Every finding on record at The Dalles Health and Rehabilitation

Based on interview and record review it was determined the facility failed to offer pneumococcal immunizations for 1 of 5 sampled residents (#2) reviewed for immunizations. This placed residents at risk for pneumonia. Findings include: Review of the facility's Pneumococcal Vaccine policy, dated 6/19/25, instructed the facility to follow the CDC Pneumococcal Vaccine Timing for Adults guide to determine appropriate vaccination and cadence. CDC's Pneumococcal Vaccine Timing for Adults, dated March 2025, revealed there were 4 types of pneumococcal conjugate vaccine (PCV13, PCV15, PCV20, and PCV21) and pneumococcal polysaccharide vaccine (PPSV23) available in the United States. For adults 65 years or older who have only received PCV13 and PPSV23 after age [AGE] years old, CDC recommended offering the PCV20 or the PCV21 at least five years after receiving the PCV13 and PPSV23. Shared clinical decision making was described to be completed together with the patient.Resident 2 was admitted to the facility in 8/2025 with diagnoses including dementia and squamous cell carcinoma (a type of skin cancer). Resident 2's clinical records revealed the resident was over [AGE] years old and last received the PCV 13 on 10/20/15 and the PPSV23 on 10/4/17. There was no evidence found in the clinical record to verify Resident 2 was offered or allowed to decline the PCV20 or PCV21.On 6/4/26 12:46 PM Staff 10 (Infection Preventionist) and Staff 2 (DNS) stated they used the CDC's PneumoRecs VaxAdvisor site to assist with confirming what and when vaccinations were due. Staff 2 and Staff 10 confirmed Resident 2 was due for pneumococcal vaccination and was not offered the PCV20 or PCV21 vaccine. Staff 2 confirmed she was unable to provide documentation to demonstrated a clinical decision to not offer the pneumococcal vaccine was discussed with Resident 2 or Resident 2's representative.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents were free from significant medication errors for 1 of 5 sampled residents (#24) observed for safe medication administration. This placed residents at risk for inadequate symptom management. The 2026 Davis's Drug Guide indicated Extended Release (ER) oral medications should not be crushed.Resident 24 was admitted to the facility in 5/2026 with diagnoses including Parkinsonism (a neurological disorder characterized by abnormal body movements and impaired muscle control).Resident 24's 7/26/26 Physician Orders included the following:-carbidopa-levodopa (an antiparkinson agent) ER 50-200 mg tablet, to be administered twice daily for generalized weakness. -There was no order in place to crush oral medications.Resident 24's 6/2026 and 7/2026 MARs indicated Staff 9 (CMA) administered Resident 24's carbidopa-levodopa ER oral medication 29 times between 6/8/26 and 7/8/26.On 7/8/26 at 6:30 AM Staff 9 was observed administering a carbidopa-levodopa ER tablet orally in crushed form.On 7/8/26 at 8:10 AM Staff 9 acknowledged they crushed the carbidopa-levodopa ER tablet and administered it to Resident 24. Staff 9 stated they did not see the medication was in ER form in the residents' orders and acknowledged there was not an order in place to crush the medication before administration. Staff 9 stated the medication should not have been crushed. Staff 9 indicated they began administering Resident 24's carbidopa-levodopa ER oral medication in crushed form approximately one month ago.On 7/8/26 at 12:20 PM Staff 8 (Nurse Practitioner) stated carbidopa-levodopa ER oral medication should not be crushed because ER medications are formulated to release medication gradually over time. Staff 8 stated crushing the medication could reduce its prolonged effectiveness, resulting in a wearing off effect and poorly controlled Parkinson's symptoms. On 7/8/26 at 12:41 PM Staff 7 (Pharmacist) stated ER medications should not be crushed. Staff 7 stated ER oral medications are designed to release medication over time and residents who repeatedly received crushed ER oral medication may not receive the full effect of the medication. Staff 7 stated this placed residents at risk for experiencing an increase in Parkinson's symptoms. On 7/9/26 at 12:22 PM Staff 2 (DNS) acknowledged extended-release medications should not be crushed and stated staff should not crush and administer ER oral medications.

Based on interview and record review it was determined the facility failed to ensure pharmacist recommendations were considered for 1 of 5 sampled residents (#2) reviewed for medications. This placed residents at risk for unnecessary medication. Findings include:A 3/2019 Medication Regimen Review (MRR) Policy indicated the pharmacist completed the MRR monthly. The facility and the attending physician were to respond to the pharmacist's recommendation within a two-to-four-week timeframe. Resident 2 was admitted to the facility in 8/2025 with diagnoses including dementia and nausea.Resident 2's physician orders revealed the resident was prescribed Ondansetron 8mg every 6 hours PRN for nausea starting 5/7/26 and Ondansetron 8 mg once a day for nausea starting 5/8/26. The pharmacist's 5/19/26 MRR identified 24mg per day was the max dose for Ondansetron and asked the physician if they wished to reduce the Ondansetron to 8mg twice per day PRN. No documentation was found in the clinical record regarding a response from the physician.On 7/8/26 at 10:14 AM Staff 7 (Pharmacist) stated he had not received a response from the physician related to the 5/19/26 MRR recommendation.On 7/9/26 at 12:18 PM Staff 4 (RNCM) and Staff 5 (RNCM) stated the RNCM's and Staff 2 (DNS) received the MRR recommendations from the pharmacist and the recommendations were either faxed, emailed, or put in designated spots in the facility for the physician to review. Staff 4 stated she did not have any responses back from the physician regarding the Ondansetron recommendation. On 7/10/26 at 9:15 AM Staff 2 stated pharmacy recommendations should be acted upon timely and confirmed the facility did not have a response from the physician for the 5/19/26 pharmacist recommendation.

Based on interview and record review it was determined the facility failed to ensure residents as needed psychotropic medications were discontinued as required for 1 of 5 sampled residents (#2) reviewed for medications. This placed residents at risk for adverse side effects of medication. Findings include:The facility's 6/2025 Psychoactive Medication Policy lists new orders for PRN (as needed) psychoactive medications (mood changing medications) were to expire after 14 days or required justification for continued use for a specific period. Resident 2 was admitted to the facility in 8/2025 with diagnoses including dementia and maxillofacial fracture (fracture of the upper jawbone).The 4/16/26 Significant Change MDS indicated Resident 2 was taking an antipsychotic and an antidepressant.Resident 2's physician orders revealed the resident was prescribed Lorazepam (an antianxiety medication) 0.5 MG as needed (PRN) in the evening for severe anxiety/agitation with a start date of 3/27/26 and a stop date of 5/5/26. Resident 2's medication administration records revealed the resident was last administered 0.5 MG of Lorazepam on 4/22/26.The pharmacist's 4/21/26 MRR indicated the PRN 0.5 MG of Lorazepam had been active over 14 days and requested the order to be discontinued or extended for a specific time with written justification for the extension. On 7/8/26 at 10:14 AM Staff 7 (Pharmacist) stated he did not see a response from the physician for the PRN Lorazepam.On 7/9/26 at 12:18 PM Staff 4 (RNCM) stated she had not obtained a response because she had seen an order for PRN Lorazepam with a stop date for 3/27/26 and missed the PRN order which had started on the same day but at a lower dose. Staff 4 confirmed the order should have had a 14-day stop date from the start date.On 7/10/26 at 9:15 AM Staff 2 (DNS) confirmed the 0.5 MG Lorazepam PRN order should have had a 14-day stop date.

Based on interview and record review it was determined the facility failed to ensure resident mail was delivered to residents on Saturdays for 1 of 1 facility reviewed for resident council. This placed residents at risk for lack of timely written communication. Findings include: Resident 5 was admitted to the facility in 5/2024 with diagnoses including encephalopathy (a syndrome characterized by diffuse brain dysfunction).During a Resident Council meeting on 7/8/26 at 10:15 AM, Resident 5 stated she/he enjoyed receiving mail and didn't know mail was delivered on Saturdays. During an interview on 7/9/26 at 12:55 PM, Staff 20 (Activities Director) stated she delivered mail to residents Monday through Friday but was unsure of who distributed mail on Saturdays.On 7/9/26 at 1:12 PM, Staff 1 (Administrator) confirmed mail was not distributed to residents on Saturdays.

Based on interview and record review, it was determined the facility failed to ensure a resident was free from sustaining a burn from a baseboard heater for 1 of 3 (#2) sampled residents revied for accidents. As a result, Resident 2 sustained second degree burns on her/his left foot and toes. Findings include:Resident 2 was admitted to the facility in 2025 with diagnosis including stroke and diabetic neuropathy (a condition that causes numbness to the hands and feet). Resident 2's 5/21/25 Care Plan indicated Resident 2 with impaired cognitive disturbance and safety awareness which included sliding out of bed at night and fidgeting with items on walls including keypads, fire alarms and picture frames.Resident 2's MDS identified the resident with a BIMS score of 13 out 15 indicating mild cognitive impairment. A 12/13/25 Facility Risk Management Report identified Resident 2 to have sustained a second degree burn on her/his left foot and toes after rolling out of bed and placing her/his foot on the residents' baseboard heater in the middle of the night. Staff 5 (CNA) was noted to have discovered Resident 2 lying on the floor whimpering with their left foot on the resident's baseboard heater. Per Staff 5's report, she removed Resident 2's foot from the heater and reported the occurrence to the charge nurse. Staff 5 confirmed the resident's bed was too close to the baseboard heater and due to the resident's diabetic neuropathy, she/he did not feel her/his foot begin to burn when Resident 2 placed her/his foot on the baseboard heater. Resident 2 was assessed and treated for second degree burns on his/her left foot. A 12/13/25 Skin and Wound Assessment indicated Resident 2 was assessed and determined after the incident to have sustained a second degree burn with multiple small blisters approximately 0.2 centimeters in length and 0.2 centimeters in width. On 4/27/26 at 2:16 PM, Staff 5 (CNA) confirmed she discovered Resident 2 on the floor and removed Resident 2's foot from the heater. Staff 5 stated the foot injury sustained by Resident 2 was pretty bad and upon assessment of the nurse the Resident 2 was treated for burns caused by direct contact with the baseboard heater. On 4/27/26 at 3:14 PM, Staff 3 (RNCM) stated Resident 2 experienced second degree burns due to rolling out of bed and placing her/his foot on the heater. Staff 3 stated that due to resident's diabetic neuropathy would not have been aware of the injury being caused by the baseboard heater. On 4/27/26 at 4:50 PM, Staff 1 (Administrator) acknowledged the findings of Resident 2 sustaining second degree burns on the resident's left foot and toes from the resident's baseboard heater. On 12/19/25, the deficient practice was identified by the facility and was corrected. The facility completed a root cause analysis of the incident and determined Resident 2 sustained a second-degree burn. The Plan of Correction included:In-service training and education for all staff.Other residents with cognitive impairment or fall risk were examined and alterations to their rooms were made accordingly to prevent burns from baseboard heaters and ensure resident safety. Findings were brought though the QAPI committee monthly for 3 months or until resolved by the committee.Daily and monthly audits were immediately implemented to prevent and ensure resident safety was maintained regarding baseboard heaters.

Based on interview and record review it was determined the facility failed to ensure staff provided two-person assistance when transferring a resident for 1 of 4 sampled residents (#33) reviewed for accidents. This failure resulted in Resident 33 falling from a mechanical lift and sustaining a laceration to the forehead which required sutures. Findings include: Resident 33 admitted to the facility in 4/2022 with diagnoses including heart disease and memory loss. A care plan dated 1/21/24 revealed Resident 33 was dependent on staff for her/his ADL care needs and required two-person assistance with a mechanical lift for transfers. A Fall Investigation initiated on 8/2/24 and completed on 8/5/24 revealed the following: -On 8/2/24 at approximately 7:30 PM, Staff 25 (Former CNA) attempted to transfer Resident 33 using a mechanical lift. While lifting the resident and moving the lift so Resident 33 was over the bed, the wheel rolled over a metal strip on the floor causing the lift to jerk. The sling tilted, and Resident 33 fell out of the sling and onto the floor. -Staff 25 attempted to stop the resident from falling, reached for the resident's right arm, and inadvertently caused lacerations with his fingers. Resident 33 hit her/his head and sustained a laceration from the fall. -Staff 8 (LPN/Social Service Director) was notified immediately, assessed the resident, and managed the bleeding from Resident 33's head and right arm. The resident was able to speak and converse appropriately per her/his baseline. -The resident was transferred to the hospital for further evaluation and received sutures to her/his left forehead. An 8/3/24 Hospital Record revealed Resident 33 sustained a laceration to the left forehead, which required three sutures, and had an abrasion to her/his right forearm from falling out of a mechanical lift. On 12/17/24 at 1:19 PM, Staff 25 stated he recalled the incident with Resident 33 on 8/2/24. Staff 25 stated Resident 33 was dependent on staff for all ADL care needs and required two-person assistance with a mechanical lift for transfers. Staff 25 stated it was a busy night and he could not find any staff to assist him with the transfer, and he wanted to get the resident into bed. Staff 25 stated Resident 33 was in the mechanical lift and when he moved the lift, the leg of the lift caught on something on the floor, causing the sling to swing. He attempted to grab the resident's right arm but it was too late, and the resident fell to the floor, hitting her/his head. Staff 25 stated there was blood coming from the resident's head and she/he had a bruise on her/his right arm from him trying to stop the fall. Staff 25 immediately got Staff 8, who assessed the resident and stopped the bleeding. Staff 25 stated it was his fault and he felt terrible about the incident. Staff 25 stated he knew Resident 33 required two-person transfer assistance but he did not follow the care plan. On 12/18/24 at 10:23 AM, Staff 3 (Assistant Executive Director/Social Service) stated he was alerted of the incident and came into the facility. Staff 3 stated he learned Staff 25 transferred Resident 33 on his own and did not follow the care plan. Staff 3 stated Resident 33's laceration was visible and bleeding when he arrived. Staff 3 stated the resident was eventually sent out to the hospital to be evaluated further. Staff 3 stated It appeared to him the wheel of the mechanical lift got caught on a metal divider on the floor, which caused Resident 33 to be tossed out of her/his sling. The sling was evaluated and found to be functional. Staff 3 stated facility staff used a different sling after the 8/2/24 incident. Staff 3 stated in-service training and education were provided to all staff regarding following the care plan, and proper use of the mechanical lift and slings. On 12/18/24 at 2:19 PM, Staff 8 (LPN) and on 12/19/24 at 1:17 PM, Staff 2 (DNS) were present for an interview. Staff 8 stated Staff 25 attempted a mechanical lift transfer with Resident 33 without a second CNA present, which caused the resident to fall out of the sling and hit her/his head on the frame of the mechanical lift. The resident had bruising to her/his right arm from Staff 25 attempting to stop the fall out of the sling. Staff 8 stated Resident 33 was bleeding and he could not get the bleeding to stop. Staff 8 stated it was evidence the the laceration needed stitches. Staff 8 stated the resident had dementia and did not understand what happened. Staff 2 and Staff 8 stated training and in-service were provided to all staff regarding the incident. The deficient practice was determined to be past noncompliance as the facility addressed the deficient practice on 8/3/24 by completing the following actions: 1. Conducted a thorough investigation of the incident. 2. Educated Staff 25 to follow the care plan and was placed on a 90 day probationary period. 3. Provided staff education on proper use of two staff persons when using the mechanical lift and following resident care plans explicitly.

Based on interview and record review it was determined the facility failed to ensure CNAs received annual performance reviews for 5 of 5 randomly selected CNA staff (#s 6, 10, 14, 23 and 24) reviewed for staffing. This placed residents at risk for lack of care by competent staff. Findings include: On 12/18/24 at 10:00 AM, Staff 2 (DNS) was asked for the annual performance reviews for Staff 6, Staff 10, Staff 14, Staff 23 and Staff 24. On 12/18/24 at 12:52 PM, Staff 1 (Administrator) and Staff 2 were present for an interview. Staff 2 stated Staff 6, Staff 10, Staff 14, Staff 23 and Staff 24 did not have annual performance reviews completed. Staff 2 stated she did not provide annual performance reviews.

Based on interview and record review it was determined the facility failed to ensure records were complete and accurate for 1 of 5 sampled residents (#12) reviewed for medications. This placed residents at risk for inaccurate medical records. Findings include: Resident 12 was admitted to the facility in 1/2024 with diagnoses including chronic heart failure and COPD (Chronic Obstructive Pulmonary Disease). a. A Physician Order dated 4/19/24, revealed the following: -Daily Weights were to be obtained every morning and staff were to contact the provider for the following weight gain related to heart failure. -Three pounds in 24 hours. -Five pounds in a week. -If weight falls less less then 195, notify the provider. A review of Resident 12's 11/2024 and 12/2024 TARs and Weights and Vitals Summary revealed the following: 11/2024: Resident 12's weight was consistently below 195 pounds. 12/2024: Resident 12's weight was below 195 pounds until 12/17/24, when her/his weight was 198.5. On 12/19/24 at 12:56 PM, and 12/20/24 at 8:37 AM, Staff 2 (DNS) stated the 4/18/24 physician order was inaccurate. Staff 2 stated the order needed to be updated because Resident 12's weight was consistently averaging in the 180s and the physician was aware of the resident's weight status b. A Physician Order dated 7/29/24, directed staff to administer seven units of insulin subcutaneously with meals for diabetes. Staff were to hold insulin for blood sugars less than 100 and were to notify the physician if blood sugars were less than 80 or greater than 350. A Physician Order dated 7/29/24, directed staff to administer insulin per sliding scale as followed: -201 - 250 administer one unit; -251 - 300 administer two units; -301 - 350 administer three units; -351 - 400 administer four units; -401 - 450 administer five units; -451 administer six units and then notify the PCP after re-checking the resident in two hours related to diabetes. A review of the 12/2024 TARs revealed the resident had four instances where her/his blood sugar was greater than 350. A review of Resident 12's medical record revealed no evidence the physician was notified of the high blood sugars. On 12/19/24 at 12:56 PM, and 12/20/24 at 8:37 AM, Staff 2 (DNS) stated the 7/29/24 physician order was not intended to include contacting the physician if Resident 12's blood sugar was greater than 350. Staff 2 stated staff were to follow the 7/29/24 sliding scale order for when to notify the physician if the resident's blood sugar was greater than 451.

Based on interview and record review it was determined the facility failed to follow physician orders for 2 of 7 sampled residents (#s 9 and 12) reviewed for hospitalization s and medications. This placed residents at risk for adverse medication side effects and fluid overload. Findings include: 1. Resident 12 was admitted to the facility in 1/2024 with diagnoses including chronic heart failure and COPD (Chronic Obstructive Pulmonary Disease). A Physician Order dated 4/19/24 revealed the following: -Daily Weights were to be obtained every morning and staff were to contact the provider for the following weight gain related to heart failure. -Three pounds in 24 hours. -Five pounds in a week. -If weight falls less less then 195, notify the provider. A review of Resident 12's 11/2024 and 12/2024 TARs and Weights and Vitals Summary revealed multiple occasions when Resident 12's weight increased by more than three pounds in a 24 hour period. There was no evidence found in Resident 12's medical record the physician was notified of the three pound weight gain in 11/2024 and 12/2024. On 12/18/24 at 3:37 PM, Staff 5 (LPN) and on 12/19/24 at 9:18 AM, Staff 8 (LPN) stated they obtained daily weights due to the resident's heart failure and concerns with edema. Staff 8 stated staff were to notify the physician when Resident 12 had a three pound increase in a 24 hour period. Staff 8 acknowledged the physician was not notified of the weight variances for 11/2024 and 12/2024. On 12/19/24 at 12:56 PM, and 12/20/24 at 8:37 AM, Staff 2 (DNS) confirmed staff did not follow physician orders related to monitoring Resident 12's weight gain. Staff 2 stated she expected staff to notify the physician when Resident 12 had a three pound increase in a 24 hour period. 48830 2. Resident 9 was admitted to the facility in 5/2023 with diagnoses including heart failure and a history of Gastrointestinal (GI) hemorrhage (any type of bleeding in the digestive tract). The 5/1/24 Annual MDS indicated Resident 9 was severely cognitively impaired. A 11/8/24 Progress Note indicated Resident 9 was sent to the hospital and admitted for a GI bleed. A 11/10/24 Hospital Discharge Summary revealed a physician order to discontinue aspirin 81 mg, hold Eliquis 5 mg for one week and start Eliquis 2.5 mg BID on 11/15/24. It was noted the dosage was reduced due to a history of GI bleed. A review of the 11/2024 and 12/2024 MAR revealed Resident 9 received the following: -Eliquis 2.5 mg BID for three days, 11/10/24 through 11/13/24 AM. -Eliquis 5 mg BID from 11/13/24 PM through 12/19/24. -aspirin 81 mg from 11/10/24 through 12/19/24. On 12/20/24 at 8:21 AM Staff 2 (DNS) stated the 11/10/24 hospital discharge orders were inaccurately transcribed in Resident 9's medical record. Staff 2 acknowledged the physician orders were not followed; Resident 9 received the incorrect dosage of Eliquis from 11/13/24 through 12/19/24, and received aspirin after it was discontinued by the physician.

Based on interview and record review it was determined the facility failed to treat residents with dignity and respect for 1 of 3 sampled residents (#2) reviewed for dignity. This placed residents at risk for a decrease in quality of life. Findings include: On 2/21/24, the Past Noncompliance was corrected when the facility identified the incident and determined Resident 2 was not treated with dignity and respect. The facility's Plan of Correction included: -Removed Staff 7 from her duties; -Audited the hall Staff 7 was assigned to; -Provided in-service training to all nursing staff for abuse and the reporting of abuse; and -Provided signature sheets verifying nursing staff had completed the training. Resident 2 admitted to the facility in 2022, with diagnoses including infection and inflammation. Resident 2's care plan dated 1/18/24, indicated she/he had moderate cognitive impairment but was able to make her/his needs and preferences known. On 2/21/24 the facility submitted a report to the state agency which indicated on 2/20/24, Staff 7 (Former CNA) yelled at Resident 2 and tried to get her/him out of her/his recliner to go to bed. When Resident 2 refused, Staff 7 threw something which hit the resident's hand. The facility initiated an investigation, determined Staff 7 verbally abused Resident 2 and terminated her employment. On 5/15/24 at 12:00 PM, Resident 2 was observed eating lunch in the dining room and later that day sleeping in her/his room. On 5/15/24 at 12:02 PM, Witness 1 (Spouse) stated she/he visited Resident 2 at the facility daily. Witness 1 saw Resident 2 the day after the incident occurred and stated she/he was not fearful or depressed about the incident but angry at Staff 7 for waking her/him up. On 5/16/24 at 1:44 PM, Staff 6 (CNA) stated she was the NOC shift CNA assigned to Resident 2 on 2/20/24. Staff 6 stated the previous shift's CNA told her Resident 2 wanted to sleep in her/his recliner that night and reported she/he had been sleeping well in the chair. Staff 6 stated Staff 7 asked her why Resident 2 was in her/his chair. Staff 6 told Staff 7, Resident 2 wanted to sleep in her/his chair as this was the best sleep the resident has had in a long time. Staff 6 stated she told Staff 7 she would take care of the resident, however, Staff 7 went to Resident 2's room. Staff 6 observed Resident 2's call light was on and went to the resident's room. Staff 6 observed Staff 7 flinging the sit to stand lift out of the resident's room and heard Resident 2 state I don't understand what's happening. I want to be left alone. Staff 6 stated she heard Staff 7 state the resident doesn't want to fucking go to bed and she/he is being a jerk and if the resident didn't go to bed and her/his butt hurt later, it would be the resident's fault. Staff 6 stated her and Staff 7 left Resident 2's room at the resident's request. Staff 6 stated she returned a few minutes later and the resident stated she/he didn't know why she/he was treated that way by Staff 7 and she/he just wanted to be left alone. Resident 2 told Staff 6 she/he was fine but Staff 7 had taken off her/his blankets, told her/him to go to bed and threw the blankets back on the resident when she/he refused. Staff 6 stated she observed the resident's blankets piled up around her/him and helped the resident straighten them out. Staff 6 stated the next day Resident 2 was fine and had no other issues as a result of the incident. On 5/17/24 at 11:50 AM, Staff 7 stated she had not yelled at Resident 2 but had to raise her voice because the resident was hard of hearing. Staff 7 stated she was not assigned to Resident 2's hall on 2/20/24, but the person assigned is lazy and wouldn't do it so I went to check on her/him. Staff 7 stated Resident 2 yelled at her when she went to her/his room and told her to get the f-out of her/his room. Staff 7 told Resident 2 that was fine and tried to put the call light on her/his blanket but the resident kept yelling at her, so she placed the call light on the bedside table and left the room. Staff 7 denied she threw the blankets or that she used profanity with the resident and stated she wanted to help her/him because she/he had sat in the recliner for over eight hours. On 5/17/24 at 12:41 PM, Staff 1 (Administrator) stated he interviewed Resident 2 the next day and the resident stated she/he didn't want Staff 7 to provide care to her/him any longer. Resident 2 stated she/he had not been sleeping well in her/his bed and wanted to sleep in the recliner, which nursing staff said was fine. Staff 1 stated Resident 2 reported to him that Staff 7 went to her/his room, woke her/him up, put the overhead light on, removed the blankets off her/him and told her/him to go to bed. Staff 1 stated Resident 2 further reported she/he asked Staff 7 to leave her/his room, which Staff 7 then threw her/his blankets back on to the resident and told the resident if her/his butt was sore not to blame her. Staff 1 stated Staff 7 was immediately placed on administrative leave, was interviewed and she stated Resident 2 was rude to her and noncompliant with getting into bed. Staff 1 confirmed he terminated Staff 7's employment when the investigation was completed and it was an expectation residents were treated with dignity and respect.

Based on observations and interviews it was determined the facility failed to maintain a homelike environment for 1 of 1 facility reviewed for environment. This placed residents at risk for living in an unkempt environment. Findings include: Observations of the facility's general environment and residents' rooms from 10/2/23 through 10/5/23 identified the following issues: -room [ROOM NUMBER] had jagged edges on the door with paint scratched and peeling. The area below the resident's sink had unfinished patches of drywall. -room [ROOM NUMBER]'s sliding glass patio door was unable to stay securely closed, allowing air to come in and not close properly. -room [ROOM NUMBER] had jagged edges on the door with paint scratched and peeling. -room [ROOM NUMBER] had jagged edges on the door with paint scratched and peeling. -room [ROOM NUMBER] had jagged edges on the door with paint scratched and peeling. -room [ROOM NUMBER] had jagged edges on the door with paint scratched and peeling. -room [ROOM NUMBER] had tape on the window to seal where the rubber was missing, the aluminum edge was missing (outside seal) and the window screen was bent approximately 2-3 inches outward. -room [ROOM NUMBER] had jagged edges on the door with paint scratched and peeling. -The front doors were jagged with paint scratched and peeling. -The carpeted area surrounding the nurses station had multiple dark brown and black areas. -Hall 300 shower room had missing tiles, missing grout, rust on top of the heater, chipped paint on the handrail and paint patches on the walls where repairs had been started but not completed. On 10/5/23 at 8:45 AM Staff 4 (Maintenance Director) stated he was notified of needed repairs when staff wrote down repair concerns or alerted him verbally notifications. Staff 4 stated he completed rounds and audits on a weekly basis. Staff 1 (Administrator) stated he was aware of the identified concerns. A facility walk through was completed with Staff 1 and Staff 4. Staff 1 and Staff 4 acknowledged the identified rooms were not homelike and the identified maintenance concerns needed to be repaired.

Based on observation, interview and record review it was determined the facility failed to accurately document in the medical record for 1 of 2 sampled residents (#6) reviewed for oxygen equipment. This placed residents at risk for inaccurate medical records. Findings include: Resident 6 was admitted to the facility in 6/2022 with diagnoses including chronic combined systolic and diastolic heart failure. Observations on 10/2/23 at 3:29 PM and on 10/3/23 at 10:30 AM revealed Resident 6 used oxygen which flowed via nasal cannula from an oxygen concentrator in her/his room. The tubing was labeled and dated 9/16/23, indicating the last time the tubing had been changed. Resident 6's 9/2023 TAR instructed staff to change Resident 6's oxygen tubing every Saturday on the NOC shift. The TAR indicated the resident's tubing was changed on 9/23/23 and 9/30/23. On 10/3/23 at 10:43 AM Staff 3 (RNCM) confirmed the oxygen tubing was dated 9/16/23 and was not changed on 9/23/23 and 9/30/23. Staff 3 stated it was her expectation the tubing was changed weekly and then documented it had been completed.

Based on observation, interview and record review it was determined the facility failed to ensure oxygen equipment was properly maintained for 1 of 2 sampled residents (#6) reviewed for respiratory care. This placed residents at risk for respiratory complications. Findings include: Resident 6 was admitted to the facility in 2022 with diagnoses including chronic combined systolic and diastolic heart failure. Observations on 10/2/23 at 3:29 PM and on 10/3/23 at 10:30 AM revealed Resident 6 used oxygen which flowed via nasal cannula from an oxygen concentrator in her/his room. The tubing was labeled and dated 9/16/23, indicating the last time the tubing had been changed. Resident 6's 9/2023 TAR instructed staff to change Resident 6's oxygen tubing every Saturday on the NOC shift. The TAR indicated the resident's tubing was changed on 9/23/23 and 9/30/23. On 10/3/23 at 10:43 AM Staff 3 (RNCM) confirmed the oxygen tubing was dated 9/16/23 and was not changed on 9/23/23 and 9/30/23. Staff 3 stated it was her expectation the tubing was changed weekly and then documented it had been completed.

Based on interview and record review it was determined the facility failed to comprehensively assess a resident for dementia for 1 of 5 sampled residents (#12) reviewed for medications. This placed residents at risk for unassessed care needs. Findings include: Resident 12 was admitted to the facility in 2020 with diagnoses including dementia. Resident 12's 5/10/23 CAA for Cognitive Loss/Dementia failed to indicate specifically how dementia was a problem for the resident, how the resident's dementia manifested, the impact on the resident or a rationale for the care planning decision. On 10/4/23 at 1:10 PM the CAA was reviewed with Staff 2 (DNS) who acknowledged the assessment was not comprehensive.

Based on interview and record review it was determined the facility failed to follow Physician Orders to notify the physician of weight changes for 1 of 2 sampled residents (#24) reviewed for nutrition. This placed residents at risk for delayed treatment. Findings include: Resident 24 was admitted to the facility in 2023 with diagnoses including diabetes and congestive heart failure. A physician order dated 8/30/23 stated Resident 24 was to be weighed daily and the physician was to be notified of weight changes of 3 pounds or greater in 2 days or 5 pounds or greater in a week. A review of Resident 24's daily Weight Summary records from 9/2023 through 10/2023 revealed the following: -From 9/8/23 to 9/10/23 Resident 24 experienced a weight change from 277 pounds to 270 pounds or 7 pounds. No physician notification was made regarding this change. -From 9/8/23 through 9/14/23 Resident 24 experienced a weight change from 277 pounds to 267.9 pounds or 9.1 pounds. No physician notification was made regarding this change. -From 9/19/23 to 9/21/23 Resident 24 experienced a weight change from 274 to 269.4 or 4.6 pounds. No physician notification was made regarding this change. -From 9/22/23 through 9/28/23 Resident 24 experienced a weight change from 262.7 pounds to 269 pounds or 6.3 pounds. No physician notification was made regarding this change. On 10/4/23 at 10:27 AM Staff 2 (DNS) confirmed Physician's Orders regarding notification of Resident 24's weight changes were not followed.

Based on interview and record review it was determined the facility failed to ensure a resident's advance directive was obtained for 1 of 4 sampled residents (#22) reviewed for advance directives. This placed residents at risk of not having their healthcare wishes honored. Findings include: Resident 22 was admitted to the facility in 2022 with diagnoses including hip fracture, cognitive impairment and dementia. Resident 22's 3/30/22 MDS indicated the resident's cognitive status was severely impaired. Resident 22's 10/5/23 face sheet indicated Witness 1 (Family) was the resident's power of attorney. A review of Resident 22's clinical record revealed no indication Witness 1 was asked if the resident had an advance directive or to provide a copy of the resident's advance directive if one already existed. On 10/4/23 at 8:49 AM Witness 1 stated she was aware of what an advance directive was. She stated Resident 22 already had an advance directive and she told the facility the resident had one, but the facility had not requested a copy. On 10/4/23 at 10:25 AM Staff 5 (SSD) stated she had previously asked Witness 1 if the resident had an advance directive and was told the resident did not have one. Staff 5 stated she would look through her notes for the documentation. No additional documentation was provided to indicate Witness 1 was asked if the resident had an advance directive or Witness 1 stated the resident did not have an advance directive.

Based on observation, interview and record review it was determined the facility failed to prevent loss of range of motion and development of contractures for 1 of 1 sampled resident (#6) reviewed for contractures. This failure resulted in Resident 6 developing bilateral (both) ankle contractures, reduced range of motion of both hips and pain in the lower extremities. Findings include: Resident 6 was admitted to the facility in 2017 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility Policy on the Restorative Program (RA) updated 3/2019 indicated the program's focus was on achieving and maintaining optimal physical, mental and psychosocial functioning of the resident and to attain and maintain each resident's practicable functioning. The Policy Guidelines included the following residents may be appropriate for a restorative program: *Any resident who had a decline in level of function from baseline. *Any resident discontinued from active therapy that required ongoing restorative to maintain their functional gains. * Any resident at risk for declining in function. Additionally, residents would be evaluated on Admission, Quarterly, or if a Significant Change occurred. No documentation was found in the resident's medical record to indicate regular evaluations of an RA program were performed for Resident 6. An undated addition to the Restorative Program Policy was stapled to the front of the policy and read: Due to staffing shortages the facility would use therapy services to provide on-going restorative training, using the gym equipment, under supervision of the therapy team and programs specific to a resident would be assigned to the nursing staff with training on how to carry out the task safely and appropriately. Resident 6 discharged from the facility's skilled physical therapy on 11/10/20. A 4/14/22 Physician/ARNP/PA Note indicated Resident 6 had contractures of both elbows, wrists, hands and a chronic right shoulder dislocation. No contractures of the ankles or issues with the knees or hips were noted. On 7/11/22 at 3:15 PM Resident 6 was observed lying in bed and appeared to be in an uncomfortable position. The resident was grimacing as if in pain. Resident 6 was non-verbal so Staff 27 (CNA) was asked to look and see if the resident's position was normal and if the resident was in pain. Staff 27 said the resident needed the pillow between her/his legs repositioned to make her/him comfortable. On 7/12/22 at 12:44 PM Resident 6 was observed lying in bed. The resident had significant contractures of the elbows, wrists and hands. It also appeared the resident had contractures of the ankles and feet and her/his feet were turned inwards. On 7/13/22 at 1:56 PM Witness 1 (Hospice RN) stated Resident 6 was admitted to hospice due to her/his decline. She stated residents would benefit from an RA program and she recommended it even for residents on hospice. On 7/14/22 at 11:06 AM Staff 28 (Therapy Manager) recalled when she started working at the facility in 5/2022 she asked if they could start an RA program because there was not one in place. With the facility's current temporary plan only two or three residents would actually be physically able to come down and exercise in the gym with a therapist present. The CNAs were responsive to assisting but the therapy department had to be cautious because they could not ensure safety without their oversight and provision of the additional training required. Resident 6 would be a perfect candidate for an RA program. When told it appeared the resident developed contractures in her/his feet she indicated she would take a look at the resident. On 7/14/22 at 12:45 PM Staff 28 returned and indicated she looked at the resident and her/his condition, including her/his feet, had worsened. She requested a PT evaluation. On 7/14/22 a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/14/22 at 1:37 PM Staff 27 (CNA) stated she made sure Resident 6 had her/his hand braces on but she did not provide any exercises or ROM with the resident. On 7/15/22 at 11:55 AM Staff 25 (CNA/CMA) indicated she did not do any exercises or ROM for residents. On 7/15/22 at 12:05 PM Staff 9 (RN) stated she did not do exercises or ROM with residents. On 7/15/22 at 1:06 PM Staff 26 (CNA) stated staff did not have a lot of time to perform RA or ROM exercises. Staff 26 stated they could really use an RA program because the CNAs did not have time to do as much as they would like and it would really benefit the residents. On 7/15/22 a Physical Therapy Evaluation was completed for Resident 6. The referral was to assess ROM of the lower extremities and positioning. The evaluation found the resident had developed bilateral ankle contractures and reduced ROM of both hips, wideswept posture in supine (abduction and external rotation of one hip with the adduction and internal rotation of the other) and was at high risk for contractures, skin breakdown and increased pain in the lower extremities. Resident 6 would benefit from skilled PT to improve ROM and flexibility. Therapy would also implement education on appropriate positioning in bed and the geri chair in order to prevent further contractures and skin breakdown and promote optimal comfort for the resident. On 7/15/22 at 1:15 PM Staff 2 (DNS) acknowledged the facility did not identify the worsening condition of Resident 6's lower extremities. She was informed of the results of the PT evaluation which indicated the resident developed new contractures of the feet, and her/his knees and hips were involved in her/his physical decline. The resident also had reduced ROM of both hips and was at high risk for further contractures, skin breakdown and increased lower extremity pain. Staff 2 indicated she was aware of the need to have an RA program in place.

Based on interview and record review it was determined the facility failed to obtain, request, review copies of advance directives if available or periodically review resident wishes to execute an advance directive for 4 of 6 sampled residents (#s 12, 14, 26, 27) reviewed for advance directives. This placed residents at risk for not having their health care decisions honored. Findings include: 1. Resident 12 admitted to the facility in 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A Statement of Receipt Advanced Healthcare Directive Information was signed by the resident on 7/30/21 with her/his admission paperwork. There was no documentation to indicate there was any follow up with the resident related to advance directives. A 5/19/22 Care Conference form contained a box to check for review of advance directives. The box was checked but no information was included in the notes section to indicate if the resident understood what an advance directive was, if the resident wanted or did not want an advance directive or if the facility staff followed up with the resident or their families who had an advance directive to ensure a copy was received and placed in the resident's medical record. A review of Resident 12's medical record indicated there was no follow up to the information provided to the resident after initial admission. There was no documentation to indicate if the resident wanted or refused an advance directive. On 7/13/22 at 11:28 AM Staff 7 (Admission Director) stated she provided the advance directive information to the resident with the admission packet but she did not follow up on it. On 7/13/22 at 3:11 PM Staff 6 (Social Service Director) said advance directives were only done on admission and she had no part in it. They reviewed advance directives annually in care meetings. There was a box that was checked on the care meeting sheet that it was reviewed. If the resident did not have an advance directive they will offer or provide the form. Staff 6 said they did not get many forms back from residents and she did not follow up on the forms. There was no documentation in the record to verify if forms were offered or provided to residents or if they accepted or refused the forms. On 7/13/22 at 3:19 PM Staff 1 (Administrator) provided the facility's Advance Directive Policy, updated August 2010. Advance directive information was offered by admissions staff and reviewed at annual care conferences. Staff 1 indicated understanding that increased documentation was needed by staff to clearly identify the resident's choices related to advance directive and follow up on advance directive forms by staff was needed. 2. Resident 26 was admitted to the facility in 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the medical record revealed Resident 26 did not have an advance directive and there was no information to indicate the facility periodically followed up with the resident related to her/his desire to execute an advance directive. On 7/12/22 at 12:53 PM Resident 26 stated she/he was not offered an advanced directive. On 7/13/22 at 3:11 PM AM Staff 6 (Social Service Director) stated residents were asked at admission about advance directives. Staff 6 added she did not follow-up with the resident after the advanced directive form was given to them. 3. Resident 27 was admitted to the facility in 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the medical record revealed Resident 27 did not have an advance directive and there was no information to indicate the facility periodically followed up with the resident related to her/his desire to execute an advance directive. On 7/12/22 at 12:47 PM Resident 27 stated she/he was not offered an advanced directive. On 7/13/22 at 3:11 PM Staff 6 (Social Service Director) stated residents were asked at admission about advance directives. Staff 6 added she did not follow-up with the resident after the advanced directive form was given to them. 4. Resident 14 was admitted to the facility in 2013 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A 5/27/22 Annual MDS revealed Resident 14 had a BIMS of 9 which indicated moderately impaired cognitive deficits. A review of Resident 14's medical record revealed no advance directive. A review of Care Conference forms from 7/22/21, 10/22/21, 2/9/22, 3/17/22, 5/27/22 revealed no advance directives were reviewed. In an interview on 7/13/22 at 3:11 PM Staff 6 (Social Services Director) stated advance directives were done on admission and reviewed annually. Staff 6 also stated she did not often get completed advance directive forms back from residents after the facility provided them and stated she did not follow up with the residents on these forms. In an interview on 7/13/22 at 4:32 PM Staff 2 (DNS) acknowledged advance directives for Resident 14 were not reviewed.

Based on observation, interview and record review it was determined the facility failed to provide nail care for 2 of 2 sampled residents (#s 5 and 18) reviewed for activities of daily living. This placed residents at risk for unmet needs. Findings include: 1. Resident 5 was admitted to the facility in 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident 5's care plan dated 1/25/22 included the resident was to be encouraged to perform self-care for showers as able and staff were to provide extensive assistance to finish the shower, including nail care. On 7/11/22 at 4:37 PM and 7/13/22 at 2:31 PM Resident 5 was observed to have very long fingernails with a dark brown substance under all the nails. On 7/14/22 at 2:24 PM Staff 22 (CNA) observed Resident 5's nails and verified they were very dirty and long. Staff 22 stated the current condition of the resident's nails was not acceptable and she would trim and clean the fingernails. 2. Resident 18 was admitted to the facility in 8/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A 6/3/22 MDS revealed Resident 18 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated Resident 18 was severely cognitively impaired. On 7/12/22 at 9:02 AM Resident 18's toenails were observed to be long and discolored. A review of Resident 18's medical record revealed there was no documentation for the last thirty days that her/his nails received care. A review of the Documentation Survey Report for June 2022 and July 2022 revealed Resident 18 rejected care three times in the last thirty days; on 6/20/22, 6/27/22, and 6/28/22. A review of Resident 18's care plan revealed staff were to check nail length, trim and clean on bath days and as necessary, and were to report any changes to the nurse. A 6/28/22 Skin Alert/Body Alert revealed Resident 18 refused nail care. A 7/1/22 Skin Alert/Body Alert revealed the staff were unable to clip Resident 18's toenails. A 7/5/22 Skin Alert/Body Alert revealed the staff did not clip Resident 18's toenails. A 7/12/22 Skin Alert/Body Alert revealed the staff did not clip Resident 18's toenails. In an interview on 7/13/22 at 11:46 AM Staff 11 (CNA) stated Resident 18 had pretty interesting toenails and the charge nurse was to provide her/his nail care. In an interview on 7/13/22 at 3:44 PM Staff 20 (CNA) stated Resident 18 received extensive assistance with cares, and her/his toenails were really thick and the nurse was to provide care. In an interview on 7/14/22 at 9:16 AM Staff 9 (RN) stated the CNAs provided care for Resident 18's toenails. In an interview on 7/14/22 at 10:26 AM Staff 5 (RNCM) stated he had not heard of any issues with Resident 18's toenails, stated the CNAs were to check them every day, and there was no order for the charge nurse to check the toenails. On 7/14/22 at 11:13 AM Staff 5 was observed trimming Resident 18's toenails. Staff 5 stated Resident 18's nails were long and one looked bad. In an interview on 7/14/22 Staff 2 (DNS) stated she was unable to find documentation of Resident 18's nail care being completed in 2022.

Based on interview and record review it was determined the facility failed to follow physician's orders as a result a resident developed two pressure ulcers, unstageable due to eschar for 1 of 3 sampled residents (#2) reviewed for pressure ulcers. This placed residents at risk for pressure ulcers, delayed healing and inappropriate treatment. Findings include: The Minimum Data Set 3.0 User's Manual revealed eschar is dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/edges of the wound. The 2016 revised National Pressure Injury Advisory Panel, NPIAP Pressure Injury Stages revealed Unstageable Pressure Ulcer: 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 2 was admitted to the facility in 1/2020 with a right femur fracture, [MEDICAL CONDITION] and [MEDICAL CONDITION]. Resident 2's 2/2020 Admission MDS revealed the resident had a BIMS score of 5 (severely impaired cognition), required staff assistance for ADL cares including mobility, transfers and locomotion. Resident 2 had no identified pressure ulcers. Resident 2's undated Admission Care Plan/SNF Care Plan revealed the resident was bed bound and required two-person mechanical lift for transfers. The resident had a femur fracture requiring the use of an immobilizer (splint/brace for stabilization) and had as needed pain medication. The 1/27/20 Physician Orders revealed Resident 2 was non-weight bearing on her/his right lower extremity. Maintain the knee immobilizer when out of bed and perform skin checks under the immobilizer daily. A Hoyer lift was recommended until Resident 2's strength recovered. The facility could not find Resident 2's 1/2020 clinical records to support Resident 2 received care as ordered by the physician. Progress Notes reviewed revealed the following: -On 1/31/20 the resident's skin under the immobilizer was clean, dry and intact (the only documented occurrence the resident's skin under her/his immobilizer was evaluated); -On 2/11/20 at 4:00 AM the resident complained of severe leg pain and pain medication was provided; -On 2/11/20 at 11:00 PM the resident had a sore area to her/his right calf area, the area was slightly red and warm to touch. Resident 2 had two dark areas to the posterior calf. The proximal dark area measured 3 cm by 1 cm, the distal area measured 1 cm by 1 cm. The physician was notified and the resident was sent to the emergency department (ED) for evaluation. The hospital records revealed the following: -On 2/11/20 the resident was evaluated in the ED; -On 2/12/20 Resident 2 was admitted in-patient to the hospital and had complaints of feeling fatigued and right leg pain. The resident was alert and oriented to self and event, had pain with movement and was conversational. The resident had two small pressure ulcers with eschar and the base of the wounds were not visible. The resident's right leg had [MEDICAL CONDITION] and [DIAGNOSES REDACTED] (skin redness caused by inflammation) with warmth. The resident was diagnosed with [REDACTED]. The resident was started on IV antibiotics. -On 2/13/20 and 2/14/20 the resident continued to receive IV antibiotics for [MEDICAL CONDITION]. -On 2/14/20 the resident was discharged from the hospital back to the facility. In an interview on 3/9/21 at 12:07 PM and 3/11/21 at 3:20 PM Staff 2 (DNS) stated Resident 2 complained of pain, the nurse evaluated the resident's leg and found two pressure ulcers. The physician was notified, Resident 2 was sent to the ED for evaluation, and was admitted to the hospital for further treatment. Staff 2 stated she completed an investigation and the nurses were not checking Resident 2's skin under the immobilizer which resulted in two pressure ulcers and [MEDICAL CONDITION]. Staff 2 stated the facility recognized the error and implemented a plan of correction. In an interview on 3/11/21 at 10:07 AM Staff 3 (RN) stated she could not recall much detail about Resident 2 but knew she/he had a brace on her/his leg. Staff 3 stated in approximately one week the resident developed two sores but should not have. In an interview on 3/11/21 at 2:20 PM Staff (RCM) stated Resident 2 admitted with a brace on her/his leg because of a fracture and developed pressure ulcers under the brace. The facility completed the following by 2/14/20 to ensure no further facility acquired pressure ulcers occurred: -Resident 2 was immediately sent to the emergency department for evaluation; -Facility wide audit of orders and skin assessments for residents; -Education was provided to nursing staff and administration regarding policies and procedures related to order entry, treatment procedures and care plan development for residents presenting with braces and/or casts; -Audits of care plans, care directives and TARs were conducted weekly for four weeks and monthly for two months.