Every finding on record at Tigard Rehabilitation and Care

Based on observation, interview and record review it was determined the facility failed to ensure the community use glucometer was properly sanitized between resident use for 2 of 2 sampled residents (#s 9 and 53) reviewed for infection control during CBG checks. This failure, determined to be an Immediate Jeopardy (IJ) situation, placed all residents who required CBG checks at significant risk for bloodborne illness. On 5/6/26 the facility was informed of the IJ situation and provided a copy of the IJ template. Findings include:The True Metrix Blood Glucose System manufacturer instructions indicated to disinfect the meter with EPA-registered wipes between each resident. The 7/2023 facility policy for Glucometer Disinfection indicated to disinfect the glucometer after each individual patient use with EPA registered wipes. On 5/6/26 at 7:39 AM Staff 3 (RN) was observed to obtain a CBG for Resident 53 in the resident's room using a True Metrix Blood Glucose System glucometer. Staff 3 exited the room, placed the glucometer on the cart and did not disinfect the glucometer. Continuous observations were made between 7:39 AM and 7:59 AM of Staff 3 completing other nursing tasks. On 5/6/26 at 7:59 AM Staff 3 gathered supplies including the same soiled (unsanitized) glucometer used for the previous resident, and prepared to enter Resident 9's room. The surveyor asked Staff 3 how often glucometers were cleaned and Staff 3 stated they were cleaned several times per shift, or when visibly soiled. Staff 3 stated he did not clean the glucometer between every patient, and within an eight hour period he probably cleaned it three times. Staff 3 proceeded into Resident 9's room without disinfecting the glucometer, and the State Surveyor intervened. When cued by the State Surveyor, Staff 3 returned to the cart and disinfected the glucometer. On 5/6/26 at 8:17 AM Staff 2 (DNS) stated staff were to use disinfecting wipes on the glucometer between each resident. On 5/6/26 at 8:35 AM Staff 2 (DNS) provided a list of 20 residents who required CBG checks, which included Resident 9 who had a diagnosis of Hepatitis C, and Resident 60 who had a diagnosis of Methicillin Resistant Staphylococcus Aureus (MRSA). According to the CDC's 9/2/25 Hepatitis C Basics document, Hepatitis C is a liver disease which ranges from mild illness to a serious, long-term illness. Most people who get infected will develop a chronic, or lifelong, infection which can cause liver failure and death. Hepatitis C is spread when blood from an infected person - even microscopic amount - enters the body of someone who is not infected. The best way to prevent contracting hepatitis C is to avoid behaviors that can spread the disease like sharing items that might come into contact with infected blood. On 5/6/26 at 10:30 AM Staff 3 stated he worked on all three of the facility's halls. On 5/6/26 at 3:30 PM the facility was informed that the facility's failure to disinfect the community use glucometer between residents constituted an Immediate Jeopardy situation. An IJ removal plan was requested. On 5/6/26 at 5:21 PM an acceptable facility IJ removal plan was submitted by the facility. The plan indicated the facility would implement the following actions: - All residents have the potential to be impacted by this deficient practice. All residents who were potentially exposed were put on alert charting to monitor for adverse effects. The physician was notified and is monitoring care. - All glucometers will be disinfected prior to next use. Staff 3 will receive individual counseling on the policy and risks to residents. - All licensed nurses will be in serviced on the policy prior to the start of their shift. All nurses will be observed following the policy correctly prior to being cleared to work independently. Licensed nurses will not be allowed to work until the in service is completed. - To ensure continued compliance, the DNS or designee will complete five random audits weekly for glucometer cleaning. Results will be reported to QAPI. This will be completed for one month minimum or until compliance is reached. The immediacy was removed on 5/9/26 after verification of completion of the IJ removal plan. following removal of the immediacy, the remaining noncompliance continued with no actual harm, with potential for more than minimal harm that is not immediate jeopardy. 2. Based on observation, interview and record review the facility failed to use proper PPE for residents on Enhanced Barrier Precautions for 1 of 6 sampled residents (#10) reviewed for infection control. This placed residents at risk for cross-contamination. Findings include: According to the Centers for Disease Control and Prevention (CDC) website (https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html): Use Contact Precautions for patients with known or suspected infections that present an increased risk for contact transmission. Use personal protective equipment (PPE) appropriately including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. The facility's Enhanced Barrier Precautions (EBP) policy, revised 12/2024, indicated EBP were utilized to prevent the spread of multi-drug-resistant organisms (MDROs) and included the following: - EBP infection prevention and control interventions designed to reduce the transmission of multi-drug-resistant organisms (MDROs) during high contact resident care activities. - EBP's employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. - Gloves and gown are applied prior to performing the high contact resident care activity - Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs included wound care. Resident 10 admitted to the facility in 9/2024 with diagnoses including right femur fracture and history of ESBL (extended-spectrum beta lactamases, enzymes that make any common antibiotics ineffective) infection. On 5/7/26 at 9:21 AM Staff 3 (RN) stated he was preparing the wound care treatments to bring into Resident 10's room. Staff 3 entered Resident 10's room which had a CDC Enhanced Barrier Precautions (EBP) sign prominently displayed on the door. Staff 10 had gloves and a face mask on, but did not wear a gown. Staff 3 completed wound care to Resident 10's left knee, doffed his gloves, exited the room, and returned to the treatment care. On 5/7/26 at 9:30 AM Staff 3 stated he had minimal resident contact and wore gloves and a mask when performing wound care on Resident 10. Staff 3 stated he did not feel that wearing a gown was necessary. Staff 3 reviewed the CDC EBP sign on Resident 10's door and stated he was unsure if the resident was still on precautions, or if the sign was old. On 5/7/26 at 2:07 PM Staff 14 (Corporate IP) stated she expected all staff to follow EBP when performing wound care.

Based on observation, interview and record review it was determined the facility failed to ensure foods and fluids were served in a manner to prevent accidental choking for 2 of 3 sampled residents (#s 28 and 30) reviewed for accidents. This failure, determined to be an Immediate Jeopardy situation (IJ), resulted in Resident 30 choking after the resident received food of the wrong texture. This failure also placed other residents at risk for choking and lack of oxygen. It was determined the IJ began on 3/26/26. On 5/6/26 the facility was notified of the IJ situation and was provided a copy of the IJ template. Findings include: a. Resident 30 admitted to the facility in 1/2026 with diagnoses including stroke and dysphagia (swallowing difficulty). A 1/23/26 admission MDS indicated Resident 30 had a BIMS score of 8 indicating moderate cognitive impairment. The MDS indicated the resident had a swallowing disorder including coughing or choking during meals. A review of Resident 30's progress notes revealed on 2/8/26 at 9:00 AM the resident was given sausage for breakfast. Resident 30 required upward pressure to abdomen by staff to dislodge a piece of sausage from the resident's throat and clear her/his airway. A review of Resident 30's current care plan for aspiration precautions, initiated on 2/16/26, indicated the resident was to receive one on one assistance for all meals. Staff were to encourage the resident to be up in the wheelchair for all meals, encourage self-feeding with taking bite size pieces on a weighted spoon and fork with meals. The care plan also indicated: Attend to left side, slow rate, small bites, upright, thin liquids and soft and bite sized diet. A review of Resident 30's progress revealed on 3/26/26 at 6:15 PM the resident requested a sandwich and was given a meat sandwich by Staff 31 (CNA). Resident 30 took several bites and began to choke. Staff 31 provided back pats to Resident 30 who coughed up pieces of food. Resident 30 continued to cough up food and choke and required the Heimlich maneuver (abdominal thrusts used in first-aid to clear upper airway obstruction caused by food, or other foreign objects in conscious individuals who cannot breathe, speak or cough effectively) from Staff 5 (Maintenance Director) who was nearby. On 5/6/26 at 9:48 AM Staff 5 stated on 3/26/26 he was moving furniture between two offices when he noticed Staff 31 and Staff 32 (LPN) racing by looking for the crash cart around the nurses station. Staff 5 stated Resident 30 looked purple and appeared to be choking. Staff 5 stated he reached behind Resident 30 and gave her/him the Heimlich maneuver and a large piece of meat flew out of her/his mouth. On 5/6/26 at 4:40 PM Staff 32 stated on 3/26/26 she was informed by Staff 31 that Staff 31 gave Resident 30 a meat sandwich and the resident was choking. Staff 32 went to retrieve the LiveVac choking device (an airway clearance device developed for resuscitating a victim with an airway obstruction when current choking protocols have been followed without success) on the crash cart. On 5/6/26 at 5:16 PM Staff 31 stated she was not the assigned CNA for Resident 30 on 3/26/26. Resident 30 requested a sandwich after dinner and Staff 31 gave the resident a meat sandwich without checking the resident's current diet. Staff 31 stated she worked with Resident 30 one previous time and she/he was on a regular diet at that time, and she assumed the resident had the same diet texture as before. Staff 31 was next to the resident while she/he was eating the sandwich and provided the initial back pats to dislodge the smaller pieces when the resident began choking. Resident 30 requested water and continued to cough and then became silent. Staff 31 stated she informed Staff 32 of the incident and went to retrieve the LiveVac choking device while Staff 5 administered the Heimlich maneuver. b. Resident 28 was admitted to the facility in 6/2024 with diagnoses including a stroke and dysphagia (difficulty swallowing). Resident 28's 2/16/26 Speech Evaluation indicated the resident had clinical signs and symptoms of dysphagia while using a straw with thin liquids. Resident 28's 4/4/26 Quarterly MDS indicated the resident was at risk of choking and required a mechanically altered diet. Resident 28's 4/20/26 care plan indicated the resident was at risk for aspiration and was required to be upright during meals with distant supervision and no straws. An observation on 5/6/26 at 12:19 PM revealed a bright red sign posted above Resident 28's bed which read STOP NO STRAWS. Resident 28 was observed to have a half empty cup of grape juice on her/his overbed table which contained a straw. On 5/6/26 at 12:24 PM Staff 30 (CNA) stated residents with aspiration precautions had a bright red stop sign posted in their room, above their bed, which was an indicator the resident had a special texture diet and could not have straws. On 5/6/26 at 12:25 PM Staff 2 (DNS) and the surveyor observed Resident 28 with a straw in her/his half empty juice cup and Staff 2 acknowledged Resident 28 was an aspiration risk and it was not safe for her/him to use a straw. c. On 5/6/26 at 3:30 PM the facility was informed that the failure to ensure treatment interventions were implemented to prevent choking accidents constituted an Immediate Jeopardy situation. An IJ removal plan was requested. On 5/6/26 at 5:21 PM an acceptable facility IJ removal plan was submitted by the facility. The plan indicated the facility would implement the following actions: - All residents have the potential to be impacted by this deficient practice. The residents with orders to not use a straw will be placed on alert charting to monitor for signs of aspiration, the physician was notified, and a speech evaluation was ordered by the physician.- The aspiration orders for all residents will be compared to the aspiration signs and binders to ensure accurate precautions are in place for the residents.- All licensed nurses, CMAs, and CNAs will be inserviced on the aspiration risk and management policy and aspiration binder prior to starting their next shift. Licensed nurses, CMAs, and CNAs will not be allowed to work until the inservice is completed. - To ensure continued compliance with the aspiration policy, dining room and hallway monitoring will be conducted to ensure residents who have aspiration risk are supervised appropriately for all 3 meals. The results of these audits will be reported to the DNS, who will report this to the QAPI committee. These audits will be completed for 1 month minimum or until compliance is achieved. On 5/11/26 at 9:40 AM it was determined the immediacy was removed on 5/9/26 after verification of completion of the IJ removal plan. Following removal of the immediacy, the remaining noncompliance continued at the scope and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy.

Based on observation and interview it was the determined the facility failed to ensure staff wore hair restraints for 1 of 1 Staff (#6) reviewed for kitchen. This placed residents at risk for cross contamination. Findings include: The facility's 2001 Food Preparation and Service Policy indicated food and nutrition service staff were to wear hair restraints (hair net, hat, beard restraint, etc.) so that hair did not contact food.On 5/4/26 at 10:10 AM Staff 6 (Cook) was observed in the kitchen at the counter prepping food wearing a bandana around her head and her hair in a clip. Staff 6's hair was not fully covered, and she was not wearing a hair restraint.On 5/4/26 at 10:11 AM Staff 6 acknowledged she was not wearing a hair restraint. Staff 7 (Dietary Manger) stated staff were to wear hair restraints and acknowledged Staff 6 was not wearing a hair restraint.

Based on observation, interview, and record review it was determined the facility failed to ensure appropriate medication storage temperatures were logged and maintained, failed to ensure proper labeling of biologicals and failed to ensure a medication cart was properly secured for 1 of 1 medication refrigerator, for 1 of 3 treatment carts and 1 of 4 medication carts reviewed for safe medication storage. This placed residents at risk for receiving medications with reduced efficacy and unauthorized access to medications. Findings include: 1. On 5/6/26 at 7:51 AM one open, undated vial of tuberculin (used for testing in the diagnosis of Tuberculosis) was observed in the medication room refrigerator.The manufacturer's instructions indicated to discard the medication 30 days after opening.On 5/6/26 at 7:51 AM Staff 3 (RN) acknowledged the vial of tuberculin was open and not labeled with an open date.On 5/6/26 at 8:17 AM Staff 2 (DNS) stated the expectation was for open medications to be labeled with open dates.2. On 5/6/26 at 8:17 AM the medication room refrigerator was observed to contain insulin and vaccines and the temperature log was observed to be incomplete on the following dates: 4/1/26; 4/2/26; 4/3/26; 4/4/26; 4/6/26; 4/7/26; 4/8/26; 4/9/26; 4/10/26; 4/11/26; 4/12/26; 4/13/26; 4/14/26; 4/15/26; 4/16/26; 4/17/26; 4/18/26; 4/20/26; 4/21/26; 4/22/26; 4/23/26; 4/24/26; 4/25/26; 4/27/26; 4/28/26; 4/29/26; 4/30/26; 5/1/26; 5/2/26; 5/4/26 and 5/5/26.On 5/6/26 at 8:17 AM Staff 2 (DNS) acknowledged the medication room refrigerator contained insulin and vaccines and acknowledged the temperature logs were incomplete. Staff 2 stated the expectation was for staff to complete the temperature logs twice daily.3. On 5/6/26 at 8:17 AM the medication room refrigerator temperature logs indicated the temperature was 34 F on 4/19/26 at 7:10 AM. The temperature requirements on the form indicated the temperatures were to be kept at 36 F to 46 F.On 5/6/26 at 8:17 AM Staff 2 (DNS) acknowledged the medication room refrigerator contained insulin and vaccines and acknowledged the temperature log indicated the temperature was 34 degrees on 4/19/26. Staff 2 stated the expectation was for temperatures to be kept between 36 F and 46 F.4. On 5/6/26 continuous observations were made from 11:14 AM to 11:42 AM of the medication cart on the 100 hall, the keys were hanging out of the cart and it was left unlocked and unattended.On 5/6/26 at 11:42 AM Staff 2 (DNS) acknowledged the medication cart was left unlocked and unattended, the keys were hanging out of the cart and the cart contained medications.5. On 5/8/26 at 9:27 AM the 200 hall treatment cart was observed to contain two open vials of Admelog insulin without open dates.On 5/8/26 at 9:27 AM Staff 13 (LPN) acknowledged the two vials of Admelog insulin were open without open dates.On 5/8/26 at 9:40 AM Staff 2 (DNS) stated the expectation was for open insulin to be labeled with open dates.

Based on observation, interview and record review it was determined the facility failed to ensure staff adhered to professional standards related to disinfection of common use glucometers, following physician orders, unnecessary medications, and infection control during wound care for 1 of 1 licensed nurse (Staff #3) reviewed for infection control and medication administration. This placed residents at risk for bloodborne illness, uncontrolled hypertension, and hypoglycemia. Findings include: 1. The True Metrix Blood Glucose System manufacturer instructions indicated to disinfect the meter between each person with EPA-registered wipes. The 7/2023 facility policy for Glucometer Disinfection indicated to disinfect after each individual patient use with EPA registered wipes. On 5/6/26 at 7:39 AM Staff 3 (RN) was observed to obtain a CBG for Resident 53. Staff 3 exited the room, placed the glucometer on the cart and did not disinfect it. Continuous observations were made between 7:39 AM and 7:59 AM of Staff 3 completing other nursing tasks. On 5/6/26 at 7:59 AM Staff 3 gathered supplies including the unsanitized glucometer and prepared to enter Resident 9's room. The surveyor asked Staff 3 how often glucometers were cleaned and Staff 3 stated they were cleaned several times in a shift, or if visibly soiled, but he did not clean it between every patient. Staff 3 stated within an eight hour period he probably cleaned it three times. Staff 3 proceeded into Resident 9's room without disinfecting the glucometer. The State Surveyor intervened and when cued, Staff 3 returned to the cart and disinfected the glucometer. On 5/6/26 at 8:17 AM Staff 2 (DNS) stated the expectation was for staff to use disinfecting wipes between resident use. Refer to F880. 2. Resident 5 admitted to the facility in 2022 with diagnoses including diabetes. A 2/20/26 physician order indicated the use of Novolog insulin. The order indicated 2 units of insulin was to be given before meals and was only to be administered if the CBG (capillary blood sugar) was greater than 150. Review the 4/2026 and 5/2026 DAR (Diabetic Administration Record) indicated from 4/1/26 to 5/6/26, Resident 5 was administered insulin when her/his blood sugars were below 150. Staff 3 (RN) was noted to have administered insulin to Resident 5 one or more times when her/his blood sugar level was under 150 for the following dates: 4/17/26 4/24/26 5/1/26 5/6/26 On 5/6/26 at 10:30 AM Staff 3 stated he was not aware the order indicated to only administer insulin for blood sugars over 150. Staff 3 stated he did not fully read the order and used his clinical judgement as the resident's blood sugar tended to run high after meals. Staff 3 acknowledged he was supposed to follow the physician's order and acknowledged he administered insulin to Resident 5 when her/his blood sugar was under 150 on the identified dates. Refer to F684. 3. Resident 10 admitted to the facility in 9/2024 with diagnoses including right femur fracture and history of ESBL (extended-spectrum beta lactamases, enzymes that make any common antibiotics ineffective) infection. On 5/7/26 at 9:21 AM Staff 3 (RN) stated he was preparing the wound care treatments to bring into Resident 10's room. Staff 3 entered Resident 10's room with a CDC Enhanced Barrier Precautions (EBP) sign prominently displayed on the resident's room door. Staff 10 had gloves and a face mask on but did not wear a gown. Staff 3 completed wound care to Resident 10's left knee, doffed his gloves, exited the room, and returned to the treatment cart. On 5/7/26 at 9:30 AM Staff 3 stated he had minimal resident contact and wore gloves and a mask when performing wound care on Resident 10. Staff 3 stated he did not feel it was necessary to wear a gown. Staff 3 reviewed the CDC EBP sign on Resident 10's door and Staff 3 stated he was unsure if the resident was still on precautions or if the sign was old. On 5/7/26 at 2:07 PM Staff 14 (Corporate IP) stated she expected all staff to follow EBP when performing wound care. Refer to F880. 4. Resident 42 was admitted to the facility in 1/2023 with diagnoses including Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1 Through Stage 4 Chronic Kidney Disease. (High blood pressure that has caused damage to the heart and kidneys, including heart failure and chronic kidney disease ranging from mild to severe stages). Resident 42's 2/1/24 Physician Order Hydralazine HCl Oral Tablet 25 MG (Hydralazine HCl), give 25 mg by mouth every 8 hours as needed related to ESSENTIAL (PRIMARY) HYPERTENSION for SBP greater than 160 or DBP greater than 80. Review of Resident 42's 4/2026 MAR indicated eleven instances when the blood pressure was outside of parameters, and the PRN medication was not provided. Resident 42 was not documented as receiving PRN Hydralazine HCl Oral Tablet 25 mg on the eleven instances from 4/5/26 through 5/3/26 despite blood pressure readings meeting parameters identified in the physician orders. On 5/7/26 at 2:23 PM, Staff 3 indicated he was not familiar with Resident 42. Staff 3 initially denied checking Resident 3's blood pressure. Staff 3 then reviewed the documentation and acknowledged checking Resident 3's blood pressure. Staff 3 was unable to provide a rationale for why the PRN medication was not administered. Staff 3 stated he probably rechecked the blood pressure later and it was fine. Staff 3 acknowledged no rechecks were documented. On 5/8/26 at 9:26 AM, Staff 2 (DNS) acknowledged Staff 3 should have administered Resident 42's PRN Hydralazine in accordance with the physician orders on the eleven instances from 4/5/26 through 5/3/26. Refer to F684

Based on observation, interview and record review it was determined the facility failed to ensure care plan interventions were individualized for 1 or 1 sampled resident (#42) reviewed for ADLs. This placed residents at risk for unmet needs and receiving non-individualized care interventions. Findings include: Resident 42 was admitted to the facility in 1/2023 with diagnoses including urinary incontinence.Resident 42's 1/22/26 Annual MDS revealed a BIMS score of 15, indicating the resident was cognitively intact, and the resident was always incontinent of bladder and bowel.Resident 42's 2/6/26 care plan identified the resident had episodes of bladder incontinence r/t limited mobility, and cognitive impairment and included the intervention to Ensure resident has bedside urinal within reach, Encourage usage, Check and empty at regular intervals.Observations from 5/4/26 through 5/6/26 between the hours of 11:50 AM and 4:30 PM revealed no urinal cup was present at Resident 42's bedside.An interview on 5/6/26 at 4:33 PM, Resident 42 stated she/he never had a urinal at bedside and indicated she/he was physically unable to use a urinal prior to admission to facility. An interview on 5/7/26 at 9:09 AM, Staff 17 (CNA) stated Resident 42 did not have a bedside urinal and to her knowledge never used one.An interview on 5/7/26 at 2:35 PM, Staff 16 (LPN) stated Resident 42 did not have a bedside urinal and indicated use of a urinal was impossible for the resident due to the resident's limitations.An interview on 5/8/26 at 9:26 AM, Staff 2 (DNS) stated urinal cup by the bed was listed as an option within the care plan template and a previous DNS may have selected the intervention in error. Staff 2 stated the intervention was not individualized or specific to Resident 42 and staff did not previously identify the discrepancy.

Based on observation, interview and record review it was determined the facility failed to clarify and follow physician orders for 1 of 1 sampled resident (#42) reviewed for Activities of Daily Living (ADLs). This placed residents at risk for unmet needs and uncontrolled hypertension. Findings include:Resident 42 was admitted to the facility in 1/2023 with diagnoses including Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1 Through Stage 4 Chronic Kidney Disease. (High blood pressure that has caused damage to the heart and kidneys, including heart failure and chronic kidney disease ranging from mild to severe stages).Resident 42's 1/22/26 Annual MDS revealed a BIMS score of 15, which indicated the resident was cognitively intact. Resident 42's 7/21/24 Physician Order indicated Obtain BP (Blood Pressure) see PRN Hydralazine order for DBP (Diastolic Blood Pressure) greater than 90 and SBP (Systolic Blood Pressure) greater than 140 three times a day.Resident 42's 2/1/24 Physician Order indicated Hydralazine HCl Oral Tablet 25 MG (Hydralazine HCl), give 25 mg by mouth every 8 hours as needed related to essential (primary) hypertension for SBP greater than 160 or DBP greater than 80.A review of Resident 42's clinical record revealed no indication that the discrepancy between the two physician orders was identified or clarified. Review of Resident 42's blood pressure readings from 4/1/26 through 5/7/26 revealed multiple readings outside ordered parameters, including:0700 hours:4/1/26 134/954/3/26 144/704/4/26 150/704/5/26 156/824/7/26 142/744/11/26 161/874/12/26 155/854/17/26 143/724/24/26 148/784/25/26 146/704/30/26 142/845/1/26 156/775/3/26 144/83 1500 hours:4/2/26 134/954/3/26 144/654/4/26 148/704/5/26 156/824/12/26 155/854/17/26 143/654/24/26 146/704/28/26 148/794/30/26 142/845/1/26 146/785/3/26 144/835/7/26 149/80 2300 hours:4/2/26 141/894/7/26 140/845/1/26 141/71Review of the 4/2026 and 5/2026 MARs revealed no indication the PRN Hydralazine was provided on identified dates. On 5/7/26 at 2:23 PM, Staff 3 (RN) initially he did not check Resident 42's blood pressure; however, after reviewing documentation showing he entered the readings, Staff 3 stated he probably rechecked the blood pressure 30 minutes later and it was fine, which was why the PRN Hydralazine was not administered. Staff 3 acknowledged rechecks were not documented. Staff 3 further indicated he did not identify the discrepancy between the physician orders and stated if he noticed it, he would have notified the physician.On 5/7/26 at 5:21 PM, Staff 18 (LPN) indicated she was familiar with Resident 42 and routinely obtained the resident's blood pressure readings. Staff 18 stated she did not recall the specific dates in April and did not recall administering PRN Hydralazine. Staff 18 acknowledged she was unaware of the discrepancy in physician orders and stated she would have contacted the physician had she identified it.On 5/8/26 at 9:26 AM, Staff 2 (DNS) acknowledged there were errors and discrepancies in the physician orders and the PRN Hydralazine was not administered according to the orders.

Based on interview and record review it was determined the facility failed to administer insulin as ordered for 1 of 5 sampled residents (#5) reviewed for medications. This placed residents at risk of receiving unnecessary medication. Findings include:A 2/20/26 physician order indicated the use of Novolog insulin. The order indicated 2 units of insulin was to be given before meals and was only to be administered if the CBG (capillary blood sugar) was greater than 150.Review the 4/2026 and 5/2026 DAR (Diabetic Administration Record) indicated from 4/1/26 to 5/6/26, Resident 5 was administered 2 units of insulin a total of 55 times when her/his blood sugars were below 150.Staff 3 (RN) was noted to have administered insulin one or more times to Resident 5 when her/his blood sugar level were under 150 for the following dates:4/17/264/24/265/1/265/6/26Staff 4 (LPN) was noted to have administered insulin one or more times to Resident 5 when her/his blood sugar level were under 150 for the following dates:4/2/264/6/264/9/264/13/264/14/264/16/264/20/264/21/264/23/264/27/264/28/265/4/265/5/26On 5/6/26 at 10:30 AM Staff 3 stated he was not aware the order indicated to only administer insulin for a blood sugar level over 150. Staff 3 stated he did not fully read the order and used his clinical judgement as the resident's blood sugar tended to run high after meals. Staff 3 further stated he should go by the physician's order and acknowledged he administered insulin to Resident 5 when her/his blood sugar was under 150 for the identified dates. On 5/7/26 at 10:14 AM Staff 4 stated he was not aware Resident 5's physician order indicated insulin was only to be administered for a blood sugar level over 150 due to the way the order was written. Staff 4 acknowledged he administered insulin to Resident 5 when her/his blood sugar was under 150 for the identified dates.On 5/8/26 at 9:04 AM Staff 2 (DNS) acknowledged Resident 5 was not administered insulin per physician orders.

Based on observation, interview and record review it was determined the facility failed to ensure resident medical records were kept secured and confidential for 2 of 2 random observations. This placed residents at risk for lack of privacy and confidentiality. Findings include: 1. On 5/6/26 continuous observations were made from 11:14 AM to 11:42 AM of the 100 hall medication cart, it was left unattended and the computer screen was open and displayed Resident 41's name, date of birth and medication administration information.On 5/6/26 at 11:42 AM Staff 2 (DNS) acknowledged the medication cart was left unattended and the computer screen was open and displayed information including Resident 41's name, date of birth and medication administration information. Staff 2 stated the computer screen was supposed to be locked when the cart was unattended.2. On 5/8/26 continuous observations were made from 9:04 AM to 9:06 AM of the 200 hall medication cart, it was left unattended and the computer screen was open and displayed Resident 30's name, date of birth and medication administration information.On 5/8/26 at 9:06 AM Staff 12 (LPN) acknowledged the medication cart was left unattended and the computer screen was open and displayed information including Resident 30's name, date of birth and medication administration information.On 5/8/26 at 9:40 AM Staff 2 (DNS) stated the expectation was for staff to lock the computer screen when it was unattended.

Based on interview and record review it was determined the facility failed to assess the appropriateness and effectiveness of psychotropic medication use for 1 of 5 sampled residents (#5) reviewed for medications. This placed residents at risk for receiving unnecessary psychotropic medications. Findings include: Resident 5 was admitted to the facility in 2022 with diagnoses including bipolar disorder.Review of Resident 5's physician orders indicated the use of Abilify (antipsychotic) and bupropion (antidepressant) for bipolar disorder.A 10/16/25 Psychoactive Drug Review indicated Resident 5 readmitted to the facility on [DATE] with a diagnosis of bipolar disorder and was administered Abilify and bupropion. The review indicated no changes were recommended and her/his depressive symptoms were to be monitored and reassessed the following month.Review of Resident 5's medical record indicated no psychoactive drug review was completed after 10/16/25.On 5/6/26 at 11:45 AM Staff 8 (SSD) stated psychoactive drug reviews were to be completed monthly. Staff 8 acknowledged Resident 5 was not reassessed with a psychoactive drug review since 10/16/25.On 5/8/26 at 9:04 AM Staff 2 (DNS) acknowledged Resident 5 did not have a psychoactive drug review since October of 2025.

Based on observation, interview and record review it was determined the facility failed to provide appropriate treatment and services to maintain and prevent a potential decrease in ROM or mobility for 1 of 1 sampled resident (#49) reviewed for positioning and mobility. This placed residents at risk for loss of ROM and mobility. Findings include:Resident 49 was admitted to the facility in 11/2024 with diagnoses including muscle wasting atrophy (a condition of thinning muscle tissue, resulting in weakness).A 11/14/25 Occupational Therapy Discharge Summary indicated Resident 49 was to participate in a restorative range of motion program to maintain the highest level of function for the resident's upper extremities.A 11/16/25 Annual MDS indicated Resident 49 had range of motion impairment to both upper and lower extremities on one side and required minimal assistance with upper body dressing.A 2/16/26 Quarterly MDS indicated Resident 49 had range of motion impairment to both upper and lower extremities on one side and required substantial/maximal assistance with upper body dressing.A 2/25/26 care plan indicated Resident 49 was at risk for pain related to decreased mobility and a listed interventions for staff to attempt to decrease pain was exercise. No additional information was found related to the preservation of Resident 49's mobility.On 5/4/26 at 11:05 AM Resident 49 stated she/he did not receive therapy and had concerns related to her/his mobility. Resident 49 stated she/he noticed a decrease in her/his ability to do normal daily activities which was related to the stiffness in her/his joints. Resident 49 denied pain and stated the decline in her/his ability to do things independently was related to not moving my body enough.On 5/6/26 at 9:28 AM Staff 17 (CNA) stated Resident 49 experienced a decline in range of motion over the past few months. Staff 17 stated she recently noticed the resident struggle to complete tasks like oral care without assistance due to the resident being unable to reach certain items on her/his overbed table which was something the resident did not struggled with before. Staff 17 stated Resident 49's care plan did not indicate the resident was to receive range of motion exercises.On 5/7/26 at 11:07 AM Staff 26 (Occupational Therapist) stated the last time Resident 49 was assessed by therapy was in 11/2025 and at that time the resident had some ability to dress her/his upper body with minimal assistance. Staff 26 stated the recommendation by therapy was for Resident 49 to receive range of motion exercises daily to maintain her/his current level of mobility to prevent decline.On 5/7/26 at 2:03 PM Staff 2 (DNS) stated Resident 49's care plan did not reflect the recommendations given by therapy to preserve the resident's range of motion and confirmed that led to a decline in the resident's range of motion ability.

Based on interview and record review it was determined the facility failed to offer and obtain consent prior to administration of influenza and pneumococcal vaccinations for 2 of 5 sampled residents (#s 11 and 28) reviewed for immunizations. This placed residents at risk for pneumonia and being uninformed of the risks and benefits of vaccination. Findings include:A review of the revised 3/2022 facility Pneumococcal Vaccine policy for residents revealed the following:All residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections.-Before receiving a pneumococcal vaccine, the resident or legal representative receives information and education regarding the benefits and potential side effects of the pneumococcal vaccine.A review of the revised 3/2022 facility Influenza Vaccination policy for residents.-All residents and staff are encouraged to receive the vaccine unless there is a medical contraindication and providing education about the risk and benefits of vaccination.1. Resident 11 was admitted to the facility in 2022 with a diagnosis of Parkinsonism.A review of Resident 11's immunization record revealed she/he had received Prevnar13 on 7/2023 and was eligible but was not offered the CDC recommended pneumococcal vaccine.On 5/7/26 at 2:01 PM Staff 14 (Corporate IP) acknowledged Resident 11 was eligible for the pneumococcal vaccine but was not offered to the resident. 2. Resident 28 was admitted to the facility in 2024 with a diagnosis of stroke.A review of Resident 28 immunization record revealed the resident received the latest pneumococcal vaccine on 3/2025 and influenza vaccine on 2/2026. A review the Resident 28's EMR revealed the pneumococcal and influenza consents were not present electronically or on paper. On 5/6/26 at 11:42 AM Resident 28 did not recall receiving education regarding the risk and benefits for the pneumococcal or influenza vaccines.On 5/6/26 at 12:24 PM Staff 2 (DNS) stated he was unable to locate the pneumococcal or influenza vaccination consents for Resident 28. Staff 2 stated the previous DNS was in charge of the immunizations and kept all the files her office.

Based on interview and record review it was determined the facility failed to ensure residents were offered the COVID-19 vaccine for 2 of 5 sampled residents (#s 11 and 62) reviewed for immunizations. This placed residents at risk for COVID-19 illness. Findings include:Review of the CDC's Staying Up To Date with COVID-19 Vaccines, dated 11/19/25, https://www.cdc.gov/covid/vaccines/stay-up-to-date.html, documented CDC recommends a 2025-2026 COVID-19 vaccine for people ages 6 months and older based on individual-based decision-making.Getting the 2025-2026 COVID-19 vaccine is especially important if you. are living in a long-term care facility.1. Resident 11 was admitted to the facility in 2022 with a diagnosis of Parkinsonism.A review of Resident 11's immunization record revealed Resident 11 was not offered the COVID-19 vaccine.On 5/7/26 at 2:01 PM Staff 14 (Corporate IP) stated Resident 11 was eligible for the COVID-19 vaccine, but it was not offered to the resident. 2. Resident 62 was admitted to the facility in 2024 with a diagnosis of osteomyelitis of the vertebrae.A review of Resident 62's immunization record revealed Resident 62 was not offered the COVID-19 vaccine.On 5/7/26 at 2:06 PM Staff 14 (Corporate IP) stated Resident 62 was eligible for the COVID-19 vaccine, but it was not offered to the resident.

Based on interview and record review it was determined the facility failed to ensure non-pressure skin wounds were monitored for 1 of 3 sampled residents (#6) reviewed for non-pressure skin wounds. This placed residents at risk for worsening wounds and delays in treatment. Findings include:Resident 6 was admitted to the facility on [DATE] with diagnoses including heart failure and diabetes.A 4/17/25 Clinical admission Progress Note, completed by Staff 4 (LPN), indicated Resident 6 had some redness with a small healing blister to her/his front left knee that was present upon admission.The 4/18/25 care plan revealed Resident 6 had impaired skin integrity due to a current blister on the left thigh/shin and immobility.A review of Resident 6's medical record, including a review of the 4/2025 TAR, revealed no assessment of the wound and no monitoring of the wound. Resident 6 discharged to the hospital on 4/22/25 for an unrelated diagnosis.On 11/13/25 at 2:45 PM Staff 4 confirmed he completed Resident 6's clinical admission assessment that included a full body skin check. Staff 4 stated when skin impairments were identified he placed a note on the TAR to monitor them. Staff 4 confirmed Resident 6 had a blister on her/his left knee. Staff 4 reviewed the TAR and acknowledged he did not implement monitoring of Resident 6's blister.On 11/14/25 at 1:48 PM Staff 25 (LPN Resident Care Manager) confirmed there were no assessments completed for Resident 6's blister on the left knee.On 11/14/25 at 2:25 PM Staff 2 (DNS) stated if a skin impairment like a blister was noted upon admission it was expected to be documented in the admission progress note, added to the TAR, the resident placed on alert charting, and a risk management note started. Staff 2 acknowledged Resident 6's blister was not assessed or monitored during her/his stay at the facility.

Based on interview and record review it was determined the facility failed to ensure newly identified pressure ulcer wounds were comprehensively assessed and wound care orders were obtained and implemented for 1 of 3 sampled residents (#7) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers. Findings include:The facility's 4/2018 Pressure Ulcer/Skin Breakdown - Clinical Protocol - Assessment and Recognition specified the nurse shall describe and document/report the following:Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates (leaking fluid) or necrotic (dying/dead) tissue and pain assessment.The 2019 National Pressure Injury Advisory Panel (NPIAP) Prevention and Treatment of Pressure Ulcers/Injuries Quick Reference Guide indicated the following recommendations regarding pressure ulcer assessment: - Assess the pressure ulcer initially and re-assess it at least weekly to monitor progress towards healing; - Document the results of all wound assessments; - Assess and document physical characteristics including: location, category/stage, size, tissue type(s), color, peri-wound condition, wound edges, sinus tracts, undermining, tunneling, exudate, and odor.Resident 7 was admitted to the facility in 10/2025 with a diagnosis of osteomyelitis of vertebrae (bone infection).Resident 7's 10/29/25 admission MDS was not completed. A Progress Note dated 11/1/25 completed by Staff 26 (LPN) indicated she was informed by a CNA of an open sore on the upper part of Resident 7's buttock.A 11/1/25 Skin Integrity Report, initiated by Staff 26, indicated a new open sore on the upper part of the resident's buttock and indicated the Resident Care Manager and Physician was notified. A note added on 11/3/25 indicated a new pressure injury to the left buttock wound which measured 1.5 x 1.1 cm and a new pressure injury to the coccyx which measured 3.1 x 5 x 0.3 cm.There was no evidence in Resident 7's health record to indicate a comprehensive assessment of the wound including measurement, location, stage, and other characteristics was completed after the wound was identified on 11/1/25 and before 11/3/25.Resident 7's 11/3/25 Physician Orders included the following: wound treatment to coccyx and sacrum wound bed, wash, pat dry, apply hydrogel to the sacrum and medihoney to coccyx wound bed, place large sacral dressing to cover both wounds. every day and PRN.There was no evidence wound care orders were obtained prior to 11/3/25. Resident 7's TAR revealed wound care was not provided until 11/4/25.On 11/14/25 at 12:20 PM Staff 26 stated she remembered a CNA notified her on 11/1/25 that Resident 7 had a new open area. Staff 26 stated she looked at the open area on resident 7's left buttock, cleaned the wound, covered it, and initiated a Skin Integrity Report. Staff 26 stated she did not measure the wound, did not obtain orders from the provider, did not document any wound treatment, and did not initiate any house wound orders on the TAR.On 11/14/25 at 12:57 PM Staff 2 (DNS) stated when a new skin issue was discovered, a Skin Integrity Report was to be initiated. She expected the nurse on duty to assess and measure the wound right away, complete wound care, implement a treatment protocol on the TAR, and place the resident on alert charting. Staff 2 acknowledged Resident 7's wound was identified on 11/1/25 and was not comprehensively assessed and measured until 11/3/25. Staff 2 confirmed there was no evidence in Resident 7's health record to indicate wound care was provided from 11/1/25 through 11/3/25.

Based on interview and record review it was determined the facility failed to ensure narcotic drug records were in order and an account of all controlled drugs was maintained for 1 of 3 narcotic books reviewed for medication administration. This placed residents at risk for drug diversion. Findings include:The facility's policy for reconciling controlled substances, revised 11/2022, stated the system for reconciling the receipt, dispensing and disposition of controlled substances included the following:-Records of personnel access and usage;-Medication administration records;-Declining inventory records; and-Destruction, waste and return to pharmacy records.-Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile and inventory the count. The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the DNS.A 3/27/25 FRI indicated narcotic medication for two residents was missing and unaccounted for.A 3/31/25 investigation report revealed the facility was unable to determine what happened to the missing narcotic medication.On 11/14/25 at 11:13 AM Staff 8 (CMA) stated she remembered hearing about missing narcotic medication and denied knowing any information related to the incident.On 11/14/25 at 1:03 PM Staff 6 (LPN) stated she remembered reports of two missing narcotic cards but denied knowledge of what happened to the medication.On 11/14/25 at 12:32 PM Staff 3 (Former DNS) stated during a review of one of the facility's narcotic books on 3/26/25 it was determined two narcotic cards were missing. Staff 3 stated as a result of the investigation completed on 3/31/25, an immediate audit of all narcotics was completed, and education was provided to all staff responsible for managing medication.The deficient practice was identified as Past Noncompliance based on the following:The deficient practice was identified by the facility and was corrected on 4/1/25 when the facility completed a root cause analysis of the incident and identified a system failure related to managing narcotic medication. The plan of correction included: A full audit of all narcotic books was completed; no additional discrepancies were found. Education was provided to staff to include the facility's updated protocol for counting narcotic medication which included to count the number of narcotics in each book and record the amount next to staff initials on the signature/sign off page upon each shift change. All narcotics were inputted into new narcotic books to reflect correct records of each narcotic medication.

Based on interview and record review it was determined the facility failed to ensure residents were free from abuse for 1 of 3 sampled residents (#5) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 5 admitted to the facility in 2011 with diagnoses including anxiety, mood and personality disorder. The 7/20/23 Care Plan indicated Resident 5 had behaviors of refusing cares, refusing all wound cares and other cares including bathing and hygiene tasks. Resident 5 was not easily directed and interventions by staff escalated the resident's agitation. Resident 5 had history of being verbally and physically aggressive toward staff. Interventions included: to not argue with the resident and to discontinue attempts to treat if she/he became agitated and reapproach later. A 1/6/25 Facility Reported Incident indicated the following:- - On 1/4/25 Resident 5 told Staff 21 (RN) to go to Hell when attempting to complete wound care. Staff 21 was heard by CNA Staff reply to Resident 5, I'm already in Hell. You're Satan's bitch, aren't you? Staff 21 also threatened to call the police on Resident 5 for assault because the resident grabbed the collar of Staff 21's isolation gown. - - Staff 19's (CNA) witness statement indicated she and Staff 20 (CNA) went to provide a brief change to Resident 5. Staff 19 indicated Resident 5 was not accepting cares, but they were able to start changing the resident's brief. Staff 21 came into the room to complete wound care. Resident 5 became upset because of the brand of cream being used. Resident 5 became agitated and grabbed Staff 21's gown, tore it and told her to Go to Hell. Staff 21 was heard replying, I'm already there and you're Satan's bitch. Staff 21 stated she was going to call the police and press charges on Resident 5 for assault. - - Staff 20's witness statement indicated she and Staff 19 went to change Resident 5's brief and Staff 21 also went into the room to complete wound care. Resident 5 did not want to be changed and was not calming down. Staff 21 informed her and Staff 19, it was fine, keep changing [her/him]. Resident 5 was upset about the cream being used and both Resident 5 and Staff 21 were yelling back and forth at each other. - - Staff 21 indicated Resident 5 was calling her names and told her to go to Hell. Staff 21 told the resident wound care had to be done, and she/he needed to be changed, the resident continued to yell. Staff 21 indicated Resident 5 grabbed her and she told the resident she could report her/him. Staff 21 indicated she stated she was in Hell but did not recall saying anything else. - - Resident 5 indicated she/he told Staff 21 to get out and Staff 21 told her/him she was going to call them to take her/him away. Resident 5 was unable to recall any other statements made by Staff 21. - - The investigation indicated Resident 5's care plan was not followed related to staff not discontinuing attempts to treat and provide care when the resident became agitated. No psychosocial harm was found, and Staff 21 was terminated. Abuse was unable to be ruled out related to the verbal abuse toward Resident 5. On 7/10/25 at 11:07 AM Resident 5 was unable to recall the incident that occurred between her/him and Staff 21. On 7/10/25 at 1:10 PM Staff 19 stated she and Staff 20 went into Resident 5's room with Staff 21 to change the resident's brief and complete wound care. Staff 19 stated they were all wearing gowns due to the resident being on Enhanced Barriers Precautions. Staff 19 stated Resident 5 lashed out and grabbed Staff 21's gown and told her to go to Hell. Staff 19 stated Staff 21 told the resident that she was already there, and she/he was Satan's bitch. Staff 19 stated they were able to change the resident, but she/he continued to lash out and Staff 21 threatened to call the police on the resident for assaulting staff. Staff 19 stated Resident 5 had a history of being resistive to care. Staff 19 stated when Resident 5 was being resistive to cares staff were to leave the room, reassess and reapproach. Staff 19 stated Staff 21 told her and Staff 20 to keep going with providing the brief change and to not worry about it even though Resident 5 was resistive.On 7/10/25 at 12:14 PM Staff 20 stated Resident 5 had known behaviors of refusing cares. Staff 20 stated her, and Staff 19 went into Resident 5's room to change her/his brief and Staff 21 was also in the room to complete wound care. Staff 20 stated Resident 5 was not complying with care and refusing to be changed. Staff 20 stated Staff 21 told her and Staff 19 to go ahead and change the resident even though she/he was freaking out and told them to get out. Staff 20 stated both Staff 21 and Resident 5 were yelling at each other. Staff 20 stated she heard Staff 21 telling Resident 5 she/he was Satan's bitch. Staff 20 stated when Resident 5 was resistive to cares, staff were to walk away and reapproach. On 7/10/25 at 12:57 PM Staff 21 stated Resident 5 was hateful and on 1/4/25 Resident 5 was calling her names, trying to hit and kick her and told her to go to Hell. Staff 21 stated she told Resident 5 that she was already there and then proceeded to say something under her breath. Staff 21 stated CNA staff overheard her and reported it. Staff 21 stated she did not argue about what she reportedly said. Staff 21 further stated she was directed by Staff 15 (Former DNS) to force brief changes at least once a day which triggered the resident's behaviors.On 7/14/25 at 11:45 AM Staff 15 stated on 1/4/25 Staff 21 attempted to complete a treatment on Resident 5. Resident 5 was noncompliant, and verbiage was said by Staff 21. Staff 15 denied having any conversations with Staff 21 to force brief changes on Resident 5. Staff 15 stated staff were to encourage cares to be completed and if Resident 5 continued to refuse then to reapproach at a later time. On 7/10/25 at 1:30 PM Staff 1 (Administrator) acknowledged the 1/4/25 incident between Staff 21 and Resident 5 resulted in abuse. No further information was provided.

Based on observation, interview and record review the facility failed to ensure refrigerator temperatures were monitored, and food was labeled and dated for 2 of 2 refrigerators reviewed for food storage. This placed residents at risk for potential foodborne illnesses. A review of the facility policy Refrigerator and Freezer policy revealed refrigerator and freezer temperatures were to be checked daily and all food items were to be marked with dates. Responsibility for implementating the policy was assigned to supervisors or their designee. On 1/13/25 at 8:25 AM the refrigerator used to store resident food items, located in the resident dining room, was observed to have a temperature recording log, however, the temperature was only recorded on 1/10/25. On 1/14/25 at 1:09 PM Staff 16 (Dietary Manager) stated he was not aware of the process for monitoring the resident foods refrigerator utilized by the care team. He stated he had taken the temperature of the refrigerator on 1/10/25 when he placed the log on the front of the refrigerator. On 1/15/25 at 9:59 AM foods were observed with no dates or names in both compartments of the resident refrigerator in the dining room. Staff 17 (CNA) stated she was not sure what the policy was for labeling and dating foods. The resident snack refrigerator behind the nurses station was also observed. The temperature log only had one recorded temperature, dated 1/14/15. In an interview on 1/16/25 at 1:00 PM Staff 16 acknowledged refrigerator temperatures were to be monitored and recorded daily, and refrigerator food was to be labeled and dated.

Based on interview and record review it was determined the facility failed to ensure residents received communication in a language they could understand for 1 of 1 resident (#52) reviewed for behavior. This placed residents at risk for lack of involvement in care. Findings include: Resident 52 admitted to the facility in 10/2024 with diagnoses including diabetes. A 10/12/24 Admission MDS revealed Resident 52's preferred language was Spanish and she/he needed an interpreter to communicate with health care staff. A 10/28/24 care plan revealed Resident 52 spoke Spanish. A review of the medical record revealed the following English language documents were issued to and signed by Resident 52: - 10/14/24 Portable Orders for Life-Sustaining Treatment (POLST), - 10/22/24 Notice of Medicare Non-Coverage, - 10/29/24 Notice of Medicare Non-Coverage, - 1/9/25 SNF Discharge Instructions/Recapitulation of Stay. On 1/14/25 at 11:52 AM Witness 2 (Complainant) stated she visited with Resident 52 and she/he complained the facility provided documents to her/him in English only and requested she translated documents to Resident 52. Unable to interview Resident 52 due to her/his phone being disconnected. On 1/15/25 at 5:04 AM Staff 11 (CNA) stated Resident 52 spoke Spanish with very little English. On 1/15/25 at 12:00 PM Staff 18 (Social Services Director) stated Resident 52 had variable English skills and required a translator for communication. Staff 18 did not know if Resident 52 read English and stated she/he needed her/his Notice of Medicare Non-Coverage to be issued in Spanish. On 1/15/25 at 2:40 PM Staff 19 (LPN) confirmed Resident 52 spoke Spanish with very little English. On 1/17/25 at 10:42 AM Staff 2 (DNS) stated Resident 52 spoke Spanish and the facility failed to provide documents to her/him in a language she/he could understand.

Based on interview and record review it was determined the facility failed to ensure resident mail was delivered to residents on Saturdays for 1 of 1 facility reviewed for resident council. This placed residents at risk for lack of timely written communication. Findings include: A facility Mail and Electronic Communication policy, revised in 2017, stated, Mail and packages will be delivered to the resident within twenty-four (24) hours of delivery on premises or to the facility's post office box (including Saturday deliveries). During the resident council meeting on 1/14/25 at 2:00 PM residents stated their mail was not delivered to them on Saturdays. On 1/15/25 at 10:04 AM Staff 20 (Activities Director) stated mail was delivered Monday through Friday only. Staff 20 stated mail delivered to the facility on Saturdays was not given to resdients until the next Monday morning. On 1/15/25 at 11:31 AM Staff 1 (Administrator) stated resident mail was to be delivered to the residents on the same day it was delivered to the facility.

Based on observation, interview and record review it was determined the facility failed to properly disinfect a glucometer between resident uses for 1 of 2 sampled residents (#107) reviewed for CBG monitoring. This failure, which was determined to be immediate jeopardy, placed Residents 156, 2, 104 and 155 at risk for [CONDITION(S)] C infection. Findings include: On 6/10/22 at 12:38 PM Staff 3 (RN) used a glucometer (a device used to check CBG levels from a blood sample) from the treatment cart to check Resident 107's CBG. Staff 3 then wiped the front of the glucometer with an alcohol wipe and placed the glucometer in the front center of the top drawer of the treatment cart. On 6/10/22 at 1:00 PM Staff 3 removed the same glucometer from the treatment cart and prepared to enter Resident 156's room to check the resident's CBG. The Surveyor stopped Staff 3 from entering the room and asked her what the facility's policy and procedure was for disinfecting glucometers. Staff 3 stated she did not know. At the Surveyors request, Staff 3 then asked Staff 2 (DNS) what the correct procedure was for disinfecting glucometers between use. Staff 2 stated there were disinfectant wipes on the treatment cart for disinfecting the glucometers. The surveyor, Staff 2 and Staff 3 returned to the cart and verified the disinfectant wipes were available on the treatment cart. Staff 2 was asked to provide a list of residents who have CBGs checked and if any of them had a bloodborne infection. Staff 2 was requested by the Surveyor to cease all resident CBG checks at this time. Staff 2 immediately removed all seven used glucometers from the two treatment carts for disposal. Staff 2 then brought six brand new unused glucometers from storage for individual resident use. Staff 2 stated the glucometers would be labeled for each resident and stored in separate bags. On 6/10/22 at 1:45 PM The facility provided a list of all residents in the facility who had their CBG's checked. The list indicated Resident 107 had [CONDITION(S)] C. On 6/10/22 at 2:39 PM Staff 1 (Administrator) was notified of the immediate jeopardy situation and was provided with a copy of the immediate jeopardy template. An immediate plan of correction was requested. On 6/10/22 at 4:03 PM Staff 1 and Staff 2 (DNS) provided a copy of the glucometer manufacturers disinfection instructions, demonstrated the manufacturers recommended disinfection cleaning wipes were available in the facility and the wipes were labeled with the correct contact time. Staff 2 provided copies of licensed nurse in-servicing materials related to glucometer disinfecting and a roster which indicted licensed nurse staff currently in the facility competed the education. On 6/10/22 at 4:11 PM Staff 1 submitted an acceptable plan of correction which included the following: Immediate: - All CBG's stopped, nurses in the building trained on policy and proper protocol as well as demonstrating competency, as well as education on the correct germicidal product to be used for cleaning the CBG machine, along with dwell times. - All open CBG machines have been pulled and discarded. New individualized CBG machines have been assigned to each resident and labeled with their name and placed in individualized bag. - RNCM has assumed charge roll of the floor and is educating RN while working side by side. - Documentation to be provided showing the germicidal product meets manufacturer's requirements for disinfection of CBG machine. Ongoing: - Resident physicians notified and obtained orders for bloodborne pathogen testing. - Blood draws ordered for residents who received CBG testing. - All remaining nurses to be trained before next working shift on proper protocol on CBG process, as well as education on the correct germicidal product to be used for cleaning the CBG machine, along with dwell times. Systemic Changes: - Germicidal product to be clearly labeled with dwell time. - DNS/RNCM or designee will perform CBG competencies all current licensed nurses employed and will conduct CBG competency for all new hires prior to end of orientation period. Monitoring: - DNS/RNCM or designee, to complete random weekly checks on 50% of residents receiving CBG testing to ensure compliance with correct CBG administration as well as monitoring of technique and ensuring correct cleaning protocols are being followed, corrections as needed. - DNS/RNCM or designee to report findings at Monthly QAPI. On 6/10/22 at 4:17 PM Staff 1 was notified the immediacy was removed and resident CBG testing could resume.

Based on interview and record review it was determined the facility failed to ensure a resident received the necessary treatment and services to prevent infection and the worsening of a Stage 4 pressure ulcer (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone) for 1 of 3 sampled residents (#22) reviewed for pressure ulcers. This failure, which was determined to be immediate jeopardy, resulted in worsening of Resident 22's pressure ulcer and subsequent transfer to the hospital where the resident died from complications related to the worsening of the pressure ulcer. Findings include: Resident 22 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 22's [DATE] Skin and Wound Evaluation from the resident's previous facility assessed the Stage 4 pressure ulcer to measure 1.9 cm x 2.0 cm (no depth was documented) with 90% epithelial tissue (tissue that forms the outer covering of skin) and no evidence of infection. No exudate (drainage) or odor was present, the wound edges were attached and the surrounding tissue was normal with no indurating (abnormal hardening of the tissue) or [CONDITION(S)] (swelling). The peri-wound (skin around the ulcer) was normal and the resident denied pain. The wound was determined to be stable but slow to heal. Resident 22's [DATE] Admission Transfer assessment revealed the resident had a Stage 4 pressure ulcer to the coccyx. [A comprehensive wound assessment was not completed.] A [DATE] Care Plan indicated Resident 22 was at risk for skin breakdown related to an existing pressure injury and changes in mobility and ADLs which were further complicated by the COVID-19 [CONDITION(S)] infection. Interventions included repositioning the resident every two hours. There was no documentation in the medical record repositioning every two hours occurred. The resident's [DATE] admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Stage 4 pressure ulcer wound care: cleanse with normal saline (NS), apply skin prep to the peri-wound, apply collagen to the wound base (mix NS with collagen powder to create paste) and then gently fill the remaining ulcer with calcium alginate and cover with a foam bordered dressing. Change daily and as needed. -Protein gel: 20 ml in 120 ml in juice daily (nutritional supplement). The [DATE] TARs revealed Resident 22 refused wound treatments on [DATE], 10, 11, 12 and 14. (A [DATE] Progress Note revealed the wound treatment was completed.) There was no evidence in the medical record the facility staff provided encouragement or education to the resident or family related to the treatment refusals. There was no evidence in the medical record the family or physician were notified of the refusals until [DATE]. A [DATE] MARs revealed Resident 22 did not receive the prescribed protein gel on [DATE], 9, 10 and 11. There was no evidence in the medical record the physician was notified the protein gel was not administered. A [DATE] Wound Management assessment indicated the resident's wound measured 3.2 cm x 3 cm x 2.7 cm with light serosanguineous (light pink/red, thin and water-like) exudate and no odor. Undermining (wounds that extend under the skin) was 9.7 cm with no tunneling (channels formed beneath the skin). Granulation tissue (new tissue) was present, wound edges were rolled under and thickened and the surrounding skin was dry, thin and scaling. The wound was determined to be stable. [The assessment failed to identify the wound had worsened since admission.] A [DATE] Progress Note revealed the resident's wound did not have odor and did not have signs of infection. The wound was painful to touch. A [DATE] Nutritional Assessment revealed Resident 22 should continue her/his current diet, add NEM (nutritionally enhanced meals), add 120 ml of 2 cal (nutritional health shake) five times a day, provide a multivitamin with minerals to the evening mediation pass and notify the RD PRN. [The assessment did not include the resident only consumed mandarin oranges, bananas and drank milk for two meals daily.] There was no evidence in the medical records the RD recommendations were initiated and followed. The [DATE] Wound Management assessment indicated the wound measured 4 cm x 3.4 cm x 2.8 cm with light seropurulent (mixture of serum and pus) drainage. A strong, foul odor was present. There was 2 cm of undermining of the entire wound and 4 cm of tunneling from one to five o'clock present. The wound was assessed to have declined. The [DATE] Wound Management assessment indicated the wound measured 4 cm x 3.4 cm x 2.8 cm with moderate seropurulent drainage. Odor was present, undermining was 4.5 cm and tunneling was 5 cm. The wound was assessed to have declined. Additionally a second wound was identified as an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough (moist, devitalized tissue) and/or eschar (dead tissue) adjacent to the Stage 4 pressure ulcer. There was no evidence in the medical record her/his physician physically assessed the Stage 4 pressure ulcer. The [DATE] Progress note revealed Resident 22 transferred back to her/his prior long-term care facility. On [DATE] the receiving facility completed a Skin and Wound evaluation which assessed the Stage 4 pressure ulcer to measure 9.6 cm x 8.7 cm (no depth identified). The wound bed had eschar and there was evidence of infection which included increased pain, redness/inflammation and a strong odor. The surrounding tissue had black/blue discoloration and [CONDITION(S)] (redness), the peri-wound skin temperature was warm and the resident complained of intermittent pain. The resident's [DATE] Hospital records revealed Resident 22 was found to be unresponsive the morning of [DATE] and was transferred to the hospital. The resident was identified to be in multi-organ failure due to chronic infection and admitted to the intensive care unit. On [DATE] Resident 22 died . The principal cause of death was septic shock present for days due to the sacral decubitus (pressure) ulcer and [CONDITION(S)]. On [DATE] at 9:09 AM Staff 7 (DNS) verified the Stage 4 pressure ulcer was identified but not assessed on admission, verified both the wound care and protein gel were not completed per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff 7 further stated the facility did not accommodate Resident 22's specific food preference, did not follow the RD recommendations, did not document care plan turning interventions and verified the physician did not visually assess the wounds during Resident 22's stay at the facility. On [DATE] at 9:27 AM Staff 20 (RD) acknowledged she was unaware of Resident 22's food preferences, likes and dislikes and was unaware Resident 22 only ate mandarin oranges, bananas and milk twice a day. Staff 20 stated she would have recommended other dietary interventions had she known of Resident 22's food preferences. Staff 20 acknowledged the [DATE] Nutritional Assessment was not a comprehensive assessment. On [DATE] at 10:05 AM Staff 3 (RNCM) acknowledged the Stage 4 pressure ulcer worsened at the time of the [DATE] assessment. Staff 3 stated she knew little of the wound prior to [DATE] when a nurse approached her regarding the frequent refusals of care. She then observed and thoroughly cleaned the wound. Staff 3 stated the nurses were complacent with the resident treatment refusals and did not provide strong encouragement or education. Additionally, Staff 3 stated the wound treatments were not completed as prescribed. Staff 3 stated on [DATE] she pulled out a dressing from the wound that was not the prescribed treatment and found the wound had deteriorated. Staff 3 further stated the second wound documented on [DATE] was a continuation of the Stage 4 pressure ulcer and not a separate wound. On [DATE] at 1:26 PM Staff 2 (Administrator) and Staff 3 (RNCM) were notified of the immediate jeopardy (IJ) and provided a copy of the IJ template related to the facility's failure to ensure a resident received the necessary treatment and services to prevent infection and the worsening of a Stage 4 pressure ulcer. An immediate plan of correction (POC) was requested. On [DATE] at 4:10 PM the submitted POC was approved. The IJ Immediacy Removal Plan included: -Immediately 1. Identification of all pressure ulcers -Ongoing 2. Verify assessments of all pressure ulcers are up to date 3. Verify current assessments are up to date with accurate measurements 4. All identified pressure ulcer care plans reviewed and updated to ensure they cover nutrition, treatment and positioning. 5. RNCM will review RD recommendations of all current residents. 6. RNCM will follow up on all RD recommendations to ensure recommendations are being implemented as recommended. 7. Residents who are refusing care and services will be provided risk versus benefit education upon refusal. The nurse will try to negotiate a reasonable alternative. If the resident continues to refuse after the risk benefit, a reapproach will be attempted prior to the end of the shift. In the event the nurse is unsuccessful and the resident continues to refuse service the facility will notify the family and physician that day. 8. Care plans will be updated as appropriate. -Systematic Changes 1. RNCM will conduct admission audits following day after admit to ensure skin issues are appropriately documented and interventions are in place. 2. Residents who are refusing care and services will be provided risk and benefit education upon refusal. The nurse will listen to why the resident is refusing to help seek/negotiate a reasonable alternative. If the resident continues to refuse after risk and benefit, a reapproach will be attempted prior to end of shift. In the event the nurse is unsuccessful and the resident continues to refuse service the facility will notify the family and physician the same day. 3. Educate the nurses starting [DATE] with nurses on staff and educate them prior to the start of the nurses next shift. a. RD recommendations b. Wound assessments and documentation c. Notification of family d. Notification of physician e. RN assessment anytime a wound is declining. f. Location of supplies g. Following physician orders h. Importance of documentation, if it is not documented it is not done. -Monitoring 4. RNCM to do wound rounds once a week to verify wound status, documentation and interventions are in place. 5. DNS or designee will audit pressure/injuries every week and report to monthly QAPI (Quality Assurance and Performance Improvement) to ensure ongoing compliance. 6. DNS or designee will audit RD recommendations every week and report to monthly QAPI to ensure ongoing compliance. 7. DNS or designee will audit MAR/TAR for refusal/not available every week and report to monthly QAPI to ensure ongoing compliance. 8. DNS or designee will audit for refusal of care every week and report to monthly QAPI to ensure ongoing compliance. 9. Audits will continue for at least three months and be re-evaluated at QAPI if auditing can be titrated to twice a month intervals, monthly intervals or no longer needed. On [DATE] at 4:26 PM Staff 2 (Administrator) and Staff 24 (Corporate RN) were notified the immediacy was removed based on observations, staff interviews and record review that the IJ removal plan was fully implemented.

Based on interview and record review it was determined the facility failed to promptly verify weights, identify and assess when residents' nutritional and hydration intake was less than the residents required needs and/or had an unintended severe weight loss for 6 of 12 sampled residents (#s 1, 2, 9, 10, 22 and 35) reviewed for change in condition, dehydration, weight loss, eating assistance and change in condition. This failure resulted in an unintended severe weight loss for Resident #s 1 and 35, worsening wounds contributing to her/his death for Resident 22 and dehydration for Resident 10. Findings include: 1. Resident 10 was admitted to the facility in 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A 7/1/21 Progress Note indicated Resident 10 was admitted to the facility and was too lethargic to sign consent forms. Resident 10's undated Kardex (CNA guide to resident specific care) revealed Resident 10 required 1 to 1 assist to eat. A Breakfast Intake report for 7/2021 revealed staff documented 10 out of 17 meals. The resident was documented to not eat breakfast on six days, ate 1-25% on three days and 26-50% on one day. A Lunch Intake report for 7/2021 revealed staff documented 10 out of 17 meals. The resident was documented to not eat lunch on five days and ate 1-25 % on five days. A Dinner Intake report for 7/2021 revealed staff documented 9 out of 17 meals. The resident was documented to not eat for three meals and 1-25 % for five meals. Resident 10's 7/2021 Fluids log indicated she/he drank 90-260 cc of fluids each day through 7/11/21. A 7/2021 Supplements Intake form indicated the resident did not receive any supplements even when the resident ate less than 25%. A 7/2021 AM Snack form revealed the resident was not offered snacks. A 7/2021 Bedtime Intake form revealed the resident was not offered snacks. A 7/11/21 Nutritional Assessment indicated the resident's current intake met 25% or less of her/his estimated needs, required 2250 cc of fluids each day and consumed less than 1000 cc per day. Staff were to offer fluids with medication pass and add a fruit based nutritional supplement BID. A 7/2021 Progress Notes and Daily Skilled Nursing notes did not have an assessment of the resident's lack of oral intake, notification to the resident's family and physician or what interventions the facility would implement to help the resident improve her/his intake. Resident 10's 7/2021 Fluids log revealed the amount of fluids consumed increased after the RD recommendation was made for staff to offer the resident additional fluids, but continued to be less than the resident's 2250 cc daily need. The resident's 7/2021 TAR revealed the resident was offered and took up to 120 cc of fluid with each medication pass after the RD recommendations. Resident 10's record did not have documentation to indicate the fruit supplement was started. On 2/15/21 at 5:20 PM Staff 16 (CNA) stated if a resident did not eat her/his meal, the resident could be offered an alternative meal, a snack and or a nutritional supplement. If the resident refused the nurse was notified. The nurse was to check with the resident. On 2/22/22 at 10:21 AM Staff 6 (RN) reviewed Resident 10's record and acknowledged the resident did not eat or drink well. Staff should let the physician know if a resident was not eating or drinking after two to three days of not eating and/or drinking. If needed staff could administer intravenous fluids (fluids administered via a vein) or clysis (fluids administered under the skin). A 7/14/21 Office Visit form indicated Resident 10 was assessed in the facility by the facility physician. The physician assessment revealed the resident was admitted with COVID-19 infection, had fair skin turgor (elasticity of the skin which could be an indication of hydration status) and did not have increased symptoms related to COVID-19. There was no assessment specific to the resident's lack of oral intake of food and fluids. Resident 10's weight on 7/8/21 was 199 pounds and was 197 pounds on 7/15/21. On 2/16/22 at 11:45 AM Staff 3 (RNCM) acknowledged Resident 10 did not eat or drink well and often the intake was less than 50% and the resident was not offered supplements when her/his intake was less than 50%. Staff 3 indicated if a snack or supplement was provided the staff documented the amount consumed in the resident's record. Staff 3 acknowledged the resident was not documented to have snacks. Staff 3 also indicated she would look for documentation the physician was notified of the resident's lack of oral intake. No additional information was provided. On 2/24/22 at 10:00 AM Staff 7 (DNS) stated during COVID-19 the RD assessed residents via virtual visits and record review. The RD wrote a report and then sent it to the facility the next day. The RD recommendations were to be implemented the same day the facility received the recommendation. Staff 7 stated the Staff 19 (Dietary Manager) and RNCM were to work together to get the recommendations in place. Staff were to offer a supplement or snacks if a resident ate less than or equal to 50 percent the meal and they were to document when snacks and supplements were offered. The nurses should assess the resident and monitor the resident if the resident consistently did not eat. Staff 7 acknowledged the resident had decreased food and fluid intake and there was no documentation of snacks or supplements provided. A request was made to Staff 7 to provide documentation the facility assessed the resident and offered additional food and/or fluids to the resident. No additional information was provided. Resident 10's 7/19/21 hospital History and Physical indicated the resident was admitted to the hospital and was nearly obtunded (slowed responses to stimulation and drowsy between sleep states). The resident had worsening oral intake resulting in dehydration. Resident 10 was assessed to have a free water deficit of approximately 2.4 liters. Resident 10 was administered one liter of intravenous fluids in the emergency department. On 2/25/22 at 12:35 PM Staff 20 (RD) reviewed the resident's record and acknowledged the resident had multiple days of poor fluid and oral intake. Staff did not add the fruit based supplement per recommendation. Staff 20 stated the resident's poor fluid intake, prior to her RD assessment, contributed to the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Resident 9 was admitted to the facility 7/19/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident 9's 7/29/21 Nutritional Assessment by the RD indicated the resident's weight on 7/20/21 was 81 pounds and was 83 pounds on 7/26/21. The resident had variable acceptance of meals with an average intake of 50%. The assessment also indicated the resident fluid intake required to meet needs was at least 1100 cc and the resident usually drank less than 1000 cc a day. The recommendation included NEMs (nutritionally enhanced meals-adding high fat foods such as butter and sauces to foods) and staff were to encourage fluids during medication pass. The resident's Active Orders report did not include NEMs and/or an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/16/22 at 11:45 AM and on 2/22/21 at 3:36 PM Staff 3 (RNCM) indicated she and the dietary manager were to work together to ensure the Staff 20 (RD) recommendations were implemented. Staff 3 indicated she reviewed Resident 9's Nutritional Assessment and acknowledged the RD recommendation was to add NEMs and to encourage fluids during medication pass. NEMs would be documented as a dietary order. Staff 3 stated when the RD recommended fluids be added with medication pass the recommendation was to be put on the MAR for at least BID fluid administration and to document the amount of fluids consumed. A request was made to Staff 3 to provide documentation NEMs and additional fluids were implemented for the resident after the 7/29/21 RD assessment. No additional information was provided. Resident 9 was discharged on [DATE], five days after the RD assessment, and no additional weights were in there resident's record after 7/26/21. The 8/16/21 hospital Discharge summary did not include the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 3. Resident 1 was admitted to the facility in 11/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident 1's weight record revealed on 11/10/21 the resident's weight was 139.2 pounds. On 11/17/21 the resident's weight was 128.6. The facility's electronic medical record flagged the 11/17/21 weight as outside the acceptable range for weight change. No re-weigh to verify the resident's weight was found. This was a 7.6% body weight loss over seven days. A review of Resident 1's clinical record revealed no indication Staff 20 (RD), the resident's family or the resident's physician were notified of the weight loss identified on 11/17/21. Resident 1's Nutritional Status care plan created on 11/11/21 indicated the resident was at risk for nutritional impairment related to COVID-19 illness. The goal was for the resident to maintain her/his admission weight within five pounds. The only intervention was to monitor the resident's meal intake. A review of Resident 1's food intake record from 11/10/21 through 11/20/21 revealed overall poor food intake including: - Seven out of ten breakfast intakes of 0-25% consumed. - Seven out of ten lunch intakes of 0-25% consumed. - Seven out of ten dinner intakes of 0-50% consumed. An RD assessment dated [DATE] indicated the resident had a severe weight loss and the resident was at increased nutritional risk due to poor intake and weight loss. The assessment indicated Interventions are in place to increase calories and protein provided and remain appropriate., however no interventions, other than meal monitoring, prior to 11/19/21 were found. On 2/25/22 at 12:00 PM Staff 20 confirmed Resident 1's weights, weight loss and poor intake. Staff 20 stated her assessment on 11/19/21 was a normal new admission assessment and was not specifically requested by the facility related to the resident's poor intake or weight loss. Staff 20 stated she would expect the facility to assess the resident and implement appropriate interventions based on the resident's documented poor intake, as well as notify her and the resident's physician. 4. Resident 35 was admitted to the facility in 1/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A 1/31/22 BIMS indicated Resident 35 was cognitively intact. A 2/2/22 RD Nutritional Assessment revealed Resident 35 had a variable acceptance of meals. Resident 35's weights revealed a 13.7% severe weight loss. The RD recommendations included to provide a house diabetic nutritional shake if less than 50% of the meal was eaten and to notify the RD as needed. A 2/11/22 Progress Note revealed Resident 35's admission weight on 1/21/22 was 197.4 pounds and Resident 35's 2/11/22 weight was 158 pounds which was a 39.4 pound loss. (This was a 19.96% severe weight loss.) Resident 35's Weight Report revealed the following weights: -1/21/22: 197.4 -1/22/22: 192 -1/28/22: 170 -2/4/22: 167 -2/11/22 158 A review of the medical record revealed no documentation the RD recommended diabetic health shakes were offered or given to Resident 35 or the RD was contacted about the ongoing weight loss. On 2/14/22 at 8:25 AM Resident 35 acknowledged she had an almost 40 pound weight loss in the past three weeks and stated the facility staff did nothing to prevent or stop the weight loss. Resident 35 stated she/he was not asked about her/his dietary preferences and was not offered nutritional shakes. Resident 35 further stated she/he sometimes needed assistance with meals due to problems in both hands but staff rarely offered assistance. Resident 35 stated when she/he needed assistance and assistance was not offered she/he just would not eat. On 2/14/22 at 8:56 AM Staff 19 (Dietary Manager) stated he did not interview residents to obtain their food preferences or specific dietary needs. On 2/23/21 at 9:12 AM Staff 20 (RD) stated before she completed a nutritional assessment resident specific information such as food preferences or special dietary needs should be brought to her by the dietary manager. Staff 20 stated she relied highly on staff to communicate with her but the facility did not contact her about Resident 35's ongoing weight loss. On 2/23/22 at 3:26 PM Staff 7 (DNS) and Staff 3 (RNCM) acknowledged Resident 35's 39.4 pound weight loss and verified Resident 35's medical record had no documentation the nutritional shakes were offered. 5. Resident 22 was admitted to the facility in 1/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/22/22 at 10:24 AM Witness 10 (Complainant) stated upon admission to the facility the facility staff were aware Resident 22 only ate mandarin oranges, bananas and drank milk for lunch and dinner. Resident 22 did not eat or drink anything else. Witness 10 stated the facility did not provide the mandarin oranges, as requested prior to Resident 22's admission, and did not notify the family Resident 22 did not get them. Witness 10 further stated Resident 22 went without the mandarin oranges for three to four days until she discovered this so she brought them in for the resident. A review of Resident 22's 1/2022 admission paperwork revealed mandarin oranges handwritten in the top right corner of the admission paperwork. A 1/7/22 Nutrition Care Plan revealed Resident 22 was at risk for nutritional impairment related to diminished appetite and poor meal acceptance related to COVID-19. The goal was to maintain weight within five pounds of her/his admission weight. The interventions included to assess and evaluate dietary likes and dislikes and weekly weights. A 1/18/22 Nutritional Assessment indicated to continue the prescribed diet, add NEM (nutritional enhanced meals), add 120 ml of 2 cal (nutritional supplement), provide a multivitamin with minerals to the evening medication pass and to notify the RD PRN. The specific diet of mandarin oranges, bananas and milk was not assessed. The Weight Record revealed on 1/7/22 Resident 22 weighed 113.2 pounds. No other weights were obtained during Resident 22's stay at the facility. Review of the medical record revealed no documentation the RD recommendations were initiated. On 2/14/22 at 8:56 AM Staff 19 (Dietary Manager) stated he did not interview residents for their food preferences or specific dietary needs. Staff 19 further stated he was not aware Resident 22 only ate mandarin oranges, bananas and drank milk for lunch and dinner. Staff 19 could not recall if the facility provided the mandarin oranges to Resident 22. On 2/14/22 at 9:04 AM Staff 16 (CNA) stated Resident 22 refused multiple meals and loved the bananas and milk. Staff 16 further stated the facility did not provide Resident 22 with mandarin oranges so the family brought in cans of them later on. On 2/14/22 at 9:09 AM Staff 7 (DNS) acknowledged the facility did not honor Resident 22's food preference for mandarin oranges. Staff 7 further stated there was no documentation the RD recommendations were followed. On 2/23/22 at 9:27 AM Staff 20 (RD) stated she was not aware of Resident 22's specific dietary preferences and was unaware Resident 22 only consumed mandarin oranges, bananas and milk. Staff 20 stated she would have recommended other dietary interventions had she known of Resident 22's food preferences. Staff 20 acknowledged the 1/18/22 Nutritional Assessment was not a comprehensive assessment. 6. Resident 2 was admitted to the facility in 10/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A 10/15/21 RD Nutritional Assessment revealed Resident 2 had a variable acceptance of meals and current weight is less than weight at admit to facility and indicates a 7.7% (weight loss) considered severe, recommend verify weight. The assessment further indicated Resident 2 was at an increased nutritional risk due to mechanically altered texture diet, decrease acceptance of meals and weight loss. The RD recommendations included to add NEM (nutritionally enhanced meals), provide a house supplement (nutritional shake) twice a day between meals and to document the ml's consumed on the MAR and to verify Resident 2's weight due to a 14 pound weight loss in one week. A CBG record revealed between 10/4/21 through 10/14/21 Resident 2's CBGs ranged from 76 to 503 (normal CBG range is 70 to 99). The resident's medical record revealed no documentation the NEM was initiated, the MARs did not document the twice daily house supplements and Resident 2's weight was not verified for accuracy. On 2/15/21 at 1:48 PM Staff 7 (DNS) acknowledged the RD recommendations were not followed. On 2/24/22 at 8:33 AM Staff 20 (RD) acknowledged the RD assessment did not include Resident 2's diabetes and varied CBG levels.

Based on interview and record review it was determined the facility failed to provide supra-pubic (SP, tube which drains from the bladder) catheter care for 1 of 3 sampled residents (#22) reviewed for catheters. This resulted in Resident 22 developing a [CONDITION(S)] with [CONDITION(S)]. Findings include: Resident 22 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 22 discharged on [DATE] to a long-term care facility. The [DATE] admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Irrigate the SP catheter with 30 ml of normal saline every shift. From [DATE] through [DATE] this was documented as refused seven times. -Apply [MEDICATION(S)] (barrier cream) and split sponge every shift. From [DATE] through [DATE] this was documented as refused six times. There was no evidence in the medical record the resident was provided risk versus benefit education related to the treatment refusals. There was no evidence in the medical record Resident 22's family or physician was notified about the refusals. Hospital records dated [DATE] revealed Resident 22 was transferred to the hospital the day after she/he discharged from the facility and diagnosed with septic shock (full body infection) due to [CONDITION(S)] and decubitus ulcer. Resident 22 died in the hospital on [DATE]. On [DATE] at 9:04 AM Staff 16 (CNA) stated Resident 22 frequently refused care and services especially personal hygiene. On [DATE] at 9:09 AM Staff 7 (DNS) verified Resident 22 refused the irrigation of the SP catheter and barrier cream and change, and the facility did not educate the resident of the risks and benefits of the refusals or contact the family and physician of the refusals.

Based on observation, 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 and effectively manage a resident's severe pain for 1 of 1 sampled resident (#302) reviewed for pain. This resulted in Resident 302 having severe unrelieved pain which affected her/his ability to sleep and participate in daily care including repositioning. Findings include: Resident 302 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The 8/5/19 physician orders [REDACTED]. The 8/5/19 nursing Pain Assessment indicated Resident 302 was currently having hip pain and the pain was excruciating, which interfered with her/his ability to carry on with daily routines such as socialization or sleep. The Temporary Care Plan completed on 8/6/19 indicated Resident 302 was in pain with a goal of resident will verbalize pain at an acceptable level which does not interfere with quality of life. On 8/6/19 at 9:47 AM Resident 302 was observed to be tearful, distraught and grunting. Resident 302 stated she/he told the facility staff she/he was in severe pain and was told her/his medication was ordered. Resident 302 stated she/he was unable to get comfortable and rest all night due to the pain. The medication flow sheet indicated Resident 302 did not receive any medications at the facility on 8/5/19. It further indicated Resident 302 received [MEDICATION NAME] 15mg one tablet at 8:00 AM on 8/6/19 which was her/his first pain medication received since admission on 8/5/19 at 7:00 PM. On 8/8/19 at 10:00 AM Staff 3 (RNCM) stated she came in to work early on 8/6/19 and checked on Resident 302. Staff 3 stated Resident 302 was experiencing pain, grimacing and posturing, so she went to the CMA and told her Resident 302 needed her/his pain medication now. Staff 3 stated Resident 302 should have received something for pain during the night without waiting. She stated an emergency locked box of common medications, including [MEDICATION NAME] was available for new admissions. On 8/8/19 at 2:45 PM Staff 13 (LPN) stated Resident 302 complained of pain and was distraught and distressed. Staff 13 stated she called the pharmacy for a code to get Resident 302's narcotic pain medication from the facility emergency lock box but Staff did not hear back. Staff 13 stated the process was to call the pharmacy back in 30 minutes for a code if they did not respond and ultimately call the doctor if unable to access the pain medication. Staff 13 stated she did not call the pharmacy back and did not notify anyone else and did not get a code to access medication for Resident 203. On 8/13/19 at 11:25 AM Staff 25 (CNA) stated Resident 302 was in too much pain to be repositioned in bed on the evening of 8/5/19. On 8/8/19 at 10:57 AM Staff 2 (DNS) acknowledged Resident 302 did not get any pain relief medication from admission on 8/5/19 at 7:00 PM until 8:00 AM on 8/6/19. Staff 2 also stated medications were available in the emergency box and Resident 302 should have received her/his PRN pain medication.

Based on interview and record review it was determined the facility failed to identify, reassess and maintain acceptable parameters for nutritional status for 1 of 2 sampled residents (#8) reviewed for nutrition. As a result Resident 8 had a severe weight loss greater than 7.5% in three month period. Findings include: Resident 8 was admitted to the facility in (MONTH) 2019 with [DIAGNOSES REDACTED]. The following weights were recorded for Resident 8: -4/11/19: 178.6 pounds. -5/3/19: 181.6 pounds. -6/25/19: 161.3 pounds. -7/1/19: 165.0 pounds. A 7.6% weight loss in three months, indicating a severe weight loss. The 4/15/19 care plan indicated Resident 8 was at nutritional risk related to her/his disease process. The goal included no significant weight loss (5% in 30 days). An updated 7/26/19 intervention included to monitor and record weight. A 5/15/19 Nutritional Assessment indicated Resident 8 had a weight decrease and lost her/his appetite prior to admitting to the facility. The resident agreed to a trial of health shakes at meals. The goal was for Resident 8's weight to be stable. The assessment included the recommendations of the trial of health shakes at meals and to notify the Dietician if the resident's weight decreased or if the resident refused the health shakes. A 7/17/19 nutritional follow-up note indicated Resident 8 had a weight decrease of 7.6% since admission. The note indicated the prior recommendations were not ordered and the trial of health shakes was again requested. The note further indicated the resident had a significant weight decrease over the past three months. Recommendations included to add health shakes TID and weekly weights for four weeks related to the resident's weight loss. an order for [REDACTED]. Review of the 7/30/19 Nutrition at Risk (NAR) meeting note indicated Resident 8 had a 8.9% weight loss in 59 days. Food requested by the resident included avocado, shrimp, mango and salmon. The identified causes indicated the resident did not like the food and requested items not available and refused to eat. The plan included to purchase selected food items, provide health shakes BID and to refer to the dietician. Review of Resident 8's medical record revealed no evidence of the following: -The resident received the recommended health shakes prior to the 7/25/19 order. -Weekly weights were implemented as recommended on 7/17/19. -The resident was placed on NAR prior to 7/30/19. On 8/5/19 at 11:52 AM Resident 8 stated she/he lost weight since admission. The resident stated she/he received health shakes for the past week and confirmed she/he did not receive health shakes prior to the previous week. On 8/8/19 at 10:06 AM Staff 26 (RD) stated she was in the facility 16 hours a month and did not participate in the NAR meetings. She stated the nutritional recommendations made were given to nursing staff and she believed they were given to the physician for a written order. Staff 26 stated she relied on nursing to follow up with recommendations due to her limited time in the facility. She stated she relied on nursing staff to follow up and complete any recommendations made. Staff 26 confirmed the recommendation for a trial of health shakes requested for Resident 8 was not ordered in (MONTH) and was again requested in July. Staff 26 further stated the recommendation for weekly weights was to be started quickly after the recommendation was made on 7/17/19. She stated the weekly weight would prompt nursing staff to monitor and work on appropriate interventions to address the resident's weight loss. Staff 26 confirmed Resident 8 had a 7.6% weight loss in three months. On 8/8/19 at 11:25 AM Staff 3 (RNCM) stated the dietician's recommendations were given to her and to the Dietary Manager (Staff 6). Staff 3 stated the recommendations were reviewed and dietary orders were requested from the physician. Staff 3 stated it did not take more than a week to obtain an order from the physician as he was in the facility weekly. Staff 3 confirmed she did not see the RD recommendation for the health shakes until it was requested again in July. She stated the (MONTH) request for the health shakes was not implemented. Staff 3 further confirmed nursing staff did not obtain an order for [REDACTED]. Staff 3 confirmed she was not aware of Resident 8's 7.6% weight loss until the implementation of the health shakes on 7/25/19 and the resident was placed on NAR. On 8/8/19 at 12:40 PM Staff 6 stated he set up the NAR meetings and selected the residents who needed to be monitored. He stated residents who were on NAR had a 3% weight loss from their previous weight. He stated he reviewed the weights which indicated to him what residents had weight loss. Staff 6 stated the RD did not participate in the NAR meetings. Staff 6 confirmed he made a mistake and did not catch (Resident 8's) weight loss and she/he should have been on NAR sooner. He stated he did not recall an RD recommendation for health shakes in (MONTH) or (MONTH) and had just decided to add the health shakes. On 8/15/19 at 1:01 PM Staff 1 (Administrator) acknowledged the RD was going to review Resident 8's recommendation for health shakes TID and the implementation of the shakes only BID.

Based on observation, interview and record review it was determined the facility failed to ensure food safety was maintained related to the distribution of poultry for 1 of 2 dining room and 1 of 3 halls. This resulted in immediate jeopardy related to the potential for outbreak of foodborne illness. Findings include: According to CDC (Centers for Disease Control) recommendations, raw chicken was often contaminated with Campylobacter, Salmonella and ,[MEDICAL CONDITION]. perfringes (various types of bacteria). Eating raw chicken placed one at risk for foodborne illness, also known as food poisoning. On 2/12/18 the following events occurred: -At 12:14 PM four residents were observed in the large dining room to have undercooked chicken on their plates. The chicken was observed to be undercooked and red in color with obvious blood. There were three CNA staff working in the dining room, and two were directly observed to be within line of sight or cutting up the undercooked chicken. The staff did not intervene prior to any of the resident's consumption of the undercooked chicken. -At 12:15 PM Staff 29 (Cook) was notified by the Survey Team of the four residents in the dining room observed to have undercooked chicken. Staff 29 acknowledged the meat was undercooked for all four residents but did not remove the uncooked chicken from the resident tables. Resident's 7, 10 and 17 (all at one table) indicated they would like new portions of the meat. Resident 51 (separate table) was observed to have consumed a leg of chicken, the bone was observed to be bloody. Resident 51 indicated she/he did not care to receive a new portion of chicken and was not concerned she/he consumed undercooked chicken. The first three residents were observed to no longer be eating their undercooked chicken. -At 12:20 PM Staff 29 returned to the dining room and was observed to remove Resident 7, 10 and 17's plates. The cook then served each of these resident's plates with new portions of chicken. -At 12:21 PM Resident 3 (seated at another table with CNA) was observed to be eating an undercooked portion of chicken. The CNA was observed to ask this resident how her/his lunch was, and the resident was not heard to respond. The CNA did not intervene in her/his consumption of undercooked chicken. The Survey Team questioned this CNA regarding the undercooked chicken and the CNA did not intervene. The Survey Team observing the dining room informed the Team Leader of the additional resident who had undercooked chicken. The Team Leader shared the information received with Staff 2 (DNS). -At 12:26 PM the Survey Team Leader informed Staff 2 of the concern with the undercooked poultry. A room by room check was facilitated by the Survey Team Leader and Staff 2 to ensure the food quality of the poultry on the hall trays. It was confirmed that three of the five trays served in the 300 hall had undercooked chicken. Resident 42, who had severe visual impairment, was observed to have consumed the majority of her/his chicken. The resident stated it did not taste cooked, however she/he fully trusted the facility so she/he ate it. The remaining meat on her/his plate was red in color. The two remaining trays with undercooked chicken were observed to be removed prior to resident consumption. -At 12:27 PM Resident 7 was observed to be cutting open her/his new portion of chicken. The chicken was again observed to be undercooked. The resident confirmed her/his piece of replacement chicken was undercooked and stated she/he was going to eat it anyway. The resident further stated once every few months the facility would serve undercooked meat. The CNA facility staff were observed in line of sight of this resident and did not intervene. -At 12:33 PM Staff 2 who continued to review the hall trays with the Survey Team Leader, stopped the dietary staff from delivering the 100 hall cart trays and instructed staff to take it back to the kitchen and remove all chicken off the trays. -At 12:34 PM Staff 2 confirmed with the Survey Team there were no trays from the 200 hall cart served to the residents. Staff 2 personally returned the hall cart to the kitchen. The Survey Team in the dining room informed the Team Leader the Dietary staff was again serving undercooked chicken. -At 12:35 PM Staff 2 was informed by the Survey Team Leader the kitchen was again serving undercooked chicken to the residents in the dining room and asked Staff 2 to intervene. -At 12:41 PM Staff 2 stated to the Survey Team she had gone to the kitchen, everything was taken care of and the kitchen was no longer serving any chicken. -At 12:56 PM Staff 6 (Dietary Manager) confirmed Staff 29 (cook) was the only kitchen staff who cooked and obtained temperatures of chicken before it was served to residents. Staff 6 indicated the temperatures which Staff 29 obtained indicated the chicken was fully cooked. Staff 6 stated Staff 29 must have temped (checked) a piece of chicken that was fully cooked, rather than one of the pieces of undercooked chicken. -At 1:08 PM Staff 6 confirmed the facility did not have a system in place to ensure accurate temperatures were obtained when staff were cooking multiple pieces of poultry, such as chicken. In the dining room there were a total of 18 plates served, with eight of them containing chicken. Of those eight plates containing chicken, five were observed to be undercooked. Of those five plates with undercooked chicken observed, three were replaced with new pieces of chicken. Of those three pieces of replacement chicken served, one was observed to still be undercooked. Three of five room trays served in the 300 hall were observed to have undercooked chicken. Of those three room trays served, one resident was observed to have consumed the undercooked chicken and two were observed to be removed prior to the residents consuming any of the undercooked chicken. There were no hall trays served in the 100 hall or 200 hall due to Staff 2 intervening. -At 1:58 PM Immediate Jeopardy (IJ) was called due to the consumption of undercooked chicken by six residents. Of these six resident who consumed undercooked chicken, five were eating in the large dining room and one consumed her/his meal in her/his room on the 300 hall. This failure resulted in the potential for foodborne illness. At this time, Staff 1 (Administrator) and Staff 2 stated all residents in the facility who ate the undercooked chicken would be placed on alert charting, and physicians were notified. Staff also stated a plan of correction had begun and would be delivered to the Survey Team once complete. -On 2/12/17 at 5:00 PM the P(NAME) (Plan of Correction) was accepted. The Plan of Correction Stated: All residents will be served food that is properly cooked. For those residents effected: Residents will be placed on alert charting for: *abdominal pain *chills *diarrhea *fever *muscle pain *nausea *vomiting *signs of dehydration (such as decreased or dark-colored urine, dry mouth, and low energy) *bloody stool Physicians were notified that residents consumed undercooked chicken. Families were notified that residents consumed undercooked chicken. For all residents: 1. The facility intervened by inspecting all tray carts and stopped further serving of chicken. 2. The residents were immediately served an alternative meal. Systematic Changes: 1. The dietary manager has enacted a new policy for checking temperature to all meats prior to serving. 2. All Cooks will be in-serviced prior to cooking the next meal, on removing sample meat from the cooking pan and placing it on a plate prior to checking the temperature. 3. Each pan of meat will be temperature checked prior to being served. 4. In addition to temperature probing, the Cook will also do a visual check the meat is completely cooked. *A visual check indicates: i. Making a small incision in the thickest part of the meat and checking the color, so you can see the color of the meat all the way through. ii. Chicken breast is done when the juices that escape are clear. iii. Chicken meat is white when it is fully cooked. iv. Pink hues in chicken will result in the chicken being cooked longer. 5. CNAs will be re-educated on reporting undercooked foods immediately, prior to serving the next meal. Ongoing Quality Assurance and Process Improvement (QAPI): 1. Dietary manager will inspect and observe meat cooking, checking temperatures and serving practices, no less than three times week for three months or until compliance is sustained. 2. Dietary manager will be required to bring temperature logs to NHA (nursing home administrator) and/or DNS one time a week for review. 3. Any issues noted brought to QAPI for review, for at least 3 months after the last issue was noted. 4. NHA and/or DNS will pull random test trays to monitor to ensure meat is cooked at least once per month for at least three months after the last issue was noted. -At 5:00 PM Staff 2 stated all staff in-services would be initiated at this time, including dietary and nursing staff. -At 5:00 PM Staff 6 stated all staff coming on shift in the coming days who had not worked since the IJ was called, would be in-serviced before the start of their shift. On 2/12/18 at 5:14 PM the facility provided the following document: Method for temping bone-in chicken products: 1. Insert probe into thickest part of the meat not touching the bone. 2. Checking multiple pieces of all sizes from several different locations in the pan, on a plate when it comes out of the oven and repeat process again using plate prior to service from the steam table. Method for temping bone out chicken products: 1. Insert the probe all the way through the piece of chicken the long way (similar to skewering). 2. Check multiple pieces of all sizes from several different locations in the pan on a plate when it comes out of the oven and repeat the process prior to service from the steam table using the same method and on a plate. On 2/12/18 at 5:15 PM the IJ was abated. *The facility provided an acceptable plan of correction. *The facility was able to show evidence of in-services being provided to all staff including direct care staff related to reporting undercooked meat products immediately. On 2/13/18 at 1:45 PM Staff 11 (Owner) stated the facility management came in before night shift and day shift between 2/12/18 through 2/13/18 to in-service all employees during these shifts, as per their plan of correction. Staff 11 stated what happened the day before should not have happened.

Based on the facility's Immediate Jeopardy in the area of resident safety which resulted in Substandard Quality of Care and citation in the area of Quality of Care, it was determined the facility was not administered in a safe, effective and efficient manner. This placed all residents at risk for not receiving the necessary care and services to attain or maintain their highest practicable physical, mental and psychosocial well-being. Findings include: The facility's administration failed to: 1. Provide adequate care and services for residents' safety while smoking to prevent accidents. Refer to F323. 2. Provide accurate assessments for residents related to adequate supervision for smoking. Refer to F272. 3. The facility failed to timely provide and implement acceptable plans of correction for Immediate Jeopardy (IJ) related to residents smoking safely on the following dates: - On 11/18/16 at 3:52 pm Staff 1 (Administrator) and Staff 7 (DNS) were informed of Immediate Jeopardy related to the failure to ensure Resident 10 received adequate safety and supervision while smoking. - On 11/18/16 at 4:04 pm the facility was asked to provide a Plan of Correction (POC) for the IJ. - On 11/18/16 at 5:50 pm the facility submitted a POC which was not accepted and corrections were requested. - On 11/18/16 at 6:27 pm the facility submitted a revised POC to ensure Resident 10 was supervised while smoking. - On 11/18/16 at 6:33 pm the POC was accepted and the IJ was abated. - On 11/21/16 at 11:36 am Staff 1 and Staff 7 were informed the IJ was continued related to the failure to ensure Resident 13 received adequate safety and supervision while smoking. - On 11/21/16 at 4:15 pm the facility submitted a POC to ensure Resident 13 was safe while smoking. - On 11/21/16 at 4:15 pm the POC was accepted and the continuation of the IJ was abated. - On 11/22/16 at 2:30 am Resident 13 was again observed smoking not supervised and in an unsafe manner. - On 11/22/16 at 11:06 am Staff 1 was informed of a continuation of the IJ for unsafe smoking by Resident 13 and a POC was requested. - On 11/22/16 at 1:20 pm the facility submitted a revised POC. - On 11/22/16 at 1:25 pm the revised POC was accepted and the IJ was abated. Refer to F323

1. Based on observation, interview and record review it was determined the facility failed to ensure 2 of 7 sampled residents (#s 10 and 13) reviewed for accidents were adequately supervised while smoking. These failures of staff to implement adequate supervision resulted in an Immediate Jeopardy situation and was determined to be in Substandard Quality of Care. Findings include: The facility's Smoking Policy included the following: -Upon admission each resident who chooses to smoke will have a smoking safety assessment completed. If the resident is determined unsafe to smoke unsupervised, the facility will develop a supervised smoking schedule. Additional safety precautions will be implemented, such as smoking apron as deemed appropriate for each resident. -Each resident will have a smoking safety assessment completed quarterly and/or as a resident's condition changes. This assessment will determine safety device(s) that are deemed necessary (i.e. smoking apron, etc.) to enhance safety of residents / others. -Oregon Administrative Law does not allow any person to smoke within 10 feet of any entrance, exit, windows or walkways to the facility. The designated smoking area for resident and visitors will be outside on the patio. The staff designated smoking area is outside in the west side of the facility. At not time shall staff, visitors, or residents smoke but in the designated smoking areas. a. Resident 10 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. A review of the resident's clinical record revealed the following events took place: On 8/19/16 a CNA reported to the nurse the resident had a cigarette burn to her/his right inner thigh. The resident stated she/he fell asleep while smoking and the resident would not allow the nurse to assess the area and wanted to be left alone. On 8/23/16 the nurse and Resident Care Manager assessed the blisters to the resident's bilateral inner thighs the resident obtained from a cigarette burn. Both skin impairments appeared to be healing well. The left inner thigh had open blisters measuring approximately 2 x 2.3 cm without drainage. The skin around the perimeter was clean and dry and the areas were covered with a foam dressing. A facility Event Report was completed on 8/22/16 and noted: -The resident indicated she/he was outside of the facility at night per her/his preference and fell asleep. The resident dropped the cigarette on her/his lap which burned through her/his pajama pants to the legs. The resident had a history of [REDACTED]. -The resident had a [DIAGNOSES REDACTED]. The side effects of the medications included, insomnia, sedation, confusion, drowsiness and may have contributed to irregular sleep patterns. -The resident was independent in her/his power chair and in making decisions and was categorized in the facility as an independent smoker. Changing her/his status to dependent smoker at this time was not advisable as she/he complied with the facility smoking rules and often smoked off the property. The resident was also at risk for behavioral issues when certain controls were taken away. The resident was consulted on how to avoid future injuries from smoking. The resident refused to wear a smoking apron or a barrier device and would not state why. -Due to the resident's level of independence and choosing to smoke off the property it was difficult to put interventions into place which staff could verify compliance. On 8/28/16 (six days later) the facility completed a Smoking Risk Acuity Report and noted the following: -The resident was a chain smoker. -The resident did not have a problem dropping cigarettes on her/himself. -The resident had no problem understanding the smoking policies. -The resident was capable of following the safe smoking policy. -The resident's smoking did not result in danger to her/himself. -Staff were to initiate a plan of care. The 8/28/16 Smoking Assessment did not include the facility identified risks to the resident including insomnia and the potential for injury while smoking independently. The 8/30/16 Progress Note revealed the resident was given a key to a lock box in the smoking area and all of the resident's smoking materials were placed in the box. The resident read the generalized Rules for Smoking, Smoking Policy and Independent Smoking Rules and signed the documents. The careplan last reviewed and revised on 7/21/16 revealed there was no problem, goal or approach to the resident's unsafe smoking. On 9/1/16 (14 days after the incident) the facility completed a Managed Risk Agreement noting the resident fell asleep sometimes in her/his wheelchair while smoking and had sustained burns from dropping the cigarettes. The resident was to wear a smoking apron or barrier but refused and preferred to be an independent smoker. The resident was aware of the risks including burns or injuries, chose to remain independent in smoking choices, and would do her/his best to report any injuries. The resident signed the agreement on 9/22/16 (over a month after the incident). On 11/8/16 (over two months after burning her/himself) Resident 10's careplan was reviewed and revised noting the resident was an independent smoker, would abide by the facility policy for smoking and would only smoke in the designated smoking areas. An initial smoking assessment was to be completed, notify the resident and re-direct the resident when smoking in unauthorized areas, may smoke at designated times for the facility, and encourage the resident to limit smoking when she/he was not feeling well. On 11/15/16 at 9:59 am Resident 10 was observed to smoke independently in the facility smoking area. The resident indicated she/he was an independent smoker and kept her/his cigarettes in the outside lockers. The resident indicated she/he was able to smoke whenever she/he wanted but the supervised smokers had certain times they could smoke. On 11/18/16 at 2:34 pm Staff 1 (Administrator) indicated Resident 10 was an independent smoker and smoked in places outside the designated smoking areas. He acknowledged the resident had the potential to fall asleep in her/his wheelchair. The facility failed to compressively reassess the resident's smoking abilities to include the resident's risk factors including insomnia and burning her/himself while smoking. The facility assessed the resident as an independent smoker and allowed the resident to smoke independently on facility property knowing the resident had a history of [REDACTED]. On 11/18/16 at 3:52 pm after consultation with the State survey supervisors the survey team informed Staff 1 and Staff 7 (DNS) of the failure to ensure Resident 10 received adequate safety and supervision while smoking which constituted a situation of Immediate Jeopardy to Resident 10. On 11/18/16 at 4:04 pm the survey team requested a plan of correction to be developed and implemented by the facility to immediately protect Resident 10 from unsafe smoking. On 11/18/16 at 5:50 pm the plan of correction submitted by the facility was not accepted and modifications were requested. On 11/18/16 at 5:50 pm Staff 7 (DNS) stated they took everything out of Resident 10's storage box in her/his room and explained to the Resident 10 it was not safe and the resident did not argue. On 11/18/16 at 6:27 pm a plan of correction was submitted by the facility which ensured Resident 10 was supervised while smoking. The Plan of Correction stated: 1. The resident in question has been assessed for safe smoking within the facility and is now a supervised smoker. Resident's care plan has been reviewed and updated and a new smoking agreement policy has been signed 2. All resident's who smoke will have new complete smoking assessments completed to ensure all risks are taken into consideration. a. All incident reports for the last year b. All risk benefit forms for the last year c. A complete new smoking assessment form will be completed d. Any care plans needing updated will be updated 3. The RCM (Resident Care Manager), SS (Social Services) and staff will receive further training in smoking assessment documentation and follow through as well as oversight to ensure comprehensiveness of assessment. 4. The DNS and or designee will do monthly audits of smoking assessments to assure they are comprehensive. results of these audits will be reported quarterly to the QAPI (Quality Assurance Performance Improvement) committee. On 11/18/16 at 6:33 pm the facility completed a new smoking assessment, updated the careplan, completed a new managed risk agreement and removed any smoking items from Resident 10's room. The plan of correction was accepted by the team and the Immediate Jeopardy was abated. b. Resident 13 was admitted to the facility in 2011 with [DIAGNOSES REDACTED]. A review of the resident's clinical record revealed the following events took place: The 9/25/15 current Smoking Assessment (over a year old) revealed: -The resident was determined not to have the ability (manual dexterity, muscle strength and sensation) to hold and manage the ash of his/her cigarette, and refused a smoking apron. -The resident had a history of [REDACTED]. -The resident had cognitive factors/[DIAGNOSES REDACTED]. -The resident frequently forgot the smoking policies. -The resident was assessed to be a supervised smoker and required the storage of her/his lighter and cigarettes. On 10/3/16 the facility completed a Managed Risk Agreement for Resident 13. The risk included the resident smoked outside the facility and smoked cigarette butts in public. The recommendation was the resident was to smoke in the authorized areas of the facility as a supervised smoker. The risks to Resident 13 included burns to her/his skin and clothing. The resident chose to smoke outside and agreed not to pick up cigarette butts in public and to smoke 10 feet away from the facility building. The resident signed the agreement on 10/3/16. The 10/3/16 careplan revealed the following: The resident was at risk for pain related to a history of stroke, schizophrenia and tobacco use. The resident also picked up cigarettes off the ground of the property and smoked them. The resident was assessed to be a supervised smoker and required assistance with smoke breaks, and the nurse was to be notified of any injuries or accidents. Observation on 11/21/16 at 10:31 am revealed Resident 13 was smoking in the facility parking lot unsupervised. On 11/21/16 at 10:31 am Staff 1 (Administrator) indicated the resident was a supervised smoker who went to the local store to buy cigarettes. The facility failed to reassess the resident's smoking abilities quarterly and monitor the resident while smoking independently in the undesignated smoking areas. On 11/18/16 at 4:04 pm an Immediate Jeopardy was called due to Resident 10's unsafe smoking. A facility plan of correction was requested. On 11/18/16 at 6:27 pm the facility provided the plan of correction to include: All resident's who smoke will have new complete smoking assessments completed to ensure all risks are taken into consideration. On 11/22/16 at 11:26 am Staff 1 and Staff 7 were notified there was a continuation of the Immediate Jeopardy since the facility failed to execute their plan of correction to reassess all of the smokers. On 11/21/16 at 4:07 pm the plan of correction submitted by the facility was not accepted and modifications were requested. On 11/21/16 at 4:15 pm a plan of correction was submitted by the facility to ensure Resident 13 and other smokers were safe to smoke. The Plan of Correction stated: 1. All resident that smokes have been assessed for safe smoking within the facility as either supervised or independent smoker. Residents' care plan have been reviewed and updated and new smoking agreement policies have been signed as of 11/21/16 2. All residents who smoke will have new complete smoking assessments completed by 3pm on 11/21/16 to ensure all risks are taken into consideration. a. All incident reports for the last year b. All risk benefit forms for the last year c. A complete new smoking assessment form will be completed d. Any care plans needing updated will be updated 3. The RCM (Resident Care Manager), SS (Social Services) and staff will receive further training in smoking assessment documentation and follow through as well as oversight to ensure comprehensiveness of assessment. This have been completed on 11/21/16 4. The DNS and or designee will do monthly audits of smoking assessments to assure they are comprehensive. Results of these audits will be reported quarterly to the QAPI (Quality Assurance Performance Improvement) committee. On 11/21/16 Resident 13 was observed during the late morning and afternoon to have one on one supervision. The resident's assessment, managed risk and careplan were updated to reflect the resident's current smoking abilities. On 11/21/16 at 4:15 pm the plan of correction was accepted by the team and the continuation of the Immediate Jeopardy was abated. On 11/22/16 at 2:30 am Resident 13 was observed sitting at the end of the walkway on facility property unsupervised. The resident was holding a cigarette butt and asked the surveyor for a light. The surveyor declined and returned 10 minutes later and Resident 13 had the cigarette butt lit. Resident 13 then put the butt out on the ground and entered the facility. On 11/22/16 at 2:55 am Staff 23 (CNA) indicated she observed the resident to go outside. On 11/22/16 at 2:55 am Staff 24 (CNA) indicated she was not aware Resident 13 was outside. On 11/22/16 9:00 am Staff 1 stated the night shift was not informed of the updated assessments and careplans for the residents who smoked. An all-staff in service would be conducted that day. The facility failure to inform the night shift staff of the plan of correction for unsafe smokers resulted in a continuation of the Immediate Jeopardy for unsafe smokers. On 11/22/16 at 11:06 am staff were notified, and a plan of correction was requested. On 11/22/16 at 11:42 am the facility was asked to provide a communication plan to inservice staff of the changes to the careplans of all the smokers. On 11/22/16 at 1:20 pm Staff 1 submitted an updated careplan for Resident 13 which included the following: 1) Resident now has 1:1 staff supervision as of 12:00 pm on 11/22/16 to ensure resident safety. 2) Continue to encourage resident to comply with Supervised Smoking Policy. 3) Resident's careplan was to be updated to reflect current careplan changes. On 11/22/16 at 1:25 pm the survey team reviewed the updated careplan for Resident 13. Throughout the remainder of the survey Resident 13 was observed to have one on one supervision. The plan of correction was accepted. The continuation of the Immediate Jeopardy was abated. 2. Based on observation, interview and record review it was determined the facility failed to re-assess the resident's wheelchair safety after she was found asleep in the middle of the road for 1 of 4 sampled residents (# 10) reviewed for accidents. This placed the resident at risk for injuries. Findings include: Resident 10 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. The clinical record revealed the following: -On 7/8/16 the PT from the facility assessed Resident 10 to be modified independent in her/his wheelchair. The resident required the use of a transfer board and increased time to perform the majority of the task. No cues or supervision were needed. -The 7/21/16 careplan revealed Resident 10 was at increased risks for falls related to [DIAGNOSES REDACTED]. The approaches were to have the resident be mindful of her/his appliances (ostomy and catheter) during transfers, keep her/his pain managed and not to use the wheelchair if there were broken parts. -On 8/11/16 the Progress Note (PN) revealed a fireman reported to the facility there was resident in a motorized wheelchair asleep in the middle of the road. The fireman checked on the resident and was concerned Resident 10 was going to get hit by a car. Resident 10 indicated she/he was fine and asked him to leave. The facility failed to complete an assessment of Resident 10's health or unsafe behavior for falling asleep in the middle of the road. The resident's careplan was not updated to reflect the resident's incident and lacked the risks of wheelchair safety in the community. An 8/23/16 the PN revealed at approximately 6:40 pm a police officer reported to Witness 1 (Former facility DNS) a resident was on the corner of the highway and had overturned in (her/his) motorized wheelchair. The 8/23/16 PN note revealed Resident 10 explained she/he was on the curb and the blanket behind her/his head fell behind her/his back. When the resident tried to pick it up she/he began to slip out of the wheelchair. The resident grabbed onto a pole with her/his right hand and held on for awhile attempting to get help. The resident then lowered her/himself to the ground once she/he was unable to hold on. Resident 10 reported that the chair fell back and she/he complained of pain all over and muscle spasms in her/his left knee, calf and foot. The resident was transported to the hospital where she was identified to have a fractured left femur. On 8/23/16 the facility investigated the fall and noted Resident 10 was alert and responded appropriately to stimuli. The facility checked the box that the supportive devices (walker/wheelchair, not in reach, brakes not working, footrests as obstacle, cushion slipping etc.) and positioning of the resident was a factor in the fall. The resident reported that the positioning of the blanket and chair was the reason for slipping out of her/his chair. The current careplan did not address the resident's history of the 8/11/16 incident of falling asleep in the middle of the road or Resident 10's fall and fracture on 8/23/16 while out in the community. The facility failed to comprehensively reassess Resident 10's health and safety after the 8/11/16 incident, including updating the careplan and considering the risks and benefits of going into the community independently. A second incident occurred on 8/23/16 with potential safety concerns for the resident and the facility failed to develop interventions to ensure the resident was safe to go into the community. On 11/22/16 at 9:15 am Witness 1 indicated she was unable to recall if they assessed the resident or updated the careplan for wheelchair safety after the 8/11/16 incident. On 11/22/16 at 9:15 am Staff 1 (Administrator) indicated he was unable to locate an assessment for the 8/11/16 incident and updates to the careplan.

Based on interview and record review it was determined the facility failed to administer the correct medications to 2 of 7 residents (#s 3 and 43) reviewed for medications. The failure to administer the correct medications to the residents resulted in emergency treatment for [REDACTED]. Findings include: Resident 3 was admitted to the facility in 2000 and had [DIAGNOSES REDACTED]. Resident 3's physician orders [REDACTED]. Resident 3's September 2016 MAR indicated [REDACTED]. Resident 43 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. Resident 43's physician orders [REDACTED]. Resident 43's September 2016 MAR indicated [REDACTED]. Resident 3's nursing progress note dated 9/23/16 at 5:53 am revealed at 5:20 am Witness 6 could not awaken the resident. She noted flaccid face, constricted pupils and shallow respiration of 8 per minute. Witness 6 could not awaken Resident 3 with shout and tap or sternal rub method. Emergency services were notified and EMTs arrived at about 5:30 am. Resident 3 began to awaken and respond before she/he left the facility. The EMTs took Resident 3 to the hospital at 5:40 am. An ED Provider Note dated 9/23/16 revealed Resident 3 was found unresponsive with pinpoint pupils at the facility. EMS was called and Resident 3 received [MEDICATION NAME] (a medication used to reverse the affects of narcotic medications) and immediately woke up. Given (her/his) rapid response to [MEDICATION NAME], this seems to be most consistent with too much narcotics on board. A urine drug abuse screen dated 9/23/16 revealed Resident 3 was positive for opiates. Resident 3's nursing progress note dated 9/23/16 at 9:09 am revealed the hospital called and asked if Resident 3 had any narcotics in her/his room because her/his MAR indicated [REDACTED]. The charge nurse reported to the hospital she did not have knowledge of any narcotics in Resident 3's room. A 9/23/16 facility investigation revealed on 9/22/16 for 8:00 pm medications, Witness 6 (Former LPN) administered the wrong medications to Resident 3 and Resident 43. The following occurred: -Witness 6 administered the following medication to Resident 3 in error: Senna (stool softener), [MEDICATION NAME] 300 mg, [MEDICATION NAME] and [MEDICATION NAME]. -Witness 6 administered the following medication to Resident 43 in error: [MEDICATION NAME] 600 mg, potassium (supplement) and [MEDICATION NAME] (muscle relaxer). -Resident 43 questioned Witness 6 about the medications 30 minutes after they were administered because the wrong name was on the cup. -Resident 3 was found unresponsive on the morning of 9/23/16, medics were called and she/he went to the hospital. -Resident 3 received [MEDICATION NAME] (a medication to reverse the affects of narcotic medications) and her/his level of consciousness improved. -Resident 3 had narcotics in her/his system and the resident's MAR indicated [REDACTED]. -Witness 6 realized on the way home she may have made a medication error by switching Resident 3 and Resident 43's medications and did not communicate the information with the facility. On 11/18/16 at 12:07 pm Witness 6 confirmed she made the medication error which involved Resident 3 and Resident 43 on 9/22/16 for the 8:00 pm medication pass. She stated at the time she administered the medications to Resident 3 and Resident 43 she thought she administered the medications correctly. Witness 6 stated she was made aware of the potential medication error by Resident 43 showing her the medication cup with Resident 3's name on it. She stated she realized after she left the facility she may have mixed the medication cups up and gave Resident 3 and Resident 43 each other's medications. Witness 6 stated she should have poured out the medications and started over when she returned to her cart. Witness 6 stated she did not notify the facility of the potential medication error until later in the day because Resident 3 was already in the hospital. On 11/23/16 at 8:58 am Staff 1 confirmed Witness 6 did not appropriately administer medications to Resident 3 and Resident 43. The failure of Witness 6 to correctly administer medications resulted emergency treatment for [REDACTED].

Based on interview and record review it was determined the facility failed to ensure Witness 6 (LPN/former staff) followed professional standards for medication administration. The failure to follow professional standards for medication administration resulted in emergency treatment for [REDACTED]. Findings include: According to the Oregon State Board of Nursing Division 45: Standards of Practice for the Licensed Practical Nurse and Registered Nurse rule [PHONE NUMBER] Scope of Practice Standards for Licensed Practical Nurses (2)(d)(A) Implementing treatments and therapy, appropriate to the context of care, including, but not limited to, medication administration . Conduct Derogatory to the Standards of Nursing Defined 851-045-0070 (1)(a)(b)(3)(h) Failing to dispense or administer medications . in a manner consistent with state and federal law . Failing to communicate information regarding the client's status to members of the health care team (physician, Nurse practitioner, nursing supervisor, nurse co-worker) in an ongoing and timely manner . Failing to communicate information regarding the client's status to other individuals who need to know; for example, family, and facility administrator . Resident 3 was admitted to the facility in 2000 and had [DIAGNOSES REDACTED]. Resident 3's physician orders [REDACTED]. Resident 3's September 2016 MAR indicated [REDACTED]. Resident 43 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. Resident 43's physician orders [REDACTED]. Resident 43's September 2016 MAR indicated [REDACTED]. A 9/23/16 facility investigation revealed on 9/22/16 for 8:00 pm medications, Witness 6 administered the wrong medications to Resident 3 and Resident 43. The following occurred: -Witness 6 (Former LPN) administered the following medication to Resident 3 in error: Senna (stool softener), [MEDICATION NAME] 300 mg, [MEDICATION NAME] and [MEDICATION NAME]. -Witness 6 administered the following medication to Resident 43 in error: [MEDICATION NAME] 600 mg, potassium and [MEDICATION NAME]. -Resident 43 questioned Witness 6 about the medications 30 minutes after they were administered because the wrong name was on the cup. -Resident 3 was found unresponsive on the morning of 9/23/16 and medics were called. -Witness 6 realized after she left the facility she may have made a medication error by switching Resident 3 and Resident 43's medications and did not communicate with the facility. -Witness 6 stated she should not have pre-popped the medications and should have started over fresh when she returned to her cart after an interruption in her medication pass. -Resident 3 received [MEDICATION NAME] (a medication to reverse the affects of narcotic medications) and her/his level of consciousness improved. -Resident 3 had narcotics in her/his system and the resident's MAR indicated [REDACTED]. On 11/18/16 at 12:07 pm Witness 6 confirmed she made the medication error which involved Resident 3 and Resident 43 on 9/22/16 for the 8:00 pm medication pass. She stated at the time she administered the medications to Resident 3 and Resident 43 she thought she administered the medications correctly. Witness 6 stated she was made aware of the potential medication error by Resident 43 showing her the medication cup with Resident 3's name on it. She stated she realized after she left the facility she may have mixed the medication cups up and gave Resident 3 and Resident 43 each other's medications. Witness 6 stated she should have poured out the medications and started over when she returned to her cart. Witness 6 stated she did not notify the facility of the potential medication error until the next day because Resident 3 was already in the hospital. On 11/23/16 at 8:58 am Staff 1 (Administrator) confirmed Witness 6 did not follow professional standards related to medication administration. The failure to follow professional standards for medication administration resulted emergency treatment for [REDACTED]. Refer to F333

1. Based on observation, interview, and record review it was determined the facility failed to comprehensively assess, care plan, and provided adequate care and services for 1 of 3 sampled residents (#61) who had an indwelling urinary catheter. As a result, the resident experienced a potential life threatening condition and required emergency care. Findings include: Resident 61 was admitted in 5/2013 with [DIAGNOSES REDACTED]. AD is an involuntary reaction of the nervous system seen in patients with spinal cord injury who have loss of bowel and bladder function, which results in impaction of the bowel and/or distention of the bladder. AD is a potential life threatening condition requiring immediate medical attention. The resident's admission care plan dated 5/10/13 indicated the resident had a Foley catheter. There was no further information as to where the catheter was located, what type and size of catheter, drainage system used, or any information related to AD. There was no information about emergent procedures for AD or should the catheter become displaced. The admission MDS dated [DATE] indicated the resident had an indwelling catheter. The corresponding CAAs further identified the catheter to be a suprapubic catheter (urinary catheter surgically placed into the bladder through the abdomen.) The resident was dependent on staff to provide catheter care. The resident was monitored by a urologist. A decision to proceed to a care plan to minimize the risk for UTI was indicated. The assessment was not comprehensive and did not include any information about the type, size, drain system, or the resident's history of AD and the potential impact to the resident. A Physician Assistant-Certified report dated 5/23/13 at 10:40 am indicated the resident had been examined. The resident's BP was identified to be 102/62. There was no indication any concerns related to the resident's urinary status or suprapubic catheter had been identified. The resident's electronic record identified on 5/23/13 at 12:48 pm, the resident's urine output was recorded as "large". The next entry on 5/24/13 at 6:01 am identified urine output as "2500 cc." There was no documented evidence the resident's urine output had been measured or that the catheter bag had been emptied between 12:48 pm on 5/23/13 and 6:01 am on 5/24/13, more than 17 hours between the data entries. According to progress notes dated 5/24/13 at 8:10 am, the resident had presented with signs and symptoms of possible AD, described as a sudden onset throbbing severely painful headache, goose bumps, nausea and emesis x 1 and blood pressure of 141/68. The resident's catheter bag was full and when emptied contained 2050 ccs. The resident was sent to the hospital for further evaluation. The hospital report (dated 5/23/13) identified a new [DIAGNOSES REDACTED]. On 6/14/13 at 12:05 pm, the resident was observed sitting up in a wheel chair. The catheter tubing lead to the drain bag that was discretely placed inside a privacy cover near the foot rest. The resident was asked about catheter care and she/he said on one occasion after admission she/he had to go to the hospital for AD because staff had not changed the smaller leg bag to the larger drain bag after placing her/him in bed for the night. There had been a delay in emptying the catheter bag. In a telephone interview on 6/18/13 at 9:00 am, Staff 17, RN said on 5/23/13 at approximately 10:00 pm, Staff 18, CNA reported the resident was experiencing a sudden onset of a severe headache, was in a lot of pain and had vomited. 911 was notified by an assisting nurse. Staff 17 retrieved a pain pill and administered it to the resident. She noticed the resident had a full urinary leg bag which held about 1000 cc of urine. The bag was emptied, it filled up again and was emptied a second time. The amount emptied was over 2000 ccs. After emptying the urine from the leg bag, the resident's symptoms subsided. The leg bag was changed over to the larger drain bag as the paramedics arrived. The resident was transferred to the hospital for evaluation. Staff 17 further stated CNAs were responsible to empty the catheter bags and to change leg bags to drain bags at night. "(Resident 61) was experiencing autonomic dysreflexia because (her/his) bladder was too full..." On 6/18/13 at 1:52 pm, Staff 19, Nursing Aide, said on 5/23/13, he was assigned to provide care for the resident on the evening shift from 2:00 pm to 10:00 pm. It was his first week of working with the residents and another CNA was his hall partner. Staff 19 stated he did not see the resident's leg bag under her/his pants and did not know she/he had a catheter. Staff 19 confirmed the resident's catheter bag had not been emptied during the evening shift. Staff 19 said he got information on how to care for the residents from their care plan on the computer or from the "book". Staff 19 could not recall if there was any information on the care plan about the resident's catheter or about changing from a leg bag to a drain bag and stated "If there was, I didn't see it." The facility investigation report dated 5/25/13 identified on 5/23/13 at approximately 10:30 pm, the resident's leg bag had not been changed to a straight drain bag and the nurse drained 2500 cc of urine prior to sending the resident to the hospital. The staff member involved did not know how to change out the bags. The conclusion: abuse was ruled out as there was no intent to harm. "Facility feels that the event was a training opportunity, as (Staff 19) is a new aide." Attached to the incident investigation was the 5/10/13 care plan. There was no information to direct staff to change catheter bags or interventions to prevent the potential for AD. The lack of a comprehensive assessment and comprehensive care plan related to the resident's catheter and potential for AD was discussed on 6/19/13 at 11:16 am with Staff 5, RNCM. Staff 5 confirmed they had not been done at the time of the incident on 5/23/13. 2. Based on observation interview and record review it was determined the facility failed to provide pain medication for 1 of 1 sampled resident (#87) who experienced pain. Failure to provide pain medication placed the resident at risk for unrelieved pain. Findings include: Resident 87 was admitted to the facility in 2/2013 with [DIAGNOSES REDACTED]. Resident 87 had a June 2013 physician order [REDACTED]. The MAR for June 2013 indicated Resident 87 had received PRN pain medication regularly. On 6/17/13 at 6:43 am, Resident 87 stated that she/he was in need of pain medication and had been up all night as a result of the facility running out of her/his pain medication. Resident 87 stated the nurse told her/him she could not find her/his pain medication. Resident 87 stated she/he could not sleep due to muscle spasms and pain. On 6/17/13 on 6:47 am, Staff 9 RN, stated the resident did not have any pain pills left and she called the pharmacy to find out where the medication was. Staff 9 said the pharmacy thought Resident 87 was discharged and had not sent a refill of the [MEDICATION NAME] when requested on 6/11/13. On 6/17/13 at 7:12 am, Resident 87 stated that she/he went to the hospital on [DATE] for throat surgery and came back at 5 pm, the same day. She/he had not been discharged from the facility. On 6/17/13 at 9:20 am, Staff 2, DNS, said the E-box (emergency medication) was used for residents when medication was unavailable. Staff 2 stated she had called the pharmacy and was told a fax had been sent regarding not refilling the resident's [MEDICATION NAME] prescription. Staff 2 said staff did not locate the fax from the pharmacy regarding filling the medication order. She acknowledged the facility had a current physician order [REDACTED]. 3. Based on interview and record review it was determined the facility failed to follow MD orders related to notification and insulin administration for 1 of 4 sampled residents (#23) who were administered insulin. This placed the residents at risk for unstable blood sugar levels. Findings include: Resident 23 was admitted in 1/2012 with [DIAGNOSES REDACTED]. Physicians orders for 03/2013 through 05/2013, directed sliding scale insulin to be administered based on the CBG. The CBG was ordered to be done four times daily, before meals and at bedtime. For a 201-250 CBG, 4 units of [MEDICATION NAME]were to be given; and for a 301-350 CBG, 8 units of [MEDICATION NAME]were to be given. Also, the physician be notified if the CBG was <70 or >300. The resident's March 2013 Diabetic flowsheet indicated on 3/12 at 6:00 am, the recorded CBG was 209 and 2 units of insulin were administered when 4 units of insulin should have been administered. On 3/27 at 6:00 am the recorded CBG was 347 and 10 units of insulin were administered when 8 units of insulin should have been administered. In addition, there was no documented evidence on 3/22 at 8:00 pm a CBG test had been done. On 15 occasions in March 2013 and April 2013 when the resident's CBG was recorded to be over 300. There is no evidence in the medical record the physician was notified. The resident's May 2013 Diabetic flowsheet indicated on 5/17 at 11:00 am, the recorded CBG was 206 and 6 units of insulin were administered. Also on 5/30 at 11:00 am the recorded CBG was 205 and 2 units of insulin were administered. For both , administrations according to physician's orders [REDACTED]. . On 6/18/13 at 3:12 pm, Staff 5, RNCM, confirmed the incorrect insulin dosages had been administered on 5/17/13 and 5/30/13. The lack of physician notification, incorrect insulin dosage and lack of CBG testing were discussed with Staff 2, DNS on 6/20/13 at 11:50 am. Staff 2 confirmed the physician orders [REDACTED].

Based on observation, interview and record review it was determined the facility failed to provide the appropriate care and services for 1 of 3 sampled residents (#1) who experienced falls. Resident 1 sustained an acute impacted fracture of the distal sacrum/coccyx. Findings include: Resident 1 was admitted to the facility in mid May, 2011 with [DIAGNOSES REDACTED]. The resident was assessed at high risk for falls related to impaired balance during transfers, dementia, impulsivity and poor safety awareness. The resident experienced several falls during the first quarter since admission to the facility. A tab alarm was implemented while the resident was in bed or the wheelchair. In latter August, 2011 the resident asked for assistance with transfers routinely and the alarms were discontinued. Record review revealed the resident experienced a fall on 11/12/11 at 3:15 pm. The IR (Incident Report) revealed the resident became startled when a staff member knocked on the door before entering the room. The IR revealed the resident sustained [REDACTED]. No neurological deficits were found. Following the fall the care plan was updated to include the use of tab alarms while the resident was in bed or the wheelchair. Record review revealed the resident experienced an additional fall on 11/15/11 at 11:30 am. The IR revealed the resident reported she/he attempted to transfer from the bed to the wheelchair. The IR did not reveal if the alarm was sounding. The resident complained of back pain and an x-ray report revealed the resident sustained [REDACTED]. The IR indicated the resident had experienced increased agitation since the fall of 11/12/11. The care plan was updated on 11/15/11 following the fall to include a tab alarm on the resident's wheelchair and a pressure pad alarm on the bed. A mat was to be placed on the floor at the side of the bed. The resident had reportedly removed the tab alarm on the wheelchair and on 11/16/11 the care plan was updated to include a pressure pad alarm on the resident's wheelchair. physician progress notes [REDACTED]. The level may have contributed to the resident's increased agitation and gait instability. During observations on 12/19/11 at 8:50 am, Resident 1 was observed sitting on the edge of her/his bed. The resident was alert with some confusion. The pressure pad alarm was not in place on the bed. It was found to be on the floor underneath the bed. A mat was not on the floor at the side of the bed place as care planned. Staff 1, DNS, was notified and witnessed with the Surveyor the alarm and mat were not in place as care planned. In interview on 12/19/11, Staff 1 stated she spoke with Staff 3, CNA, immediately following the discovery of the alarm on the floor. Staff 1 stated (Staff 3) reported the resident repeatedly removed her/his alarms. Staff 1 was not aware if the information had been reported. In interview on 12/19/11 at 10:00 am, Staff 3 stated Staff 1 asked her why the resident's alarm was not on and the fall mat was not in place. Staff 3 stated she was not assigned to the resident but knew from the past the resident had removed her/his alarms. In interview on 12/19/11 at 10:30 am, Staff 4, CNA, stated he was assigned to care for the resident on 12/11/11. He reported he checked on the resident at approximately 6:20 am. "(She/he) was sleeping at the time." Staff 4 was informed the pressure alarm was found on the floor and a mat was not on the floor at the bedside. He responded, "I didn't check to see if the alarm or mat were in place." In interview on 12/19/11 at 11:00 am, Staff 5, Activity Director, stated on 11/15/11 she went to the resident's room to inquire if Resident 1 was going to the social dining room for lunch. She found the resident on the floor. Staff 5 stated no alarms were sounding and the resident was on the bare floor and not on a mat. "(She/he) was on the floor close to the bed. I called for help." In interview on 12/19/11 at 11:30 am, Staff 6, RN Charge Nurse, stated the resident had a history of [REDACTED]. "The resident is very impulsive and (she/he) thinks (she/he) can walk alone." Staff 6 stated a few days before the fall of 11/15/11 the resident had increased agitation and it may have been related to the elevated Dilantin levels. Staff 6 reported when the fall occurred on 11/15/11 no alarms were sounding. She reported she assessed the resident for injuries. "(She/he) complained of back pain and we got an x-ray." In interview on 12/19/11 at 12:30 pm, Staff 2, RNCM stated the resident would not allow the tab alarms. "(She/he) was doing well for awhile so we discontinued them." Staff 2 reported following the fall on 11/12/11 the tab alarms were re-implemented and were to be on the wheelchair and the resident's bed. Staff 2 confirmed no alarms were sounding when the fall occurred on 11/15/11. Staff 2 was aware of the resident's history of removing the tab alarms. Staff 2 confirmed the resident had increased agitation two days prior to the fall on 11/15/11 and therefore may have required additional supervision. In interview on 12/19/11 at 2:15 pm, Staff 8, CNA, stated on 11/15/11 she placed the tab alarm on the resident while she/he was in bed. Staff 8 was the resident's assigned caregiver on that date during the day shift. Staff 8 reported she checked on the resident often as she/he frequently removed the tab alarms. "I told whoever was the Charge Nurse that (she/he) would not leave the tab alarms on. I did not get a response from any of them." In interview on 12/19/11 at 3:00 pm, Staff 1 confirmed staff were aware the resident repeatedly removed the tab alarms. The care plan was not revised until the resident fell again on 11/15/11 and sustained a fracture.