Every finding on record at Valley West Health Care Center

Based on interview and record review it was determined the facility failed to employ a qualified social worker for 1 of 1 facility reviewed for social worker. This placed residents at risk for lack of care coordination and unmet social worker care needs. Findings include:The 12/24/25 Facility Assessment revealed the facility was licensed for 121 beds. On 8/21/26 at 10:42 AM, Staff 29 (Social Service Director) stated he was recently hired into the Social Service Director role, had no formal social work training and did not have a bachelor's degree. On 8/21/26 at 3:00 PM, Staff 1 (Executive Director) verified the facility was licensed for 121 beds.

Based on interview and record review it was determined the facility failed to implement its policy and procedure related to abuse investigations for 1 of 2 sampled residents (#2) reviewed for abuse. This placed residents at risk for reoccurring abuse. Findings include: The facility's 4/1/26 Abuse Protection of Residents Policy indicated the facility must implement written policies that prohibit and prevent abuse and to investigate any such allegations. Resident 2 admitted to the facility in 10/2025 with diagnoses including left hip dislocation and cognitive communication deficit. On 11/10/25, a public complaint was received which indicated Witness 2 (Complainant) reported Resident 2 woke up in the hospital, saw bruising to her/his upper arms, and believed she/he was beaten by someone at the facility although she/he had no recollection of the incident. The facility was informed of the allegation. Resident 2's 11/4/25 Provider Progress Note indicated Resident 2 was to be transferred back to the hospital due to altered mental status and hip dislocation. Review of Resident 2's clinical record found no documented evidence an abuse allegation was investigated. On 8/21/26 at 2:03 PM, Staff 6 (Admissions Director) stated the hospital called the facility and stated Resident 2 woke up in the hospital and indicated she/he got beat up at the facility. Staff 6 stated he informed the (previous) Executive Director, Director of Nursing and Unit Manager of the allegation. Staff 6 was not aware if an abuse allegation was completed. On 8/21/26 at 3:00 PM, Staff 1 (Executive Director) stated she was unable to locate an abuse investigation for Resident 2. Staff 1 stated any allegation of abuse should have been investigated by the facility.

Based on interview and record review it was determined the facility failed to timely report an allegation of abuse to the State Agency for 1 of 2 sampled residents (#2) reviewed for abuse. This placed residents at risk for unreported abuse. Findings include: Resident 2 admitted to the facility in 10/2025 with diagnoses including left hip dislocation and cognitive communication deficit. On 11/10/25, a public complaint was received which indicated Witness 2 (Complainant) reported Resident 2 woke up in the hospital, saw bruising to her/his upper arms, and believed she/he was beaten by someone at the facility although she/he had no recollection of the incident. The facility was informed of the allegation. Review of facility records revealed no evidence Resident 2's allegation of abuse was reported to the State Agency. On 8/21/26 at 2:03 PM, Staff 6 (Admissions Director) stated the hospital called the facility and stated Resident 2 woke up in the hospital and stated she/he got beat up at the facility. Staff 6 stated he informed the (previous) Executive Director, Director of Nursing and Unit Manager of the allegation. On 8/21/26 at 3:00 PM, Staff 1 (Executive Director) verified the allegation of abuse was not reported to the State Agency as required.

Based on observation and interview it was determined the facility failed to provide ADL assistance for 2 of 5 sampled residents (#s 3 and 9) reviewed for ADL assistance. This placed residents at risk for not maintaining good hygiene and/or grooming. Findings include: 1. Resident 3 admitted to the facility in 2024 with diagnoses including anxiety. On 8/21/26 at 8:49 AM Resident 3 was observed lying in bed. Resident 3's 12/17/24 ADL Care Plan indicated Resident 3 required two-person assistance with a mechanical lift to get out of bed. On 8/21/26 at 8:49 AM Resident 3 stated there were no clean lift slings in her/his size so had to remain in bed this morning although she/he wanted to get up. On 8/21/26 at 9:03 AM Staff 30 (CNA) stated Resident 3 was still in bed because there was no sling available to get her/him up. On 8/21/26 at 9:27 AM Staff 3 (LPN/Resident Care Manager) verified Resident 3 was still in bed because the mechanical lift sling in Resident 3's size was not available 2. Resident 9 admitted the facility in 10/2023 with diagnoses including chronic pain syndrome. Resident 9's 2/5/24 ADL Care Plan indicated the resident required two-person assistance with bathing. Resident 9's Shower Schedule indicated she/he was to receive showers on Monday and Friday evenings. Resident 9's 2026 Point of Care shower documentation indicated the resident did not receive showers on 7/22/26, 7/29/26, 7/31/26, 8/3/26 and 8/12/26. Additionally, there was no documentation to indicate showers were offered between 8/13/26 through 8/18/26. On 8/18/26 at 12:26 PM, Resident 9 stated she/he missed her/his showers on Friday (8/13/26) and had frequently missed her/his scheduled showers. On 8/21/26 at 9:11 AM, Staff 44 (RN) stated Resident 9 was to be offered showers every Monday and Friday evening. On 8/21/26 at 9:19 AM, Staff 3 (LPN/Resident Care Manager) stated no showers had been documented for Resident 9 on 7/22/26, 7/29/26, 7/31/26, 8/3/26 and 8/12/26 and 8/13/26 through 8/18/26.

Based on interview and record review it was determined the facility failed to assess, monitor, and treat a resident's skin condition for 1 of 3 sampled residents (#4) reviewed for skin. This placed residents at risk for worsening skin conditions. Findings include:The facility's 6/4/26 Nursing admission Collection Tool indicated Resident 4 had a red, yeasty rash under her/his right breast and pannus. Resident 4's 6/2026 TAR found no treatment instructions for the resident's right breast and pannus rash. Review of Resident 4's clinical record found no documented evidence an assessment nor treatment was implemented for the resident's rash between 6/4/26 through 6/17/26. On 6/23/26 Resident 4 readmitted to the facility from the hospital with skin care orders for the rash. On 8/20/26 at 2:04 PM, Staff 5 (admission LPN) stated when a resident admits to the facility, she will visually look at the skin, enter any concerns into the Nursing admission Collection Tool and if she has time, open up a wound documentation assessment and initiate the standing house skin orders. Staff 5 stated the next day the Resident Care Manager would review the skin assessment and initiate skin orders if needed. Staff 5 acknowledged Resident 4 was assessed to have a red, yeasty rash under her/his right breast and pannus and did not initiate treatment orders.

Based on interview and record review it was determined the facility failed to protect the resident's right to be free from physical abuse by staff for 1 of 1 sampled resident (# 101) reviewed for abuse and neglect. This placed residents at risk for abuse. Findings include: Resident 101 was admitted to the facility in 2022, with diagnoses including a below the knee amputation, mood disturbance, and anxiety. An Incident Report dated 5/26/25 indicated there was a physical altercation involving Staff 2 (CNA) against Resident 101. Resident 101 yelled profanities at and flailed her/his arms at Staff 2 during personal cares. Staff 2 grabbed the resident's wrists to calm her/him down then hit the residents left wrist area three times. Staff 2 ran out of the room and self-reported striking the resident to the nurse. Staff 2 was suspended pending an investigation, the Executive Director, the Police, and the State Agency were notified, and an investigation was started. A 5/26/25 Progress Note indicated Staff 2 came out of the resident's room crying and stated she had punched the resident on the left wrist because the resident was being verbally abusive to her. Staff 2 wrote a statement and was sent home. An initial skin assessment yielded nothing, but five minutes later a small bruise was noted to the resident's left wrist and the resident complained of pain with movement of the area. The facility's 5/26/25 Investigation Report concluded Staff 2 hit Resident 101 with her fist on the resident's left wrist after attempting to calm the resident by holding her/his wrists down. Staff 2 acknowledged the abuse, and the potential impact of her actions on the resident's well-being. Staff 2 was terminated from employment with the facility. On 6/25/25 at 11:45 AM, Resident 101 revealed she/he remembered the incident. Resident 101 stated while Staff 2 was providing personal care, she flipped out, hit her/him three times on the wrist, then took off running. Resident 101 stated Staff 2 had never taken care of her/him previously and she/he did not want her taking care of her/him again. On 6/25/25 at 2:40 PM, Staff 2 (CNA) stated on 5/26/25 she provided personal care for Resident 101. Staff 2 stated she was trying to hurry because the resident was agitated. She attempted to calm the resident but she/he was getting increasingly aggressive. Staff 2 stated at one point she used her arms to hold the resident's wrists down to help calm her/him, which did not work, and she hit the resident's forearm, wrist area three times. Staff 2 stated she felt the resident was going to hit her. Staff 2 also stated the resident did not actually take a swing at her, but she had been scared and understood she had over-reacted. On 6/25/25 at 3:05 PM, Staff 1 (Administrator) acknowledged they had determined there was physical abuse by Staff 2 against Resident 101. On 6/2/25, the Past Noncompliance was corrected when the facility completed a root cause analysis of the incident and determined abuse was substantiated. The Plan of Correction included: -An Ad Hoc QAPI meeting was held on 5/30/25 to review the incident. -Facility employees were re-educated regarding Abuse and Burnout. -A new plan for abuse training was to be held monthly at All-Staff meetings. -All facility residents were either interviewed or had a new skin evaluation completed. -Regular monitoring observations of CNA staff in various areas of the facility such as resident rooms, shower rooms, hallways, dining rooms, and during activities were conducted. -Audits by DON or Designee of nurses' notes and reviews of Risk Management reports for any signs of abuse or neglect for three months. Any evidence found, if not already reported, would be brought to the Executive Director and the Abuse Policy would be followed.

Based on interview and record review it was determined the facility failed to staff a registered nurse (RN) for 8 consecutive hours per day 7 days per week for 4 out of 34 days reviewed for staffing. This placed residents at risk for unmet assessment needs. Findings include: A review of Direct Care Staff Daily Report revealed there were no RNs scheduled on 7/6/24, 7/7/24, 7/20/24, 7/21/24, or 8/3/24. On 5/22/25 at 12:33 PM Staff 1 (Administrator) acknowledged there were no RNs scheduled on on the above dates. The deficient practice was identified as Past Noncompliance based on the following: In 10/2024, the deficient practice was identified by the facility and was corrected when the facility completed a staffing root cause analysis and determined the facility needed to hire an additional RN. The plan of correction included hiring an agency RN on 10/21/24 to ensure seven day a week RN coverage.

Based on observation, interview and record review it was determined the facility failed to follow CDC (Centers for Disease Control and Prevention) Infection Control Guidelines related to Enhanced Barrier Precautions for 13 of 13 sampled resident rooms (#s 3, 7, 8, 12, 13, 14, 17, 21, 22, 23, 24, 29, and 33) reviewed for infection control. This placed residents at risk for exposure to infections and cross contamination. Findings include: The CDC's 4/2/24 implementation of Nursing Home PPE guidelines for prevention of spread of Multidrug-Resistant Organisms (MDROs) included a trash bin was to be placed inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room. On 5/19/25 at 10:12 AM room [ROOM NUMBER] was observed to have enhanced barrier precaution signage next to the door. A plastic storage bin with new PPE in the drawers and a garbage bin with used PPE inside was observed outside of the resident's room. On 5/19/25 at 1:20 PM Staff 10 (CNA) performed hand hygiene, donned PPE, entered room [ROOM NUMBER], exited the room at 1:28 PM and doffed PPE in the hallway and placed the soiled PPE in the garbage bin outside of the resident's room. On 5/19/25 at 1:49 PM Staff 10 stated after direct care was provided for the resident, used PPE was placed in the garbage located outside of the resident's room. On 5/20/25 from 1:52 PM to 2:50 PM rooms 7, 8, 12, 13, 14,17, 21, 22, 23, 24, 29, and 33 were observed to have enhanced barrier precaution signage next to the room door. Each room had a plastic storage bin with new PPE in the drawers and a garbage bin that contained used PPE outside of the resident's room. On 5/21/25 at 9:29 AM Staff 7 (CNA) performed hand hygiene, donned PPE, entered room [ROOM NUMBER], then exited the room at 9:31 AM, doffed PPE in the hallway and placed the soiled PPE in the garbage bin outside of the resident's room. On 5/21/25 at 10:00 AM Staff 7 stated staff were provided education from the facility related to enhanced barrier precautions and were directed to discard used PPE in the garbage bin located outside of the resident's room. On 5/21/25 at 3:57 PM Staff 3 (RN Infection Preventionist) stated management discussed enhanced barrier precautions and placement for the garbage bins and she was advised to keep the garbage bins outside of the resident's room in the hallway. Staff 3 acknowledged the facility was not following the CDC guidelines related to enhanced barrier precautions.

Based on interview and record review it was determined the facility failed to ensure residents were offered and received pneumococcal vaccines for 4 of 7 sampled residents (#s 31, 52, 267, and 268) reviewed for vaccines. This places residents at risk for pneumonia. Findings include: A review of the revised 4/8/25 facility Pneumococcal Vaccine policy for residents revealed the following: 1. Each resident should be offered pneumococcal immunizations, unless the immunization is medically contraindicated, or the resident has already been immunized. 2. Consents and declinations should be documented using the Med-Pass form (CP-1900P-25) and placed in the medical record. The facility should re-address the refusal with the resident and/or resident representative each year to ensure they have not changed their decision. These conversations should be captured in the medical record. 1. Resident 31 was admitted to the facility in 2021 with a diagnosis of heart failure. Resident 31's clinical record revealed she/he was eligible for, but was not offered a pneumococcal vaccine. On 5/22/25 at 11:16 AM Staff 3 (RN Infection Preventionist) stated all long-term residents who were eligible for a pneumococcal vaccine were not yet offered. No additional information was provided. 2. Resident 52 was admitted to the facility in 2023 with a diagnosis of diabetes. Resident 52's clinical record revealed she/he was eligible for, but was not offered a pneumococcal vaccine. On 5/22/25 at 11:16 AM Staff 3 (RN Infection Preventionist) stated all long-term residents who were eligible for a pneumococcal vaccine were not yet offered. No additional information was provided. 3. Resident 267 was admitted to the facility in 3/2024 with a diagnosis of kidney failure. Resident 267's clinical record revealed on 3/23/24 the resident was offered and consented to receive a pneumococcal vaccine. The resident's clinical record did not indicate she/he received the vaccine. No additional information was provided. 4. Resident 268 was admitted to the facility in 4/2024 with a diagnosis of heart failure. Resident 268's clinical record revealed on 4/16/24 the resident was offered and consented to receive a pneumococcal vaccine. The resident's clinical record did not indicate she/he received the vaccine. No additional information was provided.

Based on interview and record review it was determined the facility failed to conduct a Significant Change MDS assessment within the required timeframe for 1 of 1 sampled resident (#18) reviewed for hospice. This placed residents at risk for unassessed needs. Findings include: Resident 18 admitted to the facility in 12/2024 with diagnoses including heart failure. A 4/30/25 Progress Note revealed Resident 18 admitted to hospice services on 4/25/25. A Significant Change MDS assessment dated [DATE] was completed on 5/21/25, 27 days after Resident 18 admitted to hospice. On 5/23/25 at 8:36 AM Staff 15 (RN MDS Coordinator) stated Resident 18's Significant Change MDS assessment was not completed within 14 days after Resident 18 was admitted to hospice.

Based on interview and record review it was determined the facility failed failed to complete a referral for a Level ll PASARR (Pre-Admission Screening and Resident Review) for 1 of 2 sampled residents (#18) reviewed for PASARR. This placed residents with a mental health disorder at risk for delayed care, emotional distress related to mental illness and lack of services to attain their highest practicable well-being. Findings include: Resident 18 admitted to the facility in 12/2025 with diagnoses including schizophrenia (chronic mental disorder characterized by symptoms such as hallucinations, delusions, and cognitive challenges), polydipsia (excessive thirst), hyponatremia (a condition where sodium levels are low often due to excessive water consumption), and panic disorder. A 11/25/24 Level 1 PASARR was completed by the hospital on admission to the facility, no indication of serious mental illness was indicated. A 11/25/24 hospital discharge summary revealed Resident 18 had suicidal ideation on admission to the hospital. A 12/12/24 PASARR Level 1 revealed Resident 18 had serious mental illness indicators and met the conditions for an exempted hospital discharge. A review of Resident 18's physician orders revealed a 12/28/24 order for a 1500 ml/day fluid restriction. A 1/28/25 progress note revealed Resident 18 was heard yelling for five to 10 minutes and stated the voices made me drink water and I'm weak and I let them. A 3/3/25 hospital history and physical revealed Resident 18 admitted to the hospital on 3/3/25. The history and physical revealed Resident 18 admitted to the hospital with an altered mental status which appeared to be caused by consumption of a large amount of water. The history and physical also revealed Resident 18 had a history of hyponatremia due to psychogenic (originating form a psychological rather than a physical cause) polydipsia. A 4/3/25 provider progress note revealed Resident 18 had active suicidal ideation and drank approximately 10 cups of water. The provider instructed the nurse to send Resident 18 to the emergency room for symptomatic chronic hyponatremia (a condition where sodium levels are low often due to excessive water consumption) with associated symptoms of suicidal ideation. A 4/3/25 hospital history and physical revealed Resident 18 admitted to the hospital on 4/3/25 with hyponatremia due to psychogenic polydipsia. The history and physical also revealed Resident 18 reported she/he chronically heard voiced that told her/him to kill her/himself. A 5/7/25 Significant Change MDS revealed Resident 18 had a PHQ-9 score of 14 which indicated moderate depression, and reported feeling down, depressed or hopeless nearly every day. A review of Resident 18's medical record revealed no evidence of a referral for a PASARR Level II related to a serious mental illness. On 5/21/25 at 9:18 AM Staff 12 (CNA) stated Resident 18 had verbal behaviors and thought everyone was after her/him. On 5/21/25 at 9:25 AM Staff 13 (CNA) stated Resident 18 was on a fluid restriction but would hide cups in her/his room and drank too much fluids. Staff 13 stated Resident 18 would become very upset if she/he saw cups removed from her/his room and would drink water to excess. On 5/21/25 at 10:02 AM Staff 14 (LPN) stated Resident 18 had behaviors related to fluids, was redirectable but would continue to drink excessive fluids and which was detrimental to her/his health. On 5/22/25 at 12:00 PM Staff 11 (Social Services Assistant) stated Resident 18 drank fluids consistently and was diagnosed with polydipsia related to this. Staff 11 stated Resident 18 did not have current mental health involvement and a PASARR Level II was not completed. On 5/23/25 at 9:41 AM Staff 4 (LPN Unit Manager) reviewed Resident 18's clinical record and stated it would have been appropriate to request a PASARR Level II. On 5/23/25 at 10:50 AM Staff 1 (Administrator) stated she would expect a PASARR Level II to have been completed for Resident 18.

Based on interview and record review it was determined the facility failed to follow physician orders for CBGs and medications for 2 of 8 sampled residents (#s 8 and 218) reviewed for nutrition. This placed residents at risk for ineffective medication regimen. Findings include: 1. Resident 8 was admitted to the facility in 12/2024 with a diagnosis of diabetes. Resident 8's hospital After Visit Summary revealed she/he was on oral diabetic medication and CBGs were to be checked three times a day. Resident 8's 12/17/24 nurse practitioner note revealed Resident 8 reported at home she/he checked her/his CBGs up to five times a day. The nurse practitioner indicated the plan was to initiate CBG monitoring. Resident 8's clinical record did not include staff perform CBG monitoring. On 05/22/25 at 10:49 AM Staff 4 (LPN Unit Manger)stated when a resident was admitted to the facility, medical records staff entered orders into a resident's electronic record, a floor nurse reviewed the orders entered by the medical records staff, and then a second nurse reviewed the orders prior to implementing the orders. The orders were then forwarded to a nurse manager and she reviewed the admission orders one more time for accuracy. Staff 4 verified Resident 8 had orders upon admission to the facility for CBG monitoring but staff did not implement the orders. On 5/22/25 at 2:00 PM Staff 2 (DNS) stated she reviewed Resident 8's record, verified the admission orders for CBG monitoring were not implemented, and indicated after the nurse practitioner visit staff did not implement CBG monitoring. 47001 2. Resident 218 was admitted to the facility in 5/2025 with diagnoses including herpes virus infection. A review of Physician Orders revealed a 5/13/25 order for acyclovir (a medication used to treat viral infections) twice a day as needed for a herpes outbreak. On 5/19/25 at 10:13 AM Resident 218 was observed to have a sore near the left side of her/his mouth. Resident 218 stated the sore was from herpes and she/he was taking acyclovir for it. A review of Resident 218's 5/2025 MAR revealed she/he started taking acyclovir on 5/14/25. Resident 218 was administered acyclovir once daily except on 5/19/25 the acyclovir was given twice. On 5/23/25 at 8:24 AM Staff 4 (LPN Unit Care Coordinator) stated Resident 218 was given the acyclovir when she/he asked for it and acknowledged the acyclovir should be given twice a day per orders for herpes outbreak.

Based on interview and record review it was determined the facility failed to ensure the care plan related to bathing was followed for 1 of 1 sampled resident (#16) reviewed for accidents. This placed residents at risk for injuries. Findings include: Resident 16 was admitted to the facility in 2/2023 with diagnoses including depression and muscle weakness. The 2/19/25 Annual MDS revealed Resident 16 had a BIMs score of 15, which indicated the resident was cognitively intact. A review of the 3/14/25 Care Plan revealed Resident 16 required one person assistance for bathing. A facility reported incident dated 3/29/25 revealed Staff 6 (CNA) was reported to have escorted Resident 16 to the shower room, set the resident up and left the resident to shower independently. On 3/29/25 at 7:30 PM Resident 16 reported the incident to Staff 5 (LPN) and expressed she/he felt it was neglectful to have been left alone, but did not report feeling unsafe. On 5/21/25 at 11:35 AM Resident 16 stated she/he remembered the incident on 3/29/25. Resident 16 stated she/he was taken into the shower room, the CNA set her/him up then left for an unknown reason. Resident 16 stated, it made me feel very unsafe left alone in the shower. The resident reported no other incidents had occurred since. On 5/21/25 at 1:10 PM Staff 7 (CNA) stated on 3/29/25 during her shift the call light in the shower room was turned on so she answered the call light and Resident 16 was in the shower room alone. Staff 7 stated she worked with Resident 16 often and knew the resident required assistance in the shower, so she stayed with the resident and radioed for Resident 16's assigned CNA. On 5/21/25 at 1:17 PM Staff 6 (CNA) stated Resident 16 was assigned to her on 3/29/25 and this was the first time she worked with that resident. Staff 6 stated she read the care plan but never assisted Resident 16 in the shower before and, apparently missed out on some important details. On 5/21/25 at 7:51 PM Staff 5 (LPN) stated Resident 16 spoke with her on 3/29/25 and she/he was left in the shower room earlier that day and Resident 16 was upset. Staff 5 stated the resident had been back in the shower room since the incident and had no further concerns. On 5/23/25 at 11:26 AM and at 12:46 PM Staff 1 verified the incident occurred on 3/29/25 between Resident 16 and Staff 6. Staff 1 acknowledged Staff 6 was to have follow up education on 5/1/25, which did not occur until 5/23/25.

Based on interview and record review it was determined the facility failed to process physician laboratory orders timely for 1 of 5 sampled residents (#35) reviewed for unnecessary medications. This placed residents at risk unmet needs. Findings include: Resident 35 was admitted to the facility in 12/2024 with diagnoses including hypothyroidism (a condition where the thyroid gland is underactive). A review of Physician Orders revealed a 2/19/25 order for TSH (Thyroid Stimulating Hormone)lab. A review of Resident 35's medical record revealed a TSH lab was completed on 3/25/25. On 5/23/25 at 8:41 AM Staff 4 (LPN Unit Care Coordinator) acknowledged the TSH was ordered on 2/19/25 and completed on 3/25/25. Staff 4 stated the TSH lab was not completed timely.

Based on observation and interview it was determined the facility failed to ensure residents were treated with dignity related to dining needs for 1 of 2 sampled dining areas reviewed for dining. This placed residents at risk for lack of a dignified dining experience. Findings include: On 2/5/24 from 11:30 AM through 12:37 PM during lunch observations in the independent dining room, multiple residents asked staff for beverages but were told by staff they needed to wait and someone would be right with them. Multiple times staff did not return to assist the residents with their request. On 2/5/24 at 11:35 AM a resident was observed sitting in the independent dining room with a cup of coffee and seven residents were observed in the independent dining room without any beverages. On 2/5/24 at 12:43 PM Staff 7 (CNA) was asked to explain her process for serving resident meals. Staff 7 stated staff was to serve residents sitting at one table before moving to the next table. Staff 7 stated there were a lot of new staff and they were still trying to learn the process. On 2/5/24 at 12:50 PM Staff 24 (CNA) was asked about the process for serving residents. Staff 24 stated she was new and served the residents who she knew by name first since she was the only one in the dining room. Staff 24 stated normally there was one more staff member to assist in the dining room, but they were attending to another resident. Staff 24 acknowledged she could ask the residents their names or ask for additional staff assistance. Staff 24 acknowledged she should serve one table at a time. On 2/7/24 at 8:08 AM Resident 29 was observed sitting in the independent dining room at a table with one other resident, drinking a cup of coffee. At 8:13 AM Resident 29 asked staff to get Resident 43 a cup of coffee. Staff 7 (CNA) told Resident 29 she would bring the resident a cup of coffee in a minute and proceeded to serve another resident sitting at a different table. At 8:15 AM Staff 24 served Resident 43's breakfast but did not bring her/him a cup of coffee. On 2/8/24 at 8:15 AM Resident 29 asked a staff to help assist /her him back to her/his room. Staff told the resident they would help her/him in a minute but never came back to assist the resident. Fifteen minutes later Resident 29 asked the surveyor to assist her/him back to her/his room. On 2/9/24 at 10:30 AM Staff 2 (DNS) was informed of the above concerns and Staff 2 acknowledged residents were not served in a dignified manor.

Based on interview and record review it was determine the facility failed to transmit resident assessments in the required timeframe for 5 of 5 residents (#s 18, 47, 54, 55, and 56) reviewed for late assessments. Findings include: 1. Residents 18 was admitted in 2023 with diagnoses including a fracture. The clinical record indicated a discharge assessment dated [DATE] was completed but was not transmitted until 2/5/24. On 2/9/24 at 10:58 AM Staff 10 (Regional Director of Clinical Operations) stated the assessment was completed but was not transmitted in the required timeframe. 2. Resident 47 was admitted to the facility in 2023 with diagnoses including a fracture. The clinical record indicated a discharge assessment dated [DATE] was completed but was not transmitted until 2/5/24. On 2/9/24 at 10:58 AM Staff 10 (Regional Director of Clinical Operations) stated the assessment was completed but was not transmitted in the required timeframe. 3. Resident 54 was admitted to the facility in 2023 with diagnoses including a fracture. The clinical record indicated a discharge assessment dated [DATE] was completed but was not transmitted until 2/5/24. On 2/9/24 at 10:58 AM Staff 10 (Regional Director of Clinical Operations) stated the assessment was completed but was not transmitted in the required timeframe. 4. Resident 55 was admitted to the facility in 2023 with diagnoses including a fracture. The clinical record indicated a discharge assessment dated [DATE] was completed but was not transmitted until 2/5/24. On 2/9/24 at 10:58 AM Staff 10 (Regional Director of Clinical Operations) stated the assessment was completed but was not transmitted in the required timeframe. 5. Resident 56 was admitted to the facility in 2023 with diagnoses including heart disease and anxiety. The clinical record indicated a quarterly assessment dated [DATE] was completed but was not transmitted until 2/5/24. On 2/9/24 at 10:58 AM Staff 10 (Regional Director of Clinical Operations) stated the assessment was completed but was not transmitted in the required timeframe.

Based on observation, interview, and record review it was determined the facility failed to follow physician orders, monitor for abuse and respond to changes in condition in a timely manner for 4 of 6 residents (#s 24, 33, 45, and 168) reviewed for abuse, change of condition, hearing and edema. This placed residents at risk for delayed treatment and unmet needs. Findings include: 1. Resident 33 was admitted to the facility in 2017 with diagnoses including heart failure. A review of Resident 33's vital summaries from 11/1/23 through 11/18/23 revealed the following: -Pulse Summary: ranged between 56 to 88 beats per minute. -Respiration Summary: ranged between 14 to 20 breaths per minute. -O2 (Oxygen levels) Summary: Oxygen level was checked on 11/7/23 and was 92 percent. -Blood Pressure Summary: ranged between 134 systolic and 68 diastolic and 168 systolic 56 diastolic. A review of Resident 33's vital summaries on 11/19/23 revealed the following: -Pulse Summary: at 9:05 PM and 9:07 PM Resident 33's pulse was 35 beats per minute. -Respiration Summary: No documentation respirations were checked. -O2 Summary: No documentation oxygen levels were checked. -Blood Pressure Summary: at 9:05 PM and 9:07 PM Resident 33's blood pressure was 184 systolic and 84 diastolic (normal blood pressure levels are below 120 systolic and below 80 diastolic). A 11/19/23 at 9:05 PM Administration Note instructed staff to administer Lisinopril two times a day for hypertension and hold for heart rate under 50. The note indicated vitals were outside of parameters and medication was not administered and the nurse was aware. On 2/7/24 at 12:17 PM Staff 6 (LPN) stated she remembered 11/19/23 when Resident 33's pulse was in the 30's and the facility was short staffed, and Staff 6 was running from room to room. Staff 6 stated she should have sent Resident 33 to the hospital. Staff 6 stated when she got home that night she thought that was not my best work. On 2/8/24 at 8:11 AM Staff 4 (RN) stated she returned to the facility after being out and Resident 33 reported to her that her/his heart rate went as low as 32 and Staff 4 asked why no one sent her/him out to the hospital. Staff 4 stated Resident 33 should have been sent to the hospital. On 2/8/23 at 1:19 PM Staff 2 (DNS) and Staff 10 (Regional Director of Clinical) stated the expectation was to notify the physician of the low heart rate. 26991 2. Resident 168 was admitted to the facility in 2023 with a diagnosis of heart failure. A 11/20/23 Admission MDS and associated CAAs revealed Resident 168 was assessed to have cognitive impairment. A 12/5/23 Incident Summary revealed on 12/5/23 Resident 168 alleged on the night shift of 12/4/23 she/he was restrained and two CNAs of the opposite gender messed with her/him. The facility investigated the incident and was not able to support the resident's allegations. Progress Notes from 12/5/23 through 12/11/23 did not include the staff monitored Resident 168 to ensure she/he did not have psychosocial outcome related to her/his allegations of abuse. On 2/8/24 at 10:43 AM Staff 2 (DNS) stated if a resident reported abuse, even when the allegation was not supported, staff were to monitor the resident for 72 hours to ensure the resident felt safe. Staff 2 stated the staff did not monitor the resident. 41455 3. Resident 24 was admitted to the facility in 2016 with diagnoses including dementia and depression. A 1/6/23 revised care plan instructed staff to apply hearing aids in the morning and remove them at bedtime for Resident 24. The 12/9/23 Quarterly MDS indicated Resident 24's hearing was adequate and she/he wore hearing aids. On 2/5/24 at 1:57 PM Resident 24 was observed sitting up in bed with no hearing aids in use and did not engage in conversation. On 2/7/24 at 9:07 AM Resident 24 was observed sitting up in bed with the television on. Resident 24 was not engaged in watching the program on the television and did not wear her/his hearing aids. Resident 24 stated she/he heard better with her/his hearing aids but neglected to put them in that day. On 2/7/24 at 1:34 PM Staff 26 (CNA) stated she was recently employed at the facility and was not aware Resident 24 wore hearing aids. On 2/8/24 at 12:06 PM Staff 14 (CNA) stated he cared for Resident 24 occasionally but was not aware Resident 24 wore hearing aids until 2/8/24. On 2/9/24 at 9:13 AM Staff 2 (DNS) stated Resident 24's care plan should be followed for use of her/his hearing aids. 4. Resident 45 was admitted to the facility in 2021 with diagnoses including edema (swelling of body tissue) and stroke. A 9/23/23 physician order indicated Resident 45 was to wear a compression sock on her/his lower left extremity every morning and it was to be removed in the evening. The 2/2023 TAR indicated on 2/6/24 Resident 45 was sleeping (no compression sock applied) and on 2/7/24 no compression sock was located. On 2/5/24 at 4:34 PM and 2/7/24 at 10:26 AM Resident 45 was observed wearing no compression sock. Resident 45 stated her/his compression sock was routinely not applied during the day. On 2/7/24 at 9:23 AM Staff 14 (CNA) stated Resident 45's compression sock was routinely in the laundry and not applied as expected. Staff 14 stated nursing was not informed Resident 45's compression sock was routinely missing. On 2/7/24 at 9:29 AM Staff 15 (LPN) stated she regularly worked during the day and was first notified on 2/7/24 there were issues with the application of Resident 45's compression sock. On 2/9/24 at 9:12 AM Staff 2 (DNS) acknowledged physician orders for Resident 45's compression sock should be followed.

Based on observation, interview, and record review it was determined the facility failed to provide sufficient staffing to meet the needs of residents for 1 of 4 sampled residents (#33) and 1 of 1 facility reviewed for staffing. This placed residents at risk for unmet needs. Findings include: Resident 33 was admitted to the facility in 2017 with diagnoses including heart failure. A 12/4/23 Significant Change MDS indicated Resident 33 was cognitively intact and required extensive assistance from staff for toileting and brief changes. Review of 8/17/23 Resident Council Notes revealed residents had long call light wait times. On 9/1/23 a public complaint was received which indicated on night shift at times the facility only had one CNA working for 47 residents, and call light wait times were an hour and a half to two hours long. On 8/25/23 Resident 33 waited for a brief change for one hour and 55 minutes. A review of the Direct Care Staff Daily Reports from 7/1/23 through 8/31/23 revealed the facility did not have sufficient CNA staff to meet the State minimum CNA to resident staffing requirements for 68 of 186 shifts. On 2/6/24 at 8:49 AM Resident 33 stated call light wait times were an hour to an hour and a half on some days, and waiting while being wet or dirty was uncomfortable. On 2/8/24 at 9:53 AM Staff 5 (CNA) stated she worked at the facility since 2022, and staffing was always an issue. Staff 5 stated the facility was short-staffed three to four days out of the week and when understaffed it was hard to get all the work completed. On 2/8/24 at 1:25 PM AM Staff 1 (Administrator) confirmed she was aware of the facility was understaffed in 7/2023 and 8/2023. Refer to F677.

Based on observation, interview, and record review it was determined the facility failed to ensure resident food preferences were honored for 1 of 1 facility reviewed. This place residents at risk for lack of honored preferences. Findings include: 1. On 2/5/24 at 4:10 PM Staff 18 (Social Service Assistant) stated he was working as the Dietary Manager for the past eight months until a few weeks ago. Staff 18 stated he was aware of residents' concerns related to not having food preferences honored. On 2/7/24 at 8:21 AM Staff 7 (CNA) served Resident 33's breakfast. Resident 33 stated that's not mine I never order scrambled eggs. Resident 33 stated this happened a lot and the kitchen did not give residents what they ordered. On 2/7/24 at 9:18 AM Staff 23 (Cook) was asked about how staff made her aware of residents' food preferences, if they had any residents who were vegetarian and what their process included. Staff 23 confirmed Resident 368's diet slip indicated she/he was a vegetarian. Staff 23 stated the kitchen did not have a good variety of vegetarian options and the resident was served the same vegetarian patty for multiple days in a row. Staff 23 stated Resident 368 had an extensive list of food preferences, and she showed the surveyor the resident's preference list which indicated the resident liked fish and chicken. Staff 23 stated she was not aware of Resident 368's preference for fish and chicken. Staff 23 stated Resident 368 used to fill out her/his own menu, but she/he selected too many items which confused the kitchen staff, so they stopped allowing Resident 368 to fill out her/his own menus and instead staff made selections on her/his behalf. On 2/7/24 at 10:50 AM Resident 368 stated she/he considered her/himself a vegetarian, but she/he liked fish and chicken. Resident 368 stated she/he was served the same kind of vegetarian patty for five days in a row and it was burned and hard. Resident 368 further stated she/he filled out her/his menu, but the kitchen did not serve what was ordered, and she/he would like food preferences honored. On 2/8/24 at 8:04 AM Resident 11 stated she/he was never served enough scrambled eggs, and when she/he asked staff for more scrambled eggs staff stated the kitchen did not have any more. Resident 11 further stated she/he did not always get what was marked on the menu. On 2/8/24 at 10:44 AM Resident 8 stated during the past year staff did not ask about her/his food preferences. Resident 8 stated she/he would like more variety including fresh tomatoes, spinach, raviolis, and buttermilk. Resident 8 stated she/he did not always get what she/he ordered, and this happened a lot especially with buttermilk. Resident 8 stated she/he used to get buttermilk at least once a meal but now did not get it at all. 2. On 2/8/24 at 11:30 AM surveyors requested a sample lunch tray from the menu including: country fried steak, cream gravy, mashed potatoes, confetti coleslaw, dinner roll, a chocolate chip bar, juice and a vegetarian option. Staff 19 (Cook) stated the menu was changed and the main meal was no longer an option because she made a mistake when creating the menu. Staff 19 stated the main meal now included: pulled pork, cooked carrots, Texas toast and yellow cake. Staff 19 stated the alternative, which included breaded shrimp, was still available, but residents were not notified the menu changed. On 2/8/24 at 12:30 PM the sample tray was provided and included: pulled pork, baked beans, carrots and a piece of toast. The sample test tray did not include a vegetarian option, desert or beverage. On 2/9/24 at 8:28 AM Staff 25 (RD) stated all residents should have their food preferences listed on the meal ticket and staff should attempt to honor residents' food preferences. On 2/9/24 at 8:49 AM Staff 2 (DNS) stated in 1/2024 she became aware of residents' concerns related to preferences not being honored. Staff 2 stated the facility started an audit to identify residents' food preferences, and she provided surveyors a copy of the Food Preference Audit list. The Food Preference Audit list indicated 25 out of 36 residents' food preferences were not reviewed. Staff 2 confirmed the audits were not completed and residents' food preference concerns were not discussed during the last QAPI meeting in 1/2024. Staff 2 was informed on 2/8/24 the survey team requested a meal tray and was not provided what was ordered or on the menu. Staff 2 confirmed the residents' preferences were not honored and menus were not followed. 49677 3. On 2/8/24 at 11:00 AM residents were interviewed during Resident Council meeting. There were six residents present. Five of the six residents reported dissatisfaction with the food. Complaints included: - Not receiving what was requested from the menu. - Food was undercooked (chicken and shrimp especially). - Not enough variety in the meals. - Inconsistency with kitchen staff, no dietary manager. - One resident reported she/he received the same vegetarian chicken patty for five days in a row. On 2/8/24 at 3:58 PM Staff 19 (Cook) stated, We don't have many vegetarian options for people.

Based on observation, interview and record review it was determined the facility failed to implement consistent use of PPE in 2 of 5 halls and failed to perform hand hygiene when required while assisting dependent residents to eat in 1 of 2 dining rooms. This placed residents at risk for communicable diseases and spread of infection. Findings include: According to Oregon Health Authority Guidance staff caring for residents with suspect or confirmed COVID-19 are required to wear a fit-tested N95 respirator, eye protection, gown, and gloves. Public health may recommend unit-wide use of N95 and eye protection if facility is experiencing an outbreak to reduce the risk of transmission from asymptomatic or pre-symptomatic individuals. It may be appropriate to implement extended use of N95s and eye protection for the sequential care of a large volume of COVID-19 patients. Extended use should not be used when other organisms are present (e.g., multidrug-resistant organisms). Gowns and gloves are to be used for one resident, one encounter. Practice single use disposable PPE (one per resident per encounter). Extended use of N95 and eye protection permissible in cohorted area or for clustered care of confirmed COVID-19 residents/patients only. Disinfect reusable eye protection. 1. On 2/7/24 at 11:16 AM on the North Hall Staff 32 (CNA) was observed to exit the room of a resident on precautions related to COVID 19. Staff 32 was observed to perform hand hygiene with alcohol-based hand rub then remove and clean her eye protection. While holding her eye protection in one hand, Staff 32 removed the soiled N95 by touching the soiled surface of the mask. Without first performing hand hygiene, Staff 32 then obtained a clean mask from a box on the PPE bin, donned the mask and previously cleaned eye protection with potentially contaminated hands. On 2/7/24 at 11:37 Staff 17 (RN Staff Development Coordinator) was asked what the facility expectation was for staff related to PPE use for residents with COVID 19 infection. Staff 17 stated PPE was to be donned outside the room. After care was provided, gown and gloves were to be removed and discarded inside the room, eye protection was to be removed and sanitized outside the room, the used N95 respirator was to be removed and discarded and hand hygiene performed before a new mask was donned. Staff 17 stated she would inservice staff on the North Hall. On 2/8/24 at 9:36 AM Staff 29 (SLP) was observed on the North Hall to exit the room of a resident on precautions for COVID 19. Staff 29 was wearing a gown which he removed and discarded into a trash receptacle located in the hall outside the resident room. Staff 29 then removed his gloves, which he kept in his hand, picked up a clipboard and carried the gloves to nurses station where he discarded them in the trash. He then performed hand hygiene. When asked, he stated he had to remove the gown and gloves in the hall as there was no trash receptacle in the resident's room or if there was he did not see it. 49676 2. On 2/6/24 at 11:57 AM a room on the North Hall had signage on the door to stop and speak with a nurse prior to entering. The sign indicated gown, gloves, mask and eye protection were to be used. There was a sign adjacent to the door to make staff aware of the precaution. Signage on the door instructed staff to wear a mask, eye protection and gloves for resident contact. On 2/7/24 at 12:41 PM Staff 29 (SLP) was observed to exit the room of a resident on transmission based precaution. He did not change his mask or sanitize his eye protection. On 2/7/24 at 12:42 PM Staff 29 said his understanding was that he could keep the mask on all day and the eye shield throughout resident care. 41455 3. Resident 42 was admitted to the facility in 2022 with diagnoses including Parkinsonism (syndrome related to involuntary movements) and contractures (a fixed tightening of muscle or tendons) on the right side. On 2/7/24 at 12:23 PM Staff 8 (CNA) sat at a shared dining table with Resident 42 and an unidentified resident while Staff 8 provided dining assistance to both residents. No hand hygiene was observed by Staff 8 prior to the assistance of the meal for each resident at the table. On 2/7/24 at 12:36 PM Staff 8 touched the face and mouth of the unidentified resident with a napkin and next assisted Resident 42 with her/his meal without first performing hand hygiene. On 2/7/24 at 1:00 PM Staff 25 (CNA) acknowledged it was common knowledge for CNAs to perform hand hygiene prior to the assistance of each resident during dining assistance. On 2/9/24 at 8:46 AM Staff 2 (DNS) acknowledged hand hygiene should be performed by CNAs each time dining assistance was provided for each resident.

Based on observation, interview and record review it was determined the facility failed to ensure residents were free from significant medication errors for 2 of 2 sampled residents (#s 11 and 42) reviewed for medication administration. Resident 11 was administered an extended release antihypertensive medication in an inappropriate manner placing her/him at risk for clinical complications. Alteration of the medication's absorption properties can cause serious side effects up to and including fatal overdose. This failure was determined to be an immediate jeopardy situation. Findings include: 1. Resident 11 was admitted to the facility in 10/2021 with diagnoses including atrial fibrillation (irregular heartbeat), heart failure and high blood pressure. A physician's order dated 12/16/21 revealed diltiazem extended release 12 hours (for high blood pressure) was to be administered daily. On 12/6/22 at 10:06 AM Staff 31 (CMA) was observed to open a capsule of medication diltiazem HCL ER (12 hour) and place the contents in applesauce. Resident 11 was then observed to chew her/his medications. Staff 31 did not look up to see whether the medication could be administered this way. According to the Nursing Drug Handbook 2022 edition the diltiazem 12 hour extended release capsule should not be opened or chewed. Diltiazem HCL ER Capsule Extended Release (12 hour), when improperly administered, has the potential to cause side effect which include sedation, respiratory depression, irregular heat beat, swelling of face, arms and hands with difficulty breathing and death. On 12/6/22 at 10:43 AM Staff 31 acknowledged he should have verified if the capsule could be opened and its contents directly administered in applesauce. Staff 31 provided medication for 28 residents. Staff 31 continued to pass medication. Staff 31 did not double check whether the diltiazem could be administered through an alternate method. There were 13 residents with high risk medications that included diabetic medications, antidepressants and extended release potassium that could not be crushed or chewed. On 12/6/22 at 10:45 AM facility management was notified by surveyor immediately after medications were given to Resident 11. Staff 1 (Administrator), Staff 2 (DNS), Staff 3 (LPN-Unit Manager), Staff 4 (LPN/IP) and Staff 12 (Regional Nurse) acknowledged capsules were not to be opened and contents were not to be placed in applesauce. On 12/6/22 at 11:42 AM the surveyor repeated the medication error to Staff 2, Staff 3 and Staff 4 because they had not initiated interventions related to the medication error. Staff 2, Staff 3 and Staff 4 stated they should have taken vitals, notified the physician and put Resident 11 on monitoring. On 12/6/22 at 5:26 PM Staff 1 and Staff 12 were notified of an IJ situation related to a significant medication error, vital checks were not initiated and physician was not notified promptly. No investigation was started once the facility was notified of the significant medication error. Resident 11 was at high risk due to diagnoses of atrial fibrillation, heart failure, high blood pressure and resident being monitored for episode of low blood pressure. Diltiazem HCL ER Capsule Extended Release (12 hour), when improperly administered, had the potential to cause side effect which included sedation, respiratory depression, irregular heat beat, swelling of face, arms and hands with difficulty breathing and death. Staff 31 continued to pass medications and the potential for additional significant medication errors remained. The IJ template was provided and an immediate IJ removal plan was requested. On 12/6/22 at 7:46 PM an acceptable IJ removal plan was provided and indicated the following: In order to ensure resident needs are met, the facility leadership took the following immediate actions to ensure the safety and well-being of residents within the facility: 1. Immediate action for Resident 11: vital signs were obtained, resident placed on alert for adverse outcomes of ingestion of diltiazem HCL ER (12 hour) in powdered form. The physician was notified and every four hour vitals monitoring initiated. The family was notified. Resident 11 was in stable condition with no adverse outcomes noted. 2. Staff 31 administered medications to the resident on the central north unit, all of those residents assessed for possible adverse reactions to significant medication errors. 3. Staff 31 educated to verify medication can be crushed and that medication capsules cannot be opened for administration. Staff 31 educated to notify nurse immediately if medication error occurred. 4. Laminated Do Not Crush list placed on the medication cart and nurses station for reference. 5. All nurses and medication aides educated on verification of medications that can be crushed and that medication capsules cannot be opened for administration prior to working next shift. 6. All nurses and medication aides educated to perform timely assessment of residents for which a significant medication error has occurred and to implement interventions. Further, all nurses and medication aides were educated to notify the physician and to place the resident on alert charting following a significant medication error. On 12/6/22 at 7:50 PM the IJ planned was accepted and surveyors verified all elments of the IJ removal plan were completed. 40774 2. Resident 42 admitted to the facility in 10/2019 with diagnoses including diabetes, peripheral vascular disease and depression. A 5/23/22 physician order indicated staff to administer 30 mg Morphine Sulfate Extended-Release (ER) Capsule one time a day for chronic pain. A 5/23/22 physician order indicated staff to administer 30 mg Morphine Sulfate ER in the afternoon for chronic pain. A 5/23/22 physician order indicated staff to administer 15 mg Morphine SulfateER on e time a day for chronic pain. A 7/27/22 physician order indicated staff to administer two 10 mg Oxycodone PRN every four hours for pain. A 9/11/22 Incident Report indicated Resident 42 was administered an extra dose of Mophine 30 mg instead of Oxycodone 10 mg. A Black Box Warning indicated accidental ingestion of even one dose of morphine could result in serious, life-threatening, or fatal respiratory depression, and to monitor for respiratory depression, especially during initiation of morphine or following a dose increase. No documentation was found in the medical record to indicate Resident 42 was monitored for respiratory depression following an extra dose of morphine extended release. On 12/5/22 at 1:17 PM Staff 12 (Regional RN) confirmed staff failed to monitor Resident 42 for potential life-threating side affects following a significant medication error.

Based on interview and record review it was determined the facility failed to ensure residents maintained acceptable parameters of hydration and nutrition status for 5 of 9 sampled residents (#s 7, 16, 20, 54 and 259) reviewed for hydration and nutrition. Resident 7 experienced a severe weight loss. Findings include: 1. Resident 16 was admitted to the facility in 10/2022 with diagnoses including altered mental status and falls. Resident 16's record revealed fluid intake from 11/17/22 through 11/29/22 as follows: -11/17/22-1640 ml for the day -11/18/22-1,080 ml for the day -11/19/22-1,190 ml for the day -11/20/22-360 ml for the day -11/21/22-730 ml for the day -11/22/22-1,080 ml for the day -11/23/22-480 ml for the day -11/24/22-480 ml for the day -11/25/22-340 ml for the day -11/26/22-360 ml for the day -11/27/22-1,360 ml for the day -11/28/22-720 ml for the day -11/29/22-1,320 ml for the day The recommended day daily fluid intake was 2,220 ml a day. Observations from 11/28/22 through 12/1/22 on day and evening shifts revealed no fluids in Resident 16's room. On 11/28/22 at 1:47 PM Resident 16 stated she/he had to ask for fluids. Resident 16 further stated if she/he did not ask she/he would not receive fluids except with meals. On 12/1/22 at 3:52 PM Staff 13 (CNA) stated residents received fluids on their meal trays, so she did not think of offering fluids. On 12/2/22 at 9:32 AM Staff 30 (CNA) stated she tried to remember to give the residents fluids but did not always get around to it unless they asked. On 12/05/22 at 12:22 PM Staff 2 (DNS) stated it was expected for staff to offer fluids before and during shifts and residents should not have to ask for fluids. 2. Resident 20 admitted to the facility in 6/2022 with diagnoses including muscle weakness, paraplegia and need for personal care. Resident 20's record revealed fluid intake from 11/6/22 through 11/20/22 as follows: - 11/6/22 - 720 ml for the day. - 11/7/22 - 240 ml for the day - 11/8/22 - 640 ml for the day - 11/9/22 - 600 ml for the day - 11/10/22 - 480 ml day for the day - 11/11/22 - 730 ml for the day - 11/12/22 - 720 ml for the day - 11/13/22 - 720 ml for the day - 11/14/22 - 1440 ml for the day - 11/15/22 - 880 ml for the day - 11/16/22 - 1720 ml for the day - 11/17/22 - 1440 ml for the day - 11/18/22 - 1200 ml for the day - 11/19/22 - 930 ml for the day - 11/20/22 - 600 ml for the day The recommended day daily fluid intake was 1,900 ml to 2,280 ml a day. Observations from 11/30/22 through 12/3/22 on day and evening shifts revealed no fluids in Resident 20's room. On 11/30/22 at 11:36 AM Resident 20 stated staff did not bring her/him fluids. Resident 20 stated she/he had bottled water in her/his closet but staff did not get it for her/him. On 12/1/22 at 3:52 PM Staff 13 (CNA) stated residents received fluids on their meal trays, so she did not think of offering fluids. On 12/2/22 at 9:32 AM Staff 30 (CNA) stated she tried to remember to give the residents fluids but did not always get around to it unless they asked. On 12/05/22 at 12:22 PM Staff 2 (DNS) stated it was expected for staff to offer fluids before and during shifts and residents should not have to ask for fluids. 3. Resident 54 admitted to the facility in 10/2012 with diagnoses including stroke. Resident 54's record revealed fluid intake from 11/3/22 through 11/16/22 as follows: - 11/3/22 - 960 ml for the day - 11/4/22 - 1,550 ml for the day - 11/5/22 - 1,300 ml for the day - 11/6/22 - 1,680 ml for the day - 11/7/22 - 480 ml for the day - 11/8/22 - 840 ml for the day - 11/9/22 - 1,350 ml for the day - 11/10/22 - 600 ml for the day - 11/11/22 - 710 ml for the day - 11/12/22 - 600 ml for the day - 11/13/22 - 500 ml for the day The recommended day daily fluid intake was 1,920 ml a day. Observations from 11/28/22 through 12/1/22 on day and evening shifts revealed no fluids in Resident 54's room. On 11/30/22 at 11:36 AM Resident 54 stated staff did not bring her/him fluids unless she/he asked. On 12/1/22 at 3:52 PM Staff 13 (CNA) stated residents received fluids on their meal trays, so she did not think of offering fluids. On 12/2/22 at 9:32 AM Staff 30 (CNA) stated she tried to remember to give the residents fluids but did not always get around to it unless they asked. On 12/05/22 at 12:22 PM Staff 2 (DNS) stated it was expected for staff to offer fluids before and during shifts and residents should not have to ask for fluids. 40774 41453 4. Resident 259 admitted to the facility in 2022 with diagnoses including stroke and paralysis of the left side. The Resident's 6/17/22 care plan indicated Resident 259 required setup assistance with meals, including fluids. Resident 259 did not have any other interventions pertaining to fluid intake. Resident 259's fluid intake record indicated: 3/1/22 - 500 mL 3/2/22 - 700 mL 3/3/22 - 1060 mL 3/4/22 - 840 mL 3/5/22 - 1160 mL 3/6/22 - 1620 mL 3/7/22 - 840 mL 3/8/22 - 960 mL 3/9/22 - 840 mL 3/10/22 - 700 mL 3/11/22 - 920 mL 3/12/22 - 720 mL 3/13/22 - 720 mL 3/14/22 - 480 mL 3/15/22 - 840 mL 3/16/22 - 1180 mL 3/17/22 - 1280 mL 3/18/22 - 660 mL 3/19/22 - 480 mL 3/20/22 - 360 mL 3/21/22 - 1020 mL 3/22/22 - 840 mL 3/23/22 - 720 mL 3/24/22 - 480 mL 3/25/22 - 420 mL 3/26/22 - X Resident not available 3/27/22 - 0 3/28/22 - X Resident not available. 5/4/22 - 480 mL 5/5/22 - 1080 mL 5/6/22 - 980 mL 5/7/22 - 1140 mL 5/8/22 - 1340 mL 5/9/22 - 710 mL 5/10/22 - 720 mL 5/11/22 - 1300 mL 5/12/22 - 1080 mL 5/13/22 - 1020 mL 5/14/22 - 1140 mL 5/15/22 - 1180 mL 5/16/22 - 360 mL 5/17/22 - 840 mL 5/18/22 - 720 mL 5/19/22 - 1080 mL 5/20/22 - 1320 mL 5/21/22 - 1560 mL 5/22/22 - 1080 mL 5/23/22 - 600 mL 5/24/22 - 900 mL 5/25/22 - 720 mL 5/26/22 - 1080 mL 5/27/22 - 1440 mL 5/28/22 - 1090 mL 5/29/22 - 840 mL 5/30/22 - 600 mL 5/31/22 - Resident not available. A 6/14/22 Nutrition assessment indicated Resident 259's fluid intake was to range between 2050-2460 mL per day. On 12/6/22 at 10:17 AM Staff 3 (LPN-Unit Manager) stated there was no way of knowing if residents received additional water. Staff 3 further stated it appeared Resident 259's fluid intakes were low. 5. Resident 7 admitted in 2022 with diagnoses including Alzheimer's disease. Resident 7's 2/25/21 care plan indicated Resident 7 was to be provided finger foods when utensil use was difficult, and Resident 7 required assistance with all meals. Record review revealed Resident 7 was not followed by the facilities nutrition at risk program (NAR). Meal intake record revealed between 10/22/22 and 10/31/22: - Five meals 0-25% consumed - Three meals 26-50% consumed - Five meals 51-75% consumed - Seven meals 76-100% consumed - Four meals resident refused - Five meals not documented On 6/4/2022 Resident 7 weighed 190 lbs. On 7/4/2022 Resident 7 weighed 187.5 lbs. On 8/5/2022 Resident 7 weighed 182.6 lbs. On 9/15/2022 Resident 7 weighed 178 lbs. On 10/7/22 Resident 7 weighed 186.2 lbs. On 11/7/22 Resident 7's weighed 169.4 lbs. This represented a nine percent decrease in weight in one month and severe weight loss for Resident 7. An 10/29/22 progress note indicated nursing staff were aware Resident 7 refused meals and had a poor appetite. On 11/28/22 a registered dietician note requested an additional weight to confirm the weight loss. Resident 7's record review revealed no interventions in place to address Resident 7's weight loss and no indication the RD was notified or aware until 11/28/22. Resident 7 was weighed on 12/5/22, which revealed Resident 7 weighed 165.0 pounds. On 12/6/22 at 10:17 AM Staff 3 (LPN-Unit Manager) stated nursing staff met with the registered dietician every week to review residents who were at risk for nutritional deficits and weights were reviewed at every meeting. Staff 3 confirmed the 12/2022 weights were accurate.

Based on observation, interview and record review it was determined the facility failed to ensure staff followed the care plan related to fall safety and failed to provide safe transfers for 2 of 3 sampled residents (#s 1 and 13) reviewed for accidents. Resident 1 fell out of a hygiene (designed for toileting and hygiene functions) sling and she/he sustained a left [CONDITION(S)]. Findings include: 1. Resident 1 admitted to the facility in 2018 with diagnoses including chronic heart failure and a left [CONDITION(S)]. A revised care plan dated 2/26/21 indicated Resident 1 was a two-person assisted transfer using a mechanical lift and hygiene sling to the bedside commode. An Incident Report initiated on 2/27/21 revealed the following: -Resident 1 was transferred from the commode to her/his bed when Resident 1 fell out of the lift sling and landed on the floor. -Resident 1 hit the back of her/his head, then shoulders, back, hips and then her/his legs. The resident fell from approximately three feet in the air. -The resident was assessed and knew she/he fell from the lift, and was transported to the hospital. -A Magnetic Resonance Imaging (MRI) showed a small fracture to the left hip. -Staff 31 (CNA) had Resident 1 in the hygiene sling and was moving her/him back to the bed. Staff 38 (LPN/Unit Manager) was present for the transfer and Resident 1 fell out of the sling. Staff 31 did not notice the signs posted in Resident 1's room regarding the type of sling Resident 1 used and thought it looked like one she used a few weeks previously. Staff 31 thought she was trained to utilize the hygiene sling but it was not the same sling training. -Staff 38 indicated she was called into the room to assist with the transfer around 7:30 AM and Resident 1 was in the sling and Staff 38 was beginning the process for the resident's transfer. Staff 31 moved behind the resident and the commode and stated she needed to get Resident 1 back to bed for her/his brief and pants placement. Staff 38 began to turn the lift towards the bed when the resident fell . Staff 38 stated she noticed Resident 1 had her/his arms crossed inside the sling. Resident 1 complained of pain to her/his left hip. Staff 38 assessed Resident 1 and she/he was sent out to the hospital. -3/4/21 the facility ruled out abuse and neglect because Staff 31 did not realize Resident 1's arms were supposed to be on the outside of the sling which may have contributed to the resident sliding out of the sling. Staff 31 did not see the signs posted in Resident 1's room regarding the hygiene sling. The sling was discontinued for Resident 1 after the incident. Staff 38 did not realize anything was wrong until resident was observed with her/his arms crossed as she/he was falling out of the sling. Hospital records dated 2/27/21 revealed Resident 1 was in the emergency department due to a fall from a lift sling. Resident 1 stated she/he had head pain, neck pain, left hip pain, and had chronic neck pain but this was worse. On physical exam Resident 1's left leg was tender to palpate to the lateral aspect of the left hip and unable to move her/his left leg at all secondary to pain. Resident 1 had passive external and internal rotational pain to the left hip. Resident 1's MRI to the left hip revealed a comminuted and non-displaced left acetabular fracture (bone broken in two places and bone not moved out of position) extending into the posterior column of the left acetabulum. Resident 1 was discharged back to the facility on [DATE] and no surgery was recommended. On 5/24/21 at 2:04 PM Witness 11 (Family Member) stated she received a call from Staff 38 regarding Resident 1 falling out of the lift sling on 2/27/21. Witness 11 stated she was told Resident 1 fell hard on the floor hitting her head/neck and then hips. Witness 11 stated she spoke with Resident 1 prior to being sent to the hospital and encouraged her/him to go for further evaluation. Witness 11 stated after the event on 2/27/21 the facility had two care conferences with her/him and other family members, and the facility identified not all staff were trained on how to utilize the hygiene sling. Witness 11 stated the sling was recommended for Resident 1 so she/he could continue to utilize the commode for toileting. Witness 11 stated Staff 31 was not trained and did not utilize the hygiene sling correctly. On 5/27/21 at 11:03 AM Resident 1 stated she/he remembered falling out of the lift sling a couple of months ago, it hurt really bad and I broke my left hip from falling out of the lift. Resident 1 stated I hit my head on the floor but my left hip hurt the worst, and I was sent out to the hospital. Resident 1 stated two staff were in the room transferring her/him when she/he fell out of the sling. On 5/27/21 at 1:01 PM Staff 38 stated on 2/27/21 she was called into the room by Staff 31 to assist with transferring Resident 1. Staff 38 indicated she entered the room and Staff 31 already had Resident 1 in the hygiene sling and up in the air. Staff 38 stated Staff 31 needed to get Resident 1 back to bed and started to move her/him and Resident 1 fell right out of the sling onto the floor. Staff 38 stated Resident 1 was supposed to be holding onto the outside of sling straps and she/he was not. Staff 38 stated Resident 1 first hit her/his head during the fall and then the rest of her/his body. Staff 38 stated she assessed the resident who was conscious and ended up sending her/him out to the hospital. Resident 1 fractured her/his left hip due to the fall. Staff 38 stated Staff 31 was too far ahead of her by the time she entered the room and did not realize that Resident 1 was not holding onto the hygiene sling correctly. Staff 38 stated that's why we do a two person transfer assist with hygiene/lift transfers so we have an extra set of eyes and hands in the room to ensure the lift and sling was correct and Resident 1 was transferred safely. On 5/27/21 at 4:17 PM Staff 31 stated she worked with Resident 1 on 2/27/21 when the transfer fall occurred. Staff 31 stated Resident 1 recently had a change in her/his transfer status to the lift sling but during shift change staff failed to mention it was a hygiene sling, which she never used. Staff 31 stated she was not educated or trained on how to use the hygiene sling, and assumed it was similar to a sling she used a few weeks prior on another resident. Staff 31 stated she was transferring Resident 1 off the commode and needed to put Resident 1 in her/his bed to get her/his pants back on. Staff 38 was in the room as Staff 31 started to move Resident 1 in the hygiene sling towards the bed and Resident 1 fell out of the sling, hitting her head/neck, and the rest of her/his body followed. Staff 31 stated the resident was upset and kept saying leave me here to die. On 5/27/21 at 3:30 PM and 6/9/21 at 3:17 PM Staff 1 (Administrator) and Staff 2 (DNS) were present for an interview. Staff 1 acknowledged the 2/27/21 fall was an unfortunate incident and the facility completed in-service for staff regarding the use of the hygiene sling for Resident 1 prior to it being used on Resident 1. Staff 1 stated Staff 31 was not present prior to her use of the hygiene sling for Resident 1. Staff 1 stated one staff person could get a resident ready in a hygiene sling but two people were expected to be present when transferring/moving Resident 1 in the hygiene sling to ensure safety and the lift was operational. 2. Resident 13 admitted to the facility in 4/2021 with diagnoses including stroke and [CONDITION(S)]. A revised care plan dated 5/24/21 indicated Resident 13 was a fall risk related to a stroke, had weakness and a history of falls. Staff were directed to place a fall mat at her/his bedside when in bed, conduct frequent visual checks for safety and place Resident 13's soft touch call light at her/his hip when in bed. Observations on 5/24/21 at 1:43 PM and 3:24 PM revealed Resident 13 was in bed, lying on her/his right side at an angle and her/his feet were dangling off the bed. The bed was up against the wall and approximately three and a half feet from the ground. There was no fall mat in place and her/his call light was at the top right corner of her/his bed. An observation on 5/27/21 at 3:10 PM revealed Resident 13 was in the bed lying on her/his back and the bed was approximately three and a half feet from the ground, no fall mat was in place and the fall mat was pushed up against the wall. Resident 13's call light was by her/his head. On 5/27/21 at 3:40 PM Staff 39 (CNA) stated Resident 13 was alert and oriented, but confused at times. Staff 39 stated Resident 13 was a fall risk and when Resident 13 was in bed it was to be in the lowest position and a fall mat placed next to the bed. Staff 39 entered Resident 13's room and acknowledged the bed was not in the lowest position, no fall mat was in place and her/his call light was next to the resident's head. On 6/1/21 at 2:59 PM Staff 24 (CNA) stated Resident 13 was alert and oriented, but did not speak much. Staff 24 stated Resident 13 had a fall out of bed and was a fall risk. Staff 24 stated the resident's bed should be in the lowest position and a fall mat next to her/his bed. Staff 24 stated Resident 13 utilized a soft touch call light and it should be close to her/him when in bed because she/he rolled out of bed recently. On 6/1/21 at 10:20 AM Staff 14 (LPN/Unit Manager) stated Resident 13 was a fall risk and staff were expected to have the bed in a low position and a fall mat next to the resident's bed. The soft touch call light was to be close to Resident 13's body in case she/he rolled out of bed. On 6/9/21 at 3:26 PM Staff 1 (Administrator) and Staff 2 (DNS) were present for an interview. Staff 1 stated staff were expected to follow the care plan and Resident 13's soft touch call light was to be in a place where if she/he turned or rolled in bed Resident 13 would sound the alarm.

Based on interview and record review it was determined the facility failed to ensure staff were appropriately trained to provide safe transfers for a resident utilizing a hygiene sling for 1 of 3 sampled residents (#1) reviewed for accidents. Resident 1 fell out of a hygiene (designed for toileting and hygiene functions) sling and she/he sustained a left [CONDITION(S)]. Findings include: 1. Resident 1 admitted to the facility in 2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A revised care plan dated 2/26/21 indicated Resident 1 was a two person mechanical lift and hygiene sling to the bedside commode transfer. An Incident Report initiated on 2/27/21 revealed the following: -Resident 1 was transferred from the commode to her/his bed when Resident 1 fell out of the lift sling and landed on the floor. -Resident 1 hit the back of her/his head, then shoulders, back, hips and then her/his legs. The resident fell from approximately three feet in the air. -The resident was assessed and knew she/he fell from the lift, and was transported to the hospital. -A Magnetic Resonance Imaging (MRI) showed a small fracture to the left hip. -Staff 31 (CNA) had Resident 1 in the hygiene sling and was moving her/him back to the bed. Staff 38 (LPN/Unit Manager) was present for the transfer and Resident 1 fell out of the sling. Staff 31 did not notice the signs posted in Resident 1's room regarding the type of sling Resident 1 used and thought it looked like one she used a few weeks previously. Staff 31 thought she was trained to utilize the hygiene sling but it was not the same sling training. -Staff 38 indicated she was called into the room to assist with the transfer around 7:30 AM and Resident 1 was in the sling and Staff 38 was beginning the process for the resident's transfer. Staff 31 moved behind the resident and the commode and stated she needed to get Resident 1 back to bed for her/his brief and pants placement. Staff 38 began to turn the lift towards the bed when the resident fell . Staff 38 stated she noticed Resident 1 had her/his arms crossed inside the sling. Resident 1 complained of pain to her/his left hip. Staff 38 assessed Resident 1 and she/he was sent out to the hospital. -3/4/21 the facility ruled out abuse and neglect because Staff 31 did not realize Resident 1's arms were supposed to be on the outside of the sling which may have contributed to the resident sliding out of the sling. Staff 31 did not see the signs posted in Resident 1's room regarding the hygiene sling. The sling was discontinued for Resident 1 after the incident. Staff 38 did not realize anything was wrong until resident was observed with her/his arms crossed as she/he was falling out of the sling. On 5/24/21 at 2:04 PM Witness 11 (Family Member) stated she received a call from Staff 38 regarding Resident 1 falling out of the lift sling on 2/27/21. Witness 11 stated she was told Resident 1 fell hard on the floor hitting her head/neck and then hips. Witness 11 stated she spoke with Resident 1 prior to being sent to the hospital and encouraged her/him to go for further evaluation. Witness 11 stated after the event on 2/27/21 the facility had two care conferences with her/him and other family members, and the facility identified not all staff were trained on how to utilize the hygiene sling. Witness 11 stated the sling was recommended for Resident 1 so she/he could continue to utilize the commode for toileting. Witness 11 stated Staff 31 was not trained and did not utilize the hygiene sling correctly. On 5/27/21 at 11:03 AM Resident 1 stated she/he remembered falling out of the lift sling a couple of months ago, it hurt really bad and I broke my left hip from falling out of the lift. Resident 1 stated I hit my head on the floor but my left hip hurt the worst, and I was sent out to the hospital. Resident 1 stated two staff were in the room transferring her/him when she/he fell out of the sling. On 5/27/21 at 1:01 PM Staff 38 stated on 2/27/21 she was called into the room by Staff 31 to assist with transferring Resident 1. Staff 38 indicated she entered the room and Staff 31 already had Resident 1 in the hygiene sling and up in the air. Staff 38 stated Staff 31 needed to get Resident 1 back to bed and started to move her/him and Resident 1 fell right out of the sling onto the floor. Staff 38 stated Resident 1 was supposed to be holding onto the outside of sling straps and she/he was not. Staff 38 stated Resident 1 first hit her/his head during the fall and then the rest of her/his body. Staff 38 stated she assessed the resident who was conscious and ended up sending her/him out to the hospital. Resident 1 fractured her/his left hip due to the fall. Staff 38 stated Staff 31 was too far ahead of her by the time she entered the room and did not realize that Resident 1 was not holding onto the hygiene sling correctly. Staff 38 stated that's why we do a two person transfer assist with hygiene [mechanical lift] transfers so we have an extra set of eyes and hands in the room to ensure the lift and sling was correct and Resident 1 was transferred safely. On 5/27/21 at 4:17 PM Staff 31 stated she worked with Resident 1 on 2/27/21 when the transfer fall occurred. Staff 31 stated Resident 1 recently had a change in her/his transfer status to the lift sling but during shift change staff failed to mention it was a hygiene sling, which she never used. Staff 31 stated she was not educated or trained on how to use the hygiene sling, and assumed it was similar to a sling she used a few weeks prior on another resident. Staff 31 stated she was transferring Resident 1 off the commode and needed to put Resident 1 in her/his bed to get her/his pants back on. Staff 38 was in the room as Staff 31 started to move Resident 1 in the hygiene sling towards the bed and Resident 1 fell out of the sling, hitting her head/neck, and the rest of her/his body followed. Staff 31 stated the resident was upset and kept saying leave me here to die. On 5/27/21 at 3:30 PM and 6/9/21 at 3:17 PM Staff 1 (Administrator) and Staff 2 (DNS) were present for an interview. Staff 1 acknowledged the 2/27/21 fall was an unfortunate incident and the facility completed in-service training for staff regarding the use of the hygiene sling for Resident 1 prior to it being used on Resident 1. Staff 1 stated Staff 31 was not present prior to her use of the hygiene sling for Resident 1. Staff 1 stated one staff person could get a resident ready in a hygiene sling but two people were expected to be present when transferring and moving Resident 1 in the hygiene sling to ensure safety and the lift was operational.

Based on observation, interview and record review, the facility failed to ensure residents were free of abuse for 3 of 5 residents (#s 1, 2 and 3) reviewed for abuse. Resident 1, Resident 2 and Resident 3 experienced sexual abuse resulting in psychosocial harm. The residents suffered anxiety, intimidation and ongoing emotional distress. Resident 1 stated she/he did not feel safe. Findings include: The facility's Procedure on Protection of Residents: Reducing the Threat of Abuse & Neglect dated 5/2020 included the following elements: - Prohibit and prevent all forms of abuse, neglect, misappropriation of residents' property and exploitation, including sexual abuse. - Identify what constitutes abuse, neglect, exploitation and misappropriation of resident property. - Recognize signs of abuse, neglect, exploitation, and misappropriation of resident property, such as physical or psychosocial indicators. - Report abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown sources, and to whom and when staff and others must report their knowledge related to any alleged violation without fear of reprisal. - Understand behavioral symptoms of residents that may increase the risk of abuse and neglect and how to respond, including sudden or unexplained changes in behavior and/or activities such as fear of a person or place or feelings of guilt or shame. 1. Resident 1 admitted to the facility in 7/2017 with [DIAGNOSES REDACTED]. The Annual MDS dated [DATE] indicated Resident 1 had a BIMS score of 15 which indicated Resident 1 was cognitively intact. Resident 1 required extensive physical assistance with transfers, toilet use and personal hygiene. The 7/29/19 care plan indicated Resident 1 required moderate assistance of one staff for bathing. The 9/2/20 Shower Task Form indicated on 9/23/20 and 9/26/20 Staff 2 (CNA) assisted Resident 1 with her/his showers. Review of the Oregon State Board of Nursing (OSBN) Intake Investigation dated 9/28/20 at 4:25 AM indicated Witness 1 (family member) filed a complaint. Witness 1 indicated Resident 1 lived at the facility and stated she/he had been violated by Staff 2. Resident 1 also informed her that Staff 2 violated two other residents. Review of the facility Incident Investigation Report dated 9/28/20 indicated local law enforcement responded to the 9/28/20 OSBN report and arrived at the facility. The summary indicated Staff 2 was previously accused of inappropriate touching while working at the facility on 5/15/20, but due to a lack of evidence and the subjected resident's cognitive status the case was dismissed. Resident 1 indicated Staff 2 provided her/his care for the past few months, and indicated on 9/23/20 and 9/26/20 Staff 2 touched her/him inappropriately in the shower room. Resident 1 stated she/he informed Staff 4 (LPN) the night before that she/he did not want Staff 2 providing any care to her/him and wanted to speak to the administrator as soon as possible. Resident 1 informed local law enforcement that she/he felt unsafe in the facility, felt violated, and she/he was aware of two additional residents with similar allegations. A witness statement by Staff 1 (DNS) dated 9/28/20 at approximately 7:45 AM indicated Staff 3 (LPN) provided Staff 1 two notes, one written by Staff 3 and the other written by Staff 4 (LPN) during the previous shift. One note stated Resident 1 did not want Staff 2 in her/his room. The second note stated Resident 1 and Resident 2 did not want Staff 2 in their rooms. Staff 1 noted she gave the note to Staff 5 (Social Service Assistant) at 8:00 AM. A witness statement by Staff 5 dated 9/28/20 at approximately 8:00 AM indicated Staff 1 asked Staff 5 to follow up on a note received from Staff 3. The note indicated Resident 1 and Resident 2 did not want Staff 2 in their rooms and wanted to speak to the administrator as soon as possible. At 11:00 AM Resident 1 informed Staff 5 that she/he was fondled by Staff 2 during her/his showers. Resident 1 indicated this was not the first time Staff 2 touched her/him inappropriately. On 9/27/20 Resident 1 spoke with Resident 2 and Resident 3 and became aware that Staff 2 also touched them inappropriately. Resident 1 called Witness 1 to report Staff 2's inappropriate behavior. A FRI received by the State Agency on 9/28/20 at 11:07 AM indicated an un-witnessed allegation of staff to resident abuse. A witness statement by Staff 3 dated 9/29/20 at 12:30 PM indicated about a month previous to the statement another resident asked that Staff 2 not provide her/him showers and she did not follow up with the resident. Staff 3 stated she was adjusting the assignment sheets to accommodate the resident's preference but she never notified management of the resident's concern. A witness statement by Staff 7 (CNA) dated 9/30/20 at 12:05 PM indicated on 9/26/20 Staff 2 was trying to switch Staff 7's lunch break so he could provide bathing assistance to Resident 1 during her/his scheduled shower. Staff 7 stated she was capable of assisting Resident 1, but Staff 2 insisted and asked the charge nurse to switch their lunch breaks. The charge nurse did not question the reasoning and permitted Staff 2 to assist Resident 1 with her/his shower. Staff 7 stated Staff 2 was pushy about assisting Resident 1 with showers, and that it made her uncomfortable because it felt wrong. Staff 7 stated certain residents do not want (Staff 2) providing care and will refuse if he offers to assist. Staff 7 further stated she was aware of other residents who felt uncomfortable around Staff 2. A witness statement by Staff 4 (LPN) dated 10/2/20 at 5:00 AM revealed Resident 1 spoke with him on 9/27/20 and indicated she/he did not want Staff 2 in her/his room and she/he wanted to speak to the administrator. Staff 4 asked Resident 1 if he could help her/him but Resident 1 declined and only wanted to speak to the administrator. During an interview on 10/1/20 at 10:40 PM Staff 4 (LPN) stated, on 9/27/20 Resident 1 and Resident 2 approached him at approximately 10:00 PM. Resident 1 stated she/he did not want Staff 2 assigned to her/his care ever. Staff 4 indicated Resident 1 appeared to be in some distress but she/he did not want to discuss details and she/he asked to speak to the administrator as soon as possible. Staff 4 reassured Resident 2 he would write a note and give it to the administrator. Staff 4 confirmed he did not document the resident concerns and indicated he wrote her/his concerns on a note and gave the note to Staff 3 at 6:00 AM on 9/28/20. Staff 4 confirmed he failed to follow the facility abuse protocol. During an interview on 10/2/20 at 11:14 AM Staff 3 stated on 9/28/20 at 6:00 AM Staff 4 gave her a note that indicated Resident 1 and Resident 2 did not want Staff 2 assigned to their care, and both residents asked to speak with the administrator as soon as possible. Staff 3 stated at 8:00 AM she gave the note to Staff 1 (DNS). Staff 3 stated she did not think it was necessary to follow up with the residents or document their concerns and assumed management would look into it. Staff 3 wondered why Resident 1 did not want Staff 2 assigned to her/his care, but did not think there was cause for concern and did not follow up with Resident 1 or Resident 2 to ensure they felt safe. Staff 3 confirmed she was aware of other residents refusing care from Staff 2 and assumed management looked into it. Staff 3 acknowledged she failed to follow the facility abuse protocol. During an interview on 9/30/20 at 12:00 PM Staff 1 stated at that time she became aware of Staff 3 reassigning Staff 2 to accommodate resident concerns. Staff 1 confirmed Staff 3 reassigned Staff 2 for the past few months and staff should have followed up with the resident to identify any potential concerns and notify management. Staff 1 acknowledged staff failed to follow the facility abuse protocol. During an interview on 10/1/20 at 12:39 PM Staff 10 (LPN) indicated on 9/28/20 during shift change report Staff 4 stated Resident 1 and Resident 2 did not want Staff 2 assigned to their care. Staff 10 indicated she attempted to discuss this concern with the residents, but they declined and asked to speak to the administrator. Staff 10 stated she failed to document their concerns. During an interview on 10/1/20 at 2:57 PM Staff 7 stated on 9/26/20 Staff 2 asked her to switch her lunch break with him. Staff 7 declined and stated Staff 2 told her Resident 1 requested that Staff 2 provide assistance with Resident 1's shower. Staff 2 was assertive and already had the shower chair ready, so Staff 7 acquiesced and switched lunch breaks. Staff 7 did not ask Resident 1 if this was her/his preference but reported the matter to the charge nurse. Staff 7 stated Staff 2 often had inappropriate behavior and she reported this to Staff 8 (LPN) or Staff 1. During an interview on 10/1/20 at 3:47 PM Staff 5 indicated she was recently in her office and overheard a conversation between Staff 2 and Staff 7. Staff 2 asked Staff 7 to switch lunch breaks and insisted on assisting Resident 1 with her/his shower. On 9/28/20 at approximately 9:30 AM Staff 1 gave Staff 5 notes written by Staff 3 and Staff 4 during the previous shift and asked her to follow up with Resident 1 and Resident 2 who had concerns about Staff 2. On 10/1/20 at approximately 11:00 AM Resident 1 informed Staff 5 that on 9/23/20 and 9/26/20 Staff 2 touched her/him inappropriately during her/his shower. Resident 1 stated she/he reported this to Witness 1, Resident 2 and Resident 3. Resident 1 told Staff 5 she/he did not tell any staff because of all the mixed emotions she/he experienced and did not know what to do. Staff 5 stopped the interview to inform Staff 1. By the time Staff 5 reached Staff 1's office law enforcement arrived to the facility and Staff 2 was escorted out of the facility. During an interview on 10/2/20 at 12:00 PM Resident 1 stated on 9/27/27 at approximately 7:00 PM she/he notified Witness 1 she/he was assaulted by Staff 2. Resident 1 insisted she/he only wanted to speak to the administrator to address her/his concerns. Resident 1 told Staff 4 that she/he did not want Staff 2 providing any care to her/him or to Resident 2. Resident 1 further indicated she/he was touched inappropriately on two different occasions, the first on 9/23/20 when she/he was in her/his wheelchair and Staff 2 approached her/him from behind. Staff 2 then inappropriately grabbed her/his chest while he attempted to reposition her/him. Resident 1 indicated this was not necessary as she/he could reposition her/himself. The second occurrence transpired on 9/26/20 when Staff 2 touched her/him inappropriately during her/his shower. Resident 1 was shocked at the time, was unable to say anything and just froze. Resident 1 stated she/he felt unsafe in the facility. During an interview on 10/2/20 at 4:30 PM Staff 1 acknowledged the facility failed to ensure residents were free from abuse. During an interview on 10/6/20 at 10:52 AM Staff 2 stated he worked on 9/23/20 and 9/26/20 and he assisted Resident 1 with showers on both days. On 9/28/20 at 6:00 AM Staff 3 informed him that Resident 1 and Resident 2 did not want him to provide personal care to them and acknowledged he was not assigned to their care. Staff 2 denied touching Residents inappropriately, acknowledged a few months prior another resident requested that he not provide care to her/him, and confirmed a few months previously he was the subject of another abuse allegation. 2. Resident 2 admitted to the facility in 4/2012 with [DIAGNOSES REDACTED]. The Quarterly MDS dated [DATE] indicated Resident 2 had a BIMS score of 15 which indicated Resident 2 was cognitively intact. Resident 2 required two-person assistance with toileting, dressing, bed mobility and transfers and required supervision for bathing. Resident 2's care plan was last revised on 9/17/19 and indicated Resident 2 required moderate assistance with ADLs. No documentation was found to indicate Resident 2's preference for female only caregivers. The 10/6/20 Kardex (brief summary of resident care needs) indicated Resident 2 had no preference for gender of caregivers. A FRI received by the State Agency on 9/28/20 at 12:00 PM indicated an allegation of staff to resident abuse. Review of the Oregon State Board of Nursing (OSBN) Intake Investigation dated 9/28/20 at 4:25 AM indicated Witness 1 (family member) filed a complaint. Witness 1 indicated Resident 1 informed her that Staff 2 (CNA) violated Resident 2. Review of the facility Incident Investigation Report dated 9/28/20 revealed Resident 2 stated she/he had an incident with Staff 2 sometime in 8/2020. Resident 2 stated Staff 2 was observing Staff 7 (CNA) who was in training. Staff 7 was assisting Resident 2 with dressing when Staff 2 intervened, moved Staff 7's hands and touched Resident 2's chest. Resident 2 stated she/he exclaimed what the hell in response. Resident 2 told Staff 7 that she/he no longer wanted Staff 2 in her/his room because he made her/him feel uncomfortable. Resident 2 further stated after this incident Staff 2 continued to come into her/his room to provide meal service which made her/him feel uncomfortable. On 9/28/20 Resident 2 requested again she/he did not want Staff 2 in her/his room. A witness statement by Staff 3 (LPN) dated 9/29/20 at 12:30 PM indicated about a month previously Resident 2 informed Staff 3 that she/he did not want Staff 2 providing her/his bathing assistance. In a witness statement by Staff 6 (CNA) dated 9/29/20 at 1:40 PM Staff 6 acknowledged Resident 2 did not want Staff 2 providing her/his care. Staff 6 stated she did not ask Resident 2 why. In a witness statement by Staff 5 (Social Service Assistant) dated 9/29/20 at 2:40 PM she stated Resident 2 indicated when Staff 7 was still in training she was assisting Resident 2 with dressing when Staff 2 quickly leaned over her/him and aggressively grabbed her/his chest, which made her/him feel uncomfortable. After this incident Resident 2 told Staff 7 that she/he preferred female caregivers only, and that Staff 2 kept asking her/him why she/he did not want him as her/his caregiver and she/he told him I don't feel comfortable and I thought this was over, but Staff 2 continued to deliver the resident's meal trays. Resident 2 stated Staff 2 touched her/his chest each time he put the tray down on her/his bedside table. Resident 2 further stated she/he started crossing her/his arms to block Staff 2 from touching her/his chest. On 9/27/20 she/he went to Staff 4 and told him that she/he did not want Staff 2 in her/his room and asked to speak to the administrator. In a witness statement by Staff 7 dated 9/30/20 at 12:05 PM Staff 7 stated Staff 2 made certain residents feel uncomfortable and was known to make sexual jokes. Staff 7 confirmed over the past few months Resident 2 became uncomfortable with Staff 2 and did not want him providing care to her/him. Staff 7 stated every time Staff 2 worked he would answer Resident 2's call light even though he was not Resident 2's assigned caregiver, and Resident 2 refused care and asked for her/his assigned caregiver. Staff 7 stated there was a time when she was helping Resident 2 with dressing and Staff 2 came into her/his room around the privacy curtain to turn off her/his light. Staff 7 stated it was not necessary and Staff 2 could have turned it off from the door. Staff 7 stated it felt like Staff 2 invaded Resident 2's privacy and it was an opportunity for Staff 2 see Resident 2 undressed. During an interview on 10/1/20 at 1:32 PM Resident 2 stated sometime in 8/2020 Staff 2 and Staff 7 were in her/his room. Staff 7 was assisting her/him with dressing when Staff 2 abruptly moved Staff 7's hands and grabbed Resident 2's chest. Resident 2 stated she/he exclaimed what the hell and told Staff 7 she/he did not want Staff 2 in her/his room. After this incident Staff 2 continued to deliver her/his meal trays every day which made her/him feel uncomfortable. She/he had a table in front of her/his bed where staff placed her/his meal tray and when Staff 2 put her/his tray down he touched her/him inappropriately. She/he tried to protect her/himself but this made Staff 2 defensive. Staff 2 also came into Resident 2's room to answer her/his call light even though he was not the assigned caregiver, but she/he always refused his help and asked for the assigned caregiver. Resident 2 reported she/he asked Staff 7 why Staff 2 was still coming into her/his room and Staff 7 stated she did not know but reminded Staff 2 that he made Resident 2 feel uncomfortable. She/he felt intimidated and often stated out loud he's not supposed to be in my room. Resident 2 thought she/he was the only one Staff 2 was touching inappropriately, she/he felt responsible and like she/he had no control when he provided care. Resident 2 stated she/he I had a prolonged negative reaction every time he came into her/his room. During an interview on 10/1/20 at 2:57 PM Staff 7 recalled an incident sometime in 8/2020 when Staff 2 acted inappropriately toward Resident 2. Staff 7 was assisting Resident 2 with dressing when Staff 2 jumped in, moved her hands, grabbed Resident 2's chest and took over the task. Resident 2 exclaimed what the hell. Staff 7 stated she was shocked as this was not necessary and reported the incident to Staff 8 (LPN). Staff 7 confirmed Resident 2 requested that Staff 2 not be assigned to her/his care because he made her/him feel uncomfortable. Staff 7 further indicated although Staff 2 was no longer assigned to Resident 2's room he still went into her/his room to deliver meals. Staff 7 reminded Staff 2 that Resident 2 did not want him in her/his room because he made her/him feel uncomfortable. During an interview on 10/1/20 at 10:40 PM Staff 4 (LPN) stated on 9/27/20 at approximately 10:00 PM both Resident 1 and Resident 2 approached him in the hallway and requested that Staff 2 not be assigned to their care ever. Staff 4 indicated Resident 2 did not want to discuss details but requested to speak to the administrator. Staff 4 reassured Resident 2 he would write a note and give it to the oncoming shift. Staff 4 confirmed on 9/28/20 at 6:00 AM he gave the note to Staff 3. Staff 4 stated that a few month previously Staff 2 was a primary suspect in a similar allegation but stated it was unsubstantiated due to the resident having dementia. Staff 4 confirmed he did not follow the facility abuse protocol to ensure resident safety. During an interview on 10/2/20 at 11:14 AM Staff 3 confirmed a few months previously she became aware of Resident 2's preference for female only caregivers. Staff 3 stated for the past few months she reassigned Staff 2 to accommodate Resident 2's preference. Staff 3 further stated she never asked Resident 2 why she/he did not want Staff 2 assigned to her/his room but assumed management looked into it. Staff 3 also indicated she was aware Staff 2 was involved in a similar abuse allegation in the past but stated it was unsubstantiated and as a result did not report the current concerns. Staff 3 acknowledged she failed to follow facility abuse protocol. During an interview on 10/2/20 at 4:30 PM Staff 1 (DNS) acknowledged the facility failed to ensure residents were free from abuse and the current allegation was substantiated. During an interview on 10/6/20 at 10:52 AM Staff 2 confirmed a few months ago he was assigned to Resident 2's room until Staff 3 told him Resident 2 no longer wanted him assigned to room. Staff 3 never said why, and he did not ask. Staff 2 denied touching Resident 2 inappropriately. Staff 2 confirmed he was investigated for a similar allegation on 5/15/20. 3. Resident 3 admitted to the facility in 5/2018 with [DIAGNOSES REDACTED]. The Quarterly MDS dated [DATE] indicated Resident 3 had a BIMS score of 15 which indicated Resident 3 was cognitively intact. Resident 3 required partial assistance with bathing. Resident 3's care plan was last revised on 9/6/19 and indicated Resident 3 required moderate assistance with ADLs. No documentation was found to indicate Resident 3's preference for female only caregivers during showers. Resident 3's 10/9/20 Kardex (brief summary of resident care needs) indicated Resident 3 requested that all bathing assistance be provided by female staff, no exceptions. Review of the facility Incident Investigation Report 9/28/20 at 10:28 AM indicated Resident 3 stated Staff 2 (CNA) approached her/him from behind when she/he was sitting in her/his wheelchair and touched her/him inappropriately. A witness statement dated 9/28/20 at 12:10 PM revealed Staff 9 (Social Service Director) interviewed Resident 3 and asked if she/he was ever abused while at the facility. Resident 3 stated Yes and it happened to Resident 4 who has since discharged . We were both sexually abused by Staff 2 but I put a stop to it a few months ago. A FRI received by the State Agency on 9/28/20 at 4:25 PM indicated an un-witnessed allegation of staff to resident abuse. Resident 3 was questioned in a separate investigation that involved Staff 2 and other residents. Resident 3 was asked if she/he was ever abused and she/he stated yes, by Staff 2, but I put a stop to it months ago. In a witness statement by Staff 5 (Social Services Assistant) dated 9/29/20 at 4:30 PM Resident 3 stated sometime in 8/2020 Staff 2 came up from behind her/him and grabbed her/his chest to lift her/him up in her/his wheelchair. Staff 2 also kissed her/him on the lips when she/he was lying in her/his bed. Resident 3 stated it happened about five times, and she/he dreaded the days when Staff 2 would come to work. Staff 2 asked her/him if she/he was uncomfortable and Resident 3 told him Yes, this better stop. Staff 2 also told Resident 3 that he was accused of touching another resident inappropriately. During an interview on 10/1/20 at 12:20 PM Resident 3 stated sometime in 7/2020 or late 8/2020 Staff 2 came up behind her/him and grabbed her/his chest. Staff 2 asked if her/him if she/he was uncomfortable and Resident 3 stated she/he told Staff 2 Yes, you better stop that. Staff 2 touched her/him inappropriately at least one time per shift for a week, and also kissed her/him on the lips approximately five times when she/he was alone in her/his room. Resident 3 stated she/he told staff that she/he did not want Staff 2 in her/his room. During an interview on 10/2/20 at 4:30 PM Staff 1 (DNS) acknowledged the facility failed to ensure residents were free from abuse and the current allegation was substantiated. During an interview on 10/6/20 at 11:00 AM Staff 2 confirmed he worked with Resident 3. Staff 2 denied all allegations of inappropriate behavior involving Resident 3.

Based on interview and record review it was determined the facility failed to timely investigate, and report abuse for 2 of 5 residents (#s 1 and 2) reviewed for abuse. Resident 1 and Resident 2 experienced psychosocial harm as evident by feelings of anxiety, intimidation and ongoing emotional discomfort. Resident 1 stated she/he did not feel safe. Findings include: The facility's Procedure on Protection of Residents: Reducing the Threat of Abuse & Neglect dated 5/2020 included measures to implement: - Prohibit and prevent all forms of abuse, neglect, misappropriation of residents' property and exploitation, including sexual abuse. - Identify what constitutes abuse, neglect, exploitation and misappropriation of resident property. - Recognize signs of abuse, neglect, exploitation, and misappropriation of resident property, such as physical or psychosocial indicators. - Report abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown sources, and to whom and when staff and others must report their knowledge related to any alleged violation without fear of reprisal. - Understand behavioral symptoms of residents that may increase the risk of abuse and neglect and how to respond, including sudden or unexplained changes in behavior and/or activities such as fear of a person or place or feelings of guilt or shame. 1. Resident 1 admitted to the facility in 7/2017 with [DIAGNOSES REDACTED]. The Annual MDS dated [DATE] indicated Resident 1 had a BIMS score of 15 which indicated Resident 1 was cognitively intact. Resident 1 required extensive physical assistance with transfers, toilet use and personal hygiene. The 7/29/19 care plan indicated Resident 1 required moderate assistance by one staff for bathing. During an interview on 10/1/20 at 10:40 PM Staff 4 (LPN) stated, on 9/27/20 Resident 1 and Resident 2 approached him at approximately 10:00 PM. Resident 1 stated she/he did not want Staff 2 assigned to her/his care ever. Staff 4 indicated Resident 1 appeared to be in some distress but she/he did not want to discuss details and she/he asked to speak to the administrator as soon as possible. Staff 4 reassured Resident 2 he would write a note and give it to the administrator. Staff 4 confirmed he did not document the resident concerns and indicated he wrote her/his concerns on a note and gave the note to Staff 3 at 6:00 AM on 9/28/20. Staff 4 confirmed he failed to follow the facility abuse protocol. During an interview on 10/2/20 at 11:14 AM Staff 3 stated on 9/28/20 at 6:00 AM Staff 4 gave her a note that indicated Resident 1 and Resident 2 did not want Staff 2 assigned to their care, and both residents asked to speak with the administrator as soon as possible. Staff 3 stated at 8:00 AM she gave the note to Staff 1 (DNS). Staff 3 stated she did not think it was necessary to follow up with the residents or document their concerns and assumed management would look into it. Staff 3 wondered why Resident 1 did not want Staff 2 assigned to her/his care, but did not think there was cause for concern and did not follow up with Resident 1 or Resident 2 to ensure they felt safe. Staff 3 confirmed she was aware of other residents refusing care from Staff 2 and assumed management looked into it. Staff 3 acknowledged she failed to follow the facility abuse protocol. During an interview on 10/2/20 at 12:00 PM Resident 1 stated on 9/27/20 she/he told Staff 4 that she/he did not want Staff 2 providing any care to her/him and Resident 2 and asked to speak to the administrator as soon as possible. Resident 1 stated she/he did not feel safe. During an interview on 10/2/20 at 4:30 PM Staff 1 acknowledged the facility failed to act timely to protect the residents from abuse. 2. Resident 2 admitted to the facility in 4/2012 with [DIAGNOSES REDACTED]. The Quarterly MDS dated [DATE] indicated Resident 2 had a BIMS score of 15 which indicated Resident 2 was cognitively intact. Resident 2 required two person assists with toilet use, dressing, bed mobility and transfers and required supervision for bathing. Resident 2's care plan was last revised on 9/17/19 and indicated Resident 2 required moderate assistance with ADLs. During an interview on 9/29/20 at 10:15 AM Staff 6 (CNA) indicated Staff 2 (CNA) was primarily assigned to Resident 2's care until a few months ago. Staff 6 stated Staff 3 (LPN) informed her Resident 2 did not want Staff 2 assigned to her/his care and they needed to switch rooms and chart accordingly. Staff 6 indicated she never asked Resident 2 when she/he did not want Staff 2 assigned to her/his care. During an interview on 10/1/20 at 1:32 PM Resident 2 stated sometime in 8/2020 Staff 2 and Staff 7 were in her/his room. Staff 7 was assisting her/him with dressing when Staff 2 abruptly moved Staff 7's hands and grabbed Resident 2's chest. Resident 2 stated she/he exclaimed what the hell and told Staff 7 she/he did not want Staff 2 in her/his room. After this incident Staff 2 continued to deliver her/his meal trays every day which made her/him feel uncomfortable. She/he had a table in front of her/his bed where staff placed her/his meal tray and when Staff 2 put her/his tray down he touched her/him inappropriately. She/he tried to protect her/himself but this made Staff 2 defensive. Staff 2 also came into Resident 2's room to answer her/his call light even though he was not the assigned caregiver, but she/he always refused his help and asked for the assigned caregiver. Resident 2 reported she/he asked Staff 7 why Staff 2 was still coming into her/his room and Staff 7 stated she did not know but reminded Staff 2 that he made Resident 2 feel uncomfortable. She/he felt intimidated and often stated out loud he's not supposed to be in my room. Resident 2 thought she/he was the only one Staff 2 was touching inappropriately, she/he felt responsible and like she/he had no control when he provided care. Resident 2 stated she/he I had a prolonged negative reaction every time he came into her/his room. During an interview on 10/1/20 at 2:57 PM Staff 7 recalled an incident sometime in 8/2020 when Staff 2 acted inappropriately toward Resident 2. Staff 7 was assisting Resident 2 with dressing when Staff 2 jumped in, moved her hands, grabbed Resident 2's chest and took over the task. Resident 2 exclaimed what the hell. Staff 7 stated she was shocked as this was not necessary and reported the incident to Staff 8 (LPN). Staff 7 confirmed Resident 2 requested that Staff 2 not be assigned to her/his care because he made her/him feel uncomfortable. Staff 7 further indicated although Staff 2 was no longer assigned to Resident 2's room he still went into her/his room to deliver meals. Staff 7 reminded Staff 2 that Resident 2 did not want him in her/his room because he made her/him feel uncomfortable. During an interview on 10/1/20 at 10:40 PM Staff 4 (LPN) stated on 9/27/20 at approximately 10:00 PM both Resident 1 and Resident 2 approached him in the hallway and requested that Staff 2 not be assigned to their care ever. Staff 4 indicated Resident 2 did not want to discuss details but requested to speak to the administrator. Staff 4 reassured Resident 2 he would write a note and give it to the oncoming shift. Staff 4 confirmed on 9/28/20 at 6:00 AM he gave the note to Staff 3. Staff 4 stated that a few month previously Staff 2 was a primary suspect in a similar allegation but stated it was unsubstantiated due to the resident having dementia. Staff 4 confirmed he did not follow the facility abuse protocol to ensure resident safety. During an interview on 10/2/20 at 11:14 AM Staff 3 confirmed a few months previously she became aware of Resident 2's preference for female only caregivers. Staff 3 stated for the past few months she reassigned Staff 2 to accommodate Resident 2's preference. Staff 3 further stated she never asked Resident 2 why she/he did not want Staff 2 assigned to her/his care but assumed management looked into it. Staff 3 also indicated she was aware Staff 2 was involved in a similar abuse allegation in the past but stated it was unsubstantiated and as a result did not report the current concerns. Staff 3 acknowledged she failed to follow facility protocol. During an interview on 10/2/20 at 4:30 PM Staff 1 (DNS) acknowledged the facility failed to act timely to protect the residents from abuse.

Based on interview and record review it was determined the facility failed to revise care plan interventions for 3 of 5 sampled residents (#s 1, 2 and 3) reviewed for abuse. Resident 1 and Resident 2 experienced psychosocial harm as evident by feelings of anxiety, intimidation and ongoing emotional discomfort. Resident 1 stated she/he did not feel safe. Findings include: 1. Resident 1 admitted to the facility in 7/2017 with [DIAGNOSES REDACTED]. The Annual MDS dated [DATE] indicated Resident 1 had a BIMS score of 15 which indicated Resident 1 was cognitively intact. Resident 1's care plan last revised on 7/29/19 indicated Resident 1 required moderate assistance with ADLs. The care plan did not indicate Resident 1's preference for female only caregivers. During an interview on 10/1/20 at 10:40 PM Staff 4 (LPN) stated, on 9/27/20 Resident 1 stated she/he did not want Staff 2 (CNA) assigned to her/his care ever. Staff 4 confirmed he did not update Resident 1's care plan. During an interview on 10/1/20 at 12:39 PM Staff 10 (LPN) stated on 9/28/20 during shift change report Staff 4 stated Resident 1 did not want Staff 2 assigned to her/his care. Staff 10 stated she failed to document Resident 1's concerns and did not update Resident 1's care plan. During an interview on 10/2/20 at 11:14 AM Staff 3 (LPN) confirmed on 9/28/20 at 6:00 AM Staff 4 gave her a note that indicated Resident 1 did not want Staff 2 assigned to her/his care. Staff 3 confirmed she did not update Resident 1's care plan to reflect Resident 1's preferences. During an interview on 10/2/20 at 12:00 PM Resident 1 stated she/he felt uncomfortable with Staff 2 and on 9/28/20 asked to be provided care by female only caregivers because she/he felt unsafe. A review of Residents 1's clinical record revealed no indication her/his care plan was updated to reflect her/his preferences for female only caregivers. During an interview on 10/2/20 at 4:30 PM Staff 1 (DNS) confirmed the facility failed to update Resident 1's care plan reguarding her/his preference for female only caregivers. 2. Resident 2 admitted to the facility in 4/2012 with [DIAGNOSES REDACTED]. The Quarterly MDS dated [DATE] indicated Resident 2 had a BIMS score of 15 which indicated Resident 2 was cognitively intact. Resident 2's care plan, last revised on 9/17/19 did not indicate Resident 2's preference for only female caregivers. The 10/6/20 Kardex (brief summary of resident care needs) indicated Resident 2 had no preference for gender of caregivers. During an interview on 10/1/20 at 10:40 PM Staff 4 (LPN) stated on 9/27/20 Resident 2 stated she/he did not want Staff 2 (CNA) assigned to her/his care. Staff 4 confirmed he did not update Resident 2's care plan. During an interview on 10/2/20 at 11:14 AM Staff 3 (LPN) confirmed on 9/28/20 at 6:00 AM Staff 4 gave her a note that indicated Resident 2 did not want Staff 2 assigned to her/his care. Staff 3 confirmed she failed to update Resident 2's care plan. A review of Residents 2's clinical record staff failed to update her/his care plan. During an interview on 10/2/20 at 4:30 PM Staff 1 (DNS) acknowledged the facility failed to updated Resident 2's care plan. 3. Resident 3 admitted to the facility in 5/2018 with [DIAGNOSES REDACTED]. The Quarterly MDS dated [DATE] indicated Resident 3 had a BIMS score of 15 which indicated Resident 3 was cognitively intact. Resident 3 required partial assistance with bathing. Resident 3's care plan was last revised on 9/6/19 and indicated Resident 3 required moderate assistance with ADLs. The care plan did not indicate Resident 3's preference for female only caregivers during showers. Resident 3's Kardex (brief summary of resident care needs) printed on 10/9/20 indicated Resident 3 requested that all bathing assistance be provided by female staff, no exceptions. During an interview on 9/29/20 at 12:45 PM Staff 6 (CNA) stated approximately three months ago Staff 3 (LPN) informed her that Resident 3 did not want Staff 2 providing her/his care. Staff 6 stated Staff 3 told her she would reassign her to Resident 3 when Staff 2 was working. During an interview on 10/2/20 at 11:14 AM Staff 3 (LPN) confirmed a few months ago she became aware of Resident 3's request to not have Staff 2 assigned to her/his care. Staff 3 confirmed she reassigned Staff 2 to accommodate Resident 3's preference. Staff 3 confirmed she did not update Resident 3's care plan. During an interview on 10/2/20 at 4:30 PM Staff 1 (DNS) acknowledged the facility failed to updated Resident 3's care plan.

Based on interview and record review it was determined facility staff failed to adhere to professional standards related to abuse prevention for 2 of 5 Residents (#s 1 and 2) reviewed for abuse. Resident 1 and Resident 2 experienced psychosocial harm as evident by feelings of anxiety, intimidation and ongoing emotional discomfort. Resident 1 stated she/he did not feel safe. Findings include: Per Division 45 Standards and Scope of Practice for the License Practical Nurse, Oregon Administrative Rule [PHONE NUMBER] Conduct Derogatory to the Standard of Nursing Defined included the following: (1) Conduct related to general fitness to practice nursing: (a) Demonstrated incidents of violent, abusive, intimidating, neglectful or reckless behavior; (I) Failing to report actual or suspected incidents of abuse, neglect or mistreatment; (4) Conduct related to communication: (C) Failing to document information pertinent to a client's care; (8) Conduct related to other federal or state statute or rule violations: (d) Abusing a client; (f) Failing to report actual or suspected incidents of client abuse to the appropriate state agencies. 1. Resident 1 admitted to the facility in 7/2017 with [DIAGNOSES REDACTED]. The Annual MDS dated [DATE] indicated Resident 1 had a BIMS score of 15 which indicated Resident 1 was cognitively intact. A FRI received by the State Agency on 9/28/20 at 11:07 AM indicated an un-witnessed allegation of staff to resident abuse. During an interview on 10/1/20 at 10:40 PM Staff 4 (LPN) stated on 9/27/20 Resident 1 stated she/he did not want Staff 2 (CNA) assigned to her/his care ever. Staff 4 indicated Resident 1 appeared to be in some distress, but she/he did not want to discuss details and she/he asked to speak to the administrator as soon as possible. Staff 4 confirmed he did not document Resident 1's concerns in her/his chart and did not report her/his concerns to the administrator. Staff 4 indicated he gave a note to Staff 3 (LPN) during shift change on 9/28/29 at 6:00 AM. Staff 4 confirmed he failed to follow the facility abuse protocol. During an interview on 10/2/20 at 11:14 AM Staff 3 (LPN) confirmed on 9/28/20 at 6:00 AM Staff 4 gave her a note that indicated Resident 1 did not want Staff 2 assigned to her/his care and asked to speak with the administrator as soon as possible. Staff 3 stated at 8:00 AM she gave the note to Staff 1 (DNS). Staff 3 stated she did not think it was necessary to follow up with Resident 1 or document her/his concerns and assumed management would look into it. Staff 3 wondered why Resident 1 did not want Staff 2 assigned to her/his care but did not think there was cause for concern and did not follow up with Resident 1 to ensure she/he felt safe. Staff 3 confirmed for the past few months she was aware of other residents refusing care from Staff 2 and confirmed she was reassigning Staff 2 to accommodate resident preferences. Staff 3 acknowledged she failed to follow up with Resident 1 to ensure she/he felt safe. Staff 3 acknowledged she failed to report to management and document Resident 1's concerns in her/his chart. Staff 3 also confirmed she failed to follow the facility abuse protocol. During an interview on 10/2/20 at 12:00 PM Resident 1 stated on 9/27/27 at approximately 7:00 PM she/he notified Witness 1 she/he was assaulted by Staff 2. Resident 1 insisted she/he only wanted to speak to the administrator to address her/his concerns. Resident 1 told Staff 4 that she/he did not want Staff 2 providing any care to her/him or to Resident 2. Resident 1 further indicated she/he was touched inappropriately on two different occasions, the first on 9/23/20 when she/he was in her/his wheelchair and Staff 2 approached her/him from behind. Staff 2 then inappropriately grabbed her/his chest while he attempted to reposition her/him. Resident 1 indicated this was not necessary as she/he could reposition her/himself. The second occurrence transpired on 9/26/20 when Staff 2 touched her/him inappropriately during her/his shower. Resident 1 was shocked at the time, was unable to say anything and just froze. Resident 1 stated she/he felt unsafe in the facility. During an interview on 10/2/20 at 4:30 PM Staff 1 (DNS) acknowledged failed staff follow professional standards of practice after Resident 1 reported allegations of abuse related to Staff 2. Refer to F610 2. Resident 2 admitted to the facility in 4/2012 with [DIAGNOSES REDACTED]. The Quarterly MDS dated [DATE] indicated Resident 2 had a BIMS score of 15 which indicated Resident 2 was cognitively intact. Resident 2's care plan last revised on 9/17/19, indicated Resident 2 required moderate assistance with ADLs. A FRI received by the State agency on 9/28/20 at 12:00 PM indicated an allegation of staff to resident abuse. During an interview on 9/30/20 at 12:00 PM Staff 1 (DNS) stated at that time she became aware of Staff 3 (LPN) reassigning Staff 2 (CNA) to accommodate resident concerns. Staff 1 confirmed Staff 3 reassigned Staff 2 for the past few months and staff should have followed up with the resident to identify any potential concerns and notify management. Staff 1 acknowledged staff failed to follow the facility abuse protocol. During an interview on 10/1/20 at 10:40 PM Staff 4 (LPN) stated on 9/27/20 Resident 2 approached him at approximately 10:00 PM. Resident 2 stated she/he did not want Staff 2 assigned to her/his care ever. Staff 4 reassured Resident 2 he would write a note and give it to the administrator. Staff 4 confirmed he did not document Resident 2's concerns in her/his chart and did not report her/his concerns to the administrator. Staff 4 indicated he gave the note to Staff 3 (LPN) during shift change on 9/28/29 at 6:00 AM. Staff 4 confirmed he failed to follow the facility abuse protocol. During an interview on 10/1/20 at 1:32 PM Resident 2 stated sometime in 8/2020 Staff 2 and Staff 7 were in her/his room. Staff 7 was assisting her/him with dressing when Staff 2 abruptly moved Staff 7's hands and grabbed Resident 2's chest. Resident 2 stated she/he exclaimed what the hell and told Staff 7 she/he did not want Staff 2 in her/his room. After this incident Staff 2 continued to deliver her/his meal trays every day which made her/him feel uncomfortable. She/he had a table in front of her/his bed where staff placed her/his meal tray and when Staff 2 put her/his tray down he touched her/him inappropriately. She/he tried to protect her/himself but this made Staff 2 defensive. Staff 2 also came into Resident 2's room to answer her/his call light even though he was not the assigned caregiver, but she/he always refused his help and asked for the assigned caregiver. Resident 2 reported she/he asked Staff 7 why Staff 2 was still coming into her/his room and Staff 7 stated she did not know but reminded Staff 2 that he made Resident 2 feel uncomfortable. She/he felt intimidated and often stated out loud he's not supposed to be in my room. Resident 2 thought she/he was the only one Staff 2 was touching inappropriately, she/he felt responsible and like she/he had no control when he provided care. Resident 2 stated she/he I had a prolonged negative reaction every time he came into her/his room. During an interview on 10/2/20 at 11:14 AM Staff 3 confirmed on 9/28/20 at 6:00 AM Staff 4 gave her a note that indicated Resident 2 did not want Staff 2 assigned to her/his care and asked to speak with the administrator as soon as possible. Staff 3 stated at 8:00 AM she gave the note to Staff 1. Staff 3 stated she did not think it was necessary to follow up with Resident 2 or document her/his concerns and assumed management would look into it. Staff 3 did not think there was cause for concern and did not follow up with Resident 2 to ensure she/he felt safe. Staff 3 confirmed over the past few months she was aware that Resident 2 preferred not to have Staff 2 assigned to her/his care and acknowledged she reassigned Staff 2 to accommodate Resident 2's preference. Staff 3 acknowledged she failed to follow up with Resident 2 to ensure she/he felt safe. Staff 3 also acknowledged she failed to report to management and document Resident 2's concerns. Staff 3 confirmed she failed to follow the facility abuse protocol. A review of Resident 2's clinical record revealed no indication staff took any action related to her/his concern regarding Staff 2 and failed to update her/his care plan to indicate her/his preferences. During an interview on 10/2/20 at 4:30 PM Staff 1 acknowledged facility staff failed to follow professional standards of practice after Resident 2 reported allegations of abuse related to Staff 2.

Based on interview and record review it was determined the facility failed to report an allegation of neglect to the appropriate State agency within five days for 1 of 4 sampled residents (#5) reviewed for safety and falls. Resident 5's care plan was not followed regarding transfers and the resident was diagnosed with [REDACTED]. Resident 5 was admitted to the facility in 2016 with [DIAGNOSES REDACTED]. Review of an in-room care plan dated 11/28/17 revealed the resident required two person assistance with transfers. Review of a late entry nursing note for 12/16/17 revealed Resident 5 reported right leg/knee pain and decreased movement of the knee. The note indicated her/his right leg was twisted during a transfer. Review of a Corrective Action Form dated 12/19/17 revealed a facility staff member incorrectly transferred Resident 5 and did not follow the resident's care plan regarding transfers. The form indicated the resident had hip pain due to the incorrect transfer. Review of an incident investigation dated 12/21/17 revealed the resident was incorrectly transferred from bed to a wheelchair on 12/16/17. The resident required two person assistance with transfers and the use of a slide board per the resident's care plan. The resident was transferred with only one person and staff used a stand pivot technique. After the transfer the resident complained of knee and hip pain. The investigation concluded the resident care plan was not followed regarding the transfer which resulted in the resident having leg pain. An update to the investigation on 12/23/17 revealed the resident was diagnosed with [REDACTED]. Review of a Nursing Facility Incident Self-Report form dated 12/26/17 revealed the facility reported the incident to the local state agency. In an interview on 1/23/18 at 11:15 AM Staff 3 (DNS) acknowledged the incident on 12/16/17 was not reported to the local State agency within five days. Refer to F689

Based on interview and record review it was determined facility staff failed to follow professional standards of practice regarding a transfer for 1 of 3 sampled residents (#5) reviewed for falls and safety. Resident 5 was care planned for two person assistance with transfers, was transferred with one person assistance and the resident was diagnosed with [REDACTED]. Findings include: Resident 5 was admitted to the facility in 2016 with [DIAGNOSES REDACTED]. 851-063-0030 Authorized Duties and Standards for Certified Nursing Assistant 1 (CNA 1): (B) Moving and transferring clients; (d) Follow the care plan as directed by the licensed nurse; Review of an in-room care plan dated 11/28/17 revealed the resident was to be transferred with the assistance of two staff and a slide board. Review of an incident investigation dated 12/21/17 revealed Resident 5 complained of pain to the right knee and hip after a transfer on 12/16/17. The investigation concluded facility staff transferred the resident from bed to a wheelchair with the assistance of Staff 10 (CNA) and Staff 10 used a stand pivot technique. The resident's care plan indicated the resident was to be transferred with two person assistance and the use of a slide board. The investigation also indicated the resident care plan was not followed regarding transfers which resulted in right leg pain. An update to the investigation on 12/23/17 revealed the resident was sent to a local hospital and diagnosed with [REDACTED]. Review of a hospital discharge note dated 12/30/17 revealed the resident was admitted to the hospital on [DATE] and was diagnosed with [REDACTED]. In an interview on 1/19/18 at 10:22 AM Resident 5, who was alert and oriented, said on 12/16/17 she/he was transferred from bed to a wheelchair. Resident 5 said only Staff 10 transferred her/him to the wheelchair using a stand pivot technique and without the use of a slide board. Resident 5 said her/his foot was caught in between the CNAs legs and during the transfer the resident's leg was twisted. Resident 5 said she/he was diagnosed with [REDACTED]. In an interview on 1/23/18 at 9:26 AM Staff 10 (CNA) said on 12/16/17 she transferred the resident from bed to a wheelchair by herself and did not use a slide board. Staff 10 said after the transfer the resident complained of knee pain and she reported to the charge nurse. Staff 10 said she knew the resident's care plan indicated the resident required two staff and the use of a slide board for transfers. In an interview on 1/23/18 at 11:15 AM Staff 3 (DNS) acknowledged the resident's care plan was not followed regarding transfers which resulted the the resident's knee fracture. For additional information refer to F689.

Based on interview and record review it was determined the facility failed to follow the care plan regarding transfers for 1 of 4 sampled residents (#5) reviewed for safety and falls. Resident 5 was care planned for two person assistance with transfers, was transferred with one person assistance and the resident was diagnosed with [REDACTED]. Findings include: Resident 5 was admitted to the facility in 2016 with [DIAGNOSES REDACTED]. Review of an in-room care plan dated 11/28/17 revealed the resident was to be transferred with the assistance of two staff and a slide board. Review of a late entry nurse's note for 12/16/17 revealed the resident complained of right knee and leg pain. The note indicated the resident's leg was twisted during a transfer. Review of a note to the resident's physician dated 12/17/17 revealed the resident complained of severe pain of the right knee and hip. The note requested an x-ray be completed of the resident's right leg. Review of an x-ray dated 12/17/17 revealed no right leg fracture. Review of a nurse's note dated 12/18/17 at 10:37 AM revealed the resident continued to have right knee and leg pain and pain medication was administered with minimal effectiveness. The note indicated the resident's knee was not red or swollen. Review of an incident investigation dated 12/21/17 revealed Resident 5 complained of pain to the right knee and hip after a transfer on 12/16/17. The investigation concluded facility staff transferred the resident from bed to a wheelchair with the assistance of one person and used a stand pivot technique. The resident's care plan indicated the resident was to be transferred with two person assistance and the use of a slide board. The investigation also indicated the resident care plan was not followed regarding transfers which resulted in right leg pain. An update to the investigation on 12/23/17 revealed the resident was sent to a local hospital and diagnosed with [REDACTED]. Review of a nurse's note dated 12/23/17 at 8:06 AM revealed the resident was sent to a local hospital for evaluation due to right knee pain. The note indicated a resident family member called the facility and informed the facility the resident was diagnosed with [REDACTED]. Review of a hospital discharge note dated 12/30/17 revealed the resident was admitted to the hospital on [DATE] and was diagnosed with [REDACTED]. In an interview on 1/19/18 at 10:22 AM Resident 5, who was alert and oriented, said on 12/16/17 she/he was transferred from bed to a wheelchair. Resident 5 said only one CNA transferred her/him to the wheelchair using a stand pivot technique and without the use of a slide board. Resident 5 said her/his foot was caught in between the CNAs legs and during the transfer the resident's leg was twisted. Resident 5 said she/he was diagnosed with [REDACTED]. In an interview on 1/23/18 at 9:26 AM Staff 10 (CNA) said on 12/16/17 she transferred the resident from bed to a wheelchair by herself and did not use a slide board. Staff 10 said after the transfer the resident complained of knee pain and she reported to the charge nurse. Staff 10 said she knew the resident's care plan indicated the resident required two staff and the use of a slide board for transfers. In an interview on 1/23/18 at 11:15 AM Staff 3 (DNS) acknowledged the resident's care plan was not followed regarding transfers which resulted the the resident's knee fracture.

Based on interview and record review it was determined the facility failed to follow physician's orders regarding wound care for 2 of 3 sampled residents (#s 2 and 3) reviewed for wounds. Resident 2's wound vac dressing was not changed as ordered and the resident required hospitalization to surgically remove the wound dressing material from the resident's wound. Findings include: 1. Resident 2 was admitted to the facility in 2016 with [DIAGNOSES REDACTED]. Review of a hospital discharge summary dated 9/20/16 revealed the resident fell on [DATE] which resulted in a hematoma to the right arm. The note indicated the resident's hematoma worsened and the resident required surgical drainage of the area. The resident was sent to the facility with a wound vac (specialized device that promotes wound healing by applying a vacuum through a special sealed dressing) on the right arm and the facility was to provide ongoing wound care. Review of a Care Transfer Form dated 9/20/16 revealed orders for wound care included dressing changes three times a week. Review of a dressing change reference guide and manufacture's recommendations revealed the wound vac dressing should be changed no less than three times a week (kci-medical.com) Review of a nurse's note dated 9/20/16 at 9:57 pm revealed the resident was readmitted to the facility from a local hospital with a wound vac to the right arm. Review of a care plan dated 9/20/16 revealed the resident had an open wound to the right arm and staff interventions included wound care per physician's orders. Review of nurse's notes from 9/21/16 through 9/28/16 revealed the resident's wound vac dressing was changed one time on 9/23/16. Review of a TAR from 9/20/16 through 9/28/16 revealed no documentation the resident's wound vac dressing was changed. Review of a Family Nurse Practitioner (FNP) note dated 9/28/16 revealed the resident was seen at the facility for follow up of the resident's right arm wound. The note indicated the wound dressing material was completely embedded in the resident's wound and could not be removed. The note also indicated the embedded material was consistent with no wound dressing changes for several days. The resident was sent to a local hospital for removal of the dressing material from the resident's wound. Review of a nurse's note on 9/28/16 revealed the resident was sent to a local hospital for evaluation per FNP orders. Review of a hospital note dated 9/28/16 revealed the wound vac dressing material had grown into the resident's wound and the resident required surgical removal of the material on 9/29/16. In an interview on 11/21/16 at 10:24 am Witness 1 (FNP) said the resident was admitted to the facility on [DATE] with a wound vac after surgical drainage of a right arm hematoma. Witness 1 said she visited the resident on 9/28/16 to follow up on the resident's wound and found the wound vac material was embedded in the resident's wound. Witness 1 said the facility had not changed the resident's wound dressing and the dressing should have been changed at least three times a week. Witness 1 said she instructed the facility to send the resident to a local hospital for removal of the dressing material. Witness 1 said the dressing material would not have been embedded in the resident's wound if the facility had changed the resident's wound vac dressing. In an interview on 11/22/16 at 10:00 am Staff 1 (LPN) said she might have changed the resident's wound vac dressing on 9/26/16 but did not document the dressing change on the TAR. Staff 1 did not know why she did not document. In an interview on 11/22/16 at 10:10 am Staff 2 (LPN) said the standard for wound vac dressing changes was three times a week. Staff 2 said he might have changed the resident's wound vac dressing but could not remember when and did not document the change. In an interview on 11/22/16 at 10:30 am Staff 3 (LPN) she did not change the resident's wound vac dressing and did not know it was to be changed at the facility. Staff 3 said wound dressing changes are usually completed on day shift on Monday, Wednesday and Friday. In an interview on 11/22/16 at 11:10 am Staff 4 (DNS) said the standard was to change wound vac dressings at least three times a week and acknowledged the resident's wound vac was not changed as ordered. In an interview on 11/28/16 at 9:06 am Staff 5 (LPN) said the resident's wound vac dressing should have been changed three times a week and said she changed the resident wound vac dressing on 9/23/16. In an interview on 11/28/16 at 12:45 pm Staff 6 (LPN) said she worked the day shift on 9/26/16, 9/27/16 and 9/28/16. Staff 6 said she might have changed the resident's wound vac dressing but could not remember. Staff 6 said Witness 1 visited the resident on 9/28/16 and could not remove the dressing material from the resident's wound. Staff 6 said she was instructed by Witness 1 to send the resident to a local hospital for removal of the material from the resident's wound. 2. Resident 3 was admitted to the facility in 2016 with [DIAGNOSES REDACTED]. Review of an admission nursing assessment dated [DATE] revealed the resident had a post surgical back incision on the midline of the resident's spine. Review of physician's orders dated 11/17/16 revealed the facility was to wash the resident's back incision with soap and water daily. Review of a TAR from 11/18/16 through 11/22/16 revealed no documentation the resident's back incision was washed with soap and water. In an interview on 11/23/16 at 11:00 am Resident 3 said facility staff washed her/his back incision only one time since she/he was at the facility. In an interview on 11/23/16 at 11:30 am Staff 4 (DNS) acknowledged the physician's orders were not followed regarding cleansing of Resident 3's back incision.

1. Based on interview and record review it was determined the facility failed to ensure Staff 10 (LPN) accurately read the resident's order for insulin, administered insulin correctly and that resident concerns regarding the wrong dose of insulin were addressed before administering the medication for 1 of 1 sampled residents (#3). Resident 3 received an overdose of insulin and was hospitalized . Findings include: The State Board of Nursing Scope of Practice Standards for All Licensed Nurses [PHONE NUMBER] "(1) ...(c) Advocates for the client's right to receive appropriate and accurate information ....(2) ...(a) Promotes an environment conducive to safety and comfort for all levels of care ...(b) Identifies client safety and environment concerns; takes action to correct those concerns and report as needed ...(3) ...(b) Accepts responsibility for individual nursing actions ...(i) Demonstrates honesty and integrity in nursing practice ...." Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's hospital admission orders [REDACTED]. The February 2014 MAR indicated at 5:10 am 100 units of [MEDICATION NAME] were given. The MAR reflected the order for 12 units to be given of the 100 unit/ml solution. The NNs dated 1/31/14 through 2/1/14 indicated the resident was alert, oriented and able to make her/his needs known. A NN on 2/1/14 at 8:16 am indicated the resident had received the wrong dose of insulin and was transferred to the hospital for evaluation. The resident's blood sugar was noted as 402 at the time of transfer. A witness statement from Staff 10 (LPN) dated 2/1/14 and included with the incident/investigation stated she was unable to find insulin for the resident and had to determine where the facility's extra supply was located. Staff 10's statement indicated she was in a hurry to get the resident ready for [MEDICAL TREATMENT] but did read the order twice. Staff 10 documented both times she reviewed the order she saw 100 units and thought it seemed high. When she said it out loud the resident said "yeah" so Staff 10 drew up the 100 units and administered the insulin into the resident's arm. When she went to document the medication in the MAR she discovered her mistake and called another nurse on duty to assist. A hospital discharge summary dated 2/5/14 indicated the resident's [DIAGNOSES REDACTED]. The resident was not discharged back to a nursing facility, instead the resident was discharged to her/his home. "...Since several days in the hospital because of [DIAGNOSES REDACTED]. (She/he) was finally getting back to normal sugars and actually a bit on the high side and we reinstituted long acting insulin on the day of discharge. (She/he) appears to be much improved..." In an interview on 3/10/14 at 11:07 am Witness 3 (Family) and Witness 4 (Family) indicated the resident was at the facility for less than 24 hours when she/he was given too much insulin. The resident called and told them once she/he was at the hospital after the incident. The witnesses both indicated the resident was very upset, frustrated and scared. The resident stated she/he asked the nurse questions during the administration of the insulin including how much was being given but the resident was ignored. Staff 10 did not answer the resident's question about the dose until the 100 units had been administered. In an interview on 3/10/14 at 2:27 pm Witness 2 (Family) indicated the resident notified him of the insulin error and was extremely upset. Witness 2 indicated the resident told him she/he questioned Staff 10 about the dose but was ignored, until it was already almost fully administered. When the nurse answered a 100 units the resident stated she/he yelled stop and no but the nurse finished giving the insulin. In an interview on 3/10/14 at 4:52 pm Witness 7 (Family) indicated the resident was very upset about the insulin error. The resident told him she/he questioned Staff 10 but the nurse continued to give the insulin and did not respond or acknowledge the resident until the syringe was empty. In an interview on 3/12/14 at 9:21 am Staff 10 (LPN) indicated she went to prepare the resident's insulin and could not find any for the resident so she obtained some from the facility back up supply. She reviewed the order and saw that it said 100 units. Staff 10 indicated she read it a second time because 100 units seemed very high, but she apparently missed the rest of the order. She drew up the insulin and went to give it to the resident. Staff 10 stated she said 100 units out loud and the resident said "yeah" so she went ahead and administered the insulin. The resident did not really say anything else. Staff 10 discovered her error when she went to sign for the medication. The resident was very upset when she/he was told of the error. In an interview on 3/12/14 at 9:38 am Staff 5 (CNA) indicated she was present at the time the medication was administered. The resident questioned the nurse during and after the administration of the insulin as to how much was being given. Staff 5 stated the resident was alert, oriented and very vocal but was not addressed when she/he questioned the dose. Staff 5 was unsure why the resident was ignored. The resident was very agitated after she/he was told 100 units were administered. The resident was very upset and angry. Refer to F-333 2. Based on interview and record review it was determined the facility failed to ensure Staff 11 (LPN) documented a change of condition and hospitalization for 1 of 1 sampled residents (#7) and failed to document the condition of a newly admitted resident for 1 of 1 sampled residents (#16) who had a new [MEDICAL CONDITION] and did not receive nebulizer treatments as prescribed. Resident 7's recorded CBG was 30 and she/he required hospitalization . Resident 16 experienced discomfort and was placed at risk for respiratory occlusion. Findings include: The State Board of Nursing Scope of Practice Standards for Licensed Practical Nurses 851-045-0050 "(2) (a) Conduct and document initial and ongoing focused nursing assessments of the health status of clients by:(A) Collecting objective and subjective data from observations, examinations, interviews, and written records in an accurate and timely manner as appropriate to the client's health care needs and context of care; (B) Distinguishing abnormal from normal data, sorting, selecting, recording, and reporting the data;(C) Detecting potentially inaccurate, incomplete or missing client information and reporting as needed;(D) Anticipating and recognizing changes or potential changes in client status; identifying signs and symptoms of deviation from current health status; and (E) Validating data by utilizing available resources, including interactions with the client and health team members ...(B) Documenting nursing interventions and responses to care in an accurate, timely, thorough, and clear manner. (e) Evaluating client responses to nursing interventions and progress toward desired outcomes. (A) Outcome data shall be used as a basis for reassessing the plan of care and modifying nursing interventions; and (B) Outcome data shall be collected, documented and communicated to appropriate members of the healthcare team ...." a. Resident 7 was admitted to the facility in November 2013 with [DIAGNOSES REDACTED]. There was a 1/30/14 physician's order for [MEDICATION NAME] (long acting insulin) 8 units daily at bedtime and 5 units of Humalog (short acting insulin) to be administered "15-30 minutes before meals." The physician's order indicated it was "OK to hold Humalog if previous CBG was below 110 ...." The physician orders did not have specific parameters as to when to contact the physician for a low CBG reading. The February 2014 MAR documented on 2/5/14 the resident's CBG was 114 at 7:30 am and the resident received 5 units of Humalog insulin. At 11:30 am the resident's CBG was 82 and documentation indicated the resident received 5 units of Humalog insulin. There was no documentation in the resident's record to indicate the resident's physician was contacted regarding the CBG reading of 82 and an assessment of the resident's condition. The 2/5/14 local hospital emergency department records written at 3:15 pm documented the resident's CBG reading was 30 at the facility. The emergency medical transport team reported the facility staff found the resident "unconscious and unresponsive with a low CBG...." On 3/25/14 at 10:00 am Staff 6 (RNCM) reviewed the documentation from the local hospital regarding the resident's CBG being recorded as 30 in the facility. Staff 6 verified there was no documentation of the resident's condition and CBG level prior to the resident's hospitalization . Staff 6 verified there was no documentation in the record the resident was transferred to the local hospital. On 3/25/14 at 2:45 pm Staff 11 (LPN) was asked if he was aware of an occasion when Resident 7 was hospitalized for [REDACTED]. Staff 11 stated it was possible he did not chart the resident's CBG level and condition. On 4/3/14 at 3:55 pm Staff 15 (Corporate RN Consultant), Staff 16 (Corporate RN Consultant), Staff 2 (DNS) and Staff 6 (RNCM) were interviewed regarding the physician's order on 1/30/14. They stated the physician's order was confusing and there should have been a clarification of the order. They were asked about the CBG reading of 82 on 2/5/14 at 11:30 am. They confirmed the insulin was administered and they stated the expectation was the insulin would have been held when the resident's CBG level was at 82. The expectation would be for the physician to be notified of the resident's low CBG and for further instructions. On 4/7/14 at 10:11 am Staff 14 (Corporate RN Consultant) reviewed Resident 7's February 2014 MAR and stated on 2/5/14 at 11:30 am, Staff 11 initialed the resident's CBG was 82 and Staff 11 administered 5 units of Humalog insulin. On 4/10/14 at 9:50 am Staff 11 (LPN) was asked about the resident's CBG recorded at 82 and the physician's order for insulin. Staff 11 stated there was no physician's order to hold the insulin when the CBG was below 110. Staff 11 stated the physician indicated it was "OK" to hold the insulin and when CBG was below 110. Staff 11 was asked if the order should have been clarified and he stated it probably should have been. Staff 11 was informed the local hospital emergency department documentation indicated the resident's CBG was 30 at the facility. Staff 11 asked the time of the local hospital emergency department documentation. Staff 11 was informed it was written at 3:15 pm. Staff 11 stated his shift was completed at 2:00 pm so the resident was transported to the local hospital on the evening shift. Staff 11 was asked why there was no documentation of the resident's condition during the shift he worked. Staff 11 stated he would not chart if the resident did not have a change of condition. Staff 11 also stated it was possible he did not document the resident's condition because he was overworked and the facility management denied the licensed nurses to work overtime. Staff 11 stated he remembered an occasion when he found Resident 7 unresponsive and her/his CBG was 30 though Staff 11 stated he thought the incident occurred during the early morning hours and was not able to remember when the incident occurred. The resident's records were reviewed and the only occasion when the resident was transported to the local hospital for a CBG of 30 was on 2/5/14. On 4/10/14 at 1:34 pm Staff 24 (RN) stated she worked on the evening shift of 2/5/14 when Resident 7 was transferred to the local hospital. Staff 24 stated she had been at the facility a few minutes when Staff 11 (LPN) informed her Resident 7 was being transferred to the local hospital. Staff 24 stated the resident had not been feeling well for a few days. Staff 24 (RN) was asked about the physician's orders and the resident's CBG reading at 11:30 am of 82. Staff 24 stated she probably would have held the insulin if the resident's CBG was 82. Staff 24 stated the resident had a significant change of condition on 2/5/14 and there should have been documentation of the resident's condition. b. Resident 16 was admitted on [DATE] in the evening, with [DIAGNOSES REDACTED]. The resident had [MEDICAL CONDITION] and a stomach tube (PEG). There were physician's admission orders [REDACTED]. Medications for depression included [MEDICATION NAME] every 24 hours, and [MEDICATION NAME] once daily (at 7:00 am). Medications for [MEDICAL CONDITION] included [MEDICATION NAME] Acid 10 ml once daily at 1:00 pm. According to MARs the [MEDICATION NAME] and Hyper-Sal inhalers via nebulizer were not given at 7:00 am and 11:00 am on 3/25/14 and the Hyper-Sal was not given during the night every four hours on 3/24/14 - 3/25/14. The antidepressants [MEDICATION NAME] and [MEDICATION NAME] were not given on 3/25/14. The dose of [MEDICATION NAME] Acid scheduled for 1:00 pm daily was not given on 3/25/14. On 3/25/14 at 2:45 pm Staff 11, LPN stated Resident 16 was admitted on [DATE] and had not received half of the medications ordered by the physician, and had not had nebulizer treatments during the night as ordered by the physician. Staff 11 worked the day shift and he found the resident in respiratory distress due to secretions so thick they could not be suctioned out. There was no nebulizer or tubing in the resident's room and Staff 11 had to "rig" tubing in order to give the resident a nebulizer treatment. Staff 11 stated he reported this to nursing management who asked him to leave the building. Staff 11 did not have an opportunity to chart his findings. Progress Notes dated 3/25/14 did not include any information related to the lack of nebulizer treatments or the resident's thick secretions with respiratory distress. On 3/25/14 from 5:03 am to 11:45 pm there were no nurses' entries. This was discussed on 4/3/14 at 11:00 am with several staff including Staff 2, DNS and Staff 6, RNCM and no further information was provided. Refer to F-309. 3. Based on interview and record review it was determined the facility failed to have a system in place to prevent Staff 25 (RN) from the unauthorized use of narcotic pain medications purchased for 1 of 1 sampled residents (#14) and administering the medication to another resident. This placed the resident at risk for unmet needs. Findings include: The State Board of Nursing Scope of Practice Standards for All Licensed Nurses [PHONE NUMBER]-"(2) Conduct related to other federal or state statute/rule violations:(f) Unauthorized removal or attempted removal of narcotics, other drugs, supplies, property, or money from clients, the work place, or any person ...." Resident 14 was admitted to the facility in November 2013 with [DIAGNOSES REDACTED]. There was a 12/20/13 physician's order for 15 ml [MEDICATION NAME]-[MEDICATION NAME] ([MEDICATION NAME]-narcotic pain medication) via [DEVICE] (gastric feeding tube) every four hours PRN for pain. The December 2013 MAR contained no documentation the resident received a dose of PRN [MEDICATION NAME] during the month. The resident's narcotic control log on 12/21/13 indicated 120 ml of [MEDICATION NAME] was received from the pharmacy. Staff 25 (RN) wrote a late entry for 12/24/13 at 11:35 pm to indicate the dose "30 ml" with a statement "see note below ...." The note written on 12/26/13 by Staff 2 (DNS) indicated "LN (Staff 25) used this res (resident's) [MEDICATION NAME] for another res in house on 12/24/13 ..." On 12/26/13 Staff 2 (DNS) completed an Education Acknowledgment Form for Staff 25 (RN) to include "Narcotics ordered for a resident may not be given to another resident ...." On 12/26/13 Staff 25 (RN) wrote a note to the pharmacy to indicate "I borrow (sic) [MEDICATION NAME]...30 ml from one resident and gave it to another resident taking the same med. (medication) because that resident was out. I have been informed that I can't do that anymore and I am very sorry. It won't happen again ...." On 3/26/14 at 10:00 am Staff 2 (DNS) stated it was a standard of practice not to borrow medications from one resident and administer to another resident. On 3/26/14 at 10:05 am Staff 14 (Corporate RN consultant) stated it was a standard of practice for licensed nurses not to borrow medications from one resident and administer to another resident. Refer to F-431. 4. Based on interview and record review it was determined the facility failed to ensure 6 of 10 licensed nurses interviewed (#s 3, 11, 17, 19, 28 & 29) followed professional standards of practice related to the facility policy for signing that insulin doses were correct. This placed all insulin dependent diabetic residents at risk for receiving wrong doses of insulin. Findings include: The State Board of Nursing Conduct Derogatory to the Standards of Nursing Defined [PHONE NUMBER] (3)(c)(f) Conduct related to communication: Falsifying a client or agency records... including, but not limited to... signing someone else's name, record care not given, and fabricating data/values. Directing another person to falsify, alter or destroy client or agency records... a. On 3/13/14 while reviewing Resident 4's clinical record for errors in insulin administration it was found the Sliding Scale Insulin record for 3/13/14 at 12 noon reflected an error in insulin administration. The blood sugar was recorded as 337 and the sliding scale insulin prescribed for blood sugars of 300 - 349 was 10 units of insulin. However it was documented that 12 units of insulin were given. This was brought immediately to the attention of Staff 2 (DNS) who confirmed the error. Staff 3 (LPN) and Staff 11 (LPN) were identified as initialing the dose was correct. On 3/27/14 at 2:03 pm Staff 11 (LPN) stated Staff 3 (LPN) signed the insulin dose was correct for Resident 4 on 3/13/14. When he was informed there was an error made in the dose of insulin given, he reviewed his charting of the blood sugar and determined the blood sugar number was actually 351 instead of the 337. He wrote over the number to correct it to 351 and talked to Staff 3 about it, stating two nurses would not have made the same mistake related to the insulin dosage. On 3/31/14 at 1:45 pm and 2:50 pm Staff 3 (LPN) stated he was asked by Staff 11 (LPN) to sign for an insulin dose which he had not observed for correct dosage as it related to the blood sugar. This was for insulin administered to Resident 4 (on 3/13/14). The dosage documented was later identified as the wrong dosage. Staff 11 approached Staff 3 regarding clarifying the blood sugar recorded to reflect a different number, which would then reflect a correct dose of insulin. On 4/1/14 at 2:25 pm Staff 19 (LPN) stated she administered insulin to Resident 4 on 3/14/14 and noticed the error in insulin dose on 3/13/14 at 12 noon. Staff 19 reported the error to nursing management staff. In comparing Resident 4's Sliding Scale Insulin MAR obtained on 3/13/14 with one ending on 3/24/14, the blood sugar of 337 on 3/13/14 at noon appeared to have been changed to 351 on the MAR ending on 3/24/14. In contrast, a Progress Note signed by Staff 11 (LPN)on 3/13/14 included a blood sugar of 337 at 12 noon. On 4/1/14 at 2:25 pm Staff 19 (LPN) stated a new policy to have two LNs check insulin doses was recently initiated in response to an overdose of insulin given by one LN. Staff 19 believed many if not all the LNs giving insulin either ignored the policy and did not get two LNs to check each insulin dose, or they initialed they had checked the dose when they had not. b. On 3/12/14 at 10:22 am Staff 6 (RNCM) stated there was an error in insulin administration,discovered on 2/1/14. Inservices were conducted with nursing staff and a new insulin administration procedure was put in place, effective immediately. The procedure included that two nurses were required to check all insulin doses. The nursing staff would together check the insulin bottle, the dose and the number of units drawn up in the syringe before administering the insulin. The plan for two nurses to check all insulin doses did not have an established end date. On 3/31/14 at 3:00 pm Staff 35 (RN) stated on 3/21/14 she was approached by Staff 28 (RN) who asked her to sign for an insulin dose for Resident 21. Staff 28 pointed to the MAR where his initials were already noted. Staff 35 asked where the insulin was to observe and Staff 28 said the insulin "was in" Resident 21, meaning it was already administered. When Staff 35 refused to sign for insulin she had not observed, Staff 28 said "never mind" he had initials he could sign. Staff 8 (RNCM) overheard the conversation and said she would have to report the incident to nursing management. On the evening of 3/21/14 Staff 35 (RN) received a text message from Staff 2 (DNS) that she was aware of the incident and would be talking to Staff 28 (RN) on Monday (3/24/14). When Staff 35 arrived at the facility on 3/24/14, Staff 2 (DNS) told her she had talked with Staff 8 (RNCM) and Staff 8 stated there was no problem because Staff 28 (RN) had been joking. Staff 8 told Staff 35 she had signed the MAR for Staff 28. On 4/21/14 at 3:10 pm Staff 8 (RNCM) stated she signed for the insulin dose and when asked if she had observed the insulin dose she denied she signed for anything she didn't see. When asked why she reported the incident she stated she only reported Staff 28's "flip" comment (related to signing someone else's initials). Staff 8 looked at the MAR with the surveyor for 3/21/14 at 8:00 pm and confirmed her initials were not in the spot with Staff 28's initials and there were no other nursing staff's initials to show Staff 28 followed the policy to have two nurses verify the insulin dose was correct. On 4/21/14 at 3:30 pm Staff 28 (RN) stated he had a problem with Staff 35 (RN) and had only asked her and Staff 8 (RNCM) to sign for CBGs (blood sugars) before drawing up the insulin. Further review of the MAR for 3/21/14 did not include a space to sign for CBGs separate from signing that the insulin dose was correct. On 4/21/14 at 4:20 pm Staff 2 (DNS) confirmed she had received the report from Staff 8 (RNCM) about Staff 28's misconduct. Staff 2 stated she talked with Staff 8, who told her she had talked again with Staff 28 and Staff 28 told her he was just joking. Staff 2 stated she did not talk to Staff 28 and Staff 35 and Staff 2 did not investigate further. c. Interviews with LNs about signing or initializing insulin doses were correct without observing they were correct, and asking other nurses to sign that insulin doses were correct without observing the insulin dose, included the following: On 3/31/14 at 1:45 pm Staff 3 (LPN) stated he signed for insulin without observing blood sugar for sliding scale insulin. Staff 3 (LPN) signed at the request of Staff 11 (LPN). On 3/31/14 at 3:00 pm and 4/1/14 at 2:35 pm, Staff 35 (RN) stated she was asked by Staff 28 (RN) to sign for insulin already administered. Staff 35 refused to sign. On 4/1/14 at 10:00 am Staff 17 (RN) stated she was asked by Staff 28 (RN) to sign for insulin she had not observed. Staff 17 signed without observing and signed for other nurses without observing the insulin dose. On 4/1/14 at 2:35 pm Staff 19 (LPN) stated she signed for insulin she did not observe for correct dose at the request of Staff 11(LPN) and added she also signed at the request of other nurses. On 4/1/14 at 3:15 pm Staff 29 (LPN) stated she was asked to sign for insulin without seeing the bottle of insulin. She observed the insulin bottle after the insulin was drawn up and signed she observed the correct insulin was given. On 4/3/14 at 11:00 am several staff including Staff 2 (DNS) and Staff 6 (RNCM) acknowledged nurses did not adhere to standards of practice related to signing for insulin not observed and asking others to sign for insulin they did not observe. Refer to F309 and F333.

Based on interview and record review it was determined the facility failed to follow physician's orders for the provision of medications, treatments and laboratory tests; failed to obtain and clarify physician's orders as needed; failed to assess and obtain physician's orders for the treatment of [REDACTED].#s 4, 6, 7, 8, 16 and 18) reviewed for necessary care and services. Resident 7 was hospitalized for [REDACTED]. 1. Resident 7 was admitted to the facility in November 2013 with [DIAGNOSES REDACTED]. a. There was a 1/30/14 physician's order for 8 units of [MEDICATION NAME] (long acting insulin) daily at bedtime and 5 units of Humalog (short acting insulin) to be administered "15-30 minutes before meals." The physician's order indicated it was "OK to hold Humalog if previous CBG was below 110 ...." The February 2014 MAR documented on 2/5/14 the resident's CBG was 114 at 7:30 am and the resident received 5 units of Humalog insulin. At 11:30 am the resident's CBG was 82 and documentation indicated the resident received 5 units of Humalog insulin. There was no documentation in the resident's record to indicate the resident's physician was contacted regarding the CBG reading of 82 and an assessment of the resident's condition. The 2/5/14 local hospital emergency department records documented the resident's CBG reading was 30 at the facility. The emergency medical transport team reported the facility staff found the resident "unconscious and unresponsive with a low CBG ...." The 2/5/14 local hospital history and physical indicated the "chief complaint was blood sugar was 30 at the facility ...." The 2/13/14 local hospital discharge summary indicated the resident was admitted to the local hospital due to an "episode of confusion at which point she/he was found to hypoglycemic (low blood glucose) with a glucose of approximately 30. Following the resident's admission to the local hospital, Resident 7 did not have any further episodes of [DIAGNOSES REDACTED] with most of her/his (glucose) values between 100 and 200 ...." The resident was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 3/25/14 at 10:00 am Staff 6 (RNCM) reviewed the documentation from the local hospital regarding the resident's CBG being recorded as 30 in the facility. Staff 6 verified there was no documentation of the resident's condition and CBG level prior to the resident's hospitalization . Staff 6 verified there was no documentation in the record the resident was transferred to the local hospital. On 3/25/14 at 2:45 pm Staff 11 (LPN) was asked if he was aware of an occasion when Resident 7 was hospitalized for [REDACTED]. Staff 11 stated it was possible he did not chart the resident's CBG level and condition. On 4/3/14 at 3:55 pm Staff 15 (Corporate RN Consultant), Staff 16 (Corporate RN Consultant), Staff 2 (DNS) and Staff 6 (RNCM) were interviewed regarding the physician's order on 1/30/14. They stated the physician's order was confusing and there should have been a clarification of the order. They were asked about the CBG reading of 82 on 2/5/14 at 11:30 am. They confirmed the insulin was administered and they stated the expectation was the insulin would have been held when the resident's CBG level was at 82. The expectation would be for the physician to be notified of the resident's CBG for further instructions. On 4/7/14 at 10:11 am Staff 14 (Corporate RN Consultant) reviewed Resident 7's February 2014 MAR and stated on 2/5/14 at 11:30 am, Staff 11 initialed the resident's CBG was 82 and Staff 11 administered 5 units of Humalog insulin. On 4/10/14 at 9:50 am Staff 11 (LPN) was asked about the resident's CBG recorded at 82 and the physician's order for insulin. Staff 11 stated there was no physician's order to hold the insulin when the CBG was below 110. Staff 11 stated the physician indicated it was "OK" to hold the insulin and when CBG was below 110. Staff 11 was asked if the order should have been clarified. Staff 11 was informed the local hospital emergency department documentation indicated the resident's CBG was 30 at the facility. Staff 11 asked the time of the local hospital emergency department documentation. Staff 11 was informed it was written at 3:15 pm. Staff 11 stated his shift was completed at 2:00 pm so the resident was transported to the local hospital on the evening shift. Staff 11 was asked why there was no documentation of the resident's condition during the shift he worked. Staff 11 stated he would not chart if the resident did not have a change of condition. Staff 11 stated it was possible he did not document the resident's condition because he was overworked and the facility management denied the licensed nurses to work overtime. Staff 11 stated he remembered an occasion when he found Resident 7 was unresponsive and her/his CBG was 30 though this occurred during the early morning hours. Staff 11 could not remember when the incident occurred. The resident's records were reviewed and the only occasion the resident's CBG registered 30 was on 2/5/14. On 4/10/14 at 1:34 pm Staff 24 (RN) stated she worked on the evening shift of 2/5/14 when Resident 7 was transferred to the local hospital. Staff 24 stated she just came to work and Staff 11 (LPN) informed her of Resident 7's low CBG. Staff 24 stated the resident was not feeling well for a few days. Staff 24 (RN) stated she probably would have held the insulin if the resident's CBG was 82. Staff 24 stated the resident had a significant change of condition on 2/5/14 and there should have been documentation of the resident's condition. b. There was an 11/18/13 physician's order for 2 units of [MEDICATION NAME]to be administered three times a day before meals. The physician ordered the insulin to be held if CBG was below 90. The November 2013 MAR indicated on 11/22/13 at 7:00 am the resident's CBG was 93. There were circles around the nurse's initials to indicate the dose of insulin was not provided. On 3/25/14 at 10:50 am Staff 8 (RNCM) verified the physician's order was not followed. c. There was a 12/6/13 physician's order for 2 units of [MEDICATION NAME]to be administered three times a day before meals. The December 2013 MAR indicated on 12/7/13 and 12/8/13 at 11:30 am there was no documentation to indicate the resident received the insulin as ordered. On 3/25/14 at 10:50 am Staff 8 (RNCM) verified the physician's order was not followed.. d. Resident 7 was readmitted to the facility on [DATE] and there were physician's order for [MEDICATION NAME]to be administered according to a sliding scale. There were no physician's orders for the amount of insulin to be provided according to a sliding scale. On 12/11/13 the facility faxed the physician to indicate "She/he returned also with an order, sliding scale but no sliding scale parameters. Please give directions ...." On 12/12/13 the physician discontinued the order for sliding scale insulin. On 3/25/14 at 10:50 am Staff 8 (RNCM) verified there had been no physician's orders for sliding scale insulin when the resident was readmitted . e. There was a 1/4/14 physician's order to check the resident's CBGs four times a day and to notify the physician when the CBG was greater than 140. There were 78 occasions when the resident's CBGs were over 140 without documentation the resident's physician was notified. On 3/25/14 at 10:00 am Staff 6 (RNCM) reviewed the resident's record and confirmed there was a physician's order for the physician to be notified when the resident's CBGs were greater than 140. Staff 6 stated the facility staff should have clarified the order with the physician. f. There was a 2/4/14 physician's order for abdominal and pelvic ultrasound to be done on 2/5/14. On 2/5/14 the resident was admitted to the local hospital for [DIAGNOSES REDACTED] and was readmitted to the facility on [DATE]. There was no documentation of an abdominal and pelvic ultrasound was conducted on 2/5/14 when the resident was in the facility and in the local hospital. There was no documentation the resident's physician was informed the ultrasound was not conducted. On 3/25/14 at 10:00 am Staff 6 (RNCM) reviewed the resident's record and confirmed the ultrasound was not conducted and the resident's physician was not informed the ultrasound was not done. Staff 6 stated it would have been a good idea for the staff to inform the physician the ultrasound was not done. g. Resident 7 was readmitted to the facility on [DATE] with physician's orders for 10,000 units/1 ml of subcutaneous [MEDICATION NAME] (man-made form of protein to reduce or avoid the need for red blood cell [MEDICAL CONDITION]) to be administered one time a week. The February 2014 MAR indicated the [MEDICATION NAME] was to be administered on 2/15/14 and 2/22/14. The documentation on the back of the MAR indicated on 2/15/14 the "product not sent-need labs per pharmacy." Documentation for 2/22/14 indicated the "[MEDICATION NAME] not available." The March 2014 MAR indicated the [MEDICATION NAME] was to be administered on 3/1/14. The documentation indicated the medication was not available. The documentation indicated "call to pharmacy-still filling [MEDICATION NAME]." A fax to the physician dated 2/20/14 indicated lab test results were sent to the physician and the physician ordered for the [MEDICATION NAME] to continue weekly, with another CBC (complete blood count) done in 1 week. Documentation in the MAR for 2/22/14 indicated the "[MEDICATION NAME] not available." Lab test results dated 2/28/14 were faxed to the physician on 3/1/14. The March 2014 MAR indicated the [MEDICATION NAME] was to be administered on 3/1/14. The documentation indicated the medication was not available. The documentation indicated "call to pharmacy-still filling [MEDICATION NAME]." According to the MARs for February and March 2014, no [MEDICATION NAME] was given. On 3/25/14 at 10:30 am Staff 6 (RNCM) acknowledged a lack of correlation between lab work/test results, the pharmacy and the physician. There was no further information provided related to whether the physician was informed the [MEDICATION NAME] was not given, and of an assessment of the resident's condition related to [MEDICATION NAME] use/low hemoglobin. On 4/1/14 at 5:30 pm Staff 33 (Pharmacy Consultant) stated [MEDICATION NAME] was a medication which needed to be closely correlated with lab test results and was given for hemoglobin below a certain level. It was a medication not usually administered in the long-term care setting because of the difficulty of correlation and was usually given at a [MEDICAL TREATMENT] center for residents receiving [MEDICAL TREATMENT]. h. A facility non pressure skin condition report dated 11/18/13 indicated the resident had a bruise to the right wrist, a diabetic ulcer to the right foot, a diabetic ulcer to the left bottom of the foot and an abrasion to the right shin. The skin report showed inconsistent monitoring of the ulcers and abrasion during the month of November. The resident's bruises were monitored weekly and showed resolved as of 12/20/13. The foot ulcer showed only one weekly assessment on 11/27/13. The resident's November 2013 TAR showed no information regarding any skin conditions. There were no other documents in the resident's record to show the identified skin conditions were assessed, monitored or treated during the month of November. There was no documentation the resident's physician was contacted regarding any treatments or status of the resident's skin conditions. NNs for the month of November 2013 showed the resident had some swelling to both lower extremities. There was no information documented regarding any other skin conditions for the resident. The resident was discharged to the hospital on [DATE] and returned to the facility on [DATE]. Skin sheets reviewed for December 2013 and January 2014 showed all the resident's skin conditions resolved except the left foot ulcer which showed improvement. In an interview on 4/2/14 at 12:40 pm Staff 8 (RNCM) indicated she was certain treatments were being done for each of the resident's skin conditions. Staff 8 could not locate any additional documentation to show orders or treatments for November 2013. Staff 8 further indicated she could not remember a lot about the resident's skin but the information she documented on 11/18/13 was true. i. NNs dated 12/6/13 indicated the resident had ulcers to both feet that were open to the air. Additional NNs throughout the month of December 2013 addressed the resident's continued leg [MEDICAL CONDITION] but contained no information regarding any dressing changes to the ulcers. The resident's December 2013 TAR showed treatments in place as ordered by the physician to be done every other day for the resident's left foot and right calf. The TAR showed no documented treatments on 12/10, 12/12, 12/14, 12/16 and 12/18. The resident was noted to be out of the facility on 12/12, 12/16 and 12/18. There was no documentation in the record that attempts were made to provide treatment to the resident's ulcers upon her/his return to the facility. In an interview on 4/2/14 at 12:40 pm Staff 8 (RNCM) indicated she was certain treatments were being done for each of the resident's skin ulcers. Staff 8 could not locate any additional documentation to show treatments were completed for December 2013. Staff 8 further indicated the resident was frequently on outings which made treatments difficult. Staff 8 could provide no documentation that staff addressed treatments when the resident returned to the facility from outings. j. The resident's January 2014 TAR showed the left plantar foot was to be painted with [MEDICATION NAME] 3 x per week, cover with [MEDICATION NAME] or gauze and secure with woven tape. The TAR showed 11 unsigned areas between 1/8/14 and 1/31/14. There was no other documentation on the TAR to indicate if the treatments were completed or a reason why they were not completed. The signed physician order recap dated 1/19/14 showed the [MEDICATION NAME] order was still an active order. Review of the February 2014 TAR showed the [MEDICATION NAME] order continued to be documented on the treatment sheet but was yellowed out to mean it was discontinued. There was no date noted on the treatment sheet as to when the order was discontinued. In an interview on 4/2/14 at 9:50 am Staff 6 (RNCM) indicated the [MEDICATION NAME] foot treatment was discontinued for the month of February 2014. Staff 6 could not locate any information on the specific date the treatment was discontinued. In an interview on 4/3/14 at 5:23 pm Staff 15 (Corporate RN) indicated they were unable to locate any order to discontinue the [MEDICATION NAME] foot treatment. She believed it would have likely been discontinued sometime after physician order recaps were completed. k. Review of the resident's February 2014 TAR showed orders in place for treatment of [REDACTED]. There were no treatments documented as completed on the TAR from 2/13/14 through 2/17/13. The TAR contained no other information as to why treatments were not documented or if they were completed. NNs from 2/13/14 through 2/17/14 contained no information regarding skin treatments provided, refused or any other reason they would not have been completed. The resident was noted to be out of the building for one night but no information on when the resident departed/returned was noted. In an interview on 4/2/14 at 9:50 am Staff 6 (RNCM) indicated she could not find any additional information on the treatments provided between 2/13/14 and 2/17/14. Staff 6 stated she believed the staff provided the treatments as the resident's foot wound did not worsen and the resident was high risk for breakdown. Staff 6 could not provide any further documentation regarding the treatments. 2. Resident 18 was admitted to the facility on [DATE] with multiple diagnoses. The resident was admitted with physician's orders for Vitamin B12 daily, Bladder Ease Supplement twice a day, Omega 3 twice a day, [MEDICATION NAME] topical every pm and Lavena vaginal suppository every other day. Review of the resident's March 2014 MAR showed the resident had multiple consecutively missed doses of medications between 3/25/14 and 3/27/14. The medications were noted as unavailable on the back of the MAR, missed doses were as follows: Vitamin B12 three doses, Bladder Ease two doses, Omega 3 four doses, [MEDICATION NAME] one dose and Lavena suppository one dose were missed. In an interview on 4/1/14 at 4:15 pm Staff 6 (RNCM) indicated the mediations were missed because they were unavailable at the time the resident was admitted to the facility. Staff 6 stated there was difficulty finding the correct dosages as well as the correct forms (liquid and cream). Staff 6 indicated a request for alternatives was made to the physician and medications were administered within a few days of admission. 3. Resident 16 was admitted on [DATE] in the evening with [DIAGNOSES REDACTED]. The resident had a new [MEDICAL CONDITION] and a stomach tube (PEG). There were physician's admission orders [REDACTED]. Medications for depression included [MEDICATION NAME] every 24 hours, and [MEDICATION NAME] once daily (at 7:00 am). Medications for [MEDICAL CONDITION] included [MEDICATION NAME] Acid 10 ml once daily at 1:00 pm. According to MARs the [MEDICATION NAME] and Hyper-Sal inhalers via nebulizer were not given at 7:00 am and 11:00 am on 3/25/14 and the Hyper-Sal was not given during the night every four hours on 3/24/14 - 3/25/14. The antidepressants [MEDICATION NAME] and [MEDICATION NAME] were not given on 3/25/14. The dose of [MEDICATION NAME] Acid scheduled for 1:00 pm daily on 3/25/14 was not given. On 3/25/14 at 2:45 pm Staff 11 (LPN) stated Resident 16 was admitted on [DATE] and had not received half of the medications ordered by the physician as they had not arrived from the pharmacy, and had not had nebulizer treatments during the night as ordered by the physician. Staff 11 worked the day shift and he found the resident in respiratory distress due to secretions so thick they could not be suctioned out. There was no nebulizer or tubing in the resident's room and Staff 11 had to "rig" tubing in order to give the resident a nebulizer treatment. There was no evidence staff assessed the how the lack of providing respiratory treatments and medications placed the resident at risk for respiratory distress/occlusion and if the lack of receiving and administering medications as ordered by the physician placed the resident at risk for [MEDICAL CONDITION] and depression. These failures were discussed on 4/3/14 at 11:00 am with several staff including Staff 2, DNS and Staff 6 (RNCM) and no further information was provided. 4. Resident 8 was readmitted in January 2014 for follow-up care related to orthotic pin removal from the foot. There were admission physician's orders on 1/20/14 which included [MEDICATION NAME] 7.5 mg every 4-6 hours PRN pain. Progress Notes dated 1/23/14 indicated the resident was medicated with [MEDICATION NAME] 10 mg for a pain level of 10/10 with good relief. There was no evidence staff realized they gave the wrong dose of [MEDICATION NAME]. An Incident/Accident form dated on 1/23/14 for Resident 8 indicated the resident received [MEDICATION NAME] 10 mg, instead of 7.5 mg on 1/23/14. The error in dosage was not discovered until 1/25/14 when Staff 19, LPN reported finding the error. . On 4/3/14 at 11:00 am the administration of a dose of [MEDICATION NAME] in excess of what the physician ordered was discussed with several staff including Staff 2 (DNS) and Staff 6 (RNCM). No further information was provided. 5. Resident 6 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Progress Notes from 2/21/14 to 2/28/14 indicated the resident had [DIAGNOSES REDACTED] with a CBG of 53 on 2/21/14 and insulin orders were adjusted by the physician. On 2/22/14 the resident refused some of the insulin ordered and was became anxious. On 2/23/14 the resident was anxious all night and did not sleep and had heartburn. During the day there were no low blood sugars, but the resident remained extremely anxious. On 2/24/14 the resident was anxious and was unable to sleep. On 2/24/14 during the day an assessment of the resident's anxiety was thought to be related to psychiatric problems and an appointment with the psychiatrist was sought. On 2/24/14, 2/25/14 and 2/26/14 the resident continued to be anxious and blood sugars were not abnormal. On 2/27/14 the resident complained of shortness of breath and oxygen was given. Lab test results for a Comprehensive Metabolic Panel (CMP) collected on 2/24/14 and reported to facility staff on 2/26/14 at 9:52 am showed a critically high potassium of 6.30 with a reference range of 3.50 - 5.60. This information was not reported to the physician until 2/27/14 in response to a physician's telephone request for the lab values. There was no evidence in Progress Notes that nursing staff considered or were aware of the critically high potassium level and the significance of the presence of high potassium in a resident with [MEDICAL CONDITION]. On 3/12/14 at 3:35 pm Staff 14 (Corporate RN) stated she was unable to find documented evidence staff notified the physician of the critically high potassium before 2/27/14. On 4/3/14 at 11:00 am the delay in notifying the physician of the critically high potassium level, and the lack of assessment of the high potassium related to the resident's [MEDICAL CONDITION] and symptoms was discussed with several staff including Staff 2 (DNS) and Staff 6 (RNCM). No further information was provided. 6a. Resident 4 was admitted on [DATE] with physician's orders for over-the-counter (OTC) medications which included: Cyruta Plus one, twice daily, Florosinus one, twice daily, Pure Krill two daily, Super Beta Prostate one, twice daily, grape seed extract one daily, and Nitrosource Fiber Powder daily. On 2/25/14 a fax was sent to the physician regarding the OTC medications which were unavailable and the resident had not taken them since admission on 2/15/14. Staff requested they be discontinued and the physician agreed to discontinue them. On 3/25/14 at 11:15 am Staff 6 (RNCM) acknowledged that an assessment of the OTC medications was not done to determine if there were alternate medications available and whether discontinuing them without replacement medications would have an adverse effect on the resident. b. There was a physician's order for [MEDICATION NAME] (OTC medication) was present at the time of admission on 2/15/14. On 3/4/14 a fax to the physician included the resident received medications through a gastrostomy tube and the facility could not give the [MEDICATION NAME] through the gastrostomy tube. The physician directed staff to have the resident swallow the [MEDICATION NAME]. The MARs for February 2014 and March 1-10, 2014 indicated the [MEDICATION NAME] was not given because the resident could not swallow it. There was no indication the physician was notified of the inability of the resident to swallow the [MEDICATION NAME]. On 3/26/14 at 9:30 am Staff 19 (LPN) acknowledged when the physician ordered the resident to swallow the [MEDICATION NAME], staff did not follow up with the physician to let the physician know the resident was unable to swallow the medication, and did not receive the medication. On 4/3/14 at 11:00 am the lack of an assessment of the OTC medications for alternate medications and for effects on the resident, was discussed with several staff including Staff 2 (DNS) and Staff 6 (RNCM). No further information was provided.

Based on interview and record review it was determined the facility failed to ensure a resident's insulin was administered as ordered by the physician for 1 of 8 sampled residents (#3) reviewed for insulin use. This put residents at risk for over medication. Resident 3 received 100 units of [MEDICATION NAME] instead of the 12 units ordered and was transported to the hospital for evaluation. Findings include: Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's hospital admission orders [REDACTED]. The February 2014 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The NNs dated 1/31/14 through 2/1/14 indicated the resident was alert, oriented and able to make her/his needs known. The resident slept through the night without incident with no complaints of pain and no signs or symptoms of [DIAGNOSES REDACTED]. NNs on 2/1/14 at 8:16 am indicated the resident had received the wrong dose of insulin and was transferred to the hospital for evaluation. The resident's blood sugar was noted as 402 at the time of transfer. An incident/accident report dated 2/1/14 indicated the resident was mistakenly given 100 units when prescribed 12 units. The resident was noted to be alert and oriented to surroundings prior to and after administration of the insulin. The resident's other vitals were noted within normal limits with no blood sugar value noted. The report further indicated the resident was taken back to her/his room and vital signs were monitored after the incident. The resident continued to be monitored while the physician was contacted. When the physician did not return the call back the facility arranged for transportation to the hospital. A witness statement from Staff 10 (LPN) dated 2/1/14 and included with the incident/investigation stated she was unable to find insulin for the resident and had to determine where the facility's extra supply was located. Staff 10's statement indicated she was in a hurry to get the resident ready for [MEDICAL TREATMENT] but did read the order twice. Staff 10 documented that both times she reviewed the order she saw 100 units and thought it seemed high. When she said it out loud the resident said "yeah" so Staff 10 drew up the 100 units and administered the insulin into the resident's arm. When she went to document the medication in the MAR indicated [REDACTED]. The resident was returned to her/his room and vitals were monitored until the resident departed for the hospital. The resident's blood sugars were in the 400's and she/he was alert/oriented to what was going on. A witness statement from Staff 3 (LPN) dated 2/14/14 indicated when he arrived to work at 6:00 am he was informed of the error and went to check on the resident. The resident informed Staff 3 that she/he did not feel ill but was concerned how the excess insulin was going to affect her/him at [MEDICAL TREATMENT]. The resident had finished breakfast and the resident's blood sugar was recorded at 437. Staff 3 did not see any symptoms of [DIAGNOSES REDACTED], the resident's blood sugars continued to be high, the resident was monitored until transport and though the resident stated no sick feeling she/he was fearful of what was going to happen as a result of the extra insulin. A witness statement from Staff 4 (RN) dated 2/2/14 indicated he was called from the other end of the facility to assist after the wrong dose of insulin was administered. The resident was very agitated and upset. The resident was returned to her/his room and vitals were monitored. Staff 4 attempted to calm the resident and keep her/him separated from Staff 10. The resident was very upset with Staff 10 and became increasingly hostile and upset with the error. Staff 4 further indicated the resident was alert, oriented and knew that 100 units was more than she/he was to receive. The resident did not show signs of [DIAGNOSES REDACTED], vital signs were within normal limits and blood sugars were high. Staff 4 and the resident both felt the medication would not start to take affect for a few hours. The resident was very worried about when things would start to "get bad." A hospital history and physical (H&P) dated 2/1/14 indicated the resident stated she/he noticed that morning the facility nurse gave her/him the wrong dose of insulin. The resident stated it was determined she/he was given 100 units by mistake. The resident's blood sugar had remained within range without any [DIAGNOSES REDACTED] at that point. The resident was noted to otherwise be completely asymptomatic. The resident was noted to be at risk for hypoglycemic affects based on the extra insulin given but blood sugars did not currently show a downward trend. The resident was placed on a sliding scale insulin to begin after extended blood sugar checks returned within range. All long acting insulins were to be held for the next 24 hours. The H&P additionally indicated the resident was very upset about the medication error and what problems it might cause for her/him. The resident refused to return to the nursing facility because of the error. A hospital discharge summary dated 2/5/14 indicated the resident's [DIAGNOSES REDACTED]. The resident was not discharged back to a nursing facility, instead the resident was discharged to her/his home. "...Since several days in the hospital because of [DIAGNOSES REDACTED]. (She/he) was finally getting back to normal sugars and actually a bit on the high side and we reinstituted long acting insulin on the day of discharge. (She/he) appears to be much improved..." In an interview on 3/10/14 at 11:07 am Witness 3 (Family) and Witness 4 (Family) indicated the resident was at the facility for less than 24 hours when she/he was given too much insulin. The resident called and told them once she/he was at the hospital after the incident. The witnesses both indicated the resident was very upset, frustrated and scared. The resident stated she/he asked the nurse questions during the administration of the insulin including how much was being given but the resident was ignored. The staff involved did not answer the resident's question about the dose until the 100 units had been administered. Witness 3 indicated the resident stayed at the hospital several days because her/his blood sugars kept dropping, then later was sent home. Witness 3 and 4 both stated the resident was at her/his home overnight and the following day had a massive [MEDICAL CONDITION] at [MEDICAL TREATMENT] and did not make it. In an interview on 3/10/14 at 2:27 pm Witness 2 (Family) indicated the resident notified him of the insulin error and was extremely upset. The resident was a long time diabetic, knew very well how to manage her/his insulin and that 100 units was far more than the 12 units she/he was actually prescribed. Witness 2 indicated the resident told him that the administration was taking so long compared to what she/he was used to that the resident questioned the nurse. The nurse ignored the resident when asked how much was being given, until it was already almost fully administered. At that point the resident was told 100 units was the dose and the nurse finished giving the insulin. When the nurse told the resident how much was being given, the resident stated she/he yelled, stop and no, but the nurse finished giving the insulin. Witness 2 stated the resident did not return to the facility. In an interview on 3/10/14 at 4:52 pm Witness 7 (Family) indicated the resident was very upset about the insulin error. The resident told him she/he questioned the nurse but the nurse continued to give the insulin and did not respond or acknowledge the resident until the syringe was empty. Witness 7 saw the resident at the hospital on [DATE], she/he was alert within her/his usual but was shaken by the error. The resident was still very upset with the nurse and nervous when he saw her/him. Witness 7 did not ask about the resident's blood sugars at the hospital. In an interview on 3/12/14 at 9:21 am Staff 10 (LPN) indicated she went to prepare the resident's insulin and could not find any so she obtained some from the facility back up supply. She reviewed the order and saw that it said 100 units. Staff 10 indicated she read it a second time because 100 units seemed very high, but she did not see the rest of the order. She drew up the insulin and went to give it to the resident. Staff 10 stated she said 100 units out loud and the resident said "yeah" so she went ahead and administered the insulin. Staff 10 discovered her error when she went to sign for the medication. The resident was very upset when she was told of the error. The resident was monitored and sent to the hospital when the physician did not call back promptly. In an interview on 3/12/14 at 9:38 am Staff 5 (CNA) indicated she was present at the time the medication was administered. The resident questioned the nurse during and after the administration of the insulin as to how much was being given. Staff 5 stated the resident was alert, oriented and very vocal but was not addressed when she/he questioned the dose. The resident was very agitated after she/he was told 100 units were administered. Staff 5 re-checked the resident's vitals and checked in on the resident a few times as she was told, then returned to her other duties. The resident was very upset and angry. In an interview on 3/12/14 at 10:40 am Staff 4 (RN) indicated he was called from the other unit to assist Staff 10 after the insulin error was discovered. Staff 4 helped direct what needed to be done as well as checking on the resident. The resident was not showing any signs of [DIAGNOSES REDACTED] while still at the facility. Staff 4 stated the resident was extremely upset with the error and was verbally targeting Staff 10. The resident was alert, oriented and knew that 100 units was too much. The resident was concerned about how the extra insulin would affect her/him especially with [MEDICAL TREATMENT]. Staff 4 explained to the resident the likely hood she/he would be going go the hospital to be monitored and receive [MEDICAL TREATMENT]. The resident fully understood and agreed that she/he thought the extra insulin would not start to show effects for a few hours. The resident was ultimately sent out to the hospital approximately an hour from the time the dose was given. Staff 4 indicated the first physician phone call was to the wrong doctor and the second call was not returned promptly so the resident was sent out anyway. Staff 4 was concerned how much time had passed and the likelihood the insulin would start to show affects and he could not be sure how it might affect the resident. The resident did not return to the facility.

Based on observations, interview and record review it was determined the facility failed to adequately monitor a pressure ulcer for 1 of 3 sampled residents (#19). Resident 19 developed an unstageable pressure ulcer. Findings include: Resident 19 was admitted to the facility in 2013 with [DIAGNOSES REDACTED]. The resident was hospitalized and readmitted to the facility in April 2013. The Comprehensive Care Plan dated 3/16/13 included monitoring the resident's skin integrity weekly and floating her/his heels when the resident was in bed. The Nursing Home Care Transfer Form dated 4/19/13 (physician's orders [REDACTED]. The Temporary Care Plan dated 4/19/13 directed staff to perform weekly skin audits and reposition the resident every two hours when s/he was in bed. The Initial Data Collection Tool/Nursing Service (admitting nursing assessment) dated 4/19/13 and Nursing Notes dated 4/19/13 did not contain documentation of a pressure ulcer on the resident's right heel. The resident's Pressure Ulcer Status Record dated 4/20/13 revealed the facility identified a Stage 1 pressure ulcer (reddened area) on the resident's right heel. The facility did not document the resident's Pressure Ulcer Status Record from 4/21/13 through 5/6/13; a period of two weeks. The Pressure Ulcer Status Record dated 5/7/13 revealed the resident's right heel pressure ulcer was a "red black" color. The resident's April and May 2013 Treatment Sheets included: "turn side to side every 2 hours, air mattress, float heels and weekly skin audits. The May, 2013 Treatment Sheet dated 5/3/13 directed staff to ensure the resident's heels were floated at all times and her/his leg splint was on whenever the resident's heel would have pressure on it. The resident's Nursing Notes dated from 4/21/13 through 5/7/13 did not describe the condition of the resident's right heel pressure ulcer. The Pressure Ulcer Status Record dated 5/13/13 documented the onset of the resident's unstageable right heel pressure ulcer with necrosis (devitalized skin). The weekly Pressure Ulcer Status Records dated 5/14/13 through 7/20/13 indicated the resident's right heel pressure ulcer remained unstageable. On 7/25/13 at 3:15 pm Staff 3 (RNCM) stated she was new to her role and just began overseeing Resident 19's care. She was shown the resident's Initial Data Collection Tool/Nursing Service dated 4/19/13 which did not include evidence of the resident's right heel pressure ulcer. Staff 3 was shown all of the resident's Pressure Ulcer Status Records and acknowledged there was a gap of two weeks when the facility did not document the status of the resident's right heel pressure from 4/21/13 through 5/6/13. On 7/26/13 at 10:30 am Staff 2 (DNS) indicated the facility did not continually monitor the resident's right heel pressure ulcer. She acknowledged the condition of the resident's facility acquired right heel pressure ulcer worsened.

Based on observation, interview and record review it was determined the facility failed to provide the appropriate food texture for 1 of 3 sampled residents (#1) who required a mechanically altered diet. This resulted in Resident 1 receiving the incorrect food texture. Resident 1 choked, required the Heimlich maneuver and an endoscopy in the hospital to dislodge a piece of food. Findings include: Resident 1 was admitted from the hospital on [DATE] with [DIAGNOSES REDACTED]. The Care Transfer Form from the hospital signed 1/28/13 identified the resident had dysphagia (difficulty swallowing) and required a pureed textured diet. The comprehensive assessment indicated the resident had no natural teeth, did not want dentures and had a mechanically altered diet. The current care plan indicated Resident 1 required a mechanically altered diet due to lack of teeth. A Physician order [REDACTED]. A speech evaluation dated 1/29/13 revealed Resident 1 was referred to a speech therapist evaluation for reasons that included swallowing deficits. A review of the progress notes identified on 2/7/2013, Resident 1 received a regular textured food tray instead of a pureed textured food tray for lunch. The resident had "an episode where (Resident 1) was choking on the chicken and unable to breathe." A staff member "preformed (sic) the Heimlich maneuver" and the resident "started coughing and breathing again." Resident 1 was assessed and transported to the E/R for an evaluation. The E/R records dated 2/7/13 indicated Resident 1 had an esophageal obstruction and required a procedure to remove the item, "an upper endoscopy and esophageal for foreign body removal." A review of an investigation dated 2/7/13 identified the resident received the wrong diet texture for lunch. Resident 1 choked, the Heimlich maneuver was performed and the resident began breathing again and coughing. The resident was assessed and transported to the E/R for evaluation. The investigation concluded Resident 1 received the wrong texture food tray, a regular texture food tray instead of pureed. On 2/8/13 at 2:00 pm, Staff 2, DNS conducted an interview with Resident 1. The resident stated "A man brought my tray in and I asked him to put in blender, he chopped up my food I have choked before." In interview on 3/25/13 at 1:25 pm, Staff 3, Speech Therapist stated the resident had reported choking incidents in the past. In addition, Resident 1 did not want any other diet texture but pureed because the resident stated she/he would choke. In interview on 3/25/13 at 2:50 pm, Resident 1 stated the staff who delivered the lunch tray on the day she/he choked cut up the chicken for her/him. Resident 1 told the staff she/he had choking problems before coming to the facility. The staff left the food. The resident stated she/he did not remember the name of the person who delivered the tray. Resident 1 stated he only choked one time since being in the facility and all the other food had been pureed. In interview on 3/25/13 at 3:30 pm, Staff 4, CNA stated he was in the facility and passed lunch trays on the day the resident choked. He stated he does not remember if he passed Resident 1's lunch tray. Staff 4 explained he checks the diet slip against the food and the resident's name to verify he has the correct food tray. In interview on 3/25/13 at 3:55 pm, Staff 2, DNS stated she was unable to discover who passed the lunch tray during her investigation of the 2/7/2013 incident. The system for passing trays at the time of the incident was to check the diet slip for the texture of the food and liquid against the resident's name. In interview on 3/25/13 at 5:30 pm, Staff 5, RNCM sated she was working day shift as a charge nurse on 2/7/13. A staff member told her Resident 1 had received the wrong lunch tray and the Heimlich maneuver was used. Staff 5 stated the staff responded quickly to assist the resident. She doesn't know what happened the day of the incident "maybe the kitchen sent the wrong tray." In addition, there was a lot of different staff on to assist the residents. An observation on 3/25/13 at 6:00 pm, revealed Staff 7, CNA removed Resident 1's food from the food cart. She verified the consistency of the resident's food against the diet slip and a list of the residents' name with their food textures. Resident 1 was observed in her/his room sitting in bed with the head of the bed up approximately 80 degrees. Resident 1 was served pureed textured food. In interview on 3/26/13 at 10:20 am, Staff 6, Cook verified she was working the day the resident choked. Her responsibility was to put the food on the plate after the kitchen helper told her what diet was needed. She stated she did not check the diet slips. Staff 6 stated she does not know how the resident received the wrong tray. There was "confusion on the (food) line" because corporate staff were in the building. The system in the kitchen has changed since the incident both kitchen staff check the diet slip against the residents' name and food.

Based on interview and record review it was determined a facility CNA failed to follow professional standards of practice to follow the care plan for 1 of 3 sampled residents (#1) who were at risk for falls. Resident 1 fell while attempting to self transfer from the toilet and suffered a head injury requiring hospitalization . Findings include: Review of the Oregon State Board of Nursing rules: Authorized Duties and Standards for Certified Nursing Assistants section [PHONE NUMBER] (6) (d) indicated a CNA must follow the care plan as directed by the licensed nurse. Resident 1 was admitted to the facility in 2012 with [DIAGNOSES REDACTED]. Review of an in room care plan updated 12/5/12 revealed facility staff were to stay with the resident when the resident was in the bathroom. Review of an incident report dated 12/13/12 at 12:10 am revealed the resident fell in the resident's room on 12/12/12 resulting in a hematoma to the forehead. Review of a history and physical from a local hospital dated 12/12/12 at 5:07 am revealed the resident was diagnosed with [REDACTED]. Review of a NN dated 12/13/12 at 10:58 am revealed the conclusion to the resident's fall was the resident was left in the bathroom unattended by Staff 3 and the resident fell . In an interview on 12/19/12 at 1:00 pm the Staff 1 (DNS) indicated the resident was assessed as a fall risk and care planned to not be left alone while in the bathroom. In an interview on 12/27/12 at 10:21 am Staff 3 (CNA) indicated on 12/12/12 she assisted the resident to the bathroom and then left the room to go to the nurses station. Staff 3 said she did not know the resident was not to be left in the bathroom alone and did not see it on the care plan. Refer to F 323

Based on interview and record review it was determined the facility failed to provide care planned supervision of a resident while in the bathroom for 1 of 3 sampled residents (#1) who were at risk for falls. Resident 1 fell while attempting to self transfer from the toilet and suffered a head injury requiring hospitalization . Findings include: Resident 1 was admitted to the facility in 2012 with [DIAGNOSES REDACTED]. Review of a fall CAA dated 10/30/12 revealed the resident was at risk for falls due to extensive assist for ADLs, muscle weakness, history of UTI, [DIAGNOSES REDACTED] and dementia. The assessment indicated facility staff would provide adaptive equipment for the resident to move around and CNAs would assist the resident according to the resident's needs. Review of an in room care plan updated 12/3/12 revealed the resident was not to be left alone in the resident's room when the resident was in a wheelchair. Review of an in room care plan updated 12/5/12 revealed facility staff were to stay with the resident when the resident was in the bathroom. Review of an incident report dated 12/13/12 at 12:10 am revealed the resident fell in the resident's room on 12/12/12 resulting in a hematoma to the forehead. The report indicated the resident was left alone in the bathroom, staff heard a noise come from the resident's room and the resident was found on the floor in a decordicate position (abnormal posturing in which a person is stiff with bent arms, clenched fists, and legs held out straight. The arms are bent in toward the body and the wrists and fingers are bent and held on the chest. This type of posturing is a sign of damage to the brain). The report also indicated the resident had a hematoma to the left side of the resident's forehead and was unconscious for 5 minutes. The resident was assessed by a nurse and sent to a local hospital for evaluation. Review of a history and physical from a local hospital dated 12/12/12 at 5:07 am revealed the resident was diagnosed with [REDACTED]. Review of a NN dated 12/13/12 at 10:58 am revealed the conclusion to the resident's fall was the resident was left in the bathroom unattended by Staff 3 and the resident fell . In an interview on 12/19/12 at 1:00 pm the Staff 1 (DNS) indicated the resident had a history of [REDACTED]. Staff 1 indicated the resident was assessed as a fall risk and care planned to not be left alone while in the bathroom. Staff 1 said Staff 3 had taken the resident to the bathroom and then left the room for about five minutes. Staff 1 said a noise was heard which came from the resident's room and the resident was found on the floor outside the bathroom. Staff 1 said the resident had suffered a hematoma to the head and was sent to a hospital for evaluation. Staff 1 indicated the resident's fall was caused by Staff 3 not following the care plan. In an interview on 12/20/12 at 9:53 am Staff 2 (RNCM) said the resident was admitted to the facility due to potential CNS infection secondary to VP shunt malformation. Staff 2 said on 12/12/12 the resident was assisted to the toilet and was left unsupervised. Staff 2 indicated a noise was heard which came from the resident's room and the resident was found on the floor in a decorticate position. Staff 2 said the resident had tried to self transfer from the toilet. In an interview on 12/27/12 at 10:21 am Staff 3 (CNA) indicated on 12/12/12 she assisted the resident out of bed to go to the bathroom around 12:30 am. Staff 3 said she assisted the resident to the bathroom and then left the room to go to the nurses station. Staff 3 indicated a few minutes later she heard a loud noise come from the resident's room and she found the resident lying on the floor outside of the bathroom face down. She said the resident had a large bump on his/her left forehead above the eyebrow and the resident appeared to have had a seizure because there was urine on the floor under the resident. She said the nurse evaluated the resident while she took the resident's vital signs and then the nurse called 911 to have the resident sent to the hospital. Staff 3 said she did not know the resident was not to be left in the bathroom alone and did not see it on the care plan.

Based on interview and record review it was determined the facility failed to assess and monitor the skin of 1 of 3 sampled residents (#1). Resident 1 developed multiple avoidable ulcers. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Orthopedic [MEDICAL CONDITION] Discharge Rehab (rehabilitation) Orders dated 9/11/10 revealed the resident was to wear TED hose ([MEDICAL CONDITION] Embolic Deterrent hose which are tight, thick, elastic stockings used as a preventative measure to reduce the occurrence of blood clots in the legs after surgery). The TED hose were "to be worn full time for 2 weeks (off as needed for skin care and bathing) and then during daytime for 4 additional weeks." Review of the hospital Nursing Transfer Summary dated 9/15/10 revealed the resident's "Skin/Wound Condition" was a surgical site with tape blisters on the right thigh. Review of the Initial Data Collection Tool/Nursing Service dated 9/15/10 at 10:20 pm revealed staff were "unable to adequately assess or look at skin d/t (due to) pt's (patient's) pain and dtr (daughter) fussing over mom and trying to help." Review of the Braden Scale for Predicting Pressure Sore Risk dated 9/16/10 revealed the resident's score was 15, "At Risk." (The Braden Scale score denoted the risk of developing pressure ulcers with risk of ulcers increasing as the score decreased. A score of 15 to 18 denoted "At Risk," 13 to 14 denoted "Moderate Risk," 10 to 12 denoted "High Risk" and nine or lower denoted "Very High Risk.") Review of the Interim Care Plan dated 9/16/10 revealed the resident was at risk for skin breakdown related to incontinence, a surgical wound, immobility and pain. Interventions included an air mattress, repositioning every two hours when in the bed or chair, schedule time out of bed as tolerated, a vitamin supplement and weekly skin checks. Review of the Weekly Skin Integrity Data Collection dated 9/20/10 revealed the resident had bruises on the "R (right) top of foot, R (right) baby toe." Review of the Pressure Ulcer RAP dated 9/22/10 revealed the resident had bruises on the top of the right foot and right baby toe. The resident was at risk for pressure ulcers and interventions included "Licensed Nurse will monitor skin every week and report findings to MD." Review of an unsigned Non-pressure Skin Condition Record dated 9/26/10 revealed the resident had a blister on the side of the right small toe that measured 2 by 1.5 cm and a bruise on the top of the right foot that measured 9.5 by 5.5 cm. Review of an unsigned Pressure Ulcer Status Record dated 9/26/10 revealed the resident had a Stage IV pressure ulcer on the right small toe that measured 2.5 by 3.5 cm. A Stage IV pressure ulcer is a full thickness loss of skin and subcutaneous tissue exposing muscle or bone. The unsigned Pressure Ulcer Status Record dated 9/26/10 revealed the resident had a Stage IV pressure ulcer on the right heel that measured 3.5 by 4 cm, and a Stage IV pressure ulcer on the right Achilles tendon that measured 2 by 4 cm. Review of the Weekly Skin Integrity Data Collection dated 9/27/10 revealed the resident had "redness top of R (right) foot" and "black R (right) small toe, black R (right) achilles." There was no mention of the resident's right heel. Review of the NN dated 9/28/10 at 9:50 am revealed the resident was sent to the emergency department by non-emergency transport. There was no information regarding the resident's condition, vitals or reason for transport to the emergency department. Review of the NN dated 9/29/10 revealed "Late entry for 9/26/10 0430 (4:30 am) Necrotic tissue for (sic) on R (right) foot-heel, 3 1/2 x 4 cm, Achillis (sic) tendon, 4 cm x 2 cm. small toe 2.5 cm x 3.5 cm, blister on lat. (lateral or side) small toe 2 cm x 1.5 cm. Bruise on top of R (right) foot 9.5 cm x 5.5 cm. Areas traced on plastic measuring tool." Review of the clinical record revealed no evidence the facility contacted the resident's physician regarding the resident's right foot, no evidence the resident's wound assessments were reviewed by an RN, no evidence the resident's right foot wounds were monitored, no evidence the resident's right foot wounds were treated or dressed and no evidence the resident's care plan was reviewed or changed. Review of the hospital History and Physical dated 9/28/10 revealed the resident had diminished pulses in both legs. There was a bruise on the top of the right foot and a necrotic (dead) fifth toe. The skin of the top of the right foot was red and the redness extended "all the way to the calf area." The right leg was slightly cooler than the left with delayed capillary refill. "The patient also has an eschar (thick, leathery, black or brown, dead tissue) of around 5 x 5 cm over the right heel, and also a smaller one just 2 cm above the heel ulcer, which is around 1 x 1 (cm)." An ultrasound revealed "superficial femoral artery occlusion and occluded dorsalis pedis artery." The plan was to treat the resident for right foot [MEDICAL CONDITION] (bacterial skin infection). The hospital Wound Care Documentation dated 9/28/10 revealed the resident had multiple wounds: an unstageable partial thickness, soft necrotic wound of the top of the right foot, two unstageable, full thickness wounds of the right heel and back of the ankle each with eschar surrounded by red skin, an unstageable wound of the outer part of the right small toe with eschar surrounded by red skin and an unstageable wound of the inner aspect of the right small toe with eschar surrounded by red and black skin. The hospital Consultation dated 9/29/10 revealed the resident was admitted the day before with "ischemic (lack of blood flow) changes and problems with the right foot." "It appears as if there is some vascular compromise to the foot at this point in time, and an ulceration in her heel, possibly a pressure ulceration." In an interview on 11/1/10 at 12:55 pm Staff 3 (RNCM) stated an RN was to co-sign all LPN assessments. Staff 3 stated the documentation on 9/20/10 of bruising on the top of the right foot and the right small toe required completion of skin sheets and nurses were to track and monitor the bruises. Staff 3 acknowledged there were no skin sheets started for the resident's bruises. In an interview on 11/1/10 at 1:07 pm Staff 10 (LPN) stated she was the nurse who sent the resident to the emergency room (ER). Staff 10 stated the resident's lower leg was discolored and the doctor gave her a telephone order to send the resident to the ER for evaluation. In an interview on 11/1/10 at 1:40 pm Staff 4 (CNA) stated CNAs changed residents' TED hose and if CNAs noted any skin changes they were to inform the nurse. Staff 4 stated Resident 1's TED hose were changed daily and during the change, the resident's legs were cleaned. Staff 4 remembered coming back after a weekend off and noting a spot on the resident's heel and back of the heel which "got huge overnight." In an interview on 11/1/10 at 1:45 pm Staff 5 (CNA) stated the resident's TED hose were removed for bed baths and switched out for clean hose. Staff 5 stated the resident had blackened areas near the end of her stay at the facility and "except for the toe they already had problems with" the areas "just appeared." Staff 5 stated she let nursing know about the areas. In an interview on 11/1/10 at 2:20 pm Staff 8 (LPN) stated she admitted the resident and assessed her skin. Staff 8 stated she completed the assessment of the resident's legs and there were "no marks at all on the feet." Staff 8 stated she was unable to complete the skin assessment of the resident's bottom, but she saw the resident's feet, "Oh, absolutely." Staff 8 acknowledged she had documented the bruising on the resident's right foot and toe on 9/20/10 but had not completed skin sheets. Staff 8 stated she reported the bruising to the next shift and "assumed it would get done." In an interview on 11/1/10 at 2:40 pm Staff 9 (CNA) stated she was with Staff 8 during the admission assessment and the resident's feet were "clear" and without problems. Staff 9 stated she showed the nurse the bruise on the resident's foot four or five days before the resident went to the hospital. In an interview on 11/1/10 at 2:50 pm Staff 7 (CNA) stated the problem with the resident's heel was found shortly before the resident left the facility. Staff 7 added just before the resident left the facility she "hurt too much" to get the TED hose off and the family was adamant about "letting her be." In an interview on 11/1/10 at 4:30 pm with Staff 1 (Administrator) and Staff 2 (DNS) the lack of assessment, monitoring, notification of physician and treatment of [REDACTED]. No further documentation was provided.