Every finding on record at Chehalem Post Acute

Based on interview and record review, it was determined the facility failed to timely report potential allegations of neglect and abuse to the State Agency for 3 of 8 sampled residents (#s 7, 8, and 9) reviewed for abuse and elopement. This placed residents at risk for allegations of neglect and abuse not being investigated in a timely manner. Findings included:1. Resident 7 was admitted to the facility in 8/2026 with diagnoses including Alzheimer's disease, dementia and altered mental status. Resident 7's 8/7/26 Brief Interview for Mental Status assessment revealed Resident 7 moderately cognitively impaired. On 8/18/26, the State Agency received a public complaint alleging Resident 7 left the faciity on 8/12/26 and crossed a busy highway. The resident's family was concerned about her/his safety as Resident 7 was only oriented to self and received a complicated surgery on 7/21/26. A Nurse's Note dated 8/9/26 indicated Resident 7 walked to a store while pushing her/his roommates wheelchair without notifying staff. Resident 7 was too tired to walk back to the facility and called non-emergency police department to provide Resident 7 a ride back to the facility. There was no documented evidence that the elopement was reported to the State Survey Agency for the identified dates. On 8/25/26 at 12:28 PM Staff 1 (Administrator) and Staff 4 (Regional Nurse Consultant) acknowledged the elopement on 8/9/26 should have been reported to the State Survey Agency. 2. Resident 9 was admitted to the facility in 6/2021 with diagnoses including borderline personality disorder, and anxiety. Resident 2 was admitted to the facility in 2/2026 with diagnoses including anxiety, depression, and post-traumatic stress disorder. A 6/25/26 Quarterly MDS indicated Resident 9 was cognitively intact. Resident 2's 7/14/26 Behavior Note indicated Resident 2 displayed verbal behaviors during an interaction with another resident. Resident 2 called the other resident fat bitch. On 8/20/26 at 9:49 AM, Staff 17 (CNA) stated she had observed Resident 2 calling Resident 9 names one or two times in 8/2006. On 8/20/26 at 10:34 AM, Resident 9 stated Resident 2 called her/him names every day. Resident 2 called her/him a fat cow, bitch, and slob. Resident 9 stated she/he hated being in the facility and felt Resident 2 calling her/him names was verbal abuse and made her/him feel uncomfortable. On 8/20/26 at 10:58 AM, Staff 29 (CMA) she has observed Resident 2 call Resident 9 a fat bitch. On 8/24/26 at 11:31 AM, Staff 8 (LPN) stated one instance she observed Resident 2 call Resident 9 a fat ass. There was no documented evidence the facility had reported Resident 2's verbal abuse toward Resident 9 to the State Survey Agency. On 8/25/26 at 12:07 PM, Staff 1 (Administrator) and Staff 4 (Regional Nurse Consultant) expect staff to report concerns of verbal abuse and would report these allegations to the State Survey Agency. 3. Resident 8 was admitted to the facility in 6/2021 with diagnoses including paranoid schizophrenia, stroke, anxiety and dementia. On 8/20/26 at 7:31 AM Staff 7 (CNA) stated one evening in 7/2026 Resident 2 was having behaviors and was screaming at Resident 8 that staff did not love her/him and did not want to take care of her/him and she/he was just going to rot. Staff 7 stated she reported the incident to Staff 5 (LPN). There was no documented evidence that the facility reported the allegation of verbal abuse to the State Survey Agency. On 8/25/26 at 12:04 PM, Staff 1 (Administrator) and Staff 4 (Regional Nurse Consultant) stated any concerns involving Resident 2 being verbally abusive to Resident 8 he was not aware of and would expect some follow-up.

Based on interview and record review it was determined the facility failed to complete thorough investigations for alleged neglect and verbal abuse allegations for 3 of 8 sampled residents (#s 7, 8, and 9) reviewed for elopement and verbal abuse. This placed residents at risk for elopement and continued verbal abuse. Findings include:1. Resident 7 was admitted to the facility in 8/2026 with diagnoses including Alzheimer's disease, dementia and altered mental status. Resident 7's 8/7/26 Brief Interview for Mental Status assessment revealed Resident 7 moderately cognitively impaired. On 8/18/26, the State Agency received a public complaint alleging Resident 7 left the faciity on 8/12/26 and crossed a busy highway. The resident's family was concerned about her/his safety as Resident 7 was only oriented to self and received a complicated surgery on 7/21/26. Nurses Note dated 8/9/26 indicated Resident 7 walked to a store while pushing her/his roommates wheelchair without notifying staff. Resident 7 was too tired to walk back to the facility and called non-emergency police department to provide Resident 7 a ride back to the facility. On 8/21/26 at 12:35 PM, Staff 10 (LPN) stated it was the first day she had worked with Resident 7 and it was unclear if Resident 7 leaving the facility was an elopement. On 8/25/26 at 12:28 PM, Staff 1 (Administrator) and Staff 4 (Regional Nurse Consultant) acknowledged no investigation had been completed for Resident 7's elopement. 2. Resident 9 was admitted to the facility in 6/2021 with diagnoses including borderline personality disorder, and anxiety. Resident 2 was admitted to the facility in 2/2026 with diagnoses including anxiety, depression, and post-traumatic stress disorder. A 6/25/26 Quarterly MDS indicated Resident 9 was cognitively intact. Resident 2's Behavior Note dated 7/14/26 indicated the resident displayed verbal behaviors during an interaction Resident 9 and Resident 2 called the other Resident 9 a fat bitch. On 8/20/26 at 9:49 AM, Staff 17 (CNA) stated she had observed Resident 2 calling Resident 9 fat and cussing at her/him. Staff 17 stated she had observed Resident 2 calling Resident 9 names one or two times in 8/2026. On 8/20/26 at 10:34 AM, Resident 9 stated Resident 2 calls her/him names every day. Resident 2 calls her/him a fat cow, bitch, and slob. Resident 9 stated she hated being in the facility and felt Resident 2 calling her/him names was verbal abuse and made her/him feel uncomfortable. On 8/20/26 at 10:58 AM Staff 29 (CMA) she has observed Resident 2 call Resident 9 a fat bitch. On 8/24/26 at 11:31 AM Staff 8 (LPN) stated one instance she observed Resident 2 call Resident 9 a fat ass. There was no documented evidence that an investigation had been completed for the alleged verbal abuse by Resident 2 toward Resident 9. On 8/25/26 at 12:07 PM, Staff 1 (Administrator) and Staff 4 (Regional Nurse Consultant) stated he was unaware of the alleged verbal abuse concerns by Resident 2 toward Resident 9 and acknowledged an investigation should have been completed. 3. Resident 8 was admitted to the facility in 6/2021 with diagnoses including paranoid schizophrenia, stroke, anxiety and dementia. On 8/20/26 at 7:31 AM, Staff 7 (CNA) stated one evening in 7/2026 Resident 2 was having behaviors and was screaming at Resident 8 that staff did not love her/him and did not want to take care of her/him and she/he was just going to rot. Staff 7 stated she reported the incident to Staff 5 (LPN). There was no documented evidence that an investigation for the observed verbal abuse by Resident 2 toward Resident 8 had been completed. On 8/25/26 at 12:04 PM, Staff 1 (Administrator) and Staff 4 (Regional Nurse Consultant) stated he was not aware of any verbal abuse concerns by Resident 2 toward Resident 8 and would expect an investigation to be completed.

Based on interviews and record review, it was determined the facility failed to protect the residents' right to be free from verbal and physical abuse by another resident for 5 of 5 sampled residents (#s 1, 4, 8, 9, and 11) reviewed for verbal and physical abuse. This placed residents at risk for further abuse. Findings include:1. Resident 1 was admitted to the facility in 10/2025 with diagnoses including depression. Resident 2 was admitted to the facility in 2/2026 with diagnoses including anxiety, depression, and post-traumatic stress disorder. A 6/25/26 Quarterly MDS indicated Resident 1 was moderately cognitively impaired. A 2/26/26 admission MDS indicated Resident 2 was moderately cognitively impaired. Resident 1's 7/16/26 Nursing Note indicated she/he received physical aggression from another resident, sustained a skin tear to the forearm, and required monitoring for pain, additional injury, and psychosocial harm. The facility's 7/22/26 investigation indicated on 7/16/26 Resident 2 was outside in the parking lot, became upset with Resident 1, and pushed a chair into Resident 1, causing a skin tear. Prior verbal altercations had occurred, and staff encouraged separation. Witness statements were as follows:-Witness (Resident 4) stated she/he was outside smoking with Resident 1. As they returned to the facility and paused at the patio, Resident 2 was present. Staff 3 (Maintenance Assistant) walked by, and as Resident 1 attempted to enter the building, Resident 2 picked up a chair and reached forward to strike Resident 1 with the leg of the chair.-Staff 3 stated he had walked into the facility and observed Resident 2 in her/his wheelchair, lean forward, pick up a chair with both hands, and hit Resident 1's arm with the chair legs. On 8/18/26 at 12:27 PM, Resident 1 stated Resident 2 was always the aggressor. Resident 2 had called her/him a fucking bitch. Resident 1 stated she/he felt in jeopardy around Resident 2. Resident 1 was unable to remember the incident from 7/16/26. On 8/19/26 at 8:53 AM, Resident 2 stated Resident 1 kept approaching her/him. Resident 2 started to escalate and raised her/his voice and stated the nurses do not do shit. On 8/20/26 at 10:58 AM, Staff 29 (CMA) stated she had observed Resident 2 call Resident 1 a fat bitch. On 8/24/26 at 12:28 PM, Staff 11 (LPN) stated on 8/15/26 he observed Resident 2 call Resident 1 fat and disgusting. On 8/24/26 at 2:01 PM, Staff 3 stated on 7/16/26 he was entering the facility when Resident 2 called him a fat Mexican. Staff 3 continued inside, turned around, and saw Resident 2 yelling at Resident 1. Resident 2 picked up a chair and had shaken it at Resident 1. On 8/25/26 at 11:43 AM, Staff 1 (Administrator) and Staff 4 (Regional Nurse Consultant) confirmed the facility determine physical abuse occurred to Resident 1 by Resident 2. 2. Resident 4 was admitted to the facility in 6/2026 with diagnoses including anxiety. Resident 2 was admitted to the facility in 2/2026 with diagnoses including anxiety, depression, and post-traumatic stress disorder. A 2/26/26 admission MDS indicated Resident 2 was moderately cognitively impaired. A 6/19/26 admission MDS indicated Resident 4 was moderately cognitively impaired. a. The facility's 8/14/26 investigation indicated on 8/8/26 Resident 4 and Resident 2 were in the designated smoking section when another resident came into the facility to inform staff two residents were fighting. Resident 2 had been saying offensive statements to Resident 4, and she/he went over to speak to Resident 2. Resident 2 then ripped off Resident 4's shirt and attempted to kick Resident 4 in the face and chest. Resident 4 grabbed Resident 2's foot to stop it from contacting her/his chest or face and Resident 2 fell out of her/his wheelchair. Witness statements were as follows:-Resident 4 stated Resident 2 was running [her/his] mouth at the smoking area so Resident 4 approached and Resident 2 kicked her/him in the face and chest so Resident 4 grabbed Resident 2's leg.-Staff 20 (CNA) stated a resident came into the facility and yelled for help and that two residents were fighting. Resident 2 and Resident 4 were in the parking lot, Resident 4 was in her/his wheelchair shirtless, and Resident 2 was on the ground. Resident 2 was yelling Resident 4 pushed her/him to the ground. Resident 4 stated Resident 2 was talking shit and attacked her/him and pulled her/his shirt off.-Staff 16 (CNA) stated a resident told her that there were two residents fighting. Resident 2 was on the ground and Resident 4 was holding her/his leg. Resident 4 was not wearing a shirt. Staff 16 told Resident 4 to release Resident 2's leg and moved Resident 4 away from Resident 2. On 8/18/26 at 12:28 PM, Resident 4 stated she/he could not remember the incident on 8/8/26 of her/his shirt being ripped off or of Resident 2 attempting to kick her/him. On 8/19/26 at 8:53 AM, Resident 2 stated Resident 4 kept coming at her/him. Resident 2 started to escalate and raised her/his voice, stated the nurses do not do shit. Interview ended. On 8/19/26 at 12:28 PM, Staff 16 stated on 8/8/26 a resident came into the facility and reported Resident 2 and Resident 4 were fighting. Staff 16 stated Resident 2 was on the ground, and she moved Resident 4 away from the area. Resident 2 started calling Resident 4 and another resident fat bitches and fat slobs and was trying to trigger them. On 8/24/26 at 9:20 AM, Staff 14 (LPN) stated she had observed Resident 2 call Resident 4 fat ass, and ugly fat ass. On 8/25/26 at 11:55 AM, Staff 1 (Administrator) and Staff 4 (Regional Nurse Consultant) acknowledged Resident 2 abused Resident 4. b. On 8/17/26 a Facility Reported Incident was received by the State Survey Agency indicating on 8/14/26 at 4:59 PM Staff 29 (CMA) observed Resident 2 yell profanities across the parking lot at Resident 4. Resident 4 approached Resident 2 and both residents began to strike each other. Resident 2's Behavior Note dated 8/14/26 indicated she/he had multiple verbal altercations with Resident 4. Resident 4 approached Resident 2 in parking lot and hit Resident 4 with a grabber tool and started a physical altercation. An 8/17/26 Alert Charting Note indicated Resident 4 was on alert for a physical altercation with another resident. On 8/18/26 at 12:28 PM, Resident 4 stated Resident 2 had slapped her/him in the face, and four staff members came and stood between Resident 2 and Resident 4 to stop them. On 8/19/26 at 8:53 AM, Resident 2 stated Resident 4 kept coming at her/him. Resident 2 started to escalate and raised her/his voice and stated the nurses do not do shit. On 8/20/26 at 10:58 AM Staff 29 (CMA) stated on 8/14/26 around 5:00 PM Resident 2 was yelling at Resident 4 and Resident 4 went toward Resident 2 quickly. Staff 29 stated Resident 4 told her she/he was going to deal with Resident 2, and when they were together, they were hitting each other, and she could not see who started the hitting. Staff 29 stated she heard Resident 2 call Resident 4 a fat bitch. On 8/20/26 at 12:28 PM Staff 11 (LPN) stated he did not see Resident 2 slap Resident 4 but on 8/15/26 he heard Resident 2 call Resident 4 fat and disgusting. Staff 11 stated Staff 29 observed the 8/14/26 incident. On 8/25/26 at 11:55 AM Staff 1 (Administrator) and Staff 4 (Regional Nurse Consultant) acknowledged Resident 2 abuse Resident 4. 3. Resident 8 was admitted to the facility in 6/2021 with diagnoses including paranoid schizophrenia, stroke, anxiety and dementia. Resident 2 was admitted to the facility in 2/2026 with diagnoses including anxiety, depression, and post-traumatic stress disorder. A 1/19/26 Annual MDS indicated Resident 8 was rarely understood and had short- and long-term memory problems. A 2/26/26 admission MDS indicated Resident 2 was moderately cognitively impaired. Resident 8's 3/24/26 Psychiatry Progress Note indicated the resident was seen for a follow-up related to the resident's schizophrenia, and dementia. Resident had a long-standing history of anxiety disorder, and a history of delusions (false beliefs) and paranoia with her/his paranoid schizophrenia. Resident 8 had cognitive impairment consistent with dementia, impaired judgment and insight, and behavioral variability in overstimulating settings. The treatment plan was to have supportive care with structured daily routine and environmental modifications to reduce noise and distractions. Staff to perform nonpharmacological interventions of using a soft voice, tell resident You're safe. I'm here to help you., Turn off loud TV or music, move resident to a quiet, comfortable place, and talk calmly about showers. Resident 2's 7/27/26 Behavior Note indicated staff attempted to get Resident 8 ready for the morning. Resident 2 went into the room and began yelling at staff regarding the door being closed. Resident 2 was yelling repeatedly while sitting in her/his wheelchair in the middle of the room next to Resident 8's bed. Resident 2 continued to yell, and when leaving the room, she/he attempted to hit the staff with her/his wheelchair. When Resident 2 left the room, she yelled motherfuckers. On 8/20/26 at 7:31 AM, Staff 7 (CNA) stated one evening in 7/2026 Resident 2 was having behaviors and was screaming at Resident 8 that staff did not love her/him and did not want to take care of her/him and she/he was just going to rot. Staff 7 stated she reported the incident to Staff 5 (LPN). On 8/20/26 at 10:58 AM, Staff 29 (CMA) stated if Resident 8 attempted to express her/his needs and staff did not hear her/him, Resident 2 told her/him staff were not going to help her/him and they don't care about her/him. On 8/20/26 at 12:28 PM, Staff 11 stated he had observed Resident 2 tell Resident 8 no one wanted to take care of her/him and staff wanted to hide from her/him. Resident 2 also yelled at staff and threw items while Resident 8 was in the room. On 8/21/26 at 9:25 AM, Witness 10 (Family Member) stated Resident 8 had a history of trauma. On 8/24/26 at 9:20 AM, Staff 14 (LPN) stated Resident 2 told Resident 8 nobody cared about her/him. Resident 8 sometimes started yelling when Resident 2 yelled at staff or threw things. On 8/25/26 at 12:04 PM, Staff 1 (Administrator) and Staff 4 (Regional Nurse Consultant) stated Resident 8 went into the courtyard or activities room and usually was not around Resident 2. Staff 1 stated any concerns related to Resident 2 to Resident 8 he was not aware of but would expect some follow-up. Staff 1 stated he could not determine if it was abusive. 4. Resident 9 was admitted to the facility in 6/2021 with diagnoses including borderline personality disorder, and anxiety. Resident 2 was admitted to the facility in 2/2026 with diagnoses including anxiety, depression, and post-traumatic stress disorder. A 6/25/26 Quarterly MDS indicated Resident 9 was cognitively intact. A 2/26/26 admission MDS indicated Resident 2 was moderately cognitively impaired. Resident 2's 7/14/26 Behavior Note indicated the resident displayed verbal behaviors during an interaction with another resident. Resident 2 called Resident 9 a fat bitch. When staff attempted to intervene, Resident 2 stated shut the fuck up. On 8/20/26 at 9:49 AM, Staff 17 (CNA) stated she had observed Resident 2 make comments about Resident 9, telling her/him she/he was fat and cussing. Staff 17 stated she had observed one or two times in 8/2026. On 8/20/26 at 10:34 AM, Resident 9 stated Resident 2 calls her/him names every day. Resident 2 called her/him a fat cow, bitch, and slob. Resident 9 stated she hated being in the facility and felt Resident 2 calling her/him names was verbal abuse and made her/him feel uncomfortable. On 8/20/26 at 10:58 AM, Staff 29 (CMA) she has observed Resident 2 call Resident 9 a fat bitch. On 8/24/26 at 11:31 AM, Staff 8 (LPN) stated one instance she observed Resident 2 call Resident 9 a fat ass. On 8/24/26 at 1:33 PM, Staff 23 stated the 7/14/26 incident which she wrote the behavior note was directed toward Resident 9 when she called her/him a fat bitch. On 8/25/26 at 11:55 AM Staff 1 (Administrator) and Staff 4 (Regional Nurse Consultant) stated no staff had reported Resident 2 being verbally abusive to Resident 9 to him. Staff 1 stated he would expect all incidents of verbal altercations to be reported. 5. Resident 11 was admitted to the facility in 9/2025 with diagnoses including anxiety and depression. Resident 2 was admitted to the facility in 2/2026 with diagnoses including anxiety, depression, and post-traumatic stress disorder. A 2/26/26 admission MDS indicated Resident 2 was moderately cognitively impaired. The facility's 6/28/26 Verbal Aggression investigation indicated several staff responded to a loud commotion in the activity room and Resident 2 was observed yelling at multiple residents including Resident 11. Resident 2 was yelling everyone was in her/his way and needed to move and continued to yell and speak in a hostile manner toward others in the activity room. Resident 11's 7/3/26 Care Plan indicated the resident was at risk for psychosocial well-being concerns related to recent incident in activity or witness to physical aggression from another resident to staff. A 7/6/26 Quarterly MDS indicated Resident 11 was moderately cognitively impaired. On 8/24/26 at 12:28 PM, Staff 11 (LPN) stated on 7/17/26 Resident 2 told Resident 11 to shut up. On 8/24/26 at 1:33 PM, Staff 23 (Activities Director) stated she has observed Resident 2 call Resident 11 a bitch. On 8/25/26 at 7:37 AM, Resident 11 stated Resident 2 has called her/him an ugly old whore, and bitch. Resident 11 stated Resident 2 screams and she/he was afraid Resident 2 would attack her/him. On 8/25/26 at 8:06 AM, Staff 8 (LPN) stated Resident 11 was care planned for psychosocial well-being concerns due to Resident 2 constantly screaming. On 8/25/26 at 12:10 PM, Staff 1 (Administrator) and Staff 4 (Regional Nurse Consultant) stated he was not aware of Resident 11 being verbally abused by Resident 2 and would expect staff to report these concerns.

Based on interview and record review it was determined the facility failed to ensure adequate supervision was provided and a care plan intervention was implemented for 1 of 3 sampled residents (# 5) reviewed for elopement. This placed residents at risk for elopements and accidents. Findings include:1. Resident 5 was admitted to the facility in 7/2026 with diagnoses including dementia and anxiety. Signed physician orders dated 7/18/26 documented Resident 5 may leave on outings with a responsible party. An Elopement Evaluation dated 7/18/26 documented Resident 5 was a low risk of elopement and wandering. Resident 5's initial Care Plan dated 7/21/26 indicated the resident had impaired cognitive function, dementia and impaired thought processes. Staff were to notify the nurse if Resident 5 attempted to leave the parking lot unaccompanied. Resident 5 had an attention span of five minutes. Resident 5's 7/25/26 Cognitive Loss Dementia CAA indicated Resident 5 had moderate to severe cognitive impairment which impacted her/his daily memory and decision-making during transition to the facility. The resident's care plan to include simple verbal cueing during care and regular safety checks as Resident 5 adjusted. There was no documented evidence in Resident 5's clinical record that safety checks were added to the resident's care plan. A Nurse's Note dated 8/11/26 documented at approximately 7:10 PM Staff 8 (LPN) informed Staff 5 (LPN) the fire department was present to drop off Resident 5 who was found approximately two miles away from the facility. Resident 5 reported she/he left without notifying staff because she/he was looking for her/his wallet and phone. A facility's investigation dated 8/18/26 indicated on 8/11/26 at 7:30 PM Resident 5 returned to the facility and first responders informed staff she/he was found approximately two miles away from the facility. Last observation of Resident 5 at the facility was approximately 5:45 PM. Conclusion was Resident 5 left the facility without notifying staff and was found by EMS services. On 8/18/26 at 2:17 PM, Witness 1 (Witness) stated on 8/11/26 she was driving and saw Resident 5 in the middle of the road with her/his walker. Witness 1 stated she stopped and Resident 5 stated she/he was looking for a friend in a different city. Witness 1 stated she called 911 as she could tell Resident 5 was confused. While she waited Resident 5 went into a field and she/he was in some bushes laying down. Witness 1 stated she kept turning around and keeping an eye on Resident 5 until first responders arrived. Witness 1 stated Resident 5 was in an area where she/he was hard to see, and she was concerned for her/his safety. On 8/19/26 at 2:58 PM Staff 6 (CNA) stated Resident 5 would forget and not know where the restroom, dining room or where her/his room was. Staff 6 stated she did not know anything about Resident 5's elopement on the evening of 8/11/26 when she was assigned as Resident 5's CNA. On 8/19/26 at 3:13 PM, Staff 25 (CNA) stated Resident 5 was confused in 7/2026, and staff would have to tell her/him where things were. Resident 5 would follow other residents out the door to go outside, and she would go and observe her/him about every 30 minutes. On 8/21/26 at 12:00 PM, Staff 5 (LPN) stated she did not know Resident 5 was not in the facility on 8/11/26 when the ambulance arrived to return her/him to the facility. On 8/24/26 at 1:03 PM Staff 40 (CNA) stated before 8/11/26 he would see Resident 5 outside, and she/he would sit by the front door. On 8/25/26 at 9:55 AM Staff 39 (CNA) stated Resident 5 did have confusion and before 8/11/26 she/he would go out in the parking area. Staff 39 stated it was expected for CNAs to know the location of their residents with confusion to have eyes on them about every five to 10 minutes. On 8/25/26 at 12:14 PM Staff 1 (Administrator) stated Resident 5 presented as cognitively intact and then the next day she/he would present with cognitive issues. Staff 1 stated the facility attempts not to accept resident who require memory care levels of care. Staff 1 stated he would expect staff to know Resident 5's whereabouts.

Based on interview and record review, it was determined the facility failed to ensure residents were free from misappropriation of property for 1 of 2 sampled residents (#3) reviewed for misappropriation. This placed residents at risk for missing property and potential financial loss. Findings include:Resident 3 was admitted to the facility in 6/2026 with diagnoses including anxiety and depression. A 6/8/26 admission MDS indicated Resident 3 was cognitively intact. The facility's investigation dated 8/12/26 indicated on 8/5/26 a nurse received a report of missing items during a room change, which included personal checks and personal PureWick (urine collection system) supplies. Witness Statements were as follows:-Resident 3 stated while she/he was in the hospital her/his personal items were removed from her/his room. Resident 3 was missing a couple of checks, half of her PureWick supplies and her/his PureWick. Also missing a purse, Russian dolls, two brushes, shampoo, conditioner and body wash. Resident 3 notified the police of the missing checks. The facility administration would replace the missing items and reimburse the missing money.-Staff 19 (LPN) delegated Staff 24 (CNA) to gather all belongings of Resident 3, which were placed in an empty resident room.-Staff 24 packed up Resident 3's items and observed two envelopes which looked like checks. Staff 24 placed them into a garbage bag, knotted it, and put it in a box placed on Resident 3's wheelchair. The PureWick was placed in a box then on her/his wheelchair, and all items were placed into the empty resident room as instructed by Staff 19. On 8/19/26 at 12:21 PM, Staff 24 (CNA) stated she was uncomfortable packing Resident 3's personal items without the resident's consent but was directed to by Staff 19. Staff 24 stated she saw the checks and made sure all the mail was together. She did not have a secure spot to place the items so was instructed to place them into an empty resident room. Staff 24 stated that was the last time she observed Resident 3's items. On 8/20/26 at 9:04 AM, Staff 19 (LPN) stated the room change was an emergency, and she directed Staff 24 to place Resident 3's items on her/his wheelchair and place it into an empty resident room. On 8/25/26 at 11:46 AM, Staff 1 (Administrator) and Staff 4 (Regional Nurse Consultant) confirmed the items should have been placed into a secure room.

Based on interview and record review, it was determined the facility failed to notify the resident representative of a potential accident for 1 of 3 sampled residents (#5) who were reviewed for elopement. This placed residents and responsible parties at risk for delayed notification. Findings include:Resident 5 was admitted to the facility in 7/2026 with diagnoses including dementia and anxiety. An 8/11/26 Nurse's Note indicated Resident 5 left the facility without notifying staff and was brought back to the facility by the fire department. Staff 2 (DNS) and the provider were notified of the incident. There was no documented evidence that Resident 5's representative was notified of the incident. On 8/18/26 at 1:30 PM, Witness 3 (Resident 5's Representative) stated she was not notified of Resident 5's 8/11/26 elopement from the facility. On 8/21/26 at 12:00 PM, Staff 5 (LPN) stated on 8/11/26 she could not recall if she notified Witness 3 of Resident 5's elopement from the facility. On 8/25/26 at 12:20 PM, Staff 1 (Administrator) and Staff 4 (Regional Nurse Consultant) stated they would expect staff to notify Resident 5's representative of her/his elopement.

Based on interview and record review it was determined the facility failed to provide timely lab services for 1 of 3 sampled residents (#7) reviewed for labs. This placed residents at risk for delayed treatment. Findings include:Resident 7 was admitted to the facility in 8/2026 with diagnoses including benign neoplasm of pituitary gland. Physician orders dated 8/7/26 documented that a basic metabolic panel was to be obtained on 8/10/27, and results were to be faxed to the Neurological Clinic. A fax letter dated 8/12/26 from Neurological Surgery department indicated staff had attempted to reach the facility for several days without success. Resident 7's postoperative was complex and resident needed labs completed and an update on her/his status with instructions to obtain the lab. An 8/17/26, lab results showed Resident 7's basic metabolic panel was collected and reported on 8/18/26. On 8/19/26 at 10:13 AM, Witness 8 (Physician) stated Resident 7 discharged from the hospital on 8/7/26 and her/his labs were important to obtain. Witness 8 stated the facility was not communicating with them and did not hear back from the facility. Witness 8 stated hours were spent on attempting to obtain labs for Resident 7. Attempts to contact Staff 33 (LPN) on 8/20/26 and 8/24/26 were unsuccessful. On 8/25/26 at 12:27 PM, Staff 1 (Administrator) and Staff 4 (Regional Nurse Consultant) confirmed Resident 7's basic metabolic panel labs were not completed as physician ordered.

Based on observation and interview it was determined the facility failed to store food in a sanitary manner for 1 of 1 resident refrigerator reviewed for sanitary food storage and handling. This placed residents at risk for food-borne illness and contamination. Findings include:On 7/6/26 at 9:12 AM during the initial tour of the facility's dining room and kitchenette the following was observed in the communal refrigerator:-Multiple sealed reusable bags of lunch meat with the expiration date of 5/2026.-A half empty disposable cup with a sticky orange substance leaked from the top of the cup, dated 6/2026.-An undated reusable bag full of rotted watermelon.-An open, undated, bag of bread, covered in an unknown sticky substance.On 7/6/26 at 9:28 AM Staff 1 (Administrator) observed the items with the surveyor and acknowledged items needed to be discarded, and the spilled substance needed to be cleaned up.

Based on observation, interview, and record review it was determined the facility failed to provide equipment in good condition and failed to provide a well-maintained homelike environment for 2 of 2 sampled residents (#s 9 and 42) reviewed for environment. This placed residents at risk for lack of a homelike environment. Findings include: 1. Resident 9 was admitted to the facility in 12/2025. On 7/7/26 at 9:30 AM during an observation of Resident 9's bathroom sink handle came completely off while turning on the water and the surveyor was able to place the sink handle back on to turn off the water.On 7/7/26 at 9:51 AM Resident 9 stated the bathroom sink handle often came off when the water was turned on and recalled it was like that since her/his admission.On 7/9/26 at 1:48 PM Staff 5 (Maintenance Assistant) stated he worked on Resident 9's bathroom sink handle previously by tightening it and was not aware it was broken again. Staff 4 (Maintenance Director) observed the sink handle came off completely and acknowledged Resident 9's bathroom sink needed repair.On 7/10/26 at 11:57 AM Staff 1 (Administrator) stated residents were to have functional sink handles. Staff 1 stated he expected staff to report broken items and maintenance was responsible for repairs.2. Resident 42 was admitted to the facility in 2012.On 7/6/26 at 10:46 AM Resident 42's room was observed to have broken window blinds with several slats missing and/or broken in half with some broken pieces sitting on the windowsill. Resident 42 nodded yes when asked if the window blinds were broken for a while.On 7/6/26 at 12:57 PM Witness 1 (Family) stated he visited weekly and Resident 42's window blinds were broken for a long time. On 7/8/26 at 4:06 PM Staff 10 (CNA) stated she noticed the broken blinds in Resident 42's room about four months ago and told Staff 5 (Maintenance Assistant) about it.On 7/9/26 at 1:48 PM Staff 5 stated he was aware of some broken blinds in resident rooms but did not recall Resident 42's blinds were broken. Staff 4 (Maintenance Director) and Staff 5 observed the broken blinds in Resident 42's room and acknowledged the blinds needed to be replaced.On 7/10/26 at 11:57 AM Staff 1 (Administrator) stated residents were to have functional window blinds. Staff 1 stated he expected staff to report broken items and maintenance was responsible for repairs.

Based on interview and record review it was determined the facility failed ensure residents obtained dental care for 1 of 2 sampled residents (#9) reviewed for dental services. This placed residents at risk for unmet dental health needs. Findings include:Resident 9 was admitted to the facility in 12/2025 with diagnoses including adult failure to thrive and bipolar disorder.The 12/30/25 admission MDS revealed Resident 9 had a BIMS score of 10 indicating she/he had moderate cognitive impairment.A 4/9/26 Physician Progress Note revealed Resident 9 lost her/his dentures and ate a modified diet which she/he did not like. The physician's assessment and plan revealed a dental referral for dentures.A 4/22/26 Progress Note by Staff 18 (LPN) revealed Resident 9 complained she/he was unable to chew food due to the lack of dentures and requested the food to be ground up. Staff 18 indicated the Resident Care Manager was notified, the resident's food texture was downgraded, and an evaluation by a SLP was ordered. A 5/12/26 Physician Progress Note revealed Resident 9 worked with a SLP and the physician's assessment and plan revealed a dental referral for dentures.A 6/22/26 Physician Order revealed a referral to dental for new dentures. A 7/2/26 Social History Review-Quarterly revealed Resident 9 did not need any services related to dental.On 7/7/26 at 9:42 AM Resident 9 stated she/he was missing all natural teeth, and the previous dentures went missing during transport to the facility. Resident 9 stated someone at the facility spoke to her/him about obtaining dentures but there was no follow-up.On 7/9/26 at 10:47 AM Staff 6 (SSD) indicated she was responsible for referring residents for dental services when ordered. Staff 6 stated she was not aware of Resident 9's order for dentures. On 7/10/26 at 11:32 AM Staff 2 stated she expected referrals to the dentist for dentures be submitted within 72 hours of receiving it. Staff 2 acknowledged Resident 9's referral to the dentist for dentures was not followed up on timely.

Based on observation, interview and record review it was determined the facility failed to revise the plan of care to reflect the resident's needs during meals for 1 of 4 sampled residents (#80) reviewed for food. This placed residents at risk for unmet needs during mealtimes. Findings include: Resident 80 was admitted to the facility in 1/2025 with diagnoses including dementia and blindness in one eye.The resident's current care plan for eating, last revised 2/20/26, revealed Resident 80 required one-on-one assistance and encouragement to increase oral intake and to cut up meat for each meal.Resident 80's 5/12/26 Significant Change MDS indicated she/he required setup and cleanup assistance with eating.Observations from 7/8/26 through 7/9/26 revealed Resident 80 received set up assistance without supervision for lunch, frequent checks for lunch on another occasion, and one-on-one assistance for dinner. Interviews from 7/7/26 through 7/9/26 with Staff 10 (CNA), Staff 12 (CNA), Staff 13 (CNA), Staff 14 (LPN), Staff 15 (CNA), and Staff 16 (CNA) revealed an inconsistent plan of care followed for Resident 80. Staff 12 and Staff 13 stated Resident 80 was independent during meals, Staff 15 and Staff 16 stated Resident 80 only required frequent checks during meals, and Staff 10 and Staff 14 stated Resident 80 required one-on-one assistance during meals. On 7/10/26 at 11:37 AM Staff 2 (DNS) stated Resident 80 required encouragement during mealtimes which meant frequent checks by staff and did not require a staff member to sit one-on-one with the resident. Staff 2 stated Resident 80's care plan did not clearly identify what the resident's needs were during mealtimes and acknowledged the care plan needed revision.

Based on observation, interview and record review it was determined the facility failed to ensure the MDS was coded accurately related to oxygen and smoking for 2 of 4 sampled residents (#s 42 and 64) reviewed for ADLs and smoking. This placed residents at risk for inaccurate assessments. Findings include:1. Resident 42 was admitted to the facility in 2012 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD) and a stroke.A review of Resident 42's oxygen saturations recorded in the vitals tab from 5/28/26 to 6/3/26 revealed saturations were obtained by room air or while Resident 42 received oxygen via nasal cannula (NC).A review of the 6/3/26 Annual MDS revealed the resident was not using oxygen.The physician order, last signed on 6/29/26 revealed an order with a start date of 4/9/26 indicating Resident 42 was to receive oxygen as needed at two liters per minute (lpm) through NC for shortness of breath or to maintain oxygen saturations greater than 88%.On 7/6/26 at 10:46 AM, 7/7/26 at 9:14 AM, 7/8/26 at 12:25 PM, and 7/10/26 at 9:09 AM Resident 42 was observed receiving oxygen via NC. On 7/10/26 at 9:37 AM Staff 3 (Assistant DNS/IP) stated she was the former MDS Coordinator at the facility and collected information for each section of the MDS through physician orders, nursing assessments, personal assessments and interviews with the resident and staff. Staff 3 stated the look back period for Resident 42's 6/3/26 Annual MDS was 5/28/26 through 6/3/26 and stated a review of the residents oxygen saturations in the vitals tab was not included in her review. Staff 3 acknowledged Resident 42's 6/3/26 Annual MDS was coded inaccurately.On 7/10/26 at 11:30 AM Staff 2 (DNS) acknowledged Resident 42's 6/3/26 Annual MDS was coded inaccurately related to oxygen use. 2. Resident 64 was admitted to the facility in 4/2026 with diagnoses including tobacco use and heart failure.The 4/17/26 care plan revealed Resident 64 was to be assessed for the ability to smoke safely.The 4/22/26 Smoking Observation/Assessment revealed Resident 64 was a cigarette smoker and the interdisciplinary team determined Resident 64 was safe to smoke independently.A review of the 4/22/26 admission MDS revealed the resident did not use tobacco.On 7/10/26 at 9:31 AM and at 10:05 AM Staff 3 (Assistant DNS/IP) stated she was the former MDS Coordinator at the facility and collected information for each section of the MDS through hospital records, nursing assessments, personal assessments and interviews with the resident and staff. Staff 3 acknowledged Resident 64 used tobacco and she coded the 4/22/26 admission MDS inaccurately.On 7/10/26 at 11:30 AM Staff 2 (DNS) acknowledged Resident 64's 4/22/26 admission MDS was coded inaccurately related to tobacco use.

Based on interview and record review it was determined the facility failed to ensure residents received follow up care as ordered for 2 of 3 sampled residents (#s 2 and 8) reviewed for pain and medical appointments. This placed residents at risk for worsening health conditions. Findings include: 1. Resident 8 admitted to the facility in 2025 with diagnoses including below the knee amputation and neuropathy.The 12/16/25 physician order indicated Resident 8 was to receive a follow up appointment with a neurosurgery specialist due to pain in her/his neck which caused pinching of the nerves. There was no indication in the clinical record that a follow up neurosurgery specialist appointment was scheduled.On 7/6/26 at 10:57 AM Resident 8 stated she/he wanted a back appointment to address her/his back pain. On 7/10/26 at 10:52 AM Staff 2 (DNS) acknowledged Resident 8 had a physician order for a referral to the spine clinic on 12/16/25 and the facility did not complete the referral until 6/29/26.2. Resident 2 admitted to the facility in 2025 with diagnoses including below the knee amputation.The 4/13/26 physician note indicated Resident 2 had chronic issues related to her/his leg and the prosthetic concerns were discussed with Staff 2 (DNS).On 7/6/26 at 10:02 AM Resident 2 stated she/he wanted a prosthetic leg. Resident 2 further stated the physician and nursing staff were aware for months that she/he wanted an appointment to get a prosthesis.On 7/10/26 at 10:51 AM Staff 2 acknowledged the 4/13/26 physician note indicated Resident 2 had chronic issues related to her/his leg and prosthetic concerns and had not been seen by the prosthetic clinic. Staff 2 further stated the referral was not completed until 7/1/26.

Based on interview and record review it was determined the facility failed to ensure pneumococcal and influenza vaccinations were provided for 2 of 5 sampled residents (#s 9 and 78) reviewed for immunizations. This placed residents at risk for illness. Findings include: A review of the facility's 5/7/25 Influenza and Pneumococcal Immunizations policy indicated it was the policy of the center to offer the Influenza and Pneumococcal immunizations to residents in accordance with federal regulations and current CDC (Centers for Disease Control and Prevention) guidelines.1. Resident 9 was admitted to the facility in 12/2025 with diagnoses including adult failure to thrive and bipolar disorder. A review of Resident 9's medical record revealed she/he was eligible but not offered a pneumococcal vaccination and was not offered an influenza vaccination.On 7/10/26 at 9:27 AM Staff 2 (DNS) stated upon admission Resident 9 should have been offered the pneumococcal and influenza vaccinations. Staff 2 acknowledged Resident 9 was not offered pneumococcal or influenza vaccinations.2. Resident 78 was admitted to the facility in 5/2025 with diagnoses including heart failure and depression.A review of Resident 78's medical record revealed she/he was eligible but not offered a pneumococcal vaccination.On 7/10/26 at 9:27 AM Staff 2 (DNS) stated upon admission Resident 78 should have been offered the pneumococcal vaccination and re-offered yearly if initially declined or when eligible for another dose. Staff 2 acknowledged Resident 78 was not offered the pneumococcal vaccination.

Based on observation, interview, and record review it was determined the facility failed to ensure dependent residents received showers for 2 of 3 sampled residents (#12 and 16) reviewed for ADLs. This placed residents at risk for a lack of personal hygiene and loss of dignity. Findings include:The facility's Activities of Daily Living Policy dated 3/2018 indicated residents who were unable to carry out activities of daily living independently would receive services necessary to maintain good grooming and personal hygiene. 1. Resident 12 was admitted to the facility in 7/2025 with diagnoses of quadriplegia (paralysis affecting all four limbs of the body) and aphasia (a language disorder resulting from brain damage affecting speaking or comprehension). Resident 12's 7/23/25 admission MDS indicated the resident had a severe cognition deficit and was dependent with bathing/showering. The Care plan dated 7/24/25 revealed Resident 12 was dependent on staff for her/his ADL care needs and required one-person total assistance for showering. The care plan did not include frequency of showering. A review of Resident 12's 11/1/25 through 11/30/25 bathing task logs indicated the resident received showers on Wednesdays and Saturdays and revealed the following: -11/2025 the resident had 10 opportunities for showers. -11/1/25, 11/19/25, 11/26/25, and 11/29/25 a shower was provided. -11/5/25 and 11/12/25 Resident 12 received two bed baths. -11/8/25, 11/15/25, and 11/22/25 were Saturdays, and no shower was provided. -11/24/25 Resident 12 refused. -No evidence was found in the clinical record the resident was provided a make-up shower on 11/8/25, 11/15/25, 11/22/25, and 11/24/25. A Grievance Form dated 11/17/25 indicated Witness 2 (Family Member) was concerned Resident 12 was not receiving adequate showers. Witness 2 reported the resident had a strong body odor and greasy hair and face. Witness 2 requested Resident 12 receive shower three times per week instead of twice weekly. The request was not implemented until 11/24/25, seven days later. On 1/12/26 at 11:15 AM, Witness 2 stated Resident 12 was not showered at the frequency needed and, as a result, Resident 12 smelled badly. Witness 2 stated she reported the issue to Staff 16 (Assistant DNS/Former LPN Resident Care Manager) and informed her, she didn't want Resident 12 to have bed baths only showers as the bed baths were insufficient. Observation from 1/12/26 through 1/15/26 from 9:16 AM to 3:37 PM, revealed Resident 12 was either in bed or seated in her/his Geri Chair (a specialized seating solution designed for individuals with mobility challenges), was not interviewable, and had oily facial skin. On 1/13/26 at 12:36 PM, Staff 13 (CNA) stated the resident was to receive showers twice weekly in 11/2025. Staff 13 stated she provided two bed baths in 11/2025 because Resident 12 occasionally experienced pain. Staff 13 stated if Resident 12 missed a shower, it should be made up the next day unless the resident refused. Staff 13 further stated if Resident 12 refused a shower, a bed bath should be offered, and if the resident refused the bed bath, the nurse would be notified. On 1/13/26 at 1:04 PM, Staff 14 (CNA) stated Resident 12 was scheduled to be showered twice weekly and was dependent on staff for showering and did not often refuse showering. Staff 14 stated the usual process for providing Resident 12 a shower is to have her/him transferred into a shower bed, then assisting her/him with washing her/his hair and body. On 1/13/26 at 2:55 PM Staff 8 (CNA) stated she worked with Resident 12, and showering was important because the resident sweated a lot, could have smelly hair, and oily skin. On 1/13/26 at 1:13 PM, Staff 10 (LPN) stated if Resident 12 refused bathing/showering, the CNA would notify the nurse, and the nurse would approach Resident 12. If Resident 12 continued to refuse, she/he was offered a bed bath, and Resident 12 was to be offered a shower the next day. Staff 10 reported if Resident 12's shower was missed, it should be made up later in the same day or the next day. Staff 10 indicated showers were not being completed for Resident 12 in 11/2025 because the facility utilized agency staff often on Saturdays. On 1/14/26 at 2:38 PM Staff 19 () stated she was Resident 12's Resident Care Manager in 11/2025 and was contacted by Witness 2 about Resident 12 not receiving bed baths and increasing the number of showers needed from two times a week to three times a week. Staff 19 indicated she updated Resident 12's care plan to showers only on 11/17/25 and the number of showers a week to three times a week was not implemented until 11/24/25. On 1/13/26 at 3:01 PM and 1/14/26 at 2:45 PM, Staff 2 (DNS) stated she was aware Resident 12 did not receive her/his scheduled showers in 11/2025. Staff 2 stated Resident 12 was scheduled to be showered twice weekly in 11/2025. Staff 2 stated she expected residents to receive at least two showers each week or more if necessary. Staff 2 reported the facility was using a large number of agency CNAs and getting showers completed was an issue with agency staff. 2. Resident 16 was admitted to the facility in 9/2025 with diagnoses including diabetes and metabolic encephalopathy (brain dysfunction caused from an underlying cause such as diabetes or infection). Resident 16's 9/14/25 Care Plan indicated the resident was incontinent of stool, preferred showers and was totally dependent on staff to provide bathing twice a week or as necessary. Resident 16's 9/19/25 admission MDS indicated the resident had moderate cognitive impairment, required substantial to maximal assistance by staff for bathing and did not refuse care. The 12/2025 Shower Schedule indicated Resident 16 was scheduled for showers on Wednesday and Saturday evening shifts. Resident 16's 12/12/25 through 1/12/26 bathing task logs indicated the resident received a shower on 12/21/25. A review of Resident 16's progress notes from 12/13/25 through 1/14/26 revealed no evidence the resident was provided with additional showering opportunities if showering was refused, or the resident's shower was not provided. On 1/13/26 at 9:15 AM and 1/14/26 at 9:11 AM, Resident 16 was in bed, her/his hair was greasy, and the resident was in a gown. Resident 16 stated she/he was not showered regularly and estimated her/his most recent shower was approximately one month ago. Resident 16 stated, in the past, she/he showered every day because showering was her/his giddy-up and go. Resident 16 stated her/his hair was greasy and dirty and had not been washed in a while. Resident 16 stated staff did not offer her/him a shower in a long time, and she/he rarely refused to shower. Resident 16 reported she/he was surprised no one told her/him they stink since it had been so long since she/he showered. On 1/13/26 at 9:48 AM, Staff 5 (CNA) stated Resident 16 was incontinent of bowel and bladder and frequently soiled herself/himself. Staff 5 reported the facility frequently utilized agency CNA staff who often documented refused for showers without offering the resident an opportunity to shower. Staff 5 stated Resident 16 rarely refused showers. Staff 5 reviewed Resident 16's bathing task logs and stated all refusal documentation was by agency staff. On 1/13/26 at 2:31 PM, Staff 8 (CNA) stated Resident 16 was a heavy wetter and often had explosive diarrhea. Staff 8 stated residents were not getting showered like they are supposed to be because staff did not have time to get all residents' showered, especially on Saturdays when the staff were primarily agency CNAs. Staff 8 stated Resident 16 was scheduled for evening showers but sometimes it was too busy, or a second person could not be found to help, since Resident 16 required two staff and a mechanical lift transfer to provide a shower. Staff 8 stated Resident 16 did not always receive her/his showers as scheduled. On 1/13/26 at 3:01 PM, Staff 2 (DNS) stated she expected residents to receive at least two showers each week or more if necessary. Staff 2 reported the facility was using a large number of agency CNAs and getting showers completed was an issue with agency staff. On 1/13/26 at 3:05 PM, Staff 4 (Regional Assistant Director of Clinical Services) reviewed Resident 16's bathing task logs and confirmed the resident's last shower was provided on 12/21/25 and that was not acceptable.

Based on interview and record review it was determined the facility failed to provide written advance notice to a resident/responsible party prior to room changes for 2 of 3 sampled residents (#s 11 and 12) reviewed for resident rights. This placed residents at risk for potential adjustment difficulties and delayed family communication related to changes in room location. Findings include:The facility's Room/Roommate and Change Notification Policy, dated 8/1/24, indicated residents had the right to receive a written notice, including the reason for the change, before a resident's room or roommate was changed. 1. Resident 12 was admitted to the facility in 7/2025 with diagnoses including quadriplegia (paralysis affecting all four limbs of the body) and aphasia (a language disorder resulting from brain damage affecting speaking or comprehension). Resident 12's admission Profile/Face Sheet revealed Witness 2 (Family Member) was the responsible party. Progress notes from 7/2025 through 9/2025 revealed no documentation or written notification of Resident 12's room change had been provided to Witness 2. The clinical record revealed Resident 12 moved rooms on 8/21/25. On 1/12/26 at 11:15 AM Witness 2 stated she was not provided written notification of Resident 12's room change before Resident 12 was moved on 8/21/25. On 1/12/26 at 2:25 PM Staff 2 (DNS), and on 1/13/26 at 11:11 AM Staff 1 (Administrator) confirmed Witness 2 did not receive a written notification for the room change on 8/21/25. Staff 2 stated room change notification was completed by social services; however, Staff 20 (Social Service Director) did not work during the time of the room change. Staff 2 stated she expected all residents to receive written notification when there is a room change. 2. Resident 11 was admitted to the facility in 2/2025 with diagnoses including dementia and cognitive communication deficits (impaired cognition making conversation hard to follow, thoughts disorganized and word-finding difficulties). Resident 11's admission Profile revealed Resident 11 was her/his own responsible party. Resident 11's Census indicated Resident 11 changed rooms on the following dates: -12/20/25, 12/22/25, 12/30/25 and 1/3/26. On 1/12/26 at 2:18 PM and 1/14/26 at 9:22 AM, Resident 11's communication was unintelligible, and responses were unreliable when asked yes/no questions related to her/his room changes. No documentation was found in Resident 11's clinical record regarding written notification for room changes on 12/20/25, 12/22/25, 12/30/25 and 1/3/26. On 1/13/26 at 12:18 PM and 1/14/26 at 9:46 AM, Staff 1 (Administrator) reported a resident or resident's responsible party should receive a written notification of room change prior to the resident being moved. Staff 1 confirmed no written notification was provided to Resident 11 for room changes which occurred on 12/20/25, 12/22/25, 12/30/25 and 1/3/26.

Based on interview and record review it was determined the facility failed to ensure resident records were kept private for 1 of 1 sampled facility record system reviewed for privacy. This placed residents at risk for lack of privacy. Findings include:On 6/23/25 a public complaint was received that alleged the facility did not keep resident records private and sent confidential resident information to Staff 3 (Former Staff/LPN) via a phone application (app) after she quit working at the facility on 6/19/25. On 8/11/25 at 11:50 AM documentation was received that indicated Staff 3's last day at the facility was on 6/19/25. On 8/11/25 at 10:26 AM Staff 3 stated she continued to receive resident private data through a phone app which included resident names, room numbers, information about new admissions and resident behaviors. Staff 3 stated she continued to receive resident information on the app for approximately one month after she stopped working at the facility. On 8/13/25 at 10:53 AM Staff 1 (Administrator) acknowledged Staff 3's last day at the facility was on 6/19/25 and she continued to receive private resident data through the phone app until 7/8/25. Staff 1 stated the phone app was used for communication which included resident names and room numbers and information regarding admissions, discharges and hospitalizations.

Based on interview and record review, it was determined the facility failed to conduct and complete a comprehensive facility wide assessment to care for its residents competently during day to day operations. This placed residents at risk for unidentified and unmet needs. Findings include: The 3/19/25 Facility Assessment was reviewed. The assessment was not comprehensive and failed to accurately include information on the following: - How the facility assessment was used to address staffing needs and competencies. - The percentage of transmission based precautions in the facility. - The number of ADL assistance based on the average census. - The ethnic, cultural and religious makeup of the facility resident population. - The high usage of agency staff. On 3/28/25 at 3:00 PM, Staff 1 (Administrator) reviewed the Facility Assessment and acknowledged the assessment was not comprehensive and did not have accurate information related to the areas indicated. No further information was provided.

Based on interview and record review it was determined the facility failed to ensure a registered nurse was available for at least eight consecutive hours for 6 of 79 days reviewed for RN coverage. This placed residents at risk for delayed nursing assessments. Findings include: A review of the Direct Care Staff Daily Reports revealed the following dates with no RN coverage: -7/20/24 -9/16/24 -9/28/24 - 1/4/25 -1/5/25 -2/15/25 On 3/26/25 at 8:19 AM and 12:00 PM Staff 1 (Administrator) acknowledged the identified dates without the required RN coverage.

Based on interview and record review it was determined the facility failed to ensure a Quality Assurance and Performance Improvement (QAPI) program that implemented action plans to correct identified quality deficiencies. This failed practice placed all residents at risk for not receiving the care and services for optimal resident outcomes. Findings include: The facility's undated Quality Assurance/Performance Improvement (QAPI) policy indicated it used a systematic, comprehensive and data driven approach to maintain and improve safety and quality. A 3/15/25 statement of guiding principles were indicated as the following: - The mission of doing more than just enough to provide quality care because of the quality of staff. - The purpose of a better process and systems to make resident lives better and staff's lives better. - Guiding principles of: every resident your resident, accountability, love/compassion and fun. On 3/28/25 at 3:00 PM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged the QAPI program did not recognize or address the following identified concerns: - Lack of sufficient staffing based on acuity. - Addressing resident grievances related to staffing. - The regulatory requirements of the memory care unit. - Residents not receiving medications timely. - Pharmacy services not provided. - Facility construction causing displacement of residents resulting in issues of receiving medications late and lack of privacy. - Lack of apppropriate infection control practices related to following CDC guidelines. - Lack of timely lab services. - Lack of an Infection Control Preventionist in the facility for a period of time. Refert to F583, F684, F725, F727, F755, F776, F880 and F882.

Based on observation, interview, and record review it was determined the facility failed to protect the resident's right to be free from physical abuse by another resident for 1 of 3 sampled residents (#14) reviewed for abuse. This failure resulted in Resident 13 deliberately kicking Resident 14's walker which resulted in Resident 14 losing her/his balance. Resident 14 fell to the floor and received a head laceration with contusion (bruise) and a fractured hip which required surgery. This placed residents at risk for physical harm. Findings include: The facility's 8/2024 Abuse-Screening, Training, Identification, Investigation, Reporting and Protection policy and procedure stated Abuse is the willful infliction of injury resulting in physical harm, pain or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Resident 13 readmitted to the facility in 10/2024, with diagnoses including Alzheimer's and paranoid schizophrenia. Resident 13's 10/26/24 Quarterly MDS indicated the resident had a BIMS score of ten (moderate cognitive impairment). Resident 13's 10/19/24 Care Plan revealed the following focused behaviors: -Calling out/yelling/shouting; -Agitation; -Suspicious or paranoid behaviors. Behavior interventions for Resident 13 included the following: -Have tactile objects around for resident to manipulate and touch. The resident is visual and likes to do art, particularly diamond painting. -Use activity as a distraction from repetitive thoughts. -Assist to quiet area. A 11/12/24 Abnormal Involuntary Movement Scale (AIMS) indicated Resident 13 did not have any involuntary movements. Resident 14 admitted to the facility in 10/2024, with diagnoses including dementia, with other behavioral disturbances and surgical amputation of left great toe. Resident 14's 11/6/24 MDS indicated the resident had a BIMS score of six, (severe cognitive impairment). Resident 14's 11/2024 Care Plan revealed the following focused behaviors: -Agitation; and -Physical and Verbal aggression. Behavior interventions for Resident 14 included the following: -Attempt to redirect; -Provide 1:1 reassurance and support; and -Set boundaries. On 10/22/24 at 9:30 PM, the facility submitted a report to the State Survey Agency, which revealed Resident 14 entered Resident 13's room. There was a verbal altercation which escalated to a physical altercation when Resident 14 physically hit Resident 13 and Resident 13 yelled and pushed Resident 14. The residents were separated, and an intervention was put into place. The nursing assessment revealed no injuries noted. On 12/29/24 the facility submitted a report to the State Survey Agency, which revealed on 12/29/24 another physical altercation occurred between Resident 13 and Resident 14. Resident 13 was visiting with her/his family member in the hallway. Resident 14 was ambulating with her/his walker and was in close proximity to Resident 13. Resident 13 became agitated and kicked Resident 14's walker. Resident 14 lost her/his balance, fell back, and struck her/his head on the wall and then fell to the floor. No staff were present during the altercation. Resident 13's family member called out for help and Staff 7 (LPN) responded. Resident 13's family member removed Resident 13 from the vicinity. Staff 7 assessed Resident 14. Resident 14 was transferred to the hospital where she/he suffered a head laceration with contusion (bruising) and a fractured hip requiring surgery. On 1/2/25 at 9:48 AM, observations in Expressions (locked memory care unit) noted Resident 14 to be out of the facility. Shadow box outside Resident 14's door included Resident 14's name. On 1/2/25 at 9:56 AM, Resident 13 was observed to be working on crafts in her/his room. Resident 13 stated she/he felt badly she/he kicked somebody's walker the other day. Resident 13 stated she/he was talking with a family member and Resident 14 kept coming around and Resident 14 stated she/he told her/him several times to leave her/him alone. Resident 13 stated she/he was scared and frustrated at the time. Resident 13 stated she/he stayed in her/his room now because of Resident 14. On 1/2/25 at 10:15 AM, Staff 8 (CNA) stated she was providing care to a resident in another room, heard a scream, ran out to the hall and found Resident 14 on the floor being assessed by Staff 7. Staff 8 stated she was not aware of any previous incidences between Resident 13 and Resident 14. Staff 8 stated Resident 14 wanders into other residents' rooms and staff were to watch her/him and approach her/him. On 1/2/25 at 10:33 AM, Resident 13 ambulated with the physical therapist using a walker and a gait belt. Resident 13 appeared calm. On 1/2/25 at 10:39 AM, Staff 6 (Activities Assistant) stated Resident 13 gets frustrated really quickly and was less patient recently. Staff 6 stated she was not aware of any concerns with Resident 13 and other residents. Staff 6 stated she had not discussed with the nurse about Resident 13 and was not aware to watch Resident 13 and to keep her/him apart from other residents. Staff 6 stated staff would let her know if there were resident's who needed to be separated. Staff 6 stated she often saw Resident 14 walk into other resident's rooms. On 1/2/25 at 10:57 AM, Staff 9 (CNA) stated he was told to keep Resident 14 away from all residents and to keep an eye out for Resident 13. On 1/2/25 at 1:16 PM, Staff 7 (LPN) stated she did not see the incident happen. Staff 7 stated she heard Resident 13's family member scream: Stop, Mom, Stop! Staff 7 stated when she walked by, she saw Resident 14 on the floor. Staff 7 stated Resident 13 was agitated and wanted to go home. Staff 7 stated Resident 14 wanders a lot in the area. Staff 7 stated staff separated the two residents and Resident 14 was sent to the hospital later diagnosed with a hip fracture requiring surgery. On 1/2/25 at 1:41 PM, Staff 3 (LPN RCM) stated Resident 14 was originally in the room occupied by Resident 13. Staff 3 stated Resident 13 thinks it is her/his room. Staff 3 stated Resident 14 had a fixation with that room. Staff 3 stated on 12/22/24 Resident 14 entered Resident 13's room and there was a physical altercation between the two residents. The residents were separated. The facility intervention was to place a shadow box outside Resident 14's room to help her/him identify their room. Staff 3 stated she was not at work on 12/29/24. Staff 3 stated she read Resident 13 made Resident 14 trip and fall and Resident 13 sustained injuries and was sent to the hospital. Staff 3 acknowledged no staff were present during the altercation. Staff 3 stated Resident 13 usually spends time in front of the tv and had not directed anything physically towards another resident. On 1/6/25 at 3:02 PM, Staff 2 (DNS) stated it is the facility's job to supervise the residents and acknowledged the facility did not monitor Resident 13 or Resident 14.

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, and failed to ensure smoking materials were stored in a safe manner for 1 of 2 sampled residents (#27) reviewed for smoking safety. This placed the resident at increased risk for personal injury from fires. This failure, determined to be an Immediate Jeopardy situation, placed Resident 27 at increased risk for personal injury from fire. Findings include: The facility's 10/2023 revised Smoking Policy for Independent and Supervised Residents indicated: -All residents who wish to smoke will be assessed for their ability to smoke safely. -Residents who do not meet the established criteria to smoke independently will be provided assistance/supervision during all smoking activities. -No smoking or use of smoking materials will be allowed on the grounds, including parking lots, except at the following locations: Resident smoking shed; Employee smoking shed. -A suitable number of smoking aprons will be readily available. -Residents will not be allowed to borrow cigarettes or other smoking materials from other residents. -All smoking materials, including cigarettes, electronic cigarettes and lighters will be kept at the nurse's station. -In no case shall a resident be allowed to sign a deviation of care to smoke unsupervised when assessed to not be safely able to do so. Resident 27 admitted to the facility in 9/2022 with diagnoses including epilepsy, seizures, bipolar disorder and nicotine dependence. Resident 27's 9/2022 Admission Care Plan indicated the resident required supervision for smoking. Resident 27 signed the facility's Smoking Policy for Independent and Supervised smokers on 9/23/22. Resident 27's 6/2023 Quarterly MDS indicated the resident had moderate cognitive impairment and was visually impaired. Resident 27's 7/4/23 Smoking Safety Evaluation indicated the resident was observed in the employee smoking section, wore thick leather work gloves, refused a smoking apron and fell asleep while holding a lit cigarette. Resident 27 was assessed as requiring supervision to smoke safely. Resident 27's Smoking Safety Evaluations on 11/8/23 and 11/29/23 indicated Resident 27 was to be supervised while smoking. A progress note dated 11/24/23 written by Staff 28 (Infection Preventionist) revealed Resident 27 was found using a vape pen. Staff witnessed her/him using it and confiscated the vape pen along with a butane 'torch', a lighter and a partial pack of cigarettes On 11/27/23 at 1:49 PM Resident 27 was observed alone in her/his room with a pack of cigarettes and a lighter in her/his pocket. On 11/28/23 at 12:45 PM Resident 27 stated Staff 3 (Director of Operations) confiscated her/his cigarettes that morning. Resident 27 was observed sitting in an electric wheelchair with a blanket covering her/his legs which had burn marks on it. Resident 27 showed the surveyor a vape pen hidden in the blanket. Resident 27 stated, They (facility staff) saw it and know I have it. Resident 27 stated the next smoking time was Whenever I wanted to go. I go out by myself but I do not have any more cigarettes. I can bum a cigarette. On 11/28/23 at 3:35 PM Resident 27 was observed in the employee smoking area smoking alone with only a fleece blanket covering her/his legs. On 11/29/23 at 9:15 AM Resident 27 was observed alone in the resident's smoking section, smoking with no apron. On 11/29/23 at 9:18 AM the surveyor asked Staff 7 (Regional Support Nurse) to come to the resident smoking area. Staff 7 acknowledged the resident was in the smoking area unattended, and was not wearing an apron. She stated Resident 27 was supposed to be supervised during smoking. On 11/29/23 at 9:23 AM Staff 4 (CNA) stated he saw Resident 27 smoking by her/himself a lot, everywhere, including non-designated areas and the resident always had cigarettes with her/him. On 11/29/23 at 9:25 am Staff 5 (CNA) stated she worked at the facility for three weeks and was unsure if Resident 27 was a smoker. On 11/29/23 at 9:27 AM Staff 14 (CNA) stated Resident 27 was a supervised smoker. Staff 14 stated Resident 27 had a lighter and sat outside to smoke. On 11/29/23 at 9:30 AM Staff 1 (Administrator) stated Resident 27 had a lock box kept at the nurse's station with cigarettes and lighters, and was supposed to use a smoking apron. Staff 1 stated a staff member reported to him they found cigarettes and lighters on her/his person. On 11/29/23 at 9:43 AM the lock box was observed at the nurse's station, with the lid closed, and unlocked. The surveyor pushed the button and the lid opened. The box contained three packs of cigarettes and a lighter. On 11/29/23 at 9:52 AM Staff 6 (Agency CNA) was assigned to Resident 27. Staff 6 stated she worked at the facility before and was familiar with Resident 27. Staff 6 stated Resident 27 was an independent smoker. Staff 6 stated smoking materials for independent and supervised smokers were in the residents' rooms. Staff 6 stated the CNAs did not supervise Resident 27, she/he did not need assistance in the smoking section and the CNAs were not there when she/he was smoking. Staff 6 stated she was not aware of a smoking assessment for Resident 27. Staff 6 stated Resident 27 used a regular fleece blanket to cover her/his legs when smoking. On 11/29/23 at 3:28 PM the facility was notified that the failures to ensure adequate supervision while smoking, ensure smoking care planned interventions were followed and smoking materials were stored in a safe manner to prevent smoking related accidents were determined to be an Immediate Jeopardy situation. An acceptable plan to abate the Immediate Jeopardy situation was submitted by the facility on 11/29/23 at 5:41 PM. The plan indicated: -Resident 27's Care Plan and Kardex (a quick reference guide containing a brief overview of a residents care needs) has been updated. Current smoking assessment of Resident 27 was reassessed. Resident's blanket was removed with burn marks, replacement blanket has been ordered on 11/29/23 before 3:00 PM. -Resident 27 is a supervised smoker. -Resident 27 is supervised smoking during scheduled times at 9:00 AM, 2:30 PM, 4:30 PM and 7:00 PM. Resident agreed to plan. Resident will have staff supervising during scheduled smoking times as of 11/29/23 by 5:00 PM. -Resident 27 will not have smoking material in her/his room. It is to be locked away outside of her/his room at the nurse's station in lock box or Medication/Treatment cart as of 11/29/23 by 5:00 PM -A smoking apron and/or fire blanket for Resident 27 will be worn when the resident is smoking on facility property as of 11/29/23 by 5:00 PM. Encourage resident to wear smoking apron while smoking over her/his lap/chest. If resident refuses to wear apron offer smoking blanket. If she/he continues to refuse, notify the nurse for next steps. -All current smokers will be reassessed for smoking safety by 11/30/23 at 3:00 PM. -All staff will be educated regarding resident smoking policy, ie, failure of resident compliance to policy and who are independent and supervised by 11/30/23 at 3:00 PM. -The facility has updated the Care Plan, redone the smoking assessment and/or interventions for Resident 27. Care Plan has been updated to direct staff to request resident to hand in all smoking material that she/he may obtain when she/he leaves the facility by 3:00 PM on 11/30/23. -The facility will update the Care Plan and/or interventions for all current residents who smoke to ensure their safety, by 3:00 PM on 11/30/23. -Resident 27's Care Plans will be audited to ensure that identified interventions are in place. Additionally, the Care Plan and smoking assessments for all residents who smoke will be evaluated for accuracy by 5:00 PM on 11/29/23. -Resident 27 was reassessed for smoking by 5:00 PM on 11/29/23. -RCMs (Resident Care Manager) or designee will audit to ensure the accuracy of smoking assessment and care planning, as indicated, upon admission and as changes occur through the 24-hour MACC process (internal communication), as of 11/20/23 by 10:00 AM. -Administrator or designee will audit staff knowledge of smoking policy and which residents need supervision or can smoke independently. These audits will be completed, x 4 weeks, Monday-Friday and monthly x2 for 2 months or until threshold obtained. The audits will be conducted Monday-Friday and reported to the DNS. Results of audits will be reviewed by the Quality Assurance and Performance Improvement (QAPI) committee. These audits will be conducted starting on 11/30/23 by 5:00 PM. On 11/30/23 at 11:17 AM Staff 4 (CNA) stated Resident 27 did not smoke at 9:00 AM because staff could not find a smoking apron for the resident. On 11/30/23 at 11:18 AM Staff 29 (CNA) stated earlier that day she was supervising another resident in the smoking section when Resident 27 came out and bummed a cigarette from the other resident. Staff 29 stated Resident 27 did not have an apron on and she could not find an apron for either resident. Staff 29 stated the aprons used to be hanging out in the smoking section. On 11/30/23 at 11:28 AM Staff 1 (Administrator) and Staff 3 (Director of Operations) were updated on the findings there were no smoking aprons available for residents in the smoking section and the facility remained in an Immediate Jeopardy situation. On 12/1/23 at 9:51 AM Staff 30 (RN) was on duty at the facility and stated she did not receive any updated training related to smoking since the Immediate Jeopardy situation was called. On 12/1/23 at 12:01 PM Staff 1 (Administrator) was informed a staff member stated they were not educated regarding the smoking policy either verbally, via text or email, and the facility remained in an Immediate Jeopardy situation. On 12/4/23 at 1:26 PM the 12/2/23 paperwork submitted by the facility was reviewed. Additional observations and interviews revealed the facility was back in compliance as of 12/2/23. The immediacy was removed on 12/2/23 after verification of the completion of the abatement plan.

Based on observation, interview and record review it was determined the facility failed to follow care plan interventions, failed to assess for care plan effectiveness, failed to identify and implement new fall interventions and failed to provide adequate supervision needed to prevent falls for 1 of 1 sampled resident (#12) reviewed for falls. This failure resulted in the resident having 17 falls in nine months, one with serious injury which required emergency medical services and treatment at the hospital. Findings include: Resident 12 was admitted to the facility in 2/2021 with diagnoses including diabetes, dementia and stroke with right side [CONDITION(S)] (weakness or paralysis). The 2/11/21 Admission MDS revealed Resident 12 had severe cognitive impairments and required extensive assistance of one to two or more persons for transferring and toileting. Resident 12 was frequently incontinent of bladder and always incontinent of bowel and was not on a toileting program. Resident 12 had falls within the last two to six months (prior to admission) and two or more falls since her/his admission. The 2/11/21 Fall CAA indicated Resident 12 was at risk for falls due to cognitive impairments causing poor safety awareness, left sided weakness and a history of falls. Resident 12 had multiple falls at home due to leaning forward to pick items up from the floor and self-transferring and the resident had two falls since admission. The 2/16/22 Annual MDS revealed Resident 12 was cognitively intact and required extensive assistance of one person for transferring and toileting. Resident 12 was incontinent of bladder and bowel and was not on a toileting program and no toileting program had been attempted. Resident 12 had two or more falls since the last assessment. The 2/16/22 Fall CAA indicated Resident 12 was at risk for falls due to cognitive impairments causing poor safety awareness. Resident 12 had multiple falls in the facility since admission due to leaning to pick items up from the floor and self-transferring to the toilet. Resident 12 had left sided weakness due to a stroke causing impaired balance. Resident 12 had 26 fall risk assessments completed in 2021 and 19 fall risk assessments completed in 2022. All 45 fall risk assessments indicated a high risk for falling. Resident 12's current Care Plan indicated the resident was at risk for falls related to a history of falls, poor safety awareness, self-transferring, impulsivity, left sided weakness, stroke, [CONDITION(S)] (weakness on one side of the body), attempting to pick up fallen objects from the floor, incontinence and dementia. The following fall prevention interventions were in place: -Non-skid footwear at all times except when bathing. Initiated 2/4/21. Revised 2/10/21. -Remind to use call light for assistance. Initiated 2/4/21. -Reacher/grabber and personal items in reach while in room. Initiated 2/4/21. Revised 3/9/21. -Encourage out of bed for all meals sitting in line of sight from door. Initiated 2/9/21. -Incontinence rounds throughout night shift. Initiated 2/9/21. -Offer to turn off TV at bedtime. Initiated 2/9/21. -Encourage to keep room door open. Initiated 2/9/21. -Dycem (a non-slip material used to stabilize objects or hold objects firmly in place) to seat of wheelchair. Initiated 2/10/21. -Keep reacher on [her/his] right side while up in wheelchair. Initiated 3/2/21. -Room changed to have roommate-post fall 2/23/21. Initiated 3/2/21. -Anticipate and meet [her/his] needs. Initiated 3/22/21. Revised 6/30/21. -Be sure [Resident 12's] call light and reacher is within reach and encourage the resident to use it for assistance as needed. [Resident 12] needs prompt response to all requests for assistance-added after fall on 3/20/21. Initiated 3/22/21. -Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance. Initiated 4/19/21. -Maintenance to attach reacher to prevent falling. Initiated 4/21/21. -Please ensure bed wheels are locked when not being moved. Initiated 4/21/21. Revised 2/10/22. -Encourage resident to go to the bathroom following meals and stay near the resident while on the toilet. Initiated 5/17/21. -Toileting scheduled added for before and after meals and when resident wakes in the morning and before going to bed. Initiated 7/2/21. -Resident not to be left unattended or out of line of sight when being toileted. Make sure all supplies are within reach due to impulsivity and inability to wait due to urgency. Initiated 8/16/21. -Dycem attached to back of remote to prevent falling off table as much as possible. Initiated 9/16/21. -Be sure resident's call light and reacher are within reach and encourage resident to use it for assistance as needed. Initiated 8/19/21. Revised 11/17/21. -Staff to check floors and keep clear of garbage in resident's room and bathroom to keep resident from reaching to grab items off of the floor. Initiated 10/11/21. -Do not leave unattended during activities outside of room. Initiated 11/8/21. -Resident not to be left unattended or out of line of sight when being toileted. Make sure all supplies are within reach due to impulsivity and inability to wait due to urgency. Initiated 2/1/22. Revised 4/8/22. -Call bell to be placed at table where resident is participating in activity/dominoes to call for assistance. Initiated 7/28/22. From 1/25/22 through 9/6/22, Resident 12 experienced 17 falls in the facility, one with serious injury requiring emergency medical services and treatment at the hospital. 1/25/22 7:00 PM Fall Investigation revealed Resident 12 fell in her/his room due to the resident falling from her/his wheelchair while reaching for her/his grabber. The resident had been moved to a new room on the memory care unit. The resident had poor safety awareness. The recommendation was to move her/his safety equipment to her/his new room. No new fall care plan interventions were put in place. A 1/28/22 12:55 PM Fall Investigation revealed Resident 12 was found in the bathroom lying on her/his stomach on the ground. Resident 12 was assisted to the toilet and left in the bathroom alone. The resident did not use the call light for assistance. The resident was educated on the importance of using the call light and waiting for assistance. Resident 12's fall care plan was not followed as the resident was left unattended and out of line of sight when being toileted. No new fall care plan interventions were put in place. A 2/6/22 10:30 AM Fall Investigation revealed Resident 12 fell in her/his bathroom. CNAs heard noises coming from the bathroom and upon entering the bathroom Resident 12 was attempting to self transfer from the wheelchair and started to stumble. The resident did not use the call light for assistance. The resident continued with poor safety awareness and insight and was encouraged to allow staff to provide assistance for safety. Resident 12 was provided education regarding using the call light. No new fall care plan interventions were put in place. A 2/24/22 2:34 PM Fall Investigation revealed Resident 12 fell in her/his bathroom. Resident 12 reported she/he used the call light but the CNA observed the call light was not on. Resident 12 continued with poor safety awareness and insight. The resident was encouraged to allow staff to provide assistance for safety and staff needed to be more direct when asking the resident to use the bathroom. No new fall care plan interventions were put in place. A 3/5/22 2:35 PM Fall Investigation revealed Resident 12 fell in the dining room after being left alone following an activities group. The recommendation was to educate the activities director to educate all volunteers that the resident was not to be left unattended in the dining room. Resident 12's care plan was not followed as the resident was left unattended in an activity outside of her/his room. No new fall care plan interventions were put in place. A 3/11/22 3:41 PM Fall Investigation revealed Resident 12 fell in her/his bathroom and was lodged between the toilet and the wall due to the resident attempting to self-transfer and being incontinent. Resident 12's bathroom call light was illuminated. Two CNAs were giving showers, one CNA was out with a supervised smoker and the charge nurse was consulting with a medical professional. Resident 12 stated she/he put on the call light but could not wait. Resident 12's fall care plan was not followed as the resident's call light was not promptly responded to. No new fall care plan interventions were put in place. A 4/6/22 2:08 PM Fall Investigation revealed Resident 12 fell in her/his room during shift change. Resident 12 was found on her/his buttocks on the floor with the bedside table broken and all the items on the table scattered on the floor. Resident 12's grabber was on the bed farthest away from the resident. The resident reported she/he attempted to pick items up from the ground and her/his grabber was out of reach. Resident 12's fall care plan was not followed as the resident's grabber/reacher was not within reach. No new fall care plan interventions were put in place. A 4/13/22 8:00 PM Fall Investigation revealed Resident 12 fell in her/his bathroom after being left alone to brush her/his teeth. The nurse stepped out of the bathroom and a short time later heard a crash in the resident's room. Resident 12 fell while standing up to use the toilet. The resident was not supposed to be left in the bathroom alone and staff education was provided. Resident 12's fall care plan was not followed as the resident was left unattended and out of line of sight in the bathroom. No new fall care plan interventions were put in place. A 5/6/22 4:22 PM Fall Investigation revealed Resident 12 fell in her/his bathroom. The resident was left alone at the bathroom sink to brush her/his teeth. Resident dropped items and was attempting to pick them up from the floor when she/he fell . Resident 12's fall care plan was not followed as the resident was left unattended and out of line of sight in the bathroom. No new fall care plan interventions were put in place. A 5/22/22 10:06 AM Fall Investigation revealed Resident 12 fell in her/his room after dropping items and attempting to pick them up from the floor without using her/his grabber or asking for assistance. No new fall care plan interventions were put in place. A 6/5/22 9:40 AM Fall Investigation revealed Resident 12 fell in the living area while playing dominoes with another resident after reaching for a game piece that was dropped on the floor which resulted in the resident falling from the wheelchair. Resident 12 had a history of falling related to toileting and picking up items from the floor without assistance. Resident 12's fall care plan was not followed as the resident was left unattended in an activity outside of her/his room. No new fall care plan interventions were put in place. A 6/12/22 6:49 PM Fall Investigation revealed Resident 12 fell in the hallway while visiting with a resident in a room near her/his own room. The resident was visiting with another resident and attempted to walk back to her/his room, unassisted, resulting in a fall. The resident was very impulsive at times and forgot her/his limitations due to mental capacity. No new fall care plan interventions were put in place. A 7/3/22 1:45 PM Fall Investigation revealed Resident 12 fell while trying to transfer herself/himself back to bed. The resident did not activate her/his call light and did not ring her/his bell. No new fall interventions were put in place. A 7/23/22 6:57 PM Fall Investigation revealed Resident 12 fell in the bathroom, the call light was not activated. Resident 12 was observed three times attempting to self-transfer to the bed or toilet. Education was provided to the resident but the resident was non-compliant and more impulsive throughout the shift. Resident was last toileted at 2:10 PM and assisted into bed. Resident with poor insight due to dementia and cognitive impairments. No new fall care plan interventions were put in place. A 7/27/22 3:30 PM Fall Investigation revealed Resident 12 fell in the front living area where she/he played dominoes. The resident stated she/he was done playing dominoes and attempted to use her/his wheelchair to walk back to her/his room. The resident wheeled herself/himself to the outside of the living area, used the hand rails and stood resulting in a fall. Resident 12 did not call for help when finished playing dominoes. Resident 12's care plan was not followed as the resident was left unattended in an activity outside of her/his room. The care plan was updated to include placing a bell on the dominoes table so she/he could call for assistance. A 8/3/22 6:33 PM Fall Investigation revealed Resident 12 fell in her/his room as a result of attempting to pick up an item from the floor. The resident was very impulsive with poor safety awareness. An 8/3/22 Incident Note indicated Resident 12 was found on the floor on her/his stomach with a moderate sized pool of blood under the resident's head. Resident 12 appeared to have a 4 cm to 5 cm head laceration. The resident reported that she/he attempted to pick up a picture from the floor when the fall happened. The resident was previously visualized 30 minutes prior to the fall. Resident 12 was transported to the hospital for emergency medical services and treatment. The resident returned to the facility the same evening with staples. Her/his pupils were assessed to be sluggish, the resident was lethargic but arousable and was able to communicate with the staff. No new fall care plan interventions were put in place. A 9/6/22 5:54 PM Fall Investigation revealed Resident 12 fell in her/his room. Resident with poor safety awareness. Will continue to follow the care plan. No new fall care plan interventions were put in place. The facility failed to follow care plan interventions, re-assess current interventions and develop new interventions to ensure Resident 12 was adequately supervised and her/his falls were unavoidable. Resident 12 experienced 17 falls from 1/25/22 to 9/6/22 and on 8/3/22 Resident 12 fell sustaining a head laceration which required emergency services and treatment. Resident 12 required staples to close her/his head laceration. On 10/17/22 at 2:48 PM and during multiple random observations from 10/17/22 through 10/21/22 between the hours of 8:30 AM and 3:30 PM Resident 12 was observed in the front living area, unattended, playing dominoes with Resident 20. During one observation, Resident 12 stood up, unassisted, from her/his wheelchair to adjust her/his pants and shirt. Resident 20 stated Resident 12 recently fell over backwards in her/his wheelchair and she/he was afraid Resident 12 would fall again. On 10/20/22 at 8:50 AM Staff 10 (CNA) stated Resident 12 had many falls in the facility and he attempted to check on the resident as often as he could. Staff 10 stated the facility did not utilize fall alarms and Resident 12 did not receive one-on-one supervision. On 10/20/22 at 9:45 AM Staff 3 (RNCM) reviewed Resident 12's 17 falls and acknowledged staff did not follow the resident's care plan on multiple occasions. Staff 3 confirmed Resident 12's care plan was updated after the resident's fall on 7/27/22 and no other new care plan updates were made. On 10/21/22 at 8:33 AM Staff 12 (RN) stated Resident 12 was impulsive and had many falls and the staff told her/him all the time not to get up but she/he got up anyway. Staff 12 stated Resident 12 had no specific orders or care plan instructions regarding the frequency of supervision to keep the resident safe from falling but staff typically rounded every two hours. Staff 12 stated the facility provided one-on-one supervision at meals for residents with swallowing concerns but not to any other residents. On 10/21/22 at 9:03 AM Staff 2 (DNS) confirmed Resident 12 had multiple falls so far this year and one fall resulted in an injury which required emergency medical services and treatment. Staff 2 stated staff stick to the policy of checking on residents every two hours and do the best they can to supervise Resident 12. Staff 2 acknowledged the facility was required to provide the level of supervision a resident required to keep them safe from falling.

Based on observation, interview and record review it was determined the facility failed to ensure elopement interventions were in place for 1 of 3 sampled residents (#6) reviewed for elopement and failed to evaluate and supervise to promote a safe environment for 1 of 6 residents (#10) reviewed for resident to resident altercations. This failure resulted in Resident 10 to experience ongoing fear and anxiety and placed other residents at risk for elopement. 1. Resident 10 was admitted to the facility in 11/2017 with [DIAGNOSES REDACTED]. Resident 7 was admitted to the facility in 4/2019 with [DIAGNOSES REDACTED]. Resident 7 also resided in the MCC. Resident 7's wanderer care plan dated 4/16/19 with updates on 5/3/19 indicated Resident 7 wandered related to dementia. Interventions included distraction from wandering by offering pleasant diversions, structured activities, food and conversation and, to identify the resident's pattern of wandering to determine if the resident was looking for something or required more exercise. The behavioral care plan dated 7/19/19 with multiple updates through 10/24/19 indicated Resident 7 had a history of [REDACTED]. On 7/19/19 (after three physical altercations with Resident 10) the care plan indicated if the resident was agitated staff were to reduce noise, keep Resident 10's door closed with a stop sign on the door and redirect Resident 7 from others. Resident 10's behavior care plan dated 6/1/18 indicated the resident exhibited verbal and physical aggression toward peers related to dementia. Interventions included staff intervention to protect the rights and safety of others and to monitor the resident's behavioral episodes, attempt to determine the underlying cause and consider the location, time of day, persons involved and situations. Resident 10's care plan did not indicate Resident 10 did not like other residents in her/his space, near her/his room or inside her/his room. There were no interventions on her/his care plan to indicate her/his door was to be closed or a stop sign was to be used to prevent others from going into her/his room. Progress Notes for Resident 7 and Resident 10 from 4/30/19 through 6/13/19 revealed the following: *Resident 7 wandered into Resident 10's room. *Resident 10 told Resident 7 not to go near her/his room or she/he would knock Resident 7 out. *Resident 10 yelled at Resident 7 for going into her/his room and told staff she/he was afraid to go into her/his room and stated, I don't want (her/him) to go in there. *Resident 7 was exit seeking and wandered in and out of rooms. Resident 10 was highly agitated and stated she/he was scared of Resident 7 coming into her/his room. There was no documentation to indicate Resident 10's expressed concerns and fears of Resident 7 going into her/his room was evaluated or that interventions other than monitoring and redirection of Resident 7 were developed to reduce the risk of recurrence. Subsequent Progress Notes and facility investigations from 6/16/19 through 7/10/19 indicated the following: *Resident 10 was reported to exhibit increased agitation caused by another resident who wandered toward the resident's room and opened the door. Resident 10 yelled until her/his door was closed. Later, Resident 10 was verbally aggressive when the same resident came within close proximity to her/him. *Resident 10 was sleeping in the common living room area. When Resident 10 woke up she/he claimed Resident 7 was staring at her/him. Resident 10 began to yell at Resident 7 and slapped Resident 7 on the wrist before staff were able to intervene. Resident 10 was placed on one to one observation for approximately seven hours. *Resident 7 wandered around the MCC and entered other rooms. Staff re-directed the resident multiple times and with little effect. *Resident 10 was wheeling around in her/his wheelchair with noted agitation. Resident 10 called Resident 7 a creep and said get the (expletive) away from me. Progress Notes and facility investigations from 7/16/19 through 7/19/19 indicated the following: *Resident 7 was near Resident 10's door and Resident 10 yelled, Get (her/him) out of here I am going to (expletive) kill (her/him). Resident 10 was placed on one to one supervision and given PRN [MEDICATION NAME] (antipsychotic). Two days later Resident 10's one to one supervision was discontinued and less than an hour later the nurse heard shouting from Resident 10's room. Resident 10's arms were out in a defensive manner blocking Resident 7 from touching her/him. Resident 10 stated, (She/he) keeps coming in here. I want (her/him) killed, I don't want to stay here. Both residents were immediately separated. Resident 10 was found to have bruising on her/his left arm and Resident 7 was found to have bruising and a skin tear to her/his right arm. A referral was made for behavioral services for Resident 10 and a one to one sitter was provided for Resident 7. The 7/21/19 Progress Note indicated Resident 10 stated she/he was fearful for her/his safety and was afraid to go to her/his room. Resident 10 was noted to sleep in another room and the nurse noted she was okay with it for the night if it gave Resident 10 comfort as the room was empty. Resident 10 lied down for approximately half an hour, began to pace and required many words of encouragement and assurance of safety to show signs of reduced anxiety. The resident stated, I feel drunk because I haven't slept in so long. The nurse offered to sit outside the room so the resident could see her guarding it. The 7/27/19 Progress Note indicated Resident 10 was unwilling to relocate back to her/his bedroom. Progress Noted from 7/22/19 through 9/13/19 revealed Resident 10 remained on one to one supervision until she/he was moved out of the MCC. No further resident to resident to altercations were noted to occur between Resident 7 and Resident 10. Resident 10 expressed concerns with Resident 7 being near or going into her/his room beginning 6/10/19 and stated she/he was fearful of Resident 7 going into her/his room. There was no evaluation of or interventions developed to address Resident 10's expressed concern and fear of Resident 7. Subsequently, three resident to resident physical altercations occurred between Resident 7 and 10 occurred. On 10/30/19 at 9:55 AM Resident 7 was observed to wander into other resident rooms. On 10/30/19 at 10:50 AM Resident 10 was lying on her/his left side in bed with her/his eyes closed. At 12:30 PM Resident 10 was observed to sit in a wheelchair at the nurses station while a staff member braided the resident's hair. The resident appeared calm. At 2:10 PM Resident 10 was observed to sit at the nurses station in her/his wheelchair while staff assisted the resident with her/his clothing. On 10/30/19 at 9:50 AM and 9:55 AM Staff 28 (CNA) stated Resident 10 did not like it when other residents went into her/his room and she/he was in altercations with Resident 7 because Resident 10 got too close to her/him. On 10/30/19 At 10:05 AM and 10:10 AM Staff 9 (LPN) stated Resident 7 wandered a lot, would go into Resident 10's room which agitated Resident 10 and the residents were involved in altercations. On 11/6/19 at 1:40 PM Staff 4 (LPN) she did not recall if there were any interventions in place for Resident 7 and Resident 10 to prevent altercations. Staff 4 further stated if a resident was irritated or upset with another resident going into their room she would try to develop interventions such as re-direction or put up a STOP sign. If those interventions did not work she would report it to Staff 1 (DNS) and brainstorm what could be done. On 11/6/19 At 10:06 AM Staff 31 (CNA) stated Resident 10 would become upset when Resident 7 wandered into her/his room. Staff 31 stated a STOP sign was placed on Resident 10's door and they would always try to have someone watch the residents but staff were busy. Staff 31 could not recall how long the STOP sign was on Resident 10's door. On 11/6/19 at 2:00 PM Staff 29 (CNA) stated Resident 7 got into other residents' space, Resident 10 would get angry and would want to hit Resident 7. Staff 29 stated prior to any altercations between the two residents, Resident 10 would say she/he hated Resident 7 and Resident 7 had better stay away and not touch her/him. Staff 29 stated staff tried to intervene but were busy. A STOP sign was used on Resident 10's door but Resident 7 continued to go into Resident 10's room. Staff 29 further stated at one point Resident 10 would no longer go into her/his own room, would hide from Resident 7 and said she/he was afraid. Staff 29 stated she reported Resident 10's statements of fear to the nurse and was told to keep an eye on the residents. On 11/7/19 at 10:20 AM Staff 30 (LPN) stated Resident 10 said she/he did not like Resident 7 and was fearful of going back to her/his room. Staff 30 stated a STOP sign was used on Resident 10's door and then she/he was moved out of the MCC. On 11/7/19 at 11:45 AM and 12:30 PM Staff 1 (DNS) stated interventions to address Resident 7's wandering included activities to keep the resident occupied and a sign was placed on her/his door with her/his official military title. Staff 1 stated a STOP sign was placed on Resident 10's door and her/his door was kept closed. Staff 1 further stated if Resident 10 expressed agitation about another resident being near her/him it would depend on what the resident said, if she/he was agitated and what the cause was for the facility to develop interventions. Staff 1 stated the entire time she worked at the facility the resident was not alert or oriented to time or place, spoke in word salad (random words or phrases linked together in an often unintelligible manner), was not expressive enough to make statements she/he did not like Resident 7, did not want the resident near her/him or hid from Resident 7. Resident 10's progress notes were reviewed with Staff 1. Staff 1 stated the nurses should have reported Resident 10's statements of concern about Resident 7 to the Resident Care Manager (RCM) or to her. Staff 1 acknowledged interventions were lacking to protect Resident 10. On 11/12/19 at 1:25 PM Staff 11 (LPN/RCM) stated she did not recall that Resident 10 was fearful of Resident 7. 2. Resident 6 admitted to the facility in 2/2017 with [DIAGNOSES REDACTED]. The 5/3/19 and 7/15/19 Elopement Risk Evaluation forms indicated Resident 6 was at risk to wander/elope, did not wander from the facility, appeared to know her/his whereabouts and location of her/his room and expressed no desire to leave the facility. The 5/2/19 and 7/20/19 Quarterly MDS indicated Resident 6 did not wander. A Progress Note on 9/5/19 indicated at approximately 4:00 PM Resident 6 exited the front door of the facility and was intercepted by two staff who were able to redirect the resident and bring her/him back into the facility. The resident stated she/he planned to go to the store to buy cigarettes. The resident was placed on alert charting and her/his physician was notified. The 9/6/19 investigation to the incident indicated prior to the 9/5/19 elopement the resident did not wander or attempt to exit seek. The investigation further indicated Resident 6's roommate smoked, talked to the resident about smoking and the resident attempted to walk to the store to buy cigarettes. Interventions to reduce a recurrence of elopement included to remind the resident she/he did not smoke for years and to keep the doors of the facility locked. Resident 6's care plan was updated on 9/6/19 to indicate the resident was at risk for elopement and to keep the front doors of the facility locked. A Progress Note dated 9/8/19 indicated Resident 6 was found outside on the bench next to the main entrance of the facility. Resident 6 stated she/he went outside to get some fresh air. The resident was re-directed back into the facility without issue. The 9/8/19 investigation to the incident indicated the front door of the facility was not locked. On 11/6/19 at 1:30 PM Staff 4 (LPN) stated Resident 6 eloped from the facility so the doors were supposed to be locked to prevent it from happening again. On 11/7/19 at 10:15 am Staff 31 (CNA) stated Resident 6 was moved to the Memory Care Community (MCC) because she/he tried to leave the facility. On 11/7/19 at 12:35 pm Staff 1 (DNS) acknowledged the intervention to lock the doors was not in place the second time Resident 6 exited the building.

Based on interview and record review it was determined the facility failed to identify and assess residents for severe weight loss for 2 of 4 sampled residents (#s 32 and 24) reviewed for nutrition. This resulted in Resident 32 experiencing an unintended severe weight loss while on tube feeding and placed residents at risk for severe weight loss. Findings include: 1. Resident 32 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. A Lab Report dated 6/14/18 indicated the resident's [MEDICATION NAME] (a protein) and total protein were low ([MEDICATION NAME] and total protein levels can be an indication of nutritional status). An RD assessment dated [DATE] indicated Resident 32's Estimated nutrition need can be met. A Nutrition at Risk Review dated 7/5/18 failed to indicate the percentage of nutrition the resident received via feeding tube, the type of feeding tube nutrition provided or the amount. The assessment indicated the resident weighed 131 pounds on 7/4/18 (this was a 6.4% severe weight loss). The assessment identified a weight loss trend but failed to identify the severe weight loss, provide significant interventions to address the weight loss or provide a clinical rationale for the weight loss. A Nutrition at Risk Review dated 7/12/18 indicated Resident 32 weighed 134 pounds on 7/8/18 and the resident had some weight gain. The assessment failed to address the resident's overall weight loss trend and 4.3% weight loss since admission to the facility. A Nutrition at Risk progress note dated 7/19/18 indicated Resident 32's weight on 7/18/18 was 127 pounds (a 9.3% severe weight loss since admission to the facility) and the resident continued to lose weight. The plan included changing the resident's tube feeding formula from Glucerna 1.2 to 1.5 260 ml five times daily for added calories. The assessment failed to identify the severe weight loss or provide a clinical rationale for the weight loss. A Nutrition at Risk progress note dated 7/26/18 indicated Resident 32 weighed 128 pounds on 7/26/18 (an 8.6% severe weight loss since admission to the facility). The Glucerna 1.2 was still being administered because the 1.5 had to be ordered. The assessment failed to identify the severe weight loss, provide an explanation for the one week delay in starting the Glucerna 1.5 or provide a clinical rationale for the weight loss. Resident 32's weight record revealed the resident weighed 129 pounds on 7/31/18. This was an 11 pound or 7.9% severe weight loss since the resident was admitted to the facility. A Nutrition at Risk Review dated 8/2/18 indicated Resident 32 was reviewed for a tube feeding change and weight loss. The assessment failed to indicate the percentage of nutrition the resident received via feeding tube, the type of feeding tube nutrition provided or the amount. The assessment failed to indicate the resident's current weight and indicated Resident showing slight changes in weight. The assessment failed to identify the resident's severe weight loss based on the 7/31/18 weight of 129 pounds, provide a plan to address the weight loss or provide a clinical rationale for the weight loss. A Lab Report dated 8/2/18 indicated the resident's [MEDICATION NAME] (a protein) and total protein were low ([MEDICATION NAME] and total protein levels can be an indication of nutritional status). A Nutrition at Risk Review dated 8/9/18 indicated Resident 32 received all of her/his nutrition via feeding tube and the resident weighed 120 pounds on 8/7/18 (this was a 20 pound or 14% severe weight loss since the resident was admitted to the facility). The assessment indicated Weight continues slow decline. The assessment failed to refer to the low protein levels on 8/2/18, identify the severe weight loss, provide a plan to address the weight loss or provide a clinical rationale for the weight loss. Resident 32's weight record revealed on 6/8/18 the resident weighed 140 pounds and on 8/8/18 weighed 120 pounds. This was a severe 14% body weight loss over a two month time span. A physician's visit note for Resident 32 dated 8/1/18 indicated weight loss and continued decline are likely. The note did not identify the resident's severe weight loss or provide a clinical rationale for continued weight loss in a resident who was receiving all of their nutrition via tube feeding. On multiple occasions the facility failed to identify Resident 32's severe weight loss, provide significant interventions to address the weight loss or provide a clinical rationale for the unintended weight loss for the resident who received all of her/his nutrition via feeding tube. On 8/16/18 at 11:11 AM Resident 32's Nutrition at Risk assessments, weight record and lack of documented rationale for the resident's weight loss were discussed with Staff 2 (DNS). She acknowledged the incomplete assessments, verified the resident's weights and acknowledged the one week delay in starting the Glucerna 1.5. She stated she would research the resident's record for additional information. No additional information was provided. 2. Resident 24 was admitted to the facility in 8/2014 with [DIAGNOSES REDACTED]. The 4/22/18 care plan revealed the following: -Nutritional problem or potential for nutritional problem because the resident was forgetful and needed cues to eat her/his meals. -Maintain adequate nutritional and fluid intake with no decline during her/his stay as evidenced by weights, as needed labs and meal intake. -Supervision and verbal cues while eating. Review of the resident's weights revealed the following: -On 2/2/18, 175.4 pounds -On 3/13/18, 171.2 pounds -On 4/6/18, 165.3 pounds -On 5/8/18 169.2 pounds -On 6/13/18, 159.5 pounds -On 7/12/18, 160.5 pounds -On 8/7/18, 156.7 pounds The 6/13/18 Nutritional Re-Assessment revealed the following. -Identified from 5/8/18 to 6/13/18 a 5.7 percent weight loss. -In 90 days from 3/13/18 to 6/13/18 a 6.8 percent weight loss. -The diet order remained the same and meal intakes were poor to fair. -The resident's weights were trending down though not significant in the past 1, 3, and 6 months. -Recommended 120 ml of 2 cal (nutritional supplement) qid. The 6/2018 Physician order [REDACTED]. The 6/2018 MAR between the dates of 6/15/18 through 6/30/18 indicated the resident refused 2 cal 15 of 64 administrations. The 6/28/18 Nutrition At Risk Review revealed the following: -The resident had fluctuating oral intake at meals and more refusals of served meals per staff. -Staff were offering alternatives, snacks between meals. Weigh loss of approximately 10 lbs for 5/8. -The resident stated I'm not hungry. -The order was 120 ml of 2 cal qid with varied intakes at 12:00 PM and 3:00 PM. -The resident appeared more fatigued. The 7/2018 MAR between the dates of 7/1/18 through 7/11/18, indicated the resident refused 2 cal 15 of 44 administrations. The 7/5/18 Nutrition Note Text: NAR Note revealed the following: -The resident took 26-50 percent of most meals. -The resident frequently refused 12:00 PM and 3:00 PM 2 cal and at times dumped it out onto the floor. -Weight has stabilized over the last month and 2 cal at 12:00 PM and 3:00 PM to be discontinued. -Plan: to follow up in one week. The 7/2018 Physician order [REDACTED]. The 7/2018 MAR between the dates of 7/12/18 through 7/31/18 revealed the resident refused 2 cal 12 of 40 administrations. The 7/12/2018 Nutrition Note Text: NAR Note revealed the following: -Meal intake improved to 51-75 percent most meals. -Plan: to follow up in one week to monitor meal intakes. The 7/19/18 Nutritional at Risk revealed the following: -Intake was 26-75 percent. -2 cal, 120 ml bid. -Continue 2 cal. -Previous interventions were 2 cal qid. -The 2 cal order was changed from qid to bid due to refusals and the resident continued to have some refusals. -The residents weight was stable. -Follow up in two weeks. On 8/15/18 there was no additional documentation located in the resident's clinical record for a nutritional follow up. In an interview on 8/16/18 at 11:46 AM and 2:15 PM Staff 12 (Registered Dietitian) stated severe weight loss is over 5 percent in one month, 7.5 percent in three months and 10 percent in six months and the weight loss of 5.7 percent on 6/13/18 should have been identified as severe. The goal of changing the 2 cal from qid to bid was in hopes the resident would drink it more often. Staff 12 was not aware of additional interventions offered to the resident other than staff offering alternatives like soup and fruits. The two week follow up from 7/19/18 was not completed. In an interview on 8/20/18 at 10:07 AM Staff 2 (DNS) stated she expected staff to identify the severe weight loss on 6/13/18. She expected staff would provide alternative interventions since the resident continued to refuse 2 cal and expected follow up appointments to be completed within the documented recommendation.

Based on interview and record review it was determined the facility failed to perform CPR (cardiopulmonary resuscitation) on a resident found with no heartbeat and not breathing for 1 of 4 sampled residents (#1) reviewed for CPR. This failure, determined to be an immediate jeopardy situation, resulted from the facility failing to initiate CPR for Resident 1 according to physician's orders [REDACTED]. Findings include: A review of the facility's Policy and Procedure Subject: Code Status/CPR revised ,[DATE] indicated it was the facility policy staff must know the advanced directive status for residents. In the event a resident was observed not breathing or suspected [MEDICAL CONDITION] the staff member who made the observation would call for help and bring the emergency cart to the area. The first CPR responder would request the resident's code status. If the resident was a full code CPR would be initiated and 911 would be called. CPR would be continued until EMT's arrived to take over CPR. CPR would not be initiated for signs of obvious clinical death as assessed by an RN only. If there was no RN then CPR would be initiated. Resident 1 was admitted to the facility in 2017 with [DIAGNOSES REDACTED]. A review of Resident 1's Advanced Directive signed by Resident 1 on [DATE] revealed no desires or instructions related to the implementation of CPR in the event the resident had no pulse and was not breathing. Resident 1's Face Sheet with a discharge date of [DATE] indicated the resident's code status was Full Code (meaning the resident desired intervention such as CPR should her/his heart stop beating or she/he stops breathing). Resident 1's Care Plan with an admission date of [DATE] indicated the resident's code status was Full Code. Resident 1's POLST (Physician order [REDACTED]. An untitled hospice Home Services form dated [DATE] indicated Resident 1 revoked hospice services. An undated Hospice Notification For Nursing Facility Residents form indicated Resident 1 revoked hospice on [DATE]. A Resident Progress Note dated [DATE] indicated at 9:18 pm (on [DATE]) Resident 1 was assessed by Staff 3 (LPN) and had no respirations or heartbeat for two minutes. The resident's skin was cool and pale. The physician was called and a time of death was received. The resident's family was notified of the resident's death and the resident was transported to the funeral home. The note did not indicate CPR was attempted or provide a rationale for not initiating CPR. A Nursing Facility Incident Self-Report Form dated [DATE] by Staff 4 (Regional Support RN) indicated on the evening of [DATE] Resident 1 was found without respirations or pulse and CPR was not initiated even though the resident's POLST indicated the resident was a full code. Education was provided to the licensed nurses regarding code status and the facility policy regarding CPR. An hand written statement by Staff 3 dated [DATE] indicated at 9:18 pm (on [DATE]) a CNA (unnamed) reported she thought Resident 1 was dead. The statement indicated Staff 3 assumed Resident 1 was a DNR (do not resuscitate) because the resident was on hospice. On [DATE] at 11:58 am Staff 3 (LPN) stated Staff 5 (CNA) informed her Resident 1 appeared to have passed away. Staff 3 stated she should have checked Resident 1's code status at that time. Staff 3 acknowledged she should have initiated CPR and had assumed the resident was DNR because she/he had been on hospice. Staff 3 confirmed there was no RN on duty at the time Resident 1 died . On [DATE] at 4:47 pm Staff 5 (CNA) stated she went to check on Resident 1 and empty the resident's catheter sometime after 9:00 pm (on [DATE]). Staff 5 stated the resident was in her/his chair and did not respond when spoken to. Staff 5 stated she touched the resident's hand and it was cold but it was usually cold. Staff 5 stated she checked for a pulse but did not detect it so she notified the charge nurse Staff 3 who was at the nurse's station right across the hall from the resident's room. Staff 5 stated she did not perform CPR because she thought the resident was on hospice and she was told in her CPR class the nurse was the one who does CPR. On [DATE] at 12:08 pm Staff 2 (DNS) acknowledged Staff 3 did not check Resident 1's code status and initiate CPR according to facility policy. Staff 2 acknowledged CPR should have been initiated. Staff 2 verified there was no RN on duty at the time Resident 1 died . On [DATE] at 3:12 pm the facility was notified the failure by staff to initiate CPR for a resident found with no heartbeat and no respirations, and who was a full code status was determined, in consultation with survey management, to be an immediate jeopardy situation. An acceptable plan to abate the immediate jeopardy situation was submitted by the facility on [DATE] at 6:58 pm. The plan indicated the facility would honor the residents' code status and: 1. An audit of the facility was completed to determine the residents' code status. 2. Each nurse and CNA currently working were in-serviced regarding the facility code status policy and where to find the residents' code status. 3. As staff come on shift they will be in-serviced by the DNS or Administrator on the facility code status policy and where to find the residents' code status. 4. Any changes to the code status will be reviewed daily in the morning MACC (Managing Acute Condition Changes) meeting through orders and/or returned POLST forms. 5. Medical Records will be directed to forward POLST forms signed by the physician to the MACC book for nurse review when medical records receives them. 6. The first responder will verify the resident's code status on the In-Room Care Plan (IRCP). 7. On the IRCP, there will be a colored adhesive dot. RED will indicate DNR and communicates to the first responder CPR is not desired. A GREEN dot will indicate FULL CODE and communicates to the first responder CPR is desired. On [DATE] at 8:01 pm the facility's abatement plan was verified as implemented by: 1. A review of the facility's audit tool used to determine residents' code status. 2. A review of a facility In-Service Training Report regarding the facility policy on code status and CPR with 19 staff signatures. 3. An interview of all CNA and licensed nurse staff currently on shift to verify they were provided the in-service training. 4. Observation of staff placing color coded stickers on residents' in-room care plans to indicate the residents' code status. On [DATE] at 8:02 PM the facility administration was notified the Immediate Jeopardy was abated.

Based on interview and record review it was determined the facility failed to ensure Staff 3 (LPN) and Staff 5 (CNA) adhered to professional standards of practice to initiate CPR (cardiopulmonary resuscitation) for 1 of 4 sampled residents (#1) reviewed for CPR. This failure, determined to be an immediate jeopardy situation, resulted from Staff 3 and Staff 5 failing to initiate CPR for Resident 1 according to physician's orders [REDACTED]. Findings include: Oregon Administrative Rule 851-¿045-¿0070 Conduct Derogatory to the Standards of Nursing Defined included: Failing to take action to preserve or promote the client's safety based on nursing assessment and judgment. Oregon Administrative Rule 851-¿063-¿0030 Authorized Duties and Standards for Certified Nursing Assistant 1 (CNA 1) included: Performing cardiopulmonary resuscitation. Oregon Administrative Rule 851¿-063¿-0090 Conduct Unbecoming a Nursing Assistant included: Failing to take action to preserve or promote a person's safety based on nursing assistant knowledge, skills, and abilities. Resident 1 was admitted to the facility in 2017 with [DIAGNOSES REDACTED]. Resident 1's Face Sheet with a discharge date of [DATE] indicated the resident's code status was Full Code (meaning the resident desired intervention such as CPR should her/his heart stop beating or she/he stops breathing). Resident 1's Care Plan with an admission date of [DATE] indicated the resident's code status was Full Code. Resident 1's POLST (Physician order [REDACTED]. A Resident Progress Note dated [DATE] indicated at 9:18 pm (on [DATE]) Resident 1 was assessed by Staff 3 (LPN) and had no respirations or heartbeat for two minutes. The resident's skin was cool and pale. The physician was called and a time of death was received. The resident's family was notified of the resident's death and the resident was transported to the funeral home. The note did not indicate CPR was attempted or provide a rationale for not initiating CPR. A Nursing Facility Incident Self-Report Form dated [DATE] by Staff 4 (Regional Support RN) indicated on the evening of [DATE] Resident 1 was found without respirations or pulse and CPR was not initiated even though the resident's POLST indicated the resident was a full code. Education was provided to the licensed nurses regarding code status and the facility policy regarding CPR. On [DATE] at 11:58 am Staff 3 (LPN) stated Staff 5 (CNA) informed her Resident 1 appeared to have passed away. Staff 3 stated she should have checked Resident 1's code status at that time. Staff 3 acknowledged she should have initiated CPR and had assumed the resident was DNR because she/he had been on hospice. On [DATE] at 4:47 pm Staff 5 (CNA) stated she went to check on Resident 1 and empty the resident's catheter sometime after 9:00 pm (on [DATE]). Staff 5 stated the resident was in her/his chair and did not respond when spoken to. Staff 5 stated she touched the resident's hand and it was cold but it was usually cold. Staff 5 stated she checked for a pulse but did not detect it so she notified the charge nurse Staff 3 who was at the nurse's station right across the hall from the resident's room. Staff 5 stated she did not perform CPR because she thought the resident was on hospice and she was told in her CPR class the nurse was the one who does CPR. On [DATE] at 12:08 pm Staff 2 (DNS) acknowledged Staff 3 did not check Resident 1's code status and initiate CPR according to facility policy. Staff 2 acknowledged CPR should have been initiated. Refer to F678.

Based on interview and record review it was determined the facility failed to ensure resident transfers were completed per the care plan for 1 of 3 (#1) sampled residents. Resident 1 sustained a knee fracture during a transfer. Findings include: Resident 1 was admitted to the facility in 2012 with [DIAGNOSES REDACTED]. According to an 11/12/13 quarterly assessment the resident was identified to require extensive assistance with two-persons for transfers. The 12/4/13 care plan indicated the resident required two-person assistance for transfers. According to facility records on 2/3/14 Witness 1, Physical Therapy Student, transferred the resident alone, from the wheelchair to bed. The resident slid to the floor from the edge of the bed "with assist from the PT student." The resident complained of left leg pain. A 2/3/14 x-ray indicated the resident had a fracture of the distal femur (knee area.) According to a midterm evaluation completed on 1/24/14 by Staff 1, Physical Therapy Clinical Supervisor, Witness 1 required supervision "for all levels of patients at this time." In an interview on 3/18/14 Staff 1, Physical Therapy Clinical Supervisor, stated she was Witness 1's clinical supervisor at the facility. Witness 1 was in an internship at the facility. Staff 1 stated Witness 1 required visual supervision when working with residents. Staff 1 was always present when Witness 1 transferred the resident to bed. On 2/3/14 Staff 1 asked Witness 1 to take the resident back to the resident's room after a therapy session in the therapy room. Staff 1 did not instruct Witness 1 to transfer the resident to bed. In an interviews on 3/20/14 at 10:30 am and 3/31/14 at 12:00 pm Witness 1 stated he reviewed the resident's care plan every Monday. The witness didn't think the resident was care planned for two-person transfer but he couldn't remember for sure. The witness stated he would follow the resident's care plan for transfers. The witness stated the supervisor needed to be with him whenever he transferred a resident. On 2/3/14 the witness took the resident to the room after a therapy session. The resident requested to go to bed and the witness transferred the resident to bed. The resident slipped off the edge of the bed and her/his "knees flexed more than they had in a long time." The witness stated the supervisor was not present during the transfer. In an interview on 3/26/14 at 10:00 am Staff 2, CNA, stated prior to the 2/3/14 fall the resident required two-person transfers because she/he was inconsistent with transfer ability. The resident occasionally used a Hoyer lift or a sliding board for transfers. In an interview on 3/31/14 at 8:45 am, Staff 3, DNS, stated she expected therapy students to follow the care plan when working with residents outside of a therapy session.

Based on interviews and record reviews, it was determined the facility failed to contact the physician in a timely manner for 1 of 2 sampled residents (#1). Resident 1 sustained a fractured wrist and did not receive medical treatment for [REDACTED]. Findings include: State Board of Nursing Standards of Practice for Licensed Practical Nurse and Registered Nurses [PHONE NUMBER](1)(b) Intervenes on behalf of the client to identify changes in health status, to protect, promote and optimize health, and to alleviate suffering. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 4/17/11 IPN written at 5:30 am indicated the staff heard a loud crash and found the resident on the floor face down. The resident's range of motion was within normal limits though the resident's right hand grip was weaker than his/her left. The assessment indicated the resident was lying on his/her right arm and there were no complaints of pain in the right arm. The assessment indicated there were two hematomas observed on the resident's forehead. The 4/17/11 IPN written at 3:00 pm indicated the resident stated his/her right shoulder and forearm hurt. physician's orders [REDACTED]. The 4/17/11 IPN written at 7:00 pm indicated the x-ray reports were obtained and faxed to the resident's physician. The 4/18/11 IPN written at 11:30 am indicated the physician ordered the resident to be sent to the local hospital emergency room for an evaluation of injuries sustained from the fall. The 4/19/11 IPN written as a late entry for 4/17/11 at 8:00 pm indicated a message was left with the physician's answering service regarding the resident's x-ray results. The physician was informed the resident sustained [REDACTED]. The IPN indicated the resident was not complaining of pain except for right shoulder but humerus and forearm appear more swollen than they had in the morning. The resident was hosptalized on [DATE]. An interview on 4/28/11 at 11:53 am with Staff 8 (Assistant DNS) revealed Resident 1 fell the morning of 4/17/11. The resident first expressed pain in his/her wrist at 3:00 pm on 4/17/11. Staff 8 stated x-rays were ordered and obtained and a message was given to the physician's answering service. The physician called on 4/18/11 at 11:30 am and indicated the resident needed to be treated at the local hospital emergency department. Staff 8 stated the facility reviewed the incident and were in agreement that there was a lag time between the time the resident's x-ray results were obtained and the resident's treatment at the local hospital emergency department. An interview on 4/28/11 at 1:40 pm with Staff 9 (LPN) revealed on the evening of 4/17/11, the resident's wrist looked swollen. An x-ray report determined the resident had sustained a fractured wrist. Staff 9 stated she left a message with the physician's answering service regarding the x-ray results. Staff 9 stated the physician did not call her back and Staff 9 did not call the physician a second time or call the on-call physician. Staff 9 stated this was not the normal way to manage the care of fractures. Staff 9 stated the resident was not experiencing pain though the resident's arm was swollen. Refer to F-323

Based on interviews and record review, it was determined the facility failed to follow the resident's care plan for 1 of 2 sampled residents (#1). Resident 1 sustained a fractured wrist and was hospitalized . Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/15/11, the resident was assessed by the facility to be a high fall risk. The In Room Care Plan indicated the fall precautions were for the resident's bed to be in a low position, personal alarm/bed sensor in place and personal items within reach. The 4/16/11 day shift Interdisciplinary Progress Notes (IPN) indicated the resident attempted to stand from the wheelchair, ambulated with staff and had an unsteady gait. The resident was assessed to have poor safety awareness and had a personal alarm and bed sensor in place. The 4/17/11 IPN written at 5:30 am indicated the staff heard a loud crash and found the resident on the floor face down. The resident's range of motion was within normal limits though the resident's right hand grip was weaker than his/her left. The assessment indicated the resident was laying on his/her right arm and there were no complaints of pain in the right arm. The assessment indicated there were two hematomas observed on the resident's forehead. The observation indicated the resident's bed was in a low position, the bed sensor was off and the resident had pulled the personal alarm off. The 4/17/11 IPN written at 3:00 pm indicated the resident stated his/her right shoulder and forearm hurt. physician's orders [REDACTED]. The 4/17/11 IPN written at 7:00 pm indicated the x-ray reports were obtained and faxed to the resident's physician. The 4/18/11 IPN written at 11:30 am indicated the physician ordered the resident to be sent to the local hospital emergency room for an evaluation of injuries sustained from the fall. The resident was hospitalized from [DATE]. The facility's 4/18/11 Incident/Accident Report form completed by Staff 5 (LPN) indicated the resident's bed sensor was off, the personal alarm had been detached by the resident and there were no calls for help before the resident got out of bed. Staff 5 informed all of the staff of the "urgency/awareness of all alarms, the need for frequent checks and to monitor the resident closely." The Incident/Accident Report included a Witness Report completed by Staff 6 (CNA) indicating the resident used an alarm and it was functional. Staff 6 indicated the last time she saw the resident was five minutes before the fall at 5:25 am. An interview on 4/28/11 at 8:54 am with Staff 5 revealed the resident was toileted and returned to bed during the night by Staff 7 (CNA) instead of Staff 6 (Resident 1's assigned CNA). Staff 6 (CNA) informed Staff 5 (LPN) she turned on the resident's bed sensor when she assisted the resident into bed after the dinner meal. Staff 6 stated Staff 7 (CNA) assisted the resident to the toilet and into bed, during the night, without turning the bed sensor back on. Staff 6 stated she assumed the bed sensor was still turned on and did not know the bed sensor had been turned off at the time of the resident's fall. An interview on 4/28/11 at 9:25 am with Staff 7 (CNA) revealed she assisted Resident 1 to the toilet and into bed. Staff 7 stated she did not know the resident's bed sensor needed to be kept on. Staff 7 stated she had reviewed the resident's care plan and could not remember seeing the need for the bed sensor. An interview on 4/28/11 at 10:39 am with Staff 6 (CNA) revealed Staff 6 was the assigned CNA for Resident 1 on the night shift of 4/17/11. Staff 6 stated Staff 7 (CNA) assisted the resident to the toilet and into bed without putting the bed sensor on. Staff 6 stated she had seen the resident five minutes before the fall and did not check the resident's bed sensor. An interview on 4/28/11 at 11:53 am with Staff 8 (Assistant DNS) revealed it was the responsibility of Staff 6 (CNA) to make sure the pressure sensor was on after the resident was assisted to the toilet and placed in bed by a different CNA.