Every finding on record at Cascade Terrace Post Acute

Based on observation, interview and record review it was determined the facility failed to follow proper cleaning and sanitization of dishes and cookware for 1 of 1 kitchen reviewed. This placed residents at risk for food-borne illnesses. Findings include: The facility's dishwashing policy, dated 9/1/24, indicated not to run dishes until the dishwasher reached the proper temperature for the specific machine's manufacturer's guideline. In addition, staff were to check for proper temperatures and pressure, follow manufacturer's recommendations, log temperatures, and if deficient, tell the Food and Nutritional Services manager and/or Maintenance Director. The dishwasher's NSF data plate (a permanent metal label which displays the critical baseline operating specifications the dishwasher must maintain to sanitize dishes according to health codes) indicated, for a high temperature dishwasher, the wash tank minimum temperature was 160 degrees F and the final sanitizing rinse minimum temperature was 180 degrees F. On 9/2/26 at 11:09 AM, Staff 21 (Dietary Manager) confirmed the facility had a high temperature dishwasher and the final rinse cycle needed to reach at least 180 degrees F. She stated she was new to the position of dietary manager and was unaware the dishwasher was not reaching the required temperatures. Staff 22 (Dietary Aid) stated the dishwasher thermometer was broken for some time and the last time the vendor representative was at the facility, they were told the water was hot enough. On 9/2/26 at 1:26 PM, Staff 30 (Regional Maintenance Director) confirmed the facility's dishwasher was a high temperature dishwasher and needed to reach 150 degrees F to 160 degrees F during the wash cycle and 180 degrees F during the final rinse cycle. Staff 1 (Administrator) was observed testing three different final rinse cycles. The temperatures of the three final rinse cycles were: 132 degrees F, 155 degrees F and 165 degrees F. On 9/2/26 at 3:20 PM, Staff 1 and Staff 23 (Vendor Representative) confirmed the dishwasher was not reaching the required 180 degrees F temperature during the final rinse cycle and parts needed to be ordered. Staff 1 stated he was unaware the dishwasher was not properly working and expected staff to test the dishwasher temperatures daily and notifying him if the equipment was not functioning properly. Staff 1 stated his expectations were the dishwasher reached the required manufacturer's guideline of 160 degrees F for the wash cycle and 180 degrees F for the final rinse cycle and verified the dishwasher did not achieve the correct temperatures on all three final rinse cycles tested.

Based on observation, interview, and record review it was determined the facility failed to ensure use of personal protective equipment for 3 of 6 sampled residents (#s 34, 48 and 76) reviewed for transmission-based precautions. This placed residents at increased risk for infections and illness from cross contamination. Findings include: According to the Centers for Disease Control and Prevention (CDC) website (https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html) and (https://www.cdc.gov/covid/hcp/infection-control/index.html): Use Droplet Precautions for patients known or suspected to be infected with pathogens transmitted by respiratory droplets that are generated by a patient who is coughing, sneezing, or talking. Use personal protective equipment (PPE) appropriately. Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection. Personal Protective Equipment Healthcare professionals who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). The facility's Transmission-Based Precautions policy adopted 9/1/24 indicated the following: Droplets are formed when a person coughs, sneezes, speaks, spits, or undergoes oral or tracheal/bronchial suctioning. Transmission occurs when droplets containing microorganisms generated from an infected person are propelled a short distance (about 3 feet). Respiratory droplets are generated when an infected resident coughs, sneezes or talks or during procedures such as suctioning. Masks are used within 6-10 feet of a resident or upon entry into a resident's room with respiratory droplet precautions. Masks are removed prior to leaving the resident's room and hand hygiene is performed. Residents remain on droplet precautions for the duration of illness or per CDC guidelines. 1. Resident 48 was admitted to the facility in 6/2026 with diagnoses including adult failure to thrive. Resident 48's care plan revised on 9/2/26 indicated the resident tested positive for COVID-19. Interventions directed staff to maintain transmission-based precautions following infection control protocols. On 9/3/26 at 12:04 PM a special droplet/contact precautions sign was observed on Resident 48's door which directed staff to: Clean hands when entering and leaving room; Wear an N95 respirator; Wear eye protection (face shield or goggles); Gown and glove at door; Keep door closed; and Use patient dedicated or disposable equipment clean and disinfect shared equipment. On 9/3/26 at 12:04 PM Staff 9 (CMA) was observed to perform hand hygiene, put on gown and gloves, removed ear looped procedure mask, put on an N95 respirator and entered the resident's room without donning eye protection. On 9/3/26 at 12:12 PM Staff 9 stated he did not wear eye protection when providing care to Resident 48. Staff 9 acknowledged he should have worn eye protection while in Resident 48's room. On 9/3/26 at 9:15 AM Staff 10 (Infection Preventionist) stated she expected staff to perform hand hygiene, don gown, gloves, N95 mask, and goggles prior to entering droplet/contact precaution rooms every single time. On 9/3/26 at 4:45 PM Staff 2 (DNS) stated she expected staff in special droplet/contact precaution rooms to don an N95, goggles or face shield, gown, and gloves. 2. Resident 76 was admitted to the facility in 7/2026 with diagnoses including diaphragmatic hernia without obstruction or gangrene. Resident 76's care plan revised on 8/31/26 indicated the resident tested positive for COVID-19. Interventions directed staff to maintain transmission-based precautions following infection control protocols. On 9/1/26 at 1:11 PM a special droplet/contact precautions sign was observed on Resident 48's door which directed staff to: Clean hands when entering and leaving room; Wear an N95 respirator; Wear eye protection (face shield or goggles); Gown and glove at door; Keep door closed; and Use patient dedicated or disposable equipment clean and disinfect shared equipment. On 9/2/26 at 11:26 AM Staff 8 (CNA) was observed wearing an ear-looped procedure mask and donning gown and gloves. Staff 8 entered Resident 76's room without putting on an N95 respirator or eye protection. On 9/2/26 at 11:28 Staff 8 stated she delivered water to Resident 76 and normally wore an N95 and eye protection in a special droplet/contact precautions room. Staff 8 acknowledged she had not worn an N95 respirator or eye protection while she was in the resident's room. On 9/3/26 at 9:15 AM Staff 10 (Infection Preventionist) confirmed staff were to perform hand hygiene, don gown, gloves, N95 mask, and goggles prior to entering droplet/contact precaution rooms every time. On 9/3/26 at 4:45 PM, Staff 2 (DNS) confirmed that staff were required to don an N95, goggles or a face shield, gown, and gloves for any resident placed on special droplet/contact precautions. 3. Resident 34 was admitted to the facility in 8/2026 with diagnoses including right hip fracture. Resident 34's 8/25/26 admission MDS indicated Resident 34 was cognitively intact. A progress note dated 8/28/26 indicated Resident 34's room was placed on droplet precautions due to symptomatic upper respiratory infection symptoms. An 8/29/26 progress note indicated Resident 34 tested positive for COVID-19. Resident 34's 8/31/26 care plan instructed the facility to maintain transmission-based precautions following infection control practices. On 8/31/26 at 12:25 PM a Droplet Precautions sign was observed taped to Resident 69's door, which instructed individuals entering the room to wear gown, gloves, N95 face mask, and eye protection. Attached to the door was a holder with gowns, gloves, N95 and general face masks, and face shields. On 9/2/26 at 12:42 PM Staff 8 (CNA) was observed entering Resident 34's room without eye protection and two staff passed her three meal trays for the residents residing in the room. Neither staff member prompted Staff 8 to put on eye protection. On 9/2/26 at 12:46 PM Staff 8 confirmed she was not wearing eye protection. She stated she knew she was supposed to wear eye protection because she could catch COVID-19 but since she was only going to be in the room a short time to pass trays, she did not need eye protection. On 9/3/26 at 2:47 PM Staff 3 (LPN/RCM) stated anyone entering rooms on droplet precautions were always required to wear the listed PPE (personal protective equipment) listed on the sign, including eye protection.

Based on observation, interview and record review it was determined the facility failed to ensure supervision and safety interventions were in place to prevent smoking related accidents for 1 of 1 sampled resident (# 69) reviewed for smoking safety. This placed resident at risk for burns and accidents. Findings include:The facility 9/2024 Smoking Policy indicated the following:- Staff were responsible for ensuring that smoking by residents is done in a safe manner. - Residents were not allowed to give or borrow smoking materials from other residents.- All smoking materials, including cigarettes, electronic cigarettes and lighters were to be locked up, including smoking materials for residents who were assessed to be supervised smokers.Resident 69 was admitted to the facility in 5/2026 with diagnoses including absence of left thumb and aneurysm of vertebral artery.Review of Resident 69's clinical records revealed the following:- The 6/16/26 care plan indicated Resident 69 had cognitive loss related to dementia.- The 8/3/26 discharge return anticipated MDS indicated Resident 69 had short term memory deficits and severely impaired decision-making skills.- The 8/26/26 quarterly MDS indicated Resident 69 had a BIMS of 14 indicating the resident was cognitively intact- The care plan was revised on 8/31/26 indicating the resident required supervision with smoking due to smoking in inappropriate places and risk for smoking related injury. The care plan instructed staff store Resident 69's smoking material per facility guidelines.Review of Resident 69's smoking assessments revealed the following:- On 8/7/26 Resident 69 was assessed to be independent with smoking and could light her/his own cigarette.- On 8/29/26 Resident 69 was reassessed for smoking safety after she/he was found smoking a lit cigarette in her/his room. The assessment indicated Resident 69 had cognitive deficits, hand dexterity impairments, required supervision with smoking, and had her/his smoking material removed to be stored at the nursing station. An 8/29/26 progress note indicated Resident 69 was found smoking a lit cigarette in her/his room while lying in bed. Observations of Resident 69 from the doorway on 8/31/26 between 9:55 AM through 4:21 PM revealed the following:- At 11:35 AM Resident 69 was observed in her/his room with an unlit cigarette in her/his hand. Resident 69 had a visitor with her/him who was showing Resident 69 how to hide cigarettes in a black pouch bag. The visitor was telling Resident 69 to put the cigarettes in the black pouch bag and placing a small object into an inner pocket of the bag and closing it. - At 11:43 AM a bag was open on Resident 69's over bed table containing at least three visible vape pens.- At 1:09 PM Resident 69 and her/his visitor were in the resident's room taking out and putting back a cigarette pack from the resident's black pouch bag.- At 1:12 PM Resident 69 was in the smoking area where there were roughly four or five residents and a staff member. Resident 69's visitor was observed asking residents for a lighter while Resident 69 was taking a lit cigarette from another resident, puff on the cigarette, and return it to the resident. - At 1:25 PM Resident 69 returned to her/his room without returning her/his cigarettes to the nursing station. - At 3:57 PM Resident 69 was in the designated smoking area and removed a pack of cigarettes from her/his black pouch bag and another resident lit her/his cigarette. After Resident 69 finished the cigarette, Staff 25 (CNA) pushed Resident 69 through the front door and left her/him to propel back to her/his room. Staff 25 did not take Resident 69's smoking material or escort her/him to the nursing station.On 8/31/26 at 4:12 PM Staff 25 stated residents on supervised smoking were required to keep their smoking supplies in a lock box at the nursing station and staff were made aware of smoking level status through the resident's care plan a list located at the nursing station. Staff 25 stated she was unaware Resident 69 was supervised with smoking.On 8/31/26 at 4:21 PM Staff 26 (CNA) stated Resident 69 was placed on supervised smoking on 8/31/26 due to her/his smoking incident. Staff 26 stated Resident 69 should not have any smoking material in her/his possession, and the resident had told him she/he gave her/his cigarettes to the nurse. After being prompted, Staff 26 stated he checked the resident's bag and confirmed he found Resident 69 was in possession of smoking material, which he removed and placed in the lock box at the nursing station.On 9/3/26 at 2:47 PM Staff 3 (LPN/Resident Care Manager) and Staff 4 (LPN/Resident Care Manager) confirmed Resident 69 was assessed on 8/29/26 to be unsafe with smoking after she/he was caught smoking in her/his room and was placed on supervised smoking. Staff 3 stated Resident 69 should have been added to the supervised smoking list on 8/29/26 and staff should have been aware Resident 69 was changed to supervised smoking.

Based on observation, interview and record review the facility failed to ensure residents who required dialysis received care and services consistent with professional standards of practice for 2 of 6 sampled resident (#s 13 and 72) reviewed for dialysis and unnecessary medication. This placed residents at risk for adverse side effects due to lack of appropriate coordination of dialysis care and services. Findings include: Resident 13 was admitted to the facility in 9/2025 with diagnoses including end-stage renal disease requiring dialysis. 1 a. A 9/3/25 physician order indicated Resident 13 was prescribed sevelamer carbonate (a medication that attaches to food eaten while inside the digestive tract and stops the body from absorbing phosphorus) with meals for phosphorus binding due to end-stage renal disease. A review of Resident 13's 8/1/26 through 8/31/26 MAR indicated the resident's sevelamer carbonate was not administered according to physician orders on the following days:-8/4/26 lunch dose missed;-8/6/26 lunch dose missed;-8/8/26 lunch dose missed;-8/11/26 lunch dose missed; -8/13/26 lunch dose missed; -8/15/26 lunch dose missed; -8/18/26 lunch and dinner doses missed; -8/20/26 lunch dose missed;-8/25/26 lunch and dinner doses missed;-8/27/26 lunch dose missed;-8/29/26 lunch dose missed. -A total of 13 missed doses. b. A 9/3/25 physician order indicated Resident 13 was prescribed hydralazine (treats high blood pressure) every six hours for high blood pressure. A review of Resident 13's 8/1/26 through 8/31/26 MAR indicated the resident's hydralazine was not administered according to physician orders on the following days: -8/1/26 lunch dose missed;-8/4/26 lunch dose missed;-8/6/26 lunch dose missed;-8/8/26 lunch dose missed;-8/11/26 lunch dose missed;-8/13/26 lunch dose missed;-8/15/26 lunch dose missed; -8/18/26 lunch and dinner doses missed;-8/20/26 lunch dose missed; -8/22/26 lunch dose missed; -8/25/26 lunch dose missed; -8/27/26 lunch dose missed;-8/29/26 lunch dose missed. -A total of 14 missed doses. On 9/2/26 at 12:01 PM, Staff 14 (CMA) reviewed Resident 13's 8/1/26 through 8/31/26 MAR and stated the resident's sevelamer carbonate and hydralazine was missed because the resident was at dialysis and did not take her/his medications with them to the dialysis appointment. Staff 14 stated when a resident's medication was missed, the nurse should be notified. On 9/3/26 at 9:38 AM, Staff 20 (RN) reviewed Resident 13's 8/1/26 through 8/31/26 MAR and confirmed there were numerous doses of the resident's sevelamer carbonate and hydralazine which were missed. Staff 20 stated he was unaware of Resident 13's missed medications, if he had been aware of missing medications, he would have contacted the provider and had the medication times adjusted. On 9/3/26 at 12:01 PM, Staff 4 (LPN Care Manager) confirmed Resident 13 had multiple missing doses of sevelamer carbonate and hydralazine and the resident's physician should have been notified to ensure the medication administration times were adjusted. On 9/4/26 at 10:49 AM, Staff 2 (DNS) confirmed Resident 13 missed many doses of sevelamer carbonate and hydralazine. Staff 2 stated it was her expectation that residents receiving dialysis had their medications scheduled outside of dialysis times. 2. Resident 72 was admitted to the facility on [DATE] with diagnoses of end stage renal disease, heart failure, and essential primary hypertension. A review of Resident 72's care plan dated 8/7/26 indicated routine hemodialysis scheduled Monday, Wednesday and Fridays with 12:00 PM appointment time. A review of Resident 72's active orders revealed no instructions to hold the missed medications on dialysis days or to send medications with the resident to dialysis appointments. A review of Resident 72's MAR for the month of 8/2026 revealed the following doses of medications were missed while the resident was out of the facility for dialysis treatment: -Carvedilol (a medication used to treat heart failure) was missed twice, simvastatin (a medication used to reduce the risk for heart attack and stroke) was missed twice, furosemide (a medication used to manage fluid overload) was missed twice, nifedipine (a medication used to treat high blood pressure) was missed twice, hydralazine (a medication used to treat high blood pressure) was missed 12 times, and sevelamer carbonate (a medication used to bind phosphate) was missed 12 times. A progress note on 8/29/26 from Staff 24 (LPN) described communication to the physician regarding Resident 72's continued high blood pressures despite treatment with carvedilol twice daily, hydralazine three times daily, and nifedipine twice daily. Staff 4 (LPN Resident Care Manager) indicated on 9/3/26 at 12:29 PM although the provider was notified of high blood pressures, they were not made aware of any missed doses of scheduled medications. Staff 4 stated residents should receive medications prior to dialysis and upon return to facility, any missed doses of medications should be communicated to the provider with adjustment of administration times to prevent future missed doses. On 9/2/26 at 5:12 PM Resident 72 stated she/he was given medications prior to leaving for dialysis and upon return to the facility. Resident 72 stated her/his preference was to have medications sent to dialysis with her/him to prevent any missed doses. Resident 72 stated she/he associated the missed medication doses with not feeling well. On 9/3/26 at 12:32 PM Staff 9 (CMA) stated medications were due during dialysis times and were not sent with the residents to dialysis, the facility process included administration of medications while at the facility and notification of missed doses to the nurse for further follow up. On 9/4/26 at 10:11AM, Staff 2 (DNS) stated medications should be scheduled around dialysis appointment times and the facility would be investigating the reason for missed medications.

Based on observation, interview and record review it was determined the facility failed to ensure an antibiotic was not administered for an excessive duration for 1 of 5 sampled residents (#8) reviewed for unnecessary medications. This placed residents at risk for antibiotic resistance and serious infections. Findings include: The facility's 9/2024 Infection Control and Antibiotic Stewardship Policy and Procedure indicated the following:-A regular analysis of antibiotic use, prescribing trends and antibiotic resistance data would be completed.-Feedback and recommendations would be provided to practitioners related to antibiotic resistance data and prescribing practices. -Education to staff and practitioners would be provided related to antibiotic stewardship. Resident 8 was admitted to the facility in 2/2025 with diagnoses including dementia. A 7/2025 Hospital Discharge Summary documented the following:-Resident 8 was to receive one gram of cephalexin (an antibiotic used to treat bacterial infections) every 6 hours for four weeks, followed by 500mg every six hours for four weeks and then 500mg twice daily indefinitely (an unlimited, unknown, or unspecified period of time without a fixed end date) related to the presence of AICD (Automatic Implantable Cardioverter-Defibrillator) and risk of a possible lead infection (a serious infection where bacteria or other microorganisms colonize the insulated wire [lead] running from the defibrillator through the blood vessels into the heart).-The resident was referred to an Infectious Disease (ID) specialist for outpatient follow-up. A review of Resident 8's 9/2025 Progress Notes revealed a Resident Care Manager was to follow up with ID for on-going management of the resident's diagnosis of bacteremia (live bacteria in the bloodstream). Resident 8's 10/8/25 Pharmacist Note to Attending Physician/Prescriber documented the following:-The resident had been on cephalexin since 7/2025 for bacteremia. No stop date was provided for the antibiotic, and it was unclear if the antibiotic was to be used indefinitely. -Staff 46 (Physician Assistant) hand wrote on the note the cephalexin was to be continued due to an AICD lead infection. Lifelong antibiotic per Infectious Disease. Resident 8's 7/1/26 Quarterly MDS documented the resident was severely cognitively impaired and received an antibiotic. Resident 8's 9/2026 Physician orders documented the received cephalexin twice daily related to bacteremia and as a lifelong prophylactic antibiotic per ID. No evidence was found in Resident 8's clinical record to indicate Resident 8 had a follow-up appointment with ID to review the indefinite use of the prophylactic antibiotic. On 9/1/26 at 8:29 AM, Resident 8 was observed in her/his room in bed. Resident 8 was unable to answer any questions regarding her/his medications, including the use of cephalexin. On 9/2/26 at 3:19 PM, Witness 5 (Infectious Disease Receptionist) stated the ID clinic attempted to contact Resident 8 to schedule an appointment with ID but was unable to make contact. On 9/2/26 at 3:56 PM, Staff 46 stated ID started Resident 8 on a prophylactic antibiotic while in the hospital due to a concern for a lead infection. Staff 46 stated the resident's discharge hospital summary indicated she/he was to be seen by ID, and Staff 46 was unsure if the resident had been seen. On 9/2/26 at 12:36 PM and 4:38 PM, Staff 10 (Infection Preventionist/RNCM) stated she reviewed the facility's antibiotic report on a daily basis to ensure residents who received antibiotics, including those prescribed prophylactically, had an appropriate rationale for the antibiotics as well as a stop date. Staff 10 stated residents who received long-term prophylactic antibiotics were typically followed by ID. Staff 10 stated Resident 8 had been on cephalexin prophylactically since 7/2025 when the resident discharged from the hospital. Staff 10 stated Resident 8's antibiotic had not been reviewed by ID since she/he started the antibiotic in 7/2025. Staff 10 further stated the facility did not schedule a follow-up appointment with ID for the resident and should have because [you] can't just put someone on indefinite antibiotics without follow up. On 9/2/26 at 4:49 PM, Staff 2 (DNS) stated the indefinite use of an antibiotic would have been caught during the pharmacy review, and a recommendation would have been provided. Staff 2 stated she started working at the facility in 3/2026 and was unaware of any pharmacy recommendations related to Resident 8's use of cephalexin. On 9/3/26 at 9:16 AM, Staff 48 (Medical Director) stated the facility should have scheduled an appointment with ID following Resident 8's discharge from the hospital in 7/2025, but he thought it unlikely the ID specialist would have made any changes to Resident 8's antibiotic order. After reviewing the 10/2025 Pharmacist Note to the Attending Physician/Prescriber, Staff 48 stated there had been no indication the facility needed to reach out to ID because the order included a stop date.

Based on observation, interview and record review it was determined the facility failed to ensure residents were free of significant medication errors for 1 of 1 sampled resident (#64) reviewed for antibiotics. This placed residents at risk for adverse side effects of an incorrect antibiotic being administered. Findings include:The facility's 1/2023 Medication Administration Policy and Procedures directed the following:-Prior to administration, review and confirm medication orders for each individual resident on the MAR.-Compare the medication and dosage schedule on the resident's MAR with the medication label. Resident 64 was admitted to the facility in 8/2026 with diagnoses including osteomyelitis (an infection and inflammation of the bone and bone marrow). Resident 64's 8/21/26 admission MDS indicated the resident was usually able to understand and make her/himself understood to others and received intravenous (IV) medication while a resident at the facility. A review of Resident 64's 8/2026 MAR documented the resident received cefazolin sodium solution (a first-generation antibiotic used primarily to treat bacterial infections that target staphylococci and streptococci bacteria) intravenously every eight hours (at 6:00 AM, 2:00 PM and 11:00 PM) for osteomyelitis between 8/15/26 through 8/31/26.An 8/31/26 Progress Note written by Staff 28 (LPN) documented she observed an empty package of cefriaxone (a third-generation antibiotic used to treat bacterial infections that covers a wide range of gram-negative bacteria) to hang from Resident 64's IV pole at approximately 11:00 PM on 8/30/26. The note further documented the resident was stable and without signs or symptoms of an allergic reaction, and Staff 2 (DNS) was notified of the suspected medication error. On 8/31/26 at 1:38 PM, Resident 64 was observed in her/his room in bed. Resident 64 stated Staff 28 informed her/him on 8/30/26 she/he received the wrong IV antibiotics. The resident did not report any adverse side effects from receiving the incorrect antibiotics. On 9/1/26 at 1:05 PM, Staff 28 stated she always compared the label on an IV medication against what was written in the TAR prior to administering the medication to ensure the medication and dose were correct. Staff 28 stated Resident 64 was to receive cefazolin intravenously every eight hours, and when she went to administer the resident's 11:00 PM dose on 8/30/26, she observed an empty bag of ceftriaxone to hang from the resident's IV pole. Staff 28 stated Staff 29 (Agency LPN) worked the shift prior and was responsible for administering the resident's 2:00 PM IV antibiotics. Staff 28 stated she notified the resident, Staff 2 (DNS) and the resident's medical provider of the medication error. Staff 28 stated the resident did not experience any signs or symptoms of an allergic reaction from receiving the wrong antibiotic. On 9/1/26 at 1:37 PM, Staff 29 stated she administered ceftriaxone instead of cefazolin to Resident 64 on 8/30/26. Staff 29 stated she had a moment of carelessness and made a mistake. Staff 29 stated there were multiple boxes of IV supplies for residents located in the medication room and swore Resident 64's name was written on the box from which she removed the medication. On 9/1/26 at 1:48 PM, Staff 2 acknowledged Staff 29 administered the wrong IV antibiotic to Resident 64 and stated it was a simple error to avoid. Staff 2 confirmed staff were to follow the five rights of medication administration (confirming the right patient, drug, dose, route and time) to avoid medication errors, and if Staff 29 had followed the five rights, the medication error would not have happened.

Based on observation, interview and record review it was determined the facility failed to ensure routine dental services were provided for 1 of 2 sampled residents (#13) reviewed for dental care needs. This placed residents at risk for delays in receiving necessary dental care. Findings include:The facility's Dental Services policy, dated 2001, indicated routine and emergency dental services were available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. Resident 13 was admitted to the facility in 9/2025 with diagnoses including diabetes, end-stage renal disease, major depressive disorder and dysphagia (difficulty swallowing). Resident 13's 9/9/25 admission MDS indicated the resident had no cognitive impairment and had her/his own teeth. Resident 13's 5/29/26 IDT Conference Notes indicated the resident requested to have her/his teeth cleaned. Resident 13's 8/19/26 Social History Quarterly Review indicated the resident did not have a dental consultation over the previous quarter. On 8/31/26 at 3:47 PM, Resident 13 was observed in her/his room, in bed. Resident 13 was observed to have brownish colored teeth and bad breath. Resident 13 stated she/he requested to see a dentist but there was no further follow-up regarding dental services, and, as of this date, she/he had not seen a dentist. On 9/3/26 at 10:35 AM, Staff 6 (Social Service Coordinator) stated on 5/29/26 she emailed a referral to Resident 13's provider, requesting dental services. Staff 6 stated after she sent the referral on 5/29/26, there was no further follow-up regarding Resident 13's dental services and acknowledged Resident 13 was not scheduled for a dental appointment as requested. On 9/3/26 at 1:25 PM, Staff 2 (DNS) stated she expected Resident 13 to receive the dental services she/he needed.

Based on interview and record review it was determined the facility failed to ensure resident records were accurate for 1 of 2 sampled residents (#13) reviewed for showers. This placed residents at risk for inaccurate health records and missed showers/baths. Findings include:Resident 13 was admitted to the facility in 9/2025 with diagnoses including diabetes, end-stage renal disease and major depressive disorder. Resident 13's 9/9/25 admission MDS indicated the resident had no cognitive impairment and required substantial to maximal assistance with showering/bathing. Resident 13's Showering/Bathing task logs for 7/2026 were reviewed and indicated the resident's last shower/bath documented, occurred on 7/1/26. No showering/bathing task logs were available for 8/2026. An 8/5/26 Shower Schedule indicated Resident 13 was scheduled for showering/bathing on Monday and Friday, evening shift. On 9/2/26 at 9:45 AM and 4:59 PM, Staff 12 (CNA) and Staff 18 (CNA) stated residents' showers and bed baths were documented on showering/bathing task logs when the resident received a shower or bed bath. On 9/2/26 at 10:07 AM, Resident 13 stated she/he received showering/bathing at least one time per week. Resident 13 thought her/his last shower/bath was approximately one week ago. On 9/2/26 at 11:39 AM, Staff 11 (Assistant Regional Director of Clinical Services) provided Resident 13's showering/bathing records which indicated the last time Resident 13 received showering/bathing was on 7/1/26. No additional evidence relating to Resident 13's showering/bathing was found in her/his health record. On 9/2/26 at 4:53 PM, Staff 11 stated she spoke with Resident 13 who reported she/he received bed baths and had no concerns regarding missed showers/baths. Staff 11 confirmed there was no evidence Resident 13 received showers/baths since 7/1/26. On 9/4/26 at 10:48 AM, Staff 2 (DNS) stated there was no showering/bathing documentation for Resident 13 after 7/1/26 and she expected documentation to be in place to indicate if the resident received consistent showering/bathing care.

Based on interview and record review the facility failed to ensure a resident was treated with respect and dignity for 2 of 3 sampled residents (#s 1 and 5) reviewed for dignity. This placed residents at risk for undignified care. Findings include:Resident 1 was admitted to the facility in 7/2025 with diagnoses including type 2 diabetes and depression. Resident 1's 7/25/25 Care Plan identified Resident 1 was at risk for decreased psychosocial well-being and adjustment issues, including emotional distress and ineffective coping. The resident's care plan directed staff to use appropriate and effective communication, encourage personal preference and honor quality of life choices to ensure dignity and respect. Resident 5 was admitted to the facility 1/2026 with diagnoses including cellulitis and agoraphobia. Resident 5's 1/23/26 Care Plan identified Resident 5 was at risk for her/his psychosocial well-being, including increased agitation and tearfulness. The resident's care plan directed staff to honor the resident's preferences and choices to promote dignity and decrease anxiety. A 2/7/26 Facility Reported Event documented on 2/6/26, Resident 1 during a routine skin assessment reported inappropriate and undignified care from Staff 6 (RN) when performing a routine skin assessment. Staff 6 reportedly stated to Resident 1 to not fart on him while assessing the resident's peri-area. The report revealed this made Resident 1 feel both uncomfortable and undignified as the comment was inappropriate and unrelated to the cares being performed. On 2/17/26 at 10:19 AM, Resident 1 stated during the skin assessment, Staff 6 stated don't' fart on me, a lot of people fart on me, while examining the areas near the resident's anus. Resident 1 reported feeling disrespected and undignified and stated Staff 6's comment was unnecessary. Resident 1 stated she/he did not want Staff 6 to provide care in the future.On 2/17/26 at 11:15 AM, Staff 6 (RN) confirmed using the following statement with all residents during care: I am the registered nurse today. I have a couple of rules, don't fall on me, don't fart on me. Staff 6 stated he used the comment as a formal tool to establish rapport and reported he believed the comment was humorous rather than inappropriate.On 2/17/26 at 11:54 AM, Resident 5 indicated Staff 6 made unprofessional comments during cares, including weird jokes, and asked Resident 5 to not fart on him while performing routine catheter care. Resident 5 reported these comments made her/him feel awkward and uncomfortable during the time the care was provided. On 2/17/26 at 12:09 PM, Staff 7 CNA reported concerns about Staff 6's behavior. Staff 7 confirmed hearing Staff 6 told Resident 1 not to fart in [his/her] face during the skin assessment near her/his peri-area and rectum.On 2/17/26 at 3:26 PM, Staff 1 (Administrator) stated Staff 6's behavior and comments, including the phrase don't fart on me, did not honor resident dignity and were inappropriate when providing resident care.

Based on observation, interview and record review it was determined the facility failed to report an allegation of physical abuse to the State Agency within the required 2 hours for 1 of 3 sampled residents (#9) reviewed for abuse. This failure placed residents at risk of unreported physical abuse. Findings include:Resident 9 was admitted to the facility in 10/2024 with diagnoses including metabolic encephalopathy and atrial fibrillation. Resident 9's 11/4/24 Care Plan identified Resident 9 with cognitive loss affecting decision-making ability.A 2/7/26 Facility Incident Report documented on 2/15/26, that Resident 9 placed a pillow over Resident's 8 face and was witnessed throwing heat packs at Resident 8 while the resident was sleeping.On 2/17/26 at 1:44 PM, Staff 11 (RNCM) stated she reported the incident to Staff 1 (Administrator). Staff 11 stated Staff 1 informed her the incident would be investigated but not reported to the State Agency. Staff 11 stated she did not know why the incident was not reported and believed the investigation was handled by facility administration. On 2/17/26 at 2:41 PM, Staff 14 (RN) stated she did not witness the event and reported the incident based on information received from care staff. Staff 14 stated the incident was not reported to the State Agency because administration determined it was not reportable.On 2/18/26 at 4:15 PM, Staff 1 (Administrator) stated he was notified of the incident by care staff and did not report the incident to the State Agency because he did not believe the incident to be abuse. Staff 1 acknowledged that all allegations of abuse need to be reported to the State Agency within two hours of the reported allegation.

Based on interview and record review the facility failed to implement care according to the resident's care plan for 1 of 3 sampled residents (#1) reviewed for care plans. This placed residents at risk for unmet personalized care needs. Findings Include:Resident 1 was admitted to the facility in 7/2025 with diagnoses including type 2 diabetes and depression.Resident 1's 7/7/25 Cognitive Assessment revealed the resident with a 15 out 15 BIMS score indicating no cognitive impairment.Resident 1's 7/25/25 Care Plan identified Resident 1 preferred individualized preference for female caregivers to ensure and promote a level of comfort when receiving care. The resident's care plan directed staff to ensure female caregivers were available when providing care.On 2/17/26 at 10:19 AM, Resident 1 stated during a routine skin assessment, Staff 6 (RN) did not have an additional female caregiver present in the room as preferred. Resident 1 stated the facility's practice when male nurses performed skin assessments was to have at least on female caregiver present to perform additional peri-care services to ensure the resident's comfortability and preferences. On 2/17/26 at 11:07 AM, Staff 5 (LPN) stated the standard protocol based on Resident 1's care plan was to ensure that at least one female caregiver was in the room when performing routine assessments including skin assessments. Staff 5 stated he was aware of Resident 1's caregiver preference and stated staff were expected to honor the resident's preference to maintain her/his comfort.On 2/17/26 at 11:15 AM, Staff 6 (RN) stated he provided care to Resident 1 but refused to answer when asked whether a female caregiver was present when he provided nursing services.On 2/17/26 at 12:04 PM, Staff 8 (CNA) stated Resident 1's preference was for female caregivers only and stated Staff 6 provided nursing services without a female caregiver present in the room.On 2/17/26 at 3:26 PM, Staff 1 (Administrator) stated Staff 6 failed to honor Resident 1's needs and preferences by performing nursing services without ensuring female caregivers were present.

Based on interview and record review it was determined the facility failed to ensure physician orders were followed for 1 of 3 sampled residents (#1) reviewed for medication. This placed residents at risk for adverse medication side effects. Findings include:Resident 1 admitted to the facility in 2025 with diagnoses including obesity and diabetes. The 9/23/25 physician order indicated Resident 1 was to receive semaglutide (Ozempic) injection once weekly.On 12/23/25 at 11:47 AM, Resident 1 stated that she/he missed several doses of Ozempic due to the medication not being ordered. A review of Resident 1's 10/2025, 11/2025 and 12/2025 MARs and TARs indicated she/he did not receive semaglutide on the following dates:-12/16/25-10/30/25-10/23/25-10/16/25-10/9/25-10/2/25Resident 1's Progress Notes indicated that Staff 2 (LPN) administered medication to Resident 1 on 10/2/25, 10/9/25, 10/16/25, 10/23/25 and 10/30/25, but did not administer semaglutide for the following reasons: medication was not filled last week, a new order was needed, the prescription had ended, the resident requested a prescription, or the notes were left blank.On 12/23/25 at 1:19 PM, a message was left for Staff 2. A return call was not received.On 12/23/25 at 2:31 PM, Staff 3 (LPN) stated she did not administer Ozempic on 12/16/25 because she thought it had to be refrigerated and she was not aware it was kept in the medication cart once opened. On 12/23/25 at 2:52 PM, Staff 1 (DNS) acknowledged Resident 1 did not receive semaglutide as ordered on the identified dates.

Based on observation, interview and record review it was determined the facility failed to ensure chemotherapy medications were administered as ordered for 1 of 1 resident (#2) reviewed for chemotherapy medications. This failure resulted in Resident 2 experiencing thrombocytopenia (a medical condition characterized by a lower-than-normal number of platelets in the blood), pancytopenia (a medical condition characterized by a low number red blood cells, white blood cells and platelets) and neutropenia (a condition where there is an abnormally low number of neutrophils in the blood which are a type of white blood cell that plays a crucial role in fighting infections), which caused the resident to require numerous blood transfusions, emergency department visits and hospitalizations. Findings include: The facility's 1/2023 Medication Administration General Guidelines Policy and Procedure indicated medications are administered in accordance with written orders of the prescriber. If a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current diagnosis or condition, the nurse calls the provider pharmacy for clarification prior to the administration of the medication. If necessary, the nurse contacts the prescriber for clarification. This interaction with the pharmacy and the resulting order clarification are documented in the nursing notes and elsewhere in the medical record as appropriate. The U.S. Food and Drug Administration (FDA) Patient Information Fact Sheet for Temodar (temozolomide, a chemotherapy drug used to treat specific types of brain cancer, such as Glioblastoma), revised 9/2023, indicated there are two common dosing schedules for taking or receiving temozolomide depending on the type of brain cancer tumor, which include:-People with certain brain cancer tumors take or receive temozolomide one time each day for 42 to 49 days in a row, along with receiving radiation treatment. This is one cycle of treatment. After this, your healthcare provider may prescribe six more cycles of temozolomide as maintenance treatment. For each of these cycles, you take or receive temozolomide one time each day for five days in a row and then you stop taking it for the next 23 days. This is a 28-day maintenance treatment cycle.-People with certain other brain cancer tumors take or receive temozolomide one time each day for five days in a row only, and then stop taking it for the next 23 days. This is one cycle of treatment (28 days). Your healthcare provider will watch your progress on temozolomide and decide how long you should take it.The Patient Information Fact Sheet also indicated temozolomide can cause serious side effects, including decreased blood cell counts. Some people need to be hospitalized or need to receive transfusions to treat their decreased blood cell counts. Do not take more temozolomide than prescribed. If you take more temozolomide than prescribed, call your healthcare provider or get emergency medical help right away.Resident 2 was admitted to the facility in 11/2024 with diagnoses including a brain disorder. Resident 2's 2/13/25 Quarterly MDS revealed the resident was severely cognitively impaired.A 4/21/25 Neuro-Oncology Consult Encounter Note signed by Witness 2 (Medical Doctor) indicated the following:-Resident 2 had a diagnosis of Glioblastoma, experienced a left temporoparietal craniotomy for resection of mass (a removal of an abnormal growth from the areas of the brain located in the temporal and parietal lobes) in 10/2024 and was deemed not a radiation oncology candidate.-The resident's fourth cycle of chemotherapy was delayed due to thrombocytopenia and would resume following this encounter.-The resident's current medication list included 140mg and 250mg capsules of temozolomide for a total of 390mg. The capsules were to be taken once daily at bedtime and on days one to five of a 28-day treatment cycle. A 4/21/25 Chemotherapy Telephone Conversation Note completed by Witness 3 (Neuro-Oncology RN) revealed Witness 3 reviewed Resident 2's chemotherapy orders, which directed the resident to receive a total dose of 390mg temozolomide for the first five days of a 28-day cycle, with Staff 22 (Former LPN-Resident Care Manager). According to this note, Staff 22 confirmed understanding and did not have further questions. A 4/21/25 Progress Note revealed Resident 2 was placed on alert for the start of 140mg temozolomide that was to be taken at bedtime for 28 days. No additional evidence was found in Resident 2's clinical record that clarified the telephone conversation between Witness 3 and Staff 22 or that a physical order for the temozolomide was obtained. Resident 2's 4/2025 and 5/2025 Physician Orders directed the resident to receive 140mg and 250mg capsules of temozolomide once daily at bedtime for 28 days. This medication was to start 4/21/25.A review of Resident 2's 4/2025 and 5/2025 MARs revealed the resident received 390mg temozolomide once daily from 4/21/25 through 5/13/25, for a total of 23 doses. A 5/14/25 Progress Note written by Staff 23 (LPN) revealed she spoke with Witness 3 who informed her Resident 2's order for temozolomide was supposed to be discontinued on 4/26/25. The note indicated the medication was discontinued on 5/14/25 and the resident was put on alert. A review of Resident 2's clinical record revealed the resident was transferred to the emergency department on 5/19/25, 5/24/25 and 6/5/25 and hospitalized from [DATE] to 5/21/25 and 6/1/25 to 6/4/25 related to thrombocytopenia and the need for platelet transfusions. The resident's clinical record also revealed the resident was hospitalized from [DATE] to 6/10/25 for chemotherapy induced pancytopenia and a neutropenic fever (a serious complication that can occur in people undergoing chemotherapy).On 11/3/25 at 11:25 AM, Resident 2 was observed to walk with her/his walker throughout the hallways of the facility. The resident was able to answer basic yes-or-no questions but could not answer specific questions related to her/his chemotherapy medication. On 11/4/25 at 8:23 AM, Witness 4 (Pharmacist) stated the standard cycle for temozolomide for a person in the maintenance phase of their cancer treatment consisted of receiving the medication for five days followed by a 23-day rest period. Witness 4 stated this drug was extremely toxic, and when given incorrectly, could cause bone marrow toxicity, bleeding and severe infections. On 11/4/25 at 1:55 PM, Witness 2 stated Resident 2 had terminal brain cancer and was in the maintenance phase of her/his treatment. Witness 2 stated he prescribed Resident 2 temozolomide for five days in 4/2025 without any refills on the prescription, which was a standard a prescription for chemotherapy and in accordance with recommendations made by the FDA. Witness 2 stated chemotherapy treatment given greater than five days could cause pretty bad bone marrow suppression which was what happened with Resident 2. Witness 2 further stated the amount of chemotherapy Resident 2 received was so toxic and was why the resident required on-going transfusions. On 11/5/25 at 9:14 AM, Staff 22 stated he spoke with Witness 3 on 4/21/25 after Resident 2 returned to the facility from her/his neuro-oncology appointment in order to discuss the order for chemotherapy and subsequent lab work. Staff 22 stated Resident 2 returned from her/his appointment with a bottle of temozolomide and a paper order for the medication. Staff 22 stated he transcribed the order for temozolomide into the resident's clinical record as it was written but could not recall how many days the order stated the resident was to receive the medication. Staff 22 stated Staff 2 (DNS) verified he inputted the order for temozolomide into the resident's clinical record accurately and gave Staff 2 the paper order for temozolomide which was provided by the clinic. On 11/5/25 at 11:58 AM, Staff 23 stated she received a phone call from Witness 3 in 5/2025 after Resident 2 returned from an appointment at the neuro-oncology clinic. Staff 23 stated she was informed by Witness 3 the resident was not supposed to receive temozolomide past 4/26/25.Attempts to contact Witness 3 on 11/4/25 and 11/5/25 were unsuccessful. On 11/5/25 at 1:01 PM, Staff 24 (Medical Director) stated Resident 2 was supposed to receive temozolomide for five days in 4/2025 but received the medication longer than ordered. Staff 24 stated he expected nurses to contact the prescriber of resident medications to get clarification with any order that was ambiguous and that Resident 2's 4/21/25 order for temozolomide was unclear. Staff 24 further stated this incident was a big mess up which resulted in Resident 2 going back-and-forth to the hospital.On 11/6/25 at 11:04 AM, Staff 2 stated Resident 2 returned from her/his appointment on 4/21/25 with a Neuro-Oncology Consult Encounter Note which noted the resident's current medication list was to include 390mg temozolomide taken once daily at bedtime on days one to five of a 28-day treatment cycle. Staff 2 stated this note did not constitute an order for the medication. Staff 2 stated she completed a lengthy investigation of this medication error and was never able to find a paper order from the resident's neuro-oncology clinic for the temozolomide. Staff 2 denied ever visualizing a paper order for the medication or checking Staff 22's entry into Resident 2's clinical record regarding the medication. Staff 2 stated Staff 22 should have contacted Witness 2 on 4/21/24 and requested clarification for the temozolomide order in writing. The deficient practice was identified as Past Noncompliance based on the following:On 5/20/25, the deficient practice was identified by the facility and was corrected when the facility completed an investigation of the incident and determined the medication was administered for an excessive duration. The Plan of Correction included:1. Licensed nurses were educated on the process for obtaining paper copies for all prescriptions from any outside medical provider, and all prescriptions entered into a resident's medical record required a second licensed nurse to sign off for accuracy. 2. An audit of MARs was completed for all residents to ensure paper copies for all prescriptions from any outside provider were obtained and two licensed nurse signatures were present. 3. Weekly medication prescription audits were completed by Staff 2 for four weeks.

Based on observation, interview, and record review it was determined the facility failed to keep residents free from hazards, provide appropriate monitoring and supervision for residents with known substance use disorder and a history of illicit drug use, ensure staff possessed adequate knowledge and training regarding substance use, and follow up on recommendations from a fall investigation for 2 of 8 sampled residents (#s 3 and 217) reviewed for accidents and positioning/mobility. This failure was determined to be an immediate jeopardy situation which resulted in a serious adverse outcome for Resident 217, and placed residents at risk for injury, drug overdose, and death. Findings include: The facility's February 2023 policy titled Resident Possession and Use of Illegal Substances indicated the following: -The possession and use of illegal substances by residents will not be tolerated; and -Facility staff will have knowledge of signs, symptoms, and triggers of possible illegal substance use. 1. Resident 217 was admitted to the facility in ,d+[DATE] with diagnoses including encounter for surgical aftercare following surgery on the nervous system and lower back pain. A review of Resident 217's [DATE] Nursing Admission/Readmission Evaluation/Assessment revealed she/he was alert and oriented and had a history of polysubstance use but denied current use. No evidence was found in Resident 217's care plan to indicate her/his history of polysubstance use. A progress note dated [DATE] at 7:57 PM indicated Resident 217 was found unresponsive in the facility's parking lot. Facility staff administered an intramuscular dose of Narcan (a medication used to reverse the effects of an opioid overdose) to Resident 217 to reverse the effects of a suspected opioid overdose, called 911 and sent her/him to the hospital emergency department. Resident 217's physician was notified of this incident and placed Resident 217's order for Oxycodone on hold pending a face to face meeting with Resident 217 on [DATE]. A review of Resident 217's [DATE] post visit hospital summary revealed she/he was seen in the emergency department for approximately two hours where she/he was monitored following an opioid overdose in the parking lot of the facility. A review of Resident 217's electronic health record revealed she/he returned to the facility on [DATE] at 11:44 PM. No evidence was found to indicate the facility initiated monitoring for opioid use after she/he returned from the hospital. A Social Services progress note written by Staff 16 (Social Services Director) dated [DATE] at 10:28 AM indicated Resident 217 was clearly upset and agitated about her/his medication being changed due to her/his opioid use. Resident 217 stated she/he may have to self-medicate and may blow out of here. A review of the facility reported incident investigation completed on [DATE] revealed Resident 217 was not in the facility during rounds on [DATE] at 4:30 AM and staff attempted to reach her/him by calling her/his cell phone. Resident 217 was found unresponsive on the floor of her/his bathroom on [DATE] at 6:30 AM. On [DATE] at 11:30 AM Staff 27 (LPN) stated Resident 217 left the facility with her/his friends almost daily. Staff 27 stated there were times when Resident 217 was barely rousable and the facility did not have a procedure to assess residents after being out of the facility. Staff 27 stated he attempted to resuscitate Resident 217 during the incident on [DATE] but was unsuccessful and Resident 217 was pronounced dead. Staff 27 stated he found drug paraphernalia including a lighter, burnt aluminum foil, a metal straw with a rubber tip and a powdery substance on the floor with Resident 217. Staff 27 further indicated he did not receive training related to SUD (substance use disorder). On [DATE] at 12:00 PM, Staff 10 (CNA) stated she was not aware of Resident 217's drug use and staff had not been asked to keep an eye on [her/him]. Staff 10 stated she did not receive any training regarding Resident 217's drug use. On [DATE] at 12:08 PM, and at 1:33 PM Staff 9 (CMA) stated she was unaware of any residents with polysubstance abuse or SUD. Staff 9 stated after the incident where Resident 217 overdosed in the facility parking lot, her/his oxy was discontinued. Staff 9 stated Resident 217 changed drastically after this and she/he began to refuse other medications. Staff 9 stated staff were not asked to monitor Resident 217 or do extra rounds or anything. Staff 9 stated on [DATE], Resident 217 was found deceased in her/his bathroom. Once the police left, the housekeeper was asked to clean the room and found drug paraphernalia hidden in Resident 217's bathroom. Staff 9 further stated she was not provided any education on identifying signs and symptoms related to the suspicion of drug use. On [DATE] at 12:09 PM Staff 20 (CMA) stated he was made aware of Resident 217's SUD on [DATE] by the emergency medical technicians who responded to incident. Staff 20 stated prior to the incident, he did not receive any training on how to identify signs and symptoms related to the suspicion of drug use or how and when to monitor a resident with a diagnosis of SUD if they spent time away from the facility. On [DATE] at 12:33 PM, Staff 8 (Housekeeper) stated he was tasked to clean Resident 217's room after she/he died but did not know about SUD precautions. Staff 8 stated he found a lighter, a piece of aluminum foil and bag of white powder in Resident 217's bathroom, which he picked up using a paper towel, placed in a plastic bag and handed to Staff 27. On [DATE] at 2:05 PM Staff 16 (Social Services Director) acknowledged Resident 217 was sent to the hospital emergency department following an opioid overdose in the facility's parking lot and she/he was upset that her/his Oxycodone was being held as a result. Staff 16 acknowledged Resident 217 talked about self-medicating and may blow out of here as she indicated in the [DATE] progress note. Staff 16 stated staff were uneducated related to interventions and monitoring for SUD residents. Staff 16 stated she participated in a Substance Use/Abuse Training on [DATE]. Staff 16 further stated she was instructed to provide training which included signs and symptoms of SUD and possible signs of an overdose to the licensed nursing staff only but did not include CNAs or any other staff. On [DATE] at 3:06 PM Staff 1 (Administrator) acknowledged Resident 217 passed away from the incident which occurred on [DATE]. Staff 1 stated it was a group decision to educate the nurses rather than the CNAs because the nurses would be doing the assessments. 2. On [DATE] at 9:31 AM Staff 16 provided additional information to the survey team which revealed an additional five residents (#s 18, 37, 61, 119 and 417) who resided in the building that had SUD who did not have baseline care plans to address their history of SUD and potential relapse and reuse. On [DATE] at 11:26 AM, Staff 14 (CNA) stated the facility trained staff on different tasks, but could not recall a specific training for SUD. She stated there were monthly in-service meetings, but had not yet had one regarding SUD. On [DATE] at 11:30 AM Staff 15 (LPN) stated she was not aware of Resident 217 having issues with drug use. She stated she received training online, but could not recall if there was a training regarding signs and symptoms of drug use and monitoring for drug use. She stated she had not received education on how to provide information to residents related to the risk of drug use. On [DATE] at 11:30 AM, Staff 13 (CNA) reported she was aware Resident 217's overdose in her/his bathroom and passed away however the only training she recalled was a sign posted in the breakroom to be aware of different things. On [DATE] at 11:47 AM, Staff 11 (CNA) reported she was aware Resident 217's overdose in her/his bathroom and passed away but was unaware the resident used drugs before that day. Staff 11 stated the facility did not provide any trainings related to SUD after the incident related to Resident 217. On [DATE] at 12:28 PM, Staff 31 (Agency CNA) and at 1:36 PM Staff 32 (CNA) stated they did not receive any training regarding SUD or monitoring for signs and symptoms of SUD. On [DATE] at 1:38 PM Staff 12 (CNA) stated she had not received any information recently about monitoring for suspicious behavior or drug related materials for residents with SUD. On [DATE] at 1:50 PM Staff 51 (CNA) stated she was not aware any residents used recreational drugs prior to [DATE] when staff provided training. On [DATE] at 2:05 PM Staff 16 (Social Services Director) stated staff were uneducated related to interventions and monitoring for SUD residents. Staff 16 stated she participated in a Substance Use/Abuse Training on [DATE]. Staff 16 further stated she was instructed to provide training which included signs and symptoms of SUD and possible signs of an overdose to the licensed nursing staff only but did not include CNAs or any other staff. On [DATE] at 3:06 PM Staff 1 (Administrator) stated it was a group decision to educate the nurses rather than the CNAs because the nurses would be doing the assessments. Staff 1 acknowledged no other staff disciplines were provided education regarding residents with SUD. On [DATE] at 4:18 PM Staff 1 (Administrator) and Staff 50 (Regional [NAME] President) were informed of the failure to identify the need to initiate interventions related to SUD and to educate direct staff on how to identify and safely care for residents with SUD. The failure constituted a situation of immediate jeopardy to the health and welfare of residents. A plan of correction was requested to immediately ensure residents with SUD were identified, their care plans were revised to include interventions and monitoring related to SUD and staff were educated on how to identify and treat residents with SUD. On [DATE] at 7:42 PM an acceptable facility IJ removal plan was submitted by the facility. The plan indicated the facility would implement the following actions: -All residents' records would be reviewed to identify other residents with history of or active substance use disorder. -Residents identified with active, suspected or history of substance use will be identified and listed in a binder found at the nursing stations. The residents name plates outside their room will have a sticker placed to alert staff of potential hazards associated with active substance use disorder. -Residents identified with history of, or active substance use disorder will be offered substance use treatment services. -Residents identified with history of, or active substance use disorder will be assessed upon return from independent offsite outing for suspected substance use. -Residents who are assessed upon return from independent offsite outing or identified as active substance use will have an incident report generated and law enforcement notification if required. -Staff, including temporary or agency staff, will be educated to location of binder with residents identified with suspected or history of substance use disorder. -Staff, including temporary or agency staff, will be in-serviced to substance use disorder and signs of abuse related to drug use, what to do if suspected active use, and reporting suspected drug paraphernalia, as well as facility policy on resident possession and use of illegal substances. -Residents that are identified with drug paraphernalia or signs/symptoms of active drug use will be placed on alert monitoring, MD notification, POC task will be placed to alert CNA for increased monitoring for drug paraphernalia, law enforcement notification if required. In addition an incident report will be generated and resident assessment completed. On [DATE] at 10:51 AM it was determined the immediacy was removed after verification of completion of the IJ removal plan. 47000 3. Resident 3 was admitted to the facility in ,d+[DATE] with diagnoses including hemiplegia (a condition characterized by paralysis on one side of the body). Resident 3's [DATE] Care Plan revealed the following: -The resident required extensive assistance from two or more people to transfer into a car. -The resident was cleared to go out of the facility with Witness 1 (Family Member), and she had received car transfer training. Resident 3's [DATE] Annual MDS revealed the resident was severely cognitively impaired and experienced upper and lower extremity impairment on one side. A [DATE] Witnessed Fall Investigation revealed the following: -Resident 3 was lowered to the ground during an attempted transfer to the car with Witness 1. -The resident did not sustain any injuries. -A PT referral was placed for transfer training. A [DATE] PT Discharge Summary indicated Resident 3 was not tested for car transfers. On [DATE] at 11:36 AM Witness 1 stated she took Resident 3 out of the facility for an outing on [DATE]. Witness 1 stated it was getting harder and harder to transfer the resident and she could not recall the last time she received any training or education on how to safely transfer the resident into her car. On [DATE] at 11:32 AM Resident 3 was observed in her/his room in bed. Resident 3 stated she/he loved activities, including going outside and visits with Witness 1. On [DATE] at 11:55 AM Staff 30 (CNA) stated Resident 3 went out of the facility every Saturday with Witness 1. Staff 30 stated the resident went out most recently on [DATE] with Witness 1, and Witness 1 transferred the resident into the car independently. On [DATE] at 1:45 PM Staff 42 (Director of Rehab) stated Resident 3 received PT following her/his fall in ,d+[DATE] but the resident and Witness 1 did not receive any education or training regarding car transfers. Staff 42 further stated he was unaware the resident continued to go out of the facility with Witness 1 following her/his fall in ,d+[DATE]. On [DATE] at 12:12 PM Staff 2 (Regional Clinical Support) stated Witness 1 should have received car transfer training following Resident 3's fall on [DATE] and did not.

Based on interview and record review it was determined the facility failed to submit mandatory staffing information based on the payroll data journal and other verifiable and auditable data as required. This placed residents at risk for inaccurate staffing information. Findings include: - The facility's Reporting Direct Care Staffing Information (Payroll-Based Journal) policy, dated 8/2022, indicated complete and accurate direct care staffing information is reported electronically to CMS through the Payroll-Based Journal system. Staffing information is collected daily and reported for each fiscal quarter no later than 45 days after the end of the reporting quarter. Dates included Fiscal Quarter 4 with a date range of 7/1 through 9/30 to be submitted by 11/14. Review of the Payroll Based Journal Staffing Data for fiscal year 2024, quarter four (7/1/24 through 9/30/24), revealed the facility failed to submit required data for the quarter. On 4/28/25 at 12:07 PM, Staff 6 (Payroll/Human Resources) was unaware the data was not submitted and stated the corporate office was responsible for submitting the information. On 4/28/25 at 2:25PM, Staff 1 (Administrator) was unaware the data was not submitted.

Based on interview and record review it was determined the facility failed to train staff of the elements and goals of the facility QAPI program for 1 of 1 facility reviewed for QAPI training. This placed residents at risk for lack of safety and quality of care. Findings include: On 4/24/25 at 4:42 PM, Staff 6 (Payroll/Human Resources) provided a list of new hire and annual trainings offered by the facility. There was no QAPI training. On 4/25/25 between the hours of 8:15 AM and 8:36 AM, Staff 12 (CNA), Staff 35 (NA), Staff 41 (LPN) and Staff 42 (CNA) reported they were unaware of the facility's QAPI program and had not received any training related to QAPI. On 4/25/25 at 2:05 PM, Staff 1 reviewed the list of new hire and annual trainings provided by the facility and confirmed the facility did not offer QAPI training to staff. Staff 1 stated he expected the facility to provide staff required trainings.

Based on interview and record review it was determined the facility failed to ensure RN coverage for eight consecutive hours seven days per week for 4 of 33 days reviewed for staffing. This placed residents at risk for lack of care. Findings include: Review of the Direct Care Staff Daily Reports (DCSDR) on 7/20/24, 8/3/24, and from 3/21/25 through 4/21/25 revealed no RN coverage for eight consecutive hours for the following Saturdays: 7/20/24, 8/3/24, 3/22/25 and 4/12/25. On 4/24/25 at 1:14 PM, Staff 6 (Payroll/Human Resources) acknowledged the facility lacked RN coverage on 7/20/24 and 8/3/24. She stated it was very difficult to find RN coverage on weekends. On 4/24/25 at 1:26 PM, Staff 6 acknowledged the facility lacked RN coverage on the DCSDR for 3/22/25 and 4/12/25. On 4/28/25 at 2:25 PM Staff 1 (Administrator) was not aware that there was no RN coverage on the identified days.

Based on observation, interview, and record review it was determined the facility failed to post accurate and complete staffing information for 14 of 34 days reviewed for staffing. This placed residents and the public at risk for incomplete and inaccurate staffing information. Findings include: A review of the Direct Care Staff Daily Report from 3/21/25 through 4/24/25 revealed incorrect information listed on the following dates: 4/8/25, 4/10/25, 4/11/25, 4/12/25, 4/13/25, 4/14/25, 4/15/25, 4/16/25, 4/17/25, 4/18/25, 4/20/25, 4/21/25 and 4/24/25. A review of the DCSDR on 4/10/25, 4/11/25, 4/12/25, 4/13/25, 4/14/25, 4/15/25, 4/16/25, 4/17/25, 4/18/25, 4/20/25 and 4/21/25 revealed Sitter entered with hours worked for staff count. On 4/24/25 at 8:41 AM, the DCSDR for 4/24/25 was prefilled with morning, evening, and night shift information. The morning shift was signed and had no entries for Nursing Assistants. At 9:02 AM, Staff 35 was observed wearing a badge with CNA under his name and confirmed he was not a CNA. Staff 35 stated he did not have a CNA license in Oregon or any other state. At 1:45 PM, the DCSDR for 4/24/25 continued to reflect no entries for Nursing Assistants on the morning shift. On 4/24/25 at 1:14 PM, Staff 6 (Payroll/Human Resources) stated Sitter was a CNA who was assigned to perform one-on-one duties to a resident and should have been added to the CNA count. Staff 6 acknowledged the general public would not understand the role of Sitter and the DCSDR did not correctly identify the number of CNAs and hours worked for the identified dates. Staff 6 also confirmed Staff 35 was not a CNA and should have been listed as a Nursing Assistant on the DCSDR for 4/24/25. On 4/28/25 at 12:07 PM, Staff 6 confirmed Staff 35 worked with residents on 4/8/25, 4/11/25, 4/12/25, 4/13/25 and 4/14/25 and should have been counted as a Nursing Assistant. On 4/28/25 at 2:25 PM, Staff 1 (Administrator) stated he was not aware of the DCSDR having incorrect information.

Based on observation and interview it was determined the facility failed to ensure medications and biologicals were stored securely and not accessible to unauthorized individuals and failed to ensure medications were not expired for 2 of 7 medication carts and 1 of 1 medication storage room. This placed residents at risk for diminished treatment efficiency and unauthorized access to medications and biologicals. Findings include: 1. On [DATE] at 8:31 AM a medication cart was observed to be unlocked in the hallway near room eight. Staff and residents were observed walking past the unlocked medication cart. On ,d+[DATE]//25 at 8:32 AM the medication cart was observed with Staff 20 (CMA) to have over the counter medications and prescription medications inside. On [DATE] at 4:45 AM a medication cart was observed to be unlocked in the hallway near room [ROOM NUMBER]. The medication cart was observed to have ceftriaxone (an antibiotic) inside. On [DATE] at 8:50 AM a medication cart was observed to be unlocked in the hallway near room [ROOM NUMBER]. On [DATE] at 8:59 AM Staff 21 (Agency RN) returned to the unlocked medication cart. The medication cart was observed with Staff 21 to have insulin inside. On [DATE] at 9:42 AM a medication cart was observed to be unlocked in the hallway near room [ROOM NUMBER]. Staff 22 (RN) was observed siting at the nurses station near room [ROOM NUMBER] within eyesight of the medication cart, and staff and residents were observed in the hallway. On [DATE] at 9:51 AM Staff 22 was observed leaving the nurses station, the medication cart was observed to be unlocked, and staff and residents were observed in the hallway. On [DATE] at 9:56 AM Staff 22 was observed returning to the nurses station. The medication cart was observed with Staff 22 to be unlocked with insulin, prescription medications, and over the counter medications inside. On [DATE] at 11:48 AM Staff 2 (Regional Clinical Support) stated her expectation was the medication carts must be locked when not in use. 2. On [DATE] at 12:08 PM the medication storage room was observed with Staff 9 (CMA). The medication storage room was observed to have a bottle of Vitamin A which expired in ,d+[DATE], a bottle of Complete Women 50+ multi-vitamin with minerals which expired in ,d+[DATE], two bottles of L-Argine (an amino acid supplement) which expired in ,d+[DATE], and a vial of Tubersol (a testing solution for tuberculosis) which was opened and had no open date on it. On [DATE] at 12:33 PM Staff 2 (Regional Clinical Support) acknowledged the above medications were expired. Staff 2 stated Tubersol was only good for 30 days after opening and she acknowledged the bottle of Tubersol did not have an open date on it.

F800 Based on observation, and interview, it was determined the facility failed to meet dietary preferences for 1 of 3 Residents (#468) sampled residents reviewed for food preferences. This placed residents at risk for limited food choices and potential weight loss. Findings include: Resident 468 was admitted to the facility in 4/2025 with diagnoses including diabetes and below the knee amputation. Resident 468's most recent MDS dated [DATE] revealed a BIMS score of 14 which indicated the resident was cognitively intact. In an 04/21/25 interview at 1:30 PM Resident 468 stated, she/he would like more food. Resident 468 stated he/she asked staff for bigger portions but did not receive them. Resident 468 stated she/he did not get enough food. On 4/ 24/25 at 12:14 PM Resident 468's meal tray was observed to have an order card for double portions and a hamburger on the side. Resident 468 received small portions and no hamburger. On 04/24/25 at 12:23 PM Staff 36 (CNA), stated there is not a good system in place to meet resident preferences and cultural preferences for food. On 4/25/25 at 10:30 AM in an interview Staff 43 (dinning manager) stated he had spoken to Resident 468 about her/his preference for more food and the resident did request double portions per her/his preference on 4/12/25. On 4/25/25 at 11:32 AM Staff stated 46 (dietary) stated Resident 468 requested double portions and a hamburger on the side, all the time but she/he was upgraded to double portions on 4/25/25.

1. Based on observation, interview and record review it was determined the facility failed to ensure safety interventions and supervision were in place and followed to protect residents from elopement from the facility for 1 of 1 sampled resident (# 56) reviewed for elopement. This failure, determined to be an immediate jeopardy situation, resulted in Resident 56 eloping from the facility into heavily trafficked areas and placed residents at risk of avoidable accidents and death. Findings include: The facility's 6/2017 Elopement/Wandering Policy and Procedure revealed the following: -Residents deemed at risk to elope, that reside in an Expressions Unit, or have cognitive deficits will be accompanied by family, responsible party, or a facility staff member when leaving the facility for appointments/outings. -Residents evaluated as at risk for elopement would be in staff eyesight at all times when on facility outings. If staff are unable to keep the resident in line of sight, a designated staff member would accompany the resident on the outing to assist in maintaining resident safety. -Facilities with no elopement prevention system (i.e., wanderguard ((a safety monitoring device)) would place the resident on one-to-one care until their symptoms resolved or further evaluation could be completed to assist in maintaining resident safety. Resident 56 was admitted to the facility in 12/2023 with diagnoses including cancer. Resident 56 was discharged from the facility on 1/22/24. Resident 56's 12/21/23 Admission MDS indicated the resident was moderately cognitively impaired (BIMS of 9), required supervision to partial/moderate assistance with ambulation, used a walker, a manual wheelchair and received hospice care. The Cognitive Loss/Dementia CAA indicated the resident experienced forgetfulness, confusion and cognitive fluctuations. Resident 56's 12/22/23 Elopement Risk Evaluation indicated the resident was cognitively impaired with poor decision-making skills, ambulated independently, expressed the desire to leave, go home or repeatedly pack, had wandered in the past month, was actively seeking to leave the building and was at risk to wander/elope. Records revealed on 12/26/23 Resident 56 eloped around 10:27 PM and was out of the facility for approximately 30 minutes before being found four blocks away from the facility by the facility's security company. The recorded temperature on 12/26/23 ranged from 41 to 48 degrees F. Following this incident, the facility's investigation recommended one-to-one supervision for Resident 56 until a wanderguard could be used. Resident 56's 12/27/23 Elopement Risk Evaluation indicated the resident was cognitively impaired with poor decision-making skills, ambulated independently, did not understand the need to inform staff if she/he left the facility, was actively seeking to leave the building and her/his wandering placed her/him at risk of getting to an unsafe place. A 1/3/24 Care Conference Note indicated Resident 56 wanted to discharge home but was encouraged to remain at the facility due to her/his cognition and memory deficits. The note also indicated the resident continued to receive one-to-one supervision due to elopement with safety concerns related to cognition and memory deficits. A 1/3/24 SLUMS (St. Louis University Mental Status) Examination completed by Staff 51 (Hospice Social Worker) revealed a score of eight out of 30, indicating the resident experienced dementia. A 1/4/24 Physician Order indicated Resident 56 was allowed to go on one walk per day, accompanied by facility staff if available. The walk was not to exceed two hours, and if the resident failed to return to the facility, hospice was to be notified. A review of the facility's 12/2023 and 1/2024 Daily Staffing Rosters (CNA daily staffing assignments) revealed Resident 56 inconsistently received one-to-one supervision from 12/27/23 through 1/9/24. The 1/9/24 Daily Staffing Roster indicated the resident no longer required one-to-one supervision as of evening shift. Records revealed on 1/9/24 at approximately 5:40 PM Resident 56 eloped from the facility. No one-to-one supervision or wanderguard was in place at the time of her/his elopement. The recorded temperature on 1/9/24 ranged from 34 to 52 degrees F. The facility is located on a busy street, with the exit of the facility located approximately 50 feet from the street with no barrier. The resident was located at her/his apartment on 1/10/24 at 12:16 PM by her/his friend. Resident 56 was brought back to the facility by a neighbor on 1/11/24 at 7:15 AM. The facility's 1/10/24 Incident Report and Investigation indicated nursing staff had great concern about Resident 56's safety when she/he was out in the community. The report indicated staff were concerned about the resident leaving the facility independently due to her/his fluctuating cognition. The report also revealed the resident's account of her/his 1/9/24 elopement, during which she/he left the facility, caught the first bus, ended up at the chaotic airport, got a ride from a police officer to a public transit station, took a different bus, got off at the wrong station and walked in circles until she/he located her/his apartment. Resident 56's heath record revealed a wanderguard was not put in place until 1/13/24. On 1/22/24 at 8:55 AM Resident 56 was observed in her/his room in bed. Resident 56 stated she/he was going to leave the facility today one way or another. On 1/22/24 at 10:34 AM Staff 5 (LPN) stated he was unsure if Resident 56 was able to leave the facility unsupervised and was unsure of what to do should the resident elope. On 1/22/24 at 10:36 AM Staff 6 (CNA) and at 11:04 AM Staff 7 (RN) stated they were unaware of Resident 56's elopements and of any safety interventions in place to prevent an elopement. On 1/22/24 at 12:05 PM Staff 3 (LPN/Care Manager) stated the facility requested a one-to-one caregiver from hospice for Resident 56 prior to the resident's 1/9/24 elopement and were told hospice could not accommodate this request. Staff 3 stated the facility provided Resident 56 with one-to-one supervision when they had extra staff available. Staff 3 further stated she did not think the resident was safe to leave the facility unattended and that was why she requested a wanderguard. On 1/22/24 at 12:36 PM Staff 2 (DNS) stated she had concerns regarding the 1/4/24 Physician Order as she did not believe Resident 56 was able to remember to sign out from the facility or return in two hours time. Staff 2 stated the facility did not have the staff to provide one-to-one supervision should the resident leave. Staff 2 stated that one-to-one supervision was necessary and should have been in place for Resident 56. Review of Resident 56's health record revealed lack of evidence to support the facility protected the resident from an elopement as evidenced by the following: -Staff failed to consistently implement one-to-one supervision for Resident 56, who was assessed to be cognitively impaired, following her/his elopement on 12/26/23 and prior to the resident receiving a wanderguard. -Staff failed to question a physician order they felt was inappropriate and unsafe related to Resident 56 leaving the building for two hours at a time, unsupervised. -The facility failed to educate all staff of Resident 56's potential to elope and of interventions to prevent elopement. On 1/22/24 at 6:45 PM Staff 1 (Administrator), Staff 43 (Director of Operations) and Staff 52 (Regional Support Nurse) were informed of the immediate jeopardy (IJ) situation related to the facility's failure to protect Resident 56 from elopement from the facility. An IJ template was provided and an immediate IJ removal plan was requested. On 1/22/24 at 8:09 PM the facility submitted an acceptable removal plan. The IJ Removal Plan indicated the facility would implement the following actions: -Resident 56 was discharged from the facility. -Immediate evaluation of all residents in the facility conducted to determine if any other residents have been affected. -Education provided to all staff on elopement prevention and intervention, including current residents who were identified at risk. On 1/23/24 at 9:59 AM Staff 2 (DNS) provided verification that licensed staff received the required training and education and confirmed evaluations had been completed and interventions put in place for other residents identified as at risk to elope. On 1/23/24 at 10:20 AM the immediacy was removed. 41458 2. Based on observation, interview and record review it was determined the facility failed to follow care plan interventions, assess for care plan effectiveness, identify and implement new fall interventions and provide adequate supervision needed to prevent falls for 1 of 4 sampled residents (# 8) reviewed for falls. This placed residents at risk for injury. Findings include: Resident 8 was admitted to the facility in 7/2019 with diagnoses including vascular Parkinsonism (a brain condition that causes slow movements, stiffness and tremors). Resident 8's 1/6/23 Annual MDS indicated the resident had no cognitive impairments, required extensive assistance of two staff for transfers and toileting and was not steady moving from a seated to standing position. Resident 8 was frequently incontinent of bladder, always incontinent of bowel and was not on a toileting program. Resident 8 had multiple falls due to self-transferring as a result of either not asking for assistance or not waiting for help. Resident 8's 10/9/23 Quarterly MDS indicated the resident had no cognitive impairments and was dependent on staff for moving from a sitting to a standing position, for chair to bed transfers and when being transferred to and from the toilet. Resident 8 was frequently incontinent of bowel and bladder and was not on a toileting program. Resident 8's 1/7/24 Annual MDS indicated the resident had moderate cognitive impairments and required substantial to maximal staff assistance for moving from a sitting to a standing position, during a chair to bed transfer and when being transferred to and from the toilet. In addition, Resident 8 experienced numerous falls due to impulsivity and over-estimating her/his abilities. Resident 8 was frequently incontinent of bowel and bladder and was not on a toileting program. Resident 8's 1/11/24 fall risk assessment indicated the resident was a high fall risk. There were no fall risk assessments found in Resident 8's health record for 2023. Multiple fall risk assessments for 2022 all identified Resident 8 as a high fall risk. Resident 8's 1/2024 Care Plan indicated the resident was at risk for falls related to a history of falls, weakness secondary to a stroke, unsteady balance, poor safety judgement and not calling for assistance which resulted in the resident self-transferring. The following fall preventions were in place: -PT evaluate/treat as ordered and PRN. Initiated on 7/8/19. Revised on 2/4/21. -Review information on past falls and attempt to determine cause of falls. Record possible root causes and remove any potential causes if possible. Educate the resident, family, caregiver and interdisciplinary team as to causes. Initiated on 7/8/19. -Resident 8 was to wear non-skid footwear when transferring. Initiated on 7/6/19. -Resident 8's call light and personal items were to be within reach. Initiated on 7/6/19. -Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needed prompt responses to all requests for assistance. Initiated on 8/1/19. -Educate the resident, family and caregiver about safety reminders and what to do if falls occurred. Initiated 8/1/19. -Offer caregiver training to the resident's family for transfers from the wheelchair to the toilet and off of toilet. Encourage the resident's family to call staff for assistance with resident's care as needed to prevent the resident from falling. Initiated on 8/1/19. -Anticipate and meet the resident's needs. Staff to place belongings within reach and offer any items to the resident prior to leaving her/his room and after care. Staff to encourage the resident to call for assistance by using her/his bedside call light. Initiated on 8/27/19. -Remind the resident often to call for help. Continue rounding focused on toileting. Offer toilet trips before and after meals. Initiated on 1/23/20. -Assure the resident's urinal was emptied and cleaned after each use. Offer her/him help if she/he allows on each round to prevent the resident's unsafe activity. Initiated on 8/14/20. -Remind the resident to call for assistance. Keep the resident's bedside table next to the resident's bed and important items within reach. Initiated on 1/20/21. Revised on 2/4/21. -Call [Witness 1 (Family)] to notify of the resident's desire to self-transfer. Initiated on 2/2/21. -Fill out Risk and Benefits for self-transfers and remind the resident to call for assistance. Initiated on 2/2/21. -Remind the resident to call for assistance. Initiated on 2/2/21. -Staff to answer call lights in a timely manner. Remind the resident to call for help. Initiated on 2/4/21. -Bilateral grab bars for mobility. Initiated on 7/19/21. -Keep bedside table close to the patient when she/he is in bed to ensure commonly use items are easily located. Initiated on 12/6/21. - The CNAs were to ensure the call light was reset so the resident was able to call for assistance. Initiated on 12/14/21. -Staff to continue with the current care plan. Encourage the resident to ask for help and use her/his call light. Continue with frequent checks, monitoring, offering toileting, ensuring commonly used items and the resident's call light was within reach. Initiated 12/19/21. -Patient to use an easy touch call light so that all call light activity was captured. Initiated on 3/21/22. -Nursing staff to monitor for unmet needs and assist the patient as needed. If the patient was wearing a jacket indoors, offer to help remove it as the patient may be too warm. Initiated on 1/24/22. -Please keep the resident's urinal at the bedside for when the patient is unable to wait for help with toileting. Ensure the urinal is emptied to prevent spilling. Initiated on 7/29/22. -Staff to do frequent monitoring and checks. Remind resident to wait for help. Initiated on 6/9/23. -Offer toileting before meals and at bedtime. Initiated on 3/20/23. -Reminder placed in the resident's bathroom to remind the resident to use the call light. Initiated on 4/3/23. -Staff were to do frequent monitoring and checks. Remind the resident to wait for help. Initiated 6/9/23. -Offer the resident toileting after meals. Initiated on 6/15/23. -CNA to transfer the resident into bed before bedtime. She/he prefers to go to bed between 8-9:15 PM. Initiated on 9/8/23. -Resident needs assistance with transfers on and off electric wheelchair and toilets. Initiated on 1/5/24. From 1/21/23 through 1/24/24, Resident 8 experienced seven falls in the facility. Fall investigations revealed the following: -1/21/23 at 4:39 AM: Fall Investigation revealed Resident 8 experienced an unwitnessed fall in her/his room while attempting a transfer from her/his bed to her/his wheelchair. Resident 8 stated she/he fell while self-transferring to her/his wheelchair. Resident 8 was instructed to call for help. The report indicated this was the 37th fall for Resident 8. It was concluded that Resident 8 had a history of falls, was impulsive and attempted to self-transfer. Recommendations were that all fall interventions were in place, continue to monitor and minimize risk of injury. No new fall care plan interventions were put in place. -3/17/23 at 9:30 AM: Fall Investigation revealed Resident 8 was found on the floor in her/his bathroom after attempting to self-transfer without assistance. The report indicated this was the 37th fall for Resident 8. The report recommended that the care plan be updated to offer toileting before meals and at bedtime. This was consistent with care plan interventions initiated on 1/23/20 and 12/19/21. No new fall care plan interventions were put in place. -3/30/23 at 8:45 AM: Fall Investigation revealed Resident 8 was found sitting on her/his bathroom floor. It was concluded that Resident 8 self-transferred herself/himself to the bathroom and attempted to toilet herself/himself without assistance. The report indicated this was Resident 8's 38th fall. A new fall care plan intervention was put into place to put a reminder sign in Resident 8's bathroom to call for assistance. Resident 8 was referred to PT services. -6/9/23 at 4:20 PM: Fall Investigation revealed Resident 8 was found on the floor near the head of her/his bed after activating the call light. The resident was provided reminders to use the call light and fall prevention was provided. Recommendations were to continue with the current fall interventions. No new fall care plan interventions were put in place. -9/5/23 at 9:00 PM: Fall Investigation revealed Resident 8 was found on the floor in her/his bathroom after going to the bathroom on her/his own and attempting to self-transfer to the toilet. It was concluded that Resident 8 was unaware of her/his own limitations, had a significant history of falling and self-transferred against facility advice. The report indicated this was Resident 8's 42nd fall. A new fall care plan intervention was put into place to transfer the resident to bed before bedtime and the resident preferred to go to bed between 8:00 PM and 9:15 PM. -9/17/23 at 12:49 PM: Fall Investigation revealed Resident 8 was found on the floor in her/his room. Resident 8's CNA left for lunch, returned from lunch and was completing rounds when the CNA found the resident on the floor. The report indicated this was Resident 8's 43rd fall. Recommendations were to continue with the current fall interventions and adhere to any therapy recommendations for the wheelchair cushion. No new fall care plan interventions were put in place. 1/1/24 at 9:53 AM: Fall Investigation revealed Resident 8 was found on the floor of her/his bathroom. The resident stated she/he activated the call light, no one came so she/he self-transferred to the bathroom and slipped off the toilet. It was concluded that Resident 8 self-transferred without assistance, was impulsive and did not wait for staff assistance. The report indicated this was Resident 8's 44th fall. Resident 8 was instructed to use the call light for safety. Recommendations were to continue with the current fall interventions. No new fall care plan interventions were put in place. A review of Resident 8's 1/1/24 through 1/24/24 Call Light Tracking Sheet revealed the following call light response times: -1/1/24 at 10:32 AM: call light response time 17 minutes; -1/1/24 at 11:04 AM: call light response time 16 minutes; -1/2/24 at 4:40 PM: call light response time 37 minutes; -1/3/24 at 4:09 PM: call light response time 16 minutes; -1/4/24 at 11:29 PM: call light response time 17 minutes; -1/6/24 at 8:24 AM: call light response time 41 minutes; -1/7/24 at 12:59 PM: call light response time 38 minutes; -1/7/24 at 8:15 PM: call light response time 24 minutes; -1/8/24 at 11:33 AM: call light response time 25 minutes; -1/8/24 at 6:54 PM: call light response time 26 minutes; -1/10/24 at 11:22 AM: call light response time 24 minutes; -1/10/24 at 9:16 PM: call light response time 27 minutes; -1/11/24 at 4:50 PM: call light response time 16 minutes; -1/11/24 at 6:49 PM: call light response time 1 hour 6 minutes; -1/11/24 at 9:54 PM: call light response time 20 minutes; -1/12/24 at 10:03 AM: call light response time 55 minutes; -1/12/24 at 11:59 AM: call light response time 20 minutes; -1/14/24 at 2:44 AM: call light response time 17 minutes; -1/14/24 at 12:39 PM: call light response time 28 minutes; -1/14/24 at 6:30 PM: call light response time 16 minutes; -1/15/24 at 2:05 PM: call light response time 23 minutes; -1/15/24 at 7:34 PM: call light response time 17 minutes; -1/18/24 at 7:22 PM: call light response time 24 minutes; -1/18/24 at 9:21 PM: call light response time 39 minutes; -1/19/24 at 8:39 PM: call light response time 15 minutes; -1/20/24 at 2:08 AM: call light response time 40 minutes; -1/20/24 at 7:29 AM: call light response time 19 minutes; -1/20/24 at 12:56 PM: call light response time 43 minutes; -1/20/24 at 6:38 PM: call light response time 25 minutes; -1/21/24 at 6:43 PM: call light response time 18 minutes; -1/21/24 at 9:43 PM: call light response time 18 minutes; -1/22/24 at 5:15 PM: call light response time 53 minutes; -1/22/24 at 6:13 PM: call light response time 20 minutes; -1/24/24 at 11:10 AM: call light response time 21 minutes. Random observations between 1/22/24 through 1/30/24 between the hours of 7:30 AM and 9:30 PM revealed the following concerns: -Resident 8 had a sign on her/his door directing staff to keep the door closed at all times. -Resident 8 was frequently in her/his room, alone, with the door closed. -Resident 8's bed was in a high position on all observations. -When Resident 8's door was open, Resident 8 was not visible from the hallway. -Numerous staff frequently walked by Resident 8's room without checking on the resident to ensure she/he was safe. -Resident 8 was left alone in her/his bathroom with the bathroom door and the room door closed. -There were at least three observations where no staff checked on Resident 8 for over one hour. The facility failed to follow care plan interventions, re-assess current interventions and develop new interventions to ensure Resident 8 was adequately supervised and her/his falls were unavoidable. On 1/23/24 at 11:19 AM Witness 1 (Family) reported Resident 8 activated her/his call light for help but staff did not come in a timely manner so Resident 8 gets up on [her/his] own and falls. Witness 1 stated long call light response times were worse on evening shift. On 1/25/24 at 1:30 PM and 1/30/24 at 9:50 AM Resident 8 stated she/he used her/his call light to get help but staff often took a long time to respond. Resident 8 stated she/he waited for 10 to 15 minutes and after 15 minutes if staff did not answer the call light, she/he got up and, as a result, had many falls. On 1/29/24 at 9:35 AM and 11:49 AM Staff 30 (CNA) and Staff 31 (NA) reported they were unaware if Resident 8 was considered a high fall risk. On 1/29/24 at 12:05 PM Staff 32 (CNA) stated the most important fall intervention for Resident 8 was to ensure her/his call light was answered timely because if Resident 8 had to wait too long, she/he got up on her/his own. 1/29/24 at 2:37 PM Staff 10 (LPN/Care Manager) and Staff 18 (Regional RN) acknowledged an analysis was not completed of Resident 8's falls to determine any patterns or trends related to the resident's numerous falls. Staff 10 and Staff 18 acknowledged many of Resident 8's fall interventions were repetitive or not effective. Staff 10 and Staff 18 stated they identified problems with Resident 8's fall interventions and were going to review the resident with the interdisciplinary team to determine more appropriate interventions to keep the resident safe and prevent avoidable falls. 1/30/24 at 2:38 PM Staff 1 (Administrator) stated she expected Resident 8's care plan to have active, helpful and proper interventions in place to prevent Resident 8 from falling. Staff 1 stated Resident 8 had many lengthy call light response times and she expected staff to respond to call lights in under five minutes. Refer to F725.

Based on observation, interview and record review it was determined the facility failed to ensure a resident with a diagnosed mental disorder and documented history of suicide attempts received the necessary behavioral health care and services needed to prevent suicide attempts for 1 of 5 sampled residents (# 52) reviewed for unnecessary medications. This failure, determined to be an immediate jeopardy situation, resulted in Resident 52 attempting suicide and placed residents at risk for avoidable accidents and death. Findings include: Resident 52 was admitted to the facility in 11/2023 with diagnoses including delirium (confusion), dementia with a behavioral disturbance and severe major depressive disorder with psychotic features. An 11/2/23 Progress Note revealed Resident 52 was found with her/his call light cord wrapped around her/his neck, following which the resident was provided with one-to-one supervision. An 11/3/23 Encounter Psych Initial Visit Note completed by Staff 13 (Psychiatric NP) indicated Resident 52 continued to experience suicidal thoughts. The note further indicated the plan was to continue to implement the safety plan, including reducing the availability of items for self-harm and for the resident to report self-harm urges to staff. Resident 52's 11/8/23 Admission MDS indicated the resident was cognitively intact and she/he experienced moderately severe depression, delusions, inattention and disorganized thinking. The MDS assessment also indicated the resident exhibited physical and verbal behaviors directed towards others and other behavioral symptoms not directed towards others which significantly interfered with the resident's care and participation in activities/social interactions. The Self-Care and Mobility CAA indicated the resident required one-to-one supervision and the resident's food was brought in on paper plates and bowls with plastic silverware due to safety concerns related to suicidal ideation with an attempt. An 11/29/23 Provider Note completed by Staff 11 (Physician Assistant) indicated Resident 52 had not experienced any suicide attempts and it was appropriate to wean her/him off of one-to-one supervision. The note further indicated the resident had an appointment with Staff 13 on 12/5/23 and Staff 11 asked if the appointment could occur sooner. An 11/30/23 Encounter Psych Progress Note completed by Staff 13 indicated Resident 52 remained quite depressed and anxious and continued to receive one-to-one supervision due to a recent history of wrapping the call light cord around her/his neck when she/he first admitted to the facility. The note indicated staff were to contact Encounter Telehealth if Resident 52 experienced increasing symptoms, a mental status change, side effects and/or for any questions/concerns. An 11/30/23 Progress Note written by Staff 10 (LPN) indicated Resident 52 was going to be trialed off one-on-one supervision during daytime hours outside of the time period from 10:00 AM to 2:00 PM. This note also indicated if the resident appeared to be unsafe, she/he was to immediately be put back on one-to-one supervision and the provider was to be notified. A 12/5/23 Progress Note written at 12:25 PM by Staff 10 revealed one-to-one supervision was discontinued as Staff 9 (Medical Director) deemed Resident 52 to be safe. A 12/5/23 Progress Notes revealed Resident 52 was found with her/his blanket wrapped around her/his neck with the fitted sheet from her/his bed over her/his head. The sheets and blankets were removed for her/his safety. One-to-one supervision was reinstated for Resident 52. A 12/15/23 Encounter Psych Progress Note completed by Staff 13 indicated one-to-one supervision of Resident 52 was appropriate to be discontinued and replaced with checking on the resident every 15 minutes. This note further indicated one-to-one supervision was to be reinstituted should the resident have any additional attempts at self-harm over the weekend. The provider wanted to be contacted should any mental health or behavioral concerns arise. Records revealed frequent checks on Resident 21 were completed between 12/18/23 through 12/21/23. Resident 52's 12/2023 TAR indicated on 12/21/23 one-to-one monitoring was discontinued and changed to frequent checks. The TAR indicated one-to-one supervision was to be re-instituted if there were any further attempts to self-harm over the weekend. This order was discontinued on 1/12/24. No evidence was found in Resident 52's clinical record that a Self-Harm Care Plan was created until 1/1/24, 60 days after the resident's first suicide attempt and 27 days after her/his second suicide attempt. A 1/18/24 Progress Note written by Staff 16 (RN) revealed Resident 52 was found with robe ties around her/his neck, stating she/he was going to strangle her/himself. The note indicated robe ties were removed and close observation was provided. No evidence was found in Resident 52's clinical record that any further action was taken to address the resident's suicide attempt. Observations conducted from 1/22/24 to 1/24/24 between 7:30 AM to 8:30 PM revealed Resident 52 was not provided with one-to-one supervision. Resident 52 was observed during this time period in bed with bed linens present, including a sheet, and at times was not visible from the doorway due to the privacy curtain being extended. On 1/24/24 interviews conducted between 3:02 PM and 4:03 PM with Staff 14 (CNA), Staff 15 (CNA) and Staff 5 (LPN) stated Resident 52 did not require one-to-one supervision and they were unaware of any recent suicide attempts by Resident 52. On 1/24/24 at 2:42 PM Staff 11 (Physician Assistant) stated she was unaware of Resident 52's 1/18/24 suicide attempt or ideation. Staff 11 stated the resident should have been placed on one-to-one supervision and she and Staff 13 should have been notified of the suicide attempt. On 1/24/24 at 3:02 PM Staff 10 (LPN) stated she was not aware of Resident 52's 1/18/24 suicide attempt and ideation. Staff 10 indicated if she had known she would have instantly put her on a one-to-one and called the resident's provider, facility administrator and DNS. On 1/24/24 at 4:24 PM Staff 17 (Assistant DNS) stated the facility was unaware of Resident 52's 1/18/24 suicide attempt. Staff 17 stated one-to-one supervision of Resident 52 should have been initiated immediately after this attempt and the manager and DNS should have been immediately notified. On 1/24/24 at 5:18 PM Staff 16 (RN) stated on 1/18/24 an unknown CNA reported to him that she found Resident 52 with the string of her/his robe around her/his neck. Staff 16 stated he did not report this incident to the resident's provider because he did not think the resident was a danger to her/himself. Staff 16 stated he was not aware of any previous suicide attempts or ideations by Resident 52. Review of Resident 52's health record revealed a lack of evidence the facility provided the resident with the necessary behavioral health care and services needed to prevent suicide attempts as evidenced by the following: -Staff failed to complete a timely and comprehensive care plan related to the resident's history of and potential for suicide attempts and suicidal ideation. -Staff failed to comprehensively reassess the resident following her/his third suicide attempt and implement any interventions to prevent additional attempts. -Staff failed to notify the resident's physician and mental health provider following the resident's third suicide attempt. -The facility failed to educate all staff of Resident 52's potential for suicide attempts and suicidal ideation or interventions related to prevention. -The facility failed to consistently provide one-to-one supervision to ensure Resident 52's safety. On 1/24/24 at 7:25 PM Staff 1 (Administrator), Staff 2 (DNS) and Staff 18 (Regional RN) were informed of the immediate jeopardy (IJ) situation related to the facility's failure to implement further safety interventions, complete a comprehensive reassessment, update the resident's care plan and notify the resident's physician and mental health provider following Resident 52's third suicide attempt. IJ templates were provided and an immediate IJ removal plan was requested. On 1/24/24 at 9:26 PM the facility submitted an acceptable removal plan. The IJ Removal Plan indicated the facility would implement the following actions: -Resident 52 was placed on one-to-one supervision, her/his care plan was updated to reflect prior suicide attempts and to include appropriate interventions, Staff 9 and Staff 13 were notified of the resident's most recent suicide attempt and Staff 11 completed an assessment of the resident. -Immediate evaluation of all residents in the facility conducted by nursing management team to determine if any other residents have been affected. -Education provided to licensed staff on suicide prevention and intervention, including current residents who were identified at risk. On 1/25/24 at 10:19 AM Resident 52 was observed in her/his watching television with a staff member present. On 1/25/24 at 10:28 AM Staff 1 provided verification that licensed staff received the required training and education, confirmed assessments had been completed and care plans were updated for other residents identified as at risk for suicidal ideation and/or attempts. On 1/25/24 at 10:37 AM the immediacy was removed.

Based on observation, interview and record review it was determined facility staff failed to ensure professional standards of practice were followed for following care planned interventions for 1 of 4 sampled residents (#203) reviewed for accidents. Resident 203 sustained a fracture. Findings include: Division 63 Standards and Authorized Duties For Certified Nursing Assistants and Certified Medication Aides 851-063-0030 Authorized Duties and Standards for Certified Nursing Assistants (6) Standards of Care for Certified Nursing Assistants. In the process of client care the CNA shall consistently: (d) Follow the care plan as directed by the licensed nurse; 851-063-0090 Conduct Unbecoming a Nursing Assistant "A CNA, regardless of job location, responsibilities, or use of the title "CNA," who, in the performance of nursing related duties, may adversely affect the health, safety or welfare of the public, may be found guilty of conduct unbecoming a nursing assistant. Conduct unbecoming a nursing assistant includes but is not limited to: (3) Conduct related to communication: (c) Falsifying a client or agency record; including but not limited to filling in someone else's omissions, signing someone else's name, recording care not given, fabricating data/values; Resident 203 was admitted to the facility in 1/2014 with [DIAGNOSES REDACTED]. The 1/26/14 Care Plan noted the resident required two person limited assistance with transfers. The 1/26/14 Physician order [REDACTED]. The 2/4/14 Physician Assistant follow up note on a change in condition indicated Resident 203 was found to have a urinary tract infection and left facial droop, most likely from a stroke. The family requested comfort care measures for the resident. A 2/5/14 Progress Note indicated Resident 203 had some left sided weakness. Family stated the resident was getting weaker. The 2/5/14 updated Care Plan indicated Resident 203 required two person extensive assistance with transfers. A 2/9/14 8:15 am Progress Note disclosed Resident 203 was lowered to the floor in the bathroom. The resident complained of pain to her/his knee. The correlated facility investigation revealed Staff 1, CNA, reported she had taken Resident 203 to the bathroom and when the resident was done, she stood the resident up and the resident's knees buckled. Staff 1 assisted Resident 203 to the floor. The resident was care planned for a two person transfer, however there was only one caregiver present during the incident. The facility determined neglect occurred, with actions taken including care plan revision, staff counseling and termination. On 2/9/14 the physician ordered an x-ray of the left knee. A 2/9/14 Progress Note indicated due to weather and road conditions, the x-ray would not be done until the next day. The 2/9/14 8:38 pm Progress Note revealed the resident complained of left knee pain, "hurts bellow (sic) my knee", which was painful with movement. The 2/10/14 8:25 am Progress Note disclosed Resident 203 complained of left lower extremity pain, pointing about two inches above the left knee. The 2/10/14 knee x-ray was negative for fracture. A 2/11/14 Progress Note revealed Resident 203 stated she/he "is in a lot of pain from fall this weekend. Pain medication administered...." The resident remained in her/his room all shift related to pain. The 2/13/14 Physician Assistant follow up note indicated the resident had leg pain after the assisted fall to the ground. X-rays of the left femur and hip were ordered to rule out a fracture. The 2/13/14 x-rays identified a [MEDICAL CONDITION] femur. The 2/14/14 3:30 pm Progress Note indicated the resident's family did not want the resident to go to the hospital or have surgical intervention. On 2/14/14 the physician changed the [MEDICATION NAME] order from 650 mg PRN to receiving it routinely every four hours. The physician added [MEDICATION NAME] (a narcotic pain medication) 0.25 ml every three hours PRN pain. Additionally the resident was non weight bearing on the left leg and was to either have traction to the left leg or a knee immobilizer in place. According to the 2/2014 MAR, Resident 203 received the PRN [MEDICATION NAME] as ordered. From 2/16/14 to 2/18/14, the resident received the [MEDICATION NAME] for reports of left hip pain at "7" or "8." The 2/14/14 updated care plan noted Resident 203 required two person total assistance Sit to Stand transfers. On 2/20/14 at 9:15 am and 10:38 am, Resident 203 was observed lying in bed, awake and did not respond to questions. In interview on 2/20/14 at 12:00 pm, Staff 6, DNS, stated Staff 1, CNA, initially stated there were two caregivers present at the time of the transfer on 2/9/14, but during their investigation of the resident's fracture, Staff 1 admitted she was the only staff member present during the transfer. Staff 6 stated Staff 1 was aware the resident required two person assistance with transfers at the time of the incident and did not state why she transferred the resident by herself. In interview on 2/20/14 at 12:35 pm, Staff 4, RNCM, stated on 2/9/14 an aide reported to her the resident was on the floor. When staff 4 entered the room, Resident 203 was lying on the floor, with her/his hips angled to the right and knees angled to the left. Staff 4 stated Resident 203 looked like a "funny L." After the resident's body was straightened out, the resident's legs were assessed and the resident reported pain above her/his knee. In interview on 2/20/14 at 12:45 pm, Staff 3, RNCM, stated prior to the fall on 2/9/14 the resident was noted with weakness, more to the left side. Staff 3 stated Staff 1, CNA, initially reported someone was with her during Resident 203's transfer, but then later stated the resident wanted to go to the bathroom and she took the resident there by herself. The staff member admitted to lying about being by herself when she was initially asked about the resident's transfer and subsequent fall. In interview on 2/20/14 at 2:21 pm, Staff 7, LPN, stated after the 2/9/14 incident, the resident did not initially complain about a lot of pain. However, the resident indicated she/he had more pain when talking with the physician assistant. The x-ray was ordered which revealed the fracture and the resident was put on routine Tylenol and PRN [MEDICATION NAME]. In interview on 2:40 pm, Staff 8, RN, stated after the fall, every time they changed the resident, she/he stated it was painful above the knee. When the resident was lying still in bed she/he had no complaints of pain, but complained of it when staff moved her/him. Staff 8 stated the pain medication was helpful but the resident still complained of pain. At the time of the survey, Staff 1, CNA, was not available for interview. Refer to F-323.

Based on observation, interview and record review it was determined the facility failed to ensure care planned interventions for transfers were followed for 1 of 4 sampled residents (#203) reviewed for accidents. Resident 203 sustained a fracture. Findings include: Resident 203 was admitted to the facility in 1/2014 with [DIAGNOSES REDACTED]. The 1/26/14 Care Plan noted the resident required two person limited assistance with transfers. The 1/26/14 Physician order [REDACTED]. The 2/4/14 Physician Assistant follow up note on a change in condition indicated Resident 203 was found to have a urinary tract infection and left facial droop, most likely from a stroke. The family requested comfort care measures for the resident. A 2/5/14 Progress Note indicated Resident 203 had some left sided weakness. Family stated the resident was getting weaker. The 2/5/14 updated Care Plan indicated Resident 203 required two person extensive assistance with transfers. A 2/9/14 8:15 am Progress Note disclosed Resident 203 was lowered to the floor in the bathroom. The resident complained of pain to her/his knee. The correlated facility investigation revealed Staff 1, CNA, reported she had taken Resident 203 to the bathroom and when the resident was done, she stood the resident up and the resident's knees buckled. Staff 1 assisted Resident 203 to the floor. The resident was care planned for a two person transfer, however there was only one caregiver present during the incident. The facility determined neglect occurred, with actions taken including care plan revision, staff counseling and termination. On 2/9/14 the physician ordered an x-ray of the left knee. A 2/9/14 Progress Note indicated due to weather and road conditions, the x-ray would not be done until the next day. The 2/9/14 8:38 pm Progress Note revealed the resident complained of left knee pain, "hurts bellow (sic) my knee", which was painful with movement. The 2/10/14 8:25 am Progress Note disclosed Resident 203 complained of left lower extremity pain, pointing about two inches above the left knee. The 2/10/14 knee x-ray was negative for fracture. A 2/11/14 Progress Note revealed Resident 203 stated she/he "is in a lot of pain from fall this weekend. Pain medication administered...." The resident remained in her/his room all shift related to pain. The 2/13/14 Physician Assistant follow up note indicated the resident had leg pain after the assisted fall to the ground. X-rays of the left femur and hip were ordered to rule out a fracture. The 2/13/14 x-rays identified a fracture of the mid femur. The 2/14/14 3:30 pm Progress Note indicated the resident's family did not want the resident to go to the hospital or have surgical intervention. On 2/14/14 the physician changed the Acetaminophen order from 650 mg PRN to receiving it routinely every four hours. The physician added Roxanol (a narcotic pain medication) 0.25 ml every three hours PRN pain. Additionally the resident was non weight bearing on the left leg and was to either have traction to the left leg or a knee immobilizer in place. According to the 2/2014 MAR, Resident 203 received the PRN Roxanol as ordered. From 2/16/14 to 2/18/14, the resident received the Roxanol for reports of left hip pain at "7" or "8." The 2/14/14 updated care plan noted Resident 203 required two person total assistance Sit to Stand transfers. On 2/20/14 at 9:15 am and 10:38 am, Resident 203 was observed lying in bed, awake and did not respond to questions. In interview on 2/20/14 at 12:00 pm, Staff 6, DNS, stated Staff 1, CNA, initially stated there were two caregivers present at the time of the transfer on 2/9/14, but during their investigation of the resident's fracture, Staff 1 admitted she was the only staff member present during the transfer. Staff 6 stated Staff 1 was aware the resident required two person assistance with transfers at the time of the incident and did not state why she transferred the resident by herself. In interview on 2/20/14 at 12:35 pm, Staff 4, RNCM, stated on 2/9/14 an aide reported to her the resident was on the floor. When Staff 4 entered the room, Resident 203 was lying on the floor, with her/his hips angled to the right and knees angled to the left. Staff 4 stated Resident 203 looked like a "funny L." After the resident's body was straightened out, the resident's legs were assessed and the resident reported pain above her/his knee. In interview on 2/20/14 at 12:45 pm, Staff 3, RNCM, stated prior to the fall on 2/9/14 the resident was noted with weakness, more to the left side. Staff 3 stated Staff 1, CNA, initially reported someone was with her during Resident 203's transfer, but then later stated the resident wanted to go to the bathroom and she took the resident there by herself. The staff member admitted to lying about being by herself when she was initially asked about the resident's transfer and subsequent fall. In interview on 2/20/14 at 2:21 pm, Staff 7, LPN, stated after the 2/9/14 incident, the resident did not initially complain about a lot of pain. However, the resident indicated she/he had more pain when talking with the physician assistant. The x-ray was ordered which revealed the fracture and the resident was put on routine Tylenol and PRN Roxanol. In interview on 2:40 pm, Staff 8, RN, stated after the fall, every time they changed the resident, she/he stated it was painful above the knee. When the resident was lying still in bed she/he had no complaints of pain, but complained of it when staff moved her/him. Staff 8 stated the pain medication was helpful but the resident still complained of pain. At the time of the survey, Staff 1, CNA, was not available for interview. .

Based on interview and record review it was determined the facility failed to prevent injury while being transported in a wheelchair for 1 of 3 sampled residents (#1) reviewed for injuries. As a result, Resident 1 sustained ankle and knee injuries. Findings include: Resident 1 was admitted to the facility in 1/2013 with [DIAGNOSES REDACTED]. Resident 1 was admitted with physician orders [REDACTED]. A 1/21/13 Progress Note indicated Resident 1 returned from the physician's office with the immobilizer removed and a "pre existing" right leg wound. A 3/6/13 Progress Note indicated Resident 1's right leg wound required a muscle flap and a skin graft, which was scheduled for 3/11/13. A 3/11/13 Progress Note revealed Resident 1 had the planned leg wound surgery. A 4/4/13 Progress Note disclosed Resident 1 had an incident in therapy where her/his right leg was caught under the wheelchair when wheeling down the hall. The resident reported "I heard a pop and had a lot of pain." The correlating facility's investigation noted at 3:00 pm, Staff 6, OTA (occupational therapy assistant), was bringing Resident 1 back to the room after a session. The resident's leg/foot dropped and caught on the carpet, under the wheelchair. A 4/19/13 Care Plan noted the resident was to use leg rests on the wheelchair for long distances only. Staff "may" use the wheelchair without leg rests for short distances. At the time of the survey, there was no documented evidence in the clinical record of how staff were going to prevent a repeated incident if the leg rests were not in use. A 4/25/13 10:04 pm Progress Note revealed Resident 1 was being assisted in the wheelchair without leg rests and the resident's right foot boot caught on the floor, causing the resident to complain of pain. The correlating facility's investigation disclosed Staff 4, CNA, was pushing the resident in the wheelchair to the shower room without foot rests in place, when the resident's shoe caught on the carpet. The resident's right leg caught under the wheelchair, pulling the leg in a backward motion. The resident was noted to only use foot rest on an occasional basis. Staff 4 documented at the time the resident had her/his feet tucked under the wheelchair, not touching the floor or dragging. As they passed the doorframe of the resident's room, the resident's foot caught on the threshold. Staff 4 documented the resident stated she/he should have asked Staff 4 to put foot rests on the wheelchair. To help the resident, Staff 4 documented she "put footrests on which calmed (Resident 1) a bit." A 4/26/13 5:39 am Progress Note disclosed Resident 1 complained of severe pain to the right lower extremity around the ankle after being injured that evening. Per Staff 10, RN, it was not like the resident's usual pain level on assessment. The right lower extremity was swollen and the resident "jumped" when the ankle area was touched, with pain going up to the right knee. The resident had a pain level of 10 out of 10. The resident was medicated with Oxycodone, but stated it did not help with the pain. The physician was contacted, who gave orders to send the resident to the hospital for x-ray and leg evaluation. The 4/26/13 Emergency Department Provider Notes disclosed the resident was being pushed in the wheelchair without the leg rest raised. Her/his right foot caught the floor and was inverted while the right knee was twisted inward. The resident reported she/he felt pain immediately after a snapping sensation in the knee. The resident reported the pain radiated from the knee to the shin. It noted the resident's right ankle had a skin graft with a stage three pressure ulcer with surrounding redness extending to the mid shin. It was suspected the resident had a ligament or meniscal injury. The resident complained of increasing pain, which was treated with IV pain medication. The resident had [DIAGNOSES REDACTED]. A 4/27/13 Progress Note indicated the resident's right lower leg and shin were red and warm to touch. The knee was swollen with increased pain on movement. In interview on 6/24/13 at 1:40 pm, Staff 6, OTA, stated Resident 1 had weakness with the right leg. Regarding the 4/4/13 incident, Staff 6 stated when she got Resident 1 from her/his room, there were no leg rests in the room. After therapy they stopped by the nurse's station. Upon leaving the nurse's station, they had gone "a couple of feet before the resident hollered 'ow'." Staff 6 stated afterwards she went to the therapy room, located leg rests and put them on the resident's wheelchair. Additionally, she asked the charge nurse to add the use of leg rests at all times to the resident's care plan. Staff 6 stated she could not recall who the charge nurse was. In interview on 6/25/13 at 5:52 am, Staff 10, LPN, stated therapy had reported to her about the 4/4/13 wheelchair incident, however, she did not recall anything about the use of foot rests. Staff 10 stated she was concerned about the injury, especially after the resident stated hearing a pop and having pain. In interview on 6/21/13 at 2:19 pm, Staff 3, RNCM, stated Resident 1 was sent to the emergency roiagnom on [DATE] for pain related to the incident. In interviews on 6/21/13 at 2:45 pm and 3:05 pm, and 6/24/13 at 2:32 pm, Staff 4, CNA, stated she had not placed foot rests on the resident's wheelchair as it was not care planned. Staff 4 stated she was not aware the resident had a previous incident of getting her/his leg caught under the wheelchair. As they were leaving the resident's room, they were almost over the doorway when "we got stuck." Staff 4 stated the resident told her she/he should have asked Staff 4 to put foot rests on the wheelchair. In interview on 6/24/13 at 1:30 pm, Staff 5, LPN, stated after the 4/25/13 incident, he assessed the resident. Per Staff 5, the resident stated she/he did not know why she/he kept putting her/his foot down. Staff 5 stated he did not know if it was related to it being late in the evening and the resident being tired. Staff 4 stated he added the use of foot rests at all times to the care plan. Staff 4 stated he checked the resident's leg a couple of times and there was no swelling. In interview on 6/25/13 at 5:45 am, Staff 10, RN, stated after the 4/25/13 incident, the resident's leg was swollen and the resident reported the wound was painful. Staff 10 stated she gave the resident pain medication, which was not effective. The wound had not re-opened, but was swollen more than usual and was painful to touch. Staff 10 stated she had the resident sent to the hospital due to the pain medication not being effective and the leg swelling.