Every finding on record at Ashland Post Acute

Based on observation, interview, and record review it was determined the facility failed to ensure staff were competent to carry out the tasks of dishwashing for 1 of 1 kitchen reviewed for food service safety. This placed residents at risk for food borne illnesses. Findings include:During a review of the facility's dishwashing machine on 8/6/26 at 11:55 AM the manufacturer signage indicated the dishwasher was a low-temperature, chemical-sanitizing machine with a required wash temperature of 120 F in combination with proper chemical concentration to sanitize the dishes.On 8/6/26 Staff 30 (Dietary Aide) ran the dishwasher at 11:57 AM and the thermometer revealed the temperature reached a high temperature of 110 F during the dishwashing cycle.On 8/6/26 at 12:26 PM, Staff 30 stated monitoring the temperature of the dishwashing machine during the wash cycle was not part of the dishwashing process.On 8/6/26 at 5:26 PM, Staff 1 (Administrator) confirmed Staff 30 had not met facility expectations for the dishwashing process due to a failure to monitor the temperature of the dishwasher while operating it.On 8/7/26 at 10:19 AM, Staff 23 (Dietary Director) stated staff are trained to check the dishwasher temperature each time it runs to ensure the temperature is 120 F or above. Staff 23 indicated the machine sometimes must be run two cycles before it reaches the target temperature for sanitation. Staff 23 indicated Staff 30 regularly operated the dishwashing machine on the four days per week he worked in the kitchen. Staff 23 acknowledged Staff 30 had not been following proper department procedures to ensure resident safety.

Based on observation, interview and record review it was determined the facility failed to ensure food was prepared and stored in a sanitary manner for 1 of 1 kitchen and 1 of 1 resident refrigerator reviewed for food service safety. This placed residents at risk for food borne illnesses. Finding include:1. On 8/3/26 at 8:48 AM during the initial tour of the kitchen, the following items were observed in the facility kitchen walk-in refrigerator:-Large plastic container of chicken noodle soup undated, no label present-Macaroni salad dated 7/24/26, use by date: 7/29/26-Nacho cheese dated 7/24/26, use by date: 7/30/26 -Refried beans dated 7/28/26, use by date: 8/2/26 -Cherry lime gelatin dessert dated 7/21/26, use by date: 7/31/26 -Tomato puree dated 7/28/26, use by date: 8/2/26 -Spanish rice dated 7/28/26, use by date: 8/2/26On 8/6/26 at 5:24 PM, Staff 1 (Administrator) confirmed all foods in the walk-in refrigerator should be properly labeled, and he expected foods to be properly disposed of when past the use by date.An undated Food Brought in From Outside Source facility policy stated that refrigerated and frozen food items were to be labeled with date food was brought in, name of food type, resident name and room number. These foods were to be stored in a designated refrigerator/freezer space, and foods lacking proper labeling were to be discarded. Commercially prepared food in original container was to be used before manufacturer expiration date, and homemade items or restaurant leftovers were to be discarded on day three by staff.2. On 8/3/26 at 9:45 AM a review of the resident refrigerator and freezer revealed an open package of corn dogs was visible at the front of the freezer with two corn dogs open to the air and visibly freezer burned; an unlabeled plastic container of Dairy Queen leftovers was in the door of the freezer and ten homemade/restaurant takeout items in the refrigerator lacked a date.On 8/3/26 Staff 23 (Dietary Director) made observations of the refrigerator and freezer with the surveyor and confirmed the date was not present on many of the items in the refrigerator and freezer. Staff 23 confirmed the current status of the resident food refrigerator and freezer did not meet facility expectations for safe food storage.3. On 8/6/26 at 11:58 AM observations of the dish washing portion of the kitchen revealed trash and debris on the floor beneath the counter to the right of the dishwashing machine that included a used surgical mask, a straw, a paper wrapper, food debris, and wadded up blue plastic. On the floor beneath the counter to the left of the dishwashing machine were dirty towels piled up on the floor with an open spray bottle with the top off among cleaning agent containers.On 8/6/26 at 5:35 PM, Staff 1 (Administrator) acknowledged the towels and dirty rags beneath the dish washing counter did not meet expectations for cleanliness in the kitchen.

Based on observation, interview and record review it was determined the facility failed to ensure residents were provided therapeutic diets and maintained acceptable parameters to achieve weight goals for 1 of 1 sampled resident (#8) reviewed for nutrition. This placed residents at risk for unmet nutritional needs. Findings include:Resident 8 was readmitted to the facility on [DATE] with diagnoses including severe protein malnutrition, poor appetite, and a Stage 4 pressure ulcer.The 6/24/26 Discharge Summary indicated Resident 8 had severe protein malnutrition and a 17% weight loss during the previous three months. Staff were directed to administer Juven twice daily and Ensure three times daily.The 6/24/26 Transfer Orders directed staff to administer Juven twice daily and Ensure Plus three times daily.The 6/24/26 diet order indicated Resident 8 was prescribed a regular diet with Nutritionally Enhanced Meals (NEMs). The Nutrition Care Plan identified a goal of maintaining adequate nutritional status, as evidenced by stable weight. Staff were directed to administer nutrition-related medications as ordered and monitor for signs and symptoms of malnutrition, including significant weight loss and refusal of meals.The 6/29/26 Nutritional Risk Assessment indicated Resident 8 weighed 94 pounds and received Juven once daily and Ensure Plus three times daily. The assessment indicated Resident 8 consumed 100% of the supplements.The 6/30/26 admission MDS indicated Resident 8 consumed 25% or less of meals and weighed 95 pounds.The Nutrition CAA identified Resident 8 as underweight, with weight loss prior to admission and a Stage 4 pressure injury that increased the risk for impaired nutrition, delayed wound healing, and further skin breakdown.A review of the June, July, and August 2026 MARs indicated Resident 8 received Juven once daily rather than the ordered twice daily. The MARs indicated Ensure Plus was administered three times daily; however, the MARs did not include documentation of the amount consumed.The 7/7/26 Nutritional Risk Assessment indicated Resident 8 weighed 94 pounds, received Juven once daily and Ensure Plus three times daily, and consumed 100% of the supplements.Resident 8's documented weight decreased from 94 pounds on 7/7/26 to 91 pounds on 7/9/26, 88 pounds on 7/23/26, and 87 pounds on 8/1/26.On 8/3/26 at 11:00 AM, Resident 8 stated she/he believed she/he weighed 88 pounds at admission and had gained approximately one pound since admission. Resident 8 stated she/he was unable to drink three Ensure supplements daily and preferred one Ensure daily. Resident 8 also stated her/his pressure ulcer was healing very slowly.On 8/6/26 at 9:18 AM, Staff 13 (LPN) stated Resident 8 received Ensure three times daily but drank approximately half of each supplement. Staff 13 reviewed the order and confirmed it did not include instructions to document the amount consumed. Staff 13 stated residents experiencing weight loss would be expected to have an order directing staff to document supplement intake.On 8/6/26 at 9:22 AM, Staff 14 (CMA) stated Resident 8's Ensure was provided with the meal tray and staff were expected to document the amount consumed. Staff 14 confirmed the order did not include instructions for documenting intake and there was no way to document the amount consumed under the existing order.On 8/6/26 at 2:43 PM, Staff 10 (LPN Manager) reviewed Resident 8's nutritional records and confirmed the Ensure order did not instruct staff to document the percentage consumed. Staff 10 acknowledged staff documented Resident 8 consumed 100% of Ensure three times daily, although staff knew Resident 8 did not consume the prescribed amount. Staff 10 confirmed this resulted in inaccurate documentation of the resident's nutritional intake.Staff 10 confirmed Resident 8 continued to lose weight since 6/2026. Staff 10 also confirmed she had discussed nutrition with Resident 8 but did not document these discussions. Staff 10 acknowledged the Nutritional Risk Assessments did not accurately reflect Resident 8's supplement intake.On 8/7/26 at 8:33 AM, Staff 3 (LPN Manager) reviewed Resident 8's clinical record and confirmed the nutritional orders were not correctly entered upon admission. Staff 3 stated staff were expected to ensure orders were entered correctly.On 8/7/26 at 10:27 AM, Staff 2 (DNS) reviewed Resident 8's nutritional record and confirmed the facility failed to ensure the resident's nutritional orders were correctly entered and implemented. Staff 2 acknowledged Resident 8 was ordered Juven twice daily but received it once daily. Staff 2 also acknowledged staff did not accurately document the amount of Ensure consumed. Staff 2 acknowledged accurate documentation of supplemental intake was necessary to monitor the resident's nutritional status and weight loss. Staff 2 confirmed Resident 8 continued to lose weight and the goal of maintaining a stable weight was not met.

Based on interview and record review it was determined the facility failed to ensure accurate communication occurred between the facility and the dialysis provider and daily weight were obtained for 1 of 1 sampled resident (#11) reviewed for dialysis. This placed residents at risk for potential complications from dialysis care and treatment. Findings include: Resident 11 admitted to the facility on [DATE]/ with diagnoses including Encephalopathy (a condition in which the brain is not functioning normally) and ESRD (end stage kidney disease).The 6/2/26 Dialysis Care Plan indicated Resident 11 required hemodialysis and did not require a fluid restriction.The 6/3/26 physician orders directed staff to provide dialysis Monday, Wednesday, and Friday and complete pre- and post-dialysis communication forms.The 6/8/26 admission MDS indicated Resident 11 was cognitively intact, had an active diagnosis of ESRD, and received hemodialysis.The 6/10/26 and 7/7/26 Nutrition at Risk Assessments did not identify a fluid restriction.The 7/6/26 Dialysis Treatment Details Report indicated Resident 11 received education regarding fluid restrictions. The 7/8/26 and 7/13/26 Dialysis Treatment Details Reports also indicated Resident 11 received education regarding fluid restrictions.No documentation was found in the medical record to indicate the facility followed up with the dialysis provider regarding the documented fluid restriction education.On 8/4/26 at 8:56 AM, Resident 11 stated she/he received dialysis three times a week and was on a fluid restriction but was unsure of the amount of fluid allowed. Resident 11 indicated the amount using a hand gesture.On 8/5/26 at 10:07 AM, Witness 1 (Dialysis RN) stated Resident 11 did not have an order for a fluid restriction and the restriction was discussed verbally with the resident. Witness 1 stated Resident 11 was instructed to follow a 32-ounce daily fluid restriction.On 8/5/26 at 10:47 AM, Staff 27 (CNA) stated she was unsure whether Resident 11 had a fluid restriction and confirmed there was no information regarding a fluid restriction on the resident's care plan.On 8/5/26 at 11:28 AM, Staff 11 (LPN) reviewed the dialysis communication forms dated 7/6/26, 7/8/26, and 7/13/26 and confirmed Resident 11 received education regarding fluid restrictions. Staff 11 acknowledged nursing staff should have followed up with the dialysis provider and stated he had not contacted the dialysis provider.On 8/5/26 at 2:16 PM and 3:13 PM, Staff 3 (LPN Manager) confirmed Resident 11 did not have an order for a fluid restriction. Staff 3 acknowledged nursing staff should have followed up with the dialysis provider regarding the documented education. On 8/5/26 at 3:38 PM, Staff 2 (DNS) confirmed staff were expected to communicate with the dialysis provider and follow up on dialysis recommendations. Staff 2 acknowledged the facility failed to follow up regarding the documented fluid restriction education.

Based on interview and record review it was determined the facility failed to provide written notice to a resident/responsible party of a room change for 1 of 3 sampled residents (#83) reviewed for choices. This placed residents at risk for lack of notice. Findings include: Resident 83 was admitted to the facility in 2/2026 with diagnoses including hemiplegia (partial or full paralysis of one side of the body) and aphasia (communication disorder).According to Resident 83's electronic medical record, she/he was moved from room [ROOM NUMBER] to room [ROOM NUMBER] on 6/15/26.On 8/3/26 at 10:59 AM and 8/5/26 at 10:03 AM, Resident 83 stated her/his former roommate threatened me three times. [She/he] threatened to hurt me. Resident 83 reported her/his room was changed after the incident. Staff 4 (RN Manager) initiated Resident 83's room change on 6/15/26.On 8/4/26 at 5:44 PM, Staff 4 (RN Manager) indicated her process is to meet with a resident after a conflict with a roommate and document the conversation in that resident's progress notes. Resident 83's June 2026 medical record lacked a Notification of Room Change/New Roommate evaluation.On 8/6/26 at 5:39 PM, Staff 1 (Administrator) indicated Facility process for a room change is to provide as much advanced notice as possible to a resident, and this is done via the Notification of Room Change/New Roommate evaluation. Staff 1 stated the facility expectation for room changes also included documentation of a room change in progress notes and completion of alert charting in progress notes for monitoring after a room move. Staff 1 acknowledged none of the expected documentation for the 6/15/26 room change was present in Resident 83's medical record.

Based on interview and record review it was determined the facility failed to ensure a current copy of residents' advance directive was obtained and retained in the medical record for 1 of 5 sampled residents (#6) reviewed for advance directives. This placed residents at risk for not having health care decisions honored. Findings include: The facility's 8/1/24 Advance Directives policy and procedure revealed the facility should identify if the resident has an advance directive during the admission process. If so, a copy is obtained and kept in the resident's medical record, accessible to their physician and the care staff.Resident 6 was admitted to the facility in 5/2024 with diagnoses of hemiplegia (total or partial paralysis of one side of the body) and chronic obstructive pulmonary disease (irreversible lung damage which restricts breathing).A 5/13/26 Quarterly MDS revealed Resident 6 had a BIMS score of 15, indicating intact cognition.The 7/28/24 SNF Initial Care Management Meeting document for Resident 6 indicated she/he had an advance directive.On 8/4/26 at 2:25 PM, Staff 15 (SSD) stated Resident 6 had a POLST but not an advance directive. On 8/4/26 at 2:55 PM, Resident 6 stated she/he previously completed an advance directive with her/his family.On 8/4/26 at 3:37 PM, Witness 4 (Family Member) confirmed Resident 6 completed an Advance Directive in 6/2021, prior to her/his admission to this facility.An 8/5/24 Care Plan revealed a copy of Resident 6's advance directive was requested for the medical record.On 8/5/26 at 11:34 AM, Witness 4 stated they brought a copy of the resident's advance directive the same day. Witness 4 stated the facility never contacted her/him to request a copy of Resident 6's advance directive.On 8/7/26 at 12:23 PM, Staff 2 (DNS) stated facility staff should have obtained a copy of Resident 6's advance directive much sooner to ensure it was available for review in the medical record.

Based on observation, interview, and record review it was determined the facility failed to ensure grievances were followed up timely for 1 of 6 sampled residents (#6) reviewed for environment. This placed residents at risk for unresolved grievances. Findings include: Resident 6 was admitted to the facility in 5/2024 with diagnoses of hemiplegia (total or partial paralysis of one side of the body) and chronic obstructive pulmonary disease (irreversible lung damage which restricts breathing).An 8/10/25 Annual MDS revealed Resident 6 had a BIMS score of 15, indicating intact cognition.An 8/28/25 Resident Council Grievance document indicated two residents including Resident 6 voiced concerns regarding the noise level of two different facility doors near their rooms. The grievance stated the doors were loud when staff entered and exited the facility during the night. The facility's response on 9/17/25 was the [NAME] Wing Door was scheduled for repair.On 8/3/26 at 1:11 PM, Resident 6 stated the door at the end of East Wing slammed and made a lot of noise in the middle of the night when staff entered or exited the facility. Resident 6 reported frequent difficulty falling back asleep after the door slammed.On 8/5/26 at 10:36 AM, the East Wing door was tested by Staff 22 (Maintenance Director) and slammed loudly shut as it closed. Staff 22 stated the door hinge mechanism could be adjusted to slow the door closure and eliminate the loud slam noise.On 8/6/26 at 8:48 AM, Staff 15 (SSD) stated the facility response to the 8/28/25 grievance was to repair one of the two problematic doors. Staff 15 indicated the facility failed to repair the East Wing door near Resident 6's room.On 8/6/26 at 6:08 PM, Staff 1 (Administrator) acknowledged Resident 6's concern had not been resolved in a timely manner.

Based on interview and record review it was determined the facility failed to protect residents' right to be free from verbal abuse and intimidation by Resident #75 for 1 of 5 sampled residents (#83) reviewed for abuse. Findings include: Resident 75 was admitted to this facility in 8/2025 with diagnoses including moderate dementia with psychotic disturbance, mood disturbance, and anxiety.Resident 75's 5/28/26 Quarterly MDS revealed she/he had a BIMS of 9, indicating moderate cognitive impairment.Resident 83 was admitted to the facility in 2/2026 with diagnoses including hemiplegia (partial or full paralysis of one side of the body) and aphasia (communication disorder).A 5/15/26 Quarterly MDS revealed Resident 83 had a BIMS of 8, indicating moderate cognitive impairment.A 3/8/26 progress note indicated Resident 75 was involved in a resident-to-resident altercation which resulted in her/his roommate being moved to new room. The note also indicated the DNS, Administrator, and weekend supervisor were aware of the incident.Resident 75's 4/6/26 Care Plan revealed she/he had behaviors including yelling and cussing at others and agitation towards roommates. Staff were to approach the resident in a calm manner, offer coffee, encourage her/him to go outside, offer emotional support, and notify social services at the onset of behaviors.A 6/15/26 Verbal Aggression Received note for Resident 83 revealed a verbal altercation occurred between her/him and Resident 75.A 6/15/26 Verbal Aggression Initiated note for Resident 75 indicated she/he was startled by a loud noise and yelled at her/his roommates.On 8/3/26 at 10:59 AM, Resident 83 stated her/his former roommate [Resident 75] threatened me three times. [She/he] threatened to hurt me.On 8/3/26 at 10:59 AM and 8/5/26 at 10:03 AM, Resident 83 stated her/his former roommate [Resident 75] threatened me three times. [She/he] threatened to hurt me. Resident 83 stated I had to get away from her/him. [She/he] threatened me three times, [she/he] threatened to kick my ass.On 8/5/26 at 1:22 PM, Staff 9 (CNA) stated Resident 75 got upset and yelled pretty much any time we do care for her/his two roommates. Staff 9 added It happens almost daily. Staff 9 stated Resident 83 was primarily bed bound and Resident 75 was ambulatory and stood up and yelled to demand quiet.On 8/5/26 at 3:54 PM, Staff 24 (CNA) stated he witnessed the incident between Resident 75 and Resident 83 on 6/15/26. Staff 24 stated three CNAs were providing care to Resident 83 when Resident 75 began cursing and yelling at staff and Resident 83. Staff 24 stated Resident 75 continued to yell at staff and Resident 83 despite staff attempts to calm her/him. Resident 75 physically approached staff and Resident 83, yelling I'll fuck up all of you guys. Staff 24 asked Resident 75 to go back to bed while the other two CNA staff left the room. Resident 75 continued to yell at Resident 83, got out of bed again and threatened to hurt Resident 83. Staff 24 stated Resident 75 frequently yelled at Resident 83 and staff during ADL care provided at night and gets combative with everybody.On 8/5/26 at 4:49 PM, Staff 26 (CNA) stated she witnessed the incident between Residents 75 and 83 on 6/15/26. Staff 26 reported she was providing care for Resident 83 with other staff when Resident 75 began yelling and using profanity directed at Resident 83 and the staff. Staff 26 stated Resident 75 got up from her/his bed and approached Resident 83's bed while threatening her/him.On 8/7/26 at 1:57 PM, these findings were shared with Staff 1 (Administrator). He stated the facility expectation for preventing abuse when a resident has a history of aggressive behaviors towards other residents is for staff to identify triggers for those behaviors and consider the triggers as new roommates are evaluated for compatibility. No additional information was provided.

Based on interview and record review it was determined the facility failed to ensure allegations of abuse were reported timely to the State Survey Agency for 2 of 5 sampled residents (#s 83 and 92) reviewed for abuse. This placed residents at risk for continued abuse. Findings include: The facility's 8/2024 policy and procedure for Abuse-Screening, Training, Identification, Investigation, Reporting, and Protection stated The following are required by law to report abuse or suspected abuse: All nursing facility employees or any individual who contracts to provide services to/in a nursing facility and Who to report to: Facility administrator, director of nursing, charge nurse, Oregon Department of Human Services (ODHS), Supervisor, and Law enforcement agency if suspicion of abuse or a crime. This policy and procedure also provided details of how to report to ODHS a nursing facility incident report (FRI) form. 1. Resident 83 was admitted to the facility in 2/2026 with diagnoses including hemiplegia (partial or full paralysis of one side of the body) and aphasia (communication disorder). A 5/15/26 Quarterly MDS revealed Resident 83 had a BIMS of 8, indicating moderate cognitive impairment. A 6/15/26 Verbal Aggression Received note revealed a verbal altercation occurred between Resident 83 and her/his roommate. On 8/3/26 at 10:59 AM and 8/5/26 at 10:03 AM, Resident 83 stated her/his former roommate threatened me three times. [She/he] threatened to hurt me. Resident 83 stated [She/he] threatened me three times, [she/he] threatened to kick my ass. On 8/5/26 Staff 24 (CNA) and Staff 26 (CNA) on 8/5/26 stated two or more staff witnessed Resident 75 yell and threaten violence toward Resident 83 and staff around 2:00 AM or 3:00 AM on 6/15/26. On 8/7/26 at 7:45 AM, Staff 1 (Administrator) submitted a Facility Reported Incident for the alleged resident to resident verbal abuse and intimidation on 6/15/26. Refer to F0600. 2. Resident 92 was admitted to the facility in 2024 with diagnosis of a fracture. Resident 92's 4/29/26 Quarterly MDS revealed she/he was cognitively intact. Resident 92's Progress Notes from 5/11/26 through 6/18/26 revealed there were no allegations of abuse and on 6/18/26 she/he was discharged to a community facility. On 8/3/26 at 2:08 PM Witness 3 (Complainant) stated Resident 92 was admitted to a community facility and was assessed to have bruising on her/his legs. Resident 92 reported she/he was attacked by her/his former facility roommate. Witness 3 stated she called the facility and reported the allegation of abuse to Staff 16 (LPN). On 8/4/26 at 3:29 PM Staff 16 stated Witness 3 reported Resident 92 alleged her/his former facility roommate attacked her/him. Staff 16 stated Resident 92's former roommate was not physically capable of transferring out of bed by her/himself and would not be able to attack Resident 92. Staff 16 stated she recalled reporting the allegation of abuse to the administrative staff or to Staff 15 (Social Services Director). On 8/5/26 at 9:15 AM Staff 15 stated she did not recall being notified Resident 92 alleged abuse. Staff 15 stated if she was notified, she would have notified Staff 1 (Administrator). On 8/5/26 at 9:56 AM Staff 1 stated if a resident was discharged from the facility and alleged abuse, the facility staff were to report the incident to administration, or designee, and a report would have been made to the State Agency. Staff 1 stated he was not notified of Resident 92's allegation of abuse, and the State Agency was not notified.

Based on interview and record review it was determined the facility failed to thoroughly investigate alleged resident to resident abuse for 1 of 5 sampled residents (#83) reviewed for abuse. This placed residents at risk for continued abuse. Findings include: The facility's 8/2024 policy and procedure for Abuse-Screening, Training, Identification, Investigation, Reporting, and Protection included: All alleged incidents of abuse, neglect, abandonment, mistreatment, injuries of unknown source, personal and/or financial exploitation, or misappropriation of resident property must be thoroughly investigated. The policy also stated: A thorough investigation is completed through a systematic collection and review of evidence/information that describes and explains an event or a series of events. It seeks to determine if abuse, neglect, abandonment, personal and/or financial exploitation or misappropriation of resident property occurred, and how to prevent further occurrences.Resident 83 was admitted to this facility in 2/2026 with diagnoses including hemiplegia (partial or full paralysis of one side of the body) and aphasia (communication disorder).A 5/15/26 Quarterly MDS revealed Resident 83 had a BIMS of 8, indicating moderate cognitive impairment.A 6/15/26 Verbal Aggression Received note documented by Staff 4 (RN Manager) revealed a verbal altercation occurred between Resident 83 and her/his roommate. The document did not contain staff witness statements, resident interviews, root cause analysis, or planned interventions. On 8/3/26 at 10:59 AM and 8/5/26 at 10:03 AM, Resident 83 stated her/his former roommate threatened me three times. [She/he] threatened to hurt me. Resident 83 stated I had to get away from her/him. [She/he] threatened me three times, [she/he] threatened to kick my ass.Review of Resident 83's medical records revealed no evidence of an investigation of the incident, alert charting, or any updates to the care plan to prevent further abuse.On 8/6/26 at 5:49 PM, Staff 1 (Administrator) stated his expectation was for all resident-to-resident incidents to be thoroughly investigated. Staff 1 confirmed the investigation of the incident failed to meet facility expectations.Refer to F0600.

Based on interview and record review it was determined the facility failed to ensure a bed hold policy provided for 1 of 2 sampled residents (#43) reviewed for hospitalization. This placed residents at risk of not being informed of their rights. Findings include:Resident 43 was admitted to the facility in 6/2026 with diagnoses including acute osteomyelitis (infection of the bone) and fractured right thigh bone.The 6/23/26 admission MDS revealed Resident 43 had a BIMS assessment score of 15 (cognitively intact). A 7/23/26 revised Care Plan revealed Resident 43 was at risk for pain or discomfort due to the resident's fractured thigh bone and she/he expressed feelings of hopelessness related to her/his worsening health and physical discomfort. The 7/28/26 Bed Hold document revealed Resident 43 verbally consented to not hold her/his bed upon transfer to the hospital. The document did not indicate the resident was provided a copy.A 7/29/26 Note Text indicated Resident 43 returned from the hospital to address her/his pain.The 7/30/26 Census for Resident 43 revealed the resident resided in room [ROOM NUMBER] on 7/28/26 with a status of a hospital stay for less than three days and was in room [ROOM NUMBER] on 7/30/26. On 8/3/26 at 2:12 PM, Resident 43 stated she/he verbally indicated the desire to return to her/his same room when she/he left for the hospital because of the support she/he received from her/his roommate. Resident 43 stated she/he was not provided information regarding her/his rights to return to his/her previous room. On 8/6/26 at 11:43 AM, Staff 10 (LPN Manager) stated she only completed the Bed Hold form for Resident 43 and was not aware the resident was required to be given a copy. Staff 10 stated she expected the bed hold requirements were to be explained to Resident 43 by Staff 15 (Social Services Director) and assumed Resident 43 did not accept the required cost to initiate the bed hold. On 8/7/26 at 9:18 AM, Staff 15 stated she expected Staff 10 to explain the bed hold policy in detail to Resident 43 and to include information related to the additional costs associated with the bed hold. Staff 15 acknowledged Resident 43 did not receive a copy of the document as required.

Based on interview and record review it was determined the facility failed to ensure the care plan was revised for 1 of 4 sampled residents (#24) reviewed for accidents. This placed residents at risk for lack of interventions to prevent accidents. Findings include:Resident 24 was admitted to the facility in 12/2025 with diagnoses including diabetes and osteoarthritis. The 5/6/26 Quarterly MDS revealed Resident 24 had a BIMS assessment score of 14 (cognitively intact).The 12/12/25 admission MDS and associated CAA revealed Resident 24 required assistance with mobility due to the resident's weakness and pain with an increased risk for falls and injuries. A 3/6/26 (start date) Release of Responsibility for Resident Leave of Absence log revealed Resident 24 was responsible for any accident or change of condition when the resident was away when she/he signed out. A 5/28/26 Note Text revealed Resident 24 called the facility when the resident's electric wheelchair did not have sufficient power to get her/him up a hill and back to the facility. A 6/13/26 Note Text revealed Staff 6 (RN) received a call from a concerned citizen when Resident 24 was stuck in the community with her/his electric wheelchair. Medical transportation was required to return the resident to the facility.A 6/18/26 revised Care Plan revealed Resident 24 required intermittent cues to use her/his power wheelchair which was used in the facility. The care plan did not identify any interventions to ensure the resident safely operated her/his wheelchair in the community and was safe to leave.An 8/1/26 Note Text revealed Resident 24 had an unwitnessed fall on the roadway in the community when one of the wheels of her/his electric wheelchair fell off the curb. Community citizens assisted Resident 24 back into her/his wheelchair and the resident returned to the facility with minor injuries. The 8/1/26 Unwitnessed Fall investigation revealed Resident 24 was educated about her/his wheelchair safety and no safety interventions were identified. On 8/4/26 at 2:37 PM, Staff 7 (CNA) stated there were no instructions of care to ensure the resident operated her/his electric wheelchair safely or had items she/he needed for safety. On 8/4/26 at 2:23 PM, Staff 17 (Medication Aide) stated Resident 24 left the facility without her/his medications.On 8/5/26 at 9:18 AM, Staff 5 (RN) stated nursing staff were not instructed to ensure the Resident 24 had her/his phone and a full battery for her/his electric wheelchair. On 8/6/26 at 12:16 PM, Staff 6 (RN) stated on 6/13/26 Resident 24 had no cell phone or water, and it was a hot day. Staff 6 stated Resident 24 was often dismissive if staff inquired about her/his electric wheelchair battery. On 8/7/26 at 9:00 AM, Staff 9 (CNA) stated he went into the community to return Resident 24 to the facility in the past. Staff 9 stated CNAs needed increased awareness of Resident 24's location and safety interventions. On 8/7/26 at 11:05 AM, Staff 4 (RNCM) stated she was unaware of the 6/13/26 incident with Resident 24 and stated she needed improved communication from staff to update the resident's care plan. On 8/7/26 at 11:51 AM, Staff 2 (DNS) stated she relied on Staff 4 to update Resident 24's care plan and the care plan was to include instructions for staff to ensure the resident was safe when her/his electric wheelchair was used.

Based on observation, interview, and record review it was determined the facility failed to provide bathing assistance for a dependent resident for 1 of 3 sampled residents (#43) reviewed for choices. This placed residents at risk for lack of personal hygiene. Findings include:Resident 43 was admitted to the facility in 6/2026 with diagnoses including acute osteomyelitis (infection of the bone) and fractured right thigh bone.The 6/23/26 admission MDS revealed Resident 43 had a BIMS assessment score of 15 (cognitively intact) and her/his pain occasionally interfered with the resident's daily activities.A 7/7/26 through 8/5/26 Task: Bathing (CNA charting) document revealed Resident 43 was provided a shower on 7/24/26, the resident refused her/his scheduled shower on 8/1/26, and she/he received a shower on 8/4/26 (seven days without a shower). A 7/30/26 revised Care Plan revealed Resident 43 was scheduled to received showers on Wednesdays and Saturdays and required one staff to provide extensive assistance with her/his bathing. On 8/3/26 at 2:00 PM, Resident 43 was observed in bed and her/his hair was disheveled. Resident 43 stated she/he requested a make-up shower on 8/1/26. Resident 43 stated no staff addressed her/his request for a shower and she/he felt unclean.On 8/5/26 at 5:37 PM, Staff 18 (LPN) stated make-up showers were completed on Sundays. Staff 18 stated nurses were to obtain a list of residents who needed showers and assign staff to complete the task. On 8/6/26 at 10:28 AM, Staff 7 (CNA) stated Resident 43 explained her/his leg was too painful to receive a shower on 8/1/26 and the resident requested a shower for another day. Staff 7 stated staff were to provide additional showers on Sundays and place residents on a list. On 8/7/26 at 8:19 AM, Staff 6 (RN) acknowledged Staff 7 communicated Resident 43's request to receive a make-up shower. Staff 6 stated she did not follow-up with Resident 43 to ensure her/his request for a shower was honored.On 8/7/26 at 11:51 AM, Staff 2 (DNS) acknowledged seven days without a shower was too long.

Based on interview and record review it was determined the facility failed to follow physician orders for 2 of 7 sampled residents (#s 8 and 24) reviewed for nutrition and medications. This placed residents at risk for adverse side effects and unmet needs. Findings include: 1. Resident 8 was admitted to the facility on [DATE] with diagnoses including severe protein malnutrition, poor appetite, and a Stage 4 pressure ulcer. The 6/24/26 Discharge Summary indicated Resident 8 had severe protein malnutrition and a 17% weight loss over the previous three months. The discharge instructions indicated staff were to administer Juven (nutritional supplement used to support wound healing), twice daily. The 6/24/26 Transfer Orders indicated staff were to administer Juven twice daily. The 6/24/26 Diet order indicated Resident 8 was on a regular diet and staff were to add Nutritionally Enhanced Meals (NEMs). A review of the June, July, and August 2026 Medication Administration Records (MARs) indicated Resident 8 received Juven once daily rather than the ordered twice-daily frequency. On 8/3/26 at 11:00 AM, Resident 8 stated she/he admitted to the facility sometime in March with a pressure ulcer and it was healing very slowly. On 8/6/26 at 11:07 AM, Staff 21 (Cook) reviewed the lunch ticket for Resident 8 and was asked what it meant when a resident had NEMS listed on her/his ticket. Staff 21 stated Resident 8 did not have that on her/his ticket. The surveyor pointed out NEMS and he said he would guess that it meant additional protein maybe, or to give it with an ensure to drink. On 8/6/26 at 12:05 PM, Staff 20 was asked what it meant when the tray card said NEMs. Staff 20 stated I think it means extra gravy and that sort of thing, like extra moist. On 8/6/26 at 3:00 PM and 8/6/26 3:13 PM, Staff 1 (Administrator) stated all dietary staff were expected to know what NEMs was and to provide as ordered. On 8/7/26 at 8:33 AM, Staff 3 (LPN Manager) reviewed Resident 8's clinical record and confirmed the nutritional orders were not correctly entered upon admission. Staff 3 stated staff were expected to ensure the orders were entered correctly. On 8/7/26 at 10:27 AM, Staff 2 (DNS) confirmed staff were expected to correctly enter physician orders and acknowledged the orders were not correctly entered. Staff 2 further acknowledged the facility failed to ensure Resident 8 received the ordered nutritional supplementation twice daily to support the resident's nutritional status and wound healing. 2. Resident 24 was admitted to the facility in 12/2025 with diagnoses including diabetes and osteoarthritis. The 5/6/26 Quarterly MDS revealed Resident 24 had a BIMS assessment score of 14 (cognitively intact). A 9/2024 facility Bowel Protocol revealed Licensed Nurses were to identify residents who did not have a bowel movement during the last three days and determine if the PRN Bowel Protocol was initiated during the previous shift. Licensed Nurses were to assess a resident with no bowel movement after four days. A 6/18/26 revised Care Plan revealed Resident 24 was at risk for constipation and staff were to initiate the resident's bowel protocol to promote regular bowel movements and assess bowel tones as needed. The 7/2026 MAR revealed Resident 24 was administered senna (laxative medication) daily in the morning for bowel health. Resident 24 had PRN orders for Milk of Magnesia (laxative medication) for no bowel movement after three days and no PRN bowel medication was refused or administered during the month. A 7/7/26 through 8/4/26 Task: Bowel Continence (CNA charting) document revealed Resident 24 had no bowel movement from 7/7/26 through 7/12/26 (six days) and from 7/14/26 to 7/20/26 (seven days). On 8/5/26 at 3:59 PM, Staff 19 (CNA) stated Resident 24 was not identified to need bowel care interventions. On 8/5/26 at 4:04 PM, Resident 24 stated she/he was not offered any additional medications to address her/his bowel movements and staff were aware of her/his bowel routine. On 8/5/26 at 4:19 PM, Staff 17 (Medication Aide) stated Resident 24 was often out of the facility. Staff 17 stated at times Resident 24 requested to delay her/his bowel medication until she/he returned. On 8/5/26 at 5:37 PM, Staff 18 (LPN) stated she was aware Resident 24 was on the list to received bowel care interventions within the last 30 days and agency staff may not have completed the process. On 8/6/26 at 10:53 AM, Staff 4 (RNCM) acknowledged Resident 24's medications and orders for bowel care interventions were not followed and nursing staff neglected to assess the resident as required. On 8/7/26 at 11:51 AM, Staff 2 (DNS) acknowledged the orders for Resident 24's bowel care were not followed.

Based on observation, interview and record review it was determined the facility failed ensure residents received services to maintain or improve mobility for 1 of 1 sampled resident (#86) reviewed for restorative nursing. This placed the resident at risk for avoidable decline in mobility. Findings include: Resident 86 was originally admitted to the facility 6/19/25 with diagnoses including hypertensive heart disease with heart failure and depression.According to Resident 86's 6/28/26 Annual MDS, it was important for the resident to make choices and to be active.Resident 86's Care Plan Report revised 6/18/26 included a restorative nursing program for mobility to be provided five times each week. The program included ambulation using a front wheeled walker 300 feet.On 8/5/26 at 9:45 AM, Resident 86 stated she/he feared losing her/his ability to walk due to recent lack of opportunities. Resident 86 stated staff used to walk with her/him in the hallways weekly, but this no longer occurred.A 7/16/26 Nursing-RNA (restorative nurse aide) Quarterly Summary document completed by Staff 28 (RN, MDS Coordinator) revealed Resident 86 was seen zero times in the past 30 days by RNA for the ambulation program. The document indicated Resident 86 had declining functional level status and the Director of Rehabilitation and the RNA staff had been notified of this concern.The July 2026 Documentation Survey Report revealed RNA ambulation program was completed on just one date, 7/22/26.On 8/6/26 at 3:30 PM, Staff 28 stated the RNA staff reported a software issue which prevented him from documenting in Resident 86's electronic medical record. Staff 28 indicated she fixed the software documentation issue for Resident 86's RNA program on 7/17/26. On 8/6/26 at 4:11 PM, Staff 29 (RNA, Social Services Assistant) reported an inability to document Resident 86's RNA program in the electronic medical record. Staff 29 estimated he carried out Resident 86's RNA program two times per week. Staff 29 acknowledged this was less than the ordered five times per week. Staff 29 had no documentation to support whether or when the RNA program was offered to, or completed with, Resident 86. Staff 29 stated he worked 20 hours per week as the facility RNA and struggled to find time to provide all the ordered programs assigned to RNA. On 8/7/26 at 12:33 PM, Staff 2 (DNS) acknowledged the lack of documented RNA program provision for Resident 86 did not meet facility expectations for RNA services.

Based on interview and record review, it was determined the facility failed to ensure annual performance reviews for CNA staff were completed for 3 of 3 sampled CNA staff (#s 30, 31, and 32) reviewed for competent staff. This placed residents at risk for receiving care from staff who may have unidentified performance concerns. Findings include:A review of personnel profile records revealed the following.-Staff 30 (CNA) (hired on 7/23/18): No performance review provided.-Staff 31 (CNA) (hired on 9/15/23): No performance review provided.-Staff 32 (CNA) (hired on 12/7/20): No performance review provided. On 6/5/26 at 11:34 AM, Staff 32 stated she had worked at the facility approximately five years and she did not think she ever completed a performance review since she was hired. On 6/8/26 at 10:23 AM, Staff 1 (Administrator) confirmed annual performances reviews should be completed.

Based on observation and interview it was determined the facility failed to ensure a clean and homelike environment was provided for 1 of 2 shower rooms (West shower room) and 1 of 1 dining room reviewed for environment. This placed residents at risk for lack of homelike environment. Findings include:1. On 1/20/26, the State Survey agency received a complaint indicating there were environmental safety concerns, which included fallen tiles from the wall in the west shower room replaced with plastic cutting boards applied with foam glue. On 6/2/26 at 11:09 AM, four broken tiles measuring approximately five by six inches were observed in the west shower room. The joint where the wall and floor met contained a black substance, with the surrounding area appearing lighter. Additionally, on the opposite side of the wall, a metal shelving unit had a plant growing from the joint beneath its bottom shelf. On 6/2/26 at 11:14 AM, Staff 15 (RN) confirmed the cracked tiles and what appeared to be black mildew. Staff 15 got on the floor and pulled on the plant and confirmed it was growing from the outside. On 6/2/26 at 11:55 AM, Witness 11 (Complainant) confirmed the environmental concern with the west shower room. On 6/2/26 at 11:38 AM, Staff 1 (Administrator) confirmed the facility had been working on remodeling the room due to the concerns. 2. On 1/20/26, the State Survey agency received a complaint indicating there were environmental safety issues, which included a hole found in the dining room floor. An orange cone was placed over the damaged area after a staff incident, which was then later bolted to the floor. On 6/2/26 at 12:13 PM, a large orange cone approximately three feet high was observed in the main dining room between a table with residents and a counter. The cone was not removable. Four screws were observed bolting the cone to the floor. On 6/2/26 at 12:16 PM, Resident 19 stated she/he had been in the facility for about three and a half weeks and had bumped into the cone multiple times. Resident 19 stated the floor should be fixed and the cone removed. On 6/3/26 at 9:10 AM, a resident was observed with her/his walker bumping the cone while walking past it. The resident picked an item up from the counter and bumped the cone again when passing the same area. On 6/5/26 at 11:34 AM, Staff 32 (CNA) stated she had worked for the facility approximately five years. She stated there had been a large bubble on the floor which was peeling. A chair was over the damaged area, then a wet floor sign, and the orange cone had been present for approximately two years. On 6/8/26 at 8:48 AM, Staff 35 (Housekeeping Supervisor) stated the orange cone in the dining room had been there for approximately two years. On 6/8/26 at 10:25 AM, Staff 1 (Administrator) confirmed the dining room should not have a large cone in the room.

Based on interview and record review it was determined the facility failed to notify a resident's responsible party for 1 of 3 sampled residents (#1) reviewed for UTIs. This placed residents at risk for lack of representative involvement. Findings include: Resident 1 was admitted to the facility in 11/2024 with a diagnosis of UTI.a. Resident 1's Progress Notes revealed on 4/28/25 Resident 1 had a change in mental status, had abdominal pain, did not urinate, and was sent to the emergency department.Resident 1's clinical record had no evidence her/his representative was notified of her/his hospital transfer. On 10/22/25 at 10:54 AM Staff 2 (DNS) stated families were to be notified when residents were transferred to the hospital and Resident 1's family was not notified. b. Resident 1's Progress Notes revealed on 5/27/25 she/he reported abdominal pain but agreed to stay in the facility for lab tests. On 5/28/25 Resident 1 had continued abdominal pain and was transported to the hospital for evaluation and treatment. Resident 1's clinical record had no evidence her/his representative was notified of her/his hospital transfer. On 10/22/25 at 10:54 AM Staff 2 (DNS) stated families were to be notified when residents were transferred to the hospital and Resident 1's family was not notified.

Based on interview and record review it was determined the facility failed to ensure a safe discharge for 2 of 3 sampled residents (#s2 and 6) reviewed for discharge. This placed residents at risk for unmet post-discharge care needs. Findings include: 1.Resident 2 was admitted to the facility in 3/2025 with a diagnosis of cellulitis (bacterial skin infection) of the legs.Resident 2's 6/4/25 Conference Notes revealed she/he was medically stable and reported she/he wanted to go home soon. Resident 2 reported she/he could pay for caregivers and had a friend who could also help.Resident 2's 6/18/25 PT Discharge Summary indicated discharge recommendations were for Resident 2 to have 24-hour care and home health services. The summary indicated Resident 2 was discharged home with support from others. Resident 2's 6/18/25 Discharge summary revealed she/he was discharged home with home health. The discharge summary did not indicate Witness 2 (Friend) was notified of the discharge or if Resident 2 was provided resources for in-home caregivers. On 10/21/25 at 9:20 AM Witness 2 stated the facility did not call him prior to Resident 2's discharge. Witness 2 stated when Resident 2 opened her/his door she/he saw rats. Luckily Resident 2's neighbor was home and allowed Resident 2 to spend the night until she/he was transported to the hospital for additional discharge planning. Witness 2 stated Resident 2's neighbor called him to let him know Resident 2 was discharged from the facility. Witness 2 stated when he went to Resident 2's home he also discovered she/he did not have running water because the pump to the well broke. Witness 2 stated if the facility called prior to Resident 2's discharge he could have verified the condition of Resident 2's home and notified the facility. On 10/21/25 at 11:20 AM Staff 4 (Social Service Assistant) stated Resident 2 reported she/he had a friend who could help at home. Staff 4 stated she did not confirm with Witness 2 to ensure he was available to assist. On 10/21/25 at 12:07 PM Staff 5 (Social Services) stated Resident 2 did not want to pay for care givers despite recommendations from PT. Staff 5 stated she did not recall if the facility reviewed the risks of Resident 2 discharging without caregivers. On 10/21/25 at 2:13 PM Staff 3 (Director of Rehabilitation) stated the facility recommended Resident 2 be discharged to an alternative living situation, but she/he wanted to go home. Resident 2 was cognitively impaired but was able to make her/his own decisions. Resident 2 was able to get dressed after being set up, needed assistance with meal preparation, and daily caregiving. Staff 3 stated Witness 2 did not come into the facility for training or to participate in the discharge planning. On 10/22/25 at 11:14 AM Staff 12 (DNS) stated Resident 2 was not provided information about the risks of going home without 24-hour caregivers, was not provided a list of resources in her/his area, and staff did not contact Witness 2 to verify he could assist Resident 2 after discharge. 2. Resident 6 was admitted to the facility in 9/2025 with a diagnosis of a fracture. Resident 6's discharge MDS revealed she/he was cognitively intact. Resident 6's 10/9/25 Discharge Summary revealed discharge instructions included post-discharge appointments. A post-operative appointment was scheduled for 10/7/25. On 10/20/25 at 3:59 PM Witness 1 (Family) stated family was not present when the facility reviewed the discharge paperwork with Resident 6. Witness 1 stated they missed an appointment because it was not listed on the discharge paperwork. On 10/21/25 at 11:08 AM Staff 6 (LPN Resident Care Manager) stated Resident 6 went to an orthopedic appointment on 10/7/25, the same day the discharge instructions and appointments were printed. The new appointment from the 10/7/25 orthopedic appointment did not get transcribed onto the discharge instruction sheet. On 10/22/25 at 11:13 AM Staff 2 (DNS) stated staff need to ensure the most current information including appointments were on the discharge instruction sheet.

Based on interview and record review it was determined the facility failed to inform residents of the risks and benefits of psychotropic medication use for 1 of 3 sampled residents (#7) reviewed for medications. This placed residents at risk for being uninformed. Findings include:Resident 7 was admitted to the facility in 5/2025 with diagnoses including depression. A review of a 5/3/25 physician order revealed she/he received Lexapro (antidepressant) daily.A review of the medical record revealed no documentation of the risks or benefits for Lexapro and her/his signed consent for the medication.On 11/13/25 at 11:23 AM Staff 2 (DNS) verified the risks and benefits information was not reviewed with Resident 7 and there was no signed consent to receive the medication.

Based on observation, interview, and record review it was determined the facility failed to provide pain medications and clarify physician orders for 2 of 6 sampled resident (#s 2 and 212) reviewed for pain management and medications. Resident 212 experienced severe pain. Findings include: 1. Resident 212 admitted to the facility in 2024 with diagnosis which included osteomyelitis (infection of the bone). A 1/3/24 care plan revealed Resident 212 had pain with interventions including to administer medications as ordered, anticipate Resident 212's need for pain relief and respond immediately to any complaint of pain. A 1/8/24 Pain evaluation indicated Resident 212 had back pain with a pain level of three on a scale of one to 10. A 1/2024 MAR instructed staff to administer one tablet of Norco (to relieve moderate to severe pain) two times a day for pain at 7:00 AM and 11:00 AM with a start date of 1/9/24. On 1/9/24 at 8:12 AM Resident 212 stated she/he did not receive her/his 7:00 AM Norco on 1/9/24. A review of the MAR at 8:12 AM on 1/9/24 indicated the 7:00 AM Norco was not administered. On 1/10/24 the following occurred: -Review of the MAR indicated the 7:00 AM dose of Norco was not administered and referred the reader to administration notes. -9:26 AM Resident 212 stated she/he did not receive her/his morning medications. -10:29 AM Administration Note indicated the 7:00 AM Norco was not administered because the medication was too close to the next scheduled dose. -12:59 PM Resident 212's body was tense, her/his face was grimacing, and she/he did not want to talk. On 1/11/24 at 7:47 AM Resident 212 stated she/he did not get her/his medications before she/he left the facility for an appointment on 1/10/24. Resident 212 stated if there was a level above 10 on a pain scale she/he would have been above 10. Since there was not, she/he stated her/his pain level was at a 10 when she/he arrived back to the facility around 12:45 PM on 1/10/24. On 1/11/24 at 10:24 AM Staff 19 (RN) stated on 1/10/24 she was late on administering medications. Resident 212 was scheduled for her/his next pain medication at 11:00 AM and she was instructed to skip Resident 212's 7:00 AM Norco and to administer the 11:00 AM. Staff 19 stated Resident 212 stated to Staff 19 her/his pain level was at a 10. On 1/11/24 at 8:01 AM Staff 1 (Administrator) was asked to provide a medication audit report. In a 1/13/24 email, received at 9:21 PM, Staff 2 (DNS) indicated Resident 212's clinical record was reviewed and indicated an investigation was completed. A Medication Investigation indicated Resident 212 received her/his 11:00 AM Norco but not her/his 7:00 AM Norco on 1/10/24. 41455 2. Resident 2 was admitted to the facility in 2023 with diagnoses including UTI and Parkinson's disease (degenerative disease of the nervous system). A current hospital medications list dated 12/14/23 revealed to administer oxycodone (narcotic pain medication to treat moderate to severe pain) take one tablet five times daily scheduled at 4:00 AM, 8:00 AM, 1:00 PM, 6:00 PM, and 11:00 PM. A 12/14/23 hospital Discharge Summary revealed orders for oxycodone every four hours as needed for pain scheduled at 4:00 AM, 8:00 AM, 1:00 PM, 6:00 PM, and 11:00 PM. The 12/2023 and 1/2024 MARs indicated Resident 2 was only ordered oxycodone every four hours as needed. Pain levels ranged from six to 10 out of scale from one to 10 and administered one to four times daily. On 1/11/24 at 9:22 AM Resident 2 was observed with her/his legs tucked into her/his chest and resting in bed. Resident 2 stated since she/he arrived at the facility her pain medication was not being administered as it was ordered at home and the hospital. Resident 2 stated the change in her/his medication routine did not manage her/his pain. On 1/11/24 at 10:47 AM Staff 33 (CNA) stated she observed Resident 2 grimace and squint her/his eyes when her/his pain level was near seven out of 10. On 1/11/24 at 4:50 PM and 1/12/23 at 8:19 AM Staff 3 (Resident Care Manager-LPN) stated the order for Resident 2's oxycodone was confusing and acknowledged Resident 2's order as it was written needed clarification. Staff 3 stated she believed the order was clarified but no documentation was provided.

Based on interview and record review it was determined the facility failed to follow physician's orders for 2 of 8 sampled residents (#s 8 and 23) reviewed for hospitalization and medications. This failure resulted in Resident 8 requiring admission to the Intensive Care Unit (ICU) for recurrent seizures. Findings include: 1. Resident 8 admitted to the facility in 4/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An 4/6/22 physician's order indicated the resident was to receive 20 ml of [MEDICATION(S)] (an anti-[CONDITION(S)] medication) twice a day. According to [MEDICATION(S)]'s website, Stopping [CONDITION(S)] medication suddenly in a patient who has [CONDITION(S)] can cause seizures that will not stop. Resident 8's 8/2022 TAR revealed the resident did not receive the [MEDICATION(S)] on the evening of 8/19/22, the morning of 8/20/22 or the evening of 8/20/22. Progress notes related to the missed doses of [MEDICATION(S)] revealed the medication was not available at the facility. According to the resident's Progress Notes, on 8/21/22 at 7:10 AM Resident 8 was found having a [CONDITION(S)]. The resident was transferred to the hospital via ambulance and was still having seizures. An 8/21/22 History and Physical (H&P) revealed Resident 8 required intravenous anti-[CONDITION(S)] medications and was admitted to the ICU for monitoring. The H&P indicated the seizures likely occurred because the resident did not receive her/his [MEDICATION(S)] the previous 48 hours. Additionally, the H&P revealed the hospital provider contacted Resident 8's neurologist who also felt the resident's recurrent seizures were due to the resident not receiving the [MEDICATION(S)]. On 10/6/22 at 10:21 AM Staff 21 (LPN) could not identify a clear procedure to ensure the facility did not run out of residents' medications. On 10/6/22 at 10:30 AM Staff 23 (LPN) reported there was not a process in place to ensure the facility did not run out of residents' medications. She stated staff should just know when the medications were getting low and needed to be reordered. On 10/7/22 at 12:30 PM Staff 3 (Resident Care Manager LPN) confirmed Resident 8 missed three consecutive doses of her/his [MEDICATION(S)]. She stated she understood the resident's seizures were likely due to the missed doses of medication. 2. Resident 23 was admitted to the facility in 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A physician's order to change an antidepressant based on the facility's [CONDITION(S)] Drug Committee recommendation was signed 6/20/22. A Consultant Pharmacist's Medication Regimen Review dated 7/5/22 noted a [CONDITION(S)] Drug Committee recommendation for a change in an antidepressant medication and the physician's acceptance of the recommendation. A review of the 10/2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/6/22 at 9:47 AM Staff 22 (Nurse Practitioner) stated she remembered the change to the antidepressant but did not know why the change was not implemented. 10/7/22 at 12:04 PM Staff 2 (DNS) was asked about the implementation of the order change and stated she did not know why the order was not implemented.

Based on interview and record review it was determined the facility failed to ensure residents were free from abuse for 1 of 3 (#1) sampled residents reviewed for abuse. Resident 1 was subjected to verbal, physical and emotional abuse when the resident was transferred by a staff member from a wheelchair to bed resulting in psychosocial harm and pain (10 out of 10). Findings include: Resident 1 was admitted to the facility in 4/2020 with [DIAGNOSES REDACTED]. The facility's Abuse Policy dated 2/2019 directed staff to: (6) protect our residents from abuse. The care plan dated 4/23/20 directed two staff to transfer Resident 1 with a Hoyer (mechanical lift) and interventions included noise reduction to prevent triggers of the resident's [MEDICAL CONDITION]. On 5/25/20 an incident report written by Staff 8 (LPN) indicated at 4:30 PM Resident 1 reported Witness 4 (Former CNA) did a one-person transfer from the resident's wheelchair to bed without a Hoyer and Witness 4 grabbed the resident's left arm. The resident indicated Witness 4 was an inch from her/his face when Witness 4 yelled don't tell me how to do my job and Witness 4 did not stop the transfer when Resident 1 screamed no, no, no. Resident 1 stated her/his pain was 10 out of 10 (highest level on 1-10 pain scale) after Witness 4 grabbed her/his left arm. Staff 3 (CNA) provided the resident's care during the evening after Witness 4 was sent home on 5/25/20. The report indicated Resident 1 asked Staff 8 to call the police and Witness 2 (Police Officer) spoke with the resident at the facility on 5/25/20. A written statement documented by Staff 8 (LPN) indicated on 5/25/20 at approximately 4:30 PM Witness 4 was angry, did not want to take care of Resident 1 and stormed off before I could ask (Witness 4) what the situation was. Staff 8 indicated Resident 1 informed Witness 4 she/he wanted to be transferred back to bed with a Hoyer lift and two staff members. Staff 8 documented the resident told her Witness 4 grabbed me by my arms and tried to move me. My left arm felt like she tore it off my body. I was in so much pain my body just stopped working and then she grabbed me again and just jerked me on the bed. Staff 8's statement indicated after Witness 4 exited Resident 1's room Witness 4 said she did not want to provide the resident's care again and Witness 4 stormed off. Staff 8 documented she assessed Resident 1's condition and she/he was pale in color, crying, shaking all over and unable to speak clearly. Staff 8 documented the resident said the transfer back to bed by Witness 4 felt like she threw me on the bed like a sack of trash. Staff 8 said the resident was crying after Witness 4 transferred the resident without a Hoyer lift and Staff 8 saw Resident 1 was in complete distress after the incident with Witness 4 on 5/25/20. On 5/25/20 a statement written by Staff 3 indicated she provided Resident 1's one to one care after Witness 4 was removed from the resident's care. Staff 3 documented the resident said Witness 4 brutally grabbed and threw the resident onto the bed. Staff 3 wrote the resident told her Witness 4 was verbally aggressive during the transfer. Staff 3 said she saw the resident after the transfer incident and the resident was in distress, crying and seemed traumatized. In an interview on 1/28/21 at 2:00 PM Witness 4 said she did not yell at Resident 1 when she transferred Resident 1 back to bed on 5/25/20 without a Hoyer lift. Witness 4 said the resident screamed during the transfer back to bed, she positioned the resident's pillows, put the call light within reach and told the resident she was leaving the room. Witness 4 indicated she looked at at Resident 1's care plan after she transferred the resident back to bed on 5/25/20 and she saw the resident's care plan included a Hoyer transfer with two staff. On 1/28/21 at 3:15 PM Staff 2 (DNS) stated Witness 4 and facility staff were trained on abuse prevention, identification and reporting. She indicated Witness 4 was verbally, physically and emotionally abusive toward Resident 1 on 5/25/20 when Witness 4 transferred the resident back to bed. Staff 2 said the investigation of the incident was sent to the state agency timely and Witness 4 did not work at the facility after 5/25/20. On 2/1/21 at 2:30 PM Staff 6 (Social Services) indicated after the incident on 5/25/20 Resident 1 was assessed for psychosocial harm and Resident 1 spoke with a mental health professional. Staff 6 said she interviewed residents whose care was assigned to Witness 4 and the residents did not express any concerns. She indicated the Resident 1's care plan identified interventions for the resident's [MEDICAL CONDITION] triggers which included bright lights and/or loud noises. On 2/2/21 at 11:00 AM Staff 5 (CNA) indicated he provided Resident 1's care on 5/26/20 and Resident 1 was still upset about the incident with Witness 4 which happened the previous day. On 2/2/21 at 1:53 PM Staff 2 acknowledged Witness 4 acted in an intimidating and physically abusive manner toward Resident 1 on 5/25/20 and the resident's care plan included a two-person Hoyer transfer. Staff 2 acknowledged the resident sustained [REDACTED].

Based on interview and record review it was determined the facility failed to ensure pain management was provided for 1 of 1 sampled residents (#32) reviewed for pain management and accidents after Resident 32 reported an unwitnessed fall with major injury. This resulted in Resident 32 experience unmanaged pain. Findings include: Resident 32 was admitted to the facility in 2020 with [DIAGNOSES REDACTED]. Physician orders [REDACTED]. The care plan dated 1/3/20 indicated Resident 32 was a high fall risk and was to be monitored for pain, changes in usual routine, decreased functional abilities and range of motion. Facility was to notify physician if interventions were unsuccessful or if current complaint was a significant change from resident's experience of pain. A physical therapy progress note dated 1/17/20 indicated Resident 32 was independent for bed mobility, one person assist for transfers, stand by assist for gait with front wheel walker. Resident 32 had no pain. A physical therapy progress note dated 1/18/20 at 4:32 PM indicated Resident 32 reported having a ground level fall before breakfast during a transfer from the toilet to bed. Resident 32 complained of pain on her/his upper right leg with observed bruising. Resident 32 indicated her/his pain level was a nine out of ten. Residents 32's functional activities were limited due to pain. Nursing staff was notified. Resident 32 expressed increased pain on her/his right leg with weight bearing and transfers. Resident 32 was instructed to use a wheelchair until further notice. The Radiology Report dated 1/21/20 at 9:13 AM indicated Resident 32 had a right leg fracture. A progress note dated 1/21/20 at 1:43 PM indicated Resident 32 had scheduled Tylenol and the nurse practitioner was contacted for additional pain medication. A 1/29/20 Pain Assessment identified Resident 32 had pain within the past five days that decreased the resident's function. On 2/25/20 at 4:13 PM Staff 2 (Regional Director of Clinical Services) acknowledged the facility failed to assess and address Resident 32's complaints of pain in a timely manner after Resident 32 stated she/he had an unwitnessed fall, increased pain and change in functional status.

Based on interview and record review it was determined the facility failed to ensure CNAs had the appropriate skills and competencies to attain and maintain the highest practicable well-being for 1 of 3 sampled residents (#42) reviewed for accidents. This failure resulted in Resident 42 sustaining a pelvic fracture. Findings include: Resident 42 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Resident 42's Fall CAA dated 4/11/18 indicated the resident had chronic pain related to a hip surgery approximately two years prior and required a Hoyer (mechanical) lift for transfers. Resident 42's care plans dated 5/21/18 indicated the resident had healing fractures, used an electric wheelchair for mobility and a Hoyer lift for transfers. An incident report completed on 4/23/18 revealed the resident sustained [REDACTED]. Resident 42's electric wheelchair was not turned off for the transfer. As a result, the wheelchair moved into the resident's left leg. Staff 10 (CNA) and Staff 19 (NA) were the staff involved. The report revealed both staff forgot to power down Resident 42's electric wheelchair during the Hoyer lift transfer. The resident's elbow bumped the electric wheelchair control lever, causing the wheelchair to jump forward and push into the resident's left leg. The resident complained of pain and was sent to the emergency department (ED). The staff involved were immediately educated regarding powering down electric wheelchairs during transfers. A Witness Report by Staff 10 dated 4/23/18 indicated on 4/23/18 at 1:30 PM Staff 19 and Staff 10 were transferring Resident 42 with a Hoyer lift when the resident leaned on the electric wheelchair control lever which forced the resident into the Hoyer lift. The resident voiced pain and was holding her/his hip. A progress note dated 4/23/18 at 2:20 PM indicated at approximately 1:40 PM on 4/23/18 a CNA reported Resident 42's power wheelchair was left on and pushed into the resident's left leg during a Hoyer lift transfer. The hospital records from Resident 42's 4/23/18 emergency (ED) evaluation revealed the resident presented with left hip pain and stated she/he had heard a pop during a Hoyer lift transfer at the facility. Radiology results revealed a major traumatic injury, pelvic injury and pain. A CT (computerized tomography) scan was completed and revealed a traumatic injury to the resident's pelvis. An x-ray was completed and revealed a new fracture to the resident's pelvis from the injury sustained during an Hoyer lift transfer at the facility. A progress note dated 4/23/18 at 10:32 PM revealed Resident 42 returned to the facility from ED with new damage to the resident's left hip and leg. On 5/22/18 at 1:21 PM Resident 42 stated she/he was discharged to the hospital on [DATE] after the incident with the power wheelchair and the Hoyer lift where it was determined a new fractured had occurred. On 5/30/18 at 11:00 AM Staff 4 (RCM/LPN) stated Resident 42 was initially admitted to the facility for treatment for [REDACTED]. Staff 4 stated on 4/23/18 Staff 10 and Staff 19 called her to Resident 42's room to evaluate the resident's pain to her/his left hip/leg area after a Hoyer lift transfer. On 5/30/18 at 3:46 PM Staff 10 stated on 4/23/18 he was assisting Staff 19 to transfer Resident 42 from the resident's power wheelchair into the resident's bed using a Hoyer lift when the resident's forearm pushed on the power control of the wheelchair causing the wheelchair to push into the Hoyer lift. He stated he and Staff 19 both thought the the power wheelchair had been turned off by the resident and confirmed they did not check to ensure the wheelchair was powered down. As a result, the wheelchair moved forward causing the Hoyer post to push on the resident's left hip which was the resident's injured hip from a prior fracture. He stated the resident was immediately in pain from the incident. On 5/30/18 at 5:55 PM Staff 18 (OT) stated she came into the Resident 42's room and observed the incident. She stated she turned off the resident's power wheelchair when she saw what was happening and stated no one had turned if off prior to the transfer. On 5/30/18 at 2:49 PM Staff 1 (DNS) and Staff 2 (Administrator) stated the facility self-reported the 4/23/18 incident involving Resident 42, completed an incident report and concluded the resident's injuries were avoidable and the fault of the facility staff.

Based on interview and record review it was determined the facility failed to ensure residents were free from accident hazards for 2 of 3 sampled residents (#s 42 and 115) reviewed for accidents. Resident 42 sustained a pelvic fracture, Resident 115 sustained a [MEDICAL CONDITION]. Findings include: 1. Resident 42 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The facility self-reported an incident which occurred on 4/23/18 at 1:30 PM. Resident 42 was injured during a Hoyer (mechanical lift) transfer because staff forgot to turn off the resident's power wheelchair during the transfer. The resident's elbow bumped the control lever and caused the chair to jump forward. The resident complained of pain in her/his left leg and was sent to the emergency department (ED). The resident had previous fractures which were healing well but there was a new left pelvic fracture discovered during the ED evaluation. Resident 42's Admission MDS dated [DATE] indicated the resident was cognitively intact and had good safety awareness. The resident required Hoyer lift transfers, was only able to stabilize with staff assistance and was wheelchair bound related to chronic right hip pain from previous fractures and surgery. Resident 42's in-room care plan dated 4/6/18 and updated 4/25/18 indicated the resident required a Hoyer lift and two people for transfers. Interventions included turning off the power wheelchair for transfers. An incident report completed on 4/23/18 revealed the resident sustained [REDACTED]. Resident 42's power wheelchair was not turned off for the transfer. As a result, the wheelchair moved into the resident's left leg. Staff 10 (CNA) and Staff 19 (NA) were the staff involved. The report revealed both staff forgot to power down Resident 42's power wheelchair during the Hoyer lift transfer. The resident's elbow bumped the control lever on the power wheelchair causing the wheelchair to jump forward and push into the resident's left leg. The resident complained of pain and was sent to the ED. A Witness Report by Staff 10 (CNA) dated 4/23/18 indicated on 4/23/18 at 1:30 PM Staff 19 (NA) and Staff 10 were transferring Resident 42 with a Hoyer lift when the resident leaned on the electric chair control lever which forced the resident into the Hoyer lift. The resident voiced pained and was holding her/his hip. A progress note dated 4/23/18 indicated at approximately 1:40 PM on 4/23/18 a CNA reported Resident 42's power wheelchair was left on and pushed into the resident's left leg during a Hoyer lift transfer. The hospital records from Resident 42's 4/23/18 ED evaluation revealed the resident presented with left hip pain and stated she/he had heard a pop during a Hoyer lift transfer at the facility. Radiology results revealed a major traumatic injury, pelvic injury and pain. A CT (computerized tomography) scan was completed and revealed a traumatic injury to the resident's pelvis. An x-ray was completed and revealed a new fracture to the resident's pelvis from the injury sustained during the Hoyer lift transfer at the facility. A progress note dated 4/23/18 at 10:32 PM revealed Resident 42 returned to the facility from the ED with new damage to the resident's left hip and leg. On 5/22/18 at 1:21 PM Resident 42 stated she/he was discharged to the hospital on [DATE] after the incident with the power wheelchair and the Hoyer lift where it was determined a new fracture had occurred. On 5/30/18 at 11:00 AM Staff 4 (RCM/LPN) stated Resident 42 was initially admitted to the facility for treatment for [REDACTED]. Staff 4 stated on 4/23/18 Staff 10 and Staff 19 called her to Resident 42's room to evaluate the resident's pain to her/his left hip/leg area after a Hoyer lift transfer. On 5/30/18 at 3:46 PM Staff 10 stated on 4/23/18 he was assisting Staff 19 to transfer Resident 42 from the resident's power wheelchair into the resident's bed using a Hoyer lift when the resident's forearm pushed on the power control of the wheelchair causing the wheelchair to push into the Hoyer lift. He stated he and Staff 19 both thought the the power wheelchair had been turned off by the resident and confirmed they did not check to ensure the wheelchair was powered down. As a result, the wheelchair moved forward causing the Hoyer post to push on the resident's left hip which was the resident's injured hip from a prior fracture. He stated the resident was immediately in pain from the incident. On 5/30/18 at 5:55 pm Staff 18 (Occupational Therapist) stated she came into Resident 42's room and observed the incident. She stated she turned off the resident's power wheelchair when she saw what was happening and stated no one had turned it off prior to the transfer. On 5/30/18 at 2:49 pm Staff 1 (DNS) and Staff 2 (Administrator) stated the facility self-reported the 4/23/18 incident involving Resident 42, completed an incident report and concluded the resident's injuries were avoidable and the fault of the facility. 2. Resident 115 was admitted to the facility in 11/2017 with [DIAGNOSES REDACTED]. Resident 115's 12/5/17 care plan revealed the resident was at risk for falls due to weakness, poor mobility, poor safety awareness, need for staff assistance with transfers and mobility, advanced dementia and at-risk medications. Fall interventions included reminders to use the call light for assistance, bed kept at same height as wheelchair, pathways free of clutter, reminders to use non-skid socks and medication reviews PRN. A 12/5/17 Progress Note (PN) revealed Resident 115 was alert and oriented with noted confusion and able to make some needs known verbally. The PN indicated the resident was unable to use the call light effectively so her/his needs must be anticipated by staff. A 2/2/18 PN revealed Resident 115 was found on the floor on the left side of her/his bed, was unable to describe the incident and she/he had no complaints of injury. The PN indicated staff were educated to increase visual monitoring of the resident and the resident was educated to use the call light when she/he needed assistance. A 2/2/18 investigation/fall evaluation indicated Resident 115 was able to move all extremities without pain or discomfort. The cause of the incident was the resident forgot to use the call light for assistance when getting out of bed. A recommendation was made to keep the bed in a low position when the resident was in bed. On 2/20/18 the resident's care plan was revised to include [MEDICAL CONDITION] as a fall risk. Fall interventions included to assess and document the cause of an incident, document any signs and symptoms of injuries and to keep the bed in the low position with mats on the floor when the resident was in bed. A 3/16/18 PN revealed Resident 115 was found lying on her/his right side on the floor next to the recliner chair with no visible injuries noted. The 3/16/18 investigation/fall evaluation did not describe the resident's status and did not include witness statements. The cause of the incident was due to the resident was restless and tired and slid from chair. An intervention was recommended to use a one-way slide in the wheelchair. A PN on 3/19/18 revealed Resident 115 was found lying on her/his side beside a reclining chair and stated she/he slid out of the chair. The PN indicated no injuries were noted and the resident had no complaint of pain. The 3/19/18 investigation/fall evaluation lacked a description of the resident's ability to move extremities after the fall and there were no witness statements. The cause of the fall was determined to be the resident's poor strength and restlessness. An intervention to use the one-way slide in the recliner was recommended. A 3/24/18 PN indicated Resident 115 was found on the floor at the head of the bed with no visible injury noted. The 3/24/18 investigation/fall evaluation did not describe the resident's status including whether Resident 115 was able to move her/his extremities. The investigation lacked witness statements and the cause of the fall was determined to be a urinary tract infection. The use of hipsters (padded undergarment) at all times was recommended as a fall intervention. The 3/2018 MAR indicated [REDACTED] - 9:47 AM: The resident requested Tylenol for pain. - 8:26 PM: The family requested Tylenol for the resident for her/his pain. - 11:30 PM: The PRN pain medication was documented as not effective and Resident 115 stated her/his leg hurts really bad and rubbed her/his left lower extremity (LLE) crying. On 3/26/18 at 5:03 AM a PN revealed Resident 115 had increased anxiety, was yelling out and shaking due to her/his roommate flopping down on her/his bed while trying to provide comfort. Resident 115 complained of LLE pain and was moved to another room for the night. A PN at 10:58 PM on 3/26/18 indicated Resident 115 grimaced and guarded her/his LLE with movement. A 3/27/18 PN indicated Resident 115 was medicated with Tylenol for obvious complaint of pain when she/he exhibited facial grimacing with movement of her/his LLE. The PN revealed the resident's family asked staff to notify the physician of their request for an x-ray of the resident's LLE. On 3/27/18 the resident's care plan was revised with a fall intervention to use a one-way slide while in the wheelchair and recliner. A 3/28/18 PN revealed Resident 115 complained of bilateral leg pain with movement. A PN on 3/30/18 at 4:32 PM indicated Resident 115 had increased pain to the left hip with movement and the nurse practitioner was notified of the request for a hip x-ray. A PN at 11:39 PM revealed the resident had increased pain to hip/LLE and was medicated twice with Tylenol. The resident's family was present and visiting. A 4/2/18 PN at 10:34 AM revealed Resident 115 received Tylenol for complaint of left hip pain. An order was received for left hip x-rays to be completed at the facility. A PN at 10:19 PM indicated the left hip x-rays were completed and the result was positive for a fracture. Resident 115 was transferred to the emergency department (ED) for evaluation at 4:00 PM and returned to the facility at 8:38 PM after a decision was made for no surgical intervention. The physician provided additional pain medication with [MEDICATION NAME] (opioid [MEDICATION NAME]) PRN for pain not relieved by Tylenol. On 4/2/18 an investigation/fall evaluation was initiated for the 3/26/18 incident between Resident 115 and her/his roommate sitting on her/his bed/left leg (seven days after the incident occurred). The 4/2/18 x-ray results and reports from the hospital confirmed the positive left [MEDICAL CONDITION]. The physician documented there was an unknown onset of left hip pain for approximately one and one-half weeks and the resident's roommate sat on Resident 115's bed. The physician documented the circumstances of the incident were not clear to him or the staff at the facility. A Late Entry PN on 4/3/18 at 8:13 AM (for 4/2/18 at 8:05 AM) revealed a review of incident resulting in left femoral neck fracture. The PN described the 3/26/18 incident when Resident 115's roommate attempted to sit on the bed and sat on (Resident 115's) lower extremity. The PN indicated Resident 115 began to exhibit signs and symptoms of pain following the incident and the physician was notified and the resident was sent for an x-ray. (The x-ray was not obtained until 4/2/18, seven days after this incident.) A 4/3/18 PN revealed in response to family concerns and their multiple requests for x-rays for Resident 115 the physician was contacted for clarification. The facility physician indicated she was unsure whether she received a fax with that type of request and the family was notified with an update. A 4/5/18 physician's note revealed the x-rays reportedly showed early signs of healing and it was doubted the injury was caused by the resident's roommate on 3/26/18. A 4/16/18 PN at 2:58 PM indicated Resident 115's family requested another x-ray of her/his left hip due to increased pain and she/he was sent to the ED. A PN at 4:31 PM revealed the resident returned with no new findings and orders for [MEDICATION NAME] for pain. The 4/16/18 ED report revealed Resident 115's family requested bilateral hip x-rays due to increased pain and problems during transfers. The report indicated the left hip was unchanged in alignment with no acute fracture seen and the right hip was negative for a fracture. During an interview on 5/21/18 at 7:02 PM Witness 3 (Complainant) confirmed Resident 115 was unable to use a call light appropriately to request assistance. Witness 3 stated the resident was very confused and required total assistance with her/his care. Witness 3 stated x-rays were requested for the resident several times after the falls and staff did not follow-up. Witness 3 could not recall how many times the family asked for an x-ray. Witness 3 further stated the family thought the staff were not transferring the resident appropriately, may have caused more injury and they were going to call 911 to get the resident's x-rays. On 5/30/18 at 9:15 AM Staff 18 (CNA) acknowledged Resident 115 was unable to use a call light so staff tried to do more checks on her/him. Staff 18 further stated the resident frequently attempted to get up out of her/his chair or tried to get to the opposite end of the bed. On 5/30/18 at 9:25 AM Staff 17 (CNA) revealed the resident was unable to bear weight but was able to move around on her/his bed and was very confused. Staff 17 stated he heard the resident's roommate sat on her/his bed but he did not know it resulted in any injury. On 5/30/18 at 1:50 PM Staff 15 (LPN) acknowledged the resident had a couple episodes of being found on the floor because she/he tried to get out of bed. Staff 15 stated Resident 115 had complaints of pain on both left and right hips/LLEs. Staff 15 revealed the resident's family did not want the resident to receive anything stronger than Tylenol for pain including after the fracture. On 5/30/18 at 2:25 PM Staff 3 (RCM/LPN) acknowledged the resident's falls in 3/2018 and when her/his roommate sat on the bed. Staff 3 stated there were a lot of concurrent issues for Resident 115 at the time when the falls occurred. Staff 3 confirmed the family was anxious regarding the x-rays and on 4/16/18 the facility made arrangements for transfer to the ED. During interviews on 5/30/18 at 6:00 PM and 5/31/18 at 7:50 AM Staff 1 (DNS) and Staff 2 (Administrator) acknowledged the fall investigations lacked witness interviews and staff failed to thoroughly screen for the resident's ability to move her/his lower extremities. Staff 1 confirmed the 4/2/18 investigation was initiated in response to the 4/2/18 positive left [MEDICAL CONDITION] and the concluded it was caused by the roommate. Staff 1 and Staff 2 were unable to describe why Resident 115 was not sent for x-rays sooner after any of the three previous falls in 3/2018, with the exception that the resident did not complain of pain in the specific area where she/he was found on the floor. Staff 1 stated the facility reported the incident to Adult Protective Services on 4/2/18. Resident 115 experienced a series of three falls/unwitnessed episodes of being found on the floor from 3/16/18 through 3/24/18. On 3/26/18 the resident's roommate was found on her/his bed and may have sat on Resident 115's leg. The family requested x-rays be completed multiple times and no x-rays were obtained until 4/2/18 (17 days after the first fall on 3/16/18 and seven days after the roommate sat on the bed). On 4/2/18 x-ray results revealed there was a [MEDICAL CONDITION] hip in early stages of healing and the physician documented it was unclear when the injury had occurred.

Based on observation, interview and record review it was determined the facility failed to follow the care plan for fall prevention for 1 of 3 (#2) sampled residents who were reviewed for falls. Resident 2 fell and sustained a right hip fracture. This placed residents at risk for unmet needs. Findings include: Resident 2 was admitted to the facility in September, 2014 with [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed the resident required staff to provide assistance with bed mobility, transfers and toileting. The MDS indicated the resident had a history of [REDACTED]. The Morse Fall Scale dated 4/10/15 assessed the resident as a high fall risk. The In-Room Care Plan (IRCP) dated 4/23/15 directed staff to position the resident with pillows in the wheelchair, provide frequent visual checks and high visibility. The IRCP directed staff to ensure her/his bed was against the wall and a fall mat was kept in place next to her/his bed. The Incident Report dated 6/23/15 revealed at 3:30 pm Staff 16 (LPN) heard a sound which came from Resident 2's room, she saw the resident seated on the floor and putting weight on the right hip area. The Physician's Telephone Order dated 6/23/15 included x-rays of the resident's right hip and right knee. The Resident Progress Note for 6/23/15 revealed the resident was found seated on the floor, leaning against a wheelchair with her/his right knee fully flexed and right leg externally rotated. Staff 16 (LPN) indicated she saw the resident's x-ray results at 9:40 pm and they showed evidence of a fractured right hip. She indicated orders were received to send the resident to the emergency department. On 8/26/15 at 2:50 pm the resident was lying in a low bed which was not against the wall. On 8/26/15 at 3:15 pm Staff 2 (DNS) stated the resident's care plan included keeping the bed against the wall, she had been gone a few days and planned to follow up on the issue. On 8/27/15 at 12:30 pm the resident's bed was against the wall with a fall mat next to the bed. On 8/27/15 at 2:20 pm Witness 2 (family) stated she said goodbye to (Resident 2) at 3:00 pm and got a call 30 minutes later with the news the resident slid out of the wheelchair. Witness 2 stated at that time she left at 3:00 pm the resident was seated in an upright position in her/his wheelchair and two CNAs were getting ready to transfer her/him back to bed. Witness 2 indicated the facility reported the resident was alone when s/he slid out of the wheelchair which was in her/his room. Witness 2 stated there was no way that could happen if the wheelchair was tilted way back and (s/he) was supposed to be in an area where staff could observe (her/him) when out of bed. On 8/26/15 at 2:40 pm Staff 12 (CNA) stated the resident was asked if s/he wanted to go back to bed, the resident nodded no and the wheelchair was tilted back when she and (Staff 13, CNA) left the room the day the resident later fell . She stated the resident's TV was turned on and the call light was left within reach. On 8/26/15 at 2:50 pm Staff 13 (CNA) stated the day the resident fell in June it was possible the resident's wheelchair was tilted slightly back and not entirely back before the resident slid out of the wheelchair. On 8/26/15 at 3:00 pm Staff 14 (CNA) indicated she came into the resident's room to see if the two CNAs needed help with the resident's transfer back to bed. She stated the resident nodded no when (Staff 12, CNA) asked whether s/he wanted to go back to bed, the resident's wheelchair was upright and she left the resident with the two CNAs. On 8/27/15 at 3:20 pm Staff 16 (LPN) indicated she heard a loud noise which came from the resident's room and she found the resident alone in her/his room, sitting next to the wheelchair and she performed an assessment. She stated the resident had portable x-rays, she gave the resident pain medications which were effective and staff kept the resident on bed rest. Staff 16 stated there was a delay in getting the x-ray results because they were not sent to the usual fax machine and were sent electronically to the resident's actual record. She stated she saw the results before 10:00 pm and received orders to send the resident to the emergency department. On 9/8/15 at 10:15 am Staff 2 (DNS) acknowledged Resident 2's care plan was not followed when her/his bed was not against the wall on 8/26/15. She acknowledged staff did not follow the care plan when Resident 2 was left in a wheelchair in her/his room which was not a highly visible area and the resident sustained [REDACTED].