**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to ensure a resident and resident's representative had the right to direct her/his own care, refuse hospice and be aware of all treatment options for 1 of 3 sampled residents (#5) reviewed for hospice. This caused Resident 5 to be admitted to hospice and sustained a distressing and diminshed quality of life prior to death. Finding include: Resident 5 admitted to the facility on [DATE] with diagnoses including heart failure and chronic pleural effusion (an excessive accumulation of fluid in the lungs pleural space). The resident died on [DATE]. On [DATE] Resident 5 admitted with a PleurX catheter (a small, flexible tube that doctors place within the patient's chest to drain fluid from the pleural space). [All licensed nurses within the State of Oregon may drain the catheter with proper training.] The [DATE] admission Orders directed staff to drain the PleurX catheter to a maximum 1,000 cc removal at a time, note the amount drained and to notify the physician if the SpO2 (oxygen saturation) was less than 90%. The [DATE] Physician Order indicated the catheter was to be drained at a clinic or hospital only; every Monday, Wednesday and Friday. [There was no documentation the facility informed the physicin it was within the nurse's scope of practice to drain the catheter.] The facility's staffing records revealed between [DATE] through [DATE] one and a half to three RN's were on duty daily in addition to multiple LPN's. A [DATE] provider encounter noted revealed there was a concern with getting Resident 5's PleurX catheter drained. The provider noted the resident had great self awareness of when this needs to happen. And reporting that [she/he] is having difficulty breathing and needing it. The provider spoke with the DNS and it was determined if the facility had no staff available to drain the catheter then to transfer the resident to the hospital. The [DATE] Progress Note's revealed Resident 5 was transferred to the hospital for increased pulse and shortness of breath. The hospital drained 2,000 cc from the catheter. A [DATE] provider note indicated she spoke with Resident 5's healthcare POA, discussed concerns of ongoing draining of the PleurX catheter and after a long discussion of options for draining at the facility it was decided to update the POLST form for DNR comfort only and refer Resident 5 to hospice. A [DATE] Hospice note reveals Resident 5 was admitted to hospice services. A [DATE] Progress Note revealed the resident made comments about harming her/himself, asked for a hammer because she/he hurt so bad and asked the CNA if she could help her/him kill her/himself. A [DATE] Progress Note revealed Resident 5's healthcare POA was upset because she was not told why the facilty could not drain Resident 5's PleurX catheter. The note further stated the goal was to transition the resident off of hospice so they could obtain aggressive treatment with a specialist but they needed home health set up first so the resident would not have to go to the hospital to get the PleurX catheter drained. The healthcare POA stated she understood the resident may not live much longer but still did not want hospice at this time. A [DATE] Progress note revealed they spoke with Resident 5's daughter about the PleurX catheter and how we were unable to meet [her/his] needs due to the licensing of our nurses and not having an RN to do it. Options were discussed and it was decided the facility would look for alternative placement but to keep the resident on hospice so they could manage the drain. The [DATE] Discharge Summary note indicated the funeral home picked the resident up. [There were no notes related to the residents passing in the medical record.] On [DATE] at 8:47 AM Witness 7 (Complainant) stated the facility did not want to provide care and services for the PleurX catheter and placed the resident on hospice against her/his will. Resident 5's family notified Witness 7 that they did not want hospice but felt like their back was against the wall. The resident was admitted to the facility specifically for the facility to manage the catheter however care did not happen and she/he was sent to the hospital for catheter care. Resident 5 and family were given the decision to either send the resident to the hospital for routine catheter care or go onto hospice. Witness 7 stated she reached out the the facility to coordinate nurse education if that was what was needed and offered to have a provider or the catheter company provide a tutorial which the facility declined. The facility stated this [PleurX catheter] was something they did not do. Witness 7 stated care facilities should be able to manage the catheter and even lay people can be taught to do it. On [DATE] at 8:58 AM an interview was conducted with Staff 1 (Administrator), Staff 2 (DNS) and Staff 3 (LPN, Assistant DNS). Staff 1 stated the facility did not know how to care for the catheter, did not have sufficient RN staffing to care for the resident and the facility was unaware the resident had a PleurX catheter on admission but verified this information was in the resident's admission paperwork which they reviewed prior to the resident's admission. Staff 1 stated she declined training offered by the Resident's Case Manger and verified the resident went on hospice to avoid hospital emergency room visits. On [DATE] in the AM Staff 1 and Staff 3 stated they were unaware LPN's were allowed to provide care and services related to the PleurX catheter with proper training. Staff 1 verified when treatment alternatives to hospice were discussed training the LPN's was not discussed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents were free from neglect. The facility failed to ensure a resident had the right to receive skilled care from trained nurses and refuse hospice, failed to ensure resident assessments were completed timely, care plans were reviewed, interventions in place and implemented, failed to assess and monitor pressure ulcers and follow physician orders for skin conditions, failed to recognize and act on a change of condition, and failed to ensure residents did not elope from the facility. The cumulative effect of these failures in providing care and services contributed to an environment of neglect for 8 of 15 sampled residents (#s 2, 3, 4, 5, 9, 11, 13 and 15) reviewed for care and services. This caused Resident 5 to not get physician ordered treatment and coerced to agree to hospice services and placed all residents at risk for neglect of care. Findings include: According to the Centers for Medicare & Medicaid Services (CMS), §483.5, Neglect, means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. CHANGE OF CONDITION Resident 2 Resident 2 admitted to the facility in 4/2022 with diagnoses including intellectual disabilities and neurogenic bladder. The 3/11/22 Risk For Infection related to the use of a urinary catheter care plan included the following interventions: change catheter and Foley (catheter) bag as scheduled or as ordered by the physician, monitor the indwelling catheter and report to the physician signs and symptoms of UTI such as pain, burning, blood tinged urine, cloudiness, no urine output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior and change in eating patterns. The 4/6/22 Return From Hospital care plan interventions included to monitor appetite and document the percentage eaten each meal and to monitor pain and discomfort. A 4/29/22 Progress note revealed Resident 2's urine was cloudy with foul smell, had increased agitation and a UA (urinalysis) was collected. A 5/4/22 Progress note revealed a negative UA result. The 5/4/22 task documentation revealed Resident 2's UOP (urine output) was 1150 cc. Meal intake for breakfast was 26 to 50%, lunch zero to 25% and dinner was refused. Fluid intake was 980 cc. A 5/6/22 Progress note revealed Resident 2 was very irritable and refused the catheter change. Blood Pressure was 71/49 [No evidence of physician notification or assessment or monitoring was completed.] The 5/6/22 task documentation revealed Resident 2's UOP was 675 cc, fluid intake was 460 cc and meal intake for breakfast and lunch was zero to 25% and dinner 26 to 50%. A 5/7/22 Progress Note revealed Resident 2 was on alert due to having cloudy urine, having increased sediment and foul odor. The 5/8/22 task documentation revealed fluid intake was 540 cc. The 5/9/22 task documentation revealed the resident consumed zero to 25% of all meals and fluid intake was 360 cc. The 5/10/22 task documentation revealed fluid intake was 270 cc. Meal intake for breakfast was 26 to 50%, lunch zero to 25% and refused dinner. The 5/11/22 task documentation revealed 500 cc UOP, 780 cc fluid intake and meal intake varied from zero to 75%. The 5/12/22 task documentation revealed 475 cc UOP, 120 cc fluid intake, meal intake for breakfast and dinner was refused, lunch was zero to 25%. The resident took in additional nutrition in the evening between 75-100%. The 5/13/22 task documentation revealed 950 cc UOP, Fluid intake was 240 cc with one meal intake not documented and meal intake zero to 25% for breakfast and dinner and lunch was not documented. The 5/14/22 task documentation revealed 560 cc UOP, 740 cc fluid intake, breakfast and dinner refused with zero to 25% lunch meal intake. The 5/16/22 task documentation revealed UOP was 25 cc on night shift and 260 cc on day shift. Fluid intake was 20 cc for breakfast and 120 cc for lunch. Meal intake was zero to 25% for breakfast and lunch. The 5/16/22 12:01 PM Progress note revealed a CNA reported Resident 2 was not acting like [her/himself] today. Blood pressure was 94/59, resident stated she/he felt unwell and was unable to describe any specific symptoms. The urine was red/brown tinged and mucus was present. The residents speech was slurred. The provider was called and staff were waiting for a call-back. The 5/16/22 2:00 PM Progress note revealed the provider called back and gave orders to push fluids, administer an antibiotic shot, change the indwelling catheter and to obtain a stat [immediate] UA. The 5/16/22 provider encounter note revealed the resident was seen for a concern of a possible UTI. The urine was reported to have foul odor and was cloudy with a dark color. The catheter was changed and the urine was clear after the indwelling catheter change. The resident complained of stomach and ear pain. The 5/16/22 2:38 PM indicated the resident was transported to the hospital for altered mental status and hypotension (low blood pressure). The 5/17/22 Progress note revealed the hospital notified the facility the resident passed away with a small bowel obstruction, UTI, sepsis (full body infection) and acute renal failure. The 5/17/22 Hospital Records revealed Resident 2 was transferred to the hospital for malaise, fatigue and low blood pressure. The resident was diagnosed with UTI , septic syndrome secondary to UTI, acute kidney injury, anemia, hypoalbuminemia (abnormally low blood level of albumin (type of protein)), gastric outlet obstruction, gastrointestinal bleed and severe anion gap metabolic acidosis (imbalanced electrolytes). On 5/16/22, after discussion of options with the family, the residents POLST was changed to DNR and the resident passed away on 5/17/22. The 5/24/22 Death Certificate revealed Resident 2's immediate cause of death was severe sepsis with septic shock, approximate onset to death, one day, due to pseudomonas UTI, approximate onset to death, five days. Other significant conditions contributing to death gastric outlet obstruction. There was no evidence in the medical record the provider was notified of the residents decreased appetite, fluid intake, urine output, low blood pressure, increased confusion, irritability or malaise. There was no evidence of monitoring of signs and symptoms of UTI. On 12/21/22 at 9:25 AM Resident 16 (roommate) verified she was Resident 2's roommate and stated the week prior to her/his transfer to the hospital Resident 2 had increased irritability and was in pain. On 12/19/22 12:30 PM Staff 6 (Former NA) stated the week prior to Resident 2 transferring to the hospital her/his urine was brown in color and had increased confusion. On 12/19/22 at 2:21 PM Staff 11 (CNA) stated in the two weeks prior to Resident 2's hospital transfer she/he was pretty confused, tired, had a poor appetite, irritable, pretty out of it and the urine bag was not looking like it should. Staff 11 stated she recalled the nurses looking at the resident's urine bag but had no idea what the nurses did. On 12/19/22 at 3:10 PM Staff 13 (LPN) stated staff were monitoring Resident 2's urine for amber color. On 12/20/22 at 2:00 PM Staff 4 (Administrator in Training) recalled talking the Resident 2's sister about her concerns of Resident 2's health related to cognition, loss of appetite, getting up less and concerns of UTI. Staff 4 stated I finally asked [staff] to send her out so they did. On 12/20/22 at 3:30 PM Staff 16 (LPN) verified she wrote the 5/6/22 progress note, confirmed the resident was very irritable, refused the catheter change and had a blood pressure of 71/49. Staff 16 verified she did not further assess the resident or notify the physician of the low blood pressure, irritability or refusal of the catheter change. On 12/20/22 at 3:35 PM Staff 16 (LPN) stated the week prior to Resident 2's hospital transfer she/he was very irritable which was not normal because she/he was usually sweet and pleasant. On 12/21/22 at 9:50 AM Staff 7 (CNA) stated in the two weeks prior to Resident 2's hospital transfer she/he ate less because she didn't feel good enough to eat and needed more encouragement to attempt to eat and drink. Staff 7 further stated she noted a decline in Resident 2's overall abilities. On 12/21/22 at 9:59 AM Staff 5 (Support RN) verified between 5/2/22 through 5/16/22 there was only one alert note related to monitoring the resident's urine or for signs of UTI. On 12/21/22 at 10:10 AM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged Resident 2's care plans were not followed and the low blood pressure was not reported to the physician or assessed. Staff 1 and Staff 2 acknowledged the resident's decline in condition was not assessed and the physician was not notified until 5/16/22. Staff 1 acknowledged the 5/24/22 Death Certificate revealed Resident 2's immediate cause of death was severe sepsis with septic shock, approximate onset to death, one day, due to pseudomonas UTI, approximate onset to death five days. Other significant conditions contributing to death gastric outlet obstruction. On 12/21/22 at 12:08 PM the facility was notified of the Immediate Jeopardy (IJ) situation and a plan of care was requested. Refer to F690 ELOPEMENT Resident 9 Resident 9 admitted to the facility in 2022 with diagnoses including symptoms involving cognitive functions following other nontraumatic intracranial hemorrhage and cataracts. Prior to admission, the resident was homeless. The Elopement Risk Care Plan, last revised on 12/28/22, revealed Resident 9 was a high elopement risk related to impaired safety awareness; both physical and environmental. The resident had eloped on 11/17/22, 12/12/22 and 12/27/22. The interventions included to remind the resident to notify staff if she/he planned to leave the facility as needed (11/18/22), resident was high fall risk (11/18/22), to not seat the resident in the lobby near the doors without supervision at any time of the day or night. If the resident was up during late night hours to have her/him close to the nurse's station where she/he could be monitored. To walk with the resident if she/he wanted to walk, sit and talk with the resident, attempt to engage the resident to watch television, look at a magazine, offer fluids and snack. If not redirectable, alert the charge nurse, RN, resident care manager or DNS (12/14/22). Remind the resident of the sign posted in her/his room to not leave the facility without assistance for her/his safety and to show her/him the sign above the television (12/15/22). Activities to check in with the resident regularly to see if she/he needed anything from the store and to let nursing know to minimize the desire to exit the facility (12/16/22). Offer Resident 9 a bowl of ice cream (rocky road) every evening sometime after dinner and before bed time. If Resident 9 ambulated toward the front lobby late at night offer the ice cream again (12/28/22). The 9/27/22 Communication Care Plan revealed Resident 9 had a communication problem related to expressive aphasia (a form of aphasia when the person knows what they want to say but are unable to produce the words or sentence. Can be mild to severe), slurring, stroke, weak or absent voice. Interventions included to allow adequate time to respond, face the resident when speaking and make eye contact, ask yes/no questions if appropriate, use simple, brief, consistent words/cues, use alternative communication tools as needed. The resident was able to say yes or no and very short sentences and could shake/nod her/his head. Speak to the resident in a calm, quiet voice because she/he responded better with this approach. Speak on an adult level, speak clearly and slower than normal. The 11/17/22 Incident Note revealed staff noted Resident 9 was not in her/his room, was assisted to bed at 7:00 PM, last seen between 8:15 and 8:30 PM and found on the lawn outside the 200 hall door. The 11/18/22 Wandering Risk Assessment identified Resident 9 as a moderate wander risk. Resident 9 was forgetful, had a short attention span, independent with aid for mobility, early dementia, on antidepressants and had a history of wandering. The 11/18/22 facility investigation revealed the resident was found outside. When interviewed the resident indicated she/he was going to [NAME] for rocky road ice cream. [[NAME] is a store 0.6 miles away from the facility. The resident would have to walk up [NAME] Street, which facility resides on, towards [NAME] Drive which is a highly congested four lane road. The intersection of [NAME] and [NAME] has no intersection and both roads offer minimal lighting.] The 12/6/22 BIMs score was 9 which suggested the resident had moderately impaired cognition. The 12/12/22 Progress Note revealed Resident 9 walked out of the facility around 8:00 PM. The resident wore a sweater, was found down the street walking with her/his walker. The temperature was around 40 degrees and [she/he] was not dressed appropriately. The resident was non-verbal; unable to say why she/he left or where she/he was going. The 12/12/22 Elopement Event identified Resident 9 as an elopement risk, the resident eloped off facility grounds when she/he was left unattended in the front lobby and the resident was disoriented to some-spheres some of the time. The assessment revealed the resident was homeless prior to admission and was not afraid to go out at night. The resident was alert and able to converse most of the time, was slow to answer and very soft spoken which could be misconstrued for non-responsive or cognitive impairment. The 12/13/22 Wandering Risk Assessment identified Resident 9 as a moderate wander risk. Resident 9 was forgetful, had a short attention span, ambulated with one person assistance, early dementia, on antidepressants and had a history of wandering. The 12/13/22 Incident Note revealed Resident 9 was alert and able to converse most of the time but was slow to answer and very soft spoken. Resident 9 stated she/he was going to [NAME]'s for ice cream. Resident 9 stated rocky road was her/his favorite ice cream. The resident stated she/he did not have money for ice cream and stopped responding to the interviewer when repeatedly asked how she/he would have paid for the ice cream. The 12/13/22 BIMs was 14 which indicated the resident was cognitively intact. The 12/14/22 Care Conference Notes revealed safety concerns as the resident had exited the facility twice since admission. The resident stated she/he was going to [NAME]'s to get ice cream. It was arranged the resident would be asked weekly if she/he needed anything and ice cream would be available. The 12/28/22 Progress Note revealed Resident 9 walked down the hall around 11:20 PM [on 11/27/22]. The resident walked to the lobby and sat down. Staff asked what she/he needed but the resident did not respond. The CNA sat with the resident for a few minutes but when she went to answer another call light [she/he] left out the front door. The nurse went to check on the resident five minutes later and the resident was gone. Four staff initiated a search, first searching the facility and then outside. Resident 9 was found walking past the park on [NAME] Street. The resident was non-verbal and would not answer any questions. The temperature outside was 50 degrees and raining; the resident wore sweat pants and a T-shirt. The 12/28/22 Progress Note revealed the resident care manager spoke with the resident in the morning and the resident stated she/he was walking to [NAME] for ice cream. When asked if she/he had a bowl of ice cream every night would keep her/him from wanting to go outside, the resident nodded yes. The 12/28/22 Wandering Risk Assessment revealed Resident 9 was a moderate risk for wandering. The resident was forgetful, had a short attention span, did not understand surroundings, independent with mobility, on antidepressants and had a history of wandering. The 12/28/22 facility investigation revealed when Resident 9 eloped staff had not followed the care plan. On 12/28/22 at 5:04 PM Staff 21 (Resident Care Manager) stated Resident 9 exit sought at night between 8:00 PM and 11:00 PM, was homeless prior to admission and did not feel any danger when outside at night. Staff 21 stated Resident 9 always wanted to go to [NAME] to get rocky road ice cream when interviewed. Resident 9 knew she/he did not have any money and would not state how she/he would pay for the ice cream. Staff 21 stated the ice cream was in the activity room but hadn't had any of it. Staff 21 stated although Resident 9 had some cognitive issues she/he had not lost everything and waited until no staff was looking before exiting the building. Staff 21 confirmed Resident 9's care plan instructed not to leave her/him unsupervised in the front lobby which staff did on 12/27/22 when she/he eloped. On 12/28/22 at 5:16 PM Staff 22 (CNA) stated he and another staff member observed Resident 9 walk to the front lobby so he went to check on her/him. Resident 9 was ok and I didn't know [she/he] was going to try to escape. Staff 22 further stated ten or 15 minutes after he checked on the resident a nurse called him and informed him she thought Resident 9 got out so the staff started to look for her/him. Staff 22 stated this was the first time he worked with Resident 9, was not aware to not leave Resident 9 alone in the front lobby and had not read the care plan. On 12/28/22 at 5:33 PM Staff 16 (LPN) verified she worked on 12/27/22 when the resident eloped and stated there was no ice cream available after hours and she could not get into the activity room at night or if she was she was unaware of it. Staff 16 verified Resident 9 was left alone for approximately five minutes in the lobby prior to her/his elopement and stated she was not aware Resident 9's care plan instructed staff she/he was not to be left alone there. Staff 16 stated Resident 9 exit seeked at least once a week at night. On 12/28/22 at 7:30 PM Staff 20 (Social Service Director) confirmed Resident 9 eloped on 12/27/22 because the care plan was not followed. On 12/29/22 at 8:04 AM Staff 2 (DNS) stated the facility had identified 14 residents who were a moderate to high wander risk. Staff 2 confirmed on 12/27/22 Resident 9 was left alone in the front lobby and the resident's care plan was not followed which resulted in Resident 9's elopement off the facility grounds. On 12/29/22 at 9:16 AM Resident 9 stated when she/he left the facility, it was to go to either [NAME] or Walmart to get ice cream. Resident 9 stated if staff offered her/him ice cream she/he would not leave. On 12/29/22 at 10:06 AM the facility was notified of the Immediate Jeopardy (IJ) situation and a plan of care was requested. Refer to F689 QUALITY OF CARE The 2/12/22 Facility Assessment indicated the facility cared for residents with the following respiratory conditions: chronic obstructive pulmonary disease, pneumonia, asthma, chronic lung disease and respiratory failure. The assessment indicated for decisions related to caring for residents with conditions not listed above, the facility would review documentation and when there was a condition they were not familiar with they would ask questions and do some research to see if the care they would need would be something we could manage. If training was needed prior to admission the facility world request training from the hospital. If a condition developed during a resident's stay they were not familiar with the facility could reach out to the pharmacy or Medical Director for any education which could be offered. Finally, the Facility Assessment revealed six to nine licensed nurses would be scheduled every day to provide direct care to the residents. Additional licensed nursing staff included one DNS, one Assistant DNS and two Resident Care managers. Resident 5 admitted to the facilty on 3/4/22 with diagnoses including heart failure and chronic pleural effusion (an excessive accumulation of fluid in the lungs pleural space). Resident 5 admitted with a PleurX catheter (a small, flexible tube that doctors place within the patient's chest to drain fluid from the pleural space.) [All licensed nurses within the State of Oregon may drain the catheter with proper training.] The facility's staffing records revealed between 3/4/22 through 3/22/22 one and a half to three RN's were on duty daily in addition to multiple LPNs. The 3/4/22 admission orders directed staff to drain the Pleurx catheter to a maximum 1,000 cc removal at a time, note the amount drained and to notify the physician if the SpO2 (oxygen saturation) was less than 90%. The 3/4/22 Progress Note revealed a nurse to nurse report was received from the hospital and indicated Resident had a chronic right lung pleural effusion with a drain. It was last drained on 3/3/22, was scheduled to be drained every other day and to not remove more than one liter of fluid (1,000 cc). The 3/4/22 Nursing admission Assessment did not reveal the presence of the PleurX catheter. The skin integrity assessment documented a bandage on chest; did not remove. The March 2022 TARs revealed the following orders: * 3/6/22: Drain the PleurX catheter a maximum of 1,000 cc at a time and to record the amount drained. Note if Resident 5 had a SpO2 under 90%. The 3/6/22 entry was blank. * 3/7/22 through 3/9/22: Drain the PleurX catheter a maximum of 1,000 cc at a time and to record the amount drained. Note if Resident 5 had a SpO2 under 90%. On 3/7/22 documentation revealed 1,000 cc of fluid was drained from the catheter. The 3/9/22 entry was blank. *3/7/22: sterile dressing change weekly and PRN with dry gauze and occlusive dressing to PleurX site. Every Monday day shift. It was documented as completed on 3/7/22 and 3/21/22. On 3/14/22 it was documented as 9 and left blank on 3/28/22. * 3/9/22: Drain PleurX catheter only at clinic or hospital. The 3/9/22 provider encounter note revealed there was a concern with getting Resident 5's PleurX catheter drained and [the provider] was requested to see patient urgently via telemedicine in order to do a face-to-face for home health for assistance with Pleurx [sic] catheter related to recurrent pleural effusions. The provider noted the resident had great self awareness of when this needs to happen. And reporting that [she/he] is having difficulty breathing and needing it. The provider spoke with the DNS and it was determined if the facility had no staff available to drain the catheter then to transfer the resident to the hospital. The provider further noted the effort to leave their domicile to obtain outpatient services would be taxing and overburdensome for this patient. [There was no evidence the facility informed the physician it was within the nurse's scope of practice to drain the catheter.] The 3/9/22 Progress Notes revealed Resident 5 was transferred to the hospital for increased pulse and shortness of breath at 9:37 AM, the hospital drained 2,000 cc from the catheter and the resident returned to the facilty at 3:00 PM. The 3/9/22 updated Physician Order indicated the catheter was to be drained at a clinic or hospital only. Every Monday, Wednesday and Friday. The 3/11/22 provider note indicated Resident 5 experienced shortness of breath although 2,000 cc was drained from the catheter two days prior. The provider spoke with Resident 5's healthcare POA, discussed concerns of ongoing draining of the PleurX catheter and after a long discussion of options for draining at the facility it was decided to update the POLST form for DNR comfort only and refer Resident 5 to hospice. The 3/11/22 Progress Note revealed Hospice was ordered and they would manage and drain the PleurX catheter. The 3/17/22 Progress Note revealed Resident 5 healthcare POA was upset because she was not told why the facility could not drain Resident 5's PleurX catheter and wanted to transition Resident 5 off of hospice but needed home health set up first so the resident would not have to go to the hospital to get the catheter drained. The 3/21/22 Progress Note revealed the facility spoke with Resident 5's daughter about the PleurX catheter and how we were unable to meet [her/his] needs due to the licensing of our nurses and not having an RN to do it. Options were discussed and it was decided the facilty would look for alternative placement but to keep the resident on hospice so they could manage the drain. On 12/28/22 at 8:47 AM Witness 7 (Complainant) stated the facility did not want to provide care and services for the PleurX catheter and placed the resident on hospice against her/his will. Resident 5's family notified Witness 7 that they did not want hospice but felt like their back was against the wall. The resident was admitted to the facility specifically for the facility to manage the catheter however care did not happen and she/he was sent to the hospital for catheter care. Resident 5 and family were given the decision to either send the resident to the hospital for routine catheter care or go onto hospice. Witness 7 stated she reached out to the facility to coordinate nurse education if that was what was needed and offered to have a provider or the catheter company provide a tutorial which the facility declined. The facilty stated this [PleurX catheter] was something they did not do. Witness 7 stated care facilities should be able to manage the catheter and even lay people can be taught to do it. On 12/25/22 at 8:58 AM an interview was conducted with Staff 1 (Administrator), Staff 2 (DNS) and Staff 3 (LPN, Assistant DNS). Staff 1 stated the facility did not know how to care for the catheter, did not have sufficient RN staffing to care for the resident and the facilty was unaware the resident had a PleurX catheter on admission but verified this information was in the resident's admission paperwork which they reviewed prior to the resident's admission. Staff 1 stated she declined training offered by the Resident's Case Manager and verified the resident went on hospice to avoid hospital emergency room visits. On 12/29/22 in the AM Staff 1 and Staff 3 stated they were unaware LPN's were allowed to provide care and services related to the PleurX catheter with proper training. F684 and F726 RESIDENT ASSESSMENTS, CARE PLAN INTERVENTIONS Resident 15 admitted to the facility in 2020 with diagnoses including end stage renal disease and a hip fracture. The 10/14/22 Annual MDS indicated the resident was cognitively intact, required extensive assistance with bed mobility, was non-ambulatory, and had a history of falls. An 11/24/22 Fall Investigation indicated Resident 15 fell out of bed while reaching down for something and hit her/his head on the floor. The resident stated, I was laying on the edge of the bed and I felt myself sliding down and I tried to grab for something, and I fell. The resident's call light was noted to be initiated. The investigation did not indicate how long the call light had been on. The resident was noted to have been last toileted and repositioned two hours prior to the fall. The resident's air mattress was noted to be a bit high so the air in the mattress was decreased. The resident requested side rails for her/his bed. On 1/3/23 at 9:25 AM Resident 15 stated she/he had pressed her/his call light as she/he was close to the edge of the bed. The resident stated she/he yelled I am going to fall, but by the time staff came to the room the resident was on the floor. Resident 15 stated her/his call light had been initiated for 30 minute and stated the long call light time happened all the time. Resident 15 stated right after the fall she/he had requested bed mobility bars, but she/he never received them. The resident's bed was observed to be without any bed mobility bars or side rails. Resident 15 further stated she/he almost fell out of bed a few days prior, but a staff member was able to prevent the fall and helped reposition the resident in the center of the bed. On 1/3/23 at 11:29 AM and 11:55 AM Staff 3 (LPN, Assistant DNS) acknowledged the investigation did not include how long Resident 15's call light was initiated. Staff 3 further stated the expectation was for the resident to have mobility bars per the resident's request and the resident did not currently have mobility bars on her/his bed. Refer to F689 Resident 11 admitted to the facility on [DATE] with diagnoses including osteoarthritis. The 10/15/22 admission MDS was completed on 10/25/22; three days late. On 12/30/22 at 12:51 PM Staff 2 (DNS) verified the 10/15/22 admission MDS was completed late. Refer to F636 Resident 3 admitted to the facility in 2020 with diagnoses including paraplegia (paralysis of the legs and lower body). Resident 3's 9/20/22 Annual MDS was completed on 10/5/22; one day late. On 12/28/22 at 9:12 AM Staff 2 (DNS) verified the 9/20/22 Annual MDS was completed one day late. Refer to F636 Resident 13 admitted to the facility on [DATE] with diagnoses including hypertension. The 7/26/22 admission MDS was completed on 8/3/22; one day late. On 12/30/22 at 12:52 PM Staff 2 (DNS) verified the 7/26/22 admission MDS was completed late. Refer to F636 ASSESSMENT AND MONITORING OF PRESSURE ULCERS Resident 3 admitted to the facility in 2020 with diagnoses including paraplegia (paralysis of the legs and lower body) and a chronic Stage 4 (full thickness skin and tissue loss) pressure ulcer. The August 2022 and September 2022 TARs revealed wound care was completed for Resident 3's coccyx wound. The Weekly Skin Evaluations revealed the following: *8/5/22: Stage 4 coccyx pressure wound which measured 0.5 cm x 0.5 cm x 0 cm. Treatment was in place and it appeared to be healing. [The assessment was not comprehensive.] *8/12/22: Stage 4 coccyx pressure wound which measured 3 cm x 5 cm x 0.5 cm. Treatment in place. Wound was larger, periwound was macerated, wound bed had slough, no foul odor, no complaints of pain. [The assessment was not comprehensive.] *8/19/22: Stage 4 coccyx pressure wound which measured 33.5 cm x 5 cm x 0.5 cm. Treatment in place. Wound was larger, periwound was macerated, wound bed had slough, no foul odor, no complaints of pain. [The assessment was not comprehensive.] *8/26/22: Stage 4 coccyx pressure wound which measured 33.5 cm x 5 cm x 0.5 cm. Treatment in place. Wound was larger, periwound was macerated, wound bed had slough, odor present, no complaints of pain. [The assessment was not comprehensive.] *9/2/22: Stage 4 coccyx pressure wound which measured 33.5 cm x 5 cm x 0.5 cm. Treatment in place. Wound was larger, periwound was macerated, wound bed had slough, odor present, no complaints of pain. [The assessment was not comprehensive.] Review of Resident 3's medical record revealed no further skin assessments until the 10/20/22 RN Wound Assessment. The RN Wound Assessments revealed the following: *10/20/22: Stage 3 (full thickness skin loss, may extend into the subcutaneous tissue layer) coccyx pressure wound which measured 4 cm x 1.2 cm x 0/7 cm. This was a chronic wound the resident had for years. Tunneling present at 6 o'clock measured 0.7 cm. The wound bed was 50% slough and 50% pale pink tissue. [Not a comprehensive assessment; downstaged wound.] *10/27/22: Stage 3 coccyx pressure wound[TRUNCATED]

Based on interview and record review it was determined the facility failed to ensure a resident received the required care and services related to a drainage catheter and to follow physician orders for 2 of 4 sampled residents (#s 4 and 5) reviewed for catheters and skin conditions. This caused Resident 5 to experience an avoidable hospital transfer, pain, shortness of breath and an increased pulse rate. The facility failures placed residents at risk for delayed treatment and worsening wounds. Findings include: 1. The 2/12/22 Facility Assessment indicated the facility cared for residents with the following respiratory conditions: chronic obstructive pulmonary disease, pneumonia, asthma, chronic lung disease and respiratory failure. The assessment indicated for decisions related to caring for residents with conditions not listed above, the facility would review documentation and when there was a condition they were not familiar with they would ask questions and do some research to see if the care they would need would be something we could manage. If training was needed prior to admission the facility world request training from the hospital. If a condition developed during a resident's stay they were not familiar with the facility could reach out to the pharmacy or Medical Director for any education which could be offered. Finally, the Facility Assessment revealed six to nine licensed nurses would be scheduled every day to provide direct care to the residents. Additional licensed nursing staff included one DNS, one Assistant DNS and two Resident Care managers. Resident 5 admitted to the facilty on 3/4/22 with diagnoses including heart failure and chronic pleural effusion (an excessive accumulation of fluid in the lungs pleural space). Resident 5 admitted with a PleurX catheter (a small, flexible tube that doctors place within the patient's chest to drain fluid from the pleural space.) [All licensed nurses within the State of Oregon may drain the catheter with proper training.] The facility's staffing records revealed between 3/4/22 through 3/22/22 one and a half to three RN's were on duty daily in addition to multiple LPNs. The 3/4/22 admission orders directed staff to drain the Pleurx catheter to a maximum 1,000 cc removal at a time, note the amount drained and to notify the physician if the SpO2 (oxygen saturation) was less than 90%. The 3/4/22 Progress Note revealed a nurse to nurse report was received from the hospital and indicated Resident had a chronic right lung pleural effusion with a drain. It was last drained on 3/3/22, was scheduled to be drained every other day and to not remove more than one liter of fluid (1,000 cc). The 3/4/22 Nursing admission Assessment did not reveal the presence of the PleurX catheter. The skin integrity assessment documented a bandage on chest; did not remove. The March 2022 TARs revealed the following orders: * 3/6/22: Drain the PleurX catheter a maximum of 1,000 cc at a time and to record the amount drained. Note if Resident 5 had a SpO2 under 90%. The 3/6/22 entry was blank. * 3/7/22 through 3/9/22: Drain the PleurX catheter a maximum of 1,000 cc at a time and to record the amount drained. Note if Resident 5 had a SpO2 under 90%. On 3/7/22 documentation revealed 1,000 cc of fluid was drained from the catheter. The 3/9/22 entry was blank. *3/7/22: sterile dressing change weekly and PRN with dry gauze and occlusive dressing to PleurX site. Every Monday day shift. It was documented as completed on 3/7/22 and 3/21/22. On 3/14/22 it was documented as 9 and left blank on 3/28/22. * 3/9/22: Drain PleurX catheter only at clinic or hospital. The 3/9/22 provider encounter note revealed there was a concern with getting Resident 5's PleurX catheter drained and [the provider] was requested to see patient urgently via telemedicine in order to do a face-to-face for home health for assistance with Pleurx [sic] catheter related to recurrent pleural effusions. The provider noted the resident had great self awareness of when this needs to happen. And reporting that [she/he] is having difficulty breathing and needing it. The provider spoke with the DNS and it was determined if the facility had no staff available to drain the catheter then to transfer the resident to the hospital. The provider further noted the effort to leave their domicile to obtain outpatient services would be taxing and overburdensome for this patient. [There was no evidence the facility informed the physician it was within the nurse's scope of practice to drain the catheter.] The 3/9/22 Progress Notes revealed Resident 5 was transferred to the hospital for increased pulse and shortness of breath at 9:37 AM, the hospital drained 2,000 cc from the catheter and the resident returned to the facilty at 3:00 PM. The 3/9/22 updated Physician Order indicated the catheter was to be drained at a clinic or hospital only. Every Monday, Wednesday and Friday. The 3/11/22 provider note indicated Resident 5 experienced shortness of breath although 2,000 cc was drained from the catheter two days prior. The provider spoke with Resident 5's healthcare POA, discussed concerns of ongoing draining of the PleurX catheter and after a long discussion of options for draining at the facility it was decided to update the POLST form for DNR comfort only and refer Resident 5 to hospice. The 3/11/22 Progress Note revealed Hospice was ordered and they would manage and drain the PleurX catheter. The 3/17/22 Progress Note revealed Resident 5 healthcare POA was upset because she was not told why the facility could not drain Resident 5's PleurX catheter and wanted to transition Resident 5 off of hospice but needed home health set up first so the resident would not have to go to the hospital to get the catheter drained. The 3/21/22 Progress Note revealed the facility spoke with Resident 5's daughter about the PleurX catheter and how we were unable to meet [her/his] needs due to the licensing of our nurses and not having an RN to do it. Options were discussed and it was decided the facilty would look for alternative placement but to keep the resident on hospice so they could manage the drain. On 12/28/22 at 8:47 AM Witness 7 (Complainant) stated the facility did not want to provide care and services for the PleurX catheter and placed the resident on hospice against her/his will. Resident 5's family notified Witness 7 that they did not want hospice but felt like their back was against the wall. The resident was admitted to the facility specifically for the facility to manage the catheter however care did not happen and she/he was sent to the hospital for catheter care. Resident 5 and family were given the decision to either send the resident to the hospital for routine catheter care or go onto hospice. Witness 7 stated she reached out to the facility to coordinate nurse education if that was what was needed and offered to have a provider or the catheter company provide a tutorial which the facility declined. The facilty stated this [PleurX catheter] was something they did not do. Witness 7 stated care facilities should be able to manage the catheter and even lay people can be taught to do it. On 12/25/22 at 8:58 AM an interview was conducted with Staff 1 (Administrator), Staff 2 (DNS) and Staff 3 (LPN, Assistant DNS). Staff 1 stated the facility did not know how to care for the catheter, did not have sufficient RN staffing to care for the resident and the facilty was unaware the resident had a PleurX catheter on admission but verified this information was in the resident's admission paperwork which they reviewed prior to the resident's admission. Staff 1 stated she declined training offered by the Resident's Case Manager and verified the resident went on hospice to avoid hospital emergency room visits. On 12/29/22 in the AM Staff 1 and Staff 3 stated they were unaware LPN's were allowed to provide care and services related to the PleurX catheter with proper training. 2. Resident 4 admitted to the facility in 3/2022 with diagnoses including heart failure and dementia. An 8/12/22 Physician Order instructed staff to clean Resident 4's wounds daily in the first, second and third right webspaces with saline or wound cleanser and then to apply Bacitracin (antibiotic ointment). Place gauze between the webspaces. Clean the wound on the dorsal aspect of the right second toe, apply Bacitracin and cover with gauze. Secure the gauze with Kerlex dressing. The August 2022 TARs revealed the wound treatment was not initiated until 8/14/22. On 12/28/22 at 9:26 PM Staff 2 (DNS) and Staff 3 (LPN, Assistant DNS) confirmed the 8/12/22 Physician Order was not started until 8/14/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Based on interview and record review, it was determined the facility failed to ensure nursing staff received and demonstrated the appropriate competencies and skills to provide nursing services to assure resident safety and maintain highest practicable physical, mental, and psychosocial well-being of each resident for 4 of 4 staff (#s 9, 17, 18 and 19) reviewed for training. This placed residents at risk for lack of care by competent staff. Findings include: On [DATE] at 9:43 AM Staff 24 (Assistant administrator/HR) was asked to provide completed documentation of a competency checklist for Staff 9, Staff 17, Staff 18, and Staff 24. Employee paperwork provided for these employee's did not include a competency checklist of any kind. On [DATE] at 12:39 PM Staff 3 (Assistant DNS) stated no checklist for skills had been completed. 1. Based on interview and record review it was determined the facility failed to ensure the licensed nursing staff had the appropriate competencies and skill sets to provide nursing care for a resident with a PleurX Catheter (a small, flexible tube that doctors place within the patient's chest to drain fluid from the pleural space) for 1 of 3 sampled residents (#5) reviewed for hospice. This caused Resident 5 to have increased pain, shortness of breath, psychosocial harm and experienced sustained a distressing and diminished quality of life prior to death. Finding include: Resident 5 admitted to the facility on [DATE] with diagnoses including heart failure and chronic pleural effusion (an excessive accumulation of fluid in the lungs pleural space). The resident had a PleurX catheter in place and died on [DATE]. The facility's staffing records revealed between [DATE] through [DATE] one to three RN's were on duty daily in addition to LPN's. The [DATE] admission Orders directed staff to drain the PleurX catheter to a maximum 1,000 cc removal at a time, note the amount drained and to notify the physician if the SpO2 (oxygen saturation) was less than 90%. [All licensed nurses within the State of Oregon may care for and drain the catheter with proper training.] The [DATE] Physician Order indicated the catheter was to be drained at a clinic or hospital only every Monday, Wednesday and Friday. [There was no documentation the facility informed the physician it was within the nurses scope of practice to drain the catheter onsite.] A [DATE] provider encounter note revealed there was a concern with getting Resident 5's PleurX catheter drained. The provider noted the resident had great self awareness of when this needs to happen. And reporting that [she/he] is having difficulty breathing and needing it. The provider spoke with the DNS and it was determined if the facility had no staff available to drain the catheter then to transfer the resident to the hospital. The [DATE] Progress Note's revealed Resident 5 was transferred to the hospital for increased pulse and shortness of breath. The hospital drained 2,000 cc from the catheter. A [DATE] provider note indicated she spoke with Resident 5's healthcare POA, discussed concerns of ongoing draining of the PleurX catheter and after a long discussion of options for draining (the catheter) at the facility it was decided to update the resident's POLST form to DNR comfort measures only and refer to hospice. A [DATE] Hospice note revealed Resident 5 was admitted to hospice services. A [DATE] Hospice note revealed the hospice nurse drained 1,000 cc of fluid from the PleurX catheter. A [DATE] Progress note revealed the resident made comments about harming her/himself, asked for a hammer because she/he hurt so bad and asked the CNA if she could help her/him kill her/himself. A [DATE] Progress note revealed Resident 5's healthcare POA was upset because she was not told why the facility could not drain Resident 5's PleurX catheter. The note further stated the goal was to transition the resident off of hospice so they could obtain aggressive treatment with a specialist but they needed home health set up first so the resident would not have to go to the hospital to get the PleurX catheter drained. The healthcare POA stated she understood the resident may not live much longer but still did not want hospice at this time. A [DATE] Progress note revealed home health would not come to the facility. A [DATE] Progress note revealed they spoke with Resident 5's daughter about the PleurX catheter and how we were unable to meet [her/his] needs due to the licensing of our nurses and not having an RN to do it. Options were discussed and it was decided the facility would look for alternative placement but to keep the resident on hospice so they could manage the drain. The [DATE] Discharge Summary note indicated the funeral home picked the resident up. [There were no notes related to the residents passing in the medical record.] Hospice Notes revealed the PleurX catheter was drained on [DATE], 14, 16 and 20. On [DATE] at 8:47 AM Witness 7 (Complainant) stated the facility did not want to provide care and services for the Pleurx catheter and placed the resident on hospice against her/his will. Resident 5's family notified Witness 7 that they did not want hospice but felt like their back was against the wall. The resident was admitted to the facility specifically for the facility to manage the catheter however care did not happen and she/he was sent to the hospital for catheter care. Resident 5 and family were given the decision to either send the resident to the hospital for routine catheter care or go onto hospice. Witness 7 stated she reached out the the facility to coordinate nurse education if that was what was needed and offered to have a provider or the catheter company provide a tutorial which the facility declined. The facility stated this [PleurX catheter] was something they did not do. Witness 7 stated care facilities should be able to manage the catheter and even lay people can be taught to do it. On [DATE] at 8:58 AM an interview was conducted with Staff 1 (Administrator), Staff 2 (DNS) and Staff 3 (LPN, Assistant DNS). Staff 1 stated the facility did not know how to care for the catheter and did not have sufficient RN staffing to care for the resident as the majority of the RN's were agency personnel. Staff 1 stated the facility was unaware the resident had a PleurX catheter on admission but verified this information was in the resident's admission paperwork. Staff 1 verified the resident went on hospice to avoid hospital emergency room visits. On [DATE] an email was received from the Oregon State Board of Nursing which revealed LPN's could drain and care for PleurX catheters if they had the appropriate training. On [DATE] in the AM Staff 1 and Staff 3 stated they believed LPN's were not able to perform PleurX catheter care and services. The LPN scope of practice information listed PleurX catheter care as something LPN's were unable to complete and did not realize this LPN task list was from Alabama.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to address a change of condition, follow physician orders and address skin conditions for 4 of 8 sampled residents (#s 23, 58, 109, and 159) reviewed for medication, non-pressure skin, and hospitalization. This failure resulted in Resident 58 experiencing a noted decline in condition without appropriate intervention prior to the resident's hospitalization. This placed residents at risk for adverse side effects of medications, worsening conditions, and death. Findings include: 1. Resident 58 was admitted to the facility in 2019 with diagnoses including chronic obstructive pulmonary disease (COPD) and anxiety disorder. The 1/18/22 physician orders indicated to obtain oxygen saturation level and utilize PRN oxygen to maintain oxygen saturation between 88-92% every four hours. The 1/25/22 progress note indicated Resident 58 tested positive for COVID that day and was moved to the isolation unit. The 2/2/22 at 7:08 AM progress note indicated Resident 58's oxygen saturation was 84% and the resident was on oxygen 3 liters per minute. The resident's oxygen could be increased to 4 liters per minute and the oxygen was to be rechecked in 30-45 minutes. The 2/2/22 MAR indicated Resident 58's oxygen saturation was 81% at 8:00 AM. The 2/2/22 Vital Sign records indicated at 8:35 AM indicated Resident 58's oxygen saturation was 86%. There was no indication in the residents clinical record to indicate the physician was notified of Resident 58's oxygen saturations below 88%. The 2/2/22 Vital Sign records indicated at 11:43 PM Resident 58's temperature was 97.5 F. This was the last temperature documented in the clinical record. The 2/3/22 at 12:50 AM Progress Note indicated Resident 58 had shortness of breath at the start of the shift with oxygen saturations ranging between 80%-86%. The nurse assisted the resident with breathing techniques to lower rapid breathing and deepen inhalation resulting in resident becoming more relaxed and oxygen increasing to over 90%. Oxygen saturation was 98%. No fever present. Resident has been compliant with cares and isolation status. Sleeping comfortably at this time. Vital signs stable and within normal limits. Will continue to monitor. The 2/3/22 at 8:51 AM Progress Note indicated Resident 58 oxygen saturation dropped to 71% on 4 liters of oxygen per minute via mask. Oxygen was instructed to be increased to 5 liters per minute via mask and the resident was assisted with breathing techniques to help deepen breathing and reduce anxiety. Resident's oxygen saturations went up to 81%. Continue with breathing techniques and to monitor oxygen. The 2/3/22 at 11:15 AM Progress Note indicated Resident 58's oxygen saturation was at 71% on 5 liters per minute via mask. Assist resident with deep breathing exercises. Will contact on-call provider and leave a note in provider's box regarding resident. The 2/3/22 at 12:18 PM Progress Note indicated Resident 58 began coughing up a scant amount of bright red blood into tissues and her/his oxygen saturations were 69%. A message was left for on-call provider for a 20-minute call back. The 2/3/22 at 1:05 PM [late entry] Progress Note indicated the facility received a call back from the on-call provider was instructed to send Resident 58 to the hospital. Emergency services were contacted. They arrived and collected resident and left for Salem Hospital at approximately 12:55 PM on 2/3/22. The 2/3/22 hospital records indicated the following: -Resident 58 came from the care facility to the emergency department for worsening shortness of breath and recently tested positive for COVID one week ago and had been having difficulty breathing. Staff at the care facility were having a difficult time maintaining her/his oxygen saturations today and called paramedics. While at the facility, she/he had saturations of 67% while on oxygen. She/he was placed on non-rebreather by paramedics, which brought her/his oxygen saturations up to 79%. Patient arrived on CPAP with oxygen saturations at 88%. Paramedics reported a fever with temperature of 103 F. The 2/4/22 progress note indicated Resident 58 was admitted to the hospital with admitting diagnoses of COPD exacerbadtion, pneumonia due to COVID and respiratory failure. The 2/7/22 at 1:11 PM progress note indicated the hospital called to confirm that Resident 58 passed away at 8:04 AM on 2/5/22. On 3/25/22 at 10:10 AM Witness 6 (Nurse Practitioner) reviewed the findings and stated Resident 58 had an order to maintain oxygen saturations between 88-92% and the expectation was for staff to call the provider if oxygen saturations dropped below 88%. Witness 6 further stated staff did not notify the provider timely of Resident 58's change in condition and the expectation was for staff to have notified the provider the morning of 2/2/22. On 3/25/22 at 11:04 AM Staff 43 (RN) stated she worked day shift on 2/2/22 and 2/3/22. Staff 43 stated she should have notified the physician in my professional opinion on the morning of 2/2/22 after Resident 58's oxygen saturations dropped below 88%. On 3/23/22 at 2:14 PM and 3/28/22 at 8:46 AM Staff 2 (DNS) stated Resident 58's physician order indicated to keep oxygen saturations between 88-92 %. Staff 2 stated the expectation was for staff to notify the physician within 30 minutes after a change in condition and the physician should have been notified on 2/2/22 after the resident's oxygen saturations did not increase at 8:35 AM. 2. Resident 109 admitted to the facility in 10/2020 with diagnoses including heart failure. The 12/29/21 Progress Note indicated an order was received to swab sore on back of head with povidone-iodine until resolved. The 1/2022 TAR indicated the resident did not receive wound treatment on 1/1/22. The 1/3/22 Progress Note indicated wound care was provided to the sore on the back of the head the sore was drying out and resident reported less pain. The 1/5/22 Progress Note indicated head wound had no drainage, no open area and was slightly raised. The area was swabbed with povidine-iodine per order. There were no skin assessments or measurements of the sore on the resident's head in the electronic health record and no indication as to what type of sore or wound it was. On 3/28/22 at 8:49 AM Staff 2 (DNS) acknowledged there was no initial skin and wound assessment on 12/29/21 and no ongoing skin assessments indicating the type, measurements and characteristics of the head wound. Staff 2 further acknowledged the treatment for povidone-iodine was not completed on 1/1/22. 3. Resident 159 was admitted to the facility on [DATE] with diagnoses including heart failure. a. The 2/23/22 skin evaluation indicated the resident had a rash to the groin and left gluteal fold. There were no measurements of the identified areas. A review of the clinical record indicated there was no follow up skin evaluations or skin assessments completed after 2/23/22. The resident discharged on 3/12/22. No skin assessments were completed prior to her/his discharge. On 3/18/22 at 2:00 PM Staff 2 (DNS) acknowledged Resident 159 had no measurements of the rash to the groin and left gluteal fold. She further acknowledged there were no additional skin assessments prior to her/his discharge. b. The 2/7/17 Intake and Output (I and O) Policy for documentation and monitoring of I and O indicated residents who may be at risk for an imbalance in fluids or electrolytes and a comparison total for I and O may be used as part of the comprehensive assessment in residents at risk for these imbalances. The 2/23/22 physician order indicated Resident 159 was to receive torsemide (a diuretic medication used to treat heart failure) daily. A review of the clinical record indicated no documentation of intake and output. On 3/22/22 at 6:36 AM Staff 7 (LPN) stated CNA staff should have documented I and O for Resident 159 especially since the resident had a Foley catheter. On 3/22/22 at 8:28 AM Staff 11 (RN) stated she recalled Resident 159 but staff did not monitor I's and O's for her/him. On 3/23/22 at 8:28 AM Staff 2 (DNS) stated Resident 159 was receiving diuretic medication and the expectation was for staff to monitor I's and O's on any resident received a diuretic. Staff 2 acknowledged the facility did not monitor I's and O's for Resident 159. 4. Resident 23 admitted to the facility in 2019 with diagnoses including heart failure and hypertension. The 12/22/19 Physician Order indicated staff were to check blood pressure and pulse every morning related to hypertension. The 3/22 MARs indicated staff did not check blood pressure or pulse on the following dates: -3/7/22 -3/8/22 -3/9/22 -3/10/22 On 3/23/22 at 8:25 AM Staff 2 (DNS) stated an agency staff was working 3/7/22 through 3/10/22 and acknowledged Resident 23 did not received blood pressure or pulse checks as ordered by the physician.