Every finding on record at Curry Village Health and Rehab of Cascadia

Based on interview and record review it was determined the facility failed to staff a registered nurse for 8 consecutive hours per day 7 days per week for 6 out of 122 days reviewed for staffing. This placed residents at risk for unmet assessment needs. Findings include: A review of the Direct Care Staff Daily Reports dated 10/1/25 through 10/31/25, 11/1/25 through 11/31/25, 12/1/25 through 12/31/25 and 4/1/26 through 4/30/26 revealed there were 6 days:10/4/25, 11/22/25, 12/27/25, 4/4/26, 4/11/26 and 4/18/26 without 8 consecutive hours of registered nurse coverage on any shift in a 24-hour period. On 5/7/26 at 10:53 AM Staff 1 (Administrator) acknowledged there was no RN coverage on those above days.

Based on observation and interview the facility failed to ensure staff followed correct sanitation and food handling procedures to prevent the outbreak of foodborne illness for 1 of 1 kitchen reviewed. This placed residents at risk for foodborne illness. Findings include:On 5/7/26 at 12:01 PM, Staff 10 (Dietary Aide) was observed washing her hands. Staff 10 failed to practice correct hand-washing techniques by using a paper towel to turn off the faucet, a potentially contaminated surface, then drying her hands with the same paper towel. On 5/07/2026 at 12:04 PM, Staff 12 (Cook) completed buttering rolls and moved to a new task. Staff 13 changed her gloves between tasks but did not re-wash her hands. Staff 13 then removed her gloves, went to the walk-in refrigerator to remove juice and pour a glass of juice for a resident that was given to another staff person. Staff 13 did not wash her hands prior to getting the juice for the resident. On 5/7/26 at 12:17 PM, Staff 11 (Culinary Manager) was observed washing his hands. Staff 11 failed to practice correct hand-washing techniques by using a paper towel to turn off the faucet, a potentially contaminated surface, then drying his hands with the same paper towel. Staff 11 was shown proper hand-washing technique and stated, Oh, now I understand.On 5/17/26 at 12:24 PM, Staff 10 was observed delivering a food cart to a resident hall. When Staff 10 returned to the kitchen she resumed prepping lunch trays without washing her hands.On 5/7/26 at 12:25 PM, Staff 12 removed her gloves, left the steam table and performed another task. Staff 12 returned to the steam table and re-gloved without washing her hands. On 5/7/26 at 12:27 PM, Staff 10 was observed to go into the dishwashing area and return carrying dish covers pressed against her clothing. Staff 10 resumed setting up the tray line without washing her hands. The dish covers were then used on plates going out to residents. On 5/7/26 at 12:34 PM, Staff 10 and Staff 12 stated they had not received recent training on hand hygiene. Staff 10 stated she was not aware she should not carry dishes against her clothing. Staff 10 stated she found the hand-washing technique demonstrated confusing and did not understand why she needed to dry her hands before turning off the faucet with the paper towel. On 5/7/26 at 1:06 PM, Staff 13 (Dietary Manager) stated staff needed to wash their hands each time they came into the kitchen and after changing gloves or touching a potentially contaminated surface. Staff 13 agreed staff should not use a paper towel to dry their hands after it has been used to turn off the faucet. Staff 13 stated she had not performed recent observations of kitchen staff related to proper hand hygiene.

Based on interview and record review the facility failed to ensure residents were given the right to make informed treatment decisions for 1 of 5 residents (#20) reviewed for accidents. This placed residents and their representatives at risk for not being able to make informed treatment decisions. Findings include: Resident 20 was admitted to the facility in 2/2026 with a diagnosis of Alzheimer's Disease. The resident's BIMS assessment completed in 3/2026 revealed a score of 5 (cognitively impaired). The resident's representative with power of attorney (POA) was not available for an interview. The resident's clinical record revealed the resident had a tab alarm (a device that makes an audible warning when the resident attempts to stand without assistance). No assessment or informed consent for the tab alarm was located in the resident's clinical record. On 5/7/26 at 9:09 AM, Staff 9 (RN) stated an assessment should be completed prior to using a tab alarm with a resident and consent must be given by the resident or resident representative. Staff 9 stated it was nursing staff's responsibility to complete the assessment and obtain informed consent. On 5/7/26 at 10:23 AM, Staff 2 (DNS) stated nursing staff should complete an evaluation and get informed consent before using a tab alarm with a resident. Staff 2 stated she could not find an assessment or informed consent for the tab alarm in Resident 20's clinical record.

Based on interview and record review it was determined the facility failed to ensure residents' MDS assessments were completed for 3 of 8 sampled residents (#s 2, 29, and 39) reviewed for pain, unnecessary medications, and activities. This placed residents at risk for lack of activities, pain, and unmet psychosocial needs. Findings include: 1.Resident 2 was admitted to the facility in 11/2025 with a diagnosis of heart failure. Resident 2's 2/24/26 Significant Change in Status MDS revealed section F - preferences for routine and activities was not assessed. On 5/7/26 at 11:49 AM, Staff 3 (MDS Coordinator) stated she was responsible for the oversight of MDS completion, including follow up with staff regarding incomplete sections. Staff 3 confirmed the activity section for Resident 2 was incomplete. On 5/7/26 at 1:32 PM, Staff 5 (Activity Director) stated she completed the activity evaluation and submitted it to the MDS coordinator, who put the information into the residents' MDS assessment. Staff 5 said she did not know preferences for routine and activities was incomplete for Resident 2. 2. Resident 39 was admitted to the facility in 1/2025 with a diagnosis including pain and personality and behavioral disorders. Resident 39's 2/8/26 Annual MDS revealed Section C, Cognitive Patterns; Section D, Mood; Section F, Preferences for Routine and Activities; and Section J, Health Conditions, were not assessed. On 5/7/26 at 11:49 AM, Staff 3 (MDS Coordinator) stated she was responsible for the oversight of MDS completion, including follow up with staff regarding incomplete sections. Staff 3 confirmed Resident 39's cognition, mood, activity, and pain sections were incomplete. Staff 3 further stated she notified the DNS regarding the incomplete MDS. 3. Resident 29 was admitted to the facility in 4/2026 with a diagnosis of sepsis (body's life-threatening response to an infection). Resident 29's 4/19/26 admission MDS revealed Section F-Preferences for Routine and Activities was not assessed. On 5/6/26 at 4:10 PM Staff 5 (Activities Director) stated she was responsible for interviewing residents for their MDS Section F. Resident 29 was able to voice her/his preferences. Staff 5 verified Resident 29's 4/19/26 admission MDS Section F was not completed. On 5/7/26 at 11:48 AM Staff 3 (MDS Coordinator) stated she was responsible to ensure residents' MDS assessments were completed. She gathered the MDS information from staff assessments which were to be completed before the ARD (Assessment Reference Date-end date of an observation period). Staff 3 stated if the information was not available in a resident's clinical record, she communicated to the staff member who was responsible for a particular section. Staff 3 stated Staff 5 was responsible to assess Resident 29's daily routines and activity preferences, the information was not available before the ARD, and she was not able to complete Section F. On 5/7/26 at 2:59 PM Staff 2 (DNS) stated the MDS Assessments were to be complete when submitted.

Based on interview and record review it was determined the facility failed to administer pain meds per physician orders for 1 of 2 sampled residents (#50) reviewed for pain. This placed residents at risk for unresolved pain. Findings include: Resident 50 was admitted to the facility on [DATE] with a diagnosis of rib fractures. Resident 50's 9/3/26 hospital Discharge Medication List revealed staff were to administer Resident 50 Tylenol (non-narcotic pain medication) every six hours for 10 days and Robaxin (muscle relaxant) every six hours for 10 days. Resident 50's Progress Notes revealed she/he was admitted to the facility on [DATE] at 4:30 PM, was alert, able to communicate needs, and reported she/he only had pain with movement. Resident 50's 9/2025 MAR revealed her/his Robaxin and Tylenol were scheduled to be administered at 6:00 PM, 12:00 AM, 6:00 AM and 12:00 PM. Resident 50 was not administered Robaxin on 9/3/25 at 6:00 PM or on 9/4/25 at 12:00 AM. Resident 50's Tylenol was not administered on 9/3/25 at 6:00 PM. On 5/4/26 at 12:41 PM Resident 50 stated on 9/3/25 at approximately 5:00 PM she/he was admitted to the facility. Resident 50 stated she/he did not receive all her/his pain medication until 9/4/25 in the morning and she/he was very painful. On 5/6/26 at 9:47 AM Staff 2 (DNS) stated if a resident had scheduled pain medication, staff should administer the medication if it was available in the facility. Staff 2 stated Tylenol was always stocked in the facility. Staff 2 stated the nurses did not verify Resident 50's orders until 9/3/25 at approximately 7:00 PM, therefore the 6:00 PM dose of Tylenol was not administered. Staff 2 stated Resident 50 did not receive any pain medication until 9/4/25 at 12:00 AM. On 5/7/26 at 2:41 PM Staff 8 (Corporate RN) verified in 9/2025 Robaxin was available in the facility's automated medication dispensing system and staff should have pulled the Robaxin from the dispensing system to administer to Resident 50.

Based on interview and record review it was determined the facility failed to honor the resident's right to be free from physical abuse from another resident for 1 of 2 sampled residents (#2) reviewed for abuse. Resident 2 was sent to the emergency room with facial injuries inflicted by Resident 1. The facility identified an avoidable accident related to a failed mandated resident relocation. The facility relocated Resident 1 and 2 to another room, staff were trained and care plans were updated. Corrective actions were completed on 9/26/25. This failed practice was identified as past noncompliance. Findings include: Resident 1 was admitted to the facility in 7/2025 with diagnoses including stroke and lack of coordination. Resident 1's 7/22/25 admission MDS revealed a BIMS assessment with a score of 14 (cognitively intact).Resident 2 was admitted to the facility in 8/2025 with diagnoses including cognitive impairment and cancer. Resident 2's 8/10/25 admission MDS revealed a BIMS assessment with a score of 15 (cognitively intact).A 9/26/25 Facility Investigation Summary and Conclusion revealed on the morning of 9/26/25, Resident 1 and Resident 2 were in their shared room asleep when Resident 1 woke up and was found hitting Resident 2 with a book and her/his fists. Resident 1 fell and hit her/his head. Emergency Services and the Police were called. Both residents were sent to the hospital.Prior to the incident, Resident 1 was placed on intensified monitoring (15-minute checks) due to a statement she/he made regarding hurting her/his roommate. A room change request was submitted to Social Services by Victim's Advocate Staff on 9/22/25, but there was no follow up regarding the room change.The facility identified a room change was requested on 9/22/25 and scheduled to occur on 9/24/25 due to Resident 1's statement of intent to harm Resident 2. The facility did not adhere to the policy related to room change or the urgency necessitated by the potential for resident-to-resident aggression.Based on witness statements Resident 1 struck Resident 2 with a book and her/his fists. The facility identified a room change was requested on 9/22/25. The room change was to occur on 9/24/25 due to Resident 1's statement of her/his intention to harm Resident 2. The facility did not follow the policy related to room change or the urgency needed when there was potential the residents could become aggressive.The deficient practice was identified as Past Noncompliance. The facility identified and corrected the deficient practice on 9/26/25 by implementing the following measures to mitigate risk and prevent further incidents of resident-to-resident abuse:-Resident 1 and Resident 2 were separated.-The facility implemented auditing through alert charting.-The facility reviewed and updated Resident 1's care plan.On 10/16/25 at 12:45 PM Staff 1 (Administrator) acknowledged when a room change was requested it was mandated to be completed, and when a resident threatens to harm another resident, immediate relocation and physician notification were required. Staff 1 concluded the incident met the definition of abuse.

Based on observation and interview it was determined the facility failed to ensure food was stored properly in 1 of 1 resident refrigerators, failed to ensure food was stored, prepared, and handled properly in 1 of 1 kitchen, and failed to keep kitchen equipment clean. This put residents at risk for food borne illnesses. Findings include: During the initial kitchen observation on 1/27/25 at 8:15 AM the following items were found in the walk-in refrigerator: - A plastic wrapped white tube containing a soft white substance, a white tub of semi hard white substance, and a white tub with dark liquid inside did not have labels or open dates - A metal bowl covered with plastic wrap labeled streusel topping, a used jug of thickened orange juice (juice with a thickening agent mixed into it), a used jug of 1% milk, a used carton of almond milk, used bags of shredded cheddar and mozzarella cheese, a box containing opened and uncovered packages of meat, and a used package of cheese slices with hard edges wrapped in plastic wrap did not have open dates - Two uncovered trays of hamburger patties on a bottom shelf During an initial kitchen observation on 1/27/25 at 8:25 AM the walk-in freezer contained the following items without open dates: - A loosely covered pie tin containing partially eaten pie - A bag of meat opened and wrapped loosely with plastic wrap - An open bag of meat patties inside an open box On 1/27/25 at 8:32 AM Staff 12 (Culinary Manager) verified all items found and stated they would be removed and staff educated on the proper food storage policy. He stated he would bring the food storage policy to the survey team. No further documentation was provided. On 1/28/25 at 12:30 PM Staff 12 verified the following items were found in the resident refrigerator: - A used jug of 1% milk, a used carton of almond milk, two used containers of nectar consistency orange juice (juice with a thickening agent mixed into it), and a used jug of cranberry juice cocktail did not have open dates - Plastic wrapped sliced cheese with multiple hard slices did not have a label or an open date During the meal tray preparation and meal service on 1/29/25 at 11:43 AM the following were observed: - Staff 12 used a thermometer to check the temperatures for all items on the steam table without cleaning it between items or wearing gloves until instructed. When asked about the proper procedure for getting food temperatures, he stated the policy was to wear gloves and clean the thermometer between all items. He stated he would bring the food service policy to the survey team. No further documentation was provided. - Staff 20 (Dietary Aid) did not have her hair net properly in place until instructed. She stated she did not know if there was a policy for hair nets. - Staff 20 was not wearing gloves while portioning out brown sugar from a large container until instructed. She stated the policy was to wear gloves when handling food. - Staff 19 (Dietary Aid) collected supplies for preparation of salads while wearing gloves and did not change his gloves prior to touching the salad mix. He did not change gloves or throw away the contaminated mix until instructed. He stated he did not realize he needed to change his gloves before touching the salad mix and did not know if there was a glove wearing policy. - Staff 19 removed squashed grapes and grapes with fuzz from a large bag of grapes without wearing gloves, and did not wash his hands or put on gloves until instructed. He stated he did not think he needed gloves to remove the grapes from the bag. On 1/29/25 at 12:20 PM Staff 12 stated the expectation of all kitchen staff was to wear gloves while performing tasks involving food. He stated he would bring the glove wearing policy to the survey team. No further information was received by the survey team. On 1/29/25 at 3:15 PM Staff 19 stated the expectation of kitchen staff was to label and date all food items upon opening them, but he did not know if there was a policy for food storage. He also stated the kitchen was cleaned on an as needed basis with no set schedule for cleaning or deep cleaning. He revealed a cutting board in use on the steam table which had dark spots on the underside, and stated he could not get it clean and did not know how long it had been in that condition. A follow up observation of the kitchen walk-in refrigerator on 1/29/25 at 3:23 PM noted the items from the initial kitchen observation still present as well as a used container of skim milk and a used carton of liquid eggs without open dates. Staff 12 verified the identified items. On 1/29/25 at 3:27 PM Staff 12 stated he did not have cleaning audits or a cleaning schedule for the kitchen. He stated he did not know about the dark spots on the underside of the cutting board, and upon visualizing the dark spots he stated the cutting board would be cleaned or thrown away. A kitchen observation on 1/30/25 at 10:31 AM revealed the following: - The cutting board with the dark spots underneath was being used on the steam table - All verified undated and unlabeled items from previous observations were still in place in the walk-in refrigerator, walk-in freezer, and resident refrigerator A follow up kitchen observation on 1/30/25 at 11:08 AM noted Staff 21 (Regional Culinary Manager) taking the steam table cutting board to the dumpster. She stated the board would not be used again, a new board had been ordered, and a cleaning schedule had been made for the kitchen staff.

Based on observation, interview and record review it was determined the facility failed to ensure food for the residents was prepared in a manner which preserved the nutritional value for pureed texture diets. This placed residents at risk for nutritional deficits. Findings include: An observation of lunch meal service on 1/29/25 at 11:43 AM revealed pureed cranberry chicken as a main course available to residents with puree texture diets. On 1/29/25 at 3:15 PM Staff 19 (Dietary Aid) stated food was mixed with water to create the puree texture. He also stated the puree texture consistency was determined by sight. On 1/29/25 at 3:27 PM Staff 12 (Culinary Manager) stated the recipes and texture guidelines for the kitchen came from Sysco (a kitchen food and non-food product supplier). He stated the kitchen staff were instructed to use water to make the puree texture. Staff 12 stated he would bring the survey team the recipes and guidelines from Sysco. No further information was provided to the survey team. A 1/30/25 review of pureed food recipes and texture guidelines on Sysco's website revealed the following: - Pureed food texture was determined by using a two-step testing method prior to serving it - Foods were to be mixed with gravy, sauce, broth, or milk to create a puree texture.

Based on observation, interview, and record review it was determined the facility failed to ensure a resident was assessed to self-administer medications for 1 of 1 resident (#2) observed during dining observations. This placed residents at risk for an unsafe medication regimen. Findings include: Resident 2 was admitted to the facility in 6/2006 with a diagnosis of paralysis of the lower body. A 1/19/25 quarterly MDS revealed Resident 2 was cognitively intact and did not have difficulty swallowing. On 1/30/25 at 8:22 AM Resident 2 was observed in the dining room sitting alone at a table with her/his breakfast tray. Next to Resident 2's tray on a paper napkin were 12 medications and a staff member was not by her/his side to ensure she/he swallowed the medications. On 1/30/25 at 8:23 AM Staff 10 (RN) stated she always left Resident 2's medications on a napkin at breakfast because Resident 2 liked to take them while she/he ate. Staff 10 stated Resident 2 sat alone at meals. On 1/30/25 at 8:25 AM with Staff 2 (Chief Nursing Officer) and Staff 3 (Clinical Resource) Staff 2 stated if medications were left with a resident the resident was to be assessed to ensure she/he was safe to self-administer medications. Staff 3 stated a self-medication administration assessment was not completed and not in Resident 2's clinical record. On 1/30/25 at 8:59 AM Resident 2 stated she/he preferred to take her/his morning medications on her/his own time, she/he was very capable of taking the medications, and did not have issues with swallowing. Resident 2 stated she/he sat alone and other residents did not interrupt her/him during meals.

Based on observation, interview, and record review it was determined the facility failed to ensure dependent residents received required assistance with ADLs for 1 of 3 sampled residents (#36) reviewed for ADLs. This placed residents at risk for unmet needs. Findings include: Resident 36 was admitted to the facility in 1/2025 with diagnoses of Alzheimer's disease and diabetes. A review of the Admission MDS with an Aessment Review date of 1/7/25 revealed Resident 36's BIMS was six, indicating a severe cognitive impact. Resident 36 required partial to moderate assistance with personal hygiene. A review of Resident 36's care plan dated 1/7/25 revealed she/he had an ADL self-care performance deficit and required partial to moderate assistance with personal hygiene and bathing. A Documentation Survey Report from 1/2025 revealed Resident 36 received bathing on Saturdays and Tuesdays. On 1/25/25 there was no record Resident 36 was offered or refused bathing. An unnamed document dated 1/25/25 indicated Resident 36 was not assigned to a staff member for bathing on 1/25/25. On 1/27/25 at 1:00 PM Witness 2 (Family) stated she would prefer Resident 36 not have facial hair. Witness 2 did not know staff could remove the resident's facial hair. On 1/27/25 at 11:51 AM Resident 36 was observed in her/his room with facial hair approximately two inches long. Resident 36 stated she/he did not remember the last time she/he received a shower. On 1/28/25 the following occurred: -9:07 AM: Resident 36 stated she/he used to use a razor to shave but she/he no longer owned one. She/he wanted her/his facial hair removed. -12:11 PM Resident 36 was observed in the main dining room with other residents. Resident 36's facial hair was approximately two inches long. On 1/29/25 the following occurred: -7:36 AM Staff 9 (CNA) stated if a resident was diabetic, he would ask a nurse to shave the resident while in the shower. Staff 9 stated he did not have Resident 36 assigned for a shower on 1/25/25 so he did not provide her/him a shower. -7:48 AM Staff 22 (LPN) stated nurses would shave diabetic residents' facial hair if they did not have an electric razor. CNAs sometimes did not know how to get a nurse while the resident was showering. -9:02 AM Staff 17 (CNA) assisted Resident 36 into her/his room. Resident 36 was observed with approximately two-inch long facial hair. Staff 17 stated some residents had an electric razor for facial hair, but she did not know the process for residents without an electric razor. -3:20 PM Staff 1 (Chief Executive Officer), Staff 2 (Chief Nursing Officer), and Staff 3 (Clinical Resource) expected staff to offer and provide shaving for the residents. Staff 2 stated the staff member who was responsible for the assignment sheet for bathing had left unexpectedly and Resident 36's shower was missed.

Based on observation, interview, and record review it was determined the facility failed to ensure a resident received ROM for 1 of 2 sampled residents (#18) reviewed for mobility. This placed residents at risk for decreased ROM. Findings include: Resident 18 was admitted to the facility in 2/2024 with a diagnosis of incomplete quadriplegia (limited movement below the neck). An 8/5/24 significant change MDS revealed Resident 18 had dementia, was blind, and required assistance with ADLs due to her/his quadriplegia. Resident 18 had functional limitations in ROM to both sides to the arms and legs. A 10/22/24 quarterly MDS revealed Resident 18 continued to have functional limitation in ROM to both sides to the arms and legs. A care plan initiated 11/4/24 revealed Resident 18 had Parkinson's disease and quadriplegia. Goals included Resident 18 would remain free of complications related to Parkinson's disease and maintain optimal quality of life within limitations imposed by her/his neurological deficits. Interventions staff were to provide included passive ROM with AM and PM care. A current (as of 1/29/25) Kardex (CNA guide for resident specific care) revealed there was no ROM task set up for CNAs. On 1/29/25 at 11:14 AM Staff 17 (CNA) stated if a resident was to be provided ROM it was on the resident's Kardex. Staff 17 stated she was able to do ROM if it was on the Kardex and if there were directions for the type of ROM to be provided. On 1/29/25 at 3:04 PM Staff 14 (OT) stated Resident 18 did not tolerate therapy, had poor pain tolerance, poor insight, and was discharged from therapy services. When Resident 18 was discharged from therapy the facility did not have an RA program. Staff 14 stated CNAs were able to do simple, passive ROM. On 1/29/25 at 3:21 PM Staff 16 (CNA) stated he learned how to do ROM in her/his CNA certification class, was comfortable providing ROM, and provided ROM if it was on a resident's Kardex. On 1/29/25 at 4:01 PM Staff 14 (CNA) stated she worked with Resident 18 and she/he did not have ROM on the Kardex and she did not provide Resident 18 ROM. On 1/29/25 at 3:42 PM Staff 4 (Resident Care Manager RN) acknowledged Resident 18's care plan directed staff to provide ROM with AM and PM care. Staff 4 stated the ROM was not on the Kardex as a task and staff did not do the ROM. On 1/30/25 at 7:57 AM with Staff 2 (Chief Nursing Officer) and Staff 3 (Clinical Resource) Staff 2 stated CNAs could do ROM but were not doing ROM.

Based on observation, interview, and record review it was determined the facility failed to ensure residents did not receive unnecessary psychotropic medications and failed to monitor for side effects of psychotropic medications for 2 of 5 sampled residents (#s 7 and 28) reviewed for medications. This placed residents at risk for adverse side effects of medications. Finding include: 1. Resident 7 was admitted to the facility in 10/2017 with diagnoses including anxiety disorder. A review of Resident 7's signed physician orders dated 1/15/25 instructed staff to administer Xanax (to treat anxiety) every eight hours PRN for anxiety for 90 days, starting on 10/18/24. A review of the 1/2025 MAR instructed staff to administer Xanax every eight hours PRN for anxiety for 90 days, starting on 10/18/24. The MAR indicated Resident 7 was administered Xanax on 1/17/25, 1/18/25, 1/19/25 1/22/25, 1/23/25, 1/26/25, 1/27/25 and 1/28/25. Resident 7 was administered Xanax eight times after the end date of 1/16/25. No end date was documented on the MAR. On 1/30/25 at 6:28 AM, Staff 8 (LPN) stated staff should document the end date in clinical records. On 1/30/25 at 7:55 AM Staff 1 (Chief Executive Officer), Staff 2 (Chief Nursing Officer), and Staff 3 (Clinical Resource) expected staff to document an end date in clinical records for a medication that was ordered for 90 days. 26991 2. Resident 28 was admitted to the facility in 9/2024 with a diagnosis of cancer. A 1/2025 MAR revealed Resident 28 was administered trazodone (antidepressant) daily at bedtime for sleep. A care plan dated 10/1/24 indicated Resident 28 was administered an antidepressant and the goal was for her/him to be free from adverse reactions including sedation, agitation, and confusion. A 1/2025 MAR and TAR revealed staff did not monitor Resident 28 for side effects from her/his antidepressant. On 1/28/25 at 7:49 AM, 1/28/25 at 9:55 AM, and 1/28/25 at 12:05 PM Resident 28 was observed to be alert, sitting up, at the dining room, and conversing with others. On 1/28/25 at 3:56 PM Staff 11(LPN) stated the nurses monitored residents for side effects of medications and if they observed side effects they documented in residents' progress notes. Psychotropic medications with potential side effects which were to be monitored were on the MAR or TAR. Staff 11 stated Resident 28 was administered an antidepressant but did not have side effects which were to be monitored listed on the MAR or TAR. On 1/28/25 at 4:01 PM Staff 4 (Resident Care Manager RN) stated the monitoring of psychotropic medication side effects were to be completed on the MAR or TAR. Staff 4 stated Resident 28 did not have antidepressant side effect monitoring in her/his clinical record. On 1/28/25 at 4:11 PM Staff 2 (Chief Nursing Officer) and Staff 3 (Clinical Resource) verified Resident 28's psychotropic side effect monitoring was to be documented on the MAR and TAR but was not done.

Based on observation, interview, and record review it was determined the facility failed to ensure a medication error rate of less than 5%. The facility administration error rate was 7.41% with two errors in 27 opportunities. This placed residents at risk for an ineffective medication regimen. Findings include: Resident 92 was admitted to the facility in 1/2025 with a diagnosis of malnutrition. A 1/27/25 hospital After Visit Summary form revealed Resident 92 was to be administered medications including Ferrous Sulfate EC (enteric coated) 324 mg (supplement) and Calcium with Vitamin D (supplement). On 1/28/25 at 7:48 AM Staff 11(LPN) was observed to administer Resident 92 medications including one Slow Iron 45 mg tablet. Staff 11 did not administer Calcium with Vitamin D. On 1/28/25 at 9:24 AM Staff 11 stated when a resident was admitted to the facility with new orders Staff 18 (Medical Records) entered the orders into a resident's clinical record and a nurse was to review the orders prior to administering the medications to ensure all the orders were entered correctly. Staff 11 reviewed Resident 92's admission orders and he acknowledged he administered the wrong dose of iron, stated the Calcium with Vitamin D was not transcribed onto the MAR, therefore, he did not administer the medication as ordered. On 1/28/25 at 9:26 AM Staff 1 (Chief Executive Officer) stated resident admission orders were entered into the clinical record by medical record staff and a nurse had to approve the orders before the medications could be administered. Staff 2 (Chief Nursing Officer) was notified the Calcium with Vitamin D was not transcribed onto the MAR. On 1/28/25 at 10:27 AM Staff 18 stated she did not enter the Calcium with Vitamin D order into Resident 92's clinical record and the nurse did not see the omitted order when they verified her/his orders.

Based on observation, interview, and record review it was determined the facility failed to ensure residents were treated with dignity and respect for 1 of 3 sampled residents (#2) and 2 of 4 halls (#s 1 and 3) reviewed for dignity and random observations. This placed residents at risk for lack of dignity. Findings include: 1. Resident 2 was admitted to the facility in 12/2010 with diagnosis including quadriplegia. A 7/24/23 Quarterly MDS revealed Resident 2 had an indwelling catheter. On 9/18/23 at 2:37 PM Resident 2 stated she/he preferred to have her/his urinary catheter bag covered with a privacy bag when she/he was in bed. The urinary catheter bag was observed hanging on the bed with no privacy cover and urine could be seen in the bag. Resident 2 stated people should not have to look at her/his urine. On 9/20/23 at 7:18 AM Resident 2 was in bed with urinary catheter bag hanging on the bed with no privacy bag. Urine could be observed in the bag from the hallway outside of Resident 2's room. On 9/20/23 at 10:48 AM Staff 4 (CNA) stated Resident 2's urinary catheter bag should have a privacy bag on it while she/he was in bed. On 9/21/23 at 10:59 AM Staff 1 (Chief Executive Officer) and Staff 2 (DNS) stated it was expected urinary catheter bags should be covered with privacy bags. 2. During observations on 9/20/23 at 7:18 AM Staff 5 (CNA) was in Resident 2's room while Resident 2 was in her/his bed. Staff 5 stated to Resident 2 as soon as she got all the feeders (residents who require assistance with eating) up, she would come back and assist Resident 2 to get out of bed. At 11:15 AM when asked if the dining room was available for interview, Staff 5 stated it was stating she started to get the feeders ready around noon. When asked if feeders was the term that facility staff used to address residents who required assistance with eating Staff 5 stated she should address residents who require assistance as assist. On 9/22/23 at 8:08 AM Staff 1 (Chief Executive Officer) and Staff 2 (DNS) confirmed it was not appropriate for staff to call residents who required assistance with eating feeders.

Based on interview and record review it was determined the facility failed to ensure a care conference with the interdisciplinary team occurred and failed to ensure a resident's care plan related to a UTI and medications were revised for 5 of 8 sampled residents (#s 1, 3, 5, 8, and 14) reviewed for care planning and medications. This placed residents at risk for adverse medication reactions and unmet needs. Findings include: 1. Resident 3 was admitted to the facility in 2023 with diagnoses including heart disease. An 8/15/23 Admission MDS indicated Resident 3 was cognitively intact. An 8/24/23 Progress Note indicated the resident refused to schedule a care conference. Resident 3's record did not reveal the Interdisciplinary Team met to develop the resident's care plan. On 9/20/23 at 3:22 PM Staff 2 (DNS) stated a care conference was to be held to develop the resident's care plan and was based on the MDS schedule. A request was made to Staff 2 to provide documentation a care conference was held to develop Resident 3's care plan. No additional information was provided. 2. Resident 5 was admitted to the facility in 2023 with diagnoses including failure to thrive. A Care Plan initiated 7/20/23 revealed Resident 5 was administered an antidepressant for depression. An 8/14/23 Progress Note revealed all Resident 5's non-essential medications were discontinued. A 9/2023 MAR revealed Resident 5 was not administered an antidepressant. On 9/20/23 at 10:53 AM Staff 15 (RNCM) stated Resident 5 had a decline in health and all her/his medications were discontinued except for the resident's seizure medication. Staff 15 acknowledged the care plan was not revised to reflect the discontinuation of the antidepressant. 3. Resident 8 was admitted to the facility in 2020 with diagnoses including a muscular disease. A 7/17/23 Admission MDS indicated the resident was cognitively intact. Resident 8's record revealed the last care conference held with the resident was on 11/3/22. On 9/18/23 at 3:45 PM Resident 8 stated she/he did not have a care conference for a while. On 9/19/23 at 2:13 PM Staff 15 (RNCM) stated Staff 3 (Social Services Coordinator) scheduled and documented all the care conferences for residents. Staff 15 stated she did not see a recent care conference documented in Resident 8's record. On 9/20/23 at 12:19 PM Staff 3 stated each resident was to have a quarterly care conference. Staff 3 stated Resident 8 was due for her/his last care conference 5/2023 and it did not occur. 34667 4. Resident 14 was admitted to the facility in 2023 with diagnoses including heart failure. On 9/19/23 at 9:28 AM Resident 14 was asked about participation in care planning and she/he stated she/he did not remember a care plan conference with facility staff. There was no evidence in the clinical record to indicate a care plan conference occurred for Resident 14. On 9/20/23 at 4:34 PM Staff 2 (DNS) was asked about care conferences and she stated care conferences should follow the MDS schedule. Staff 2 added she was unable to find evidence of a care conference for Resident 14. 35855 5. Resident 1 was admitted to the facility in 6/2002 with diagnosis including cerebral palsy (a movement disorder). An 8/3/23 Multidisciplinary Care Conference form revealed the following: -Meeting time and date were blank. -Attendance was blank. -Key review section was blank. -Resident and responsible party expectations and concerns were blank. -Comments and recommendations had notes with names of two other people who were not the resident and information about the two other people. -Recommendation section was blank. -The check boxes for care plan reviewed and updated and current orders and care plans reviewed with resident or representative and copies provided were not marked. A review of Social Services Notes for 7/2023 and 8/2023 revealed no social service notes pertaining to care conferences. On 9/21/23 at 12:52 PM Staff 3 (Social Services Coordinator) stated Resident 1's care conference date was noted as 8/3/23 on her hand-written calendar. Staff 3 stated she would have to look for additional information about the care conference. No additional information was provided. On 9/22/23 at 8:13 AM Staff 1 (Chief Executive Officer) and Staff 2 (DNS) were informed of the findings.

Based on interview and record review it was determined the facility failed to ensure a RN was available for at least eight consecutive hours per day seven days per week for 9 out of 32 days reviewed for staffing. This placed residents at risk for unmet assessment needs. Findings include: Direct Care Daily Staff Reports reviewed from 8/19/23 through 9/19/23 indicated there was no RN coverage on the following dates: 8/25/23, 8/26/23, 8/30/23, 9/1/23, 9/7/23, 9/8/23, 9/9/23, 9/15/23, and 9/16/23. On 9/21/23 at 10:45 AM Staff 1 (Chief Executive Officer) and Staff 2 (DNS) stated one of the facility's RNs retired and there were now some days without the required RN staffing.

Based on interview and record review it was determined the facility failed to ensure an antibiotic stewardship program was implemented for 1 of 1 facility and for 1 of 1 sampled resident (#3) reviewed for UTI. This placed residents at risk for worsening infections. Findings include: An Antibiotic Stewardship Policy last revised on 10/15/22 revealed the IP would track cultures and sensitivity reports routinely as part of the surveillance of the infection. Resident 3 was admitted to the facility in 2023 with diagnoses including heart disease. Resident 3's 9/15/23 and 9/16/23 Progress Notes revealed the resident had increased confusion, the physician was notified and a urine sample was obtained to rule out a UTI. The resident was started on Levofloxacin (antibiotic) per physician orders. The 9/15/23 final urine culture was received at the facility via fax on 9/20/23. This was five days after the culture was verified. The culture results revealed the resident was on the appropriate antibiotic to eliminate Resident 3's infection. On 9/20/23 at 2:07 PM with Staff 2 (DNS) and Staff 14 (LPN IP), Staff 14 stated the nurses who worked with the residents watched for the culture results when they were ordered for residents. Staff 14 stated she did not have a system in place to track and monitor the current residents to ensure the urine cultures came back in a timely manner. Staff 14 acknowledged the culture for Resident 3 was resulted on 9/15/23 and the facility did not receive the culture results until staff requested the results for this surveyor.

Based on interview and record review it was determined the facility failed to ensure residents received vaccines, education, and risk and benefits for 5 of 5 sampled residents (#s 2, 7, 11, 15, and 16) reviewed for immunizations. This placed residents at risk for infections and lack of information. Findings include: 1. Resident 2 was admitted to the facility in 2010 with diagnoses including paralysis. Resident 2's record revealed the resident received a pneumonia vaccine but the consent with risk and benefits was not located in the resident's record. The record also did not indicate which pneumonia vaccine the resident received. On 9/20/23 at 4:00 PM and 9/21/23 at 12:33 PM Staff 2 (DNS) stated Resident 2 received the PPSV23 vaccine, acknowledged Resident 2's pneumonia series was not complete and the record did not include the consent with risk and benefits. 2. Resident 7 was admitted to the facility in 2018 with diagnoses including heart failure. Resident 7's record revealed the resident received the PPSV23 vaccine but the consent with risk and benefits was not in the resident's record. The resident was eligible for an additional pneumonia vaccine but the record did not indicate it was offered. On 9/20/23 at 4:00 PM and 9/21/23 at 12:33 PM Staff 2 (DNS) stated she did not locate the resident's previous vaccine consent form and documentation to indicate additional vaccines were offered. 3. Resident 11 was admitted to the facility in 2020 with diagnoses including kidney failure. Resident 11's record revealed the resident received PPSV23 vaccine in 2021 by facility staff but the consent with risk and benefits was not in the record. The resident was eligible for another pneumonia vaccine but there was no documentation it was offered. On 9/20/23 at 4:00 PM and 9/21/23 at 12:33 PM Staff 2 (DNS) stated she did not find the resident's consent for the previous vaccine and no additional pneumonia vaccines were documented as offered. 4. Resident 15 was admitted to the facility in 2022 with diagnoses including kidney disease. Resident 15's record revealed she/he refused the PPSV23 and PCV20 vaccine on two occasions. Dates of the refusals were not documented and there was no documentation education was provided on the risks and benefits for the refusals. On 9/20/23 at 4:00 PM and 9/21/23 at 12:33 PM Staff 2 (DNS) stated she did not have documentation related to the residents refusals and if the resident was provided risk and benefits for the vaccine refusals. 5. Resident 16 was admitted to the facility in 2022 with diagnoses including a stroke. Resident 16's record revealed she/he refused the flu and PCV20 vaccines in 2022. There was no education found in the resident's record including the risks and benefits of the vaccines. On 9/20/23 at 4:00 PM and 9/21/23 at 12:33 PM Staff 2 (DNS) stated she did not locate documentation related to the risk and benefits of vaccine refusals.

Based on observation, interview, and record review it was determined the facility failed to ensure preferences were honored for 1 of 2 sampled residents (#2) reviewed for choices. This placed residents at risk for lack of support for preferences. Findings include: 1. Resident 2 was admitted to the facility in 12/2010 with diagnosis including quadriplegia. The 7/24/23 Quarterly MDS revealed Resident 2's BIMS score was 15 which indicated the resident was cognitively intact. a. A revised 8/7/23 care plan indicated Resident 2 had a self-care performance deficit and needed assistance with her ADLs. Resident 2 preferred to be up in her/his wheelchair for breakfast and required two staff assist for morning care. Resident 2 prefered early morning showers. On 9/19/23 at 8:46 AM Resident 2 was observed in bed eating her/his breakfast. On 9/20/23 at 7:18 AM Staff 5 (CNA) was in Resident 2's room while Resident 2 was in her/his bed. Staff 5 stated to Resident 2 as soon as she got all the feeders (residents who require assistance with eating) up she would come back and assist Resident 2 to get out of bed. At 11:15 AM Staff 5 stated Resident 2 preferred to be out of bed for her/his breakfast and there were times she did not have the time to get her/him up. Staff 5 stated she was able to get Resident 2 up out of bed about 75 percent of the time. On 9/21/23 at 11:00 AM Staff 1 (Chief Executive Officer) and Staff 2 (DNS) stated it was a rare exception when Resident 2 was not out of bed in the morning for breakfast. b. A 9/26/18 care plan indicated Resident 2 had a self-care performance deficit and needed assistance with her/his ADLs. Resident 2 preferred to have her/his lunch at 11:30 AM every day. On 9/19/23 at 12:10 PM Resident 2 was in her/his room and reported her/his lunch had not been served. No lunch tray was observed in the room. On 9/20/23 at 11:15 AM Staff 5 stated Resident 2 was provided lunch when all other residents' lunches were served between 12:30 PM and 1:00 PM. On 9/21/23 at 11:00 AM Staff 1 (Chief Executive Officer) and Staff 2 (DNS) stated Resident 2's lunch should be set out early and provided by 11:30 AM. c. A revised 8/7/23 care plan indicated Resident 2 had a self-care performance deficit and needed assistance with her/his ADLs. Resident 2 preferred to have all evening care completed by 9:00 PM. On 9/18/23 at 2:33 PM Resident 2 stated the CNAs determined when she/he got up and went to bed. Resident 9 stated she/he preferred to be in bed and all cares and treatments to be completed by 9:00 PM. Resident 2 stated Staff 8 (LPN) did not always come in to assist her/him until 9:00 PM or 10:00 PM and all other nurses were able to complete treatments by 9:00 PM. On 9/21/23 at 9:20 AM Staff 8 stated sometimes it was difficult to get into Resident 2's room and complete her/his cares before her/his preferred bedtime. On 9/22/23 at 7:53 AM Staff 9 (CNA) stated Resident 2 became upset if staff did not have her/his evening cares completed by an exact time. When Staff 9 was asked if Resident 2 was care planned to have evening cares completed by a certain time Staff 9 stated she did not know Resident 2's care planned preferences for evening. On 9/21/23 at 11:00 AM Staff 1 (Chief Executive Officer) and Staff 2 (DNS) stated in the evening it was a challenge for staff to complete all the diabetic treatments and staff attempted to get to Resident 2 for her/his care and treatment before her/his preferred time for sleep. d. An 10/21/22 Annual MDS indicated it was very important for Resident 2 to choose what clothes to wear. A revised 8/7/23 care plan indicated Resident 2 had a self-care performance deficit and needed one-person staff assistance with dressing. On 9/18/23 at 2:33 PM Resident 2 stated when she/he did not pick out her/his clothing with the evening CNA, the morning CNA picked her/his clothing without allowing her/him to choose what to wear. On 9/21/23 at 7:04 AM Staff 5 (CNA) stated she usually picked out Resident 2's clothing for the day and if the night shift helped Resident 2 pick them out, they would be set out for the morning. Staff 5 also stated she asked Resident 2 what she/he wanted and got the clothing out. On 9/21/23 at 11:00 AM Staff 1 (Chief Executive Officer) and Staff 2 (DNS) stated Resident 2 should have the choice of what to wear for her/his clothing in the mornings.

Based on interview and record review it was determined the facility failed to ensure a resident was provided advance directive information for 1 of 2 sampled residents (#3) reviewed for advance directives. This placed residents at risk for end-of-life decisions not being honored. Findings include: Resident 3 was admitted to the facility in 2023 with diagnoses including heart disease. An 8/10/23 Clinical Evaluation Admission form revealed the resident did not have an advance directive. An 8/15/23 Admission MDS indicated Resident 15 was cognitively intact. An 8/31/23 Care Plan revealed staff were to review advance directive information with Resident 3 and/or her/his appointed representative on admission, with a change of condition and at least quarterly. There was no documentation on the care plan to indicate advance directive information was provided. On 9/20/23 at 12:26 PM Staff 3 (Social Services Coordinator) stated if a resident had an advance directive it was scanned into the record. If the resident did not have one, the information was offered and then documented in the resident's record. Staff 3 thought she offered the information to Resident 3 and the resident declined, but there was no documentation in the resident's record.

Based on interview and record review it was determined the facility failed to provide care and services to maintain acceptable parameters of nutritional status for 1 of 1 sampled resident (#128) reviewed for nutrition. This failure resulted in Resident 128 having a severe weight loss of 8 percent in 20 days. Findings include: Resident 128 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the residents weights from admitted [DATE] through 7/25/22 revealed Resident 128 had a weight loss of eight percent. Nutrition parameters indicate a greater than five percent weight loss in one month (or less) was designated as a severe weight loss. Resident 128's Weight Summary Report printed on 7/29/22 included the following weight loss alert indicators in red ink adjacent to the resident's weights: On 7/7/22 at 10:16 AM a weight loss alert was triggered to indicate a change from last weight of -3.6%. The alert was cleared by an LPN. On 7/9/22 at 9:52 AM a weight loss alert was triggered to indicate a change of weight of -6%. The alert was cleared by an LPN. On 7/11/22 at 10:15 AM a weight loss alert was triggered to indicate a change of -7.1%. The alert was cleared by an RN. On 7/18/22 at 9:17 AM a weight loss alert was triggered to indicate a change of -7.5%. The alert was cleared by an LPN. On 7/25/22 at 9:00 AM two weight loss alerts were triggered to indicate a change of -7.9%. The alerts were cleared by an LPN. There was no documentation found to indicate any steps were taken by nursing staff to address the severe weight loss alerts in the report. Resident 128's 5-day/Admission MDS dated [DATE] contained a Nutritional Status CAA which indicated the resident weighed 97 pounds and did not have a loss of five percent or more in the last month. Review of the MDS revealed the facility did not use the resident's weight on admission of 104.2 pounds. Using the resident's actual admission weight of 104.2 pounds would indicate the resident had a seven percent weight loss on 7/12/22. On 7/26/22 at 2:50 PM a review of Resident 128's medical record revealed there was no initial Dietician Assessment found in the record. The Dietician Assessment was due within 14 days of the resident's admission. There were also no NAR (Nutrition at Risk) notes or Nutritional Status Notes located in the record as of 7/26/22. No documentation was found in the medical record to indicate the resident's initial weight of 104.2 lbs was not accurate. An Initial Nutritional Status Dietitian Assessment was located in progress notes on 7/27/22 and included the following: Effective Date: 7/18/2022 10:36 AM Department: Dietary Created By: Registered Dietician Created Date : 7/27/2022 1:22 PM The Created Date was 7/27/22 or 21 days after Resident 128's admission. Dietician Assessments were due on or before 14 days. The assessment included the resident's admission weight of 104 pounds and current weight of 96 pounds. The resident's caloric intake, protein intake and fluid intake were inadequate. A review of the resident's medical record found no documentation to indicate the physician was notified of Resident 128's weight loss. On 7/29/22 at 10:10 AM Staff 7 (RD) indicated she did not provide onsite visits for the residents at the facility. She attended the facility's NAR meeting virtually when it was held once a month. She acknowledged the initial assessment was done on 7/27/22 and not within the 14 day requirement. She agreed the resident had an eight percent weight loss and understood it was considered a severe weight loss per regulation. Staff 7 also indicated the Resident 128 received fortified meals and an afternoon health shake as interventions but continued to lose weight.

Based on interview and record review it was determined the facility failed to obtain orders and monitor the use of a medical device for 1 of 3 sampled residents (#74) reviewed for pressure ulcers. Resident 74 developed an unstageable (full thickness tissue loss in which the base of the wound is covered by dead tissue) pressure ulcer. Findings include: Resident 74 was admitted to the facility in August 2017 with [DIAGNOSES REDACTED]. The Skilled Nursing Facility Transfer Summary dated 8/30/17 included orders for physical and occupational therapy. The transfer form did not indicate Resident 74 had a dressing and a sling, include orders for the dressing and care of her/his fractured arm or the presence of a pressure ulcer. The Nursing Admit/Readmit Data Collection Tool dated 8/30/17 noted Resident 74's left arm had a surgical dressing, used a trough on her/his forearm (a hard device used to support a fracture), ace wrap and a sling. There was no indication Resident 74's skin was assessed under the dressing or she/he had a pressure ulcer. There is no evidence in Resident 74's medical record to show her/his skin was monitored underneath the dressing, use of the trough was clarified with the physician, whether the pressure ulcer was present on admission, treatments were provided or monitoring occurred prior to 9/5/17. No observations were made of Resident 74's wound during survey due to being hospitalized for [REDACTED]. A progress noted dated 9/5/17 documented the removal of the dressing and noted a 3 cm by 1.5 cm unstageable wound to the left elbow with slough (dead tissue that is cream or yellow in color). On 9/5/17 at 4:30 pm the facility obtained a physician's orders [REDACTED]. On 10/5/17 at 12:39 pm Staff 3 (RNCM) stated when Resident 74 was admitted to the facility she believed the surgical dressing to be new and the facility practice was to not remove a surgical dressing until a follow up with the surgeon occurred. Staff 3 confirmed the facility did not contact the physician for orders or remove the dressing to assess Resident 74's skin for 6 days.

Based on observations, interviews and record review it was determined the facility failed to ensure the resident had adequate devices as identified on the care plan to prevent accidents for 1 of 3 sampled residents with falls (# 1). The resident fell from the wheelchair and suffered lacerations requiring sutures. Resident 1 was admitted to the facility in 2009 with [DIAGNOSES REDACTED]. Review of the 10/19/10 quarterly MDS revealed the resident was totally dependent with the assistance of one facility staff for locomotion on and off the unit. Review of the resident's 10/28/10 Falls Data Collection Tool revealed the resident was a high risk for falls. Review of the Resident's 10/28/10 Quarterly Nursing Assessment revealed the resident did not attempt to self transfer. The assessment also referred to the resident's annual RAP for information regarding falls. Review of the 10/28/10 Comprehensive Care Plan provided by the facility on 2/17/11 revealed the resident had impaired mobility related to left hip fracture and polio. The interventions included " Encourage to propel own w/c (wheelchair) with leg rests to build LE (lower extremity) strength " , transport resident to areas of destination PRN and the resident used the wheelchair for mobility. Review of the resident's 12/28/10 Comprehensive Care Plan revealed the resident had impaired mobility and care planned interventions included leg-rests on the wheelchair and to transport the resident PRN. The care plan also revealed the resident was at risk for falls and care planned interventions included alarms to be used when in the wheelchair. Review of the resident's 4/27/10 Resident RAP Key Guideline Report-Online revealed the resident triggered for falls secondary to receiving an antidepressant. The resident had a history of [REDACTED]. Precautions in place included having an alarm on at all times, a fall mat was to be next to the resident's bed and visual checks were to be done as facility staff walked by the resident's room. A self releasing seat belt was discontinued because the resident did not try to self transfer from wheelchair to bed. Review of the 12/23/10 Interdisciplinary Progress Notes revealed at 6:30 pm the resident fell forward from the wheel chair while being transported to the dining room. The resident had a laceration above the eye and was sent to the hospital for evaluation and treatment. At 11:00 pm the resident returned with sutures. Review of the 12/23/10 Incident Details and investigation revealed the resident was being assisted to the dining room in the resident's wheelchair, fell forward, obtained a laceration to the eye and was transported to the hospital. Review of the 12/23/10 hospital emergency room Dictation revealed the resident was seen in the emergency room for an observed forward fall out of the wheelchair and the resident's head hit a hard object. The resident had a 3 cm laceration of the left eyebrow that required sutures and two small skin tears on the left hand. The resident was returned to the facility. Review of the Resident's 12/27/10 fall Investigation revealed Staff 14 (LPN) reported the resident was in the wheelchair in the television room. Staff 15 (CNA) came to the television room to take the resident to the dining room. The resident leaned forward in the wheelchair and "came out." Staff 14 reported the "foot pedals" were not on the wheelchair, the resident's wheelchair was not moving and when the resident leaned forward the resident's "feet went back" and the resident fell . Staff 15 (CNA) reported Resident 1 was transported from the television room to the dining room. Staff 15 described the resident as "stiff in the chair" and the resident was sitting upright. The resident was being pushed "not fast" in the wheelchair. Staff 15 stopped to talk with another resident and as Staff 15 had his head turned toward the other resident, Resident 1 fell to the floor. On 1/17/11 at 10:20 am Staff 3 (RNCM) stated the leg rests were on the resident ' s wheelchair because the resident did not propel the wheelchair and the leg rests were used to keep the residents feet up for transporting. On 1/17/11 at 10:25 am Staff 13 (CNA) stated the leg rests were used because the resident had swelling to the legs. Staff 13 did not know if the resident could hold his/her legs up when being transported in the wheelchair. On 1/17/11 at 1:32 pm Staff 15 (CNA) stated he did not work with Resident 1 very often. Staff 15 was transporting the resident from the television room to the dining room. Another resident in the television room was making multiple requests and Staff 15 turned to address the other resident and continued to "very slowly" push Resident 1's wheelchair. Resident 1 fell forward and Staff 15 was not able to stop the resident's fall. Staff 15 verified the resident did not have leg rests on the wheelchair. Staff 15 did not feel the resident's feet catch on the carpet as he pushed the resident forward. Staff 2 (DNS) and Staff 14 (LPN) stated the resident did not have the leg rests on the wheelchair at the time of the 12/23/10 accident. Staff 14 stated the resident's legs were down and as the wheelchair moved forward the resident fell . Review of a 1/17/11 faxed statement from the facility revealed Staff 2 (DNS) felt Resident 1 would have fallen even if the leg-rests were on the wheelchair. The fall was caused by the resident suddenly bending forward. Observations on 1/16/11 and 1/17/11 revealed Resident 1's care planned interventions were in place.