plan noted the resident had potential for restlessness and agitation .when needs are not being met and feeling pain, as evidenced by wrapping cords around herself/himself, trying to get out of bed, and frequent movements in bed. Interventions included assessing the resident's needs and pain, keeping the resident engaged and offering activities that would keep her/his hands busy, and low bed with a mattresses on the floor next to the bed and the bed against the wall. The 5/15/18 at 8:41 AM Progress Note disclosed the resident's behaviors and activities were at baseline. The resident was described as pleasant and cooperative with care. The 6/5/18 at 8:48 AM Progress Note revealed the resident's behaviors and activities were at baseline. The 6/2018 and 7/2018 Physician order [REDACTED]. and restless leg syndrome) 0.25 mg daily, senna (a bowel care medication) 8.6 mg twice a day, polyethylene [MEDICATION NAME] (bowel care medication) 17 grams twice a day, and [MEDICATION NAME] (a narcotic medication) 5-325 mg 0.5 tablet PRN every six hours. Progress Notes from 6/22/18 through 7/9/18 documented the resident exhibited an increase/new onset of behaviors including: The 6/22/18 at 7:35 PM Progress Note disclosed the resident was . very agitated and trying to leave all day. no PRN for anxiety. WCTM (will continue to monitor) and request if behavior continues. The 6/23/18 at 4:15 AM Progress Note revealed the resident's agitation resulted in skin tears to the hand and foot. The 6/23/18 8:46 AM, 9:04 AM, 9:14 AM and 1:18 PM Progress Notes disclosed the resident was agitated on the floor mat and would not allow any cares, medications or any movement. The resident removed her/his pants and incontinence brief and when a CNA attempted to place another brief on the resident she/he ripped it off and started fighting with everyone that came close. The resident refused to get into bed or the wheelchair and remained on the floor mattress. The resident ripped off a dressing and refused treatment. A family member who was called for support took the resident outside and the resident refused to come back in the building, placing her/his arms in the wheelchair wheels so they would not move. The physician was contacted regarding a PRN medication for agitation. The physician ordered STAT (immediate) labs. The labs were drawn while the resident was in a parking lot. At 5:25 PM staff documented the resident was convinced to return to the facility. The 6/2018 and 7/2018 MARs noted the resident continued refusing her/his medications from 6/24/18 to 6/30/18, 7/3/18, 7/4/18, and 7/6/18 to 7/9/18. The 7/2/18 at 11:29 AM and 6:11 PM Progress Notes disclosed Resident 1 was observed in the hallway with her/his hands and arms in between the wheelchair wheels making the wheelchair unmovable while waiting to talk with a staff member. A family member was contacted for assistance. The resident was noted as agitated most of the day and when the family member attempted to visit the resident, the resident told him to leave. The 7/3/18 Physician Discharge Summary documented the resident refused medications for several days and was agitated, kicking and striking out at caregivers. The resident reported she/he was very frustrated by her/his current debility. The 7/6/18 at 11:45 PM Progress Note disclosed the resident was found lying on the floor between the wall and the bed. The resident grimaced and nodded her/his head when asked if she/he was in pain. The 7/8/18 at 5:00 AM Progress Note revealed at night the . resident became uncontrollable, was unable to handle and kicking with 3 staff present in room. Staff contacted a family member who stated he thought the resident did not want to live anymore. The 7/8/18 at 5:00 PM Progress Note disclosed Resident 1 had purple bruising to the right eye. Several times throughout the morning the resident climbed out of bed and onto the floor mattress. The resident aggressively took off her/his incontinence brief and clothing and made it difficult for staff to change the resident or move her/him back onto the bed or wheelchair. At around 5:00 PM the resident attempted to lodge her/his head under the side table and reached for any object she/he could place her/his head under. Staff removed the side tables from the resident's room due to the resident's attempts to lodge herself/himself under side tables or the bed frame. The resident was difficult to provide care throughout the shift by aggressively moving body in the wheelchair. The 7/9/18 at 3:10 AM Progress Note documented the resident had a knot at the end of her/his right eyebrow with a bruise below the right eyebrow. Before bed time resident became aggressive tried to jump off (Resident 1's) bed . The resident attempted to hit and kick staff. Staff 7 (RN) contacted the on-call Nurse Practitioner who ordered [MEDICATION NAME] (an antianxiety medication) 1 mg STAT, which the resident spit out. The swelling on the resident's eyebrow increased to the size of a golf ball and her/his eyes were bloodshot. The Nurse Practitioner was contacted again and the resident was sent to the hospital for evaluation. The resident was given [MEDICATION NAME] for pain, which the resident spit out. While waiting for medical transportation the resident's eye started to bleed and while Staff 7 attempted to clean the blood from the resident's face the resident .was kicking everywhere. The 7/9/18 at 4:28 AM, 1:53 PM, and 1:58 PM Progress Notes revealed the resident returned to the facility at 3:30 AM. During the day shift the resident climbed off of the floor mattress, closed the door behind her/him and wedged herself/himself behind the door, with the wheelchair and a room chair against the resident. Staff were not able to get in the resident's room. After talking to the resident for 10 minutes the resident moved slightly enough for staff to reach in and help the resident move out of the way. The resident was discharged to an adult foster home at 1:50 PM. In interviews on 9/5/18 at 2:35 PM and 9/10/18 at 11:39 AM Staff 4 (SSD) stated the resident was angry and her/his agitation increased when the discharge from the facility was delayed. One to one visits were increased, however, there was no discussion on obtaining a mental health evaluation. Per Staff 4, staff were to keep the resident engaged and involved and address her/his needs which was not documented as done. Staff 4 stated she was aware the resident hit and kicked staff but did not know the resident had incidents of jumping off the bed. When asked about a documented assessment of the resident's new/increased behaviors and revision to the care plan Staff 4 stated the care plan remained the same. No documented assessment was provided. Staff were to document behaviors on the Behavior Monitoring Logs which she reviewed regularly, however, staff documentation on the records needed work. On 9/10/18 at 2:33 PM Staff 5 (Interim LPN/RCM) stated after a delay in the resident's discharge the resident's behaviors increased. The resident was angry and had significant falls with injuries and staff had to change their interventions as the resident's behaviors changed. On 9/11/18 at 10:59 AM Staff 18 (CNA) stated the resident worsened at the end of her/his stay in the facility. The resident was extremely agitated, she/he tried to throw herself/himself on the ground, and hit and pinched staff. Staff 18 stated if she observed the behaviors but was not the assigned CNA she did not document on the behavior log and passed the information to the assigned CNA. On 9/11/18 at 11:34 AM Staff 10 (LPN) stated the resident's behaviors increased after moving to another section of the facility and she was not sure if the increase was related to an adjustment issue from being in a new room. Towards the end of the resident's stay in the facility staff had to remove side tables from her/his room due to the resident's attempts to place her/his head under tables. The resident would get her/his head stuck in the closet and locked her/his hands in the wheelchair. On one occasion the resident locked her/his hands in the wheelchair and it took 45 minutes to get the resident to remove her/his hands. Staff 10 stated she advised CNA staff to document behavioral incidents on the monitoring log. On 9/11/18 at 12:00 PM Staff 17 (CNA) stated the resident told Staff 17 and others she/he was trying to hurt her/his head on the bed frame and the floor mattresses were shoved up against the bed frame to protect the resident. Staff 17 stated staff were to document incidents on the Behavior Monitoring Logs. The lack of assessment including obtaining a mental health evaluation and care plan revision was discussed with Staff 1 (Administrator) and Staff 2 (Regional Support Nurse) on 9/11/18 at 1:58 PM. No additional documentation was provided. In interview on 9/11/18 at 3:04 PM Staff 26 (CNA) stated during the resident's last two weeks in the facility the resident changed significantly from her/his baseline. The resident was more restless, threw herself/himself out of the wheelchair, would lock her/his arms in the wheelchair wheel, and would refuse to communicate with staff. On 7/6/18 the resident fell between the bed and the wall. Prior to the incident the bed was next to the wall and the brakes were locked, making it hard to move the bed. When the resident was found on the floor the bed was pushed out away from the wall. Per Staff 26 multiple interventions did not work with the resident and it was difficult when a family member was not present. When incidents occurred staff were directed to document the incidents on the Behavior Monitoring Logs. In interview on 9/11/18 at 3:26 PM Staff 13 (LPN) stated the resident exhibited behaviors including purposely hitting her/his head on the wall and attempted to place her/his head under furniture. Staff 13 stated interventions did not work and the resident needed constant supervision. On 9/12/18 at 4:55 AM Staff 7 (RN) stated the resident had behaviors including intentionally hitting her/his head on the floor, cabinets, anywhere she/he could and tried to force herself/himself under the bed. Staff placed the resident in the wheelchair and the resident tried to get out of the wheelchair. The resident always jumped off of the bed. When Staff 7 called a family member for assistance the family member told her the resident wanted to die. During the 7/8/18 to 7/9/18 night shift the resident did not sit still, she/he spit medications on her, attempted to hit her and required one to one assistance. On 9/12/18 at 5:12 AM Staff 28 (CNA) stated during the last two weeks in the facility the resident stated she/he wanted to go home with family and hit the door until her/his hand bled. The resident placed her/his hands in the wheelchair wheel and again would not remove them until they bled. The resident hit her/his head on the wall and her/his face on the floor and if staff attempted to stop the resident from hurting herself/himself she/he spit in their face, hit, and tried to run over their feet with her/his wheelchair. Staff 28 stated when the resident was angry nothing helped the resident. On 9/12/18 at 8:05 AM Staff 30 (RN) stated on 7/9/18 the resident fell on to the floor from bed several times. The resident managed to get behind her/his room door while lying on the floor and closed the door. The resident would not allow staff to enter the room. Staff attempted to talk with the resident and eventually the resident moved enough that a staff member was able to get through the small opening in the doorway. The resident was agitated and said no when asked about care needs. The resident was discharged from the facility later that day. In interview on 9/12/18 at 9:50 AM Witness 1 (Transition Coordinator) stated after the resident's discharge to the adult foster home she followed up with Staff 4 (SSD). Staff 4 reported to Witness 1 prior to discharge the resident became a little agitated due to the delay in her/his discharge and did not exhibit extreme behaviors. However, the resident sustained [REDACTED]. On 9/12/18 at 10:27 AM Witness 2 (Adult(NAME)Home Provider) stated after a day and a half in the adult foster home the resident was agitated and became aggressive, including throwing herself/himself out of bed and intentionally kicking staff. The resident was sent to the hospital at least twice related to her/his behaviors. On 9/12/18 at 12:09 PM Staff 15 (CNA) stated during the resident's last two weeks in the facility she/he was super agitated, combative, and miserable. The resident was very strong and she/he would place herself/himself onto the floor then hold onto the bed so staff could not move her/him or would grab the wheelchair wheel spokes so staff could not move the wheelchair. The resident would hurt herself/himself and not let staff clean the injury and would bite or hit staff. On 9/12/18 at 3:20 PM Witness 3 (Physician) initially stated the resident did fairly well, she/he fell due to impulsivity, and when the resident left she/he .was in a pretty good place I believe. The resident expressed frustration with her/his state of health, she/he did not want to take medications, and reported to her she/he no longer wanted to live. The combativeness was related to staff attempting to give the resident medication. Per Witness 3 the resident was mostly re-directable and she received no reports the resident was not re-directable. Witness 3 stated she was aware the resident had an incident of her/his head under the bed headboard but did not know if it was deliberate. Witness 3 could not recall if she was made aware of the resident intentionally placing her/his head under side tables and in the closet door. Witness 3 was not aware of the 7/9/18 incident when the resident wedged herself/himself behind the room door or was hitting her/his head and hand on walls/objects to the point of bleeding. Witness 3 stated she did not have a good appreciation of how the resident's behaviors escalated and if she was made aware of everything she would have started an anti-depressant, considered an anti-psychotic medication, and obtained a mental health evaluation.

Based on interview and record review it was determined Staff 5 (Activities Director) and Staff 14 (former Activities Director) failed to intervene and protect residents from unsafe driving for 5 of 5 sampled residents (#s 2, 7, 8, 9 and 10) reviewed for organized facility outings. Resident 2 sustained a left arm fracture during a facility outing. Findings include: A facility Incident Investigation dated 7/21/16 indicated on 7/20/16 Resident 2 went to the coast as part of an organized facility activity on a bus owned by the facility's corporation. The resident was strapped into the bus in the resident's personal electric wheelchair. The bus went over a bump which threw the resident up in the air. The resident braced her/himself with the left hand hurting her/his wrist. In a statement as part of the investigation the resident stated The driver that was taking them to the beach was driving crazy by going too fast and swerving. I was sitting in the back of the bus and my electric wheelchair was bumping around. The bus driver was going fast and at one point I bounced so hard out of my chair and lift up from my seat and when I was coming back down I put my hands down on the armrests to brace myself. I'm fine but my wrist is swollen and hurts a little. I was defiantly (definitely) scared by that bus driver . In a statement by Staff 14 (former Activities Director) she stated The driver was driving erratic on the way to the beach by driving too fast and swerving in and out of lanes. It was scary and I was worried. (Resident 2) was bouncing up and down in (her/his) electric wheelchair and (she/he) ended up going up high off (her/his) chair and came down on the chair and basically put all (her/his) weight down on (her/his) wrists. The investigation indicated Resident 2 received an x-ray of the left wrist which showed a fracture and swelling. An x-ray report dated 7/21/16 indicated Resident 2 had a left wrist fracture and tissue swelling. Hand written orders from the nurse practitioner on the report indicated the resident was to be sent to urgent care for splinting of the left wrist. On 9/20/16 at 10:42 am Resident 2 stated the bus driver was weaving, speeding and texting while driving all the way to the coast. The resident stated they went over a bumpy road, hit a big bump and slammed her/his left arm on the armrest. The resident was asked if any staff on the bus asked Staff 10 to slow down and she/he stated on one occasion during the trip Staff 14 asked the driver if he wanted to take a break and he said no. She/he could not recall if Staff 5 (Activities Director) said anything to Staff 10. The resident stated she/he declined to go on two other outings because Staff 10 was the driver. On 9/22/16 at 9:44 am Staff 5 stated they went to the coast for an outing. She stated Staff 10 was in a hurry and rushing and she was car sick. She said she heard residents gasping as they went around corners. She stated there was a lot of traffic in town so they took an alternate route and were going quick because Staff 10 had an engagement. The bus went over some train tracks and hit them so hard everyone bounced out of their seats. She stated Resident 2 yelled out and was holding her/his arm and the resident stated her/his arm hurt really bad. Staff 5 stated during the trip to and from the coast the residents on the bus, Staff 14 and herself made comments among themselves regarding Staff 10's driving. She stated on the trip back to the facility Staff 14 asked Staff 10 to take it easy and he replied that he had a birthday party to go to. She stated Staff 10 asked to borrow a cell phone to make a phone call while driving. Staff 5 stated she canceled the last three outings because Staff 10 was assigned to be the driver and the residents do not want to go with him. On 9/22/16 at 1:05 pm Staff 10 stated on the day of the incident he was driving the bus through an industrial area watching for cross traffic at several intersections which lacked traffic control devices when the bus went over an abandoned rail line where the actual tracks had been removed. The bus went over a bump in the road and a resident in the back of the bus was upset. He stated he was not aware of any injury to the resident at that time and he apologized to the residents on the bus. When asked if Staff 14 or Staff 5 commented on his driving Staff 10 stated there was only one comment from Staff 14 who asked him if he was alright. Staff 10 acknowledged he borrowed Staff 14's cell phone to make a call while he was driving the bus with residents aboard. On 9/26/16 at 10:48 am Staff 1 (Administrator) stated if all the allegations (by Staff 5, Staff 14 and Resident 2) were true then one possible course of action was to disembark from the bus and arrange other transportation. Staff 1 stated if it was sufficiently dangerous then you would not allow the driver to continue to transport residents. When asked if Staff 14 should have loaned her cell phone to Staff 10 to use while driving Staff 1 stated you do not use a cell phone while driving and it was not something they would endorse. Staff 1 acknowledged he was pretty sure it is illegal to use a cell phone while driving in Oregon. The facility Incident Investigation failed to include interviews with Staff 10 (Bus Driver) or the other residents on the bus (#s 7, 8, 9 and 10) at the time of the incident. Despite the missing interviews, the injury to Resident 2 and staff statements of unsafe driving by Staff 10 the investigation ruled out abuse or neglect although neither Staff 14 or Staff 5 intervened to stop the reportedly unsafe driving which resulted in Resident 2 suffering a wrist fracture. Staff 14 contributed to the unsafe behavior by loaning her cell phone to Staff 10 to make a phone call while driving. Refer to F-323

Based on interview and record review it was determined the facility failed to ensure resident safety for 1 of 3 sampled residents (#2) reviewed for accidents. Resident 2 sustained a left arm fracture during a facility outing. Findings include: Resident 2 was readmitted to the facility in 2016 with [DIAGNOSES REDACTED]. A facility Incident Investigation dated 7/21/16 indicated on 7/20/16 Resident 2 went to the coast as part of an organized facility activity on a bus owned by the facility's corporation. The resident was strapped into the bus in the resident's personal electric wheelchair. The bus went over a bump which threw the resident up in the air. The resident braced her/himself with the left hand hurting her/his wrist. In a statement as part of the investigation the resident stated The driver that was taking them to the beach was driving crazy by going too fast and swerving. I was sitting in the back of the bus and my electric wheelchair was bumping around. The bus driver was going fast and at one point I bounced so hard out of my chair and lift up from my seat and when I was coming back down I put my hands down on the armrests to brace myself. I'm fine but my wrist is swollen and hurts a little. I was defiantly (definitely) scared by that bus driver . In a statement by Staff 14 (former Activities Director) she stated The driver was driving erratic on the way to the beach by driving too fast and swerving in and out of lanes. It was scary and I was worried. (Resident 2) was bouncing up and down in (her/his) electric wheelchair and (she/he) ended up going up high off (her/his) chair and came down on the chair and basically put all (her/his) weight down on (her/his) wrists. The investigation indicated Resident 2 received an x-ray of the left wrist which showed a fracture and swelling. An x-ray report dated 7/21/16 indicated Resident 2 had a left wrist fracture and tissue swelling. Hand written orders from the nurse practitioner on the report indicated the resident was to be sent to urgent care for splinting of the left wrist. On 9/20/16 at 10:42 am Resident 2 stated the bus driver was weaving, speeding and texting while driving all the way to the coast. The resident stated they went over a bumpy road, hit a big bump and slammed her/his left arm on the armrest. The resident stated she/he just got the brace off today. The resident stated they were supposed to stop at a fast food restaurant but Staff 10 (bus driver) said no. The resident was asked if any staff on the bus asked Staff 10 to slow down and she/he stated on one occasion during the trip Staff 14 asked the driver if he wanted to take a break and he said no. She/he could not recall if Staff 5 (Activities Director) said anything to Staff 10. The resident stated she/he declined to go on two other outings because Staff 10 was the driver. On 9/22/16 at 9:44 am Staff 5 stated they went to the coast for an outing. She stated Staff 10 was in a hurry and rushing and she was car sick. She said she heard residents gasping as they went around corners. She stated there was a lot of traffic in town so they took an alternate route and were going quick because Staff 10 had an engagement. The bus went over some train tracks and hit them so hard everyone bounced out of their seats. She stated Resident 2 yelled out and was holding her/his arm and the resident stated her/his arm hurt really bad. Staff 5 stated during the trip to and from the coast the residents on the bus, Staff 14 and herself made comments among themselves regarding Staff 10's driving. She stated on the trip back to the facility Staff 14 asked Staff 10 to take it easy and he replied that he had a birthday party to go to. She stated Staff 10 asked to borrow a cell phone to make a phone call while driving. Staff 5 stated she canceled the last three outings because Staff 10 was assigned to be the driver and the residents do not want to go with him. On 9/22/16 at 1:05 pm Staff 10 stated on the day of the incident he was driving the bus through an industrial area watching for cross traffic at several intersections which lacked traffic control devices when the bus went over an abandoned rail line where the actual tracks had been removed. The bus went over a bump in the road and a resident in the back of the bus was upset. He stated he was not aware of any injury to the resident at that time and he apologized to the residents on the bus. Staff 10 stated he was already over his eight hours for the day and Staff 14 had not told him they were going to have lunch and dinner. He stated it was close to 7 pm when they arrived back from the trip and Staff 14 wanted to go through a drive-through (to get dinner for the residents). Staff 10 stated the bus is too big for drive-through's. When asked if Staff 14 or Staff 5 commented on his driving Staff 10 stated there was only one comment from Staff 14 who asked him if he was alright. Staff 10 acknowledged he borrowed Staff 14's cell phone to make a call while he was driving the bus with residents aboard. On 9/26/16 at 10:48 am Staff 1 (Administrator) stated if all the allegations (by Staff 5, Staff 14 and Resident 2) were true then one possible course of action was to disembark from the bus and arrange other transportation. Staff 1 stated if it was sufficiently dangerous then you would not allow the driver to continue to transport residents. When asked if Staff 14 should have loaned her cell phone to Staff 10 to use while driving Staff 1 stated you do not use a cell phone while driving and it was not something they would endorse. Staff 1 acknowledged he was pretty sure it is illegal to use a cell phone while driving in Oregon.

1. Based on observation, interview and record review it was determined that the facility failed to meet professional standards of quality for medication administration. The failure to complete the medication administration within the identified timeframes and to communicate and/or address problems as they occurred resulted in significant medication errors for 3 of 5 sampled residents (#'s 20, 55 and 108) and placed all residents receiving medications at risk for medication errors with the potential for serious harm. Surveyors intervened with facility staff on three occasions on 3/2/12 between 12:58 pm and 3:04 pm when staff failed to recognize the immediacy/potential risks or to notify physician's immediately of the errors that had occurred. Due to the lack of communication between nurses and a failure to respond in a timely manner when the issue was identified, an immediate jeopardy was called. Findings Include: According to The Oregon Nurse Practice Act Standards and Scopes of Practice: Scope of Practice Standards for All Licensed Nurses 851-045-0040 (5)(c)(e)(f)(g) "Standards related to the licensed nurse's responsibility to assign and supervise care ... ensures documentation of the activity ... provides follow-up on problems and intervenes when needed ... evaluates the effectiveness of the assignment and the outcomes of the interventions; and ... revises or recommends changes to the plan of care as needed." "Standards related to the licensed nurse's responsibilities for ethics, including professional accountability and competence ... retains professional accountability when accepting, assigning, or supervising nursing care and interventions" Scope of Practice Standards for Licensed Practical Nurses 851-045-0050 (2)(d)(A) "Standards related to the Licensed Practical Nurse's responsibility for nursing practice implementation ... the Licensed Practical Nurse shall ... (implement) treatments and therapy, appropriate to the context of care, including but not limited to, medication administration ..." Conduct Derogatory to the Standards of Nursing Defined 851-045-0070 (1)(a)(b)(3)(h) "Nurses, regardless of role, whose behavior fails to conform to the legal standard and accepted standards of the nursing profession ... shall include, but is not limited to ... Conduct related to the client's safety and integrity ... Developing, modifying, or implementing standards of nursing practice/care which jeopardize patient safety ... Failing to take action to preserve or promote the client's safety based on nursing assessment and judgment ... Failing to communicate information regarding the client's status to members of the health care team (physician, Nurse practitioner, nursing supervisor, nurse co-worker) in an ongoing and timely manner." On 3/2/12, the following events occurred: At 12:00 pm, Staff 14, LPN, was observed passing medications. Staff 14 informed the surveyor that the 8:00 am medication pass was still in progress on the hallways assigned to Nursing Station 1. From 12:23 to 12:30 pm, Staff 14 was observed administering medications scheduled at 8:00 am to Resident 100. In a 12:40 pm interview, Staff 14 stated that five residents (#'s 9, 20, 55 100 and 108) had received their 8:00 am medications after 10:00 am that day. At 12:58 pm, Staff 14 identified that when staff fell behind on the scheduled medication pass, they informed the charge nurse. When asked if Staff 14 had done that, she replied "No, but she knows." In a 1:00 pm interview, Staff 15, RN Charge Nurse, stated that she was unaware that Staff 14 was still administering 8:00 am medications. Staff 15 indicated that Staff 14 needed to stop giving medication after the hour window (an hour before and an hour after the scheduled medication pass), but was unsure what to do in response to the late medication pass as it had never happened before. The surveyor directed Staff 15 to notify her DNS. Staff 15 failed to recognize the need to speak with Staff 14 regarding the late medication pass, who continued to give medication. At 1:19 pm, Staff 14 gave a verbal report to Staff 15 regarding the residents who received late medications and shared that the 8:00 am pass was complete. At 1:24 pm, Staff 2, DNS, spoke with Staff 15 who stated that she would write a report and Staff 2 would follow up with the physicians for the five residents who received late medications. Resident 55's 3/2012 MAR indicated [REDACTED]. According to the facility's medication error investigation, the resident also received her 8:00 am dose of [MEDICATION NAME] at 12:00 pm that day. There was no evidence that the late administration of the medication had been communicated with the staff responsible for giving the 2:00 pm medication. At 2:50 pm, Staff 8, LPN Evening Charge Nurse, Staff 16 and Staff 17, CMAs, reported that they had not been given any information regarding medication time changes or medications that had been given late. Preparation for the 4:00 pm medication pass was in process. As a result, at 3:04 pm, surveyors approached Staff 2 who stated that she had heard something about the concerns with the medication pass that day, but would need to look at it and "haven't got to it." Staff 2 was unaware of the names of the residents who received late medications and stated that the CMAs needed to communicate late medication issues to her. The surveyors provided the names of the five residents to Staff 2. At 3:49 pm, Staff 2 informed surveyors that she had spoken to Staff 14 who verified that she had combined the 8:00 am and 12:00 pm medication doses for some residents. More than two hours after Staff 15 indicated that Staff 2 would be following up with physicians, there was no indication that the resident's physicians had been contacted or a comprehensive plan addressing residents possible negative outcomes from the late medication pass had been developed. The MARs for Resident's 9, 20, 55, 100 and 108 were reviewed and it was identified that there was no documentation that medications had been given late. Staff 14 failed to communicate timely the late medication pass to the charge nurse and independently made the decision to combine doses for the 8:00 am and 12:00 pm passes. Staff 15 lacked knowledge of the protocol to follow when a late medication pass occurred and did not inform necessary staff, which included the oncoming Charge Nurse and CMAs, of the late medication administration. Staff 2 failed to respond in a timely manner to develop a plan when notified of the late medication administration. This resulted in significant medication errors, which had the potential for serious harm, for Residents 20, 55 and 108. Resident 55 received double doses of [MEDICATION NAME] and Tylenol with additional lab work ordered by the physician and a drop in blood pressure documented. Resident 108 received two doses of [MEDICATION NAME] within a two-and-a-half hour period which placed the resident at risk for overdose and/or adverse reactions. Resident 20 received a double dose of Sodium [MEDICATION NAME] which placed the resident at risk for adverse reactions such as unstable pH blood level. Refer to F333 regarding significant medication errors. On 3/2/12 at 5:10 pm, following consultation with the State survey agency supervisors, the surveyors informed Staff 1, Administrator, that the facility failed to respond to late medication administration, incorrect dose administration as well as lack of communication and coordination between staff constituted a situation of immediate jeopardy to residents. Surveyors requested a plan of correction to immediately protect the residents from harm be developed and implemented. On 3/2/12 at 6:25 pm, a plan of correction was provided by the facility that ensured residents safety regarding safe medication administration. It was accepted by the survey team and the immediate jeopardy was abated on 3/2/12 at 6:45 pm. 2. Based on interview and record review it was determined that the facility failed to develop a care plan, provide pressure ulcer treatments and maintain accurate clinical records in accordance with accepted nursing standard of practice for 1 of 1 sampled resident (# 81 ) who had chronic pressure ulcers. The failure of nursing staff to discontinue and/or change treatments without physician's orders, and lack of documentation of treatments placed residents at risk for infection, decline in overall well-being and delay in healing. Findings include: According to The Oregon Nurse Practice Act Standards and Scopes of Practice: Scope of Practice Standards for Licensed Practical Nurses 851-045-0050 (2)(d)(A)(B) "...the Licensed Practical Nurse's responsibility for nursing practice implementation. Under the clinical direction of the RN or other licensed provider who has the authority to make changes in the plan of care...the Licensed Practical Nurse shall: Implement the plan of care by:Implementing treatments and therapy, appropriate to the context of care...and Documenting nursing interventions and responses to care in an accurate, timely, thorough, and clear manner." Scope of Practice Standards for Registered Nurses 851-045-0060 (2)(c)(A)(B)(C)(d)(B)(8)(l) "...the Registered Nurse shall Develop and coordinate a comprehensive and/or focused plan of nursing care. This includes: Identifying priorities in the plan of care; Setting realistic and measurable goals to implement the plan of care in collaboration with the client and the healthcare team; and Developing nursing orders and identifying nursing strategies, interventions and actions...(document) nursing interventions and responses to care in an accurate, timely, thorough, and clear manner... Supervises others to whom nursing activities are delegated and monitors performance, progress, and outcomes. Ensures documentation of the activity;" 851-045-0070 (3)(a)(b) Conduct Derogatory to the Standards of Nursing Defined "...Inaccurate recordkeeping in client or agency records. Incomplete recordkeeping regarding client care; including, but not limited, to failure to document care given or other information important to the client's care or documentation which is inconsistent with the care given." Resident 81 was admitted in 12/2011 with multiple Stage 3 and Stage 4 pressure ulcers. The admission Physician Orders directed a daily treatment that included cleansing and dry Mesalt ribbon packing for the Stage 4 bilateral ischial tuberosity (lower buttocks area) and sacrum/coccyx ulcers, and a twice a day treatment to the Stage 3 right thigh and buttock ulcers. A 12/7/11 wound clinic ANP noted regarding the ischial and coccyx ulcers, " palpable bone in each one of those ulcerations..." The 12/16/11 admission care plan identified the resident's skin to be at risk with a goal of no avoidable breakdown. The approaches included "...plan (related to) current ulcer or skin conditions (see Care Plan)." There was no documented evidence that a care plan related to the current ulcers had been done. Resident 81's 12/27/11 admission MDS identified the resident was admitted with two Stage 3 pressure ulcers and three Stage 4 pressure ulcers. The CAA further described the resident frequently refused wound treatments and turning. The resident had the potential for wound infections,[MEDICAL CONDITION] or death. A decision to proceed to a plan of care was made. Staff 4's, RNCM, signature on the MDS indicated that careplanning had been completed. There was no documented evidence that a comprehensive plan of care related to care and treatment of [REDACTED]. In an interview on 3/2/12 at 1:00 pm Staff 3, RNCM, said that she had been assigned as the resident's care manager in 1/2012. Staff 3 indicated the resident's care plan identified the resident to be at risk for further skin issues and the resident at times refused care. Staff 3 said that she felt this information had been sufficient. Staff 3 confirmed there was no comprehensive care plan regarding the treatment of [REDACTED]. According to the resident's 12/2011 TAR, on 12/28/11 the treatment to the bilateral ischial tuberosities and right thigh ulcers had been discontinued. There was no evidence of a physician order to discontinue the treatment to the bilateral ischial ulcers. The MD orders and TAR reflected a 12/28/11 treatment change for the right thigh ulcer to a daily [MEDICATION NAME] dressing (a moist, sterile dressing) and cover with a dry sterile dressing. The resident's Skin Impairment weekly documentation form indicated from 12/30/11 to 2/24/12 the bilateral ischial ulcers and right thigh ulcers were unhealed and still present. From 12/28/11 to 2/29/12, more than two months, there was no documented evidence that staff had directions to provide any wound care treatment to the bilateral ischial tuberosity ulcers. From 1/01/12 through 2/29/12 there was no documented evidence that a treatment had been provided to the resident's right thigh ulcer as the physician directed. In interviews on 3/1/12 at 8:58 am and 10:57 am, Staff 25, LPN treatment nurse, reported she had applied a barrier cream of "ilex and [MEDICATION NAME]" to the right ischial ulcer because it had been getting better but recently she changed it back to Mesalt packing. Staff 25 said that she did not have a physician order for [REDACTED]. The 12/2011 through 2/1012 TARs and physician orders were reviewed with Staff 25 on 3/1/12 at 10:57 am. Staff 25 stated that she had spoke with the resident's physician on 12/28/11 and that the treatment to the ulcers had changed. Staff 25 acknowledged that she had discontinued the treatment on the TAR for the ischial wounds on 12/28/12 and confirmed that no physician order had been written. Staff 25 acknowledged that treatments for the bilateral ischial ulcers and right thigh ulcer, when provided, had not been documented. On 3/1/12 at 11:59 am, Staff 3, RNCM, stated that the treatment orders for the right thigh wound had not been transcribed onto the 1/2012 and 2/2012 TAR. Staff 3 further stated that she had observed and assisted Staff 25 with treatments for the resident's ulcers including the ischial wounds. Staff 3 confirmed that the ischial treatment had been changed without written physician approval and acknowledged that the required documentation of a provided treatment had not been done.

Based on observation, interview and record review it was determined that the facility failed to ensure that residents were free from significant medication errors for 3 of 5 sampled residents (#'s 20, 55 and 108) who received medications beyond the scheduled time. The failure of staff to problem solve medication administration issues resulted in the significant medication errors and placed all residents receiving medications at risk for medication errors with the potential for serious harm. Surveyors intervened with facility staff on three occasions on 3/2/12 between 12:58 pm and 3:04 pm when staff failed to recognize the immediacy/potential risks or to notify physicians' immediately of the medication errors that had occurred. Resident 55 experienced a drop in her blood pressure and required additional monitoring and lab work. An immediate jeopardy was called on 3/2/12. Findings include: On 3/2/12, the following events occurred: - At 12:00 pm, Staff 14, LPN, was observed passing medications. She informed the surveyor that the 8:00 am medication pass was still in progress on the hallway assigned to Nursing Station 1. In a 12:40 pm interview, Staff 14 stated that five residents had received their 8:00 am medications after 10:00 am that day. - At 12:58 pm, Staff 14 identified that when staff fell behind on the scheduled medication pass, they informed the charge nurse. When asked if Staff 14 had done that, she replied "No, but she knows." - At 1:00 pm, Staff 15, RN Charge Nurse, was informed of the late medication pass by a surveyor. Staff 15 stated that Staff 14 needed to stop giving medication after the hour window, an hour before and an hour after the scheduled medication pass, was reached. - At 1:19 pm, Staff 14 gave a verbal report to Staff 15 regarding the residents who received late medications and shared that the 8:00 am pass was complete. - At 1:24 pm, Staff 2, DNS, spoke with Staff 15 who stated that she would write a report and Staff 2 would follow up with the physicians for the five residents who received late medications. - At 2:50 pm, Staff 8, LPN Evening Charge Nurse, Staff 16 and Staff 17, CMAs, reported that they had not been given any information regarding medication time changes or medications that had been given late. Preparation for the 4:00 pm medication pass was in process. - As a result, at 3:04 pm, surveyors approached Staff 2 who stated that she had heard something about the concerns with the medication pass that day, but would need to look at it and "haven't got to it." Staff 2 was unaware of the names of the residents who received late medications and stated that the CMAs needed to communicate late medication issues to her. The surveyors provided the names of the five residents to Staff 2. The late medication pass resulted in the following significant medication errors: 1. Resident 55 had [DIAGNOSES REDACTED]. According to a 3/2/12 Medication Error Report, Resident 55 received all scheduled 8:00 am medications at 12:00 pm that day. The 3/2012 MAR indicated [REDACTED]. All three medications had a scheduled dose for 8:00 am. According to the facility's investigation, [MEDICATION NAME] 20 mg was given at 12:00 pm and again at 2:30 pm (a two-and-half hour time span), and both the 8:00 am dose and the 12:00 pm dose of the [MEDICATION NAME] was given together for a total dose of 20 mg. On 3/2/12 at 3:49 pm, Staff 2, DNS, stated that the resident received both the 8:00 am and 12:00 pm dose of Tylenol at noon that day. This meant that a total dose of 1300 mg of Tylenol had been provided, although only 650 mg had been ordered by the physician at noon. There was no indication on the MAR indicated [REDACTED]. The lack of accurate documentation placed the resident at further risk for medication errors which had the potential for serious harm. A 3/2/12 Nurses Note identified that Resident 55's physician had been notified of the medication errors at 4:00 pm. At 5:28 pm, a telephone order from the physician directed a stat basic metabolic panel lab (to check electrolytes) for the "[MEDICATION NAME] medication error", and to hold the 5:00 pm dose of Tylenol until 10:00 pm that night. A nurses note on 3/3/12 at 2:50 am indicated that the resident's blood pressure had dropped with further monitoring necessary. 2. Resident 108 had [DIAGNOSES REDACTED]. According to a 3/2/12 Medication Error Report, Resident 108 received all scheduled 8:00 am medications at 12:00 pm that day. The 3/2012 MAR indicated [REDACTED]. The medication had a scheduled dose for 8:00 am. The facility's investigation identified that the 8:00 am dose of [MEDICATION NAME] had been given at 12:00 pm and at 2:30 pm, a second dose was administered. [MEDICATION NAME] was identified to have a peak reaction time of 1-2 hours with a duration [MEDICATION NAME] 2-4 hours. The administration of two doses of [MEDICATION NAME] within a two-and-a-half hour period of time with the resident's medical condition placed the resident at risk for possible overdose or adverse reactions. As a result, the physician ordered that the evening dose of [MEDICATION NAME] be delayed. 3. Resident 20 had [DIAGNOSES REDACTED]. According to a 3/2/12 Medication Error Report, Resident 20 received all scheduled 8:00 am medications at 12:00 pm that day. The 3/2012 MAR indicated [REDACTED]. The medication had a scheduled dose at 8:00 am and 12:00 pm. The facility's investigation identified that both the 8:00 am dose and 12:00 pm dose were given together at 12:00 pm that day. Due to the resident's medical condition, the administration of two doses of Sodium [MEDICATION NAME] placed the resident at risk for adverse reactions such as unstable blood pH. As a result, the physician ordered that all 8:00 am medications that had been given late and were scheduled again at 4:00 and 5:00 pm, be held that evening. On 3/2/12 at 5:10 pm, following consultation with the State agency survey supervisors, the surveyors informed Staff 1, Administrator, that the failure of the facility to respond to the late medication administration constituted a situation of immediate jeopardy to residents. Surveyors requested a plan of correction to immediately protect the residents from harm to be developed and implemented. On 3/2/12 at 6:25 pm, a plan of correction was provided by the facility that ensured residents safety regarding safe medication administration. It was accepted by the survey team and the immediate jeopardy was abated on 3/2/12 at 6:45 pm. `

Based on interview and record review it was determined the facility failed to implement care planned interventions to prevent falls for 1 of 3 residents (# 1) who were at risk for falls. Resident 1 sustained a right [MEDICAL CONDITION]. 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 10/2009 with [DIAGNOSES REDACTED]. According to the care plan the resident was at risk for falls due to the effects of the stroke. The resident had numerous falls since admission to the facility and was care planned to not be left alone on the toilet. According to an Incident Report, on 6/21/11 Staff 2, CNA, assisted the resident to the toilet then left, leaving the resident alone, to assist another resident. When Staff 2 returned to the resident's bathroom the resident was on the floor. The resident complained of right hip pain and was transferred to the hospital and was diagnosed with [REDACTED]." In an interview on 6/28/11 at 3:40 pm Staff 2 stated on the morning of 6/21/11 he assisted Resident 1 to the toilet and was monitoring her/him when another resident down the hall started yelling. Staff 2 stated the other resident was a fall risk. Staff 2 asked Resident 1 to wait on the toilet until he returned. Staff 2 stated he left Resident 1 on the toilet for approximately a minute and a half. Refer to F-323 for additional information.

Based on observation, interview and record review it was determined the facility failed to implement care planned interventions to prevent falls for 3 of 3 residents (#s 1, 2 and 3) who were at risk for falls. Resident 1 fell and sustained a right hip fracture. Findings include: 1. Resident 1 was admitted to the facility in 10/2009 with [DIAGNOSES REDACTED]. According to the care plan the resident was at risk for falls due to the effects of the stroke. The resident had numerous falls since admission to the facility and was care planned to not be left alone on the toilet. According to an Incident Report, on 4/5/11 the resident fell off the toilet after Staff 1, CNA, left the resident alone on the toilet. The resident sustained [REDACTED]. The Incident Report concluded "CNA should have stood by while toileting, CNA verbal counseling given." In and interview on 6/27/11 at 1:15 pm Staff 1 stated when the resident fell on [DATE] she did not know the resident was not suppose to be left alone on the toilet. Staff 1 stated she had not looked at the care plan prior to assisting the resident. According to an Incident Report, on 6/21/11 Staff 2, CNA, assisted the resident to the toilet then left, leaving the resident alone, to assist another resident. When Staff 2 returned to the resident's bathroom the resident was on the floor. The resident complained of right hip pain and was transferred to the hospital and was diagnosed with [REDACTED]." In an interview on 6/28/11 at 3:40 pm Staff 2 stated on the morning of 6/21/11 he assisted Resident 1 to the toilet and was monitoring her/him when another resident down the hall started yelling. Staff 2 stated the other resident was a fall risk. Staff 2 asked Resident 1 to wait on the toilet until he returned. Staff 2 stated he left Resident 1 on the toilet for approximately a minute and a half. 2. Resident 2 was admitted in 2/2006 with [DIAGNOSES REDACTED]. The resident was assessed to be a fall risk. To prevent falls the resident was care planned to use a TAB alarm when in the wheelchair. On 6/27/11 at 1:40 pm the resident was observed in the hallway sitting in a wheelchair without a TAB alarm in place. Staff 3, CNA, who was assigned to Resident 2, verified the resident did not have a TAB alarm in place. Staff 3 went to the resident's room and obtained the TAB alarm which was attached to the bed under the covers. In an interview on 6/27/11 at 1:45 pm Staff 3 stated earlier in the day she assisted the resident into the wheelchair from bed. Staff 3 stated she could not find the TAB alarm but the resident appeared safe in the wheelchair. Staff 3 stated she got busy with other tasks and forgot to find the TAB alarm. 3. Resident 3 was admitted in 5/2011 with [DIAGNOSES REDACTED]. The resident was assessed to be a fall risk. To prevent falls the resident was care planned to have a pressure alarm in place when in bed. On 6/27/11 at 1:30 pm the resident was observed lying in bed with the pressure alarm turned off. Staff 4, CNA, verified the pressure alarm was turned off and then she turned it on. In an interview on 6/27/11 at 1:35 pm Staff 5, CNA, who was assigned to the resident, stated she had turned on the pressure alarm when she assisted the resident to bed earlier. Staff 5 stated sometimes other CNAs assist the resident to bed without turning on the alarm. Staff 4 did not know who assisted the resident to bed without turning on the alarm.

Based on interview and record review it was determined the facility failed to transport a resident with a stretcher, as identified as necessary, for 1 of 2 sampled residents (# 1) who were transported to the hospital during a change of condition. Resident 1's pain was increased due to the method of transport. Findings include: Resident 1 was admitted to the facility on [DATE] after an ER visit for wrist pain with [DIAGNOSES REDACTED]. On 11/5/10 Physical Therapy (PT) evaluated the resident and identified on the Plan of Treatment the resident tolerated upright sitting in chair/wheelchair for less than five minutes. On 11/8/10 an untimed PT note indicated the resident rated her pain level to be 8 out of 10 and reported feeling nauseous. The resident's MAR indicated [REDACTED]. On 11/8/10 at 1:30 pm nursing notes identified the resident had a body temperature of 100.7 degrees Fahrenheit, had four loose stools, and complained of nausea. On 11/8/10 at 3:45 pm nursing notes indicated the resident's physician ordered the resident sent to the ER for evaluation due to increased body temperature, loose stools, nausea/vomiting, hypertension, [MEDICAL CONDITION] weakness and complaints of lower back pain. The note identified Staff 6, RN, would "call for transport to ER." In an interview on 12/2/10 at 12:20 pm Witness 1, Family Member, reported the resident was very ill and bedridden when admitted to the facility via stretcher after multiple hospitalization s for severe back pain. Witness 1 stated the resident was in pain and could not sit up due to the severe level of back pain. Witness 1 reported after a few days at the facility, the resident's condition worsened and the resident was sent out to the hospital in a taxi cab, forcing the resident to sit up for the ride to the hospital. Witness 1 reported being told by the facility that Medicaid would not pay for transportation via stretcher. Witness 1 identified the hospital where the resident was sent and reported the resident was diagnosed with [REDACTED]. According to Yahoo Maps, the trip from the facility to the hospital would have taken approximately eight minutes, which does not include the time the resident waited in the wheelchair for transportation or the time it took to load the resident in the vehicle. In an interview on 12/8/10 at 11:00 am Witness 2, Medicaid Caseworker, reported on 11/4/10 the facility had been informed the resident would require transportation with a stretcher due to severe back pain if the need arose. Witness 2 stated that Staff 2, DNS, was informed of the resident's need for stretcher transport on 11/4/10 and reminded by the caseworker on 11/8/10. Witness 2 reported the facility sent the resident to the hospital on [DATE] in a cab, rather than by stretcher. In an interview on 12/9/10 at 10:50 am Staff 4, RN, reported the resident generally had pain in her back and refused to "get up due to back pain." In an interview on 12/9/10 at 11:05 am Staff 3, RNCM, confirmed knowledge of the resident's stretcher requirement and reported he assumed Staff 6, RN, would send the resident to the hospital by stretcher. In an interview on 12/9/10 at 11:45 am Staff 5, PT, reported the resident had pain in multiple joints and gout and was in "a lot of pain." Staff 5 stated that during the PT evaluation (on 11/5/10) the resident reported her pain level to be a 10 out of 10 while sitting up and that she was "more comfortable lying down" flat due to lower back pain. Staff 5 reported the resident was able to sit up for "less than five minutes" because sitting was too painful. In an interview on 12/9/10 at 2:55 pm Staff 2, DNS, reported the resident's caseworker had informed the facility of the resident's need for stretcher transportation related to back pain. Staff 2 stated the resident's back pain had worsened (on 11/8/10) and the facility had made the decision to send the resident out for evaluation. Staff 2 reported she assumed the resident would be transported via stretcher. In an interview on 12/9/10 at 3:15 pm Staff 1, Administrator, confirmed the facility staff had been advised of the resident's need for stretcher transport due to severe back pain and stated the resident should have been sent out on a stretcher. In an interview on 12/20/10 at 2:45 pm Staff 6, RN, reported Staff 3, RNCM, had informed her the resident required stretcher transportation. Staff 3 reported the Medicaid transportation line said that a stretcher would take three hours to arrive at the facility to transport Resident 1 to the hospital. Staff 6 stated that rather than wait that long, the resident agreed to be sent out by other means, which was arranged by Medicaid transport. Staff 6 reported she did not observe how the resident left the building and did not know how the resident was transported to the hospital. Staff 6 stated the resident was not transported on a stretcher. In an interview on 12/28/10 at 1:30 pm Resident 1 reported being admitted to the facility (on 11/4/10) on a stretcher due to body pain and weakness. The resident reported (on 11/8/10) feeling nauseous, feverish, and having bouts of diarrhea which prompted the need for an emergency room visit. The resident stated the facility reported that medical (stretcher) transport was not available at that time of night and the facility "put me into a wheelchair which was quite uncomfortable" and called a cab with wheelchair access to transport me to the emergency room . The resident denied agreeing to the cab transportation and reported the act of sitting upright in the wheelchair for that length of time increased the level of pain in her back.

Based on interview and record review it was determined that the facility failed to provide the necessary care and services for 1 of 3 sampled residents (# 2) who had pressure ulcers. Resident 2 was harmed. Findings include: The resident's closed record was reviewed as she had been discharged from the facility to the hospital on [DATE]. Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had a quarterly MDS completed on 7/14/10 which revealed she required extensive assistance for bed mobility and transfer. She was non-ambulatory. The resident was incontinent of bowel and continent of bladder with an indwelling urinary catheter. She did not have pressure ulcers. The resident was assessed at risk for pressure ulcers related to her [DIAGNOSES REDACTED]. The care plan interventions included to reposition every two hours, pressure reducing mattress, weekly skin audits, heel protectors and to elevate her legs when in bed. On 9/21/10 the Nurse's Notes revealed, "Has 3 x 3 cm Stage 2 ulcer to her R posterior inner thigh....and another 1/2 x 1/2 cm Stage 2 ulcer." The Skin Impairment Record revealed the wound beds were clean and without slough, red drainage and no odor was present. On 10/10/10 the Nurse's Notes revealed a Roho cushion for the resident's wheelchair had been added and the following day an air mattress would be applied. The care plan had not been updated since 9/21/10 and therefore did not reflect the changes. The Skin Impairment Record revealed the wound that measured 1/2 x 1/2 cm remained a Stage II during the resident's stay at the facility. The final wound assessment was conducted on 12/3/10 and revealed the wound was 2 cm, without slough, increased granulation, wound bed pink and the surrounding skin was pink. The Skin Impairment Record revealed the wound that measured 3 x 3 cm and a Stage II initially had developed to a Stage III on 11/26/10. The wound bed was described as 3 cm in diameter with a depth of 0.25 cm, 1/4 slough, 1/2 granulation and 1/4 eschar and the surrounding skin as pink. The final wound assessment was conducted on 12/3/10. The wound bed was described as 4 cm in diameter (number had been written over) with a depth of 0.25 cm, 1/4 slough, 1/2 granulation, 1/4 eschar with surrounding tissue pink. No drainage or odor was documented. Both wound assessments had been conducted by Staff 3, RNCM. The resident's clinical record revealed on 11/24/10 [MEDICATION NAME] DS two times daily for ten days was ordered to treat a urinary tract infection. The resident was to continue on the [MEDICATION NAME] DS daily for suppressive therapy. She was afebrile and remained afebrile until 11/28/10 at which time her temperature was 101.2 degrees F axillary. The Nurse's Notes indicated the resident had a poor appetite and reported not feeling well. From 11/28/10 through 12/4/10 the residents temperature remained 99.2 up to 102 degrees F axillary. The physician had not been notified. On 12/5/10 at 4:00 am, the Nurses' Notes revealed the resident had a temperature of 101.6 degrees F axillary. "R labia with redness and a great deal of swelling, a couple of pustules seen on labia area but no drainage....2 [MEDICATION NAME] given for labia pain and fever." At 6:30 am the notes revealed, "The report from nite nurse of resident R buttocks and labia red and hot to touch....call placed to (physician) for antibiotic treatment." An antibiotic was ordered. On 12/6/10 at 4:00 am, the Nurses' Notes revealed the resident had a temperature of 102.1 degrees F axillary. At 1:00 pm the notes revealed, "Call to (physician) change in skin treatment, R labia very red,tender...." At 8:45 pm the notes revealed, "Afebrile, increased confusion noted. Dressing changed to wound on right buttocks, tissue surrounding wound very red, swelling all the way up to the labia.....Will continue to monitor closely." On 12/7/10 at 2:00 pm, the Nurses' Notes revealed "....Wound to R Glut/peri area 7 cm necrotic ulcer with 22 cm long reddened area surrounding site with fluid pocket hard to to the touch, 6 cm long and 3 cm wide. Call placed to MD." A physician order [REDACTED]. The next Nurses' Note on 12/7/10 was written at 7:30 pm and was a summary of events, "Temp 100.3 at 16:00....Dressing changed at 16:30 with 7 x 7 cm hard dk green to black area with red right open area to labia....At 18:00 very flushed with temp of 101.6 (Ax) with worse confusion and incoherent at times. (MD) called and said could go to ER if okay with family. Family here and wanted her sent to the hospital. Ambulance here and BP 90/56." Admission hospital history and physical revealed, "........Pt with unstageable pressure ulcer, septic, to right ischial area which measure 7 x 4.5 cm with another spot more towards the hips of 1.5 cm in diameter. Both wounds are 100% black soft necrotic tissue, with small amount of purulent drainage on pad. Odor is fowl. [DIAGNOSES REDACTED] noted from right labia area back and up around to coccyx/sacral area. Red area is indurated, warm and painful to the touch. Pt very contracted.....Bilateral lower extremities bent so heels almost touch buttocks....." A hospital physician report on 12/8/10 revealed "....white count 31,000 and an infected sacral decubitus ulcer with significant tissue necrosis....A CT of the abdomen and pelvis was reviewed and air present throughout the right superficial inguinal region, perineum and medical aspects of both buttocks...." There was a surgeon note that there was concern that the infection had extended down into her labia and vulvar area.... Hospital reports revealed a final [DIAGNOSES REDACTED]. The resident's prognosis was hours to days. On 12/8/10 a physician consultation revealed "....it was determined that the best course of action would be to implement comfort measures. given the likelihood of extensive and overly burdensome treatments, including extensive wound care and surgical interventions." The resident passed away on 12/11/10 with hospice care in place. In interview on 12/20/10 at 11:10 am, Witness 3, Complainant, hospital physician, stated, "These sores did not develop overnight. They developed over time and should have been addressed much earlier. She was sent to the hospital when she exhibited a change in her mental status and lowered BP. She was a picture [MEDICAL CONDITION]. The wounds became too extensive." In interview on 12/20/10 at 11:22 am, Witness 4 family member, stated she was informed approximately two months ago the resident had a pressure ulcer that was the half-dollar size. "They thought it was healing and they told me it was healing right up to her discharge. On Thanksgiving (November 25 th), she was at my house. She was not feeling well and had increased confusion. I told the facility that she seemed different. I was always told she was doing better. On the 5 th of December a nurse (Staff 4) told me she was concerned for her (resident) because she had a cyst on her vulva. When she went to the hospital the doctors were shocked at what they saw. They said she needed major surgery. They said she was red and swollen from the back all the way to her groin." In interview on 12/20/10 at 12:30 pm, Staff 4, LPN charge nurse, stated, "The night nurse told me on 12/5/10 that her labia was 3-4 times its size and that it was red and hot. The physician did not see the wound but I told him it looked like [MEDICAL CONDITION]. He said it sounds like [MEDICAL CONDITION] and ordered an antibiotic. I reported the findings to the RNCM (Staff 3). The wound was more to the right of the sacrum. There was black eschar in the center of the wound and the surrounding tissue was red and hot. I saw the wound on 12/6/10 and it looked the same. She spiked a temperature and I didn't call the doctor that day. She did not seem painful with wound care." At 2:50 pm, Staff 4 asked if she could speak with the surveyor again. At that time she stated, "I wanted to talk with you and correct the information I gave you. The wound was covered with eschar on 12/3/10. It was not hot and the labia was benign. On 12/5/10 the wound was total eschar and there was an odor. The skin edges were red and she was swollen to her labia. Maybe I should have pursued for her to go out to the hospital. I did report the findings to the RNCM (Staff 3)." In interview on 12/20/10 at 1:30 pm, Staff 8, LPN Treatment Nurse, stated the resident's wound was described as her right posterior upper thigh but it was right at the crease of her buttocks. "I didn't like the way it appeared for about two weeks. The past two weeks it had advanced quickly and really smelled. I reported this to the RNCM (Staff 3). The wound had darkened approximately three weeks prior to the resident's discharge. The RNCM noted the foul odor on 12/6/10. I told him that the area seemed to have fluid pressure underneath." In interview on 12/20/10 at 3:10 pm, Staff 3, RNCM, stated on 12/7/10 the wound was covered with eschar. "I was not aware that she had been having fevers." Staff 4 was shown documentation from the resident's clinical record she had experienced fevers since 11/28/10. "I was told on 12/6/10 that things were progressively worse. I thought she should go to the hospital but the physician wanted to keep her here. He would say, 'Let's just watch.' The family decided to send her out on 12/7/10." In interview on 12/20/10 at 4:00 pm, Witness 5, Complainant, Hospital SW, stated the physicians at the hospital were shocked at what they found. "I was told that the wounds were so severe it would take a series of operations to repair. She had gangrene and was in ICU. There was a concern related to the severity and that this was her first hospitalization to treat the wounds. The wounds were allowed to progress. She passed away on 12/11/10."