Every finding on record at Avalon Care Center - Portland

Based on interview and record review it was determined the facility failed to ensure residents were informed in writing of the facility's bed-hold policy and notice of transfer at the time of hospital transfer for 3 of 3 residents (#s 4, 7 and 8) reviewed for notification. This placed residents and responsible parties at risk for not being informed of transfer and bed-hold policy fees. Findings include: The facility's 7/2018 Notification of Changes of Condition Policy instructs the facility to promptly notify the resident representative when there was a decision to transfer a resident from the facility to the hospital.a. Resident 7 was admitted in 6/2024 with diagnoses including urinary tract infections (UTIs) and sepsis (an infection that enters the bloodstream).Resident 7's admission Profile indicated she/he was responsible for themselves.Review of Resident 7's clinical record revealed she/he was transferred to the hospital on 2/12/26 but no evidence was found in Resident 7's clinical record to indicate the resident was provided with the notice of transfer and facility bed-hold policy.b. Resident 4 was admitted to the facility in 2/2025 with diagnoses including peripheral vascular disease (a condition that restricts blood flow usually with legs and feet).Resident 4's admission Profile indicated Witness 4 (Resident 4's Daughter) was the resident's responsible party.A review of Resident 4's clinical record revealed she/he was transferred to the hospital on [DATE] and 12/18/25. No evidence was found in Resident 4's clinical record to indicate the resident's representative was notified of the hospital transfers. c. Resident 8 was admitted to the facility in 4/2025 with diagnoses including chronic heart failure.Resident 8's admission Profile indicated she/he was responsible for themselves.A review of Resident 8's clinical record revealed she/he was transferred to the hospital on 2/12/26 but no evidence was found in Resident 8's clinical record to indicate the written notice of transfer and facility's bed-hold policy were provided to the resident.On 4/7/26 at 8:56 AM Staff 17 (LPN) stated she did not document which documents she sent with residents transferring to the hospital and the facility did not have written transfer notices to provide to residents or resident representatives.On 4/7/26 at 9:34 AM Staff 4 (LPN) stated he was unaware he needed to provide a bed hold policy or a transfer notice when residents were transferred to the hospital. On 4/7/26 at 1:06 PM Staff 2 (DNS) was unable to locate documentation confirming the bed hold policy or written notification of transfer were provided to Resident 4, Resident 7, Resident 8, or their representatives. Staff 2 stated she was unaware a written transfer notification was required when transferring a resident out of the facility, but Staff 1 (Administrator) acknowledged a written notification of transfer and the facility bed-hold were supposed to be provided to residents or residents' representatives when transferred out of the facility.

Based on observation, interview and record review, it was determined the facility failed to promote and facilitate resident self-determination to support a resident's preference for health care providers for 1 of 3 sampled residents reviewed for abuse. This placed residents at risk for lack of self-determination and autonomy. Findings include: The facility's Resident Rights: Right to Self-Determination Policy, dated 7/2018, indicated the following: -The facility would support each resident to have the opportunity to exercise his or her autonomy regarding those things that are important to his or her life. This included the resident's interests and preferences. -The resident had a right to, and the facility would promote and facilitate resident self-determination through support of resident choices, including but not limited to the rights specified in the regulation. -The resident had the right to choose activities, schedules, health care and providers of health care services consistent with his or her interests, assessments and plan of care. -The resident had a right to make choices about aspects of his or her life in the facility that are significant to the resident. Resident 1 was admitted to the facility in 5/2024 with diagnoses including Parkinson's Disease (a progressive neurological disorder) and anxiety. Resident 1's 5/30/25 revised Trauma Care Plan instructed staff to involve Resident 1 in her/his cares and daily decisions. Resident 1's 11/6/25 Modification Quarterly MDS and 2/4/26 Quarterly MDS indicated the resident had no cognitive impairment. On 4/6/26 at 9:39 AM, Resident 1 stated she/he spoke with several staff members and administration about not wanting Staff 3 in her/his room or providing care to her/him, on several occasions. Resident 1 stated she/he tried to get her to not work with me but Staff 3 continued to be assigned to her/him and was her/his CNA, today. Resident 1 stated she/he told them and told them she/he did not want Staff 3 as her/his CNA, but nothing changed. On 4/6/26 at 11:16 AM, Witness 1 (Complainant) stated Resident 1 did not want Staff 3 to be her/his CNA. Witness 1 stated we complained to the facility several times but it doesn't do anything. Witness 1 stated they had no idea why the facility continued to assign Staff 3 as Resident 1's CNA but was told the facility did not have anyone else. A review of the 3/24/26 through 4/6/26 staff assignment sheets indicated Staff 3 (CNA) was assigned to Resident 1 on the following days: -3/25/26, 3/26/26, 3/27/26, 3/28/26, 3/29/26, 3/31/26, 4/1/26, 4/2/26, 4/3/26, 4/5/26 and 4/6/26. Observations on 4/6/26 between the hours of 9:30 AM and 2:30 PM revealed Staff 3 provided care and services to Resident 1 during day shift. On 4/6/26 at 1:04 PM, Staff 3 stated Resident 1 did not like her as her/his CNA and the nursing staff and upper management were aware. Staff 3 stated they continued to assign her as Resident 1's CNA despite being aware Resident 1 doesn't want me. On 4/7/26 at 9:19 AM, Staff 8 (CNA) stated her and Staff 3 worked as partners in Resident 1's section and had been assigned to care for Resident 1 for awhile. Staff 8 stated Resident 1 did not want Staff 3 assisting her/him. On 4/7/26 at 10:04 AM, Staff 9 (Social Services) stated Resident 1 reported she/he did not want Staff 3 as her/his CNA, several times. Staff 9 stated the concern was talked about amongst us all for a while. Staff 9 stated Resident 1 mentioned it to him again on Monday (4/6/26) and he passed the information up the line to Staff 1 (Administrator) and Staff 2 (DNS). On 4/7/26 at 10:50 AM, Staff 10 (Staffing Coordinator/Human Resources) stated she was responsible for assigning CNAs to specific resident rooms in conjunction with Staff 2. Staff 10 confirmed Resident 1 verbalized complaints regarding Staff 3 and stated changes in CNA assignments were made if a teammate asked to make a change and Staff 3 did not have any issues providing care to Resident 1. Staff 10 stated Staff 1 and Staff 2 were aware of Resident 1's request and had spoken to the resident and her/his sister. On 4/7/26 at 11:10 AM, Staff 2 stated she was aware Resident 1 did not want Staff 3 assigned to her/him. Staff 2 reviewed CNA assignment sheets for 3/24/26 through 4/6/26 and confirmed Staff 3 was assigned to Resident 1 on 3/25/26, 3/26/26, 3/27/26, 3/28/26, 3/29/26, 3/31/26, 4/1/26, 4/2/26, 4/3/26, 4/5/26 and 4/6/26. Staff 2 stated it was Resident 1's right to have a choice regarding who cared for her/him, but there were challenges with staffing and many considerations when it came to CNA assignments.

Based on interview and record review it was determined the facility failed to notify a resident's representative of a hospital transfer for 1 of 3 sampled residents (#4) reviewed for notification of changes. This placed residents and responsible parties at risk for not being informed of transfers: Findings include:The facility's 7/2018 Notification of Changes of Condition Policy instructs the facility to promptly notify the resident representative when there was a decision to transfer a resident from the facility to the hospital.Resident 4 was admitted to the facility in 2/2025 with diagnoses including peripheral vascular disease (a condition that restricts blood flow usually with legs and feet).Resident 4's admission Profile indicated Witness 4 (Complainant) was the resident's responsible party and emergency contact.A review of Resident 4's clinical record revealed she/he was transferred to the hospital on [DATE] and 12/18/25. No evidence was found in Resident 4's clinical record to indicate the resident's representative was notified of the hospital transfers. On 4/7/26 at 8:56 AM Staff 17 (LPN) stated the emergency contact or representative listed on the face sheet was to be notified before or immediately after the resident left the facility and the information was to be documented in the resident's clinical record.On 4/7/26 at 9:34 AM Staff 4 (LPN) stated family were to be contacted when residents transferred out of the facility to the hospital by who was listed as emergency contact or responsible party on the face sheet and he documented who was contacted in the clinical record. On 4/7/26 at 1:06 PM Staff 2 (DNS) and Staff 1 (Administrator) confirmed Witness 4 was not notified on 12/18/25 when Resident 4 was transferred to the hospital and acknowledged nursing staff were not contacting resident representatives.The deficient practice was identified as Past Noncompliance based on the following:On 12/19/25, the deficient practice was identified by the facility and was corrected when the facility did a root cause analysis of the incident and determined the facility had not consistently notified required parties for condition changes including hospital transfers. 1. Nursing staff were educated on Notification of Changes and Best Practices for Nursing Documentation on 12/19/25, 2. One-to-one education was provided on 12/19/25 with Staff 18 (RN), the nurse on shift at time of the transfer, 3. Notification of Changes was added as a focus area for the facility's Quality Assurance Performance Improvement (QAPI) team on 12/19/25, 4. Ongoing audits and tracking were initiated on 1/2026. Staff 2 continued to complete audits and ongoing education was provided as needed.

Based on interview and record review it was determined the facility failed to ensure a resident was free from sexual abuse for 1 of 3 sampled residents (#2) reviewed for abuse. This placed residents at risk for a decrease in their quality of life and at risk for psychosocial difficulties. Findings include: The facility's 11/2017 Freedom from abuse, neglect, and exploitation policy defined sexual abuse as non-consensual sexual contact of any type with a resident who appears to want the contact to occur but lacks the cognitive ability to consent or a resident who does not want the contact. Resident 2 was admitted to the facility in 11/2017 with diagnoses including relapsing multiple sclerosis (a disease where the immune system attacks the lining of nerve cells in the brain and spinal cord) and mild cognitive impairment. Resident 2's 11/26/25 Quarterly MDS indicated she/he had severe cognitive impairment.Resident 2's 10/27/25 care plan identified the resident had past sexual assault trauma, preferred female staff, and had impaired cognition. Resident 3 was admitted to the facility in 8/2023 with diagnoses of alcohol-induced persisting dementia and high-risk heterosexual behavior. Resident 3's 4/30/25 Annual MDS indicated she/he had moderate cognitive impairment.Resident 3's 5/6/25 care plan identified the resident had a history of sexual behaviors towards female residents and instructed staff to ensure she/he was supervised when around female residents. Staff were to redirect Resident 3 when sexual behaviors were anticipated and place the resident on intermittent one to one supervision after incidents for safety of others. Review of Resident 3's clinical records revealed the resident had attempted to touch a female resident on 10/15/25, was found in a female resident's room twice and sexually touched female staff on 10/31/25, and, on 11/3/25, been having increased sexual behaviors. No evidence was found in the resident's clinical record to indicate Resident 3 had been placed on 1:1s after these incidents. Review of the facility's 11/5/25 incident report revealed on 11/5/25 at 3:50 PM Staff 10 (Staffing Coordinator/Human Resources) saw Resident 3 with her/his hand under Resident 2's shirt while in the dining room. The report did not list any other witnesses but did identify that Resident 3 had been involved in similar incidents in the past. On 4/6/26 at 11:12 AM Staff 13 (CNA), 4/6/26 at 1:56 PM Staff 14 (CNA), 4/7/26 at 9:23 AM Staff 15 (CNA), and 4/7/26 at 9:45 AM Staff 16 (CNA) reported Resident 3 was not supposed to be alone with female residents due to a known history of sexually inappropriate behaviors towards female residents and when Resident 3 was not on 1:1s, staff were to redirect Resident 3 from entering resident rooms or when she/he demonstrated sexual behaviors. On 4/7/26 at 10:32 AM Staff 10 (Human Resources/Staffing Coordinator) stated on 11/5/25 she walked to the nursing station and observed Resident 3 fondling Resident 2's breast from under Resident 2's shirt. Staff 10 stated Resident 2 was trying to push Resident 3's hands away at the time of the incident. Staff 10 reported no other staff were in the area and confirmed Resident 3 was not supposed to be alone with female residents. On 4/7/26 at 1:34 PM Staff 1 (Administrator) and Staff 2 (DNS) confirmed Resident 3 had a known history of sexual behaviors towards others and acknowledged the incident between Resident 2 and Resident 3 on 11/5/25 was considered abuse.

Based on observation, interview and record review it was determined the facility failed to ensure a resident's right to a dignified existence with use of a power mobility device for 1 of 1 resident (# 19) reviewed for choices. This placed residents at risk for diminished independence and freedom of socialization with other residents. Findings include:The facility's Resident Right Policy dated 7/2018 indicated the resident has a right to and the facility will promote and facilitate resident self-determination through support of resident choice.Resident 19 was admitted to the facility in 11/2022 with diagnoses including cerebral infarction (blockage of blood flow to the brain) and depression.A 5/8/25 Occupational Therapy Evaluation included a goal for Resident 19 to operate a power chair with standby assist in the facility to maximize socialization skills.Review of Occupational Therapy Encounter Notes from 5/8/25 through 7/21/25 revealed Resident 19 received therapy services from Staff 5 (Rehabilitation Director) focused on improving skills involved with operating a power wheelchair, but no assessment on the use of a power wheelchair was performed. The resident's plan of treatment included power wheelchair mobility training in therapy on 5/23/25, 5/27/25, and 5/28/25, however power wheelchair training did not occur on those dates. On 6/3/25, an Occupational Therapy Encounter Note stated the use of power wheelchair was trialed and discontinued, stating Resident 19 experienced tactile feedback and visual scanning deficiencies.A cognitive assessment dated [DATE] revealed Resident 19 had a BIMS score of 13 which indicated the resident had normal cognitive function.A 5/23/25 Quarterly MDS stated Resident 19 had adequate vision without corrective lenses.A 6/3/25 Therapy to Facility Communication note stated Resident 19 was unsafe to continue use of a power wheelchair due to her/his decreased tactile feedback in her/his hands and visual scanning.On 7/22/25 at 9:08 AM Resident 19 stated she/he wanted to use her/his power wheelchair to increase her/his freedom to move in the facility and community. Resident 19 stated therapy would assess her/him to determine if she/he was safe with using the power wheelchair, but no time was spent in a power wheelchair to determine Resident 19's abilities to use a power wheelchair safely.On 7/22/25 at 1:49 PM Staff 6 (CNA) stated Resident 19's functional use of her/his hands improved in the last month with Resident 19 demonstrating an ability to perform self-care tasks like brushing teeth, caring for dentures, face washing, upper body dressing and using a call button without assistance.On 7/22/25 at 1:56 PM Staff 5 stated Resident 19 had a goal to use a power wheelchair with standby assist, meaning a staff member was next to Resident 19. Skills related to power wheelchair use including sitting balance, fine motor skills and spatial reasoning were assessed, but no assessment which involved the use of a power wheelchair was performed with Resident 19. Staff 5 stated fine motor skills and spatial reasoning were impaired. When asked for a record of these assessments, no information related to operating a power wheelchair was provided.On 7/23/25 at 3:14 PM Resident 19 was observed independently participating in bingo which required fine motor and visual scanning techniques. The resident was also able to visually scan the bingo card and bin containing bingo markers, pick up a small bingo marker and place that marker on the correct number.On 7/23/25 at 3:33 PM Staff 7 (CNA) stated Resident 19 was not observed to have any difficulty with her/his vision or fine motor skills when participating in activities. Staff 7 stated Resident 19 previously had grasping problems when performing activities, but those impairments improved in the last month.On 7/24/25 at 10:14 AM Staff 2 (DNS) stated Resident 19 actively participated in occupational therapy which was focused on improving skills required to operate a power wheelchair and confirmed an assessment with Resident 19's use of a power wheelchair should have been performed to make a determination of Resident 19's independent use of a power wheelchair.

Based on interview and record review it was determined the facility failed to ensure an appropriate PASARR (Preadmission Screening for individuals with a mental disorder and/or individuals with intellectual disability) was completed for 2 of 3 sampled resident (#s 8 and 34) reviewed for PASARR. This placed residents at risk for not receiving specialized services. Findings include: An 8/2018 facility policy revealed, a PASARR will be completed for each resident prior to admission. The applicants are evaluated for a serious mental disorder. Specialized services will be offered to individuals with mental disorders.1. Resident 34 admitted in 2/2025 with diagnoses including schizophrenia and anxiety.A PASARR I assessment completed on 5/5/24 revealed Resident 34 should receive a PASARR-II due to her/his diagnoses of schizophrenia.A review of Resident 34's electronic health record revealed no PASARR II was completed for Resident 34.On 7/24/25 at 10:06 AM Staff 2 (DNS) confirmed a PASARR-II had not been completed for Resident 34 to address her/his schizophrenia diagnoses.2. Resident 8 was admitted in 11/2024 with diagnoses including bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and PTSD (Post Traumatic Stress Disorder). A review of the resident's electronic health record (EHR) at the time of the survey revealed there was no PASARR I available in the record. In an interview on 7/23/25 at 3:26 PM Staff 14 (Admissions/Social Services) stated he reported the lack of PASARR I screenings to Staff 1 (Administrator).7/23/25 at 3:37 PM, Staff 4 (MDS Coordinator) acknowledged a PASARR 1 was not completed for Resident 8.On 7/23/25 at 3:48 PM Staff 1 stated Resident 8 should have had a PASARR I completed upon admission to the facility.

Based on observation, interview and record review the facility failed to ensure activities were honored for 1 of 1 sampled resident (#9) reviewed for activities. This placed residents at risk for boredom, and loneliness. Findings include:Resident 9 was admitted to the facility in 12/2024 with diagnoses including dementia and PTSD (Post Traumatic Stress Disorder).The resident's admission MDS dated [DATE] indicated the resident had a BIMS score of six which indicated the resident had severe cognitive impairment. The MDS revealed it was very important for Resident 9 to be around animals such as pets, do her/his favorite activities, go outside when the weather was good, and listen to music she/he liked.The resident's care plan initiated on 12/20/24 revealed Resident 9 liked music. The resident was provided an activity calendar, invited to activities, and calling family/friends. The care plan did not include specific preferences for Resident 9 which included, pet visits, listening to music of her/his choice, doing things with groups of people, and going outside on nice days. Random observations from 7/21/25 through 7/24/25, revealed Resident 9 sitting alone either in the main dining room or in the halls with little to no staff interaction and no activities of interest provided to her/him. Group activities were observed to be occurring near Resident 9.On 7/22/25 at 2:25 PM Resident 9 was observed sitting in the main dining room at a table alone. Two activities were occurring in the dining room; the resident was not included in either one. Resident 9 told a staff member she/he was looking for a hiding place because no one wanted to hang out with her/him.On 7/23/25 from 2:15 PM to 3:20 PM Resident 9 was sitting in the hallway staring at the floor and no staff interacted with her/him and no activities were offered. During an interview on 7/21/25 at 2:05 PM and 7/24/25 at 10:30 AM Witness 1 (Resident Representative) stated, Resident 9 slept when she/he was bored, was usually in bed or out sitting in the hallway when Witness 1 came to visit. Witness 1 stated the resident enjoyed listening to country music and older rock music. On 7/24/25 at 10:10 AM Resident 9 stated she/he liked country music, going outside, and liked dogs. Resident 9 stated she/he would like to be invited to activities.During an interview on 7/24/25 at 1:07 PM and 7/25/25 at 9:05 AM Staff 9 (CNA) stated Resident 9 enjoyed visiting with dogs and would go to activities if she/he was invited.During an interview on 7/24/25 at 1:30 PM Staff 17 (CNA) stated Resident 9 would go to activities if she/he was invited but was unaware of activity preferences.During an interview on 7/25/25 at 9:18 AM Staff 12 (Activities Director) stated she completed one on one visits twice weekly, but Resident 9 was not on her list. Staff 12 confirmed three activities which were very important to Resident 9 were missing from the care plan and were not being offered to Resident 9.During an interview on 7/25/25 at 10:02 AM Staff 1 (Administrator) stated she expected activities to be offered to all residents and ensure preferences and activities were reflected on the care plan. Staff 1 acknowledged Resident 9's care plan was not reflective of her/his activities and was not being offered to participate in activities.

Based on observation, interview and record review, it was determined that the facility failed to implement care planned transfer interventions to prevent falls for 1 of 2 sample residents (#4) reviewed for accidents. This placed residents at risk for physical injury. Findings include:Resident 4 was admitted to the facility in 1/2025 with diagnoses including right leg amputation.Resident 4's 4/2025 and 6/2025 care plan revealed the resident required two-person assistance with a mechanical lift when moving from bed to a shower chair. A Fall Incident dated 5/21/25 revealed Resident 4 had a fall while being transferred out of bed into a shower chair. The resident was transferred by one CNA who did not utilize a mechanical lift.On 7/24/25 at 2:19 PM Staff 11 (CNA) stated she was told by Resident 4 she/he no longer used the mechanical lift and only needed one staff person to assist with her/his transfer status because the resident was working with therapy.On 7/24/25 at 3:00 PM Staff 13 (LPN) stated Resident 4's transfer status in 5/2025 (before the fall) was a two-person mechanical lift transfer.On 7/25/25 at 10:22 AM Staff 2 (DNS) stated Resident 4 told Staff 11 she/he did not need the mechanical lift anymore because the resident was working with therapy utilizing a slide board transferring. Staff 2 stated she was aware of the fall on 5/21/25 and acknowledged Staff 11 did not follow the care plan. Staff 2 indicated she expected all staff to review and follow the residents care plan.On 5/28/25, the Past Noncompliance was corrected by the facility with the following: 1. Staff 11 was educated and retrained in the moment regarding reviewing and following the care plan. 2. All CNAs were educated regarding reviewing and implementing the care plan. 3. All staff attended monthly CNA meetings to ensure they provided safety checks for those residents which were considered a high fall risk.4. The QAPI team monitored/audited any kind of falls whether a resident was injured or not and ensured staff reviewed, implemented and followed the care plan.

Based on interview and record review it was determined the facility failed to ensure a resident's prophylactic use of an antibiotic was reviewed and a rationale for continued use was documented when duplicate antibiotic treatment occurred for 1 of 1 sampled resident (#12) reviewed for antibiotic usage. This placed residents at risk for adverse medication consequences and drug-resistant infections. Findings include: The facility's Infection and Control: Antibiotic Stewardship policy, last revised 3/2019, indicated the facility would validate antibiotics were prescribed for the correct indication, the correct dose, the correct route and the correct duration. Resident 12 was admitted to the facility in 5/2024 with diagnoses including acute kidney failure, dysuria (painful or uncomfortable urination) and urinary retention (inability to completely empty the bladder). A 10/15/24 physician order indicated Resident 12 was prescribed Bactrim (an antibiotic) one time a day for UTI prophylaxis (ongoing antibiotic administration not intended to treat an existing infection, but to reduce the risk of developing one). A 6/14/25 progress note written at 6:40 PM indicated Resident 12 reported complaints of a possible UTI including burning with urination, weakness and low back pain. Resident 12 was transported to the Emergency Department (ED) for evaluation. A 6/14/25 progress note written at 11:00 PM indicated Resident 12 returned to the facility from the ED. Resident 12 had no UTI and blood work revealed no infection. The resident was diagnosed with possible muscle pain. Resident 12 was to follow-up with her/his PCP (Primary Care Physician). A 6/14/25 ED After Visit Summary revealed Resident 12 was evaluated for a possible UTI, no infection was identified and the resident was diagnosed with flank pain (discomfort located in the side of the abdomen, between the lower ribs and hips). Resident 12's 6/15/25 through 6/19/25 progress notes indicated there were no further concerns of burning with urination, weakness or low back pain voiced by the resident. A 6/19/25 PCP After Visit Summary indicated Resident 12 was started on cefuroxime (an antibiotic) twice a day for seven days (6/19/25 through 6/25/25) due to trace leukocytes (a small amount of white blood cells) identified during a urine dipstick test (a quick way to access various aspects of urine). Resident 12's June 2025 MAR indicated the resident received prophylactic Bactrim in addition to, cefuroxime from 6/19/25 through 6/25/25. A 6/20/25 progress note written at 9:29 AM indicated nursing staff attempted to contact Resident 12's PCP to clarify the resident's Bactrim usage due to Resident 12 receiving Bactrim and cefuroxime at the same time for the same condition. A review of Resident 12's electronic health record indicated the resident's PCP did not respond. On 7/22/25 at 1:04 PM, Staff 8 (LPN) stated Resident 12 was prescribed Bactrim for UTI prophylaxis in 10/2024. She stated on 6/14/25, Resident 12 went to the ED for abdominal pain and a possible UTI. Staff 8 reported when Resident 12 returned from the ED, there was no UTI found. Staff 8 reported Resident 12 was prescribed cefuroxime on 6/19/25, after a visit to the resident's outside provider. Staff 8 reported she was unsure why Resident 12 received two antibiotics at the same time for the same condition, and if she noticed a resident being prescribed two different antibiotics for the same condition, she would contact the provider for clarification. On 7/22/25 at 1:22 PM and 7/24/25 at 12:24 PM, Staff 2 (DNS) reported Resident 12 was placed on Bactrim, prophylactically for a history of UTI's, in 10/2024. On 6/14/25, Resident 12 went to the ED with symptoms of a possible UTI and was found to have no UTI. In addition, Resident 12's bloodwork indicated no infection. Staff 2 stated on 6/19/25, Resident 12 had a follow-up appointment with her/his PCP and returned to the facility with orders for a second antibiotic. Staff 2 stated she attempted to contact Resident 12's PCP office for clarification and to have a conversation regarding the resident's antibiotic use, but the PCP office did not return her call. Staff 2 stated Staff 4 (Infection Control Preventionist/MDS Coordinator) should have reached out to the PCP office to discuss the ongoing need and appropriateness of Resident 12's antibiotics. Staff 2 stated her expectations were for staff to have a clear understanding of why Resident 12 was on two antibiotics, Resident 12's antibiotics were evaluated and assessed to be appropriate and there was a rationale for dual antibiotic use. On 7/22/24 at 3:16 PM, Staff 4 stated she was aware Resident 12 received two different antibiotics at the same time for UTI management. Staff 4 stated she wondered why Resident 12 had two antibiotics and an antibiotic time-out form was faxed to the resident's PCP. Staff 4 stated Resident 12's PCP was not responsive, and she was unable to get through to the PCP office thus no follow-up regarding Resident 12's dual antibiotic use was completed. Staff 4 stated she would not want to see a resident receive two antibiotics for the same condition without clarification and a rationale provided and confirmed there was no clarification or rationale for Resident 12's dual antibiotic use.

Based on observation, interview, and record review it was determined the facility failed to ensure the facility's smoking policy was implemented and followed for 1 of 3 (#2) sampled residents reviewed for accidents and hazards. As a result, Resident 2 sustained a second degree burn to her/his left hand. Findings include: The facility's 1/20/23 Smoking Policy indicated the facility will furnish a supervised designated smoking area where smoking and smoking paraphernalia items will be managed and distributed by staff. The facility indicated residents who smoke must return all smoking and smoking paraphernalia items to the facilities centralized storage box. Residents who smoke were to be informed that a violation of the facility smoking policy could place other residents at risk for endangerment which could lead to a facility initiated discharge. Resident 2 was admitted to the facility in 2/2024, with diagnoses including chronic kidney disease. A 10/4/24 Facility Incident Report stated Resident 2 set her/his hand on fire while refilling Resident 3's butane (gas) lighter. Resident 2 stated she/he was refilling Resident 3's butane lighter when she/he striked Resident 3's lighter and set fire to her/his middle, ring, and left finger of her/his left hand. A 10/8/24 Skin and Wound Evaluation indicated Resident 2 sustained 2nd degree burns to her/his middle, ring, and little finger of her/his left hand. On 10/16/24 at 10:28 AM, Resident 2 stated she/he sustained a 2nd degree burn to her/his left hand as a result of striking the [NAME] of Resident 3's lighter that she/he had overfilled with butane liquid fluid. Resident 2 was observed with significant burns on her/his left hand near the middle, ring and little finger. Resident 2 also stated the facility used to have a designated smoking area, but residents decided to leave the facility to smoke independently. Resident 2 stated the facility was aware of this and did not enforce the smoking policy and did not ask for residents to return smoking materials after use. On 10/16/24 at 11:27 AM, Resident 3 stated the facility did not enforce their smoking policy to return all smoking paraphernalia after use, which led to her/his continued use of her/his butane lighter fluid and butane lighter in the facility. On 10/16/24 at 1:00 PM, Staff 4 (CNA) confirmed residents were required to grab all smoking materials from the nurse's station and return the materials after use. Staff 4 indicated the facility did not enforce this requirement due to facility's inability to manage the smoking policy with residents. On 10/24/24 at 10:36 AM, Staff 1 (Administrator) acknowledged the facility failed to ensure resident safety related to the possession and management of smoking paraphernalia.

Based on observation, interview, and record review it was determined the facility failed to protect the resident's right to be free from physical and sexual abuse for 2 of 7 sampled residents (#s 3 and 12) reviewed for abuse. This placed residents at risk for physical and psychological harm. Findings include: 1. Resident 12 was admitted to the facility in 6/2023 with diagnoses including a communication deficit and dementia. Resident 12's behavioral care plan initiated on 6/7/23 indicated the following: -The resident had a behavior issue related to a lack of spatial awareness (Resident does not recognize when she/he is close to others personal space.) -[Staff] consistently check on whereabouts of resident if found in room other than her/his or attempting to enter other rooms . -Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Resident 12's 3/10/24 Quarterly MDS revealed the resident had short and long-term memory problems, no memory recall ability, and her/his decision making was severely impaired. Resident 17 was admitted to the facility in 1/2023 with two different types of dementia. Resident 17's 2/6/24 behavioral care plan indicated the following: - The resident had potential to be physically aggressive. - The resident's triggers for physical aggression were interactions with another resident invading her/his space. The resident's behavior was de-escalated by removing the other resident or this resident from the situation. Resident 17's 3/20/24 Quarterly MDS indicated the resident was moderately cognitively impaired. A Facility Reported Incident (FRI) dated 8/6/23 revealed Resident 12 was observed to be on her/his hands and knees on the floor next to Resident 17's bed. Resident 17 was observed to be holding a book in both hands and Resident 12 was noted to have multiple skin tears on both arms. A facility event report dated 8/11/23 revealed the following: - Resident 17 used to be homeless and had no space to call her/his own. - Resident 12 had behavioral issues related to other people's personal space. - Resident 12's location was to be consistently checked on due to her/his tendency to wander into other resident rooms. - Resident 17 stated she/he struck Resident 12 and considered striking her/him again. - Resident 12 was unable to be interviewed due to cognitive status. On 5/27/24 and 5/28/24 Resident 12 and 17 were interviewed. Neither resident had any recollection of an altercation. On 6/3/24 at 12:13 PM Staff 18 (Housekeeper) stated she witnessed Resident 12 on the floor on her/his hands and knees. Staff 18 witnessed Resident 17 holding a book over Resident 12 and told Staff 18 to get her/him out of here before I hit her/him again. There were no other witnesses to this altercation. On 5/31/24 at 7:48 AM Staff 17 (CNA) stated Resident 12's skin was very very fragile something as simple as trying to help Resident 12 transfer, if not done properly, will cause a skin tear. Staff 17 confirmed physical contact with Resident 12's arms by Resident 17 could easily cause skin tears. 05/30/24 07:42 AM Staff 8 (CNA) stated knowledge of Resident 12's and Resident 17's behaviors. Staff 8 stated an altercation and physical contact occurred but was unsure of the exact specifics. 05/31/24 10:45 AM Staff 3 (LPN/RCM) and Staff 4 (RNCM) - confirmed the facility knew Resident 12 wandered and had a history of climbing into other resident's beds. Staff 3 and 4 confirmed the facility was aware Resident 17 had a history of being aggressive when people entered her/his personal space. Staff 3 and 4 confirmed Residents 12 and 17 had a physical altercation and Resident 12 was injured as a result. 48830 2. Resident 3 was admitted to the facility in 1/2020 with diagnoses including anxiety. The 6/16/23 Annual MDS indicated Resident 3 was cognitively intact. Resident 33 was admitted to the facility in 4/2023 with diagnoses including dementia. The 4/30/24 Annual MDS indicated Resident 33 was cognitively intact and was ambulatory using a walker. A facility investigation dated 4/29/24 indicated on 4/23/24 around 8:45 PM Resident 3 reported that Resident 33 touched her/his breast inappropriately. Resident 3 stated Resident 33 walked by her/his room, stopped, stated she/he looked good and grabbed her/his breast and left the room. Resident 3 reported she/he was in her/his wheelchair in between the door and the bed at the time of the incident. On 5/28/24 at 12:32 PM Resident 3 stated she/he had arrived back to her/his room after breakfast on 4/23/24 and was in her/his wheelchair watching tv. Resident 3 stated Resident 33 entered the room, made a comment to her/him, then grabbed her/his breast inappropriately. Resident 3 stated she/he told Resident 33 to go away, and Resident 33 left the room. Resident 3 stated she/he did not report the incident until later that evening to the nurse. Resident 3 stated she/he does feel safe in her/his room and the facility. On 5/30/24 at 10:43 AM Witness 2 (Resident 3's roommate) stated she/he witnessed the incident on 4/23/24. Witness 2 stated she/he was laying in bed when Resident 3 arrived back to the room after breakfast and sat in her/his wheelchair watching tv and was in direct line of sight of her/him. Resident 33 entered the room, stood next to Resident 3 and Resident 3 told Resident 33 to leave which she/he did not. Resident 33 proceeded to approach Resident 3 and touched her/his breast inappropriately then left the room. Witness 2 stated she/he does feel safe in her/his room and the facility. On 6/3/24 at 10:02 AM Staff 20 (RN) stated Resident 3 reported the incident to her on 4/23/24 during the evening rounds. Resident 3 explained after breakfast that morning she/he went back to her/his room, watched tv while in her/his wheelchair and Resident 33 entered the room and touched her/his breast inappropriately. Staff 20 stated since the incident occurred Resident 3 did not have a change in mood or behavior. On 6/3/24 at 1:54 PM Resident 33 declined she/he ever touched a resident inappropriately and did not remember the incident. On 6/3/24 at 2:15 PM Staff 2 (DNS) stated she talked with Resident 3 frequently and since the incident occurred Resident 3 did not have a change in mood or behavior and her/his daily routine had not changed.

Based on observation and interview it was determined the facility failed to store and handle food in a sanitary manner for 1 of 2 facility kitchens (dining room kitchenette) reviewed for sanitary food storage and handling. This placed residents at risk for food-borne illness and contamination. Findings include: On 5/28/24 at 11:34 AM during the initial tour of the dining room kitchenette, the following was observed: Refrigerator: -One piece of cake with whipping cream not covered, labeled or dated. -One small plastic container of an unknown substance not labeled or dated. -One covered plate with a pork chop, baked potato and corn not labeled or dated. -One tray with multiple covered juice drinks not labeled or dated. -One opened container of prune juice on the top shelf that spilled to the lower shelves and out onto the floor. Freezer: -Seven small plastic containers with unknown substances not labeled or dated. -Two individual strawberry yogurt containers with a use by date of 5/20/24. -Two opened one pint ice cream containers with resident names not dated. -One opened gallon of chocolate ice cream without a secure lid and not dated. -Three small plastic containers of fish snack crackers on top of the refrigerator not labeled or dated. On 5/28/24 at 11:43 AM Staff 1 (Administrator) confirmed the identified items were not appropriately stored.

Based on observation, interview and record review it was determined the facility failed to ensure resident needs and preferences related to lighting were accommodated for 1 of 3 sampled residents (# 13) reviewed for accommodation of needs. This placed residents at risk for lack of access to lighting and an unhomelike environment. Findings include: Resident 13 was admitted to the facility in 3/2024 with diagnoses including a non-pressure chronic ulcer and Type 2 Diabetes (a condition that happens as a result of the way the body regulates sugar as fuel). A review of Resident 13's 4/4/24 Admission MDS revealed her/his cognition was moderately impaired. On 5/29/24 at 9:34 AM Resident 13 stated her/his overbed light switch only had a short cord and she/he could not reach it to turn her/his light on or off. Resident 13 stated she/he reported it to staff but she/he was still waiting for it to be fixed. On 6/3/24 at 1:42 PM Staff 19 (Maintenance Director) stated he expected CNAs to report maintenance issues to him using the facility's work order system. He also stated he is notified of maintenance issues via word of mouth from staff members and residents. On 6/3/24 at 2:08 PM Staff 19 acknowledged the pull cord for Resident 13's overbed light was not long enough for her/him to use independently. Staff 19 stated the pull cord should be fixed. On 6/3/24 at 3:39 PM Staff 1 (Administrator) stated she expected residents to be able to turn their lights on and off and the broken pull cord needed to be repaired.

Based on interview and record review it was determined the facility failed to obtain copies of advance directives and inform residents of the right to formulate advance directives for 2 of 2 sampled residents (#s 8 and 13) reviewed for advance directives. This placed residents at risk of not having their health care decisions honored. Findings include: 1. Resident 8 was admitted to the facility in 8/2017 with diagnoses including Type 2 Diabetes (a condition that happens as a result of the way the body regulates sugar as fuel) and morbid (severe) obesity. Resident 8's 2/16/24 Quarterly MDS revealed she/he was cognitively intact. Resident 8's Care Plan revealed the following: -Focus: I have a Living Will or other Advance Directive: Health Care Agent. -Goal: I will have my desires and wishes followed according to my signed directive. -Interventions: Facility will place my Advance Directive in my medical record. Staff will review my healthcare directives with me at least quarterly to verify that my wishes have not changed. Staff will understand and follow my healthcare directives. (Date initiated: 6/8/23) No evidence was found in Resident 8's health record to indicate the facility obtained a copy of her/his advance directive or discussed it with her/him since the date the care plan intervention was initiated. On 5/30/24 at 9:33 AM Staff 1 (Administrator) stated she expect advance directives to be discussed with each resident at a minimum on a quarterly basis. She acknowledged the facility did not obtain a copy of Resident 8's advance directive and there was no documentation in her/his health record to indicate it was discussed with her/him since her/his care plan was initiated. 2. Resident 13 was admitted to the facility in 3/2024 with diagnoses including a non-pressure chronic ulcer and Type 2 Diabetes (a condition that happens as a result of the way the body regulates sugar as fuel). Resident 13's 4/4/24 Admission MDS revealed her/his cognition was moderately impaired. A review of Resident 13's health record revealed she/he was her/his own responsible party. No evidence was found in Resident 13's health record to indicate she/he had an advance directive or that staff discussed her/his wishes related to creating an advance directive. On 5/30/24 at 9:33 AM Staff 1 (Administrator) stated she expect advance directives to be discussed with each resident at a minimum on a quarterly basis. She acknowledged there was no documentation in Resident 13's health record to indicate the facility discussed her/his wishes related to developing an advance directive.

Based on interview and record review it was determined the facility failed to notify a resident's representative of an appointment out of the facility for 1 of 1 sampled resident (#289) reviewed for notification of change. This placed residents at risk of their representatives being uninformed. Findings include: Resident 289 was admitted to the facility in 12/2016 with diagnoses including chronic congestive heart failure (a long-term condition in which the heart cannot pump blood efficiently) and type 2 diabetes (a condition that happens as a result of the way the body regulates sugar as fuel). A review of Resident 289's 8/29/22 CAA related to cognition revealed she/he had severe cognitive decline including impaired memory and decision making. Resident 289's admission agreement indicated her/his representative/legal guardian was her/his daughter. A review of Resident 289's health record revealed she/he was sent out of the facility for an appointment on 11/10/2022. No evidence was found in Resident 289's health record to indicate her/his representative was notified she/he would be attending an appointment out of the facility. On 6/3/24 at 2:16 PM Staff 1 (Administrator) acknowledged Resident 289 was out of the facility for an appointment on 11/10/22 and she expected her/his representative to be notified of this.

Based on observation and interview it was determined the facility failed to maintain a homelike environment for 1 of 3 sampled residents (# 13) reviewed for environment. This placed residents at risk for living in an unkempt environment. Findings include: Resident 13 was admitted to the facility in 3/2024 with diagnoses including a non-pressure chronic ulcer and type 2 diabetes (a condition that happens as a result of the way the body regulates sugar as fuel). A review of Resident 13's 4/4/24 Admission MDS revealed her/his cognition was moderately impaired. On 5/29/24 at 9:40 AM a gouge approximately 16 inches in length and 36 inches above the floor was observed in the wall adjacent to the head of Resident 13's bed. On 6/3/24 at 1:42 PM 19 (Maintenance Director) acknowledged the gouge in the wall and stated it should have been fixed prior to the resident moving into the room. On 6/3/24 at 3:39 PM Staff 1 (Administrator) stated the gouge in Resident 13's wall was unacceptable and she expected residents' rooms to be painted and homelike before they move in.

Based on interview and record review it was determined the facility failed to ensure written summary of a baseline care plan was provided to residents within 48 hours of admission for 2 of 4 sampled residents (#s 7 and 241) reviewed for baseline care plans. This placed residents at risk for being uninformed about their plan of care. Findings include: 1. Resident 7 was admitted to the facility in 5/2024 with diagnoses including kidney failure and anxiety. On 5/31/24 Resident 7's clinical record was reviewed. No record was found to show Resident 7 had a baseline care plan reviewed or provided to her/him. On 5/31/24 at 7:40 AM Resident 7 stated she/he had not been provided a baseline care plan. On 5/31/24 at 10:39 AM Staff 3 (LPN/RCM) and Staff 4 (RNCM) stated they were not aware baseline care plans were to be provided to and reviewed with residents. 2. Resident 241 was admitted to the facility in 5/2024 with diagnoses including heart failure and high cholesterol. On 5/31/24 Resident 241's clinical record was reviewed. No record was found to show Resident 241 had a baseline care plan reviewed or provided to her/him. On 5/31/24 at 10:39 AM Staff 3 (LPN/RCM) and Staff 4 (RNCM) stated they were not aware baseline care plans were to be provided to and reviewed with residents.

Based on interview and record review it was determined the facility failed to develop a person-centered comprehensive care plan for 1 of 4 residents (#16) reviewed for mood and behavior. This placed residents at risk for lack of care planning. Findings include: Resident 16 was admitted to the facility in 1/2024 with diagnoses including post-traumatic stress disorder (PTSD). The Mood State CAA from Resident 16's 2/6/24 Admission MDS noted Resident 16 had a diagnosis of PTSD and the care plan addressed the PTSD symptoms with interventions to assist with mood. A review of Resident 16's comprehensive care plan (last revised 4/14/24) revealed no focus, goals or interventions for Resident 16's PTSD symptoms. On 6/3/24 at 9:30 AM Staff 16 (Social Services Director) stated he completed a PTSD evaluation for Resident 16, and thought he completed the comprehensive care plan. Staff 16 confirmed Resident 16's comprehensive care plan related to PTSD symptoms with interventions to assist with mood was not completed.

Based on observation, interview and record review it was determined the facility failed to follow physician orders regarding wound care for 1 of 1 resident (# 241) reviewed for wound care. This placed residents at risk of unmet care needs. Findings include: Resident 241 was admitted to the facility in 1/2018 with diagnoses including lymphedemia (swelling of the extremities) and erythmia (skin redness caused by swelling or irritation). A cognitive assessment from 1/18/24 indicated Resident 241 had normal cognitive function. A Physician Order from 4/3/24 instructed staff to apply ACE wraps to both lower extremities in the morning before Resident 241 got out of bed and take them off at night. Review of the 5/2024 TAR revealed the ACE wraps were documented as not applied to Resident 241's lower extremities on the following dates: - 5/20/24, - 5/21/24, - 5/22/24, - 5/23/24, - 5/24/24, - 5/25/24, - 5/26/24, - 5/28/24, - 5/29/24, - 5/30/24 and - 5/31/24. On 5/28/24 at 1:13 PM Resident 241 was observed wearing ACE wraps which appeared ragged and nearly falling off. Resident 241 stated she/he had worn the same ACE wraps for a week with the wraps never being taken off during the night. On 5/31/24 at 11:08 AM Staff 3 (LPN RCM) reviewed Resident 241's active orders and stated ACE wraps were to be applied to Resident 241's lower extremities in the morning and removed in the evening. Staff 3 was requested to determine if these orders were being followed. Upon observation of Resident 241 legs, Staff 3 confirmed Resident 241 was not wearing ACE wraps as ordered.

Based on observation, interview and record review it was determined the facility failed to provide adequate care and hazard removal for 2 of 2 residents (#s 239 and 240) reviewed for accidents. This placed residents at risk of injury. Findings include: 1. Resident 239 was admitted to the facility in 5/2022 with diagnoses including obesity and dementia. A Care Plan from 3/16/23 included instructions for two staff members to be present when providing all care. An 8/18/23 Progress Note stated Resident 239 rolled out of bed onto the floor when care was provided. On 5/30/24 at 1:13 PM Staff 10 (CNA) stated she recalled Resident 239 falling out of bed. Staff 10 stated care was provided by only one staff member when Resident 239 experienced the fall out of bed when care was being provided. On 5/31/24 at 2:37 PM Staff 1 (Administrator) confirmed Resident 239 was ordered to receive care from two staff members but care was only provided by one staff member when the fall occurred. 2. Resident 240 was admitted to the facility in 5/2024 with diagnoses including dementia. A cognitive assessment from 5/2024 indicated Resident 240 had severe cognitive impairment. On 5/31/24 at 12:39 PM two electric burners were observed unplugged on the floor of Resident 240's room. Resident 240 stated she/he has not used the electric burners but intended to use them. On 5/31/23 at 1:19 PM Staff 21 (CNA) stated she/he was unaware of the burners. On 5/31/23 at 1:25 PM Staff 1 (Administrator) confirmed the electric burners were unsafe and immediately removed them from Resident 240's room.

Based on interview and record review it was determined the facility failed to provide assessment and pain management for 1 of 1 sampled resident (#1) reviewed for fracture. As a result, Resident 1's fracture was not assessed in a timely manner, nor was timely pain management provided. Findings include: Resident 1 was admitted to the facility in 2005 with [DIAGNOSES REDACTED]. The 8/4/13 10:10 pm Progress Note indicated significant swelling was noted and the resident was very vocal about extreme pain. The physician was contacted, who ordered a STAT x-ray and [MEDICATION NAME] (a narcotic pain medication). The resident was given the pain medication and was "still very vocal, moaning in pain. Resident has been placed on alert status." The 8/4/13 Final X-Ray Report revealed the resident had a fractured humerus. The 8/4/13 10:30 pm Progress Note disclosed the physician was contacted regarding the x-ray results. The physician gave orders to send the resident to the hospital for evaluation and treatment. An 8/10/13 Progress Note revealed Resident 1 passed away from unrelated concerns. Per the facility's investigation of Resident's 1's humerus (upper arm) fracture, during the 8/3/13 Day Shift, Staff 10, CNA, reported to Staff 4, LPN, the resident complained of pain during cares in the morning and throughout the shift. Staff 4 asked the resident if he/she was in pain, which the resident responded "perhaps" and did not want anything for pain. Per Staff 4, nothing else was brought to her attention during that shift regarding left arm pain. During the 8/3/13 Evening Shift, Resident 1 refused to get out of bed and Staff 11, CNA, reported the refusal along with possible pain to Staff 6, RN. The resident denied possible pain to Staff 6. The facility's investigation was unable to determine a definite cause of the fracture. At the time of the survey, there was no documentation in the clinical record of the resident's reports of pain during the day and evening shifts on 8/3/13. The Medication Refusal & PRN Tracking report documented Resident 1 received Tylenol for left elbow pain on 8/4/13 at 3:30 am. According to the facility's investigation of the resident's fracture, during the 8/4/13 Day Shift, Staff 10 reported the resident was in pain and was not using or allowing anyone to touch or move his/her left hand and arm. The resident would not allow care to be done due to pain, which was a change from the previous day when he/she allowed care while having complaints of pain. Again, at the time of the survey, there was no documentation in the clinical record regarding the resident's complaints of pain and refusals to use his/her left hand and arm, nor was there documented evidence the physician was notified at that time. Per the facility's investigation, during the 8/4/13 Evening Shift, Staff 11, CNA and Staff 9, CNA, attempted to get the resident up for dinner. The resident stated he/she was in pain and did not want to go to the dining room. The resident denied pain and pain medication when checked by Staff 6, RN. At approximately 8:00 pm, Staff 11 had Staff 6 check the resident again due to complaints of pain and Staff 6 noted the left arm was swollen and red compared to the right arm. In interview on 9/4/13 at 1:23 pm, Staff 10, CNA, stated during the morning on 8/3/13, Resident 1 complained of left arm pain when she was getting the resident dressed and the resident complained of the pain all day. Staff 10 reported the resident's pain to Staff 4, LPN. Per Staff 10, the resident had reported to Staff 4 he/she was not sure if he/she had pain. During the day shift on 8/4/13, the resident was not able to move his/her arm at all, related to pain. The resident continued to complain of pain during care, which she reported to Staff 4. In interview on 9/4/13 at 3:05 pm, Staff 4, LPN, described Resident 1 as confused. Staff 4 stated when she asked Resident 1 regarding his/her complaints of pain during the day shift on 8/3/13, the resident stated "perhaps yes and perhaps no." Staff 4 stated she had assessed the resident's arm, but had not done range of motion due to the resident not reporting specific pain. Staff 4 stated she did not learn of the resident's pain on 8/4/13 until the end of day shift, when Staff 10, CNA, reported the resident's complaints of pain. In interview on 9/4/13 at 11:42 am, Staff 11, CNA, stated on the 8/3/13 Evening Shift, Resident 1 asked to not be touched due to left arm pain, which she reported to the nurse. On 8/4/13, the resident initially refused to get up for dinner and had pain. When assisting the resident with dressing after dinner, Staff 11 observed the resident's left arm was swollen, which was different from the previous day. In interviews on 9/4/13 at 12:25 pm and 3:17 pm, Staff 6, RN, stated she did not recall the resident's complaints of pain being reported at shift change on 8/4/13. Staff 6 stated she checked the resident for pain concerns when they were reported by the CNA during the evening shift. At that time, the resident's left arm was remarkably swollen, from the upper arm to the hand and the resident complained of pain. The physician was contacted, who ordered the STAT x-ray, which identified the fracture. In interview on 9/4/13 at 10:35 am, Staff 3, RNCM, stated if a more thorough assessment had been completed, including range of motion, the fracture would have been identified and immobilized sooner and staff would have been more proactive in administering pain medication to make the resident comfortable.

Based on observation, interviews, and record review it was determined the facility failed to ensure care planned interventions for safety were followed for 1 of 3 sampled residents (#23) reviewed for falls. As a result the resident fell and was injured. Findings include: Resident 23 was admitted to the facility in 7/2005 with [DIAGNOSES REDACTED]. On 2/13/13 at 12:05 pm the resident was observed in the dining room in a w/c with her head slightly forward. At 12:09 pm, the resident was observed rocking back and forth. At 12:14 pm, the resident was leaning forward in the w/c with her head face first over the table. A Significant Change MDS assessment, dated 1/13/13, identified the resident rarely or never made herself understood or understood others, had short and long-term memory problems, and was severely impaired in her daily decision making skills. A Fall Risk Assessment, dated 1/14/13, identified the resident was at moderate risk of falling, confined to chair or bed, and was non-ambulatory. The resident's comprehensive care plan, dated 1/16/13, indicated she was at risk for falls due to tardive dyskinesia, decreased physical function, and lack of safety awareness due to cognitive deficits. The care plan identified safety interventions which included instruction to have the resident "lie down after meals when leaning forward in w/c" (wheelchair) and to monitor the resident "for fatigue or other risk factors of tendency for falls." The resident's bedside care plan, dated 1/25/13, directed caregivers to "lie (the resident) down after meals and when leaning forward in w/c." A Progress Note, written by Staff 2, RN, dated 2/3/13 at 11:00 am, identified at 9:30 am the resident fell from her w/c onto floor in a prone position. Staff 2 indicated the resident sustained [REDACTED]. The resident was sent out to the hospital at 10:20 am for evaluation. A Progress Note dated 2/3/13 at 1:15 pm, indicated the resident would be returned to the facility with sutures in place. The facility's Incident Report and Investigation Form, dated 2/3/13, identified, the resident had been sliding in the w/c and a CNA (Staff 9) went to find the assigned CNA (Staff 10) to lay the resident down but did not notify the RN of the resident's behavior. The report indicated the resident should have been laid down in bed after breakfast or placed directly in front of the nursing station for observation. The Facility's Incident Self-Report Form, dated 2/4/13, identified at 9:25 am the resident was sitting in her w/c in the main hallway after breakfast near the utility room when she leaned forward and fell out of the w/c face down. The resident sustained [REDACTED]. The report indicated resident's care plan was not followed. In interview on 2/13/13 at 11:15 am, Staff 8, CNA, stated that on 2/3/13 she observed the resident leaning over in the wheelchair and she repositioned her. Staff 8 stated she went into the break room to inform Staff 10 the resident needed to be laid down, however, Staff 10 wasn't there. Staff 8 reported she took her break and assumed Staff 10 was back from break and assisted Resident 23 to bed. In interview on 2/14/13 at 9:00 am, Staff 10, CNA, reported on 2/3/13 she took the resident out of the dining room and placed the resident next to the nurse's station because the CMA told Staff 10 the resident's medications had not been administered yet. This occurred before Staff 10 took her break at 9:00 am. Staff 10 stated she was out on the smoking patio until approximately 9:15 am. Staff 10 reported she had not seen the resident leaning prior to going on break and was not told by other staff the resident had been leaning. In interview on 2/14/13 at 9:19 am Staff 1, RNCM, reported Resident 1 was at risk for falls due to falling asleep and leaning and rocking. Staff 1 reported the resident was to be laid down if observed leaning. In interview on 2/14/13 at 10:55 am Staff 3, Administrator and Staff 5, DNS, reported the cause of the resident's fall had multiple causative factors. Staff 3 stated the staff who repositioned the resident in the chair should have alerted a nurse or the resident's aide when the resident was observed leaning.