Aidan Senior Living At Reedsport

Based on interview and record review it was determined the facility failed to ensure a personalized care plan was created for 1 of 1 resident (#4) reviewed for activities. This put residents at risk for lack of personal preferences being honored. Findings include:
The facility Care Planning policy, revised 9/2013, indicated the care planning team, including the activities director/coordinator, was responsible for developing an individualized comprehensive care plan for each resident.
Resident 4 admitted to the facility in 11/2024 with diagnoses including depression and diabetes.
A 12/6/24 admission MDS indicated Resident 4 had mild cognitive impairment and depression. The MDS also indicated being around animals, doing things with groups of people, doing her/his favorite activities, and going outside to get fresh air in good weather were somewhat important to her/him.
A 3/4/25 Activities Participation Review indicated Resident 4 liked independent activities in her/his room, liked to color pictures, liked to watch the deer on the patio, and liked to watch tv in her/his room.
Resident 4's care plan, revised on 3/5/25, contained no personalized goals, interventions, or information under the activities focus area.
During an interview on 3/28/25 at 12:59 PM, Staff 5 (Activities Director) stated Resident 4's care plan was up to date with personalized goals and interventions. She reviewed the care plan and acknowledged it did not have personalized information about Resident 4's activities.
On 3/28/25 at 1:56 PM, Staff 7 (DNS) acknowledged Resident 4's care plan did not have personalization for the activities focus area. She stated the expectation was for care plans to be personalized in all focus areas.

Based on interview and record review it was determined the facility failed to follow physician orders for 2 of 5 residents (#s 18 and 19) reviewed for medications. This placed residents at risk for delayed treatment and unmet needs. Findings include:
1. Resident 18 was admitted to the facility in 3/2024 with diagnoses including dementia and insomnia.
A 3/2025 MAR instructed staff to instill two drops of Ciprofloxacin (an antibiotic used to treat bacterial infections) in both eyes every two hours for conjunctivitis (also known as pink eye, a bacterial or viral infection, or allergic reaction) for two days, starting on 3/21/25. The MAR referred the reader to Administration Notes on 3/21/25 at 12:30 AM, 2:29 AM, 4:30 AM, and 3/22/25 at 6:30 AM.
Administration Notes revealed the following for Resident 18 and Ciprofloxacin:
-3/21/25 at 1:52 AM: Resident was asleep, refused.
-3/21/25 at 3:30 AM: Resident was asleep.
-3/21/25 at 4:17 AM: Resident was asleep.
-3/22/25 at 6:46 AM: Resident was asleep.
On 3/28/25 at 8:17 AM, Staff 10 (LPN) stated she was instructed not to wake Resident 18 to instill her/his eye drops as she/he became agitated. Staff 10 did not think the physician was notified.
On 3/28/25 at 11:50 AM, Staff 1 (Administrator), Staff 7 (DNS), and Staff 49 (Regional Nurse Consultant) confirmed staff should have contacted the physician regarding instructions for when Resident 18 was asleep and did not receive her/his eye drop.
2. Resident 19 was admitted to the facility in 7/2024 with diagnoses including dementia and depression.
A review of the signed physician orders dated 1/31/25 instructed staff to administer Rexuliti (used to treat schizophrenia, and as an add-on treatment for major depressive disorder) in the morning for depressive disorder, with a start date of 1/2/25.
A 3/2025 MAR instructed staff to administer Rexuliti in the morning for depressive disorder, with a start date of 1/2/25. On 3/6/25, 3/7/25, 3/8/25, and 3/9/25 the MAR referred the reader to Administration Notes.
Administration Notes revealed the following for Rexuliti:
-3/6/25 was not administered as the medication needed to be ordered from the pharmacy.
-3/7/25 waiting for delivery of the medication.
-3/8/25 medication was not in stock; the nurse was notified.
-3/9/25 medication was not in stock, ordered from the pharmacy.
On 3/28/25 at 8:06 AM Staff 8 (LPN) stated Resident 19's Rexuliti did not arrive at the facility from the pharmacy. Staff 8 stated she did not remember if she called the pharmacy on 3/6/24 when she documented Rexuliti needed to be ordered from the pharmacy.
On 3/28/25 at 11:44 AM Staff 1 (Administrator), Staff 7 (DNS), and Staff 49 (Regional Nurse Consultant) stated if a medication was not available, the expectation would be for staff to notify the physician to obtain instructions.

Based on interview and record review it was determined the facility failed to ensure a resident's environment remained free from accident hazards for 1 of 1 sampled resident (#19) reviewed for falls. This placed residents at risk for accidents. Findings include:
Resident 19 was admitted to the facility in 7/2024 with diagnoses including dementia and disc degeneration (condition when the discs between the vertebrae in the spine wear down).
A 7/26/24 admission MDS revealed Resident 19 sustained a fall in the last two to six months.
A Care Plan Report revealed on 7/29/24 Resident 19 required the assistance of one person for toileting. Resident 19 had a history of falls and impaired safety awareness. Interventions included to review information on past falls and attempt to determine the cause of the falls. Record possible root causes and alter and remove any potential causes.
A 9/29/24 Unwitnessed Fall investigation revealed on 9/29/24 at 11:27 AM Resident 19 sustained a fall in the bathroom. The CNA reported Resident 19's call light was activated and the CNA found Resident 19 on the floor in the bathroom. The investigation determined it was an isolated incident, and the care plan was not revised.
A 11/11/24 Unwitnessed Fall investigation revealed on 11/11/24 at 4:28 PM Resident 19 was found on the floor in her/his bathroom by the CNA. The CNA reported she took Resident 19 to the bathroom, assisted her/him onto the toilet, and gave her/him the call light. The CNA heard the toilet flush and entered the bathroom and found Resident 19 on the floor. It was determined Resident 19's care plan needed to reflect she/he should not be left unattended while in the bathroom.
A Care Plan Report revealed on 12/5/24 Resident 19 required assistance of one staff member for toileting and was not to be left unattended while on the toilet.
A 12/31/24 Unwitnessed Fall investigation revealed on 12/31/24 at 6:30 AM Resident 19 was found on the floor in the bathroom. Staff 30 assisted Resident 19 on to the toilet in the bathroom and pulled the curtain for privacy. Staff 37 (CNA) and Staff 30 (CNA) were in the resident's room at the time of the fall. Staff 30 and 37 heard Resident 19 fall in the bathroom and responded.
On 3/24/25 at 12:24 PM Witness 1 (Family Member) stated Resident 19 sustained three falls. Witness 1 stated staff would assist Resident 19 to the toilet and leave her/him unattended.
On 3/27/25 at 9:24 AM Staff 37 stated on 12/31/24 she was working with Resident 19's roommate when Resident 19 fell. Staff 37 stated when a care plan instructed staff not to leave a resident unattended she understood unattended as staff should not leave a resident where they could not be seen.
On 3/28/25 at 7:51 AM Staff 30 stated she was straightening Resident 19's bed when Resident 19 fell in the bathroom on 12/31/24. Staff 30 stated she should not have left Resident 19 alone in the bathroom because Resident 19 was care planned not to be left unattended.
On 3/28/25 at 11:44 AM Staff 1 (Administrator), Staff 7 (DNS), and Staff 49 (Regional Nurse Consultant) stated the expectation was for staff to follow Resident 19's care plan.

Based on observation, interview and record review it was determined the facility failed to ensure resident medication was not expired for 1 of 1 medication storage refrigerator. This placed residents at risk for lack of medication efficacy and adverse reactions from expired medications. Findings include:
The Tuberculin manufacturer insert indicated a multi-dose vial of Tuberculin should be dated when opened and thrown away after 30 days to avoid oxidation and degradation.
During an observation of the medication storage refrigerator on 3/25/25 at 3:42 PM, the following was found:
- One open and used multi-dose vial of Tuberculin (solution used in testing for Tuberculosis) with an open date of 2/18/25.
On 3/25/25 at 3:48 PM, Staff 8 (LPN) stated the expectation was Tuberculin vials were to be destroyed 28 days after being opened.
On 3/27/25 at 1:37 PM, Staff 7 (DNS) stated all Tuberculin multi-dose vials should be dated when opened and thrown away after 28 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to ensure food was stored properly in 1 of 1 resident refrigerator, and failed to ensure food was stored, prepared, and handled properly in 1 of 1 kitchen. This put residents at risk for food borne illnesses. Findings include:
During the initial kitchen observation on 3/24/25 at 9:18 AM, the following item was found in the cook's freezer:
- One unlabeled clear plastic cup with frozen brown liquid inside and no open date.
During the initial kitchen observation on 3/24/25 at 9:22 AM, the following items were found in the walk-in freezer:
- One opened and used bag of frozen sliced bananas with no open date.
- One opened and used bag of frozen blueberries with no open date.
- One opened and used bag of filled square pasta with no open date.
- One opened and used bag of frozen cherries with no open date.
During the initial kitchen observation on 3/24/25 at 9:26 AM, the following items were found in the walk-in refrigerator:
- One closed plastic container labeled vanilla mousse with a use by date of 3/17/25.
- One closed plastic container labeled blondie bits with a use by date of 3/17/25.
- One closed plastic container labeled [NAME] cream with a use by date of 3/18/25.
- One closed plastic container labeled coffee extract with a use by date of 3/17/25.
- One closed plastic container labeled chocolate cake with a use by date of 3/17/25.
- One opened and used bottle of key lime juice with no open date.
- One closed plastic container labeled cake with a use by date of 2/20/25.
On 3/24/25 at 9:31 AM, Staff 52 (Dietary Aide) acknowledged all items found and stated the policy was for all foods to be labeled with an open date and all expired foods to be discarded.
During a review of the resident refrigerator on 3/24/25 at 12:29 PM, the following item was found:
- One bottle of whipped topping with no open date.
On 3/24/25 at 12:33 PM, Staff 5 (Activities Director) acknowledged the item found and stated the policy was for all foods to be labeled with an open date.
During the meal tray preparation and meal service on 3/26/25 at 11:33 AM, the following were observed:
- Staff 51 (Cook) did not remove her dirty gloves before portioning out salad mix until instructed. She stated the policy was to change gloves between touching kitchen items and touching food items.
- Staff 50 (Cook) did not remove her dirty gloves before touching meatloaf until instructed. She stated the policy was to change gloves between touching kitchen items and touching food items.
On 3/26/25 at 12:12 PM, Staff 49 (Dietary Manager) stated the policy was for staff to change their gloves before touching food items and after touching kitchen items. He also stated the expectation was for all expired foods to be discarded.

Based on observation, interview and record review it was determined the facility failed to follow infection control standards for 1 of 5 residents (#18) reviewed for medications. This placed residents at risk for exposure and contraction of infectious diseases. Findings include:
Resident 18 was admitted to the facility in 3/2024 with diagnoses including dementia and insomnia.
A 3/7/25 Annual MDS revealed Resident 18 had a severe cognitive impact.
A 3/2025 MAR instructed staff to instill two drops of Ciprofloxacin (an antibiotic used to treat bacterial infections) in both eyes every two hours for conjunctivitis (Also known as pink eye, a bacterial or viral infection, or allergic reaction) for two days, starting on 3/21/25. The MAR referred the reader to Administration Notes on 3/21/25 at 12:30 AM, 2:29 AM, 4:30 AM, and 3/22/25 at 6:30 AM.
Administration Notes revealed the following for Resident 18 and Ciprofloxacin:
-3/21/25 at 1:52 AM: Resident was asleep and refused.
-3/21/25 at 3:30 AM: Resident was asleep.
-3/21/25 at 4:17 AM: Resident was asleep.
-3/22/25 at 6:46 AM: Resident was asleep.
No documentation was found in Resident 18's clinical record indicating she/he had been placed on precautions for an infection.
On 3/24/25 at 12:04 PM, Staff 48 (RN) stated to be careful in Resident 18's room as she/he had conjunctivitis. Staff 48 stated he did not think Resident 18 needed to be on any type of precautions as she/he was on the downside of it. No infection control precaution signs were observed on or around Resident 18's room.
On 3/26/25 at 11:18 AM, Staff 22 (CNA) stated she wore gloves while assisting Resident 18 and she did not know Resident 18 had an infection.
On 3/26/24 at 12:49 PM, Staff 19 (CNA) stated Resident 18 touched many items, including the handrails in the hallways, and her/his name plate on her/his door. Staff 19 stated she provided care to Resident 18 and was not notified she/he had an infection.
On 3/28/25 at 9:32 AM, Staff 28 (CNA) stated she worked with Resident 18 on 3/21/25 through 3/24/25. Staff 28 stated she would set up Resident 18's meals, clean up after she/he completed her/his meals, and assist her/him with showers. Staff 28 stated on occasion she would have to remind Resident 18 to wash her/his hands. Staff 28 stated she was not aware Resident 18 had any type of infection. Staff 28 stated she would receive information verbally during shift change if a resident required precautions.
On 3/28/25 at 7:18 AM, Staff 4 (Infection Preventionist LPN) stated staff would use contact precautions with gloves and no gowns for Resident 18's conjunctivitis. Staff 4 stated after 72 hours, Resident 18 would no longer be infected, and staff would stop using the gowns.
On 3/28/25 at 10:07 AM Staff 9 (LPN) stated she would inform CNAs verbally of any changes for residents during shift change.
On 3/28/25 at 11:51 AM, Staff 1(Administrator), Staff 7 (DNS), and Staff 49 (Regional Nurse Consultant) confirmed staff should be notified when a resident was on precautions.

Based on observation, interview, and record review it was determined the facility failed to follow care plan transfer interventions for 1 of 2 sampled residents (#1) reviewed for accidents. This failure resulted in a fall for Resident 1 with hospitalization for a fractured back. Findings include:
Resident 1 was readmitted to the facility in 11/2022, with diagnoses including above the knee amputation of both legs, diabetes, and dementia.
A facility Incident Report dated 8/4/23, indicated Resident 1 had a witnessed non-injury fall while being propelled in the shower chair in the shower room. The CNA who assisted the resident stated she was backing up with the resident in the shower chair. The wheel of the chair dropped down into the recessed floor drain and the chair flipped over backwards. The CNA was able to lower the resident to the floor. The root cause of the fall was determined to be related to the resident's absence of legs which made the resident top heavy in the shower chair. When the chair wheel dropped in the drain area the chair became unstable and flipped backwards. The care plan was updated following the fall to include two staff to assist resident while in the shower chair.
Resident 1's care plan revised 8/8/23 indicated the resident had an ADL self-care performance deficit with impaired balance related to bilateral amputations. The resident required two staff to move her/him to and from the shower while in the shower chair, with an additional intervention for staff which stated, DO NOT move shower chair alone.
Resident 1's 4/14/24 Annual MDS CAA for Falls indicated the resident had a fall with an injury in the last quarter. The resident suffered a T8 (toward the lower end of the twelve thoracic vertebrae within the central, torso section of the spine) fracture.
The facility's investigation of Resident 1's fall on 3/19/24 indicated she/he was sent to the emergency department following the fall. On 3/21/24 a CT scan (computed tomography) was completed for Resident 1 which documented a fracture in the thoracic region of the spine. The facility's investigation concluded Resident 1 was only assisted by one staff member during a shower chair transfer instead of two staff members as required by Resident 1's care plan.
On 7/19/24 at 1:20 PM, an observation of the facility shower room was conducted. There were four shower chairs stored in the room. The floor drain was located between a far wall where the shower head was located and the door. The shower chairs would pass over the drain to get to the shower area. The flooring around the circumference of the drain sloped downward into the drain. Two of the shower chairs were tested for performance rolling across the drain area by the surveyor and Staff 4 (CNA) and Staff 5 (NA). The two chairs both had a wheel leave the ground when pushed across the drain area. The wheels which left the ground caused the chair to pitch forward or back depending on the way the chair was pushed.
On 7/19/24 at 10:18 AM, Staff 3 (CNA) stated on 3/19/24 at approximately 7:20 AM she pushed Resident 1 by the front of the shower chair into the shower room when something stopped the chair and it flipped backwards and the resident fell and hit her/his head. Staff 3 stated she had transferred the resident by herself and knew the resident was supposed to have two staff when using the shower chair. Staff 3 stated she was aware of the resident's previous fall while in the shower chair. Staff stated she forgot about the two-person transfer and it was not a staffing issue as there was staff available to assist at the time.
On 7/19/24 at 11:02 AM, Staff 4 (CNA) and Staff 5 (NA) were asked about the shower drain and the shower chairs. Staff 5 indicated the smallest shower chair was an issue and they had to push residents on a path along the right wall to avoid the drain area for safety. Staff 5 (NA) stated the bigger chairs had a wider base and could handle the drain area better. Both staff indicated they were aware the drain area could cause problems with the shower chairs.
On 3/19/24 at 11:27 PM, Staff 1 (Administrator) and Staff 2 (DNS) acknowledged the fall in the shower room resulted in a fractured back for Resident 1 and Staff 3 did not follow the resident's care plan related to transfers in the shower chair.

Based on interview and record review, it was determined the facility failed to have a system in place to ensure CNA staff received required 12 hours of in-service training annually for 2 of 5 sampled CNAs (#s 9 and 10) reviewed for sufficient and competent nurse staffing. 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 9 (CNA), hired 6/9/21, had six hours of documented training from 6/9/22 through 6/9/23.
-Staff 10 (CNA), hired 1/27/20, had six hours of documented training from 1/27/22 through 1/27/23.
On 12/14/23 at 9:04 AM Staff 9's and Staff 10's training hours were reviewed with Staff 2 (DNS). No additional documentation of training was provided.

Based on interview and record review, it was determined the facility failed to ensure CNA staff annual performance reviews were completed for 3 of 5 sampled CNA staff (#s 8, 11, and 12) reviewed for staffing. This placed residents at risk for a lack of competent staff. Findings include:
A review of personnel records on 12/13/23 indicated the following employees did not receive their annual performance evaluations:
-Staff 12 (CNA), hired on 6/1/78, no evaluation on file for 6/1/22 through 12/13/23.
-Staff 11 (CNA), hired on 7/29/19, no evaluation on file for 7/29/22 through 12/13/23.
-Staff 8 (CNA), hired on 11/9/17, no evaluation on file for 11/9/22 through 12/13/23.
On 12/14/23 at 9:04 AM Staff 2 (DNS) stated she did not find annual performance reviews for the above listed staff.

Based on interview and record review it was determined the facility failed to ensure proper monitoring prior to medication administration for 2 of 5 sampled residents (#s 7 and 18) reviewed for medications. This placed residents at risk for adverse medication reactions. Findings include:
1. Resident 7 was admitted to the facility in 2019 with diagnoses of heart disease and diabetes.
A 12/2023 MAR revealed Resident 7 was to be administered Metoprolol two times a day and her/his blood pressure and pulse were to be obtained prior to administration. If the pulse was under 50 beats per minute and the top number of the blood pressure was under 100 the medication was to be held. The blood pressure and pulse were not obtained on 12/7/23 though the 12/12/23 morning dose.
On 12/14/23 at 10:08 AM Staff 2 (DNS) acknowledged the blood pressure and pulse were not obtained on the identified dates.
2. Resident 18 was admitted to the facility in 9/2023 with a diagnosis of chronic kidney disease.
A review of Resident 18's comprehensive care plan revealed no information about Resident 18 receiving a diuretic (medication that helps body get rid of water by increasing urine output).
A 11/2023 MAR instructed staff to administer furosemide (a diuretic) once a day starting 9/27/23, and to check Resident 18's vital signs and weight weekly every Wednesday with a start date of 9/27/23. On 11/1/23, 11/8/23, and 11/15/23 no vital signs or weights were documented as completed.
On 12/13/23 at 8:17 AM Staff 2 (DNS) and Staff 3 (RN Consultant) stated for a resident who was new on a diuretic the expectation was to check the resident's weight daily, and for someone on a diuretic for a long time the expectation was to check weight weekly.

Based on interview, and record review it was determined the facility failed to ensure residents did not receive unnecessary psychotropic medications for 2 of 5 sampled residents (#s 8 and 18) reviewed for medications. This placed residents at risk for adverse side effects of psychotropic medications. Finding include:
1. Resident 8 was admitted to the facility in 2019 with a diagnosis of post-traumatic stress disorder.
Resident 8's care plan last updated 10/2023 revealed she/he at times had triggers related to trauma, had vivid dreams and was administered an antianxiety medication. Interventions for mood and behaviors included to provide activities, identify the cause of the behavior, remove the trigger, and to provide consistent routines.
A 12/2023 MAR and associated progress notes revealed the resident was administered Ativan (anti-anxiety) eight times from 12/1/23 though 12/10/23 and there were no non-pharmacological interventions provided prior to administration.
On 12/13/23 at 7:42 PM Staff 23 (RN) stated he worked with Resident 8 on the evening shift and the resident often became anxious. The resident looked for lost items including passports and money, and wanted to walk even though the resident could not walk for years. Staff 23 stated if PRN antianxiety medications were administered staff were to provide non-pharmacological interventions before administering the medication.
On 12/14/23 10:08 AM Staff 2 (DNS) acknowledged there were no interventions tried prior to the administration of the Ativan from 12/1/23 through 12/10/23.
2. Resident 18 was admitted to the facility in 9/2023 with a diagnosis of dementia.
A review of Resident 18's comprehensive care plan revealed no information about Resident 18 receiving sertraline (a medication used to treat depression).
A 11/2023 signed physician order instructed staff to administer sertraline once a day for dementia, with unspecified severity, and without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety starting on 9/27/23.
A Note to Attending Physician Prescriber dated 11/8/23 revealed Resident 18 received sertraline without a clear diagnosis. The purpose was to evaluate the continued need for sertraline and to provide a diagnosis for the facility records and ongoing therapy. The diagnosis of F32.A (depression) was handwritten.
No documentation was found in the clinical record Resident 18 was monitored for side effects of sertraline.
On 12/14/23 at 9:32 AM Staff 2 (DNS) and Staff 3 (RN Consultant) stated they would review Resident 18's monitoring for sertraline. No additional information was provided.

Based on interview and record review it was determined the facility failed to ensure a resident was provided routine dental care for 1 of 2 sampled residents (#11) reviewed for dental. This placed residents at risk for dental pain. Findings include:
Resident 11 was admitted to the facility in 12/2022 with a diagnosis of a stroke.
A 12/6/22 admission MDS indicated Resident 11 was cognitively intact and did not have dental issues.
On 12/11/23 at 11:24 AM Resident 11 stated she/he fell prior to admission to the facility and fractured her/his back teeth. The teeth did not hurt, but she/he did not go to a dentist for an exam and normally was examined yearly.
On 12/14/23 at 10:08 AM Staff 2 (DNS) stated Resident 11 did not report dental pain and acknowledged Resident 11 was not provided routine dental care since admission to the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined the facility failed to maintain cleanliness for 1 of 1 Kitchen and 1 of 1 dining room. This placed residents at risk for cross contamination. Findings include:
1. On [DATE], during initial kitchen tour, the dry storage area fan above the door, which moves air from the kitchen into the dry storage area, was observed to be covered in black chunks of dirt and debris. The door from the outside into the kitchen was open, with screen door closed. The screen door was covered in a layer of dust.
On [DATE] at 10:12 AM Staff 6 (Dietary Manager) stated he did not have a scheduled time to clean the fan and screen door. Staff 6 stated he would assign a staff member to clean them when he noticed they needed cleaned and confirmed they needed cleaned.
2. A 11/2023 Refrigerator Temperature Log for the dining room revealed for the month of 11/2023 the refrigerator temperature was not checked 19 out of 30 days.
On [DATE] at 7:02 AM, in the main dining room, the resident snack refrigerator was observed to contain a slice of pizza dated [DATE], a store-bought cake with two dates (one [DATE] and a second of [DATE]), and an orange with green mold on the bottom. Staff 11 (CNA) confirmed the pizza, store-bought cake and orange should be discarded. Staff 11 did not know about the temperature log for the refrigerator and did not know who was responsible for documenting the temperature.
A 12/2023 Refrigerator Temperature Log for the dining room revealed from [DATE] through [DATE] the refrigerator temperature was not checked six out of 12 days.
On [DATE] at 10:12 AM Staff 6 (Dietary Manager) stated it was expected for the CNAs to log the temperatures for the dining room refrigerator, and for both the dietary staff and the CNAs to remove expired items from the dining room refrigerator.

Based on observation and interview it was determined the facility failed to assess and develop a water management plan and failed to perform laundry in a sanitary manner for 1 of 1 facility. This placed residents at risk for infections. Findings include:
1. On 12/14/23 at 8:25 AM Staff 7 (Maintenance Director) stated he worked at the facility for multiple years and was not aware of a water management plan related to Legionella (water-borne pathogen).
On 12/14/23 at 9:00 AM Staff 1 (Administrator) stated she had the facility's water flow map. A request was made to Staff 1 to provide documentation the facility identified where water-borne pathogens could grow, measures to prevent the growth of the pathogens and how the facility would monitor the measures they had in place. No additional information was provided.
2. On 12/14/23 at 7:41 AM Staff 8 (CNA) stated the night shift staff brought residents' dirty laundry in plastic bins and lined the bins up against the wall in the clean laundry area until the washing machine was available, which was behind a locked door next to the clean laundry room. Staff 8 stated there was no other area to store the dirty linens. The clean laundry area was observed to have mechanical lift slings and dirty gowns in plastic bins under the table where clean linens were folded. The bins had dried feces on them. The room smelled of feces. Staff 8 stated dirty slings were placed under the tables until they were able to be washed on the night shift.
On 12/14/23 at 7:47 AM Staff 2 (DNS) observed the the clean laundry area with the dirty bins, linens and dried feces. Staff 2 stated dirty linen was not to be in the clean laundry area.

Based on interview and record review it was determined the facility failed to ensure antibiotics were not used unless indicated for 1 of 5 sampled residents (#18) reviewed for medications. This placed residents at risk for the development of antibiotic resistant organisms. Findings include:
Resident 18 was admitted to the facility in 2023 with a diagnosis of diabetes.
A 12/1/23 through 12/6/23 vital sign log revealed Resident 18 did not have a temperature greater than 98.5 degrees Fahrenheit (normal 98.6).
A 12/6/23 nurse practitioner note indicated the resident was examined and was assessed to probably have pneumonia and the diagnoses was based on presentation and history. The note indicated a chest x-ray was not going to be obtained because it would take the facility an extended amount of time to obtain the x-ray.
A 12/6/23 Progress Note indicated Resident 18 was started on an antibiotic for pneumonia.
On 12/14/23 at 10:14 AM Staff 2 (DNS) stated Resident 18 was diagnosed with pneumonia and the resident was not tested for other types of respiratory infections prior to the initiation of the antibiotics. Staff 2 also stated the facility was able to obtain x-rays in a timely manner. If there was a concern Resident 18 would become septic (life threatening complications of an infection) antibiotics could have been started until x-ray results were reviewed to confirm or rule out pneumonia. If the resident was determined not to have pneumonia the antibiotics would be stopped.

Based on interview and record review it was determined the facility failed to ensure pneumonia vaccines were offered for 3 of 5 sampled residents (#s 3, 5, and 9) reviewed for immunizations. This placed residents at risk for pneumonia. Findings include:
1. Resident 3 was admitted to the facility in 2018 with a diagnosis of chronic lung disease.
Resident 3's clinical record revealed she/he received a pneumonia vaccine in 2019 but did not indicate the type of vaccine and was potentially eligible to receive another vaccine.
On 12/13/23 at 9:46 AM a request was made to Staff 2 (DNS) to provide documentation Resident 3's vaccines were complete. No additional information was provided.
2. Resident 5 was admitted to the facility in 2019 with a diagnosis of a neuromuscular disease.
Resident 5's clinical record revealed she/he received a pneumonia vaccine and was eligible to receive another vaccine. There was no documentation to indicate the resident was offered an additional vaccine.
On 12/13/23 at 9:46 AM a request was made to Staff 2 (DNS) to provide documentation Resident 5 was offered an additional pneumonia vaccine. No additional information was provided.
3. Resident 9 was admitted to the facility in 2021 with a diagnosis of a stroke.
Resident 9's clinical record revealed she/he did not have a pneumonia vaccine and was eligible for one. There no documentation to indicate the resident was offered a vaccine.
On 12/13/23 at 9:46 AM a request was made to Staff 2 (DNS) to provide documentation Resident 9 was offered a pneumonia vaccine. No additional information was provided.

Based on interview and record review it was determined the facility failed to review a consent for medications with a resident's representative for 1 of 5 sampled residents (#12) reviewed for medications. This placed residents at risk for unnecessary medications. Findings include:
Resident 12 was admitted to the facility in 2021 with a diagnosis of dementia.
A 11/26/21 facility admission documentation revealed Witness 1 (Family) signed the resident's paperwork as Resident 12's responsible party.
An Informed Consent for Psychotropic Drugs dated 10/20/23 revealed Resident 12 was administered mirtazapine (antidepressant) and olanzapine (antipsychotic). The consent was signed by two staff and not Witness 1.
On 12/12/23 at 2:50 PM Staff 2 (DNS) stated, annually, the facility reviewed and obtained new consents for residents' psychotropic medication administration. Staff 2 acknowledged Resident 12's consent was signed by two staff members and not Witness 1 and stated she was not sure if the resident's family was called in regards to the resident's current medication dose. No additional information was provided to indicate family consented to Resident 12's current use of psychotropic medications.

Based on interview and record review, it was determined the facility failed to provide the risks and benefits for the use of psychotropic medications prior to administration for 1 of 5 sampled residents (#18) reviewed for medications. This placed residents at risk for lack of informed consent. Findings include:
Resident 18 was admitted to the facility in 9/2023 with a diagnosis of dementia.
A 11/2023 signed physician orders instructed staff to administer sertraline (a medication used to treat depression) once a day for dementia, and anxiety starting on 9/27/23.
A review of clinical records found Resident 18 was not provided the risk and benefits of taking sertraline.
On 12/14/23 at 9:32 AM Staff 2 (DNS) and Staff 3 (RN Consultant) confirmed Resident 18's risk and benefits for sertraline was not completed timely.

Based on interview, it was determined the facility failed to have a system in place to deliver mail on Saturdays. This placed residents at risk for lack of timely written communication. Findings include:
On 12/13/23 at 9:56 AM during the Resident Council meeting Staff 5 (Activities Director) stated the mail was not delivered to the residents on Saturdays because she did not work on Saturdays.
On 12/13/23 at 12:02 PM Staff 5 stated the mail was delivered to the facility on Saturdays, there was no one available to distribute it to the residents. Staff 5 further stated she would deliver the Saturday mail on Mondays.

Based on interview and record review it was determined the facility failed to assist a resident with completing an advance directive for 1 of 4 sampled residents (#2) reviewed for advance directives. This placed residents at risk for end of life choices not being honored. Findings include:
Resident 2 was admitted to the facility in 2021 with diagnoses of stroke and diabetes.
A 4/26/23 Care Plan revealed Resident 2 had blindness in both eyes from diabetes.
A 5/24/23 Care Conference meeting form revealed Resident 2 requested a staff member read the advance directive to her/him to see if she/he would like help filling it out.
A 9/26/23 Annual BIMS revealed Resident 2 was cognitively intact.
Resident 2's record did not reveal staff reviewed the advance directive with her/him.
On 12/13/23 at 11:15 AM Staff 3 (RN Consultant) stated she would look to see if staff reviewed the advance directive with the resident. No additional information was provided.

Based on interview and record review it was determined the facility failed to provided a two day notice prior to the ending of skilled services for 1 of 3 sampled residents (#71) reviewed for beneficiary notifications. This placed residents at risk for lack of timely appeals. Findings include:
Resident 71 was admitted to the facility in 2023 with a diagnosis of liver disease.
Resident 71's Notice of Medicare Non-Coverage form revealed her/his services ended on 10/31/23. The notice was provided on 10/30/23.
On 12/13/23 at 3:09 PM Staff 5 (Activities Director) stated she was trained the two day notice included the day the resident was discharged from the facility and not when the services ended. Staff 5 acknowledged the resident discharged on 11/1/23 and the notice was given on 10/30/23, one day before services ended.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to clean filters on the heater air-conditioning equipment for 1 of 1 facility reviewed for environment. This placed residents at risk for unclean and unhomelike environment. Findings include:
No documentation was found related to cleaning of the heater air-conditioning equipment.
A 12/7/23 Resident Council minutes indicated the heaters needed cleaned.
On 12/11/23 at 12:51 PM Resident 14 stated she/he accidently dislodged the dining room heater air-conditioning face plate and the filter was covered in a layer of dust and dirt. Resident 14 stated she/he reported the dirty filters to Staff 1 (Administrator), but the filters were still not cleaned after several weeks.
On 12/14/23 at 8:11 AM, in the presence of Staff 21 (Assistant Environment Services Manager) the heater air-conditioner equipment in room [ROOM NUMBER] was observed. Staff 21 stated he did not know how long it was since it was last cleaned. Staff 21 further stated he did not think it was recorded when maintenance completed the cleaning. The filter was observed covered in a layer of dust. On top of the heater air conditioner there were debris particles and dust. Staff 7 (Environment Services Director) stated he was not surprised by the look of the equipment being dirty as items often got spilled on the equipment. Staff 7 further stated that the amount of dust on the filter depended on what was going on in the room, which would determine how much accumulation would occur.

Based on interview and record review, it was determined the facility failed to implement its abuse prevention program policy and procedure for screening for 1 of 5 sampled staff members (#16) reviewed for facility personnel. This placed residents at risk for abuse and neglect of care. Findings include:
The Abuse Prevention Program Policy and Procedure, dated 10/2/19, indicated as part of the resident abuse prevention, the administrator or their designee would conduct employee background checks.
A New Hire List from 8/12/23 through 12/12/23 revealed Staff 16 was hired on 9/22/23.
An Application Report (background check) from 9/1/23 through 10/31/23 revealed Staff 16's application status was closed because her fingerprints were not obtained.
A Person Summary revealed Staff 16's training period was completed on 10/28/23 and she started assisting residents without supervision.
No documentation was found in Staff 16's personnel folder indicating she was supervised from 10/28/23 through 12/13/23.
On 12/14/23 at 8:37 AM Staff 1 (Administrator) stated she was not aware Staff 16's fingerprints were not completed, and her application was closed.

Based on interview and record review it was determined the facility failed to developed care plans for 2 of 2 sampled residents (#s 12 and 18) reviewed for activities. This placed residents at risk for lack of social engagement. Findings include:
1. Resident 12 was admitted to the facility in 2021 with a diagnosis of dementia.
A 11/28/23 Activities Participation Review form revealed Resident 12 liked to observe other residents during group activities more than participating and reported to staff she/he wanted to color.
Review of the comprehensive care plan last updated 10/16/23 revealed there was no activity focus with goals and interventions.
On 12/12/23 at 2:22 PM and 12/13/23 at 11:16 PM Staff 5 (Activities Director) stated Resident 12 had dementia and her/his activity involvement fluctuated but she/he liked to color, watch movies, listen to music and watch her/his peers while they participated in an activity. Staff 5 acknowledged Resident 12 did not have a care plan related to activities.
2. Resident 18 was admitted to the facility in 9/2023 with a diagnosis of dementia.
An 10/6/23 admission MDS indicated Resident 18 was cognitively intact. Resident 18 felt it was not very important to have items to read, listen to music and keep up with news. It was very important to be around animals and engage in her/his favorite activities. It was somewhat important for Resident 18 to do things with groups of people and go outside when weather was good.
A review of Resident 18's comprehensive care plan revealed no information about her/his activity interests.
On 12/14/23 at 9:30 AM Staff 2 (DNS) and Staff 3 (RN Consultant) stated they would review the care plan regarding Resident 18's activity interests. No additional information was provided.

Based on interview and record review it was determined the facility failed to revise care plan interventions for 5 of 6 sampled residents (#s 7, 8, 12, 13, and 19) reviewed for accidents, nutrition, dignity, activities, and medications. This placed residents at risk for unmet needs. Findings include:
1. Resident 7 was admitted to the facility in 2019 with a diagnosis of diabetes.
Progress notes revealed the following:
-11/5/23 Resident 7 choked on food and was sent to the emergency room for evaluation and treatment.
-11/30/23 Resident 7 choked in bed. Resident 7 was aware of her/his need to eat meals out of bed.
-12/4/23 Resident 7 was found flat in bed and was choking.
A 11/30/23 RD assessment indicated the resident had recent choking events and it was likely related to position and the resident did not have swallowing issues. The note indicated the RD agreed with the plan to provide all meals for the resident out of bed.
On 12/11/23 during lunch observation, Resident 7 did not eat in the dining room.
On 12/11/23 at 2:25 PM Resident 7 was observed in bed with her/his head of the bed at a 45 degree angle and was observed to eat food and drinks were within reach. The resident was not observed to choke or cough.
On 12/12/23 at 3:21 PM Staff 2 (DNS) stated Resident 7's care plan was not updated to include the resident was to be up for all meals due to her/his history of choking. The resident did not have swallowing issues and did not need to be supervised, but it was best for the resident to eat in the dining room.
2. Resident 8 was admitted to the facility in 2021 with a diagnosis of heart failure.
An 10/10/23 Annual MDS and associated CAAs revealed the resident required extensive assistance for most ADLs and the medications the resident was administered contributed to her/his fall risk. Staff were to monitor the resident for increased confusion and agitation. The CAA also indicated the resident had several falls in the past and one fall resulted in a fracture.
A care plan last updated 10/26/23 revealed the resident was a high risk for falls and did not have a history of falls.
On 12/13/23 at 2:34 PM Staff 2 (DNS) acknowledged Resident 8's care plan was not updated to reflect the resident had falls including one with an injury.
3. Resident 12 was admitted to the facility in 2021 with a diagnosis of dementia.
An 8/31/23 quarterly MDS revealed Resident 12 attended some activities, but only participated for a short period of time. Resident 12 liked to observe her/his peers during the activity. The MDS note indicated she/he also liked to watch television, participate in balloon toss and board games.
A care plan last updated 7/2023 revealed Resident 12 depended on others for her/his decision making. There were no resident specific interventions related to activities.
Resident 12's 11/1/23 through 12/8/23 activity log revealed the resident participated in coloring, people watching, movies, and was provided a fidget blanket (provided sensory stimulation when touching different textures).
On 12/13/23 at 11:16 PM Staff 5 (Activity Director) stated Resident 12 had dementia and her/his participation level varied day to day. All staff had access to activity supplies when Staff 5 was not in the facility. Staff 5 acknowledged Resident 12's care plan was not updated with resident specific interventions related to activities.
4. Resident 19 was admitted to the facility in 2023 with a diagnosis of dementia and was on hospice services.
An 10/22/23 admission MDS and associated CAAs revealed Resident 12 had little interest in activities and staff would familiarize the resident with available activity supplies.
A care plan last revised on 11/14/23 did not include activities staff should try to provide to Resident 19.
On 12/13/23 at 10:08 AM Witness 2 (Hospice RN) stated when Resident 19 first arrived at the facility the resident wanted to stay in bed. Now, when Witness 2 visited Resident 19, the resident was observed to be sitting in her/his wheel chair with magazines by the nurses station. Witness 2 stated overall the resident was more engaged.
On 12/13/23 at 11:16 PM Staff 5 (Activity Director) stated after staff provided Resident 19 a shower the resident participated in activities. The resident liked happy hour and karaoke. The resident participated as long as she/he was able to tolerate being in her/his wheelchair. Staff 5 stated she did not have very much information about Resident 19 when the resident was admitted to the facility and Staff 5 did not update the care plan once she learned what the resident liked to do.
5. Resident 13 was admitted to the facility in 9/2022 with a diagnosis of a fractured leg.
A 9/21/23 care plan indicated Resident 13 tested positive for COVID-19 on 9/13/23 with interventions which included placing the resident on transmission-based precautions with personal protective equipment provided at the entrance of her/his room.
From 12/11/23 through 12/14/23 no transmission-based precautions were observed at the entrance of Resident 13's room.
On 12/14/23 at 9:30 AM Staff 2 (DNS) and Staff 3 (RN Consultant) confirmed Resident 13's care plan was outdated, and COVID-19 precautions needed to be removed.

Based on observation, interview and record review it was determined the facility failed to ensure a resident's nails were trimmed for 1 of 1 sampled resident (#8) reviewed for ADLs. This placed residents at risk for lack of hygiene. Findings include:
Resident 8 was admitted to the facility in 2021 with diagnoses including heart disease and diabetes.
An 10/10/23 annual MDS and CAAs revealed Resident 8 required extensive assist with ADLs.
A care plan last revised on 10/26/23 revealed Resident 8 was dependent on staff for cares including showers. Resident 8 was to receive showers every Monday and Thursday.
11/2023 and 12/2023 TARs revealed Resident 8 was to receive diabetic nail care every Monday evening and she/he refused on on 11/27/23, 12/4/23, and 12/11/23. No documentation was found the staff reapproached the resident after refusals.
On 12/11/23 at 1:07 PM Resident 8 was observed with long fingernails with brown debris underneath the nails. The resident stated she/he was not able to independently cut her/his nails.
On 12/13/23 at 12:37 PM Staff 11 (CNA) stated if a resident was not diabetic the CNAs provided nail care on shower days. If a resident was diabetic then the nurse provided nail care. Staff 11 observed Resident's 8's nails to be long. The brown debris was no longer under the nails. Staff 11 stated she cleaned under the nails with a wash cloth. Resident 8 stated she hated her/his nails because they were too long.
On 12/13/23 at 12:42 PM Staff 22 (LPN) stated the resident should have been provided nail care on 12/11/23.
On 12/14/23 at 2:00 PM a request was made to Staff 2 (DNS) to provide documentation Resident 8 was provided nail care. No additional information was provided.

Based on observation, interview and record review it was determined the facility failed to protect the resident's right to be free from mental and verbal abuse by staff and a resident for 2 of 4 sampled residents (#s 501 and 502) reviewed for abuse. This placed residents at risk for abuse. Findings include:
1. Resident 501 was admitted to the facility in 2022 with diagnoses including stroke and adjustment disorder (excessive reactions to stress that involve negative thoughts, strong emotions and changes in behavior) with mixed anxiety and depressed mood.
On 5/30/23 Resident 501 reported to Staff 11 (Social Service Assistant) she/he had high anxiety and increased muscle spasms due to the stress she/he felt because she/he overheard Staff 6 (CNA) tell another CNA she could not be alone with the resident because the resident was targeting her. Staff 6 would also not assist other staff in providing appropriate and timely care for the resident which upset Resident 501 because the resident did not understand why Staff 6 was avoiding her/him or what she/he had done wrong. When interviewed by facility staff the resident showed symptoms of escalating anxiety as evidenced by the resident's tone of voice, tremors and body language while discussing the issue. The facility determined Staff 6 did cause psychosocial harm to Resident 501 which manifested itself with physical symptoms.
A 5/30/23 facility Investigation document indicated the facility interviewed Staff 6 regarding the incident which occurred on 5/28/23. Staff 6 indicated she felt threatened by the resident and said the resident followed her around the building and was always telling her how to provide care. Staff 6 admitted to talking about the resident outside the resident's room and did so even though five days earlier staff had been in-serviced on resident rights, abuse, effective communication and the importance of ensuring all communication on the floor was positive and HIPPA compliant. The investigation also indicated multiple staff members corroborated the resident's statements including Staff 6's failure to provide timely assistance with cares for the resident.
On 8/28/23 at 3:16 PM Resident 501 indicated Staff 6 was working the day shift on Sunday which was her/his shower and go to church day. Staff 6 should have completed the shower and been done by 7:00 AM but Staff 6 did not come to get her/him for the shower. Resident 501 said out of the blue Staff 6 told the nurse she was not allowed in the resident's room. Resident 501 said she/he knew nothing about it and was very upset to hear what Staff 6 said and her/his muscles starting to have increased spasms. Another CNA came to help with the shower but Staff 6 would not assist and pretended not to know which shower chair or Hoyer lift was needed. Staff 6 delayed the process so long that the resident did not get a shower and did not go to church because of being so upset. Resident 501 said Staff 6 just did not want to give her/him a shower and the resident did not understand why. Resident 501 also said she/he heard Staff 6 tell another CNA she could not be alone with her/him because she/he was targeting her. This made the resident sick all weekend and she/he was upset because of not understanding what happened or what she/he did wrong. Resident 501 stated he never said she/he did not want Staff 6 in her/his room.
On 8/30/23 at 3:15 PM Staff 6 denied not assisting the resident with care needs. Staff 6 stated it was Staff 10 (Agency CNA) who made the remarks about the resident targeting her.
On 8/30/23 at 4:15 PM Staff 10 (Agency CNA) stated it was Staff 6 who made the statement about the resident targeting her. Staff 6 was training her because she was a new CNA and Resident 501 did not even know who she was. Staff 6 told her to watch out for Resident 501 because she/he had the state agency on speed dial and the resident would time CNAs to see how long it took to get her/him to bed and to answer call lights. Staff 6 never directly said she would not care for the resident but she always made sure she did not have the resident on the hall she was working. Staff 6 also told her she was not supposed to go into the resident's room by herself but that was not true per nursing staff. Staff 10 said many of the residents did not care for Staff 6 because she did not take her time and was rougher than other aides.
On 8/31/2023 at 3:57 PM Staff 1 (Administrator) acknowledged they substantiated the resident's complaint and identified psychosocial harm to the resident. The facility's investigation document did not specify what abuse triggered the psychosocial harm but the investigation indicated the following:
-Verbal abuse: Staff 6 willfully made disparaging remarks about the resident within hearing distance of the resident even after receiving recent in-service training on abuse.
-Mental abuse related to the deprivation of caregiving services directed at the resident including Staff 6 avoiding and delaying assistance of the resident's care needs which increased the resident's anxiety response and included physical and emotional manifestations of distress.
2. Resident 502 admitted to the facility in 2022 with diagnoses including diabetes and functional quadriplegia (complete immobility due to severe disability or frailty from another medical condition without injury to the brain or spinal cord).
A facility investigation dated 4/13/23 indicated Resident 502 was completing a trauma screening interview in her/his room with Staff 11 (Social Service Assistant). The resident's roommate Resident 505 began to make multiple negative statements about Resident 502 eating herself/himself to death and all the resident ever did was eat. Staff 11 told Resident 505 she/he was belittling the resident and needed to stop but she/he did not stop. Resident 505 had a history of lashing out towards staff but this was the first time she/he was abusive to another resident. After the comments from her/his roommate Resident 502 started crying and asked to be removed from the room. This was the first time she/he was on the receiving end of negative interactions with a roommate. The residents were separated.
On 8/29/23 at 1:34 PM Resident 502 stated her/his roommate Resident 505 said nasty things to her/him when they were alone but she/he had not reported anything to staff, but this time staff was present. Resident 502 went on to say it made her/him feel so bad she/he wanted to leave the building and be homeless but was not physically able to do so.
On 8/29/23 at 2:10 PM Staff 1 (Administrator) acknowledged verbal abuse had occurred to Resident 502 by Resident 505.

5. Resident 5 was admitted to the facility in 2022 with diagnoses including Parkinson's disease.
On 4/28/22 at 4:15 AM Resident 5 was found on the floor next to her/his bed after staff heard Resident 5 call for help.
The 4/28/22 fall investigation noted Resident 5 indicated with the help of a family member, she/he had a nightmare and tried to get out of bed.
The investigation did not include the position of the side rails or who may have seen the resident prior to the event. There were no interviews of staff present and on shift at the time of the fall included in the investigation.
On 9/16/22 at 11:59 PM Resident 5 was found on the floor next to her/his wheelchair in the sunroom.
The 9/16/22 fall investigation concluded Resident 5 was away from the table, leaned forward to access her/his bell and fell out of the wheelchair.
The investigation did not include information related to why Resident 5 was in the sunroom late at night or who may have seen the resident prior to the event. There were no interviews of staff present and on shift at the time of the fall included in the investigation.
On 10/19/22 at 1:13 PM Staff 2 (Assistant DNS) stated she did the investigations and talked with staff. Staff 2 was asked about documentation of witness statements and how she determined the cause of the falls. Staff 2 had no additional information to provide.
Based on interview and record review it was determined the facility failed to thoroughly investigate incidents for 5 of 7 sampled residents (#s 1, 2, 5, 16, and 17) reviewed for abuse and accidents. This placed residents at risk for abuse. Findings include:
1. Resident 17 admitted to the facility in 1/2022 with diagnoses including diabetes and depression.
On 10/14/22 a Written Warning report revealed the following:
- Staff 11 (CNA) had four individual complaints within the last week (10/7/14 through 10/14/22) regarding treatments of residents, specifically her attitude when providing care and the way she spoke to the residents.
-Resident 17's statement indicated Staff 11 had a rude tone when she/he asked to be placed on the bed pan and Resident 17 could do it herself/himself. Resident 17 did not want assistance from Staff 11 because of her attitude.
-Resident 3, Resident 17's roommate indicated Staff 11 was grumpy but did not want to give any other information regarding the incident due to possible retaliation from Staff 11.
-Staff 9 (CNA) and Staff 7 (LPN) statements verified Staff 11's interaction with Resident 17.
-Staff 11 was placed on corrective action regarding her abrasive approach towards residents.
The facility did not provide an investigation related to the 10/14/22 incident. There were no interviews with other residents who may have been affected by Staff 11 and no additional interviews of staff present on shift at the time of the incident included in the Written Warning report.
On 10/19/22 at 1:12 PM and 10/20/22 at 2:29 PM Staff 1 (Administrator), Staff 2 (Assistant DNS) and Staff 14 (DNS) were present for an interview. Staff 2 stated it was expected staff initiate an incident report regarding the 10/14/22 incident, and she would follow up to ensure the investigation was complete and thorough which would include interviewing staff, residents and those involved in the incident. Staff 2 stated they spoke with other staff and residents regarding the 10/14/22 incident but did not document the information or initiate an investigation. Staff 1, Staff 2 and Staff 14 acknowledged the incident on 10/14/22 was not thoroughly investigated.
2. Resident 1 admitted to the facility in 6/2018 with diagnoses including dementia and anxiety disorder.
Resident 16 admitted to the facility in 11/2021 with diagnoses including bipolar (a mental condition marked by altering periods of elation and depression) disorder and hypoxic-anoxic (lack of oxygen to the brain) brain damage.
On 8/6/22 a Facility Reported Incident revealed the following:
-On 8/6/22 Resident 1 was in the solarium and just finished lunch. Resident 16 self-propelled in her/his wheelchair and hollered at Resident 1 she/he was in Resident 16's spot.
-Resident 1 started to move her/his wheelchair and accidentally bumped into Resident 16 and Resident 16 became angry and raised her/his voice and used profanity to Resident 1.
-Staff heard the interaction and separated both Resident 1 and Resident 16 from the incident.
-Staff thought Resident 1 was upset by the situation but in conversation with Resident 1 on 8/6/22 she/he did not remember what Resident 16 said but only that Resident 16 acted like a patootie. Resident 1 felt safe and indicated it was her/his home.
-Staff spoke with Resident 16 who indicated she/he was not upset but wanted her/his spot back in the solarium.
-Neither Resident 1 nor Resident 16 had any affects from the result of the incident on 8/6/22.
The investigation did not include interviews of staff present on shift at the time of the incident or other residents who may had been affected by the disruption on 8/6/22 included in the investigation.
On 10/19/22 at 1:12 PM and 10/20/22 at 2:29 PM Staff 1 (Administrator), Staff 2 (Assistant DNS) and Staff 14 (DNS) were present for an interview. Staff 2 stated it was expected staff initiate an incident report regarding the 10/14/22 incident, and she would follow up to ensure the investigation was complete and thorough which would include interviewing staff, residents and those involved in the incident. Staff 1, Staff 2 and Staff 14 acknowledged the incident on 10/14/22 was not thoroughly investigated.
3. Resident 12 admitted to the facility in 6/2021 with diagnoses including diabetes and a stroke.
Resident 16 admitted to the facility in 11/2021 with diagnoses including bipolar (a mental condition marked by altering periods of elation and depression) disorder and hypoxic-anoxic (lack of oxygen to the brain) brain damage.
On 8/27/22 an Abuse Investigation revealed:
-On 8/27/22 Resident 16 was taken down to the shower room by Staff 12 (CNA) and prior to taking Resident 16 down to the shower she/he cursed at staff at the nurse's station.
-Staff 12 got Resident 16 into the shower and Resident 16's back was towards the door when Resident 12 opened the shower door and attempted to get past Staff 12. Resident 12 had a homemade weapon in her/his hand a sock with a rock tied in it.
- Staff 15 (CNA) came up behind Resident 12 and was able to separate her/him from Staff 12 and Staff 12 was able to close the door to the shower room.
-Staff 12 indicated and documented in progress notes Resident 16 did not hear the interaction because she/he was hard of hearing.
-The investigation concluded Resident 12 did not witness or hear what occurred on 8/27/22 and abuse was ruled out.
The investigation did not include staff interviews, witness statements and no information was provided if the facility interviewed Resident 16 regarding the incident on 8/27/22.
On 10/19/22 at 1:12 PM and 10/20/22 at 2:29 PM Staff 1 (Administrator), Staff 2 (Assistant DNS) and Staff 14 (DNS) were present for an interview. Staff 2 stated it was expected staff initiate an incident report regarding the 10/14/22 incident, and she would follow up to ensure the investigation was complete and thorough which would include interviewing staff, residents and those involved in the incident. Staff 1, Staff 2 and Staff 14 acknowledged the incident on 10/14/22 was not thoroughly investigated.
4. Resident 2 admitted to the facility in 9/2021 with diagnoses including diabetes and a stroke.
Resident 16 admitted to the facility in 11/2021 with diagnoses including bipolar (a mental condition marked by altering periods of elation and depression) disorder and hypoxic-anoxic (lack of oxygen to the brain) brain damage.
A progress note dated 8/30/22 indicated Staff 2 (Assistant DNS) spoke to Resident 2 regarding Resident 16 being loud and scaring her/him the night of 8/29/22. Resident 2 indicated she/he felt safe and secure but the loud yelling and slamming of cabinets scared her/him because Resident 2 could not see what was going on. Resident 2 indicated she/he did not want to be separated from Resident 16 but wanted frequent checks when in the solarium area.
A 9/25/22 Annual MDS indicated Resident 2 had a BIMs score of 14 which indicated she/he was cognitively intact. Resident 2's Visual CAA indicated she/he was legally blind due to her/his diabetic retinopathy.
On 10/18/22 at 10:15 PM Staff 7 (LPN) stated she was present for the 8/29/22 incident and Resident 16 hollered obscenities and threw items in the solarium. Staff 7 (LPN) stated Resident 2 was legally blind and in the solarium during the time of the incident and a CNA removed Resident 2 from the area because she/he was scared. Staff 7 stated after the incident Resident 2 was back to her/his baseline and was placed into bed. Staff 7 stated she reported the incident to upper management.
On 10/19/22 at 11:40 AM Staff 8 (CNA) stated he recalled the incident on 8/29/22 because Resident 16 threw items in the solarium and cursed. Staff 8 stated Resident 2 was seated in the solarium and was startled by the noise because she/he was blind. Staff 8 stated staff removed Resident 2 from the solarium and once in her/his room was calm and back to her/his baseline.
On 10/19/22 at 12:00 PM Staff 2 (Assistant DNS) provided a copy of the progress note and indicated she did not have any further information regarding the 8/30/22 incident and no incident report was initiated.
On 10/19/22 at 1:12 PM and 10/20/22 at 2:29 PM Staff 1 (Administrator), Staff 2 (Assistant DNS) and Staff 14 (DNS) were present for an interview. Staff 2 stated it was expected staff initiate an incident report regarding the 10/14/22 incident, and she would follow up to ensure the investigation was complete and thorough which would include interviewing staff, residents and those involved in the incident. Staff 1, Staff 2 and Staff 14 acknowledged the incident on 10/14/22 was not thoroughly investigated.

Based on interview and record review it was determined the facility failed to accurately assess, monitor and document skin issues for 1 of 1 sampled resident (#9) reviewed for skin conditions. This placed residents at risk for additional skin issues. Findings include:
Resident 9 was admitted to the facility in 2021 with diagnoses including diabetes and bed confinement status.
The facility's Skin and Wound Care Documentation form dated 8/6/20 included the following:
-All skin and wound issues would be updated weekly by the LN.
-A new skin and wound care progress record would be completed each week with a short narrative regarding the progress of the skin/wound issue.
-The LN was to make a note with the size of the wound by length and width (to show progression and if healing or not).
-Narrative nursing notes should include description or issue, surrounding area, drainage, measurements, date and intials.
-Once the skin and wound issue is resolved the progress record and chart should be placed in the record.
-Now tracking skin and wound in the electronic record.
-Notify the MD and the DNS if wound is worsening or there is no change to the healing of the wound.
The facility's Skin Issues for Charge Nurses updated 8/6/20 included the following:
- For new skin issues the nurse was to fill out a Risk Management report.
-Complete a skin and wound progress record for each skin issue, update weekly under skin assessment on first shower day of the week.
-Treatment order must be initiated per wound protocols .
-Initiate a temporary care plan
-Place the resident on alert charting
-Notify the Physician
-Notify family
-Write a nurse's note regarding the skin issue found and interventions, treatment, etc.
A Skin Observation Tool dated 8/28/22 and completed by Staff 16 (LN) indicated Resident 9 had left lower leg (front) bruising, left knee (front) bruising and an open wound on the back measuring 1.5 inches in length by 0.75 inches wide. The note section of the document contained the following: open wound on the lower left side of the back, optifoam bandage applied. Multiple bruises on the left shin, calf, knee, behind the knee and lower thigh.
A Skin Observation Tool dated 9/4/22 and completed by Staff 17 (RN) included the same information related to bruising and an open wound on the resident's back and an optifoam bandage was applied. The information from the Tool was copied and pasted from the previous form. A new skin assessment was not completed and there was no documentation to indicate the current condition of the wound or if any follow up was completed. No documentation was found in the medical record regarding the wound.
The Skin Observation Tools for 9/5/22 and 9/12/22 completed by Staff 5 (LPN) also contained the information related to the bruising and the open wound on the resident's back and an optifoam bandage was applied. The information from the Tool was copied and pasted from the previous form. A new skin assessment was not completed and there was no documentation to indicate the current condition of the wound or if any follow up was completed. No documentation was found in the medical record regarding the wound.
A Skin Observation Tool dated 9/19/22 completed by Staff 5 (RN) did not contain the information related to the open wound on the resident's back. There was no information to indicate what had happened to the wound, if the wound had healed, how the wound was acquired and if any additional treatments were done. No documentation was found in the resident's medical record related to the wound or wound care.
A Skin Observation Tool dated 9/26/22 completed by Staff 18 (LPN) contained information on the resident's bruises and a new skin issue. The resident had a new ulcer on the right buttock. It was reported by CNAs at the end of shift. The nurse was unable to assess the wound as the patient refused because she had just been changed and wanted to sleep. It was reported to the next shift for follow up. No documentation was found to indicate the following shift followed up.
The Skin Observation Tools dated 10/3/22 and 10/10/22 completed by Staff 5 (LPN) contained the information related to skin bruising that appeared to be healing and the new ulcer on the right buttock. There was no documentation found in the Tool or in the medical record to indicate the area was assessed, treatment was provided, if the area was open or had healed and no measurements or description were updated.
The Skin Observation Tool dated 10/17/22 completed by Staff 5 (LPN) did not contain information on the new pressure ulcer to the right buttock. No assessment was completed. There was no follow up documented by staff in the medical record, no indication of treatment or if the area had healed.
On 10/19/22 at 6:30 PM Staff 5 (LPN) indicated she copied and pasted the Skin Observation Tool information from the previous sheets into the sheets for 9/5/22 and 9/12/22. She did not update the wound information and she did not place any optifoam bandages. Staff 5 indicated she did not remember seeing any wounds on the resident's back. There was no documentation to indicate the skin assessment was completed.
On 10/19/22 at 6:35 PM Staff 5 (LPN) (regarding the Skin Observation Tool dated 9/26/22) indicated she did not remember the LN reporting the new pressure ulcer to her. No assessment was completed to verify the skin observation noted in the tool and no documentation for any follow up was located in the medical record or provided by facility staff.
On 10/20/22 at 9:50 AM Staff 16 (LPN) indicated (regarding the 8/28/22 Skin Observation Tool) she remembered putting a dressing on the resident but did not remember what the wound looked like. She asked the CNAs if it was a new issue and was told the bruising was an old issue but the wound was new.
On 10/20/22 at 10:15 AM Staff 17 (RN) indicated (regarding the 9/4/22 Skin Observation Tool) she copied and pasted the skin sheet from the prior week (8/28/22) and she did not put on an optifoam dressing. She could not remember if the resident had a pressure injury or open area but it was definitely below the waist. The resident had a rash that came and went related to diarrhea from fruit and refusals to be changed when soiled. Staff 17 did not complete the assessment, did not follow up on the wound and did not update documentation on the Skin Observation Tool.
On 10/20/22 at 4:24 PM Staff 2 (Assistant DNS) indicated the Skin Observation Tools were not completed correctly. She was aware there were issues with the staff not following the facility's skin and wound process. No Risk Management forms were provided.

Based on observation, interview and record review it was determined the facility failed to provide adequate foot care for 1 of 1 sampled resident (#9) reviewed for ADL care. This placed residents at risk for unmet foot care needs. Findings include:
Resident 9 was admitted to the facility in 2021 with diagnoses including diabetes and bed confinement status.
Resident 9's care plan initiated 10/14/21 related to the diabetes diagnosis included staff were to inspect the resident's feet daily for open areas, sores, pressure areas, blisters, edema or redness.
Resident 9's care plan dated 10/12/21 revealed the resident was on anticoagulant (prevent or reduce coagulation of blood, prolonging the clotting time) medication and staff should complete a daily skin inspection.
A physician order dated 10/18/21 indicated the licensed nurse was to complete diabetic nail care once weekly, every Monday, on the evening shift of shower day.
On 10/20/22 at 12:56 PM Resident 9's feet were observed. The skin on the feet and legs was very dry and flaky. The resident's toe nails were overgrown. The nails were curved downward towards the bottom of the feet. The little toe nail on the right foot was pressing against the skin of the next toe and was at risk for creating a pressure injury.
On 10/20/22 at 1:06 PM Staff 2 (Assistant DNS) observed the resident's toenails and acknowledged they were overgrown and needed to be clipped and the resident's skin was dry and could use some lotion.

Based on interview and record review it was determined the facility failed to ensure a resident was treated with respect and dignity for 1 of 5 sampled residents (#17) reviewed for abuse. This placed residents at risk for lack of self-worth. Findings include:
Resident 17 admitted to the facility in 1/2022 with diagnoses including diabetes and depression.
On 10/14/22 a Written Warning report revealed the following:
- Staff 11 (CNA) had four individual complaints within the last week (10/7/14 through 10/14/22) regarding treatments of residents, specifically her attitude when providing care and the way she spoke to the residents.
-Resident 17's statement indicated Staff 11 had a rude tone when she/he asked to be placed on the bed pan and Resident 17 could do it herself/himself. Resident 17 did not want assistance from Staff 11 because of her attitude.
-Resident 3, Resident 17's roommate indicated Staff 11 was just grumpy but did not want to give any other information regarding the incident due to possible retaliation from Staff 11.
-Staff 9 (CNA) and Staff 7 (LPN) statements verified Staff 11's interaction with Resident 17.
-Staff 11 was placed on corrective action regarding her abrasive approach towards residents.
On 10/17/22 at 1:00 PM Resident 3 stated Staff 11 was known to be grumpy.
On 10/17/22 at 4:38 PM Resident 17 stated approximately a week ago (10/7/22 through 10/14/22) on night shift Staff 11 responded to her/his call light, was rude and asked, what do you want? Resident 17 stated Staff 11 assisted her/him with incontinence care but was mumbling under her breath the entire time and Resident 17 did not feel she/he was treated with dignity and respect. Resident 17 further stated she/he did not want Staff 11 to assist her/him because of Staff 11's gruff attitude.
On 10/18/22 at 10:26 PM Staff 7 stated Staff 11 was extremely irritable and the 10/14/22 incident was reported by Staff 9. Staff 7 spoke with Resident 17 who stated Staff 11 was rude and short with her/him when Staff 11 provided incontinence care. Staff 11 placed the wrong size bed pan under Resident 17 but did not ask for the bed pan to be replaced because she/he felt like it was a bother after Staff 11's attitude towards her/him.
On 10/18/22 at 11:00 PM Staff 11 stated she assisted Resident 17 onto a bedpan on evening shift and Resident 17 was upset because it was not the correct size. Staff 11 stated she did not recall being abrupt or gruff with Resident 17.
On 10/19/22 at 10:24 AM Staff 9 stated she recalled the incident on 10/14/22 and was in the room when Staff 11 responded in an angry and annoyed tone asking Resident 17 what do you need? Staff 9 stated she stepped out of the room to retrieve a gown and some ice water for Resident 17 and when she returned Resident 17 had asked to be put on the bed pan and Staff 11 mumbled under her breath are you serious? Staff 11 placed the bed pan under Resident 17 in a hurried fashion and then left the room. Staff 9 stated Resident 17 was not fearful or hurt but was upset regarding Staff 11's tone towards her/him and did not want Staff 11 to assist with her/his ADL care needs. Staff 9 further stated she completed Resident 17's ADL care needs that evening.
On 10/20/22 at 2:29 PM Staff 1 (Administrator), Staff 2 (Assistant DNS) and Staff 14 (DNS) were present for an interview. Staff 2 stated they spoke with staff and residents regarding the 10/14/22 incident and determined Staff 11 was rude at times toward residents and was placed on corrective action to improve her/his interaction between residents.

Based on observation, interview and record review it was determined the facility failed to assess the risk of entrapment, attempt alternatives and explain the risk and benefits for the use of side rails for 1 of 2 sampled residents (#5) reviewed for accidents. This placed residents at risk for side rail injuries. Findings include:
Resident 5 was admitted to the facility in 2022 with diagnoses including Parkinson's disease.
Resident 5 had an order which stated may use side rails based on Restraint/device assessment dated 4/4/22.
On 4/28/22 a fall investigation noted Resident 5 likely had a nightmare, attempted to get out of bed and fell on the floor. New interventions included a low bed and fall mats on both sides of the bed. There was no information related to the use or position of the side rails in the investigation notes.
Resident 5 had an order dated 4/28/22 for full bed length mobility bars.
On 10/18/22 at 10:30 PM Resident 5 was observed in bed with fall mats in place, the bed was in the low position and both side rails were up with pillows leaning against the rails.
Physical restraint/device assessments dated 4/6/22, 7/6/22 and 10/7/22 indicated the rails were used as a means to transfer in and out of bed. The assessments did not include consent dates for the use of the bed rails.
On 10/20/22 at 1:58 PM Witness 3 (family member) stated the side rails were to prevent Resident 5 from falling out of bed. Witness 3 stated she was not aware of the potential risks of using bed rails.
On 10/20/22 at 4:44 PM Staff 2 (Assistant DNS) stated Resident 5's side rails were for bed mobility and provided a barrier. Staff 2 added she did not consider any alternatives to the use of side rails or discuss the potential risk of entrapment or injury as a result of the use of side rails with Resident 5 or her/his family.

Based on interview and record review it was determined the facility failed to ensure the daily staff posting was accurate for 17 out of 30 days reviewed for staffing report accuracy. This placed residents at risk for lack of staffing information. Findings include:
A review of the Direct Care Staff Daily Reports dated 9/8/22 through 10/17/22 revealed 14 out of 30 days the registered nurse information was not documented and three out of the 30 days revealed portions of the forms were blank or inaccurate.
On 10/20/22 at 1:55 PM Staff 2 (Assistant DNS) confirmed the reports were inaccurate three out of the 30 days and did not have the registered nurse coverage included on the forms for 14 out of 30 days.

Based on interview and record review it was determined the facility failed to provide ROM/RA services for 3 of 4 residents (#s 12, 13 and 17) reviewed for positioning and mobility. This placed residents at risk for decline in mobility. Findings include:
1. Resident 13 was admitted to the facility in 2021 with diagnoses including multiple sclerosis.
On 10/17/22 at 2:46 PM Resident 13 stated she/he wanted more therapy. Resident 13 added she/he was not receiving assistance with exercises, got some stretching but it was not consistent.
Review of the medical record indicated Resident 13 had a restorative program developed to maintain her/his ROM. There was no documentation after 8/5/22 indicating Resident 13 received her/his restorative program.
On 10/20/22 at 12:19 PM Staff 2 (Assistant DNS) stated restorative services were not being provided due to lack of enough staff. Staff 2 added staff were expected to provide ROM with care and should be documenting the ROM provided.
2. Resident 17 was admitted to the facility in 1/2022 with diagnoses including diabetes and depression.
On 10/17/22 at 4:34 PM Resident 17 stated she/he wanted more RA (restorative therapy) but had not received any RA and would like her/his strength to improve. Resident 17 further stated she/he had a conversation with staff but did not receive any RA services.
Review of the medical record indicated Resident 17 had a RA program developed to maintain her/his ROM and strength. There was no documentation after 8/5/22 indicating Resident 17 received her/his RA program.
On 10/20/22 at 12:19 PM Staff 2 (Assistant DNS) stated RA services were not being provided due to lack of staff. Staff 2 added staff were expected to provide RA services including ROM with care and should document RA and any ROM provided.
3. Resident 12 was admitted to the facility in 2021 with diagnoses including stroke with right sided deficit and chronic pain syndrome.
Resident 12's Baseline Care Plan dated 6/5/21 indicated the resident's physical functional goals included: maintain current functional status and minimize decline.
A Care Conference meeting note dated 7/15/21 indicated the resident wanted a walking program built into her/his care plan and mornings were the best time to walk.
A Restorative Program Note dated 5/24/22 at 7:19 PM was the last RA note for Resident 12. No other documentation was found to indicate RA services were provided after that date.
A Care Conference meeting note dated 8/11/22 indicated Resident 12 still needed an updated RA program and the DNS was to contact therapy.
On 10/18/22 at 9:52 AM Resident 12 indicated she/he was a physical fitness instructor while in the army. The resident stated she/he was not currently receiving any type of ROM or RA services but would like to. The resident stated on home visits she/he used a walker. The resident wanted to do assisted walking in the facility to maintain or increase her/his mobility and do other exercises as well.
The MDS Indicator Facility Rate Report dated through 11/14/22 indicated Resident 12 was identified as having limited ROM and was not receiving services.
On 10/20/22 at 12:19 PM Staff 2 (Assistant DNS) stated restorative services were not being provided due to lack of enough staff.