Every finding on record at Woodside Post Acute

Based on observation, interview and record review it was determined the facility failed to ensure residents were able to share a room with a roommate of choice for 2 of 2 sampled residents (#s 11 and 56) reviewed for accommodation of needs. This placed residents at risk for emotional distress. Findings include:On 8/17/26 the survey team observed multiple resident rooms with up to three residents residing in one room. Resident 56 admitted to the facility in 7/2024 with diagnoses including diabetes.Resident 56's IDT Conference Notes indicated the following:-2/12/26: Resident inquired if/when she/he and her/his girlfriend/boyfriend could share a room. The resident was aware that there was no open bed at this time.-3/19/26: Resident reported she/he wanted to share a room with another resident in the building. The resident was aware we are waiting for an appropriate room share at this time.-5/27/26: Resident still wished to share a room with her/his girlfriend/boyfriend when a room became available.The 1/16/26 grievance submitted by Resident 56 and Resident 11 indicated the following:-Resident 56 and Resident 11 requested to share a room a few months prior to the date of the grievance and were told by staff it would be a matter of time to get a room to accommodate them. The residents felt the request was not being taken seriously, they loved each other and wanted to be together. -The 1/19/26 response by Staff 11 (Former SSD) indicated SSD spoke with both [residents] letting both know their [sp] validated however facility is bed locked at the moment per [administrator]. Once married, facility can look into that option once/if a room comes available.On 8/17/26 at 1:08 PM and 8/18/26 at 8:56 AM Resident 56 and Resident 11 were observed to reside in two different rooms on two different halls. On 8/17/26 at 1:08 PM and 8/21/26 at 11:24 AM Resident 56 stated she/he requested to share a room with Resident 11 several months ago and staff stated there was not a room available. Resident 56 stated Resident 11 did not use the bathroom, and she/he would use a commode if needed in order to share a room with Resident 11. Resident 56 stated staff did not ask her/him if using a commode would be an option in order to make a room change.On 8/18/26 at 8:56 AM and 8/21/26 at 11:39 AM Resident 11 stated she/he requested to move into a room with Resident 56 in October of 2025 and filled out a grievance. Resident 11 stated she/he did not use the bathroom and that should not have been an issue with placing the two residents in a room together. Resident 11 stated several staff were aware of their request and told them there was no room available. On 8/20/26 at 9:35 AM Staff 9 (CMA) stated Resident 56 and Resident 11 requested to be roommates for a long time. Staff 9 stated Staff 5 (Former Administrator) told the residents they would be able to share a room, but nothing was done to accommodate the residents.On 8/20/26 at 9:56 AM Staff 4 (Former SSD) stated she worked at the facility from January 2026 until August 2026. Staff 4 stated she was aware Resident 56 and Resident 11 wished to share a room together and it was brought up in care conferences but there was no room available. On 8/20/26 at 1:11 PM Staff 11 stated she was aware Resident 56 and Resident 11's requested to share a room and Resident 56 submitted grievances about it. Staff 11 stated there were a multitude of conversations in morning meetings and she was told they had to be in a private room and one was not available. She stated the facility did not attempt to talk to other residents about possibly moving rooms to accommodate Resident 56 and Resident 11's room request.On 8/20/26 at 1:59 PM Resident 56 and Resident 11 talked about their roommate request concerns during the resident council meeting. Both residents expressed feeling like they were being ignored and they wanted to be together. Resident 11 stated she/he felt like nobody cares.On 8/21/26 at 10:12 AM Staff 5 (Former Administrator) stated he worked at the facility until 3/31/26. Staff 5 stated Resident 56 and Resident 11 asked to share a room for months but the facility was always full. Staff 5 stated he had Staff 4 (Former SSD) or Staff 11 working on alternative placements until they could find a room that would accommodate them since they needed a jack and [NAME] restroom.On 8/21/26 at 11:12 AM and 11:59 AM Staff 1 (Administrator) stated he started on 5/1/26 and was aware of Resident 56 and Resident 11's request to share a room. Staff 1 stated there was not a private room available. Staff 1 acknowledged a grievance was filed by the residents on 1/16/26. Staff 1 further acknowledged Resident 11 did not use the bathroom and Resident 56 agreed to use a commode if that meant she/he could share a room with Resident 11. Staff 1 acknowledged the facility did not accommodate the residents' requests to share a room.

Based on interview and record review it was determined the facility failed to administer medications per physician orders for 1 of 5 sampled residents (#10) reviewed for medications. This placed residents at risk for worsening medical conditions. Findings include: Resident 10 was admitted to the facility in 6/2025 with diagnoses including anxiety disorder, paraplegia and psychosis. Resident 10's 9/2025 Care Plan indicated the resident required anticoagulant and psychotropic medications, which were to be administered as ordered. Resident 10's 7/3/26 signed physician's order included the following:-buspirone (an antianxiety medication) 10 mg two times daily for anxiety.-olanzapine (an antipsychotic medication) 10 mg two times daily for psychosis. -rivaroxaban (an anticoagulant medication) 10 mg daily for paraplegia. Resident 10's 7/2026 and 8/2026 MARs revealed the following:-The morning and evening buspirone administration referred to nursing notes on 7/7.-The morning olanzapine administration referred to nursing notes on 7/31. -The evening olanzapine administration referred to nursing notes on 7/18, 7/21, 7/22, 7/23, 7/24, 7/30, 7/31 and 8/1 (eight instances)-The morning rivaroxaban administration referred to nursing notes on 7/4 and 7/11. A review of progress notes from 7/2026 and 8/2026 revealed the following:-Staff 15 (CMA) indicated Resident 10's buspirone was not on hand on 7/7/26. -Staff 15 indicated none on hand or none in stock in reference to Resident 10's evening olanzapine administration on the eight identified dates from 7/2026 to 8/2026. -Staff 16 (CMA) indicated Resident 10's morning olanzapine was on order on 7/31/26. -Staff 16 indicated Resident 10's rivaroxaban was on order on 7/4/2026 and 7/11/2026.A review of Resident 10's medical record revealed no evidence the facility notified the pharmacy or physician of the resident's unavailable medications. On 8/20/26 at 7:52 PM Staff 14 (LPN) stated CMAs administered scheduled medications to residents in the facility. Staff 14 stated the CMA was to notify the nurse if a scheduled medication was unavailable and resulted in a missed administration. Staff 14 stated she was unaware of Resident 10's unavailable anticoagulant and psychotropic medications. On 8/21/26 at 8:52 AM Staff 12 (LPN) stated if a scheduled medication was unavailable, she checked the CUBEX (a medication storage device), notified the pharmacy or delegated pharmacy notification to a CMA. Staff 12 stated the CUBEX was not accessed to obtain medication for Resident 10, and she did not contact the pharmacy for unavailable anticoagulant and psychotropic medications in 7/2026. On 8/21/26 at 10:30 AM an attempt to contact Staff 15 was unsuccessful. On 8/21/26 at 10:54 AM Staff 16 stated he administered scheduled medications to Resident 10 in 7/2026. Staff 16 stated a medication was not administered when CMAs documented that a medication was not on hand or on order, which included the administration of Resident 10's rivaroxaban and olanzapine in 7/2026. Staff 16 stated he did not notify the nurse or pharmacy of Resident 10's unavailable anticoagulant and psychotropic medications in 7/2026. On 8/21/26 at 11:24 AM Staff 17 (LPN-Resident Care Manager) stated staff were to notify the pharmacist and provider when a medication was not available in the facility and resulted in a missed administration. Staff 17 stated nurses were to be notified of unavailable medications because CMAs did not have access to the CUBEX. Staff 17 stated she was unaware of instances when Resident 10's anticoagulant and psychotropic medications were unavailable or not administered as ordered in 7/2026 and 8/2026. Staff 17 confirmed the facility did not notify the pharmacy or the provider to ensure Resident 10 received her/his medications as ordered.

Based on observation, interview and record review it was determined the facility failed to maintain a medication error rate of less than 5%. There were 5 errors in 29 opportunities resulting in a 17% error rate. This placed residents at risk for adverse medication side effects. Findings include:1. Resident 20 readmitted to the facility in 7/2026 with diagnoses including diabetes.The 7/30/26 physician order indicated Resident 20 was to receive insulin lispro five units TID with meals.The manufacturer instructions for insulin lispro indicated to prime the insulin pen with two units prior to drawing up the insulin for administration.On 8/17/26 at 11:19 AM Staff 6 (RN) was observed to administer insulin lispro five units via insulin pen to Resident 20. Staff 6 did not prime the insulin pen prior to administration.On 8/17/26 at 11:19 AM and 11:42 AM Staff 6 acknowledged she did not prime the insulin pen prior to administration of insulin and stated she was not aware the insulin lispro pen needed to be primed prior to use. On 8/21/26 at 10:55 AM these findings were shared with Staff 2 (DNS) and nothing further was added. 2. Resident 81 readmitted to the facility in 7/2026 with diagnoses including gastro-esophageal reflux disease.The 7/26/26 physician order indicated Resident 81 received omeprazole-sodium bicarbonate before breakfast for GERD.On 8/19/26 at 10:05 AM Staff 7 (RN) was observed to administer morning medications to Resident 81. Staff 7 did not administer omeprazole-sodium bicarbonate to Resident 81.On 8/19/26 at 10:05 AM Staff 7 stated the omeprazole-sodium bicarbonate was unavailable and it needed to be ordered from the pharmacy.On 8/21/26 at 10:55 AM these findings were shared with Staff 2 (DNS) and nothing further was added. 3. Resident 70 admitted to the facility in 10/2025 with diagnoses including hypothyroidism. The 1/13/26 physician order indicated Resident 70 was to receive levothyroxine daily.The manufacturer instructions indicated to administer levothyroxine before breakfast.On 8/20/26 at 8:55 AM Staff 8 (CMA) was observed to administer levothyroxine to Resident 70.On 8/20/26 at 9:03 AM Staff 8 acknowledged levothyroxine was to be administered before breakfast and acknowledged Resident 70 ate breakfast prior to receiving the medication.On 8/21/26 at 10:55 AM these findings were shared with Staff 2 (DNS) and nothing further was added. 4. Resident 6 admitted to the facility in 2024 with diagnoses including hypertension.The 8/20/26 8:39 AM physician order indicated Resident 6 was to receive lisinopril 10 mg and omeprazole 20 mg before breakfast.On 8/20/26 at 9:20 AM Staff 9 (CMA) was observed to administer omeprazole and lisinopril 20 mg to Resident 6.On 8/20/26 at 9:20 AM and 12:18 PM Staff 9 acknowledged omeprazole was to be administered before breakfast and acknowledged the resident ate breakfast prior to receiving the medication. Staff 9 acknowledged she administered lisinopril 20 mg to Resident 6 instead of the ordered 10 mg.On 8/21/26 at 10:55 AM Staff 2 (DNS) stated she was aware of the medication errors, and the physician was notified of the errors on 8/20/26.

Based on observation, interview, and record review it was determined the facility failed to ensure proper labeling of biologicals for 1 of 1 medication room reviewed for medication storage. This placed residents at risk for reduced efficacy of medicaitons. Findings include:On 8/20/26 at 11:03 AM two open vials of tuberculin (used for the testing in the diagnosis of tuberculosis) were observed in the medication room refrigerator. There was no open date on either of the open tuberculin vials.The manufacturer's instructions indicated to discard the medication 30 days after opening.On 8/20/26 at 11:03 AM Staff 10 (RN) acknowledged the two vials of tuberculin were open and not labeled with the date opened.On 8/20/26 at 11:13 AM Staff 2 (DNS) acknowledged the two vials of tuberculin were open and not labeled with the date opened. Staff 2 acknowledged the expectation was for the vials to be labeled with an open date.

Based on interview and record review it was determined the facility failed to protect the residents' right to be free from physical abuse by a resident for 1 of 4 sampled residents (# 7) reviewed for abuse. This placed residents at risk for physical abuse. Findings include:1. Resident 7 admitted to the facility in 11/2025 with diagnoses including anxiety and depression. Resident 11 admitted to the facility in 1/2026 with diagnoses including left knee dislocation and cannabis dependence. Resident 7's 6/3/26 Quarterly MDS indicated a BIMs (cognitive assessment) score of 15 out of 15, which indicated Resident 7 was cognitively intact. Resident 7's 5/12/26 Progress Note indicated Resident 7 was visualized on the outside patio being aggressive toward Resident 11. Resident 7 blew smoke into Resident 11's face and attempted to ram her/his wheelchair foot pedals in Resident 11's left leg. When staff arrived on the patio Resident 7 was on the ground and stated Resident 11 punched her/him on the right side of her/his head and knocked her/him out of the wheelchair. Resident 7's 5/13/26 Progress Note indicated Resident 7 had a headache related to the incident, acetaminophen did not help and requested stronger pain relief. The 5/12/26 Facility Investigation indicated two facility residents heard yelling coming from outside of the building and called out for help. A nurse responded and found Resident 7 on the ground beside her/his wheelchair. There were no witnesses who observed the incident between Resident 7 and Resident 11. The investigation revealed Resident 11 admitted she/he had punched Resident 7. Abuse was substantiated. On 6/16/26 at 9:01 AM, Resident 11 declined to be interviewed. On 6/16/26 at 12:47 PM, Resident 7 stated she/he was attacked, sucker punched and was physically abused by Resident 11. On 6/16/26 at 1:06 PM, Staff 2 (DNS) verified that Resident 7 antagonized Resident 11. Resident 11 then punched Resident 7 in the face, causing her/him to fall out of her/his wheelchair and onto the ground.

Based on observation and interview it was determined the facility failed to ensure the most recent survey results were readily accessible to residents and visitors for 1 of 1 facility reviewed for survey postings. This placed residents and visitors at risk for not having access to the most recent survey results. Findings include: On 6/17/26 at 7:15 AM, an observation was made of the 2024 Survey Findings Binder in the Fireplace Room. The binder did not contain any 2025 or 2026 survey findings. On 6/17/26 at 7:30 AM, an observation of the front entry, main dining room, hallway nook, and nursing station was made, and no recent survey findings could be located.On 6/17/26 at 8:15 AM, Staff 22 (Receptionist) stated she was unaware of the presence of a survey binder and did not know where the recent survey findings were located.On 6/17/26 at 9:20 AM, Staff 2 (DNS) stated she did not know where the recent survey findings were and acknowledged they were not readily accessible to residents and visitors.

Based on interview and record review it was determined the facility failed to investigate allegations of sexual abuse for 3 of 3 sampled residents (#s 102, 103, and 108) reviewed for allegations of sexual abuse. This placed all residents at risk for sexual abuse and constituted substandard quality of care. A determination was made that the facility's noncompliance placed Residents 102, 103, and 108 in immediate jeopardy, beginning on 3/17/26.On 3/17/26 at 2:12 PM, Staff 14, Staff 15 (Regional Directors of Clinical Service), and Staff 2 (DNS) were notified of the immediate jeopardy (IJ) situation and provided a copy of the IJ template related to the facility's failure to investigate allegations of sexual abuse. Findings include: Resident 105 was admitted to the facility in 2025 with diagnoses including stroke affecting the non-dominant side, and depression. Resident 105's 11/2025 MDS indicated the resident was cognitively intact and used a wheelchair for mobility.1. Resident 102 was admitted to the facility in 2025 with diagnoses including cognitive loss related to pathological development (cognitive status equal to a young child), legal blindness, and non-verbal communication.On 3/4/26 at 9:55 AM, Staff 11 (Anonymous Complainant) reported that a night shift CNA placed Resident 102 on Alert Charting as they believed Resident 105 had performed or attempted to perform sexual acts on Resident 102. Staff 11 believed this due to Resident 102's briefs being ripped open; the resident was crying and did not want her/his brief changed. Staff 11 said Resident 105 was placed on alert for inappropriate behavior, the incident was reported to facility management, and no investigation was completed.On 3/9/26 at 2:21 PM, Staff 8 (CNA) stated she was not happy that no action was taken by management when they were told about Resident 102's brief being torn and the resident did not want to be touched or have her/his brief changed. Staff 8 stated she told the Nurse and spoke to the Human Resources department, Staff 2 (DNS) and Staff 1 (Administrator). Staff 8 said she reported Resident 105 was being sexually inappropriate and had attempted sexual behaviors with multiple residents.On 3/11/26 at 8:03 AM, Staff 7 (Social Service Director) stated she was aware of Resident 105's behaviors and the possible sexual contact with Resident 102. Staff 7 stated Staff 1 was aware of this incident of potential abuse.On 3/11/26 at 11:10 AM, Staff 6 (Social Service Director) stated she was told about the incident involving Resident 102 during a morning meeting attended by Staff 1 and Staff 2.On 3/10/26 at 10:30 AM and 3/11/26 at 12:11 PM, Staff 1 stated he had spoken to staff and believed the incident with Resident 102 and Resident 105 was based assumptions by other staff and no investigation was completed.2. Resident 103 was admitted to the facility in 2019 with diagnoses including Alzheimer's Disease and Parkinson's Disease.On 3/4/26 at 9:55 AM, Staff 11 (Anonymous Complainant) reported Resident 105 attempted to put Resident 103 into a shower room to do sexual acts with Resident 103, but a staff member intervened. Staff 11 stated she did not witness the incident but had spoken to Resident 103 after the incident, who stated Resident 105 was sick and made bad comments to her/him. Staff 11 stated the incident was reported to management and no investigation was completed.On 3/9/26 at 2:21 PM, Staff 8 (CNA) stated she spoke to the human resources department, Staff 2 (DNS) and Staff 1 (Administrator) and informed them that Resident 105 was being sexually inappropriate and attempted to instigate sexual behaviors with multiple residents. Staff 8 stated Resident 105's behavior included attempting to take a resident into a shower room to unclothe the resident.On 3/11/26 at 11:10 AM, Staff 6 (Social Service Director) stated she was told by staff that Resident 105 attempted to video Resident 103 and stated Resident 105 wanted to kiss Resident 103 and get her/him into a shower room. Staff 6 confirmed she had reported the incident to Staff 1.On 3/10/26 at 10:30 AM and 3/11/26 at 12:11 PM, Staff 1 stated he was aware of the incident with Resident 103 and Resident 105 and stated no investigation was completed.3. Resident 108 was admitted to the facility in 2025 with diagnoses including Huntington's Disease (neurodegenerative disorder which progressively affects movement, cognition and mental health), and dementia.On 3/4/26 at 9:55 AM and 3/9/26 at 1:13 PM, Staff 11 (Anonymous Complainant) stated on 2/28/26 they observed Resident 105 telling Resident 108 to take off her/his shirt and made gestures for Resident 108 to remove her/his shirt. Staff 11 stated they completed a written statement and gave it to Staff 12 (LPN/Unit Manager).On 3/11/26 at 8:03 AM, Staff 9 (CNA) stated Resident 105 had behaviors with multiple residents. Staff 9 state he heard from another staff that Resident 105, along with other residents, were laughing, and encouraging Resident 108 to take her/his top off. Staff 9 state he had observed Resident 105 rubbing the backs of other residents more physically than was appropriate, which he reported to the nurse.On 3/11/2026 at 11:10 AM, Staff 6 (Social Service Director) stated she was told in the morning by Staff 2 that Resident 105 was verbalizing a desire to marry Resident 108. Staff 6 stated she was made aware by an unnamed staff member that Resident 108 was removing her/his top while Resident 105 was in the dining room with her/his phone. Staff 6 stated she spoke to Resident 105 who did admit to her/his behaviors and stated, it was innocent, and she informed Staff 1 of the incident.On 3/10/26 at 10:30 AM and 3/11/26 at 12:11 PM, Staff 1 stated he was aware of Resident 108 removing her/his top. Staff 1 stated there was no investigation completed for the incident involving Resident 108 removing her/his shirt while Resident 105 was in the dining room.On 3/17/26 at 3:18 PM, the facility submitted an acceptable IJ Removal Plan, which included the following:-Resident 102, 103, and 108 received head to toe skin assessments completed by RCMs with no observed findings.-Resident 105 was placed on one-to-one observations pending investigations.-Staff 1 (Administrator) and Staff 2 (DNS) were re-educated of the facility's abuse policy, reporting and thorough investigations.-Social Services to interview all interviewable residents regarding abuse.-Nurses will complete a head-to-toe assessment on all non-interviewable residents.-All staff, including agency staff, will be re-educated on the facility's abuse policy and reporting.The immediate jeopardy was removed on 3/18/26 at 3:08 PM when surveyors verified implementation of the facility's IJ Removal Plan. Following the removal of the immediacy, noncompliance remained at isolated without actual harm that is not IJ.

Based on interview and record review the facility failed to ensure care plan interventions were followed for transfers for 1 of 3 sampled residents (#107) reviewed for falls. This placed residents at risk for injury and falls. Findings include:Resident 107 admitted to the facility in 2/2026 with diagnoses including multiple sclerosis. Resident 107's 2/25/26 ADL Care Plan indicated Resident 7 was dependent on two staff members for transfer and to utilize a Hoyer (mechanical) lift. A 3/9/26 Facility Reported Incident indicated Resident 107 reported she/he was transferred by Staff 3 (CNA) on 2/28/26 without the use of the Hoyer lift. Resident 107 reported right flank pain and was assessed to have no visible injury. Resident 107's 3/10/26 x-ray indicated no rib fractures or dislocation was noted. On 3/10/26 at 10:40 AM, Resident 107 stated Staff 3 gave her/him a giant bear hug and made several attempts to transfer the resident from the chair to the bed. Resident 107 stated the transfer caused three broken ribs. On 3/10/26 at 11:21 AM, Staff 3 stated she completed a stand-pivot transfer with Resident 107 and verified she had not read Resident 107's care plan. On 3/10/26 at 11:50 AM, Staff 1 (Administrator) stated on 2/28/26 Staff 3 completed a stand-pivot transfer with Resident 107 when the resident was care planned to be a Hoyer lift transfer by two staff members.

Based on interview and record review it was determined the facility failed to ensure rehabilitative services were provided for 1 of 3 sampled residents (#107) reviewed for rehabilitation services. This placed residents at risk for a decline in range of motion. Findings include:Resident 107 admitted to the facility in 2/2026 with diagnoses including multiple sclerosis. Resident 107's 2/24/26 admission Orders included an order for physical therapy and occupational therapy.Review of Resident 107's clinical record found no documented evidence Resident 107 received therapy as ordered.On 3/11/26 at 10:58 AM, Resident 107 stated she/he had not received therapy since her/his admission.On 3/11/26 at 10:40 AM, Staff 2 (Director of Rehabilitation) stated Resident 107 had not received any therapy services from her/his date of admission through 3/11/26. Staff 2 verified Resident 107's admission Orders included orders for physical therapy and occupational therapy.

Based on interview and record review, it was determined the facility failed to timely administer CPR for 1 of 3 sampled residents (#1) reviewed for CPR. This failure, determined to be an immediate jeopardy situation, resulted in Resident 1 receiving emergency CPR 13 to 20 minutes after Resident 1 was found unresponsive. This placed all residents at risk for not receiving timely CPR and constituted substandard quality of care. Findings include: The facility's [DATE] Policy and Procedure on Code Status and CPR stated in the event of a medical emergency where a resident is observed not breathing a staff member should initiate the following steps: - Call for help and bring crash cart to the area;- First CPR responder will verify code status of the resident in the EHR;- If the resident is full code, CPR will be initiated and 911 will be called. CPR will be continued until EMTs arrive to take over CPR.Resident 1 was admitted to the facility in 7/2025, with diagnoses including hemiparesis and tracheostomy. Resident 1's POLST status was identified as Full Code, which required CPR. Resident 1's [DATE] Care Plan identified the resident was at risk for complications of hypoxia related to acute and chronic respiratory failure, which included altered levels of consciousness.The facility's Investigation Report indicated that on [DATE] at around 9:30 AM, staff noticed Resident 1 was non-responsive and sought assistance from nursing. The nurse on scene indicated a response time of 10 to 20 minutes after the resident's initial assessment. Resident 1 was identified to be a full code status. The nurse's delay in initiating CPR resulted in an extensive delay of immediate lifesaving treatment for Resident 1.Per Resident 1's Progress Note dated [DATE] at 11:04 AM, Staff 5 (CNA) noted between 9:20 and 9:30 AM, Resident 1 was unresponsive to physical and verbal stimulation and reported the concern to Staff 4 (LPN). Staff 4, upon examination, declared Resident 1 dead at 9:33 AM. Staff 4 contacted Staff 2 (DNS) between 9:35 AM to 9:40 AM for further instruction, and from 9:40-9:45 AM, Staff 2 instructed Staff 4 to gather DNR status, start CPR, and call EMS. On [DATE] at 1:20 PM, Staff 4 (LPN) stated he did not initiate CPR lifesaving services due to his belief that the resident was already deceased . Staff 4 stated he determined Resident 1 deceased as of 9:33 AM due to the resident's lack of physical or verbal stimulation and yellowing of the skin near the resident's face. Staff 4 stated that around 9:42 AM, he received instructions from Staff 2 to check Resident 1's code status and initiate CPR. Staff 4 confirmed he began initiating CPR between 13 and 20 minutes after receiving direction from Staff 2 (DNS). Staff 4 further confirmed he did not call a Code Blue and did not check on Resident 1's code status because he declared Resident 1 had passed away. On [DATE] at 1:57 PM, Staff 5 (CNA) stated he was the care staff member who discovered Resident 1 was nonresponsive and had called for immediate assistance. Staff 5 stated he had noticed Resident 1 looked yellow and was nonresponsive. Staff 5 reported to Staff 4 of the event and further stated Code Blue and CPR was not initiated as Staff 4 believed Resident 1 was dead. Staff 5 stated he saw Resident 1 still conscious around 8:40 AM with no signs of concern. On [DATE] at 2:50 PM, Staff 6 (LPN) stated she was the additional nurse called to the emergency. Staff 6 stated at least 10 minutes or longer had passed between the time Resident 1 was assessed to when CPR services had begun. Staff 6 stated a Code Blue had not been called, but Staff 6 had contacted 911 for emergency services. On [DATE] at 3:07 PM, Staff 2 (DNS) stated that around 9:30 AM, Staff 4 contacted Staff 2 to request if law enforcement or if family needed to be contacted as Resident 1 had been determined by Staff 4 to be deceased . Staff 2 requested Staff 4 to begin CPR services after Resident 1's code status was determined. On [DATE] at 1:30 PM, Staff 1 (Administrator) confirmed the facility did not initiate CPR services in a timely manner to Resident 1. On [DATE] at 4:06 PM, the facility was notified of the Immediate Jeopardy (IJ) situation and immediacy removal plan was requested. On [DATE] at 5:19 PM, the facility submitted an acceptable immediacy removal plan.The deficient practice was identified as Past Noncompliance based on the following:On [DATE], the deficient practice was identified by the facility to be corrected when the facility completed a root causes analysis of the incident and determined there was a delay in initiating and conducting CPR. The Plan of Correction included:Re-educating LNs on the process of verifying code status, including POLST or physician orders when residents were observed with no pulse or respirations. All LNs were reeducated before their oncoming shift including float and agency LNs on emergency response.Medical records conducted audits on all new residents for a signed POLST or physician's order to determine resident's status until substantial compliance was met. Daily audits were immediately implemented to ensure proper initiation of emergency CPR services were provided during mock code blue for all shifts with no deficient practice found.

Based on interview and record review it was determined the facility failed to implement policies and procedures for screening potential employees to prevent abuse for 3 of 3 sampled new employees (#s 16, 17, and 18) reviewed for employee screening. This placed residents at risk for abuse. Findings include: The facility's Abuse Screening, Training, Identification, Investigation, Reporting, and Protection policy, dated 8/2024, indicated the screening process for potential employees included: - Contact previous employers requesting employment history to include but not limited to: dates of service, position held, performance history, history of abuse, neglect, misappropriation of resident property, exploitation, or mistreating residents. - Obtain criminal background information. 1. On 5/8/25 at 11:00 AM a random sample of newly hired staff members was reviewed for reference checks with Staff 14 (Human Resources) and Staff 15 (Human Resources Business Partner). Staff 15 stated reference checks were not completed for Staff 16 (CNA), Staff 17 (CNA), and Staff 18 (RN). On 5/8/25 at 3:33 PM Staff 1 (Administrator) acknowledged the new employee reference checks were not completed for Staff 16, Staff 17, and Staff 18 per the facility abuse screening policy. 2. On 5/8/25 at 11:00 AM a random sample of newly hired staff members was reviewed for criminal background checks with Staff 14 (Human Resources) and Staff 15 (Human Resources Business Partner). The review revealed the following: - Staff 16 (CNA) began working in the facility on 2/7/25, but her criminal background check was not started until 5/7/25. - Staff 17 (CNA) began working in the facility on 4/21/25, but her criminal background check was not started until 4/30/25. - Staff 18 (RN) began working in the facility on 4/16/25, but her criminal background check was not started until 5/7/25. On 5/8/25 at 3:33 PM Staff 1 (Administrator) acknowledged the criminal background checks were not completed for Staff 16, Staff 17, and Staff 18 per the facility abuse screening policy.

Based on interview and record review it was determined the facility failed to notify the physician of blood sugar measurements outside of parameters for 1 of 5 sampled residents (#4) reviewed for medications. This placed residents at risk for diabetic complications. Findings include: Resident 4 was admitted to the facility in 2020 with diagnoses including diabetes and dementia. A 4/11/25 physician order indicated staff were to check Resident 4's CBG (blood sugar measurement) level three times a day and to notify the physician for a CBG level less than 70 or greater than 350. A review of the 4/2025 Diabetic Administration Record revealed the following occurrences of a CBG greater than 350: -4/16/25 at 12:00 PM, CBG was 379. -4/29/25 at 12:00 PM, CBG was 442. -4/29/25 at 5:30 PM, CBG was 427. -4/30/25 at 12:00 PM, CBG was 368. No documentation was found in Resident 4's clinical record to indicate the physician was notified of the elevated CBGs. On 5/9/25 at 12:26 PM Staff 18 (RN) stated she did not notify the physician as Resident 4's CBG was not over 450. On 5/9/25 at 12:29 PM Staff 2 (DNS) acknowledged staff were not notifying the physician due to the belief it was not needed unless Resident 4's CBG was over 450.

Based on observation, interview and record review it was determined the facility failed to provide care and assistance to prevent accidents for 1 of 5 sampled residents (#1) reviewed for accidents. This placed residents at risk for unmet care needs. Findings include: Resident 1 was admitted to the facility in 10/2024 with diagnoses including traumatic brain injury and anxiety disorder. Resident 1's MDS 5-Day assessment dated [DATE] revealed a BIMS score of 11, indicating moderate cognitive impairment. Resident 1's revised Care Plan dated 11/11/24 revealed she/he was at risk for falls related to her/his immobility. Care plan interventions were to anticipate and meet needs, educate and remind the resident to call for assistance with all transfers and to provide verbal cues for assistance. On 1/31/25 the facility submitted a report to the State Agency which revealed Resident 1 was found with her/his legs hanging off the bed. Resident 1's left leg was observed lying on the baseboard heater and Staff 4 (CNA) immediately placed the resident's legs back on her/his bed. Staff 4 observed redness and what appeared to be a burn on the resident's leg. Staff 3 (LPN) was notified and provided care to the wound. Resident 1 was unable to tell staff what happened due to her/his confusion. On 2/4/25 at 12:30 PM, Staff 3 stated she was the nurse on duty the day of the incident on 1/31/25. She stated in late afternoon, Staff 4 informed her he had found the resident with her/his legs dangling off the bed touching the heating unit which resulted in a burn on the resident's leg. She immediately went to the resident's room and observed the resident's bed was really close to the heating unit, approximately 1 to 2 feet away. She told Staff 4 that was too close to the heating unit and they moved the bed away from it. Staff 3 stated she examined Resident 1's lower left leg and noted the skin was red, slightly peeled and the wound appeared to be a burn. Staff 3 treated the wound, bandaged it and stated the resident was fine, was conversing and seemed okay. She stated she did not observe any other objects around the resident's bed that could have caused the injury and in her opinion the wound appeared to be a burn. On 2/4/25 at 1:34 PM, Staff 5 (CNA) stated he was familiar with Resident 1 and the resident frequently tried to get out of bed. He stated care plan interventions were to offer to get the resident up and in her/his wheelchair and to make sure no objects were around or blocking the bed due to Resident 1's fall risk. He stated the resident moved her/his legs around frequently. On 2/4/25 at 1:40 PM, Staff 6 (Housekeeping) stated she was familiar with Resident 1 and she/he frequently swung her/his legs off the bed. She stated residents' beds were supposed to be 3 feet away from the heaters. On 2/4/25 at 2:00 PM, Staff 7 (CNA) stated she was familiar with Resident 1 and she/he was a wiggle worm, frequently wiggled around in the bed and staff frequently did checks on her/him. She stated she had not heard of any incidents of this type in the year and a half she had worked at the facility. On 2/4/25 at 2:25 PM, Staff 4 stated he was Resident 1's assigned CNA on 1/31/25, and heard the resident calling for help. Staff 4 went into Resident 1's room and observed her/him in bed, with both legs off the bed and her/his hands holding onto the bed rail. Staff 4 stated he observed the resident's lower left leg was lying on the top of the heating unit and Resident 1 acted like she/he was in pain, saying help me. Staff 4 moved the resident's legs onto the bed, observed the injury on the leg and immediately left to find Staff 3, who was in another resident room. When Staff 3 was available, she and Staff 4 went back to Resident 1's room and Staff 4 stated he observed the skin on the lower left leg peeling back a little. Staff 4 stated the skin touching the heating unit was where the injury was and he did not observe any other objects between the resident's bed and the heating unit which could have caused the injury. Staff 4 stated the resident's bed was close to the heating unit and demonstrated the distance of approximately 1 foot between the heating unit and the resident's bed. Staff 4 did not recall how long the resident's bed had been near the heating unit. On 2/4/25 at 3:40 PM, Staff 2 (DNS) stated she had provided wound care to Resident 1 earlier in the afternoon and the wound's measurements were 4.5 cm long and 2.4 cm wide. The resident reported no pain during the wound care. Observations were made of Resident 1 on 2/4/25 from 11:00 AM through 4:00 PM. Resident 1 was observed in bed with a bandage on her/his lower left leg but was not interviewed due to her/his confusion. Random audits were completed on 2/4/25 of baseboard heaters throughout the day with Staff 8 (Maintenance Director). An infrared heat detector was utilized to obtain temperatures, which were found to be under 120 degrees Fahrenheit. Resident 1's heating unit was very warm to the touch on the top of the unit. Staff 8 stated he completed weekly audits of the heating units and provided reports that confirmed his weekly audits. On 2/5/24 at 4:00 PM, Staff 1 (Administrator) and Staff 2 (DNS) were informed of the findings of the investigation and provided no additional information.

Based on interview and record review it was determined the facility failed to ensure a resident was safe from elopement for 1 of 1 sampled resident (#9) reviewed for elopement. This failure, determined to be an immediate jeopardy situation, resulted in Resident 9 leaving the facility without appropriate supervision and placed the resident at risk for serious injury or death. Findings include: Resident 9 admitted to the facility on [DATE] with diagnoses including stroke and dementia. The 7/30/24 hospital referral records indicated Resident 9 was withdrawn, and answered most questions with, I don't know. The record indicated, disorientation noted overnight and patient trying to leave, though was redirectable. The record also indicated, At this time the resident does not have the capacity to make decisions regarding leaving the hospital so [she/he] would be placed on elopement precautions. Resident 9's Elopement Risk Evaluations indicated the following: -8/20/24: the resident had poor impulse control and was at risk for elopement. -9/12/24: the resident had two attempts to get out of the side door unattended. -11/5/24: the resident eloped, did not communicate when leaving, and left to the community. The 9/12/24 care plan indicated Resident 9 had impaired cognitive function related to dementia and was an elopement risk due to impaired safety awareness. Progress Notes indicated the following: -8/27/24: Resident unable to communicate wants and needs, has a history of wandering and innocently wandered out of facility about 6:00 PM. -8/28/24: Resident wandered out of the facility about 6:00 PM. The note stated, Located 5 minutes at back entrance of facility. -9/12/24: Resident Care Manager notified by medication aide that the resident attempted to leave the building out the side door two times yesterday. The resident was easily redirected, but was confused with cognitive impairment. The resident's information was placed in elopement book. -11/3/24 at 1:30 PM: The note indicated staff were notified that Resident 9 absconded from the facility's property, local law enforcement was notified. Administrative staff were notified and were waiting for local law enforcement. -11/3/24 at 2:45 PM: Resident 9 returned to the facility unharmed, and stated, I'm cold. The resident was offered hot chocolate and a snack. -11/5/24: Resident 9 stated she/he would like to leave and go home, staff asked if she/he knew how to get there, and the resident stated, No. Later in the shift the resident was seen at the back door looking up in the doorway to show the nurse she/he knew the door code. The nurse told the resident it was dark and cold and she/he should not go outside. The resident stated, ok. The resident continued to walk around the building but no other attempts to get outside of the door were made. -11/10/24 at 11:56 AM: Resident 9 was found in the parking lot in the morning, was able to be redirected back to the facility, and then asked when she/he would be discharged . No facility investigations were found related to Resident 9's elopements on 8/27/24, 8/28/24, and 11/10/24. The 11/7/24 Facility Investigation of the 11/3/24 elopement indicated on 11/3/24 at 1:30 PM staff became aware Resident 9 was missing and the on duty nurse called local police to notify them that the resident was not able to be located. During this time the facility received a call from the off-duty Activities Director who reported she saw Resident 9 at a convenience store parking lot about ten minutes walking distance from the facility. The resident was quickly redirected back to the facility and was back inside the facility by 2:30 PM. No harm or injuries were noted at the time of her/his return. The resident was fully clothed in a long-sleeved shirt and jeans but did make a statement that she/he was cold. She/he was given a blanket and some hot chocolate to warm up and was content. During the time Resident 9 was gone, staff thought she/he was wandering around the facility or the outdoor courtyard per her/his usual routine. Observations on 11/13/24 from 10:54 AM through 3:06 PM revealed Resident 9 walked independently throughout the facility, participated in activities, and sat on the bed in her/his room. On 11/13/24 at 11:18 AM one of the facility's exit doors was observed to open without entering a code. The outside area led to a set of double gates that were open and led to the road. On 11/13/24 at 11:30 AM Staff 1 (Administrator) was observed to walk out of the identified exit door without entering a code. Staff 1 stated the door was supposed to shut and lock. Staff 1 acknowledged the door leading to the outside area was unlocked and the outside area led to the road and parking lot. On 11/13/24 at 11:36 AM Staff 3 (Maintenance Director) was observed to walk out the identified exit door without entering a code. Staff 3 acknowledged the door was not locked and stated a code should be entered to unlock the door. On 11/13/24 at 3:06 PM Resident 9 was alert but not oriented to place and time. Resident 9 stated she/he wanted to go home and started crying. During the interview the resident stated she/he was trapped here. Resident 9 stated she/he left the facility and went to a convenience store previously. Resident 9 stated she/he knew the numbers on the doors to get out of the facility and went to the window and stated she/he could exit out the window. The surveyor observed it appeared possible for the resident to exit through the window, but the resident did not attempt to go out the window at that time. Staff interviews from 11/13/24 at 11:30 AM to 11/14/24 at 12:28 PM indicated the following: -Staff 4 (CNA) stated Resident 9 wanted to go home and attempted to open the doors using the door codes. Staff 4 stated the identified door did not always lock and staff had to pull on the door to get it to lock and it was like that for a long time. Staff 4 stated she was unsure if it was reported to maintenance. Staff 4 further stated that several staff including agency staff were unaware the door did not close and had to be pulled shut. Staff 4 stated Resident 9 was exit-seeking on a daily basis. -Staff 5 (CNA) stated Resident 9 got bored, wanted to go outside and asked a couple of times for the door code. Staff 5 stated the resident sought outside activities but the resident was not safe to go outside alone. -Staff 6 (CNA) stated today was her first day working here and she was unaware of any residents who were at risk for elopement, and nobody told her of residents who were an elopement risk. -Staff 7 (NA) stated there was one resident who was exit-seeking but he could not remember the resident's name. -Staff 8 (CNA) stated Resident 9 was an elopement risk and the resident eloped to the front parking lot on two occasions. Staff 8 stated Resident 9 was the only resident who was an elopement risk. -Staff 9 (CNA) stated he worked at the facility for a month and was not aware of residents who were at risk for elopement. -Staff 10 (CNA) stated Resident 9 attempted to leave the facility multiple times by using the door codes and was able to figure out the codes no matter how many times they were changed. Staff 10 stated on one occasion about a week or week and half ago the resident's roommate reported the resident was down by the street and brought Resident 9 back inside the facility. Staff 10 stated she reported the incident to the charge nurse but could not remember the nurse's name. -Staff 11 (LPN) stated Resident 9 had dementia and was able to go outside the facility on multiple occasions. Staff 11 stated on one occasion the resident went to a convenience store and police were notified and the resident arrived back to the facility by her/himself. Staff 11 stated the resident was out in the parking lot at least two weeks prior to going to the convenience store. Staff 11 stated on one occasion when the resident was in the parking lot a dietary staff made him aware the resident was outside. Staff 11 stated the door codes were changed multiple times, but the resident was able to figure out the codes. -Staff 12 (LPN Resident Care Manager) stated Resident 9 eloped on one occasion to a convenience store and on another occasion was found in the parking lot. Staff 12 stated she read a progress note by Staff 11 that indicated the resident got out to the parking lot and the resident should not be alone. Staff 12 stated an investigation was not completed for the incident when the resident got out to the parking lot and was unsure if the resident was unattended in the parking lot. On 11/13/24 at 1:35 PM and 3:40 PM Staff 1 and Staff 2 stated Resident 9 eloped to a convenience store on 11/3/24 and the off-duty activity person stopped there and talked to her/him. The resident stated she/he was out for a walk. The staff told the resident to return to the facility and she contacted the nurse at the facility. Staff 1 stated after the resident was found at the convenience store, she/he was determined to be an elopement risk. Staff 1 and Staff 2 stated after the elopement to the convenience store the resident was placed on 1:1 supervision until the door codes could be changed the following day. Staff 1 and Staff 2 were asked about the 11/10/24 progress note that indicated Resident 9 was found in the parking lot by nursing staff. Staff 1 and Staff 2 acknowledged an investigation was not completed for the 11/10/24 incident when Resident 9 was found outside the facility unattended. Staff 1 and Staff 2 stated they were unaware of any other elopement attempts by Resident 9. The staff indicated the facility had other residents who were also at risk for elopement. On 11/13/24 at 4:22 PM Staff 1 and Staff 2 were notified of the Immediate Jeopardy (IJ) situation and provided a copy of the IJ template related the to facility's failure to ensure individualized care planned interventions to prevent elopement were implemented. On 11/13/24 at 6:12 PM an acceptable facility IJ removal plan was submitted by the facility. The plan indicated the facility would implement the following actions: *11/13/24 at 5:15 PM the facility immediately placed Resident 9, who was at the highest risk for elopement, on one-to-one supervision and was care planned accordingly to prevent any possibility of elopement. This would be indefinite until the resident's discharge. *The facility would perform a full facility chart audit to identify any other residents at risk for elopement and their care plans would be updated. *A facility wide inspection would be conducted immediately by the environmental services team and nursing staff to identify any doorways that may not be properly secured. All doors would be inspected to ensure locking mechanisms are functional. Any issues identified would be resolved. *A staff-wide education had begun and all staff would be in-serviced on the elopement policy, elopement binder, and all residents at risk for elopement and their care plans. Alerting administration of attempted or actual elopements, ensuring doors remain locked. All staff would sign off on this education prior to beginning their next shift. Any agency or outside staff would be alerted prior to their entering the facility regarding the elopement procedures and policy and would be shown at entry where the elopement binder was and associated policies were located. *The administrator or designee would audit all doors to ensure locking mechanisms were functioning and doors were locked daily x 7, biweekly x 2 weeks, weekly x 1 month, and results would be taken to QAPI to identify any further trends and concerns. The immediacy was removed on 11/14/24 after verifying the plan of correction was sufficiently implemented.

Based on observation, interview and record review it was determined the facility failed to maintain a comfortable and homelike environment for 3 of 3 halls reviewed for environment. This placed residents at risk for living in an uncomfortable and unhomelike environment. Findings include: 1. Observations on 1/8/24 at 12:53 PM and on 1/11/24 at 9:48 AM revealed eight ceiling tiles on the South Hall, two ceiling tiles on the East Hall, and two ceiling tiles on the North Hall all had brown or gray stains. On 1/11/24 at 9:48 AM Staff 15 (Maintenance Director) acknowledged the stains and stated the gray stains on the ceiling tiles were from tape used when separating the hall during COVID isolation. Staff 15 stated the brown stains were from an unknown source and were there for some time. Staff 15 stated the facility had no current plans to change the tiles. On 1/17/24 at 12:48 PM Staff 1 (Administrator) stated she was not aware of the stains on the ceiling tiles. 2. Observations on 1/8/24 at 12:53 PM and on 1/11/24 at 2:35 PM revealed one air vent on the South Hall, two air vents on the East Hall, and two air vents on the North Hall had rust stains on the air vents. On 1/11/24 at 9:48 AM Staff 15 (Maintenance Director) acknowledged the rust stains on the air vents and stated he repainted the air vents every year, but the air vents leaked water during heavy rain which caused the rust. On 1/11/24 at 11:32 AM Staff 15 provided a work order invoice dated 8/24/21 to address the water leak through the air vents. Staff 15 stated he was trained by the contractor and fixed the roof leak with duct tape. On 1/11/24 at 2:35 PM water was observed dripping from the air vent on the East Hall between room [ROOM NUMBER] and room [ROOM NUMBER]. Staff 11 (CNA) stated every time it rained the air vents leaked. Staff 11 stated a wet floor sign and a bucket was provided for the CNAs to put under the leak on each hall. On 1/11/24 at 3:01 PM Staff 15 acknowledged water leaked from the air vents. On 1/17/24 at 12:48 PM Staff 1 (Administrator) stated she was not aware the air vents leaked during heavy rain.

Based on interview and record review it was determined the facility failed to comprehensively assess 5 of 9 sampled residents (#s 2, 5, 11, 13 and 21) reviewed for medications and ADLs. This placed residents at risk for lack of timely assessment care needs. Findings include: 1. Resident 2 was admitted to the facility in 2008 with diagnoses including dementia and a communication deficit. A review of the 1/1/24 Psychotropic Drug Use CAA revealed referred to provider notes and H & P (History and Physical). The CAA did not include information regarding Resident 2's potential problems, risk factors and rationale for the care plan. The assessments or documentation referred to did not include any specific dates or time frames to refer to. On 1/17/24 at 12:30 PM Staff 1 (Administrator) and Staff 2 (Interim DNS) were presented with the lack of comprehensive information in Resident 2's Psychotropic Drug Use CAA. Staff 1 and Staff 2 stated CAAs were completed by an outside provider, and they were not aware of the process, but indicated the CAAs were utilized to initiate the care plan for all residents. 2. Resident 5 was admitted to the facility in 2020 with diagnoses including dementia and a stroke. A review of the 7/12/23 Psychotropic Drug Use CAA revealed Resident 5 was on psychotropic drugs and was followed in monthly psychotropic review monthly and quarterly. The CAA did not include information regarding Resident 5's potential problems, risk factors and rationale for the care plan. On 1/17/24 at 12:30 PM Staff 1 (Administrator) and Staff 2 (Interim DNS) were presented with the lack of comprehensive information in Resident 5's Psychotropic Drug Use CAA. Staff 1 and Staff 2 stated CAAs were completed by an outside provider, and they were not aware of the process, but indicated the CAAs were utilized to initiate the care plan for all residents. 46841 3. Resident 21 was admitted to the facility in 6/2022 with diagnoses including morbid obesity. Resident 21's 7/12/23 Nutrition Status CAA indicated the resident had a weight gain of more than ten percent since admission to the facility. The CAA did not include the resident's status or weight, any alternatives discussed or tried, and did not contain an overall analysis of the weight gain and the impact on the resident. The 7/21/23 hospital discharge summary indicated Resident 21's BMI was 100.07 and impacted all aspects of the resident's care. On 1/17/24 at 12:30 PM Staff 1 (Administrator) and Staff 2 (Interim DNS) were presented with the lack of comprehensive information in Resident 21's Nutrition Status CAA. Staff 1 and Staff 2 stated CAAs were completed by an outside provider, and they were not aware of the process, but indicated the CAAs were utilized to initiate the care plan for all residents. 47005 4. Resident 11 admitted to the facility in 9/2020 with diagnoses including kidney failure and congestive heart failure. Resident 11's 11/25/23 CAA for Dehydration/Fluid Maintenance did not include how constipation was a problem for the resident or the impact on the resident. On 1/17/24 at 12:37 PM Staff 1 (Administrator) and Staff 2 (Interim DNS) were presented with the lack of comprehensive information in Resident 11's CAA. Staff 1 and Staff 2 stated the Dehydration/Fluid Maintenance CAAs were completed by an outside provider, and they were not aware of the process, but indicated the CAAs were utilized to initiate the care plan for all residents 5. Resident 13 admitted to the facility in 12/1/2020 with diagnoses including congestive heart failure. Resident 13's 10/4/23 CAA for Cognitive Loss/Dementia had no information and failed to indicate specific cognitive changes, how the resident's cognitive changes manifested, and the impact on the resident. On 1/17/24 at 12:30 PM Staff 1 (Administrator) and Staff 2 (Interim DNS) were presented with the lack of comprehensive information in Resident 13's Cognition Loss/Dementia CAA. Staff 1 and Staff 2 stated CAAs were completed by an outside provider, and they were not aware of the process, but indicated the CAAs were utilized to initiate the care plan for all residents.

Based on observation, interview, and record review the facility failed to provide sufficient nursing staff to ensure residents attained or maintained their highest practicable mental, physical, and psychosocial well-being for 6 of 7 sampled residents (#s 3, 15, 30, 33, 88 and 237) and 2 of 3 halls reviewed for call light wait times and staffing. This placed residents at risk for delayed ADL care needs. Findings include: 1. On 1/8/23 the facility provided lists of residents who: -Required assistance with eating: 2 -Required a mechanical lift: 9 -Required two-person assistance with ADL care: 15 -Required interventions for behaviors: 22 -Required supervision for smoking: 7 -Required bariatric care: 5 Interviews with residents revealed the following concerns: On 1/8/24 at 11:18 AM Resident 15 stated the facility was short staffed all the time and had pissed herself/himself because no one answered the call lights. Resident 15 stated call light response times were at least 30 minutes long. On 1/8/24 at 11:36 AM Resident 3 stated call light response times ranged from five minutes to the next day. Resident 3 stated she/he was sick during the week of Christmas and requested a basin to vomit in and staff never retrieved one for her/him. Resident 3 stated the call light system did not work well at all. On 1/8/24 at 2:21 PM Resident 88 stated she/he had diarrhea issues and waited 15 to 45 minutes on evening and night shift to receive assistance. Resident 88 stated she/he sat in a soaked brief and bed on more than one occasion. On 1/8/24 at 4:01 PM Resident 30 stated the facility did not have enough staff to provide care and she/he did not always receive her/his showers timely. On 1/9/24 at 8:59 AM Resident 33 stated call lights were long. The resident stated staff turned the call light off, did not assist her/him, said, I will be back, and then did not return timely. Interviews with staff revealed the following concerns: On 1/10/24 at 7:05 AM Staff 6 (CNA) stated the facility did not have enough staff based off acuity in the building, the amount of two-person assistance and bariatric residents. Staff 6 indicated they were short staffed since approximately 7/2023. Staff 6 stated residents often sat in wet and soiled briefs longer than 15 minutes especially around mealtime and during shift change. Staff 6 further stated two CNAs were assigned in the memory care unit and were not always available to assist on the other two hallways. On 1/10/24 at 10:14 AM Staff 4 (CNA) stated staffing was a concern because two CNAs were designated for the memory care unit which put extra burden on the remaining CNAs for the other two hallways due to acuity. Staff 4 stated this was an issue since the summer of 2023. Staff 4 stated residents complained because they sat in a wet or a soiled brief for extended periods of time which ranged from 20 minutes up to 60 minutes. Staff 4 further stated it was difficult to find additional staff for those residents who needed two-person assistance with transfers or ADL care needs. On 1/10/24 at 1:14 PM Staff 12 (CNA) stated the facility consistently (since 7/2023) was short staffed and residents were upset because they sat in wet or soiled briefs for greater than 30 minutes. Staff 12 stated only CNAs carried a phone to answer call lights and the computer screen at the nurses station displayed how long the call lights were on, but there was not always staff at the nurses station to monitor or assist with call lights. Staff 12 stated two CNAs were assigned to the memory care unit and were difficult to utilize on the other two hallways. Staff 12 stated all the residents that were smokers in the building were supervised and during smoke break times a CNA was pulled from the floor to assist the smokers outside. Staff 12 stated the CNA who assisted with the supervised smokers was unavailable for greater than 30 minutes. Staff 12 further stated it was frustrating because she could not provide adequate ADL care and was always running to get to the next resident. On 1/10/24 at 12:41 PM Staff 11 (LPN) stated she worked long hours and struggled at times to prioritize her workload due to acuity. Staff 11 stated timing of diabetic medications, wound treatments, and tube feedings were a challenge. Staff 11 stated roughly 11 to 14 residents had a variety of creams, powders, pain patches or a muscle rub and she was not always able to provide them to the residents. Staff 11 stated she utilized CNAs as much as possible but they were busy as well. Staff 11 stated residents complained about not receiving their muscle rubs and powders. On 1/11/24 at 9:30 AM Staff 10 (CNA) stated the facility was short staffed since the summer of 2023 consistently and a lot of residents in the building required two-person extensive assist with ADLs. Staff 10 stated they had approximately 8 to 10 residents who were supervised smokers and required a CNA to be pulled from the floor to assist with the smoke breaks, which took roughly 30 minutes. Staff 10 stated she had difficulty finding a hall partner the week of 1/1/24 for a resident who sat in a shower chair while wet and cold for greater than 20 minutes after a shower was completed because there was not enough staff to go around. On 1/11/24 at 11:03 AM Staff 9 (RN) stated she worked long hours and there was not enough of her to go around and she rarely took a break. Staff 9 stated the facility did not provide enough staff based on acuity in the building. On 1/16/24 at 12:33 PM Staff 25 (CNA) stated staffing was an ongoing issue since 7/2023 and call light response times could be longer than 20 minutes due to staffing. Staff 25 stated meals, smoke breaks for residents and shift change were the most difficult. Staff 25 stated many residents required two-person extensive assistance for ADL care and there was just not enough staff to go around. Staff 25 stated residents sat in wet and soiled briefs on multiple occasions and felt this infringed on residents' dignity. On 1/11/24 at 9:30 AM Staff 1 (Administrator) and Staff 2 (Interim DNS) stated the facility staffed to the state minimum ratios including the bariatric guidance. Staff 1 stated they provided two CNAs for the memory care unit, which was required but one CNA could assist with the other two halls as needed. Staff 1 stated all seven residents who were smokers in the building were supervised and required one CNA to assist with the smoking breaks. Staff 1 stated only CNAs carried phones for the call light system and the computer at the nurses stations were watched by the nurses and CMAs. Staff 1 stated no audible sound was present at the nurses station or on the hallways for the call light system but CNAs were alerted on their phones. 48820 2. Resident 237 was admitted to the facility in 1/2024 with diagnosis including dementia. The Five-Day MDS dated [DATE] revealed Resident 237 had a BIMS score of seven, which indicated severe cognitive impairment. On 1/11/24 at 9:06 AM Resident 237 was observed in bed with unbrushed hair, a breakfast tray was in front of her/him, and there was an odor of bowel movement in and around the room. Resident 237 had white film at the corners of her/his mouth. On 1/11/24 during a continuous observation from 9:06 AM through 11:27 AM the surveyor witnessed staff members walk by Resident 237's room or enter the resident's room [ROOM NUMBER] times without providing incontinent care. On 1/11/24 at 11:27 AM Staff 12 (CNA) was observed to prepare to enter Resident 237's room to provide care. Staff 12 stated the facility was fully staffed but staff were very busy answering call lights. On 1/17/24 at 12:49 Staff 1 (Administrator) and Staff 2 (Interim DNS) stated CNA staff were expected to provide appropriate timely incontinent care for Resident 237. Staff 1 and Staff 2 stated the facility staffed to the state minimum ratios. Refer to F690.

Based on interview and record review it was determined the facility failed to ensure CNAs received annual performance reviews for 4 of 5 randomly selected CNA staff (#s 5, 6, 7 and 8) reviewed for staffing. This placed residents at risk for lessened quality of care. Findings include: The Facility's 1/2024 Team Member Handbook indicated the following about performance evaluations: - The performance evaluation process was designed to provide a dialogue between the supervisor and the team member on job performance, competencies, and goals. - Performance evaluations were conducted annually. - Annual performance evaluations for non-exempt team members were scheduled to be completed on the anniversary of the date of hire. A review of personnel records on 1/12/24 indicated Staff 5 (CNA), Staff 6 (CNA), Staff 7 (CNA), and Staff 8 (CNA) had annual performance reviews in 2023 which lacked the following documentation: - Date of the appraisal. - Three of four did not contain the supervisor/reviewer's name. - Staff self-assessment. - Development plan and/or goals. - Competency review. - Signature of the staff. - Signature of the supervisor/reviewer. The performance appraisals for Staff 5, Staff 6, Staff 7, and Staff 8 all indicated staff did not participate in their performance reviews. On 1/16/24 at 9:01 AM Staff 7 stated she was aware she had an appointment for her performance review but left after her shift and was not reapproached to receive the review. On 1/16/24 at 12:33 PM Staff 5 stated she did not receive a performance review in 2023. Staff 5 revealed she had an appointment for her performance review, but the managers were in a meeting during her appointment time, and she did not yet receive her review. On 1/17/24 at 1:16 PM Staff 1 (Administrator) and Staff 2 (Interim DNS) stated the purpose of performance reviews was to give staff feedback about their performance and areas in which they were excelling or needed improvement. Staff 1 and Staff 2 could not speak to the lack of information of the performance reviews for Staff 5, Staff 6, Staff 7, and Staff 8.

Based on interview and record review it was determined the facility failed to have a system in place to ensure CNA staff received 12 hours of in-service training annually for 4 of 5 randomly selected staff members (#s 5, 6, 7, and 8) reviewed for in-service training. This placed residents at risk for lack of competent staff. Findings include: A review of the facility's staff training records revealed the following: - Staff 5 (CNA) received 0.5 hours of annual training. - Staff 6 (CNA) received zero hours of annual training. - Staff 7 (CNA) received 0.5 hours of annual training. - Staff 8 (CNA) received 0.5 hours of annual training. On 1/17/24 at 1:16 PM Staff 1 (Administrator) and Staff 2 (Interim DNS) stated a new computer-based program was implemented in response to staff education completion rates and needed improvement. Staff 1 acknowledged Staff 5, Staff 6, Staff 7, and Staff 8 lacked the required 12 hours of in-service training.

Based on interview, and record review it was determined the facility failed to ensure a resident was treated in a dignified manner for 1 of 4 sampled residents (#2) reviewed for ADL care. This placed residents at risk for being treated in a dishonorable manner. Findings include: Resident 2 was admitted to the facility in 2008 with diagnoses including dementia and a communication deficit. Review of Resident 2's care plan dated 1/11/24 revealed the resident was independent with eating, required set up assistance and staff were to cut up meats and other food items. Staff were to assist the resident with meals as needed. Resident 2 preferred to eat in her/his room and eating - Feeder. Encourage fluids. On 1/10/24 at 1:14 PM Staff 12 (CNA) stated Resident 2 was a feeder and she/he needed assistance with her/his meals. Staff 12 stated the facility had a lot of feeders and not enough staff to assist with meals. On 1/11/24 at 9:10 AM Staff 10 (CNA) stated Resident 2 was a supervised feeder but needed staff to sit with her/him to assist with her/his meals. On 1/17/24 at 12:44 PM Staff 1 (Administrator) and Staff 2 (Interim DNS) stated staff were not to refer to Resident 2 or any other resident as a feeder as it was not consistent with treating residents with dignity and respect. Refer to F677

Based on interview and record review it was determined the facility failed to ensure Staff 10 (LPN) followed current standards of practice and followed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This resulted in Resident 4 not having the opportunity for treatment and resulted in Resident 4's death. This failure resulted in an immediate jeopardy situation. This placed residents at risk for lack of a higher level of care, treatment and death. Findings include: [NAME] [DATE] Conduct Derogatory of the Standards of Nursing Define Conduct that adversely affects the health safety, and welfare of the public, fails to conform to legal nursing standards, or fails to conform to accepted standards of the nursing profession, is conduct derogatory to the standard of nursing. Such conduct includes, but is not limited to: (2) conduct related to achieving and maintaining clinical competency (a) failing to conform to the essential standards of acceptable and prevailing nursing practice. (3) conduct related to the client's safety and integrity. (c) failing to develop, implement or modify the plan of care. Resident 4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident 4's Progress Notes revealed the following: -On [DATE] at 3:16 PM Resident 4 was assessed to have no respiratory issues throughout the day shift. O2 sats were 96%. -On [DATE] at 3:57 PM Resident 4 was found lying on the floor. Resident 4 indicated she/he was on the floor for approximately 15 minutes and was assessed to have bruising to her/his right hip and thigh. Witness 1 (Physician) was informed of the fall. -On [DATE] at 11:20 PM Resident 4's O2 sat was 76% on 4L oxygen per the verbal physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A voice message was left for Witness 1 to update him on Resident 4's status. -On [DATE] at 1:59 AM the note indicated Witness 1 was called again at 1:00 AM and a message was left to call the facility back. At 1:45 AM Resident 4 was found with no blood pressure, pulse or respirations. The [DATE] Record of death indicated Resident 4 died on [DATE] at 1:45 AM. Staff 10 was present. The [DATE] Facility Investigation written witness statements revealed the following: -Staff 4 (Evening Shift LPN) indicated both she and Staff 10 completed a status check on Resident 4 at change of shift. Resident 4 was pale and had poor capillary refill (a sign of low oxygen levels). Witness 1 was updated of Resident 4's status by Staff 7 (Evening Shift LPN) and interventions which were put into place. A verbal order was given to increase the oxygen to 4L and if Resident 4's O2 sat fell below 88% to transfer Resident 4 to the hospital. -Witness 1 indicated he had received a phone call from Staff 7 where he reported Resident 4 had a low BP. Witness 1 indicated he directed Staff 7 to provide hydration, which increased Resident 4's blood pressure. Witness 1 indicated he later received another call from Staff 7 who reported Resident 4 had supplemental oxygen up to 4L. Witness 1 directed Staff 7 if he could not keep Resident 4's oxygen at 88% or above to send Resident 4 to the hospital. Witness 1 indicated he was concerned for a possible pulmonary embolism (blood clot in the lung) related to Resident 4 being taken off [MEDICATION(S)] (blood thinner medication) approximately one week prior. -Staff 7 indicated a CNA discovered Resident 4 lying the the floor, neurological checks were started and Resident 4 was assessed to have a low BP. Staff assisted the resident to drink water which raised her/his BP but her/his O2 sats began to drop. Staff 7 indicated he called Witness 1 and received an order to place the resident on oxygen up to 4L and to maintain her/his O2 sats at 88% or above. If the O2 sats could not be maintained then to send Resident 4 to the hospital. Staff 7 indicated Staff 10 began work at 10:00 PM, called Witness 1 and informed Witness 1 Resident 4 was a DNR. [No new or additional orders were received.] -Staff 10 indicated she arrived to work and began counting medications with Staff 4; Staff 7 was waiting for Witness 1 to return his call. Staff 10 indicated when the count was completed Staff 6 (CNA) reported Resident 4's O2 sat was 76% on 4L of oxygen. Staff 10 and Staff 7 went to assess Resident 4 who had no capillary refill, grey color skin and no signs or symptoms of distress. [No capillary refill and grey skin color are both signs of respiratory distress.] Staff 10 stated she then received report [from the off-going shift] and indicated Staff 7 had received a verbal order for Resident 4. Staff 10 then reassessed Resident 4, O2 sat was 76% on 4L of oxygen, the resident was fidgeting with the oxygen tubing, frequent checks were completed and staff replaced the oxygen tubing on the resident. Between 11:00 PM and 11:15 PM, Staff 10 placed a call to Witness 1 and left a message to update him on Resident 4's status and to clarify when to send Resident 4 to the hospital. Staff 10 did not receive a return call, called Witness 1 again around 1:00 AM and again left a voice message. Resident 4's O2 sats were around 76% on 4L of oxygen. - Staff 5 (CNA) reported Staff 10 asked all night shift CNA's to take turns checking on Resident 4. Resident 4 talked a little bit, had few word responses to questions or direction, did not want anything on her/his face and did not want to keep the oxygen tubing on. Resident 4 would become agitated when staff assisted putting the oxygen back on. Resident 4 was not able to follow encouragement to breath through her/his nose. Staff 5 further indicated at 10:00 PM Resident 4's O2 sats were in the low 60's to 70's. Staff 5 indicated he last checked on the resident between 1:25 AM to 1:30 AM and returned around 1:,d+[DATE]:45 AM and found the resident was not breathing. Staff 10 was immediately notified and came into the room at 1:45 AM. -Staff 6 (CNA) indicated she was Resident 4's assigned CNA on both evening and night shift on [DATE]. Staff 6 reported on evening shift Resident 4's BP was low but her/his BP came back up after she/he was assisted with fluids. Staff 6 stated Resident 4's O2 sats ranged from ,d+[DATE]% and when Staff 7 placed oxygen on her/him the O2 sats raised to ,d+[DATE]%. Staff 6 indicated staff performed visual checks every 15 to 20 minutes. Around 10:00 to 10:30 PM Resident 4's O2 sats were ,d+[DATE]% on 2L of oxygen. Staff 7 updated Witness 1 and instructed staff could increase the oxygen rate to 4L. If Resident 4's O2 sat remained under 88% Witness 1 instructed staff to transfer her/him to the hospital. Staff 6 further reported on night shift the CNA's checked on the resident every 10 to 15 minutes. She notified Staff 10 of Resident 4's O2 sat of ,d+[DATE]% on 4L [at shift change]. Around 11:00 PM Staff 10 left a voice message for Witness 1. Later, Staff 10 left another voice message. Staff 6 indicated she last saw Resident 4 between 1:25 AM to 1:30 AM. She returned to check on her/him between 1:40 AM to 1:45 AM and the resident had passed. The [DATE] Facility Investigation written summary indicated Staff 10 did not follow a verbal order given by the medical provider and Resident 4 had a significant change of condition. The summary further indicated it was unknown if Resident 4 was sent to the hospital if it would have resulted in a different outcome. On [DATE] at 10:45 AM Staff 7 stated Staff 10 assumed care of Resident 4 at the change of shift [10:00 PM]. Staff 7 verified he received a verbal order for Resident 4 to have oxygen up to 4L, maintain her/his O2 sats at 88% or above and to transfer Resident 4 if unable to maintain O2 sats at 88%. Staff 7 stated he verbally told Staff 10 of the new order. On [DATE] at 10:55 AM Staff 6 verified her written witness statement was correct. Staff 6 stated Resident 4 was a DNR and Staff 10 indicated it was hard on the resident to be transferred to the hospital so Staff 10 kept attempting to check with Witness 1. On [DATE] at 11:07 AM Staff 5 verified his written statement was correct. Staff 5 stated he was told by Staff 10 she was waiting to here back from the physician before transferring Resident 4 to the hospital. Staff 5 stated staff were all trying to figure out why the doctor wasn't sending [her/him] out. Staff 5 stated Resident 4 was not getting any better and the facility was not equipped to handle this type of situation. On [DATE] at 11:06 AM and 12:09 PM Staff 1 (Administrator) stated Staff 10 was placed on suspension on [DATE] through her termination on [DATE]. Staff 1 verified Resident 1 had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff 1 verified the facility was unable to maintain Resident 4's O2 sats at 88% and did not transfer the resident to the hospital. Staff 1 verified pale to grey colored skin, poor to no capillary refill, restlessness and agitation were all signs of respiratory distress. Staff 1 stated the facility terminated Staff 10 because the facility felt Staff 10's nursing judgment was off. Staff 1 further stated if any staff could not get a hold of the physician they should send the resident out to the hospital. Staff 1 stated it was definitely poor nurse care. On [DATE] at 12:30 PM Staff 1 and Staff 3 (Previous DNS) verified on [DATE] Staff 10 failed to recognize a significant change of condition and follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility began the investigation on [DATE], Staff 10 was suspended through the conclusion of the investigation on [DATE] when Staff 10 was terminated from the facility. All nursing staff were provided education on [DATE] and [DATE] and monitoring was immediately put into place. On [DATE] at 11:50 AM Staff 1 and Staff 2 (DNS) were notified the incident on [DATE] through [DATE] was an Immediate Jeopardy situation. As the facility had identified the deficient practice, instituted corrections and maintained the correction, this was determined to qualify for the designation as past non-compliance. Survey determined the Past Noncomplaince was corrected on [DATE] when the facility identified deficient practice and initiated corrections. The Plan of Action included; 1. All nursing staff were educated on [DATE] and [DATE] related to medication and treatment orders and the emar (electronic medication administration record), and detecting and communicating change in resident's condition and the role of the licensed nurse, 2. Monitoring was immediately initiated, 3. Monday through Friday management staff reviewed multiple items from the previous day including checking for change of condition, response to the change of condition, new physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility utilized check-lists to ensure monitoring was completed. Refer to F684

Based on interview and record review it was determined the facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] Resident 4's O2 sats dropped to 76% and was not transported to the hospital. Resident 4 did not have the opportunity for treatment which resulted in Resident 4's death. This failure resulted in an immediate jeopardy situation. This placed residents at risk for the lack of a higher level of care, treatment and death. Findings include: Resident 4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident 4's Progress Notes revealed the following: On [DATE] Resident 4 experienced diarrhea, complained of severe abdominal pain, dizziness and then had a syncopal episode (fainted). Resident 4 was assessed to have low blood pressure (,d+[DATE]), O2 Sat of 62% which raised to 78% with 2L oxygen. Witness 1 (physician) was notified and the Resident was transferred to the hospital. -On [DATE] Resident 4 returned to the facility at 2:40 AM with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . -On [DATE] at 3:16 PM Resident 4 was assessed to have no respiratory issues throughout the day shift. O2 sats were 96%. -On [DATE] at 3:57 PM Resident 4 was found lying on the floor. Resident 4 indicated she/he was on the floor for approximately 15 minutes and was assessed to have bruising to her/his right hip and thigh. Witness 1 was informed of the fall. - On [DATE] at 11:20 PM Resident 4's O2 sat was 76% on 4L oxygen per the verbal physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A voice message was left for Witness 1 to update him on Resident 4's status. -On [DATE] at 1:59 AM note indicated Witness 1 was called again at 1:00 AM and a message was left to call the facility back. At 1:45 AM Resident 4 was found with no blood pressure, pulse or respirations. The [DATE] Record of death indicated Resident 4 died on [DATE] at 1:45 AM. Staff 10 was present. The [DATE] Facility Investigation written witness statements revealed the following: -Staff 4 (Evening Shift LPN) indicated both she and Staff 10 completed a status check on Resident 4 at change of shift. Resident 4 was pale and had poor capillary refill (a sign of low oxygen levels). Witness 1 was updated of Resident 4's status by Staff 7 (Evening Shift LPN) and interventions which were put into place. A verbal order was given to increase the oxygen to 4L and if Resident 4's O2 sat fell below 88% to transfer Resident 4 to the hospital. -Witness 1 indicated he had received a phone call from Staff 7 where he reported Resident 4 had a low BP. Witness 1 indicated he directed Staff 7 to provide hydration, which increased Resident 4's blood pressure. Witness 1 indicated he later received another call from Staff 7 who reported Resident 4 had supplemental oxygen up to 4L. Witness 1 directed Staff 7 if he could not keep Resident 4's oxygen at 88% or above to send Resident 4 to the hospital. Witness 1 indicated he was concerned for a possible pulmonary embolism (blood clot in the lung) related to Resident 4 being taken off [MEDICATION(S)] (blood thinner medication) approximately one week prior. -Staff 7 indicated a CNA discovered Resident 4 lying the the floor, neurological checks were started and Resident 4 was assessed to have a low BP. Staff assisted the resident to drink water which raised her/his BP but her/his O2 sats began to drop. Staff 7 indicated he called Witness 1 and received an order to place the resident on oxygen up to 4L and to maintain her/his O2 sats at 88% or above. If the O2 sats could not be maintained then to send Resident 4 to the hospital. Staff 7 indicated Staff 10 began work at 10:00 PM, called Witness 1 and informed Witness 1 Resident 4 was a DNR. [No new or additional orders were received.] -Staff 10 indicated she arrived to work and began counting medications with Staff 4; Staff 7 was waiting for Witness 1 to return his call. Staff 10 indicated when the count was completed Staff 6 (CNA) reported Resident 4's O2 sat was 76% on 4L of oxygen. Staff 10 and Staff 7 went to assess Resident 4 who had no capillary refill, grey color skin and no signs or symptoms of distress. [No capillary refill and grey skin color are both signs of respiratory distress.] Staff 10 stated she then received report [from the off-going shift] and indicated Staff 7 had received a verbal order for Resident 4. Staff 10 then reassessed Resident 4, O2 sat was 76% on 4L of oxygen, the resident was fidgeting with the oxygen tubing, frequent checks were completed and staff replaced the oxygen tubing on the resident. Between 11:00 PM and 11:15 PM, Staff 10 placed a call to Witness 1 and left a message to update him on Resident 4's status and to clarify when to send Resident 4 to the hospital. Staff 10 did not receive a return call, called Witness 1 again around 1:00 AM and again left a voice message. Resident 4's O2 sats were around 76% on 4L of oxygen. - Staff 5 (CNA) reported Staff 10 asked all night shift CNA's to take turns checking on Resident 4. Resident 4 talked a little bit, had few word responses to questions or direction, did not want anything on her/his face and did not want to keep the oxygen tubing on. Resident 4 would become agitated when staff assisted putting the oxygen back on. Resident 4 was not able to follow encouragement to breath through her/his nose. Staff 5 further indicated at 10:00 PM Resident 4's O2 sats were in the low 60's to 70's. Staff 5 indicated he last checked on the resident between 1:25 AM to 1:30 AM and returned around 1:,d+[DATE]:45 AM and found the resident was not breathing. Staff 10 was immediately notified and came into the room at 1:45 AM. -Staff 6 (CNA) indicated she was Resident 4's assigned CNA on both evening and night shift on [DATE]. Staff 6 reported on evening shift Resident 4's BP was low but her/his BP came back up after she/he was assisted with fluids. Staff 6 stated Resident 4's O2 sats ranged from ,d+[DATE]% and when Staff 7 placed oxygen on her/him the O2 sats raised to ,d+[DATE]%. Staff 6 indicated staff performed visual checks every 15 to 20 minutes. Around 10:00 to 10:30 PM Resident 4's O2 sats were ,d+[DATE]% on 2L of oxygen. Staff 7 updated Witness 1 and instructed staff could increase the oxygen rate to 4L. If Resident 4's O2 sat remained under 88% Witness 1 instructed staff to transfer her/him to the hospital. Staff 6 further reported on night shift the CNA's checked on the resident every 10 to 15 minutes. She notified Staff 10 of Resident 4's O2 sat of ,d+[DATE]% on 4L [at shift change]. Around 11:00 PM Staff 10 left a voice message for Witness 1. Later, Staff 10 left another voice message. Staff 6 indicated she last saw Resident 4 between 1:25 AM to 1:30 AM. She returned to check on her/him between 1:40 AM to 1:45 AM and the resident had passed. The [DATE] Facility Investigation Notes indicated based on a record review timeline it was determined the hospital did not contact the facility to inform the facility Resident 4's [MEDICATION(S)] (antibiotic) should be discontinued and a new antibiotic started after Resident 4 returned to the facility. The hospital called the resident directly and left voice messaged for him on [DATE] and [DATE]. The urine culture and sensitivity identified the prescribed antibiotic did not work on the identified bacteria and the antibiotic needed to be changed. The [DATE] Facility Investigation written summary indicated Staff 10 did not follow a verbal order given by the medical provider and Resident 4 had a significant change of condition. The summary further indicated it was unknown if Resident 4 was sent to the hospital if it would have resulted in a different outcome. On [DATE] at 10:45 AM Staff 7 stated Staff 10 assumed care of Resident 4 at the change of shift [10:00 PM]. Staff 7 verified he received a verbal order for Resident 4 to have oxygen up to 4L, maintain her/his O2 sats at 88% or above and to transfer Resident 4 if unable to maintain O2 sats at 88% Staff 7 stated he verbally told Staff 10 of the new order. On [DATE] at 10:55 AM Staff 6 verified her written witness statement was correct. Staff 6 stated Resident 4 was a DNR and Staff 10 indicated it was hard on the resident to be transferred to the hospital so Staff 10 kept attempting to check with Witness 1. On [DATE] at 11:07 AM Staff 5 verified his written statement was correct. Staff 5 stated he was told by Staff 10 she was waiting to here back from the physician before transferring Resident 4 to the hospital. Staff 5 stated staff were all trying to figure out why the doctor wasn't sending [her/him] out. Staff 5 stated Resident 4 was not getting any better and the facility was not equipped to handle this type of situation. On [DATE] at 11:06 AM and 12:09 PM Staff 1 (Administrator) stated Staff 10 was placed on suspension on [DATE] through her termination on [DATE]. Staff 1 verified Resident 1 had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff 1 verified the facility was unable to maintain Resident 4's O2 sats at 88% and did not transfer the resident to the hospital. Staff 1 verified pale to grey colored skin, poor to no capillary refill, restlessness and agitation were all signs of respiratory distress. Staff 1 stated the facility terminated Staff 10 because the facility felt Staff 10's nursing judgment was off. Staff 1 further stated if any staff could not get a hold of the physician they should send the resident out to the hospital. Staff 1 stated it was definitely poor nurse care. On [DATE] at 12:30 PM Staff 1 and Staff 3 (Previous DNS) verified on [DATE] Staff 10 failed to recognize a significant change of condition and follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility began the investigation on [DATE], Staff 10 was suspended through the conclusion of the investigation on [DATE] when Staff 10 was terminated from the facility. All nursing staff were provided education on [DATE] and [DATE] and monitoring was immediately put into place. On [DATE] at 11:50 AM Staff 1 and Staff 2 (DNS) were notified the incident on [DATE] through [DATE] was an Immediate Jeopardy situation. As the facility had identified the deficient practice, instituted corrections and maintained the correction, this was determined to qualify for the designation as past non-compliance. Survey determined the Past Noncomplaince was corrected on [DATE] when the facility identified deficient practice and initiated corrections. The Plan of Action included; 1. All nursing staff were educated on [DATE] and [DATE] related to medication and treatment orders and the emar (electronic medication administration record), and detecting and communicating change in resident's condition and the role of the licensed nurse, 2. Monitoring was immediately initiated, 3. Monday through Friday management staff reviewed multiple items from the previous day including checking for change of condition, response to the change of condition, new physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility utilized check-lists to ensure monitoring was completed.

Based on interview and record review it was determined the facility failed to implement written policies for reporting suspected abuse in a timely manner for 1 of 3 sampled residents (#12) reviewed for accidents. Resident 12 experienced a fall with multiple fractures, increased pain and delayed treatment. Findings include: Per the facility's abuse policies and procedures (revised January 2016), mandatory reporters included nursing facility employees or any individual who contracts to provide services in a nursing facility. The policy further indicated: All persons are encouraged to report abuse and suspected abuse. The following persons are required to immediately report abuse and suspected abuse to the Division or law enforcement agency: - Facility Administrator - Director of Nursing - Charge Nurse - Department of Human Resources - Local Senior and Disabled Services Division - Law enforcement agency--if suspicion of crime must report immediately The facility's Accident/Incident Policy and Procedure (revised January 2016) indicated: It is the policy to investigate incidents and accidents in accordance with State and Federal regulations. Immediately following an incident the investigation and incident report shall be initiated in Origami. Investigation shall be completed within 5 days in Origami. In interview on 5/12/16, Staff 1 (Administrator) indicated it is the intent of the facility's abuse prevention policies and procedures all staff immediately report suspected abuse. Resident 12 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. Resident 12's In Room Care Plan dated 11/11/15 indicated the resident needed extensive assistance of one person for transfers using a Hoyer lift (mechanical assistive device). A progress note dated 1/13/16 at 11:31 pm revealed Resident 12 had pain, and bruising and swelling to resident's right ankle was observed. The cause was undetermined, the resident's physician was notified, and an X-ray requested. An Incident Report dated 1/14/16 at 4:40 pm indicated nurses reported in a 1/13/16 progress note Resident 12 was in pain on 1/13/16. Staff indicated the source of pain was undetermined. The report indicated at 9:00 am on 1/14/16, a CNA reported bruising and swelling covering the resident's right anterior ankle. Witness 1 (former CNA responsible for Resident 12's care on 1/13/16) was interviewed, and did not reveal knowledge of any causative incident for Resident 12's bruising and swelling covering the resident's right anterior ankle. Progress notes on 1/14/16 indicated the resident's right foot was bruised, swollen and painful, and X-ray results revealed a fracture to the resident's right ankle. In a 1/14/16 progress note the nurse practitioner indicated there were no reports of falls or injury. The resident's January 2016 MAR indicated [REDACTED]. The resident's January 2016 MAR indicated [REDACTED] 1/13/16 administered three times 1/14/16 administered four times 1/15/16 administered five times 1/16/16 administered four times 1/17/16 administered four times 1/18/16 administered two times 1/19/16 administered three times 1/20/16 administered three times 1/21/16 administered three times 1/22/16 administered two times Progress notes dated 1/18/16 indicated Resident 12 had increased pain with transfer and an immobilizer was in place. In progress notes dated 1/20/16 and 1/21/16, the nurse practitioner indicated the resident's left ankle was painful and swollen, and there was a bruise which appeared to be several days old. The nurse practitioner further indicated X-rays revealed a fracture to the resident's left ankle, and the fracture likely occurred during the same incident as the right ankle fracture identified on 1/14/16. An Incident Report dated 1/20/16 at 7:30 pm noted bruises to Resident 12's left ankle were observed. The report indicated an X-ray of the left ankle was completed and revealed a left ankle fracture. Witness 1 was interviewed on 1/21/16 by the facility in conjunction with the Incident Report , and did not reveal knowledge of any causative incident for Resident 12's injuries. A Fracture Investigation dated 1/25/16 included a Witness Statement from Witness 1. Witness 1 stated while she transferred Resident 12 from the shower chair to the bed with a Hoyer lift on 1/13/16 after the resident's 6:30 am shower, the strap on the resident's right side closest to the resident's feet came off, and the resident slid out of the sling and hit the floor. Witness 1 confirmed she did not report the fall, stated it was an accident and she should have reported it right away. The investigation included the opinion of the nurse practitioner the left and right ankle fractures occurred during the same incident on 1/13/16. On 5/6/16 at 8:40 am Staff 2 (DNS) stated Witness 1 was interviewed several times after Resident 12's injuries were discovered, but denied knowing why the resident had the fractures until 1/25/16 when Witness 1 acknowledged she knew about the accident and did not report it. Staff 2 confirmed Witness 1 should have reported the accident immediately. In interview on 5/11/16 at 12:25 pm, Witness 1 acknowledged she did not report the accident in a timely manner. For additional information refer to F309

Based on interview and record review it was determined facility staff failed to meet professional standards of care in reporting falls in a timely manner for 1 of 3 sampled residents (#12) reviewed for accidents. Resident 12 experienced a fall with multiple fractures, increased pain and delayed treatment. Findings include: Per OAR [PHONE NUMBER](4)(f) it is conduct unbecoming a CNA to fail to communicate information regarding a person's status to the supervising nurse or other appropriate member of the healthcare team in an on-going and timely manner and as appropriate to the context of care. Resident 12 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. Resident 12's In Room Care Plan dated 11/11/15 indicated the resident needed extensive assistance of one person for transfers using a Hoyer lift (mechanical assistive device). A progress note dated 1/13/16 at 11:31 pm revealed Resident 12 had pain, and bruising and swelling to resident's right ankle was observed. The cause was undetermined, the resident's physician was notified, and an X-ray requested. An Incident Report dated 1/14/16 at 4:40 pm indicated nurses reported in a 1/13/16 progress note Resident 12 was in pain on 1/13/16. Staff indicated the source of pain was undetermined. The report indicated at 9:00 am on 1/14/16, a CNA reported bruising and swelling covering the resident's right anterior ankle. Witness 1 (former CNA responsible for Resident 12's care on 1/13/16) was interviewed, and did not reveal knowledge of any causative incident for Resident 12's bruising and swelling covering the resident's right anterior ankle. Progress notes on 1/14/16 indicated the resident's right foot was bruised, swollen and painful, and X-ray results revealed a fracture to the resident's right ankle. In a 1/14/16 progress note the nurse practitioner indicated there were no reports of falls or injury. The resident's January 2016 MAR indicated [REDACTED]. The resident's January 2016 MAR indicated [REDACTED] 1/13/16 administered three times 1/14/16 administered four times 1/15/16 administered five times 1/16/16 administered four times 1/17/16 administered four times 1/18/16 administered two times 1/19/16 administered three times 1/20/16 administered three times 1/21/16 administered three times 1/22/16 administered two times In progress notes dated 1/20/16 and 1/21/16, the nurse practitioner indicated the resident's left ankle was painful and swollen, and there was a bruise which appeared to be several days old. The nurse practitioner further indicated X-rays revealed a fracture to the resident's left ankle, and the fracture likely occurred during the same incident as the right ankle fracture identified on 1/14/16. An Incident Report dated 1/20/16 at 7:30 pm noted bruises to Resident 12's left ankle were observed. The report indicated an X-ray of the left ankle was completed and revealed a left ankle fracture. Witness 1 was interviewed on 1/21/16 by the facility in conjunction with the Incident Report, and did not reveal knowledge of any causative incident for Resident 12's injuries. A Fracture Investigation dated 1/25/16 included a Witness Statement from Witness 1. Witness 1 stated while she transferred Resident 12 from the shower chair to the bed with a Hoyer lift on 1/13/16 after the resident's 6:30 am shower, the strap on the resident's right side closest to the resident's feet came off, and the resident slid out of the sling and hit the floor. She did not recall if she double-checked the sling straps for proper placement prior to executing the transfer and stated I don't know - it just slipped off. I don't remember - I usually check them real good so I'm pretty sure I did that time. Witness 1 further stated I just can't live with this anymore - I have to confess. What happened to (Resident 12) is all my fault. I dropped (her/him) from the lift - that's how (she/he) got hurt. In the statement, Witness 1 confirmed she did not report the fall, stated it was an accident and she should have reported it right away. The investigation included the opinion of the nurse practitioner the left and right ankle fractures occurred during the same incident on 1/13/16. On 5/6/16 at 8:40 am Staff 2 (DNS) stated Witness 1 was interviewed several times after Resident 12's injuries were discovered, but denied knowing why the resident had the fractures until 1/25/16 when Witness 1 acknowledged she knew about the accident and did not report it. Staff 2 confirmed Witness 1 should have reported the accident immediately. In interview on 5/11/16 at 12:25 pm, Witness 1 acknowledged she did not report the accident in a timely manner. For additional information refer to F309

1. Based on interview and record review it was determined the facility failed to provide treatments and manage pain in a timely manner for 1 of 3 sampled residents (#12) reviewed for accidents. Resident 12 experienced a fall with multiple fractures, increased pain and delayed treatment. Findings include: Resident 12 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. Resident 12's In Room Care Plan dated 11/11/15 indicated the resident needed extensive assistance of one person for transfers using a Hoyer lift (mechanical assistive device). Record review revealed as of 1/13/16 Resident 12's pain medication orders included PRN [MEDICATION NAME] (narcotic pain medication) 2.5mg- 5mg, and PRN Tylenol 650mg, and did not include any routine pain medication orders. A progress note dated 1/13/16 at 11:31 pm revealed Resident 12 had pain, and bruising and swelling to resident's right ankle was observed. The cause was undetermined, the resident's physician was notified, and an X-ray requested. An Incident Report dated 1/14/16 at 4:40 pm indicated nurses reported in a 1/13/16 progress note Resident 12 was in pain on 1/13/16. Staff indicated the source of pain was undetermined. The report indicated at 9:00 am on 1/14/16, a CNA reported bruising and swelling covering the resident's right anterior ankle. Witness 1 (former CNA responsible for Resident 12's care on 1/13/16) was interviewed by the facility, and did not reveal knowledge of any causative incident for Resident 12's bruising and swelling covering the resident's right anterior ankle. Progress notes on 1/14/16 indicated the resident's right foot was bruised, swollen and painful. X-ray results revealed a fracture to the resident's right ankle. Staff were directed to immobilize the right leg and provide support to the leg. ACE wraps (used for a bandage with elastic properties) were applied, and routine pain medication Tylenol 650mg three times per day was ordered. The nurse practitioner noted there were no reports of falls or injury. The resident's January 2016 MAR indicated [REDACTED]. The resident's January 2016 MAR indicated [REDACTED] 1/13/16 administered three times 1/14/16 administered four times 1/15/16 administered five times 1/16/16 administered four times 1/17/16 administered four times 1/18/16 administered two times 1/19/16 administered three times 1/20/16 administered three times 1/21/16 administered three times 1/22/16 administered two times Progress notes dated 1/18/16 indicated Resident 12 had increased pain with transfer and an immobilizer was in place. In progress notes dated 1/20/16 and 1/21/16, the nurse practitioner indicated the resident's left ankle was painful and swollen, and there was a bruise which appeared to be several days old. The nurse practitioner further indicated X-rays revealed a fracture to the resident's left ankle, and the fracture likely occurred during the same incident as the right ankle fracture identified on 1/14/16. Resident 12's January 2016 MAR indicated [REDACTED]. An Incident Report dated 1/20/16 at 7:30 pm noted bruises to Resident 12's left ankle were observed. The report indicated an X-ray of the left ankle was completed and revealed a left ankle fracture. Witness 1 was interviewed on 1/21/16 by the facility in conjunction with the Incident Report, and did not reveal knowledge of any causative incident for Resident 12's injuries. A progress noted dated 1/25/16 indicated ACE wraps and braces to both lower extremities were in place. A Fracture Investigation dated 1/25/16 included a Witness Statement from Witness 1. Witness 1 stated while she transferred Resident 12 from the shower chair to the bed with a Hoyer lift on 1/13/16 after the resident's 6:30 am shower, the strap on the resident's right side closest to the resident's feet came off, and the resident slid out of the sling and hit the floor. She did not recall if she double-checked the sling straps for proper placement prior to executing the transfer and stated I don't know - it just slipped off. I don't remember - I usually check them real good so I'm pretty sure I did that time. Witness 1 further stated I just can't live with this anymore - I have to confess. What happened to (Resident 12) is all my fault. I dropped (her/him) from the lift - that's how (she/he) got hurt. In the statement, Witness 1 confirmed she did not report the fall, stated it was an accident and she should have reported it right away. The investigation included the opinion of the nurse practitioner the left and right ankle fractures occurred during the same incident on 1/13/16. A progress noted dated 2/1/16 indicated the resident had returned from an orthopedic appointment with a cast on her/his right leg and a soft boot on her/his left foot/ankle. On 5/6/16 at 8:40 am Staff 2 (DNS) stated Witness 1 was interviewed several times after Resident 12's injuries were discovered, but denied knowing why the resident had the fractures until 1/25/16 when Witness 1 acknowledged she knew about the accident and did not report it. Staff 2 confirmed Witness 1 should have reported the accident immediately. In interview on 5/11/16 at 12:25 pm, Witness 1 acknowledged she did not report the accident in a timely manner. 2. Based on interview and record review the facility failed to communicate with a provider for 1 of 1 sampled residents (#18) reviewed for [MEDICAL TREATMENT]. This placed residents at risk for unmet [MEDICAL TREATMENT] needs. Findings include: Resident 18 was admitted to the facility in 1/2016 with [DIAGNOSES REDACTED]. The resident's Admission MDS, dated [DATE], indicated the resident received [MEDICAL TREATMENT] (process of removing waste and excess water from the blood, used primarily as an artificial replacement for lost kidney function in people with kidney failure). The resident's care plan for [MEDICAL TREATMENT], dated 4/8/16, indicated the facility was to collaborate with the [MEDICAL TREATMENT] provider. On 5/4/16 at 1:06 pm Witness 2 (physician) stated the facility had poor communication with the [MEDICAL TREATMENT] provider. Witness 1 stated the facility was not aware of what medication the resident received or whether the resident had any complaints while at [MEDICAL TREATMENT]. On 5/4/16 at 2:27 pm Staff 4 (RNCM) stated the facility only received information from the [MEDICAL TREATMENT] provider upon request. On 5/4/16 at 2:47 pm Staff 2 (DNS) acknowledged that prior to 5/4/16 there was no process in place for communicating with the [MEDICAL TREATMENT] provider.

Based on interview and record review it was determined the facility failed to investigate potential allegations of abuse for 4 of 5 sampled residents (#s 5, 9, 53 and 56) who were reviewed for accidents. The facility's failure to investigate potential incidents of abuse led to prolonged aggressive behavior by Residents 9 and 53 toward other residents which caused prolonged distress, fear and preventable resident-to-resident incidents among other residents in the memory care unit including Residents 5 and 56. Findings include: 1. Resident 53 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. A PASRR Level II Psychiatric Evaluation dated 6/10/15 indicated starting in April 2015 Resident 53's behavior changed and the resident started making verbal and physical sexual advances toward female residents. A female resident suddenly became fearful of Resident 53 and was asking staff to stay near her. The female resident hit Resident 53. Resident 53 had been hovering over female resident's beds while they were asleep, standing behind their door and following them around the unit. On several occasions Resident 53 had touched other's female parts. Resident 53 was found locked in a bathroom with a female resident who was on the toilet with her pants and brief down. Resident 53 had been found in that female resident's bed. Resident 53 stated I love her and She wants to (f__k) me. The evaluation indicated Resident 53 was independent with mobility, was strong and agile. Since the end of April 2015 Resident 53 was targeting several female residents and staff with verbal and physical advances. Staff were concerned about Resident 53 following female residents, groping them, and being locked in a bathroom with a female resident. The evaluation indicated a concern Resident 53 may have been at a higher level of physical functioning than the other residents which put others at risk for harm due to the resident's sexual advances and independent status. The evaluation recommended it was very important for staff to be vigilant regarding Resident 53's whereabouts on the unit at all times. A review of Resident 53's Resident Behavior Report Sheet from 4/23/15 through 8/14/15 revealed the resident had 73 behaviors noted by facility staff including the following entries which indicated: On 4/23/15 the resident entered a female resident's room and started pulling down her covers. On 4/24/15 the resident entered a female resident's room and started pulling down her covers. On 4/29/15 the resident entered a female resident's room and started pulling down her covers. On 5/1/15 the resident's hand was in a female's lap. On 5/1/15 the resident was standing over a female's bed starting to uncover her. On 5/7/15 the resident would not leave a female resident alone and followed her into the bathroom. On 5/8/15 the resident was following a female resident everywhere including into the bathroom. On 5/8/15 the resident followed a female into the bathroom and locked the door. On 5/13/15 the resident was in a bathroom with a female resident and the door was locked. On 5/23/15 the resident had her/his hand on a female resident's private parts and was laughing. On 5/23/15 the resident was trying to take female residents into her/his room. On 5/25/15 the resident was touching other resident's private parts. On 5/25/15 the resident was in a female resident's room with the door closed. One of the female residents stated He is crazy. On 5/27/15 the resident was found at a female resident's bedside with the covers pulled down and attempting to get in the bed and stated She wants to (f__k) me. On 6/8/15 the resident grabbed a female resident's crotch. The female resident begged staff to stay with her. On 6/9/15 the resident was going after two female residents all day. One of the female residents hit Resident 53 and said stay away. The other female resident jumped up from a chair and said go go away. On 6/13/15 the resident had a hand on a female resident's crotch under a blanket. The female resident was shaking badly. On 6/15/15 the resident was trying to get another resident to go into her/his room. On 6/16/15 the resident touched another resident's private parts. On 6/18/15 the resident tried to kiss a female resident. The female resident said no. On 6/21/15 the resident went into a female resident's room and staff heard the female resident yell. On 6/22/15 the resident was standing over a female resident holding the blankets up and with a hand on the female's privates. On 6/24/15 the resident wanted to take a female resident into her/his room without the female resident's permission. On 6/26/15 the resident tried to touch two female residents without their permission. On 6/28/15 the resident was following a female resident down the hall muttering about her having sex with her/him. On 7/2/15 the resident was forcing a female resident into her/his room without her consent. On 7/2/15 the resident was trying to reach out for a female resident while she was sleeping. On 7/5/15 the resident was trying to take a female resident into her/his room and said she/he was going to (f__k) her. On 7/8/15 the resident kept going into a female resident's room and staff had to put my hand around (her/his) arm and pull (her/him) out! On 7/18/15 the resident was in a female resident's room trying to uncover a female resident. On 7/18/15 the resident was trying to get into a female resident's room without their permission and yelling that (she/he) wanted to (f__k) her. On 7/19/15 the resident was in a female resident's room trying to uncover her. The resident refused to leave the room and staff put arm around (her/him) and pulled (the resident) out of room. On 7/20/15 the resident was trying to go into a female resident's room wanting to (f__k). On 7/21/15 the resident was trying to go into a female resident's room and said (she/he) is going to wake her so (she/he) can (f__k). The resident would not move so staff had to take by the arm a little. On 7/24/15 the resident kept calling out to a female resident asking her to (f__k) and going over to another female resident asking her to (f__k) the female resident said he's scary. On 7/24/15 through 7/25/15 the resident was chasing a male resident around the male resident's room while masturbating. On 7/30/15 the resident was trying to get into a male resident's bed. Of the 37 behaviors listed above the facility provided four incident investigation reports for the incidents on 5/13/15, 6/13/15, 6/16/15, and 7/24/15 through 7/15/15. On 8/24/15 at 10:06 am Staff 3 (DNS) and Staff 4 (Administrator) acknowledged the other 33 behaviors should have either been investigated or followed up on. Refer to F226 example 1 and F323 example 1. 2. Resident 56 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. Resident 56's progress note dated 4/20/15 at 1:46 pm indicated the RNCM was notified Resident 56 was found in her/his bed with a male resident. No investigation or any other documentation was provided by the facility related to this incident. Resident 53's progress note dated 4/21/15 at 10:27 pm indicated at 9:30 pm Resident 53 was found in Resident 56's bed fully dressed. No investigation or any other documentation was provided by the facility related to this incident. A review of Resident 53's Resident Behavior Report Sheet from 4/23/15 through 8/14/15 revealed the resident had 73 behaviors noted by facility staff including the following entries which involved Resident 56 but was not included in her clinical record: 4/25/15 the resident wanted to get into bed with a nurse and Resident 56. She/he told him no. 5/7/15 the resident would not leave Resident 56 alone and followed her/him into the bathroom. 5/8/15 the resident was following Resident 56 everywhere including into the bathroom. 5/8/15 the resident followed Resident 56 into the bathroom and locked the door. 5/23/15 the resident had her/his hand on Resident 56's private parts and was laughing. 6/8/15 the resident grabbed Resident 56's crotch. She/he begged staff to stay with her/him. 6/9/15 the resident was going after Resident 56 and another resident. One of the residents hit Resident 53 and said stay away. Resident 56 jumped up from a chair and said go go away. 6/13/15 the resident had a hand on Resident 56's crotch under a blanket. The female resident was shaking badly. 6/22/15 the resident was standing over Resident 56 holding the blankets up and with a hand on her/his privates. 6/26/15 the resident tried to touch Resident 56 and another resident without their permission. 7/2/15 the resident was forcing Resident 56 into her/his room without her/his consent. 7/18/15 the resident was in Resident 56's room trying to uncover a female resident. 7/18/15 the resident was trying to get into Resident 56 and her/his roommate's room without their permission and yelling that (she/he) wanted to [***] her. 7/24/15 the resident kept calling out to Resident 56 asking her/him to f___ and going over to another female resident asking her to f___ the female resident said he's scary. Of the 14 behaviors listed the facility provided three incident investigation reports for the incidents on 5/13/15, 6/13/15 and 6/16/15. On 8/24/15 at 10:06 am Staff 3 (DNS) and Staff 4 (Administrator) acknowledged the other 14 behaviors should have either been investigated or followed up on. Refer to F 226 example 4 F323 example 4. 3. Resident 9 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. The resident resided in the memory care unit. Resident 9's Behavioral Report Sheet revealed from 2/3/15 to 8/10/15 the resident exhibited numerous aggressive behaviors including punching a hole in the wall, throwing chairs, bed tables, utensils, potted plants, plugging toilets, tearing the inside tank of the toilet apart, broke a glass frame, got her/his roommate out of bed and shoved her/him into a chair in the dining room, and exhibited sexually inappropriate behaviors. The facility failed to investigate all the of Resident 9's resident to resident aggressive behaviors which had a negative impact on the residents in the memory care unit which included: *2/19/15 1:19 pm: Resident 9 pulled the dollie off the piano then dumped a potted plant onto the floor. If the CNA hadn't been there the plant would have hit another resident in the head. *3/22/15 3:20 pm: Resident 9 got her/his roommate out of bed and brought her/him into the dining room and shoved the resident into a chair. Resident 9 was very aggressive with the other resident. *5/22/15 10:45 am: Resident 9 tried kissing another resident and the other resident screamed get off of me. *7/20/15 6:30 pm: Resident 9 was sitting on the edge of the bed facing Resident 53. Resident 53 had her/his back to Resident 9. Staff was standing in the hall and heard Resident 53 sit up quickly and say something to Resident 9. Staff asked Resident 53 what happened and the resident said Resident 9 hit (her/him) in the back. Resident 9 denied it and Staff brought Resident 53 to the TV room. On 8/26/15 at 8:40 am Staff 2 (RNCM) and Staff 3 (DNS) were asked about Resident 9's aggressive behaviors, and if the facility investigated all of the resident to resident incidents. Staff 2 indicated the investigations for Resident 9 did not include the four resident to resident incidents. Staff 3 indicated there should have been a follow up. Refer to F 226 example 2 F323 example 3 4. Resident 5 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. Incidents involving Resident 5 were located in Resident 53's Resident Behavior Report Sheet. From 5/25/15 through 7/21/15 Resident 53 had inappropriate physical contact and stalking behaviors towards Resident 5 on approximately nine occasions. The facility failed to investigate three of Resident 53's resident to resident behaviors towards Resident 5. These included: *6/9/15: (Resident 53 going after Resident 5 and 56) all day. Resident 5 hit Resident 53 and said stay away. *6/18/15 10:45 pm: Resident 53 tried to kiss Resident 5. Resident 5 said No.; and *6/21/15 6:45 am: Resident 53 went into Resident 5's room and closed the door, we heard female (residents) yell and I opened the door and (Resident 53) was standing by (her/him). On 8/19/15 at 12:50 pm Staff 3 (DNS) was asked about the incident on 6/18/15 when Resident 53 tried kissing Resident 5. Staff 3 indicated the kiss was something Resident 5 consented to and was not unhappy with it just a smooch on the cheek. She acknowledged there was no investigation or update to the care plan regarding the incident. On 8/25/15 at 9:54 am Staff 2 (RNCM) confirmed there were no investigations for the three resident to resident incidents between Resident 53 and Resident 5. Refer to F226 example 3 and F323 example 2

Based on interview and record review it was determined the facility failed to operationalize policy and procedure related to abuse for 4 of 5 sampled residents (#s 5, 9, 53 and 56) who were reviewed for accidents. The facility's failure to led to prolonged aggressive behavior by Residents 9 and 53 toward other residents which caused prolonged distress, fear and preventable resident-to-resident incidents among other residents in the memory care unit including Residents 5 and 56. Findings include: The facility's March 2006 Policy and Procedure, Subject: Accident/Incident indicated incidents and accidents would be investigated in accordance with State and Federal regulation and would be completed in five days. An investigation was to be filled out for allegations of abuse, neglect, negligent treatment by staff, family, or other residents. All resident to resident altercations required an incident investigation to be started for each resident regardless of whether the altercation was physical, verbal or attempted. Incident reports were to be completed by the charge nurse at the time of the incident and all persons with knowledge of events surrounding the incident would complete a witness statement. A plan to prevent reoccurrence was to be initiated at the time of the incident. Once the investigation was completed the care plan and in-room care plans were to be updated with the interventions. The RNCM was to complete the incident investigation and submit it to the DNS and ensure care plan interventions were completed in accordance with the investigation. A copy of the revised care plan was to be attached to the investigation. The facility's August 2010 Policy and Procedures, Subject: Abuse screening, training, identification, investigation, reporting and protection - Oregon indicated the facility was to use the Incident/Accident Investigation policy and procedure to investigate concerns and incidents. The policy defined sex abuse as sexual contact, including fondling, with a resident caused by an employee, agent or other resident of a long term care facility by force, threat, duress or coercion, or sexual contact where the resident has no ability to consent. Residents with sexual behaviors would be assessed by social services or nursing to determine their ability to give informed consent related to sexual acts. The assessment was to include the resident's cognitive status, what the resident verbalized regarding sexual desires, a history of their prior sexual habits and value system related to sexuality. Family members would be used in the assessment as appropriate. Residents would be reassessed as needed following condition changes. Residents with sexually abusive behaviors would be assessed by social services or nursing to determine appropriate referrals and care plan interventions to protect other residents. Residents unable to give informed consent were to be protected from unwanted sexual contact. Staff with knowledge of inappropriate sexual comments or contact between staff and resident or resident and resident were to report immediately to the facility social services director, DNS or Administrator. The facility's social services director, DNS, or Administrator were to investigate incidents of sexual abuse and act to protect other residents by suspending accused staff or closely monitoring accused residents. 1. Resident 53 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. A review of five resident to resident incident investigations involving Resident 53 dated 4/22/15, 5/13/15, 6/13/15, 6/16/15, and 7/24/15 revealed no witness statements from the residents involved and no updated care plan attached. On 8/21/15 at 9:20 am Staff 2 (RNCM) acknowledged she did not attach the updated care plans to the incident investigations. On 8/24/15 at 10:06 am Staff 2 (RNCM), Staff 3 (DNS), Staff 4 (Administrator) and Staff 5 (Social Services Director) acknowledged there was no assessment of Resident 53's sexual behaviors as per the facility's policy and procedure. A review of Resident 53's behavior monitoring with Staff 3 and Staff 4 on 8/24/15 at 10:06 am revealed 73 behaviors from 4/23/15 through 8/14/15. Staff 3 and Staff 4 acknowledged 10 of the behaviors dated 4/24/15, 4/29/15, 5/1/15, 5/23/15, 5/25/15, 5/27/15, 6/8/15, 6/9/15, 6/22/15 and 7/2/15 were not investigated but should have been. The facility's repeated failure to operationalize policy and procedure related to abuse led to unabated sexual advances by Resident 53 toward other residents which caused fear, distress and preventable resident-to-resident incidents. Refer to F323 example 1 2. Resident 9 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. The resident resided in the memory care unit. A review of four resident to resident incidents on 2/20/15, 3/22/15, 5/22/15, and 7/20/15 from the Behavior Monitoring log and Progress notes revealed the facility failed to investigate the resident to resident incidents involving Resident 9. On 8/26/15 8:40 am Staff 3 (DNS) and Staff 2 (RNCM) were asked about Resident 9's incidents, Staff 2 indicated the investigation did not include the four resident to resident incidents. The DNS said there should have been a follow up note. The facility's repeated failure to operationalize policy and procedure related to resident to resident abuse led to resident to resident advances, and aggressive behaviors by Resident 9 toward other residents which caused fear, distress and preventable resident-to-resident incidents. Refer to F323 example 3 3. Resident 5 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. Incidents involving Resident 5 were located in Resident 53's Behavior Monitoring log and Progress notes. The documentation revealed there were two resident to resident incidents on 6/9/15 and 6/18/15 involving Resident 5, and were not investigated by the facility. On 8/24/15 at 1:52 pm Staff 3 (DNS) and Staff 2 (RNCM) confirmed the resident to resident incidents involving Resident 5 should have been documented in Resident 5's medical record. The facility's repeated failure to operationalize policy and procedure related to resident to resident abuse permitted sexual advances and aggressive behaviors by Resident 53 toward Resident 5 which caused fear, distress and preventable resident-to-resident incidents. Refer to F225 example 2 and F323 example 2. 4. Resident 56 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. Resident 56's progress note dated 4/20/15 at 1:46 pm indicated RCM notified this writer that resident was found in bed with a male resident. This writer notified family. No investigation or any other documentation was provided by the facility related to this incident. Resident 53's progress note dated 4/21/15 at 10:27 pm and 9:30 pm resident was found in female bed (Resident 56), fully dressed. Redirected to his room. No investigation or any other documentation was provided by the facility related to this incident. A review of Resident 53's behavior monitoring with Staff 3 (DNS) and Staff 4 (Administrator) revealed 73 behaviors from 4/23/15 through 8/14/15. Staff 3 and Staff 4 acknowledged 6 behaviors which involved Resident 56 dated 5/23/15, 5/25/15, 6/8/15, 6/9/15, 6/22/15 and 7/2/15 were not investigated but should have been. A review of the resident to resident incident investigations related to resident to resident incidents between Resident 56 and Resident 53 dated 4/22/15, 5/13/15, 6/16/15 revealed no witness statements from the residents involved. On 8/21/15 at 9:20 am Staff 2 (RNCM) acknowledged she did not attach the updated care plan to the incident investigations. On 8/24/15 at 10:06 am Staff 2 (RNCM), Staff 3 (DNS), Staff 4 (Administrator) and Staff 5 (Social Services Director) acknowledged there was no assessment of Resident 56 and Resident 53's sexual relationship as per the facility's policy and procedure. The facility's repeated failure to operationalize policy and procedure related to abuse permitted unabated sexual advances by Resident 53 toward Resident 56 which caused fear, distress and preventable resident-to-resident incidents. F323 example 4.

Based on observation, interview and record review, it was determined the facility failed to provide adequate supervision for residents residing in the memory care unit to prevent resident to resident incidents and falls, for 4 of 5 sampled residents (#s 5, 9, 53 and 56) who were reviewed for accidents. The facility's failure to adequately supervise residents led to prolonged aggressive and violent behaviors by Residents 9 and 53, toward other residents which caused prolonged distress, fear and preventable resident-to-resident incidents among other residents in the memory care unit including Residents 5 and 56. Findings include: 1. Resident 53 was admitted to the facility in 2015, with [DIAGNOSES REDACTED]. The resident's 3/7/15 initial MDS revealed the resident did not have any behaviors. The initial care plan dated 3/12/15, indicated the resident required a locked community for safety, and s/he had a potential for mood/behavioral decline related to the nursing home placement. Staff were to encourage the resident to make his/her needs known, attend activities to come out of her/his room and establish a social role at the facility. Review of Resident 53's Resident Behavior Report Sheet and Progress Notes from 4/23/15 through 8/14/15, revealed the resident had 77 behavioral symptoms noted by facility staff, including the following: *4/21/15 at 9:30 pm, the resident was found in female bed (5A), fully dressed. Redirected to (her/his) room.; and *4/22/15 at 6:24 am, the resident went into a female resident's room several times, redirected out of the room by the nurse and CNA. An incident report for the 4/21/15 incident indicated Resident 53 went into Resident 56's room and removed her/his clothing from the lower extremities. Resident 53 was found on her/his hands and knees fully dressed on Resident 56's bed. The intervention was to place an above door chime on Resident 56's door to alert staff of anyone entering her/his room. The care plan was not updated to Resident 53's care plan to reflect the use of the door chime until 7/28/15. *4/23/15 at 1:07 pm, the resident was affectionate at times. She/he liked to hold hands with a female resident. The care plan was not updated; and *4/23/15 and 4/24/15: The resident entered a female resident's room and started pulling down the covers. On 4/27/15, the care plan was updated to include the resident made unwanted sexual advances on others, went into others' rooms and had been seen pulling back covers, standing behind doors or hiding from staff. The resident felt the need at times to masturbate. The goal indicated the resident would express satisfaction with her/his relationships with the female resident. The resident would be monitored for signs of distress because of the relationship. The resident would not intrude on the privacy of others and would be closely monitored for any inappropriate sexual behavior. There were no interventions noted. *4/29/15: The resident entered a female resident's room and started pulling down her covers; *5/1/15: The resident's hand was in a female's lap; *5/1/15: The resident was standing over a female's bed starting to uncover her; and *5/7/15: The resident would not leave a female resident alone and followed her into the bathroom. On 5/7/15, the care plan was updated to indicate the resident enjoyed the company of women and often made advances towards them. The goal was the resident would participate in social activities, make needs known and enjoy the company of women appropriately, and not make other residents feel uncomfortable. The intervention included to encourage the resident to maintain healthy relationships with female residents. *5/8/15: The resident followed a female resident everywhere including into the bathroom; *5/8/15: The resident followed a female into the bathroom and locked the door; and *5/13/15: The resident was in a bathroom with a female resident and the door was locked. An investigation for 5/13/15, indicated the resident was found at 6:00 pm, by a CNA, in the bathroom with Resident 56. The CNA reported, the door was locked and Resident 53 wouldn't open the door until the CNA started banging on it. (Resident 53) was standing up, holding toilet paper in his hand. Resident 56 resident was sitting on the toilet with her pants and brief down. The CNA redirected (Resident 53), and helped Resident 56. The investigation recommended the resident's had the right to sexual expression if it didn't harm others or themselves. The activity must not be done in public spaces. Resident 53 was recently moved to a room without a roommate. Family members were aware and ok with actions. The care plan was to be updated to allow the residents private time in Resident 53's room as long as they were safe and would not fall off the bed. Staff were being educated in the importance of human touch. The facility was unable to provide a copy of the updated care plan which included the recommended interventions. The facility was unable to provide an assessment of Resident 53 and 56 having the capacity to make decisions about their sexuality, and if the relationship was consensual. On 5/14/15 Resident 53's care plan was updated to reflect the resident had befriended a female resident (Resident 56) and enjoyed her company as well as physical contact. The resident's family was aware of this relationship and was supportive of it. The goal was the resident would express satisfaction with his relationship with the female resident. The resident would be monitored for signs of distress because of the relationship. The intervention was to encourage the resident to maintain healthy relationship with the female resident and have physical affection needs met. *5/23/15: The resident had her/his hand on a female resident's private parts and was laughing; *5/23/15: The resident was trying to take female residents into her/his room; *5/25/15: The resident was touching other resident's private parts; *5/25/15: The resident was in Resident 5's room with the door closed. Resident 5 stated (She/He) is crazy; *5/27/15: The resident was found at a female resident's bedside with the covers pulled down and attempting to get in the bed and stated she wants to (f--k)me Resident 53's 6/4/15 quarterly nursing summary indicated the resident had no acute changes in cognition and continued to make her/his own decisions. She/he struck up friendships with women in the unit that included holding hands and cuddling. He had a history of [REDACTED]. The resident was independent with most all ADLs and ambulated without devices around unit. Resident 53's 6/5/15 quarterly social services summary noted the resident had an increase in sexual behaviors which including making advances toward other residents. The resident struck up friendships with women in the unit which included holding hands and cuddling. The interventions in place included the resident had her/his own room and to encourage the resident to attend group activities. The resident was pleasant, cooperative and easily redirected, and enjoyed the affection of others. The facility failed to address how the facility would monitor and keep the other residents safe from Resident 53's ongoing sexually aggressive behaviors. *6/8/15: The resident grabbed Resident 56's crotch. Resident 56 begged staff to stay with her/him; and *6/9/15: The resident was going after Resident (5 and 56) all day. Resident 5 hit Resident 53 and said stay away. Resident 56 jumped up from a chair and said go away. On 6/10/15 a fax was sent to the physician indicating the resident was having inappropriate behaviors toward female residents and requested s/he be started on an antidepressant. This was more than seven weeks after Resident 53 began exhibiting sexually inappropriate behaviors. On 6/11/15 the care plan was updated with a new intervention to redirect the resident to an activity of her/his interest such as resting in her/his room, watching TV, eating snacks or monitored group activities. The facility did not include interventions to keep other residents safe from Resident 53's ongoing sexually aggressive behaviors. On 6/13/15 Resident 53 had a hand on a female resident's crotch under a blanket. The female resident was shaking badly. The investigation revealed motion alarms ordered to alert staff if (he) tried to get into a female's room. Staff were directed to place female residents in the common area where staff available to monitor. The resident was not to be left alone in the living room with female residents and staff were to provide sensory stimulation. The doctor would be contacted for medication that can curb libido. The recommendations included an alternate placement that may better suit (her/his) needs. On 6/15/15, the facility requested an order for [REDACTED]. The resident received one dose, on 6/15/15 at 8:30 pm. On 6/15/15 at 8:41 pm Resident 53 attempted to approach other residents, extending hands toward them as if to fondle them. After going to bed Resident 53 kept getting up, approaching Resident 9 and standing over her/his bed preventing Resident 9 from sleeping. Resident 53 attempted to close either the door or the curtains to block the view from the hall and from staff. On 6/16/15 Resident 53 sat next to a female resident holding hands, Resident 53 placed her/his hand under the blanket covering the resident's lap rubbing her genital area. The female resident said stop that. Resident 53 was taken out of the TV room. The investigation revealed the female resident had no recollection of the incident and does not appear to be in distress over it. The interventions included the motion alarms which had been ordered and were to be placed over the doorways of female residents on the unit, and Resident 53 was to be monitored while in the living room. The facility did not reassess the interventions. The motion alarm/chime was an intervention on 4/22/15, and the facility failed to follow the 6/13/15 interventions including: staff were directed to place female residents in the common area when staff available to monitor, and the resident was not to be left alone in the living room with female residents. On 6/17/15, the facility received the results of Resident 53's PASRR Level II Psychiatric Evaluation. The evaluation indicated, starting in April 2015 Resident 53's behavior changed and the resident started making verbal and physical sexual advances toward female residents. A female resident suddenly became fearful of Resident 53 and was asking staff to stay near her. The female resident hit Resident 53. Resident 53 had been hovering over female resident's beds while they were asleep, standing behind their door and following them around the unit. On several occasions Resident 53 had touched other resident's female parts. Resident 53 was found locked in a bathroom with a female resident who was on the toilet with her pants and brief down. Resident 53 had been found in that female resident's bed. Resident 53 stated I love her and She wants to f**k me. The evaluation indicated Resident 53 was independent with mobility, was strong and agile. Since the end of April 2015 Resident 53 targeted several female residents and staff with verbal and physical advances. Staff were concerned about Resident 53 following female residents, groping them, and being locked in a bathroom with a female resident. The evaluation indicated a concern Resident 53 may have been at a higher level of physical functioning than the other residents which put others at risk for harm due to the resident's sexual advances and independent status. The evaluation recommended it was very important for staff to be vigilant regarding Resident 53's whereabouts on the unit at all times. The care plan was not updated to reflect the PASARR II recommendations including it was very important for staff to be vigilant regarding Resident 53's whereabouts on the unit at all times. From 6/18/15 through 7/24/15 Resident 53 continued to exhibit unwanted sexual advances towards the resident's in the memory care unit without interventions from the facility including: *6/18/15: The resident tried to kiss a female resident. The female resident said no; *6/21/15: The resident went into a female resident's room and staff heard the female resident yell; *6/22/15: The resident was standing over a female resident holding the blankets up and with a hand on the female's privates; *6/24/15: The resident wanted to take a female resident into her/his room without the resident's permission; *6/26/15: The resident tried to touch two female residents without their permission; *6/28/15: The resident was following a female resident down the hall muttering about having sex with her; *7/2/15: The resident was forcing a female resident into her/his room without consent; *7/2/15: The resident was trying to reach out for a female resident while she was sleeping; *7/5/15: The resident was trying to take a female resident into her/his room and said she/he was going to (f--k) her; *7/8/15: The resident kept going into a female resident's room and staff had to put my hand around (his) arm and pull (him) out!; *7/18/15: The resident was in a female resident's room trying to uncover the resident; *7/18/15: The resident was trying to get into a female resident's room without their permission and yelling that (she/he) wanted to (f--k) her.; *7/19/15: The resident was in a female resident's room trying to uncover her. The resident refused to leave the room and staff put arm around (Resident 53) and pulled (him) out of room.; *7/20/15: The resident was trying to go into a female resident's room wanting to f--k); *7/21/15: The resident was trying to go into Resident 5's room and said (he) is going to wake her so (he) can f--k). (Resident 53) would not move so staff had to take by the arm a little.; *7/24/15: The resident kept calling out to a female resident asking her to [***] and going over to another female resident asking her to (f--k) the female resident said (he's) scary. There were no new interventions introduced for the resident's increased sexually aggressive behavior nor was there evidence the resident was being supervised closely to keep the other residents safe from Resident 53. On 7/24/15 and 7/25/15 during the night shift, staff documented they were unable to find Resident 53. They found her/him in Resident 9's room and Resident 53 exposed her/himself to Resident 9 and chased Resident 9 around the room, masturbating. The investigation noted there was no actual contact between resident's. Resident 9 didn't remember the event so there does not appear to be a lasting psychosocial impact. Resident 53 was moved to a different room and staff requested maintenance place a motion alarm above Resident 53's room. The staff also noted Resident 53 had a large libido and needed staff re-direction to her/his own room. A pyschotropic review committee note dated 7/24/15 indicated the facility spoke to Resident 53's physician on 7/22/15 and he was going to discontinue the Zoloft and start a different medication since Resident 53 was having continued inappropriate sexual behaviors towards other residents. The physician ordered cimetidine (histamine) 400 mg QD. The physician indicated the cimetidine was effective in decreasing sexually inappropriate behaviors in patients with dementia. The resident started the cimetidine on 7/30/15. After three months of Resident 53's sexually aggressive behaviors, on 7/28/15 at 12:23 pm the facility spoke to a specialist in dementia care, about Resident 53's behavior and asked for suggestions for interventions. He stated that current interventions were appropriate and suggested the resident be sent to a neurologist for possible [DIAGNOSES REDACTED]. On 7/28/15 the In Room Care Plan was updated to include if the resident was masturbating to have her/him go to her/his room for privacy, and there was a motion alarm on the door. Staff 5 (SSD) updated the comprehensive care plan to reflect the resident made unwanted sexual advances on others. The resident went into others' rooms and had been seen pulling back covers, standing behind doors or hiding from staff. The resident had the need to masturbate at times. The goal included (Resident 53) would be closely monitored for any inappropriate sexual behavior. The resident would masturbate in the privacy of her/his room. The interventions included to encourage the resident to maintain healthy relationship with other residents, redirect the resident from others' rooms, remind the resident it was not ok to go uninvited into others' rooms and give the resident space and privacy. On 7/30/15 at 7:00 am and 10:00 am the resident tried to get into Resident 9's bed, and the same day at 6:00 pm Resident 53 pulled her/his pants down in Resident 9's room. On 8/1/15 and 8/15/15 Resident 53 tried to get into Resident 9's room. From 4/22/15 through 8/15/14 Resident 53 exhibited numerous sexually aggressive and inappropriate behaviors towards residents in the memory care unit. The facility failed to provide timely and appropriate interventions and supervision to keep the other residents on the unit safe. The facility also failed to assess Resident 53 and Resident 56's facility-approved relationship in order to establish consent. The failure to do so, resulted in Resident 53 causing psychosocial distress to Resident 5 and 56 as evidenced by their outcries in response to Resident 53's behaviors. On 8/20/15 at 1:35 pm Staff 5 (SSD) and Staff 2 (RNCM) indicated the facility was trying to relocate the resident, but were not having any luck. Staff 2 indicated they put a stop sign up and sensor bells to stop Resident 53 from going in other resident rooms, and the CNAs had eyes on Resident 53 as much as possible. Staff 2 acknowledged Resident 53's behaviors had escalated and Staff 5 was trying to relocate him. On 8/24/15 at 10:06 am Staff 3 (DNS) and Staff 4 (Administrator) acknowledged the behaviors should have either been investigated or followed up on. 8/24/15 at 1:52 pm in an interview with Staff 2, Staff 3, Staff 4 and Staff 5 they stated the facility could not continually monitor Resident 53 because staff had other residents to care for. 8/24/15 at 2:25 pm Staff 5 stated the facility was unable to find a new facility for Resident 53 because of the resident's sexual behaviors. On 8/25/15 at 10:02 am Staff 4 stated she thought the facility was doing everything they could for Resident 53 and acknowledged the resident was not appropriate for the memory care unit and the facility never considered a one-on-one intervention to keep other residents safe. 2. Resident 5 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. a. The 7/2/15 quarterly Nursing Assessment revealed Resident 5 continued to have cognitive deficits related to dementia and to expect further decline in cognition as her/his dementia progressed. The resident also continued to be impulsive with poor safety awareness. Resident 5's 3/24/15 to 8/24/15 Care Plan noted the resident had impaired decision making and would have positive experiences in her daily routine, and to calm the resident if distressed. Incidents involving Resident 5 were located in Resident 53's Resident Behavior Report Sheet. From 5/25/15 through 7/21/15 Resident 53 had inappropriate physical contact and stalking behaviors towards Resident 5 on approximately nine occasions including: *5/25/15 at 11:30 pm: Resident 53 was in Resident 5's room with the door shut, Resident 5 said (Resident 53) is crazy. *6/9/15: Resident 53 going after (Resident 5 and 56) all day. Resident 5 hit Resident 53 and said stay away. The facility failed to provide new interventions to Resident 5's care plan to keep Resident 53 way from her. *6/18/15 at 10:45 pm : Resident 53 tried to kiss Resident 5. Resident 5 said No.; *6/21/15 at 6:45 am Resident 53 went into Resident 5's room and closed the door, staff said we heard (Resident 5 and 56) yell and I opened the door and (Resident 53) was standing by (her). There were no new interventions noted on Resident 5's care plan to keep resident 53 away from her room. *6/22/15 at 6:30 pm Resident 53 tried to get into Resident 5's room, Resident 53 kept going over and over for about an hour; *6/26/15: Resident 53 was going into Resident 5's room; *6/26/15 at 8:40 pm: Resident 53 kept going into Resident 5's room and tried to touch Resident 5 without permission; *7/2/15 at 7:30 pm: Resident 53 was going into Resident 5's room. (Resident 53) was trying to reach out for (Resident 5) while (she) was sleeping.; *7/7/15 at 2:35 pm: Couldn't find (Resident 53) searched unit, notified nurse, searched unit more and found (him) in (Resident 5's room) between the wall and bed. res said I'm hiding.; *7/8/15 at 2:35 pm: Resident 53 kept going into Resident 5's room and would not come out; *7/17/15 at 11:00 am: Caught Resident 53 in Resident 5's room trying to shut the door; *7/17/15 at 11:45 am: Caught Resident 53 in Resident 5's room; *7/18/15 at 6:00 pm: Resident 53 trying to get into Resident 5's room without permission yelling (he) wanted to (f--k) her. *7/20/15: Resident trying to go into Resident 5's room wanting to (f---); and *7/21/15 - Resident 53 was trying to go into Room 5's room, said (he) was going to wake (her) so (he) can f--k). Observations on 8/17/15 at 9:51 am revealed when entering and exiting Resident 5's room there was a bell alarm that sounded. No staff came to the room when the alarm sounded. On 8/18/15 at 12:55 pm Resident 5 ambulated towards the door and set off the alarm. The resident called out and the bell was ringing. She/he stood next to the door holding the door frame and the alarm repeatedly went off. There were two staff near the medication room and they didn't provide assistance when the alarm sounded. On 8/19/15 at 6:10 pm Staff 16 (CNA) was asked about the alarm on Resident 5's room and she indicated it was so Resident 53 didn't wander into Resident 5 and 56's because Resident 53 bothered them. From 5/25/15 through 7/21/15, Resident 53 exhibited aggressive sexual behaviors towards Resident 5. This resulted in Resident 5 striking Resident 53, screaming for Resident 53 to get out of her room, and saying no to Resident 53's sexual advances. The facility failed to provide interventions to keep Resident 5 safe from Resident 53's aggressive sexual behaviors. On 8/24/15 at 1:52 pm Staff 3 (DNS) and Staff 2 (RNCM) confirmed documentation related to incidents listed from Resident 53's Resident Behavior Report Sheets should have been included in Resident 5's medical record. On 8/25/15 at 10:02 am Staff 4 stated she thought the facility was doing everything they could for Resident 53 and acknowledged the resident was not appropriate for the memory care unit and the facility never considered a one-on-one intervention to keep other residents safe. b. Resident 5's 3/31/15 initial MDS noted the resident did not have falls since admission to the facility. The Falls CAA indicated the resident had many different risk factors that placed her/him at risk for falls. The resident required assistance with ADL's including transfers, and used a wheelchair for mobility. The resident had attempted to self transfer since admission to the facility and required reorientation and redirection. The resident had [DIAGNOSES REDACTED]. Resident 5's 4/6/15 care plan noted the resident was a risk for falls and the interventions included: *Assure the floor is free of glare, liquids, foreign objects; *Give the resident verbal reminders not to ambulate/transfer without assistance; *Keep the bed in the lowest position with brakes locks; *Keep the call light in reach at all times while in bed. Does not always remember to use; *Keep personal items and frequently used items within reach; *Obtain PT (Physical Therapy) consult PRN for strength training, toning, positioning, transfer training, gait training, mobility devices; *Orient the resident when the environment had changed; and *Provide proper, well-maintained footwear as the resident would allow. The progress notes revealed from 5/6/15 to 7/14/15 the resident had seven falls, five were non injury and two were injury falls. On 5/6/15 at 2:15 pm the resident was found sitting on the floor next to the bathroom door in Room 5. The resident denied hitting her/his head and was unable to say what happened. There was no injury noted and the investigation noted the resident was wearing non-skid socks. New interventions included to place a non-slip rug by bedside and a magnetic lock to secure clothing in her/his closet. The magnetic lock intervention was not placed on the care plan. The facility completed a Morse Fall Scale (Acuity) on 5/8/15 and noted a score of 40 which indicated the resident was a low risk for falls. On 5/17/15 the resident had a non-injury fall and was placed on alert charting. The investigation noted the resident was found near her/his wheelchair and must have slid down. New interventions included to add auto brakes to her/his wheelchair. The interventions were not placed on the care plan. The facility completed a Morse Fall Scale on 5/18/15 noting a score of 65 which indicated the resident was a high risk for falls. No new interventions were put into place. On 6/16/15 the resident was in the dining room for breakfast, the resident stood up from her/his chair and staff heard a scream, the resident was found on the floor. The resident stated she/he was trying to sit down. The resident was holding the top of her/his head and said ouch. The assessment revealed no bump or hematoma. Neuro checks were done per the facility policy. The investigation revealed the resident fell while trying to stand up. A new intervention was a referral to PT. The physical therapy started on 6/25/15 for improved standing balance. On 7/1/15 at 5:00 am the resident was found sitting on floor in the hallway by her/his door. The CNA stated the resident was in bed sleeping at 4:45 am. There were no injures seen and no complaints of pain. The resident indicated she/he was going to get some food. The investigation revealed the resident fell in the hallway. A new intervention included placing a perimeter mattress on her/his bed. The perimeter mattress was in place but was not on the care plan. On 7/1/15 at 3:47 pm the resident was found on the floor in the hallway next to her/his wheelchair with her/his face down. The resident was bleeding from her/his nose and there was a 2 cm laceration above the resident's top right upper lip. The area was cleansed, ice was applied, and neuro checks were started. The investigation noted the resident was found on the floor in the hallway face down next to her/his wheelchair. The resident bled from her/his nose and had a 2 cm laceration just above top right upper lip. The resident was sent to the ER but refused stitches. The interventions included working with therapy to place a scoop mattress on her/his bed. The nursing summary for 7/2/15 revealed the resident did not have any acute changes noted and continued to have cognitive deficits that were related to dementia. The resident had times where she/he was distressed and paced or wandered around the unit. Expect further declines in cognition as dementia progressed. The resident continued to be impulsive with poor safety awareness. Staff were to assist her/him with ADLs PRN. The resident also had changed in ADLs and needed more assistance with ambulation the past quarter. The resident did not ask for assistance and was working with PT for strengthening and endurance. The resident used a wheelchair for mobility and did not remember to use a walker. Resident 5's 7/1/15 Morse Fall Acuity was scored at 95 which indicated a high risk for falls. No new interventions were recommended. On 7/14/15 at 3:45 pm the resident was found on the floor in the hallway. The wheelchair was next to the resident. The resident indicated she/he got up and fell and bumped her/his head on the door jam. The investigation revealed the resident was found on the floor with her/his wheelchair and bumped her/his head on the door jam. The interventions included to place a non-skid mat in her/his wheelchair. Expect (Resident 5) to continue to fall (her/his) dementia is impacting (her/his) safety awareness. On 7/17/15 the resident was found on the floor in the hallway sitting in front of her/his wheelchair. No apparent injuries noted, but the resident stated she/he was was painful. The facility added the non-skid mat in the wheelchair to the care plan on 7/20/15, six days after the facility suggested the intervention, and after the resident fell again on 7/17/15. Observations on 8/17/15 at 9:51 am revealed when entering and exiting Resident 5's room there was a bell alarm that sounded. No staff came to the room when the alarm sounded. On 8/18/15 at 12:55 pm Resident 5 ambulated towards the door and set off the alarm. The resident called out and the bell was ringing. She was stood next to the door holding the door frame and the alarm repeatedly went off. There were two staff near the medication room, and they did not provide assistance when the alarm sounded. On 8/18/15 at 5:24 pm Resident 5 was in the dining room with her/his walker. Staff 12 (CNA) was the only staff in the dining room with approximately nine residents and, two residents needing to be fed. Resident 5 was observed to get up and down from the table and left the dining room then stopped and re-entered the dining room. Staff 12 assisted the resident to her/his seat. The resident was observed to be unsteady on her/his feet. The resident got up again and Staff 12 left the residents she was feeding to re-direct Resident 5 back to her/his chair. Staff 10 (CNA) was asked about the resident's falls on 8/21/2015 at 9:30 am. She indicated the resident may stumble on pants because they were too long. She also indicated the resident was up at night a lot and liked to walk around. The resident was doing better when they put weights on her/his walker. On 8/25/15 at 8:54 am there was a wet floor sign in the dining room. Resident 5 and three other residents were in the dining room unsupervised. Resident 5 had her/his walker and was leaning on it. There were no staff present on the unit except Staff 2 (RNCM) and Staff 3 (DNC) who were in Staff 2's office, which was not in site of the residents. Staff 2 was asked where staff were and she indicated one was in the bathroom toileting a resident and the other was on break. There was no supervision of Resident 5 who was a fall risk and was left in the dining room with three other residents alone. From 5/6/15 to 7/14/15 the resident had seven falls, five were non-injury and 2 were injury. The facility failed to update the care plan after each fall and failed to ensure the resident was closely supervised to prevent falls, which resulted in Resident 5 sustaining a lip laceration on 7/1/15. On 8/25/15 at 9:01 am Staff 4 (Administrator) was alerted of the lack of supervision on the memory care unit. She indicated the procedure now was to have two people on the unit and when someone went on break there was only one person back there, and they normally didn't pull someone back there to help. She said she would work on it. On 8/25/15 at 9:30 am Staff 2 (RNCM) was asked about the resident's fall interventions. Staff 2 indicated the interventions were on the In Room Care Plan. She indicated the interventions were attempted and discontinued and get re-evaluated quarterly. Staff 2 was asked about the 7/1/15 incident, and she indicated the interventions would be put into pla

Based on findings of Substandard Quality of Care and multiple citations in the areas of Resident Rights, Resident Assessment, Quality of Care and Administration, it was determined the facility was not administered by the management team in an effective and efficient manner. The failure to effectively manage the memory care unit resulted in Resident 76's laceration worsening, Resident 53 and Resident 9 continuing to exhibit aggressive and prolonged behavior toward other residents and Resident 5 and 56 experiencing prolonged distress, fear and preventable resident-to-resident incidents among other residents in the memory care unit. Findings include: The facility's administration failed to: 1. Have a system in place to conduct timely and accurate investigations for resident to resident altercations in the memory care unit, and to follow the facilities abuse policies and procedures. Refer to F225, and F226 2. Provide an activity program for one resident in the memory care unit. Refer to F248 3. Review and revise resident care plans. Refer to F280 4. Provide appropriate care and services in the areas of skin conditions and follow physician's orders [REDACTED]. 5. Provide appropriate ADL care. Refer to F312 6. Provide adequate supervision for residents residing in the memory care unit to prevent resident to resident incidents to protect residents from harm. Refer to F323 7. Ensure PRN antipsychotic medications were given after trying non pharmacological interventions, and following the physician's orders [REDACTED]. 8. Ensure staff changed soiled linens. Refer to F441 9. Maintain residents clinical records in a complete, accurately documented and systematically organized manner. Refer to F514 10. Have a Quality Assessment and Assurance Committee in place to identify deficiencies and develop plans of action. Refer to F520 11. Provide staff to adequately care for the residents and accurately post the numbers of staff working on each shift. Refer to OAR [PHONE NUMBER](3)(d) 12. Provide identifiers for resident rooms in the memory care unit. Refer to OAR [PHONE NUMBER](8) 13. Secure outdoor space with drop offs and moveable furniture. Refer to OAR [PHONE NUMBER](5) The facility failed to provide timely wound care for Resident 76 which resulted in a worsening of a wound requiring antibiotic treatment. The facility also failed to investigate and provide timely interventions for Resident 53 and Resident 9's resident to resident incidents which caused prolonged distress, fear and preventable resident-to-resident incidents for Resident 5 and Resident 56, and other residents in the memory care unit.

Based on observation, interview and record review it was determined the facility failed to review and revise the plan of care for 4 of 7 sampled residents (#s 5, 8, 53 and 76) who were reviewed for accidents, skin and nutrition. The failure to review and revise the plan of care resulted Resident 76's laceration worsening, Resident 53 and Resident 9 continuing to exhibit aggressive and prolonged behavior toward other residents. This resulted in causing prolonged distress, fear and preventable resident-to-resident incidents among other residents in the memory care unit including Residents 5. Findings include. Findings include: 1. Resident 76 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. The resident resided in the memory care unit. Resident 76's 7/24/15 initial RN assessment noted there was a laceration to the back of the resident's scalp measuring 2 cm by 1 cm. The 7/24/15 Skin Grid sheets noted the resident had a laceration to the back of the head, and there were entries on 7/24/15, 7/28/15, 8/3/15 and 8/17/15. The laceration remained at 2 cm by 1 cm for all the entries. On 8/6/15 staff noted on the comprehensive care plan the resident was a low risk for pressure ulcers and to avoid shearing the resident's skin during positioning, transferring and turning. There was nothing specific noted about the resident's laceration. The 8/17/15 In Room Care Plan indicated skin checks per protocol. There was nothing specific noted about the resident's laceration. On 8/13/15, the resident saw a neurologist and noted the resident's hair was matted at the occipital (back of head) site and was cleansed with saline, and noted redness of the skin. The skin was abraded and there was scant drainage. The physician directed the facility staff to consult a wound care RN for the scalp site. The facility failed to obtain the wound care orders as of 8/19/15. On 8/19/15 at 12:56 pm, the laceration was treated by Staff 7 (RN). Staff 7 noted the wound had worsened to 3.5 cm length by 1 cm width, and became infected requiring antibiotics to be administered. On 8/19/15 the facility updated the care plan to include the resident's skin would remain in tact and to heal without difficulty or signs and symptoms of infection. The facility failed to provide, and update interventions on the care plan for the resident's laceration to the back of the head. On 8/19/15 at 2:37 pm Staff 7 indicated the resident refused treatment but did not document the resident's refusals of treatment. On 8/19/15 at 2:37 pm Staff 2 (RNCM) acknowledged the resident's wound worsened. Refer to F309 example 1 2. Resident 53 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. Resident 53's Resident Behavior Report Sheet revealed from 3/25/15 through 8/1/15, the resident exhibited numerous unwanted sexually inappropriate behaviors including being found in bed with male and female residents, fondling residents, masturbating while chasing a resident, kissing a resident, pulling covers down in resident's room, toileting a resident and entering female and male resident rooms uninvited. Resident 53's In Room Care Plan and the comprehensive care plan indicated interventions to re-direct the resident and remind the resident it was not ok to go uninvited in others rooms was placed on the care plan 7/28/15. There was no documentation on the resident's care plan to keep the resident away from other residents involved in these incidents prior to 7/28/15 (four months after the behaviors started). Refer to F323 example 1 3. Resident 5 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. Incidents involving Resident 5 were located in Resident 53's Resident Behavior Report Sheet. From 5/25/15 through 7/21/15 the resident had inappropriate behaviors towards Resident 5 on 16 occasions. Resident 5's care plan was not updated to address the unwanted advances of Resident 53. Resident 5's 7/2/15 Nursing Quarterly assessment failed to address the inappropriate advances from Resident 53 and how it impacted Resident 5. The 3/24/15 to 8/24/15 Care Plan noted the resident had impaired decision making and would have positive experiences in her/his daily routine, and to calm the resident if distressed. There were no interventions in place on Resident 5's care plan to keep Resident 53 away from Resident 5. Refer to F323 example 2. 4. Resident 8 was admitted to the facility in March of 2015 with [DIAGNOSES REDACTED]. Resident 8's Nutrition CAA, dated 4/8/15, indicated the resident was at risk for weight loss and the resident was to be discussed at weekly Nutrition At Risk (NAR) meetings. Resident 8's medical record indicated the resident's weights were as follows: 264 pounds on 3/30/15. 268 pounds on 4/1/15. 269 pounds on 4/6/15. 274 pounds on 4/14/15. 271 pounds on 4/21/15. 261 pounds on 5/5/15. 250 pounds on 6/1/15. 255 pounds on 6/1/15. 276 pounds on 6/30/15. 264 pounds on 7/1/15. 292 pounds on 7/15/15. 264 pounds on 8/1/15. 257 pounds on 8/11/15. 275 pounds on 8/17/15. Resident 8's Nutrition Re-assessment dated [DATE] indicated the resident's weight fluctuated due to fluid status and whether her/his foot prosthetic was worn or not when weighed. On 8/20/15 at 1:02 pm Resident 8 stated she/he didn't know if she/he was losing weight or gaining weight. On 8/20/15 at 1:51 pm and 2:10 pm Staff 9 (CNA) and Staff 25 (CNA) both stated Resident 8 was weighed in her/his wheelchair while wearing the prosthesis, and then the weight of the wheelchair was subtracted from the total weight to determine the resident's accurate weight. On 8/20/15 at 2:08 pm Staff 6 (LPN) stated Resident 8 was weighed in her/his wheelchair while wearing the prosthesis, and then the weight of the wheelchair and prosthesis was subtracted from the total weight to determine the resident's accurate weight. On 8/24/15 at 10:14 am Staff 22 (CNA) stated the resident was weighed using the Sara-lift (electronic lifting device), with her/his prosthetic on. Staff 22 stated she observed the Sara-lift and the wheelchair scale to differ by as much as three pounds. On 8/24/15 at 11:07 am Staff 24 (Dietitian) stated the resident's weights were not stable. Staff 24 stated she believed many of the weights were erroneous due to inconsistent weighing practices or mathematical errors. Staff 24 stated she discussed the need for consistent weighing practices with Staff 1 (RNCM) at the NAR meetings. Staff 24 stated it was Staff 1's responsibility to develop a plan for how the resident was consistently weighed. Staff 24 stated the resident's weights should have been stable based upon her/his eating habits. No documentation was found to indicate a plan for Resident 8 to be weighed in a consistent manner. On 8/25/15 Staff 3 (DNS) acknowledged there was no documented plan for how Resident 8 was to be weighed in a consistent manner.

Based on observations, interviews and record reviews it was determined facility staff (Staff 2) failed to act within professional standards of practice by failing to investigate potential allegations of abuse, operationalize policy and procedure related to abuse, provide meaningful ongoing activities, review and revise the plan of care, ensure appropriate wound care was provided, ensure needed assistance with eating was provided, ensure adequate supervision was provided to prevent accidents and resident-to-resident incidents, ensure linen was sanitary, ensure residents admitted to the memory care unit had a [DIAGNOSES REDACTED]. Findings include: Oregon State Board of Nursing Division 45 standards of practice OAR [PHONE NUMBER] indicated: Scope of Practice Standards for All Licensed Nurses (1) (a) Advocates for the client's right to receive appropriate care, including person-centered care and end-of-life care, considerate of the client's needs, choices and dignity; (b) Intervenes on behalf of the client to identify changes in health status, to protect, promote and optimize health, and to alleviate suffering; (a) Promotes an environment conducive to safety and comfort for all levels of care, including self-care and end-of-life care; and (b) Identifies client safety and environment concerns; takes action to correct those concerns and report as needed. (5)(b) Supervises others to whom nursing activities are assigned by monitoring performance, progress, and outcomes. (c) Ensures documentation of the activity; (d) Matches client needs with available, qualified personnel, resources and supervision; (e) Provides follow-up on problems and intervenes when needed; (f) Evaluates the effectiveness of the assignment and the outcomes of the interventions; and (g) Revises or recommends changes to the plan of care as needed. (a) May accept and implement orders for client care from licensed health care professionals who are authorized by Oregon statute to independently diagnose and treat; (6)(b) May accept and implement recommendations for care in collaboration with other health care professionals; Oregon State Board of Nursing Division 45 standards of practice OAR [PHONE NUMBER] indicated: Scope of Practice Standards for Registered Nurses (2) (a) Conduct and document initial and ongoing comprehensive and 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; (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 (b) Establish and document nursing diagnostic statements and/or reasoned conclusions which serve as the basis for the plan or program of care. (c) Develop and coordinate a comprehensive and/or focused plan of nursing care. This includes: (A) Identifying priorities in the plan of care; (B) Setting realistic and measurable goals to implement the plan of care in collaboration with the client and the healthcare team; and (C) Developing nursing orders and identifying nursing strategies, interventions and actions; (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; and (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. (3) Standards related to the Registered Nurse's responsibility for collaboration with an interdisciplinary team. The Registered Nurse: (a) Functions as a member of the healthcare team to collaborate in the development, implementation and evaluation of integrated client-centered plans of care; (c) Communicates with other relevant personnel regarding integrated client-centered plans of care; and (d) Makes referrals as necessary and ensures follow-up on those referrals. (4) Standards related to the Registered Nurse's responsibility for leadership. The Registered Nurse: (a) Formulates, interprets, implements and evaluates the policies, protocols and operating guidelines related to nursing practice, and the needs of the clients served; (c) When available, uses evidence to identify needed changes in practice, standards for policy development, and clinical decision-making. (5) Standards related to the Registered Nurse's responsibility for quality of care. The Registered Nurse: (a) Identifies factors that affect the quality of client care and develops quality improvement standards and processes; (b) Applies the knowledge and tools of continuous improvement in practice to improve the delivery of healthcare; and (c) Measures outcomes of nursing care and overall care at the individual and aggregate level. Oregon State Board of Nursing Division 45 standards of practice OAR [PHONE NUMBER] indicated: Conduct Derogatory to the Standards of Nursing Defined (1) Conduct related to the client's safety and integrity: (b) Failing to take action to preserve or promote the client's safety based on nursing assessment and judgment. (c) Failing to develop, implement and/or follow through with the plan of care. (d) Failing to modify, or failing to attempt to modify the plan of care as needed based on nursing assessment and judgment, either directly or through proper channels. (2) Conduct related to other federal or state statute/rule violations: (d) Failing to report actual or suspected incidents of client abuse through the proper channels in the work place and to the appropriate state agencies. (3) Conduct related to communication: (b) Incomplete recordkeeping regarding client care; including, but not limited, to failure to document care given or other information important to the client's care or documentation which is inconsistent with the care given. (i) Failing to communicate information regarding the client's status to other individuals who need to know; for example, family, and facility administrator. Staff 2 (RNCM) was the nurse care manager for all residents in the memory care unit. 1. In the memory care unit there was prolonged aggressive behavior by Residents 9 and 53 toward other residents which caused prolonged distress, fear and preventable resident-to-resident incidents among other residents in the memory care unit including Residents 5 and 56. Refer to F225, F226, F280 examples 2 and 3 and F323 2. Residents in the memory care unit were at increased risk of social isolation. Refer to F248 3. Resident 76's laceration worsened, becoming infected and required a treatment of [REDACTED]. Refer to F280 example 1 and F309 example 1 4. Residents in the memory care unit were at risk of lack of assistance with dining. Refer to F312 5. Residents in the memory care unit were at risk of cross contamination. Refer to F441 6. Resident 76 was inappropriately placed in the memory care unit without a [DIAGNOSES REDACTED]. Refer to Z160 7. Residents in the memory care unit were at risk of tripping hazards and elopement. Refer to Z173 8. Residents in the memory care unit were at risk of being unable to identify their rooms. Refer to Z176

Based on observation, interview and record review it was determined the facility failed to provide appropriate wound care and necessary services and follow physicians orders for 3 of 7 sampled residents (#s 5, 76 and 77) reviewed for skin and unnecessary medications. The failure to provide appropriate wound care services resulted in Resident 76's laceration worsening, becoming infected and required a treatment of [REDACTED]. Findings include: 1. Resident 76 was admitted to the facility in 7/2015 with [DIAGNOSES REDACTED]. The resident resided in the Expressions Unit. Resident 76's 7/24/15 initial RN assessment noted there was a laceration to the back of the scalp. Resident 76's 8/12/15 comprehensive care plan revealed an entry dated 8/19/15 which indicated the resident was admitted with a wound, the area was to be without signs or symptoms of infections. Interventions included staff were to provide wound care per MD orders. The 8/17/15 In Room Care Plan indicated skin checks per protocol. The Skin Grid Sheets revealed the resident was treated for [REDACTED]. *7/24/15: 2 cm by 1 cm red; *7/28/15 2 cm length 1 cm width red color; *8/3/15: 2 cm by 1 cm brown red in color, healing scab formation; *On 8/10/15 the TAR was initialed indicating the skin was checked but there was no documentation of the wound on the Skin Grid Sheet; and *8/17/15: 2 cm length by 1 cm width. A physician's progress note dated 8/13/15 indicated the resident's hair was matted at the occipital (back of head) site and was cleansed with saline, and noted a skin redness. The skin was abraded and there was scant drainage. The physician directed the facility staff to consult a wound care RN for the scalp site. A 8/13/15 progress note revealed the facility received a call from the physician's office regarding Resident 76 and recommended a wound care specialist to provide recommendations for wound care. There was also a 8/13/15 telephone order from the resident's attending physician for wound care RN for laceration area care. Observations on 8/18/15 at 1:07 pm, revealed there was a matted portion of hair on the back of Resident 76's head that appeared stuck together. The resident indicated it was leaking on her/his pillow. Observations on 8/19/15 at 8:36 am revealed the back of the resident's head was matted and her/his hair appeared stuck together. The resident indicated her/his hair was washed a few days ago. On 8/19/15 at 11:35 am, Staff 2 (RNCM) was asked about Resident 76's laceration to the head and the 8/13/15 orders. Staff 2 didn't think the scab was actively leaking so the resident was taking showers. As of 8/19/15 the orders for the wound care RN were not obtained. On 8/19/15 at 12:27 pm Staff 7 (RN) indicated she would look at the wound in 10 minutes but wanted to put a warm pack on it to loosen up the hair. She indicated the resident wouldn't keep the dressing on. On 8/19/15 at 12:56 pm Staff 7 was in the resident's room to assess the resident's wound. Staff 7 indicated the resident had a dressing on the back of the her/his head which the resident didn't like them and Resident 76 had pretty long hair that was stuck together. Staff 7 indicated they wanted a wound care specialist to check it out, but they had not heard back. Staff 7 informed the resident she wanted to cut the resident's hair around the wound and place a dressing on it, Resident 76 agreed. The resident and Staff 7 both stated the last time the wound was cleaned was yesterday, and it's just gunky. The resident's hair was matted on the back of her/his head and was stuck to the skin and in the scab. The area had visible chunks of dead skin peeling away with the residents hair. Staff 7 used saline to cleanse the wound and a wooden pick to clean the area. The wound was dark and the resident closed her/his eyes and winced as the cleansing occurred. Staff 7 used the wooden pick to press and roll down in the center of the scab, the open area had thick white/yellow purulent drainage coming out after pressure was applied on three different occasions. Staff 7 indicated the resident did not take anything for pain, but would ask, and indicated she was going to call the doctor to see about an antibiotic order. Staff 7 also indicated the wound was about the size of a quarter, was mushy, and did not drain yesterday. Staff 2 (RNCM) indicated the clinic would call her back regarding the wound care. She advised Staff 7 to call the doctor and let them know what she was seeing and what they wanted the facility to do. Staff 7 noted the wound was originally a 50 cent size the first time she saw it. Staff 7 peeled away matted tissue in a large layer and started rolling out puss, wanting to get off as much of the scab as she could. Staff 7 continued to cut and the resident moaned once. Staff 7 stated most of the time Resident 76 the treatment stopped. Staff 7 measured the wound to be three and a half cm long and one cm wide. Staff 7 cleansed around the site and a foam pad was applied. Staff 7 combed the hair around the area and dead skin fell out of the comb. A progress note dated 8/19/15 indicated during wound care matted hair was removed from around the laceration and when the wound was pressed yellow purulent drainage emerged. On 8/19/15 at 2:37 pm Staff 2 (RNCM) and Staff 7 were asked about the worsening of the wound. Staff 7 indicated she may not have documented all of the resident's refusals of care, but tried to give the resident care. She also indicated she should have gotten the physician orders for wound care. On 8/19/15 at 3:40 pm Staff 7 contacted Resident 76's physician, who directed her to contact the wound care clinic and to continue the treatment she provided that day. On 8/19/15 at 4:08 pm Staff 7 indicated the physician ordered antibiotics for the infection. The facility failed to consistently treat the laceration and follow the physician's orders to obtain a wound care specialist. As a result the wound worsened, became infected and required antibiotic treatment. This was discussed with Staff 2 (RNCM) on 8/19/15 at 3:40 pm. Staff 2 indicated she thought the wound care orders were an FYI, and was waiting for the wound clinic to contact the facility. She also acknowledged the wound got worse and there was infection. 2. Resident 77 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. A physician's order dated 8/18/15 indicated Resident 77 was to receive a maximum of 3000 mg of [MEDICATION NAME] from all sources in a 24 hour period. Resident 77's August 2015 MAR indicated [REDACTED]. On 8/25/15 at 9:51 am Staff 3 (DNS) acknowledged Resident 77 received 3250 mg of Tylenol on 8/19/15. 3. Resident 5 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. a. A physician's order dated 7/22/15 indicated Resident 5 was to receive [MEDICATION NAME] sliding scale insulin before meals. Resident 5's July MAR indicated [REDACTED]. The sliding scale [MEDICATION NAME] order indicated [MEDICATION NAME] should not have been administered. Resident 5's August MAR indicated [REDACTED]. The sliding scale [MEDICATION NAME] order indicated 8 units of [MEDICATION NAME] should have been administered. The MAR indicated [REDACTED]. b. Resident 5's bowel record indicated the resident did not have a bowel movement on 8/15/15, 8/16/15, 8/17/15, 8/18/15 or 8/19/15. On 8/20/15 at 10:27 am Staff 3 (DNS) acknowledged the last documented bowel movement for Resident 5 was on 8/14/15 and her expectation was to call the doctor for orders if a resident did not have a bowel movement after three days. c. Resident 5's faxed physician's order dated 8/12/15 indicated [MEDICATION NAME] (a pain medication) was to be administered three times daily and to discontinue Tylenol three times daily. Resident 5's August 2015 MAR indicated [REDACTED]. On 8/20/15 Staff 2 (RNCM) acknowledged Tylenol should have been discontinued on 8/12/15.

Based on observation, interview and record review it was determined the facility's quality and assurance committee (QAA) failed to identify and correct deficiencies with systems related to accidents, investigation of potential allegations of abuse, and operationalizing policy and procedure for the protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, and mistreatment. The facility's failure to identify and correct these deficiencies led to prolonged abusive behavior by Residents 9 and 53 toward other residents which caused prolonged distress, fear and preventable resident-to-resident incidents among other residents in the memory care unit including Residents 5 and 56. Findings include: On the morning of 8/25/15, Staff 4 (Administrator) stated the QAA committee met monthly with the medical director joining quarterly, and had identified issues related to new employee orientation, meal service, and general environment. Staff 4 acknowledged the QAA committee had not identified any issues in the memory care unit. Refer to tags F225, F226 and F323.

1. Based on interview and record review it was determined that the facility failed to provide adequate supervision to prevent repeated resident to resident altercations involving 1 of 1 sampled residents (#29) who displayed sexual behaviors towards other residents while residing in the locked Memory Care Community. As a result resident (#15) hid from and stated fear of Resident 29. Findings include: Resident 15 was admitted to the facility in 11/2008 with [DIAGNOSES REDACTED]. A quarterly nursing summary dated 8/29/11 indicated that Resident 15 was "verbally able to make her needs known." Resident 29 was admitted [DATE] with [DIAGNOSES REDACTED]. On 1/24/11 a physician order [REDACTED]. An admission RAI ADL CAA was completed on 2/2/11 and indicated the resident had a history of [REDACTED]. Resident 29's Interdisciplinary Progress Notes (NN) and Resident Behavior Report Sheets (behavior monitor) indicated that the resident made sexual comments towards staff members on 15 separate days during February, March, and April 2011. On 5/28/11 the resident's NN indicated Resident 29 was found guiding a female resident's hand into his pants. The resident's care plan was updated on 5/28/11 with directions for staff to monitor Resident 29 every 15 minutes when awake. The every 15 minute monitoring was discontinued on 6/7/11. Resident 29 had 2 further episodes of inappropriate touching and sexual comments toward female residents during June 2011. No behaviors were documented in July or August 2011. On 9/7/11 the resident's behavior monitors indicated the resident was found at 9:00 am holding a female resident's hand encouraging her to "grab his crotch". At 10:30 am when he was found kissing a resident, at 10:50 am he was observed trying to kiss a female resident and telling her he "wants in her pants," and at 11:00 am he was found putting a female resident's "hand against his crotch." On 9/8/11 at 1:50 pm, the resident's behavior monitors indicated that Resident 29 "stuck his hands between legs" of another female resident. On 9/9/11 he was observed by staff trying to "stick his tongue" in the mouths of three different female residents then "taking their hands and putting between his legs". On 9/11/11 Resident 29's behavior monitors indicated the resident again tried to kiss three female residents and attempted to take their hands and put them on his crotch. On 9/12/11 at 1:00 pm Resident 29's NN indicated the resident was found being "very sexually aggressive" towards Resident 15 touching her in "groin area and breasts" and trying to kiss her. Resident 15 was crying out "help me" and was "very fearful". Resident 29's behavior monitor dated 9/12/11 indicated that staff heard a female resident yelling and verified that staff found Resident 29 with his hands up by Resident 15's "crotch...she was pushing him away." Staff separated the residents. The facility initiated 1:1 caregiver monitoring of Resident 29 on 9/12/11 and his care plan was updated to include directions to remove the other female residents if Resident 29 was acting sexually inappropriate. No sexual behaviors were noted during the 1:1 observations and it was discontinued 2 days later on 9/14/11. On 9/15/11 at 5:00 pm Resident 29's NN indicated that the resident attempted to touch a female resident in "inappropriate places. On 9/18/11 at 3:00 PM the NN indicated Resident 29 attempted to put his hand down the top of another resident's dress. The resident was transferred to the hospital on [DATE] and returned to the facility on [DATE]. On 10/7/11 Staff 1, documented that the facility would discontinue the 1:1 observations to promote his psychosocial well being. On 10/11/11 at 11:00 am the behavior monitoring record indicated that Resident 29 was observed with his right hand down a female resident's top on her right breast. On 10/15/11, during the day shift, the NN indicated that Resident 29 was noted to be following Resident 15 around and went into her room. The Resident 15 was found by staff "hiding in another resident's room to get away from" Resident 29. Resident 29 was transferred out of the facility on 11/1/11. During interview on 11/4/11 at 3:18 pm Staff 2, RNCM, and Staff 9, LPN RCM, stated they were aware of the resident's sexual behaviors but was unaware of the frequency of the behaviors. Staff 2 and Staff 9 were unaware that the resident had received Provera for sexual behaviors upon admission. On 11/7/11 Staff 1 at 11:00 am verified that the resident's behavior improved during times of 1:1 observations and that she had made the decision to discontinue it in an attempt to improve his quality of life without staff observations of his actions. 2. Based on observation, interview and record review, it was determined that the facility failed to have a system in place to ensure the resident's side rails did not pose a potential accident risk for 1 of 1 sampled resident (#6) who had side rails. Findings include: Resident 6 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On the 9/11/11 Annual MDS assessment the resident was coded as extensive assist with bed mobility and transfers. The side rail evaluation completed on 9/14/11 identified the resident was dependent for transfers and the side rails were used by the resident while care was provided and to "promote greater functional independence." During a resident interview on 10/31/11 at 2:00 pm, the resident's raised bilateral 1/2 side rails were observed to be loose and wobbly. The resident reported that she used them to help her get in and out of bed. On 11/2/11 at 12:29 pm, an observation of the resident's bilateral 1/2 side rails was made. Both side rails were loose and could be easily moved back and forth and from side to side. When one end of a rail was pushed on, it quickly dropped and other end of the rail came up. In interview with Staff 7, CNA, on 11/2/11 at 2:35 pm, she stated that the rails are not always loose, that there is a knob at the bottom to tighten them, but then would come loose again. Staff 7 stated that when she works with the resident, if the rails are loose, she tightens them. In interview with Staff 8, Maintenance Director, on 11/3/11 at 2:52 pm he was not aware the side rails were loose and said that he would tighten them. On 11/4/11 at 3:00 pm, Staff 2, RNCM, stated in interview that he was unaware that the side rails were loose and needed to be tightened. Staff 2 confirmed that there was no system in place to ensure sure staff knew the side rails could become loose and need to be tightened. On 11/8/11 at 9:45 am, Staff 10, CNA, stated that the resident used the side rails to move herself around in bed and it caused them to loosen. She stated that she was always tightening them with the knob on the bottom.