Every finding on record at Tierra Rose Care Center

Based on observation, interview and record review it was determined the facility failed to implement interventions to promote wound healing for 1 of 2 sampled residents (#5) reviewed for pressure ulcers. This placed the residents at risk for worsening pressure ulcers. Findings include: Resident 5 was admitted to the facility in 2024 with diagnoses including dementia. An 8/3/25 Significant Change MDS indicated Resident 5 was not cognitively intact and was at high risk for developing sores. Resident 5 was on a turning/repositioning program.An 8/22/25 Care Plan indicated the following:- Resident 5 required limited assistance by one staff to turn and reposition in bed two to three times a shift and as necessary. - Resident 5 was assisted to reposition often to reduce the risk of pressure related skin breakdown. - Staff were to follow facility policies/protocols for the prevention/treatment of skin breakdown. An 10/5/25 physician order indicated Resident 5 had a MASD (Moisture-Associated Skin Damage) wound in her/his coccyx. From 10/13/25 through 10/16/25, on eleven occasions between 9:00 AM and 4:00 PM, the surveyor observed Resident 5 to lay flat on her/his back with no offloading or other pressure relieving devices present. On 10/14/25 at 2:43 PM, Staff 9 (RN) stated Resident 5's wound was healed and closed.On 10/15/25 at 4:16 PM, Resident 5 was observed in her/his bed and was lying flat. Resident 5 was awake and stated her/his bottom was painful and she/he was not comfortable. Resident 5 was unable to lift her/his legs and was unable to wiggle her/his toes.On 10/16/25 at 1:20 PM, Staff 7 (CNA) stated a turning/repositioning program indicated staff turned residents in bed to the left and right side and onto their backs with pillow support every two hours. Staff 7 stated she was informed by the CNA lead staff and/or the nurses when a resident was on a turning/repositioning program. Staff 7 stated Resident 5 was bed bound and had limited ROM to her/his left and right arm. Staff 7 stated Resident 5 required repositioning when she/he slid down in bed. Staff 7 stated she noticed a small sore on Resident 5's bottom and notified nursing. Staff 7 stated she applied barrier cream to her/his bottom and she notified staff when the dressing was soiled. Staff 7 stated Resident 5 was not on a turning/repositioning program.On 10/16/25 at 1:46 PM, Staff 8 (CNA) stated a turning/repositioning program indicated staff turned residents in bed to the left and right side with pillow support every one to two hours. Staff 8 stated there no residents on a turning/repositioning program. Staff 8 stated Resident 5 had dementia, was bed bound, slept most of the time and refused to get out of bed. Staff 8 stated Resident 5 did not have any skin issues and was not on a turning/repositioning program. Staff 8 stated she was informed about residents on a turning/repositioning program during shift change and/or the resident's care plan. On 10/16/25 at 1:52 PM, Staff 9 stated all residents who had wound care treatment orders were on a turning/reposition program. Staff 9 stated Resident 5 required maximum assistance when turned to the side. Staff 9 stated Resident 5 was on a turning/repositioning program and expected staff repositioned Resident 5 to the right, left and on her/his back every one to two hours. Staff 9 stated she ensure staff implemented repositioning interventions by listening on the radios used by floor staff and observed the residents throughout the day and indicated, But I have three halls. On 10/17/25 at 8:50 AM, Staff 11 (RN) was observed performing wound care on Resident 5. Resident 5 was lying flat and Staff 10 (CNA) turned her/him to the right side. The wound was observed to be open, with a pink wound bed and non-blanchable on the resident's coccyx. Staff 11 acknowledged the open, non-blanchable, pink wound. Resident 5 verbalized pain when the wound was touched and during the wound care dressing change. Staff 11 placed a new dressing, positioned Resident 5 onto her/his back and placed pillows under her/his knees.On 10/17/25 at 9:04 AM, Staff 11 stated residents on a turning/repositioning program were repositioned every two hours and she was unsure if Resident 5 had repositioning orders. Staff 11 returned to the surveyor a few minutes later and said Resident 5 was on a turning/repositioning program. On 10/17/25 at 9:09 AM, Staff 10 (CNA) stated Resident 5 was not on a turning/repositioning program. On 10/17/25 at 10:25 AM, Staff 6 (LPN Resident Care Manager) stated Resident 5 was bed bound. Staff 6 stated Resident 5 had one wound that was classified as MASD and stated the pictures taken by staff showed a closed wound. Staff 6 stated Resident 5 received incontinence care several times per shift and had scheduled wound care treatment. Staff 6 stated she expected staff to reposition Resident 5 every one to two hours with pillow support. Staff 6 stated she considered Resident 5's wound to be unavoidable due to Resident 5's lack of memory and the inability for Resident 5 to communicate needs. Staff 6 acknowledged Resident 5 did not use the call light and depended on staff to reposition her/him in bed. On 10/17/25 at 10:41 AM, Staff 3 (LPN, Assistant DNS) stated there was no specific program that required using pillow support when staff repositioned residents. Staff 3 stated she expected staff to check residents regularly for skin breakdown. Staff 3 acknowledged using pressure relieving devices to offload Resident 5's coccyx was beneficial for wound healing.

Based on observation, interview and record review it was determined the facility failed to follow infection control procedures for hand hygiene and PPE use for 1 of 1 facility reviewed for infection control. This placed residents at risk for exposure to infection and cross contamination. Findings include: 1. The CDC's 6/24/24 Infection Control Guidance: SAS-CoV-2 indicated staff who provided care to residents with confirmed COVID-19 were to wear a respirator with N95 filters and a barrier face covering. Resident 39 was admitted to the facility in 9/2/25 with a diagnosis of Parkinson's disease. A review of Resident 39's Progress Notes revealed she/he tested positive for COVID-19 on 10/14/25 at 10:23 AM. On 10/14/25 at 12:25 PM Resident 39's room was observed to have contact and droplet precaution signage on the door. On 10/14/25 at 12:25 PM Staff 12 (CNA) donned a gown, gloves, and surgical mask, but did not don eye protection and a N95 respirator before entering Resident 39's room. Staff 12 stated Resident 39 was on transmission-based precautions for COVID-19. Staff 12 stated he used contact precautions without eye protection because he did not provide direct care to Resident 39. On 10/15/25 at 11:48 AM Staff 13 (CNA) donned a gown, gloves, surgical mask, and a face shield hanging on the wall next to the doorway inside room [ROOM NUMBER]. Staff 13 was observed to enter room [ROOM NUMBER] to deliver a meal tray, proceeded to doff her PPE at the doorway, hung the face shield on the wall next to the doorway inside the resident's room and did not disinfect the face shield prior to exit. On 10/15/25 at 12:14 PM Staff 14 (CNA) stated a face shield was stored inside the room of a resident with COVID-19 and she used it when she provided care. On 10/15/25 at 1:58 PM Staff 2 (DNS) and Staff 3 (Assistant DNS) confirmed re-usable face shields should not be stored inside resident rooms and staff needed to wear both N95 respirators and eye protection when they entered the rooms of residents with COVID-19. 2. On 10/13/25 at 12:05 PM during the lunch meal service on the South Unit Hallway, Staff 15 was observed to place his hands inside a garbage bag to dispose of trash then prepared and delivered a cup of coffee to room [ROOM NUMBER] without completing hand hygiene. On 10/13/25 at 12:19 PM Staff 15 acknowledged he did not perform the needed hand hygiene. In a concurrent interview on 10/15/25 at 1:58 PM Staff 2 and Staff 3 confirmed staff were expected to complete hand hygiene as needed.

Based on observation and interview it was determined the facility failed to ensure food was stored appropriately and discarded in a timely manner, and failed to maintain a clean freezer for 1 of 1 kitchen and 1 of 1 resident refrigerator reviewed for sanitary conditions. This placed residents at risk for foodborne illness. Findings include: 1. On [DATE] at 7:48 AM during the initial tour of the facility's walk-in refrigerator and walk-in freezer the following was observed: Walk-in refrigerator: *An opened half-gallon heavy whipping cream container with a manufacturer use by date of [DATE]. *A red and brown liquid approximately 60 inches in length on the floor directly under a metal rack with food items including raw meat defrosting. Walk-in freezer: *An opened bag of pre-made egg and cheese omelets, undated. *Food crumbs and small dirt clumps approximately one centimeter and smaller on the floor throughout the entire freezer. On [DATE] at 8:05 AM Staff 6 (Dietary Manager) acknowledged the identified findings. 2. On [DATE] at 12:54 PM the resident refrigerator located in the therapy gym was reviewed. The following was observed: -Opened bottle of sriracha mustard, expired [DATE]. -Undated plastic container of moldy strawberries. -Undated plastic sandwich bag of moldy blueberries and strawberries. -Styrofoam container with a lid of chocolate pudding with a use by date of [DATE]. On [DATE] at 1:03 PM Staff 1 (Administrator) and Staff 3 (Assistant DNS) acknowledged the identified items. Staff 3 stated food was to be labeled and discarded after three days or after the use by dates.

Based on observation, interview, and record review it was determined the facility failed to maintain essential kitchen equipment in a safe operating condition for 1 of 1 kitchen reviewed for kitchen services. Findings include: On 6/24/24 at 7:48 AM an observation of the walk-in freezer in the kitchen revealed long vertical ice crystals approximately 15 inches in length attached to a pipe that connected to the freezer temperature unit. On 6/24/24 at 8:05 AM Staff 6 (Dietary Manager) acknowledged the identified findings. He stated the facility had two repair companies look at the walk-in freezer and each were unsuccessful with repairs. Staff 6 stated Staff 7 (Plant Manager) broke the ice crystals in the walk-in freezer weekly as the ice crystals accumulated rapidly and a log of this was kept. On 6/26/24 at 9:25 AM Staff 6 provided the facility's Kitchen Freezer Maintenance log and it revealed Staff 7 completed weekly maintenance in the walk-in freezer related to the ice crystals since 9/2023.

Based on observation, interview and record review it was determined the facility failed to provide appropriate foot care for 1 of 3 sampled residents (#66) reviewed for ADLs. This placed residents at risk for lack of nail care and skin impairments. Finding include: Resident 66 admitted to the facility in 2024 with diagnoses including heart failure and weakness. Resident 66's 5/7/24 care plan indicated staff were to check nail length, trim and clean on bath days and as necessary and report any changes to the nurse. On 6/25/24 at 9:33 AM Resident 66 was observed wearing sandals and had thick toenails extending past the end of her/his toes. The 6/26/24 bathing records indicated Resident 66 had a bath on 6/26/24 at 11:52 AM. On 6/26/24 at 2:22 PM Staff 4 (CNA) stated nail care was to be provided to residents weekly and the nurse was responsible for giving CNA staff a list of who needed nail care. On 6/26/24 at 2:30 PM Staff 5 (LPN) observed Resident 66 and confirmed Resident 66's toenails were long, thick, and extended past the end of her/his toes.

Based on observation, interview and record review it was determined the facility failed to follow care planned interventions and revise care plans to prevent falls for 3 of 6 sampled residents (#s 1, 64 and 66) reviewed for falls and during a random observation. This placed residents at risk for injury from falls. Findings include: 1. Resident 64 admitted to the facility in 2024 with diagnoses including stroke and dementia. a. The 3/1/24 care plan indicated Resident 64 was to have a fall mat on the left side of the bed. Resident 64's 6/10/24 fall investigation indicated the following: - Resident 64 had dementia and a history of falls. - Resident 64 had a non-injury fall. The Resident was found on the right side of her/his bed and stated she/he attempted to transfer to the wheelchair and fell . -Resident 64 had weakness and balance issues and overestimated the ability to transfer independently. Though the call light was in reach, the resident had poor safety awareness as evidenced by all of her/his previous falls and chose to attempt to transfer and fell . Ongoing resident education on safety was provided. There was no indication in the clinical record to indicate an assessment was completed to determine if current interventions were effective, or if additional interventions including a right sided fall mat, were needed. On 6/24/24 at 12:08 PM Resident 64 was observed to be in bed with a fall mat to the left side of the bed only. On 6/24/24 at 12:21 PM Staff 8 (CNA) stated she observed Resident 64 attempt to get out of bed in the past and the resident only attempted to get up on the right side of the bed. On 6/26/24 at 2:35 PM Staff 11 (RNCM) reviewed the 6/10/24 fall progress note and stated Resident 64 had a fall on the right side of the bed. Staff 11 stated after the fall no new interventions were put in place and a new intervention of bilateral fall mats was warranted after the 6/10/24 fall. b. The 6/26/24 updated care plan indicated Resident 64 was to have bilateral fall mats in place. On 6/27/24 at 9:16 AM Staff 12 (CNA) was observed to assist Resident 64 into bed and exited the room without placing bilateral fall mats. On 6/27/24 at 9:16 AM Staff 12 was asked to review Resident 64's care plan. Staff 12 stated the care plan indicated the resident was supposed to have bilateral fall mats. Staff 12 entered the room and placed a fall mat on the left side of the bed only and then exited the room. On 6/27/24 at 9:27 AM Staff 3 (Assistant DNS) acknowledged Resident 64 was care planned for bilateral fall mats and she/he had a fall mat on the left side of the bed but not the right side. 2. Resident 66 admitted to the facility in 2024 with diagnoses including heart failure and weakness. The 5/29/24 care plan indicated Resident 66 was to have a fall mat on the right side of the bed. On 6/24/24 at 12:05 PM Resident 66 was observed to be in bed with a fall mat on the left side of the bed and no fall mat on the right side of the bed. On 6/24/24 at 12:19 PM Staff 8 (CNA) observed Resident 66 and acknowledged the fall mat was on the left side of the bed and no fall mat was located on the right side of the bed. On 6/26/24 at 2:30 PM Resident 66 was observed in bed and had a fall mat on the left side of the bed. There was no fall mat located on the right side of the bed. On 6/26/24 at 2:30 PM Staff 5 (LPN) observed Resident 66 and acknowledged the fall mat was on the left side of the bed and no fall mat was located on the right side of the bed. Staff 5 acknowledged the care plan indicated she/he was to have a right sided fall mat. On 6/26/24 at 2:35 PM Staff 11 (RNCM) stated Resident 66's care plan indicated a fall mat was to be on the right side of the bed. Staff 11 stated Resident 66 was to have bilateral fall mats in place and the care plan was not updated. 3. Resident 1 admitted to the facility in 2009 with diagnoses including weakness and stroke. The 7/28/21 care plan indicated Resident 1 had a history of falls and was to have bilateral fall mats in place. On 6/27/24 at 9:16 AM Resident 1 was observed to have one fall mat to the right side of the bed and no fall mat on the left side of the bed. On 6/27/24 at 9:16 AM Staff 12 (CNA) was observed to remove Resident 1's fall mat on the right side of the bed and place it across the room next to the bed of the resident's roommate. On 6/27/24 at 9:27 AM Staff 3 (Assistant DNS) observed Resident 1 and acknowledged her/his care plan indicated she/he was to have bilateral fall mats and acknowledged there were no fall mats in place for Resident 1.

Based on observation, interview, and record review it was determined the facility failed to ensure proper storage and labeling of medication and biologicals for 1 of 2 medication carts and 1 of 1 medication and biologicals refrigerator reviewed for biologicals and medication storage. This placed residents at risk for inaccurate tuberculosis testing, decreased vaccine efficacy, improper medication administration, and reduced efficacy of medication. Findings include: According to the facility Medication Labeling and Storage Policy Statement, Revised 2/23, Multi-dose vials that are opened were dated and discarded within 28 days unless the manufacturer specified a shorter or longer date for the open vial. The policy also stated that medications may not be transferred between containers, and medications and biologicals were stored in the packaging, containers, or other dispensing systems in which they were received. On 6/26/24 at 10:15 AM a review of the biologicals and medication storage area was conducted with Staff 5 (LPN). One medication cart, and one refrigerator were reviewed for proper medication and biologicals storage and labeling. On 6/26/24 at 10:19 AM the refrigerator was noted to contain one sealed multi-dose vial of Tubersol (solution used in testing for Tuberculosis), and one opened multi-dose vial of Tubersol. Staff 5 (LPN) and Staff 10 (CMA) verified the opened vial of Tubersol did not have a date on the box or the vial. On 6/26/24 at 10:33 AM the medication cart was noted to have a small cup that contained multiple round white pills with no markings and another small cup placed on top of the pills. The bottom small cup was labeled with the word, Loratadine. On 6/26/24 at 10:33 AM Staff 5 (LPN) indicated the white pills were improperly stored and, we shouldn't be doing that, we need to get rid of those. On 6/26/24 at 2:45 PM Staff 3 (Assistant DNS) acknowledged the vial of Tubersol and the cup of white pills were not labeled and stored appropriately.

Based on interview and record review it was determined the facility failed to ensure resident records were complete and accurate for 1 of 1 sampled resident (#7) reviewed for therapy services. This placed residents at risk for inaccurate medical records and unassessed needs. Findings include: Resident 7 was admitted to the facility in 4/2024 with diagnoses including arthritis, gait and mobility abnormalities and muscle weakness. Resident 7's Comprehensive Care Plan, dated 5/29/24, indicated the resident had an ADL self-care performance deficit. Interventions included the provision of a restorative nursing program with range of motion exercises for the resident's lower extremities. Resident 7 did not have active orders for Physical Therapy, Occupational Therapy, or Restorative Aid Therapy. On 6/26/24 at 12:55 PM Resident 7 stated she/he did not receive any therapy services or Restorative Aid Therapy services since her/his admission. On 6/26/24 at 1:46 Staff 13 (CNA/RA) stated Resident 7 was not receiving Restorative Aid Therapy at this time. On 6/27/24 at 1:49 PM Staff 15 (LPN/Resident Care Manager) stated all resident care plans were revised and kept up to date by the Resident Care Manager, and Resident 7 did not have a Restorative Aid Therapy program on her/his care plan. On 6/27/24 at 2:01 PM Staff 15 (LPN/Resident Care Manager) acknowledged Resident 7's care plan included a plan for Restorative Aid Therapy services, with an initiation date of 5/29/24. She stated I don't know how that got there, she/he doesn't do Restorative Aid Therapy. On 6/27/24 at 2:41 PM Staff 3 (Assistant DNS) stated the intervention related to a Restorative Aid Therapy plan was placed in Resident 7's care plan in error and was intended for a different resident in the facility.

Based on observation, interview and record review it was determined the facility failed to provide sufficient nursing staff to attain and maintain the highest practicable well-being for 3 of 3 halls (100, 200, 300) reviewed for staffing. This placed residents at risk for unmet needs. Findings include: Interviews with residents revealed the following concerns: -On 4/17/23 at 10:53 AM Resident 23 stated call light response times could take over an hour during shift change especially when staff were leaving the night shift and day shift was beginning their shift. -On 4/17/23 at 11:03 AM Resident 63 stated right after lunch and shift change was difficult to receive assistance. Resident 63 indicated call light response times were 30 minutes or greater and she/he needed assistance with incontinence care, emptying of her/his urinal or adjusting the heat in her/his room. -On 4/17/23 at 11:10 AM Resident 43 stated call light response times were 30 minutes or greater and she/he used the call light to receive assistance with incontinence care and for her/his urinal to be emptied. -On 4/17/23 at 11:40 AM Witness 2 (Family Member) stated call light response times were 30 minutes or greater for Resident 9 and she/he sat in a wet and soiled brief on more than one occasion. Witness 2 stated he changed Resident 9 at times because of long call light response times which often occurred during mealtime or evening shift. -On 4/17/23 at 12:36 PM Resident 28 stated call light response times were greater than 30 minutes on any shift. -On 4/17/23 at 2:06 PM Resident 16 stated call light response times especially after 10:00 PM were 30 minutes or greater to receive help. Random observations of call light response times: -On 4/18/23 at 10:15 AM room [ROOM NUMBER], 306, 311 and 312 call lights were activated. -Staff answered room [ROOM NUMBER]'s call light at 10:26 AM (11 minutes later) and the resident requested a pain pill. The CNA indicated she would let the nurse know regarding the pain pill request. At 10:34 AM (18 minutes later) the resident was saying hello, hello. At 10:40 AM (24 minutes later) the resident was asleep in her/his bed and no staff returned to her/his room. -Staff answered room [ROOM NUMBER]'s call light at 10:29 AM (13 minutes later). -Staff answered room [ROOM NUMBER]'s call light at 10:34 AM (18 minutes later) and the resident wanted coffee. -Staff answered room [ROOM NUMBER]'s call light at 10:35 AM (19 minutes later) and the resident requested some water. On 4/18/23 at 10:34 AM room [ROOM NUMBER]'s (Bed A) call light was activated and the resident needed assistance to use the bathroom for a bowel movement. Multiple staff were in and out of the room from 10:35 AM to 11:00 AM. The resident was not assisted to the bathroom until 11:07 AM (33 minutes later) when two CNAs entered the room to assist her/him to the bathroom. Staff interviews revealed the following: -On 4/19/23 at 9:22 AM Staff 16 (CNA) stated call lights were to be answered within seven minutes and was difficult at times because not all staff assisted with answering call lights. Staff 16 stated during mealtimes call lights were a struggle to answer timely. -On 4/19/23 at 9:46 AM Staff 8 (CNA) stated call lights were to be answered within five minutes if possible and this was not always the case. Staff 8 stated not all staff assisted answering call lights which made it difficult to assist all residents timely. -On 4/19/23 at 12:44 PM Staff 14 (CNA) stated call lights were to be answered within five minutes and no longer than 15 minutes. Staff 14 stated this was difficult during mealtime, during shift change or when residents required two-person assistance. -On 4/20/23 at 3:16 PM Staff 2 (Assistant DNS) stated all staff were expected to answer call lights as quickly as possible and ideally to answer within five minutes. Staff 2 stated the facility struggled at times with call light response times during meals and at shift change.

Based on observation, interview and record review it was determined the facility failed to ensure residents received reasonable accommodation of needs for 1 of 1 sampled resident (#62) reviewed for accommodation of needs. This placed residents at risk for being dependent on bed mobility and repositioning in bed. Findings include: Resident 62 was admitted to the facility in 2/2022 with diagnoses including a stroke with left-sided weakness. The 2/2023 Annual MDS revealed Resident 62 was cognitively intact and required total two-person assistance with bed mobility. At 12:14 PM observed Resident 62 in bed attempting to use the bedrail to reposition herself/himself. Resident 62 stated she/he had a doctor's order for an over the bed trapeze bar to assist with repositioning and bed mobility. No trapeze bar was observed in Resident 62's room. Resident 62's 3/2023 physician's order revealed a trapeze bar for bed mobility order dated 2/22/22. On 4/19/23 at 2:30 PM Staff 3 (RNCM) stated she was aware Resident 62 had an order for a trapeze bar and thought the trapeze bar was ordered sometime in 3/2023 by Staff 19 (Staffing Coordinator/Unit Clerk). Staff 3 started at facility in 11/2022 and was unable to provide explanation of why the order was not addressed prior 3/2023. On 4/20/23 at 2:56 PM Staff 19 (Staff Coordinator/Unit Clerk) stated she ordered the trapeze bar in 3/2023 but was notified by the manufacturer the type of trapeze bar ordered was no longer made and was not ordered.

Based on interview and record review it was determined the facility failed to ensure a resident centered care plan was developed for 1 of 1 sampled resident (#17) reviewed for hospice. This placed residents at risk for lack of care planning. Findings include: Resident 17 admitted to the facility in 2022 with diagnoses including heart disease. An active physician order dated 12/8/22 indicated Resident 17 was administered lorazepam (an anti-anxiety) PRN for nausea and agitation. A review of Resident 17's clinical record did not include indications for use of lorazepam or indications to monitor for side effects related to the use of lorazepam On 4/20/23 at 3:50 PM Staff 2 (Assistant DNS) confirmed Resident 17 received PRN lorazepam for nausea and agitation from 12/15/22 to 4/20/23 without a care plan in place.

Based on interview and record review it was determined the facility failed to follow physician orders for 2 of 7 sampled residents (#s 5 and 63) reviewed of medications. This placed residents at risk for worsening medical conditions. Findings include: 1. Resident 5 admitted to the facility in 2022 with diagnoses including hypo-osmolality/hyponatremia (abnormally low concentration of sodium in the blood). The 7/5/22 Care Plan indicated Resident 5 received Samsca related to hypo-osmolality/hyponatremia. Interventions included to administer medications as ordered by the physician. A 10/5/22 physician order indicated Resident 5 was to be given 15 mg of Samsca (treats low sodium levels) at bedtime every other day for hypo-osmolality/hyponatremia. Review of the 2/2023 and 3/2023 MARs indicated Resident 5 did not receive Samsca from 2/26/23 through 3/12/23 (eight doses). Review of progress notes revealed the following: - 3/3/23 at 8:54 AM the Samsca medication for the resident was not covered by insurance. Due to non-coverage of the medication, the pharmacy will not be sending the medication. - 3/3/23 at 3:43 PM communication from the resident's provider was received about Samsca. The provider ordered the resident to continue to take the medication. - 3/8/23 the resident was on alert for the missing medication of Samsca. No negative effects were noted. On 4/20/23 at 10:00 AM Staff 2 (Assistant DNS) acknowledged Resident 5 was not administered Samsca from 2/26/23 through 3/12/23 as ordered. 2. Resident 63 was admitted to the facility in 2022 with diagnoses including diabetes and hypertension. The 12/5/22 Care Plan indicated Resident 63 had hypertension and received eplerenone (treats high blood pressure). Interventions included to administer hypertensive medications as ordered. A physician order dated 1/28/23 indicated Resident 63 was to receive eplerenone 50 mg BID for hypertension. Review of the 2/2023 and 3/2023 MARs indicated Resident 63 did not receive eplerenone from 2/28/23 through 3/8/23 (nine days). Review of progress notes revealed the following: - 2/16/23 pharmacy faxed a non-covered medication notification form stating resident's medication eplerenone was not covered. - 2/28/23 eplerenone medication was not available. Waiting on delivery from the pharmacy. - 3/1/23 eplerenone was unavailable. Waiting on delivery from Pharmacy. - 3/2/23 eplerenone unavailable. - 3/3/23 eplerenone unavailable. - 3/4/23 eplerenone unavailable. - 3/5/23 eplerenone unavailable. - 3/6/23 eplerenone not available. - 3/7/23 eplerenone not available. - 3/8/23 eplerenone not available. On 4/17/23 at 9:26 AM Witness 3 (Complainant) stated Resident 63 went without her/his medication for nine days. On 4/17/23 at 11:07 AM and 4/19/23 at 10:02 AM Resident 63 stated in 3/2023 the facility ran out of her/his eplerenone medication because it was not ordered timely. Resident 63 stated the medication was not new and she/he took the medication for a few years. Resident 63 stated she/he was not informed the medication was unavailable for the nine days in 2/2023 and 3/2023. On 4/19/23 at 8:40 AM and 9:28 AM Staff 10 (CMA) stated there were issues with the pharmacy sending medications or staff did not order medications on time. On 4/20/23 at 10:00 AM Staff 2 (Assistant DNS) acknowledged Resident 63 did not receive the eplerenone medication as ordered for the identified dates.

Based on observation, interview and record review it was determined the facility failed to ensure fall safey interventions were in place for 1 of 2 sampled residents (#9) reviewed for accidents. This placed residents at risk for falls. Findings include: Resident 9 admitted to the facility in 2/2022 with diagnoses including multiple sclerosis, anxiety and dementia. The current Care Plan revised on 2/11/23 revealed Resident 9 was a moderate fall risk related to confusion, incontinence and gait/balance problems. Resident 9 had a non-injury fall out of bed on 1/21/23. Staff were directed to have her/his call light within reach and to encourage the resident to use the call light for assistance. A fall mat was to be placed on the right side of her/his bed and the bed kept in a low position when not working with her/him. On 4/17/23 at 12:29 PM Resident 9 was observed in bed asleep with her/his bed in the lowest position but no fall mat was on the right side of her/his bed. On 4/17/23 at 11:27 AM Witness 2 (Family Member) indicated he had concerns with appropriate care plan interventions being in place for Resident 9 who was a fall risk. Random observation from 4/18/23 through 4/20/23 revealed Resident 9 in bed asleep and her/his bed was approximately two feet from the floor. Resident 9 had a fall mat down on the right side of her/his bed. On 4/19/22 at 9:22 AM Staff 16 (CNA) and at 12:44 PM Staff 14 (CNA) both stated Resident 9 was a fall risk and her/his bed was to be in the lowest position when not providing cares and a fall mat was to be placed on the right side of her/his bed. On 4/20/23 at 9:14 AM Staff 17 (LPN) stated Resident 9 was a fall risk and staff were to keep her/his bed in the lowest position when not providing ADL care and a fall mat was to be placed to the right side of her/his bed. Staff 17 stated he had to lower Resident 9's bed down because the bed was not in the lowest position on more than one occasion. On 4/20/23 at 10:29 AM Staff 3 (RNCM) stated Resident 9 was to have her/his bed in the lowest position and a fall mat to the right side of the bed. At 10:35 AM Staff 3 entered Resident 9's room with the surveyor and acknowledged her/his bed was not in the lowest position and was approximately two feet from the floor. Staff 3 acknowledged the bed was not in the lowest position and staff were expected to follow the care plan.

Based on interview and record review it was determined the facility failed to ensure physician visits occurred at least every 60 days for 2 of 7 sampled residents (#s 17 and 65) reviewed for medications. This placed residents at risk for unmet care needs. Findings include: 1. Resident 65 admitted to the facility in 10/2022 with diagnoses including atrial fibrillation. A review of Resident 65's clinical record on 4/19/22 revealed the last physician visit occurred on 1/24/23 (85 days prior). No evidence was found to indicate physician visits occurred every 60 days. On 4/19/23 at 12:00 PM Staff 2 (Assistant DNS) acknowledged Resident 65's last physician visit was on 1/24/23 and there was no evidence to indicate Resident 65 had a physician visit every 60 days. 41453 2. Resident 17 was admitted to the facility in 2022 with diagnoses including heart disease. A review of Resident 17's clinical record on 4/20/23 revealed the last documented physician visit occurred in 11/2022. No evidence was found to indicate physician visits occurred every 60 days. On 4/20/23 at 3:43 PM Staff 2 (Assistant DNS) acknowledged there was no evidence to indicate Resident 17 had a physician visit every 60 days.

Based on interview and record review it was determined the facility failed to follow pharmacy recommendations for 2 of 5 sampled residents (#s 17 and 65) reviewed for medications. This placed residents at risk for adverse medication side effects. Findings include: 1. Resident 65 admitted to the facility in 10/2022 with diagnoses including atrial fibrillation. The 1/18/23 pharmacy recommendation indicated the following: *Resident 65 received Eliquis (anticoagulant medication) 2.5 mg BID and cilostazol (antiplatelet medication) 50 mg BID. *Please evaluate the above combined therapy and if appropriate consider discontinuing the cilostazol. *Rationale for recommendation: concomitant [occuring at the same time] use of apixaban [Eliquis] and select medications may further increase the risk for serious, potentially fatal bleeding. Combination therapy with an antiplatelet agency may be an appropriate choice in select higher risk individuals. The pharmacy recommendation was not signed by the provider until 2/3/23 (16 days later) and indicated the recommendations were accepted and please implement as written. The 2/2023 MARs record indicated the cilostazol was discontinued on 2/4/23 at 12:33 PM. On 4/19/23 at 12:00 PM Staff 2 (Assistant DNS) stated her expectation for follow up of pharmacy recommendations was to be completed within 72 hours and acknowledged the facility did not follow up with the pharmacy recommendation timely. 41453 2. Resident 17 admitted to the facility in 2022 with diagnoses including heart disease. A 2/8/23 Physician Order indicated Resident 17 received carvedilol for high blood pressure. A 2/16/23 Pharmacy Recommendation recommended carvedilol should have been taken with meals. The recommendation was left blank and not signed by the physician. A 3/16/23 Pharmacy Recommendation again recommended carvedilol should have been taken with meals. The recommendation was left blank and not signed by the physician. On 4/20/23 at 3:50 PM Staff 2 (Assistant DNS) confirmed the facility did not act upon the pharmacist recommendation.

Based on interview and record review it was determined the facility failed to ensure gradual dose reductions (GDRs) were attempted for residents on psychotropic medications for 1 of 5 sampled residents (#62) reviewed for unnecessary psychotropic medications. This placed residents at risk for side effects of unnecessary medications. Findings include: Resident 62 was admitted to the facility in 2/2022 with diagnoses including a stroke and depression. An admit order dated 2/11/22 revealed Resident 62 received 30 mg of duloxetine (an antidepressant) one time a day for depression. An 8/18/22 pharmacist recommendation revealed a GDR from 30 mg of duloxetine to 20 mg one time a day. On 9/19/22 Resident 62's physician agreed to the pharmacist's GDR recommendation. Resident 62's 9/2022, 10/2022 and 11/2022 MARs revealed no GDR was completed. On 4/19/23 at 2:17 PM Staff 3 (RNCM) stated she was not aware a GDR for the duloxetine was not completed.

Based on interview and record review it was determined the facility failed to provide adequate meal portions and honoring preferences timely for 2 of 6 sampled residents (#s 43 and 63) reviewed for food. This place residents at risk for weight loss and lessened quality of life. Findings include: 1. Resident 43 admitted to the facility in 2019 with diagnoses including diabetes and depression. The revised 10/6/22 Care Plan indicated Resident 43 had a potential for nutritional issues related to co-morbidities of diabetes, pain, depression and a pressure ulcer. Interventions included to provide and serve diet as ordered. On 4/17/23 at 11:03 AM Resident 43 stated the facility's food was the worst food she/he had ever ate. Resident 43 stated the facility ran out of food and she/he was not served enough food on multiple occasions. On 4/19/23 at 10:10 AM Resident 43 indicated records were kept by Resident 63 of the food from recent meals and those records included the following observations: -One dinner roll, a half scoop of a white food substance and approximately less than half of a portion size of lasagna. -A scoop of white rice and a half of a quesadilla. -One dinner roll and approximately less than half a portion of lasagna. -A small scoop of corn and a small scoop of a casserole type food. -One dinner roll, a small scoop of beans, seven brussels sprouts and three slices of sausage. -A dinner roll, with two raviolis and a scoop of spinach. -One dinner roll, a small scoop of white rice and a small scoop of a meat vegetable medley. - A half of a sandwich, a small scoop of watery coleslaw and a small side of fries. On 4/19/23 at 1:08 PM Staff 7 (Dietary Manager) reviewed the documented records of the food and indicated the meals were not the normal portion size for what residents should have received. On 4/20/23 at 10:00 AM Staff 2 (Assistant DNS) stated she was aware of the food issue related to portion size and stated she once observed residents being served one ravioli. 2. Resident 63 admitted to the facility in 2022 with diagnoses including heart failure and hypertension. On 4/17/23 at 9:26 AM Witness 3 (Complainant) stated the facility often ran out of food. Witness 1 stated on 4/16/23 Resident 63 was only served a half of a sandwich and a roll. Witness 3 stated she took the resident fruit and snacks when she could as she lived 45 minutes away and it was difficult for her to get to the facility. On 4/17/23 at 11:04 AM Resident 63 stated she/he was often served not enough food. Resident 63 stated on 4/16/23 for dinner she/he only received a half of a grilled cheese sandwich and a few tater tots. On 4/19/23 at 10:10 AM Resident 63 indicated she/he kept records of recent meals which included the following observations: -One dinner roll, a half scoop of a white food substance and approximately less than half of a portion size of lasagna. -A scoop of white rice and a half of a quesadilla. -One dinner roll and approximately less than half a portion of lasagna. -A small scoop of corn and a small scoop of a casserole type food. -One dinner roll, a small scoop of beans, seven brussels sprouts and three slices of sausage. -A dinner roll, with two raviolis and a scoop of spinach. -One dinner roll, a small scoop of white rice and a small scoop of a meat vegetable medley. - A half of a sandwich, a small scoop of watery coleslaw and a small side of fries. On 4/19/23 at 1:08 PM Staff 7 (Dietary Manager) stated reviewed the pictures of the food and indicated the meals were not the normal portion size for what residents should have received. On 4/20/23 at 10:00 AM Staff 2 (Assistant DNS) stated she was aware of the food issue related to portion size and stated she once observed residents being served one ravioli.

Based on interview and record review it was determined the facility failed to provide meals at a palatable temperature for 2 of 6 sampled residents (#s 43 and 63) reviewed for food. This placed residents at risk for receiving unpalatable food. Findings include: 1. Resident 43 admitted to the facility in 2019 with diagnoses including diabetes and depression. The 2001 facility Food Preparation and Service Policy indicated proper hot and cold temperatures were to be maintained during food distribution and service. The revised 10/6/22 Care Plan indicated Resident 43 had a potential for nutritional issues related to co-morbidities of diabetes, pain, depression and a pressure ulcer. Interventions included to provide and serve diet as ordered. On 4/17/23 at 10:19 AM Resident 43 stated the facility's food was the worst food she/he ever ate. Resident 43 stated at times the food was cold. Resident 43 stated she/he was informed by CNA staff the food was unable to be reheated because it was a burn hazard and they needed to have a food handlers card. On 4/19/23 at 12:10 PM Staff 8 (CNA) stated she was unable to reheat resident's food for sanitary reasons. On 4/19/23 at 2:45 PM Staff 20 (CNA) stated she believed CNAs needed to have a food handlers card to be able to reheat residents' food. On 4/20/23 at 9:10 AM Staff 9 (CNA) stated she was not able to reheat resident food due to the inability to ensure the correct temperature and she needed to have a food handlers card. On 4/19/23 at 1:08 PM Staff 7 (Dietary Manager) stated he was aware of complaints related to the temperature of the food. Staff 7 stated he encouraged residents to eat in the dining room to avoid potential food temperature issues. Staff 7 further stated he believed CNA staff were not able to reheat resident food because the microwave was removed. On 4/19/23 at 2:30 PM and 4/20/23 at 10:00 AM Staff 2 (Assistant DNS) stated she was aware of the food issue reported by residents. Staff 2 stated CNA staff were able to reheat residents food and did not require a food handlers card. 2. Resident 63 admitted to the facility in 2022 with diagnoses including heart failure and hypertension. A 3/1/23 Care Conference note indicated Resident 63 complained about the food. The solutions provided were for the resident to change rooms or eat in the dining room. On 4/17/23 at 9:26 AM Witness 3 (Complainant) stated the food served to Resident 63 was not always hot. Witness 3 stated she brought up food issues during the care conference but nothing was done. On 4/17/23 at 11:04 AM Resident 63 stated due to being at the end of the hall her/his food was often cold. Resident 63 stated she/he was informed by CNA staff they were unable to reheat her/his food. On 4/19/23 at 12:10 PM Staff 8 (CNA) stated she was unable to reheat residents food for sanitary reasons. On 4/19/23 at 2:45 PM Staff 20 (CNA) stated she believed CNAs needed to have a food handlers card to be able to reheat residents' food. On 4/20/23 at 9:10 AM Staff 9 (CNA) stated she was not able to reheat resident food due to the inability to ensure the correct temperature and she needed a food handlers card. On 4/19/23 at 1:08 PM Staff 7 (Dietary Manager) stated he was aware of complaints related to the temperature of the food. Staff 7 stated he encouraged residents to eat in the dining room to avoid potential food temperature issues. Staff 7 further stated he believed CNA staff were not able to reheat resident food because the microwave was removed. On 4/19/23 at 2:30 PM and 4/20/23 at 10:00 AM Staff 2 (Assistant DNS) stated she was aware of the food issue reported by residents. Staff 2 stated CNA staff were able to reheat resident food and they did not require a food handlers card.

Based on interview and record review it was determined the facility failed to honor meal preferences for 1 of 6 sampled residents (#54) reviwed for food. This placed residents at risk for lessened quality of life. Findings include: 1. Resident 54 admitted to the facility in 4/2019 with diagnoses including stroke and dementia. The revised 5/19/22 Care Plan indicated Resident 54 was at risk for weight loss. Interventions included to offer alternates of disliked food. On 4/17/23 at 10:47 AM and 4/19/23 at 2:37 PM Resident 54 stated the food was terrible and she/he did not feel meal requests were honored timely. Resident 54 stated she/he often refused lunch and would then request a quesadilla from the alternative menu. Resident 54 stated residents could not request an alternative meal unless they refused the lunch meal and then had to request food from the alternative meal ticket which was completed by a CNA and returned to the kitchen. Resident 54 stated and it took the kitchen forever for her/him to receive the quesadilla and at times when she/he received the quesadilla the cheese was not even melted. On 4/19/23 at 9:22 AM Staff 16 (CNA) stated Resident 54 often refused her/his lunch meal and requested a quesadilla from the alternative meal ticket. Staff 16 stated the kitchen honored the request but Resident 54 was the last to be served her/his alterative preference or at times did not receive the alternative meal at all. Staff 16 stated the week of 4/10/23 Resident 54 did not receive her/his quesadilla until 1:30 PM and lunch started being served at around 11:30 AM. On 4/19/23 at 9:46 AM Staff 8 (CNA) stated residents did not have a choice of what they received for lunch until they refused the meal that was delivered to them. Staff 8 stated Resident 54 usually refused her/his lunch meal and then she assisted Resident 54 with completing an alternate meal ticket, which was returned to the kitchen but Resident 54 did not get her/his meal sometimes until 1:30 PM in the afternoon. Staff 8 stated Resident 54 requested quesadillas a lot. On 4/19/23 at 1:08 PM Staff 7 (Dietary Manager) stated he was new to the position and residents did not have a choice for breakfast, lunch or dinner but the facility provided an alternative meal ticket that was completed when a resident refused the regular meal. Staff 7 stated all regular meals were served first and residents had to refuse the current meal and request something from the alternative meal ticket. Staff 7 stated the alternative meal ticket was returned to the kitchen but resident's requests/preferences were not honored from the alternative meal ticket until all other regular meals were delivered. Staff 7 stated this process took time and was not efficient for the kitchen or residents. On 4/20/23 at 3:16 PM Staff 2 (Assistant DNS) stated she was aware of concerns regarding the kitchen and the facility recently hired Staff 7 to assist with addressing concerns in the kitchen including residents preferences being honored timely.

Based on interview and record review it was determined the facility failed to provide rehabilitation services for 2 of 4 sampled residents (#s 10 and 63) reviewed for rehabilitation services. This placed residents at risk for declined mobility and lack of quality of life. Findings include: 1. Resident 63 was admitted to the facility in 2022 with diagnoses including diabetes and hypertension. A 2/24/22 physician order indicated a referral for physical and occupational therapy for Resident 63. The 3/15/22 Care Plan indicated Resident 63 had an ADL performance deficit related to limited mobility. A rehabilitation provider note dated 11/21/22 indicated Resident 63 was progressing well. Physical therapy was to be discharged due to a changed in staffing and the inability of therapy to continue. The note indicated Resident 63 was resume therapy services that was medically necessary to allow the resident to transfer with a slide board and to improve independence of mobility and social engagement. The note indicated therapy was to be discontinued with the expectation Resident 63 was to continue with therapy. The 2/21/23 Annual MDS indicated Resident 63 received two-person assistance using mechanical lift for transfer. The resident previously worked with physical therapy in learning how to perform a slide-board transfer. Resident 63 previously participated in physical therapy but was discharged from physical therapy in November 2022. The resident expressed wanting to restart physical therapy and an order from his primary care provider to restart physical therapy. A 3/7/23 progress note indicated the resident was spoken to about therapy coming into the facility to work with her/him. The note indicated Resident 63 had a current order for therapy. A 3/8/23 Care Conference note indicated Witness 3 (Complainant) stated she wanted Resident 63 in therapy and was informed it was in the works. On 4/17/23 at 9:26 AM Witness 3 stated Resident 63 went four months without therapy. Witness 3 stated the facility indicated the resident had therapy but she/he did not. On 4/17/23 at 10:12 AM Resident 63 stated she/he went four months without any therapy. The resident stated there was no therapy staff to provide any therapy services. Resident 63 stated the facility also had no RA program therefore that was not an option. On 4/20/23 at 9:30 AM Staff 6 (Social Service Director) stated she recently was able to get therapy services for Resident 63 due to a therapy agency reaching out to her. Staff 6 stated Resident 63 wanted therapy and she was unaware why she/he did not have therapy prior. On 4/20/23 at 10:00 AM Staff 2 (Assistant DNS) indicated due to not having therapy staff, residents were not able to have therapy services provided. Staff 2 acknowledged Resident 63 did not receive therapy from 11/21/22 until recently due to staffing. Staff 2 stated the facility also had no RA program to offer residents as an alternative to therapy. 47005 2. Resident 10 was admitted to the facility on [DATE] with diagnoses including weakness complicated by quadriplegia (paralysis of all four limbs from spinal injury). On 4/17/23 at 9:16 AM Resident 10 was observed attempting to sit up in bed. On 4/18/23 at 9:20 AM Resident 10 was observed attempting to sit at the edge of the bed. Resident 10 stated she/he was sent to the facility for therapy but did not receive any therapy services and had to do her/his own rehab in the exercise room. A 3/8/23 hospital discharge orders included orders for physical and occupational therapy. On 4/19/23 at 3:12 PM Staff 4 (LPN/Resident Care Manager) stated the hospital discharge orders is used as the facility admission orders. Staff 4 stated she overlooked Resident 10's physical and occupational therapy orders in the 3/8/23 hospital discharge orders.

1. Based on interview and record review it was determined the facility failed to ensure Resident 9 did not elope from the facility for 1 of 1 sampled residents (#9) reviewed for elopement. This failure was determined to be an immediate jeopardy situation because the facility failed to follow the residents care plan and provide supervision which resulted in Resident 9's elopement from the facility. Findings include: Resident 9 admitted to the facility in 2022 with diagnoses including symptoms involving cognitive functions following other nontraumatic intracranial hemorrhage and cataracts. Prior to admission, the resident was homeless. The 9/27/22 Communication Care Plan revealed Resident 9 had a communication problem related to expressive aphasia (a form of aphasia when the person knows what they want to say but are unable to produce the words or sentence. Can be mild to severe), slurring, stroke, weak or absent voice. Interventions included to allow adequate time to respond, face the resident when speaking and make eye contact, ask yes/no questions if appropriate, use simple, brief, consistent words/cues, use alternative communication tools as needed. The resident was able to say yes or no and very short sentences and could shake/nod her/his head. Speak to the resident in a calm, quiet voice because she/he responded better with this approach. Speak on an adult level, speak clearly and slower than normal. The 9/27/22 Fall Care Plan revealed Resident 9 was a high risk for falls related to gait and balance problems. The 11/18/22 Vision Care Plan revealed Resident 9 was at risk for poor vision related to cataracts. The Elopement Risk Care Plan, last revised on 12/28/22, revealed Resident 9 was a high elopement risk related to impaired safety awareness; both physical and environmental. The resident had eloped on 11/17/22, 12/12/22 and 12/27/22. The interventions included to remind the resident to notify staff if she/he planned to leave the facility as needed (11/18/22), resident was high fall risk (11/18/22), to not seat the resident in the lobby near the doors without supervision at any time of the day or night. If the resident was up during late night hours to have her/him close to the nurse's station where she/he could be monitored. To walk with the resident if she/he wanted to walk, sit and talk with the resident, attempt to engage the resident to watch television, look at a magazine, offer fluids and snack. If not redirectable, alert the charge nurse, RN, resident care manager or DNS (12/14/22). Remind the resident of the sign posted in her/his room to not leave the facility without assistance for her/his safety and to show her/him the sign above the television (12/15/22). Activities to check in with the resident regularly to see if she/he needed anything from the store and to let nursing know to minimize the desire to exit the facility (12/16/22). Offer Resident 9 a bowl of ice cream (rocky road) every evening sometime after dinner and before bed time. If Resident 9 ambulated toward the front lobby late at night offer the ice cream again (12/28/22). The 11/17/22 at 9:34 PM Incident Note revealed staff noted Resident 9 was not in her/his room, was assisted to bed at 7:00 PM, last seen between 8:15 PM and 8:30 PM and found on the lawn outside the 200 hall door. The 11/18/22 Wandering Risk Assessment identified Resident 9 as a moderate wander risk. Resident 9 was forgetful, had a short attention span, independent with aid for mobility, early dementia, on antidepressants and had a history of wandering. The 11/18/22 facility investigation revealed the resident was found outside. When interviewed the resident indicated she/he was going to Fred [NAME] for rocky road ice cream. [Fred [NAME] is a store 0.6 miles away from the facility. The resident would have to walk up [NAME] Street, which facility resides on, towards Lancaster Drive which is a highly congested four lane road. The intersection of [NAME] and Lancaster has no intersection and both roads offer minimal lighting.] The 12/6/22 BIMs score was 9 which suggested the resident had moderately impaired cognition. The 12/12/22 Progress Note revealed Resident 9 walked out of the facility around 8:00 PM. The resident wore a sweater, was found down the street walking with her/his walker. The temperature was around 40 degrees and [she/he] was not dressed appropriately. The resident was non-verbal; unable to say why she/he left or where she/he was going. The 12/12/22 Elopement Event identified Resident 9 as an elopement risk, the resident eloped off facility grounds when she/he was left unattended in the front lobby and the resident was disoriented to some-spheres some of the time. The assessment revealed the resident was homeless prior to admission and was not afraid to go out at night. The resident was alert and able to converse most of the time, was slow to answer and very soft spoken which could be misconstrued for non-responsive or cognitive impairment. The 12/13/22 Wandering Risk Assessment identified Resident 9 as a moderate wander risk. Resident 9 was forgetful, had a short attention span, ambulated with one person assistance, early dementia, on antidepressants and had a history of wandering. The 12/13/22 Incident Note revealed Resident 9 was alert and able to converse most of the time but was slow to answer and very soft spoken. Resident 9 stated she/he was going to Fred [NAME]'s for ice cream. Resident 9 stated rocky road was her/his favorite ice cream. The resident stated she/he did not have money for ice cream and stopped responding to the interviewer when repeatedly asked how she/he would have paid for the ice cream. The 12/13/22 BIMs was 14 which indicated the resident was cognitively intact. The 12/14/22 Care Conference Notes revealed safety concerns as the resident had exited the facility twice since admission. The resident stated she/he was going to Fred [NAME]'s to get ice cream. It was arranged the resident would be asked weekly if she/he needed anything and ice cream would be available. The 12/28/22 Progress Note revealed Resident 9 walked down the hall around 11:20 PM [on 11/27/22]. The resident walked to the lobby and sat down. Staff asked what she/he needed but the resident did not respond. The CNA sat with the resident for a few minutes but when she went to answer another call light [she/he] left out the front door. The nurse went to check on the resident five minutes later and the resident was gone. Four staff initiated a search, first searching the facility and then outside. Resident 9 was found walking past the park on [NAME] Street. The resident was non-verbal and would not answer any questions. The temperature outside was 50 degrees and raining; the resident wore sweat pants and a T-shirt. The 12/28/22 Progress Note revealed the resident care manager spoke with the resident in the morning and the resident stated she/he was walking to Fred [NAME] for ice cream. When asked if she/he had a bowl of ice cream every night would keep her/him from wanting to go outside, the resident nodded yes. The 12/28/22 Wandering Risk Assessment revealed Resident 9 was a moderate risk for wandering. The resident was forgetful, had a short attention span, did not understand surroundings, independent with mobility, on antidepressants and had a history of wandering. The 12/28/22 facility investigation revealed when Resident 9 eloped staff had not followed the care plan. On 12/28/22 at 5:04 PM Staff 21 (Resident Care Manager) stated Resident 9 exit sought at night between 8:00 PM and 11:00 PM, was homeless prior to admission and did not feel any danger when outside at night. Staff 21 stated Resident 9 always wanted to go to Fred [NAME] to get rocky road ice cream when interviewed. Resident 9 knew she/he did not have any money and would not state how she/he would pay for the ice cream. Staff 21 stated the ice cream had been in the activity room but hadn't had any of it. Staff 21 stated although Resident 9 had some cognitive issues she/he had not lost everything and waited until no staff was looking before exiting the building. Staff 21 confirmed Resident 9's care plan instructed not to leave her/him unsupervised in the front lobby which staff did on 12/27/22 when she/he eloped. On 12/28/22 at 5:16 PM Staff 22 (CNA) stated he and another staff member observed Resident 9 walk to the front lobby so he went to check on her/him. Resident 9 was ok and I didn't know [she/he] was going to try to escape. Staff 22 further stated ten or 15 minutes after he checked on the resident a nurse called him and informed him she thought Resident 9 got out so the staff started to look for her/him. Staff 22 stated this was the first time he worked with Resident 9, was not aware to not leave Resident 9 alone in the front lobby and had not read the care plan. On 12/28/22 at 5:33 PM Staff 16 (LPN) verified she worked on 12/27/22 when the resident eloped and stated there was no ice cream available after hours and she could not get into the activity room at night or if she was she was unaware of it. Staff 16 verified Resident 9 was left alone for approximately five minutes in the lobby prior to her/his elopement and stated she was not aware Resident 9's care plan instructed staff she/he was not to be left alone there. Staff 16 stated Resident 9 exit seeked at least once a week at night. On 12/28/22 at 7:30 PM Staff 20 (Social Service Director) confirmed Resident 9 eloped on 12/27/22 because the care plan was not followed. On 12/29/22 at 8:04 AM Staff 2 (DNS) stated the facility had identified 14 residents who were a moderate to high wander risk. Staff 2 confirmed on 12/27/22 Resident 9 was left alone in the front lobby and the resident's care plan was to followed which resulted in Resident 9's elopement off the facility grounds. On 12/29/22 at 9:16 AM Resident 9 stated when she/he left the facility, it was to go to either Fred [NAME] or Walmart to get ice cream. Resident 9 stated if staff offered her/him ice cream she/he would not leave. On 12/29/22 at 10:06 AM the facility was notified of the Immediate Jeopardy (IJ) situation and a plan of care was requested. On 12/29/22 at 12:40 PM the facility submitted an acceptable immediacy removal plan which would abate the IJ situation. The immediacy removal plan included the following: *Resident 9 would be visually monitored by staff at all times from dinner until 2:00 AM. Ice [NAME] would be offered every evening before bed. The visual monitoring would remain in place until the wander guard that was ordered arrived and was put into place. *The elopement care plans for the 13 residents who were moderate to high risk for wandering would be printed and required to be reviewed by the nursing staff prior to them working with the residents. *The facility had identified on 12/20/22 some staff had not read care plan changes and a new system of notifying staff was implemented. *All residents had a potential to be affected. *All staff would be informed of what residents were at risk for wandering/elopement. All nursing staff would receive education on the new system for notifying staff of care plan changes and the expectation to read the care plan prior to providing care to the resident. Education would begin on 12/29/22 and would by completed by 12/30/22 at 3:00 PM or upon return if on a leave of absence prior to working with residents. *Random weekly audits of care plans would be completed to ensure staff were notified of changes per the new system for 30 days. Results of the audits would be reviewed by the QAPI (Quality Assurance and Performance Improvement) team to determine if further auditing was necessary On 12/30/22 staff interviews verified re-education per the immediacy removal plan was competed. A review of facility documentation revealed all aspects of the immediacy removal plan was implemented. On 12/30/22 at 2:50 PM it was determined the IJ immediacy was removed. 40767 2. Based on observation, interview and record review it was determined the facility failed to ensure interventions were in place to prevent accidents for 1 of 3 sampled residents (#15) reviewed for falls. This placed residents at risk for injury. Findings include: Resident 15 admitted to the facility in 2020 with diagnoses including end stage renal disease and a hip fracture. The 10/14/22 Annual MDS indicated the resident was cognitively intact, required extensive assistance with bed mobility, was non-ambulatory, and had a history of falls. An 11/24/22 Fall Investigation indicated Resident 15 fell out of bed while reaching down for something and hit her/his head on the floor. The resident stated, I was laying on the edge of the bed and I felt myself sliding down and I tried to grab for something, and I fell . The resident's call light was noted to be initiated. The investigation did not indicate how long the call light had been on. The resident was noted to have been last toileted and repositioned two hours prior to the fall. The resident's air mattress was noted to be a bit high so the air in the mattress was decreased. The resident requested side rails for her/his bed. On 1/3/23 at 9:25 AM Resident 15 stated she/he had pressed her/his call light as she/he was close to the edge of the bed. The resident stated she/he yelled I am going to fall, but by the time staff came to the room the resident was on the floor. Resident 15 stated her/his call light had been initiated for 30 minute and stated the long call light time happened all the time. Resident 15 stated right after the fall she/he had requested bed mobility bars, but she/he never received them. The resident's bed was observed to be without any bed mobility bars or side rails. Resident 15 further stated she/he almost fell out of bed a few days prior, but a staff member was able to prevent the fall and helped reposition the resident in the center of the bed. On 1/3/23 at 11:29 AM ad 11:55 AM Staff 3 (LPN, Assistant DNS) acknowledged the investigation did not include how long Resident 15's call light was initiated. Staff 3 further stated the expectation was for the resident to have mobility bars per the resident's request and the resident did not currently have mobility bars on her/his bed.

Based on interview and record review it was determined the the facility failed to monitor and assess Resident 2 for signs of UTI (urinary tract infection) such as decreased food and fluid intake and decreased urine output and failed to notify the provider of condition changes for 1 of 3 sampled residents (#2) reviewed for change of condition. This failure was determined to be an immediate jeopardy situation because the facility failed to recognize and treat a UTI which resulted in severe sepsis and death. Findings include: Resident 2 admitted to the facility in 4/2022 with diagnoses including intellectual disabilities and neurogenic bladder. The 3/11/22 Risk For Infection related to the use of a urinary catheter care plan included the following interventions: change catheter and Foley (catheter) bag as scheduled or as ordered by the physician, monitor the indwelling catheter and report to the physician signs and symptoms of UTI such as pain, burning, blood tinged urine, cloudiness, no urine output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior and change in eating patterns. The 4/6/22 Return From Hospital care plan interventions included to monitor appetite and document the percentage eaten each meal and to monitor pain and discomfort. A 4/29/22 Progress note revealed Resident 2's urine was cloudy with foul smell, had increased agitation and a UA (urinalysis) was collected. A 5/4/22 Progress note revealed a negative UA result. The 5/4/22 task documentation revealed Resident 2's UOP (urine output) was 1150 cc. Meal intake for breakfast was 26 to 50%, lunch zero to 25% and dinner was refused. Fluid intake was 980 cc. A 5/6/22 Progress note revealed Resident 2 was very irritable and refused the catheter change. Blood Pressure was 71/49 [No evidence of physician notification, assessment or monitoring was completed or offered additional food and fluids.] The 5/6/22 task documentation revealed Resident 2's UOP was 675 cc, fluid intake was 460 cc and meal intake for breakfast and lunch was zero to 25% and dinner 26 to 50%. A 5/7/22 Progress Note revealed Resident 2 was on alert due to having cloudy urine, having increased sediment and foul odor. The 5/8/22 task documentation revealed fluid intake was 540 cc. The 5/9/22 task documentation revealed the resident consumed zero to 25% of all meals and fluid intake was 360 cc. The 5/10/22 task documentation revealed fluid intake was 270 cc. Meal intake for breakfast was 26 to 50%, lunch zero to 25% and refused dinner. The 5/11/22 task documentation revealed 500 cc UOP, 780 cc fluid intake and meal intake varied from zero to 75%. The 5/12/22 task documentation revealed 475 cc UOP, 120 cc fluid intake, meal intake for breakfast and dinner was refused, lunch was zero to 25%. The resident took in additional nutrition in the evening between 75-100%. The 5/13/22 task documentation revealed 950 cc UOP, Fluid intake was 240 cc with one meal intake not documented and meal intake zero to 25% for breakfast and dinner and lunch was not documented. The 5/14/22 task documentation revealed 560 cc UOP, 740 cc fluid intake, breakfast and dinner refused with zero to 25% lunch meal intake. The 5/16/22 task documentation revealed UOP was 25 cc on night shift and 260 cc on day shift. Fluid intake was 20 cc for breakfast and 120 cc for lunch. Meal intake was zero to 25% for breakfast and lunch. The 5/16/22 12:01 PM Progress note revealed a CNA reported Resident 2 was not acting like [her/himself] today. Blood pressure was 94/59, resident stated she/he felt unwell and was unable to describe any specific symptoms. The urine was red/brown tinged and mucus was present. The residents speech was slurred. The provider was called and staff were waiting for a call-back. The 5/16/22 2:00 PM Progress note revealed the provider called back and gave orders to push fluids, administer an antibiotic shot, change the indwelling catheter and to obtain a stat [immediate] UA. The 5/16/22 provider encounter note revealed the resident was seen for a concern of a possible UTI. The urine was reported to have foul odor and was cloudy with a dark color. The catheter was changed and the urine was clear after the indwelling catheter change. The resident complained of stomach and ear pain. The 5/16/22 2:38 PM indicated the resident was transported to the hospital for altered mental status and hypotension (low blood pressure). The 5/17/22 Progress note revealed the hospital notified the facility the resident passed away with a small bowel obstruction, UTI, sepsis (full body infection) and acute renal failure. The 5/17/22 Hospital Records revealed Resident 2 was transferred to the hospital for malaise, fatigue and low blood pressure. The resident was diagnosed with UTI , septic syndrome secondary to UTI, acute kidney injury, anemia, hypoalbuminemia (abnormally low blood level of albumin (type of protein)), gastric outlet obstruction, gastrointestinal bleed and severe anion gap metabolic acidosis (imbalanced electrolytes). On 5/16/22, after discussion of options with the family, the residents POLST was changed to DNR and the resident passed away on 5/17/22. The 5/24/22 Death Certificate revealed Resident 2's immediate cause of death was severe sepsis with septic shock, approximate onset to death, one day, due to pseudomonas UTI, approximate onset to death, five days. Other significant conditions contributing to death gastric outlet obstruction. There was no evidence in the medical record the provider was notified of the residents decreased appetite, fluid intake, urine output, low blood pressure, increased confusion, irritability or malaise. There was no evidence of monitoring of signs and symptoms of UTI. On 12/21/22 at 9:25 AM Resident 16 (roommate) verified she was Resident 2's roommate and stated the week prior to her/his transfer to the hospital Resident 2 had increased irritability and was in pain. On 12/19/22 12:30 PM Staff 6 (Former NA) stated the week prior to Resident 2 transferring to the hospital her/his urine was brown in color and had increased confusion. On 12/19/22 at 2:21 PM Staff 11 (CNA) stated in the two weeks prior to Resident 2's hospital transfer she/he was pretty confused, tired, had a poor appetite, irritable, pretty out of it and the urine bag was not looking like it should. Staff 11 stated she recalled the nurses looking at the resident's urine bag but had no idea what the nurses did. On 12/19/22 at 3:10 PM Staff 13 (LPN) stated staff were monitoring Resident 2's urine for amber color. On 12/20/22 at 2:00 PM Staff 4 (Administrator in Training) recalled talking the Resident 2's sister about her concerns of Resident 2's health related to cognition, loss of appetite, getting up less and concerns of UTI. Staff 4 stated I finally asked [staff] to send her out so they did. On 12/20/22 at 3:30 PM Staff 16 (LPN) verified she wrote the 5/6/22 progress note, confirmed the resident was very irritable, refused the catheter change and had a blood pressure of 71/49. Staff 16 verified she did not further assess the resident or notify the physician of the low blood pressure, irritability or refusal of the catheter change. On 12/20/22 at 3:35 PM Staff 35 (LPN) stated the week prior to Resident 2's hospital transfer she/he was very irritable which was not normal because she/he was usually sweet and pleasant. On 12/21/22 at 9:50 AM Staff 7 (CNA) stated in the two weeks prior to Resident 2's hospital transfer she/he ate less because she didn't feel good enough to eat and needed more encouragement to attempt to eat and drink. Staff 7 further stated she noted a decline in Resident 2's overall abilities. On 12/21/22 at 9:59 AM Staff 5 (Support RN) verified between 5/2/22 through 5/16/22 there was only one alert note related to monitoring the resident's urine or for signs of UTI. On 12/21/22 at 10:10 AM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged Resident 2's care plans were not followed and the low blood pressure was not reported to the physician or assessed. Staff 1 and Staff 2 acknowledged the resident's decline in condition was not assessed and the physician was not notified until 5/16/22. Staff 1 acknowledged the 5/24/22 Death Certificate revealed Resident 2's immediate cause of death was severe sepsis with septic shock, approximate onset to death, one day, due to pseudomonas UTI, approximate onset to death five days. Other significant conditions contributing to death gastric outlet obstruction. On 12/21/22 at 12:08 PM the facility was notified of the Immediate Jeopardy (IJ) situation and an immediacy removal plan was requested. On 12/21/22 at 2:44 PM the facility submitted an acceptable immediacy removal plan which would abate the IJ situation. The immediacy removal plan included the following: *All residents with signs and symptoms of UTI will be monitored and provider would be notified via SBAR to assure residents were being treated timely and appropriately. RCM's (Resident Care Managers) would monitor residents who ate less than 50% for two or more meals. The RCMs would assess if the resident needed to stay on alert or if it was an indication of a problem that needed to be further assessed by the provider. *All residents had the potential to be affected. *All licensed nurses would be re-educated on the signs and symptoms of UTI including decreased urine output, pain, burning, blood-tinged urine, cloudiness, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior and change in eating pattern. The nurses would be re-educated on the new alert process, when to notify the provider and how it relates to addressing a resident with any of the above symptoms. Education would begin on 12/21/22 and be completed by 12/22/22 at 12:00 PM. *Random weekly audits of resident progress notes would be done for 30 days by the DNS or designee to ensure any reports of signs and symptoms of UTI were addressed appropriately. *Results of these audits would be reviewed by the QAPI (Quality Assurance Process and Improvement) team to determine if further auditing was necessary. On 12/21/22 3:06 PM through 12/22/22 7:58 PM staff interviews were completed and verified re-education per the POC was completed. A review of facility documentation revealed all aspects of the POC was implemented. On 12/22/22 at 7:58 AM it was determined the immediacy was removed.

Based on interview and record review it was determined the facility failed to correct and monitor a quality deficiency identified on the previous survey related to resident elopement and to respond to adverse events timely. This failure was determined to be an immediate jeopardy situation because the facility failed to prevent Resident 9's elopement from the facility three times since the 10/20/22 QAPI committee meeting. Findings Include: The 10/21/22 State Operations Manual, Appendix PP instructs facilities to create a formal action plan for identified deficiencies which included determining contribution causes of the problem; measurable goals, step by step interventions to correct the problem and achieve stable goals, and a description of how the QAPI committee would monitor the concern to ensure changes yield the expected results. The 3/28/22 Annual Survey identified a resident elopement as an immediate jeopardy situation. The 4/21/22 QAPI meeting notes revealed the QAPI team discussed the 3/28/22 Survey results. No other discussion or plan was documented related to elopement. The 7/21/22 QAPI meeting notes revealed a review of weekly elopement audits were completed to ensure the elopements were reported as necessary and monthly audits of residents who were at risk for elopement to ensure interventions were in place to prevent elopement. The 10/20/22 QAPI meeting notes revealed a review of the monthly audits of residents who were at risk for elopement to ensure interventions were in place to prevent elopement. Audits revealed not all resident care plans were up to date. The Administrator's report revealed audits of elopements were completed to ensure they were reported as necessary. Two elopements (Resident 20 and Resident 21) occurred and were reported. The recommendation was to discontinue further auditing the following month. A review of the facilities QAPI meeting notes revealed no formal action plan for resident elopement. Resident 9 eloped from the facility on 11/17/22, 12/12/22 and 12/27/22. On 12/12/22 and 12/27/22 Resident 9 was found on [NAME] street heading toward Lancaster Road which is a highly congested four lane road. There is no crosswalk at the intersection of [NAME] and Lancaster and both roads offer minimal lighting. The resident was walking outside, inappropriately dressed, in the winter weather late at night. The resident's goal was to walk the 0.6 miles to Fred [NAME] to obtain rocky road ice cream although she/he was aware she/he did not have any money. Resident 9's elopement from the facility on 11/17/22, 12/12/22 and 12/27/22 was identified as an immediate jeopardy situation. There was no evidence the QAPI team met after Resident 9's elopement. There was no evidence the facility made a good faith effort to correct the identified deficiency related to elopement from the 3/28/22 Annual Survey. Review of facility records revealed the facility failed to collect relevant data and monitor their system for resident elopement. This resulted in a lack of adequate action to correct the systemic high risk issue which created a situation where residents were likely to experience serious injury, harm or death. On 1/9/23 at 1:30 PM Staff 39 (anonymous QAPI member) stated the follow-up to identified concerns was a mess as they were mentioned in title but the QAPI team did not analyze the data which was collected. On 1/10/23 at 8:27 AM Staff 40 (anonymous QAPI member) stated much of the QAPI meeting conversations went over her/his head and she/he did not understand much of the conversation. Staff 40 was unable to explain the QAPI process for reviewing identified concerns, stated the QAPI team could do better at monitoring and analyzing the data brought to the team and stated communication was a problem. On 11/10/23 at 11:30 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 3 (LPN, Assistant DNS) were interviewed for QAPI. Staff 1 stated she considered the POC (plan of correction) for the 3/28/22 Annual Survey to be the Action Plan. Staff 1 acknowledged while resident elopement had been reviewed in QAPI since the 3/28/22 survey, resident elopement had not been corrected and further stated she did not know if the facility would ever stop people from eloping. Staff 1 stated the facility was trying to ensure there was no bad outcome, the focus was to prevent harm and the prevention of resident elopement might not be ever 100%. Staff 1 acknowledged the QAPI committee may meet quarterly, monthly or as needed. Staff 1 and Staff 3 did not answer what would trigger an as need QAPI meeting. Staff 1, Staff 2 and Staff 3 confirmed a formal QAPI meeting was not held after any of Resident 9's facility elopements. Staff 1 confirmed the goals from the facilty audits changed each quarter and included both reporting elopements, adding moderate elopement risk residents to the Code Green book and ensuring care plan interventions were in place to prevent elopements. Staff 1 acknowledged no long-term goals related to the prevention of elopement were in place. On 1/10/23 at 1:55 PM the facility was notified of the Immediate Jeopardy (IJ) situation and an immediacy removal plan was requested. On 1/10/23 at 3:37 PM the facility submitted an acceptable immediacy removal plan which would abate the IJ situation. The immediacy removal plan included the following: *A formal action plan would be developed and implemented by the QAPI team to include: contributing causes of the problem, measurable goals, step by step interventions to correct the problem, achieve stable goals and description of how the QAPI committee would monitor to ensure changes yield the expected results. *All residents who are at risk for elopement have a potential to be affected by this. *QAPI team would received education on the formal action plan. *Education would begin on 1/1/23 and would be completed by 1/11/23 at 3:00 PM or upon return if on leave of absence prior to working with residents. *Random weekly audits of the action plan would be done to ensure that relevant data was collected and the elopement system was being followed for 30 days. The audits would continue monthly until next QAPI meeting. Results of the audits would be reviewed by the QAPI team at the time to determine if further auditing was necessary. On 1/11/23 from 12:15 PM through 1/11/23 at 1:06 PM staff interviews were completed which verified re-education per the immediacy removal plan was completed. A review of facility documentation revealed all aspects of the immediacy removal plan was implemented. On 1/11/23 PM at 1:08 it was determined the IJ situation was abated.

Based on interview and record review it was determined the facility failed to ensure a resident and resident's representative had the right to direct her/his own care, refuse hospice and be aware of all treatment options for 1 of 3 sampled residents (#5) reviewed for hospice. This caused Resident 5 to be admitted to hospice and sustained a distressing and diminshed quality of life prior to death. Finding include: Resident 5 admitted to the facility on [DATE] with diagnoses including heart failure and chronic pleural effusion (an excessive accumulation of fluid in the lungs pleural space). The resident died on [DATE]. On [DATE] Resident 5 admitted with a PleurX catheter (a small, flexible tube that doctors place within the patient's chest to drain fluid from the pleural space). [All licensed nurses within the State of Oregon may drain the catheter with proper training.] The [DATE] admission Orders directed staff to drain the PleurX catheter to a maximum 1,000 cc removal at a time, note the amount drained and to notify the physician if the SpO2 (oxygen saturation) was less than 90%. The [DATE] Physician Order indicated the catheter was to be drained at a clinic or hospital only; every Monday, Wednesday and Friday. [There was no documentation the facility informed the physicin it was within the nurse's scope of practice to drain the catheter.] The facility's staffing records revealed between [DATE] through [DATE] one and a half to three RN's were on duty daily in addition to multiple LPN's. A [DATE] provider encounter noted revealed there was a concern with getting Resident 5's PleurX catheter drained. The provider noted the resident had great self awareness of when this needs to happen. And reporting that [she/he] is having difficulty breathing and needing it. The provider spoke with the DNS and it was determined if the facility had no staff available to drain the catheter then to transfer the resident to the hospital. The [DATE] Progress Note's revealed Resident 5 was transferred to the hospital for increased pulse and shortness of breath. The hospital drained 2,000 cc from the catheter. A [DATE] provider note indicated she spoke with Resident 5's healthcare POA, discussed concerns of ongoing draining of the PleurX catheter and after a long discussion of options for draining at the facility it was decided to update the POLST form for DNR comfort only and refer Resident 5 to hospice. A [DATE] Hospice note reveals Resident 5 was admitted to hospice services. A [DATE] Progress Note revealed the resident made comments about harming her/himself, asked for a hammer because she/he hurt so bad and asked the CNA if she could help her/him kill her/himself. A [DATE] Progress Note revealed Resident 5's healthcare POA was upset because she was not told why the facilty could not drain Resident 5's PleurX catheter. The note further stated the goal was to transition the resident off of hospice so they could obtain aggressive treatment with a specialist but they needed home health set up first so the resident would not have to go to the hospital to get the PleurX catheter drained. The healthcare POA stated she understood the resident may not live much longer but still did not want hospice at this time. A [DATE] Progress note revealed they spoke with Resident 5's daughter about the PleurX catheter and how we were unable to meet [her/his] needs due to the licensing of our nurses and not having an RN to do it. Options were discussed and it was decided the facility would look for alternative placement but to keep the resident on hospice so they could manage the drain. The [DATE] Discharge Summary note indicated the funeral home picked the resident up. [There were no notes related to the residents passing in the medical record.] On [DATE] at 8:47 AM Witness 7 (Complainant) stated the facility did not want to provide care and services for the PleurX catheter and placed the resident on hospice against her/his will. Resident 5's family notified Witness 7 that they did not want hospice but felt like their back was against the wall. The resident was admitted to the facility specifically for the facility to manage the catheter however care did not happen and she/he was sent to the hospital for catheter care. Resident 5 and family were given the decision to either send the resident to the hospital for routine catheter care or go onto hospice. Witness 7 stated she reached out the the facility to coordinate nurse education if that was what was needed and offered to have a provider or the catheter company provide a tutorial which the facility declined. The facility stated this [PleurX catheter] was something they did not do. Witness 7 stated care facilities should be able to manage the catheter and even lay people can be taught to do it. On [DATE] at 8:58 AM an interview was conducted with Staff 1 (Administrator), Staff 2 (DNS) and Staff 3 (LPN, Assistant DNS). Staff 1 stated the facility did not know how to care for the catheter, did not have sufficient RN staffing to care for the resident and the facility was unaware the resident had a PleurX catheter on admission but verified this information was in the resident's admission paperwork which they reviewed prior to the resident's admission. Staff 1 stated she declined training offered by the Resident's Case Manger and verified the resident went on hospice to avoid hospital emergency room visits. On [DATE] in the AM Staff 1 and Staff 3 stated they were unaware LPN's were allowed to provide care and services related to the PleurX catheter with proper training. Staff 1 verified when treatment alternatives to hospice were discussed training the LPN's was not discussed.

Based on observation, interview and record review the facility failed to ensure residents were free from neglect. The facility failed to ensure a resident had the right to receive skilled care from trained nurses and refuse hospice, failed to ensure resident assessments were completed timely, care plans were reviewed, interventions in place and implemented, failed to assess and monitor pressure ulcers and follow physician orders for skin conditions, failed to recognize and act on a change of condition, and failed to ensure residents did not elope from the facility. The cumulative effect of these failures in providing care and services contributed to an environment of neglect for 8 of 15 sampled residents (#s 2, 3, 4, 5, 9, 11, 13 and 15) reviewed for care and services. This caused Resident 5 to not get physician ordered treatment and coerced to agree to hospice services and placed all residents at risk for neglect of care. Findings include: According to the Centers for Medicare & Medicaid Services (CMS), S483.5, Neglect, means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. CHANGE OF CONDITION Resident 2 Resident 2 admitted to the facility in 4/2022 with diagnoses including intellectual disabilities and neurogenic bladder. The 3/11/22 Risk For Infection related to the use of a urinary catheter care plan included the following interventions: change catheter and Foley (catheter) bag as scheduled or as ordered by the physician, monitor the indwelling catheter and report to the physician signs and symptoms of UTI such as pain, burning, blood tinged urine, cloudiness, no urine output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior and change in eating patterns. The 4/6/22 Return From Hospital care plan interventions included to monitor appetite and document the percentage eaten each meal and to monitor pain and discomfort. A 4/29/22 Progress note revealed Resident 2's urine was cloudy with foul smell, had increased agitation and a UA (urinalysis) was collected. A 5/4/22 Progress note revealed a negative UA result. The 5/4/22 task documentation revealed Resident 2's UOP (urine output) was 1150 cc. Meal intake for breakfast was 26 to 50%, lunch zero to 25% and dinner was refused. Fluid intake was 980 cc. A 5/6/22 Progress note revealed Resident 2 was very irritable and refused the catheter change. Blood Pressure was 71/49 [No evidence of physician notification or assessment or monitoring was completed.] The 5/6/22 task documentation revealed Resident 2's UOP was 675 cc, fluid intake was 460 cc and meal intake for breakfast and lunch was zero to 25% and dinner 26 to 50%. A 5/7/22 Progress Note revealed Resident 2 was on alert due to having cloudy urine, having increased sediment and foul odor. The 5/8/22 task documentation revealed fluid intake was 540 cc. The 5/9/22 task documentation revealed the resident consumed zero to 25% of all meals and fluid intake was 360 cc. The 5/10/22 task documentation revealed fluid intake was 270 cc. Meal intake for breakfast was 26 to 50%, lunch zero to 25% and refused dinner. The 5/11/22 task documentation revealed 500 cc UOP, 780 cc fluid intake and meal intake varied from zero to 75%. The 5/12/22 task documentation revealed 475 cc UOP, 120 cc fluid intake, meal intake for breakfast and dinner was refused, lunch was zero to 25%. The resident took in additional nutrition in the evening between 75-100%. The 5/13/22 task documentation revealed 950 cc UOP, Fluid intake was 240 cc with one meal intake not documented and meal intake zero to 25% for breakfast and dinner and lunch was not documented. The 5/14/22 task documentation revealed 560 cc UOP, 740 cc fluid intake, breakfast and dinner refused with zero to 25% lunch meal intake. The 5/16/22 task documentation revealed UOP was 25 cc on night shift and 260 cc on day shift. Fluid intake was 20 cc for breakfast and 120 cc for lunch. Meal intake was zero to 25% for breakfast and lunch. The 5/16/22 12:01 PM Progress note revealed a CNA reported Resident 2 was not acting like [her/himself] today. Blood pressure was 94/59, resident stated she/he felt unwell and was unable to describe any specific symptoms. The urine was red/brown tinged and mucus was present. The residents speech was slurred. The provider was called and staff were waiting for a call-back. The 5/16/22 2:00 PM Progress note revealed the provider called back and gave orders to push fluids, administer an antibiotic shot, change the indwelling catheter and to obtain a stat [immediate] UA. The 5/16/22 provider encounter note revealed the resident was seen for a concern of a possible UTI. The urine was reported to have foul odor and was cloudy with a dark color. The catheter was changed and the urine was clear after the indwelling catheter change. The resident complained of stomach and ear pain. The 5/16/22 2:38 PM indicated the resident was transported to the hospital for altered mental status and hypotension (low blood pressure). The 5/17/22 Progress note revealed the hospital notified the facility the resident passed away with a small bowel obstruction, UTI, sepsis (full body infection) and acute renal failure. The 5/17/22 Hospital Records revealed Resident 2 was transferred to the hospital for malaise, fatigue and low blood pressure. The resident was diagnosed with UTI , septic syndrome secondary to UTI, acute kidney injury, anemia, hypoalbuminemia (abnormally low blood level of albumin (type of protein)), gastric outlet obstruction, gastrointestinal bleed and severe anion gap metabolic acidosis (imbalanced electrolytes). On 5/16/22, after discussion of options with the family, the residents POLST was changed to DNR and the resident passed away on 5/17/22. The 5/24/22 Death Certificate revealed Resident 2's immediate cause of death was severe sepsis with septic shock, approximate onset to death, one day, due to pseudomonas UTI, approximate onset to death, five days. Other significant conditions contributing to death gastric outlet obstruction. There was no evidence in the medical record the provider was notified of the residents decreased appetite, fluid intake, urine output, low blood pressure, increased confusion, irritability or malaise. There was no evidence of monitoring of signs and symptoms of UTI. On 12/21/22 at 9:25 AM Resident 16 (roommate) verified she was Resident 2's roommate and stated the week prior to her/his transfer to the hospital Resident 2 had increased irritability and was in pain. On 12/19/22 12:30 PM Staff 6 (Former NA) stated the week prior to Resident 2 transferring to the hospital her/his urine was brown in color and had increased confusion. On 12/19/22 at 2:21 PM Staff 11 (CNA) stated in the two weeks prior to Resident 2's hospital transfer she/he was pretty confused, tired, had a poor appetite, irritable, pretty out of it and the urine bag was not looking like it should. Staff 11 stated she recalled the nurses looking at the resident's urine bag but had no idea what the nurses did. On 12/19/22 at 3:10 PM Staff 13 (LPN) stated staff were monitoring Resident 2's urine for amber color. On 12/20/22 at 2:00 PM Staff 4 (Administrator in Training) recalled talking the Resident 2's sister about her concerns of Resident 2's health related to cognition, loss of appetite, getting up less and concerns of UTI. Staff 4 stated I finally asked [staff] to send her out so they did. On 12/20/22 at 3:30 PM Staff 16 (LPN) verified she wrote the 5/6/22 progress note, confirmed the resident was very irritable, refused the catheter change and had a blood pressure of 71/49. Staff 16 verified she did not further assess the resident or notify the physician of the low blood pressure, irritability or refusal of the catheter change. On 12/20/22 at 3:35 PM Staff 16 (LPN) stated the week prior to Resident 2's hospital transfer she/he was very irritable which was not normal because she/he was usually sweet and pleasant. On 12/21/22 at 9:50 AM Staff 7 (CNA) stated in the two weeks prior to Resident 2's hospital transfer she/he ate less because she didn't feel good enough to eat and needed more encouragement to attempt to eat and drink. Staff 7 further stated she noted a decline in Resident 2's overall abilities. On 12/21/22 at 9:59 AM Staff 5 (Support RN) verified between 5/2/22 through 5/16/22 there was only one alert note related to monitoring the resident's urine or for signs of UTI. On 12/21/22 at 10:10 AM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged Resident 2's care plans were not followed and the low blood pressure was not reported to the physician or assessed. Staff 1 and Staff 2 acknowledged the resident's decline in condition was not assessed and the physician was not notified until 5/16/22. Staff 1 acknowledged the 5/24/22 Death Certificate revealed Resident 2's immediate cause of death was severe sepsis with septic shock, approximate onset to death, one day, due to pseudomonas UTI, approximate onset to death five days. Other significant conditions contributing to death gastric outlet obstruction. On 12/21/22 at 12:08 PM the facility was notified of the Immediate Jeopardy (IJ) situation and a plan of care was requested. Refer to F690 ELOPEMENT Resident 9 Resident 9 admitted to the facility in 2022 with diagnoses including symptoms involving cognitive functions following other nontraumatic intracranial hemorrhage and cataracts. Prior to admission, the resident was homeless. The Elopement Risk Care Plan, last revised on 12/28/22, revealed Resident 9 was a high elopement risk related to impaired safety awareness; both physical and environmental. The resident had eloped on 11/17/22, 12/12/22 and 12/27/22. The interventions included to remind the resident to notify staff if she/he planned to leave the facility as needed (11/18/22), resident was high fall risk (11/18/22), to not seat the resident in the lobby near the doors without supervision at any time of the day or night. If the resident was up during late night hours to have her/him close to the nurse's station where she/he could be monitored. To walk with the resident if she/he wanted to walk, sit and talk with the resident, attempt to engage the resident to watch television, look at a magazine, offer fluids and snack. If not redirectable, alert the charge nurse, RN, resident care manager or DNS (12/14/22). Remind the resident of the sign posted in her/his room to not leave the facility without assistance for her/his safety and to show her/him the sign above the television (12/15/22). Activities to check in with the resident regularly to see if she/he needed anything from the store and to let nursing know to minimize the desire to exit the facility (12/16/22). Offer Resident 9 a bowl of ice cream (rocky road) every evening sometime after dinner and before bed time. If Resident 9 ambulated toward the front lobby late at night offer the ice cream again (12/28/22). The 9/27/22 Communication Care Plan revealed Resident 9 had a communication problem related to expressive aphasia (a form of aphasia when the person knows what they want to say but are unable to produce the words or sentence. Can be mild to severe), slurring, stroke, weak or absent voice. Interventions included to allow adequate time to respond, face the resident when speaking and make eye contact, ask yes/no questions if appropriate, use simple, brief, consistent words/cues, use alternative communication tools as needed. The resident was able to say yes or no and very short sentences and could shake/nod her/his head. Speak to the resident in a calm, quiet voice because she/he responded better with this approach. Speak on an adult level, speak clearly and slower than normal. The 11/17/22 Incident Note revealed staff noted Resident 9 was not in her/his room, was assisted to bed at 7:00 PM, last seen between 8:15 and 8:30 PM and found on the lawn outside the 200 hall door. The 11/18/22 Wandering Risk Assessment identified Resident 9 as a moderate wander risk. Resident 9 was forgetful, had a short attention span, independent with aid for mobility, early dementia, on antidepressants and had a history of wandering. The 11/18/22 facility investigation revealed the resident was found outside. When interviewed the resident indicated she/he was going to Fred [NAME] for rocky road ice cream. [Fred [NAME] is a store 0.6 miles away from the facility. The resident would have to walk up [NAME] Street, which facility resides on, towards Lancaster Drive which is a highly congested four lane road. The intersection of [NAME] and Lancaster has no intersection and both roads offer minimal lighting.] The 12/6/22 BIMs score was 9 which suggested the resident had moderately impaired cognition. The 12/12/22 Progress Note revealed Resident 9 walked out of the facility around 8:00 PM. The resident wore a sweater, was found down the street walking with her/his walker. The temperature was around 40 degrees and [she/he] was not dressed appropriately. The resident was non-verbal; unable to say why she/he left or where she/he was going. The 12/12/22 Elopement Event identified Resident 9 as an elopement risk, the resident eloped off facility grounds when she/he was left unattended in the front lobby and the resident was disoriented to some-spheres some of the time. The assessment revealed the resident was homeless prior to admission and was not afraid to go out at night. The resident was alert and able to converse most of the time, was slow to answer and very soft spoken which could be misconstrued for non-responsive or cognitive impairment. The 12/13/22 Wandering Risk Assessment identified Resident 9 as a moderate wander risk. Resident 9 was forgetful, had a short attention span, ambulated with one person assistance, early dementia, on antidepressants and had a history of wandering. The 12/13/22 Incident Note revealed Resident 9 was alert and able to converse most of the time but was slow to answer and very soft spoken. Resident 9 stated she/he was going to Fred [NAME]'s for ice cream. Resident 9 stated rocky road was her/his favorite ice cream. The resident stated she/he did not have money for ice cream and stopped responding to the interviewer when repeatedly asked how she/he would have paid for the ice cream. The 12/13/22 BIMs was 14 which indicated the resident was cognitively intact. The 12/14/22 Care Conference Notes revealed safety concerns as the resident had exited the facility twice since admission. The resident stated she/he was going to Fred [NAME]'s to get ice cream. It was arranged the resident would be asked weekly if she/he needed anything and ice cream would be available. The 12/28/22 Progress Note revealed Resident 9 walked down the hall around 11:20 PM [on 11/27/22]. The resident walked to the lobby and sat down. Staff asked what she/he needed but the resident did not respond. The CNA sat with the resident for a few minutes but when she went to answer another call light [she/he] left out the front door. The nurse went to check on the resident five minutes later and the resident was gone. Four staff initiated a search, first searching the facility and then outside. Resident 9 was found walking past the park on [NAME] Street. The resident was non-verbal and would not answer any questions. The temperature outside was 50 degrees and raining; the resident wore sweat pants and a T-shirt. The 12/28/22 Progress Note revealed the resident care manager spoke with the resident in the morning and the resident stated she/he was walking to Fred [NAME] for ice cream. When asked if she/he had a bowl of ice cream every night would keep her/him from wanting to go outside, the resident nodded yes. The 12/28/22 Wandering Risk Assessment revealed Resident 9 was a moderate risk for wandering. The resident was forgetful, had a short attention span, did not understand surroundings, independent with mobility, on antidepressants and had a history of wandering. The 12/28/22 facility investigation revealed when Resident 9 eloped staff had not followed the care plan. On 12/28/22 at 5:04 PM Staff 21 (Resident Care Manager) stated Resident 9 exit sought at night between 8:00 PM and 11:00 PM, was homeless prior to admission and did not feel any danger when outside at night. Staff 21 stated Resident 9 always wanted to go to Fred [NAME] to get rocky road ice cream when interviewed. Resident 9 knew she/he did not have any money and would not state how she/he would pay for the ice cream. Staff 21 stated the ice cream was in the activity room but hadn't had any of it. Staff 21 stated although Resident 9 had some cognitive issues she/he had not lost everything and waited until no staff was looking before exiting the building. Staff 21 confirmed Resident 9's care plan instructed not to leave her/him unsupervised in the front lobby which staff did on 12/27/22 when she/he eloped. On 12/28/22 at 5:16 PM Staff 22 (CNA) stated he and another staff member observed Resident 9 walk to the front lobby so he went to check on her/him. Resident 9 was ok and I didn't know [she/he] was going to try to escape. Staff 22 further stated ten or 15 minutes after he checked on the resident a nurse called him and informed him she thought Resident 9 got out so the staff started to look for her/him. Staff 22 stated this was the first time he worked with Resident 9, was not aware to not leave Resident 9 alone in the front lobby and had not read the care plan. On 12/28/22 at 5:33 PM Staff 16 (LPN) verified she worked on 12/27/22 when the resident eloped and stated there was no ice cream available after hours and she could not get into the activity room at night or if she was she was unaware of it. Staff 16 verified Resident 9 was left alone for approximately five minutes in the lobby prior to her/his elopement and stated she was not aware Resident 9's care plan instructed staff she/he was not to be left alone there. Staff 16 stated Resident 9 exit seeked at least once a week at night. On 12/28/22 at 7:30 PM Staff 20 (Social Service Director) confirmed Resident 9 eloped on 12/27/22 because the care plan was not followed. On 12/29/22 at 8:04 AM Staff 2 (DNS) stated the facility had identified 14 residents who were a moderate to high wander risk. Staff 2 confirmed on 12/27/22 Resident 9 was left alone in the front lobby and the resident's care plan was not followed which resulted in Resident 9's elopement off the facility grounds. On 12/29/22 at 9:16 AM Resident 9 stated when she/he left the facility, it was to go to either Fred [NAME] or Walmart to get ice cream. Resident 9 stated if staff offered her/him ice cream she/he would not leave. On 12/29/22 at 10:06 AM the facility was notified of the Immediate Jeopardy (IJ) situation and a plan of care was requested. Refer to F689 QUALITY OF CARE The 2/12/22 Facility Assessment indicated the facility cared for residents with the following respiratory conditions: chronic obstructive pulmonary disease, pneumonia, asthma, chronic lung disease and respiratory failure. The assessment indicated for decisions related to caring for residents with conditions not listed above, the facility would review documentation and when there was a condition they were not familiar with they would ask questions and do some research to see if the care they would need would be something we could manage. If training was needed prior to admission the facility world request training from the hospital. If a condition developed during a resident's stay they were not familiar with the facility could reach out to the pharmacy or Medical Director for any education which could be offered. Finally, the Facility Assessment revealed six to nine licensed nurses would be scheduled every day to provide direct care to the residents. Additional licensed nursing staff included one DNS, one Assistant DNS and two Resident Care managers. Resident 5 admitted to the facilty on 3/4/22 with diagnoses including heart failure and chronic pleural effusion (an excessive accumulation of fluid in the lungs pleural space). Resident 5 admitted with a PleurX catheter (a small, flexible tube that doctors place within the patient's chest to drain fluid from the pleural space.) [All licensed nurses within the State of Oregon may drain the catheter with proper training.] The facility's staffing records revealed between 3/4/22 through 3/22/22 one and a half to three RN's were on duty daily in addition to multiple LPNs. The 3/4/22 Admission orders directed staff to drain the Pleurx catheter to a maximum 1,000 cc removal at a time, note the amount drained and to notify the physician if the SpO2 (oxygen saturation) was less than 90%. The 3/4/22 Progress Note revealed a nurse to nurse report was received from the hospital and indicated Resident had a chronic right lung pleural effusion with a drain. It was last drained on 3/3/22, was scheduled to be drained every other day and to not remove more than one liter of fluid (1,000 cc). The 3/4/22 Nursing Admission Assessment did not reveal the presence of the PleurX catheter. The skin integrity assessment documented a bandage on chest; did not remove. The March 2022 TARs revealed the following orders: * 3/6/22: Drain the PleurX catheter a maximum of 1,000 cc at a time and to record the amount drained. Note if Resident 5 had a SpO2 under 90%. The 3/6/22 entry was blank. * 3/7/22 through 3/9/22: Drain the PleurX catheter a maximum of 1,000 cc at a time and to record the amount drained. Note if Resident 5 had a SpO2 under 90%. On 3/7/22 documentation revealed 1,000 cc of fluid was drained from the catheter. The 3/9/22 entry was blank. *3/7/22: sterile dressing change weekly and PRN with dry gauze and occlusive dressing to PleurX site. Every Monday day shift. It was documented as completed on 3/7/22 and 3/21/22. On 3/14/22 it was documented as 9 and left blank on 3/28/22. * 3/9/22: Drain PleurX catheter only at clinic or hospital. The 3/9/22 provider encounter note revealed there was a concern with getting Resident 5's PleurX catheter drained and [the provider] was requested to see patient urgently via telemedicine in order to do a face-to-face for home health for assistance with Pleurx [sic] catheter related to recurrent pleural effusions. The provider noted the resident had great self awareness of when this needs to happen. And reporting that [she/he] is having difficulty breathing and needing it. The provider spoke with the DNS and it was determined if the facility had no staff available to drain the catheter then to transfer the resident to the hospital. The provider further noted the effort to leave their domicile to obtain outpatient services would be taxing and overburdensome for this patient. [There was no evidence the facility informed the physician it was within the nurse's scope of practice to drain the catheter.] The 3/9/22 Progress Notes revealed Resident 5 was transferred to the hospital for increased pulse and shortness of breath at 9:37 AM, the hospital drained 2,000 cc from the catheter and the resident returned to the facilty at 3:00 PM. The 3/9/22 updated Physician Order indicated the catheter was to be drained at a clinic or hospital only. Every Monday, Wednesday and Friday. The 3/11/22 provider note indicated Resident 5 experienced shortness of breath although 2,000 cc was drained from the catheter two days prior. The provider spoke with Resident 5's healthcare POA, discussed concerns of ongoing draining of the PleurX catheter and after a long discussion of options for draining at the facility it was decided to update the POLST form for DNR comfort only and refer Resident 5 to hospice. The 3/11/22 Progress Note revealed Hospice was ordered and they would manage and drain the PleurX catheter. The 3/17/22 Progress Note revealed Resident 5 healthcare POA was upset because she was not told why the facility could not drain Resident 5's PleurX catheter and wanted to transition Resident 5 off of hospice but needed home health set up first so the resident would not have to go to the hospital to get the catheter drained. The 3/21/22 Progress Note revealed the facility spoke with Resident 5's daughter about the PleurX catheter and how we were unable to meet [her/his] needs due to the licensing of our nurses and not having an RN to do it. Options were discussed and it was decided the facilty would look for alternative placement but to keep the resident on hospice so they could manage the drain. On 12/28/22 at 8:47 AM Witness 7 (Complainant) stated the facility did not want to provide care and services for the PleurX catheter and placed the resident on hospice against her/his will. Resident 5's family notified Witness 7 that they did not want hospice but felt like their back was against the wall. The resident was admitted to the facility specifically for the facility to manage the catheter however care did not happen and she/he was sent to the hospital for catheter care. Resident 5 and family were given the decision to either send the resident to the hospital for routine catheter care or go onto hospice. Witness 7 stated she reached out to the facility to coordinate nurse education if that was what was needed and offered to have a provider or the catheter company provide a tutorial which the facility declined. The facilty stated this [PleurX catheter] was something they did not do. Witness 7 stated care facilities should be able to manage the catheter and even lay people can be taught to do it. On 12/25/22 at 8:58 AM an interview was conducted with Staff 1 (Administrator), Staff 2 (DNS) and Staff 3 (LPN, Assistant DNS). Staff 1 stated the facility did not know how to care for the catheter, did not have sufficient RN staffing to care for the resident and the facilty was unaware the resident had a PleurX catheter on admission but verified this information was in the resident's admission paperwork which they reviewed prior to the resident's admission. Staff 1 stated she declined training offered by the Resident's Case Manager and verified the resident went on hospice to avoid hospital emergency room visits. On 12/29/22 in the AM Staff 1 and Staff 3 stated they were unaware LPN's were allowed to provide care and services related to the PleurX catheter with proper training. F684 and F726 RESIDENT ASSESSMENTS, CARE PLAN INTERVENTIONS Resident 15 admitted to the facility in 2020 with diagnoses including end stage renal disease and a hip fracture. The 10/14/22 Annual MDS indicated the resident was cognitively intact, required extensive assistance with bed mobility, was non-ambulatory, and had a history of falls. An 11/24/22 Fall Investigation indicated Resident 15 fell out of bed while reaching down for something and hit her/his head on the floor. The resident stated, I was laying on the edge of the bed and I felt myself sliding down and I tried to grab for something, and I fell . The resident's call light was noted to be initiated. The investigation did not indicate how long the call light had been on. The resident was noted to have been last toileted and repositioned two hours prior to the fall. The resident's air mattress was noted to be a bit high so the air in the mattress was decreased. The resident requested side rails for her/his bed. On 1/3/23 at 9:25 AM Resident 15 stated she/he had pressed her/his call light as she/he was close to the edge of the bed. The resident stated she/he yelled I am going to fall, but by the time staff came to the room the resident was on the floor. Resident 15 stated her/his call light had been initiated for 30 minute and stated the long call light time happened all the time. Resident 15 stated right after the fall she/he had requested bed mobility bars, but she/he never received them. The resident's bed was observed to be without any bed mobility bars or side rails. Resident 15 further stated she/he almost fell out of bed a few days prior, but a staff member was able to prevent the fall and helped reposition the resident in the center of the bed. On 1/3/23 at 11:29 AM and 11:55 AM Staff 3 (LPN, Assistant DNS) acknowledged the investigation did not include how long Resident 15's call light was initiated. Staff 3 further stated the expectation was for the resident to have mobility bars per the resident's request and the resident did not currently have mobility bars on her/his bed. Refer to F689 Resident 11 admitted to the facility on [DATE] with diagnoses including osteoarthritis. The 10/15/22 Admission MDS was completed on 10/25/22; three days late. On 12/30/22 at 12:51 PM Staff 2 (DNS) verified the 10/15/22 Admission MDS was completed late. Refer to F636 Resident 3 admitted to the facility in 2020 with diagnoses including paraplegia (paralysis of the legs and lower body). Resident 3's 9/20/22 Annual MDS was completed on 10/5/22; one day late. On 12/28/22 at 9:12 AM Staff 2 (DNS) verified the 9/20/22 Annual MDS was completed one day late. Refer to F636 Resident 13 admitted to the facility on [DATE] with diagnoses including hypertension. The 7/26/22 Admission MDS was completed on 8/3/22; one day late. On 12/30/22 at 12:52 PM Staff 2 (DNS) verified the 7/26/22 Admission MDS was completed late. Refer to F636 ASSESSMENT AND MONITORING OF PRESSURE ULCERS Resident 3 admitted to the facility in 2020 with diagnoses including paraplegia (paralysis of the legs and lower body) and a chronic Stage 4 (full thickness skin and tissue loss) pressure ulcer. The August 2022 and September 2022 TARs revealed wound care was completed for Resident 3's coccyx wound. The Weekly Skin Evaluations revealed the following: *8/5/22: Stage 4 coccyx pressure wound which measured 0.5 cm x 0.5 cm x 0 cm. Treatment was in place and it appeared to be healing. [The assessment was not comprehensive.] *8/12/22: Stage 4 coccyx pressure wound which measured 3 cm x 5 cm x 0.5 cm. Treatment in place. Wound was larger, periwound was macerated, wound bed had slough, no foul odor, no complaints of pain. [The assessment was not comprehensive.] *8/19/22: Stage 4 coccyx pressure wound which measured 33.5 cm x 5 cm x 0.5 cm. Treatment in place. Wound was larger, periwound was macerated, wound bed had slough, no foul odor, no complaints of pain. [The assessment was not comprehensive.] *8/26/22: Stage 4 coccyx pressure wound which measured 33.5 cm x 5 cm x 0.5 cm. Treatment in place. Wound was larger, periwound was macerated, wound bed had slough, odor present, no complaints of pain. [The assessment was not comprehensive.] *9/2/22: Stage 4 coccyx pressure wound which measured 33.5 cm x 5 cm x 0.5 cm. Treatment in place. Wound was larger, periwound was macerated, wound bed had slough, odor present, no complaints of pain. [The assessment was not comprehensive.] Review of Resident 3's medical record revealed no further skin assessments until the 10/20/22 RN Wound Assessment. The RN Wound Assessments revealed the following: *10/20/22: Stage 3 (full thickness skin loss, may extend into the subcutaneous tissue layer) coccyx pressure wound which measured 4 cm x 1.2 cm x 0/7 cm. This was a chronic wound the resident had for years. Tunneling present at 6 o'clock measured 0.7 cm. The wound bed was 50% slough and 50% pale pink tissue. [Not a comprehensive assessment; downstaged wound.] *10/27/22: Stage 3 coccyx pressure wound which measured 3 cm x 1 cm x 0.6 cm. Tunnel at 6 o'clock was deeper and slough at wound base was thicker and covered most of the wound bed. [Not a comprehensive assessment; downstaged wound.] *10/29/22: Stage 3 coccyx pressure wound 90% slough and 10% pink tissue. [Not a comprehensive assessment; downstaged wound.] 11/3/22[TRUNCATED]

Based on interview and record review it was determined the facility failed to ensure a resident received the required care and services related to a drainage catheter and to follow physician orders for 2 of 4 sampled residents (#s 4 and 5) reviewed for catheters and skin conditions. This caused Resident 5 to experience an avoidable hospital transfer, pain, shortness of breath and an increased pulse rate. The facility failures placed residents at risk for delayed treatment and worsening wounds. Findings include: 1. The 2/12/22 Facility Assessment indicated the facility cared for residents with the following respiratory conditions: chronic obstructive pulmonary disease, pneumonia, asthma, chronic lung disease and respiratory failure. The assessment indicated for decisions related to caring for residents with conditions not listed above, the facility would review documentation and when there was a condition they were not familiar with they would ask questions and do some research to see if the care they would need would be something we could manage. If training was needed prior to admission the facility world request training from the hospital. If a condition developed during a resident's stay they were not familiar with the facility could reach out to the pharmacy or Medical Director for any education which could be offered. Finally, the Facility Assessment revealed six to nine licensed nurses would be scheduled every day to provide direct care to the residents. Additional licensed nursing staff included one DNS, one Assistant DNS and two Resident Care managers. Resident 5 admitted to the facilty on 3/4/22 with diagnoses including heart failure and chronic pleural effusion (an excessive accumulation of fluid in the lungs pleural space). Resident 5 admitted with a PleurX catheter (a small, flexible tube that doctors place within the patient's chest to drain fluid from the pleural space.) [All licensed nurses within the State of Oregon may drain the catheter with proper training.] The facility's staffing records revealed between 3/4/22 through 3/22/22 one and a half to three RN's were on duty daily in addition to multiple LPNs. The 3/4/22 Admission orders directed staff to drain the Pleurx catheter to a maximum 1,000 cc removal at a time, note the amount drained and to notify the physician if the SpO2 (oxygen saturation) was less than 90%. The 3/4/22 Progress Note revealed a nurse to nurse report was received from the hospital and indicated Resident had a chronic right lung pleural effusion with a drain. It was last drained on 3/3/22, was scheduled to be drained every other day and to not remove more than one liter of fluid (1,000 cc). The 3/4/22 Nursing Admission Assessment did not reveal the presence of the PleurX catheter. The skin integrity assessment documented a bandage on chest; did not remove. The March 2022 TARs revealed the following orders: * 3/6/22: Drain the PleurX catheter a maximum of 1,000 cc at a time and to record the amount drained. Note if Resident 5 had a SpO2 under 90%. The 3/6/22 entry was blank. * 3/7/22 through 3/9/22: Drain the PleurX catheter a maximum of 1,000 cc at a time and to record the amount drained. Note if Resident 5 had a SpO2 under 90%. On 3/7/22 documentation revealed 1,000 cc of fluid was drained from the catheter. The 3/9/22 entry was blank. *3/7/22: sterile dressing change weekly and PRN with dry gauze and occlusive dressing to PleurX site. Every Monday day shift. It was documented as completed on 3/7/22 and 3/21/22. On 3/14/22 it was documented as 9 and left blank on 3/28/22. * 3/9/22: Drain PleurX catheter only at clinic or hospital. The 3/9/22 provider encounter note revealed there was a concern with getting Resident 5's PleurX catheter drained and [the provider] was requested to see patient urgently via telemedicine in order to do a face-to-face for home health for assistance with Pleurx [sic] catheter related to recurrent pleural effusions. The provider noted the resident had great self awareness of when this needs to happen. And reporting that [she/he] is having difficulty breathing and needing it. The provider spoke with the DNS and it was determined if the facility had no staff available to drain the catheter then to transfer the resident to the hospital. The provider further noted the effort to leave their domicile to obtain outpatient services would be taxing and overburdensome for this patient. [There was no evidence the facility informed the physician it was within the nurse's scope of practice to drain the catheter.] The 3/9/22 Progress Notes revealed Resident 5 was transferred to the hospital for increased pulse and shortness of breath at 9:37 AM, the hospital drained 2,000 cc from the catheter and the resident returned to the facilty at 3:00 PM. The 3/9/22 updated Physician Order indicated the catheter was to be drained at a clinic or hospital only. Every Monday, Wednesday and Friday. The 3/11/22 provider note indicated Resident 5 experienced shortness of breath although 2,000 cc was drained from the catheter two days prior. The provider spoke with Resident 5's healthcare POA, discussed concerns of ongoing draining of the PleurX catheter and after a long discussion of options for draining at the facility it was decided to update the POLST form for DNR comfort only and refer Resident 5 to hospice. The 3/11/22 Progress Note revealed Hospice was ordered and they would manage and drain the PleurX catheter. The 3/17/22 Progress Note revealed Resident 5 healthcare POA was upset because she was not told why the facility could not drain Resident 5's PleurX catheter and wanted to transition Resident 5 off of hospice but needed home health set up first so the resident would not have to go to the hospital to get the catheter drained. The 3/21/22 Progress Note revealed the facility spoke with Resident 5's daughter about the PleurX catheter and how we were unable to meet [her/his] needs due to the licensing of our nurses and not having an RN to do it. Options were discussed and it was decided the facilty would look for alternative placement but to keep the resident on hospice so they could manage the drain. On 12/28/22 at 8:47 AM Witness 7 (Complainant) stated the facility did not want to provide care and services for the PleurX catheter and placed the resident on hospice against her/his will. Resident 5's family notified Witness 7 that they did not want hospice but felt like their back was against the wall. The resident was admitted to the facility specifically for the facility to manage the catheter however care did not happen and she/he was sent to the hospital for catheter care. Resident 5 and family were given the decision to either send the resident to the hospital for routine catheter care or go onto hospice. Witness 7 stated she reached out to the facility to coordinate nurse education if that was what was needed and offered to have a provider or the catheter company provide a tutorial which the facility declined. The facilty stated this [PleurX catheter] was something they did not do. Witness 7 stated care facilities should be able to manage the catheter and even lay people can be taught to do it. On 12/25/22 at 8:58 AM an interview was conducted with Staff 1 (Administrator), Staff 2 (DNS) and Staff 3 (LPN, Assistant DNS). Staff 1 stated the facility did not know how to care for the catheter, did not have sufficient RN staffing to care for the resident and the facilty was unaware the resident had a PleurX catheter on admission but verified this information was in the resident's admission paperwork which they reviewed prior to the resident's admission. Staff 1 stated she declined training offered by the Resident's Case Manager and verified the resident went on hospice to avoid hospital emergency room visits. On 12/29/22 in the AM Staff 1 and Staff 3 stated they were unaware LPN's were allowed to provide care and services related to the PleurX catheter with proper training. 2. Resident 4 admitted to the facility in 3/2022 with diagnoses including heart failure and dementia. An 8/12/22 Physician Order instructed staff to clean Resident 4's wounds daily in the first, second and third right webspaces with saline or wound cleanser and then to apply Bacitracin (antibiotic ointment). Place gauze between the webspaces. Clean the wound on the dorsal aspect of the right second toe, apply Bacitracin and cover with gauze. Secure the gauze with Kerlex dressing. The August 2022 TARs revealed the wound treatment was not initiated until 8/14/22. On 12/28/22 at 9:26 PM Staff 2 (DNS) and Staff 3 (LPN, Assistant DNS) confirmed the 8/12/22 Physician Order was not started until 8/14/22.

1. Based on interview and record review it was determined the facility failed to ensure the licensed nursing staff had the appropriate competencies and skill sets to provide nursing care for a resident with a PleurX Catheter (a small, flexible tube that doctors place within the patient's chest to drain fluid from the pleural space) for 1 of 3 sampled residents (#5) reviewed for hospice. This caused Resident 5 to have increased pain, shortness of breath, psychosocial harm and experienced sustained a distressing and diminished quality of life prior to death. Finding include: Resident 5 admitted to the facility on [DATE] with diagnoses including heart failure and chronic pleural effusion (an excessive accumulation of fluid in the lungs pleural space). The resident had a PleurX catheter in place and died on [DATE]. The facility's staffing records revealed between [DATE] through [DATE] one to three RN's were on duty daily in addition to LPN's. The [DATE] Admission Orders directed staff to drain the PleurX catheter to a maximum 1,000 cc removal at a time, note the amount drained and to notify the physician if the SpO2 (oxygen saturation) was less than 90%. [All licensed nurses within the State of Oregon may care for and drain the catheter with proper training.] The [DATE] Physician Order indicated the catheter was to be drained at a clinic or hospital only every Monday, Wednesday and Friday. [There was no documentation the facility informed the physician it was within the nurses scope of practice to drain the catheter onsite.] A [DATE] provider encounter note revealed there was a concern with getting Resident 5's PleurX catheter drained. The provider noted the resident had great self awareness of when this needs to happen. And reporting that [she/he] is having difficulty breathing and needing it. The provider spoke with the DNS and it was determined if the facility had no staff available to drain the catheter then to transfer the resident to the hospital. The [DATE] Progress Note's revealed Resident 5 was transferred to the hospital for increased pulse and shortness of breath. The hospital drained 2,000 cc from the catheter. A [DATE] provider note indicated she spoke with Resident 5's healthcare POA, discussed concerns of ongoing draining of the PleurX catheter and after a long discussion of options for draining (the catheter) at the facility it was decided to update the resident's POLST form to DNR comfort measures only and refer to hospice. A [DATE] Hospice note revealed Resident 5 was admitted to hospice services. A [DATE] Hospice note revealed the hospice nurse drained 1,000 cc of fluid from the PleurX catheter. A [DATE] Progress note revealed the resident made comments about harming her/himself, asked for a hammer because she/he hurt so bad and asked the CNA if she could help her/him kill her/himself. A [DATE] Progress note revealed Resident 5's healthcare POA was upset because she was not told why the facility could not drain Resident 5's PleurX catheter. The note further stated the goal was to transition the resident off of hospice so they could obtain aggressive treatment with a specialist but they needed home health set up first so the resident would not have to go to the hospital to get the PleurX catheter drained. The healthcare POA stated she understood the resident may not live much longer but still did not want hospice at this time. A [DATE] Progress note revealed home health would not come to the facility. A [DATE] Progress note revealed they spoke with Resident 5's daughter about the PleurX catheter and how we were unable to meet [her/his] needs due to the licensing of our nurses and not having an RN to do it. Options were discussed and it was decided the facility would look for alternative placement but to keep the resident on hospice so they could manage the drain. The [DATE] Discharge Summary note indicated the funeral home picked the resident up. [There were no notes related to the residents passing in the medical record.] Hospice Notes revealed the PleurX catheter was drained on [DATE], 14, 16 and 20. On [DATE] at 8:47 AM Witness 7 (Complainant) stated the facility did not want to provide care and services for the Pleurx catheter and placed the resident on hospice against her/his will. Resident 5's family notified Witness 7 that they did not want hospice but felt like their back was against the wall. The resident was admitted to the facility specifically for the facility to manage the catheter however care did not happen and she/he was sent to the hospital for catheter care. Resident 5 and family were given the decision to either send the resident to the hospital for routine catheter care or go onto hospice. Witness 7 stated she reached out the the facility to coordinate nurse education if that was what was needed and offered to have a provider or the catheter company provide a tutorial which the facility declined. The facility stated this [PleurX catheter] was something they did not do. Witness 7 stated care facilities should be able to manage the catheter and even lay people can be taught to do it. On [DATE] at 8:58 AM an interview was conducted with Staff 1 (Administrator), Staff 2 (DNS) and Staff 3 (LPN, Assistant DNS). Staff 1 stated the facility did not know how to care for the catheter and did not have sufficient RN staffing to care for the resident as the majority of the RN's were agency personnel. Staff 1 stated the facility was unaware the resident had a PleurX catheter on admission but verified this information was in the resident's admission paperwork. Staff 1 verified the resident went on hospice to avoid hospital emergency room visits. On [DATE] an email was received from the Oregon State Board of Nursing which revealed LPN's could drain and care for PleurX catheters if they had the appropriate training. On [DATE] in the AM Staff 1 and Staff 3 stated they believed LPN's were not able to perform PleurX catheter care and services. The LPN scope of practice information listed PleurX catheter care as something LPN's were unable to complete and did not realize this LPN task list was from Alabama. 41453 2. Based on interview and record review, it was determined the facility failed to ensure nursing staff received and demonstrated the appropriate competencies and skills to provide nursing services to assure resident safety and maintain highest practicable physical, mental, and psychosocial well-being of each resident for 4 of 4 staff (#s 9, 17, 18 and 19) reviewed for training. This placed residents at risk for lack of care by competent staff. Findings include: On [DATE] at 9:43 AM Staff 24 (Assistant administrator/HR) was asked to provide completed documentation of a competency checklist for Staff 9, Staff 17, Staff 18, and Staff 24. Employee paperwork provided for these employee's did not include a competency checklist of any kind. On [DATE] at 12:39 PM Staff 3 (Assistant DNS) stated no checklist for skills had been completed.

1. Based on observation, interview, and record review it was determined the facility failed to ensure residents with dementia did not elope from the facility and the facility failed to ensure residents who were at risk for aspiration were supervised while eating for 4 of 14 sampled residents (#s 2, 17, 18 and 158) reviewed for elopement and aspiration precautions. These failures resulted in immediate jeopardy situations and placed other residents at risk for accidents. Findings include: A. Resident 158 admitted on ,d+[DATE] with diagnoses including [CONDITION(S)], dementia and acute kidney failure. The 2/18/22 hospital discharge diet orders indicated Resident 158 required 1:1 supervision with feeding. The 2/18/22 RN Admission Progress Note indicated the resident was on a regular/pureed thin liquids diet. The note did not indicate Resident 158 was to receive 1:1 supervision with meals. The revised 2/23/22 Admission care plan revealed there was no indication of the resident's diet or whether the resident required supervision with meals. The 2/25/22 Admission MDS indicated the resident had severely impaired cognition. A 2/25/22 narrative note entered by Witness 13 (hospice RN) on the Hospice Client Coordination Note Report, stated Resident 158 was 'up to WC (wheelchair) with the assist of one, ambulated in hall with assist of one, fed self after set up.' The meal monitoring sheets from 2/27/22 through 3/27/22 revealed the resident had setup help only for all meals and twice the resident had one person physical assist. On 3/14/22 at 11:42 AM Resident 158 was observed alone in her/his room. No aspiration signage noted in resident's room. On 3/15/22 at 3:20 PM Staff 53 (CNA) stated so often residents were not supervised while eating as there were so many Personal Care Assistants (PCAs) and there were not enough staff to monitor residents. Staff 53 stated management had been told over and over and believed this was a form of neglect. Staff 53 further stated the facility needed a system for which residents received thickened liquids. Staff 53 stated new staff were not educated on who required supervision or thickened liquids and Staff 53 had seen residents not supervised during meals or provided thickened liquids. On 3/15/22 at 5:31 PM Staff 13 (Personal Care Assistant) delivered Resident 158's dinner tray to her/his bedside table. Resident 158 was left unattended with the meal and staff closed the door. On 3/15/22 at 5:35 PM Resident 158 was observed eating independently in the room with no staff present. On 3/15/22 at 5:36 PM Staff 13 acknowledged Resident 158 was eating in her/his room independently and stated she/he ate independently and was not an aspiration risk. On 3/15/22 at 5:41 PM Staff 7 (LPN) reviewed Resident 158's physician orders which indicated the resident was to be 1:1 supervision for meals. Staff 7 confirmed staff were not providing 1:1 supervision during meals and 1:1 meal supervision was not indicated on the resident's Kardex or care plan. On 3/15/22 a request was made for the meal supervision policy. Staff 2 (DNS) stated the facility did not have a policy for meal supervision. On 3/15/22 at 7:33 PM hospice physician's orders indicated to discontinue 1:1 feeding and the resident was able to self feed after set-up. There was no indication Resident 158 was assessed prior to the order change. On 3/15/22 at 9:47 PM Staff 1 (Administrator) and Staff 2 (DNS) were notified of the immediate jeopardy (IJ) situation and were provided a copy of the IJ template related to the facility's failure to ensure residents were adequately supervised during meals. On 3/16/22 at 3:00 PM Witness 12 (Hospice RN) performed a swallow evaluation recommending a dysphagia level three (mechanical soft/minced/moist) diet with thin liquids and the resident no longer needed 1:1 assist with meals, set-up only. On 3/16/22 at 4:12 PM hospice physician orders: 'DC previous diet order. New diet order: dysphagia level three, mechanical soft, thin liquids, set up assistance only.' A plan to abate the immediate jeopardy situation was submitted by the facility and accepted on 3/16/22 at 12:59 AM. An immediate plan of correction (POC) was requested. The IJ Removal Plan included: -The facility will follow the order for 1:1 supervision starting at breakfast on 3/16/22 by encouraging Resident 158 to go to the dining room and if unwilling facility will have the resident eat in the hall so the resident can be visualized by staff for meals. -Resident 158 will be assessed by hospice for need of this supervision and orders will be obtained depending on the outcome of the assessment. -Resident 158's care plan will be updated according to the assessment by 3/18/22. -Orders for all residents will be reviewed to assure they are accurate and that all precautions are in place and assessed for appropriate meal supervision by 3/17/22. -The facility will develop a policy and procedure for meal supervision by 3/18/22. -Licensed nurses will be in-serviced on the process of entering admission orders and identifying precautions that need to be included in the orders. -All nursing staff will be trained on what is required when a resident needs meal supervision from the policy that we develop 3/18/22. -There will be a binder for agency staff to read our expectations regarding meal supervision and the staff who orient agency and new employees to the floor will include this policy and procedure. -Random monthly audits of all new admit orders will be done by the DNS or designee to assure that precautions are in place for three months and then quarterly thereafter. 2. Resident 18 admitted to the facility in 2021 with diagnoses including dysphagia (difficulty swallowing) and Alzheimer's disease. The 1/6/21 and 3/22/21 Care Plans indicated the following: -Resident 18 had a swallowing problem; -Resident 18 was to eat only with 1:1 supervision; -Instruct the resident to eat in an upright position as close to 90 degrees as possible, body in midline position, upright 15 minutes after eating or drinking; -Eat small bites slowly and to chew each bite thoroughly; -Monitor, document and report PRN any signs and symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, and appear concerned during meals. a. On 3/17/22 at 8:26 AM and 8:29 AM Resident 18 was observed to be in bed with her/his bedside table in reach with a bowl of blueberries and strawberries. The resident was observed to be laying on her/his right side facing the bedside table with the head of bed slightly elevated. No staff were present in the room. Resident 18 took a bite of a strawberry and the Surveyor immediately exited the room to alert nursing staff. On 3/17/22 at 8:31 AM Staff 11 (RN) entered Resident 18's room and acknowledged Resident 18 had blueberries and strawberries within reach. Staff 11 was informed of the observation of the resident eating independently and Staff 11 removed the food items. On 3/17/22 at 8:40 AM Staff 54 (CNA) stated she was Resident 18's primary CNA today [3/17/22] and assisted the resident at breakfast earlier that morning. Staff 54 stated she left the strawberries and blueberries in a bowl on her/his bedside table that was pushed away from [her/him] and left the room. Staff 54 stated the resident was not to be left alone with food in the room and the resident must have grabbed the table and pulled it toward her/him. Staff 54 stated the resident was more alert and hungrier this morning than usual and grabbed the French toast off the fork at breakfast when she was assisting the resident which she/he usually did not do. On 3/17/22 at approximately 9:00 AM Staff 1 (Administrator) was informed of the observation of Resident 18 having strawberries and blueberries in her/his room and was observed eating without staff present and was care planned to be 1:1 supervision with meals. b. On 3/18/22 at 8:59 AM Resident 18 was observed in bed laying on her/his side facing the bedside table. There was a cup of grapes on the table and it was within the resident's reach. On 3/18/22 at 9:01 AM Staff 55 (CMA) entered the room to pass medication to Resident 18's roommate. Staff 55 was asked by the Surveyor to observe Resident 18. Staff 55 acknowledged Resident 18 had a cup of grapes on her/his bedside table within reach. Staff 55 stated the resident was not to be left unattended with food in her/his room and removed the grapes from the room. On 3/18/22 at 9:08 AM Staff 1 (Administrator) was informed of the observation of Resident 18 being unattended with grapes on her/his bedside table and she/he was care planned to be 1:1 supervision with meals. 3. Resident 2 admitted to the facility in 2021 with diagnoses including stroke. The 2/9/21 physician order indicated Resident 2 was to receive a dysphagia mechanical soft diet with nectar thick consistency. The 2/9/21 Care Plan indicated Resident 2 had swallowing problems related to a history of a stroke and required nectar thick liquids. On 3/25/22 at 6:26 PM Resident 2 was observed in her/his room with the head of bed slightly elevated and had a water cup on the bedside table with a straw in it. The water was regular consistency and was not thickened. Resident 2 stated she/he had a swallow study completed and it was determined stuff was going into my lungs. Resident 2 stated she/he preferred to have thickened liquids to be safe but had drank some thin water that was on her/his bedside table on 3/25/21. On 3/25/22 at 6:33 PM Staff 33 (LPN) acknowledged Resident 2 had regular water in her/his cup on the bedside table within reach and acknowledged the resident was care planned to have thickened liquids. Staff 33 removed the water from the room. On 3/25/22 at 6:47 PM Staff 1 (Administrator) and Staff 2 (DNS) were informed of the observation of Resident 2 having thin liquids at the bedside within reach and acknowledged she/he was care planned for thickened liquids. On 3/28/22 at 12:59 PM Staff 1 and Staff 2 that immediacy has been removed for the aspiration portion of F689 regulation. B. Resident 17 admitted to the facility in 12/2021 with diagnoses including dementia with behaviors and delusions. Resident 17 admitted from a memory care unit. The 12/10/22 Admission MDS indicated the resident was moderately cognitively impaired. The MDS did not indicate Resident 17 had wandering behaviors. The Care Plan, last updated 12/28/21, did not indicate Resident 17 was an elopement risk. The 12/14/21 Wandering Risk Assessment was not completed in full with the Behavior/Mood section, the Mobility section, and History of Wandering section left blank. The assessment categorized Resident 17 as a Low Risk for Wandering. Record review from 1/2022 through 3/2022 indicated Resident 17 had wandering and exiting-seeking behaviors with documentation of behaviors starting on 1/15/22. The records indicated: *1/15/22 at 12:57 AM Resident wandering in hallways per wheelchair locomotion, accepting of staff redirection when attempts to go behind nurses desk or into wrong room. *1/16/22 at 9:32 AM Resident was wheeling her/himself down the hall and yelling in other residents' rooms that she/he was going to put them on the law suit. Resident if difficult to re-direct and she/he was resistive to cares. *A 1/21/22 Physician Encounter Note completed by Witness 6 (Nurse Practitioner) indicated staff discussed Resident 17 going into other residents' rooms. *1/24/22 at 12:25 AM Resident continued to have delusions and behaviors, such as going into other residents' rooms. *1/25/22 6:35 PM Resident 17 was opening the facility door to head outside and was stopped by staff informing the resident it was cold outside. Later that evening staff heard the 300-hall door alarm sound and it was Resident 17 and staff redirected the resident back into the building. *1/27/22 at 9:20 PM Resident had been increasingly exit seeking. The resident had some 1:1 time for redirection. It worked temporarily and redirection was needed again. Will continue to keep a close eye on resident. *1/29/22 at 2:29 AM Resident currently now wandering throughout the facility via wheelchair. *1/31/22 at 6:45 AM It was reported the resident was wandering and the staff could not find the resident for a while. The resident was in another resident's room. Resident needs constant reorientation and reassurance and was unaware of her/his situation *1/31/22 at 2:47 PM Resident continued to have delusions and was wandering and going into other residents' rooms. *2/1/22 at 4:48 PM Social Services spoke with Resident 17's daughter regarding Resident 17's behaviors today of agitation, exit seeking, hallucinations, and unable to re-direct behaviors. Daughter stated she was looking into Memory Care for the resident. *2/2/22 at 10:34 PM Resident was caught wandering into other residents rooms, mostly male rooms. The resident was found at the back door by kitchen trying to get out of the facility. *2/4/22 at 2:23 PM Resident experiencing a lot of hallucinations and confusion on this shift. Resident was unable to be redirected and was barging into multiple other resident rooms. While attempting to remove resident from a resident's room Resident 17 yelled profanity at the nurse and hit the nurse twice. *2/4/22 at 11:51 AM Resident went into room 102 and was asked to leave room after being reminded that it was against facility rules to enter rooms without permission. Resident was asked to leave, but refused. Resident was asked again to leave, but refused to do so. Resident was removed from room by staff. *A 2/4/22 Physician Encounter Note completed by Witness 6 (Nurse Practitioner) indicated this week the resident had been exit-seeking and that day the resident was difficult to redirect and tried going to multiple residents' rooms. *2/12/22 at 2:48 AM Exit seeking behavior noted, redirected with good effect. *2/14/22 at 12:34 PM Resident was wrapping catheter around door handle last night and she/he was wandering throughout the facility. *2/15/22 2:46 AM Call made to Resident 17's daughter to reinforce the resident is not safe in the building due to it not being a locked building. *2/15/22 12:34 PM Resident 17 out in the parking lot attempting to get into a staff's vehicle and required multiple redirection to come back into the facility after explaining the resident would be warmer as it was cold outside. *2/15/22 Provider Note completed by Witness 6 (Nurse Practitioner) indicated that day the resident had been exit seeking and hyper focused and going to other residents' rooms. That afternoon the resident got out into the parking lot and it took the resident's daughter coming in and redirecting the resident back inside. *2/16/22 at 12:08 PM Resident asking where her/his mother was this AM. Staff able to redirect the resident when she/he was exit seeking. *3/12/22 at 5:29 AM Resident having hallucinations, heightened restlessness, agitation and having difficulty staying asleep. The Resident had been wandering into other residents rooms. The 2/15/22 Incident Investigation indicated on 2/15/22 at 12:20 PM Resident 17 was reported to be outside the facility in the parking lot next to a staff member's car with the door open. Resident 17 kept insisting she/he was going to leave. Staff attempted to redirect the resident multiple times and finally after getting Staff 2 (DNS) the resident agreed to return to the facility. The conclusion indicated: Resident 17 had diagnoses of [CONDITION(S)], dementia with behavioral disturbance and visual hallucinations. Able to redirect resident's behaviors. Staff will continue to check [Resident 17] and reorient as [she/he] is noted with confusion. There were no witness statements. There was no documented evidence the facility analyzed the hazards and risks related to Resident 7's elopement, updated the care plan, or implemented new interventions to reduce the hazards and risk associated with her/his elopement. On 3/14/22 at 4:37 PM Witness 1 (Family Member) stated she was Resident 17's responsible party and was informed the night prior by Staff 15 (Unit Clerk) that Resident 17 had wandered outside the facility because the exit door down the 100-hall was unlocked. Witness 1 stated Resident 17 was an elopement risk and had attempted to leave the facility multiple times due to her/his diagnoses, but Witness 1 was only informed once when the resident would not come back inside the facility. On 3/14/22 at 5:13 PM Staff 7 (LPN) stated on 3/13/22 the door down the 100-hall was left unlocked as the morgue had a collected a resident previously that day, but he was not aware of Resident 17 leaving the building. On 3/14/22 at 5:17 PM Staff 15 (Unit Clerk) stated Resident 17 was an escape artist and she was informed a couple nights prior that Resident 17 got out of the emergency exit down the 100-hall and was informed by morning staff. Staff 15 was unable to recall who specifically informed her of the incident, but believed the incident occurred over the past weekend (3/12/22 through 3/13/22). Staff 15 was unsure how long the resident was out of the facility, but management was aware of the incident. On 3/14/22 at 5:23 PM Staff 39 (CNA) stated Resident 17 was always exit seeking and had previously gotten out of the back door that residents used to go smoke. Staff 39 stated on Thursday (3/10/22) the resident had gotten outside, but Staff 39 saw the resident right away and redirected the resident back inside. Staff 39 stated a few weeks prior she was coming onto her shift and found Resident 17 outside in the parking lot. Staff 39 stated staff did not have the ability to stop the resident as she/he was so quick and if staff were caring for another resident Resident 17 would leave. On 3/15/22 at 8:50 AM Resident 19 stated before Resident 17 moved rooms the resident would come into Resident 19's room and she/he would have to tell Resident 17 to leave. Resident 19 further stated the week prior staff were unable to locate Resident 17, so they went through all the rooms looking for Resident 17 and found the resident in another resident's bathroom. On 3/15/22 at 4:13 PM Staff 19 (Admissions) stated he was not aware Resident 17 was outside the facility but was informed by Witness 1 on 3/13/22 that the resident attempted to leave the facility that day due to the door down the 100-hall being unlocked. Staff 19 stated he reported the incident to Staff 1 (Administrator). On 3/15/22 at 4:18 PM Staff 1 (Administrator) stated she was aware Resident 17 had left the facility previously, but was not aware of Resident 17 recently leaving the facility out the 100-hall door as the door was always locked. On 3/15/22 at 4:44 PM Staff 26 (LPN) stated Resident 17 had wandering behaviors and liked to wander into other residents' rooms and all hallways. Staff 26 reported there were times staff could not find the resident and had to look throughout the facility for her/him. On 3/15/22 at 8:11 PM Staff 28 (CNA) stated Resident 17 had wandering behaviors, including going into other residents' rooms and had nearly gotten out of the exit door down the 300-hall. Staff 28 stated Resident 17 would often go past the nurses' station, so staff would shut the fire doors to prevent the resident from leaving. There was no investigation for the alleged incident Resident 17 left the facility during the month of 3/2022, until 3/24/22. The care plan did not indicate wandering and elopement behaviors or interventions. There was no updated assessment of Resident 17's wandering and elopement behaviors. There was no policy in place for wandering or elopement prior to 3/16/22. On 3/15/22 at 9:47 PM Staff 1 (Administrator) and Staff 2 (DNS) were notified Resident 17's elopement and attempted elopements constituted an immediate jeopardy situation. A plan to abate the immediate jeopardy situation was submitted by the facility and accepted on 3/16/22 at 12:59 AM. The plan included: *Resident 17 would be assessed for wandering/elopement March 16, 2022. The care plan would be updated to reflect the resident's risk of elopement and interventions by March 16, 2022. *No other residents wander, therefore would not be at risk of elopement. However, if staff observe elopement/exit seeking/wandering behavior, an assessment would be completed. *Visual observations of Resident 17's location would be done every 30 minutes for two weeks to establish a potential pattern. Observations would be adjusted accordingly if a pattern was identified. *Visual observations would be documented on a spreadsheet, that identified the time, location, and staff member. *Licensed nurses would be in-serviced on how to assess for wandering and elopement and an assessment would be implemented for all new admission residents by March 18, 2022. All staff would receive dementia training related to wandering and elopement by March 18, 2022. *Random monthly audits of new admission orders would be completed by Staff 2 (DNS) or designee to assure residents who were assessed to be at risk of elopement were care planned for three months and then quarterly thereafter. On 3/24/22 at 3:12 PM Staff 1 and Staff 2 were notified the immediacy was removed based on observations, staff interviews, and record review that the IJ immediacy removal plan was fully implemented. 2. Based on observation, interview, and record review it was determined the facility failed to ensure interventions were implemented and interventions were assessed and updated to prevent falls for 2 of 4 residents (#s 22 and 40) reviewed for falls. This placed residents at risk for repeated falls and injury. Findings include: A. Resident 40 admitted to the facility on [DATE] with diagnoses including dementia and anxiety. The 10/21/21 Quarterly MDS indicated Resident 40 was significantly cognitively impaired and indicated the resident had two or more falls since admission with no injury. The Fall Care Plan was last revised 2/23/22. There were no interventions updated to prevent falls post the 9/20/21 fall until 1/10/22 when the care plan indicated Resident 40 was to wear non-skid socks and staff were to remind the resident to use the call light with each meet and greet. The care plan had already included the interventions for non-skid socks and to remind the resident to use the call light on 7/15/21 and 7/18/21. The care plan did not indicate signs were to be placed in the resident's room to remind the resident to ask for assistance before transferring. The 9/20/21 Post Fall Assessment indicated Resident 40 was found in her/his room on the floor after self-ambulating barefoot. The investigation indicated the resident hit her/his head on the dresser and was bleeding at the base of her/his skull. The resident was sent out to the hospital. Preventive measure included: Signs placed in room and bathroom to remind the resident she/he needs assistance with transfers. Recommendations to prevent further falls indicated: frequent checks, lower bed, and constant reminding to use the call light because of her/his dementia and her/his tendency to overestimate her/his abilities. There were no witness statements documented or neurological assessments post fall. The Post Fall Assessment was completed on 9/30/21. Resident 40 sustained multiple falls since the 9/20/21 incident. On 3/24/22 at 2:06 PM Resident 55's (Resident 40's roommate) call light was initiated. Resident 55 told Staff 49 (CNA) that Resident 40 had self-transferred to the restroom. Staff 49 was observed to enter the restroom with Resident 40. There were no signs in the resident's room or door of the restroom to remind Resident 40 to call for assistance prior to transferring. On 3/24/22 at 2:09 PM Resident 55 stated she/he pressed her/his call light 10 minutes prior to alert staff that Resident 40 had self-transferred to the restroom. Resident 55 stated the facility was so short handed and stated Resident 40 had four falls since Resident 55 had been the resident's roommate. On 3/24/22 at 2:16 PM Staff 50 (CNA) stated Resident 40 experienced multiple falls and interventions included: a gait belt, non-skid socks and the resident used to have signs in the room to remind her/him to use the call light. Staff 50 confirmed there were no signs in Resident 40's room or restroom door to remind the resident to call for assistance. On 3/24/22 at 2:23 PM Staff 2 (DNS) acknowledged the fall investigation was not thorough for the 9/20/22 incident, the investigation was completed 10 days after the incident, and confirmed there were no signs in the resident's room or bathroom per care planned interventions. B. Resident 22 was admitted to the facility on ,d+[DATE] with diagnoses including [CONDITION(S)] ([CONDITION(S)]/Stroke) and [CONDITION(S)]. The 12/2020 initial care plan indicated the resident required extensive assistance by two staff to turn and reposition in bed and required a mechanical lift with two staff assistance for transfers. The 12/2021 MDS indicated the resident had a BIMS score of 11, moderately impaired cognition. The revised 3/23/21 care plan identified the resident as a high risk for falls. Interventions included: Be sure bed is in lowest position when not providing care. The 3/1/22 Post Fall Assessment stated Resident 22 had a witnessed fall in the room while being changed by a single staff member and was sent to the hospital to rule out a knee fracture. The 3/11/22 Physician Orders: Bed rails, both sides for mobility and fall mats on both sides of bed. On 3/14/22 at 10:42 AM observations of Resident 22's room revealed bed at regular height, no fall mats, and no side rails. Resident 22 stated she/he had a recent fall on 3/1/22 and had been in misery ever since. Resident 22 stated she/he was leery about being dropped. On 3/17/22 at 1:22 PM observed Staff 30 (Personal Care Assistance/PCA) in room with resident. Staff 30 acknowledged Resident 22's bed was not in the low position, there were no fall mats on either side of the bed and no side rails on the bed. On 3/17/22 at 1:29 PM Staff 10 (LPN) confirmed Resident 22 did not have the bed in low position, no bed rails and no fall mats. On 3/17/22 at 1:44 PM Staff 2 (DNS) observed Resident 22's room and confirmed the bed was not in low position, no bed rails on the bed and no fall mats. Staff 2 stated she expected orders to be implemented as soon as possible and she did not do it because she did not have time.

Based on interview and record review it was determined the facility failed to address a change of condition, follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure resulted in Resident 58 experiencing a noted decline in condition without appropriate intervention prior to the resident's hospitalization . This placed residents at risk for adverse side effects of medications, worsening conditions, and death. Findings include: 1. Resident 58 was admitted to the facility in 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 1/18/22 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 1/25/22 progress note indicated Resident 58 tested positive for COVID that day and was moved to the isolation unit. The 2/2/22 at 7:08 AM progress note indicated Resident 58's oxygen saturation was 84% and the resident was on oxygen 3 liters per minute. The resident's oxygen could be increased to 4 liters per minute and the oxygen was to be rechecked in 30-45 minutes. The 2/2/22 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/2/22 Vital Sign records indicated at 8:35 AM indicated Resident 58's oxygen saturation was 86%. There was no indication in the residents clinical record to indicate the physician was notified of Resident 58's oxygen saturations below 88%. The 2/2/22 Vital Sign records indicated at 11:43 PM Resident 58's temperature was 97.5 F. This was the last temperature documented in the clinical record. The 2/3/22 at 12:50 AM Progress Note indicated Resident 58 had shortness of breath at the start of the shift with oxygen saturations ranging between 80%-86%. The nurse assisted the resident with breathing techniques to lower rapid breathing and deepen inhalation resulting in resident becoming more relaxed and oxygen increasing to over 90%. Oxygen saturation was 98%. No fever present. Resident has been compliant with cares and isolation status. Sleeping comfortably at this time. Vital signs stable and within normal limits. Will continue to monitor. The 2/3/22 at 8:51 AM Progress Note indicated Resident 58 oxygen saturation dropped to 71% on 4 liters of oxygen per minute via mask. Oxygen was instructed to be increased to 5 liters per minute via mask and the resident was assisted with breathing techniques to help deepen breathing and reduce anxiety. Resident's oxygen saturations went up to 81%. Continue with breathing techniques and to monitor oxygen. The 2/3/22 at 11:15 AM Progress Note indicated Resident 58's oxygen saturation was at 71% on 5 liters per minute via mask. Assist resident with deep breathing exercises. Will contact on-call provider and leave a note in provider's box regarding resident. The 2/3/22 at 12:18 PM Progress Note indicated Resident 58 began coughing up a scant amount of bright red blood into tissues and her/his oxygen saturations were 69%. A message was left for on-call provider for a 20-minute call back. The 2/3/22 at 1:05 PM [late entry] Progress Note indicated the facility received a call back from the on-call provider was instructed to send Resident 58 to the hospital. Emergency services were contacted. They arrived and collected resident and left for Salem Hospital at approximately 12:55 PM on 2/3/22. The 2/3/22 hospital records indicated the following: -Resident 58 came from the care facility to the emergency department for worsening shortness of breath and recently tested positive for COVID one week ago and had been having difficulty breathing. Staff at the care facility were having a difficult time maintaining her/his oxygen saturations today and called paramedics. While at the facility, she/he had saturations of 67% while on oxygen. She/he was placed on non-rebreather by paramedics, which brought her/his oxygen saturations up to 79%. Patient arrived on [CONDITION(S)] with oxygen saturations at 88%. Paramedics reported a fever with temperature of 103 F. The 2/4/22 progress note indicated Resident 58 was admitted to the hospital with admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/7/22 at 1:11 PM progress note indicated the hospital called to confirm that Resident 58 passed away at 8:04 AM on 2/5/22. On 3/25/22 at 10:10 AM Witness 6 (Nurse Practitioner) reviewed the findings and stated Resident 58 had an order to maintain oxygen saturations between 88-92% and the expectation was for staff to call the provider if oxygen saturations dropped below 88%. Witness 6 further stated staff did not notify the provider timely of Resident 58's change in condition and the expectation was for staff to have notified the provider the morning of 2/2/22. On 3/25/22 at 11:04 AM Staff 43 (RN) stated she worked day shift on 2/2/22 and 2/3/22. Staff 43 stated she should have notified the physician in my professional opinion on the morning of 2/2/22 after Resident 58's oxygen saturations dropped below 88%. On 3/23/22 at 2:14 PM and 3/28/22 at 8:46 AM Staff 2 (DNS) stated Resident 58's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff 2 stated the expectation was for staff to notify the physician within 30 minutes after a change in condition and the physician should have been notified on 2/2/22 after the resident's oxygen saturations did not increase at 8:35 AM. 2. Resident 109 admitted to the facility in 10/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The 12/29/21 Progress Note indicated an order was received to swab sore on back of head with [MEDICATION(S)]-iodine until resolved. The 1/2022 TAR indicated the resident did not receive wound treatment on 1/1/22. The 1/3/22 Progress Note indicated wound care was provided to the sore on the back of the head the sore was drying out and resident reported less pain. The 1/5/22 Progress Note indicated head wound had no drainage, no open area and was slightly raised. The area was swabbed with [MEDICATION(S)]-iodine per order. There were no skin assessments or measurements of the sore on the resident's head in the electronic health record and no indication as to what type of sore or wound it was. On 3/28/22 at 8:49 AM Staff 2 (DNS) acknowledged there was no initial skin and wound assessment on 12/29/21 and no ongoing skin assessments indicating the type, measurements and characteristics of the head wound. Staff 2 further acknowledged the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. Resident 159 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] a. The 2/23/22 skin evaluation indicated the resident had a rash to the groin and left gluteal fold. There were no measurements of the identified areas. A review of the clinical record indicated there was no follow up skin evaluations or skin assessments completed after 2/23/22. The resident discharged on [DATE]. No skin assessments were completed prior to her/his discharge. On 3/18/22 at 2:00 PM Staff 2 (DNS) acknowledged Resident 159 had no measurements of the rash to the groin and left gluteal fold. She further acknowledged there were no additional skin assessments prior to her/his discharge. b. The 2/7/17 Intake and Output (I and O) Policy for documentation and monitoring of I and O indicated residents who may be at risk for an imbalance in fluids or electrolytes and a comparison total for I and O may be used as part of the comprehensive assessment in residents at risk for these imbalances. The 2/23/22 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the clinical record indicated no documentation of intake and output. On 3/22/22 at 6:36 AM Staff 7 (LPN) stated CNA staff should have documented I and O for Resident 159 especially since the resident had a Foley catheter. On 3/22/22 at 8:28 AM Staff 11 (RN) stated she recalled Resident 159 but staff did not monitor I's and O's for her/him. On 3/23/22 at 8:28 AM Staff 2 (DNS) stated Resident 159 was receiving diuretic medication and the expectation was for staff to monitor I's and O's on any resident received a diuretic. Staff 2 acknowledged the facility did not monitor I's and O's for Resident 159. 4. Resident 23 admitted to the facility in 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The 12/22/19 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The 3/22 MARs indicated staff did not check blood pressure or pulse on the following dates: -3/7/22 -3/8/22 -3/9/22 -3/10/22 On 3/23/22 at 8:25 AM Staff 2 (DNS) stated an agency staff was working 3/7/22 through 3/10/22 and acknowledged Resident 23 did not received blood pressure or pulse checks as ordered by the physician.

1. Based on interview and record review it was determined the facility failed to assess a change of condition for 1 of 3 sampled residents (#5) reviewed for change of condition. This resulted in Resident 5 experiencing weight loss, a change of condition and hospitalization . Findings include: Resident 5 was admitted to the facility in 2/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/24/20 BIMS indicated Resident 5 was cognitively intact. The 2/14/20 care plan indicated Resident 5 needed one person staff assistance for toileting and transfers. Resident 5 had bowel and bladder incontinence. The care plan indicated Resident 5 was to receive weekly skin assessments by nursing staff. Resident 5's nutrition record indicated the following: *8/10/20 the resident refused breakfast and lunch. *8/11/20 the resident refused breakfast, lunch, and dinner. *8/12/20 the resident refused breakfast, lunch, and dinner. *8/13/20 the resident refused breakfast, lunch, and dinner. *8/14/20 the resident refused breakfast, lunch, and dinner. Resident 5's supplement intake record indicated the following: *8/10/20 480 mls *8/11/20 refused *8/12/20 refused *8/13/20 refused *8/14/20 refused Resident 5's weight records indicated she/he had the following weights: *7/2/20 290.6 lbs. *8/3/20 276.4 lbs. (indicating a 14.2 lb weight loss in 32 days and a 4% weight loss). *8/11/20 271.8 lbs. (indicating an additional 4.6 lb. weight loss in 8 days and an overall 6% weight loss since 7/2/20). An 8/4/20 physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The previous physician note dated 6/11/20 indicated Resident 5's previous weight was 296.8 lbs. The note did not address the 22 lb. weight loss. The 8/4/20 physician note indicated Resident 5 had a left below the knee amputation and amputation of the right toes. The note did not indicate a head to toe skin assessment was completed for Resident 5. An 8/12/20 progress note indicated Resident 5 was on alert for starting [MEDICATION(S)] for [MEDICATION(S)] rash and was started on 8/11/20. Resident 5 was offered [MEDICATION(S)] options multiple times but declined. An 8/13/20 progress note indicated Resident 5 was doing well with antibiotics and was complaining of pain in areas of the [MEDICATION(S)] infection but continued to go outside and sit in the sun for long periods of time. An 8/14/20 progress note indicated Resident 5 continued to refuse to eat and was no longer getting out of bed. Resident 5 was refusing to be changed. Resident 5 had [MEDICATION(S)] and open skin areas with foul smell and skin sloughing noted and nothing worked to treat the [MEDICATION(S)] and open skin areas. Resident 5 had been drinking supplements. The 8/14/20 skin assessment indicated the resident had a skin tear to the right ankle. There was no indication a head to toe skin assessment was completed The 8/13/20 Fall Assessment indicated Resident 5 had a fall at 9:20 PM and was found on the floor. The resident was unable to verbalize clearly the events that led to the fall. Resident 5 had two skin tears, one on the forearm and one on the right leg stump. The physician was notified by note in box. The note indicated the resident's last fall was on 5/8/20. An 8/14/20 progress note indicated Resident 5 became increasingly aggressive and had a recent fall on 8/13/20 and was almost on the floor x 2 thus far. [resident had near falls on two occasions]. On 8/14/20 The resident was noted to have altered mental status with hallucinations. The noted stated suspected illicit drug use and that the resident was coming down from being high. The resident complained of un-retractable abdominal pain. The resident was sent to the hospital for treatment on 8/14/20. An 8/14/20 email from the charge nurse to Staff 1 (Administrator) indicated Resident 5 was transported to the hospital by ambulance on 8/14/20 at 6:55 PM for uncontrolled pain and suspected illicit drug use. The 8/14/20 hospital record indicated the following: -Resident 5 admitted at 7:14 PM with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . -The resident was admitted to the Intensive Care Unit for [CONDITION(S)]. After the resident was stabilized Resident 5 told hospital staff she/he was sick for a number of days with poor appetite and did not have any desire to eat. There was no indication in the resident's clinical record to indicate the dietitian or physician were notified of the meal refusals from 8/10/20 through 8/14/20, the continued weight loss and change of condition. There was no indication a head to toe skin assessment was completed after 8/6/20. The physician no longer worked at the facility. On 6/15/21 at 1:19 PM and 6/24/21 at 2:15 PM Staff 41 (LPN) stated she noticed Resident 5 having a decline for about 3 weeks before she/he was hospitalized . She stated the resident went from frequently enjoying time out of the facility to staying in her/his room and was bedridden. Staff 41 stated she was aware of Resident 5's meal refusals for the day of 8/14/20, but was not aware of her/his past meal refusals. Staff 41 stated CNA staff reported Resident 5 did not eat on 8/14/20 and she was concerned because the resident had elevated blood sugars even though she/he was not eating. Staff 41 further stated she didn't notify the physician or RD of Resident 5's meal refusals, or the change in condition. Staff 41 stated she was working under a Resident Care Manager (RCM) at that time and due to her being supervised, she had to check with the the RCM before notifying the physician. Staff 41 further stated Resident 5 had undue suffering three weeks before she/he was sent to the hospital. Staff 41 stated Resident 5 was hospitalized after the end of her shift on 8/14/20. On 6/15/21 at 3:43 PM Staff 12 (RN) stated she believed she was the staff who sent Resident 5 to the hospital on 8/14/20 for unretractable pain. She stated the RCM staff felt like it was due to withdrawal from drugs, but she had no recollection of Resident 5 using drugs. On 6/18/21 at 2:17 PM Staff 24 (CNA) stated she was familiar with Resident 5 and she/he had a gradual decline, stayed in bed, and was not as hungry as usual. On 6/18/21 at 2:23 PM Staff 18 stated a skin event was completed on 8/14/20 for a skin tear on the right ankle and she did not complete a head to toe assessment. Staff 18 further stated at that time the Resident Care Managers were completing the weekly head to toe skin assessments. On 6/21/21 at 9:55 AM and 6/22/21 at 2:44 PM Staff 17 (LPN Resident Care Manager) stated the last head to toe skin assessment for Resident 5 was completed on 8/6/20. Staff 17 acknowledged a weekly skin assessment was due on 8/13/20 and was not completed. Staff 17 stated it was the care manager's job to identify residents' patterns of concern. Staff 17 stated the physician visited Resident 5 but did not complete comprehensive head to toe skin assessments. Staff 17 stated Resident 5 had an anal fissure and pressure ulcer upon admission to the hospital on 8/14/20. She stated she was not aware of anal fissure or pressure ulcer prior to the resident's admission to the hospital. Staff 17 stated the resident did not have feeling of her/his lower body and would not have been able feel a pressure ulcer or anal fissure. Staff 17 further stated Resident 5 had a fall on 8/13/20 and did not have a recent history of falls. Staff 17 stated Resident 5 was not assessed timely for meal refusals which was a change in the resident's condition. On 6/23/21 at 2:23 PM Staff 39 (RD) stated she worked two days a month at the facility and had not worked in the building since pre-Covid [approximately February 2020] and worked remotely. Staff 39 stated on 8/11/20 Resident 5 was added to the Nutrition At Risk (NAR) list. Staff 39 stated if nursing staff told her a resident needed a priority RD assessment she put a star next to the resident's name. Staff 39 further stated she reviewed her notes and Resident 5 did not have a star by her/his name and the resident was not assessed for NAR on 8/11/20. Staff 39 stated by the time she went to complete Resident 5's NAR assessment the resident was discharged to the hospital. 2. Based on observation, interview and record review it was determined the facility failed to provide treatments as ordered for 1 of 3 sampled residents (#11) reviewed for skin. This placed residents at risk for worsening skin conditions. Findings include: The 6/3/21 Resident Council Notes indicated multiple residents showed concerns regarding wound care not being completed as scheduled. Resident 11 was admitted to the facility in 1/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/10/21 BIMS indicated Resident 11 was cognitively intact. a. The 11/12/20 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply daily and PRN. The 1/31/20 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/15/21 at 3:55 PM the 6/2021 TAR was reviewed and indicated Staff 13 (LPN) documented the treatment to Resident 11's gluteal fold was completed and the catheter was checked on 6/15/21. On 6/15/21 at 3:59 PM Resident 11 stated staff had not treated the area to her/his gluteal fold and had not looked at her/his catheter today (6/15/21). Resident 11 stated she/he was up in her/his chair all day and had not been back to bed or received treatment. On 6/15/21 at 4:15 PM and 4:44 PM Staff 13 stated he documented and completed treatment to the gluteal wound at approximately 2:00 PM. Staff 13 was informed Resident 11 reported she/he was in her/his chair all day and had not received treatments to the gluteal fold. Staff 13 then stated I have not done [her/his] wound today, that must have been yesterday. Staff 13 further stated he documented catheter care was completed, but had not checked Resident 11's catheter. Staff 13 stated he documented catheter care was complete because CNA staff completed that care. On 6/15/21 at 5:07 PM Staff 2 (DNS) was informed Staff 13 did not complete treatments but documented it was done for Resident 11. Staff 2 stated Staff 13 was currently being coached due to not having a long term care background. b. The 4/10/21 nursing order indicated to cleanse the right heel wound every day shift and apply foam dressing, monitor for worsening. The 4/10/21 note to the physician indicated Resident 11 had an open area to her/his right heel measuring 0.5 cm x 1.5 cm. The note indicated ok to cleanse with wound cleanser and cover in foam dressing and discontinue when resolved? Please advise. The provider response on 4/14/21 indicated ok with treatment, resident refused to allow me to see it. The 4/21/21 note to the provider indicated there was a nursing order dated 4/11/21 for right heel wound to cleanse with wound cleanser and apply foam dressing and monitor for worsening? On 4/21/21 The provider indicated yes. The 4/2020, 5/2020 and 6/2020 TARs indicated Resident 11 received a foam dressing to her/his right heel on 4/15/21. There was no indication Resident 11 received additional treatments. On 6/14/21 at 1:36 PM Resident 11 stated she/he had an area on her/his heel that has been there for six months and staff did not assess the heel, but would apply a Band-Aide if the resident directed them to. On 6/15/21 at 4:03 PM Staff 12 (RN) stated Resident 11's heel treatments were to be completed daily starting on 4/10/21. Staff 12 stated treatments have not been done due to the treatment not being added to the TAR. Staff 12 stated she added the daily heel treatments to the TAR on 6/15/21. On 6/15/21 at 4:21 PM Resident 11's heel was observed with Staff 13. Resident 11 had an open area (approximately the size of a pencil eraser) to the back of the right heel. On 6/22/21 at 10:15 AM Staff 17 (LPN Resident Care Manager) stated Resident 11's orders were entered incorrectly into the electronic health record for heel treatments. Staff 17 acknowledged treatments were not completed to Resident 11's heel as ordered from 4/10/21 through 6/15/21.

Based on interview and record review it was determined the facility failed to properly administer insulin medication to 1 of 5 sampled residents (#1) reviewed for medication administration. Resident 1 received an incorrect dose of fast-acting insulin and was hospitalized . Findings include: Resident 1 admitted to the facility in 2019 with [DIAGNOSES REDACTED]. Resident 1's 9/14/19 physician orders [REDACTED]. The 9/15/19 Transfer to Hospital Summary note indicated Resident 1 was administered [MEDICATION NAME] 40 units instead of the ordered four units per sliding scale at 7:30 AM. Resident 1 recognized the mistake and requested the facility staff call 911. 911 was called, the medics arrived at 7:40 AM and Resident 1 was transported to the hospital for treatment. The 9/15/19 Hospital records indicated Resident 1 was diagnosed with [REDACTED]. The initial hospital plan was to monitor the blood glucose levels for several hours due to the half life of the insulin. At 9:14 AM Resident 1's blood glucose level trended down so the physician increased the D10. At 3:00 PM Resident 1's blood labwork revealed [MEDICAL CONDITION] and no other adverse side effects were noted from the incorrect insulin dose administration. At 4:00 PM the repeated blood labwork verified the [MEDICAL CONDITION]. The physician noted, I would expect a large potassium intracellular shift with such a high dose of insulin. Patient will be treated with other [MEDICAL CONDITION] medications and will likely benefit from admission for further management. Resident 1 was hospitalized from [DATE] through 9/18/19. On 10/17/19 at 9:30 AM Resident 1 stated she/he verified with Staff 3 (LPN) he administered 40 units of the fast-acting insulin instead of the long-acting insulin directly after the insulin was administered, insisted Staff 3 call 911 and stated she/he was transported to the hospital for treatment. On 10/17/19 at 9:40 AM Staff 2 (DNS) verified Staff 3 administered 40 units of fast-acting insulin instead of the ordered four units. Staff 2 stated Staff 3 was a new nurse, had both insulin pens out at the same time, administered the wrong insulin, this was a one time occurrence and the insulin administration was reviewed and revised to prevent future insulin administration error. Staff 2 verified Resident 1 was hospitalized from [DATE] through 9/18/19 and had a history of [REDACTED]. Staff 2 stated the incorrect insulin administration was a significant medication error.

1. Based on observation, interview and record review it was determined the facility failed to have a system in place to ensure residents were transferred with mechanical lift slings of appropriate size based on their weight and measurements, failed to ensure slings were in good repair and failed to ensure manufacturer care instructions were followed for 3 of 5 sampled residents (#s 6, 8 and 24) reviewed for accidents. This failure, determined to be an immediate jeopardy situation, resulted in Residents 6 and 8 experiencing a fall and Resident 24 being placed at risk for a fall when the mechanical lift sling broke during a transfer. Findings include: a. Resident 6 was readmitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 4/2019 MAR indicated [REDACTED]. The care plan, last updated 4/8/19 indicated Resident 6 required two person assistance for mechanical lift transfers. The care plan did not include which size sling the resident used. On 7/22/19 at 9:05 AM Resident 6 stated two staff were assisting her/him in the mechanical lift when the straps snapped causing the resident to fall to the floor. The resident was unable to recall the date of the fall. On 7/22/19 at 6:03 PM Staff 30 (Human Resources) stated the mechanical lift slings were ordered every 30-45 days. She stated staff were to leave the mechanical lift slings that were were not in good repair on her door. Staff 30 further stated the facility had no written audit of the mechanical lift slings. On 7/22/19 at 10:52 AM Staff 20 (CNA) stated there were issues with mechanical lift slings tearing. On 7/22/19 at 2:54 PM Staff 9 (CNA) stated the mechanical lift slings were not in good condition and when the slings wore out staff continued to use them. On 7/23/19 at 12:53 PM Staff 14 (CNA) stated she and Staff 31 (CNA) were present for Resident 6's fall when the mechanical lift sling broke on 4/8/19. She stated they were attempting to transfer the resident to bed and as soon as she/he was lifted with the mechanical lift she heard something break and the resident fell to the floor. Staff 14 stated, it was scary and . horrible when the resident fell . She further stated the mechanical lift sling loop broke off and detached from the sling and there was no time to get her/him over the bed or chair. She stated the resident sustained [REDACTED]. Staff 14 stated there were not enough slings for each resident and they were washed daily. On 7/25/19 at 2:07 PM Staff 31 stated she was present for Resident 6's fall when the mechanical lift sling broke on 4/8/19. She stated they were trying to get Resident 6 into bed and lift her/him with the mechanical lift when one of the sling hooks snapped and continued to rip and Resident 6 fell to the floor on her/his bottom. Staff 31 was unable to recall if the resident sustained [REDACTED]. A 4/8/19 Post Fall Assessment indicated Staff 14 and Staff 31 were present during a fall. The resident was transferred by mechanical lift from the wheelchair to the bed and the sling broke at both hook up points for the legs and the resident landed on the floor by the bed on her/his left side. The resident complained of hip and shoulder pain and had a scrape on the inside of the wrist. An X-ray of the left hip and shoulder were ordered and were negative for fracture. The report indicated the resident had faulty equipment and was given a new sling. The Alert Charting Guidelines indicated if a resident had a fall, documentation was to be completed each shift for 72 hours and include information regarding injury, change in ROM, complaints of pain, change in gait, dizziness, changes in level of consciousness, abnormal movements, abnormal blood pressure, signs and symptoms of infection and vital signs. The 4/8/19 Radiology Report indicated shoulder and hip X-rays were completed and the resident did not have a fracture. On 7/22/19 at 5:01 PM Staff 9 (CNA) stated she was unsure if there was a list of which slings should be used for the residents. She stated the green (larger size) slings were not always available to use because many residents required the larger slings. On 7/23/19 at 1:39 PM two mechanical lift slings were observed to be clean in the laundry room and were frayed and torn. On 7/23/19 at 1:42 PM Staff 15 (Laundry Supervisor) stated the mechanical lift slings were bleached with chlorine bleach if they were to be put in with white laundry. She reviewed the manufacturer's instructions which indicated chlorine bleach was not to be used on the slings. She stated she was unaware that chlorine bleach was not to be used. On 7/23/19 at 1:49 PM Staff 9 (CNA) was asked to observe the two frayed and ripped slings. She stated the one sling had a tear and she was told it was fine to use because the tear was not over the strap. She stated she would not use the other sling due to it being frayed. She stated she found a sling that needed to be thrown out about once per week. On 7/23/19 at 2:01 PM Staff 16 (CNA) was asked to observe the two frayed and ripped slings. She acknowledged the slings were in disrepair and stated she would not use the slings for residents due to the condition of the slings. On 7/23/19 at 2:16 PM Staff 2 (DNS) was asked to observe the two frayed and ripped slings. She stated the slings were not in good repair and should not be used. On 7/26/19 at 11:28 AM Staff 2 (DNS) and Staff 6 (RNCM) acknowledged the Post Fall Assessment was not reviewed by the RNCM until 4/15/19 (7 days later) and was not reviewed by the DNS until 5/1/19 (23 days later). Staff 2 stated fall investigations were to be completed within five days by the RNCM and DNS staff and it was not completed timely. Staff 2 and Staff 6 acknowledged there was no root cause analysis, was missing witness statements and resident interview and alert charting was not completed after the fall for Resident 6. Staff 2 and Staff 6 further acknowledged [MEDICATION NAME] increased the resident's risk for bleeding. b. Resident 8 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 8/2018 MAR indicated [REDACTED]. The care plan, last updated 10/25/18, indicated Resident 8 required two person assistance for mechanical lift transfers. The care plan did not include which size sling the resident used. On 7/22/19 at 6:03 PM Staff 30 (Human Resources) stated the mechanical lift slings were ordered every 30-45 days. She stated staff were to leave the mechanical lift slings that were not in good repair on her door. Staff 30 further stated the facility had no written audit of the mechanical lift slings. On 7/22/19 at 10:52 AM Staff 20 (CNA) stated there were issues with mechanical lift slings tearing. She stated there was one instance when Resident 8's mechanical lift sling tore during a transfer in (MONTH) or (MONTH) of (YEAR). Staff 20 stated the resident was not injured. On 7/25/19 at 11:41 AM Staff 23 (CNA) stated he observed Resident 8's fall on 8/24/18. He stated Witness 4 (Former CNA) was with him during the mechanical lift transfer when Resident 8 was transferred into bed and the upper part of the sling ripped and broke and the resident hit her/his toes. Staff 23 further stated it was odd because if the sling was going to rip, it usually ripped over the bed. The 8/24/18 Post Fall Assessment indicated the resident was being transported by mechanical lift via sling by Staff 23 and Witness 4 when the two upper straps broke and Resident 8 fell to the floor. The resident was assessed and had abrasions to the top of the right toes. The resident was placed on alert charting. The fall assessment did not include witness statements from Staff 23 and Witness 4. The DNS did not review the assessment until 9/10/18. The Alert Charting Guidelines indicated if a resident had a fall, documentation was to be completed each shift for 72 hours and include information regarding injury, change in ROM, complaints of pain, change in gait, dizziness, changes in level of consciousness, abnormal movements, abnormal blood pressure, signs and symptoms of infection and vital signs. On 7/22/19 at 5:01 PM Staff 9 (CNA) stated she was unsure if there was a list of which slings should be used for the residents. She further stated Resident 8 was put in a smaller purple sling and had a fall. She stated they were supposed to use the green slings for her/him which were larger. She stated the green slings were not always available because many residents required the bigger slings. On 7/23/19 at 1:39 PM two mechanical lift slings were observed to be clean in the laundry room and were frayed and torn. On 7/23/19 at 1:42 PM Staff 15 (Laundry Supervisor) stated the mechanical lift slings were bleached with chlorine bleach if they were to be put in with white laundry. She reviewed the manufacturer's instructions which indicated chlorine bleach was not to be used on the slings. She stated she was unaware that chlorine bleach was not to be used. On 7/23/19 at 1:49 PM Staff 9 (CNA) was asked to observe the two frayed and ripped slings. She stated the one sling had a tear and she was told it was fine to use because the tear was not over the strap. She stated she would not use the other sling due to it being frayed. She stated she found a sling that needed to be thrown out about once per week. On 7/23/19 at 2:01 PM Staff 16 (CNA) was asked to observe the two frayed and ripped slings. She acknowledged the slings were in disrepair and stated she would not use the slings for residents due to the condition of the slings. On 7/23/19 at 2:16 PM Staff 2 (DNS) was asked to observe the two frayed and ripped slings. She stated the slings were not in good repair and should not be used. On 7/25/19 at 11:13 AM Resident 8 stated she/he fell twice in the past year due to slings breaking during a transfer. Resident 8 stated she/he felt scared of falling during transfers. On 7/25/19 at 2:07 PM Staff 31 (CNA) stated on one occasion almost a year ago she transferred Resident 8 and as the sling was pushed over the bed it snapped and she/he fell on top of the bed. She stated after that happened the resident got nervous during mechanical lift transfers and would hang on to her/his sling really tightly. She further stated she told her boss, Staff 30 (Human Resources), about the incident. A review of the clinical record did not reveal an investigation was completed for the fall from the mechanical lift sling to the bed. On 7/26/19 at 11:28 AM Staff 2 (DNS) and Staff 6 (RNCM) acknowledged the Post Fall Assessment was not reviewed by the RNCM until 9/6/18 (12 days later) and was not reviewed by the DNS until 9/10/18 (23 days later). Staff 2 stated fall investigations are supposed to be completed within 5 days by RNCM and DNS staff and it was not completed timely. Staff 2 and Staff 6 acknowledged there was no root cause analysis, the investigation was missing witness statements and resident interview and alert charting was not completed after the fall for Resident 8. Staff 2 and Staff 6 further acknowledged the resident's [MEDICATION NAME] use increased her/his risk for bleeding and were unaware of the fall from the mechanical lift sling to the bed. c. Resident 24 admitted to the facility 1/2019 with [DIAGNOSES REDACTED]. The 5/3/19 MDS indicated Resident 24 was cognitively intact and the resident was totally dependent on staff for transfers. The Kardex (staff instructions) indicated Resident 24 required a mechanical lift and two staff members for transfers. The Kardex did not indicate what size mechanical lift sling the resident required. On 7/22/19 at 11:23 AM Resident 24 stated an incident occurred approximately a month prior when staff transferred the resident from her/his chair back to bed using a mechanical lift and the sling strap broke. Resident 24 stated she/he was not injured and was fearful at the time, but was not currently afraid. Observations from 7/22/19 through 7/24/19 revealed Resident 24 had a green (size large) mechanical lift sling either under her/him or in the resident's room on her/his wheelchair. Review of Resident 24's medical record did not indicate an investigation was completed for the alleged incident. On 7/22/19 at 5:01 PM Staff 9 (CNA) stated she was one of the CNAs working with Resident 24 when the mechanical lift sling strap broke. Staff 9 stated the resident did not fall out of the sling and was not injured. Staff 9 stated the other CNA who assisted her no longer worked at the facility, but Staff 10 (CNA) came and assisted them when the strap broke. Staff 9 further stated she reported the incident to the charge nurse Staff 11 (LPN). On 7/22/19 at 5:12 PM Staff 11 (LPN) stated she was unaware of the alleged incident and it was never reported to her. On 7/22/19 at 6:01 PM Staff 1 (Administrator) and Staff 2 (DNS) both stated they were unaware of the alleged incident with Resident 24. They further stated they expected staff to inform them of accidents or equipment failures. Staff 1 and 2 both confirmed the alleged incident was not investigated. On 7/22/19 at 6:04 PM Staff 10 (CNA) confirmed Resident 24's mechanical lift sling broke and he assisted Staff 9 and another CNA with Resident 24. Staff 10 stated he recalled the sling was green. He stated the green slings were not readily available in the facility. He further stated he did not report the incident to anyone and could not recall if the incident was reported by someone else. A progress note completed 7/23/19 by Staff 6 (RNCM) indicated the incident occurred 6/6/19. The report confirmed the mechanical lift sling strap broke, which jolted Resident 24, however the resident did not fall. The progress note further indicated Resident 24's daughter (Witness 1) was present during the incident. On 7/25/19 at 10:22 AM Witness 1 confirmed Resident 24's mechanical lift sling strap broke when staff transferred the resident using a mechanical lift. Witness 1 stated Resident 24 did not fall, but was hanging crooked. Witness 1 was unsure if nursing or administrative staff were notified. Witness 1 further stated sometimes the staff used a smaller sized sling to transfer Resident 24 because they did not have enough of the larger size slings. d. During interviews on 7/23/19 at 11:38 AM and 1:59 PM Staff 1 (Administrator) provided a list of 38 residents in the facility who required use of a mechanical lift. The list identified five residents who required use of an extra-large sized sling. Staff 1 stated the facility only had three extra-large sized slings on hand. No evidence was found to indicate the five identified residents were provided with use of the extra-large sized slings. Based on the facility's failure to have a system in place to safely transfer residents with appropriately sized equipment in good repair, which resulted in residents experiencing multiple falls, an immediate jeopardy situation was declared on 7/23/19 at 4:41 PM. An immediate plan of correction was requested. On 7/23/19 at 5:35 PM an approved immediate plan of correction was received. The plan indicated the facility identified the appropriate size sling for each resident, ordered additional slings to be delivered the following day, care plans were to be updated to include information about the appropriate sling size, staff would be in-serviced regarding proper use of mechanical lifts and slings, housekeeping was in-serviced regarding proper cleaning of the slings and audits would be completed to ensure appropriate sling use. On 7/25/19 at 4:47 PM the immediate jeopardy situation was removed after observations and interviews revealed appropriate equipment was available, staff were trained on use and cleaning of the equipment and resident care plans were updated. 2. Based on observation interview and record review it was determined the facility failed to ensure residents were free from accident hazards for 3 of 5 sampled residents (#s 1, 13 and 15) reviewed for accidents. This placed residents at risk for accidents. Findings include: a. Resident 1 admitted to the facility in 2014 with [DIAGNOSES REDACTED]. The 4/2017 Fall/Injury facility policy included the following: *Staff were to implement interventions to prevent future accidents. *Interview the resident, if appropriate, regarding the incident and include any additional information obtained. *The DNS will prepare a weekly Report to Administrator, summarizing all incidents. The 6/15/19 Annual MDS indicated Resident 1 required total dependence by two staff to transfer out of bed, and extensive assistance by one staff for toileting needs. The assessment further indicated the resident was alert and oriented. On 7/18/19 Resident 1 was observed to have a commode in her/his room. The resident indicated she/he used the commode for bowel movements. The resident further stated she/he had a fall off the commode within the last few months, and cracked four ribs. The 7/18/19 Falls and Urinary Incontinence CAAs indicated Resident 1 had poor balance and a fall with fracture from her/his commode which resulted in multiple fractured ribs, limited range of motion and poor center core control. Resident 1 was noted to have an overactive bladder, to wear incontinence briefs and could inform staff when she/he needed her/his incontinence brief changed. The current, undated Kardex (CNA care plan) indicated Resident 1 used disposable incontinence briefs, and the resident was to be changed as needed. The 4/1/19 Care Plan for falls indicated the resident was at risk for falls and staff were to review information on past falls and attempt to determine the cause and document possible root causes. They were then to remove any potential causes if possible and educate the resident, family, caregivers and the interdisciplinary team. It further indicated staff were to follow the facility fall protocol, and anticipate the resident's needs. A 6/15/19 Incident Note completed at 2:23 PM indicated Resident 1 fell in her/his room while seated on the commode with a CNA in the room attempting to readjust her/him. The resident fell forward, hit her/his chin and bit her/his lip. The treatment nurse was notified of a need to look at her/his lip, and indicated there were no noted injuries aside from the resident's complaint of pain on her/his right side. The progress note indicated it appeared the resident pulled something and alert charting was implemented. A 6/15/19 Incident Note completed at 2:53 PM indicated a decision was made by the resident and her/his family member that she/he would be taken to the emergency department. A 6/16/19 Nursing Note indicated facility staff contacted the hospital and were informed Resident 1 had fractured ribs on her/his right side. The 6/15/19 revision to Resident 1's Care Plan for falls indicated the resident had a fall that resulted in fractured ribs. A 6/28/19 revision included the resident was a high risk for falls due to gait, balance, vision, weakness and a decrease strength of core muscles. The 6/28/19 revision directed staff to continue interventions on the at-risk plan. A 6/19/19 Admission Note indicated Resident 1 readmitted after a stay at the hospital following her/his 6/15/19 fall. Multiple pain medications were noted to be ordered and the note indicated her/his care plan would be updated. The 7/16/19 Post Fall Assessment indicated Resident 1 had a witnessed fall on 6/15/19 after she/he lost balance while a staff person assisted the resident to readjust her/his position while seated on the commode. Current interventions noted to be effective were correct positioning on the commode after (she/he) has already sat down while current interventions noted to not have been effective included having to try and readjust sitting on commode after (she/he) has already sat down. Additional interventions noted to be added to the are plan included frequent checks and a toileting schedule. The summary read, (Resident 1) was on the commode trying to readjust her/his sitting position when she/he leaned forward and fell to the floor. CNA was present. Taking to the hospital. [DIAGNOSES REDACTED]. The Post Fall Assessment was signed as completed by Staff 7 (RNCM) on 6/28/19 (13 days), and was not signed as completed by Staff 2 (DNS) until 7/16/19 (31 days). On 7/22/19 at 1:51 PM Staff 32 (CNA) stated Resident 1 wore incontinence briefs for intermittent episodes of incontinence, but would regularly request to use a bedpan to urinate. She further stated the resident used the bedside commode for bowel movements. On 7/24/19 at 8:54 AM Staff 19 (CNA) stated the resident wore briefs, used a bedpan to urinate and the bedside commode for bowel movements. On 7/24/19 at 9:29 AM at Staff 7 acknowledged Resident 1's toileting care plan was in place at the time of the fall. Staff 7 further acknowledged the following: - The Post Falls Assessment was not signed as complete by the DNS until 7/16/19. - There was no indication the Administrator had reviewed the Post Falls Assessment as per facility policy. - The investigation was not thorough. - The investigation did not include appropriate new implemented interventions or witness interviews. - The care plan was not updated to include person centered interventions related to Resident 1's 6/15/19 fall with fracture. On 7/24/19 at 9:43 AM Staff 1 (Administrator) acknowledged there was no indication she reviewed the 7/16/19 Post Fall Assessment for Resident 1. b. Resident 13 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 4/22/19 BIMS indicated Resident 13 was cognitively intact. The 4/22/19 Quarterly Summary indicated Resident 13 was not have straws due to swallowing precautions. The care plan last updated 4/23/19 indicated Resident 13 was on swallow precautions due to a stroke and trouble swallowing. The care plan further indicated she/he was not to have straws. On 7/18/19 at 10:13 AM Resident 13's room was observed with a sign on the door and above the bed indicating she/he was not to have straws due to swallowing precautions. The resident had a cup on her/his bedside table and a straw with a lid sitting next to the cup. The resident was resting. On 7/18/19 at 12:15 PM Resident 13 stated staff brought the straw in earlier in the morning and she/he was not supposed to have straws because it caused her/him to choke. The resident stated she/he did not use straw. On 7/18/19 at 12:26 PM Staff 3 (CNA) stated she was unsure if Resident 13 was to have straws. On 7/18/19 at 12:27 PM Staff 4 (CNA) stated she believed Resident 13 was able to have straws. Staff 4 then read the sign on the door and then stated Resident 13 should not have straws. On 7/19/19 at 9:37 AM Resident 13's room was observed to have a cup full of ice water with a straw on the bedside table, the resident was resting. On 7/19/19 at 9:37 AM Staff 5 (Hospitality Aide) stated she gave Resident 13 a cup with a straw because she had not been told otherwise. Staff 5 then went to the kitchen and returned to the room and removed the water cup with the straw from the room. Staff 5 further stated Resident 13 was not to have a straw and she just saw the sign on the door indicating the resident was not to have straws. No evidence was found to indicate Resident 13 experienced an outcome related to being given straws. On 7/23/19 at 10:24 AM Staff 6 (RNCM) acknowledged Resident 13 was not to have straws due to swallowing precautions. c. Resident 15 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 7/12/18 Significant Change MDS Falls CAA indicated Resident 15 had a history of [REDACTED]. The Alert Charting Guidelines indicated if a resident had a fall, documentation was to be completed each shift for 72 hours and include information regarding injury, change in ROM, complaints of pain, change in gait, dizziness, changes in level of consciousness, abnormal movements, abnormal blood pressure, signs and symptoms of infection and vital signs. The 6/24/19 and 7/8/19 Post Fall Assessment indicated Resident 15 was found on the floor between her/his bed and the window and attempted to get out of bed without assistance. The nurse on duty evaluated the resident and no injuries were noted and the resident was assisted off the floor. The note further indicated the resident was confused and unable to describe events related to the fall. The 6/24/19 and 7/8/19 fall summaries were written verbatim by different RNCMs. There was no CNA witness statements included in the investigations. There was no indication alert charting was completed for Resident 15 after 6/24/19 and the 7/8/19 falls. The 6/24/19 fall was not reviewed by the RNCM until 7/3/19 (9 days later) and was not reviewed by the DNS until 7/16/19 (22 days later). The 7/8/19 fall was not reviewed by the RNCM until 7/18/19 (10 days later) with no indication the DNS reviewed the fall. On 7/26/19 at 11:28 AM the findings were reviewed with Staff 2 (DNS) and Staff 6 (RNCM). Staff 2 stated she had not reviewed Resident 15's 7/8/19 fall and the expectation was for fall investigations to be completed within 5 days by the RNCM and the DNS. Staff 2 and Staff 6 acknowledged the fall investigations were not completed timely, alert charting was not completed for the falls, there was no CNA witness statements included in the investigations.

Based on observations, interview and record review it was determined the facility failed to provide the correct therapeutic diet and supervision during a meal for 1 of 3 samples residents (# 2) reviewed for nutrition. Resident 2 was observed to eat the incorrect diet and was not supervised during her/his meal. This placed Resident 2 at risk for choking on the incorrect diet. Findings included: Resident 2 was readmitted to the facility in 2/2019 with [DIAGNOSES REDACTED]. The 2/9/19 Progress Notes (PN) revealed the resident was readmitted to the facility with a new diet and fluids order, The new diet orders were: -Staff supervision for meals -One on one staff at bedside -The resident required set up for eating and swallow precautions -Nectar thick liquids -Dysphagia 2 diet (moist and soft textured foods) -Swallow precautions The 1/22/19 care plan revealed the resident had nutritional problems related to her/his stroke and left side [MEDICAL CONDITION] ([DIAGNOSES REDACTED] on one side). Staff were to monitor for choking, coughing and holding food in her/his mouth and the 7/2018 interventions was to serve the diet as ordered. The care plan was not updated to reflect the resident's new diet and swallow precautions. On 2/12/19 at 12:31 PM the resident was observed in bed eating a soft sandwich and canned fruit with staff providing one on one assistance. There was a sign above the bed which revealed the resident was to have a mechanical soft diet (incorrect diet, should be dysphagia 2) with nectar thick liquids and must have 1:1 when consuming anything by mouth. Staff 19 (CNA) indicated the resident required one on one supervision with eating since she/he returned from the hospital. On 2/13/19 at 8:53 AM the resident was observed to be leaning over to the right side while in bed eating a piece of toast (not dysphagia 2), scrambled eggs and fruit and there was no staff present to monitor the resident while she/he ate her/his breakfast. The resident indicated she/he was eating on her/his own. On 2/13/19 at 8:55 AM Staff 24 (CNA) indicated she told Staff 13 (CNA) and Staff 23 (CNA) who worked Resident 2's hall that Resident 2 required one on one assistance with her/his meals. On 2/13/19 at 9:00 AM Staff 23 indicated she knew about the resident requiring one on one assistance. Staff 23 showed the surveyor the online Kardex (care plan for CNAs) and the care plan revealed the resident was eating in the dining room and only required set up assistance with her/his meals. On 2/13/19 at 9:03 AM Staff 13 indicated it was his bad, he knew the resident required one on one assistance but got called away to a different room and left the resident without supervision. On 2/13/19 at 9:14 AM Staff 2 (DNS) indicated she thought the Speech Therapist from the hospital ordered the new diet because Resident 2 was having trouble swallowing and required one on one assistance. On 2/13/19 at 11:37 AM the facility was notified of the failure to provide supervision and the correct diet for Resident 2 who was on swallow precautions and a dysphagia 2 diet. It was determined to be an immediate jeopardy situation, following consultation with survey management. An acceptable plan to abate the immediate jeopardy situation was submitted to the survey team by the facility on 2/13/19 at 1:48 PM. The plan included: -Immediately: Resident 2's care plan was updated to reflect the current diet status. The resident's diet was changed from a dysphagia 2 diet to a mechanical soft diet. The resident would be placed in the RA feeding program in the dining room and would be supervised by a RA or CNA during all meal times, and staff were counseled regarding the care plan. The DNS was to review all the recent admits or re-admits in the last 30 days who were on therapeutic diets to ensure the diets were being followed and care plans were accurate. -Education: The RNCM's were inserviced on base line care plans and the licensed staff were inserviced on resident's admitted with therapeutic diets, accurate care plans and following care plans. -Ongoing Education: The inservice materials were placed in the inservice binder for the staff to review and sign upon returning to work. -Audits: The DNS would audit all new admits for the last 90 days to ensure compliance, and the audits would be discussed at the weekly Quality Assurance Performance Improvement meetings. On 2/13/19 at 2/13/19 at 2:30 PM the facility's implementation of the abatement plan was verified with staff interviews to ensure the staff were educated on therapeutic diets, monitoring residents with swallowing precautions and following the care plans.

Based on the immediate jeopardy in the area of Quality of Care it was determined the facility was not administered by the management team in an effective and efficient manner. As a result Resident 2 received the incorrect diet and was not supervised during her/his meal placing the resident at risk for choking. Findings include: Resident 2 was readmitted to the facility in 2/2019 with [DIAGNOSES REDACTED]. The 2/9/19 Progress Notes (PN) revealed the resident was readmitted to the facility with a new diet and fluids. The new diet orders were: -Staff supervision for meals -One on one staff at bedside -The resident required set up for eating and swallow precautions -Nectar thick liquids -Dysphagia 2 diet (moist and soft textured foods) -Swallow precautions On 2/13/19 at 8:53 AM the resident was observed to be leaning over to the right side while in bed eating a piece of toast (not dysphagia 2), scrambled eggs and fruit and there was no staff present to monitor the resident while she/he ate her/his breakfast. The resident indicated she/he was eating on her/his own. The facility failed to ensure the resident received the new diet order and staff supervised the resident during meals. Refer to F 692

Based on interview and record review it was determined the facility failed to ensure a resident's ordered pain medication was available on admission to the facility to effectively manage the resident's severe pain for 1 of 3 sampled residents (#1) reviewed for pain. This resulted in Resident 1 having severe breakthrough pain. Findings include: Resident 1 was re-admitted to the facility on [DATE] at 5:15 PM with [DIAGNOSES REDACTED]. On 10/2/18 there was an order the resident was on a pain pump (a pump system implanted between the muscles and skin of abdomen that carries pain medications from the pump to the spinal cord and nerves. The pump was programmed to slowly release medication over a period of time). The pain pump contained [MEDICATION NAME] (muscle spasms) and [MEDICATION NAME] (narcotic). The 12/6/18 admission orders [REDACTED] -[MEDICATION NAME] sulfate solution 10 mg/ml give 5 ml via gastrointestinal tube every 4 hours as needed for pain. -[MEDICATION NAME] suppository 650 mg every six hours as needed for pain. -[MEDICATION NAME] 10 mg three times per day for muscle spasms related to [MEDICAL CONDITION]. The 12/6/18 Nursing Admission Database assessment revealed the resident was admitted at 5:15 PM and had complained of pain all over and had a 7 out of the 1-10 pain scale. The resident indicated the pain medication made the pain better. The nurse noted the resident received PRN pain medication. There was no evidence on the 12/2018 MAR indicated [REDACTED]. The Progress Notes revealed the following entries: -12/6/18 11:23 PM The resident complained of pain and the facility was unable to provide the pain medication as the emergency kit dose was not the same dose for the [MEDICATION NAME]. The pharmacy was faxed to send the [MEDICATION NAME] as soon as possible. They were contacted twice and had yet to deliver. -12/6/18 4:14 AM: The resident complained of pain from toes to the top of (his/her) head. The facility noted they were unable to administer the pain medication as the pharmacy had not delivered the pain medication. The 12/2018 MAR indicated [REDACTED]. This constituted a 14 and a half hour delay from when the resident received the last dose of [MEDICATION NAME] for breakthrough pain relief. On 2/21/19 at 5:41 AM Staff 10 (LPN) indicated she was the nurse on shift and stated the pharmacy did not send the [MEDICATION NAME] and they did not have the correct dose of the ordered [MEDICATION NAME] in the emergency pharmacy kit. She also indicated the resident was a pain clinic client and they did not have physicians on call and Resident 1's primary care physician did not like to change her/his pain medications. She stated the CNAs provided repositioning throughout the night and she was unaware the resident had a PRN [MEDICATION NAME] order. She indicated she would have offered the [MEDICATION NAME] to the resident if she knew about the order. On 2/21/19 at 10:44 AM Staff 2 (DNS) indicated if the nurses on shift had difficulties after hours getting medications they should have contacted the RNCM or DNS. She also indicated Staff 10 should have offered the resident the PRN [MEDICATION NAME] as pain relief.

Based on interview and record review it was determined the facility failed to prevent abuse and initiate and conduct a thorough investigation for 3 of 6 sampled residents (#s 21, 49 and 57) reviewed for dignity and abuse. The failure resulted in a lack of corrective actions which caused psychosocial harm and abuse and placed additional residents at risk. This failure resulted in an Immediate Jeopardy situation and was determined to be Substandard Quality of Care. Findings include: Review of the facility's Abuse and Neglect Policy revised 11/2016 indicated Any incidents involving resident abuse must be reported immediately .for follow up and investigation. 1. Resident 49 admitted to the facility in 2015 with [DIAGNOSES REDACTED]. On 11/28/16 at 2:04 pm Resident 49 stated she/he felt abused by Staff 12 (CNA). Approximately one month prior Resident 49 asked for assistance with her/his blankets. Staff 12 threw the blankets at her/him, refused to help, and told the resident to do it her/himself. The resident stated she/he reported the incident to a CMA. The resident did know the CMA's name. Resident 49 stated she/he no longer asked Staff 12 for assistance. On 11/28/16 at 2:09 pm Staff 13 (CMA) entered Resident 49's room and the resident restated how she/he felt abused by Staff 12. Staff 13 then stated she was going to report the allegation to the RNCM immediately. On 11/29/16 at 3:15 pm Staff 4 (RNCM) acknowledged on 11/28/16 Staff 13 reported Resident 49's allegation. On 11/30/16 at 11:00 am Staff 2 (DNS) stated if an allegation of abuse was made against a staff member the facility policy was the staff member would be removed from the schedule until an investigation is complete. Staff 2 stated she was not aware of any prior investigations of Staff 12. On 11/30/16 at 11:23 am Staff 9 (Staffing Coordinator) confirmed Staff 12 was not removed from the work schedule until 11/30/16 and worked the night of 11/28/16, which was after the investigation into Resident 49's allegations was initiated. A review of the November 2016 payroll time sheet confirmed Staff 12 continued to have contact with residents and worked the night of 11/28/16. On 11/30/16 at 12:37 pm after consultation with State agency survey managers, the survey team informed Staff 1 (Administrator) the failure to complete a thorough investigation of Resident 49's allegations of abuse, resulted in continued deficient practice which placed residents at risk for psychosocial harm. These findings constituted an Immediate Jeopardy situation and Substandard Quality of Care. The survey team requested a plan of correction be developed and implemented by the facility to immediately protect residents from abuse. During this discussion, Staff 2 stated Staff 12 had apologized to Resident 49 for making her/him feel uncomfortable. On 11/30/16 at 3:45 pm a plan of correction was provided by the facility that ensured resident safety regarding completing thorough investigations. It was reviewed and approved by the survey team and the Immediate Jeopardy was abated on 11/30/16 at 3:45 pm. The plan of correction included: - A new process for investigations which included: - Any incident that occurs with a resident must be investigated to determine if abuse has occurred. - The DNS will be notified within 2 hours of an incident involving potential abuse. - All statements and interview information must be accurately documented on the investigation form. - If an accusation is made toward a particular staff member, that person will be called in for interview and a statement. That person will not be allowed to work with residents while the investigation is pending and until a determination is made by the DNS. - The DNS will report to Adult Protective Services as required. - In-service records indicating administrative staff reviewed the facility abuse prevention policies, including the Event Reporting and Investigation policy. 2. Resident 57 admitted to the facility in 2015 with [DIAGNOSES REDACTED]. On 11/28/16 at 2:04 pm Resident 57 described feeling verbally abused by Staff 12 (CNA). Resident 57 stated Staff 12 made a vulgar hand gesture to her/him and made weight-related comments about her/his inability to exercise. Resident 57 stated she/he reported the incident to Staff 9 (Staffing Coordinator). On 11/29/16 at 3:33 pm and on 11/30/16 at 11:23 am Staff 9 acknowledged Resident 57 made allegations to her about Staff 12 sometime in September 2016. Staff 9 confirmed she did not follow facility policy to report the allegations of abuse to the DNS when Resident 57 reported the allegations of abuse against Staff 12. Staff 9 acknowledged no investigation was completed at the time of the allegation because she did not report the incident. Staff 9 reassigned Staff 12 to no longer work with Resident 57. She felt the issue was resolved with her decision to reassign Staff 12. 3. Resident 21 admitted to the facility in 2015 with [DIAGNOSES REDACTED]. Review of the 11/13/16 Behavior Monitor and Plan note on 12/1/16 at 9:47 am revealed Resident 21 yelled out for help. Staff 24 (CNA) and another CNA began to assist Resident 21. Resident 21 then told Staff 24 not to help her. Another CNA assisted me, (she/he) pleded (sic) and pleded (sic) for help. (She/he) yelled at me and said not to help (but) I did anyway (she/he) proceeded to scream and tried to hit me multiple times as she called me a (vulgar name). We continued to clean (her/him) up . On 12/1/16 at 2:40 pm Staff 24 (CNA) verified she did not stop when Resident 21 requested to because she felt Resident 21 needed to be cleaned in order to be comfortable. On 12/1/16 in the afternoon Staff 2 (DNS) stated Staff 24 should have backed away from Resident 21 and not proceeded. Staff 2 stated a resident had the right to refuse care.

Based on interview and record review it was determined the facility staff (#13, LPN) failed to meet professional standards related to medication administration for 1 of 4 sampled residents (#7) for whom medication administration was reviewed. Resident 7 was administered an overdose of [MEDICATION NAME] (narcotic pain reliever) and hospitalized . Findings include: According to the Oregon Board of Nursing Scope of Practice Standards for Licensed Practical Nurses [PHONE NUMBER] .(2) Standards related to the Licensed Practical Nurse's responsibility for nursing practice implementation .(d) (A) Implementing treatments and therapy, appropriate to the context of care, including but not limited to, medication administration .(B) Documenting nursing interventions and responses to care in an accurate, timely, thorough, and clear manner . Resident 7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 8/5/16 physician's orders [REDACTED]. The 8/6/16 Resident Care Notes written at 8:30 am by Staff 7 (RN) documented the resident had decreased level of consciousness. The resident's family member was asked if the resident was a heavy sleeper and difficult to arouse. Staff 7 documented Staff 14 (CMA) reported two doses of 30 mg of [MEDICATION NAME] ER were administered to the resident on the evening shift of 8/5/16. The Emergency Medical Transport staff (EMTs) were at the facility and were informed the resident received a double dose of [MEDICATION NAME]. The EMTs administered a dose of [MEDICATION NAME] (used to reverse the effects of narcotic pain medications) and resident was alert before being transported to the local hospital emergency department. The 8/6/16 local hospital emergency department notes documented the resident received two doses of 30 mg of [MEDICATION NAME] and the EMTs provided a dose of [MEDICATION NAME]. She/he was diagnosed with [REDACTED]. The August 2016 MAR documented the resident was to receive a dose of [MEDICATION NAME] ER every twelve hours and directed the staff to provide the medication at 8:00 am and 8:00 pm. The MAR contained the initials of Staff 13 (LPN) who provided the resident with one dose of [MEDICATION NAME] on [DATE]. The back of the MAR documented the resident received [MEDICATION NAME] on [DATE] at 7:30 pm. There was no other documentation on the MAR to indicate the resident received another dose of [MEDICATION NAME]. The Narcotic Record for [MEDICATION NAME] ER was reviewed and Staff 13 (LPN) documented the resident received a dose of [MEDICATION NAME] on [DATE] at 5:30 pm and another dose of [MEDICATION NAME] ER at 8:30 pm. Staff 13 wrote a description of the incident dated 8/5/16. Staff 13 documented the charge nurse informed her the pharmacy was satelliting [MEDICATION NAME] for Resident 7 and the charge nurse requested a dose be given to the resident when the medication arrived at the facility. Staff 13 indicated when the [MEDICATION NAME] arrived at the facility Staff 13 accepted the medication and administered the first dose to the resident at 7:30 pm. Staff 13 stated later during the medication pass, she noted the [MEDICATION NAME] was scheduled to be given at 8:00 pm. Staff 13 documented she gave another dose of the [MEDICATION NAME] at 9:00 pm having neglected to note that there was no order on the MAR for the [MEDICATION NAME] to given less than 8 hours apart and not having considered that the medication was MSER ([MEDICATION NAME] ER), which is 'extended release' The error that occurred next, was that this nurse, having realized, after the fact, that I had given more [MEDICATION NAME] than was ordered or scheduled, neglected to mention to the present charge nurse or on-coming nurse of the error, thus leading to the resident having become non-responsive .This nurse accepts and understands responsibility events due to the medication error Interviews conducted 8/10/16 at 11:00 am through 8/11/16 11:13 am revealed the following: Staff 13 (LPN) stated she made an error when she documented the resident received a dose of [MEDICATION NAME] on [DATE] at 5:30 pm on the Narcotic Record. Staff 13 stated she administered the first dose of [MEDICATION NAME] medication at 7:30 pm. Staff 13 administered the first dose of [MEDICATION NAME] to the resident and then she provided the second dose of [MEDICATION NAME]. Staff 13 stated she did not immediately notice the mistake of providing the additional [MEDICATION NAME] and the [MEDICATION NAME] was extended release. Staff 13 stated later in the shift she noticed she gave the medication in error though she did not tell the charge nurse. Staff 13 stated she did not know why she made the error in medication administration though stated she must not have been paying attention. Staff 13 didn't know why she didn't tell the charge nurse when she noticed the error. Staff 13 stated she accepted full responsibility for the medication error and for not notifying the charge nurse immediately. Staff 7 (RN) stated she was the charge nurse on the day shift of 8/6/16. Staff 7 stated Staff 14 (CMA) asked her to review the narcotic record because Staff 14 stated the resident had received two doses of [MEDICATION NAME] ER during the evening shift of 8/5/16. Staff 7 stated she would expect anyone who administered medication to read and follow the order, assess for pain and follow the physician's orders [REDACTED]. Staff 7 stated nurses are taught to conduct multiple checks, correct dose, correct route and assess if the medications were effective. Staff 7 stated she would expect the staff to immediately report if there was a medication error. Staff 7 stated when she reviewed Resident 7's MAR there was no documentation the resident received two doses of [MEDICATION NAME] on [DATE]. Staff 14 (CMA) stated on 8/6/16 she walked to Resident 7's room to see how she/he wanted her/his medications administered. Staff 14 stated she went into the resident's room and she could not wake her/him up. She reviewed the resident's MAR and narcotic record and noticed Resident 7 had received two doses of [MEDICATION NAME] ER. She checked the physician's orders [REDACTED]. Staff 14 stated Staff 7 informed the EMTs of a double dose of [MEDICATION NAME] on the evening shift of 8/5/16. Staff 8 (LPN) stated she was the charge nurse on the evening shift of 8/5/16. Staff 8 stated when the [MEDICATION NAME] ER arrived from the pharmacy she gave one tablet to Staff 13 (LPN) to administer to Resident 7. Staff 8 stated she did not know Staff 13 provided another dose of [MEDICATION NAME] ER during the evening shift. Staff 8 stated it was her expectation the facility staff administering medications would follow physician's orders [REDACTED]. Staff 2 (DNS) stated she would expect the facility staff administering medications to read the physician's orders [REDACTED]. Staff 2 stated she would expect any staff who were aware they made a medication error to inform the charge nurse immediately. Staff 2 stated she was not aware of the medication error until 8/6/16. Refer to F333

Based on observations, interviews and record review it was determined the facility failed to follow the care plan of no bed rails and a low bed for 2 of 5 sampled residents (#s 6 and 8) reviewed for falls. Resident 8 fell out of bed and her/his right arm was twisted around a bed rail on the bed and left arm underneath her/his chest. Resident 8 sustained a fractured left wrist. Findings include: 1. Resident 8 was admitted to the facility in September 2014 with [DIAGNOSES REDACTED]. The 2/1/16 Fall Risk and Bed Fall Assessment indicated the resident did not have a fall in the prior three months and no bed rails were to be used on the resident's bed. The 2/3/16 In Room Care Plan did not direct the staff to use bed rails on the bed. The care plan directed the staff to use a personal alarm when she/he was in bed and to have low bed to floor. The 2/29/16 Resident Care Notes indicated a staff member was putting away supplies when they found the resident lying on the floor. The charge nurse documented she saw the resident lying on the floor face down with her/his right arm twisted around the bed rail and left arm underneath her/his chest. The resident complained of pain in her/his right arm. The resident was transported to the local hospital emergency department. The 2/29/16 local hospital reports revealed x-rays were taken of the resident's right arm, left arm, head and spine. The x-rays revealed the resident sustained [REDACTED]. The 2/29/16 Incident Report prepared by Staff 3 (RNCM) indicated the resident's right arm was around a loop bar on the side of the bed. Staff 3 documented the loop bar was removed from the resident's bed after the incident. The bed was not all the way to the floor, it was some what (sic) between knee high and the lowest position There was no discussion whether the resident's personal alarm was on or sounding. Interviews conducted 8/3/16 at 12:15 pm through 3:40 pm revealed the following: Staff 3 (RNCM) verified the resident was assessed not to have a loop bar in place prior to the resident's fall on 2/29/16. Staff 3 stated the loop bar did not cause the resident's fracture of the left wrist. Staff 3 stated the bed was not low to the floor as care planned. Staff 3 stated the resident would remove the personal alarm. Staff 2 (DNS) was informed of the documentation not to have a loop bar in place and the bed was not low to the floor as care planned. Staff 2 was asked to provide any additional information. No additional information was provided. 2. Resident 6 was admitted to the facility in January 2016 with [DIAGNOSES REDACTED]. On 8/3/16 at 9:00 am Resident 6 was observed to be in bed with quarter bed rails up on the head of the bed. The 5/31/16 Bed Fall Risk and Falls Risk Assessment indicated no bed rails were to be used for the resident. The 6/1/16 In Room Care Plan did not include the use of bed rails for the resident. Interviews conducted 8/3/16 from 1:50 pm through 3:00 pm revealed the following: Staff 11 and 17 (CNAs) stated they used the In Room Care Plan to provide resident care. They stated the resident had quarter bed rails up when she/he was in bed. Staff 3 (RNCM) stated Resident 6 was not to have bed rails used when she/he was in bed. Staff 2 (DNS) stated she would expect the facility staff to follow the In Room Care Plan of no bed rails to be used.

Based on interview and record review it was determined the facility failed to administer [MEDICATION NAME] (narcotic pain medication) as ordered for 1 of 4 sampled residents (#7) for residents reviewed for [MEDICATION NAME] usage. Resident 7 was administered an overdose of [MEDICATION NAME] and hospitalized . Findings include: Resident 7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 8/5/16 physician's orders [REDACTED]. The 8/5/16 Resident Care Notes written by Staff 8 (LPN) documented the resident was admitted to the facility at 7:20 pm. The resident complained of pain and was administered [MEDICATION NAME] through the facility's emergency supply of medications. The notes indicated the resident continued to be painful though the facility was unable to administer [MEDICATION NAME] as there were no tablets of [MEDICATION NAME] ER in the emergency drug supply. The contract pharmacy was contacted and the pharmacy delivered the [MEDICATION NAME] to the facility at 7:30 pm. The notes indicated the [MEDICATION NAME] was administered. The 8/6/16 Resident Care Notes written at 1:35 am documented the resident had some sleep apnea during the night though rested comfortably. The 8/6/16 Resident Care Notes written at 8:00 am by Staff 7 (RN) documented the resident had somnolence and lethargy. Resident was difficult to waken, stirred when her/his name was called though returned to snoring. The 8/6/16 Resident Care Notes written at 8:30 am by Staff 7 (RN) documented the resident had decreased level of consciousness. The resident's family member was asked if the resident was a heavy sleeper and difficult to arouse. The family member stated the resident had long periods of time when she/he was difficult to arouse. The CNA was unable to arouse Resident 7 for the breakfast meal. The charge nurse assessed the resident and was unable to have the resident respond to name calls, sternal rub or physical stimuli. The nurse had the CNA stay with the resident while the nurse called the resident's family member and they requested the resident be assessed at the local hospital emergency department. Staff 7 documented Staff 14 (CMA) then reported the resident received two doses of 30 mg of [MEDICATION NAME] on the evening shift of 8/5/16. The Emergency Medical Transport staff (EMTs) were informed of the double dose of [MEDICATION NAME] and the resident was administered a dose of [MEDICATION NAME] (used to reverse the effects of narcotic pain medications). The 8/6/16 local hospital emergency department notes documented [DIAGNOSES REDACTED]. The 8/6/16 local hospital history and physical indicated the resident had long apneic pauses (suspension of external breathing). The resident was provided with another dose of [MEDICATION NAME] and her/his breathing was even. The resident then fell into obtundation (altered level of consciousness) and was transferred to the Intermediate Care Unit. The facility's August 2016 MAR documented the resident was to receive a dose of [MEDICATION NAME] ER every twelve hours and directed the staff to provide the medication at 8:00 am and 8:00 pm. The MAR contained the initials of Staff 13 (LPN) who provided the resident with one dose of [MEDICATION NAME] on [DATE]. The back of the MAR documented the resident received [MEDICATION NAME] on [DATE] at 7:30 pm. There was no other documentation on the MAR to indicate the resident received another dose of [MEDICATION NAME]. The Narcotic Record for [MEDICATION NAME] ER was reviewed and Staff 13 (LPN) documented the resident received a dose of [MEDICATION NAME] on [DATE] at 5:30 pm and another dose of [MEDICATION NAME] ER at 8:30 pm. Staff 13 wrote a description of the incident dated 8/5/16. Staff 13 documented the charge nurse informed her the pharmacy was satelliting [MEDICATION NAME] for Resident 7 and the charge nurse requested a dose be given to the resident when the medication arrived at the facility. Staff 13 indicated when the [MEDICATION NAME] arrived at the facility Staff 13 accepted the medication and administered the first dose to the resident at 7:30 pm. Staff 13 stated later during the medication pass, she noted the [MEDICATION NAME] was scheduled to be given at 8:00 pm. Staff 13 documented she gave another dose of the [MEDICATION NAME] at 9:00 pm having neglected to note that there was no order on the MAR for the [MEDICATION NAME] to given less than 8 hours apart and not having considered that the medication was MSER ([MEDICATION NAME] ER), which is 'extended release.' The error that occurred next, was that this nurse, having realized, after the fact, that I had given more [MEDICATION NAME] than was ordered or scheduled, neglected to mention to the present charge nurse or on-coming nurse of the error, thus leading to the resident having become non-responsive .This nurse accepts and understands responsibility events due to the medication error Interviews conducted 8/10/16 at 11:00 am through 8/11/16 11:13 am revealed the following: Staff 13 (LPN) stated she made an error when she documented the resident received a dose of [MEDICATION NAME] on [DATE] at 5:30 pm on the Narcotic Record. Staff 13 stated she administered the first dose of [MEDICATION NAME] medication at 7:30 pm. Staff 13 stated when the resident was admitted she/he resided in room [ROOM NUMBER]A and Staff 13 administered the first dose of [MEDICATION NAME] to the resident. Resident 7 was then transferred to room [ROOM NUMBER]B when she provided the second dose of [MEDICATION NAME]. Staff 13 stated she did not immediately notice the mistake of providing the additional [MEDICATION NAME] and the fact the [MEDICATION NAME] was extended release. Staff 13 stated she noticed she gave the medication in error though she did not tell the charge nurse. Staff 13 stated she did not know why she made the error in medication administration though stated she must not have been paying attention. Staff 13 didn't know why she didn't tell charge nurse when she noticed the error. Staff 13 stated she accepted full responsibility for the medication error and for not notifying the charge nurse immediately. Staff 7 (RN) stated she was the charge nurse on the day shift of 8/6/16. Staff 7 stated she talked with the resident's family member to determine if the resident was a heavy sleeper as the staff were having a difficult time to arouse her/him. Staff 7 stated the CNA informed her the resident would not wake up for breakfast. Staff 7 stated she assessed the resident and she was not able to wake the resident by calling her/him name or sternal rub. Staff 7 stated she talked with the resident's family member and they requested the resident be sent to the local hospital emergency department. Staff 7 stated she called for the EMTs to transport the resident to the local hospital. Staff 7 stated Staff 14 (CMA) asked her to review the narcotic record because Staff 14 stated the resident had received two doses of [MEDICATION NAME] ER during the evening shift. Staff 7 informed the EMTs of the findings and the EMTs administered [MEDICATION NAME] for the resident. Staff 7 stated she would expect anyone who administered medication to read and follow the order, assess for pain and follow the physician's orders [REDACTED]. Staff 14 (CMA) stated on 8/6/16 she walked to Resident 7's room to see how she/he wanted her/his medications administered. Staff 14 stated she went into the resident's room and she could not wake her/him up. Staff 14 stated she reviewed the resident's MAR and narcotic record and noticed the resident received two doses of [MEDICATION NAME] ER. She checked the physician's orders [REDACTED]. Staff 14 stated Staff 7 (RN) informed the EMTs of a double dose of [MEDICATION NAME] on the evening shift of 8/5/16. Staff 8 (LPN) stated she was the charge nurse on the evening shift of 8/5/16. Staff 8 stated didn't know what happened until she returned to work the evening shift of 8/6/16. Staff 8 stated the resident was in a lot of pain when she/he was admitted . Staff 8 stated the [MEDICATION NAME] was not effective in managing the resident's pain. Staff 8 stated she talked with the resident's family member who was in the resident's room and they were concerned about the administration of [MEDICATION NAME] ER. Staff 8 stated when the [MEDICATION NAME] ER arrived from the pharmacy she gave one tablet to Staff 13 (LPN) to administer to Resident 7. Staff 8 stated the resident was moved to a different room an hour later. Staff 8 stated she did not know Staff 13 provided another dose of [MEDICATION NAME] ER during the evening shift. Staff 8 it was her expectation the facility staff administering medications would follow physician's orders [REDACTED]. Staff 2 (DNS) stated she would expect the facility staff administering medications to read the physician's orders [REDACTED]. Staff 2 stated she would expect any staff who were aware they made a medication error to inform the charge nurse immediately. Staff 2 stated she was not aware of the medication error until 8/6/16.

Based on observation, interview and record review it was determined the facility failed to ensure resident safety for smoking for 4 of 4 sampled residents (#s 18, 36, 53 and 64) who smoked. The facility failed to follow their Smoking Policy for smoking assessments, care planning, securing smoking materials, ensuring resident safety while smoking and disposal of smoking materials. Resident 53 was observed smoking in a non-designated smoking area, disposing of ashes on her/himself, extinguishing a cigarette between her/his fingers, and disposing the cigarette butt in a trash receptacle inside the facility. No smoking assessment had been completed for Resident 53 to assess smoking safety or risk, despite recent medication changes and decreases in her/his level of consciousness. A staff interview revealed knowledge of Resident 53 keeping unsecured cigarettes and a lighter in her/his pocket. This put residents at risk for immediate jeopardy related to fire hazards. The severity of example one, for Resident 53, constituted substandard quality of care. Findings include: The facility's Resident Smoking Policy indicated if a resident chose to smoke, they were required to follow the guidelines outlined in the policy. If the smoking rules of the facility were violated, the resident may lose smoking privileges. The policy further indicated it was mandatory that all smoking supplies be locked up when not in use and a safety assessment was required to be conducted by a licensed nurse prior to a resident being allowed to smoke independently. Smoking aprons were to be worn by a resident if deemed required. The residents were to return their smoking materials to the Nurses Station when finished and would allow staff to inspect their clothing and wheelchair for smoldering ashes or cigarette butts. The policy also included the facility would not provide direct supervision during smoking and that all smoking materials were to be kept in the locked medication room. Residents were to check in with a nurse or CMA to obtain their smoking materials prior to going outside to smoke. Residents were not to keep lighters, matches, cigarettes, or any other smoking supplies in their room or on their own person. 1. Resident 53 was admitted to the facility in 2012 with [DIAGNOSES REDACTED]. Resident 53 was identified by the facility to be one of four residents who smoked. Resident 53 did not smoke upon admit, but started again after other smokers were admitted . On 1/13/14 Resident 53 signed an Acknowledgement of Smoking Risks and agreed to the following conditions: -to smoke on the front porch by the ashtray -to extinguish all lighted materials in the ashtray -to return the lighter and cigarettes to the nurse or CMA upon return into the building. "I may not keep lighters...cigarettes...on my person." The 4/21/14 Quarterly Summary revealed Resident 53 had short-term and long-term memory problems. The Care Card dated 4/23/14 indicated Resident 53 required assistance with all ADLs and special instructions included "frequent visual checks." The resident's mental status included "forgetful." Resident 53's Care Plan dated 4/23/14 indicated the resident was sleepy and less active and had physician orders [REDACTED]. It was identified the resident smoked and would: -continue to smoke safely -follow smoking policies -pass a smoking assessment for safety upon admission, quarterly and prn (by the RNCM) -be observed for unsafe smoking habits to include ashes on clothing. There was no evidence of a Smoking Assessment for Resident 53 in the medical record. The 4/23/14 Interdisciplinary Care Conference meeting notes identified Resident 53 smoked as an activity. There was no discussion of the resident's safety while smoking nor whether the resident adhered to the facility's Resident Smoking Policy. On 5/6/14 a Psychoactive/Behavior Review and Assessment was completed for Resident 53. It indicated the resident had hallucinations and was being monitored for schizophrenia by the County Mental Health Department. The Behavior Monitor and Plan identified on 5/30/14 at 3:00 pm the receptionist smelled smoke in the hall and found Resident 53 smoking. The receptionist attempted to stop her/him from smoking and the resident was angry. NN dated 7/10/14 indicated the resident continued with confusion and was, "slow to rouse & goes right back to sleep." NN dated 7/11/14 revealed Resident 53 was, "Slow to respond @ times. Has been outside smoking x 4 today per (her/his) usual routine prior to (her/his) recent (decreased level of consciousness)...change in condition..." NN dated 7/12/14 indicated Resident 53 was, "Difficult to rouse slow to respond." On 7/16/14 at 4:07 pm and 4:46 pm Staff 3, RNCM, Resident 53's assigned RNCM, stated he was familiar with the Resident Smoking Policy. He confirmed no Smoking Assessment had been completed for Resident 53, but rather informal assessments, such as seeing the resident in the hall and determining the resident was safe. When asked how Resident 53 was assessed for changes, Staff 3 stated staff would notify him the resident was somewhat confused and they would hold the resident's smoking for a while. On 7/16/14 at 5:01 pm the lack of current smoking assessments and the facility's knowledge of residents not returning their smoking supplies was discussed with Staff 1, Administrator, and Staff 2, DNS. They were notified the safety of all residents superceded the right to privacy for one resident. They understood and agreed. A Smoking assessment dated [DATE] indicated Resident 53 had no memory problems and was able to light and dispose of ashes based on the "visual observation" made by Staff 3, RNCM. Whether the resident required supervision, wore a smoker's apron and kept smoking materials locked were not includedin the assessment. An observation on 7/17/14 at 9:43 am revealed an unsecured small basket placed on a shelf behind the desk at the Nurses Station. Inside the basket were four packs of cigarettes, two metal containers containing e-cigarettes and one lighter. On 7/17/14 during continuous observation from 10:49 am through 11:10 am Resident 53 was observed sitting in a wheelchair approximately 15 feet from the designated smoking area. Resident 53 was talking to Staff 14, Life Enrichment Coordinator. Staff 14 then walked inside and told front desk staff Resident 53 was okay and she would check on the resident in 10 minutes. The surveyor went outside to talk to the resident and noted there was a cigarette in her/his mouth. It took several minutes for Resident 53 to get the lighter out of her/his left shirt pocket, then three attempts and several more minutes to light the cigarette. Resident 53 tapped the ashes with her/his left hand which landed on her/his left pant leg. Ashes were observed scattered on the resident's shirt and pants. Once the unfiltered cigarette was nearly burned to the resident's fingertips the resident extinguished it by pinching off the tip onto the driveway. Resident 53 kept the butt in her/his left hand. The resident wanted to go back inside but was unable to move the wheelchair by her/himself. Staff 14 then returned, Resident 53 stated she/he was ready, and they both went back inside. Resident 53 was observed to throw the cigarette butt in a trash can located inside the facility lobby. Staff 14 took Resident 53 directly to the dining room for lunch. On 7/17/14 at 11:11 am Resident 53 was in the dining room. The resident stated she/he usually retrieved her/his lighter and two cigarettes in the morning from the nurses station. The resident stated she/he saved them to smoke after meals. Resident 53 kept her/his lighter on her/him all day and turned it in after dinner. The resident stated she/he was supposed to wear a smoking apron but sometimes another resident used it and sometimes the nurses were busy, so she/he just smoked without it. Staff 15, CNA, stated on 7/17/14 at 11:19 am Resident 53 used to be an independent smoker but lately was tired, run down and groggy and would go out with someone to smoke. She confirmed the resident would get one or two cigarettes from a nurse in the morning and saved one for later. Staff 15 was aware Resident 53 kept the lighter and did not turn it back in for secure storage. On 7/17/14 at 11:40 am Staff 14, Life Enrichment Coordinator, stated she was unaware the resident had smoked after she left her/him outside. She stated sometimes Resident 53 was not very cognitively aware, didn't know there was something in her/his hands, fell asleep really quickly and wasn't safe to smoke like that. Once the resident told Staff 14 there were three cigarettes in the resident's hand, but there were actually none. The resident was "not reality based" sometimes. The resident was supposed to wear a smoking apron if she/he was not cognitive enough to make the right choices, was falling asleep or was delusional. She said the resident wasn't safe during those times and needed to be supervised. Staff 14 stated the resident was not always compliant with the smoking policy and other smoking residents were noncompliant, too. On 7/17/14 at 12:40 pm Staff 16, Staff Development Director, stated whether Resident 53 was able to smoke safely was determined on a day to day basis. Some days the resident was lucid and awake, and sometimes the resident was confused. Staff 3, RNCM, was interviewed on 7/17/14 at 1:10 pm. He stated Resident 53 was in and out of confusion, refused to wear a smoking apron, unsafely extinguished cigarettes with her/his fingers and was generally not safe lately. On 7/17/14 at 1:10 pm and 1:38 pm Staff 2, DNS, stated Resident 53 had recent medication changes and was confused. She stated if the resident was unsafe she/he couldn't have her/his smoking supplies and someone had to supervise the smoking. Staff 2 confirmed the smoking supplies used to be locked up in the medication room but staff got tired of it. When notified of residents not turning in their smoking supplies she stated staff got sympathetic and felt uncomfortable taking smoking items from the residents. She stated Staff 3, RNCM, did Resident 53's Smoking Assessment 7/16/14 with the help of Staff 8 (Social Service Director). She stated Staff 3 had not directly observed the resident for the smoking assessment the previous night, but had observed the resident in the past. On 7/17/14 at 2:42 pm, following survey team determination and consultation with NFSU (Nursing Facility Survey Unit) supervisors, Staff 2, DNS, was informed the lack of safety and supervision of smoking constituted a situation of immediate jeopardy to residents. A plan of correction was requested to immediately be developed and implemented to protect residents from risk of fire hazards. Staff 2 was notified of the need for an extended survey due to substandard quality of care. On 7/17/14 at 2:49 pm Staff 17, Assistant Administrator, confirmed there was an unfiltered cigarette butt in the lobby trash can. On 7/17/14 at 5:18 pm a plan of correction was provided by the facility to monitor and ensure resident safety related to smoking. It included supervision for all smokers. The immediate jeopardy was abated at 5:27 pm. On 7/18/14 at 1:23 pm Resident 53 was observed at the designated smoking area. The resident was wearing a smoking apron. Other non-smoking residents were present, a staff member was present and holding the smoking materials in a container. 2. Resident 36 was admitted to the facility in November 2013 with [DIAGNOSES REDACTED]. MDS assessments dated 11/18/13 and 2/5/14 indicated the resident was cognitively intact and required limited to no assistance with most ADLs. The Smoking assessment dated [DATE] indicated the resident smoked one to two cigarettes in the evening, needed reading glasses, routinely saved a half cigarette if unable to finish it and wore a smoking apron. A quarterly smoking assessment and signed Acknowledgement of Smoking Risk was dated 3/28/14. The Smoking Care Plan for Resident 36 dated 6/9/14 indicated the resident would smoke safely, follow smoking policies and would pass a smoking assessment for safety upon admission, quarterly and as needed. The Care Plan also indicated the following: Resident 36 would sign a smoking waiver of risk of smoking upon admission. Staff were to observe for unsafe smoking habits or effects on unsafe smoking. Any observations were to be reported to the charge nurse or RNCM. The Care Plan identified evidence of unsafe smoking to include: burn holes in clothing, blisters to fingers or other body parts, ashes on clothing, or singed mustache/beard/hair. The Care Plan indicated Resident 36 was to check out with a nurse or aide when leaving to smoke, wear a smoker's apron due to the fact she/he fell asleep easily and to turn in lighter and cigarettes at the nurses' station after smoking. On 7/17/14 at 11:00 pm Staff 4, Clinical Records, stated Resident 36 was quite ill when admitted and did not start smoking until 2014. On 7/17/14 at 11:46 am Resident 36 confirmed she/he smoked. The resident had not smoked for about four days. The resident stated she/he always used a smoking apron and kept it in her/his wheelchair. When asked where the resident kept the lighter and cigarettes, the resident gestured towards the bedside table. A pack of cigarettes was observed on the bedside table. The resident showed she/he kept the lighter inside the pack, tucked between the cigarettes. No smoking apron was observed in the resident's wheelchair. On 7/17/14 at 11:52 am Staff 5, CNA, stated he worked both day and evening shifts. He stated the resident did not smoke during the day very often and was more likely to smoke on the evening shift. He did not know where Resident 36 kept her/his smoking materials. On 7/17/2014 at 12:39 pm Staff 6, LPN, stated Resident 36 was a smoker and had never asked her for smoking supplies. Staff 3, RNCM, was responsible for Resident 36 while her/his assigned RNCM was on medical leave. On 7/17/14 at 12:42 pm Staff 3, RNCM, stated Resident 36 was not a frequent smoker, smoked "once in a blue moon," was "pretty safe with it and didn't necessarily need an apron." The facility had more than one apron but he was not sure where they all were. Resident 36 had a history of [REDACTED]. The resident had no history of injury related to smoking. Staff 6 stated if any resident looked "loopy" when (she/he) came to the nurses' station to get smoking supplies, staff would withhold the materials. On 7/17/2014 at 12:53 pm Resident 36 recalled something about not keeping smoking supplies in her/his room but had always kept them there. The resident indicated she/he had never turned them in to the nurses' station and staff had not asked for them. On 7/17/14 at 1:08 pm Staff 7, CMA, stated she knew Resident 36 kept smoking materials in her/his room and the policy was to keep them at the nurses station. She stated the resident was physically weak but able to make decisions. On 7/18/14 at 12:01 pm the observation of smoking materials at Resident 36's bedside and the interview with her/him were discussed with Staff 2, DNS. She stated the facility was trying to accommodate residents' individual preferences and acknowledged that Resident 36's smoking care plan was not followed related to securing smoking materials. 3. Resident 18 was admitted in September 2012 with [DIAGNOSES REDACTED]. Observations on 7/15/14 at 9:19 am and 11:08 am revealed the resident smoked independently at the designated smoking area. The resident had smoking materials (cigarettes and a lighter) in her/his possession. An observation on 7/17/14 at 9:43 am revealed an unsecured small basket placed on a shelf behind the desk at the Nurses Station. Inside the basket were four packs of cigarettes, two metal containers containing e-cigarettes and one lighter. The 3/12/14 MDS assessment indicated the resident was cognitively intact and required limited to no assistance with ADLs. There was no smoking assessment or care plan in the resident's record that addressed the resident's ability to safely smoke independently and ensure the resident's smoking materials were secured. A signed Acknowledgment of Smoking Risks was dated 7/15/14. On 7/15/14 at 11:08 am Resident 18 stated she/he was able to smoke whenever she/he wanted because she/he was independent. Resident 18 stated she/he kept smoking materials with her/him at all times and facility staff were aware she/he kept her/his smoking materials. Resident 18 stated she/he had kept her/his smoking materials with her/him for about two years and staff had never questioned her/him about it. During interviews on 7/15/14 at 10:17 am and 10:19 am Staff 19, CNA, and Staff 18, RA, stated residents who smoked were supposed to wear a smoking apron and would go to the designated smoking area to smoke independently. Both Staff 19 and 18 also said the residents were supposed to ask each time they wanted to go out to smoke and all smoking materials were to be kept at the nurses' station. On 7/16/14 at 4:07 pm and 4:46 pm, Staff 3, RNCM, Resident 18's assigned RNCM, stated only independent smokers were allowed to smoke. Staff 3 acknowledged no written assessment was completed for Resident 18 to determine if the resident was able to safely smoke independently. Staff 3 then stated he and other staff were aware that Resident 18 kept her/his smoking materials in her/his own possession and did not return them to the nurses' station. On 7/16/14 at 5:01 pm the lack of current smoking assessments and the facility's knowledge of residents not returning their smoking supplies was discussed with Staff 1, Administrator, and Staff 2, DNS. Staff 2 stated she was not surprised Resident 18 had not returned her/his smoking supplies. They were notified the safety of all residents superceded the right to privacy for one resident. They understood and agreed. On 7/17/19 at 10:09 am, Staff 20, LPN, identified Resident 18 was one of the residents who smoked independently. Staff 20 stated residents who smoked were to keep their smoking materials at the nurses' station when not in use. Staff 20 then stated Resident 18 was "stubborn at times" in returning her/his smoking materials and was known to keep them. On 7/17/14 at 10:44 am, Staff 16, Staff Development Director, stated any resident who smoked would be assessed to determine if they were safe to smoke. Staff 16 stated that all resident smoking supplies were to be kept at the nurses' station and were not kept in the locked Medication Room. 4. Resident 64 was admitted in September 2013 with [DIAGNOSES REDACTED]. A signed Acknowledgment of Smoking Risks was dated 1/15/14. The 6/4/14 MDS assessment indicated the resident was cognitively intact and required limited to no assistance with ADLs. The Care Plan for smoking was dated 6/11/14 and indicated Resident 64 smoked about eight times daily, would smoke safely and follow the Resident Smoking Policy. Observation on 7/16/14 at 12:26 pm revealed Resident 64 wheeled her/himself to the Nurses Station and asked for her/his smoking supplies from Staff 21, Plant Services. Resident 64 received her/his smoking materials (pack of cigarettes and lighter), which Staff 21 retrieved from the wicker basket, and then obtained a smoking apron that was kept on a small swinging door to the nurses' station. Resident 64 donned the smoking apron with the assistance of Staff 21. Resident 64 then self-propelled outside to the designated smoking area where Resident 64 smoked independently. There was no smoking assessment in the resident's record that addressed the resident's ability to safely smoke independently. On 7/17/14 at 9:53 am Resident 64 verified she/he smoked independently in the designated smoking area and all of her/his smoking materials were kept at the nurses' station. Resident 64 stated she/he could only use her/his right side due to a stroke and her/his left side was paralyzed. Resident 64 stated she/he did not wear a smoking apron until January 2014. Resident 64 then stated she/he cannot secure the smoking apron to the lower part of her/his body as the apron would then have to be tied to her/his wheelchair over her/his legs. Resident 64 said staff had informed her/him they could not do this it would be considered as a restraint since the resident could not untie and remove the apron her/himself if both the upper and lower apron ties were used. Resident 64 stated she/he could only have the smoking apron tied around her/his neck and there had been occasions when the wind had blown the smoking apron up towards the resident and had knocked cigarettes out of the resident's hand and onto the ground. Resident 64 confirmed she/he was independent with smoking and staff did not accompany her/him when she/he smoked. On 7/16/14 at 4:07 pm and 4:46 pm Staff 3 RNCM, Resident 64's assigned RNCM, stated only independent smokers were allowed to smoke. Staff 3 acknowledged Resident 64 smoked independently and no written assessment had been completed to determine if the resident was able to safely smoke independently. Staff 3 mentioned Resident 64 did have physical deficits and the resident was required to wear a smoking apron for her/his safety. On 7/17/14 at 10:44 am, Staff 16, Staff Development Director, stated any resident who smoked would be assessed to determine if they were safe to smoke. Staff 16 stated all resident smoking supplies were to be kept at the nurses' station and were not kept in the locked Medication Room.

1. Based on observation, interview and record review, it was determined the facility failed to provide a resident environment that was as free of accident hazards as possible, and failed to ensure supervision and assistive devices to prevent accidents for 2 of 13 sampled residents (#s 6 and 9). Resident 6 fell on [DATE], experienced increased pain and was transported to the hospital for evaluation following the fall. Findings include: a. Resident 6 was admitted to the facility during 2010 with [DIAGNOSES REDACTED]. Dementia with Lewy Bodies is characterized by progressive cognitive decline, fluctuations in alertness and attention including frequent drowsiness and lethargy, recurrent visual hallucinations and parkinsonian motor symptoms such as rigidity and loss of spontaneous movement. The 3/28/10 Initial MDS revealed the resident was moderately cognitively impaired, needed limited staff assistance with ambulation and extensive staff assistance for bed mobility and transfers. The Resident Care Notes, dated 6/18/10 at 1:10 am, 7:30 pm and 10:30 pm, revealed the resident had fallen, had a dark purple bruise over the left hip and complained of pain with movement and palpitation of the left leg. The resident was diagnosed with [REDACTED]. The 6/18/10 Occurrence Report/Investigation form revealed frequent visual checks were to be implemented and the care plan was adjusted to include use of the personal alarm at all times. The Resident Care Notes, dated 6/27/10 at 7:25 pm and 10:10 pm, revealed the resident had fallen, was lying on the right side, rubbing the left hip and was painful with movement. The personal alarm was not on the resident. 911 was called, and the resident was transported to the hospital. The resident returned from the hospital with no new fractures or new orders. The resident was to continue on the previous orders for Vicodin. The order for routine scheduled Vicodin every six hours was changed on 6/25/10 to one tablet of Vicodin every six hours PRN for pain. On 6/26/10, an order was received for half a tablet to one tablet of Vicodin PRN. The June 2010 MAR revealed the resident received one tablet of PRN Vicodin for complaints of pain on 6/26/10 and 6/27/10. The June 2010 MAR documented the resident had complaints of pain and received one and one half tablets of Vicodin on 6/28/10 and two tablets of Vicodin on 6/29/10 and 6/30/10. The Resident Care Notes, dated 6/28/10 at 2:10 am and 10:30 pm, indicated the resident was experiencing pain and was medicated with good effect. The resident experienced a decline and the 6/30/10 Significant Change RAI revealed the resident had declined in ADL function. Resident 6 was non-weight bearing on the left leg and totally dependent on staff for transfers. On 8/13/10 at 11:00 am, the 6/27/10 fall when the resident did not have the personal alarm on as care planned was reviewed with Staff 28 (RNCM). Staff 28 acknowledged the personal alarm was not on as care planned. No additional documentation was provided. b. Resident 9 was admitted to the facility in 2010 with [DIAGNOSES REDACTED]. Review of the resident's Short Term Care Plan dated 4/13/10 revealed the resident's behaviors included exit seeking. Interventions included "monitor frequently for behaviors, redirect as needed, console as needed, offer food, drink, toileting." The care plan indicated the issue of exit seeking was resolved on 5/2/10. Review of the resident's NN revealed the resident had multiple incidents of exit seeking and eloped on 4/18/10, 4/20/10, 4/21/10, 4/22/10 and 4/24/10. Review of the resident's Behavior Monitor and Plan (BMP) revealed the resident had multiple incidents of exit seeking and eloped on 4/14/10, 4/16/10, 4/21/10, twice on 4/22/10 and 4/29/10. BMP documentation of the elopement on 4/29/10 at 3:00 pm revealed the resident was "found in back parking lot exited out back staff door." Observation on 8/11/10 at 2:05 pm revealed an alarm at the nurses' station sounded when each of the doors at the ends of the 100, 200 and 300 hallways was opened and stopped when the door closed. In an interview on 8/11/10 at 4:40 pm Staff 30 (DNS) stated the employee door alarmed at the nurses' station when the door was open but the alarm was turned off during busy times such as shift change. Staff 30 added there was an alarm code board at the nurses' station but it was not currently labeled as to which door was open. In an interview on 8/11/10 at 5:10 pm Staff 34 (LPN) stated she always worked in the evening and did not know what the system was for the alarm code board or how to tell which door was opened. Staff 11 (RNCM) and Staff 28 (RNCM) were unable to identify which door was opened on the alarm code board. On 8/11/10 at 5:21 pm Staff 30 (DNS), Staff 11 (RNCM) and surveyors tested doors and alarms and determined the employee door to the back parking lot did not have a functional alarm. In an interview on 8/11/10 at 6:12 pm Staff 30 stated the employee door to the back parking lot was now alarmed and the alarm code board was labeled. 2. Based on interviews and record review it was determined the facility failed to assess, care plan and provide adequate supervision to ensure safety for 1 of 2 sampled residents with elopements (#9). Findings include: Resident 9 was admitted to the facility in 2010 with [DIAGNOSES REDACTED]. Review of the resident's clinical record revealed a Short Term Care Plan dated 4/13/10 for exit seeking behaviors. Interventions included "Monitor frequently for behaviors, redirect as needed, console as needed, offer food, drink, toileting." Interventions did not include placement in an independently licensed, adjoining, locked Residential Care Facility (RCF). Review of the resident's NN dated 4/22/10 at 2:00 pm revealed the resident was taken to the RCF. "Staff over there informed of (the resident's) presence and told to call (the facility) if needed. PM (evening) staff aware." NN dated 4/22/10 at 7:00 pm revealed the resident "Tried to get out several times. Took (the resident) to (RCF) for a couple of hours." NN dated 4/24/10 at 12:50 pm revealed the resident was taken to the RCF "for safety d/t (due to) requires constant supervision while OOB (out of bed) d/t (due to) exit seeking." NN dated 4/24/10 at 6:40 pm revealed the resident was at the RCF "till (sic) dinner." NN dated 4/26/10 at 7:00 pm revealed the resident was "up in M/W (Merry Walker (enclosed frame, wheeled walker with a seat)) pacing rapidly, unable to maintain control in DR (dining room). Res (resident) taken to (RCF) dt (due to) constant exit seeking." NN dated 4/27/10 at 9:00 pm revealed the "Res (resident) went to (RCF) in MW (Merry Walker) (at) 2p (2:00 pm) returned at 4p (4:00 pm)." NN dated 4/28/10 at 7:15 pm revealed the resident was "alert restless was taken to (the RCF) at state (sic) (start) of shift back for dinner." NN dated 4/29/10 at 2:30 pm revealed the resident was "exit seeking. Taken to (the RCF) for awhile then brought back for lunch." Review of the resident's April 2010 NN and Behavior Monitor and Plan revealed the resident eloped nine times between 4/14/10 and 4/29/10. Review of the resident's clinical record revealed no assessment or care plan for the resident's ongoing elopements. In an interview on 8/11/10 at 12:25 pm Staff 30 (DNS) stated the resident did not have a care plan for elopement. In an interview on 8/11/10 at 1:28 pm Staff 10 (Social Services Director/SSD) stated facility staff took the resident to the RCF to pace the halls "where it was safe." In an interview on 8/11/10 at 3:55 pm Staff 30 (DNS) stated due to the resident's medical issues the resident was not appropriate to admit to the RCF. In an interview on 8/11/10 at 4:40 pm Staff 30 stated taking the resident to the RCF was a planned intervention in response to the resident's behaviors. Staff 30 added the use of the RCF was an Interdisciplinary Team decision. In an interview on 8/11/10 at 5:25 pm Staff 11 (RNCM) stated the staff at the RCF would watch the resident. The facility's main concern was the resident's exit seeking and eloping. In an interview on 8/12/10 at 1:50 pm Staff 5 (CNA) stated when residents were taken to the RCF, he would check on them before and after meals. Staff 5 stated residents were usually left at the RCF for an hour and a half until they "calmed down." In an interview on 8/12/10 at 1:57 pm Staff 10 (SSD) stated if a resident was exit seeking the facility sent the resident to the locked RCF where it was safe, it helped to pass the time and "burn the energy out." Staff 10 stated Resident 9 was exit seeking, eloping and needed one-on-one supervision. "So at that point (the facility) used (the RCF) as an option." Staff 10 stated facility staff did not accompany residents to the RCF. Staff at the RCF were alerted to the presence of facility residents left there and facility staff would check on the residents while they were in the RCF. If RCF staff "had difficulty" with a facility resident, they would call the facility charge nurse. In an interview on 8/12/10 at 4:18 pm Staff 2 (Administrator) and Staff 30 (DNS) were asked to provide documentation of an assessment prior to leaving the resident unaccompanied at another facility; risk/benefit analysis that included the lack of access of the resident to the resident's room, familiar staff and familiar surroundings; Interdisciplinary Team meeting minutes; a care plan that included placement at the RCF as an intervention; information for the RCF staff regarding the resident's care needs, behaviors and interventions; and monitoring by facility staff while the resident was out of the facility at the RCF. No further documentation was provided.