Every finding on record at Avamere Rehabilitation Of Hillsboro

Based on observation, interview, and record review, the facility failed to ensure residents were adequately supervised and protected from avoidable accidents. Specifically, the facility failed to:(1) Ensure adequate supervision to prevent accidents for 1 of 4 sampled residents (#44), a severely cognitively impaired resident, who was left unsupervised in the community in a high-traffic, [NAME] area for an unknown period of time and was subsequently located and returned to the facility by law enforcement. This failure was determined to constitute an Immediate Jeopardy (IJ) situation, placing Resident #44 at risk of being struck by a motor vehicle, resulting in serious injury, serious harm, impairment, or death; and(2) Ensure accurate and updated care plans for 2 of 4 sampled residents (#s 3 and 47). Specifically, the facility failed to revise Resident 47's care plan following two elopement incidents and failed to implement care plan interventions related to multiple falls for Resident 3, placing both residents at risk for avoidable accidents. Findings Include: The facility's Wandering and Elopements policy, dated 11/2025, indicated the following: -If a resident went missing, the facility was to initiate the elopement/missing resident emergency procedure. The facility's, undated, Missing Resident Action Plan per the emergency preparedness plan, indicated when a resident went missing and was found, the facility would: -Arrange transportation for the resident back to the facility if needed. (1). Resident 44 was admitted to the facility in 10/2024 with diagnoses including cognitive impairment, right leg above the knee amputation, diabetes, dementia and epilepsy (a seizure disorder). Resident 44's 10/2024 Care Plan indicated the following: -The resident had a right leg above the knee amputation, was at moderate risk for falling and used a wheelchair for mobility. -The resident spoke primarily Spanish with limited English and required the use of an interpreter to communicate. -The resident had altered cognition. -The resident was hard-of-hearing. -The resident required one person assistance with transfers. -The resident was allowed to be outside, on the facility property only, independently. Resident 44's 1/17/26 Quarterly MDS revealed the resident had severely impaired cognition and used a wheelchair. The facility's 4/20/26 Significant Noncompliance Investigation revealed the following: -On 4/17/26, Resident 44 experienced a potential for major injury or death due to the resident leaving the facility unsupervised and being unable to find her/his way back. -On 4/17/26 at approximately 3:30 PM, Staff 33 (CMA) was driving back to the facility after completing a personal errand and saw Resident 44 on a busy arterial/commuter highway. Staff 33 parked her car and approached the resident. Resident 44 expressed that she/he had difficulty getting back to the facility due to the poor condition of the sidewalks, and had fallen. -Staff 33 contacted Staff 34 (Former Administrator) and spoke with her multiple times, with the aid of Staff 12 (Staffing Coordinator) who spoke fluent Spanish and provided interpretation assistance. Staff 34 instructed Staff 33 to leave Resident 44 and return to the facility. Staff 33 informed Staff 34 that Resident 44 requested help back to the facility and the resident reported she/he had fallen. Staff 33 was told under no circumstances was she allowed to push the resident back to the facility or take Resident 44 back to the facility in her car. Staff 33 confirmed with Staff 34 that she was to leave Resident 44 and was told the resident was allowed to be out, and since the resident chose to leave, she/he had to find her/his way back. -Staff 33 had Resident 44 turn her/his wheelchair in the direction of the facility, encouraged the resident to return to the facility and left Resident 44 on the busy street. -Staff 33 returned to the facility at approximately 3:40 PM. At approximately 3:45 PM, Staff 2 (DNS) and Staff 12 left the faciity on foot to look for Resident 44 and were unable to locate her/him and returned to the facility at approximately 5:00 PM. Upon return, Staff 34 informed Staff 2 and Staff 12 that Resident 44 was able to be independently outside and if the resident was not back by 8:00 PM, they were to contact the police. -At approximately 5:15 PM, the facility received a call from the police stating Resident 44 was at the police station and was lost. -Resident 44 was brought back to the facility by her/his daughter around 5:40 PM, uninjured. -Resident 44 was last seen at approximately 2:15 PM, inside the facility. -The investigation substantiated neglect due to Staff 34 instructing Staff 33 to not assist Resident 44 to return to the facility. -Staff 34 was terminated. A review of Resident 44's health record found no documented evidence the resident was assessed to be safe to leave the facility premises or be in the community in a high traffic area, without supervision. On 5/5/26 at 11:45 AM, Staff 40 (CNA) stated Resident 44 spoke primarily Spanish and was very confused and thought her/his meal tickets were money and tried to pay staff using her/his meal tickets. On 5/5/26 at 2:18 PM, Staff 3 (Regional Director of Operations) stated Resident 44 was care planned to go outside, independently, but was not allowed to leave the facility premises because she/he had a BIMS of four which indicated severe cognitive impairment. On 4/17/26, Resident 44 was found by Staff 33, far from the facility, on her/his way to the store. Resident 44 asked Staff 33 to help her/him get back to the facility because the resident had difficulty navigating the sidewalk due to the poor condition of the sidewalks. Staff 33 contacted Staff 34 and was instructed to return to the facility and it was ok for Resident 44 to be off facility premises and to leave the resident where she/he was at. Staff 33 returned to the facility. Staff 3 stated Staff 2 and Staff 12 decided to walk to where Staff 33 had last seen Resident 44, but the resident was no longer there. Staff 2 and Staff 12 walked and walked and finally returned to the facility, unable to locate Resident 44. Other staff also looked for Resident 44 but were unable to locate her/him. Staff 3 further stated Staff 2 and Staff 12 were then instructed by Staff 34 to contact the police if Resident 44 did not return to the facility by 8:00 PM (three hours later). Not long after that, the police contacted the facility and reported they had Resident 44 at the police station because she/he was lost. Staff 34 was later terminated. On 5/6/26 at 9:38 AM, Staff 34 stated on 4/17/26, she received a phone call from Staff 33 who reported she had run into Resident 44 at a nearby store. Resident 44 told Staff 33 the sidewalks were difficult to navigate and asked Staff 33 to push her/him back to the facility. Staff 34 stated it was her understanding that Resident 44 was not asking for help but wanted to be pushed back to the facility so she told Staff 33 it was not best practice, due to safety concerns for both Staff 33 and Resident 44. Staff 34 stated if the resident needed assistance, Staff 33 should call 911. Staff 34 stated about one hour later, Staff 2 and Staff 12 told her Resident 44 was not back and they were going to go look for her/him. Staff 34 stated she told Staff 2 and Staff 12; it was the resident's right to be off the premises since she/he was care planned to leave the facility and they were making assumptions that something was wrong. Staff 2 and Staff 12 returned about an hour later; unable to locate the resident. Staff 2 and Staff 12 asked what the next steps were and Staff 34 instructed them to wait an hour and a half and if Resident 44 did not return by then, staff were to initiate the elopement protocol. Staff 34 reported about 20 minutes later, she was informed the facility received a call from the police department and Resident 44 was at the police station and was lost. On 5/6/26 at 10:18 AM, Staff 33 stated on 4/17/26, she was doing a double and had to pick up her daughter from school. At about 3:30 PM, she was returning to the facility and saw Resident 44 on a busy street, away from the facility. Staff 33 stated she was not sure if Resident 44 should be there because she/he was confused at baseline, so she parked her car and approached Resident 44. Staff 33 called Staff 12 and was told as far as she knew, Resident 44 could be out there. Staff 33 stated Resident 44 told her she/he was going to the store, which was at least another half mile away, so she encouraged Resident 44 to turn around and go back to the facility. Staff 33 stated while on the phone with Staff 12, Staff 12 went to ask, and was told it was ok for Resident 44 to be out there. Staff 33 stated she hung up with Staff 12 but then Resident 44 asked her to walk beside her/him and told her she/he had fallen, pointing to where the sidewalk went down. Staff 33 called back Staff 12 and reported to her that it was not safe for Resident 44 to be out there. Staff 12 stated it was Resident 44's right to be out here so Staff 33 asked to speak to Staff 34, again. Staff 33 told Staff 34 that Resident 44 was on a very busy street and Staff 33 was told under no circumstances was she allowed to touch Resident 44 because it was her/his right to leave the facility and if she/he wanted to leave the facility, she/he had to get herself/himself back. Staff 33 told Staff 34 that Resident 44 reported she/he fell and asked if she could bring Resident 44 back and was, again, told no by Staff 34. Staff 33 stated she did not think Resident 44 was safe to be out in the community, alone, which is why she contacted Staff 34 for direction. Staff 33 stated when she returned to the facility she was really upset because she did not want Resident 44 to get hurt and the resident was left on a very busy street. Staff 33 then spoke to Staff 2 and Staff 12 who went looking for the resident but were unable to locate her/him. Staff 33 stated she was not instructed by Staff 34, at any time, to contact 911 and she was told to leave Resident 44 where she/he was and return to the facility. On 5/6/26 at 10:40 AM, Staff 7 (LPN-Resident Care Manager) stated on 4/17/26, she was contacted by Staff 2 to come to the facility to help interpret and complete an assessment on Resident 44 after she/he returned from being lost in the community. Staff 7 completed a full head-to-toe assessment and Resident 44 had no injuries. Staff 7 stated Resident 44 was unable to remember any details regarding being lost. On 5/6/26 at 11:37 AM, Staff 12 stated on 4/17/26 around three something she received a phone call from Staff 33 who found Resident 44 out in the community. Staff 12 reported she went to find Staff 2 and Staff 34. Staff 12 handed the phone to Staff 34 and walked away while Staff 34 and Staff 33 spoke. Staff 34 handed the phone back to Staff 12 once the phone call ended. A few minutes later, Staff 33 called back asking what she should do about Resident 44 because Staff 34 told her to leave the resident where she/he was and she did not feel it was safe. Staff 33 spoke with Staff 34, again, and was told Resident 44 could not get into Staff 33's car so Staff 12 conveyed the information in Spanish to Resident 44 and asked the resident if she/he felt safe getting back to the facility which Resident 44 responded, yes. Around 3:35 PM, Staff 33 returned to the facility. According to Staff 12, around 3:40 PM to 3:45 PM, Staff 2 and Staff 12 decided to look for Resident 44 but were unable to find her/him and returned back to the facility around 5:00 PM. Staff 2 and Staff 12 asked Staff 34 what they should do next and were instructed to contact the police if Resident 44 did not return to the facility by 8:00 PM. On 5/6/26 at 1:20 PM, Staff 4 (Regional Director of Quality Assurance) stated she was contacted by Staff 34 around 5:00 PM on 4/17/26 and was told Staff 34 was initiating an elopement protocol and risk management for Resident 44 who was found lost in the community. Staff 4 stated over the weekend (4/18/26 or 4/19/26) an anonymous caller reported the whole scene to the company's fraud and abuse hotline. Staff 4 stated her and Staff 3 went to the facility on 4/20/26 and suspended Staff 2 and Staff 34 until an investigation was completed. Staff 4 stated as soon as she realized Resident 44 had a BIMS score of four, she knew the resident was not supposed to be out in the community by herself/himself, unsupervised. Staff 4 reported this was a huge safety concern for Resident 44 and a liability for the facility. Staff 4 stated Staff 34 was terminated. On 5/8/26 at 9:20 AM, 9:26 AM and 10:09 AM, Staff 29 (CNA), Staff 47 (CNA) and Staff 14 (Social Services Coordinator) stated Resident 44 spoke mainly Spanish, was hard of hearing, was confused and her/his thoughts did not always make sense. Staff reported the resident required an interpreter, and even with an interpreter, had difficulties holding a conversation and remembering information. On 5/11/26 at 9:55 AM, Staff 1 (Administrator), Staff 2 and Staff 4 stated Resident 44 should have been brought back to the facility and not left alone when found off the facility premises. Staff 4 stated Staff 34 had a duty to instruct Staff 33 to assist Resident 44 back to the facility and Resident 44 should not have been left unsupervised in the community. On 5/7/26 at 2:19 PM the facility was notified that the deficient practice constituted an IJ. An IJ removal plan was requested. On 5/7/26 at 5:10 PM the IJ removal plan was approved and the facility provided documentation which indicated the facility previously identified and corrected the deficient practice. The corrective measures included: On 4/22/26, the Past Noncompliance was corrected when the facility completed a root cause analysis of the incident and determined there was deficiency in leaving cognitively impaired residents out in the community, unsupervised. The Plan of Correction included: a. Resident 44 received a complete head to toe assessment, was placed on alert monitoring, was added to the Code Pink binder, a Wander Guard (a specialized, electronic wander management system) was placed on the resident's wheelchair, and her/his care plan was updated with her/his elopement risk. b. An updated BIMS and Elopement Risk Assessment was completed on all residents and care plans were updated. c. The Code Pink binder was updated. d. Staff 34 was terminated on 4/22/26. e. Staff were in-serviced on ensuring adequate supervision for residents with cognitive impairments for community outings.f. Monitoring and audits of the implemented system were performed to ensure correction. (2). Resident 47 was admitted to the facility in 5/2025 with diagnoses including lower extremity amputation, traumatic brain injury and mild cognitive impairments. The 5/8/25 Care Plan revised on 6/6/25 Indicated Resident 47 was at risk for elopement related to a known attempt to leave the facility to withdraw money and had mild cognitive impairment. Interventions included completion of elopement evaluation upon admit, with a significant change of condition and as needed. Determine reasons for wanting to leave and develop activity plan and interventions. Evaluate for acute condition: infection, alteration in blood sugar and implement CODE Pink Protocol. A 6/6/25 Alert Chart Note at 11:15 AM revealed Resident 47 was found outside by Staff 46 (Occupational Therapist) under the car port out front. Brought back inside and was educated on letting the staff know when she/he was going to go outside. The resident stated she/he wanted to go to the bank and get money. A 6/6/25 Nursing Note at 7:39 PM revealed the resident Feels like [she/he] was being held against [her/his] will. Staff discussed with the resident and asked why she/he felt that way. The resident wished to go to the bank and get money. Staff discussed the importance of her/him going with someone due to not wanting the resident to get lost or be alone outside of the facility. The DNS and Administrator were notified. A 6/6/25 Elopement Risk Evaluation and Code Pink document were completed and revealed the following: -Resident 47 was considered low risk for wandering. -Know trends was front door. -Resident 47 stated I am escaping, I want to go home, and I am not staying here forever. -Resident 47 indicated she/he wanted to go to the bank or ATM for money. No evidence was found in the resident's clinical record indicating that the care plan interventions had been revised or updated to address or mitigate the resident's urge to leave the facility. A 9/10/25 Significant Noncompliance Investigation regarding Resident 47's elopement revealed the following: -Resident 47 was last seen in the facility on 9/10/25 between 4:00 PM and 4:30 PM by Staff 44 (CMA). Resident 47 was unable to be found by Staff 42 (LPN) on two attempts for blood sugar checks. -On 9/10/25 at 5:00 PM a call was received from a hospital reporting Resident 47 was found at the bank and had fallen out of her/his wheelchair. Was in the emergency room for further evaluation due to the fall. -A 9/10/25 Emergency Department Provider Record reported Resident 47 was found after a fall out of her/his wheelchair on the way to a bank. As a result of the fall, Resident 47 experienced a 3 cm in length by 3 mm deep laceration on her/his amputated left lower extremity at an amputation site. Four sutures were used to close Resident 47's laceration as result of the fall. -On 9/11/25 an Elopement Risk Evaluation was completed and determined Resident 47 to be a moderate risk for elopement related to known attempts to leave the facility to withdraw money at the bank. Staff were to complete Elopement evaluation upon admit, quarterly, with a significant change of condition and as needed. Determine reasons for wanting to leave and develop activity plan/interventions, implement CODE Pink Protocol. No evidence was found in the resident's clinical record indicating that the care plan interventions had been revised or updated to address or mitigate the resident's urge to leave the facility. Attempts to interview Staff 42 regarding Resident 47's 9/10/26 elopement were made on 5/6/26 and 5/7/26 but were unsuccessful. On 5/6/26 at 10:06 AM Staff 13 (Social Services Director) stated Resident 47 was confused and experienced anxiety about wanting to go to the bank to pay her/his rent. Staff 13 stated was aware of the two elopements, and the resident was at risk for wandering with the focus on going to the bank. On 5/6/26 at 10:32 AM Resident 47 stated My memory is shot. The resident stated she/he remembered wanting to go to the bank and was concerned she/he would be kicked out of the facility for not paying her/his bills. On 5/6/26 at 12:58 PM Staff 19 (RN) stated Resident 47 had short-term memory loss and forgot things easily. Staff 19 stated It's an everyday conversation about the bank. Staff 19 stated the resident spent most of her/his time in the facility and to her knowledge, had never asked to go outside but was at risk for wandering with the focus on going to the bank. On 5/6/26 at 3:28 PM Staff 45 (CNA) stated Resident 47 was verbally aggressive, tired of being at the facility and wandered throughout the facility but did not go outside often. Staff 45 stated she recalled her/him wanting to go to the bank and the resident was not present during dinner time. Staff 45 stated she believed the resident was not supposed leave the facility without a staff person present. On 5/7/25 at 11:05 AM Staff 6 (LPN-Resident Care Manager) stated on 6/6/25 Resident 47 was found by Staff 46 outside of the facility attempting to go to the bank and required redirection from Staff 46 to return to the facility. Staff 6 stated an elopement risk assessment was completed on Resident 47 on 6/6/25 after the elopement and was incorrectly scored. Staff 6 stated the section regarding a history of elopements should have been marked which would have resulted in Resident 47's elopement risk to be moderate instead of low. Staff 6 stated care plans were to be updated to reflect Resident 47 elopement risks. Staff 6 confirmed Resident 47 eloped from the facility on 9/10/25 with an attempt to go to the bank alone and fell out of her/his wheelchair. On 5/8/26 at 2:30 PM, Staff 44 (CMA) stated she was aware Resident 47 was at risk for wandering and elopement. She reported on 9/10/25, while she was working, Resident 47 could not be located. Staff 44 stated during the facility's search for the resident, she received a call from a hospital informing her Resident 47 had fallen, sustained an injury, and required emergency care. On 5/11/26 at 1:46 PM Staff 1 (Administrator) and Staff 2 (DNS) confirmed Resident 47 was at risk for elopement upon admission, exited the facility unsupervised on 6/6/25, and again on 9/10/25 which resulted in a fall. On 9/30/25, the Past Noncompliance was corrected when the facility completed a root cause analysis of the incident and determined there was deficiency in monitoring residents for elopement. The Plan of Correction included: a. Staff were educated on how to identify residents at risk for elopement which included pink tape on the back of resident wheelchairs, b. Elopement risk assessments were completed on all residents and that information was available in a binder, c. A Wander Guard system was installed to alert staff of an attempted elopement which included setting off an alarm and doors becoming closed and locked, d. Monitoring and audits of the implemented system were performed to ensure correction. (3). Resident 3 was admitted to facility in 2/2026 with a diagnosis of facial weakness following cerebral infarction. The Admissions MDS with an ARD of 2/19/26 revealed Resident 3 had a BIMS score of 5, which indicated the resident had severe cognitive impairment. The resident had multiple falls in the last six months. A review of Resident 3's clinical record revealed the resident had a fall with injury on 2/12/26 and two non-injury falls on 2/12/26 and 2/16/26. A review of Resident 3's care plan effective 2/13/26 identified the resident as a fall risk and interventions included to not leave the resident unsupervised in her/his bathroom. The care plan was revised on 2/16/26 which included interventions to not leave the resident alone in her/his room while up in wheelchair. A review of Resident 3's Fall Investigation from 2/27/26 revealed the resident was left alone in her/his room with the door closed during a fire drill. The resident attempted to transfer, which resulted in a non-injury fall. Observations on 5/5/26 at 12:46 PM and 5/6/26 at 8:35 AM revealed Resident 3 out in the common area near the 300 Hall nurse's station. On 5/8/26 at 11:52 AM, Staff 39 (CNA) stated Resident 3 was known to get up on her/his own and attempt to walk. She stated the resident stayed in the common areas in order for staff to have eyes on her/him, due to the resident's history of falling and impulse to get up. Staff 39 stated Resident 3 was a fall risk, required supervision and was not to be left alone in her/his room during a fire drill. On 5/8/26 at 12:19 PM, Staff 40 (CNA) and at 12:25 PM, Staff 27 (CNA) stated during a fire drill, residents who were identified as fall risks were to be kept in a common area for staff to supervise them and should not be left alone. On 5/8/26 at 12:38 PM, Staff 17 (LPN) stated Resident 3 was left in her/his room with the door closed on 2/27/26 during a fire drill and confirmed the resident had a non-injury fall. She stated during a fire drill, Resident 3 was not to be left alone in her/his room and required supervision. On 5/8/26 at 12:48 PM, Staff 18 (LPN) stated during a fire drill the protocol was to direct residents back to their rooms with the door closed. Staff 18 stated the residents who required supervision or were at risk for falls were to be kept close to staff. She stated if the residents wanted to stay in their rooms, staff were to be in the room with them. On 5/11/26 at 9:08 AM, Staff 2 (DNS) stated during the fire drill on 2/27/26, Staff 34 (Former Administrator) was the person who kept Resident 3 in her/his room with the door closed. Staff 2 acknowledged Resident 3's care plan interventions included not to leave her/him alone in a room, the resident had a non-injury fall while she/he was in the room and stated it was inappropriate to have the resident in the room by her/himself. On 5/11/26 at 9:59 AM, Staff 20 (RN) stated during the fire drill on 2/27/26, Staff 34 (Former Administrator) instructed him to place Resident 3 in her/his room and to shut the door. Staff 20 stated he did not agree with Staff 34 and asked if the resident could stay with him, but after a short conversation of disagreement Staff 20 followed Staff 34's order and placed Resident 3 in her/his room and shut the door. The deficient practice was identified as Past Noncompliance based on the following:On 3/2/26, the deficient practice was identified by the facility and was corrected when the facility completed a root cause analysis of the incident and determined there was a deficiency in leaving residents identified as a fall risk alone in a room during safety drills:a. Staff 34 was educated on 2/28/26.b. The resident's care plan was updated on 3/2/26 to include a staff member to remain with resident during safety drills.c. Staff interviewed had a good understanding of how to keep residents identified as fall risks safe during fire drills.

Based on interview and record review, it was determined the facility failed to provide necessary treatment to promote healing of pressure ulcers for 1 of 1 sampled resident (#92) reviewed for pressure ulcers. This failure resulted in worsening of Resident 92's pressure ulcers and subsequent hospitalization. Findings include: The facility's Pressure Injuries Overview and Wound Staging Skin Management policy dated 3/2020 included the following:Pressure Ulcer/Injury refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device.Avoidable means that the resident developed a pressure ulcer/injury and that one or more of the following was not completed:- Definition or implementation of interventions that are not consistent with resident needs, resident goals, and processional standards of practice.- Monitoring or evaluation of the impact of the interventions.CMS Guidance and Staging:Stage 2 Pressure Ulcer: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. This stage should not be used to describe moisture associated skin damage including incontinence associated dermatitis, intertriginous dermatitis (inflammation of skin folds), medical adhesive related skin injury, or traumatic wounds (skin tears, burns, abrasions).Stage 4 Pressure Ulcer: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the wound bed, it is an unstageable PU/PI. Resident 92 was admitted to the facility on [DATE] with diagnosis including Stage 2 pressure ulcers and was sent to the hospital on 2/27/26.The Admissions MDS with an ARD of 2/19/26 revealed Resident 92 had severe cognitive impairment. The resident had Stage 2 pressure ulcers present upon admission and required extensive assistance with ADLs. Resident 92's 2/13/26 Physician Orders included: Cleanse left buttock and coccyx (tailbone) with NS (normal saline), pat dry, apply foam dressing. Change daily on day shift and PRN for soilage. The order was discontinued on 2/23/26. Resident 92's 2/2026 TAR revealed the order was entered erroneously as PRN only. No wound care was provided on 2/14/26, 2/15/26, 2/16/26, 2/17/26, 2/18/26, 2/19/26, 2/20/26, 2/21/26, 2/22/26 and 2/23/26, for a total of 10 days. Resident 92's 2/23/26 Physician Orders included: Cleanse buttock and coccyx with wound cleanser, pat dry, apply skin prep to surrounding intact skin, cover wound with vashe (a professional-grade, hypochlorous acid wound cleanser) moistened gauze and cover with foam dressing, complete daily and PRN. The order was discontinued on 2/26/26. Resident 92's 2/2026 TAR revealed the resident received treatment on 2/24/26 and 2/25/26 but no evidence was found wound treatment was provided on 2/26/26. Resident 92's 2/26/26 Physician Orders included: Cleanse buttock and coccyx with wound cleanser, or NS and pat dry, apply vashe soaked to the wound bed and allow to sit for 15 minutes, dry the area and apply medi-honey (medical grade honey product) to the wound bed only, apply skin prep to surround intact skin and cover wound with adhesive bordered foam dressing complete daily and PRN. Everyday shift and every two days. This order was discontinued on 3/2/26. Resident 92's 2/26/26 TAR through 3/2/26 revealed no wound care was completed on 2/26/26 or 2/27/26. A review of Resident 92's Wound Evaluations from 2/13/26 through 2/23/26 revealed the following information:- 2/13/26: the resident admitted with a Stage 2 pressure ulcer to the left buttock with partial thickness. The wound measured 3 cm by 2.5 cm. The wound had light amount of sanguineous (blood drainage), was red in color, no odor present, the wound bed was 100 percent epithelial (skin is healing and regenerating) and wound edges were attached. No pain was reported. - 2/13/26: the resident admitted with a Stage 2 pressure ulcer to the right side of coccyx with partial thickness. The wound measured 3 cm by 2.3 cm. The wound had light amount of sanguineous, was red in color, no odor present, the wound bed was 100 percent epithelial and wound edges were attached. No pain was reported. - 2/18/26: the left buttock wound measured 3.1 cm by 3.4 cm with partial thickness. The wound had light amount of sanguineous, was red in color, no odor present, the wound bed had granulation (new, highly vascular connective tissue that fills the base of an open wound) and slough (impediment, dead tissue), wound edges were attached, with the wound noted to have worsened and pain present. - 2/18/26: the right side of coccyx wound measured 0.3 cm by 0.4 cm with partial thickness. The wound had light amount of sanguineous, was red in color, no odor present, the wound bed had 90 percent granulation with 10 percent slough, wound edges were attached with the wound noted to be improved and pain present. - 2/23/26: the resident's two wounds had merged into one. The wound measured 5.5 cm by 6.5 cm with partial thickness. The wound had light serosanguineous (thin, watery, pale, red/pink drainage), was pink in color, no odor present, the wound bed had 60% granulation and 40% slough, wound edges were attached, with the wound noted to have worsen and pain present. A review of Resident 92's progress notes revealed the following:- From 2/13/26 through 2/21/26 and on 2/25/26 Resident 92's skin was documented as intact and no wounds present. - Physician Notes from Staff 41 (Physician's Assistant) indicated on 2/13/26 and 2/20/26 Resident 92 had a Left buttock stage 2 pressure ulcer measuring 3.1 by 3.3 cm with no depth. Small stage 2 pressure ulcer in right medial gluteal cleft. Coccyx (tailbone) area with blanchable discoloration, patient denies pain at this site.-Physician Note on 2/25/26 revealed wounds were not evaluated. - On 2/26/26, Staff 17 (LPN) expressed concerns for Resident 92's wound being a lot worse since it was last assessed. A review of Resident 92's provider notes on 2/27/26 revealed Staff 2 (DNS) and Staff 41 (Physician's Assistant) went to see Resident 92's wounds due to two nurse's notes expressing concern with her/his worsening wound. Staff 41's physical exam revealed the pressure ulcers had merged to a Stage 4 pressure ulcer approximately 5 cm round with depth at approximately 4 cm. There was a significant amount of stool present and packed into the ulcer with a foul odor and slough present. Staff 41 noted it was difficult to tell if there was active bleeding or purulent drainage given how dirty the wound was found and the bone was exposed. Given the severity of the ulcer, Resident 92 was sent to the hospital. On 5/11/26 at 10:47 AM, Staff 17 (LPN) stated she inputted Resident 92's orders from the provider on 2/13/26 and confirmed there were scheduled daily wound care orders and PRN. Staff 17 stated she was unsure why the scheduled daily orders were discontinued the same day they were inputted. Staff 17 stated she was directed to perform wound care based on orders reflected on the TAR and if the orders were not on the TAR, then she would not be alerted to provide wound care treatment. Staff 17 stated she recalled doing wound care, but confirmed she did not document the information. Staff 17 stated if there was no documentation of wound care being performed on the TAR, then there was no other way to confirm it was done. Staff 17 stated she did not know what made the resident's wound worsen so quick. On 5/11/26 at 11:07 AM, Witness 1 (Family Member) stated family were frequently with Resident 92 from the morning until evening each day. Witness 1 stated Resident 92 expressed pain, but was unsure if wound care was being provided. Witness 1 stated she/he trusted the facility to provide appropriate wound care to Resident 92. On 5/11/26 at 11:54 AM, Staff 20 (RN) stated he knew Resident 92 had a big wound, but could not recall performing wound care on her/him. He stated he would perform wound care based on orders, which were located on a Resident 92's TAR. Staff 20 stated if he provided wound care for Resident 92, he would notate it was completed on the TAR. On 5/11/26 at 11:56 AM, Staff 19 (RN) stated she could not recall Resident 92 had wound care orders and confirmed she did not perform wound care on Resident 92. She stated a resident's TAR would dictate whether or not she would need to perform wound care for Resident 92. She stated if she provided wound care to a resident, she would document on the TAR it was completed. On 5/11/26 at 12:06 PM, Staff 6 (LPN Care Manager) stated staff were directed to perform wound care based on the orders reflected on a resident's TAR. Staff 6 stated on 2/13/26, Resident 92's wound care orders for scheduled daily and PRN were deleted, and reentered incorrectly as only the PRN orders which were reflected on Resident 92's TAR. Staff 6 stated she expected staff to document on TAR when wound care was performed. Staff 6 stated if wound care was not documented on the TAR, then it was not clear it was done. Staff 6 stated when she saw Resident 92's wound on 2/23/26, she stated she was concerned because it did not look like it was getting better. On 5/11/26 at 12:24 PM, Staff 38 (Assistant DNS) stated staff were directed to perform wound care based on orders reflected on a resident's TAR. She stated staff were expected to document on the TAR any wound care completed for a resident, because if it was not documented then it was unclear if the wound care was completed. On 5/11/26 at 12:43 PM, Staff 41 (Physician's Assistant) stated she saw Resident 92's wounds on 2/13/26 and they were pretty small and not significant, and both wounds were a Stage 2. Staff 41 stated she ordered daily wound care and PRN. Staff 41 indicated on 2/23/26 she changed the orders based on staff noting in the clinical record the wound had worsened and she was not asked to come in to assess the wound. Staff 41 stated on 2/26/26, she received more concerns regarding Resident 92's wound worsening and on 2/27/26 when she entered Resident 92's room, there was a foul odor. Staff 41 stated when she saw Resident 92's wound, she was shocked. Staff 41 stated the left buttock and coccyx wound had merged into one wound, was bigger than when she last evaluated the wound on 2/13/26. Staff 41 stated the wound was a Stage 4 pressure ulcer, because she could see structures (the visible tissue types within a wound bed) and bone, and the wound had a significant amount of feces impacted inside of it. Staff 41 stated due to the severity of the wound, she had Resident 92 sent out to the hospital on 2/27/26. On 5/11/26 at 1:36 PM, Staff 2 (DNS) stated she expected staff to enter physician's orders correctly into their system. Staff 2 acknowledged Resident 92's wound worsened, acknowledged scheduled wound care effective 2/13/26 were discontinued erroneously and confirmed there were minimal entries on Resident 92's TAR indicating wound care was performed. Staff 2 stated she expected staff to document on the TAR when orders were performed for a resident. Staff 2 confirmed the wound worsened. The deficient practice was identified as Past Noncompliance based on the following:On 2/27/26, the deficient practice was identified by the facility and was corrected when the facility completed a root cause analysis of the incident and determined there was a failure to follow physician's orders for wound care:a. On 2/27/26, the facility identified all residents with wounds and verified each were appropriately staged and wound care was accurate according to physician's orders.b. 3/2/26, education was provided to staff on order entry verification and the importance of repositioning.c. 3/9/26, education was provided to staff on proper wound staging and following provider's orders.d. 3/15/26, all care managers, Assistant DNS and DNS completed online comprehensive wound care certification course to enhance wound care knowledge. e. Implementation of a verification system to ensure orders are entered correctly.f. Ongoing audits with wound care, order entry and repositioning.

Based on observation, interview, and record review it was determined the facility failed to ensure rooms and bathrooms were free from damages and use of garbage bags as pull cords for 21 out of 55 sampled resident rooms (Room #s 202, 203, 204, 205, 206, 207, 208, 210, 212, 214, 501, 502, 504, 505, 506, 507, 508, 509, 510, 511, and 513) and 2 of 4 sampled residents (#s 8 and 75) reviewed for environment. This placed residents at risk for an unhomelike environment. Findings include:The facility's 12/2009 Maintenance Service policy instructed the facility's maintenance personnel to maintain the building in compliance with current federal, state, and local laws, regulations, and guidelines as well as to maintain the building in good repair and free from hazards. The facility's 2/2021 Homelike Environment policy instructed the facility to ensure a clean, sanitary, and orderly environment for the facility. 1. On [DATE] at 11:34 AM Resident room [ROOM NUMBER] was observed to have multiple areas of damage to the floor: - A crack raised about one quarter of an inch, approximately four feet long running parallel with the door frame. In front of the raised crack was a four-inch by three-inch spot of missing flooring with exposed subfloor. - A three-foot-long scratch crossing perpendicularly to the raised crack had the subfloor visible. - Multiple divots and gouges were observed in the flooring around each of the four legs of the bed, some of which exposed the subfloor and the rest had dark staining and debris visible. - Other scratches observed to have dark staining and debris visible in them. On [DATE] at 10:48 AM three of five Resident Council Members expressed concerns over the state of the floors in resident rooms, stating the floors looked terrible and suggested the facility cut out the damage sections at least until they replaced the whole floors. On [DATE] at 11:34 AM Staff 11 (Maintenance Director) stated room [ROOM NUMBER] was one of the worst rooms of the facility for floor damage and intended to level the floor but had not scheduled the repair yet. He also stated he was told the carpet from the hallways were going to be replaced, but was unsure when this would occur, and acknowledged multiple resident rooms needed to be replaced as well. 2. On [DATE] between 8:12 AM and 9:16 AM a tour of the facility revealed 22 resident rooms had multiple damages to the flooring, which included a combination of the below listed damages: - Circular and square shaped gouges (circular, arched, and square shaped) located around where the four legs of the bed had been pressed into the floor when locking the bed in place. Most of these gouges exposed the subfloor or had a buildup of a dark material in them. - Flooring seams that were separated apart, which exposed one quarter to one half of an inch wide by as much as 36 inches long of subflooring. - Deep enough scratches that the subfloor was exposed and dark staining had built up in them. Some of the scratches were a few inches long and others were over a foot in length. - One resident room and one shower room were missing transition strips. One resident room had a transition strip that had begun to lift, which was a potential trip hazard. - One or more areas of exposed subfloor due to missing flooring material. One of rooms, the missing portion of flooring was approximately 4 feet by 2 feet jaggedly around the toilet (shared bathroom between room [ROOM NUMBER] and room [ROOM NUMBER]). - The flooring under the toilet in the shared resident bathroom between room [ROOM NUMBER] and room [ROOM NUMBER] was observed to have a different texture than the rest of the flooring as it was discolored and felt dry, leathery, and porous and the room had a strong urine-like odor with no visible signs of urine present. On [DATE] at 9:40 AM Staff 1 (Administrator) and Staff 11 entered each of the 22 rooms and confirmed the damages and acknowledged the flooring needed to be repaired. Staff 1 stated plans on repairing the floors in resident rooms were paused due to plumbing issues that started in [DATE] which required emergent attention. At 12:39 PM Staff 1 provided copies of bids completed on [DATE] and [DATE] both bids were expired one on [DATE] and the other on [DATE]. Review of the bids revealed multiple rooms were not included in the bids from the 200 hall and none of the rooms in the 500 hall. 3. Resident 8 was admitted to facility in 3/2026 with diagnosis of urinary tract infection. The Admissions MDS with an ARD of [DATE] revealed Resident 8 had a BIMS score of 4, which indicated the resident had severe cognitive impairment. Observations on [DATE] at 10:17 AM, [DATE] at 12:17 PM and [DATE] at 8:20 AM revealed Resident 8's light cord was made of a piece of cloth and plastic trash bag. On [DATE] at 11:06 AM, Staff 36 and at 3:29 PM, Staff 32 (CNA) stated if residents couldn't reach a light cord, the protocol was to input the issues into TELS, which was an electronic messaging system where environmental issues could be reported to the Maintenance Director. Staff 36 and Staff 32 stated it took time for maintenance issues to be resolved. On [DATE] at 3:37 PM, Staff 37 (RN) stated if a resident couldn't reach their light cord, she would let maintenance know by leaving a note in the message box by their office. On [DATE] at 3:46 PM, Staff 11 (Maintenance Director) stated work orders for residents took priority when managing his work for the day. Staff 11 stated he received work orders based on staff submitting issues in TELS. Staff 11 stated when a resident discharged from the facility, housekeeping informed him of any issues that needed to be fixed prior to another resident moving into the room. At 3:58 PM, he confirmed Resident 8 had a trash bag and cloth as a pull cord for her/his light and stated it didn't look good and was not homelike. Staff 11 stated he had plenty of pull cords in stock and the issue was easily replaced. On [DATE] at 4:29 PM, Staff 1 (Administrator) and Staff 3 (Regional Director of Operations) acknowledged the plastic bags tied to the light cord and Staff 1 stated it was not homelike for residents. Staff 1 and Staff 3 stated they expected for staff to notify maintenance via TELS when residents have issues with their environment. 4. Resident 75 was admitted to facility in 3/2023 with diagnosis of local infection of the skin and subcutaneous tissue (deepest layer of skin). The Admissions MDS with an ARD of [DATE] revealed Resident 75 had a BIMS score of 15, which indicated the resident was cognitively intact. Observations on [DATE] at 10:37 AM, [DATE] at 11:49 AM and [DATE] at 9:15 AM revealed Resident 75's light cord was made of a plastic trash bag. On [DATE] at 10:37 AM, Resident 75 stated the plastic bag was brought to her/him when she/he could not reach the light cord. Resident 75 stated she/he did not know there were actual light cords to replace it and would rather have the real one. Resident 75 stated staff had just tied a bag to the short light cord so she/he could reach it. On [DATE] at 11:06 AM, Staff 36 and at 3:29 PM, Staff 32 (CNA) stated if residents couldn't reach a light cord, the protocol was to input the issues into TELS, which was an electronic messaging system where environmental issues could be reported to the Maintenance Director. Staff 36 and Staff 32 stated it took time for maintenance issues to be resolved. On [DATE] at 3:37 PM, Staff 37 (RN) stated if a resident couldn't reach their light cord, she would let maintenance know by leaving a note in the message box by their office. On [DATE] at 3:46 PM, Staff 11 (Maintenance Director) stated work orders for residents took priority when managing his work for the day. Staff 11 stated he received work orders based on staff submitting issues in TELS. Staff 11 stated when a resident discharged from the facility, housekeeping informed him of any issues that needed to be fixed prior to another resident moving into the room. At 3:58 PM, he confirmed Resident 75 had a trash bag as a pull cord for her/his light and stated it didn't look good and was not homelike. Staff 11 stated he had plenty of pull cords in stock and the issue was easily replaced. On [DATE] at 4:29 PM, Staff 1 (Administrator) and Staff 3 (Regional Director of Operations) acknowledged the plastic bags tied to the light cord and Staff 1 stated it was not homelike for residents. Staff 1 and Staff 3 stated they expected for staff to notify maintenance via TELS when residents have issues with their environment.

Based on observation, interview, and record review it was determined the facility failed to ensure resident care was provided in a manner that maintained and promoted dignity for 1 of 1 sampled resident (#10) reviewed for dignity. This placed residents at risk for receiving care that did not promote their dignity. Findings include:Resident 10 admitted to the facility in 7/2025 with diagnoses including diabetes and dementia.Resident 10's 4/20/26 quarterly MDS indicated the resident had a BIMS of 3, which indicated severe cognitive impairment.1. On 5/4/26 at 12:15 PM Staff 35 (LPN) performed a CBG check on Resident 10 in the dining room. Resident 10 required an insulin injection. At 12:19 PM Staff 35 raised the resident's shirt and administered the insulin into her/his abdomen in the dining room. Both incidents were conducted without Resident 10's permission to allow Staff 35 to complete the CBG check and insulin administration in the dining room. There were eleven residents and one family member present in the dining room.On 5/4/26 at 12:25 PM Staff 35 confirmed he did not ask permission from Resident 10 to do the CBG check and insulin injection in the dining room with other individuals present. On 5/4/26 at 2:06 PM Resident 10 stated she/he preferred to have her/his insulin administered in a private space.On 5/6/26 at 10:50 AM Witness 3 (Family Member) stated Resident 10 was very modest all her/his life and would want the CBG testing and insulin injections completed in private.On 5/8/26 at 10:00 AM Staff 2 (DNS) confirmed Staff 35 should have asked Resident 10 to go to a private area for the CBG check and insulin injection and not complete those cares in front of other people.2. On 5/6/26 at 10:08 AM Witness 4 (Phlebotomist [person who draws blood for testing]) was observed drawing blood from Resident 10's left arm while she/he was in the dining room with three other residents. Witness 4 obtained Resident 10's blood without offering to take her/him to a private area. On 5/6/26 at 10:11 AM Witness 4 stated she typically drew blood from residents in the dining room. Witness 4 stated she had asked Resident 10 for permission to draw Resident 10's blood but had not asked the other residents if they were okay with being present. On 5/6/26 at 10:14 AM Staff 25 (CNA) stated he observed Witness 4 completing the blood draw without asking Resident 10's permission to complete the blood draw in the dining room. He stated drawing blood, CBG checks, and injections were supposed to be completed in rooms. Staff 25 stated he did not stop her but had intended to speak with her afterwards.On 5/6/26 at 11:11 AM Resident 10 stated she/he was not comfortable having her/his blood drawn in the dining room.On 5/6/26 at 10:50 AM Witness 3 (Family Member) stated Resident 10 was very modest all her/his life and would want her/his blood drawn in private.On 5/8/26 at 7:35 AM Witness 5 (Lab Supervisor) and Witness 6 (Phlebotomist Supervisor) stated the laboratory's policy was to have their phlebotomists draw blood from residents in resident rooms, not in the dining room with others present, due to sanitary concerns and to protect the resident's privacy. On 5/8/26 at 10:00 AM Staff 2 (DNS) confirmed Witness 3 should not have drawn blood from Resident 10 in the dining room and the resident should have been assisted to her/his room should have been assisted to her/his room.

Based on observation, interview and record review it was determined the facility failed to promote self-determination for 1 of 3 sampled residents (#30) reviewed for choices. This placed residents at risk for lack of honoring choices and care preferences. Findings include: The facility's 10/2025 Dignity Policy indicated resident goals, choices, preferences, values and beliefs were respected and honored to the extent possible, which began with the initial admission and continued throughout the resident's facility stay. Resident 30 was admitted to the facility in 5/2025 with diagnoses including depression. The facility's 12/31/25 CNA Assignment Restrictions Form did not indicate Staff 32 (CNA) could not provide assistance to Resident 30. Resident 30's 2/22/26 Quarterly MDS revealed the resident was cognitively intact and required substantial-to-maximal assistance from staff to bathe. Resident 30's 5/2026 ADL Care Plan revealed the resident required physical assistance from one staff with bathing. Resident 30's 5/2026 Shower Task Log revealed Staff 32 assisted the resident with a shower on 5/4/26.On 5/4/26 at 10:53 AM and 5/8/26 at 10:20 AM, Resident 30 was observed in her/his wheelchair in her/his room. Resident 30 stated she/he asked several times to not have Staff 32 assist her/him with showers because Staff 32 did not wash her/his left side thoroughly but continued to receive assistance from Staff 32 with showers. Resident 30 further stated her/his scheduled shower days were the hardest days of the week for her/him because she/he never knew who was going to provide shower assistance and if her/his preferences would be honored. On 5/8/26 at 10:02 AM, Staff 13 (Social Services Director) stated she informed Staff 2 (DNS) of resident care preferences as soon as she was made aware of them, but Staff 2's response was for residents to tough it out. Staff 13 stated care preferences should be prioritized for Resident 30 because routine was really important to her/his overall well-being. Staff 13 stated she was unaware of the resident's preference to not receive assistance from Staff 32 until 5/8/26. On 5/8/26 at 10:41 AM, Staff 27 (CNA) stated she was not aware of Resident 30's care preferences but was aware that showers were stressful for the resident, and new staff or those staff unfamiliar with her/his routine, could cause the resident to have anxiety or be upsetOn 5/8/26 at 10:58 AM, Staff 26 (CNA) stated Resident 30 did not like to receive assistance from Staff 32 with showers, but Staff 32 still got assigned to [her/him] a lot. Staff 26 stated she did not know why Staff 32 continued to be assigned to assist Resident 30 in spite of the resident's known preference. On 5/8/26 at 12:43 PM, Staff 32 stated she was assigned to assist Resident 30 weekly, which included providing assistance with showers. Staff 32 stated she was aware Resident 30 preferred other male CNAs to help instead of me and confirmed she assisted Resident 30 with a shower on 5/4/26. On 5/11/26 at 12:25 PM, Staff 12 (Staffing Coordinator) stated she was aware of Resident 30's preference to not receive care or showers from Staff 32, and Staff 2 was responsible for updating the CNA Assignment Restrictions Form.On 5/8/26 at 12:01 PM, Staff 2 stated the facility maintained a CNA Assignment Restrictions Form in order to accommodate resident care preferences, and she was responsible to keep the form updated. Staff 2 stated she was aware Resident 30 did not like to receive assistance from Staff 32 with showers. Staff 2 confirmed the preference form had not been updated to include the resident's current preferences, the resident continued to receive showers from Staff 32 despite her/his expressed preference not to and there was no reason her/his shower preferences could not be accommodated.

Based on interview and record review it was determined the facility failed to provide SNF ABN (Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage) notifications to 2 of 3 sampled residents (#s 67 and 100) reviewed for Beneficiary Notification. This placed residents and their representatives at risk for unknown financial liabilities. Findings include:1. Resident 67 was admitted to the facility on [DATE] with Medicare Part A benefits.A 4/15/26 NOMNC (Notice of Medicare Non-Coverage) indicated the Resident 67's Medicare Part A benefits ended on 4/17/26. A review of Resident 67's health record indicated the resident remained in the facility and was financially responsible for her/his care from 4/18/26 through 4/20/26. There was no documentation indicating the SNF ABN notification was provided to Resident 67 or their representative to inform them of the resident's daily out-of-pocket expenses.On 5/5 26 at 1:14 PM Staff 13 (Social Services Director) stated they did not provide the SNF ABN form to Resident 67 or their representative. On 5/5/26 at 2:20 PM Staff 1 (Administrator) acknowledged Resident 67 was not provided with the SNF ABN form. Staff 1 stated their expectation was residents or their representatives were informed of the resident's daily out-of-pocket costs using an SNF ABN notification form.2. Resident 100 was admitted to the facility on [DATE] with Medicare Part A benefits. A 3/13/26 NOMNC (Notice of Medicare Non-Coverage) indicated Resident 100's Medicare Part A benefits ended on 3/15/26. A review of Resident 100's health record indicated the resident remained in the facility and was financially responsible for her/his care from 3/16/26 through 3/17/26. There was no documentation indicating the SNF ABN notification was provided to Resident 100 or their representative to inform them of the resident's daily out-of-pocket expenses.On 5/5 26 at 1:14 PM Staff 13 (Social Services Director) stated they did not provide the SNF ABN form to Resident 100 or their representative. On 5/5/26 at 2:20 PM Staff 1 (Administrator) acknowledged Resident 100 was not provided with the SNF ABN form. Staff 1 stated their expectation was residents or their representatives were informed of the resident's daily out-of-pocket costs using an SNF ABN notification form.

Based on interview and record review it was determined the facility failed to provide a bed hold policy to 1 of 1 resident (#89) reviewed for hospitalization. This placed residents at risk for miscommunication of the discharge process. Findings include:The facility's Bed Hold and Return Policy dated 10/2022 states all residents/representatives were provided written information regarding the facility and state be hold policies, which address holding or reserving a resident's bed during periods of absence. Residents were to be provided written notice about these policies at least twice. First, was upon admission to the facility. Second, was at the time of transfer or within 24 hours if the transfer was an emergency.A 2/11/26 at 10:14 AM Progress Note indicated Resident 89 was assessed by Staff 17 (LPN) and determined to require transfer to the hospital due to a change of condition. Resident 89 was not provided a physical copy of the facility's bed hold policy on or after 2/11/26. On 5/8/26 at 8:47 AM Staff 17 confirmed she assessed Resident 89 on 2/11/26. She stated the process involved when a resident was transferred to the hospital did not include providing the resident with information about the facility's bed-hold policy. Staff 17 stated she was unaware she needed to provide resident with the bed-hold policy information when a resident was transferred to the hospital.On 5/8/26 at 9:27 AM Staff 6 (LPN-Resident Care Manager) stated residents were provided bed-hold policy information upon admission but not when they were discharged to the hospital and expected to return. She stated she was unaware residents needed to receive the bed hold policy at the time of transfer.On 5/8/26 at 9:33 AM Staff 2 (DNS) confirmed Resident 89 was not provided the bed-hold policy when she/he discharged to the hospital on 2/11/26.

Based on observation, interview, and record review it was determined the facility failed to provide meaningful activities for dependent residents for 1 of 1 sampled resident (#44) reviewed for activities. This placed residents at risk for lack of social interaction, boredom and isolation. Findings include: The facility's Activity Program policy, dated 11/2025, indicated the following: -The activities program was to support the well-being of residents and to encourage both independence and community interaction. -Activities offered were based on the comprehensive resident-centered assessment and the preferences of each resident. -The activities program was ongoing and included facility-organized group activities, independent individual activities and assisted individual activities. -Activity programs were designed to encourage maximum individual participation and were geared to the individual resident's needs. Resident 44 was admitted to the facility in 10/2024 with diagnoses including cognitive impairment, right leg above the knee amputation, diabetes, dementia and epilepsy (a seizure disorder). Resident 44's 10/2024 Activity Profile indicated the resident spoke Spanish with minimal English, used to own a dog and enjoyed gardening, watching TV and religious studies. Resident 44's 10/2024 activity care plan indicated Resident 44's interests included gardening, watching TV and religious study. Resident 44 preferred independent or self-directed activities and she/he enjoyed being outside and was safe to do so. Activity staff were to: -Provide the resident with supplies to facilitate independent activities such as reading materials, puzzles, word searches, cards and crafts.Resident 44's 9/26/25 Activities Profile indicated the resident was able to read and enjoyed movies. Resident 44's 10/17/25 Annual MDS indicated the resident had severe cognitive deficits. Resident 44's activity preferences indicated it was very to somewhat important to listen to music, be around animals and go outside when the weather was good. Resident 44 indicated it was not very important to have books, newspapers or magazines or keep up with the news. Resident 44's 12/26/25 psychosocial and well-being care plan related to restriction of social activities and interactions with other residents and staff due to the resident speaking Spanish only included activity staff were to: -Provide one-on-one visitations with a Spanish interpreter to meet Resident 44's needs.-Resident 44 would be encouraged to go outside in the courtyard to view wildlife, flowers and enjoy good weather when applicable.-Resident 44 would be encouraged to participate in hallway activities such as music, audio books, games, snacks and drinks. Resident 44's 4/17/26 at risk for elopement care plan indicated the resident was no longer safe to go outside, unsupervised. Social service staff and the Resident Care Manager was to determine reasons why Resident 44 wanted to leave the facility and develop an activity plan and interventions to address those findings. Resident 44's Activity Participation Logs including group, one-on-one and independent activities from 4/5/26 through 5/5/26 revealed the following: -The resident watched TV on 4/13/26 and 4/16/26.-The resident went outside for fresh air/outdoor activity on 4/18/26.-On 20 out of 25 days reviewed, it was documented that Resident 44 was keeping up with the news which was not a preferred activity for the resident. Multiple random observations from 5/4/26 through 5/8/26 between the hours of 8:21 AM and 4:19 PM revealed Resident 44 was either in bed with no television on or music playing or was wandering the halls in her/his wheelchair. There were no independent activity materials such as reading materials, puzzles, word searches, cards or crafts available in her/his room. When Resident 44 was up in her/his wheelchair, she/he wandered throughout the facility hallways, at times watching the traffic from the rehabilitation gym's large picture window. Resident 44 was not seen outside which was his very important activity. The resident was not seen in any hallway or group activities, and no one-to-one activities were provided to the resident. On 5/5/26 at 11:45 AM, Staff 40 (CNA) stated Resident 44 did not speak English, liked to watch TV, used to enjoy going outside but was no longer allowed to go outside by herself/himself. Staff 40 stated she had not seen Resident 44 engaged in any group, independent or self-directed activities and the resident primarily wandered throughout the facility in her/his wheelchair. On 5/5/26 at 11:00 AM, Resident 44, with an interpreter present, stated she/he loved to go outside, go to the park and to the store. Resident 44 stated she/he liked to watch movies but not all day. Resident 44 stated she/he used to be a gardener/landscaper, mowed lawns and at one time, worked on a Christmas tree farm. Resident 44 stated she/he hoped to go to the park today and would enjoy and be able to do small gardening projects.On 5/8/26 at 9:20 AM, Staff 29 (CNA) stated Resident 44 roamed up and down the hallways in her/his wheelchair. Staff 29 stated Resident 44 spoke primarily Spanish. She stated the resident used to be able to go outside, alone but was no longer able to do so. Staff 29 stated she did not see Resident 44 engaged in any group, independent or self-directed activities. On 5/8/26 at 9:26 AM, Staff 47 (CNA) stated Resident 44 spoke Spanish and needed an interpreter when providing care. Staff 47 stated the resident wheeled around the facility or watched TV. Staff 47 stated the resident used to sit outside by the front door but was no longer allowed to do so. Staff 47 reported he did not see Resident 44 ever involved in any activities. On 5/8/26 at 10:09 AM, Staff 13 (Social Service Director) stated Resident 44 spent her/his time going around the facility in her/his wheelchair. She reported Resident 44 loved to be outside and used to sit outside all the time but was no longer allowed to do so without supervision. Staff 13 stated Resident 44 took pride as a gardener. She stated she did not see Resident 44 involved in group, independent or one-on-one activities. Staff 13 stated she was not notified of Resident 44's 4/17/26 care plan intervention for social services to determine reasons for the resident wanting to leave and developing an activity plan and interventions for her/him so she did not develop any activity plans or interventions for the resident. On 5/8/26 at 12:27 PM, Staff 7 (LPN Resident Care Manager) stated Resident 44 loved to go outside but the resident could no longer go outside without a staff member being with her/him and was not sure if that was even possible at this time. Staff 7 stated she did not determine reasons for the resident wanting to leave the facility and had not developed an activity plan or interventions for her/him. On 5/11/26 at 8:45 AM, Staff 15 (Activity Director) stated Resident 44 loved to go outside but was no longer able to do that. Staff 15 stated she did not provide any materials for Resident 44 to complete independent or self-directed activities. Staff 15 stated the resident's primary interests were gardening, being outside and being around animals and the resident had not been provided with activities related to her/his preferences. Staff 15 stated she wished she could do more for Resident 44, especially regarding her/him being outside, but she needed another staff member to accompany her outside with Resident 44 and staff were usually not available. Staff 15 stated she needed to make a point of providing activities of interest to Resident 44. Staff 15 stated the resident had little interest in keeping up with the news so this would not be an activity she/he enjoyed or preferred.On 5/11/26 at 9:55 AM, Staff 1 (Administrator) stated it was his expectation for residents to have activities developed based on their interests and preferences and acknowledged Resident 44's activity program did not meet the resident's needs, especially since Resident 44 was no longer able to sit outside without supervision.

Based on observation, interview, and record review it was determined the facility failed to follow physician orders and monitor skin conditions for 1 of 2 sampled residents (#10) reviewed for skin conditions. This placed residents at risk for worsening skin conditions. Findings include:The facility's 11/2025 Weekly Skin Audit policy instructed the facility to mark yes or no in the TAR for any new skin conditions observed during the skin assessment and document findings in the resident's clinical record. Resident 10 admitted to the facility in 7/2025 with diagnoses including diabetes and dementia.Resident 10's 4/20/26 quarterly MDS indicated the resident' did not have any skin issues and was severely cognitively impaired.On 5/4/26 Witness 3 (Family Member) stated two to three weeks prior, she had noticed a growth on top of Resident 10's left wrist she had not seen before and requested a CNA notify the nurse to look at it because she thought the growth should be examined for possible removal but no one had followed up with her.On 5/6/26 at 11:36 AM Resident was observed to have raised growth about the size of a pencil eraser on the top of her/his wrist about where a watch would normally rest. The growth looked to have a rough and dry texture. Resident 10 stated the left wrist growth bothered her/him sometimes, so she/he kept her/his watch pulled back away from it. Review of Resident 10's clinical records revealed the following:- The physician order dated 7/14/25 instructed the facility to complete weekly skin audits, mark a 'Y' or a 'N' for new skin conditions, and document the findings of the skin audit in the resident's clinical records.- The TAR revealed nurses had put a check mark for the Weekly Skin Audit order on 4/13/26, 4/20/26, 4/27/26, and 5/4/26 but the nurse did not document what was observed on those days. - There was no documentation about Resident 10's left wrist growth.On 5/6/26 at 9:47 AM Staff 27 (CNA) stated she was aware of Resident 10's left wrist growth for a while. Staff 27 stated she was unsure how long the growth had been there, but thought other staff knew about the growth so she did not notify the nurse.On 5/6/26 at 1:38 PM Staff 18 (LPN) and 5/6/26 at 3:38 PM Staff 42 (LPN) stated they were unaware of Resident 10's left wrist growth and acknowledged nurses were expected to complete Weekly Skin Evaluation forms when completing weekly skin audits. They stated the Weekly Skin Audit was a head-to-toe examination of the resident's skin to identify new or worsening skin conditions and the Weekly Skin Evaluation form was a required form used to document the status of known skin issues and if there were any new skin conditions identified during the skin audit.On 5/7/26 at 12:18 PM Staff 35 (LPN) stated he looked at Resident 10's arms on 5/4/26 during the weekly skin check but did not notice a left wrist growth. He stated he was supposed to fill out a Weekly Skin Evaluation form but did not.On 5/8/26 at 12:22 PM Staff 7 (LPN - Resident Care Manager) stated she was not notified about Resident 10's left wrist growth and no one notified her of Witness 3's request to have the growth examined by a physician.On 5/11/26 at 9:30 AM Staff 2 (DNS) observed Resident 10's left wrist growth and stated she was unaware of the growth. Staff 2 confirmed Staff 35 should have seen it when he completed the skin audit, documented his findings, and notified the provider.

Based on observation, interview and record review it was determined the facility failed to ensure residents with limited range of motion received necessary services to prevent a further decrease in range of motion for 1 of 1 sampled resident (#64) reviewed for position and mobility. This placed residents at risk for the development of contractures. Findings include:The facility's 10/2025 Restorative Nursing Services Policy directed the following:-Residents will receive restorative nursing care as needed to help promote optimal safety and independence.-Residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care.-Restorative goals and objectives are individualized and resident-centered and are outlined in the resident's plan of care. -The resident or representative will be included in determining goals and the plan of care. -Restorative goals may include but are not limited to supporting and assisting the resident in participating in the development and implementation of their plan of care. Resident 64 was admitted to the facility in 11/2022 with diagnoses including hemiplegia (severe or complete paralysis on one side of the body) and hemiparesis (partial, one-sided muscle weakness) following a stroke, affecting the left side. An 8/21/23 Physical Therapy (PT) Evaluation & Plan of Treatment revealed the following:-Resident 64 was evaluated to determine her/his ability to use her/his power wheelchair independently. -No deficits were noted related to the resident's right upper extremity. -The resident experienced left sided weakness.-The resident demonstrated good safety using her/his power wheelchair. Resident 64's 12/1/25 Annual MDS revealed the resident was cognitively intact, experienced upper and lower extremity impairment on one side and was dependent on staff assistance for all ADLs outside of eating and oral hygiene. The Functional Abilities CAA revealed the resident had left-sided weakness and impaired mobility. The CAA indicated the current care plan would be continued with the goals of avoiding complications and maintaining the resident's current level of functioning. Resident 64's 1/24/26 ADL Care Plan revealed the following:-The resident required assistance from one-to-two staff to reposition and to turn in bed. -Staff were to turn and reposition the resident every two hours. -The resident required a mechanical lift for transfers. -A therapy evaluation was to be completed as indicated for decline. A review of Resident 64's Rehabilitation Task Form from 4/7/26 to 5/6/26 revealed the resident received left and right lower extremity passive range of motion (the movement of a joint through its full range by an external force) three times weekly. No evidence was found in Resident 64's clinical record to indicate the resident received any assistance with upper body range of motion or on-going assessments and monitoring related to the functioning of her/his upper body. On 5/6/26 at 10:11 AM, Resident 64 was observed in her/his room in bed. Resident 64 used her/his right hand to pull back the blankets that covered her/his left arm. The resident's left arm was bent at the elbow and her/his left thumb bent into the palm of her/his left hand. The resident stated she/he needed to use her/his right hand to move the fingers on her/his left hand because her/his left side was paralyzed. The resident stated Staff 23 (Restorative Aide) provided range of motion for her/his lower body, she/he did not receive any range of motion to her/his upper body, and she/he wanted it. The resident stated her/his left arm was often sore and any therapy was welcome. On 5/6/26 at 9:11 AM, Staff 48 (CNA) stated Staff 23 was responsible for providing range of motion to residents, and CNAs only assisted residents with range of motion if it was in their care plan. Staff 48 stated Resident 64 could not move her/his left side, and her/his left hand was contracted. Staff 48 stated the resident cooperated with range of motion exercises with Staff 23. On 5/6/26 at 9:16 AM, Staff 25 (CNA) stated Staff 23 provided range of motion to residents and range of motion was not a CNA responsibility. Staff 25 stated the resident always cooperated with Staff 23 when he provided range of motion exercises. On 5/6/26 at 12:52 PM, Staff 23 stated Resident 64 was pretty much bedridden, he assisted her/him with restorative exercises to her/his lower body three times weekly, and she/he was always cooperative. Staff 23 stated he did not know why the resident did not have a range of motion program for her/his upper body, but the process to add range of motion program to her/his upper body was easy to do. On 5/6/26 at 1:02 PM, Staff 16 (Director of Rehabilitation) stated residents at risk to develop pressure ulcers and contractures included those who were bed bound and/or needed assistance to move, and for these types of residents, we would do something like a restorative program. Staff 16 stated Resident 64 had range of motion limitations and would be appropriate to receive upper extremity restorative exercises. On 5/6/26 at 1:19 PM, Staff 7 (LPN-Resident Care Manager) stated residents who were bed bound were appropriate to receive passive range of motion exercises for both upper and lower body extremities. Staff 7 stated she did not complete any specific assessments or on-going monitoring related to contracture prevention or development, and she relied on CNAs to tell me when [residents] needed something. Staff 7 stated Resident 64 did not get out of bed, confirmed she/he had a range of motion program for her/his lower extremities but did not have one for her/his upper extremities, and she/he should have one in place. On 5/6/26 at 1:36 PM, Staff 2 (DNS) stated residents with limited mobility and need for assistance with ADLs were at risk for contracture development. Staff 2 stated resident mobility was assessed quarterly by way of the MDS Assessment, but this assessment only noted if the resident had an upper or lower body impairment but did not capture specific details about the impairment, including whether or not a previously noted impairment had worsened. Staff 2 stated Resident 64 never got out of bed and was at risk for upper and lower body extremity contractures. At 1:49 PM, Staff 2 observed Resident 64's left arm and stated the resident could use a therapy evaluation and an RA program.

Based on observation, interview and record review it was determined the facility failed to provide adequate catheter care for 1 of 1 sampled resident (#8) reviewed for catheter care. This placed resident at risk for unmet catheter needs and infection. Findings include: The facility's Catheter Care, Urinary Disease Management policy dated 8/2022 included the following:- Infection Control: Be sure the catheter tubing and drainage bag are kept off the floor. 1. Resident 8 was admitted to facility in 3/2026 with diagnoses of urinary tract infection, inflammatory reaction due to indwelling urethral catheter (bacteria entering urinary tract along catheter, causing inflammation) and chronic kidney disease. The Admissions MDS with an ARD of 4/18/26 revealed Resident 8 had a BIMS score of 4, which indicated the resident had severe cognitive impairment. A review of Resident 8's clinical record revealed she/he had an indwelling catheter and interventions included being provided with catheter care.Observations on 5/4/26 at 10:17 AM, 5/5/26 at 8:55 AM, 5/5/26 at 3:09 PM, 5/6/26 at 8:20 AM, and 5/6/26 at 12:26 PM revealed Resident's catheter drainage bag laying flat on the floor of her/his room. On 5/5/26 at 8:55 AM, Staff 36 (CNA) entered Resident 8's room and assisted the resident into her/his wheelchair. At 8:57 AM, Staff 36 exited the room and the resident was observed sitting in her/his wheelchair brushing her/his teeth at the sink with the catheter drainage bag laying flat on the floor beside her/his wheelchair.On 5/6/26 at 9:03 AM, Staff 36 and another CNA entered Resident 8's room to answer her/his call light. At 9:04 AM, Staff 36 and another CNA exited Resident 8's room and Resident 8's catheter drainage bag was observed to be laying flat on the ground beside her/his bed.On 5/6/26 at 11:06 AM, Staff 36 stated Resident 8's catheter drainage bag should not be on the floor.On 5/6/26 at 3:29 PM, Staff 32 (CNA) stated Resident 8's catheter drainage bag was not supposed be lying on the floor.On 5/6/26 at 3:37 PM, Staff 37 (RN) stated Resident 8 was known to take out her/his catheter, move it around, and drop it on the ground. She stated even if staff pick up the catheter bag and placed it in the appropriate place, Resident 8 was known to drop it down on the floor. Staff 37 stated management was fully aware of the resident's behaviors and stated, The catheter issue is not going to be fixed, it's going to end up on the floor again.On 5/6/26 at 4:05 PM, Staff 6 (LPN Resident Care Manager) stated she expected staff to ensure Resident 8's catheter drainage bag was not on the floor, as it was not sanitary and had potential for infection. At 4:18 PM, Staff 6 entered Resident 8's room and confirmed her/his catheter drainage bag was lying flat on the floor beside the bed and stated she had not received reports of the bag being on the floor.On 5/6/26 at 4:20 PM, Staff 2 (DNS) and Staff 4 (Regional Director of Quality Assurance) stated they expected staff to ensure catheter care was followed, which included ensuring the resident's catheter drainage bag was not on the floor. Staff 2 acknowledged Resident 8 was known to have the catheter drainage bag on the floor, as she had recently picked it up off the floor. Staff 2 and Staff 4 stated there was potential for infection with Resident 8's catheter drainage bag on the floor. 2. Observations on 5/6/26 at 1:30 PM revealed Staff 36 (CNA) donning PPE and preparing to empty Resident 8's catheter drainage bag. Staff 36 provided Resident 8 with peri care and a brief change, and was observed not changing gloves or performing hand hygiene before emptying the resident's catheter bag into a graduated container. On 5/7/26 at 8:05 AM, Staff 36 stated he had donned two pairs of gloves before providing peri care and changing Resident 8's brief. Staff 36 stated he doffed one pair of gloves and confirmed he did not perform hand hygiene before touching the spout on the resident's catheter drainage bag. Staff 36 stated he double gloved all the time when he performed catheter care. On 5/7/26 at 8:10 AM, Staff 8 (LPN Infection Preventionist) stated she did not know why a person would double glove when performing catheter care. Staff 8 stated staff should not double glove, peel off a layer, and continue with care as this was not sanitary and was inappropriate when providing care. Staff 8 stated if staff were going to go from a contaminated site to a clean site, she expected them to doff gloves, perform hand hygiene, and don new gloves before touching the clean site.

Based on observation, interview and record review it was determined the facility failed to develop and implement individualized care plans that addressed the emotional and psychosocial needs of the residents for 2 of 3 residents (#s 15 and 30) reviewed for choices. This placed residents at risk for unmet behavioral and emotional needs and a decrease in their quality of life. Findings includeThe facility's 2/2026 Suicide Threats Policy indicated the following:-Staff shall report any resident threats of suicide immediately to the nurse supervisor who shall immediately assess the situation.-After assessing the resident in more detail, the nurse supervisor shall notify the resident's physician and responsible party and seek further direction from the physician. -All nursing personnel and other staff involved in caring for the resident shall be informed of the suicide threat and instructed to report changes in the resident's behavior immediately. -Staff will monitor the resident's mood and behavior and update care plans accordingly, until a physician has determined that a risk of suicide does not appear to be present. 1. Resident 30 was admitted to the facility in 5/2025 with diagnoses including depression, anxiety and PTSD (Post-Traumatic Stress Disorder). Resident 30's 2/22/26 Quarterly MDS revealed the resident was cognitively intact, and she/he felt down, depressed or hopeless for several days over the last two weeks.A 4/25/26 Progress Note revealed the following: -On 4/24/26, Resident 30 was sent to the emergency department for an evaluation after she/he was found in her/his room with an altered mental status.-An open bottle of over-the-counter pain medicine was found on her/his table and approximately 10 tablets were found scattered on the floor. -The resident returned to the facility on 4/25/26, was placed on frequent checks and the facility implemented further evaluations for safety. Resident 30' 4/25/26 Care Plan revealed the following interventions: -The resident's room door was to be propped open to allow staff to complete a visual check and to hear the call bell.-All hazardous objects were to be removed from the resident's access such as eating utensils.-The resident's call light and bed control cords were to be zip tied to shorten the length of the cord. On 5/4/26 at 10:53 AM, the door to Resident 30's room was observed to be closed. A sign hung on the outside of the door that read, Please close door when leaving. A long plastic bag was observed tied to the outside handle of the door and a long rubber exercise band was tied to the inside handle of the door. Resident 30 was observed in her/his room and sat in her/his wheelchair. The resident's call light cord was zip tied to a bar on her/his bed and the bed control cord appeared shortened; however, various other cords were in reach of the resident such as her/his phone charger. Resident 30 stated she/he recently attempted to end her/his life by taking pills, but she/he did not feel like she was in a space where she/he would do it again. Resident 30 stated the facility shortened the cord to her/his call light after her/his suicide attempt, but they never talked to her/him about other cords and stated, I have a lot of cords in my room. Resident 30 stated the door to her/his room was supposed to be left open a crack for safety, but staff continuously closed it. Resident 30 stated she/he was comfortable with staff knowing about her/his recent suicide attempt and the safety interventions put in place. On 5/5/26 at 12:28 PM, Staff 31 (CNA) was observed at the door of Resident 30's room in the hallway, and the door was open. Staff 31 called into the resident's room and asked the resident if she/he wanted her/his door left open or closed. Resident 30 requested her/his door to be left open. On 5/5/26 at 2:22 PM, the door to Resident 30's room was observed to be closed. Resident 30 was alone inside her/his room and stated staff leave and just shut it behind them. On 5/6/26 at 5:43 AM, the door to Resident 30's room was observed to be closed. Resident 30 was alone inside her/his room. At 5:49 AM, the state surveyor exited the resident's room and left the door cracked open per the resident's request. On 5/6/26 at 5:53 AM, Staff 28 (CNA) stated she was unaware of any safety concerns for Resident 30, and the door to the resident's room was okay to be closed because [she/he] was not a fall risk. On 5/6/26 at 6:08 AM, Staff 21 (RN) stated Resident 30 was suicidal a couple of weeks ago, and because of that, the door to her/his room was supposed to be left cracked open. Staff 21 stated he was in the resident's room at 5:00 AM this morning and closed the door after he left because he knew dayshift would be there soon. On 5/6/26 at 6:49 AM, the door to the resident's room was observed to be closed and the resident was alone inside. The state surveyor exited the resident's room and left the door cracked open per the resident's request. On 5/6/26 at 7:21 AM, two unidentified staff exited Resident 30's room and closed the door behind them. On 5/8/26 at 8:25 AM, Staff 22 (RN) stated the door to Resident 30's room was to be left open so staff could peak in and check on her/his well-being following her/his recent suicide attempt. On 5/8/26 at 10:02 AM, Staff 13 (Social Services Director) stated she discussed safety interventions with Resident 30 following her/his recent suicide attempt. Staff 13 stated the resident understood her/his door needed to be left open wide enough for staff to see inside, and she/he was in agreement with the intervention. Staff 13 stated the resident's call light cord was zip tied to her/his bed and the cord to her/his bed control was shortened but the resident still had access to other long cords in her/his room which did not make sense. On 5/8/26 at 10:41 AM, Staff 27 (CNA) stated she was not informed of any specific safety interventions in place for Resident 30 and was unsure if the resident's door was supposed to be open or not. On 5/8/26 at 10:58 AM, Staff 26 (CNA) stated she was unaware Resident 30 made any attempts of self-harm or of any safety interventions in place. Staff 26 stated the resident's door was shut at all times because that was the resident's preference. On 5/8/26 at 12:01 PM, Staff 2 (DNS) and Staff 7 (LPN-Resident Care Manager) were present for an interview. Staff 7 stated she discussed safety interventions with Resident 30 following her/his return from the hospital after her/his suicide attempt. Staff 7 stated the resident was in agreement to keep her/his door open, and saw the other long cords, plastic bag and rubber exercise band in the resident's room but did not discuss these safety concerns with the resident. Staff 2 stated the sign on the outside of the resident's door that indicated to keep it shut should have been removed, and the resident's door should be kept open whenever the resident was in the room. Staff 2 further stated the other cords in the resident's room should have been evaluated as safety concerns but were not. 2. Resident 15 was admitted to the facility in 10/2024 with diagnoses including dementia.Resident 15's 9/8/25 Trauma Care Plan revealed the resident was to join in decision-making about her/his care. Resident 15's 4/13/26 Quarterly MDS revealed the resident was cognitively intact, and she/he had no mood symptoms or behaviors. A 4/25/26 Progress Note written by Staff 7 (LPN-Resident Care Manager) indicated the following:-An unidentified resident reported to Staff 7 that Resident 15 stated she/he wished she/he could just take a bunch of pills.-Resident 15 did not recall making this statement, and she/he denied suicidal ideation, intent or plan to harm her/himself. -Resident 15 was placed on alert and frequent checks, and her/his care plan was updated to include suicide risk monitoring interventions, including plastic utensils with meals. Resident 15's 4/25/26 Care Plan revealed the following:-The resident verbalized she/he had a thought to take multiple medications at once.-Frequent checks were initiated for the resident's safety.-All hazardous objects were removed from the resident, including eating utensils. -The resident self-initiated activities, and she/he enjoyed crocheting. A 4/26/26 Social Services Note written by Staff 13 (Social Services Director) revealed Resident 15 made a comment on 4/25/26 about taking pills in a joking way and she/he didn't mean it serious.Resident 15's 4/30/26 Long Term Care Evaluation revealed the resident was alert and oriented, and her/his mood was pleasant. A 4/30/26 Progress Note written by Staff 49 (Physician) revealed Resident 15 had an active diagnosis of an adjustment disorder (a short-term, stress-related mental health condition triggered by a major life change or traumatic event) but her/his insight was intact, she/he had a normal affect (outward expression of a person's internal emotional state) and she/he was generally in a good mood. On 5/4/26 at 12:17 PM, Resident 15 was observed in the facility's dining room. The resident's lunch tray sat on the table along with a plastic fork, spoon and knife. Resident 15 threw the plastic spoon across the table and stated, stupid plastic. At 12:31 PM, an unidentified resident who sat at the same table in the dining room yelled out, How come [Resident 15] was the only one who got a plastic fork?On 5/4/26 at 3:32 PM, Resident 15 stated she/he made a statement two weekends ago to Staff 2 (DNS) about taking pills that was misunderstood, and as a result, a number of suicide prevention interventions had been implemented. Resident 15 stated she received plastic silverware at mealtimes for a week, and facility staff removed her/his personal scissors but never asked to remove her/his crochet supplies following her/his comment. Resident 15 stated she was informed of the interventions that were to be implemented and was not involved in the decision-making process. Resident 15 stated the interventions were crazy, and she/he had a happy life and would never attempt suicide. Resident 15 stated she/he wanted to receive regular silverware at mealtimes because the plastic silverware broke in her/his food and made it so she/he could not eat. On 5/5/26 at 12:14 PM, Resident 15 was in the facility's dining room, and her/his lunch tray with a set of plastic silverware sat on the table in front of her/him. Resident 15 threw her/his fork across the table. An unidentified resident handed Resident 15 a metal fork, which she/he used to eat. At 12:20 PM, Resident 15 exited the dining room crying and stated, They treat me like a child. On 5/5/26 at 1:22 PM, Staff 10 (Dietary Manager) stated Resident 15 received plastic silverware at mealtimes because it was her/his preference. On 5/5/26 at 1:29 PM, Staff 25 (CNA) stated he was told Resident 15 made a comment about self-harm, but he thought the resident made the comment as a joke. Staff 25 stated he knew the resident very well, and she/he always joked, laughed and was a social person. On 5/5/26 at 1:36 PM, Staff 47 (CNA) stated she was unaware of any statements of self-harm for Resident 15 and stated the resident should receive regular silverware. On 5/5/26 at 1:42 PM, Staff 30 (CMA) stated she was unaware of Resident 15's statement of self-harm until she was notified by Staff 25 on 5/5/26. Staff 30 stated this was why the resident received plastic silverware at mealtimes and the resident needed to be checked on frequently. On 5/5/26 at 1:49 PM, Staff 27 (CNA) stated Resident 15 was really upset about receiving plastic silverware at mealtimes. Staff 27 stated she observed the resident to throw her/his plastic silverware as well as use regular silverware that was given to her/him from other residents. Staff 27 stated she was unaware why the resident received plastic silverware at mealtimes or of any concerns related to self-harm. On 5/5/26 at 2:08 PM, Staff 42 (LPN) stated she was not informed of Resident 15's statement of self-harm that was made on 4/25/26 until 5/4/26. Staff 42 stated she had never heard Resident 15 to make any statements or exhibit behaviors indicative of self-harm.On 5/5/26 at 2:31 PM, Staff 7 (LPN-Resident Care Manager) stated Resident 15's statement about taking pills came off as a joke but the facility's policy was to implement safety interventions regardless of the resident's intent. Staff 7 stated residents who made threats of or attempted self-harm got the same interventions. Staff 7 stated she was not concerned Resident 15 would harm her/himself. Staff 7 stated she asked the resident for her/his scissors, which the resident surrendered, but did not indicate other potentially hazardous items were identified or requested. Staff 7 stated the resident's crochet needles appeared in my box last week, which she still needed to ask [Staff 2] about. Staff 7 stated she informed the resident of the safety interventions that were going to be implemented on 4/25/26 but had not discussed the interventions with the resident after this time.On 5/6/26 at 7:32 AM, Resident 15 was observed in her/his room in her/his recliner chair. A meal tray with a set of plastic silverware was observed on a table next to the resident. Resident 15 stated she/he did not like to use plastic silverware as it made her/him feel like a baby but she/he was not given an opportunity to provide any input related to this intervention. Resident 15 pulled a crochet hook (a handheld tool with a hooked, pointed tip used to pull yarn or thread through loops to create stitches in crochet work and typically made of metal, wood, bamboo or plastic) out of a bag that was next to her/his recliner and stated it was unclear why she/he had to use plastic silverware but was able to retain her/his crochet hook. On 5/6/26 at 9:06 AM, Staff 48 (CNA) stated she was unaware of any safety concerns for Resident 15, and the resident was allowed to receive regular silverware at mealtimes. On 5/6/26 at 9:39 AM, Staff 13 (Social Services Director) stated Resident 15 received standard interventions for safety following her/his statement of self-harm on 4/25/26. Staff 13 stated the resident was very apologetic about making this comment as she/he intended it to be a joke. Staff 13 stated she did not talk to the resident about her/his feelings about receiving plastic silverware at mealtimes and did not think to remove any of her/his crochet supplies but that definitely would be a concern. On 5/6/26 at 10:26 AM, Staff 2 stated residents received the same interventions no matter if a comment or an action related to self-harm was made, which included limiting access to harmful materials and plastic silverware at mealtimes. Staff 2 stated she was unaware Resident 15 disliked plastic silverware or other residents were providing the resident with regular silverware. Staff 2 stated she was unaware the resident had crochet hooks and acknowledged the resident's safety interventions were not person-centered and contradictory given she/he maintained her/his crochet supplies. Staff 2 stated she was unaware if the resident was involved in the care planning around her/his safety, but the resident should have been.

Based on observation, interview and record review the facility failed to ensure the state survey inspection results were readily accessible for 1 of 1 facility reviewed for resident council. This placed residents and the public at risk of not being informed of the facility's survey history. Findings include:On 5/7/26 at 10:48 AM, five of five members of the resident council answered they were unaware where to access a copy of previous year's survey results or if they were allowed to look at past survey results.On 5/7/26 at 12:00 PM, a tour of the facility found one clear plastic file folder holder attached to the wall near the kitchen entrance labeled Survey Results with a three-ring binder placed in the with survey results included in it. Review of the survey results inserted in the binder revealed the last survey results were dated 8/25/23 for the 7/31/23 recertification survey and 4/19/24 complaint survey result. There was no survey results observed for the 1/2025 recertification survey in the binder. On 5/8/26 at 9:40 AM Staff 43 (Receptionist) identified a second location for survey results. A three-ring binder labeled Survey Results in green highlighter color ink was observed resting against the wall on the corner of her desk. Review of the binder revealed the last survey results were dated 8/25/23 for the 7/31/23 recertification and there were no observed survey results for the 1/2025 recertification survey in the binder. On 5/8/26 at 10:15 AM Staff 1 (Administrator) confirmed the binders had survey results for the 7/31/23 recertification survey and last year's survey results were not available for review.

Based on interview and record review it was determined the facility failed to follow physician orders for 2 of 3 sampled residents (#s 5 and 13) reviewed for bowel and wound care. This placed residents at risk for unmet care needs. Findings include: A 2025 Facility Bowel Care Protocol revealed the facility will administer the following interventions to prevent and treat complications related to no bowel movement within 3 days or longer. These include residents who upon admission received opioid, iron, psychotropics, immobility and neurological disorders. Interventions included the following:-Residents who've experienced over 3 days without a bowel movement will be administered Senna to treat the identified constipation. -After 4 days with no bowel movement, residents will be administered polyethylene glycol (MiraLAX). -After 5 days with no bowel movement, residents will be administered a suppository.-After 6 days with no bowel movement, residents will be administered an enema. 1. Resident 5 was admitted to the facility in 11/2025, with diagnoses including hypothyroidism, breast cancer and depression. Resident 5's 11/8/25 Care Plan revealed the resident was prescribed an anti-depressant with an identified side effects including issues with constipation and voiding. Resident 5's 11/14/25 admission MDS revealed the resident with a BIMS of 14 out of 15 indicating no cognitive impairment. An Incident Note dated 11/13/25 revealed the resident was administered a suppository due to not having a bowel movement for 6 days. A review of Resident 5's 11/2025 MAR revealed the resident was prescribed both Senna and MiraLAX (laxative medications used to treat constipation). Further review revealed the resident was not administered either medication during the time of the resident's identified constipation from 11/7/25 to 11/13/25 and was only administered the suppository after 6 days with no bowel movement. On 1/7/25 at 1:24 PM, Staff 24 (RN) stated residents are administered suppositories after 5 days when additional bowel care interventions such as Senna and MiraLAX fail to be effective. Staff 24 further stated it was not recommended to only administer a suppository after 6 days with no bowel movement as it did not follow the facility's bowel care protocol. On 1/7/26 at 2:00 PM, Staff 22 (CMA) confirmed she administered Resident 5 the suppository per nursing orders. Staff 22 stated she was unaware of the facility's bowel care protocol. On 1/7/26 at 2:09 PM, Staff 3 (RCM) confirmed the facility failed to follow the facility's bowel care protocol after reviewing Resident 5's 11/2025 MAR. On 1/8/26 at 1:29 PM, Staff 1 (Administrator) and Staff 2 (DNS) acknowledged Resident 5 did not receive appropriate bowel care. 2. Resident 13 admitted to the facility in 4/2025, with diagnoses including infection of amputation stump, unspecified open wound right thigh, acute posthemorrhagic anemia and acquired absence of right leg above the knee. a. A 10/13/25 Physician Order indicated Resident 13 was to receive lubricant eye drops: two drops in each eye twice a day and as necessary for complaint of dry eyes. Resident 13's 10/2025 MAR indicated lubricant eye drops were not given from 10/14/25 to 10/29/25. On 1/8/26 at 11:36 AM, Staff 26 (LPN/Resident Care Manager) stated the order for eyedrops was transcribed incorrectly, the eye drops were not given to Resident 13 and Resident 13 missed at least 28 doses, which placed the resident at risk for discomfort related to dry eyes. b. An 8/14/25 Physician order indicated Resident 13 was to receive wound care to his/her right leg two times a day. Resident 13's 9/2025 TAR indicated Staff 25 (LPN) charted a 5 on 9/16/25, which indicated to hold treatment or see nurse note. Resident 13's 9/16/25 Progress Note indicated care conference, endorsed to evening shift nurse. There was no documented evidence Resident 13's wound care treatment to his/her right leg was completed BID on 9/16/25. c. A 9/18/25 Physician Order indicated Resident 13 was to receive wound care to his/her right leg each day shift. Resident 13's 9/2025 TAR indicated Staff 25 charted a 5 on 9/30/25, which indicated to hold treatment or see nurse note. Resident 13's 9/30/25 Progress Note indicated meeting with social services. There was no documented evidence Resident 13's wound care treatment to his/her right leg was completed on 9/30/25. d. A 9/18/25 Physician Order indicated Resident 13 was to receive wound care to his/her chest wound each day. Resident 13's 9/2025 TAR indicated Staff 25 (LPN) charted a 5 on 9/30/25, which indicated to hold treatment or see nurse note. Resident 13's 9/30/25 progress note indicated meeting with social services. There was no documented evidence Resident 13's chest wound care treatment was completed on 9/30/25. On 1/8/26 at 12:21 PM, Staff 25 stated on 9/16/25 Resident 13 was in a care conference, so she did not complete Resident 13's wound care as ordered. She stated on 9/30/25 Resident 13 was in a meeting with social services so she did not complete Resident 13's wound care. On 1/8/26 at 12:39 PM, Staff 2 (DNS) stated physician orders were to be followed.

Based on interview and record review, it was determined the facility failed to implement care plan interventions to prevent a fall for 1 of 1 sampled resident (#3) reviewed for accidents. As a result, Resident 3 sustained a fracture of the right distal femur (the lower portion of the thigh bone). Findings include: Resident 3 was admitted to the facility in 2013, with diagnoses including fracture of the right hip joint and right femur. Resident 3's 7/26/24 Care Plan revealed Resident 3 was a high fall risk related to a prior fall with right hip injury. Resident 3 was identified as a 2-person transfer with a Hoyer lift (a mechanical device used to lift and transfer residents who have difficulty moving themselves). A facility reported incident dated 8/29/24 revealed Staff 21 (CNA) reported Resident 3 had a fall while being transferred from her/his wheelchair to bed. Staff 21 reported Resident 3 slid from the edge of the bed which resulted in her/him twisting their ankle and falling on their right knee. The report indicated Staff 21 confirmed Resident 3 was transferred by one staff member instead of two staff members which resulted in her/him falling from the bed to the floor and a result was sent to the hospital for evaluation. A 9/6/24 Hospital Summary noted Resident 3 sustained a right distal femur fracture as a result of the fall. On 5/14/25 at 11:56 AM, Staff 17 (CNA) confirmed staff received training as a result of the fall that occurred between Staff 21 and Resident 3. Staff 17 stated Staff 21 attempted to self-transfer Resident 3 without a Hoyer lift, which resulted in the resident's fall with fracture. On 5/14/25 at 12:15 PM, Staff 21 (CNA) could not be reached for interview. A review of the facility's Investigation Summary dated 8/29/24, revealed the facility determined an accident had occurred with Resident 3 as a result of Staff 21 not following the resident's transfer care plan which resulted in Resident 3 sustaining a right distal fracture. On 5/15/25 at 1:00 PM, Staff 1 (Administrator) and Staff 2 (DNS) verified the incident occurred on 8/29/24 between Resident 3 and Staff 21, which resulted in Resident 3 sustaining a fracture from the fall.

Based on observation, interview and record review it was determined the facility failed to ensure overbed lights and television remotes were accessible for 3 of 5 sampled residents (#s 6, 362 and 364) reviewed for accommodation of needs. This placed residents at risk for loss of independence. Findings include: The facility's 3/2021 Accommodation of Needs Policy indicated the following: -Staff attitudes and behaviors are directed towards assisting residents in maintaining independence, dignity and well-being to the extent possible and in accordance with the residents' wishes, including arranging personal items so that they are in easy reach of the resident. -Adaptations may be made to the physical environment, including the resident's bedroom and bathroom, as well as the common areas in the facility. Examples of such adaptations include installing longer cords or providing remote controlled overhead or task lighting so that they are easily accessible. 1. Resident 6 was admitted to the facility in 1/2023 with diagnoses including chronic kidney disease. Resident 6's 11/7/24 Quarterly MDS revealed the resident was cognitively intact and dependent on staff for assistance with transfers. On 1/13/25 at 1:33 PM Resident 6 was observed in her/his room in bed with her/his television on. Resident 6 asked the state surveyor to turn off her/his television since she/he did not have a remote control. Resident 6 stated she/he did not have a remote for her/his television for over a month and she/he called everyone to inform them the remote was missing. Resident 6 stated she/he was so angry because every time I want to change the channel or turn the television on or off, someone has to come in. I don't want to piss anyone off, so I just don't do it. On 1/16/25 at 11:30 AM Staff 21 (CNA) stated maintenance staff fixed Resident 6's television a month ago but did not provide the resident with a remote for her/his television. On 1/16/25 at 11:44 AM Staff 20 (CNA) stated Resident 6's television remote was missing for two-to-three weeks. Staff 20 stated she thought the resident reported the missing remote to management, they were not doing anything and the resident was frustrated. On 1/17/25 at 10:05 AM Staff 10 (Maintenance Director) stated he was unaware Resident 6 did not have a remote control for her/his television. On 1/17/25 at 12:30 PM Staff 1 (Administrator) acknowledged the findings of this investigation and did not provide any additional information. 51846 2. Resident 362 was admitted to the facility in 1/2025 with a diagnosis of pneumonitis (inflammation of lung tissue). On 1/13/25 at 10:25 AM, Resident 362 could not reach the overbed light above her/his bed. The overbed light cord was approximately 3 inches long and out of the resident's reach. There were no other means of adjusting the overbed light. On 1/15/25 at 9:53 AM, Staff 31 (LPN) stated residents should be able to turn the light off on their own and not have to rely on staff to do so. On 1/15/25 at 10:16 AM, Staff 10 (Maintenance) stated that residents should be able to turn their overbed light on and off independently and that cords should be at least 24 inches long. On 1/21/25 at 12:10 PM Staff 1 (Administrator) confirmed the cord to residents' overhead lights should be long enough to drape on the bed for residents to have access. 3. Resident 364 was admitted to the facility in 12/2024 with a diagnosis of severe protein-calorie malnutrition. On 1/15/25 at 9:52 AM, Resident 364's overbed light cord was about 11 inches long and out of the resident's reach. On 1/15/25 at 9:53 AM, Staff 31 (LPN) stated residents should be able to turn the light off on their own and not have to rely on staff to do so. On 1/15/25 at 10:16 AM, Staff 10 (Maintenance) stated residents should be able to turn their overbed light on and off independently and cords should be at least 24 inches long. On 1/21/25 at 12:10 PM Staff 1 (Administrator) confirmed the cord to resident overhead lights should be long enough to drape on the bed for residents to have access.

Based on observation, interview and record review it was determined the facility failed to ensure resident records were accurate for 4 of 5 sampled residents (#s 6, 31, 35 and 363) reviewed for vaccination records. This placed residents at risk for inaccurate health records. Findings include: The facility's Immunization Documentation Procedure (undated) indicated the following: - Make sure all signatures and dates are filled in on form. 1: Resident 31 was admitted to the facility in 12/2019 with diagnoses including Huntington's disease (a genetic disorder that causes nerve cells in the brain to break down, which leads to uncontrolled movements, cognitive decline and emotional disturbances). Resident 31's 1/6/25 Nutritional Problem Care Plan indicated the resident was to receive aspiration precautions (a set of practices that help prevent food or liquid from entering the airway), which included close supervision by staff at meal times. Resident 31's 1/6/25 ADL Self Care Performance Deficit Care Plan indicated the resident required occasional supervision from staff at meal times. On 1/13/25 at 10:35 AM Resident 31 was observed to eat independently in her/his room. On 1/14/25 at 3:02 PM Staff 28 (CNA) stated Resident 31 required close supervision at meal times, so you need to sit one-by-one with [her/him]. On 1/15/25 at 11:03 AM Staff 29 (RN) stated Resident 31 was pretty independent with eating and staff were to check on Resident 31 every so often during meal times. On 1/15/25 at 12:33 PM Staff 7 (LPN/RCM) stated Resident 31 required occasional supervision from staff at meal times and the resident's Nutritional Problem Care Plan was inaccurate. On 1/17/25 at 12:17 PM Staff 1 (Administrator), Staff 2 (DNS) and Staff 3 (Regional Nurse Consultant) acknowledged the findings of this investigation and confirmed Resident 6's care plan was inaccurate. 51846 2. Resident 6 was admitted to the facility in 1/2023 with a diagnosis of Urinary Tract Infection. A review of Resident 6's records revealed vaccine consent forms missing ID number, Nursing Care Center, Living Unit, Address, Physician, the person giving resident education, and the date the forms were signed. On 1/16/25 at 10:00 AM, Staff 6 (LPN, Infection Preventionist)'s stated expectations included vaccine consent forms should be accurately dated and completely filled out. On 1/21/25 at 11:40 AM, Staff 2 (DNS) confirmed resident consent forms were expected to be completed prior to being administered a vaccine, including being dated with the resident's name and physician information. 3. Resident 35 was admitted to the facility in 3/2024 with a diagnosis of infectious gastroenteritis and colitis (inflammation of stomach/intestines and colon). A review of Resident 35's records revealed vaccine consent forms missing ID number, Nursing Care Center, Living Unit, Address, Physician, the person giving resident education, and the date on which the forms were signed. On 1/16/25 at 10:00 AM, Staff 6 (LPN, Infection Preventionist)'s stated expectations included vaccine consent forms should be accurately dated and completely filled out. On 1/21/25 at 11:40 AM, Staff 2 (DNS) confirmed resident consent forms were expected to be completed prior to being administered a vaccine, including being dated with the resident's name and physician information. 4. Resident 363 was admitted to the facility in 1/2025 with signs and symptoms involving the musculoskeletal system. A review of Resident 363's records revealed the vaccine consent form missing ID number, the person giving resident education, Address, and the date on which the form was signed. On 1/16/25 at 10:00 AM, Staff 6 (LPN, Infection Preventionist)'s stated expectations included vaccine consent forms should be accurately dated and completely filled out. On 1/21/25 at 11:40 AM, Staff 2 (DNS) confirmed resident consent forms were expected to be completed prior to being administered a vaccine, including being dated with the resident's name and physician information.

Based on observation, interview and record review it was determined the facility failed to ensure a resident request for a personal computer was honored for 1 of 1 sampled resident (#31) reviewed for behavioral-emotional needs. This placed residents at risk for unmet psychosocial and activity needs. Findings include: Resident 31 was admitted to the facility in 12/2019 with diagnoses including Huntington's disease (a genetic disorder that causes nerve cells in the brain to break down, which leads to uncontrolled movements, cognitive decline and emotional disturbances). A 12/3/24 Care Conference Note indicated Resident 31 requested a personal computer to use that was not too hard. A 12/4/24 Social Service Note indicated Witness 1 (Representative Payee) was to load more funds onto [Resident 31's] Visa so a personal computer could be purchased. Resident 31's 12/4/24 Annual MDS revealed the resident was cognitively intact. On 1/21/25 at 9:41 AM Witness 1 stated she received a request to load money onto [Resident 31's] card back in December 2024. Witness 1 further stated she loaded the funds onto the resident's card on 12/4/24, the computer had still not been purchased and someone at the facility was supposed to assist with this purchase. On 1/21/25 at 10:47 AM Resident 31 was observed in her/his room in her/his wheelchair. No computer was observed in her/his room. Resident 31 stated she/he requested a personal computer in early December 2024 but never received one. Resident 31 further stated she/he still wanted a computer because she/he felt sort of cut off. On 1/21/25 at 11:11 AM Staff 12 and 13 confirmed Resident 31 made a request for a personal computer on 12/4/24, the resident had the funds available to purchase a computer and one had still not been purchased. On 1/21/25 at 11:35 AM Staff 1 (Administrator) acknowledged the facility did not assist Resident 31 to purchase a computer.

Based on interview and record review it was determined the facility failed to provide SNF ABN (Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage) notifications to 2 of 3 sampled residents (#s 12 and 48) reviewed for Beneficiary Notification. This placed residents and their representatives at risk for lack of knowledge regarding their right to appeal and unknown financial liabilities. Findings include: 1. Resident 12 was admitted to the facility on [DATE] with Medicare Part A benefits. Resident 12's SNF Beneficiary Protection Notification Review provided by the facility indicated the resident's last covered day for Medicare Part A services was 11/1/24 and Resident 12 remained in the facility. According to the SNF Beneficiary Notification form, the resident was not provided with a SNF ABN notification to inform them or their representative of potential out-of-pocket expenses. On 1/15/25 at 1:40 PM Staff 12 (Social Services Director) stated the facility did not issue SNF ABN notifications to residents when they were discharged from Medicare Part A services and remained in the facility and confirmed Resident 12 did not receive the required SNF ABN notification. On 1/17/25 at 11:43 AM Staff 1 (Administrator) acknowledged the facility did not issue SNF ABN notifications to residents and their representatives as required. 2. Resident 48 was admitted to the facility on [DATE] with Medicare Part A benefits. Resident 48's SNF Beneficiary Protection Notification Review provided by the facility indicated the resident's last covered day for Medicare Part A services was 10/28/24 and Resident 48 remained in the facility. According to the SNF Beneficiary Notification form, the resident was not provided with a SNF ABN notification to inform them or their representative of potential out-of-pocket expenses. On 1/15/25 at 1:40 PM Staff 12 (Social Services) stated the facility did not issue SNF ABN notifications to residents when they were discharged from Medicare Part A services and remained in the facility and confirmed Resident 48 did not receive the required SNF ABN notification. On 1/17/25 at 11:43 AM Staff 1 (Administrator) acknowledged the facility did not issue SNF ABN notifications to residents and their representatives as required.

Based on interview and record review it was determined the facility failed to address a grievance for 1 of 3 sampled residents (#38) reviewed for personal property. This placed residents at risk for unresolved grievances. Findings include: The facility's 9/2004 Lost Item Policy indicated the following: -It is the policy of this facility to protect residents' items from theft or loss to the extent possible. Every effort will be made to insure against theft or loss, to recapture lost items, or to make restitution should a lost item not be recovered. Resident 38 was admitted to the facility on ,d+[DATE] with anemia (a condition in which blood lacks adequate healthy red blood cells) and chronic kidney disease (a long-term condition in which the kidneys are damaged and decrease in function). Resident 38's 12/26/24 Quarterly MDS revealed the resident was cognitively intact. On 1/13/25 at 11:03 AM Resident 38 stated she/he was missing several clothing items and a personalized blanket received as a birthday gift several months ago. Resident 38 stated she/he told everyone and someone assisted her/him to file grievances on the missing items with no resolution. Staff 38 stated he/he ran out of clothing and that the CNAs had to get clothing from the donated rack in laundry. On 1/15/25 at 10:24 AM Staff 34 (CNA) stated Resident 38 reported missing clothing and assisted the resident to fill out the Lost or Damaged Item form several months ago. On 1/15/25 at 3:36 PM Staff 12 (Social Services) stated Resident 38 submitted two Lost or Damaged Items forms on 9/19/24 for six missing shirts and a personalized blanket the resident received as a gift. Staff 12 stated the items were not located or replaced. 1/21/25 at 10:32 AM Staff 1 (Administrator) acknowledged Resident 38 had missing items and the grievance was unresolved from 9/2024. Staff 1 stated it was her expectation grievances were to be followed-up with the resident and family for an agreeable resolution.

Based on observation, interview and record review it was determined the facility failed to ensure resident skin impairments were identified, comprehensively assessed, routinely assessed, treated and monitored for healing or worsening for 1 of 2 sampled residents (#45) reviewed for skin conditions. This placed residents at risk for unidentified, untreated and worsening skin impairments. Findings include: The facility's 12/2010 Skin Program Guideline specified upon admission the nurse will complete a skin evaluation and document the resident's skin condition on the Nursing Database and the resident's clinical record. If a resident is identified to have a skin alteration, the licensed nurse will notify the Resident Care Manager who will investigate the potential cause, develop and implement interventions, complete the appropriate skin form, notify the physician, obtain new orders as indicated, update the MAR and TAR, notify the resident or responsible party and document skin conditions. Actual skin areas will have weekly documentation that includes measurements and how the wound is progressing towards healing (improvement, worsening or unchanged). [For] wounds that are worse or unchanged for two weeks, the licensed nurse will reassess, the physician will be contacted and a new treatment will be considered. Resident 45 was admitted to the facility in 11/2022 with diagnoses including stenosis (restriction of blood flow) of the cerebral artery. Resident 45's Profile Sheet (summary of important resident information) included a photo of the resident taken at the time of admission. Resident 45 had a small skin impairment on her/his right nostril and in the center of her/his forehead. Resident 45's 11/22/22 Admission MDS indicated the resident did not have any skin issues and was cognitively impaired. Review of Resident 45's 2/22/23 Quarterly MDS, 5/25/23 Quarterly MDS and the 6/15/23 Significant Change MDS indicated the resident had no skin issues and was cognitively impaired. On 7/24/23 at 12:25 PM Resident 45 was unable to provide information related to the lesions on her/his nose and forehead. On 7/24/23 through 7/26/23 between the hours of 7:00 AM and 4:00 PM Resident 45 had a reddish-black, raised, thick, scabbed lesion of crusted blood which covered her/his right nostril and a black, scabbed lesion, approximately one centimeter in length, in the center of her/his forehead. Resident 45's health record revealed no documentation the lesions were identified, assessed, treated and monitored for healing or worsening and no evidence to indicate the physician was notified to obtain a treatment order. On 7/25/23 at 3:05 PM Staff 17 (CNA) stated Resident 45 had the scab on her/his nose for awhile and stated the resident picked at the scab a lot which often made it bleed. Staff 17 stated he was unsure about the skin impairment on Resident 45's forehead and stated anything to do with wounds was the nurse's responsibility. 7/26/23 at 8:50 AM Staff 12 (CNA) stated she was unsure what was wrong with Resident 45's nose and forehead. She stated Resident 45's nose was scabbed for a long time, the resident picked at her/his nose scab all the time and she thought the nurses knew about it. On 7/26/23 at 9:00 AM Staff 10 (LPN) stated Resident 45 had a small scrape on her/his nose upon admission, stated the nose lesion was much bigger now and looked cancerous. Staff 10 stated there were no physician orders for treatment, no skin sheet to monitor for healing or worsening, no documented measurements or characteristics of the lesion and no initial assessment completed. When asked how the nose lesion was monitored for healing or worsening, Staff 10 stated she tried to look at it when she worked. When asked about Resident 45's forehead lesion, Staff 10 stated she was unaware the resident had a skin impairment on her/his forehead. On 7/26/23 at 10:30 AM Staff 3 (LPN Resident Care Manager) stated when a skin issue was identified, the facility protocol included to write an incident report, assess the skin issue, notify the physician, obtain a treatment order and routinely monitor for healing on the TAR. Staff 3 stated if a skin issue was identified as worsening, the protocol included to notify the physician. Staff 3 stated Resident 45's nose lesion was present upon admission, she did not think it was assessed or monitored for healing and acknowledged the lesion was larger compared to the resident's admission photo. Staff 3 stated she spoke with the physician several times regarding Resident 45's nose lesion, the physician did not order a treatment and the physician said it wouldn't heal because the resident picked at it. Staff 3 was unable to locate documentation of the physician statements and notification. Staff 3 stated she as unaware Resident 45 had a lesion on her/his forehead and acknowledged there was no assessment, monitoring or treatment for the forehead lesion. On 7/27/23 at 12:35 PM Staff 2 (DNS) was notified Resident 45's health record did not include an initial assessment of the resident's nose and forehead lesions, there was no ongoing assessment and monitoring for healing or worsening, and there was no physician notification and treatment in place. Staff 2 acknowledged the lesions appeared worsened and bigger compared to the admission photo and the lesions looked like cancer. Staff 2 stated she spoke with the nurse who completed Resident 45's admission skin assessment, the nurse confirmed the lesions were present upon the resident's admission and she did not document the lesions. Staff 2 stated the lesions should have been identified, assessed and documented upon the resident's admission and acknowledged the lesions should have been routinely monitored thereafter.

Based on interview and record review the facility failed to develop and implement an effective discharge planning process to ensure post-discharge care and safety needs were met for 1 of 3 sampled residents (#10) reviewed for discharge. This failure to provide a safe discharge, determined to be an immediate jeopardy situation, placed resident's health and safety at risk, including symptoms of pain, medical complications, hospital readmission and death. Findings include: The facility's Transfer or Discharge, Preparing a Resident for policy, revised 2016, directed a post-discharge plan would be developed for each resident prior to her/his transfer or discharge. Staff were to obtain orders for discharge, recommended discharge services and equipment. Resident 10 was admitted to the facility on [DATE] for skilled nursing care and therapy after a hospitalization related to falls. Prior to the hospitalization , the resident lived at home alone, with no friends or family involved in her/his care. Resident 10's [DIAGNOSES REDACTED]. Other [DIAGNOSES REDACTED]. Resident 10's care plan initiated on [DATE] and continued until [DATE], at the time of discharge. The care plan revealed an anticipated discharge plan was to be determined. Interventions included to make arrangements with required community resources to support independence post-discharge and home health to be ordered prior to discharge. Resident 10 had self-care performance deficit and limited mobility related to weakness. She/he required assistance for bathing, eating, mobility, toilet use, and transfers. Resident 10 had bowel and bladder incontinence related to impaired mobility and staff were to check routinely, encourage resident to use bedside commode instead of the floor, briefs were to be worn by the resident and staff were to assist to change. Resident had oxygen therapy related to [MEDICAL CONDITION] and staff were to change resident position every two hours to facilitate lung secretion movement and drainage. The care plan addressed pain with direction to follow physician orders, which included [MEDICATION NAME], topical medication and patches for pain. The resident diabetes was care planned to follow physician orders [REDACTED]. Additionally, the care plan included the resident was at risk of falls related to incontinence and fall history. Review of the [DATE] progress note by Staff 3 (Social Services Director) revealed Resident 10 lived in a single level home with four to five steps to enter the home with no rail. Prior to facility admission, Resident 10 had a care giver for five hours per week and had crutches, oxygen, and life alert (call for help with home/cell phone). A [DATE] at 1:14 PM, therapy progress note by Staff 19 (PT) revealed Resident 10 was confused, disoriented and unable to place her/his nasal cannula (tube for oxygen) back on. Resident 10 had an episode of urinary incontinence and required CNA assistance. When Staff 19 returned after an hour, the nasal cannula was off again, the resident kept pulling it off of her/his self. The [DATE] Admission MDS indicated Resident 10 required extensive assistance (one to two-person assistance) with bed mobility, transfers, dressing, locomotion off unit and toileting. Section Q. Participation in Assessment and Goal Setting, indicated Resident 10 had no family, she/he expected to return to the community, active discharge planning was already occurring for the resident to return to the community and no referral was needed. A [DATE] at 4:48 PM, therapy progress note by Staff 20 (Physical Therapy Assistant) revealed Resident 10 was seated in her/his wheelchair and required moderate cues for focus. Once Resident 10 was able to stand, she/he stated she/he was not able to walk due to pain and discomfort. The resident required an increased amount of time for initiation of each activity. A [DATE] at 6:36 PM, therapy note by Staff 22 (OT) indicated Resident 10 was given an ACL (Allen Cognitive Level) and scored 4.2, which indicated the resident required 24-hour supervision to remove dangerous objects outside of visual field and solve any problems which arose from minor changes in the environment. The SLUMS (St. Louis University Mental Status) score of 17 of 30 indicated dementia. Progress note on [DATE] at 12:05 AM, indicated Resident 10 was found on the floor between her/his bed and the bedside commode. The floor was wet with urine, the resident had stated she/he could not make it to the commode which was about two feet from the bed. Resident 10 was assisted back to bed with a mechanical lift. The [DATE] Fall Risk Assessment indicated Resident 10 fell on e to two times in the last month. Resident 10 scored a 19, which indicated a high risk of falls. Staff 11 (LPN) documented a progress note on [DATE] at 9:19 PM, which revealed Resident 10 was alert and oriented, both incontinent and continent of urine and used a bed side commode to void. A progress note dated [DATE] at 8:42 PM, by Staff 15 (LPN) reported Resident 10 was incontinent of urine, poor balance, bedfast most of the time and used a wheelchair. The note indicated the resident wore adult briefs, her/his gait was unsteady, and she/he had poor balance. Incontinent care was provided. Staff 13 (LPN) entered a progress note, dated [DATE] at 6:29 AM, which indicated Resident 10 was paranoid and had delusions. Resident 10 yelled and swung at staff, picked up a lamp to throw and continued to escalate with behaviors. At 4:30 AM, 911 was called and the EMT (emergency medical technician or ambulance technician) fire department, and police arrived shortly after the call and took about 20 minutes to get Resident 10 into the ambulance. Resident 10 would not leave until the clock turned to 5:00 AM and then was taken by stretcher to the hospital at 5:05 AM. Record review of the [DATE] discharge visit progress notes by Staff 6 (Physician Assistant) revealed Resident 10 was expected to discharge on [DATE], she/he was paranoid and eager to return home. Nursing staff reported Resident 10 was agitated and combative last night. Resident 10's insight and judgement was poor and she/he experienced anxiety. Resident 10 required a wheelchair upon discharge from the facility and her/his mobility was limited due to weakness. Her/his mobility limitation impaired her/his ability to participate in one or more ADL and could not be resolved with the use of a walker or cane. There were no concerns from staff with the resident's ability to use the wheelchair and she/he had been trained by therapy how to use the wheelchair. The use of a manual wheelchair would significantly improve her/his ability to participate in her/his ADL's. Resident 10 had difficulty ambulating distances even within her/his home and would benefit from a bedside commode to reduce her/his risk of falls, which would reduce the risk of re-hospitalization . Staff 6 reviewed notes from the previous hospital stay which indicated the need to consider palliative or hospice care and the resident's functional status was too poor to allow palliative [MEDICAL CONDITION]. Resident 10 was to be discharged home as insurance would no longer cover her/his staff as she/he had plateaued with therapy. Home health and MSW (Master's in Social Work) was ordered. Date signed [DATE] at 11:14 AM. A [DATE] at 10:34 PM progress note by Staff 11, indicated Resident 10 had moderate impairment (memory loss), she/he was forgetful and confused, her/his gait was unsteady, balance was poor, she/he was bedfast all or most of the time and incontinent care was provided. A [DATE] at 11:23 AM, progress note by Staff 3 indicated she talked with Resident 10's previous home care worker (Witness 2) about the resident's discharge, on [DATE]. A [DATE] at 12:56 PM, progress note by Staff 3 indicated she called Resident 10's case manager about the upcoming discharge, [DATE], and requested an assessment for resident to get more home caregiver hours. The [DATE] at 4:10 PM, therapy progress notes by Staff 21 (Occupational Therapy Assistant) indicated the discharge summary was completed. Resident 10 had poor insight and recommended increased caregiver hours at home. Resident 10 was unaware she/he was being discharged the next day and was very emotional. Resident 10 requested to speak to the social services staff. There was no evidence indicating a follow up social services visit was completed for Resident 10's request. The [DATE] Discharge MDS indicated the resident required extensive assistance with bed mobility, transfers, dressing, locomotion off unit and toileting. Section Q. Participation in Assessment and Goal Setting, indicated Resident 10 had active discharge planning to return to the community and no referral needed. Resident 10's [DATE] discharge paperwork indicated the resident needed PT, OT, MSW, home health aide, a wheelchair and a bed side commode for her/his home care. The wheelchair was to be delivered to her/his home. No additional equipment or services were ordered. In an interview on [DATE] at 9:51 AM, Witness 1 (Hospital staff) confirmed she was involved in Resident 10's care for the [DATE] hospital admission. The physician documented the resident had no intake by mouth (food or water) since the discharge. The resident was alert and oriented to self and to some locations but not situation, she/he could not answer history questions. At the time of admission, the resident was verbal but had significant word finding problems. Witness 1 reported hospital records revealed the cause of death was metastatic [MEDICAL CONDITION], and other contributing [DIAGNOSES REDACTED]. Witness 1 reported, in her opinion, it was a mixture of everything, her/his medical condition and the unsafe discharge which contributed to her/his passing. Witness 1 stated even though the resident had several underlying conditions, she believed the weekend trauma without care likely contributed to the resident's death. Witness 1 contacted the Home Health agency from a prior hospitalization to see if they were assigned for the resident's care post discharge ([DATE] start), the home health agency reported not being contacted for the resident's resumption of care. Witness 1 was concerned the resident was sent home alone with no support, no working phone, not able to care for her/his self and was without the ability to call 911 for help. In an interview on [DATE] at 12:49 PM, Witness 2 reported Staff 3 called her on [DATE], for Resident 10's discharge on [DATE] and she told Staff 3 she would not be able to go to the resident's home until [DATE], three days after discharge. Witness 2 reported Staff 3 stated Resident 10 would still be discharged on [DATE]. Witness 2 stated Staff 3 was aware she was a home care worker for 5 hours a week, two times per week a little over two hours each time, prior to Resident 10's stay in facility. Witness 2 reported Resident 10 had no working phone as her/his cell phone bill had not been paid while she/he was in the facility. The resident was transferred home from the facility in a cab or wheelchair transport van. Witness 2 found Resident 10 in her/his home on [DATE], 3 days after discharge. Witness 2 reported when she opened the door to Resident 10's home, the resident's crutches were inside on floor, blocking the door, the resident was on the floor near the door, nude, covered in feces and urine, confused, unable to rise from the floor, as she/he held a sheet of popped out pills which were also covered in feces. Witness 2 reported the resident was found mostly unresponsive, she/he was really confused and disoriented with [MEDICAL CONDITION] (loss of ability to speak or understand). Prior to the discharge home on [DATE], Witness 2 cleaned the home and stocked it with food. When Witness 2 arrived on [DATE], no food had been touched, there were broken items that looked like the resident knocked them over, and there were trails of urine and feces. It appeared the resident crawled around on the floor. There were five cats and a dog, there was animal waste as well. Witness 2 called 911 and it took almost an hour to get her/him loaded into the transport. Resident 10 was admitted to the hospital, where she/he died on [DATE]. In an interview on [DATE] at 3:45 PM, Witness 3 (Case Manager) reported she received the first contact for Resident 10's discharge on [DATE] by a voicemail. Witness 3 stated Staff 3 reported the resident needed increased home care worker hours and no additional information was shared. Witness 3 was unaware Resident 10 did not have a working cell phone and attempted to call the resident on [DATE]. Witness 3 reported, to her knowledge, Resident 10 did not have oxygen at home prior to the facility stay, used crutches, and a cane for mobility assistance and had no wheelchair. Witness 3 reported, although Resident 10 was strong willed she/he would have accepted more services, with the right approach, to allow her/him to stay at home, such as Hospice services. In an interview on [DATE] at 12:21 PM, Staff 7 (CMA) reported she cared for Resident 10 and the resident was very confused most of the time, her/his care needs varied daily, from dependent to independent, possibly due to pain and pain medications, as she/he had routine and PRN pain medication. During an interview on [DATE] at 12:39 PM, Staff 4 (CNA) observed Resident 10's urinary incontinence and the resident seemed to be able to do some things one day and not the next day, example provided was to walk. In an interview on [DATE] at 1:18 PM, Staff 18 (Rehab Manager) reported she attended the weekly UR (utility review) meetings on Wednesdays to report therapy progress of residents in therapy. Staff 18 reported Resident 10 fluctuated in her/his level of participation and performance. On [DATE], the day before discharge, Resident 10 was a moderate assist. Staff 18 reported the therapy department recommended Resident 10 go to higher level of care than home, such as an Adult Foster Home or Assistive Living Facility. During an interview on [DATE] at 1:34 PM, Staff 5 (LPN) reported Resident 10's ADLs often varied day to day and hour by hour. Staff 5 reported Resident 10 would not sign the discharge papers and stated she/he did not come here voluntarily and was not leaving here voluntarily. Staff 5 reported he was told by Staff 2 (DNS) to mark the papers as the resident refused to sign. In an interview on [DATE] at 3:00 PM, Staff 3 was asked where it was documented for home health and medical equipment referrals made on behalf of Resident 10 for post-discharge care. Staff 3 reported she did not document such things anywhere and once the resident discharges from the facility, they are not a resident any more, and that's not my problem. Staff 3 reported she did not have a system or process other than attending the Wednesday Meeting for discharge planning. Staff 3 confirmed she was aware Resident 10 required an increase of home care giver hours and Witness 2 reported she would not check on the resident until [DATE]. Staff 3 said Witness 2 stated Resident 10 had oxygen at home, so she did not order oxygen equipment. Staff 3 stated she did not know Resident 10 had no phone. On [DATE] at 3:40 PM, Staff 2 reported the process for residents to discharge was to have the weekly UR meeting and any equipment, home health or home services which were needed were to be ordered by the Social Services Director. Staff 2 confirmed the facility staff talked about Resident 10's discharge but she was not aware of any notes taken in the UR meeting and none to her knowledge in the resident's health record. On [DATE] at 4:12 PM, Staff 2 provided documents the facility provided to Resident 10 at the time of discharge which included a check list sheet, order summary and discharge summary. On [DATE] at 1:09 PM, Staff 9 (RCM) reported she did not talk to Resident 10 about Hospice or Palliative care. Staff 9 believed she mentioned possible increased care to Resident 10 but had not use the words hospice and did not documented the conversation. Staff 9 stated she was on vacation the week prior to Resident 10's discharge. Staff 9 acknowledged Resident 10 varied in her/his abilities with ADLs and mental health. Staff 9 reported it was Staff 3's responsibility to ensure DME and home health services were in place for the resident's discharge. In an interview on [DATE] at 1:24 PM, Staff 1 (Administrator) reported the IDT (Inter-disciplinary Team) met weekly and communicated about residents pending discharge and would expect any concerns of resident safety were brought to the meeting. Staff 1 confirmed it was Staff 3's responsibility to order recommend medical equipment, home health and home services. He added he would expect services ordered prior to residents leaving the facility. On [DATE] at 4:00 PM, Staff 3 stated she had no additional discharge information on Resident 10. When asked to provide any piece of paper for Resident 10, Staff 3 provided a discharge check list sheet, which the charge nurse gave the resident at time of discharge and a blank social services assessment. The check list sheet revealed a [DATE] date for DME of a wheelchair and bed side commode. Staff 3 could not tell the surveyors if this date was the date the DME was ordered or the date it was required for the [DATE] discharge. Staff 3 stated Witness 2 told her the resident had oxygen at home but did not know the details whether it was an oxygen concentrator or tanks. Staff 3 confirmed no oxygen supplies were ordered as it was not on the check list sheet to be ordered. Staff 3 stated Resident 10 did not participate in the social services assessment and that was why it was blank. Staff 3 reported, after discharge, the bedside commode was denied by insurance and would not be delivered. Staff 3 reported the wheelchair was to be delivered to the resident's home but Staff 3 did not know when, as the resident had discharged and was not a resident any longer. The surveyors contacted and received information on [DATE] at 11:48 AM from Witness 7 (DME vendor) and Witness 8 (DME vendor) which included the faxed page sent by Staff 3 for the request of Resident 10's DME. The fax was dated [DATE] for the [DATE] discharge. The equipment was directed to be delivered to Resident 10's home. The insurance denial for the bedside commode was attached. The wheelchair was scheduled to be delivered [DATE], which was 4 days after discharge. The DME equipment, wheelchair, and bed side commode were not delivered to Resident 10. The surveyor contacted the Home Health agency which Staff 3 reported she requested home health services for Resident 10. On [DATE] at 1:18 PM, Witness 9 (home health vendor) provided Resident 10's records which confirmed no referral was made for the resident's care for the [DATE] discharge. A [DATE] at 1:35 PM, Hospital ED (emergency department) triage note by Witness 10 (RN) revealed Resident 10 was covered in stool, combative and had pills adhered to her/his skin. At 6:43 PM, Witness 11 (Medical Doctor) documented Resident 10 was reported more confused than normal, EMS reported fast heart rate and she/he was covered in stool, positive for confusion, disoriented, impaired memory, and [MEDICAL CONDITION] associated pain. Witness 11 noted Resident 10 was previously seen by Palliative care on [DATE] for assistance for pain management. Due to poor performance status Resident 10 was not a candidate for [MEDICAL CONDITION] and was a candidate for hospice. Note on [DATE] by Witness 12 (OT) assessed Resident 10 as deficits with ADLs, safety during ADLs, activity tolerance, cognition, bed mobility, transfers, ambulation, balance, and strength. Resident 10 demonstrated impaired functional cognition with difficulty following one step commands consistently, impaired safety awareness and insight. Note on [DATE] by Witness 13 (PT) revealed Resident 10 displayed minimal ability to follow commands, moved legs somewhat on her/his own but only able to wiggle toes and slightly move legs when cued. Final hospital notes by Witness 14 (Doctor of Osteopathic Medicine) revealed the chem panel (basic metabolic panel) showed signs of dehydration, and the resident continued to lack capacity to make major decisions about her/his care. After transitioning to comfort measures on [DATE], Resident 10 expired on [DATE]. On [DATE] at 11:30 AM, Staff 1 and Staff 2 were informed of the IJ (immediate jeopardy) situation related to the facility's failure to develop interventions to meet Resident 10's discharge needs and ensure a smooth and safe transition from the facility to the post-discharge setting. The IJ template was provided and an immediate IJ removal plan was requested. On [DATE] at 2:36 PM, the facility submitted a removal plan which was accepted and approved by the survey team. The IJ Removal Plan indicated the facility would implement the following actions: - Implementation of the discharge tracking tool which included: when home health and medical equipment were ordered with name of company and contact information, and if a home caregiver needed with name and contact information. - Any discharge determined not a safe discharge and resident directed, would be reported to adult protective services. - Inservice LN (licensed nurse), RCM and SSD on the following: LN to notify RCM if concerned of resident discharge: SSD/RCM to arrange any resident home health to start day of discharge; SSD/RCM to ensure family/caregiver support in place prior to discharge and meets resident's needs; SSD/RCM/LN medical equipment delivered to the facility, when possible, or to the resident's home in a timely manner; SSD/RCM to use the discharge tracking tool; SSD will notify Adult Protective Services if resident chooses to discharge unsafely with in 24 hours of discharge; All information related to discharge planning will be documented in the EHR (electronic health record). - All new admissions will be added to the discharge tracking tool. - SSD or designee will report any changes and discuss options in meetings. - Administrator or DNS will audit the tracking tool to ensure proper notifications and orders were made for a safe discharge. - Audit findings will be brought to the monthly Quality Assurance meeting for 3 months or until committee deems not necessary. On [DATE] at 2:43 PM, Staff 1 acknowledged the facility dropped the ball for Resident 10 and would ensure corrections were made for all future discharges. On [DATE] at 11:52 AM, surveyors verified all elements of the IJ removal plan were in process and completed to ensure the discharge needs of each resident are identified and resulted in the development of a discharge plan to meet the individuals resident's needs.

Based on interview and record review it was determined the facility failed to ensure medically related social services were provided related to discharge for 1 of 3 sampled residents (#10) reviewed for discharge. This resulted in Resident 10's health complications, pain, hospital readmission and death with the unsafe discharge. Findings include: The facility's Transfer or Discharge, Preparing a Resident for policy, revised 2016, directed a post-discharge plan would be developed for each resident prior to her/his transfer or discharge. Staff were to obtain orders for discharge and recommended discharge services and equipment. Resident 10 was admitted to the facility on [DATE] for skilled nursing care and therapy after a hospitalization related to falls. Prior to the hospitalization , the resident lived at home alone, with no friends or family involved in her/his care. Resident 10's [DIAGNOSES REDACTED]. Other [DIAGNOSES REDACTED]. Resident 10's care plan initiated on [DATE] and continued until [DATE], time of discharge, revealed an anticipated discharge plan was to be determined. Interventions included to make arrangements with required community resources to support independence post-discharge and home health to be ordered prior to discharge. Resident 10 had self-care performance deficit and limited mobility related to weakness. She/he required assistance for bathing, eating, mobility, toilet use, and transfers. Identified on [DATE], Resident 10 had bowel and bladder incontinence related to impaired mobility and staff were to check routinely, encourage resident to use bedside commode instead of the floor, briefs were to be worn by the resident and staff were to assist to change. Resident had oxygen therapy related to [MEDICAL CONDITION] and staff were to change resident position every two hours to facilitate lung secretion movement and drainage. Oxygen was set at ,[DATE] liters per minute. Additionally, the care plan included the resident was at risk of falls related to incontinence and fall history. Review of the [DATE] progress note by Staff 3 (Social Services Director) revealed Resident 10 lived in a single level home with four to five steps to enter the home with no rail. Resident 10 previously had a care giver for five hours per week, crutches, oxygen, and life alert (call for help with home/cell phone). A [DATE] at 6:36 PM, therapy note by Staff 22 (OT) indicated Resident 10 was given an ACL (Allen Cognitive Level) and scored 4.2, which indicated the resident required 24-hour supervision to remove dangerous objects outside of visual field and solve any problems which arose from minor changes in the environment. The SLUMS (St. Louis University Mental Status) score of 17 of 30 indicated dementia. The [DATE] Fall Risk Assessment indicated Resident 10 fell on e to two times in the last month. Resident 10 scored a 19, which indicated a high risk of falls. Record review of the [DATE] discharge visit progress notes by Staff 6 (Physician Assistant) revealed Resident 10's insight and judgement was poor and she/he had experienced anxiety. Resident 10 required a wheelchair upon discharge from the facility and her/his mobility was limited due to weakness. Resident 10 had difficulty ambulating distances even within her/his home and would have benefit from a bedside commode. The bedside commode would reduce her/his risk of falls, thereby reduced the risk of rehospitalization . Home health and MSW (Master's in Social Work) was ordered. Date signed [DATE] at 11:14 AM. A [DATE] progress note by Staff 3 revealed she talked with Resident 10's previous home care worker (Witness 2) about the resident's discharge, on [DATE]. A [DATE] progress note by Staff 3 indicated she called Resident 10's case manager about the upcoming discharge, on [DATE], and requested an assessment for the resident to get more home care giver hours. The [DATE] at 4:10 PM, therapy progress notes by Staff 21 (Occupational Therapy Assistant) indicated the completion of the discharge summary revealed Resident 10 had poor insight and recommended increased care giver hours at home. Resident 10 was unaware she/he was being discharged the next day and was very emotional. Resident 10 requested to speak to the social services staff. There was no evidence indicating a follow up visit by social services was completed from Resident 10's request. The [DATE] Discharge MDS indicated the resident required extensive assistance (one to two person) with bed mobility, transfers, dressing, locomotion off unit and toileting. Section Q. Participation in Assessment and Goal Setting, indicated Resident 10 had active discharge planning to return to the community and no referral needed. Resident 10's [DATE] discharge paperwork indicated the resident needed PT, OT, MSW, home health aide, a wheelchair and a bed side commode for her/his home care. The wheelchair was to be delivered to her/his home. No additional equipment or services were ordered. In an interview on [DATE] at 9:51 AM, Witness 1 (Hospital staff) was involved in Resident 10's care for the [DATE] hospital admission. The physician documented the resident had no intake by mouth (food or water) since the facility discharge. The resident was alert and oriented to self and to some locations but not situation, she/he could not answer history questions. At the time of admission, the resident was verbal but had significant word finding problems. On [DATE] she/he went downhill and stopped talking. On [DATE] it was determined nothing could be done to help the resident and she/he was transferred to comfort care and died on [DATE]. Witness 1 contacted the Home Health agency from a prior hospitalization to see if they were assigned for the resident's care post discharge ([DATE] start), the home health agency reported not being contacted for the resident's resumption of care. In an interview on [DATE] at 12:49 PM, Witness 2 reported Staff 3 called her on [DATE], for Resident 10's discharge on [DATE] and she told Staff 3 she would not be able to go to the resident's home until [DATE], three days after discharge. Witness 2 reported Staff 3 stated Resident 10 would still be discharged on [DATE]. Witness 2 stated Staff 3 was aware she was a home care worker for 5 hours a week, two times per week a little over two hours each time, prior to Resident 10's stay in facility. Witness 2 reported Resident 10 had no working phone as her/his cell phone bill had not been paid while she/he was in the facility. The resident was transferred home from the facility in a cab or wheelchair transport van. Witness 2 found Resident 10 in her/his home on [DATE], 3 days after discharge. Witness 2 reported when she opened the door to Resident 10's home, the resident's crutches were inside on floor, blocking the door, the resident was on the floor near the door, nude, covered in feces and urine, confused, unable to rise from the floor, as she/he held a sheet of popped out pills which were also covered in feces. Witness 2 reported the resident was found mostly unresponsive, she/he was really confused and disoriented with [MEDICAL CONDITION] (loss of ability to speak or understand). Prior to the discharge home on [DATE], Witness 2 cleaned the home and stocked it with food. When Witness 2 arrived on [DATE], no food had been touched, there were broken items that looked like the resident knocked them over, and there were trails of urine and feces. It appeared the resident crawled around on the floor. There were five cats and a dog, there was animal waste as well. Witness 2 called 911 and it took almost an hour to get her/him loaded into the transport. Resident 10 was admitted to the hospital, where she/he died on [DATE]. In an interview on [DATE] at 3:45 PM, Witness 3 (Case Manager) reported she received the first contact for Resident 10's discharge on [DATE] by a voicemail. Witness 3 stated Staff 3 reported the resident needed increased home care worker hours and no additional information was shared. Witness 3 was unaware Resident 10 did not have a working cell phone and attempted to call the resident on [DATE]. Witness 3 reported, to her knowledge, Resident 10 did not have oxygen at home prior to the facility stay, used crutches, and a cane for mobility assistance and had no wheelchair. Witness 3 reported, although Resident 10 was strong willed she/he would have accepted more services, with the right approach, to allow her/him to stay at home, such as Hospice services. In an interview on [DATE] at 1:34 PM, Staff 5 (LPN) reported Resident 10 would not sign the discharge papers and stated she/he did not come here voluntarily and was not leaving here voluntarily. Staff 5 reported he was told by Staff 2 (DNS) to mark the papers as the resident refused to sign. In an interview on [DATE] at 3:00 PM, Staff 3 was asked where it was documented for home health and medical equipment referrals made on behalf of Resident 10 for post-discharge care. Staff 3 reported she did not document such things anywhere and once the resident discharges from the facility, they are not a resident any more, and that's not my problem. Staff 3 reported she did not have a system or process other than attending the Wednesday Meeting for discharge planning. Staff 3 confirmed she was aware Resident 10 required an increase of home care giver hours and Witness 2 reported she would not check on the resident until [DATE]. Staff 3 said Witness 2 stated Resident 10 had oxygen at home, so she did not order oxygen equipment. Staff 3 stated she did not know Resident 10 had no phone. On [DATE] at 3:40 PM, Staff 2 (DNS) reported the process for residents to discharge was to have the weekly UR (utility review) meeting and any equipment, home health or home services which were needed were to be ordered by the Social Services Director. In an interview on [DATE] at 1:24 PM, Staff 1 (Administrator) reported the IDT (Inter-disciplinary Team) met weekly and communicated about residents pending discharge. Staff 1 confirmed it was the responsibly of Staff 3 to order the recommend medical equipment, home health and home services. On [DATE] at 4:00 PM, Staff 3 stated she had no additional discharge information on Resident 10. When asked to provide any piece of paper for Resident 10, Staff 3 provided a discharge check list sheet, which the charge nurse gave the resident at time of discharge and a blank social services assessment. The check list sheet revealed a [DATE] date for DME of a wheelchair and bed side commode. Staff 3 could not tell the surveyors if this date was the date the DME was ordered or the date it was required for the [DATE] discharge. Staff 3 stated Witness 2 told her the resident had oxygen at home but did not know the details whether it was an oxygen concentrator or tanks. Staff 3 confirmed no oxygen supplies were ordered as it was not on the check list sheet to be ordered. Staff 3 stated Resident 10 did not participate in the social services assessment and that was why it was blank. Staff 3 reported, after discharge, the bedside commode was denied by insurance and would not be delivered. Staff 3 reported the wheelchair was to be delivered to the resident's home but Staff 3 did not know when, as the resident had discharged and was not a resident any longer. Staff 3 reported she never had called Adult Protective Services to report or ask for a wellness safety check for a resident with safety concerns post discharge. The surveyors contacted and received information on [DATE] at 11:48 AM from Witness 7 (DME vendor) and Witness 8 (DME vendor) which included the faxed page sent by Staff 3 for the request of Resident 10's DME. The fax was dated [DATE] for the [DATE] discharge. The equipment was directed to be delivered to Resident 10's home. The insurance denial for the bedside commode was attached. The wheelchair was scheduled to be delivered [DATE], which was 4 days after discharge. The DME equipment, wheelchair, and bed side commode were not delivered to Resident 10. The surveyor contacted the Home Health agency which Staff 3 reported she requested home health services for Resident 10. On [DATE] at 1:18 PM, Witness 9 (home health vendor) provided Resident 10's records which confirmed no referral was made for the resident's care for the [DATE] discharge. On [DATE] at 11:16 AM, Staff 1 acknowledged he expected home health services, DME and sufficient home care giver assistance to be in place prior to Resident 10's discharge. Staff 1 acknowledged the facility failed Resident 10 with post-discharge care, which included the medical equipment ordered timely, home health services, caregiver needs and to ensure a safe discharge. On [DATE] at 8:43 AM, review of Resident 10's Hospital Records for the [DATE] admission, revealed Resident 10 was admitted to the Emergency Department on [DATE], three days after the facility discharge, with Emergency Medical Technicians reporting Resident 10 was found on the floor of her/his home, covered in stool, with a high heart rate, nude and unable to rise from the floor. Resident 10 had pills adhered to her/his body. Resident 10 had underlying conditions, was in pain, dehydrated and anemic. The medical records confirmed Resident 10 died in the hospital on [DATE]. Refer to F660

Based on interview and record review it was determined the facility failed to ensure Resident 1's safety device was in place for 1 of 3 residents (#1) who were reviewed for falls. Resident 1 fell and suffered a fracture. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A 2/10/17 Safety device assessment and consent form included a pressure alarm which was to be used in Resident 1's bed and wheelchair for frequent falls. A 2/11/17 fall incident report indicated on 2/10/17 Staff 3 (LPN) checked on Resident 1 multiple times and found the resident sleeping. At 9:00 pm Staff 3 was alerted by Staff 7 (CMA) that the resident was on the floor in her/his room. Staff 3 observed the resident on her/his left side, off of the landing pad and the pressure alarm was observed on the bedside table. The resident was assessed, neuro checks were within normal limits. The doctor and the family were notified. An x-ray was ordered and pain medication was administered. In a 2/10/17 statement included with the fall investigation Staff 4 (CNA) stated when she brought a dinner tray into Resident 1's room on 2/10/17, she observed a pressure alarm on the bedside table. Staff 4 continued that she did not put the pressure alarm under Resident 1 because she/he was eating dinner and (Resident 1) was new. I was not sure why it was not under her/him. The 2/10/17 X-Ray report showed Resident 1 had a fracture of the left femur. Resident was transferred to the hospital on [DATE]. In interview on 3/14/17 at 5:00 pm Staff 3 (LPN) stated when Resident 1 was admitted she/he did not want to go to bed so the resident was placed in a room chair. Staff 3 placed a pressure alarm under Resident 1 because the resident was agitated and confused. After Resident 1 was transferred to bed, she checked on the resident many times and assumed the pressure alarm was under Resident 1. When she was alerted to Resident 1's fall and went to the resident's room, she saw the alarm was on the bedside table. She did not know who transferred Resident 1 to bed. In interview on 3/16/17 at 12:50 pm Staff 1 (DNS) stated Resident 1 was not care planned for an alarm because the resident was in the facility for a very short time and we have 24 hours to complete the interim care plan. Staff 3 (LPN) placed the pressure alarm because of Resident 1's agitation. Staff 1 continued that the family wanted the resident administered something for the agitation. The Physician was called and an order for [REDACTED]. The resident calmed down and was sleeping in bed. Staff 1 stated if the assessment for the careplan showed the resident required a pressure alarm, then the information would be shared with other staff. In interview on 3/17/17 at 12:00 pm Witness 1 (Complainant) stated she saw the pressure alarm under Resident 1 when she/he sat on the chair. She stated she left the room to call Resident 1's doctor and when she returned the resident was already in bed. She saw the pressure alarm on the floor, placed it on the bedside table and hoped a staff would see it. In interview on 3/17/17 at 12:25 pm Staff 4 (CNA) stated she did not transfer Resident 1 to the chair or the bed and did not know who did. When she dropped off Resident 1's dinner tray, she observed the bed alarm on the bedside table. She stated she planned to ask a nurse if the resident needed the alarm but was unable to find her. She helped other residents and went to break. After her break, she saw the resident had fallen.

Based on interview and record review it was determined Staff 2 (former CNA) failed to adhere to the standards of practice for Certified Nursing Assistants for 1 of 3 sampled residents (#199) reviewed for accidents. Resident 199 suffered a fall which required transport to the hospital and sutures. Findings include: Oregon Administrative Rule 851¿063¿0090 Conduct Unbecoming a Nursing Assistant indicated the following: A CNA, regardless of job location, responsibilities, or use of the title CNA, whose behavior fails to conform to the legal standard and accepted standards of the nursing assistant profession, or who may adversely affect the health, safety or welfare of the public, may be found guilty of conduct unbecoming a nursing assistant. Such conduct includes but is not limited to: (2) Conduct related to achieving and maintaining clinical competency: (a) Failing to conform to the essential standards of acceptable and prevailing nursing assistant performance of duties. Actual injury need not be established. (3) Conduct related to client safety and integrity: (b) Failing to implement the plan of care developed by the registered nurse. Resident 199 was admitted to the facility in 2016 with [DIAGNOSES REDACTED]. A 6/8/16 Fall Risk Evaluation indicated Resident 199 was at high risk for falls. Resident 199's Care Plan revised 6/20/16 indicated the resident required one person assistance with mobility using a front wheel walker. A facility incident investigation dated 7/12/16 indicated Resident 199 was assisted to the sink by Staff 2 (former CNA). Staff 2 told the resident to wait there while he went to get some linen. After Staff 2 left, the resident reached for some paper towels and fell backwards and suffered a deep laceration to the left arm. The resident was sent to the emergency room and received sutures for the laceration. A Hospital Emergency Department Clinical Summary and Patient Summary dated 7/12/16 indicated Resident 199 was treated for [REDACTED]. The sutures were to be removed in 7-10 days. The summaries did not describe the exact wound location, size, depth or number of sutures required. On 10/6/16 at 8:38 am Resident 63 (Resident 199's former roommate) stated Staff 2 (CNA) assisted Resident 199 to the bathroom and then to the sink to wash her/his hands. Staff 2 told the resident to stay where she/he was and he left the room to get a pad for the bed with Resident 199 standing at the sink. Resident 199 stepped back from the sink and fell tipping over her/his walker and hitting her/his elbow on the closet. The resident was taken to the hospital for stitches. On 10/6/16 at 9:19 am Staff 4 (DNS) acknowledged Staff 2 left Resident 199 unattended standing at the sink while he left the room. While unattended, the resident fell and injured her/his left arm which required sutures at the hospital. Refer to F-323

Based on interview and record review it was determined the facility failed to ensure resident safety for 1 of 4 sampled residents (#199) reviewed for accidents. Resident 199 suffered a fall which required transport to the hospital and sutures. Findings include: Resident 199 was admitted to the facility in 2016 with [DIAGNOSES REDACTED]. A 6/8/16 Fall Risk Evaluation indicated Resident 199 was at high risk for falls. A 6/17/17 Quarterly Review and Care Conference Information indicated Resident 199 used a bed pressure alarm, wheelchair pressure alarm and fall mats on both sides of the bed. Resident 199's Care Plan revised 6/20/16 indicated the resident required one person assistance with mobility using a front wheel walker. A 7/6/16 Brief Interview for Mental Status indicated Resident 199 was cognitively intact. A facility incident investigation dated 7/12/16 indicated Resident 199 was assisted to the sink by Staff 2 (former CNA). Staff 2 told the resident to wait there while he went to get some linen. After Staff 2 left, the resident reached for some paper towels and fell backwards and suffered a deep laceration to the left arm. The resident was sent to the emergency room and received sutures for the laceration. A Hospital Emergency Department Clinical Summary and Patient Summary dated 7/12/16 indicated Resident 199 was treated for [REDACTED]. The sutures were to be removed in 7-10 days. The summaries did not describe the exact wound location, size, depth or number of sutures required. On 10/6/16 at 8:38 am Resident 63 (Resident 199's former roommate) stated Staff 2 (CNA) assisted Resident 199 to the bathroom and then to the sink to wash her/his hands. Staff 2 told the resident to stay where she/he was and he left the room to get a pad for the bed with Resident 199 standing at the sink. Resident 199 stepped back from the sink and fell tipping over her/his walker and hitting her/his elbow on the closet. The resident was taken to the hospital for stitches. On 10/6/16 at 9:19 am Staff 4 (DNS) acknowledged Staff 2 left Resident 199 unattended standing at the sink while he left the room. While unattended, the resident fell and injured her/his left arm which required sutures at the hospital.

Based on observation, interview and record review it was determined that the facility failed to provide the necessary care and services for 2 of 5 sampled residents (#s 1 and 4) who experienced incident/accidents. Resident 1 and 4 were harmed. Findings include: 1. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 10/17/10 Annual MDS (Minimum Data Set) indicated the resident had not had any falls since his admission and had not experienced pain on a daily basis. The resident was non-ambulatory and was transferred with a mechanical lift. The resident was assessed at risk for falls related to his dependence with all mobility and his inability to stabilize without assistance. The resident was care planned to be transferred with a mechanical lift and a two person assist. The IR (Incident Report) of 10/18/10 revealed the resident was transferred from his bed with a mechanical lift and the assistance of one person. He slid out of the sling and fell to the floor landing on his back. The incident occurred at 6:30 am. The resident was returned to bed and in approximately 20 minutes he complained of back pain. The resident was sent to the hospital for an evaluation. X-rays did not reveal any fractures and no other injuries had been found. Vicodin (narcotic analgesic) 5/500 mg was ordered every six hours as needed for pain. The resident was medicated as directed and continued to complain of back pain. On 10/20/10 the resident had additional x-rays. A compression fracture of the thoracic spine was found. The physician stated it was an old fracture. The Vicodin was increased to every four hours. On 10/22/10 the physician was notified of the residents increased complaints of pain. Oxycodone (narcotic analgesic) 5-10 mg was ordered every four hours as needed for pain. The MAR revealed the resident received the Oxycodone 10 mg usually two to three times in a 24 hour period consistently. Effectiveness was described as "helpful." Review of MAR for the month of October revealed the resident had not required narcotic medication for pain until after the fall. In interview on 10/29/10 at 8:35 am, Staff 2, DNS, stated it was facility policy that all transfers with a mechanical lift were to be performed with two staff members. "The CNAs have training related to transfers with a mechanical lift upon employment. It was also on the resident's care plan to be transferred with the assist of two persons." In interview on 10/29/10 at 10:30 am, Staff 4, CNA, stated she was aware the resident was a two person transfer. "I knew he was care planned to use two people. The first thing in the morning it is more difficult to get help as it is a busy time. I had the sling in the right position. I heard a sliding sound. It happened so fast I couldn't stop it." She reported the resident had not been resistant with the transfer and had not moved during the procedure. In interview on 10/29/10 at 1:30 pm, Staff 5, CNA, stated he entered the room following the incident. "He was lying on the floor off of the sling. The sling was approximately four feet from the floor surface. He didn't complain of pain initially but did about 20 minutes later. The CNA (Staff 4) told me she was alone during the transfer and didn't know how he came out of the sling. It is facility policy to always use a two person mechanical lift transfer." In interview on 10/29/10 at 1:40 pm, Staff 7, LN, reported the CNA (Staff 4) told her she was alone and did not have assistance with the transfer. "The sling was approximately 3 feet from the floor. I asked her if she guided him to the floor and she would not answer. He started to complain of pain after he returned to bed." During random interviews on 10/29/10, Resident 1 could not recall the incident of 10/18/10. 2. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 8/2/10 Quarterly MDS indicated the resident required total assist for bed mobility and transfers. She did not have any incidents/accidents. The resident was care planned to have a two person assist in transfers with a mechanical lift. On 10/23/10 at approximately 9:00 am, the IR revealed the resident sustained [REDACTED]. Reportedly she hit her head on the nightstand. The resident was transported to the hospital immediately following the incident. The hospital report of 10/23/10 at 9:32 am revealed the resident sustained [REDACTED]. Alert and oriented to person, place, time and situation. No focal neurological deficit observed, normal sensory observed, normal motor observed, normal speech observed, normal coordination observed." Her vital signs were recorded within normal limits and her oxygen saturation level was 98% on room air. The wound was sutured and the resident returned to the facility. In interview on 10/23/10 at 8:35 am, Staff 2, DNS, stated a CNA (Staff 6) was changing the resident's bed at the time of the incident. "When he turned her she had moved her head at the same time. She hit the corner of the nightstand. Pressure was applied to the wound immediately and she was sent to the hospital. I spoke with a family member who believed the resident was to have a two person assist with repositioning. I informed her that the two person assist was related to transfers and not repositioning. I did revise the care plan to include a two person assist with all cares following the incident." During observations on 10/29/10 at 8:45 am the resident was noted to be sitting in her wheelchair. The left periorbital area had what appeared to be fading ecchymosis which extended to the left neck. She had a hematoma of the left forehead and a left scalp wound which measured approximately 5 cm and was sutured. No drainage noted. The resident could not recall the event. She denied any discomfort. In interview on 10/29/10 at 9:45 am, Witness 1, Complainant, stated the nightstand was on the right side of the bed and close to the bed. "CNA (Staff 6) was on the left side when it happened. She is to be repositioned with two people. The CNA told me he had her on her side and gave the sheet a quick jerk and she hit her head. It makes me nervous to have her turned without someone on both sides. Witness 1 had previously stated the nightstand drawer was open when the incident occurred. When asked who provided the information she stated, "Well I just assumed it was open." In interview on 10/29/10 at 1:40 pm, Staff 7, LN, stated the CNA (Staff 6) came to me and asked me to come to the resident's room. "He told me he was turning her to her side to change her bed as it was wet. He stated when he started pulling on the sheets she lost her balance and hit the nightstand. He ran over to the other side of the bed and caught his knee on her knee as she was coming off the bed. When we provide care we always turn the resident toward us and not away and always have a hand on them. The resident's skin is very fragile." In interview on 11/2/10 at 10:30 am, Staff 6 stated on the day of the incident (10/23/10) he had provided incontinent care for Resident 4. He then proceeded to change the linens on her bed as they were wet. "The resident was turned on her right side and I was on the left side of the bed. I had removed most of the linens and I only needed to remove the bottom fitted sheet. I pulled on the bottom of the sheet to release it and it got stuck. It was like a jerk. I then leaned down to undo the sheet and she went into the nightstand. The nightstand was right next to the bed. When this happened I turned her to her back and that is when I saw the injury. If I could do it again I would not have tried to pull on the fitted sheet until she was on her back." The resident required total assistance with bed mobility. It is an expectation that during the provision of care and services for a resident the care would be provided to in a manner to maintain and ensure the safety of the resident.