Every finding on record at Willamette View Health Center

Based on interview and record review it was determined the facility failed to contact the physician when indicated by a physician order for 1 of 4 sampled residents (#12) reviewed for medications. This placed residents at risk for lack of needed treatment for a low heart rate. Findings include:Resident 12 was admitted to the facility in 4/2026 with diagnoses including heart failure and dependence on renal dialysis (a medical treatment that removes waste products from the blood when the kidneys are not working properly).The 4/26/26 admission MDS revealed Resident 12 had a BIMS score of 8 indicating the resident had moderate cognitive impairment.The 6/1/26 hospital re-admission physician orders revealed an order to call the covering provider if Resident 12's HR (heart rate) was greater than 100 bpm (beats per minute) or less than 55 bpm. A review of Resident 12's vital signs from 6/1/26 through 6/17/26 revealed her/his HR was out of range on the following dates:-6/5/26, HR 47 bpm-6/11/26, HR 53 bpmA review of Resident 12's progress notes and full medical record revealed no indication the provider was notified on 6/5/26 and 6/11/26 of the low HR reading.On 6/15/26 at 12:11 PM Staff 5 (CNA) stated she obtained Resident 12's vital signs on her shift and if the vital signs were out of range, she told the charge nurse who then rechecked the vital signs. On 6/16/26 at 1:38 PM Staff 6 (RN) stated the CNA or sometimes the nurse obtained vital signs and the nurse reviewed the vital signs to verify they were within normal range. Staff 6 stated the CNAs communicated with the nurse if there was an abnormal reading, and the nurse rechecked to verify the accuracy of the reading, then contacted the provider and documented in a progress note. On 6/16/26 at 2:24 PM Staff 7 (RN) stated the CNA or the nurse obtained vital signs and she, as the nurse, always reviewed to ensure vital signs were within normal range. Staff 7 stated she contacted the provider if there were any abnormal readings and then documented in a progress note. Staff 7 stated she was unsure what happened on the identified dates and stated if she called a provider, it was documented in the progress notes.On 6/17/26 at 10:14 AM Staff 3 (DNS) stated the charge nurse oversaw all vital signs and was to contact the provider of any abnormal readings, and then document in a progress note that the provider was contacted. Staff 3 acknowledged the physician order was not followed as Resident 12's provider was not notified of the low HR on 6/5/26 and 6/11/26.

Based on observation, interview and record review it was determined the facility failed to ensure biologicals were stored securely and not accessible to unauthorized individuals for 1 of 1 sampled medication room reviewed for medication storage. This placed residents at risk for unauthorized access to drugs and biologicals. Findings include: The facility's 8/2024 Medication Management Policy & Procedure specified refrigerated medications were kept in a locked, secure refrigerator and all medications were stored in rooms accessible to authorized personnel. On 3/11/25 from 9:05 AM through 10:02 AM the unit's skilled nursing office door was propped open. During this time, various staff members went in and out of the room, and non-staff construction workers walked by the room. A white refrigerator and a silver refrigerator were observed inside the office. On 3/11/25 at 10:02 AM, Staff 4 (RN) reviewed the contents of the refrigerators. The silver refrigerator was empty and the white refrigerator contained an Aplisol vial (used for tuberculosis testing). Staff 4 stated the white refrigerator was used to store drugs and biologicals. On 3/11/25 at 10:18 AM, Staff 4 stated the refrigerator was not routinely locked. Staff 4 confirmed the office door was open and unlocked since 9:00 AM and the contents of the unlocked refrigerator were accessible to unauthorized staff and personnel. Staff 4 stated the office door should be locked at all times since the refrigerator remained unlocked. On 3/11/25 at 3:53 PM, the office door was observed open and no staff were in the office. On 3/12/25 at 8:22 AM, the office door was observed open and no staff were in the office. On 3/12/25 at 9:29 AM, Staff 3 (DNS) stated the office refrigerator was used to store drugs and biologicals. Staff 3 was notified the office door was unlocked and accessible to unauthorized personnel on 3/11/25 and 3/12/25 and the refrigerator was left unlocked. At 9:37 AM, Staff 3 observed the unlocked refrigerator and stated the door to the office and the refrigerator were to be locked at all times.

Based on observation, interview and record review it was determined the facility failed to ensure residents were assessed for self administration of medications for 1 of 1 sampled resident (#1) reviewed for medication administration. This placed residents at risk for adverse medication related consequences. Findings include: The facility's 8/2024 Self-Medication policy outlined the following criteria for a resident to self-administer medications: -The resident must successfully pass the Medication Self-administration Safety Screen; -Their primary care physician must approve their request to self-administer medications; and -They must consistently secure their medications out of the reach of others. Resident 1 was admitted to the facility in 2/2025 with diagnoses including left leg fracture and amnesia. A review of Resident 1's 2/18/25 Admission MDS revealed she/he had moderately impaired vision and required cueing for recall. On 3/11/25 at 10:36 AM, Resident 1 was observed to have the following medications on her/his bedside table: -Two tubes of Benadryl itch stopping cream. -One tube of Benadryl extra strength itch stopping gel. -One tube of GC dry mouth gel. -Three tubes of Systane night time eye lubricant gel. -Two bottles of TheraTears lubricant eye drops. On 3/11/25 at 10:36 AM, Resident 1 stated the medications on the bedside table were her/his and she/he applied the Benadryl and TheraTears herself/himself several times each day. Resident 1 also stated she/he did not remember the last time she/he used the Systane. On 3/11/25 at 11:16 AM, Staff 4 (RN) stated residents were allowed to self administer medications with a physician's order and successful completion of an evaluation. Staff 4 stated the resident needed to name the medication, its use, and when it was given. Staff 4 acknowledged Resident 1 did not complete the evaluation and did not have an order from her/his physician for medication self administration. On 3/11/25 at 11:30 AM, Staff 3 (DNS) stated she expected residents to have a physician order and complete an assessment to self administer medications.

Based on interview and record review it was determined the facility failed to the ensure the Direct Care Staff Daily Report (DCSDR) postings were accurate for 35 of 39 days reviewed for staffing. This placed residents and visitors at risk for inaccurate staffing information. Findings include: The facility's Nursing Staffing Plan policy, dated 1/9/24, indicated that staffing information on the Daily Staff Public Posting form must be an accurate reflection of the actual staff working each shift. A review of the facility's DCSDRs revealed the following: From 2/1/25 through 3/10/25, 39 days were reviewed and revealed 35 days when licensed nursing staff hours were inaccurate on 2/2/25, 2/3/24, 2/4/25, 2/5/25, 2/6/25, 2/7/25, 2/8/25, 2/9/25, 2/10/25, 2/11/25, 2/12/25, 2/13/25, 2/14/25, 2/15/25, 2/16/25, 2/17/25, 2/19/25, 2/20/25, 2/21/25, 2/22/25, 2/23/25, 2/24/25, 2/26/25, 2/27/25, 2/28/25, 3/1/25, 3/2/25, 3/3/25, 3/4/25, 3/5/25, 3/6/25, 3/7/25, 3/8/25, 3/9/25 and 3/10/25. On 3/11/25 at 11:18 AM, Staff 2 (Assistant Administrator) reviewed the 2/1/25 through 3/10/25 DCSDRs and verified the reports were inaccurate on the days identified. Staff 2 stated she was currently responsible for ensuring the accuracy of the reports and expected the DCSDRs to accurately reflect the correct hours licensed nursing staff worked each shift.

Based on interview and record review it was determined the facility failed to have a system in place to monitor and document food temperatures for 1 of 1 kitchen reviewed for safe food preparation. This placed residents at risk for food borne illness. Findings include: Review of the facility census indicated two residents resided in the facility. Resident 1 and Resident 2 indicated no concerns regarding food. Review of the residents' medical records revealed no indication of food related illnesses. On 1/3/24 at 10:42 AM during a kitchen observation, Staff 4 (Dining Manager) and Staff 5 (Executive Sous Chef) were asked to provide documentation of the food temperature logs. Staff 4 stated once food was prepared in the kitchen it was placed into the hot box (temperature controlled food cart). Food temperatures were taken and documented by the staff in the skilled unit when the food was removed from the hot box. Staff 4 and Staff 5 stated food temperatures were not taken in the kitchen and there was no documentation of food temperatures. On 1/3/24 at 11:20 AM Staff 3 (RN) stated there was no documentation kept of food temperatures in the skilled unit. On 1/3/24 11:20 AM Staff 2 (DNS) stated nursing staff took food temperatures only when food was reheated. On 1/3/24 at 1:10 PM Staff 1 (Administrator) acknowledged the facility did not have a system in place for monitoring food temperatures and did not have documentation of food temperatures.

Based on observation, interview, and record review it was determined the facility failed to ensure proper food handling practices and assure the kitchen was maintained in a sanitary manner for 1 of 1 kitchen reviewed. This placed residents at risk for food-borne illness. Findings include: The 2012 Food Sanitation Rules incorporated by reference to USDA Food code 2009 directs .the following foods may not be provided: home-canned or home processed foods .Pasteurized eggs shall be substituted for raw eggs in preparation of foods .that are not fully cooked .Equipment and utensils, air drying required after cleaning and sanitizing .Employees shall use effective hair restraints to prevent the contamination of foods or food-contact surfaces .Prohibit contacting ready-to-eat food with bare hands . On 8/22/16 at 8:40 am, Staff 1 (Administrator) stated all meals were prepared and transported to the Health Center residents from an off-site kitchen. On 8/22/16 at 8:53 am and on 8/23/16 at 11:15 am observations were conducted in the off-site kitchen. Staff 2 (Dietary Tech), Staff 3 (Executive Chef), Staff 4 (Executive Chef), Staff 5 (Kitchen Department Head) and/or Staff 6 (Sous Chef) accompanied the surveyor. The following conditions were observed: 1 . The Dry-Storage area contained: a. Sixteen home-made unlabeled and undated glass quart jars containing vegetables. Staff 2 stated the pickles were canned (preserved) over the week-end and would be served to residents. b. Four large rolling storage bins which contained bulk flour, sugar, rice and corn starch. A scoop was stored with each bulk product. Staff 2 stated scoops should not be stored with the product. c. Multiple tomatoes on an open pan with mold spots. Fruit flies were observed over the tomatoes. 2. The exterior walk-in refrigerator contained: a. Two cases of unpasteurized raw eggs. Staff 2 said poached eggs were prepared and served daily. The facility did not purchase pasteurized eggs. b. Three sheet pans with 12 uncovered/unlabeled/undated raw beef roasts on an open shelving unit. Staff 4 said the meat was thawing, should be covered and date labeled when placed on the pans. 3. The dish storage area: a. Clean dish racks contained multiple wet stacked dishes which included plates and pans. Staff 5 (Department Head) said the dishes were stacked too soon after washing and were not allowed to air dry. b. An opened package of snack cake and a lidded paper coffee cup which contained liquid were stored amongst the clean dishes. Staff 5 removed both and provided no additional comments. c. A pan contained multiple soiled plastic beverage bottles. Staff 5 confirmed the bottles were ready for use and were unclean. 4. Two dietary staff with unrestrained long hair and another dietary staff with unrestrained short hair. Staff 2 (Dietary Tech) said hair nets were not required. 5. The walk-in refrigerator contained an open shelving unit labeled Health Center. Approximately 25 uncovered and undated ready-to-eat individual custard/pudding cups were stored on a pan in the shelving unit. The cup's contents were retracting from the edge of the containers. Staff 2 (Executive Chef) said the containers should be removed and not served. 6. In the kitchen in direct contact with the garbage bin was an open rack containing two uncovered pans with food labeled HC Chix. Staff 6 (Sous Chef) moved the rack and confirmed it was too close to the garbage bin and the food should have been covered. 7. Staff 7 (Dietary Tech) was observed moving prepared ready-to eat crepes from pan to pan using his bare hand to touch the top of each crepe. Staff 7 confirmed he should not have touched the food with his bare hand. On 8/23/16 at 12:25 pm, Staff 5 confirmed foods were not appropriately stored, prepared, and handled to prevent potential contamination and dietary staff had not used effective hair restraints.

Based on observation and interview it was determined the facility failed to ensure food was stored in a sanitary manner for 1 of 1 ice machines. This placed residents at increased risk for food borne illness. Findings include: On 5/29/14 at 11:58 am, it was observed the drain for an ice machine in the kitchen's dry storage room did not have an air gap. The drain pipe from the ice machine was inserted into the floor drain and pushed up against the side of the floor drain. The ice machine drain was contaminated from being in contact with the floor drain. There was also the potential for contamination from sewage back-up from the floor drain which could potentially contaminate the ice stored in the ice machine used for resident consumption. On 5/29/14 at 12:17pm, Staff 1 (Sous Chef) acknowledged the ice machine did not have an air gap.

Based on observation, interview and record review it was determined that the facility failed to provide choices in the areas of medication administration, timing of meals and timing of therapies for 2 of 3 sampled residents (15 and 21) and 1 non-sampled residents (23) who were reviewed for choices related to preferred routines. Findings include: 1. On 10/24/11 Resident 21 was admitted to the facility with [DIAGNOSES REDACTED]. a. On 11/1/11 at 8:12 am, Staff 1, RN, entered the dining room with medications for Resident 21, and stated she was going to sit and give all of the pills. This interrupted breakfast, as Resident 21 was required to swallow seven oral medications with water. Resident 21 was not afforded a choice in determining when to take the medications. During an interview with Resident 21 on 11/1/11 at 8:50 am, she stated that her medications were normally taken "after breakfast." b. On 11/1/11 during the breakfast meal Resident 21 was observed to have eggs included on her meal tray. On 11/2/11 at 8:40 am, Resident 21 was observed eating breakfast which included an omelet. The surveyor asked the resident how her food was and she stated, "You know I am not an egg eater. I have told them that I like cold cereal, that is what I eat all the time when I am in my apartment." When asked if she ever got cold cereal, the resident stated, "One day I had Raisin Bran." The resident's dietary tray card on 11/2/11 at 9:05 am identified her dislikes including eggs at breakfast and her likes/preferences including dry cereals such as Corn Flakes, Total, Special K. The Dietary Services assessment dated [DATE] stated the resident was receiving high protein using tuna and peanut butter sandwiches to help with wound healing. The assessment did not include any mention of egg or egg protein. In a 11/2/11 interview at 1:54 pm, Staff 2, Dietary Technician, stated that residents were interviewed regarding their food likes and dislikes within three days of arrival to the Health Care Center. She indicated kitchen staff knew what to serve each resident based on their preferences. She reported that there was a book accessible to the kitchen aides and cooks and that every day the residents were asked what they would like regarding their choices. Staff 2 did not know why resident 21 had received eggs on two occasions after they were identified as a food dislike. She acknowledged that the person plating the food possibly did not read the tray card regarding likes and dislikes before serving the food. During an interview with Staff 3, CNA, on 11/2/11 at 1:50 pm, she stated Resident 21 "... she gets scrambled eggs and hashbrowns, she does not really like eggs. Sometimes we can put sausage in there. She needs to eat protein because she is diabetic." c. On 11/2/11 at 8:49 am, Resident 21 shared, "I am a big duck fan, my husband went to U of O and so did I, I watch the game every Saturday." According to Resident 21, the therapist had shown up the previous Saturday during game time and she was unhappy about the interruption, stating that she was less than welcoming. She stated, " It was a good thing that it was half time" and indicated that the therapy session was cut short. During a phone interview on 11/2/11 at 1:50 pm, Staff 4, PT Director, stated that there was no formal schedule for therapy and the time that therapy was given was not documented. She acknowledged that residents sometimes had interference like showers or appointments. Usually physical therapy was provided in the morning and occupational therapy was provided in the afternoon. If a resident requested a scheduled appointment, "we try and set that up and if not, it is filled in." d. During a 10/31/11 interview at 3:39 pm, Resident 21 reported that she did not like getting up at 7 am, and when at home she preferred to sleep until 9 am. In a 11/2/11 interview at 2:24 pm, Staff 1, RN, stated that a charge nurse assessed residents upon arrival to the Health Care Center. When asked how they collect information regarding preferences for routine/activities, she stated that she would like to defer on that question and that it was based more on observation and word of mouth or nursing notes. She indicated the residents were not asked any specific questions regarding customary routines. 2) Resident 15 was admitted to the facility in September 2011 with a [DIAGNOSES REDACTED]. On 11/1/11 at 9:10 am, Resident 15 was observed in her bedroom, sitting in a chair with a hot breakfast placed in front of her on the bedside table. Staff 1, RN, was passing medications, and Resident 15 asked to take her medications after eating. The nurse said, "Let's just get some of them in." Resident 15 took some of the nine oral morning medications, drank some water, then the nurse asked Resident 15 to take the rest of the medications and "get them over with." Resident 15 had a moist cough and was not easily swallowing a large vitamin. The nurse said she would come back with the last two vitamins after breakfast. Resident 15 repeated she did not want to take them now. On 11/1/11 at 12:09 pm, Resident 15 was observed eating a sandwich for lunch. Staff 1 walked in and asked if Resident 15 could take the two remaining vitamins. Resident 15 took them in her hand, sighed, and swallowed them with water. The nurse then listened to Resident 15's lungs with a stethoscope, and discussed her impending transfer that day. In interview on 11/1/11 at 1:08 pm, Resident 15 was asked when her medications would normally be taken. She stated before or after meals. When asked if Resident 15 felt there was a choice of when to take her medications, she stated, "Yeah, I guess, I mean if they're standing right here, waiting for you to take them..." In observation on 11/2/11 at 8:35 am, Staff 1 gave medications to Resident 15 in her bedroom, during the middle of breakfast. The nurse then proceeded to take Resident 15's blood pressure and oxygen saturation. The nurse stated that the resident took her [MEDICATION NAME] and [MEDICATION NAME], but was unable to take her vitamins at that time as she was not feeling well. 3. On 11/4/11 at 7:30 am, three female residents were observed seated at the table in the Health Care Center dining room. All were fully dressed, well groomed and had a cup of coffee in front of them on the table. When asked if they were "early-risers," Resident 23 stated she was " not an early riser" and "neither is she" pointing to Resident 15, seated next to her. When asked if she could sleep in if she wished, she stated, "I thought I just needed to do what they said."

Based on observation, interview and record review it was determined the facility failed to properly sanitize glucose monitoring equipment intended for multi-resident use during three observations for 1 of 1 sampled resident (#21) for whom routine glucose monitoring was prescribed. Findings include: On 11/1/11 at 7:33 am, Staff 1, RN, was observed using a glucose meter to check Resident 21's CBG level. After testing, the licensed nurse used an alcohol wipe to clean the meter. Staff 1 stated the meter was not Resident 21's personal meter, and it was used for any resident requiring CBG testing on the skilled wing. The licensed nurse verified that an alcohol wipe had been used to clean the meter. On 11/1/11 at 10:08 am, Staff 1 was observed using a glucose meter to re-check Resident 21's CBG level, and used an alcohol wipe to clean the meter. Again, Staff 1 verified that an alcohol wipe was used to clean the meter. On 11/1/11 at 11:32 am, Staff 1 was observed teaching Staff 6, Student Nurse, to clean the glucose meter with an alcohol wipe before using it. On 11/1/11 at 11:49 am, Staff 6 was observed using the meter to again check Resident 21's CBG level. Staff 1 instructed the student to leave the meter on top of the medication cart and indicated they would clean it later. At 11:54 am, Staff 1 came back to the nurses station and stated she couldn't remember if they had cleaned the glucose meter. The glucose meter was left uncleaned on top of the medication cart while the licensed nurse passed medications to another resident. On 11/1/11, Staff 5, Interim DNS, provided a copy of the facility's Policy & Procedure for disinfection of glucose monitoring equipment. The policy stated that glucose monitoring equipment would be appropriately disinfected using a disinfectant wipe after each use. The policy made no mention of the use of alcohol. According to current CDC disinfection guidelines, glucose meters must be cleaned and disinfected after each use according manufacturer's instructions, using a disinfectant effective against all blood-borne viruses. On 11/2/11 at 8:32 am, Staff 1 showed a surveyor a container of "Germicidal Disposable Cloth(s)" that were supposed to be used to clean the glucose meter after each use. In an interview with Staff 5 on 11/4/11 at 8:05 am, she was asked how it occurred that licensed staff were disinfecting glucose monitoring equipment with alcohol wipes versus the disinfectant quaternary wipes referenced in the facility's Policy & Procedure. She stated that the nurse involved was the newest nurse on staff and the wipes were readily available under the sink in the nursing station.

Based on observation, interview and record review it was determined that the facility failed to identify and address weight loss in a timely manner for 2 of 2 sampled residents (#s 17 and 22) with weight loss. Findings include: 1. Resident 22 was admitted on [DATE] with [DIAGNOSES REDACTED]. An 8/5/11 Nutritional Assessment, from her previous living situation, was available in the medical record and identified that the resident had been receiving palliative care. She had weighed 131 pounds and there had been no weight change in the last 90 days. A 2 cal supplement (80 cc TID) was provided to increase available calories and discourage weight loss. Weight gain was desired. Appetite was small, although it had improved. The 10/21/11 Preliminary Nursing Assessment identified that her appetite was good and she weighed 125 pounds. CNA Flow Sheets from 10/21 to 10/31/11 documented appetite for breakfast to range from 60-100%, lunch 70-100% and dinner 80-100%. No meal replacements or supplements were documented as offered. Fluid intake was adequate. The resident was documented to require supervision or was independent when eating. On 11/1/11, a dietitian's assessment identified that her current weight was 125 pounds with no weight changes noted. The resident was receiving an appropriate diet (general regular with nourishments available) and intake was good. It was expected that the resident would be able to meet her nutritional needs. Weight was within the ideal body weight parameters and her body mass index was in the healthful range. A goal for stable weights was established. The plan was to continue the diet with weight maintained at 125 +/- 3 pounds. No other weights were available for review. On 11/2/11 at 12:10 pm and 11/4/11 at 7:50 am, Resident 17 was observed eating her meals in the resident dining room. Limited staff supervision was provided and the resident ate almost all of her meal with no cues provided. In a 11/2/11 interview at 10:11 am, Staff 1, RN, stated that weights were done on a weekly basis upon admission. She could not explain why a second weight was not available for Resident 22. The Weight Record identified that on 11/2/11, the resident weighed 118.2 pounds (an almost 7 pound drop in weight). There was no acknowledgement of the weight loss in the resident record including an identification or assessment of the weight loss, referral to the dietitian or notification of the MD when reviewed on 11/4/11. In a 11/4/11 interview at 8:15 am, Staff 3, CNA, shared that all residents were weighed weekly. Staff 3 was responsible to get and compare the resident's weight. She had taken Resident 22's weight on 11/2/11 and noticed that she had lost weight. Staff 3 reported the loss to the charge nurse and asked if she could begin giving the resident a supplement as the resident did not always eat well. Staff 3 began giving the resident a supplement on 11/2/11 at 10:00 am and 2:00 pm, so it would not interfere with her meal intake. On 11/4/11 at 9:40 am, Staff 5, Interium DNS, stated that the charge nurse was responsible to assure that weights were taken and the dietary technician checked in daily and monitored for changes. In the case of Resident 22, Staff 5 stated that they should have responded to the weight loss and there was work to be done. When interviewed on 11/4/11 at 10:10 am, Staff 2, Clinical Diet Technician, stated that the 6 pound weight loss upon admission had not surprised her due to the resident's recent surgery during hospitalization . The supplement was missed on admission, but should have followed her from the previous placement. Staff 2 was not notified of the resident's weight taken on 11/2/11 and was unaware of the loss. She had been reliant on the previous DNS' system for monitoring which was no longer in use and described the system for weight monitoring as "in limbo" now. 2. Resident 17 was admitted on [DATE] following hospitalization for a tibia/fibia fracture with surgical repair. Additional [DIAGNOSES REDACTED]. A 7/25/11 Nutritional Assessment Dietitian Report identified that the resident was on a no concentrated sweets diet with nourishments available. The resident had requested more fresh fruit with his meals, but was otherwise satisfied with portion size. Resident 17 reported a weight loss from 330 pounds to 270 pounds over the past 4-5 months which he related to [MEDICAL CONDITION] with poor appetite. The resident reported that his appetite had improved and he was identified to be eating well. Weight was documented as 276 pounds with a lower extremity cast. The resident was considered to be morbidly obese. Skin excoriation, the [DIAGNOSES REDACTED]. A goal for weight stabilization with weight to remain at 276 +/- 3 pounds was documented. An 8/5/11 Care Plan entry identified that the resident was at risk for malnourishment. A goal to maintain weight at 276 +/-3 pounds was noted. Approaches included to encourage good intake, offer meal replacements, keep a low sugar drink at the bedside and weigh weekly. The next recorded weight was documented on 8/17/11 as 259.8 pounds. Although this represented more than a 16 pound weight loss in one month, there was no evidence that the resident was re-weighed, an assessment to evaluate/explain the weight loss was completed and/or care planned approaches had been re-evaluated for effectiveness. The resident was discharged on [DATE]. On 11/4/11 at 8:15 am, Staff 3, CNA, shared that all residents were weighed weekly. Staff 3 was responsible to get and compare the resident's weight. The charge nurse and "dietary lady" were notified of any weight losses. When interviewed on 11/4/11 at 9:40 am, Staff 5, Interium DNS, stated that the charge nurse was responsible to assure that weights were taken and the dietary technician checked in daily and monitored for changes. In the case of Resident 17, she agreed that there had been a lack of follow-up regarding the missing weekly weights and the weight loss. In a 11/4/11 interview at 10:10 am, Staff 2, Clinical Diet Technician, stated that she had not been good about checking weekly weights and had relied on the previous DNS' system for monitoring which was no longer in use. She also indicated that Resident 17 had experienced ongoing issues with diarrhea and drank large quantities of 7-up while at the facility. There had also been a new cast placed on his leg prior to discharge. After reviewing the resident's record, she confirmed that there had been no documentation which explained or addressed the resident's weight loss.

Based on observation, interview and record review it was determined that the facility failed to assess potential risk factors for skin breakdown and to develop an individualized plan of care to minimize those risks for 2 of 2 sampled residents (#s 1 and 21) who developed pressure ulcers after admission to the facility. Findings include: 1) Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was no documented assessment found related to the resident's risks for development of pressure ulcers. The resident's admission nursing assessment dated [DATE] reflected the resident was admitted without pressure ulcers. The resident's initial care plan contained no entries outlining risks for pressure ulcer development or approaches for preventing ulcer development. ADL records from the time of admission through the end of June 2011 indicated Resident 1 required extensive (weight bearing) assistance for bed mobility and transfer, was dependent for personal hygiene, and was incontinent. A fax to the resident's physician dated 6/9/11 revealed the resident had developed a 1.3 cm by 1.4 cm serum filled blister on his left heel. At that time (16 days after admission) a physician order [REDACTED]. A care plan entry dated 6/13/11 (4 days after the blister was discovered) identified the resident was at increased risk for pressure ulcers with an actual pressure ulcer on left heel. Care plan approaches added at that time included: Turn every 2 hours back to side, pressure redistribution mattress and wheelchair cushion, heel float device in bed, treatments as ordered, monitor left heel every day with treatment and assessment every week. During interviews with Staff 5, the interim DNS, on 11/2/11 at 3:00 pm and 11/4/11 at 8:00 am, she confirmed there was no Braden scale or other skin at risk assessment found in the medical record. The resident's initial care plan did not address risk factors for skin breakdown or approaches for mitigating risks prior to the resident developing a pressure ulcer. 2) Resident 21 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident's 10/24/11 Initial Nursing Assessment indicated the resident was admitted with no pressure ulcers present. A Braden scale assessment, dated 10/24/11, revealed a score of 21, indicating the resident was not at high risk for pressure ulcer development. The resident's mobility was coded as a "4", indicating she had no mobility limitations and was able to make major and frequent changes in position without assistance. Aide documentation of assistance levels required since admission reflected the resident was receiving limited (non-weight bearing) assistance for both bed mobility and transfer. Prior to 11/1/11 there was no nursing assessment found which addressed the resident's altered mobility related to her right femoral neck fracture with arthroplasty, diabetic status (MARs from admission through 11/2/11 reflected widely fluctuating blood sugar levels), history of lower extremity digit amputations, or [MEDICAL CONDITION]. On 10/29/11 nurses notes contained the following entry: "4 1/2 x 3 1/2 sheer with .5 cm blood blister in center on lower spine." The etiology of the wound was not defined. Prior to the discovery of the undefined and unstaged wound the resident's care plan contained no identification of risks for skin breakdown or individualized preventative approaches to prevent skin breakdown. The first care plan entry related to skin was dated 10/30/11. At that time, a wound was documented along with the need to provide dressing changes, a Geomat cushion in chair, and side to side turning. On 11/1/11 (three days after the pressure ulcer was first noted), in nurses notes, a comprehensive assessment of the resident's risk factors was documented and the ulcer was documented as a stage II open area, 0.4 by 0.4 cm with scant sero-sanguinous drainage. On 11/1/11 at 10:15 am, the resident was observed to have a stage II, non-draining ulcer on her coccyx , 0.4 x 0.4. cm in size. During the wound observation Staff 1, RN, stated that on 10/31/11 the wound had measured 0.6 x 0.6 cm and was oozing. On 11/2/11 at 9:15 am Resident 21 had a Geo bed mattress and cushion on chair in her room On 11/2/11 at 11:55 am during a treatment observation, the ulcer on the resident's coccyx area was observed to be 0.3 x 0.3 cm with scant serosanguinous drainage. The depth was superficial and the surrounding 2 x 1.3 cm skin area was reddened and non-blanching. During the wound observation, Staff 1, RN, reported that the wound area first presented as sheared with a closed blood blister and had significantly improved. The resident was also observed to have a stage I, 0.2 x 0.6 cm area on the left medial heel. The skin on the resident's bilateral lower extremities were tight and shiny with diffuse erythremia from knees to ankles. During an interview on 11/2/11 at 10:00 am, Staff 3, the CNA who routinely cared for the resident, stated she thought the resident had a wheelchair cushion and bed cushion in use prior to the discovery "this weekend." She stated nursing ordered a better mattress and cushion (Geomatt) when the resident was discovered to have "small open area."The aide stated the resident was encouraged to take the Geo cushion to the DR with her this am and the resident had refused. Resident 21 was described by the aide as resistive to staying off her back and onto her side, even when aides assisted her to turn. She indicated that night shift aides reported that the resident generally rolled back onto her back within half an hour. In a 11/2/11 interview at 12:05 pm, Staff 1 stated the resident had a pressure reducing mattress on the bed prior to the ulcer being discovered. However, the chair did not have a pressure reducing cushion until after that ulcer was found, at which time a Geo cushion was put on her chair. "Now that a turning schedule is in place she stays off back more, I've been told she was a back lyer." She indicated the resident was newly insulin dependent and had widely fluctuating blood sugar levels. " If we could get the blood sugars under control it would help with healing." On interview with Staff 5, Interim DNS, on 11/4/11 at 8:00 am, she stated that she knew that the resident had other risk factors including her diabetic status. She was unable to provide any additional evidence that the resident had been care planned related to risk factors, prior to pressure ulcer development.

Based on interview and record review it was determined that the facility failed to assure that residents were not charged for services while waiting for a demand bill determination for 1 of 1 sampled resident (1) reviewed for demand bills. Findings include: A Medicare Denial Letter was provided to Resident 1 on 5/25/11 which explained that the type of care needed by the resident did not meet the criteria for Medicare skilled care. On the same date, the Power of Attorney for the resident requested, in writing, that the bill be submitted for a Medicare decision. According to the facility's financial records, the demand bill was submitted to Medicare on 7/11 and 7/18/22. A 5/31/11 statement which was provided to the resident identified charges for medical supplies, pharmacy, and seven days of room and board from 5/25 through 5/31/11 with a notation to "Please pay this amount due upon receipt." In a 11/1/11 interview at 11:30 am, Staff 7, Accountant, stated a Medicare Denial bill was submitted for Resident 1 on 7/11 and 7/18/11. A private bill was also given to the resident each month prior to the determination, but she was not required to pay it until the Medicare claim was denied. No interest was charged if the resident chose not to pay. Resident 1 did not pay the bill, but Staff 7 had other residents who had paid in the past. Facility records identified that five residents had requested Demand Bills in the last 6 months. Staff 7 stated that all residents would have received private billing while waiting for the Medicare determination. .

Based on interview and record review it was determined the facility failed to ensure professional standards were followed regarding care planned fall interventions for 1 of 1 sampled residents (#1) reviewed for falls. The resident fell and sustained fractures. Findings include: Division 45 Scope of Practice Standards for Registered Nurses 851-045-0060 (2) Standards related to the Registered Nurse's responsibility for nursing practice implementation. Applying nursing knowledge, critical thinking and clinical judgment effectively in the synthesis of biological, psychological, social, sexual, economic, cultural and spiritual aspects of the client's condition or needs, the Registered Nurse shall: (d) Implement the plan of care by: (A) Implementing treatments and therapy, appropriate to the context of care, including emergency measures, interpretation of medical orders, medication administration, independent nursing activities, nursing, medical and interdisciplinary orders, health teaching and health counseling Resident 1 admitted to the facility in 9/2011 with [DIAGNOSES REDACTED]. The 9/21/11 care plan noted the resident had a history of [REDACTED]. A 10/4/11 Interdisciplinary Resident Note revealed the resident was having dinner in the dining room. The resident was getting up to leave and Staff 2, RN, heard a loud noise. The resident stated she/he had fallen, hitting her/his head and the right middle and ring fingers were painful. The resident was able to stand and ambulate, but had severe pain in the right groin area. The resident was transferred to a local hospital emergency room for evaluation. The 10/4/11 Emergency Department Physician Summary revealed the resident had sustained fractures of the pelvis and a finger and a minor head injury. The 10/5/11 Investigation Note indicated the resident had ambulated approximately 60 feet, from her/his apartment to the dining room, without the walker. After dinner, the resident stood up to walk back to the apartment. It was noted the resident walked approximately five steps before the fall. In interview on 10/24/11 at 9:37 am, Staff 1, Acting DNS, stated if the resident did not have the walker, she expected staff to intervene and get the walker for the resident. In interview on 10/24/11 at 11:54 am, Staff 2, RN, stated she was the RN on the skilled floor with three residents, including one resident who had admitted to the facility that afternoon. Staff 2 asked Resident 1 and another resident if they wanted to go to the dining room. Both residents stated yes and walked themselves to the dining room. Staff 2 stated she did not see Resident 1 walk to the dining room, nor did she notice the walker not being in place until another staff member asked about it after the fall. Staff 2 stated she had served dinner to the residents and was at the nurse's station completing admission paperwork at the time of the fall. Staff 2 stated the resident fell where she/he stood up at the table.

Based on interview and record review it was determined the facility failed to follow care planned interventions for use of an assistive device for 1 of 1 sampled residents (#1) reviewed for falls. The resident fell and sustained fractures. Findings include: Resident 1 admitted to the facility in 9/2011 with [DIAGNOSES REDACTED]. The 9/21/11 care plan noted the resident had a history of [REDACTED]. A 10/4/11 Interdisciplinary Resident Note revealed the resident was having dinner in the dining room. The resident was getting up to leave and Staff 2, RN, heard a loud noise. The resident stated she/he had fallen, hitting her/his head and the right middle and ring fingers were painful. The resident was able to stand and ambulate, but had severe pain in the right groin area. The resident was transferred to a local hospital emergency room for evaluation. The 10/4/11 Emergency Department Physician Summary revealed the resident had sustained fractures of the pelvis and a finger and a minor head injury. The 10/5/11 Investigation Note indicated the resident had ambulated approximately 60 feet, from her/his apartment to the dining room, without the walker. After dinner, the resident stood up to walk back to the apartment. It was noted the resident walked approximately five steps before the fall. On 10/24/11 at 8:58 am, the resident was observed in her/his room, sitting in a chair by the bed, eating breakfast, with the walker in the corner of the room and a sign posted reminding the resident to use the walker. When asked about the fall, she/he recalled fracturing her/his pelvis, but did not recall any details about the fall itself, " I just fell . " In interview on 10/24/11 at 9:37 am, Staff 1, Acting DNS, stated if the resident did not have the walker, she expected staff to intervene and get the walker for the resident. In interview on 10/24/11 at 11:54 am, Staff 2, RN, stated she was the RN on the skilled floor with three residents, including one resident who had admitted to the facility that afternoon. Staff 2 asked Resident 1 and another resident if they wanted to go to the dining room. Both residents stated yes and walked themselves to the dining room. Staff 2 stated she did not see Resident 1 walk to the dining room, nor did she notice the walker not being in place until another staff member asked about it after the fall. Staff 2 stated she had served dinner to the residents and was at the nurse's station completing admission paperwork at the time of the fall. Staff 2 stated the resident fell where she/he stood up at the table.