Every finding on record at Avalon Care Center - Scappoose

Based on observation, interview and record review it was determined the facility failed to ensure appropriate nail care services was provided for 1 of 4 sampled residents (#2) reviewed for nail care. This placed the resident at risk for unmet care needs and potential complications related to diabetes. Findings includeResident was admitted on 9/2024 with diagnosis of diabetes.A Physician's Order dated 1/24/26 directed Resident 2 to receive diabetic nail care every week on Saturdays.Resident 2's 1/19/26 Care Plan indicated licensed nurses were responsible for providing nail care to Resident 2.On 4/2/26 at 2:11 PM, observation revealed Resident 2's left thumb nail was approximately 3/4 inches thick, significantly elevated off nail bed and discolored. Resident 2's left index finger had minimal nail bed remaining. Resident 2 denied pain to her/his left fingers at time of observation.In an interview on 4/2/26 at 11:35 AM, Staff 10 (CNA) stated they do not provide nail care to Resident 2's nails due to Resident 2's diabetic status. Staff 10 reported occasionally cleaning but indicated Resident 2's nail care was the responsibility of the nursing staff.On 4/2/26 at 1:41 PM, Staff 6 (RN) stated they had not performed nail care for Resident 2 and confirmed Resident 2's left hand nails appeared not to have been maintained for at least a month. Staff 6 reported Resident 2's nail care needs had been discussed among other nursing staff and that a note had been submitted to the provider for further evaluation; however, no follow-up has occurred.On 4/3/26 at 6:17 AM, Staff 7 (RN) stated they documented completion of Resident 2's nail care in the DAR for Resident 2's right hand only. Staff 7 reported they had not performed care on Resident 2's left hand due to lack of skill, knowledge, and comfort level. Staff 7 stated the DAR instructions were vague and acknowledged Resident 2 requires specialized nail care services.On 4/2/26 at 5:15 PM, Staff 2 (DNS) acknowledged concern regarding the condition or Resident 2's left thumb nail and stated Resident 2 had a history of ongoing fungal infection. Staff 2 stated they believed Resident 2's health insurance provider was responsible for managing Resident 2's nail care, Staff 2 was unable to provide documentation to support that nail care services had been completed.

Based on interview and record review it was determined the facility failed to provide notice of bed hold policies for 2 of 2 sampled residents (#s 8 and 18) reviewed for hospitalizations. This placed residents at risk for miscommunication of the discharge process. Findings include:1.Resident 8 was readmitted to the facility in 9/2025 with diagnoses including mechanical complications of an indwelling ureteral stent (a tube from the kidney to the bladder to maintain drainage). Resident 8's medical record indicated she/he was transferred to the hospital on 5/18/25, 6/15/25, 7/23/25 and 9/18/25. No evidence was found in Resident 8's clinical record indicating written notice of the facility's bed hold policy was provided to her/his representative when she/he was transferred to the hospital on 6/15/25, 7/23/25 and 9/18/25. On 12/18/25 at 10:43 AM, Staff 9 (RN) stated the nurses, or social services staff completed the bed hold policy. Staff 9 stated she didn't complete the bed hold policy when Resident 8 was hospitalized . On 12/19/25 at 10:51 AM, Staff 14 (Social Services Director) stated all residents were provided a bed hold policy when they admitted . Staff 14 stated she provided a bed hold policy once to the Resident 8's family representative. She acknowledged Resident 8's family representative wasn't provided a bed hold policy on 6/15/25, 7/23/25 and 9/18/25 when the resident was hospitalized . On 12/19/25 at 3:49 PM, Staff 2 (DNS) stated he expected staff to complete and provide the bed hold policy to the resident or representative prior to residents leaving to the hospital. Staff 2 acknowledged Resident 8's family representative was not provided a bed hold policy prior to his/her hospitalization on 6/15/25, 7/23/25 and 9/18/25. 2. Resident 18 was admitted to the facility in 12/2024 with diagnoses including ischemic stroke (obstruction of blood flow to a part of the brain) and hemiplegia (decrease or loss of function of one side of the body). A review of Resident18's medical records revealed the resident was hospitalized on [DATE], 4/14/25, 9/13/25, 10/15/25, and 10/29/25. Resident 18 was not provided a physical copy of the bed hold policy on those dates. On 12/17/25 at 3:51 PM Staff 14 (Social Services Director) stated a bed hold policy was to be provided to residents when they discharged to the hospital and were expected to return to the facility. Staff 14 confirmed the bed hold policy was not provided to Resident 18 on 3/12/25, 4/14/25, 9/13/25, 10/15/25, and 10/29/25. On 12/17/25 at 4:14 PM Staff 7 (RN) stated the paperwork provided to residents upon hospitalization was a face sheet, current orders, progress notes and a transfer notice. Staff 9 stated a bed hold policy form was not part of the paperwork provided to residents upon hospitalization. On 12/18/25 at 1:32 PM Staff 1 (Administrator) and Staff 2 (DNS) confirmed Resident 18 should have received a bed hold policy every time she/he was hospitalized and expected to return to the facility.

Based on interview and record review it was determined the facility failed to ensure care plans accurately reflect bowel care needs for 1 of 1 resident (#1) reviewed for constipation. The placed residents at risk for constipation and fecal impaction. Findings include.The facility's 11/2017 Comprehensive Care Plans policy and procedure indicated a care plan will be comprehensive and person-centered. It will drive the type of care and services that a resident receives and will describe the resident's medical and nursing needs as well as how the facility will assist in meeting those needs.Resident was admitted to the facility in 7/2019 with diagnoses including quadriplegia (a form of paralysis that affects all four limbs and torso).A Care Plan revised 9/6/25 stated Resident 1 was at risk of constipation as result of bowel incontinence and was to have one bowel movement every three days. No information was included regarding Resident 1's normal bowel movement consistency.On 12/18/25 at 4:58 PM Staff 9 (RN) stated Resident 1 was at risk for constipation due to quadriplegia and she/he was monitored daily to ensure she/he had two bowel movements each day. Staff 9 stated Resident 1's normal bowel movements were of loose consistency. Staff 9 stated if the expected frequency or consistency did not occur, a bowel assessment was to be performed on Resident 1 and she/he was to receive a suppository to prevent constipation and fecal impaction.On 12/19/25 at 12:20 PM Staff 2 (DNS) confirmed Resident 1's care plan did not accurately reflect Resident 1's bowel care needs including frequency of bowel movements, bowel movement consistency and what Resident 1's normal bowel movements were. Staff 2 stated having Resident 1's care plan reflect her/his bowel care needs was important to prevent complications from constipation and fecal impaction.

Based on observation and interview it was determined the facility failed to provide a safe and clean homelike environment for 1 of 1 sampled resident (#11) reviewed for environment. This placed residents at risk for an unkept environment. Findings include: Resident 11 was admitted to the facility in 4/2025 with diagnoses including Alzheimer's disease.The 12/8/25 Quarterly MDS indicated Resident 11 had a BIMS score of zero and was not cognitively intact. The 4/15/24 Care Plan indicated, notifying maintenance when the padded mobility bars were damaged or removed. On 12/15/25 through 12/16/2025 from 8:00 AM to 4:00 PM, the padding around the bed rails in Resident 11's room was unkept, the metal was rusty, and parts of the mobility bars were left uncovered, and the metal was exposed. On 12/17/25 at 1:19 PM, Staff 15 (CNA) stated she told maintenance, the nurses and the administrator when equipment was damaged and made sure equipment was safe before she used it. Staff 15 stated she didn't report any damaged equipment in Resident's 11 room. Staff 15 entered Resident 11's room and acknowledged the padding on the mobility bars were damaged. On 12/17/25 at 4:09 PM, Staff 12 (CNA) stated she didn't have concerns with the equipment in Resident 11's room. Staff 12 stated she reported broken and damaged equipment to maintenance and the nurses. Staff 12 entered Resident 11's and stated she guessed the padding on the bed rails needed replacement. Staff 12 acknowledged the padding was ripped. On 12/17/25 at 4:23 PM, Staff 3 (LPN- Unit Manager) stated she communicated with staff on the floor when damaged equipment was observed. Staff 3 stated she notified maintenance immediately. Staff 3 stated the paddings around the mobility bars were used for all residents to help prevent injury. Staff 3 stated she was unaware the padding in Resident 11's room was damaged. Staff 3 stated all staff had access and were expected to utilize the communication system to report damaged and broken equipment. On 12/19/25 at 3:48 PM, Staff 16 (Maintenance Director) stated he wasn't notified about damaged padding around the mobility bars in Resident 11's room. Staff 16 stated all staff had access to a communication system when damaged equipment was reported and should be entered in the system to alert him. Staff 16 stated he monitored the communication system daily.

Based on observation, interview and record review it was determined the facility failed to accurately complete MDS assessments for 1 of 1 resident (#19) reviewed for communication and sensory needs. This placed residents at risk for lack of timely assessed care needs. Findings include:The facility's 11/2017 Resident Assessment policy and procedure specified the following:-The facility would address residents' needs and strengths regardless of whether or not the issue was included in the MDS or CAAs.-The facility would use resident observation and communication as the primary source when completing assessments and also review records, communicate with staff and other sources as needed to complete residents' assessments.Resident 19 was admitted to the facility in 5/2025 with diagnoses including metabolic encephalopathy (a change in brain function due to an underlying condition) and hearing loss.A review of Resident 19's 6/5/25 admission MDS and 12/6/25 Quarterly MDS revealed she/he had severe cognitive impairment and she/he did not have hearing aids. The CAA for communication indicated she/he was hard of hearing without hearing aids and staff were to elevate their voices when speaking to her/him.On 12/18/25 at 5:17 PM Staff 4 (MDS Coordinator) stated she was responsible for completing the facility's MDS assessments and acknowledged information about Resident 19's need to use hearing aids was not captured in the 6/5/25 admission MDS or the 12/6/25 Quarterly MDS assessment. Staff 4 stated it was necessary for MDS assessments to be accurate to ensure care plan interventions would be developed in a timely manner.

Based on observation, interview and record review it was determined the facility failed to ensure staff assisted a resident with wearing hearing aids for 1 of 1 sampled resident (#19) reviewed for hearing. This placed residents at risk for a decline in communication. Findings include:Resident 19 was admitted to the facility in 5/2025 with diagnoses including metabolic encephalopathy (a change in brain function due to an underlying condition) and hearing loss.A review of Resident 19's 6/5/25 admission MDS revealed she/he had severe cognitive impairment, functional limitation in range of motion of both sides of her/his upper body, was dependent on staff for completion of ADLs and she/he did not have hearing aids. The CAA for communication indicated she/he was hard of hearing without hearing aids and staff were to elevate their voices when speaking to her/him.A review of Resident 19's care plan revealed she/he had a communication deficit related to being hard of hearing without hearing aids. No evidence was found in the care plan for staff to provide Resident 19 with assistance to use her/his hearing aids.Random observations from 12/15/25 through 12/16/25 from the hours of 11:00 AM through 2:00 PM, Resident 19 was observed without hearing aids.On 12/16/25 at 3:29 PM Resident 19 was observed wearing hearing aids. Resident 19 stated they were her/his hearing aids but she/he did not know who helped her/him put them in or take them out. Resident 19 stated she/he did not know who was supposed to put her/his hearing aids in the charger when she/he was ready for bed.On 12/17/25 at 10:47 AM Staff 10 (CNA) stated he normally worked with Resident 19 during the day shift and was unaware she/he had hearing aids because it was not listed in her/his Kardex (a quick reference summary of resident needs). He stated when Resident 19 stated she/he could not hear him he spoke louder.On 12/17/25 at 12:49 PM Staff 11 (CNA) stated Resident 19 was hard of hearing and her/his family told him she/he had hearing aids. Staff 11 stated Resident 19's hearing aids were not listed in her/his Kardex and he thought it was odd because she/he lived in the facility for several months.On 12/17/25 at 2:02 PM Staff 12 (CNA) stated she worked with Resident 19 in the evening three days each week. Staff 12 stated when Resident 19 was in bed, she occasionally found hearing aids sitting on the windowsill next to her/his bed. Staff 12 stated she believed they were Resident 19's and she put them in the charger on her/his nightstand. Staff 12 stated Resident 19's hearing aids were not listed in her Kardex and her/his family never said anything about the hearing aids when they visited her/him.On 12/18/25 at 1:28 PM Resident 19 was observed in her/his room and not wearing hearing aids. Resident 19 was unable to hear questions asked of her/him by the Surveyor in a normal speaking voice. Resident 19 stated she/he had hearing aids and wanted to wear them when she/he was out of bed. On 12/18/25 at 5:00 PM Staff 3 (LPN, Unit Manager) acknowledged Resident 19 was very hard of hearing and required hearing aids which the resident had in her/his room for hearing and communication. Staff 3 stated staff members did not provide adequate assistance with Resident 19's hearing aids because it was not reflected in the care plan.

Based on observation, interview and record review it was determined the facility failed to provide the necessary care and assistance to maintain good grooming and hygiene for 1 of 2 sampled residents (#11) reviewed for ADLs. This placed residents at risk for poor grooming. Findings include:Resident 11 was admitted to the facility in 2024 with diagnoses including Alzheimer's disease. The 4/15/24 Care Plan indicated Resident 11 required one person substantial to dependent assistance completing personal hygiene and directed staff to offer and encourage nail care twice per week on shower days. The 12/8/25 Quarterly MDS, revealed Resident 11 had a BIMS score of zero which indicated the resident was not cognitively intact and required maximum assistance to complete personal hygiene. The 12/2025 Documentation Survey Report indicated Staff 15 (CNA) completed a shower for Resident 11 on 12/16/25 and didn't provide nail care. On 12/15/25 through 12/17/25 from 8:00 AM to 4:00 PM, Resident 11 had untrimmed nails. The left hand had uneven trimmed fingernails. Two nails had a brown substance under the nailbed. The right hand had untrimmed fingernails, and four nails had a yellow and brown substance under the nailbed. On 12/15/25 at 3:35 PM and 12/15/25 at 2:22 PM, Resident 11 stated she/he was unsure when staff performed nail care and would allow staff to complete nail care when they offered. On 12/17/25 at 1:35 PM, Staff 15 stated Resident 11 was pleasant and cooperative. Staff 15 stated she had great rapport with the resident and was able to complete personal hygiene tasks. Staff 15 stated she didn't provide nail care on 12/16/25 and stated she didn't double check her/his nails post shower. Staff 15 stated she was unsure if nail care was supposed to be provided on shower days. Staff 15 entered Resident's 11 room and acknowledged the resident's nails were dirty, cracked and needed to be trimmed. On 12/17/25 at 4:13 PM, Staff 12 (CNA) stated CNAs were able to perform nail care since Resident 11 was not diabetic. Staff 12 stated she performed nail care when resident's nails were long and typically completed nail care post shower. Staff 12 entered Resident 11's room and acknowledged the resident's nails were covered in gunk under the nailbed and required trimming. Staff 12 stated she didn't perform nail care for Resident 11. On 12/17/25 at 4:23 PM, Staff 3 (LPN- Unit Manager) stated CNAs were able to perform nail care on non-diabetic residents. Staff 3 stated Resident 11 was combative and refused nail care. Staff 3 acknowledged Resident 11's nails were unkept and expected staff to perform nail care after showers. Staff 3 stated Resident 11 was dependent on staff for personal hygiene and expected CNAs to implement and follow the care plan. On 12/18/25 at 10:51 AM, Staff 9 (RN) stated she was unaware Resident 11 refused nail care and expected staff to perform nail care after Resident 11 showered.

Based on observation, interview and record review it was determined the facility failed to provide an ongoing person-centered activities program for 1 of 1 sampled resident (#13) reviewed for activities. This placed the resident at risk for a decline in psychosocial well-being and diminished quality of life. Findings include:The 11/2017 Quality of life: Activities Policy indicated the following:-The facility activities will be meaningful to the residents. -Activities will enhance the physical, cognitive and emotional health of the residents.-Activities are scheduled daily, and residents are given an opportunity to contribute to the planning, preparation and conducting of the program as able and as appropriate.-The activity program consists of individual, small and large activities which are designed to meet the assessed needs and interest of each resident.Resident 13 was admitted in 9/2025 with diagnoses including chronic pain and muscle weakness. The 9/29/25 Care Plan indicated the following:-Resident 13 wishes to attend spiritual activities. -Staff to post calendar in room and remind and offer her/him to participate in activities. The 10/5/25 admission MDS indicated Resident 13 was cognitively intact. The MDS indicated the resident liked listening to music, being around animals, read the newspapers/magazines and participating in religious services were important activities to the resident. The 11/2025 Documentation Survey Report indicated Resident 13 didn't participate in any in or out of the room activities.On 12/15/25 through 12/18/25 from 8:00 AM to 4:00 PM, Resident 13 was observed in her/his room in bed. No music, books, magazines or newspapers were visible in the resident's room. No activity calendar was posted in her/his room.On 12/15/25 at 1:33 PM, Resident 13 was lying flat in bed and stated she/he was in pain and didn't tolerate sitting in the wheelchair to participate in group activities. Resident 13 stated staff didn't offer an alternative activity to do in her/his room. On 12/17/25 at 8:51 AM, Resident 13 was lying flat in bed and stated using the Hoyer (mechanical) lift and frequent incontinence episodes were barriers to getting out of bed and participating in group activities. Resident 13 stated an activities calendar was not offered. Resident 13 stated group activities were offered daily including the weekends.On 12/18/25 at 10:10 AM, Staff 10 (CNA) stated Resident 13 tolerated being out of bed for one hour but preferred to stay in bed due to pain in her/his legs. Staff 10 stated Resident 13 participated in group activities when she/he was out of bed but was unsure in room activities were offered. Staff 10 stated Resident 13 was discouraged because she enjoyed activities in her/his room but was not offered things to do in her/his room. On 12/18/25 at 10:35 AM, Staff 17 (CNA) stated Resident 13 preferred staying in bed when group activities were offered. Staff 17 stated one on one visits were not an option due to lack of staffing, but group activities were offered daily. Staff 17 stated Resident 13 refused coloring pages and books when offered. On 12/18/25 at 10:58 AM, Staff 9 (RN) stated Resident 13 participated in group activities. Staff 9 stated Resident 13 didn't get out of bed due to chronic pain. Staff 9 stated in room activities included card games and were facilitated by the CNAs or the Staff 18 (Activity Director). On 12/18/25 at 11:10 AM, Staff 18 stated she offered residents who preferred to stay in bed word searches, coloring pages and card games. Staff 18 stated she provided activity calendars for all residents. Staff 18 stated Resident 13 preferred staying in bed and didn't participate in group activities. Staff 18 stated a sound machine and activities calendar was in Resident 13's room. Staff entered Resident 13's room and acknowledged the resident didn't have an activities calendar or sound machine in her/his room. On 12/19/25 at 10:55 AM, Staff 3 (LPN Unit Manager) stated residents who preferred to stay in bed were offered one on one visits. Staff 3 stated Resident 13 participated in group activities, napped and watched tv. Staff 3 was aware Resident 13 refused participating in group activities. Staff 3 stated Resident 13 complained staying out of bed for long periods of time due to chronic pain. Staff 3 acknowledged Resident 13 wasn't offered in room activities.

Based on observation, interview and record review it was determined the facility failed to provide pressure ulcer care consistent with professional standards of practice for 1 of 2 sampled residents (#1) reviewed for pressure ulcer. This placed residents at risk for new and worsening pressure ulcers. Findings include: The 8/2018 Quality of Care Skin Integrity Policy indicated the following:A weekly evaluation of the PU/PI (Pressure Ulcer/Pressure Injury) will include:-Evaluation of the PU/PI, if no dressing is present.-Evaluation of the status of the dressing, is present.-Status of the area surrounding the PU/PI (without removing existing dressing).-If pain is present, is it being controlled. PU/PI documentation will include:-The type of injury (pressure versus non-pressure)-The stage-A description of the PU/PI's characteristics-Progress toward healing and identification of potential complications-If infection is present. Resident 13 admitted to the facility in 9/2025 with diagnoses including quadriplegia (paralysis or significant weakness in both arms and legs).A 2024 Care Plan indicated the following:-Monitor/document wound size, depth, margins: peri wound skin, sinuses, undermining, exudate, edema, granulation, infection, necrosis, eschar, gangrene. Document progress in wound healing on an ongoing basis. Notify physician as indicated. A 11/2025 Skin & Wound Evaluation indicated Resident 1 developed a facility acquired stage three pressure ulcer (wound extends through skin into fat). Revealed the following.-11/20/25 the wound measured 1.6 in length and 0.9 in width. New wound. Staff did not include a description of the wound.-11/29/25 the wound measured 0.2 in Length and 0.2 in width. Wound was improving. Staff did not include a description of the wound.-12/9/25 the wound measured 1.45 in length and 1.23 in width. Wound was improving. Staff did not include a description of the wound.-12/17/25 the wound measured 2.95 in length and 3.11 in width. The wound was healed and resolved. Staff did not include a description of the wound.The medical record indicated Resident 1's wound care order started on 11/21/25 and ended on 12/18/25. The wound care order indicated the following:-Cleanse buttocks, apply collagen and hydrogel, pack with alginate and cover with a foam dressing. Change every 2 days and as needed. One time a day every 2 day(s).On 12/18/25 at 11:38 AM and 2:01 PM, Staff 9 (RN) performed PPE (Personal Protective Equipment) prior to exposing Resident 1's coccyx (bone located at the end of the spine). There was no dressing over the area which was closed and was blanchable. Staff 9 stated the residents wound was healed and wound care orders were discontinued. On 12/18/25 at 2:11 PM, Staff 9 stated staff used a wound care app which monitored progression and measurements of wounds. Staff 9 stated no training was offered for the wound app and she was trained by other staff who utilized the wound app. Staff 9 stated she was unsure what the wound app measured when she documented the wound. Staff 9 stated the measurements she took were not accurate and additional instructions were not provided on how to utilize the wound app.On 12/19/25 at 2:14 PM, Staff 3 (LPN- Unit Manager) stated staff used a wound app to monitor progression and the size of wounds. When staff used the wound app they used a paper measuring tape to compare wound measurements for accuracy. Staff 3 stated her and Staff 2 (DNS) monitored the wound app daily. Staff 3 stated the wound app measured growth and progression of wounds when a sticker was placed near the wound. Staff 3 stated staff were able to manually enter measurements if the wound app measured the wounds incorrectly. Staff 3 stated no policy or education was provided relating to the wound app. Staff 3 stated a healed wound wouldn't have measurements. Staff 3 stated the wound to Resident 1's buttocks was not measured or documented accurately. Staff 3 acknowledged proper measurements and documentation were an important part of wound care to ensure appropriate healing of a wound. On 12/19/25 at 3:00 PM, Staff 2 stated staff used a wound care app that was used for pictures and measurements. The wound care app included a sticker and communicated with a cell phone. The sticker was placed near the wound and Staff 2 expected staff to place the sticker accurately to ensure accurate measurement of the wound. Staff 2 stated no formal education was provided on how to use the wound app but Staff 9 trained other staff on the floor on how to use the wound care app. Staff 2 stated he was unsure what the wound care app measured taken by Staff 9 once Resident 1's wound was healed. Staff 2 acknowledged measurements were not accurate and expected staff verified measurements and used a paper measuring tape for accuracy.

Based on observation, interview, and record review, it was determined the facility failed to manage contractures and provide continued treatment and services to prevent decrease in ROM and mobility for 2 of 4 residents (#s 1 and 3) reviewed for contracture and mobility. This placed residents at risk for contractures and decreased mobility. Findings include:The facility's 11/2017 Quality of Life ADLs/Maintain Abilities Policy indicated the facility provided necessary care and services to prevent avoidable decline in ADLs, ensured residents received treatment to maintain or improve ADL abilities, including mobility, and staff avoided using clinical diagnoses as the sole justification for decline. 1. Resident 3 was admitted to the facility in 3/2023 with diagnoses including Alzheimer's disease, generalized weakness, and pain. Random observations from 12/15/25 through 12/19/25 from 8:50 AM to 2:47 PM revealed Resident 3 was seated in a recliner with her/his left foot and ankle resting on a footrest, and the left foot and ankle were rotated towards the midline of the body. Resident 3 was not grimacing or groaning while in the recliner. On 12/17/25 at 11:21 AM and 12/18/25 at 4:56 PM Staff 5 (CNA) stated Resident 3's left foot and ankle were rotated inward, and she adjusted the position of Resident 3's left ankle and foot when she noticed it turned inward in the recliner. Staff 5 stated she reported the issue to the DNS in 9/2025 or 10/2025, but the issue was not addressed. On 12/17/25 at 11:59 AM and 12/18/25 at 4:43 PM Staff 6 (CNA) stated Resident 3's left ankle and foot rotated inward when seated in the recliner. Staff 6 stated Resident 3 sat in her/his recliner often. Staff 6 stated he was concerned regarding Resident 3's foot positioning, and he reported the issue to a nurse a few months ago but did not recall which nurse he informed. On 12/17/25 at 1:01 PM Staff 7 (LPN) stated Resident 3 sat in her/his recliner often and noticed Resident 3's left foot rotated toward the midline whenever she/he was sitting in the recliner. Staff 7 stated she was unaware if an assessment was completed regarding Resident 3's left foot. On 12/18/25 at 11:50 AM and 12/19/25 at 9:06 AM and 11:45 AM, Staff 8 (Director of Rehabilitation) stated he worked with Resident 3 from 7/2025 to 9/2025 on gait training, transfers, and balance, and discharged her/him from physical therapy on 9/12/25. Staff 8 stated there was no foot or ankle rotation present with Resident 3 when she/he discharged from therapy. Staff 8 confirmed Resident 3's inward ankle rotation placed the ankle in an unstable position and her/his ankle bone close to the skin, increasing the risk for decreased ROM and skin impairment. Staff 8 stated Resident 3's ankle had been unstable, and the inward rotation of the left ankle had developed gradually over time. 2. Resident 1 was admitted to the facility in 7/2019 with diagnoses including quadriplegia (a form of paralysis that affects all four limbs and torso). A 12/4/23 physician order included hand splints to be placed on both hands at night and remain on the resident's hands for four hours for skin care. The order was discontinued on 9/19/25 with no information was located to indicate why the splints were discontinued. A 9/6/25 Care Plan included instructions for splints to be worn on both hands for four hours at night to prevent contractures. On 12/18/25 at 12:35 PM Resident 1 stated she/he was unaware he was supposed to wear hand splints at night, and staff did not assist her/him with placing or removing the bilateral hand splints. On 12/18/25 at 1:10 PM Staff13 (CNA) stated she followed care instructions from a computer to determine Resident 1's care needs and documented when care was provided. Staff 13 reviewed Resident 1's task records for each shift and stated no instructions were found regarding Resident 1 wearing bilateral hand splints at night and no place to document if the resident wore her/his bilateral hand splints. On 12/18/25 at 1:42 PM Staff 3 (LPN - Unit Manager) stated instructions for Resident 1 wearing bilateral hand splints were missing from her/his orders. Staff 3 stated the orders for the bilateral hand splints were discontinued on 9/18/25 and she was unable to locate documentation on why the order was discontinued. Staff 3 stated Resident 1's bilateral hand splint orders should have continued after 9/17/25 to prevent contractures and skin issues. On 12/18/25 at 1:59 PM Staff 2 (DNS) confirmed Resident 1's care instruction regarding the use of wearing bilateral hand splints were missing from the order. Staff 2 stated no records indicated Resident 1 had been assisted with bilateral hand splints since 9/17/25.

Based on interview and record review it was determined the facility failed to honor a grievance resolution for 1 of 3 residents (#401) reviewed for grievances. This placed residents at risk of not having their preferences honored regarding ADL care. Findings include:Resident 401 was admitted to the facility in 3/2025 with diagnoses including dementia and a femur fracture.A 3/30/25 admission MDS indicated Resident 401 had significant cognitive impairments.A 6/19/25 Grievance Form revealed concerns of Staff 4 (CNA) forcing Witness 1 (Power of Attorney) to leave Resident 401's room when care was provided. When Witness 1 requested to remain present, Staff 4 was reported to have stormed out of the room. A request was made by Witness 1 for Staff 4 to no longer provide care to Resident 401.A 6/24/25 Grievance Summary Report completed by Staff 2 (DNS) revealed the resolution was for Staff 4 to no longer provide care to Resident 401.Review of the 6/2025 and 7/2025 Documentation Survey Reports revealed Staff 4 provided ADL care which included brief changes, oral hygiene and/or showers to Resident 401 on 6/25, 6/27, 7/2, 7/3, 7/4, 7/5, 7/16 and 7/22.Review of vital tracking records during 6/2025 and 7/2025 revealed Staff 4 assessed Resident 4's vitals on 6/25 and 7/22. A 7/23/25 Interdisciplinary Team Care Plan Conference Quarterly Review included comments from Witness 1 ensuring Staff 4 did not provide care to Resident 401.On 8/26/25 at 12:18 PM ADL care and vital records from 6/2025 and 7/2025 were reviewed with Staff 4. Staff 4 acknowledged her initials were were recorded as having provided care to Resident 401 on 6/25, 6/27, 7/2, 7/3, 7/4, 7/5, 7/16 and 7/22. On 8/26/25 at 2:23 PM Witness 1 stated she/he visited Resident 401 on 7/16/25 and observed Staff 4 providing one on one care to Resident 401. Witness 1 stated she/he reported her/his concerns regarding Staff 4 not providing care to Resident 401 on 7/16/25 and again during a care conference on 7/23/25.On 8/26/25 at 2:40 PM Staff 2 was informed Staff 4 continued to provide care to Resident 401 after the grievance was addressed. Staff 2 did not provide any additional information. Staff 2 confirmed records showed Staff 4 continued to provide care to Resident 401 following the resolution of the grievance.

Based on interview and record review it was determined the facility failed to provide care in accordance with care planned interventions while pushing a resident in a wheelchair for 1 of 1 sampled resident (#1) reviewed for accidents. This failure resulted in an avoidable fracture to Resident 1's left ankle. Findings include: Resident 1 was admitted to the facility in 2015 with diagnoses including dementia. The 6/2023 Annual MDS revealed Resident 1 had a BIMS of 11 (moderate cognitive impairment). Resident 1's mobility care plan dated 12/9/22 instructed staff to promote Resident 1's independence with locomotion as tolerated without leg rests and revealed Resident 1 needed assistance with leg rests in place for wheelchair mobility when being pushed by staff. A 12/6/23 FRI report revealed on 12/3/23 Resident 1 mobilized her/himself independently while in her/his wheelchair from the dining room toward her/his room. Resident 1 became tired and Staff 11 (CNA) pushed Resident 1 towards her/his room. Staff 11 felt resistance while pushing Resident 1 and immediately stopped while Resident 1 yelled Ow! Staff 12 (LPN) was nearby and told Staff 11 to put Resident 1 into bed so he could look at Resident 1's ankle. Resident 1's ankle had a normal range of motion. Staff 12 administered medication for pain management and applied ice to the resident's ankle. Resident 1's physician was notified and staff were instructed to obtain an X-ray if the resident experienced increased pain or swelling. The FRI revealed Resident 1 had moderate pain and swelling to her/his left ankle, and 12/5/23 X-ray notes revealed she/he sustained an .oblique [slanting] fracture involving the distal fibula [a prominent bone on outside of the ankle] with minimal callus [a temporary development that occurs at the site of a bone fracture and helps the bone move from the inflammatory phase to the repair phase] and mild displacement. The joint alignment is maintained. There is associated soft tissue swelling . The resident was taken to the emergency department for an evaluation. A 12/4/23 5:57 PM progress note by Staff 12 revealed Resident 1 was on alert charting, rested in bed, and her/his behavior was at baseline. Resident 1 stated her/his left ankle hurt when it was moved. The resident's left ankle was noted to be slightly swollen and tender, and she/he complained of pain twice during the shift. Staff 12 administered pain medication. A 12/5/23 3:10 AM progress note by Staff 13 (LPN) revealed Resident 1's left ankle was swollen and painful to touch. The resident requested an ice pack for comfort which was effective. A 12/5/23 10:15 PM progress note by Staff 14 (LPN) revealed a new physician's order was received for a left ankle X-ray to rule out a fracture. A 12/6/23 1:54 AM progress note by Staff 15 (LPN) revealed X-ray results of Resident 1's left ankle found an oblique fracture with mild displacement and soft tissue swelling. Resident 1's physician was notified and orders were provided to offer ice packs and to send Resident 1 to the emergency department in the morning since the resident was stable and effective pain management was in place. Resident 1's 12/6/23 hospital after visit summary and X-ray results revealed she/he had a left foot ankle fracture. The facility obtained a follow up statement from Staff 11 on 12/6/23 at 9:00 AM. Staff 11 stated Resident 1 wheeled her/himself partway down a hall. Staff 11 assisted Resident 1 as she/he sounded out of breath and wanted to go to bed. As they approached the nurses station Resident 1 dropped her/his foot. Staff 11 felt resistance and stopped pushing the wheelchair. Resident 1 cried out and her/his ankle was assessed by another staff. Staff 11 was instructed to assist the resident back to her/his room. Staff 11 stated she then pushed Resident 1 very slowly and reminded her/him to hold her/his legs up. Staff 11 stated she knew how to access care plans and thought she reviewed Resident 1's care plan. An untitled facility document dated 12/8/23 by Staff 16 (former DNS) revealed Staff 11 pushed Resident 1 in her/his wheelchair without leg rests which resulted in Resident 1's fractured left ankle. An interview with the resident found she/he felt safe and comfortable with Staff 11 continuing to provide care. On 8/12/24 at 1:00 PM Resident 1 was observed self propelling slowly in her/his wheelchair with no leg rests. During an interview on 8/12/24 at 2:46 PM Staff 12 stated he assessed the resident at the time of the incident and put ice on her/his foot because she/he complained of pain but there was no swelling or bruising at the time. He indicated the resident was able to identify pain appropriately. Staff 12 stated Resident 1 self propelled in her/his wheelchair independently but when she/he got tired staff placed leg rests on her/his wheelchair before pushing her/him. On 8/13/24 at 10:47 AM Witness 1 (resident representative) stated she was informed of the 12/3/23 incident right away and believed it was a pure accident. She added, Resident 1 would take the leg rests off her/his wheelchair or she/he would ask the staff to remove them. Witness 1 stated Resident 1 was pretty independent and liked to move her/his wheelchair on her/his own but when she/he got tired or was not feeling well she/he asked for help and staff would place the leg rests on the wheelchair before pushing her/him. On 8/14/24 at 3:58 PM Staff 11 confirmed she pushed Resident 1 down the hallway to her/his room without the leg rests on her/his wheelchair, which resulted in Resident 1 sustaining a fractured ankle. Staff 11 stated the resident's foot was not swollen and had no bruising immediately after the accident. On 8/15/24 at 7:18 PM Staff 15 confirmed the incident happened when she was not on shift but she did observe Resident 1's foot on 12/5/24. Staff 15 stated Resident 1 was placed on alert charting, was monitored every shift and received pain medication. Staff 15 stated she observed Resident 1's foot was swollen and the resident said it was slightly painful when she/he moved it. Staff 15 said the day shift nurse ordered the X-ray but she received the X-ray report. Since Resident 1 was stable at the time and it was the middle of the night, a physician's order was received for ice packs if Resident 1 needed it and the on-call doctor gave the okay to go to the hospital in the morning which allowed the resident to sleep. Staff 15 stated if Resident 1 was in a lot of pain she/he would have been sent to the emergency room sooner. Staff 15 added, she believed Resident 1 was care planned to have the footrests on the wheelchair when being pushed by staff before the incident happened and this hasn't happened again to her knowledge. During an interview on 8/16/24 at 9:40 AM Staff 1 (Administrator), Staff 2 (DON), and Staff 3 (Regional Nurse Consultant) were informed of the findings of this investigation. They all confirmed the incident occurred. On 12/8/23, the Past Noncompliance was corrected when the facility completed a root cause analysis of the incident and determined there was a failure to follow Resident 1's care plan to ensure leg rests were on her/his wheelchair before pushing her/him. The Plan of Correction included: 1. Staff education, for all staff, on placing leg rests onto resident wheelchairs, and how to look resident care plans and resident profiles. 2. A notice was created for Resident 1's wheelchair to remind staff to put the leg rests on her/his wheelchair before pushing her/him and what to do if Resident 1 declined the use of the leg rests. 3. Licensed nursing staff monitored use of leg rests on resident wheelchairs for residents who required assistance with mobilizing in wheelchairs.

Based on observation, interview, and record review it was determined the facility failed to monitor temperatures and cleanliness of 1 of 1 unit refrigerator. This placed the residents at risk for food-borne illness. Findings include: The facility guideline for Dietary Service Resident Community Refrigerator stated: -Housekeeping staff/designee will monitor the refrigerator daily for cleanliness. Concerns will be delegated to the designated department. - Each refrigerator will have an approved thermometer inside the refrigerator. Designated staff will record the temperature at least daily. On 8/14/24 at 12:48 PM the unit refrigerator used for resident snacks and personal foods was observed to have yellow liquid spilled on a lower shelf. There was no thermometer in the refrigerator. On 8/14/24 at 12:49 PM Staff 5 (Dietary Manager) stated the cleaning and monitoring of unit refridgerators was the responsibility of the kitchen staff. She confirmed the refridgerator needed to be cleaned and no thermometer was present. She was not able to locate a temperature log for the refrigerator.

Based on observation, interview, and record review it was determined the facility failed to ensure proper food temperatures were maintained for meals served to residents on 3 of 3 halls reviewed for dining. This placed residents at risk for increased risk for impaired nutrition. Findings include: Observation on 8/12/24 at 11:45 AM during tray pass Resident 1 complained of cold food. Observation on 8/12/24 at 11:47 AM during tray pass Resident 4 complained of cold food. Resident Council Meeting documentation from 5/2024 recorded residents complaints that breakfast was often cold. On 8/14/24 at 3:37 PM Staff (5) Dietary Manager confirmed the residents had complained about cold food. Twelve residents were interviewed during a Resident Council meeting on 8/15/24 at 10:21 AM. The residents complained about cold food on all halls. On 8/15/24 at 2:51 PM the concern related to cold food was shared with Staff 1 (Administrator). No additional information was provided.

Based on observation, interview and record review it was determined the facility failed to implement a comprehensive person-centered care plan for 1 of 1 sampled resident (#24) reviewed for communication-sensory services. This placed residents at risk for decreased ability to communicate their wants and needs. Findings include: Resident 24 was admitted to the facility in 6/2024 with diagnoses including aphasia (a language disorder that affects a person's ability to communicate) following non-traumatic subarachnoid hemorrhage (bleeding in the space between the brain and the surrounding membrane) and dysarthria (weakness in the muscles used for speech, causing slowed, slurred speech) following non-traumatic subarachnoid hemorrhage. A review of Resident 24's 6/27/24 Admission MDS revealed she/he had adequate hearing but did not speak during the assessment. On 8/13/24 at 9:31 AM Resident 24 was observed sitting up in bed. Her/his eyes were closed and she/he was awake. She/he did not speak when asked how she/he felt, but she/he gestured to a pool of saliva on her/his shirt. A review of Resident 24's 6/20/24 care plan revealed she/he was at risk of impaired communication related to low tone of voice, post subarachnoid hemorrhage and some cognitive impairment. Resident 24's care plan revised on 6/28/24 indicated she/he was able to read written communication and had a picture board for communication kept at the nurses' station. On 8/13/24 at 10:41 AM Resident 24 was observed in her/his room with a caregiver. Resident 24 did not communicate verbally with the caregiver and there was no evidence of a communication board in her/his room. On 8/14/24 at 9:15 AM Staff 7 (CNA) reported Resident 24 nodded to indicate she/he understood but and used weird facial expressions to indicate she/he did not understand. Staff 7 stated staff did not have a communication board for Resident 24 and she thought, it would be a great idea. She also stated, I don't know if a board is in the works. On 8/14/24 at 12:49 PM Staff 6 (Activities / Recreation Director) reported she was not aware of a communication board on Resident 24's care plan but she thought it would be a good tool for many departments to use when communicating with her/him. On 8/14/24 at 1:21 PM Staff 6 reported she found the communication board at the nurses station under a big pile of stuff and stated I didn't even know it was there. It's not specific for her. I don't know if she has ever used it. On 8/14/24 at 1:30 PM Staff 1 (Administrator) acknowledged staff members were not using the communication board as instructed on Resident 24's care plan. He stated, I expect that if it is on the care plan, the caregivers and nurses should be following it. There should be a copy of it for her in her room rather than just at the nurses station.

Based on observation, interview and record review, it was determined the facility failed to ensure residents were treated in a dignified manner for 1 of 2 sampled residents (#72) reviewed for dignity. This placed residents at risk for lack of dignity. Findings include: Resident 72 was admitted to the facility in 9/2018 with [DIAGNOSES REDACTED]. The 9/18/19 MDS indicated Resident 72 had a BIMS score of 15, which indicated no cognitive impairment. Resident 72's Care Plan under Alteration in Elimination indicated a Foley catheter was added on 10/2/19 for urine retention. Multiple observations were made of Resident 72 on 12/9/19 and 12/11/19 between the hours of 8:30 AM to 4:30 PM. The door to the resident's room was open and the right side of the resident's bed was visible from the hallway. During these observations, the urinary drainage bag from the Foley catheter was hanging on the right side of the bed with no privacy cover and was visible from the hallway. The urinary drainage bag had contents of yellow urine inside. In an interview on 12/10/19 at 11:51 AM, Resident 72 stated she/he was bothered by the urinary drainage bag being uncovered and visible from the doorway to her/his room. She/he also stated the staff never covered the drainage bag when she/he was up in her/his wheelchair and out in common areas. She/he further stated at one time there was a privacy bag used, but was unsure as to what happened to it. In an interview on 12/12/19 at 9:29 AM, Staff 5 (CNA) stated she was unaware a privacy bag was not being used for Resident 72's urinary drainage bag. She stated she had seen one used before but was not sure what happened to it. She verified there was currently no privacy cover on the urinary drainage bag which was hanging from the right side of the resident's bed and visible from the hallway. She stated one was supposed to be used. In an interview on 12/12/19 at 3:15 PM, Staff 2 (DNS) was informed of the observations of Resident 72's urinary drainage bag not being covered and visible from the hallway. She stated the urinary drainage bag should be covered by a privacy cover at all times when visible.

Based on interview and record review it was determined the facility failed to ensure residents were free from physical abuse for 1 of 4 sampled residents (#6) reviewed for resident to resident incidents. This placed residents at risk for potential abuse. Findings include: The 12/2018 Facility Abuse Prohibition Policy outlined the following: - All residents will be free from verbal, sexual, physical, mental abuse and involuntary seclusion. d. Physical abuse includes hitting, slapping, pinching, kicking, biting, unnecessary restraints or other means of inappropriate physical contact. Resident 1 was admitted to the facility in 11/2017 with [DIAGNOSES REDACTED]. Resident 1's 4/26/19 Significant Change MDS indicated the resident had moderate cognitive impairment and poor memory recall. Resident 6 was admitted to the facility in 7/2018 with [DIAGNOSES REDACTED]. Resident 6's 10/16/19 Significant Change MDS indicated the resident had moderate cognitive impairment and poor memory recall. Review of the 8/25/19 Facility Incident & Accident Report revealed Resident 6 slapped Resident 1 and caused a 4 cm abrasion with scant bleeding on Resident 1's arm. At the time of the incident, Resident 1's statement included it hurts, (she/he) hit me. Interviews related to the 8/25/19 incident were not conducted with Resident 1 and Resident 6 due to the residents' [DIAGNOSES REDACTED]. On 12/11/19 at 9:11 AM Staff 3 (RN) stated she was the nurse on duty during the 8/25/19 incident. She stated Staff 8 (CNA) informed her Resident 6 hit Resident 1 in the facility dining room. Staff 3 stated she attempted to interview both residents regarding the incident but the residents were cognitively impaired and unable to provide details. Staff 3 stated she conducted an assessment for injury and psychosocial harm, directed staff to ensure the residents were not seated next to one another and provided first aid treatment to Resident 1's arm. Staff 3 stated Resident 1 and Resident 6 were monitored after the incident and did not appear to suffer any psychosocial harm. On 12/11/19 at 9:35 AM Staff 8 (CNA) stated she was in the dining room during the 8/25/19 incident. Staff 8 stated Resident 1 hollered, Resident 6 told Resident 1 to shut up and smacked her/him on the arm. Staff 8 stated she separated the residents immediately and notified Staff 3 (RN). On 12/11/19 at 10:31 AM Staff 2 (RNCM/DNS) stated she was notified of the 8/25/19 incident directly after it occurred. Staff 2 stated Resident 1 yelled, Resident 6 was irritated and slapped Resident 1's arm. Staff 2 stated she conducted an assessment for injury and Resident 1 sustained a small scratch on her/his arm. Staff 2 stated both residents appeared calm and did not suffer any emotional distress. Staff 2 stated she notified the state agency, the physician and the family of the incident and the residents' care plans were updated. Staff 2 stated there was no history of physical or verbal altercations between Resident 1 and Resident 6. On 12/13/19 at 10:38 AM Staff 1 (Administrator) was notified of the findings for this investigation and no pertinent information was provided.

Based on interview and record review it was determined the facility failed to ensure the care plan was followed for 3 of 3 sampled residents (#s 4, 18 & 172) whose care plans were reviewed for falls. This placed residents at risk for falls. Findings include: 1. Resident 172 was admitted to the facility in 8/2017 with [DIAGNOSES REDACTED]. The 10/7/19 Quarterly MDS Section J: Health Conditions indicated Resident 172 had a history of [REDACTED]. Resident 172's Care Plan directed Resident 172 was not to be left alone while in her/his wheelchair. The 6/17/19 Facility Reported Incident described Resident 172's 6/14/19 unwitnessed, non-injury fall from her/his wheelchair. The incident report indicated staff left Resident 172 alone and did not follow the care plan. In an interview on 12/11/19 at 10:22 AM Staff 2 (DNS) confirmed Resident 172 had an unwitnessed, non-injury fall from her/his wheelchair, was left alone in her/his wheelchair and staff did not follow the care plan. In an interview on 12/11/19 at 12:27 PM Staff 1 (Administrator) acknowledged Resident 172 was left alone in her/his wheelchair and staff did not follow the care plan. 2. Resident 4 was admitted to the facility in 9/2015 with [DIAGNOSES REDACTED]. On 8/1/19 a Facility Reported Incident was received by the State Agency which indicated Resident 4 had a fall as a result of Staff 6 (CNA) not following the resident's care plan. The facility's description of the incident indicated Resident 4 required two persons to safely transfer her/him; however, Staff 6 completed the transfer without assistance which resulted in Resident 4 falling. The facility Fall Incident Report dated 8/1/19 indicated Resident 4 required two persons to transfer her/him and Staff 6 transferred Resident 4 without assistance. The 7/24/19 transfer care plan indicated Resident 4 required two persons to transfer her/him when completing a stand pivot transfer. In an interview on 12/10/19 at 3:10 PM, Staff 6 (CNA) stated on 8/1/19 he completed a stand-pivot transfer with Resident 4 without assistance. Staff 6 stated Resident 4's care plan was available and accurate. He reported he did not make himself aware of the care plan thus was unaware Resident 4 required two persons to transfer her/him which resulted in Resident 4 falling. In an interview on 12/11/19 at 1:54 PM, Staff 2 (RNCM/DNS) stated Staff 6 did not follow the care plan which resulted in Resident 4 sustaining a fall. In an interview on 12/13/19 at 10:16 AM, Staff 1 (Administrator) confirmed Resident 4 fell as a result of the care plan not being followed. 3. Resident 18 was admitted to the facility in 9/2018 with [DIAGNOSES REDACTED]. On 7/8/19 a Facility Reported Incident was received by the State Agency which indicated Resident 18 had a fall as a result of Staff 4 (CNA) not following the resident's care plan. The facility's description of the incident indicated Resident 18 required two persons to safely transfer her/him; however, Staff 4 completed the transfer without assistance which resulted in Resident 18 falling. The facility Fall Incident Report dated 7/11/19 indicated Resident 18 required two persons to transfer her/him and Staff 4 transferred Resident 18 without assistance. The 7/2/19 transfer care plan indicated Resident 18 required two persons to transfer her/him. In an interview on 12/11/19 at 11:18 AM, Staff 4 (CNA) stated she thought Resident 18 was a one person transfer. She stated she transferred the resident without assistance and the resident slid to the ground. In an interview on 12/11/19 at 1:54 PM, Staff 2 (RNCM/DNS) stated Staff 4 did not follow the care plan which resulted in Resident 18 sustaining a fall. In an interview on 12/13/19 at 10:16 AM, Staff 1 (Administrator) confirmed Resident 18 fell as a result of the care plan not being followed.

Based on observation, interview and record review it was determined the facility failed to ensure care and services were provided for residents to maintain their level of range of motion for 4 of 7 sampled residents (#s 7, 11, 18 and 228) reviewed for range of motion. This placed residents at risk for a decrease in their range of motion. Findings include: 1. Resident 11 was admitted to the facility in 3/2012 with [DIAGNOSES REDACTED]. The 2/13/18 Quarterly MDS under Section G: Functional Status indicated Resident 11 had impairments on one side to upper extremities (UE) and lower extremities (LE) and Section O: Special Treatments, Procedures and Programs indicated the resident had seven days of active range of motion (AROM) for restorative nursing during the look back period. The 8/21/17 ADL CAA Summary indicated Resident 11 ambulated with RA staff at least five days a week and was always eager to participate. The 2/13/18 quarterly Nursing Assessment indicated Resident 11 participated in the RA program and worked on AROM and PROM. The 2/23/18 Alteration in Self Care ADL's and Alteration in Mobility care plans were related to limited range of motion, [MEDICAL CONDITION] and weakness. The care plan goals included maintain/increase strength of upper and lower limbs and maintain the highest level of self-care possible, with assistance as needed. Interventions included restorative program; active range of motion (AROM) and passive range of motion (PROM). The 2/2018, 3/2018 and 4/2018 Restorative Aide (RA) Flow Sheets indicated Resident 11 was to be provided AROM/PROM to left leg/foot in bed, PROM to left arm/hand/fingers and AROM to right upper and lower extremities five times weekly. The documentation on the flow sheets indicated Resident 11 did not receive the AROM/PROM five times a week due to restorative not being available or offered. On 4/11/18 at 9:13 AM Staff 4 (CNA/RA) stated RA services were not provided at times because she was pulled from RA duties to work as a CNA. On 4/12/18 at 10:54 AM, Staff 5 (CNA/RA/Maintenance) stated RA services were not provided at times because he was rushed or did not have the time to do RA services due to needing to do other duties (CNA or maintenance). On 4/12/18 at 11:25 AM, Staff 2 (DNS) indicated RA may not have been available due to the need for RA staff to work in other positions. On 4/16/18 at 10:26 AM, Staff 1 (Administrator), Staff 2 (DNS) and Staff 7 (RNCM) were asked about the RA program and the documentation of RA services not being done consistently. Staff 1 acknowledged the documentation on Resident 11's RA flow sheet indicated no RA services were provided and the RAs were pulled to do CNA duties at times. 2. Resident 18 was admitted to the facility in 5/2016 with [DIAGNOSES REDACTED]. The 2/17/18 Quarterly MDS under Section G: Functional Status indicated Resident 18 had no physical impairments and Section O: Special Treatments, Procedures and Programs indicated the resident had three days of walking for restorative nursing during the look back period. The 8/21/17 ADL CAA Summary indicated Resident 18 ambulated with RA staff at least five days a week and was always eager to participate. The 2/17/18 quarterly Nursing Assessment indicated Resident 18 had a restorative plan in place as resident tolerated. The resident worked routinely with the RA ambulating in the hallway using a gait belt, front-wheeled walker (FWW) and RA stand by assist (SBA). The 2/28/18 Alteration in Self Care ADL's care plan was related to impaired balance/coordination, weakness, impaired mobility. The care plan goals included maintain the highest level of self-care possible, with assistance as needed. Interventions included restorative program and walk with FWW to restroom and with restorative. The 2/2018, 3/2018 and 4/2018 Restorative Aide (RA) Flow Sheets indicated Resident 18 was to ambulate in the hallway with FWW and SBA five times weekly. The documentation on the flow sheets indicated Resident 18 did not receive the RA services five times a week due to restorative not being available or offered. On 4/11/18 at 9:13 AM Staff 4 (CNA/RA) stated RA services were not provided at times because she was pulled from RA duties to work as a CNA. Staff 4 acknowledged Resident 18 was not getting RA services. On 4/12/18 at 10:54 AM, Staff 5 (CNA/RA/Maintenance) stated RA services were not provided at times because he was rushed or did not have the time to do RA services due to needing to do other duties (CNA or maintenance). On 4/12/18 at 11:25 AM, Staff 2 (DNS) indicated RA may not have been available due to the need for RA staff to work in other positions. On 4/16/18 at 10:26 AM, Staff 1 (Administrator), Staff 2 (DNS) and Staff 7 (RNCM) were asked about the RA program and the documentation of RA services not being done consistently. Staff 1 acknowledged the documentation on Resident 18's RA flow sheet indicated no RA services were provided and the RAs were pulled to do CNA duties at times. 3. Resident 7 was admitted to the facility in 10/2003 with [DIAGNOSES REDACTED]. The 1/2018 Alteration in Mobility care plan revealed the resident was on a restorative program which included Active Range of Motion (AROM) to maintain and increase strength of upper and lower limbs. The 2/2018 Restorative Aide flow sheet indicated Resident 7 was to be provided various leg strengthening exercises, arm exercises and ambulation in the hallway two times per week. The documentation on the flow sheet revealed Resident 7 was provided restorative services one time (2/25/18) between 2/15/18 through 2/28/18. The 2/2018 Restorative Nursing Program Monthly Record progress notes revealed .restorative services was not available like it should be. On 4/9/18 at 9:15 AM, Staff 4 (CNA/RA) indicated RA was not available because she was often pulled from RA duties to work as a CNA. On 4/12/18 at 10:54 AM, Staff 5 (CNA/RA/Maintenance Director) confirmed RA was not available due to being rushed and he did not have the time to do it. On 4/12/18 at 11:25 AM, Staff 2 (DNS) indicated RA may not have been available due to the need for RA staff to work in other positions. On 4/12/18 at 11:50 AM, Staff 1 (Administrator) confirmed RA services were not provided. 4. Resident 228 was admitted to the facility in 3/2018 for [DIAGNOSES REDACTED]. The 3/22/18 Admission MDS under section G: Functional Status indicated Resident 228 had impairments to both upper extremities (UE) and section O: Special Treatments, Procedures, and Programs indicated Resident 228 had two days of passive range of motion (PROM) services. The 3/29/18 ADL Self Care Deficit care plan indicated Resident 228 was to have no further decline in strength and function with ADLs and mobility. The 4/2018 Restorative Aide (RA) Flow Sheet indicated Resident 228 was to be provided PROM to upper and lower extremities three to five times weekly. The documentation on the flow sheet indicated Resident 228 did not receive PROM at all between 4/1/18 through 4/9/18. On 4/9/18 at 10:08 AM, Resident 228 stated PROM was not provided and was observed to have limited movement with both arms. On 4/11/18 at 10:46 AM, Staff 4 (CNA/RA) stated RA services were not provided because she was pulled from RA duties to work as a CNA. On 4/13/18 at 2:54 PM, Staff 1(Administrator) and Staff 2 (DNS) stated the documentation on Resident 228's RA flow sheet indicated no RA services were provided.

4. Resident 228 was admitted to the facility in 3/2018 for diagnoses including osteoarthritis and generalized muscle weakness. The 3/22/18 admission MDS under section G: Functional Status indicated Resident 228 had impairments to both upper extremities (UE) and section O: Special Treatments, Procedures, and Programs indicated Resident 228 had two days of passive range of motion (PROM) services. The 3/29/18 ADL Self Care Deficit care plan indicated Resident 228 was to have no further decline in strength and function with ADLs and mobility. The 4/2018 Restorative Aide (RA) Flow Sheet indicated Resident 228 was to be provided PROM to upper and lower extremities three to five times weekly. The documentation on the flow sheet indicated Resident 228 did not receive PROM at all between 4/1/18 through 4/9/18. On 4/9/18 at 10:08 AM, Resident 228 stated PROM was not provided and was observed to have limited movement with both arms. On 4/11/18 at 10:46 AM, Staff 4 (CNA/RA) stated RA services were not provided because she was pulled from RA duties to work as a CNA. On 4/13/18 at 2:54 PM, Staff 1(Administrator) and Staff 2 (DNS) stated the documentation on Resident 228's RA flow sheet indicated no RA services were provided. 3. Resident 7 was admitted to the facility in 10/2003 with diagnoses including cerebral palsy, muscle spasms and traumatic brain injury. The 1/2018 Alteration in Mobility care plan revealed the resident was on a restorative program which included Active Range of Motion (AROM) to maintain and increase strength of upper and lower limbs. The 2/2018 Restorative Aide flow sheet indicated Resident 7 was to be provided various leg strengthening exercises, arm exercises and ambulation in the hallway two times per week. The documentation on the flow sheet revealed Resident 7 was provided restorative services one time (2/25/18) between 2/15/18 through 2/28/18. The 2/2018 Restorative Nursing Program Monthly Record progress notes revealed .restorative services was not available like it should be. On 4/9/18 at 9:15 AM, Staff 4 (CNA/RA) indicated RA was not available because she was often pulled from RA duties to work as a CNA. On 4/12/18 at 10:54 AM, Staff 5 (CNA/RA/Maintenance Director) confirmed RA was not available due to being rushed and he did not have the time to do it. On 4/12/18 at 11:25 AM, Staff 2 (DNS) indicated RA may not have been available due to the need for RA staff to work in other positions. On 4/12/18 at 11:50 AM, Staff 1 (Administrator) confirmed RA services were not provided. Based on observation, interview and record review it was determined the facility failed to ensure care and services were provided for residents to maintain their level of range of motion for 4 of 7 sampled residents (#s 7, 11, 18 and 228) reviewed for range of motion. This placed residents at risk for a decrease in their range of motion. Findings include: 1. Resident 11 was admitted to the facility in 3/2012 with diagnoses including hemiplegia (paralysis of half of the body) and hemiparesis (weakness of one entire side of the body). The 2/13/18 Quarterly MDS under Section G: Functional Status indicated Resident 11 had impairments on one side to upper extremities (UE) and lower extremities (LE) and Section O: Special Treatments, Procedures and Programs indicated the resident had seven days of active range of motion (AROM) for restorative nursing during the look back period. The 8/21/17 ADL CAA Summary indicated Resident 11 ambulated with RA staff at least five days a week and was always eager to participate. The 2/13/18 quarterly Nursing Assessment indicated Resident 11 participated in the RA program and worked on AROM and PROM. The 2/23/18 Alteration in Self Care ADL's and Alteration in Mobility care plans were related to limited range of motion, hemiplegia and weakness. The care plan goals included maintain/increase strength of upper and lower limbs and maintain the highest level of self-care possible, with assistance as needed. Interventions included restorative program; active range of motion (AROM) and passive range of motion (PROM). The 2/2018, 3/2018 and 4/2018 Restorative Aide (RA) Flow Sheets indicated Resident 11 was to be provided AROM/PROM to left leg/foot in bed, PROM to left arm/hand/fingers and AROM to right upper and lower extremities five times weekly. The documentation on the flow sheets indicated Resident 11 did not receive the AROM/PROM five times a week due to restorative not being available or offered. On 4/11/18 at 9:13 AM Staff 4 (CNA/RA) stated RA services were not provided at times because she was pulled from RA duties to work as a CNA. On 4/12/18 at 10:54 AM, Staff 5 (CNA/RA/Maintenance) stated RA services were not provided at times because he was rushed or did not have the time to do RA services due to needing to do other duties (CNA or maintenance). On 4/12/18 at 11:25 AM, Staff 2 (DNS) indicated RA may not have been available due to the need for RA staff to work in other positions. On 4/16/18 at 10:26 AM, Staff 1 (Administrator), Staff 2 (DNS) and Staff 7 (RNCM) were asked about the RA program and the documentation of RA services not being done consistently. Staff 1 acknowledged the documentation on Resident 11's RA flow sheet indicated no RA services were provided and the RAs were pulled to do CNA duties at times. 2. Resident 18 was admitted to the facility in 5/2016 with diagnoses including dementia and age related physical debility. The 2/17/18 Quarterly MDS under Section G: Functional Status indicated Resident 18 had no physical impairments and Section O: Special Treatments, Procedures and Programs indicated the resident had three days of walking for restorative nursing during the look back period. The 8/21/17 ADL CAA Summary indicated Resident 18 ambulated with RA staff at least five days a week and was always eager to participate. The 2/17/18 quarterly Nursing Assessment indicated Resident 18 had a restorative plan in place as resident tolerated. The resident worked routinely with the RA ambulating in the hallway using a gait belt, front-wheeled walker (FWW) and RA stand by assist (SBA). The 2/28/18 Alteration in Self Care ADL's care plan was related to impaired balance/coordination, weakness, impaired mobility. The care plan goals included maintain the highest level of self-care possible, with assistance as needed. Interventions included restorative program and walk with FWW to restroom and with restorative. The 2/2018, 3/2018 and 4/2018 Restorative Aide (RA) Flow Sheets indicated Resident 18 was to ambulate in the hallway with FWW and SBA five times weekly. The documentation on the flow sheets indicated Resident 18 did not receive the RA services five times a week due to restorative not being available or offered. On 4/11/18 at 9:13 AM Staff 4 (CNA/RA) stated RA services were not provided at times because she was pulled from RA duties to work as a CNA. Staff 4 acknowledged Resident 18 was not getting RA services. On 4/12/18 at 10:54 AM, Staff 5 (CNA/RA/Maintenance) stated RA services were not provided at times because he was rushed or did not have the time to do RA services due to needing to do other duties (CNA or maintenance). On 4/12/18 at 11:25 AM, Staff 2 (DNS) indicated RA may not have been available due to the need for RA staff to work in other positions. On 4/16/18 at 10:26 AM, Staff 1 (Administrator), Staff 2 (DNS) and Staff 7 (RNCM) were asked about the RA program and the documentation of RA services not being done consistently. Staff 1 acknowledged the documentation on Resident 18's RA flow sheet indicated no RA services were provided and the RAs were pulled to do CNA duties at times.