Every finding on record at Avamere Rehabilitation Of Eugene

Based on interview and record review, it was determined the facility failed to timely report an allegation of potential neglect to the State Agency for 1 of 1 sampled resident (#3) reviewed for CPR. This placed residents at risk of neglect. Findings included:Resident 3 was admitted to the facility in 2/2026 with diagnoses including respiratory failure and pneumonia. The facility's [DATE] investigation documented that staff found Resident 3 and suspected the resident was deceased during routine rounds. The nurse was notified, and the resident was confirmed as deceased . Resident 3 was not on hospice, had a Full Code status, and CPR was not initiated. Included in the investigation on [DATE], six days after the resident's death, that upon the nurse assessment Resident 3 did not have rigor mortis and the nurse did not initiate code blue or resuscitation interventions. A Nursing Facility Reported Incident Form, dated [DATE], indicated the incident from [DATE] was reported to the State Agency on [DATE]. On [DATE] at 12:48 PM, Staff 26 (Regional Director of Quality Assurance) confirmed the facility did not report the incident to the State Agency within the required two-hour timeline.

Based on interview and record review, it was determined the facility failed to ensure a safe and orderly discharge was provided for 1 of 3 sampled residents (#8) reviewed for discharge. This placed residents at risk for an unsafe discharge. Findings include:Resident 8 was admitted to the facility in 3/2026 with diagnoses including chronic pain, absence of left leg below the knee, and after care following a surgical amputation. A 3/10/26 admission MDS indicated Resident 8 was cognitively intact and required supervision or touching assistance with toileting, transfers, and bathing. No referrals were documented for medical equipment ordered, or home health referral submitted. A 3/11/26 Discharge Instructions documented Resident 8 was being discharged home and noted her/his current physical status required assistance and assistive devices. A 3/13/26 Nursing Note indicated at 12:23 AM, Resident 8 returned after an outing. The facility notified the police because her/his location was unknown. Resident 8 had been out with friends and was unaware of any concern. A 3/13/26 Social Services Note documented because Resident 8 was out past midnight, she/he was discharging from the facility. NOMNC was not issued due to leaving prior to scheduled discharge and leaving on own initiative. A 3/13/26 Discharge Summary note documented the discharge instructions were reviewed with Resident 8 and she/he refused to sign leaving the facility voluntarily. The facility's Voluntary Consent form included a handwritten statement that Resident 8 refused to sign. On 3/26/25 at 10:58 AM, Resident 8 stated he was kicked out of the facility for coming back late. Resident 8 stated she/he was currently sleeping on a friend's couch, and it was difficult to get around. On 3/30/26 at 10:36 AM, Staff 21 (Business Office Manager) stated Resident 8 did not have any financial notes for lack of payment and she did not have any information about why she/he discharged from the facility. On 3/30/26 at 12:06 PM, Staff 19 (Social Services Coordinator) stated Resident 8 stayed out late and the facility called the police. Resident 8 returned to the facility after midnight and because she/he was a Medicare resident, insurance would not cover her/him if out of the facility past midnight. Staff 19 stated Resident 8 was scheduled for discharge from the facility on 3/17/26. On 3/30/26 at 12:57 PM, Staff 27 (Regional Director of Operations) stated he thought it was a clerical error and confirmed the facility should have completed a normal discharge for Resident 8.

Based on interview and record review it was determined the facility failed to maintain medical records for 2 of 3 sampled residents (#s 6 and 37) reviewed for advanced directives. This placed residents at risk for incomplete medical records. Findings include:1. Resident 6 was admitted to the facility in 12/2024 with diagnoses including end stage kidney disease.On 1/13/26 at 10:28 AM, a review of Resident 6's medical record revealed an untitled form signed by Resident 6 on 3/29/25 which indicated Resident 6 wanted to initiate an advance directive.On 1/13/26 at 3:00 PM, a review of Resident 6's medical record revealed the untitled form signed by Resident 6 on 3/29/25 was no longer found in the electronic medical record.On 1/13/26 at 3:47 PM, Staff 4 (Regional Nurse Consultant) stated she deleted the untitled forms from Resident 6's, Resident 37's, and 19 additional active residents' medical records. Staff 4 stated she deleted the untitled forms because they were not official corporate forms. Staff 4 acknowledged medical records were expected to be retained and not deleted.2. Resident 37 was admitted to the facility in 12/2024 with diagnoses including diabetes.On 1/13/26 at 11:01 AM, a review of Resident 37's medical record revealed an untitled form signed by Resident 37 on 12/24/24 which indicated Resident 37 had an advance directive and would bring it into the facility within 72 hours.On 1/13/26 at 3:05 PM, a review of Resident 37's medical record revealed the untitled form signed by Resident 31 on 12/24/24 was no longer found in the electronic medical record.On 1/13/26 at 3:47 PM, Staff 4 (Regional Nurse Consultant) stated she deleted the untitled forms from Resident 6's, Resident 37's, and 19 additional active residents' medical records. Staff 4 stated she deleted the untitled forms because they were not official corporate forms. Staff 4 acknowledged medical records were expected to be retained and not deleted.

Based on observation and interview it was determined the facility failed to ensure laundry was cleaned and sorted in a safe manner for 1 of 1 laundry rooms reviewed for infection control. This places residents at risk for exposure to mold and bacteria. Findings include: During the walk through of the facility laundry room on 1/15/26 at 12:11 PM, a hole in the wall was observed next to the wash machine. Behind the two wash machines and a clean linen cart was a large pool of standing water, the water appeared brown and dirty. Along the baseboard of the wall behind the two wash machines was a black substance which extended about an inch up the wall and an inch on the floor. Staff 13 (Housekeeping Director) stated the hole in the wall was present for some time but did not extend into the outside of the building. Staff 13 stated maintenance was notified of the standing water a few weeks ago, but it was not yet repaired. Staff 13 did not know what the black substance was.On 1/15/26 at 1:35 PM the standing water in the laundry room was observed, a cart of clean linen and laundry was near the water and a blanket from the cart was observed partially in the water. Staff 12 (Laundry Aide) confirmed the blanket touched the water and stated the blanket would be recleaned. On 1/15/25 at 3:15 PM Staff 1 (Administrator) walked through the laundry room; there was less standing water and some of the black substance appeared removed. Staff 1 confirmed the standing water and black substance on the wall and floor and acknowledged the laundry area needed to be repaired. Staff 1 asked Staff 12 if the water on the floor happened often, Staff 12 stated it occurred for the last three weeks when the wash machines were in use. Staff 12 stated the water and some of the black substance on the wall were just cleaned up.

Based on interview and record review it was determined the facility failed to ensure residents or resident representatives received education regarding the potential side effects of the pneumococcal and influenza vaccines for 5 of 5 sampled residents (#s 3, 10, 13, 14, and 30) reviewed for immunizations. This placed residents at risk for lack of information. Findings include:1. Resident 3 was admitted to the facility in 6/2025 with diagnosis of hemiparesis (one-sided weakness) following a stroke. Resident 3's record revealed the resident was offered but declined a PCV20 vaccine on 6/18/25. The Declination of Influenza or Pneumococcal Vaccination form signed by Resident 3 on 6/18/25 did not include education on the potential side effects of the pneumococcal vaccine.Resident 3's record revealed the resident received an influenza vaccine 9/22/25.In an interview on 1/16/26 at 11:30 AM, Staff 25 (IP) confirmed no education was provided related to the possible adverse side effects of the influenza or pneumococcal vaccines.2. Resident 10 was admitted to the facility in 6/2019 with diagnosis of severe morbid obesity.Resident 10's immunization record revealed the resident received an influenza vaccine on 9/23/25. The immunization record indicated education on the potential side effects of the influenza vaccine did not occur.In an interview on 1/16/26 at 11:30 AM, Staff 25 (IP) confirmed no education was provided related to the possible adverse side effects of the influenza vaccine.3. Resident 13 was admitted to the facility in 10/2025 with diagnosis of diabetes with hyperglycemia. Resident 13's immunization record revealed the resident was offered a PCV20 and an influenza vaccine on 10/14/25 and chose to decline both.The Declination of Influenza or Pneumococcal Vaccination form signed by Resident 13 on 10/14/25 did not include education on the potential side effects of the pneumococcal and influenza vaccines.In an interview on 1/16/26 at 11:30 AM, Staff 25 (IP) confirmed no education was provided related to the possible adverse side effects of the influenza or pneumococcal vaccines.4. Resident 14 was admitted to the facility in 11/2025 with diagnosis of rheumatoid arthritis.Resident 14's record revealed the resident was offered a PCV20 and an influenza vaccine on 11/6/25 and chose to decline both. The Adult Vaccination Declination Form verbally reviewed with resident on 11/6/25 did not include education on the potential side effects of the pneumococcal and influenza vaccines.In an interview on 1/16/26 at 11:30 AM, Staff 25 (IP) confirmed no education was provided related to the possible adverse side effects of the influenza or pneumococcal vaccines.5. Resident 30 was admitted in 5/2024 with diagnosis of Diabetes.Resident 30's immunization record revealed the resident was offered a PCV20 vaccine and declined it on 11/5/25.The Adult Vaccination Declination Form reviewed verbally with Resident 30 on 11/5/25 did not include education on the potential side effects of the pneumococcal vaccine. Resident 30's immunization record revealed the resident received an influenza vaccine on 9/22/25. The immunization record indicated education on the potential side effects of the influenza vaccine did not occur.In an interview on 1/16/26 at 11:30 AM, Staff 25 (IP) confirmed no education was provided related to the possible adverse side effects of the influenza or pneumococcal vaccines.

Based on interview and record review it was determined the facility failed to ensure residents or resident representatives received education regarding the potential side effects of the COVID-19 vaccine for 5 of 5 sampled residents (#s 3, 10, 13, 14, and 30) reviewed for immunizations. This placed residents at risk for lack of information. Findings include:1. Resident 3 was admitted to the facility in 6/2025 with diagnosis of hemiparesis (one-sided weakness) following a stroke. Resident 3's immunization record revealed she/he received a COVID-19 vaccine on 10/8/25.The Vaccine Consent Form signed by Resident 3 on 9/19/25 did not include education on the potential side effects of the COVID-19 vaccine.In an interview on 1/16/26 at 11:30 AM, Staff 25 (IP) confirmed no education was provided related to the possible adverse side effects of the COVID-19 vaccine.2. Resident 10 was admitted to the facility in 6/2019 with diagnosis of severe morbid obesity.Resident 10's immunization record revealed the resident was offered a COVID-19 vaccine on 9/19/25 and chose to decline. The Declination of COVID-19 Vaccination form did not include education on the potential side effects of the COVID-19 vaccine.In an interview on 1/16/26 at 11:30 AM, Staff 25 (IP) confirmed no education was provided related to the possible adverse side effects of the COVID-19 vaccine.3. Resident 13 was admitted to the facility in 10/2025 with diagnosis of diabetes with hyperglycemia. Resident 13's immunization record revealed the resident was offered a COVID-19 vaccine on 10/14/25 and chose to decline. The Declination of COVID-19 Vaccination Form did not include education on the potential side effects of the COVID-19 vaccine.In an interview on 1/16/26 at 11:30 AM, Staff 25 (IP) confirmed no education was provided related to the possible adverse side effects of the COVID-19 vaccine.4. Resident 14 was admitted to the facility in 11/2025 with diagnosis of rheumatoid arthritis.Resident 14's immunization record revealed the resident was offered a COVID-19 vaccine on 11/6/25 and chose to decline. The Adult Vaccination Declination Form verbally reviewed with resident on 11/6/25 did not include education on the potential side effects of the COVID-19 vaccine.5. Resident 30 was admitted in 5/2024 with diagnosis of diabetes.Resident 30's immunization record revealed the resident was offered a COVID-19 vaccine on 11/5/25 and chose to decline.The Adult Vaccination Declination Form verbally reviewed with resident on 11/5/25 did not include education on the potential side effects of the COVID-19 vaccine.In an interview on 1/16/26 at 11:30 AM, Staff 25 (IP) confirmed no education was provided related to the possible adverse side effects of the COVID-19 vaccine.

Based on interview and record review the facility failed to ensure the resident's rights to make decisions regarding her medication administration for 1 of 1 of resident (# 25) reviewed for insulin. This place residents at risk for not being able to make choices about their health care. Findings include:Resident 28 was admitted to the facility in 9/2025 with diagnoses including type 2 diabetes mellitus.Resident 28's 12/10/25 Brief Interview for Mental Status revealed a BIMS of 15 (cognitively intact).On 1/12/26 at 1:40 PM, Resident 25 stated she/he had discussions with some of the nurses about her/his insulin because she/he wanted it administered before meals and it often was given after her/his dinner in the evenings. On 1/15/26 at 10:15 AM, Staff 10 (CNA) stated Resident 25 told her multiple times she/he wanted her/his insulin administered before meals. Staff 10 stated she reported the concern to nursing staff. On 1/16/26 at 12:53 PM, Staff 9 (LPN) stated a CNA told her Resident 25 was unhappy because she/he had not been administered her/his insulin before meals. Staff 9 stated she had not followed up with the physician about Resident 25's concern. On 1/16/26 at 1:10 PM, Staff 2 (DNS) stated when nurses became aware Resident 25 was requesting to have insulin administered before meals, they should have notified the physician to ensure Resident 25's insulin orders could be changed.

Based on interviews and record review it was determined the facility failed to ensure advanced directives were completed per resident preference for 2 of 3 sample residents (#s 6 and 37) reviewed for advanced directives. This placed residents at risk for healthcare decisions to conflict with resident wishes. Findings include:1.Resident 6 was admitted to the facility in 12/2024 with diagnoses including end stage kidney disease and diabetes.A review of Resident 6's medical record revealed an untitled form signed by Resident 6 on 3/29/25 which indicated Resident 6 wanted to initiate an advance directive.A record review revealed no evidence of an advance directive in Resident 6's medical record.On 1/13/26 at 1:41 PM, Staff 3 (Regional Nurse Consultant) stated Resident 6 did not have an advance directive completed.On 1/20/26 at 12:00 PM, Staff 2 (DNS) stated staff were expected to follow up with residents regarding initiating and/or obtaining their advance directive.Resident 37 was admitted to facility in 12/2024 with diagnoses including diabetes and heart failure.A review of Resident 37's medical record revealed an untitled form signed by Resident 37 on 12/24/24 which indicated Resident 37 had an advance directive and would provide it to the facility in 72 hours.A record review revealed no evidence of an advanced directive in Resident 37's medical record.On 1/13/26 at 1:41 PM, Staff 3 (Regional Nurse Consultant) stated Resident 37 did not have an advance directive completed.On 1/20/26 at 12:00 PM, Staff 2 (DNS) stated staff were expected to follow up with residents regarding initiating and/or obtaining their advance directive.2.Resident 37 was admitted to facility in 12/2024 with diagnoses including diabetes and heart failure.A review of Resident 37's medical record revealed an untitled form signed by Resident 37 on 12/24/24 which indicated Resident 37 had an advance directive and would provide it to the facility in 72 hours.A record review revealed no evidence of an advanced directive in Resident 37's medical record.On 1/13/26 at 1:41 PM, Staff 3 (Regional Nurse Consultant) stated Resident 37 did not have an advance directive completed.On 1/20/26 at 12:00 PM, Staff 2 (DNS) stated staff were expected to follow up with residents regarding initiating and/or obtaining their advance directive.

Based on interview and record review the facility failed to ensure the resident was free of unnecessary psychotropic medications for 1 or 1 resident (#15) reviewed for pain management. This placed residents at risk for receiving unnecessary psychotropic medications and chemical restraint. Findings include: Resident 15 was admitted to the facility in 6/2025 with diagnoses including insomnia. Resident 15's 12/18/25 Brief Interview for Mental Status revealed a BIMS of 15 which indicated Resident 15 was cognitively intact.A review of the resident's clinical record indicated an order for 50 mg of trazodone had been entered in the Medical Administration Record (MAR) on 12/17/25.A review of the resident's clinical record indicated an order for 50 mg of trazodone had been entered in the Medical Administration Record (MAR) on 1/7/26 in addition to the existing order.On 1/13/26 at 10:30 AM, Resident 15 stated she/he thought she/he had received extra doses of trazodone and had not been able to do anything but sleep for two days. Resident 15 stated she/he was upset because she/he had been too sleepy to attend her/his physical therapy session and therapy was very important to her/him. On 1/14/26 at 2:14 PM, Witness 1 (Family Member) stated last week when she talked to Resident 15 she/he had been in tears and told Witness 1 she/he was so tired she/he couldn't function. Witness 1 called the facility and spoke to Staff 17 (CMA) who told her Resident 15's trazodone had been increased by 50 mg on 1/7/26 and 1/8/26.On 1/15/26 at 8:45 AM, Staff 17 stated when she saw there was a second order for 50 mg of trazodone in Resident 15's clinical record on 1/9/26 she checked with the resident and did not administer the medication. Staff 17 stated she noticed the extra dose had been administered on 1/7/26 and 1/8/26. Staff 17 stated she notified the nurse on duty of the duplicate order and again notified the nurse on duty the following day when she saw the order was unchanged in the system. On 1/15/25 at 1:30 PM, Staff 19 (LPN) stated she was unsure of the date but had looked at pending orders to teach Staff 18 (RN) how to enter orders. She stated she remembered there was a pending order for trazodone and she had Staff 18 enter the order in the clinical record. Staff 19 stated she was unaware there was an additional process to verify the orders before confirming them. On 1/16/2026 at 10:14 AM, Staff 18 stated Staff 19 had been training her on how to enter orders. Staff 18 stated she logged into the computer but had not realized she was actually creating an order and had not paid attention to the resident or medication information. On 1/16/26 at 8:17 AM, Staff 2 (DNS) stated the order was an error and should have been deleted, not confirmed. Staff 2 stated nurses should be verifying orders when they implemented them.

Based on observations, interview, and record review it was determined the facility failed to report allegations of abuse and neglect to the State Survey Agency for 1 of 3 sampled residents (#60) reviewed for abuse and accidents. This placed residents at risk for further abuse and neglect. Findings include: Resident 60 was admitted to the facility in 7/2024 with diagnoses including heart failure and kidney disease.The 3/4/25 Annual MDS indicated Resident 60 was cognitively intact.A care plan dated 12/24/25 indicated if Resident 60 accusatory comments about family, and/or staff not treating her/him well and denying her/his medications, staff must alert the nurse so they may assess for signs and symptoms of urinary tract infection since this had been the case in the past.On 1/12/26 at 2:13 PM Resident 60 indicated a CNA/CMA abused her/him. Resident 60 stated the staff member spoke meanly and was rough with her/him and she/he felt abused. Resident 60 stated the staff member treated her/him like a bad dog. Resident 60 stated Staff 11 (LPN) was aware the staff member treated her/him badly but had not stopped the staff member. Resident 60 stated she/he was afraid of retaliation from the staff member and being discharged from the facility. On 1/12/26 at 2:16 PM Staff 11 stated the staff member she heard being rude to Resident 60 was Staff 26 (CNA/CMA). Staff 11 stated Staff 26's demeanor changed if she felt rushed or if she had a bad day. Staff 11 stated she heard Staff 26 be rude to other residents and other staff members observed this behavior as well, but she did not report the behavior to management.On 1/12/26 at 2:42 PM Staff 1 (Administrator) and Staff 2 (DNS) were notified Resident 60 stated she/he felt abused by Staff 26. Staff 1 indicated this was the first he had heard of Resident 60 feeling abused by Staff 26. On 1/12/26 at 2:52 PM Staff 1 and Staff 2 stated their expectation when a resident felt abused by a staff member was for staff to notify both of them immediately. Staff 2 stated staff must notify the provider and family and ensure the safety of all residents.

Based on observation, interview, and record review it was determined the facility failed to provide care-planned eating assistance for 1 of 4 sampled residents (#14) reviewed for nutrition. This placed residents at risk for reduced nutritional intake and decline in positioning. Findings include:Resident 14 was admitted to the facility in 11/2025 with diagnoses including rheumatoid arthritis, dementia, and unspecified deformity of the fingers.A 11/11/25 admission MDS indicated Resident 14's BIMS score was nine which indicated she/he had moderately impaired cognition. Resident 14 required setup and cleanup assistance for eating.A 11/6/25 Care Plan indicated Resident 14 required setup assistance for eating. Observations on 1/12/26 from 12:12 PM to 1:10 PM revealed Resident 14 arrived in the facility main dining room for lunch at 12:30 PM. Resident 14 received her/his meal at 12:42 PM. Resident 14 was seated in a wheelchair at a dining table, and the meal was not within her/his reach. Resident 14 was observed leaning forward in the chair two to three times, bringing her/his trunk closer to the dining table with effort, then sat back in the wheelchair. Staff in the dining room did not approach Resident 14 until 1:04 PM when assistance was provided in repositioning her/his feet on the wheelchair footrests. Staff removed Resident 14's meal at 1:10 PM without asking if she/he was done eating. Staff assisted Resident 14 back to her/his room. During lunch service Resident 14 did not have any food or drink while in the dining room.Observations on 1/13/26 from 1:16 PM to 2:05 PM revealed Resident 14 was positioned in bed with the head of the bed elevated, and the overbed table was across her/his body from the left side of the bed. The lunch meal tray was on the overbed table. Resident 14 stated she/he had missed breakfast and was hungry. Resident 14's right knee was in a bent position which limited the overbed table position towards Resident 14's left side. Resident 14's tray had one beverage with the lid removed, one beverage with the lid on, the lid was removed from the soup, and the meal included an open plate stewed beef and a baked potato. Resident 14's baked potato was uncut, and the containers of butter and sour cream were unopened. Resident 14's utensils were to the far-left side of the meal tray, and she/he reached them with difficulty after several tries with her/his right hand. Resident 14 attempted to use a fork to cut into the baked potato but only speared the potato on the fork. Resident 14 was then observed taking a bite of beef with some effort to reach and secure the food on her/his fork. When Staff 8 (CNA) removed the tray at 2:05 PM very little food was consumed, and all the unopened items remained unopened and uneaten. The uneaten baked potato was observed lying on the tray to the right of the plate. Resident 14 drank the entire opened beverage.In an interview on 1/13/26 at 2:05 PM, Staff 8 indicated Resident 14 could not cut her/his potatoes, apply butter to items on the tray, or open containers. On 1/14/26 at 2:20 PM Staff 9 (LPN) stated staff were expected to set up meals by placing the tray in front of the resident, cutting the meat, removing all lids, and making sure the resident had everything she/he needed within reach.On 1/20/26 at 11:38 AM, Staff 2 (DNS) stated staff were expected when setting up a meal to ensure food items were within reach, to remove the cover from the plate and open all containers and lids. Staff 2 stated staff were also encouraged to offer as a courtesy to cut foods if the resident wanted assistance.

Based on observations, interviews, and record review it was determined the facility failed to provide ADL care to dependent residents for 1 of 1 sampled resident (#11) reviewed for ADLs. This placed residents at risk for lack of nail care. Findings include: Resident 11 was admitted to the facility in 1/2024 with diagnoses including below the knee amputation, legal blindness, and diabetes.Resident 11's 1/29/26 Annual MDS indicated the resident had moderate cognitive impairment.The 2/1/24 care plan indicated Resident 11 had ADL self-care performance related to legal blindness, heart failure, and limited mobility, required one staff member to set-up and offer location of items on her/his overbed table and plate, and was able to feed and drink independently. Resident 11 preferred to eat with her/his hands.The 12/2025 TAR indicated Resident 11's nails were trimmed on 12/24/25.The 12/2025 TAR indicated diabetic nail care weekly every evening shift every Wednesday for diabetes.The 1/2026 task document indicated on 1/8/26 Resident 11 had a shower.On 1/12/26 at 10:34 AM, 1/13/26, and 1/14/26 at 12:30 PM, Resident 11 was observed to have long nails with dark brown debris under them. On 1/13/26 at 12:30 PM, Resident 11 was observed eating lunch with her/his hands and continued to have dark brown debris under them.On 1/13/26 at 1:34 PM, Staff 13 (CNA) acknowledged the resident's nails were long and had brown debris under them, Staff 13 did not offer Resident 11 a washcloth to clean her/his hands, she stated she would alert Resident 11's care giver the resident's nails needed to be cleaned.On 1/14/26 at 12:44 PM, Staff 5 (LPN/Resident Care Manager) acknowledged Resident 11's nails were long and had dried brown debris under them. Staff 5 stated her expectation was for nurses to check resident's nails weekly, especially diabetics and perform trimming, cleaning and filing as needed. Staff 5 asked Resident 11 if she could perform nail care, and the resident agreed.On 1/16/26 at 2:32 PM Staff 1 (Administrator), Staff 2 (DNS), and Staff 3 (Regional Nurse Consultant) stated if a resident refused care by a staff member, staff should ask another staff member to try and approach the resident. Staff 3 stated staff should alert the nurse of the refusals and keep trying to provide care to the resident. Staff 2 stated the expectation was for nurses to document every refusal Resident 11 had.

Based on observation, interview and record review it was determined the facility failed to ensure staff provided two-person assistance when transferring a resident and failed to ensure a environment remained free from accident hazards for 2 of 4 sampled resident (#s 31 and 42) reviewed for accidents. This placed residents at risk for accidents. Findings include: Resident 31 was admitted to the facility in 12/2025 with diagnoses including dementia. A 12/5/25 care plan indicated Resident 31 was at risk for falls and padded fall mats were to be placed at both sides of the bed when Resident 31 was in bed. On 1/13/26 at 9:27 AM, Resident 31 was observed in bed without a fall mat on the left side of her/his bed. On 1/14/26 at 9:01 AM, Resident 31 was observed in bed with the left side of the bed fall mat on the floor, but not next to Resident 31's bed. On 1/14/26 at 2:43 PM, Resident 31 was observed in bed without a fall mat on the left side of her/his bed. On 1/14/26 at 2:45 PM, Staff 4 (CNA) stated Resident 31 was at risk for falls and was to have fall mats on the floor next to her/his bed while Resident 31 was in bed. Staff 4 confirmed Resident 31 did not have a fall mat on the left side of her/his bed and Staff 4 placed the fall mat on the left side of Resident 31's bed. On 1/15/26 at 1:31 PM, Resident 31 was observed in bed, the fall mat for the left side of her/his bed was folded up and leaning against the foot of the bed. On 1/16/26 at 10:26 AM, Staff 5 (LPN Resident Care Manager) stated Resident 31 was at risk for falls and rolled out of bed when she/he first admitted . Staff 5 stated Resident 31 was care planned to have fall mats on the floor on both sides of the bed when she/he was in bed. Staff 5 stated staff were expected to follow the care plan. 2. Resident 42 was admitted to the facility in 5/2025 with diagnoses including stroke and weakness. A 5/23/25 care plan revealed Resident 42 required two-person assistance with transfers using FWW (Front Wheeled Walker). A 7/21/25, fall investigation revealed at approximately 10:00 AM Staff 15 (Former CNA) indicated she took Resident 42 to her/his room after a shower. Staff 15 grabbed Resident 42's FWW and assisted her/him to stand. Resident 42 felt her/his legs weaken, lost balance, and fell to the floor. Staff 15 did not review the care plan. -On 7/22/25 Staff 16 (Former LPN) was notified and indicated no injuries were found on the resident. -The investigation indicated during training, CNAs were taught to read the care plan for the residents' care needs. Staff 15 transferred Resident 42 without assistance when the care plan clearly stated she/he was a two-person transfer. -The Root Cause Analysis indicated the biggest contributing factor was Resident 42 was a two person assist with her/his FWW and Staff 15 did not check the care plan. On 1/14/26 4:24 PM Staff 15 stated she transferred Resident 42 to her/his wheelchair with the FWW, and the resident stood up and slid to the floor. Staff 15 stated she did not review the care plan which indicated Resident 42 was a two-person transfer with a FWW before she transferred her/him. On 1/14/26 4:25 PM Staff 16 stated Staff 15 notified her she gave resident 42 a shower and attempted to transfer her/him back to her/his wheelchair when the resident fell. Staff 16 stated Resident 42 was care planned as a two person assist with transfers and Staff 15 completed the transfer alone. On 1/15/26 at 3:02 PM Staff 1 (Administrator), Staff 2 (DNS), and Staff 3 (Regional Nurse Consultant) acknowledged Resident 42 was a two person transfer which was on her/his care plan. Staff 2 stated expectations were for staff to always look at the care plan before providing care for residents. Staff 3 stated the expectation was for an allegation of abuse or neglect to be reported to the State Survey Agency timely.

Based on observations, interviews, and record review it was determined the facility failed to provide specialized rehabilitation services for 1 of 2 sampled residents (#31) reviewed for positioning. This placed residents at risk for decline in physical ability. Findings include:Resident 31 was admitted in 12/2025 with diagnoses including dysphagia (difficulty swallowing) and dementia.A review of Resident 31's 12/14/25 hospital discharge summary indicated Resident 31 had orders for PT, OT, and ST.A review of Resident 31's medical record revealed no evidence of PT, OT, or ST documentation since 12/14/25.On 1/12/26 at 12:21 PM, Resident 31 was observed up in a wheelchair that was tilted back, without a headrest, and without footrests. Resident 31's head was observed to hang off the back of the wheelchair without support and Resident 31's feet were not supported.On 1/16/26 at 10:26 AM Staff 5 (LPN Resident Care Manager) stated Resident 31 was re-admitted to the facility on an altered textured diet due to dysphagia, but stated Resident 31 was not re-admitted with orders for PT, OT, or ST.On 1/16/25 at 11:07 AM, Staff 6 (Speech Therapist) stated Resident 31 had dysphagia and should have been seen by ST.On 1/16/26 at 11:09 AM, Staff 7 (Therapy Manager) stated he was not notified of Resident 31's order for PT, OT, and ST.On 1/16/26 at 11:24 AM, Staff 5 acknowledged Resident 31's discharge summary indicated orders for PT, OT, and ST and stated Resident 31 should have been seen by therapy per orders at admission.On 1/20/26 at 12:00 PM, Staff 2 (DNS) stated therapy was expected to be provided per orders.

Based on interview and record review it was determined the facility failed to ensure a resident received wound care according to physician orders for 1 of 3 sampled residents (#102) reviewed for wound care. This placed residents at risk for worsening wounds or infection. Findings include: Resident 102 was admitted to the facility in 3/2025, with diagnoses including an open fracture of the left lower leg with a deep incisional surgical site and diabetes. Resident 102's Hospital Discharge Instruction Orders dated 3/15/25 revealed staff were to make a follow-up appointment with the surgeon in two weeks and provide the following surgical wound care instructions: -Honeycomb dressing on for 7 days. Change if saturated more than 50%. Leave off after 7 days. Resident may shower. -Call MD for excessive drainage. -OK to remove staples two weeks after surgery if patient is still present in facility. -Apply ice to affected area as needed (typically 20 minutes every 2-3 hours) to control swelling and pain. -If splint or cast in place please keep clean and dry until first post visit. Resident 102's Admission Nursing Database dated 3/15/25 contained no information related to the resident's deep incisional surgical site of the left shin or for the care and treatment of the wound. The 3/2025 MAR and TAR for Resident 102 revealed no orders for wound care or monitoring of the wound from 3/15/25 to 3/31/25. Resident 102's Provider Progress Note dated 4/1/25 indicated the resident had missed her/his two week follow-up appointment with the surgeon and staff reported the resident's surgical wound had new slough (necrotic tissue), increased redness and some drainage. The provider determined the presence of cellulitis (bacterial infection of the skin and underlying tissue) and started the resident on an antibiotic. The 4/2025 updated MAR and TAR for Resident 102 revealed an order for wound care to the left shin daily and PRN every day shift. The TAR revealed no wound care was provided on 4/2/25 or 4/4/25. On 5/23/25 at 8:30 AM, Staff 4 (Wound Care/LPN) indicated Resident 102's surgical site should have been checked and monitored by nursing staff on admission. Staff 4 acknowledged the sutures had not been removed per the resident's physician's order. Staff 4 stated he saw the wound on 4/1/25 and reported his concerns regarding the resident's wound to the physician. On 5/23/25 at 9:00 AM, Staff 3 (RNCM) indicated the orders for wound care for the resident upon admission were not transcribed into the resident's medical record. Staff 3 acknowledged Resident 102's orders for her/his dressing was not implemented for the first seven days, there was no documentation for monitoring the resident's wound, the resident's follow-up appointment was missed and the resident's sutures were not removed.

Based on interview and record review it was determined the facility failed to ensure interventions to prevent a resident's elopement were in place for 1 of 3 sampled residents (#315) reviewed for accidents. This placed residents at risk for lack of a safe enviroment. Findings include: Resident 315 admitted to the facility in 5/2024 with diagnoses including Parkinson's disease (disease of the nervous system) and repeat falls. A 9/15/24 revised care plan indicated Resident 315 was an elopement risk with impaired safety awareness, she/he was not to leave the facility unattended and staff were to determine the reason for her/him wanting to leave the facility with pleasant diversions offered. A 9/16/24 Nursing Care Note indicated Resident 315 was observed exiting the facility out the back door (close to her/his room) by Staff 10 (CNA) and two staff followed the resident. Resident 315 came back into the building with assistance by Staff 3 (Resident Care Manager-LPN). Resident 315 acknowledged she/he attempted to leave the building (unattended) and 15-minute checks were implemented. A 9/16/24 Elopement Risk Evaluation indicated Resident 315 was cognitively impaired with poor decision-making skills, verbally expressed the desire to leave the building, had a history of wandering, but no history of elopement. A 9/27/24 revised care plan indicated Resident 315 was able to self-propel with the use of a manual wheelchair and may need one staff to assist for mobility if weak and fatigued. A 9/28/24 at 2:26 PM Alert Note indicated Resident 315 was observed in her/his wheelchair in the hall at 2:00 PM. At 2:03 PM a staff member observed the resident from a facility window at the top of the hill on the road next to the stop sign which was next to the facility. Resident 315 hid her/his wheelchair in the courtyard and went out a different back door (not close to his room). Resident was placed on 15 minute checks. A 9/28/24 at 10:01 PM Situation, Background, Assessment and Recommendation Progress Note indicated Resident 315 did not seek to leave the building for the last 30 days until 9/28/24. Resident 315 was interviewed and was able to described how and why she/he left the building. On 9/30/24 at 11:59 AM Staff 11 (CNA) stated he was aware Resident 315 was exit-seeking over the last seven days. On 9/30/24 at 12:28 PM Staff 3 stated there was no investigation completed related to the 9/16/24 elopement incident because Resident 315 did not leave the facility grounds. On 9/30/24 at 1:08 PM and 1:30 PM Staff 10 stated on 9/16/24 she observed Resident 315 on the outside of the back door with no other staff around. Staff 10 stated she assumed the resident knew the code for the back door based on her observation of the 9/16/24 incident because no other staff were in the vicinity. On 9/30/24 at 8:50 PM Staff 7 (LPN) stated she began an investigation when Resident 315 eloped from the building at 2:00 PM on 9/28/24. Staff 7 acknowledged Resident 315 was not asked how she/he exited the building until she/he exited the building the second time in the evening on 9/28/24. On 10/1/24 at 3:52 PM Staff 1 (Administrator in Training) stated an investigation for Resident 315's exit seeking behavior was not started as required for the 9/16/24 incident. Staff 1 stated because she was unaware of the 9/16/24 incident, she believed 15 minute checks were sufficient to keep Resident 315 safe on 9/28/24 at 2:00 PM when she was informed. Staff 1 acknowledged interventions related to her/his ability to leave the building unattended and elope was not discovered and implemented due to the lack of investigations after the first two incidents.

Based on observation, interview, and record review it was determined the facility failed to follow appropriate infection control procedures, had delayed infection control implementation, inappropriate cohorting of residents for 1 of 1 facility. This deficient practice was determined to be an immediate jeopardy situation and the deficiency resulted in the spread of COVID 19. This placed residents at risk for continued spread of potential deadly infectious diseases. Findings include: According to the CDC website dated 6/2024 health care providers who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). According to the CDC website dated 3/2024 patients with suspected clostridium difficile should be placed in a singe-patient room, if a single-patient room is not available patients with confirmed clostridium difficile may room together. On 7/29/24 at 9:30 AM Staff 1 (Administrator in Training) informed surveyors upon entrance that the facility is in a COVID outbreak, 4 staff and 5 residents, there was no sign on the door to indicate a COVID outbreak. Staff 1 stated 4 staff and 5 residents tested positive on 7/29/24. On 7/29/24 at 10:57 AM the dispensers in the hall near rooms 507, 513, 517 and 520 had no sanitizer in them. On 7/29/24 at 12:01 PM Staff 4 (CNA) entered room [ROOM NUMBER], a COVID 19 precaution room, without eye protection. On 7/29/24 at 12:14 PM Staff 4 removed her dirty gown, gloves and mask, then proceeded to place a clean mask on. Staff 4 failed to perform hand hygiene after taking off the dirty mask and before putting on a clean mask. On 7/29/24 at 12:26 PM Staff 5 (LPN) was observed checking Resident 20's CBG. Resident 20 was on enteric (intestinal)contact precautions. Staff 5 exited the room with her dirty gloves still on and stated she was going to remove the dirty gloves after she sanitized the CBG monitor. Staff 5 sanitized the CBG monitor, removed the dirty gloves and used alcohol based sanitizer to clean her hands. When asked why Staff 5 did not wash hands with soap and water per the verbiage on the enteric precaution sign, Staff 5 stated she did not need to use soap and water because she did not change Resident 20. On 7/29/24 at 12:29 PM Witness 11 (Family) asked about staff wearing N95 masks. Witness 11 stated she was not notified the facility was in a COVID 19 outbreak and she would not have brought her son into the facility had she notified. On 7/29/24 at 12:46 PM Staff 26 (CNA) was observed delivering a lunch tray to Resident 20. Resident 20 was on enteric contact precautions. Staff 26 removed her dirty PPE and used alcohol based sanitizer upon exiting the room. When asked why Staff 26 did not wash her hands with soap and water, Staff 26 stated there was no need to wash with soap and water if not touching, down below and stated Resident 20 was on precautions for her/his catheter. On 7/29/26 at 12:46 PM Staff 4 was observed assisting Resident 43 with eating her/his lunch in a room with COVID 19 and enteric precautions. without wearing eye protection. Staff 4 stated she was informed she did not need to wear eye protection when providing care to Resident 43 since she/he had not tested positive for COVID 19, only her/his roommate had tested positive for COVID 19. On 7/26/24 at 1:08 PM Staff 34 (Infection Preventionist) stated staff entering a room on precautions for COVID 19, staff are expected to wear a gown, gloves, a mask and eye protection. Staff 34 stated when staff exit a room on COVID 19 precautions, staff are expected to remove their dirty PPE, including their mask, perform hand hygiene and then put a clean mask on. Staff 34 stated upon entering a room in enteric contact precaution room, staff are expected to wear a gown and gloves, and upon exiting the room staff are expected to remove the gown and gloves and wash their hands with soap and water. On 7/29/24 at 2:25 PM Staff 39 (housekeeping) stated she was aware there were multiple dispensers out of hand sanitizer in the COVID positive hall. Staff 39 stated she was unable to refill the dispensers because the facility had been out of hand sanitizer for a week. On 7/29/24 at 2:26 PM Staff 37 (CNA) was observed without eye protection while in a room on COVID 19 precautions. Staff 37 stated he does not wear eye protection and stated he usually wore his glasses with blinders on the side and acknowledged his glasses did not have blinders on them now. On 7/30/24 at 8:30 AM Staff 42 (CNA) was observed removing a dirty face shield, placing the dirty face shield in the clean PPE cart and without changing his face mask. On 7/30/24 at 12:57 PM Witness 10 (family) was observed in the facility without a face mask on. Witness 6 stated no one stopped her as she walked down the 500 hall and stated she was not informed of the COVID 19 outbreak in the facility. On 7/30/24 at 1:00 PM Staff 8 (CNA) was observed exiting room [ROOM NUMBER], a COVID 19 precaution. Staff 8 removed her dirty mask and placed on a clean mask without performing hand hygiene in between. Staff 34 was standing next to Staff 8 and had not intervened. Staff 8 acknowledged she should have performed hand hygiene before she obtained a clean mask and stated the clean cart of PPE was now contaminated, the clean PPE needed to be disposed of and the PPE cart needed to sanitized prior to being restocked. On 7/30/24 at 1:00 PM a cart was observed to have used COVID tests on the bottom shelf. Staff 34 acknowledged the used COVID 19 tests and stated he was going to throw them away when COVID testing was completed. On 7/30/24 at 1:28 PM Staff 40 (CNA) was observed exiting room [ROOM NUMBER], which was on COVID 19 precautions, wearing dirty PPE. Staff 40 went into the hall and put dirty dishes in a cart located in the hallway. Staff 40 stated he was trained to wear the same PPE worn in a COVID 19 precaution room when placing dirty dishes into the cart in the hallway. Staff 40 was observed going back to room [ROOM NUMBER], where he removed his dirty gown, gloves, and eye protection. Staff 40 was observed walking down the hall with his dirty mask on. Staff 40 stated he was looking for a new mask and then he located a new mask in the PPE cart outside room [ROOM NUMBER]. On 7/30/24 at 2:07 PM Staff 34 stated the first staff and resident tested positive for COVID 19 on 7/25/24 and two more residents tested positive on 7/30/24. Staff 34 stated Resident 35 was placed on enteric precautions on 6/11/24 related to suspicion of clostridium difficile (a type of bacteria that can cause inflammation of the colon). Resident 30 was moved into Resident 35's room on 6/14/24, and Resident 35 tested positive for clostridium difficile on 6/17/24. Staff 34 stated Resident 30 should not have been moved in with Resident 35 due to the contagious risk of clostridium difficile. On 7/30/24 at 2:29 PM Staff 31 (Housekeeper) was observed exiting room [ROOM NUMBER], a COVID 19 precaution room. Staff 31 did not complete hand hygiene after she removed dirty surgical mask. Staff 31 was observed touching clean the laundry and entering into room [ROOM NUMBER] with the potentially contaminated laundry. On 7/30/24 at 6:31 PM Staff 43 (dietary aid) was observed washing dishes and walking through the kitchen with no face mask on. On 7/30/24 at 6:38 PM Staff 1, Staff 10 (Regional Nurse), Staff 2 (Administrator) and Staff 2 (DNS) were notified of the immediate jeopardy situation related to infection control. On 7/30/24 at 8:53 PM an acceptable immediate risk removal plan to address the serious risk to residents' health and welfare was received and implemented by the facility. The plan indicated the following facility actions: -The DNS and Administrators were educated on the COVID 19 Policy, Outbreak Checklist and COVID 19 Infection Control Manual. -The Infection Preventionist was placed on suspension due to the enormity of the deficiencies. -The new Infection Preventionist was educated on the COVID 19 Policy, Outbreak Checklist and COVID 19 Infection Control Manual and skills demonstrated. -New Infection Preventionist will be educated on the COVID 19 Policy, Outbreak Checklist and COVID 19 Infection Control Manual upon hire. -Starting on 7/30/24 all staff were educated on the COVID 19 Policy, Outbreak Checklist and COVID 19 Infection Control Manual for continued compliance of these policies, with emphasis on proper PPE usage and hand hygiene for each type of infection. -All staff will wear N95 masks while in resident care areas, and in COVID positive rooms will wear a N95 mask, gown, sanitized or disposable goggles and gloves when providing direct patent care and remove all these items before they leave COVID positive room and a new N95 mask will be placed. -DNS will put face shields on all the COVID 19 isolation carts to replace the need to use goggles exclusively. Staff were educated regarding the face shields usage and disposal. A few clean goggles were left in the isolation carts in case of need. -Starting 7/30/24 wide base resident testing will be completed every 2-3 days and as symptoms are present until the facility goes two weeks without any positive tests. -Starting 7/30/24 wide base staff testing will happen before staff members start their shift and as symptoms present until the facility goes two weeks without any positive test. -The SSD called the first emergency contact for each resident and informed them of the current COVID outbreak. -All new residents will be informed of the current COVID outbreak before admission the the facility. -A sign was place on all entrance doors to inform visitors about the COVID 19 outbreak and was placed next to the sign in sheet in the lobby. -Facility acquired hand sanitizer to fill all dispensers and extra to make sure it is accessible to staff for proper hand hygiene. The DNS and designees will conduct spot checks of proper hand hygiene, donning and doffing PPE, signage and equipment cleansing at least three times per shift per day for one week. Then once daily for one week. then once a week for 4 weeks. then once a month for four months. Any discrepancies will be brought to the QAPI team for further review. -The DNS or designee will review the 24-hour report and bowel care list Monday through Friday, Saturday and Sunday will be reviewed on Monday, for any symptoms of clostridium difficile, and to ensure policies had been followed correctly. Any discrepancies will be brought to the QAPI team for further review. On 7/31/24 at 9:28 AM Staff 25 (NA) stated she had just received training on infection control procedure and hand hygiene on 7/31/24 a few minutes before the interview. At 9:30 AM Staff 25 was observed exiting a room on COVID 19 precautions, Staff 25 failed to change her mask upon exit from the room. Staff 25 stated she was not trained on the need to change her mask after exiting a COVID 19 precaution room. Staff 25 was observed getting a clean mask, she held the clean mask in one hand while she removed her dirty mask with the other hand, she applied her clean mask with one hand while holding her dirty mask with the other hand, she balled up dirty mask in her hand, walked down the hall and threw away her dirty mask in a room that was not on precautions for COVID 19. Staff 25 had not performed hand hygiene until reminded to do so. On 7/31/24 at 9:51 AM Staff 11 (CNA) stated she tested herself for COVID 19 prior to working on 7/31/24. Staff 11 stated she was trained by Staff 6 (LPN Unit Manager/IP) to swab each nostril 3 times. On 7/31/24 at 9:53 AM Staff 32 (Housekeeper) stated she was tested for COVID 19 by Staff 33 (Housekeeping Manager) prior to start of work on 7/31/24. On 7/31/24 at 9:55 AM Staff 33 stated she was trained to perform COVID 19 tests by Staff 2 and to swab each nostril three times. A review of the COVID 19 testing instructions on 7/31/24 at 10:00 AM revealed each nostril needed to swabbed five times for 15 seconds. On 7/31/24 at 10:10 AM the COVID 19 testing instructions were reviewed with Staff 10 (Regional Nurse). Staff 10 acknowledged each nostril needed to be swabbed five times for 15 seconds and stated all staff and residents would be retested on [DATE]. On 7/31/24 at 3:15 PM it was determined the immediacy was removed after verification of completion of the immediate jeopardy removal plan.

Based on interview and record review it was determined the facility failed to update care plans for 4 of 11 sampled residents (#s 4, 15, 18, and 48) reviewed for UTIs, medications, ADLs, and accidents. This placed residents at risk for unmet care needs. Findings include: 1. Resident 4 was admitted to the facility in 1/2024 with a diagnosis of MS (multiple sclerosis: lack of electrical impulses from the brain to the body creating impaired body functions). Resident 4's care plan initiated on 5/7/24 revealed her/his urinary catheter was to be flushed (instilling a sterile solution into the catheter to ensure the tubing does not clog) three times per week. A 7/20/24 Progress Note revealed Resident 4's urology (specialized in urinary systems i.e. bladder, kidneys etc.) clinic sent physician orders to flush her/his urinary catheter (medical tubing inserted in the bladder to drain urine) one to two times each day. On 8/2/24 at 10:59 AM Staff 23 (LPN Resident Care Manager) stated when new orders were received for residents, the floor nurses were to update care plans. Staff 23 stated Resident 4's care plan was not updated to reflect a change in urinary catheter flushes. 2. Resident 15 was admitted to the facility in 11/2016 with a diagnosis of heart disease. A Care Plan revised on 5/16/24 revealed Resident 15 was at risk for falls and non-slip material was to be placed on her/his walker handles to prevent her/his hands from slipping. A 5/22/24 quarterly MDS indicated Resident 15 was cognitively intact. On 7/31/24 at 10:58 AM Resident 15's walker handles were observed without non-slip material. Resident 15 stated the non-slip material always came off and she/he did not use it because her/his hands did not slip. On 8/2/24 at 8:39 AM Staff 23 (LPN Resident Care Manager) stated she was not aware the resident no longer used the non-slip material on her/his walker and acknowledged the care plan was not updated. 47001 3. Resident 18 was admitted to the facility in 5/2016 with diagnoses including atrial fibrillation (an irregular heartbeat). A review of Resident 18's physician orders revealed a 7/11/22 order for apixaban, an anticoagulant medication (a blood thinner). A 7/31/24 review of Resident 18's care plan revealed no evidence of a care plan for anticoagulant medication. On 8/2/24 at 1:52 PM Staff 23 (LPN Resident Care Manager) Stated Resident 18 took an anticoagulant medication, apixaban, and confirmed Resident 18 was not care planned for anticoagulant medications. 34703 4. Resident 48 was admitted to the facility in 4/2024 with diagnoses including paranoid schizophrenia (mental disorder), chronic bed confinement, and hospice care. Resident 48's 3/14/24 care plan indicated the resident was moderate risk for falls related to a history of falls. The resident is bedbound with impaired mobility. Observations from 7/29/24 through 8/1/24 on day and evening shifts revealed Resident 48 had bilateral fall mats. On 7/31/23 at 11:06 AM Witness 9 (Caregiver) stated Resident 48 had fall mats for a while related to falls. On 8/2/24 at 9:35 AM Staff 23 (LPN-Resident Care Manager) acknowledged Resident 48 had bilateral fall mats related to falls but the care plan was not revised for the fall mats.

Based on observation, interview, and record review it was determined the facility failed to follow-up with pain medication, perform neuro checks, follow physician orders and perform wound assessments for 5 of 10 sampled residents (#s 4, 15, 42, 163, and 165) reviewed for pain, accidents, UTI, and hospice. This placed residents at risk for unmet care needs. Findings include: 1. Resident 4 was admitted to the facility in 1/2024 with a diagnosis of MS ((multiple sclerosis: lack of electrical impulses from the brain to the body creating impaired body functions). A 7/2024 TAR revealed when Resident 4's urinary catheter (medical tubing inserted in the bladder to drain urine) was replaced, staff were to obtain a UA and culture (identified orginisms which caused a UTI). A 7/18/24 Progress Note revealed Resident 4 reported abdominal pain and there was no urine in the resident's catheter tubing or catheter urine collection bag. Staff replaced the existing catheter with a new sterile catheter and obtained a urine sample. A 7/18/24 Lab Results Report revealed the UA was not completed because the temperature of the sample was not correct and the urine was sent in the incorrect specimen collection tube. Resident 4's clinical record revealed no information to indicate a new sample was obtained. On 8/2/24 at 10:59 AM Staff 23 (LPN Resident Care Manager) stated if the sample was not able to be processed in the lab, staff should communicate with the physian and obtain orders if the UA was to be recollected. Staff 23 stated this was not done for Resident 4's 7/18/24 urine sample. 2. Resident 15 was admitted to the facility in 11/2016 with a diagnosis of heart disease. A 5/15/24 fall investigation revealed Resident 15 fell and hit her/his head. The fall was not observed by staff. A 5/15/24 Neurological Flow Sheet (a tool to identify a head injury) revealed staff were to obtain vital signs, check pupil size, assess if a resident could follow commands, and the assess the strength of her/his legs and arms. 12 of 22 opportunies a complete assessment was not performed. Eight of the incomplete assessments indicated Resident 4 refused the assessment or was sleeping. A 5/22/24 quarterly MDS revealed Resident 15 was cognitively intact. On 7/31/24 at 12:11 PM Resident 15 stated she/he did not refuse the neurological assessments and stated the assessments were important for the staff to monitor her/him after a fall when her/his head hit the floor hard. On 7/31/24 at 1:16 PM Staff 2 (DNS) stated the assessments should have been done to ensure the resident did not have a head injury. If the resident was asleep, staff should wake the resident and complete the assessment. 3. Resident 163 was admitted to the facility in 5/2024 with a diagnosis of cervical (neck) spine surgery. A 5/29/24 Admission Nursing Database assessment revealed Resident 163 had a neck incision and it was covered with a neck brace. There was no assessment of the incision. Resident 163's clinical record from 5/29/24 through 6/3/24 did not include any assessment of her/his incision. A 6/3/24 Discharge Skin Summary revealed the resident had a surgical incision that was covered. There was no assessment to describe the status of the incision. On 7/29/24 at 12:30 PM Witness 7 (Complainant) stated the dressing to the incision was not removed until 6/3/24 when Resident 163 was discharged from the facility and admitted to a new nursing facility. Witness 7 stated when the new facility staff removed the dressing the incision did not have signs of infection and was healing. On 8/1/24 at10:35 AM Staff 2 (DNS) stated she was not able to find an assessment of Resident 163's incision. 47001 4. Resident 42 was admitted to the facility in 7/2023 with diagnoses including spinal stenosis (a narrowing of the spinal canal in the lower part of the back). A review of a 12/7/23 neurology appointment form revealed orders for a MRI (magnetic resonance imaging test that uses magnets and radio waves to make detailed pictures of the inside of the body) of Resident 42's spine. A 2/15/24 Progress Note stated Resident 42 was unable to get an MRI completed due to a pacemaker with no information available on the type of pacemaker. The Progress Note stated the neurologist's office was to fax an order for a CT scan (computed tomography is a diagnostic test that uses a series of computerized views take from different angles to create internal pictures of the body). A review of Resident 42's medical record revealed no evidence of an order for a CT scan and no evidence it was completed. On 8/5/24 at 9:39 AM Staff 2 (DNS) stated Resident 42 was unable to get a MRI completed because there was no information about her/his pacemaker that was placed in China. Staff 2 stated the neurology office was notified in 2/2024 and was to send orders for a CT scan. Staff 2 confirmed there was no other documentation related to the CT scan and the it had not been completed. 34703 5. Resident 165 was admitted to the facility in 7/2024 with diagnoses including hospice. The 7/19/24 care plan for Resident 165 provide instructions for pain management including: assessment, monitoring for pain as well as prompt treatment with ordered pain medication. The goal was for Resident 165 to verbalize satisfaction with pain management by decreased reports of pain. The 7/23/24 Admission MDS indicated Resident 165 had pain related to lower left extremity infection. A progress note dated 7/21/24 at 5:20 PM indicated Resident 165 stated her/his pain was not well controlled with current medications. The on-call hospice nurse was to inform the hospice office on the morning of 7/22/24. A progress note dated 8/2/24 at 11:28 PM indicated hospice had an order for Resident 165 to receive morphine IR (immediate release). The note further indicated the resident was made aware due to her/him requesting the medication for a while. A progress note dated 8/2/24 at 1:31 PM indicated Resident 165 was not getting pain relief from the current regimen. Staff 17 (LPN) stated she told hospice again of the resident's concerns, but no new orders were provided. On 7/29/24 at 1:06 PM Resident 165 stated she/he had been asking hospice for morphine IR because the regimen she/he was on did not control her/his pain. On 7/30/24 at 1:44 PM Resident 165 was observed in her/his room and stated she/he was painful and her/his pain medications were not working. On 8/1/24 at 1:46 PM Resident 165 was observed in her/his room and stated she/he was in a lot of pain. Resident 165 stated she/he thought hospice was supposed to keep her/him comfortable but they were not. On 8/5/24 at 10:00 AM Staff 2 (DNS) stated she could not find physician notes indicating why the resident was not started on morphine IR when hospice was notified on 7/21/24.

Based on interview and record review it was determined the facility failed to ensure CNAs received 12 hours of training for 3 of 5 sampled staff (#s 3, 4, and 7) reviewed for staffing. Findings include: Review of CNA training records revealed: -Staff 3 was hired in 7/2016 and did not have 12 hours of training for the last one year. -Staff 4 was hired in 7/2022 and did not have 12 hours of training for the last one year. -Staff 7 was hired in 9/2021 and did not have 12 hours of training for the last one year. On 8/1/24 at 8:30 AM Staff 2 (DNS) verified Staff 3, 4, and 7 did not have 12 hours of training in the last year.

Based on interview and record review it was determined the facility failed to ensure assistive devices were implemented to prevent accidents for 1 of 3 sampled residents (#2) reviewed for falls. The resident fell , had a decreased level of consciousness and was sent to the hospital for additional treatment. Findings include: Resident 2 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. The resident's [DATE] hospital Care Transfer Form (orders from the hospital to the facility) indicated the resident was on Coumadin (anticoagulation medication) for an irregular heartbeat. The resident was also identified to be a high risk for falls and it was documented Recommend bed/chair alarm. The resident's [DATE] Fall Assessment indicated the resident was a Moderate Risk for falls. The resident's Care Plan initiated on [DATE] included the resident was at risk for falls due to balance problems, medications and cognitive problems. Interventions included the resident was to be monitored for a a decline or improvement in mobility and a gait belt (assistive device placed around a resident's trunk to provide support during transfers and walking) was to be used. On [DATE] at 12:54 pm Staff 1 (DNS) acknowledged the resident had a recommendation for a Tab Alarm. The facility assessed the resident to be a moderate risk for falls and attempted to implement the least restrictive interventions to prevent falls. The resident's [DATE] at 4:15 am Progress Note indicated the resident was found on the floor. The resident sustained [REDACTED]. The resident's Care Plan was updated on [DATE] to include the resident's bed was to be in the lowest position. The [DATE] at 6:31 am note written by Staff 2 (RN) indicated the resident was found to be disrobed and the resident was confused at times. The note indicated Staff 2 requested the day nurse to obtain orders for a Tab Alarm (device with a pull cord alarm that is clipped on the back of the resident's clothing and if they move too far the pull cord will release a magnet or tab and the alarm will sound). The [DATE] at 3:34 am note indicated the resident was found on the floor at 1:22 am. The resident was observed to seize. The [DATE] Incident Report included staff interviews. Staff 2 (RN) reported on the morning of [DATE] she requested a Tab Alarm be placed on Resident 2. The resident fell on [DATE] and the resident did not have a Tab Alarm in place. On [DATE] at 1:49 pm Staff 2 (RN) stated on the night shift of [DATE] the resident attempted many times to stand and transfer without assistance. Staff 2 requested Staff 3 (Day Shift LPN) to place a Tab Alarm on the resident. Staff 2 indicated she worked on [DATE], the resident was found on the floor, seized and was transported to the hospital for evaluation and treatment. Staff 2 indicated the resident did not have a Tab Alarm on at the time of the fall. On [DATE] at 2:00 pm Staff 3 (LPN) stated she recalled on [DATE] Staff 2 requested a Tab Alarm be placed on Resident 2. Staff 3 indicated she instructed a CNA to place the alarm. Staff 2 did not recall the CNA's name. Staff 3 also acknowledged she did not follow up to ensure the resident had an alarm. The resident's [DATE] hospital Discharge Summary indicated the resident was admitted on [DATE] with an altered level of consciousness. The resident's medical condition was nonsurvivable and nonoperable. The resident was transitioned to comfort care and died on [DATE]. The cause of death was intracranial hemorrhage (brain bleed) due to anticoagulation medication. The resident's Oregon Health Authority Center for Health Statistics Death Certificate included the resident had significant conditions contributing to death including end stage liver disease and an irregular heart beat with treatment including anticoagulation therapy. The immediate cause of death was listed as complications from blunt force head trauma due to a fall. On [DATE] at 2:30 pm with Staff 1 (DNS) and Staff 4 (Administrator) acknowledged Resident 2's chart included documentation Staff 2 (RN) assessed the resident to need a Tab Alarm to monitor the resident for unassisted transfers. Staff 1 and Staff 4 acknowledged the Tab Alarm was not implemented prior to the resident's [DATE] fall.

Based on observations, interview and record review it was determined the facility failed to accurately assess, revise the care plan, monitor and provide consistent interventions for 2 of 3 sampled residents (#s 1 and 2) with pressure sores and act timely on dietary recommendations for 1 of 3 sampled residents (#1). This resulted in Resident 1 not receiving appropriate treatment and services to promote healing and prevent a new pressure sore from developing. Findings include: 1. Resident 1 was admitted to the facility in 2013 with [DIAGNOSES REDACTED]. Review of a nursing admission assessment dated [DATE] revealed the resident did not have a stage one or greater pressure ulcer and was considered at risk for skin breakdown. The assessment indicated staff would continue with current treatment physician orders [REDACTED]." The assessment did not indicate the location or size of any wounds on the resident. Review of a NN dated 2/15/13 at 10:06 pm revealed the resident was admitted from another local nursing facility with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Review of the TAR for February 2013 revealed no documentation the resident's dressing on the resident's sacrum was changed. Review of a NN dated 2/21/13 at 7:15 pm revealed the resident buttock dressing was changed, no open areas, continued redness and the dressing was left on the resident to protect the area. Staff to continue to monitor. Review of a pressure ulcer CAA dated 2/24/13 revealed the resident was admitted with a stage 2 pressure ulcer on the coccyx and the wound was now closed.. The assessment indicated the resident's skin was fragile and the resident had decreased mobility. The assessment also indicated the resident needed assistance for repositioning. Review of a weekly wound progress note dated 2/25/13 revealed the resident had a stage 2 pressure ulcer on the coccyx which was present on admission. The wound measured 0.1 cm x 0.1 cm x 0.1 cm. The assessment indicated interventions included a dressing change every other day. Review of an RD assessment dated [DATE] revealed the resident had a pressure ulcer to the lower back and recommendations included Promod (protein supplement) 30 ml once a day. Review of the MAR for February and March 2013 revealed the resident had not received the Promod until 3/6/13. Review of a care plan dated 2/27/13 revealed the resident was at risk for skin breakdown due to a history of pressure ulcers and decreased mobility. The care plan indicated the coccyx wound was closed. The care plan interventions included an air mattress and staff were to turn the resident every 2-3 hours as the resident allowed. The care plan was not revised to reflect the resident's current wound status as of 4/10/13. Review of a Pressure/Vascular Wound Log dated 3/1/13 revealed the resident coccyx wound was closed. Review of a NN dated 3/8/13 revealed the resident was readmitted to the facility after an overnight stay at a local hospital due to increased confusion. The note indicated the resident had a stage 3 and stage 2 pressure wounds to the coccyx. Review of a nursing admission assessment dated [DATE] revealed the resident had a pressure ulcer on the coccyx. The assessment indicated there was one wound and did not describe the size or stage of the wound. Review of a nursing order dated 3/12/13 revealed the resident coccyx wound was to be measured on Wednesday or Thursday starting 3/14/13 and to record the results in the weekly wound report. No documentation could be located the resident's wound was measured on 3/14/13. Review of a NN dated 3/14/13 at 1:53 pm revealed the nurse was unable to change the resident's dressing today and no reason was documented. Review of an RD assessment dated [DATE] revealed the resident had a pressure sore on the coccyx and recommendations included the resident receiving 30 ml of Promod (protein supplement) BID. Review of the MAR for March 2013 revealed the resident had not received the Promod until 3/30/13. Review of a weekly wound progress note dated 3/21/13 revealed the resident had a stage 3 pressure sore on the coccyx which measured 1.7 cm x 1.1 cm x 0.2 cm. The assessment indicated the resident's dressing was to be changed every three days. Review of a physician's orders [REDACTED]. Review of the TAR for March and April 2013 revealed the resident dressing was changed two times from 3/22/13 and 4/6/13. Review of a weekly wound progress note dated 3/29/13 revealed the resident had a stage 2 pressure sore on the coccyx which measured 1 cm x 0.5 cm x 0.4 cm. Review of physician orders [REDACTED]. Review of a TAR for April 2013 revealed no documentation the resident coccyx wound dressing was changed daily. Review of a wound clinic note dated 4/2/13 revealed the resident's physician expressed "frustration at the nursing home not tending adequately to" the resident's wounds. Review of a weekly wound progress note dated 4/5/13 revealed the form was blank and had no documentation of the resident's wound status. Review of a wound care clinic note dated 4/9/13 revealed the resident had two coccyx pressure wounds measuring 1.4 cm x 1 cm x 0.4 cm and 0.4 cm x 0.2 cm x 0.2 cm. The note also indicated the facility was inconsistent about dressing changes and the facility needed to be reminded of the wound care directions. Review of a Resident Status Sheet (pocket care plan for CNA care) dated 4/10/13 revealed the resident was to be repositioned every hour. In an interview on 4/11/13 at 9:30 am Staff 3 (CNA) indicated the resident was to be repositioned every 2 hours. Observations on 4/10/13 at 2:20 pm revealed Staff 2 (LPN) and another nurse entered the resident's room to change the resident's dressing and measure the resident's wounds. The resident had two wounds on the coccyx approximately 2 cm apart. The first wound measured 2 cm x 1 cm x 0.5 cm and the second wound measured 1 cm x 0.75 cm x 0.25 cm which was verified by both nurses. In an interview on 4/10/13 at 11:00 am the resident indicated he/she had one wound on the tailbone (coccyx) and this was present on admission to the facility. The resident said the facility was responsible for changing the dressing on the coccyx wound. In an interview on 4/10/13 at 1:19 pm Staff 2 (LPN) indicated the resident had one pressure ulcer to the coccyx. Staff 2 said the physician order [REDACTED]. In an interview on 4/11/13 at 1:15 pm Staff 1 (RNCM) indicated the facility had no system in place to respond timely to RD recommendations or follow up on faxes to the resident's physician. Staff 1 acknowledged the facility failed to complete accurate wound assessments, revise the care plan regarding the status of the resident's wounds, monitor and provide consistent interventions for wound care. 2. Resident 2 was admitted to the facility in 2013 with [DIAGNOSES REDACTED]. Review of an admission nursing assessment dated [DATE] revealed the resident had no pressure ulcers or open areas. The assessment indicated the resident's right heel was red and blanchable. Review of a care plan dated 2/4/13 revealed the resident was at risk for skin breakdown related to a cognitive impairment, immobility, incontinence and vascular insufficiency. Interventions included notifying the resident family and physician of any new skin issues and provide treatments as ordered. The care plan had not indicated the resident had a new pressure sore on the right heel, interventions for treatment and was not revised until 4/11/13. Review of a NN dated 3/9/13 at 2:31 pm revealed the resident had a small skin tear on the right heel. The wound was treated and the resident's physician was notified. Review of the resident's record revealed no assessment of the resident's right heel wound. Review of a NN dated 3/12/13 at 8:52 pm revealed the facility had received physician orders [REDACTED]. Review of a physician's orders [REDACTED]. Review of the TAR for April 2013 revealed no documentation the resident's dressing was changed on 4/2/13, 4/4/13 and 4/5/13. Review of a NN dated 3/16/13 at 12:56 pm revealed staff were to measure the right heel pressure wound once a week on Saturday and record the results in the weekly wound progress report. The note indicated the wound was not measured and no reason was given. No documentation could be located the right heel wound was measured on 3/16/13, 3/23/13, 3/30/13. Review of a NN dated 3/20/13 at 2:31 pm revealed treatment was not completed to right heel and no reason was given. The note indicated the nurse would notify evening shift. No documentation could be located the resident's dressing was changed on the evening shift. Review of a Weekly Wound Progress note dated 4/5/13 revealed the resident had a left heel pressure sore which was present on admission. The wound was described as 4.6 am x 2.8 cm and was a stage 2. The assessment indicated care plan interventions included dressing changes and staff were to float the resident's heels. Review of a Resident Status Sheet (pocket care plan for CNAs) dated 4/11/13 revealed the resident's heels were to be floated. Observations on 4/12/13 at 9:00 am revealed the resident was in bed asleep. The resident's heels were observed to be against the mattress and were not floated. In an interview on 4/12/13 at 1:45 pm Staff 1 (RNCM) acknowledged the facility failed to accurately assess, revise the care plan, monitor and provide consistent interventions for the resident's right heel.