Based on interview and record review, it was determined the facility failed to ensure resident care equipment was monitored as recommended for 1 of 3 sampled residents (#12) reviewed for accidents. Resident 12 experienced a fall from a broken shower chair, sustained rib fractures, and a closed head injury. Findings include: Resident 12 was admitted to the facility in 9/2024 with diagnoses including stroke. A 5/14/25 Fall investigation revealed Staff 12 (CNA) was providing Resident 12 with a shower. Resident 12's shower chair broke and Resident 12 fell onto the shower room floor, complaining of head and right rib pain. Resident 12 was sent to the hospital. A 5/14/25 hospital After Visit Summary revealed Resident 12 was diagnosed with a rib fracture, a closed head injury, and a bruise. A review of the undated shower chair owner's manual revealed the chair was to be checked at least monthly for glued fittings by attempting to pull the polyvinyl chloride (type of plastic) out of the fittings. The pipes on the shower chair needed to be checked for cracking, fractures, or other damage at least monthly. A Work History Report printed on 7/9/25 revealed no inspections of shower chairs were completed in 2024 or 2025. On 7/8/25 at 12:35 PM, Resident 12 stated on 5/11/25 the shower chair came apart and two CNAs put the chair back together. On 5/14/25 she/he received a shower and the chair collapsed causing fractured ribs. On 7/8/25 at 2:03 PM, Staff 11 (CNA) stated on 5/11/25 Resident 12 was in the shower chair and Staff 10 (CNA) noticed a piece was coming apart on the chair. Staff 11 stated they transferred Resident 12 to her/his wheelchair and Staff 10 took the shower chair to the maintenance room. Attempts to reach Staff 10 on 7/8/25 and 7/9/25 were unsuccessful. On 7/8/25 at 2:24 PM, Staff 8 (Maintenance Lead) stated on 5/12/25, there was a shower chair in the boiler room. Staff 8 stated there was no note on the chair and no work order was received for the chair. Staff 8 stated he did a visual inspection and figured a work order would come in. The shower chair was gone from the boiler room on 5/13/25. Staff 8 stated he did not do anything with the chair. On 7/9/25 at 10:37 AM, Staff 12 stated she obtained the shower chair from the shower room on 5/14/25 and placed Resident 12 in the shower chair. Staff 12 did not hear any cracking noises when setting Resident 12 into the chair or while taking her/him to the shower room. After the shower was completed, Staff 12 rolled the chair toward her so she could dry Resident 12's feet and the shower chair collapsed. On 7/9/25 at 11:09 AM, Staff 1 (Administrator) stated during the investigation they identified the process for broken equipment needed to be more streamlined. The deficient practice was identified as Past Noncompliance based on the following: On 5/16/25, the deficient practice was identified by the facility and was corrected when the facility completed an investigation and identified system failures of using the same equipment which previously was broken. The Plan of Correction included: -Broken shower chair was removed and discarded. -A facility wide audit and inspection of all shower chairs was completed. A new process was implemented for logging equipment inspections as well as a new tagging process for equipment requiring maintenance. -Facility wide education was provided to staff on equipment safety checks, the process for when equipment needed maintenance, and the new tagging process for equipment requiring maintenance. -Audits were completed for random staff knowledge on equipment not functioning properly and audits of shower chairs' functional status were completed on the following dates: 5/23/25, 5/30/25, 6/6/25, 6/7/25, 6/13/25, 6/20/25, 6/27/25, and 7/3/25.

**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 professional standards were followed for 2 of 6 sampled residents (#s 39 and 442) for medication administration. This placed residents at risk for adverse side effects and cross contamination. Findings include: Per OAR [PHONE NUMBER] Scope of Practice Standards for All Licensed Nurses (1) Standards related to the licensee's responsibility for safe nursing practice. The licensee shall: (A) Adhere to professional practice and performance standards; Per OAR [PHONE NUMBER] Conduct Derogatory to the Standards of Nursing Defined: 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 standards 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. Actual injury need not be established; (3) Conduct related to the client's safety and integrity: 1. Resident 442 admitted to the facility in 4/2024 with diagnoses including bipolar disorder (mental health disorder). A public complaint was received on 5/30/24 which alleged on 5/29/24 at 7:30 AM Staff 28 (RN) administered Resident 442's morning medications, and within 30 minutes Witness 2 (Complainant) noticed the resident was not responding to staff when spoken to and became out of it. An 4/6/24 physician order indicated staff were to administer chlorpromazine (antipsychotic for mental disorder) PO, vitamin D3 PO, Protonix (treat reflux) PO, lithium ER (extended release for bipolar disorder) PO, and propranolol (for high blood pressure) PO. On 10/10/24 Drugs.com indicated lithium ER should not be crushed, chewed, or broken. A 5/29/24 Progress Note indicated Resident 442 had a difficult time swallowing her/his medication in the morning, so Staff 28 (RN) crushed Resident 442's medication and administered the medication in pudding. On 10/9/24 at 12:11 PM Staff 28 (RN) acknowledged she crushed Resident 442's lithium, which was not to be crushed, and no Medication Error documents were found in the resident's electronic record. On 10/9/24 at 3:03 PM Staff 2 (DNS) acknowledged Staff 28 crushed Resident 442's lithium medication, which was not to be crushed, and no Medication Error documents were found in the resident's electronic record. 2. Resident 39 admitted to the facility in 2/2024 with diagnoses including diabetes. On 10/9/24 at 11:50 AM Staff 28 (RN) was observed to check Resident 39's CBG (blood sugar measurement) level in the dining room. Staff 28 placed the glucometer on the North medication cart and cleaned the glucometer with small alcohol prep wipes. On 10/9/24 at 12:10 PM Staff 28 stated she always used alcohol prep wipes to sanitize the glucometer, and she was not aware of another sanitizing wipe. On 10/9/24 12:15 PM Staff 3 (LPN-Resident Care Manager) and Staff 30 (LPN-Resident Care Manager) stated the glucometer should be sanitized with the proper sanitizing wipes.

Based on interview and record review it was determined the facility failed to ensure residents were free from significant medication errors for 1 of 4 sampled residents (#442) reviewed for change of condition. This placed residents at risk for adverse side effects of medications. Findings include: Resident 442 admitted to the facility in 4/2024 with diagnoses including bipolar disorder (mental health disorder). An 4/6/24 physician order indicated staff were to administer lithium ER (extended release antipsychotic for bipolar disorder). On 10/10/24 Drugs.com indicated lithium ER should not be crushed, chewed, or broken. A 5/29/24 Progress Note indicated Resident 442 had a difficult time swallowing her/his medication in the morning, so Staff 28 (RN) crushed Resident 442's medication and administered the medication in pudding. On 10/9/24 at 12:11 PM Staff 28 (RN) acknowledged she crushed Resident 442's lithium, which was not to be crushed, and no Medication Error documents were found in the resident's electronic record. On 10/9/24 at 3:03 PM Staff 2 (DNS) acknowledged Staff 28 crushed Resident 442's lithium medication, which was not to be crushed, and no Medication Error documents were found in the resident's electronic record. Refer to F658

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 16 was admitted to the facility in 2021 with diagnoses including multiple sclerosis (a disease of the central nervous system), pressure ulcer and on hospice. A 12/15/22 Significant Change MDS indicated Resident 16 was on hospice and at risk for pressure ulcers due to decreased mobility and urinary incontinence. Staff were to provide skin treatments as ordered and monitor for any changes in Resident 16's skin condition. A 5/13/23 Wound Nursing Order indicated to cleanse Resident 16's genital area wound. Apply Iodosorb (iodine gel) to the wound bed and cover with an adhesive foam dressing. The dressing was to be changed as needed if soiled or loose. A 6/12/23 Wound Nursing Order indicated to monitor a blanchable (skin that turns white when pressed) redness located at the the base of Resident 16's genital area and notify the provider of any worsening. A 6/13/23 Progress Note at 6:59 AM revealed Resident 16 had a very loose bowel movement and Staff 13 (LPN) redressed her/his pressure ulcer with new dressing after Resident 16 was cleaned. No additional information about Resident 16's wounds were documented. On 6/13/23 at approximately 1:15 PM a hospice encounter note indicated the original wound to Resident 16's genital area continued to improve and a new Stage 1 pressure ulcer (wound which remained red when touched) was at the base of Resident 16's genital area according to a facility nurse since Resident 16 declined a wound assessment during the visit. A 6/14/23 at 1:04 PM Skin and Wound Evaluation revealed Resident 16's wound located at the the base of her/his genital area was a Stage 3 (full-thickness skin loss) pressure ulcer and measured 4.3 cm long and 1.7 cm wide. Evidence of infection included increased drainage, redness and warmth and the wound was bleeding and had a scab. The evaluation also revealed the loss of skin was due to urine or friction. A note revealed it was the first time a nurse assessed the pressure ulcer wound and nursing used the 5/16/23 order to treat the wound. On 6/29/23 at 5:06 PM Staff 13 stated on 6/13/23 at 6:59 AM she observed Resident 16 already had a scab on another pressure ulcer. On 6/28/23 at 10:12 AM Staff 2 (DNS) stated the facility neglected to complete a wound assessment for Resident 16's second pressure ulcer and no investigation related to the wound was started. Based on interview and record review it was determined the facility failed to assess and treat residents' pressure ulcers for 2 of 3 sampled residents (#s 16 and 79) reviewed for pressure ulcers. Resident 16 developed at Stage 3 pressure ulcer. This placed residents at risk for infections. Findings include: 1. Resident 79 was admitted to the facility 6/9/23 (Friday) with diagnoses including respiratory failure. Hospital Discharge Orders Report dated 6/9/23 revealed Resident 79 had a pressure ulcer to the tailbone region. Wound care was to be provided every Monday, Wednesday and Friday. A 6/9/23 admission Nursing Database indicated the resident had a pressure ulcer to the tailbone. There were no measurements or descriptions of the ulcer on the form. A 6/2023 TAR revealed no wound care was provided until 6/13/23. This was four days after admission to the facility. Progress Notes revealed the following: -6/10/23 wound care was not provided because the resident started to fall asleep and refused -6/11/23 at 8:54 PM resident had pain to the tailbone region -6/11/23 at 9:08 PM tailbone region open with yellow green purulent (pus-indicative of infection) drainage, MD notified. -6/13/23 Wound nurse indicated she was asked to see the resident. The ulcer, which spanned from the tailbone to the anus, was 7.5 cm long and was full of slough (non-viable tissue). The resident verbalized pain to the buttock region. The wound nurse applied a dressing, but the resident immediately removed it. -6/14/23 the resident's physician assessed the resident and sent the resident to the hospital emergency department due to agitation and to rule out a stroke or sepsis from a wound infection. The resident returned with a diagnoses of wound infection. Skin and Wound Evaluation Forms revealed the following: -There was no form filled out when the resident was admitted on [DATE] -6/13/23 the ulcer was described as an unstageable pressure ulcer (unable to determine depth due to slough), the wound had 90% slough, signs of infection including increased drainage, redness and pain, moderate amount of purulent (pus) drainage. There was no length or width documented. -No form documented for 6/20/23 -6/27/23 the ulcer was noted to be improved. The ulcer was 7.9 cm long, was 100% covered with slough, did not have signs of infection and the note indicated the resident frequently removed the dressings. On 6/29/23 at 10:20 AM Staff 1 (LPN-Resident Care Manager) stated Resident 79 was admitted to the facility with a pressure ulcer to the tailbone region. Staff 1 stated staff were to assess all wounds, including pressure ulcers, and document in the clinical record on the skin assessment forms. Staff were to document treatment provided on the TAR. If a resident refused a treatment, staff were to attempt to provide the treatment on different shifts until the treatment was provided. Staff 1 also stated the pressure ulcers were to be monitored weekly. Staff 1 acknowledged the resident's pressure ulcer was not described in detail on the skin assessment sheet, treatments were not documented as provided for four days and skin assessments were not done on 6/20/23 when the wound nurse did not come into the facility. Staff 1 indicated the facility staff should have filled out the assessment if the wound nurse was not in the building.

Based on interview and record review it was determined the facility failed to ensure Staff 6 (LPN) adhered to professional standards of practice related to abuse and residents' changes in condition for 5 of 8 sampled residents (#s 305, 309, 312, 314 and 315) reviewed for abuse and change of condition. This failure resulted in Residents 305, 309 and 314 who experienced mental and verbal abuse and Residents 312 and 315 experienced a noted decline in condition without timely intervention prior to the residents' hospitalization. Findings include: OAR 8510450040 Scope of Practice Standards for All Licensed Nurses indicated the following: (1) Standards related to the licensed nurse's responsibilities for client advocacy. The licensed nurse: (b) Intervenes on behalf of the client to identify changes in health status, to protect, promote and optimize health, and to alleviate suffering. OAR 8510450050 Scope of Practice Standards for Licensed Practical Nurses indicated the following: (2) Standards related to the Licensed Practical Nurse's responsibility for nursing practice implementation. Under the clinical direction of the RN or other licensed provider who has the authority to make changes in the plan of care, and applying practical nursing knowledge drawn from the biological, psychological, social, sexual, economic, cultural and spiritual aspects of the client's condition or needs, the Licensed Practical Nurse shall: (a) Conduct and document initial and ongoing focused nursing assessments of the health status of clients by: (A) Collecting objective and subjective data from observations, examinations, interviews, and written records in an accurate and timely manner as appropriate to the client's health care needs and context of care. (D) Anticipating and recognizing changes or potential changes in client status; Identifying signs and symptoms of deviation from current health status; and (C) Selecting appropriate nursing interventions and strategies. OAR 8510450070 Conduct Derogatory to the Standards of Nursing Defined indicated the following: Nurses, regardless of role, whose behavior fails to conform to the legal standard and accepted standards of the nursing profession, or who may adversely affect the health, safety, and welfare of the public, may be found guilty of conduct derogatory to the standards of nursing. Such conduct shall include, but is not limited to, the following: (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. (2) Conduct related to other federal or state statute/rule violations: 1. a.) Resident 305 was admitted to the facility in 2020 with diagnoses including hemiplegia (one-sided paralysis) and hemiparesis (one-sided weakness), major depression and epilepsy. Resident 305 was alert and oriented. A complaint intake dated 12/8/22 indicated Staff 5 (CNA) and Staff 7 (CNA) heard Staff 6 (LPN) yelling and screaming at Resident 305 to take her/his medications. Staff 6 had also turned on all the lights in the resident's room, even though it was careplanned not to turn all the lights on, because it triggered the resident and set her/him off. Staff 7 attempted to stop Staff 6 from yelling at the resident and to leave the room to deescalate the situation but Staff 6 would not cooperate so she left to get help. The complaint indicated facility management was aware of Staff 6's behaviors but no corrective action was taken. On 3/21/23 at 9:45 AM Staff 14 (RCM/LPN) acknowledged she had not identified the incident as possible mental and verbal abuse by Staff 6 and she failed to investigate the incident. Staff 14 did notify Staff 1 (Administrator) and Staff 2 (DNS) of the incident but they also failed to identify it as possible abuse. The incident was later determined to be mental and verbal abuse of Resident 305 by Staff 6. b.). Resident 309 was admitted to the facility in 2018 with diagnoses including stroke with hemiplegia (one-sided paralysis) and hemiparesis (one-sided weakness) and respiratory failure. On 3/22/23 at 12:01 PM Staff 4 (RCM/LPN) indicated she was aware Staff 6 had multiple negative interactions with residents including Resident 309. Staff 6 would raise her voice to residents, throw temper tantrums and argue with residents. She had given verbal corrections to Staff 6. Staff 4 said she was aware that Resident 309 had also reported complaints about Staff 6. Social Services was aware of the resident's concerns and it was discussed at the resident's care conference. The resident stated she did not feel safe around Staff 6. Staff 14 stated she took her concerns to Staff 1 (Administrator) and Staff 2 (DNS) but was not aware that any corrective action was taken. The incident was later determined to be mental and verbal abuse of Resident 309 by Staff 6. c.) Resident 314 was admitted to the facility in 2018 with diagnoses including neurocognitive disorder with Lewy bodies (progressive dementia that leads to a decline in thinking, reasoning and independent function). On 3/22/23 at 12:01 PM Staff 14 (RCM/LPN) indicated she was aware Staff 6 had multiple negative interactions with residents including Resident 314. Staff 6 would raise her voice to residents, throw temper tantrums and argue with residents. She had given verbal corrections to Staff 6. Resident 314 had verbalized complaints such as Staff 6 was belittling (made her/him feel stupid), not patient with her/him and Staff 6 demanded the resident take her/his pills and she/he had no right to refuse. Staff 14 stated she took her concerns to Staff 1 (Administrator) and Staff 2 (DNS) but was not aware that any corrective action was taken. 2. a.) Resident 312 was admitted to the facility in 2022 with diagnoses including hemicraniectomy (surgical procedure where a large flap of the skull is removed and the dura is opened; this gives space for the swollen brain to bulge and reduces the intracranial pressure), HIV disease and viral Hepatitis C. On 3/22/23 at 12:18 PM Staff 15 (CNA) stated she had been working on Sunday 3/12/23. She was in the dining room and noticed that Resident 312 had fluid coming out of the back of her/his head, her/his hair was matted down with fluid and there was leaking onto the neck area. Due to the resident's background of brain surgery with a skull flap (allows access to the brain) she was very concerned. She asked the resident's CNA Staff 9 if the nurse Staff 6 (LPN) knew about the drainage. Staff 6 said she would contact the doctor but then did nothing about it. Staff 15 felt Staff 6 would not respond so went to Staff 18 (LPN). Staff 18 looked at the resident and said the resident should go out to the hospital. Staff 18 spoke to Staff 6 and expressed concerns about the resident's condition. Staff 6 said the resident was fine and she was not sending the resident to the hospital and just wiped off the fluid with gauze without using gloves (on a resident with a brain wound and infectious diseases). Staff 9 came by later and told her Staff 6 was squeezing the resident's head like a pimple and they both knew that was wrong. Staff 18 had talked to the DNS but nothing was done to correct the situation. The evening shift came on and finally sent the resident to the hospital. No documentation was found in the resident's medical record to indicate Staff 6 called or tried numerous times to contact the physician; no assessment of the resident was completed by Staff 6 related to the possible change of condition for Resident 312 and no interventions were noted. No documentation was found to indicate Staff 6 had followed nursing standards of practice to address a possible change of condition for Resident 312 or that Staff 2 (DNS) had done any follow up to ensure the resident received appropriate care. On 3/27/23 at 5:50 PM Staff 11 (RCM/LPN) stated the Central Hall charge nurse called her about Resident 312. Cognitively the resident was at baseline so she left it in the hands of the DNS. On Friday 3/10/23 the resident had complained about her/his head hurting. Staff 11 stated she expected the LPNs to know when they should send a resident to the hospital. They should do an assessment. She found no assessment for Resident 312. Staff 6 said she tried to reach the physician but there was no documentation to verify she had tried. Staff 11 thought Staff 6 had sent the resident out to the hospital but she did not. Staff 6 just put the note in the medical record for the evening shift nurse. Staff 6 should have been able to make the determination to send the resident out as needed without waiting for the physician to return a call. She knew it was a Sunday and reaching the physician would not be easy. There were also instructions to send the resident to the hospital if her/his condition worsened because the neurosurgeon was on call that weekend. b.) Resident 315 was admitted to the facility in 2018 with diagnoses including spastic cerebral palsy, persistent asthma and chronic respiratory failure and chronic obstructive pulmonary disease (COPD). On 3/24/23 at 8:58 AM Staff 17 (CNA) said Staff 15 (CNA) and Staff 9 (CNA) reported concerns to her about the condition of a couple of residents that day (3/12/23) including Resident 315. They told her the resident was having difficulty breathing so Staff 6 told the CNA to give her/him a shower to help the breathing but the resident needed to go to a hospital not take a shower. The resident had trouble breathing since early morning and she/he could not eat. The resident's respirations were 135. They told Staff 6 this was not normal for the resident but she would not send the resident out. She did one breathing treatment which did not help. Nothing else was done by Staff 6. The resident was finally sent out by the evening shift nurse by Staff 13. A hospital H&P dated 3/12/23 indicated the resident's chief complaint was shortness of breath for the last few days and much worse today. In the Emergency Department Resident 315 was noted to be in respiratory distress. The resident received nebulizer treatment, IV steroids, oxygen and IV magnesium. The resident remained with increased difficulty breathing and audible rhonchi (secretions in the airway) and therefore the hospitalist was consulted for admission. The Hospital Course: resident was admitted with acute asthma exacerbation and human metapneumovirus infection (same virus family as RSV). On 3/27/23 at 5:50 PM Staff 11 (RCM/LPN) indicated she expected LPNs to know when they should send someone out to the hospital and when to do an assessment. There was no assessment or documentation by Staff 6. Staff 11 said if Resident 315's breathing was as bad as staff indicated she/he should have been sent out to the hospital without waiting. Staff 11 understood Staff 6 did one nebulizer treatment for Resident 315 but it was not effective. Staff 11 also said Staff 6 directed the CNA to give the resident a shower to help his breathing. That was not an appropriate medical treatment for a resident in respiratory distress. See F600 and F684

Based on interview and record review it was determined the facility failed to to identify, assess and select appropriate interventions for residents' change in condition for 2 of 2 sampled residents (#s 312 and 315) reviewed for a change of condition. This failure resulted in Resident 312 and Resident 315 experiencing a noted decline in condition without timely medical intervention prior to the residents' hospitalizations. Findings include: 1. Resident 312 was admitted to the facility in 2022 with diagnoses including hemicraniectomy (surgical procedure where a large flap of the skull is removed and the dura is opened; this gives space for the swollen brain to bulge and reduces the intracranial pressure), HIV disease and viral Hepatitis C. A hospital History & Physical dated 3/12/23-3/16/23 indicated the resident had a hemicraniectomy on 6/20/22. The resident underwent a cranioplasty (neurosurgical procedure designed to repair or reshape irregularities or imperfections in the skull) on 1/12/23 it was noted the right brain hemisphere had necrosis and turned into a soupy yellow substance. Later the brain broth grew staph epidermidis (gram-positive bacteria). The resident was sent to the Emergency Department for swelling and drainage from the recent head injury site and was admitted to the hospital's neurosurgical service. An operative Note indicated the resident underwent: 1. Incision, irrigation and sharp debridement of the right posterior cranial wound. 2. Removal of underlying hardware. A Neurosurgery Progress Note dated 3/14/23 indicated the resident's primary admitting diagnoses included cellulitis (skin infection) of the scalp. The skull flap was not removed. It did not look infected, but there was a need to keep pressure on the head to prevent the fluid from reaccumulating. A broad spectrum antibiotic was ordered and staples needed to be removed in 2-3 weeks. On 3/21/23 at 12:01 PM Resident 312 stated she/he did not remember much about the day she/he went to the hospital but staff told her/him they would send her/him when they were ready. The resident remembered her/his head not feeling right and she/he wanted to go to the hospital for a couple of days prior. On 3/22/23 at 12:18 PM Staff 15 (CNA) stated she had been working on Sunday 3/12/23. She was in the dining room and noticed Resident 312 had fluid coming out of the back of her/his head, her/his hair was matted down with fluid and there was leaking onto the neck area. Due to the resident's background of brain surgery with a skull flap she was very concerned. She asked Staff 9 (CNA) if Staff 6 (LPN) knew about the drainage. Staff 6 said she would contact the doctor but then did nothing about it. Staff 15 felt Staff 6 would not respond so went to Staff 18 (LPN). Staff 18 looked at the resident and said the resident should go out to the hospital. Staff 18 spoke to Staff 6 and expressed concerns about the resident's condition. Staff 6 said the resident was fine and she was not sending the resident to the hospital and just wiped off the fluid with gauze without using gloves (on a resident with an surgical brain wound and infectious disease). Staff 9 came by later and told her Staff 6 was squeezing the resident's head like a pimple and they both knew that was wrong. Staff 18 had talked to the DNS but nothing was done during the entire day shift. On 3/23/23 at 10:48 Staff 9 indicated she got the resident up that morning and into her/his chair. She noticed the leakage from the back of the resident's head. She went and told Staff 6 who looked and touched it (with her hands not gloved for a resident with an open brain wound and infectious disease) but did not do anything else about it. She was very concerned so she spoke to Staff 15 (CNA) and Staff 17 (CNA). Staff 15 went and told another nurse Staff 18 because they felt it was serious and Staff 6 was not responding. Later Staff 9 said she saw Staff 6 squeezing the area on the resident's head with her two thumbs like she was squeezing a pimple. Staff 18 was told again and Staff 9 asked if she should contact the DNS. Staff 18 contacted the DNS. Later that day Staff 9 reported to Staff 6 the wound was still swollen and draining and Staff 6 just told her to change the pillowcase. It felt that Staff 6 was not acting fast enough and the resident needed to go to the hospital. This went on for all of day shift. When the evening shift nurse came on duty, she sent the resident out within the hour. The resident never said no to going out to the hospital. On 3/23/23 at 3:30 PM Staff 2 (DNS) indicated the leaking had been identified by an RCM/LPN on 3/10/23 and an appointment had been made for Monday 3/13/23. He received a call from the day shift nurse indicating the wound was draining a lot and staff felt Staff 6 was not addressing the issue. He called Staff 6 who told him she was cleaning the drainage out of the resident's hair. Staff 6 said she called the physician's office and left a message and was waiting for a call back. Staff 6 told him she kept trying to get a hold of the physician. The resident was not sent out until the evening shift came on duty. Staff 2 did not indicate he had done anything else about the situation. No documentation was found in the resident's medical record to indicate Staff 6 called or tried numerous times to contact the physician; no assessment of the resident was completed by Staff 6 related to the possible change of condition for Resident 312 and no interventions were noted. No documentation was found to indicate Staff 6 had followed nursing standards of practice to address a possible change of condition for the resident. No documentation was found to indicate Staff 2 (DNS) had done anything else about the situation. On 3/23/23 at 3:00 PM Staff 18 (LPN) said a CNA came to her and said Staff 6 was not listening to her about a problem with Resident 312. The resident (who had recent brain surgery) had an area on the head that was swollen and draining a significant amount of a clear but lightly bloody fluid from the surgical site. Staff 18 went and spoke with Staff 6 who said she would take care of it. Staff 18 told Staff 6 if there was significant drainage, she should send the resident to the hospital. Staff 18 knew an RCM/LPN had noticed a little drainage the day before and they had called the neurosurgeon and set an emergency appointment for Monday but were told if the area got worse (swollen and drainage) the resident should go to the hospital because the neurosurgeon was on call at the hospital that weekend. Staff 6 said it was just an abscess and blew her off. Staff 18 stated another staff member, Staff 17 (CNA) came to her and said she saw Staff 6 trying to drain the wound herself. Staff 6 had her two thumbs and was pushing on the wound area like you would squeeze a pimple. Staff 18 indicated you should never do that for a brain surgery patient. The RCM/LPN was notified and then the DNS but nothing happened. The resident did not get sent to the hospital until the evening shift nurse came to work and she sent the resident out. Staff 6 should have assessed the resident but she did not. The resident was admitted to the hospital and had a surgical procedure and also had cellulitis (a skin infection) of the scalp. On 3/24/23 at 9:28 AM Staff 13 (LPN) said she worked the evening shift on 3/12/23. When she came in to work CNAs came up to her and told her there was a problem with Resident 312. The resident had fluid leaking from her/his surgical incision, the area was swollen and Staff 6 had been pressing on the area trying to drain it. They were all worried about the resident and felt Staff 6 was not addressing the issue. Staff 6 told her Resident 312 did not want to go to the hospital. Staff 13 went and saw the resident and thought she would have to convince the resident to go to the hospital but the resident told Staff 13 she/he had been asking to go to the hospital for three days so of course she/he would go. Then Staff 19 (CMA) told me Staff 6 kept telling her to give Resident 312 a pain pill, but you are not supposed to give pain medication if the resident may be going out to the hospital. Staff 6 first told Staff 13 to give the pain pill but Staff 13 would not because it should not be done under the circumstances and Staff 6 should know that was the case. Staff 13 said she had to assess the resident first. Staff 13 sent the resident out within the first hour she was on duty. Staff 6 put a note in the record which made it appear she had sent the resident out but she did not. Staff 13 indicated Staff 6 did not like to take recommendations from other staff and did not listen to them. Staff 13 was upset about the issue with Resident 312 because the resident wanted to go to the hospital. She tried to explain to Staff 6 as a nurse you should be able to assess a resident and determine that it would be more important to send the resident to the hospital if needed than to wait for a call back from a physician on a weekend. Staff 13 stated Staff 6 did not identify the change of condition, did not assess the resident and failed to intervene on the resident's behalf. On 3/27/23 at 5:50 PM Staff 11 (RCM/LPN) stated the Central Hall charge nurse had called her about Resident 312. Cognitively the resident was at baseline so she left it in the hands of the DNS. On Friday 3/10/23 the resident had complained about her/his head hurting. Staff 11 stated she expected the LPNs to know when they should send a resident to the hospital. They should do an assessment. She found no assessment for Resident 312. Staff 6 said she tried to reach the physician but there was no documentation to verify she had tried. Staff 11 thought Staff 6 had sent the resident out to the hospital but she did not, the evening shift nurse did. Staff 6 just put the note in the medical record. She should have been able to make the determination to send the resident out as needed without waiting for the physician to return a call. She knew it was a Sunday and reaching the physician would not be easy. 2. Resident 315 was admitted to the facility in 2018 with diagnoses including spastic cerebral palsy, persistent asthma and chronic respiratory failure and chronic obstructive pulmonary disease (COPD). On 3/12/23 at 10:22 AM Staff 6 (LPN) wrote: Resident presented with complaints of cough and congestion and audible wheezing noted. Breathing treatment inhaler given with little relief. Resident had Duoneb (breathing treatment) prior to breakfast. The resident stated, It helped a little. On 3/23/23 at 10:11 AM Staff 21(CNA) said Resident 315 was breathing wrong. The resident's vitals were off and the resident said she/he needed to go to the hospital. Staff 21 said she had just started her evening shift when she noticed the resident was not breathing right. A CNA on the front hall called her into the room and the resident said she/he could not breath well so Staff 21 ran and grabbed the nurse. Another staff told her the resident was in bed all day and that was not normal behavior for the resident. She was very concerned about the resident. She knew the resident well and he did not look or sound good. On 3/24/23 at 8:58 AM Staff 17 (CNA) indicated Staff 15 (CNA) and Staff 9 (CNA) reported concern to her about the condition of a couple of residents that day (3/12/22) including Resident 315. They told her the resident was having difficulty breathing and Staff 6 told the CNA to give the resident a shower to help the breathing but the resident needed to go to a hospital not take a shower. The resident had trouble breathing since early morning and she/he could not eat. The resident's respirations were 135. The CNAs stated they told Staff 6 but she did not send the resident out. She had done one breathing treatment earlier which did not help. Nothing else was done by Staff 6. The resident was finally sent out by the evening shift nurse Staff 13. On 3/24/23 at 9:28 AM Staff 13 (LPN) said she worked the evening shift on 3/12/23. When she came in to work CNAs came up to her and told her there was a problem with Resident 315. Multiple staff came to tell her to keep an eye on Resident 315 as the resident was not breathing well and did not look good. Within an hour she sent the resident out to the hospital. After shift change report she went in to see Resident 315. The resident's stats were down and she/he looked bad. The resident should have been sent out earlier. Staff 13 stated she had never sent two people out to the hospital in that short amount of time. The resident had a c-pap mask on and by the way she/he was breathing she could tell she/he must have had breathing issues for quite a while. Two CNAs changed the resident and said the resident could barely breathe. Staff 13 looked at the resident's history and the aides got her/ him ready. When she was on the phone with 911 for Resident 315 she requested Staff 6 to assist with the call to the hospital on the conditions of the resident during the day but Staff 6 would not do so. Staff 13 said Staff 6 should have sent both the residents out to the hospital but did not do so. No documentation was found to indicate Staff 6 had assessed Resident 315 or provided appropriate interventions for a resident with respiratory distress. A hospital H&P dated 3/12/23 indicated the resident's chief complaint was shortness of breath for the last few days and much worse today. In the Emergency Department Resident 315 was noted to be in respiratory distress. The resident received nebulizer treatment, IV steroids, oxygen and IV magnesium. The resident remained with increased difficulty breathing and audible rhonchi (secretions in breathing) and therefore the hospitalist was consulted for admission. The Hospital Course: resident was admitted with acute asthma exacerbation and human metapneumovirus infection (same virus family as RSV). On 3/27/23 at 5:50 PM Staff 11 (RCM/LPN) indicated she expected the LPNs to know when they should send someone out to the hospital and when to do an assessment. There was no assessment or documentation by Staff 6. Staff 11 said if the resident's breathing was as bad as they said, she/he should have been sent out to the hospital without waiting. She understood Staff 6 did one nebulizer treatment for Resident 315 but it was not effective. Staff 11 also said for Staff 6 to direct the CNA to give the resident a shower to help his breathing was not an appropriate medical treatment for a resident in respiratory distress.

Based on deficient practice in the areas of Freedom from Abuse, Neglect and Exploitation, Investigate/Prevent/Correct Alleged Violations and failure to adhere to Professional Standards of Practice of nursing to identify, assess and intervene for residents' Change of Condition it was determined the facility was not administered by the management team in an effective and efficient manner to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. As a result: Residents 305, 309 and 314 were mentally and verbally abused and Residents 312 and 315 experienced delays in treatment for significant changes of condition requiring hospitalization. Findings include: 1.The facility failed to ensure residents were free from mental and verbal abuse. a. On 12/8/22 Staff 5 (CNA) heard Staff 6 (LPN) yelling and screaming at Resident 305 to take her/his medications. Staff 5 indicated facility management was aware of Staff 6's behaviors but had done nothing about it and Staff 6 continued to work with residents. On 12/8/22 Staff 7 (CNA) heard Staff 6 (LPN) yelling and screaming at Resident 305. Staff 7 said she felt Staff 6 deliberately antagonized residents and many of them did not care for her. Staff 7 said she knew some residents would refuse their medications so they would not have to interact with Staff 6. Staff 7 said she believed this was verbal abuse but no one at the facility ever interviewed her about this incident and Staff 6 continued to work with residents. On 3/23/23 Staff 14 (RCM/LPN) indicated Staff 6 had negative interactions with Resident 305 and with other residents also. Staff 6 would raise her voice to the residents and throw temper tantrums. Staff 14 said she told Staff 6 not to argue with residents and she had given verbal corrections. Staff 6 was also belittling, demeaning and disrespectful to residents and other staff. She reported her concerns to Staff 1 (Administrator) and Staff 2 (DNS) but nothing was done. On 3/20/23 Staff 1 (Administrator) and Staff 2 (DNS) indicated Staff 4 (RCM/LPN) would have the information about this incident. No documentation was provided to indicate an investigation had been done by Staff 1 or Staff 2. On 3/21/23 Staff 4 (RCM/LPN) said CNAs came and told her there was a problem between Staff 6 and Resident 305. She told Staff 1 (Administrator) and Staff 2 (DNS) about the incident. Staff 4 acknowledged she had not identified the incident as possible abuse and she failed to investigate the CNAs abuse allegations. She stated she did not complete an investigation and she should have. She did not interview or speak to the CNAs who were present during the incident or to other residents or staff. Staff 1 (Administrator) and Staff 2 (DNS) were notified of the incident but also failed to identify it as possible abuse. b. On 3/23/23 Resident 314 stated one of the nurses was very mean to her. The resident said the nurse was very rude to her/him, she was not patient or nice and made her/him feel bad. The resident's roommate was alert and oriented and identified the nurse in question as Staff 6. On 3/22/23 Staff 14 (RCM/LPN) indicated she was aware Staff 6 had multiple negative interactions with residents including Resident 314. Staff 14 stated she took her concerns to Staff 1 (Administrator) and Staff 2 (DNS) but no corrective action was taken. On 3/23/23 Staff 1 (Administrator) and Staff 2 (DNS) provided no additional documentation related to this incident. c. On 3/23/23 Resident 309 indicated there was a problem with Staff 6. Staff 6 was very belligerent and rude to her/him, her/his roommate, other residents and staff. Staff 6 snapped at everyone. Resident 309 also stated she did not like to come out of her/his room when Staff 6 worked because it was so unpleasant to be around her. On 3/22/23 Staff 14 (RCM/LPN) indicated she was aware Resident 309 had reported complaints about Staff 6. The resident stated she did not feel safe around Staff 6. Staff 14 stated she took her concerns to Staff 1 (Administrator) and Staff 2 (DNS) but was not aware that any corrective action was taken and Staff 6 continued to work with residents. On 3/23/23 at 3:45 PM Staff 1 (Administrator) and Staff 2 (DNS) provided no additional documentation related to this incident. Refer to F 600 2. The facility failed to ensure staff to resident incidents were investigated to rule out abuse. a. On 12/8/22 Staff 5 (CNA) said she heard Staff 6 (LPN) yelling and screaming at Resident 305. Staff 5 stated she felt it was verbal abuse but no one interviewed her about it and Staff 6 continued to work with residents. On 12/8/22 Staff 7 (CNA) indicated she heard Staff 6 yelling at Resident 305. She tried to get Staff 6 to stop yelling and leave the room but Staff 6 would not. Staff 7 felt it was abuse but no one interviewed her about it. On 3/21/23 at 9:45 AM Staff 4 (RCM/LPN) said CNAs came and told her there was a problem between Staff 6 and Resident 305. Staff 4 acknowledged she had not identified the incident as possible abuse and she failed to investigate the CNAs abuse allegations. Staff 1 (Administrator) and Staff 2 (DNS) were notified of the incident but also failed to identify it as possible abuse. No documentation of an investigation was provided by Staff 1 (Administrator) or Staff 2 (DNS) when requested. Refer to F 610 3. The facility failed to ensure residents were comprehensively evaluated and received timely treatment for serious changes of conditions which resulted in hospital admissions. a. Resident 312 was admitted to the facility in 2022 with diagnoses including hemicraniectomy (surgical procedure where a large flap of the skull is removed and the dura is opened; this gives space for the swollen brain to bulge and reduces the intracranial pressure), HIV disease and viral Hepatitis C. On 3/22/23 Staff 15 (CNA) stated she went to Staff 6 about Resident 312 having swelling and fluid draining from the site where she had brain surgery. Due to the resident's background of brain surgery with a skull flap (allows access to the brain) she was very concerned. Staff 6 said she would contact the doctor but did not and did nothing else about the CNAs concerns. Staff 15 then notified another nurse Staff 18 (LPN) who recommended Staff 6 send the resident out to the hospital. Staff 6 did not. Staff 18 spoke to the DNS and he called Staff 6 but nothing was done to correct the situation and no additional interventions were attempted. On 3/23/23 at 10:48 Staff 9 (TITLE) indicated noticed swelling and leakage from the back of Resident 312's head. She told Staff 6 who looked and touched it (with her hands not gloved for a resident with an open brain wound and infectious disease) but did not do anything else about it. Staff 9 also said she saw Staff 6 squeezing the area on the resident's head with her two thumbs like she was squeezing a pimple. Later Staff 9 reported to Staff 6 the resident's head was still swollen and draining and Staff 6 told her to change the pillowcase. Staff 9 felt that Staff 6 was not acting fast enough and the resident needed to go to the hospital On 3/23/23 at 3:30 PM Staff 2 (DNS) indicated the leaking had been identified by an RCM/LPN on 3/10/23 and an appointment had been made for Monday 3/13/23. He received a call from the day shift nurse indicating the wound was draining a lot and staff felt Staff 6 was not addressing the issue. He called Staff 6 who told him she was cleaning the drainage out of the resident's hair. Staff 6 said she called the physician's office and left a message and was waiting for a call back. She did not send the resident to the hospital although numerous staff had indicated she should. Staff 2 did not indicate he had done anything else about the situation. On 3/24/23 at 9:28 AM Staff 13 (LPN) said she worked the evening shift on 3/12/23. She was the nurse who send finally sent Resident 312 to the hospital. Staff 6 did not identify the resident's change of condition, did not assess the resident and failed to intervene on the resident's behalf. No documentation was found in the resident's medical record to indicate Staff 6 called or tried numerous times to contact the physician; no assessment of the resident was completed by Staff 6 related to the serious change of condition for Resident 312 and no interventions were noted. No documentation was found to indicate Staff 6 had followed nursing standards of practice to address a possible change of condition for the resident. No documentation was found to indicate Staff 2 (DNS) had done anything about the situation or provide any intervention for the resident. b. Resident 315 was admitted to the facility in 2018 with diagnoses including spastic cerebral palsy, persistent asthma and chronic respiratory failure and chronic obstructive pulmonary disease (COPD). On 3/24/23 at 8:58 AM Staff 17 (CNA) indicated Staff 15 (CNA) and Staff 9 (CNA) reported concerns to her about the condition of Resident 315. They told her the resident was having difficulty breathing and Staff 6 told the CNA to give the resident a shower to help the breathing. They felt the resident needed to go to a hospital not take a shower. The resident had trouble breathing since early morning and could not eat. The resident's respirations were 135. The CNAs stated they told Staff 6 but she would not send the resident to the hospital. Staff 6 did one breathing treatment earlier which did not help. Nothing else was done by Staff 6. On 3/24/23 at 9:28 AM Staff 13 (LPN) said she worked the evening shift on 3/12/23. When she came in to work multiple CNAs came to her and told her there was a problem with Resident 315. Resident 315 was not breathing well and did not look good. Staff 13 went in to see the resident. The resident's stats were down and she/he looked bad. The resident had a c-pap mask on and by the way she/he was breathing she could tell she/he must have had breathing issues for quite a while. She assessed the resident, checked the resident's history and sent him out with an hour of starting her shift. When she was on the phone with 911 for Resident 315, she requested Staff 6 assist with the call to the hospital on the conditions of the resident during the day but Staff 6 would not do so. Staff 13 said Staff 6 should have sent the resident out to the hospital in the morning when his breathing issues had worsened, but she did not. This was the second resident Staff 6 had failed to send out to the hospital that day. No documentation was found to indicate Staff 6 had assessed Resident 315 or provided appropriate interventions for a resident with respiratory distress. A hospital H&P dated 3/12/23 indicated the resident's chief complaint was shortness of breath for the last few days and much worse today. In the Emergency Department Resident 315 was noted to be in respiratory distress. The resident received nebulizer treatment, IV steroids, oxygen and IV magnesium. The resident remained with increased difficulty breathing and audible rhonchi (secretions in breathing) and therefore the hospitalist was consulted for admission. The Hospital Course: resident was admitted with acute asthma exacerbation and human metapneumovirus infection (same virus family as RSV). Refer to F600, F610, F658 and F684 4. The facility failed to ensure Professional Standards of Practice were adhered to related to Abuse and Changes of Condition. a.) On 3/21/23 at 9:45 AM Staff 4 (RCM/LPN) said CNAs came and told her there was a problem between Staff 6 and Resident 305. Staff 4 acknowledged she had not identified the incident as possible abuse and she failed to investigate the CNAs abuse allegations. Staff 1 (Administrator) and Staff 2 (DNS) were notified of the incident but also failed to identify it as possible abuse. The incident was later determined to be mental and verbal abuse of Resident 305 by Staff 6. On 3/21/23 no documentation of an investigation was provided by Staff 1 (Administrator) or Staff 2 (DNS) when requested. b.) On 3/22/23 at 12:01 PM Staff 4 (RCM/LPN) indicated she was aware Staff 6 had multiple negative interactions with residents including Resident 309 and she was aware that Resident 309 had also reported complaints about Staff 6. The resident stated she did not feel safe around Staff 6. Staff 14 took her concerns to Staff 1 (Administrator) and Staff 2 (DNS) but was not aware that any corrective action was taken and Staff 6 continued to work with residents. The incident was later determined to be mental and verbal abuse of Resident 309 by Staff 6. No documentation was found or provided related to Resident 309's reported complaints about Staff 6. c.) On 3/22/23 at 12:01 PM Staff 14 (RCM/LPN) indicated Staff 6 had multiple negative interactions with residents including Resident 314 who complained Staff 6 was mean to her/him. Staff 14 stated she took her concerns to Staff 1 (Administrator) and Staff 2 (DNS) but was not aware that any corrective action was taken and Staff 6 continued to work with residents. The incident was later determined to be mental and verbal abuse of Resident 314 by Staff 6. No documentation was found or provided related to Resident 314's reported complaints about Staff 6. d.) On 3/22/23 Staff 15 (CNA) stated she went to Staff 6 about Resident 312 having swelling and fluid draining from the site where she had brain surgery. Due to the resident's background of brain surgery with a skull flap (allows access to the brain) she was very concerned. Staff 6 said she would contact the doctor but did not and did nothing else about it. Staff 15 then notified another nurse Staff 18 (LPN) who recommended Staff 6 send the resident out to the hospital. Staff 6 did not. Staff 18 spoke to the DNS and he called Staff 6 but nothing was done to correct the situation. On 3/27/23 Staff 11 (RCM/LPN) stated she expected LPNs to know when they should send a resident to the hospital. They should do an assessment. She found no assessment for Resident 312. Staff 6 said she tried to reach the physician but there was no documentation to verify she had tried. Staff 6 failed to make the determination to send the resident out as needed. Staff 6 knew it was a Sunday and reaching the physician would not be easy. There were also instructions to send the resident to the hospital if her/his condition worsened because the neurosurgeon was on call that weekend. Staff 6 failed to identify, assess or intervene for the resident with a change of condition that required hospitalization. No documentation was found to indicate Staff 6 had followed nursing standards of practice to address a serious change of condition for Resident 312 or that Staff 2 (DNS) had done any follow up to ensure the resident received appropriate care. e.) On 3/24/23 Staff 17 (CNA) indicated Staff 15 (CNA) and Staff 9 (CNA) reported concerns to her about the condition of Resident 315. The resident had trouble breathing since early morning and she/he could not eat. The resident's respirations were 135. Staff 17 said they told Staff 6 this was not normal for the resident but she would not send the resident out. She did one breathing treatment for the resident which did not help. Nothing else was done by Staff 6. A hospital H&P dated 3/12/23 indicated the resident's chief complaint was shortness of breath for the last few days and much worse today. In the Emergency Department Resident 315 was noted to be in respiratory distress. The Hospital Course: resident was admitted with acute asthma exacerbation and human metapneumovirus infection (same virus family as RSV). On 3/27/23 Staff 11 (RCM/LPN) indicated she expected LPNs to know when they should send someone out to the hospital and when to do an assessment. There was no assessment or documentation by Staff 6. Staff 11 said if Resident 315's breathing was as bad as staff indicated he should have been sent out to the hospital without waiting. She understood Staff 6 did one nebulizer treatment for Resident 315 but it was not effective. Staff 11 also said Staff 6 had directed a CNA to give the resident a shower to help her/his breathing. That was not an appropriate medical treatment for a resident in respiratory distress. Refer to F600 and F658

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to assess, monitor and follow physician orders that were consistent with professional standards of practice for 1 of 4 sampled residents (# 37) reviewed for pressure ulcers. Resident 37 had a worsening wound. Findings include: Resident 37 was admitted to the facility in 8/2020 with diagnoses including diabetes and stroke. A revised care plan dated 10/25/21 indicated Resident 37 had an ADL self-care performance deficit and limited mobility related to stroke, morbid obesity and depression. Resident 37 required two-person assistance with bed mobility and repositioning. Resident 37 was at risk for impaired skin integrity and staff were to consult the wound nurse as appropriate. Resident 37 was readmitted on [DATE] with diagnoses of MRSA (methicillin resistant staphylococcus). A 4/25/22 admission Nursing Database revealed Resident 37's BIMS was 15 indicating she/he was cognitively intact. Resident 37 had a right heal blister. The length was 2.0 cm by a width of 1.5 cm. The blister was intact with brown edges. A physician order dated 4/25/22 directed staff to protect the blister by covering with Meplilex (a border dressing), and change the dressing every three days on Mondays and Thursdays. Staff were directed to keep the heel offloaded from the bed surface at all times and were to use a green offloading boot or pillow. -There was no clinical documented evidence of weekly wound assessments for Resident 37's and the care plan was did not direct staff to offload her/his right heel. On 5/2/22 at 10:20 AM and 5/5/22 at 11:06 AM Resident 37 stated she had a wound on her/his right heel and was not sure how she/he acquired it. Resident 37 stated she/he was to have a heel protector on her/his right foot when in bed but it was was not always done. Resident 37 stated she/he only had her/his right heel bandage changed one time that she/he could recall. Random observations on 5/4/22 from 12:43 PM through 3:00 PM revealed Resident 37 was in bed and her/his right foot was resting on the mattress without a boot protector or pillow underneath the right foot. On 5/5/22 at 11:14 AM Resident 37 was in bed with her/his right foot uncovered, her/his right foot was rolled outward as she/he tried to lift her/his foot, her/his heel stuck to the sheet. Resident 37's right heel was not bandaged the wound was nickel size, red in the center and white around the outside edges of the wound. On 5/5/22 at 3:11 PM Staff 26 (RCM/LPN) entered the room and acknowledged Resident 37's right heel was not offloaded. Staff 26 described the wound and indicated a circle at the base of her/his right heel, the wound was reddish/purple and the outer portion was white, not hot or warm, no drainage to the wound and Resident 37 indicated the wound was not painful. On 5/5/22 interviews were completed with Staff 27 (CNA) at 12:30 PM, Staff 32 (CNA) at 2:39 PM and Staff 31 (CNA) at 2:56 PM. All stated Resident 37 was dependent for bed mobility and repositioning in bed. Staff stated they were not aware of and wounds on Resident 37 except for her/his incision site from a previous fall. On 5/5/22 at 3:25 PM Staff 26 (RCM/LPN) acknowledged Resident 37's wound was not monitored appropriately. The right heel wound did not have a dressing on it, was not offloaded while the resident was in and Resident 37 was not placed on weekly wound rounds. A Skin and wound Evaluation on 5/6/22 revealed Resident 37 had a deep tissue injury (persistent non-blanchable deep red, maroon or purple discoloration) and was present upon admission. The wound area measured 2.1 cm squared by 1.7 cm in length by 1.8 cm in width. On 5/9/22 at 11:25 Staff 1 (Administrator) and Staff 2 (DNS) expected staff to complete thorough skin audits upon admission or re-admission, ensure weekly skin and wound rounds were initiated and completed, the care plan to be reflective of Resident 37's skin integrity and staff to follow the care plan.

Based on interview and record review the facility failed to ensure a resident was transferred safely for 1 of 2 sampled residents (#37) reviewed for accidents. Resident 37 sustained a fracture to her/his left femur. Findings include: Resident 37 was admitted to the facility in 8/2020 with diagnoses including diabetes and stroke. A revised care plan dated 10/25/21 indicated Resident 37 had an ADL self-care performance deficit and limited mobility related to stroke, morbid obesity and depression. Resident 37 required two-person assistance with bed mobility, repositioning and required a mechanical lift for transfers. A Fall Incident Report dated 3/27/22 revealed the following: -Resident 37 was being transferred from her/his bed to her/his wheelchair by Staff 28 (CNA) and Staff 29 (CNA) and the mechanical lift tipped over during the transfer. -Staff 28 indicated while transferring Resident 37, the mechanical lift legs were partially open to allow her/his wheelchair to fit as close to her/him as possible and Resident 37 was sideways in the mechanical lift directly above her/his wheelchair which was also sideways. When Staff 28 and Staff 29 pulled up the straps on the back of the mechanical lift to get her/him positioned correctly the entire mechanical lift tipped over sideways. -Staff 29 indicated while transferring Resident 37 she/he was hooked up to the mechanical lift and the mechanical lift legs were partially opened to get her/him as close to her/his wheelchair as possible. Resident 37 was sideways directly above the wheelchair when Staff 28 and Staff 29 pulled her/him back her/his weight shifted towards the bathroom and the mechanical lift just fell on top of her/him towards the bathroom and Staff 29 tried to push the mechanical lift out of the way but could not catch the lift in time. -The mechanical lift legs were not in a locked position and were not fully open when the mechanical lift tipped over onto Resident 37. The mechanical lift was rated for Resident 37's weight. -Resident 37 was on the floor and her/his head was against the bathroom door and the mechanical lift was pressed on top of her/him. -Staff 17 (LPN) assessed Resident 37 for injuries once the mechanical lift was removed off her/him. Resident 37 was yelling and screaming throughout the assessment and her/his pain level was 10 out 10. Resident 37 bumped her/his head during the fall, complained of pain to her/his left knee and left hip and her/his right great toenail was partially off and bleeding. -Resident 37 was sent to the hospital which revealed she/he had fractured her/his left leg. A 5/1/22 Plan of Correction revealed the following: -A facility incident report was completed regarding the 3/27/22 incident which revealed Resident 37 was being transferred from her/his bed to her/his wheelchair by Staff 28 (CNA) and Staff 29 (CNA) and the mechanical lift tipped over during the transfer. The mechanical lift legs were not in a locked position and were not fully open when the mechanical lift tipped over onto Resident 37. The mechanical lift was rated for Resident 37's weight. Resident 37 fractured her/his leg due to the fall. -All staff were educated and completed competencies regarding safe transfers. -Continued education occurred at the all staff meetings, CNA meetings and the Hoyer lift manufacturer training video was viewed at the meetings. -The results of the weekly audits completed were brought to Quality Assurance and Performance Improvement and further audits would be completed as directed. On 5/2/22 at 10:27 AM Resident 37 stated she/he had fractured her/his left leg due to a transfer in the mechanical lift. Resident 37 stated two CNAs were transferring her/him from her/his bed to her/his wheelchair and the whole lift tipped over and she/he was still in the sling when she/he hit the floor. Resident 37 stated staff got her/him unattached from the sling and moved the mechanical lift off her/him and her/his entire left side was very painful. Resident 37 stated she/he was sent to the hospital and x-rays confirmed she/he broke her/his left femur as a result from the mechanical lift fall. On 5/6/22 at 11:28 AM Staff 28 stated she assisted with the transfer on 3/27/22 for Resident 37. Staff 28 stated she was behind the mechanical lift and had the control in her hand. Staff 29 was the other CNA in the room and Staff 29 was repositioning Resident 37 while in the sling to get her/him in the wheelchair. When Staff 29 pulled on the sling, the mechanical lift fell over on top of Resident 37. Staff 28 stated she remembered the legs of the mechanical lift being partially opened and one of them she thought was in a locked position. Staff 28 stated Resident 37 was still attached in the sling when the mechanical lift fell on top of her/him. Staff 28 stated Resident 37 was crying in pain and yelling her/his leg hurt and she/he did not want to be on the floor. Staff 28 stated Staff 17 entered the room, assessed her/him and the mechanical lift was pulled off Resident 37. On 5/9/22 at 9:36 AM Staff 29 stated she assisted with the transfer on 3/27/22 for Resident 37. Staff 29 stated Resident 37 was in the mechanical lift moving her/him from the bed to the wheelchair when Staff 28 (her CNA partner) pulled Resident 37 towards her, the mechanical lift tipped over on the floor and was on top of Resident 37. Staff 29 did not recall if the mechanical lift legs were locked or open because it happened so fast. Staff 29 stated Resident 37 had some blood to her/his toe and landed on her/his left side. On 5/9/22 at 10:01 AM Staff 17 stated she was in the building working at the nurses' station on 3/27/22 when she heard a loud crash and entered Resident 37's room, and found her/him on the floor with the mechanical lift on top of her/him. Staff 17 stated the mechanical lift legs were not fully opened and they were not in a locked position causing the mechanical lift to tip over. Staff 17 stated Resident 37 was hysterical, talking fast and swearing. On 5/9/22 at 11:25 AM Staff 39 (Regional Nurse Consultant) stated he was in the building when Resident 37 had her/his fall on 3/27/22. Staff 39 stated he entered the room and Resident 37 was up against the bathroom door and complained of pain to her/his left side. Staff did move her/him away from the bathroom door and she/he was having increased pain to her/his left leg. Staff 39 stated Staff 28 and Staff 29 were doing a side transfer with Resident 37 and should not have attempted the transfer. Staff 39 further stated the mechanical legs were not fully open or in a locked position when attempting to place Resident 37 in her/his wheelchair.