Every finding on record at Green Valley Rehabilitation Health Center

Based on interview and record review it was determined the facility failed to complete a discharge summary, including a recapitulation of the resident's stay and the resident's functional status upon discharge for 3 of 4 sampled residents (#s 2, 3, 5 and 8) reviewed for discharge. This placed residents at risk for an unsafe discharge. Findings include:1. Resident 3 was admitted to the facility in 1/2026 with diagnoses including pneumonia. A Discharge Planning Questionnaire dated 2/23/26 indicated Resident 3 was to be discharged home on 2/24/26. The form did not include a recapitulation of the resident's stay or the resident's functional status upon discharge. In an interview on 5/21/26 at 8:10 AM, Staff 5 (Social Services) stated the facility used the Discharge Planning Questionnaire for all discharges from the facility. Staff 5 acknowledged Resident 3's discharge summary did not include the resident's recapitulation of stay and the resident's functional status. 2. Resident 2 was admitted to the facility in July 2025 with diagnoses including kidney cancer. A Discharge Planning Questionnaire dated 9/12/25 indicated Resident 2 was discharged home on 9/15/25. The form did not include a recapitulation of the resident's stay or the resident's functional status upon discharge. In an interview on 5/21/26 at 8:10 AM, Staff 5 acknowledged Resident 2's discharge summary did not include the resident's recapitulation of stay and the resident's functional status. 3. Resident 8 was admitted to the facility in 2/2026 with diagnoses including dementia. A Discharge Planning Questionnaire dated 5/11/26 indicated Resident 8 was to be discharged home on 5/12/26. The form did not include a recapitulation of the resident's stay or the resident's functional status upon discharge. In an interview on 5/21/26 at 8:10 AM, Staff 5 acknowledged Resident 8's discharge summary did not include the resident's recapitulation of stay and the resident's functional status.

Based on interview and record review it was determined the facility failed to ensure a safe and orderly discharge for 1 of 3 sampled residents (#8) reviewed for discharge. This placed residents at risk for an unsafe and disorderly discharges. Findings included: Resident 8 was admitted to the facility in 2/2026 with diagnoses including dementia. Review of a Resident 8's Care Plan dated 2/13/26 indicated the resident had an ADL self-care performance deficit and limited physical mobility. Interventions included ambulation with a four-wheeled walker. The care plan also indicated the resident was at risk for elopement due to Alzheimer's, with the goal to ensure the resident did not leave the facility unattended. The resident's care plan also indicated the resident wished to be discharged to her/his home where a family member lived with the resident. Interventions including to discuss the discharge planning process with the family. Review of Resident 8's BIMS Evaluation dated 2/17/26 documented the resident scored a 5 out of 15 (indicating severe cognitive impairment). A Physician Assistant's (PA) Note dated 5/11/26 indicated discharge planning concerns for failure to thrive at home. Resident 8 was being discharged home (65 miles away) despite clinical reservations given past concerns at home. Cognitive status appeared to be at baseline. A Discharge Readiness form dated 5/11/26 at 3:24 PM, indicated the resident was to be discharged to home approximately 65 miles from the facility. The resident was to be transported home via public transportation. A Nurse's Note dated 5/12/26 at 2:51 PM, indicated the resident was discharged from the facility at 2:45 PM. A train ticket dated 5/12/26 indicated Resident 8 was to depart via bus from the local train station to a grocery store in the resident's hometown one mile from the resident's home. The bus was scheduled to leave at 3:45 PM and arrive at 5:26 PM. A Nurse's Note dated 5/12/26 at 7:53 PM, documented the resident arrived back at the facility after missing the bus to her/his hometown. The note indicated the resident's family was informed. A Physician Assistant's Note dated 5/13/26 at 9:21 PM, indicated the resident was seen for readmission to the facility after being sent to the bus stop via taxi to take a bus back home where family were to meet Resident 8. The note indicated the resident did not get on the bus due to a severe cognitive impairment and the inability to find the correct bus on her/his own. In an interview on 5/20/26 at 12:15 PM, Resident 8, who was alert, stated the facility treated her/him well and had no concerns with care. Resident 8 wanted to go home to her/his family on the coast but did not know what city she/he resided. The resident stated she/he was currently at a hospital but did not know which hospital. The resident stated she/he was recently sent home via a car, there was an accident on the way home and the car brought her/him back to the facility. Resident 8 did not remember being at the bus stop. In an interview on 5/20/26 at 12:25 PM, Staff 3 (RCM) stated Staff 4 (RCM) made a suggestion during a pre-discharge meeting the facility should send a staff person with the resident to the bus stop and not be sent alone. Staff 3 stated no staff went with the resident to the bus station. Staff 3 stated an attendant at the bus station called the facility to report the resident missed the bus. In an interview on 5/20/26 at 12:42 PM, Staff 5 (Social Services) stated Staff 4 had concerns regarding the resident's cognition and being dropped off at the bus station to catch a bus to go home. Resident was sent alone by the facility via taxi to the local bus stop. Staff 5 stated Witness 8 (Family Member) member was supposed to meet the resident in their hometown when the resident arrived and had called the facility to let them know the resident did not get on the bus. In an interview on 5/20/26 at 1:27 PM, Staff 6 (LPN) stated on 5/12/26 he received a call from Witness 8 who stated a bus station attendant had called her to tell her Resident 8 had missed the bus to go home. Staff 6 stated the resident was found by the bus station attendant, confused, and the bus station attendant had called Witness 8 to let them know. Staff 6 immediately called Staff 1 (Administrator) and Staff 2 (DNS) and an ambulance was sent to pick up the resident at the bus station who was taken back to the facility. In an interview on 5/20/26 at 1:40 PM, Staff 1 and Staff 2 stated Resident 8 was sent via taxi to the bus station on 5/12/26 with a prepaid bus ticket to go home. Resident 8 was not accompanied by staff and failed to get on the scheduled bus to go home. Resident 8 was found by a bus attendant who called Witness 8 who then notified the facility. Staff 2 was present at the pre-discharge meeting and was aware of the concerns by Staff 4. The facility did not feel sending the resident to the bus station alone would be a problem. In an interview on 5/21/26 at 7:13 AM, Witness 8 stated she received a call from the local bus station who informed her the resident had missed the bus to go home. Witness 8 called the facility who dispatched EMS to pick up the resident.

Based on observation, interview and record review the facility failed to effectively manage the resident's pain for 1 of 3 (#66) sampled residents reviewed for pain management. This placed residents at risk for unmanaged pain. Findings include: Resident 66 was admitted to the facility in 2022 with diagnoses including severe osteoarthritis (a disease which destroys the cartilage protecting bones and cause pain, stiffness and reduced mobility) and chronic pain. The resident's 11/2025 BIMS revealed a score of 14 (cognitively intact).A review of the resident's pain monitoring (1-10 scale of pain level with 10 indicating the worst pain possible) in the TAR for the previous 12 months revealed the following:2/2025: Pain levels of 6-10 reported on 26 of 28 days.3/2025: Pain levels of 6-9 reported on 27 of 31 days.4/2025: Pain levels of 6-10 reported on 28 of 30 days.5/2025: Pain levels of 6-10 reported on 30 of 31 days. 6/2025: Pain levels of 6-8 reported on 25 of 30 days. 7/2025: Pain levels of 6-8 reported on 25 of 31 days.8/2025: Pain levels of 6-8 reported on 30 of 31 days.9/2025: Pain levels of 6-9 reported on 23 of 30 days.10/2025: Pain levels of 6-9 reported on 28 of 31 days.11/2025: Pain levels of 6-8 reported on 25 of 30 days.12/2025: Pain levels of 6-8 reported on 26 of 31 days.1/2026: Pain levels of 6-7 reported on 26 of 28 days. Resident 66's clinical record revealed orders for Tylenol, Lyrica (a medication used to treat nerve pain), lidocaine patches, and cyclobenzaprine (a muscle relaxer) for pain. In a Pain Assessment completed 12/23/25 by Staff 7 (LPN) the resident reported severe pain that interfered with sleep, activity, and participation in therapy. The report indicated the resident reported an acceptable pain level would be a level five.On 1/27/26 at 8:25 AM, Resident 66 stated she/he had chronic, unrelieved pain and the only thing she/he could do was lay completely still as movement usually exacerbated the pain. The resident stated she/he received opioid pain medication in the past but was taken off of it due to using a marijuana gummy. The resident stated she/he used the marijuana gummy because she/he was desperate to stop the pain and nothing was working. The resident stated she/he had no quality of life and felt frustrated, trapped and hopeless. On 1/28/26 at 8:45 AM, the resident was observed in her/his room with ice packs on her/his right shoulder. The resident was in tears and stated the shoulder pain was severe. On 2/1/26 at 12:49 PM, Staff 39 (CMA) stated Resident 66 had chronic pain in her/his shoulders and back and she sometimes found Resident 66 crying from pain. On 2/1/26 at 3:17 PM, Staff 7 stated he did a Pain Assessment for Resident 66 on 12/23/25 and was very familiar with the resident. Staff 7 stated in the past year Resident 66 experienced pain experienced significant pain 4 out of 5 days. Staff 7 stated he wrote an SBAR (an internal communication which does not become part of the clinical record) sometime after the assessment as the resident had reported a pain level of ten out of ten. He stated he was aware she/he was chronically in pain and did not think her/his pain regimen of Tylenol and Lyrica was alleviating her/his pain. Staff 7 stated Resident 66 was more independent in the past but now was dependent on staff for most of her/his care. On 2/1/26 at 4:45 PM, Staff 16 (CMA) stated Resident 66 experienced was in a lot of pain chronically. Staff 16 stated he saw Resident 66 in tears from pain frequently and she/he would cry out in pain when she/he tried to move. Staff 16 stated he spoke to the Unit Manager about Resident 66's pain.On 2/1/26 at 6:47 PM, Staff 38 (CNA) stated Resident 66 was chronically in pain and she would see Resident 66 crying or grimacing in pain. She stated Resident 66 rarely left her/his room and wanted to be left alone when she/he was in a lot of pain. She stated she would attempt comfort measures with Resident 66 and sometimes she could distract her/him but didn't really think anything was helping alleviate Resident 66's pain. On 2/2/26 at 11:18 AM, Staff 37 (Physician's Assistant) stated the resident had severe osteoarthritis. She stated Resident 66 was on a pain contract from a previous provider and refused a urinalysis which meant she/he was weaned off opioids. Staff 37 stated Resident has severe osteoarthritis and a hernia and was not a candidate for corrective surgery due to her/his weight. Staff 37 stated Resident 66 could find another provider, but she was not going to risk her license by prescribing Resident 66 opioids since she/he violated the pain contract. On 2/2/26 at 11:28 AM, Staff 8 (Social Services Director) stated Resident 66's last interdisciplinary team conference was in 2/2025. Staff 8 stated he did not assist Resident 66 to obtain an appointment with a pain management clinic.On 2/2/26 at 11:38 AM, Staff 28 (LPN/Unit Manager) stated Resident 66 reported her/his pain was not managed but when Staff 28 asked staff they reported Resident 66 did not present symptoms of pain. Staff 28 stated staff did not inform her Resident 66's pain regimen was not effective and she did not interview Resident 66 about her/his pain. Staff 28 stated she had heard Resident 66 used methamphetamine and violated her/his pain management contract. Staff 28 stated she did not request Resident 66 be evaluated for substance use disorder (SUD) and was not aware there was no diagnosis for SUD in Resident 66's clinical record. On 2/2/26 at 11:50 AM, Staff 2 (DNS) stated the facility had an obligation to provide oversight and care of residents and collaborate regularly on the effectiveness of resident care. Staff 2 stated the facility needed to review Resident 66's situation and to assist Resident 66 to reach her highest practicable level of wellbeing.

Based on observation, interview, and record review it was determined the facility failed to determine the appropriateness for the self-administration of medication for 4 of 9 sampled residents (#s 5, 10 12, 68, and 108) reviewed for accidents and nutrition. This placed residents at risk for an ineffective medication regimen. Findings include:1. Resident 5 was admitted to the facility in 3/2024 with a diagnosis of heart failure. Resident 5's 3/11/24 Self-Administration of Medication form revealed she/he was capable but did not want to self-administer medications. Resident 5's Order Details form revealed Salonpas was to be administered PRN left knee pain. The order indicated the medication could be kept at Resident 5's bedside. Resident 5's 12/17/25 Quarterly MDS revealed she/he had moderate cognitive and memory problems. Resident 5's clinical record revealed there was no assessment to ensure she/he was safe to administer Salonpas. On 1/28/26 at 10:50 AM Staff 4 (LPN) stated a resident could have medications at the bedside after an assessment was completed. Staff 4 stated Resident 5 had orders to keep the medication at the bedside. On 1/28/26 at 10:57 AM Staff 3 (RNCM) stated If a resident was to have medications at the bedside there needed to be a physician order, the medication was to be kept in a secure location, and a self-medication assessment was to be completed before allowing medications at the bedside. Staff 3 stated Resident 5 was not assessed to ensure she/he was able to self-administer medications. On 2/2/26 at 10:08 AM Staff 2 (DNS) stated if a resident had medications at the bedside, a resident was to be assessed to ensure she/e was capable of self-administration, the medication was to be in a secure location, and orders were to be obtained. 2. Resident 10 was admitted to facility in 6/2018 with diagnoses including calcific tendinitis of left shoulder (a painful condition caused by calcium deposit buildup within the rotator cuff tendons) and pneumonia. The quarterly MDS with an ARD of 10/31/25, revealed Resident 10 had a BIMS score of 12, which indicated the resident had moderate cognitive impairment, and experienced occasional severe pain. Observations on 1/26/26 at 3:35 PM and 1/27/26 at 3:28 PM revealed Resident 10 had lidocaine cream on her/his nightstand and a bottle of 3% hydrogen peroxide first aid antiseptic spray on her/his shelf. Resident 10 stated she/he had the lidocaine cream and antiseptic for a few months. On 1/27/26 at 3:28 PM, Resident 10 applied lidocaine cream onto her/his left neck, shoulder and wrist. Resident 10 also demonstrated the use of the first aid antiseptic by holding the spray to her/his mouth. Resident 10 stated she/he sprayed the antiseptic into her/his mouth before rinsing it out with mouthwash. A review of Resident 10's clinical record revealed no self-administration of medication assessment was completed to determine the resident's ability to safely self-administer topical lidocaine or first aid antiseptic spray. On 1/28/26 at 11:46 AM, Staff 11 (CNA) stated she was not aware of Resident 10 having medications in her/his room or if Resident 10 had been authorized to have medications at her/his bedside. On 1/29/25 at 8:38 AM, Staff 12 (CNA) stated she was not aware of Resident 10's ability to self-administer medications or if Resident 10 had been authorized to have medications at her/his bedside. Staff 12 stated if medications were found by a resident's bedside, she would inform the nurse. On 1/29/26 at 8:52 AM, Staff 13 (CMA) stated Resident 10 was known to purchase a variety of her/his own medications and keep the medications in her/his room. Staff 13 stated she has taken medications from Resident 10's room in the past and reported the incident to the nurse. Staff 13 stated there was a process for residents to self-administer their own medications. On 1/29/26 at 9:20 AM, Staff 7 (LPN) stated he was not aware of Resident 10 having authorization to self-administer medications. Staff 7 stated as of 1/28/26 at 1:32 PM, an order was received for Resident 10 to have lidocaine cream at her/his bedside. Staff 7 stated there was no order for Resident 10 to use antiseptic in her/his mouth. On 1/30/26 at 3:02 PM, Staff 1 (Administrator) and Staff 2 (DNS) stated they expected an evaluation and orders to be in place for residents to self-administer medications. 3. The facility's 3/2023 Right to Self-Administer Medication outlined the following criteria for a resident to self-administer medications: 1. If a resident has requested to self-administer medications, it is the responsibility of the interdisciplinary team to determine it is safe before the resident exercise the right. A resident may self-administer medications after the interdisciplinary team has determined which medications be self-administered. 2. Considerations in determining of the resident is clinically appropriate to self-administer include: a. Which medications are appropriate and safe for self-administration. b. The resident physical capacity to swallow without difficulty and to open medication packaging. c. The resident's cognitive status, including ability to correctly identify medications and know for which conditions s/he is taking medication. 3. Appropriate documentation of the determinations will be documented in the resident's medical record and care plan. Resident 12 was admitted to the facility in 4/2025 with diagnosis including acute respiratory failure and chronic obstructive pulmonary disease. A review of Resident 12's 10/30/25 Quarterly MDS revealed she/he was cognitively intact. On 1/27/26 at 2:41 PM a Breyna inhaler (also known as Symbicort, a combination of budesonide and formoterol fumarate, a corticosteroid and long-acting agonist) and Albuterol Sulfate inhaler (a bronchodilator that relaxes muscles in the airways and increases air flow to the lungs) was observed on Resident 12's bedside table. Resident 12 stated the blue inhaler (Breyna) was her/his medicine which her/he took one or two times a day and the green (albuterol) inhaler was her/his rescue inhaler and she/he used when needed. A review of Resident 12's 1/2026 MAR indicated the resident was approved by her/his provider to keep Symbicort and Albuterol Sulfate at bedside. An 8/15/25 Self-Administration of Medication assessment revealed Resident 13 was evaluated for wanting to self-administer medication, the list of medications approved to self-administer, and location of storage was not assessed. On 1/28/26 at 3:59 PM Staff 26 (LPN) stated Resident 12 did not have any inhalers at bedside and she/he was not capable of accessing the nightstand drawer to lock/unlock to get the medications. On 1/28/26 at 4:07 PM Staff 25 (CMA) stated Resident 12 had one inhaler (Symbicort) at bedside and would use it twice a day. On 1/30/26 at 9:30 AM Staff 4 (LPN) stated Resident 12 had one inhaler (Albuterol Sulfate) at bedside and would use it as needed. On 1/30/26 at 11:03 AM Staff 3 (RN, Unit Manager) stated she was aware Resident 12 had Symbicort inhaler at bedside and was not aware the resident had Albuterol Sulfate or did not have a lockbox. Staff 3 stated she expected any residents who had medications at their bedside to have a completed self-administration assessment which includes the names of the medications and a lock box for the medication. On 1/30/26 at 2:10 PM Staff 2 (DNS) stated she expected staff to be aware of all residents who are allowed to have medications at bedside, the specific medications, and have the medications secured in a lockbox. 4. Resident 68 was admitted to the facility 7/2023 with a diagnosis of Alzheimer's disease. The quarterly MDS with an ARD of 1/3/26, revealed Resident 68 had a BIMS score of 8, which indicated the resident had moderate cognitive impairment. Observations on 1/27/26 at 11:57 AM and 1/28/26 at 4:05 PM revealed Resident 68 had a tube of Ammonium Lactate cream by her/his bedside and two tubes in her/his shelf. Resident 68's name and instructions were observed on the prescription label. On 1/27/26 at 4:04 PM, Resident 68 stated staff did not assist with applying the cream to her/his feet. Resident 68 stated the cream was for the gangrene on her/his feet. On 1/28/26 at 4:05 PM, Resident 68 could not explain the quantity or frequency of the cream's use and stated staff did not assist her/him with the application. A review of Resident 68's clinical record revealed no self-administration of medication assessment was completed to determine the resident's ability to safely self-administer ammonium lactate cream to her/his feet. On 1/29/26 at 8:49 AM, Staff 10 (CNA) stated she was not aware of Resident 68 having medications at her/his bedside. She stated if she saw medications at Resident 68's bedside, she would let the nurse know. On 1/29/26 at 8:52 AM, Staff 13 (CMA) stated she was not aware of Resident 68 having the ability to self-administer medications. Staff 13 stated there was a process for residents to self-administer their own medications. On 1/29/26 at 9:40 AM, Staff 7 (LPN) acknowledged the ammonium lactate cream by Resident 68's bedside and shelf. Staff 7 stated he was not sure what the cream was for and confirmed it was not on Resident 68's orders, and the resident did not have skin issues on her/his feet. On 1/30/26 at 3:02 PM, Staff 1 (Administrator) and Staff 2 (DNS) stated they expected an evaluation and orders to be in place for residents to self-administer medications. 5. Resident 108 was admitted to facility 6/2023 with diagnoses including muscle weakness and chronic pain. The quarterly MDS with an ARD of 12/1/25, revealed Resident 108 had a BIMS score of 15, which indicated the resident was cognitively intact. Observations on 1/26/26 at 1:21 PM revealed Resident 108 had antifungal powder, Aspercreme, and Icy Hot on her/his shelf. Resident 108 stated she/he sometimes used the products on her/himself. Observations on 1/27/26 at 3:39 PM revealed Resident 108 had antifungal powder at her/his bedside and the Apsercreme on her/his shelf. A review of Resident 108's clinical record revealed no self-administration of medication assessment was completed to determine the resident's ability to safely self-administer Aspercreme, antifungal powder, or Icy Hot. On 1/29/26 at 8:41 AM, Staff 10 (CNA) stated she was not aware of Resident 108's ability to self-administer medications. On 1/29/26 at 9:00 AM, Staff 7 (LPN) stated Resident 108 and her/his family were known to purchase over-the-counter medications and bring them to her/his room. On 1/29/26 at 9:34 AM, Staff 7 confirmed there was no order for Resident 108 to self-administer medications. On 1/30/26 at 3:02 PM, Staff 1 (Administrator) and Staff 2 (DNS) stated they expected an evaluation and orders to be in place for residents to self-administer medications.

Based on observation, interview, and record review it was determined the facility failed to ensure food temperatures were maintained and to provide palatable food from 1 of 1 facility kitchen and 3 of 5 sampled residents (#s 11, 29 and 57) reviewed for food. This placed residents at risk for food that was not palatable, safe, or appetizing. Findings include: 1.Resident 11 was admitted to the facility in 1/26 with diagnoses including anemia (low red blood cell count) and kidney failure. The 1/18/26 admission MDS revealed a BIMS assessment revealed a score of 15 for Resident 11. On 1/26/26 at 9:41 AM, Resident 11 was observed with her/his breakfast in her/his room. Resident 11 stated the food was not warm and she/he refused to eat it. Staff 32 (CNA) entered the room and Resident 11 stated her/his eggs, toast, and oatmeal were cold. Staff 32 did not offer to address her/his cold food. On 1/26/26 at 12:36 PM, meal trays were loaded on a cart from the dining room and taken to Resident 11's hall. On 1/29/26 at 10:49 AM, Resident 11 stated her/his meals were often cold. Resident 11 stated she/he would ask for an alternative, but staff did not return with warm food. Resident 11 stated the food was always cold; therefore, she/he had family bring snacks to the facility. Resident 11 stated she/he informs the staff daily the food is cold, but nothing changes regarding her/his breakfast of scrambled eggs, toast, and oatmeal. On 1/29/26 12:37 PM, Staff 23 (CNA) stated the residents complain frequently about cold food. Staff 23 stated it was difficult to warm all the trays for the residents and still perform work duties. Staff 23 stated management needed to ensure the residents had hot meals. Staff 23 stated staff do the best they can to get meal trays out, but it does not take long for the food to become cold. On 1/30/26 at 12:10 PM, Staff 2 (DNS) and Staff 22 (Regional Dining Director) acknowledged the facility was aware of cold food complaints by residents. Staff 2 and Staff 22 stated sufficient food delivery equipment was required to address the cold food concerns. 2. Resident 29 was admitted to the facility in 12/2025 with diagnosis including heart disease. A 12/13/25 Care Plan indicated Resident 29 required staff to assist with the set-up of her/his meals. The 12/19/25 admission MDS revealed a BIMS assessment score of 14 (cognitively intact) for Resident 29. On 1/26/26 at 12:36 PM, meal trays were loaded on a cart from the dining room and taken to Resident 29's hall. On 1/26/26 at 12:41 PM, Resident 29 was observed with her/his meal in her/his room and stated the food was not warm. An unidentified CNA in the resident's room did not offer to address her/his cold food. On 1/27/26 at 10:49 AM, Resident 29 stated her/his meals were often late and cold and reheated food took too long to be returned. On 1/28/26 at 1:23 PM, Resident 29 was observed in her/his room with a lunch tray and napkin on her/his plate. Resident 29 stated she completed her/his meal and acknowledged her/his meal was half eaten. Resident 29 stated her/his lunch arrived 10 minutes earlier and her/his potato arrived cold and could not melt butter. Resident 29 stated the meal was late and she/he expected food to arrive around noon. On 1/30/26 at 9:01 AM, Staff 27 (CNA) stated residents frequently complained about cold food when served in the residents' rooms and food was often cold from the beginning of service. Staff 27 stated meals were late two to three times each week and there was no effective method to reheat residents' food. Staff 27 stated any lack of staffing impacted the ability for meals to be delivered timely. On 1/30/26 at 12:10 PM, Staff 22 (Regional Dining Director) acknowledged the facility was aware of cold food complaints by residents and sufficient food delivery equipment was required to address the cold food concerns. 3. Resident 57 was admitted to the facility in 4/2025 for muscle wasting and diabetes. The 1/25/26 Quarterly MDS revealed a BIMS score of 14 (cognitively intact) for Resident 57. Resident 57 was on a CCD (controlled carbohydrate diet) regular texture diet. On 1/29/26 at 12:40 PM several lunch meals were observed to be plated without metal warming plates and loaded on to the cart. On 1/29/26 at 12:43 PM the lunch cart was sent out from the kitchen to Sequoia Hall. On 1/29/26 at 1:04 PM Staff 35 (CNA) delivered Resident 57's lunch tray to her/his room. Resident 57 ordered a three-ounce pork chop, Italian pasta salad, tossed salad with dressing and dinner roll. Resident 57 received one pork chop on the plate and tossed salad. The resident stated there was no food warmer under the plate and the pork chop did not feel warm. Resident 57 stated food is often served cold. On 1/29/26 at 1:08 PM Staff 35 stated she went to the kitchen to request the missing items for Resident 57. Staff 35 stated the dietary staff stated the Italian pasta salad and dinner roll had run out. Staff 35 stated residents frequently complained about cold food served in the residents' rooms and the kitchen running out of food. On 1/30/26 at 1:19 PM Staff 1 (Administrator) acknowledged Sequoia Hall had complaints of cold food complaints and food running out.

Based on interview and record review it was determined the facility failed to ensure residents were informed of the risks and benefits of psychotropic medications for 1 of 5 sampled residents (#13) reviewed for unnecessary medications. This placed residents at risk for being uninformed about their medications. Findings include: Resident 13 was admitted to the facility in 7/2025 with diagnoses including right femur fracture and visual hallucinations. Resident 13's 1/2026 Physician Orders indicated the resident was prescribed risperidone for dementia with behaviors ordered on 8/18/25 and trazodone for insomnia ordered on 11/17/25.Resident 13's consent for risperidone was verbally obtained on 9/26/25 and no consent was found for trazadone.A review of Resident 13's 1/2026 MAR revealed the resident received risperidone twice a day and trazadone daily in the evening. On 1/30/26 at 2:10 PM Staff 2 (DNS) acknowledged Resident 13 was not informed of the risks and benefits of the use of risperidone and trazodone prior to use.

Based on interview and record review it was determined the facility failed to have a process in place to ensure resident rights to execute an advance directive, provide follow up and obtain copies for the medical record for 3 of 4 sampled residents (#s 10, 30, 108) reviewed for advance directives. Findings include: The facility's policy and guidelines for Advance Directives dated 3/2023 included the following:- If the resident has not formulated an advance directive, the facility will determine if the resident wishes to formulate an advance directive and provide assistance to the resident in the development of advance directives in accordance with state law. Documentation in the medical record will reflect the discussion of advance directives occurred, that assistance has been offered to the resident, and the resident's acceptance or declination of assistance. - The facility will periodically review the advance directives with the resident and/or the resident's representative. 1. Resident 10 was admitted to facility in 6/2018 with diagnoses including calcific tendinitis of left shoulder (a painful condition caused by calcium deposit buildup within the rotator cuff tendons) and pneumonia. The quarterly MDS with an ARD of 10/31/25, revealed Resident 10 had a BIMS score of 12, which indicated the resident had moderate cognitive impairment. On 1/27/26 at 3:28 PM, Resident 10 stated she/he had an advance directive, and staff did not discuss the details of her/his advance directives with her/him. A review of Resident 10's clinical record revealed on 6/19/18 she/he indicated having an advance directive, but the copy was not on file and there were no subsequent notes to indicate any attempts at obtaining the document. On 1/29/26 at 2:58 PM, Staff 8 (SSD) stated he expected a copy of a resident's advance directive to be on file when a resident indicated to have one. Staff 8 confirmed Resident 10 indicated to have an advance directive, but it was not on file. On 1/30/26 at 3:02 PM, Staff 1 (Administrator) and Staff 2 (DNS) stated it was expected for staff to obtain a copy of a resident's advance directive if the resident indicated to have one. 2. Resident 30 was admitted to the facility in 9/2025 with a diagnosis including heart failure. A 12/17/25 signed Advance Directive Resident Information form revealed Resident 30 had an advance directive. The 1/10/25 revised Care Plan indicated Resident 30 did not have an advance directive. On 1/29/26 at 4:13 PM, Staff 9 (Director of Social Services) acknowledged Resident 30 did have an advance directive and there was no copy on file. Staff 9 stated the resident's care plan was not revised to reflect accurate information about her/his advance directive and a copy of her/his advance directive was not obtained within a week as expected. 3. Resident 108 was admitted to facility 6/2023 with diagnoses including muscle weakness and chronic pain. The quarterly MDS with an ARD of 12/1/25, revealed Resident 108 had a BIMS score of 15, which indicated the resident was cognitively intact. On 1/27/26 at 11:40 AM, Resident 108 stated the facility had not talked to her/him about an advance directive and she/he did not know what an advance directive was. On 1/30/26 at 2:58 PM, Staff 8 (SSD) stated if a resident did not have an advance directive, he expected staff to follow up and educate and offer information to the resident every quarter. Staff 8 confirmed Resident 108 did not have an advance directive and confirmed there were no notes to indicate she/he was educated and offered one. On 1/30/26 at 3:02 PM, Staff 1 (Administrator) and Staff 2 (DNS) stated it was expected for staff to educate, offer and assist residents with an advance directive when residents indicate to not have one.

Based on observation and interview it was determined the facility failed to ensure residents' health information was kept private for 2 of 2 sampled residents (#s 82 and 105). This placed residents at risk for lack of privacy. Findings include: 1. On 1/26/26 at 10:44 AM a treatment cart was observed with a computer screen unlocked. Resident 82's information was visible including her/his code status, allergies, and care to be provided. Staff were not at the cart. On 1/29/26 at 10:51 AM Staff 15 (IP) was observed to lock the computer screen.On 1/29/26 at 10:51 PM Staff 7 (LPN) stated she/he was in charge of the treatment cart, and the computer screen should be locked. On 2/2/26 at 10:08 AM Staff 2 (DNS) stated staff were to lock the computer screens before leaving the cart. 2. On 1/26/26 at 4:10 PM a medication cart computer screen was observed with Resident 105's medication list visible. Staff were not within sight of the cart. Staff 16 (CMA) was observed to exit a resident room. Staff 16 stated the computer screen was to be locked when not in use. Staff 16 stated he was called away from the computer and did not lock the computer screen before leaving the cart. On 2/2/26 at 10:08 AM Staff 2 (DNS) stated staff were to lock the computer screens before leaving the cart.

Based on observation, interview, and record review it was determined the facility failed to ensure resident toilets were repaired timely for 1 of 7 sampled residents (#15) reviewed for environment. This placed residents at risk for an unhomelike environment. Findings include: Resident 115 was admitted to the facility in 3/2025 with a diagnosis of chronic lung disease.Resident 115's Significant Change MDS revealed she/he was cognitively intact. On 1/26/26 at 12:24 PM Resident 115 stated when the toilet flushed at night, it made a really loud noise, and it scared [her/him' to death.On 1/28/26 at 12:10 PM Staff 16 (CNA) stated Resident 115's toilet was very loud when flushed and was loud for approximately two months. Staff 16 stated if equipment needed to be repaired maintenance was notified with an online communication system. On 1/28/26 at 12:12 PM with Staff 6 (Maintenance) Resident 115's toilet was flushed and was heard to make a loud foghorn like noise. Staff 6 stated he was not aware and was not notified by staff that Resident 115's toilet was loud when flushed.

Based on observation, interview and record review it was determined the facility failed to develop and implement comprehensive care plans for 1 of 3 sampled residents (# 92) reviewed for activities. This placed residents at risk for unmet needs. Findings include:Resident 92 was admitted to the facility in 12/2025 with diagnoses including alcohol abuse and encephalopathy (a disease in which the brain is affected by toxins or infection in the blood).Resident 92's 12/16/25 admission MDS indicated Resident 92 was at risk for isolation, depression, and further decline. he MDS further indicated Resident 92 will be referred to activities to avoid isolation.The 1/11/26 revised care plan failed to address Resident 92's preferences, likes, dislikes, and activities to avoid isolation.On 1/26/26 at 3:57 PM Resident 92 stated she/he was not aware of any activities in the facility and would like to participate.On 1/28/26 at 3:19 PM Resident 92 was observed sitting in the hallway alone.On 1/29/26 at 12:30 PM Resident 92 was observed eating lunch in her/his room alone.Random observations from 1/29/26 through 2/2/26 on day and evening shifts revealed Resident 92 sitting in her/his room or walking the halls alone.On 1/26/26 at 10:38 AM Staff 39(CNA) stated the resident did not participate in the facility but did mention she/he would like to try the music exercise. Staff CNA stated she did not know if the resident actually went.On 1/26/26 at 3:57 PM Resident 92 stated she/he was not aware of any activities in the facility and would like to participate.On 1/30/26 at 10:57 AM Staff 42 (LPN) stated she was not aware if Resident 92 participated in the activities provided in the facility but was aware she/he walked around the facility.On 1/30/26 at 1:50 PM Staff 23 (Activities Director) acknowledged the care plan was not comprehensive.On 1/30/26 at 2:04 PM Staff 2(DNS) stated her expectation was for the (RCMs) and Staff to work together to provide preferences and activities for the residents and have a comprehensive care plan to reflect the resident's preferences.

Based on observation, interview and record review it was determined the facility failed to ensure appropriate interdisciplinary team members were present for resident care conferences, failed to ensure care plans were updated to reflect current status, and failed to hold care planning meetings for 3 of 6 sampled residents (#s 5, 30, and 71) reviewed for dentures and care planning. This placed residents at risk for lack of care planning participation and unmet care needs. Findings include: 1. Resident 5 was admitted to the facility in 3/2024 with a diagnosis of heart disease. Resident 5's Care Plan updated on 9/19/25 revealed she/he was at risk for ADL self-care. Interventions included bilateral bed canes for mobility. On 1/27/26 at 3:14 PM Resident 5 was observed in a recliner. Resident 5 did not have a bed in her/his room. On 1/29/26 at 2:53 PM Staff 3 (RNCM) stated Resident 5 did not have a bed for a while, and the care plan was not updated to reflect the changes. On 2/2/26 at 10:08 AM Staff 2 (DNS) stated care plans were to be updated at least quarterly, with a change of condition, and as needed to reflect current care. 2. Resident 30 was admitted to the facility in 9/2025 with diagnoses including heart failure and diabetes. The 9/22/25 and 11/15/25 IDT (Interdisciplinary Team) Care Plan Conference Evaluations revealed Staff 18 (Assistant Social Worker) was present at the meeting, social services needs were addressed with Resident 30, no additional staff were present at the meetings, and no nursing subject matter was documented as discussed. The 1/7/26 Quarterly MDS revealed a BIMS assessment score of 12 (moderate cognitive impairment) for Resident 30. A 1/10/26 Hemoglobin A1c (a laboratory test measuring the average glucose level over three months) Clinical Report revealed Resident 30's diabetes was well controlled. On 1/27/26 at10:28 AM, Resident 30 stated she/he wanted to address concerns regarding heart medication changes and a desire for a Hemoglobin A1c but did not. Resident 30 could not recall any IDT meetings to discuss medical concerns when a nurse was present. Resident 30 stated she/he was not aware of any Hemoglobin A1c results which was necessary to understand changes in her/his diabetic medications. On 1/30/26 9:45 AM, Staff 18 stated invitations for Resident 30's care conferences were not sent out timely to those staff who were to attend her/his meetings. The expectation was for concerns of residents to be addressed at care conference and for team members to attend to address issues and resident questions. On 1/30/26 at 10:08 AM, Staff 19 (Unit Manager-LPN) acknowledged she did not attend the last two care conferences for Resident 30. Staff 19 expected any medical concerns to be addressed and documented during care conferences and communicated to those who could not attend. On 1/30/26 at 10:39 AM, Staff 2 (DNS) stated Unit Mangers and other IDT team members were to attend care conference meetings and, if unavailable, a representative needed to attend the meetings to address the resident's care concerns. 3. Resident 71 was admitted to the facility in 8/2023 with a diagnosis of kidney disease. On 1/27/26 at 9:27 AM Resident 71 stated she did not have dentures and was observed to not have teeth. Resident 71's Care Plan revised on 10/14/25 revealed she/he did not have teeth, and staff were to assist with denture care. On 1/30/26 at 8:36 AM Staff 31 (CNA) stated he never saw Resident 71's dentures. On 1/29/26 at 2:53 PM Staff 3 (RNCM) stated she was not aware Resident 71 did not have dentures and indicated the care plan did not reflect her/his current dental status needs. On 2/2/26 at 10:08 AM Staff 2 (DNS) stated care plans were to be updated at least quarterly, with a change of condition, and as needed to reflect current care.

Based on interview and record review it was determined the facility failed to provide a Restorative program for 1 of 1 sampled resident (#55) reviewed for restorative. This placed residents at risk for increased weakness. Findings include: Resident 55 was admitted to the facility in 9/2024 post joint replacement. Resident 55's Care Plan revised on 9/26/25 revealed she/he had limited mobility, and interventions include a nursing restorative program. The program included walking. Resident 55's 12/22/25 Quarterly MDS revealed she/he was cognitively intact. On 1/26/26 at 11:22 AM Resident 55 stated she/he received exercises and then it suddenly stopped. Resident 55's clinical record did not have documentation to indicate she/he currently received a restorative program or a rationale for discontinuation. On 1/29/26 at 10:29 AM Staff 5 (Director of Rehabilitation) stated Resident 55 was not on the current list of residents who received restorative services. On 1/29/26 at 11:05 AM Staff 33 (Restorative Aide) stated Resident 55 had a respiratory illness and restorative was discontinued. Staff stated she informed the RNCM. On 1/30/26 at 1:39 PM Staff 3 (RNCM) stated Resident 55 had a respiratory illness and Staff removed her/him from services. Staff 3 stated if a resident's restorative program was discontinued there should be a note for the rationale. Staff 3 stated there was no assessment or rationale for the discontinuation of Resident 55's restorative program. On 2/2/26 at 10:08 AM Staff 2 (DNS) stated after therapy develops a restorative program for a resident, it is then nursing driven and the RNCM should be involved with the decisions to discontinue a resident's program.

Based on observation interview and record review it was determined the facility failed to ensure personal hygiene was provided for 1 of 4 sampled residents (#55) reviewed for ADLs. This placed residents at risk for poor hygiene. Findings include: Resident 55 was admitted to the facility in 9/2024 with a diagnosis of joint replacement. Resident 55's 12/22/25 Quarterly MDS revealed she/he was cognitively intact. Resident 55's Care Plan last revised on 9/26/25 revealed she/he had an ADL self-care performance deficit and interventions included she/he was dependent on staff for personal hygiene. On 1/26/26 at 11:17 AM Resident 55 stated she/he needed assistance to shave and preferred to be clean shaven. Resident 55 also stated she/he did not receive many showers. Resident 55 was observed in bed and was not shaved. Resident 55's facial hair was approximately 0.25 inches long. An undated facility shower schedule revealed Resident 55's shower days were scheduled for Tuesday and Thursday mornings. Resident 55's 12/31/25 through 1/21/26 shower documentation and Progress Notes revealed the following:-12/31/25- Resident 55 refused a shower. There was no progress note to indicate nursing communicated with her/him.-1/2/26- Resident 55 was offered two times, and a progress note indicated she/he would accept a shower on another day.-1/3/26 (Saturday) Resident 55 received a shower -1/5/26 (Monday) Resident 55 refused a shower. There was no progress note to indicate nursing communicated with her/him.-1/6/26 Resident 55 refused a shower. There was no progress note to indicate nursing communicated with her/him.-1/7/26- Resident 55 refused a shower on two occasions. There was no progress note to indicate nursing communicated with her/him.-1/9/26 Resident 55 refused a shower on two occasions. There was no progress note to indicate nursing communicated with her/him.-1/14/26 Resident 55 received a shower-1/21/26 Resident 55 refused a shower. There was no progress note to indicate nursing communicated with her/him.Resident 55 received two showers in 30 days. On 1/30/26 at 8:33 AM Staff 34 (CNA) stated if a resident refused a shower, the resident was to be offered assistance two more times that day. If a resident refused a shower after the third offer, the nurse was notified, and the nurse was to communicate with the resident. Staff 34 stated residents were usually shaved on shower days. On 1/30/26 at 8:39 AM Staff 34 (LPN) stated if a resident refused a shower, the CNA was to notify the nurse, and the nurse was to communicate with the resident to offer an alternative shower day and was also to encourage the resident to bathe. On 1/30/26 at 1:39 PM Staff 3 (RNCM) stated Resident 55 often refused showers and her/his shower days were changed. Staff 3 stated Resident 55's care plan did not address her/his shaving preference and acknowledged if staff shaved residents on shower days, Resident 55 would not be shaved often. On 2/2/26 at 10:08 AM Staff 2 (DNS) stated a resident's shower, and shaving preferences were to be determined upon admission. If a resident refused a shower the nurse should find out the reason for the refusal and document in the resident's clinical record. Staff 2 stated she did not see documentation for shower refusals.

Based on observation, interview, and record it was determined the facility failed to provide meaningful activities for dependent residents for 1 of 3 sampled residents (#61) reviewed for activities. This placed residents at risk for lack of social interaction and isolation. Findings include: Resident 61 was admitted to the facility in 11/2025 with diagnoses including dementia, post-traumatic seizures, and anxiety. The 11/11/25 admission MDS indicated a BIMS assessment score of 15 (cognitively intact) and Resident 61 was unable to complete her/his interview for her/his Preferences for Routine and Activities. The MDS indicated staff knew it was important for Resident 61 to participate in religious activities, spend time outdoors and do things with groups of people.A 11/14/25 Care Plan indicated staff were to invite the resident to leisure programs. No information about Resident 61's preferences for activities were identified. The 12/28/25 through 1/27/26 Task: Activity Involvement document revealed Resident 61 was not offered activities during the last 30 days.On 1/27/26 at 9:40 AM, Resident 61 was observed sitting alone on her/his bed in her/his room, the resident indicated no staff interviewed her/him regarding her/his preferences for activities, and the resident was interested in bingo. On 1/28/26 at 11:39 AM, Staff 21 (CNA) stated no information about Resident 61's preferences for activities were in her/his care plan and the resident liked to stay secluded in her/his room.On 1/28/26 at 11:47 AM, Staff 24 (Activity Assistant) stated she was not surprised she did not know Resident 61. Staff 24 revealed she offered books to residents who were on the skilled wing. Staff 24 stated when residents decline books or room activities, we move on.On 01/28/26 at 12:01 PM, Staff 23 (Activity Assistant) stated she interviewed Resident 61 about her/his activities preferences, and the resident was able to answer all the questions. Staff 23 stated she did not complete care plans for activities and was aware she did not correctly complete Resident 61's admission MDS due to lack of training. Staff 23 stated she perceived Resident 61 was anxious during her/his interview, religious and group activities were important to the resident, and acknowledged follow-up with Resident 61 for activities did not occur. Staff 23 expected CNAs to offer activities and communicate when a resident was interested to attend. Staff 23 acknowledged improved communication between CNAs and activity staff was necessary. On 1/29/26 at 3:02 PM, Staff 1 (Administrator) acknowledged training was needed for activity staff. Staff 1 expected correct information about Resident 61's activities and preferences in the MDS, and care plan and activities offered to Resident 61 based on those preferences.

Based on observation, interview, and record review it was determined the facility failed to ensure a resident's smoking paraphernalia was stored securely and failed to ensure a resident was evaluated for safety after a fall for 1 of 3 sampled residents (#71) reviewed for smoking and falls. This placed residents at risk for injury. Findings include.Resident 71 was admitted to the facility in 8/2023 with a diagnosis of paraplegia. Resident 71's 1/2/26 BIMS revealed she/he was cognitively intact.1. A Smoking -Supervised Smokers policy last revised 12/2025 revealed residents who wish to smoke were to be evaluated. Smoking paraphernalia would be managed by nursing staff and made available during smoking times. Resident 71's Care Plan last revised on 12/31/25 revealed she/he was an independent smoker. Interventions included cigarettes and lighters were required to be stored at the nurse's station. On 1/27/26 at 9:32 AM Resident 71 was observed in the smoking area. Resident 71 had a black bag in her/his lap. When Resident 71 opened her/his bag one pack of cigarettes and one lighter was observed. On 1/29/26 8:45 AM Staff 38 (CNA) stated Resident 71 smoked in the morning with other residents. Staff 38 stated Resident 71 was allowed to smoke without supervision. Staff 38 stated Resident 71 kept her/his lighter in her/his black bag. On 1/29/26 at 9:14 AM Staff 3 (RNCM) stated Resident 71 was assessed to be able to smoke independently. Staff 3 was not aware Resident 71 kept her/his lighter and cigarettes in her/his black bag, but stated it was likely the reason she never saw Resident 71 obtain her/his smoking paraphernalia from the nurses station. On 2/2/26 at 10:02 AM Staff 1 (Administrator) stated staff were to monitor residents who smoke. The designated smoking area had locked boxes for residents to store their smoking paraphernalia. Staff 1 stated residents were not always compliant with storing smoking supplies. 2. Resident 71's Power Wheelchair or Scooter Safety Skills Assessment Supplement form revealed she/he was safe to use a power wheelchair. Resident 71's 12/31/25 Unwitnessed Fall investigation revealed she/he fell on [DATE]. Resident 71 was in her/his power wheelchair and reported she/he unbuckled her/his seatbelt prior to the fall. The investigation revealed she/he sustained a brain bleed. Actions taken to prevent further occurrences were to have OT evaluate Resident 71 in her/his chair to see if a different type of chair or adjustments to the current chair were appropriate for her/his safety. Resident 71's 1/7/26 OT Evaluation and Plan of Treatment revealed she/he was referred to OT after a fall from her/his wheelchair after she/he removed the seal belt resulting in a brain bleed and leg fracture. Resident 71 also reported left shoulder pain. The OT assessment evaluated the resident's ability to sit at the edge of the bed. The assessment did not include an evaluation of the wheelchair to see if adaptations could be made for safety. The assessment indicated continued OT services were not needed. Resident 71's 1/7/26 PT Evaluation and Plan of Care revealed she/he was assessed after she/he fell two times after unbuckling her/his seat belt. The first fall resulted in facial fractures and the second fall resulted in a small brain bleed and a left hip fracture. The evaluation indicated resident 71 was not able to use her/his leg for six weeks and no ROM or exercise program was appropriate. The evaluation also indicated Resident 71 had extensive education by staff to use the seatbelt when in the chair. It was determined continued PT services were not indicated. The evaluation did not include an assessment to determine if additional adaptations could be made to Resident 71's power wheelchair for safety. On 1/29/26 at 9:14 AM and at 2:53 PM Staff 3 (RNCM) stated Resident 71 fell two times in 12/2025 because she/he unbuckled her/his seatbelt. After the fall OT was to evaluate the power chair to see if there was anything which could increase her/his safety. On 1/29/26 at 2:31 PM Staff 5 (Director of Rehabilitation) stated in 2025 Resident 71 was evaluated for the use of her/his power wheelchair and was assessed to be safe. Staff 5 stated after the falls therapy evaluated Resident 71, but the order did not indicate it was to evaluate wheelchair safety, and she/he was assessed for physical needs.

Based on observation, interview, and record review it was determined the facility failed to thoroughly assess a resident with trauma for 1 of 2 sampled residents (#61) reviewed for behaviors. This placed residents at risk for re-traumatization. Findings include:Resident 61 was admitted to the facility in 11/2025 with diagnoses including insomnia, post-traumatic seizures, and anxiety. The 11/11/25 admission MDS indicated a BIMS score of 15 (cognitively intact) for Resident 61. The 11/11/25 ACTs My Way assessment indicated Resident 61 was sensitive to loud noises due to military service and Staff 23 (Activity Assistant) conducted the interview.A 11/14/25 Care Plan revealed no information about Resident 61's PTSD (Post Traumatic Stress Disorder) triggers. The 1/2026 Monitors revealed Resident 61 slept from two to 11 hours per day during the month. On 1/27/26 at 10:05 AM, Resident 61 stated she/he had PTSD and no one was aware he/she required a particular environment to sleep well. Resident 61 sat at the side of her/his bed with the television on and stated she/he needed sound in the room with the television on and the drapes tucked against the window to ensure no person was looking in from the outside. Resident 61 stated it was helpful to the resident for staff to know that information in order to feel safe.On 1/27/26 at 4:13 PM, Staff 20 (CNA) stated she was aware Resident 61 was afraid of the dark, needed the shades closed, and she reported the issue to nursing. On 1/28/26 at 12:01 PM, Staff 23 acknowledged Resident 61 was uneasy when she interviewed the resident about her/his PTSD. Staff 23 did not report any concerns to nursing and was unsure how information was communicated to CNAs in order to improve care for Resident 61. On 1/29/26 at 4:13 PM, Staff 9 (Director of Social Services) stated he expected communication from staff when Resident 61 indicated she/he had triggers related to PTSD. Staff 9 acknowledged Resident 61 lacked a thorough assessment and expected interventions in the resident's care plan to ensure the resident felt safe.

Based on observation, interview, and record review it was determined the facility failed to provide dental services for 1 of 3 sampled residents (#5) reviewed for dental. This placed residents at risk for weight loss and unmet dental needs. Findings include: Resident 5 was admitted to the facility in 3/2024 with a diagnosis of diabetes. Resident 5's 3/19/25 health care provider summary revealed Resident 5 was seen for chronic conditions and her/his dental status. The summary indicated Resident 5 requested to see a dentist for possible implants. Resident 5's 1/20/26 NP Wound Note reveals she/he had mild cognitive impairment. Resident 5's 1/27/26 Care Plan revealed she/he did not have teeth, and staff were to refer to a dentist for evaluations. On 1/26/26 at 3:58 PM Resident 5 stated she/he did not have teeth and wanted implants. Resident 5 stated no one spoke to her/him forever regarding dental services. On 1/29/26 at 2:53 PM Staff 3 (RNCM) stated Resident 5 was able to be transported to dental appointments, but she did not see any dental referrals in her/his clinical record.

Based on interview and record review it was determined the facility failed to ensure consents were obtained prior to administering an influenza vaccine to 2 of 5 sampled residents (#s 9 and 62) reviewed for vaccinations. This put residents at risk for not being informed of their rights. Findings include:1. Resident 9 admitted to the facility in 1/2023 with diagnoses including paralysis of the left side following a stroke and diabetes. An 10/23/25 Quarterly MDS indicated Resident 9 was cognitively intact.A review of Resident 9's medical record indicated she/he received an influenza vaccine on 10/2/25. No consent for the influenza vaccine was found in Resident 9's medical record. On 1/29/26 at 2:44 PM, Staff 15 (RN/IP) stated all residents were offered influenza vaccines when they were available, and a consent was signed prior to receiving the vaccine. She verified Resident 9 did not have a signed consent for the influenza vaccine she/he received on 10/2/25.On 2/2/26 at 1:04 PM, Staff 2 (DNS) stated she expected all nursing staff to obtain a signed consent prior to giving any vaccinations. 2. Resident 62 admitted to the facility in 6/2024 with diagnoses including end stage renal disease and paralysis of the left side following a stroke. A 12/21/25 Quarterly MDS indicated Resident 62 was cognitively intact. A review of Resident 62's medical record indicated she/he received an influenza vaccine on 10/7/25. No consent for the influenza vaccine was found in Resident 62's medical record. On 1/29/26 at 2:44 PM, Staff 15 (RN/IP) stated all residents were offered influenza vaccines when they were available, and a consent was signed prior to receiving the vaccine. She verified Resident 62 did not have a signed consent for the influenza vaccine she/he received on 10/7/25.On 2/2/26 at 1:04 PM, Staff 2 (DNS) stated she expected all nursing staff to obtain a signed consent prior to giving any vaccinations.

Based on interview and record review it was determined the facility failed to ensure consents were obtained prior to administering a COVID-19 vaccine to 2 of 5 sampled residents (#s 9 and 62) reviewed for vaccinations. This put residents at risk for not being informed of their rights. Findings include:The facility Infection Prevention & Control COVID-19 Immunization policy with revision date 1/7/25 indicated all residents would be offered the COVID-19 vaccine when available and the resident's medical record would contain documentation of an acceptance or refusal of the vaccine. 1. Resident 9 admitted to the facility in 1/2023 with diagnoses including paralysis of the left side following a stroke and diabetes. An 10/23/25 Quarterly MDS indicated Resident 9 was cognitively intact.A review of Resident 9's medical record indicated she/he received a COVID-19 vaccine on 10/2/25. No consent for the COVID-19 vaccine was found in Resident 9's medical record. On 1/29/26 at 2:44 PM, Staff 15 (RN/IP) stated all residents were offered COVID-19 vaccines when they were available, and a consent was signed prior to receiving the vaccine. She verified Resident 9 did not have a signed consent for the COVID-19 vaccine she/he received on 10/2/25.On 2/2/26 at 1:04 PM, Staff 2 (DNS) stated she expected all nursing staff to obtain a signed consent prior to giving any vaccinations. 2. Resident 62 admitted to the facility in 6/2024 with diagnoses including end stage renal disease and paralysis of the left side following a stroke. A 12/21/25 Quarterly MDS indicated Resident 62 was cognitively intact.A review of Resident 62's medical record indicated she/he received a COVID-19 vaccine on 10/7/25. No consent for the COVID-19 vaccine was found in Resident 62's medical record. On 1/29/26 at 2:44 PM, Staff 15 (RN/IP) stated all residents were offered COVID-19 vaccines when they were available, and a consent was signed prior to receiving the vaccine. She verified Resident 62 did not have a signed consent for the COVID-19 vaccine she/he received on 10/7/25.On 2/2/26 at 1:04 PM, Staff 2 (DNS) stated she expected all nursing staff to obtain a signed consent prior to giving any vaccinations.

Based on interview and record review, it was determined the facility failed to staff a registered nurse (RN) for eight consecutive hours per day seven days per week for 21 out of 78 days reviewed for staffing. This placed residents at risk for unmet assessment needs. Findings include:A review of the facility's Direct Care Staff Daily Reports for 8/2025, 9/2025, 10/2025, and 11/2025 indicated there were 21 days without RN coverage for eight consecutive hours. The dates were as follows: -8/3/25-8/8/25-8/10/25-8/11/25-8/16/25-8/17/25-8/18/25-8/19/25-8/24/25-8/25/25-8/29/25-8/31/25-9/1/25-9/7/25-9/15/25-9/29/25-10/20/25-10/25/25-10/27/25-10/28/25-11/3/25 On 1/15/26 at 9:23 AM, Staff 27 (Staffer) and Staff 23 (LPN) stated they were told to start reporting the RN manager on the Direct Care Staff Daily Report on 1/13/25. On 1/15/26 at 11:52 AM, Staff 1 (Administrator) stated it was the expectation for staff to call off work two hours before their shift to give time for additional staff to be found to cover. Payroll documentation of RN working on the above listed days were requested. No additional documentation was provided.

Based on interview and record review it was determined the facility failed to protect residents' right to be free from physical abuse by staff for 1 of 1 sampled resident (#82) reviewed for abuse. Resident 82 was mistreated by staff resulting in physical injury. Findings include: Resident 82 admitted to the facility in 1/2024 with diagnoses including stroke. A 1/19/24 Admission MDS indicated Resident 82 was moderately impaired with decision making due to aphasia (unable to formulate language). Resident 82 was able to answer yes or no questions and used thumbs up for yes, and thumbs down for no. A 7/24/24 FRI indicated Staff 74 (CNA) showered Resident 82 and bumped the resident's foot on the wall while exiting the shower room. Staff 74 left the hall and left Resident 82 sitting in the shower chair. Staff 75 (CNA) reported the resident's toe was bleeding and no report or communication was given to her. On 9/11/24 at 3:44 PM Staff 34 (LPN) stated Staff 74 was the shower aide on 7/24/24 and gave Resident 82 a shower. Staff 34 stated a staff member did not show up for work and Staff 74 was reassigned to provide direct care to residents. Staff 34 stated Staff 74 became angry, pushed Resident 82's shower chair hard out of the shower room causing the resident's toe to hit the door. Staff 34 stated the toenail was lifted off the toenail bed and was bleeding badly. Staff 34 stated Staff 74 left Resident 82 in the room alone without a call light and did not report to another CNA she was leaving. On 9/11/24 at 4:02 PM Staff 5 (Unit Manager-LPN) and Staff 6 (Unit Manager-LPN) stated Staff 34 reported Staff 74 was pulled from the bath aide position to care for residents, became angry, injured the resident's toe on the shower room door, and left the facility without reporting to another CNA. Staff 5 stated Staff 74 left the resident alone in her/his room in the shower chair without a call light. On 9/11/24 at 4:33 PM Staff 75 (CNA) stated on 7/24/24 she provided showers for residents. Staff 75 stated Staff 74 arrived to help complete showers. Staff 75 stated Staff 74 was told she would be pulled from showers to provide care to residents. Staff 75 stated Staff 74 became angry, walked out of the shower room with Resident 82 still in the shower with the water running and no call light, and started yelling down the hall. Staff 75 stated she came into the hall to see what happened and observed Staff 74 pull the shower chair roughly and hit the resident's toe on the shower room door. Staff 75 stated the resident's toe was bleeding badly. Staff 75 stated Staff 74 pushed the resident into her/his room and left her/him alone with only a towel on and without a call light. On 9/11/24 at 4:38 PM Staff 2 (DNS) stated Staff 74 did not complete a proper hand-off or report to another CNA she was leaving the floor before she left. Staff 2 acknowledged Resident 82's toe was hit on the shower room door as a result of Staff 74's mistreatment of Resident 82.

Based on observation, interview and record review it was determined the facility failed to ensure supervision for dysphagia, execute fall interventions, and execute elopement interventions for 3 of 8 sampled resident (#s 55, 93, and 164) reviewed for accidents. The facility failed to ensure a safe environment for residents on 1 of 1 unit (skilled) identified during random interviews. Resident 164 fell from an elevated bed resulting in fractured legs. Findings include: 1. Resident 55 admitted to the facility in 7/2024 with diagnoses including dysphagia (difficulty in swallowing) and dementia. Review of Resident 55's care plan revised on 7/29/24 revealed the resident had an ADL self-care performance deficit due to decreased mobility and generalized weakness. Interventions included to have Resident 55 in the dining room for meals with supervision. On 9/8/24 at 12:56 PM Resident 55 was observed in the dining room with pureed food on a plate. No staff were observed in the dining room. On 9/10/24 at 12:52 PM Resident 55 was observed in her/his room sitting on her/his bed with the bedside table in front of her/him. Resident 55 had pureed food on her/his plate with approximately half the food eaten. No staff were in the room or observed in the hallway within line of sight. On 9/11/24 at 1:10 PM Resident 55 was observed in her/his room with no staff in the room. Food was on Resident 55's plate with approximately half the food eaten. On 9/13/24 at 8:33 AM Staff 1 (Administrator) Staff 2 (DNS) and Staff 56 (Regional Nurse) stated they expected staff to supervise Resident 55 as care planned. 2. A review of an undated Resident Leaving the Facility policy revealed the following: -Residents who leave the facility are expected to sign out in the sign out book. -Information needed in sign out book: method of contact and expected time of return. -Medications will be provided to the resident or responsible party taking the resident out. -Upon return the resident or responsible party will sign the resident back into the facility. A review of an undated Elopement Preventions Guidelines facility policy revealed the following: -Residents will have a physician order indicating if the resident can leave the facility. The order will indicate if the resident can leave independently or must have supervision. -Each resident who leaves the facility will sign out and sign in upon return. -If employee observes a resident leaving the premises, and the employee does not know if the resident has a physician order allowing the resident to leave independently the employee will stay with the resident and notify another employee to verify the resident has an order. -An employee who intervenes in an elopement attempt will stay with the resident until other staff arrive to assist. -If a resident cannot be located, staff will verify whether the resident was on an authorized leave or pass. -If elopement was suspected the action checklist will be implemented. Resident 93 admitted to the facility in 6/2024 with diagnoses including dementia, stroke, alcohol abuse and seizures. A review of Resident 93's care plan dated 6/10/24 revealed she/he had an ADL self-care performance deficit, a communication problem due to dementia, and an alteration in neurological status due to dementia which required cueing and reorientation as needed. Resident 93 had a seizure disorder and was at risk for injury. The care plan indicated Resident 93 had a history of alcohol abuse and limited physical mobility. The admission MDS with ARD of 6/15/24 revealed Resident 93 had a BIMS score of 15 which indicated the resident was cognitively intact. The cognitive loss CAA indicated Resident 93 had episodes of confusion. Resident 93 was not able to care for herself/himself for quite some time. A review of signed physician orders dated 8/12/24 revealed Resident 93 was approved for therapeutic leave of absence with a responsible person and took prescribed medications. A review of the MAR dated 9/2024 instructed staff to administer hydration of choice four times a day, and on 9/6/24 at 4:00 PM indication Resident 93 was not in facility. A review of 9/6/24 Nursing Notes revealed the following: -10:42 PM Resident 93 was not in the facility all evening shift which was reported to Staff 38 (LPN), and to follow protocol when Resident 96 was considered a missing person. -11:19 PM Resident 93 had not returned to the facility since the morning of 9/6/24. Staff 38 contacted Staff 21 (RN-Staff Coordinator) who was the on-call weekend nurse. Staff 21 instructed to call him again if Resident 93 was not back in the facility by 5:00 AM on 9/7/24. A review of 9/7/24 Nurses Notes revealed the following: -5:12 AM, it was nearly 20 hours since Resident 93 left the facility and she/he did not returned all night. Staff 38 placed another call to Staff 21. Resident 96's emergency contact was called but there was no answer, and then local law enforcement was called on the non-emergent line to report Resident 93 missing. Details of Resident 93's recent alcohol use and volatile behaviors was provided, and law enforcement suggested to call local hospitals. -5:33 AM Local hospitals were contacted, but with no results. -1:02 PM Resident 93 was on alert for behaviors. At approximately 8:00 AM on 9/7/24 local law enforcement arrived to let the facility know Resident 93 was located. Resident 93 was found with a non-functioning power wheelchair.The on-call nurse was alerted and assisted helping the resident back to the building. On 9/8/24 at 4:24 PM Resident 93 stated she/he was lost five miles away from the facility and the police found her/him. Resident 93 stated no one answered when she/he attempted to call. Resident 93 stated she/he was missing overnight, and no staff spoke to her/him about the incident. Resident 93 stated she/he was cold and uncomfortable and she/he missed all her/his treatments. Resident 93 stated she/he did not tell anyone she/he left the facility. Resident 93 felt like no one cared about her/him being missing. A Nursing Facility Reported Incident dated 9/9/24 indicated on 9/6/24 Resident 93 left the faciity on the evening shift around 11:00 PM and she/he did not sign out. The facility LPN called the emergency contact and local law enforcement. Law enforcement was able to find Resident 93 approximately six miles away from the facility in her/his powerchair with a failed battery in the morning on 9/7/24. Observations from 9/10/24 through 9/12/24 revealed Resident 93 in a manual wheelchair in the facility or outside on facility property. On 9/10/24 at 11:03 AM Staff 44 (LPN) stated Resident 93 was missing for 24 hours. At 2:00 PM on 9/6/24 she/he was not in the facility. At 10:00 PM he/she was still not back and typically Resident 93 would be back in the facility. Staff 44 stated Resident 93 was a danger to herself/himself and to other people. Resident 93 had become violent, aggressive and did not listen to rules. Staff 44 stated she did not check if Resident 93 had signed out in the book to notify staff of her/him leaving the facility. Staff 44 stated she was taught after eight to 10 hours of a resident missing the resident would be reported as a missing person. Staff 44 stated there was chaos on her shift and she left the information with the night nurse. On 9/10/24 at 11:21 AM Staff 32 (LPN) stated it was not uncommon for Resident 93 to leave the facility. Resident 93 had dementia and forgot to sign out. On 9/6/24 she/he left the facility around 7:00 AM. Usually if she/he left that early she/he came back around 12:00 PM or 1:00 PM. Staff 32 stated she was not concerned when Resident 93 had not returned to the facility at 2:00 PM and she notified the oncoming nurse. Staff 32 stated when Resident 93 returned to the facility she/he reported she/he had become lost. Staff 32 did not believe Resident 93 was safe to leave the facility. On 9/10/24 at 12:07 PM Staff 38 stated Resident 93 was absolutely not cognitively and physically able to be out in the community on her/his own. When Resident 93 first arrived at the facility Staff 38 took 15 to 20 minutes explaining a document so Resident 93 could understand what she/he was signing. Staff 38 stated when she was completed with her shift on 9/7/24 at 6:00 AM Resident 93 was not back to the facility. On 9/11/24 at 9:06 AM and 9/13/24 at 8:41 AM Staff 1 (Administrator) Staff 2 (DNS) and Staff 56 (Regional Nurse) stated they were working on a discharge plan for Resident 93 and continued to work on the investigation for Resident 93's elopement. Staff 1 confirmed Resident 93 did not sign out of the facility when she/he left on 9/6/24. 26991 3. Resident 164 admitted to the facility 7/2022 with a diagnosis of high blood pressure. According to the National Library of Medicine, a comminuted fracture was a break or splinter of the bone into more than two fragments. Considerable force and energy was required to fragment bone, fractures of this degree occur after high-impact trauma such as vehicle accidents and falling from a high place. Fractures of this type which may happen with low pressure include cancer and weak bones. An 8/6/24 annual MDS revealed Resident 164 was previously assessed and care planned for cognitive loss. Resident 164 was assessed for further loss of vision, physical safety , ie (sic) Falls. A care plan was developed to minimize risks, promote socialization, and prevent falls. Resident 164 had limitations which included the inability to walk due to a femur fracture in 2022, decreased ROM to the shoulders and elbows, muscle weakness, reconditioning and balance abnormalities. Resident 164 had Cognitive: fear of falling and dementia with moderate cognitive impairment deficits. A care plan initiated 7/28/22 revealed Resident 164 was at risk for falls due to deconditioning, balance problems, incontinence, and her/his unawareness of safety needs. Interventions included ensuring Resident 164's commonly used items were within reach, bilateral bed canes, and non-skid footwear. 8/25/24 Progress Notes revealed Staff 18 (LPN) heard a resident scream from room [ROOM NUMBER]. Staff 18 entered the room and found resident 164 falling out of bed, her/his body was out of the bed but both arms were hanging onto the bed canes, and she/he was screaming for help. Resident 164's legs were bent in a kneeling position and the left leg was twisted under the bed side table. A large amount of blood was on the floor from a laceration to Resident 164's left leg (shin). Resident 164 reported severe pain and her/his bed was noted to be in the high position. The note indicated Resident 164's CNA visualized her/him 30 minutes prior to the fall. An 8/25/24 Unwitnessed Fall investigation revealed Resident 164 fell to the floor quite hard landing on both legs. Resident 164 reported she/he attempted to reposition. The investigation indicated the air mattress may have deflated when Resident 164 was close to the edge of the mattress. The air mattress was removed to prevent future slips out of bed. An 8/25/24 hospital New Consult Note Hospital Medicine summary revealed Resident 164 fell out of bed and had fractures of the left and right leg. The right leg fracture was comminuted. The imaging studies were suggestive of pathological fractures (fracture caused by weak bones) and metastatic cancer (cancer which spread). An 8/31/24 hospital Discharge Summary did not include a diagnosis of cancer. An 8/31/24 hospice Admission Visit Summary revealed Resident 164 had a fall from her/his raised hospital bed. An 8/31/24 NSG (nursing) Admission/Readmission Evaluation form revealed Resident 164's reason for admission was a fall from a great height, broke both legs, and was to be admitted to hospice immediately. On 9/10/24 at 4:09 PM Staff 69 (CMA) stated Resident 164 kept her/his bed at least waist high so she/he could see the television better. It was never in the normal low position. Resident 164 was able to adjust her/his bed independently. Staff 68 (CNA) stated on 8/25/24 she was not assigned to Resident 164 when she/he fell . Staff 68 heard yelling and went to Resident 164's room. Staff 18 (LPN) was already in her/his room. Resident 164 reported she/he tried to reposition, her/his legs became stuck in a blanket and she/he fell . Resident 164's bed was high even for her/his normal high. Staff 68 stated when she worked with Resident 164 she tried to encourage her/him to lower the bed because it was always so high up, and propped pillows between the resident and the rail to prevent rolling out of bed. Resident 164 was able to use the bed controls to elevate the bed. The bed should never have been that high. Staff 68 stated Resident 164 did not have mats on the ground even when the bed was in a high position. On 9/10/24 at 8:25 PM Staff 74 (CNA) stated when she arrived on shift at 6:00 AM she observed Resident 164 in bed sleeping. Resident 164 was laying on her/his right side. Staff 18 stated she did not remember the height of Resident 164's bed but she/he liked to elevate the bed. There were no mats on the ground and the call light was activated. On 9/10/24 at 5:02 PM Staff 70 (CNA) stated she worked the day Resident 164 fell . She was in another room at the time and heard a noise and went to Resident 164's room. The nurse and CMA were already in the room. Resident 164 was hanging onto the bed rails and would not let go. eventually Resident 164 was lowered to the floor. Staff 70 stated when she entered the 164's room the bed was at least waist high. Resident 164 liked to have the bed high so she/he could watch television. The resident's bed was at least waist high the dayshe/he fell . Resident 164 was able to adjust the bed, did not have mats on the ground, and had an air mattress. On 9/10/24 at 5:12 PM Staff 71 (CMA) stated at approximately 6:45 AM she administered Resident 164 her/his medicine. Later she heard the nurse call for help. When she entered Resident 164's room the resident was holding onto her/his bed cane and was upright but not standing. Resident 164's legs were contorted and wrapped in a blanket. Resident 164 reported she/he tried to adjust her/his position, her/his legs fell over the side of the bed, and the momentum carried her/him off the bed. Resident 164's bed was pretty high and she/he liked it high so she/he could see the television better. Staff 71 stated she did not recall seeing pillows between the resident and the bed rails. On 9/11/24 at 10:53 AM Staff 5 (LPN Resident Care Manager) stated Resident 164 was at risk for falls and liked to keep her/his bed elevated. The resident had an air mattress. Staff 5 stated the standard of care was to keep the bed in a normal or low position and not high. Staff 5 stated she never reviewed the risks with Resident 164 of keeping her/his bed elevated. After the resident returned from the hospital the bed was care planned to be in a low position and mats on the floor. On 9/13/24 at 1:22 PM Staff 33 (LPN) stated Resident 164 liked to keep her/his bed high and not at a normal height of a bed. After Resident 164 fell staff educated other residents to keep their beds in a low position. Staff 18 stated the resident's bed height was the resident's choice. On 9/13/24 at 1:42 PM Witness 9 (Friend) stated Resident 164's bed was always high. Staff raised the bed to provide care and never lowered it. 50930 4. On 9/11/24 at 12:39 PM Staff 79 (LPN) stated there was an incident in 5/2024 involving Staff 77 (Former NA) who smoked methamphetamine (controlled stimulant medication) in the staff bathroom while working on shift, and continued to finish the shift after it was reported to management. She stated staff reported Staff 77 hallucinated on the unit, and there was a strong chemical smell in the staff bathroom. Review of Staff 77's 5/28/24 time punch record indicated she clocked in at 1:57 PM, clocked out at 5:53 PM, and did not clock in again until 6/1/24. On 9/12/24 at 6:14 PM Staff 78 (CNA) stated she was working evening shift (2:00 PM until 10:00 PM) on 5/28/24 with Staff 77 as her skilled unit hall partner. She stated Staff 77 was missing for a long stretch of time and was later seen walking down the hallway making swiping motions to her head, mumbling to herself, and shaking her head vigorously. Staff 78 stated when asked if Staff 77 was ok, she replied she was trying to get it off, get it off, there are screws in my head. Staff 78 stated she reported to her charge nurse and wrote a statement about the incident and gave it to management. On 9/13/24 at 12:53 PM Staff 1 (Administrator) stated she received a phone call on 5/28/24 about the reported incident. Staff 1 stated she told Staff 77 to go home and suspended her until an investigation was completed. Staff 1 stated it took two days to create an account with a drug testing center, and Staff 77's drug test results were negative on 5/30/24 so she did not do further investigation. Staff 1 acknowledged the complete investigation for this incident was the drug test dated 5/30/24.

1. Based on observation, interview and record review it was determined the facility failed to provide supervision to ensure an environment free of accident hazards for 1 of 7 residents (#10) who smoked. Resident 10 was identified as an independent smoker on 7/19/13 although the resident had a history of [REDACTED]. The resident was observed with an ignition source and extinguished cigarettes were found in a trash can in the resident's room. This placed the resident at risk for immediate jeopardy and constituted substandard quality of care. Findings include: Resident 10 was readmitted to the facility in 2013 with [DIAGNOSES REDACTED]. Review of the facility smoking policy and procedures dated June 2013 revealed an assessment would be conducted upon admission to the facility for any resident who wished to smoke. The assessment would determine if the resident was considered independent, a high risk smoker or the need for supervision while smoking. High risk smokers were those resident who exhibited unsafe clinical, physical or behavioral traits including but not limited to: a. Attempting to hide smoking materials from staff; b. A history of non-compliance with smoking rules; c. Smoking in a resident room or other non-smoking areas; d. Inability to obtain and operate a fire extinguisher; e. Short term memory problems and; f. Use of medications that could cause severe drowsiness. The policy also indicated if a resident was determined to be a high risk smoker, all tobacco products and lighters would be kept at the nurses station and issued only by staff. Review of a Smoking Risk Predictor form dated 7/19/13 revealed the resident had short term memory problems, had a history of [REDACTED]. The assessment concluded the resident was an independent smoker. The form had no answers marked to the questions if the resident was capable of using a fire extinguisher and if the resident used any medications that could cause drowsiness. Review of a care plan updated 8/15/13 revealed the resident was at risk for complications and injury related to tobacco use. The care plan indicated the resident had short term memory loss, a history of non-compliance with smoking rules and cigarettes were to be locked at the nurses station. The care plan revealed the resident was to be checked for cigarettes and lighter after visitors left and monitor the resident's smoking habits, location, safety and storage of smoking supplies. Review of medications for October 2013 revealed the resident was receiving hydromorphone (pain medication) and Fentanyl (pain medication). Both medications had the potential to cause drowsiness. Review of a nurse's note dated 9/21/13 at 9:45 pm revealed the resident was seen going out to the patio off the 30/40s hall (north hall of the ICF/Intermediate Care Facility-this was not a designated smoking area) and pulled a pack of cigarettes out of the resident's pocket. The note indicated the resident was about to smoke. The resident was asked to turn in the cigarette to be locked up per facility policy and the resident refused. The RNCM was informed and the next shift was instructed to keep trying to get the resident to turn in the cigarettes. Review of a progress note dated 9/30/13 revealed Staff 19 (LPN) saw the resident smoking in the hallway between the long term care unit and the skilled unit. Staff 19 escorted the resident outside and informed Staff 15 (DNS). Review of an incident report dated 10/1/13 revealed the resident was found smoking in the hallway and the resident was re-educated on the facility's smoking policy. Review of an investigation report, dated 10/3/13, revealed the resident lit a cigarette in the hallway on the way out of the facility to smoke on 9/30/13. The investigation indicated this was a first time occurrence lighting a cigarette in the building and the resident indicated she/he was not aware this was not allowed. The resident was told by staff she/he could only have a few cigarettes at a time. Observations on 10/2/13 at 9:34 am, the resident exited the facility onto a patio (non-designated area for smoking). The resident was observed removing an orange lighter from her/his coat pocket, lighting a cigarette and smoking until 9:37 am. The resident then deposited the cigarette butt in a porcelain coffee cup which was sitting on a small table, in the corner of the patio. The resident then re-entered the facility and went back into her/his room. The patio contained no ash trays and had no fire extinguisher. Observation on 10/2/13 at 10:48 am the resident's spouse entered the facility with two packs of cigarettes and handed them to the nurse at the nurse's station. Observation on 10/2/13 at 11:00 am revealed three cigarette butts in the resident's trash can next to the resident's bed. The trash can was made of plastic and had a plastic garbage liner. The trash can also contained a wadded up facial tissue and an apple core. The cigarette butts in the trash can were filtered cigarettes similar to the Marlboro brand the resident smoked. Staff 14 was informed of the cigarette butts and removed them from the trash can. In an interview on 10/2/13 at 9:55 am Staff 21 (LPN) said the resident's cigarettes were locked in the medication room behind the nurses station in a locked box. Staff 21 said the resident did not have cigarettes in the box and had been out for a few days. Staff 21 said the designated smoking area was under a gazebo outside on the south side of the long term unit. Staff 21 said the resident was considered an independent smoker and must come to the nurse's station to get cigarettes. Staff 21 said the resident would be given cigarettes and a lighter when she/he left the facility to go to dialysis and staff were to make sure the resident turned in the cigarettes and lighter when the resident returned to the facility. Staff 21 said the resident did not have a lighter on her/him now. In an interview on 10/2/13 at 10:19 am the resident said she/he used the north patio (non-designated smoking area) to smoke out of convenience since the patio is next to his room In an interview on 10/2/13 at 10:39 am Staff 21 indicated staff had taken a lighter away form the resident two days ago and staff did not know where she/he got it. Staff 21 said staff was not checking the resident's room for smoking materials after visitors left the facility. (The resident's care plan indicated the staff were to check the resident's room for smoking materials after visitors left the facility.) In an interview on 10/2/13 at 10:48 am Staff 14 (RNCM) asked the resident to give her the lighter she/he used to light a cigarette and the resident denied having cigarettes and a lighter. The resident told Staff 14 the lighter was obtained outside of the facility. The resident then left the facility with a family member for lunch. In an interview on 10/2/13 at 10:55 Staff 14 indicated the resident was supposed to smoke in the designated smoking area and had a history of [REDACTED]. The resident smoked in the hallway of the facility and cigarettes and lighter were found in her/his room in the past. Staff 14 acknowledged the resident did not follow the facility's smoking policy. In an interview on 10/2/13 at 1:28 pm Staff 21 said the resident returned to the facility and a family member gave the resident's cigarettes and lighter, that the resident used to light a cigarette earlier today, to her. The cigarettes and orange lighter were placed in the resident's box in the medication room. In an interview on 10/2/13 at 2:35 pm Staff 23 (Administrator) and Staff 15 (DNS) were informed Resident 10 lit a cigarette in a non-designated smoking area, had a lighter and cigarette butts were found in the resident's trash can. The immediate jeopardy was abated on 10/2/13 at 4:05 pm when the survey team received the plan of correction. 2. Based on observation and interview it was determined the facility failed to ensure the side rail was secure for 1 of 2 sampled residents (#101) reviewed for accidents. This placed residents at risk for injury. Findings include: Resident 101 was admitted to the facility in 2010 with [DIAGNOSES REDACTED]. On 10/1/13 and 10/4/13 a loose half rail was noted on the left side of the resident's bed. The rail moved approximately two inches inward toward the bed mattress and could be raised approximately two inches higher from its original position on the lower half of side rail. On 10/3/13 at 11:08 am the resident was laying in bed with the side rail up. On 10/7/13 at 3:50 am and 4:42 am Staff 17 (CNA) acknowledged the side rail was loose. Staff 17 stated she previously reported the rail was loose and it was fixed. Staff 17 stated the rail was loose again and she did not report it to maintenance

Based on interview and record review it was determined the facility failed to follow the care plan and use a Hoyer sling appropriately for 1 of 3 sampled residents (#3) who required a Hoyer lift for transfers. This caused Resident 3 to slip out of a Hoyer sling and fall to the floor which resulted in an arm fracture and increased pain. Findings include: Resident 3 was admitted to the facility in 2012 with [DIAGNOSES REDACTED]. Review of an In Room Care Plan dated 12/23/12 revealed the resident was a two person Hoyer transfer and a medium size sling was to be used. Review of a physician's orders [REDACTED]. Review of a NN dated 4/17/13 at 3:08 pm revealed the resident had shown a decrease in the use of morphine for break through pain. Review of a NN dated 4/18/13 at 1:58 pm revealed the resident had "slipped out of Hoyer sling" during a transfer from the resident's bed to a wheelchair. The note indicated the resident complained of severe right shoulder pain. At 6:28 pm an x-ray was completed on the resident's shoulder which showed a displaced right humeral (upper arm) fracture. The note indicated the resident continued to complain of right shoulder pain. Review of an x-ray report dated 4/18/13 revealed the resident had a subtle impaction fracture of the right humeral neck. Review of a written statement dated 4/18/13 Staff 2 (CNA) indicated she had switched the resident's large Hoyer sling for a medium sling to avoid another incident. Review of an incident investigation note dated 4/19/13 indicated the resident had slipped out of the Hoyer sling sideways and Staff 2 had "braced" the resident fall. The note indicated the sling size "may have been too big" and a medium was obtained for better positioning. The investigation concluded the incident was accidental. Review of a physician's orders [REDACTED]. Review of the MAR for April 2013 revealed from 4/1/13 to 4/17/13 the resident received PRN morphine for back, legs and arm pain rated a 6-7 out of 10. The MAR also indicated on 4/18/13 and 4/19/13 the resident's pain was rated a 9 out of 10. In an interview on 5/3/13 at 9:00 am Staff 2 said on 4/18/13 she and another CNA were attempting to transfer the resident from the bed to a wheelchair. Staff 2 indicated she used the Hoyer lift with a large sling to transfer the resident. Staff 2 said she placed the sling under the resident while in bed and attached the sling to the Hoyer lift. Staff 2 said as the resident was lifted up the resident did not appear centered in the sling and the resident slipped out of the sling. Staff 2 said she hugged the resident and both she and resident fell to the floor. In an interview on 5/3/13 at 11:00 am Resident 3 indicated he/she had fallen out of the Hoyer sling during a transfer from bed. The resident indicated staff were using a large sling which was not the right size and was positioned incorrectly in the sling. The resident indicated he/she hit the floor with his/her right shoulder which resulted in a fracture. The resident indicated his/her right shoulder hurts all the time and takes pain medication which does help decrease the pain. In an interview on 5/3/13 at 11:10 am Staff 3 (CMA) said the resident had right shoulder pain prior to the fall but experienced increased pain after the fall. Staff 3 said the resident received an increased dose of morphine to accommodate the increased pain. In an interview on 5/3/13 at 2:05 pm Staff 4 (CNA) indicated she was in the resident's room to assist Staff 2 with a transfer of the resident out of bed. Staff 4 said the resident had slipped out of the Hoyer sling feet first during the transfer and fell to the floor. Staff 4 said the sling straps were not placed in between the resident's legs which would have prevented the resident from slipping out. Staff 4 said the sling might have been to big for the resident.

Based on observation, interview and record review it was determined the facility failed to ensure staff professional standards of practice were followed related to care planned transfer instructions for 1 of 1 sampled resident's (# 1) who had a face forward fall while being improperly transported in a wheelchair. Resident 1 sustained an avoidable fall from a moving wheelchair and experienced pain from facial bruising, swelling and a sprained left wrist. Findings include: Review of the Oregon State Board of Nursing, Authorized Duties and Standards for Certified Nursing Assistants [PHONE NUMBER] revealed, (6) Standards of Care for Certified Assistants. "In the process of client care the CNA shall consistently: (d) Follow the care plan as directed by the licensed nurse." Resident 1 was admitted to the facility in 2011. [DIAGNOSES REDACTED]. The comprehensive care plan dated 11/22/12 indicated a problem area for ADL function. The resident required assistance from staff due to chronic pain and decreased range of motion. One of the approaches instructed staff to review the In Room Care Plan for instructions. The MDS dated [DATE] indicated the resident was cognitively alert and oriented. The resident required extensive assistance from staff for bed mobility, transfers, dressing, hygiene and bathing. The resident was non-ambulatory, had impaired range of motion and was independent with eating. According to the Resident Incident Report, on 10/29/12 at 5:15 pm, the resident was being transported in her/his wheelchair. The wheelchair did not have foot pedals, the resident was unable to continue to hold her/his feet up, with feet falling down the wheelchair suddenly stopped and the resident fell forward onto the floor. Resident 1 sustained a 5.5 cm bump to the forehead. The IRCP intervention to always have foot-rests on Resident 1's wheelchair at all times was added 10/29/12. According to the Resident Incident Report, on 12/7/12 at 4:30 pm, Resident 1 was in her/his wheelchair "being pushed to the dining room, resident caught toe on the floor and fell forward from the wheelchair and hit head on the floor, hoyer lift back to wheelchair." The CNA's (Staff 4) statement indicated "I was taking the resident to dinner without foot rests at the resident's request, when (she/he) dropped her/his feet and went flying forward in front of room [ROOM NUMBER]." The Nurse's notes dated 12/7/12 at 4:30 pm, indicated the resident fell forward out of wheelchair "caught foot on the floor" and sustained a 7 cm by 6.5 cm hematoma on her/his forehead, no change of consciousness, neuro checks done every four hours, medicated for pain, family and physician were notified. The Nurse's notes of 12/8/12 at 10:58 am, indicated both of the resident's eyes were turning black and blue. The Nurse's notes of 12/10/12 at 11:56 am, indicated the resident was experiencing facial twitching. The doctor was called and an order was received for a facial Xray. Review of the MAR for December 2012 indicated prn usage of [MEDICATION NAME] and Tylenol on 12/7/12 through 12/10/12, for pain due to injuries from the fall. On 12/11/12 the Xray report indicated there was a "possible chip on the mandible." An order was received for a facial CT scan and a tilt back wheelchair with foot rests. The results of the facial CT scan were received during the evening shift of 12/12/12. The physician reviewed the findings and documented "no fracture noted." The 12/12/12 RNCM incident follow-up report indicated during the RNCM's interview with Resident 1, the resident stated she/he did not have time to tell the CNA to put the foot rests down because "he was moving (the wheelchair) too fast." "My foot touched down and I fell forward." The RNCM (Staff 3) noted the care plan had been changed in October 2012 to indicate the need for use of foot rests on the IRCP and staff training was done. Staff 3 indicated the resident's IRCP was in the resident's closet and a copy was in a notebook at the nurse's station. Staff 3 indicated Staff 4 stated the foot rests were not in place at the time of the incident and he was not aware the resident needed foot rests. Staff 3 asked Staff 4 if he had looked at the resident's IRCP, he responded "not recently." During an interview on 12/12/12 at 2:00 pm, Resident 1 stated she/he was going to the dining room and Staff 4 was "going fast and rushing." Resident 1 stated her/his feet were down and no foot pedals were on the wheelchair "they were either off or turned outside of the chair." Resident 1 stated when her/his feet touched the ground the chair came to a sudden stop and she/he flipped out of the wheelchair onto her/his face and forehead. Resident 1 was observed to have a large "goose-egg" on her/his forehead, two black eyes and holding a sore wrist (determined to be sprained). Resident 1 stated she/he can no longer hold her/his legs up due to weakness and now used the foot pedals when in a wheelchair. Resident 1 stated she/he was upset because she/he had a similar fall and this one did not have to happen. On 12/12/12 at 2:20 pm, Staff 3 (RNCM) stated the resident had a similar fall on 10/29/12 where she/he fell because the foot pedals were not on the wheelchair. Staff 3 stated she put the new intervention onto the IRCP to always use the foot pedals when transporting the resident because the resident was no longer strong enough to hold up her/his feet due to [MEDICAL CONDITION] and the need for constant oxygen. Staff 3 stated she talked with all the staff about the importance of this intervention and the staff voiced their understanding. Staff 3 stated Staff 4 was present for the inservice. Staff 3 stated the resident denied she/he told the CNA not to use the foot pedals. Staff 3 stated Staff 4 did not follow the resident's care plan. On 12/12/12 at 2:35 pm, Staff 4 (CNA) stated he had toileted Resident 1 before taking her/him to the dining room for dinner. Staff 4 stated the foot pedals were attached but were in the up position and the resident wanted to hold her/his feet up. Staff 4 stated the care plan was not in the holder in the resident's room at that time, "not until yesterday." Staff 4 was asked, during interview, if he looked at the copy in the notebook at the nurse's station, Staff 4 did not answer. According to the medical record on 12/12/12, during the evening shift, the resident had an Xray taken of her/his left wrist due to pain. The results indicated a sprain and the physician ordered a splint to be worn. Refer to F-323.

Based on observation, interview and record review it was determined the facility failed to provide a safe environment for 1 of 1 sampled resident's (# 1) who had a face forward fall while being improperly transported in a wheelchair. Resident 1 sustained an avoidable fall from a moving wheelchair and experienced pain from facial bruising, swelling and a sprained left wrist. Findings include: Resident 1 was admitted to the facility in 2011. [DIAGNOSES REDACTED]. The In Room Care Plan (IRCP) up-dated on 10/29/12 indicated a new intervention had been initiated to make sure Resident 1 had foot pedals on her/his wheelchair at all times. The dated intervention was circled in yellow. The resident used a mechanical lift for transfers. The comprehensive care plan dated 11/22/12 indicated a problem area for ADL function. The resident required assistance from staff due to chronic pain and decreased range of motion. One of the approaches instructed staff to review the In Room Care Plan for instructions. The MDS dated [DATE] indicated the resident was cognitively alert and oriented. The resident required extensive assistance from staff for bed mobility, transfers, dressing, hygiene and bathing. The resident was non-ambulatory, had impaired range of motion and was independent with eating. According to the Resident Incident Report dated 10/29/12 at 5:15 pm, the resident was being transported in her/his wheelchair. The wheelchair did not have foot pedals, the resident was unable to continue to hold her/his feet up, with feet falling down the wheelchair suddenly stopped and the resident fell forward onto the floor. Resident 1 sustained a 5.5 cm bump to the forehead. The IRCP intervention to always have foot-rests on Resident 1's wheelchair was added 10/29/12. The Resident Incident Report dated 12/7/12 at 4:30 pm, indicated Resident 1 was in her/his wheelchair "being pushed to the dining room, resident caught toe on the floor and fell forward from the wheelchair and hit head on the floor, hoyer lift back to wheelchair." The CNA's ( Staff 4) statement indicated "I was taking the resident to dinner without foot rests at the resident's request, when (she/he) dropped her/his feet and went flying forward in front of room 26." The Nurse's notes dated 12/7/12 at 4:30 pm, indicated the resident fell forward out of wheelchair "caught foot on the floor" and sustained a 7 cm by 6.5 cm hematoma on her/his forehead, no change of consciousness, neuro checks done every four hours, medicated for pain, family and physician were notified. The nurse's notes of 12/8/12 at 10:58 am, indicated both of the resident's eyes were turning black and blue. The nurse's notes of 12/10/12 at 11:56 am, indicated the resident was experiencing facial twitching. The doctor was called and an order was received for a facial Xray. An Xray was taken of the resident's face at the facility by an outside mobile Xray company. The facial Xray report dated 12/10/12 indicated there was a "recent chip fracture suggested on anterior mandible, advise further evaluation-consider CT of facial bones." Review of the December 2012 MAR indicated prn usage of oxycodone and Tylenol on 12/7/12 through 12/10/12 for pain due to injuries from the fall. On 12/11/12 an order was received for a facial CT scan (due to a possible jaw fracture) and a tilt back wheelchair with foot rests. The 12/12/12 RNCM incident follow-up report indicated during the RNCM's interview with Resident 1, the resident stated she/he did not have time to tell the CNA to put the foot rests down because "he was moving (the wheelchair) too fast." "My foot touched down and I fell forward." The RNCM (Staff 3) noted the care plan had been changed in October 2012 to indicate the need for use of foot rests on the IRCP and staff training was done. Staff 3 indicated the resident's IRCP was in the resident's closet and a copy was in a notebook at the nurse's desk. Staff 3 indicated Staff 4 stated the foot rests were not in place at the time of the incident and he was not aware the resident needed foot rests. Staff 3 asked Staff 4 if he had looked at the resident's IRCP, he responded "not recently." During an interview on 12/12/12 at 2:00 pm, Resident 1 stated she/he was going to the dining room and Staff 4 was "going fast and rushing." Resident 1 stated her/his feet were down and no foot pedals were on the wheelchair "they were either off or turned outside of the chair." Resident 1 stated when her/his feet touched the ground the chair came to a sudden stop and she/he flipped out of the wheelchair onto her/his face and forehead. Resident 1 was observed to have a large "goose-egg" on her/his forehead, two black eyes and a sore wrist (determined to be sprained). Resident 1 stated she/he can no longer hold her/his legs up due to weakness and now used the foot pedals when in a wheelchair due to a similar fall. Resident 1 was waiting for transportation to have the CT scan done on that day. The resident stated she/he was upset because she/he had a similar fall and this one did not have to happen. On 12/12/12 at 2:20 pm, Staff 3 (RNCM) stated the resident had a similar fall on 10/29/12 where she/he fell because the foot pedals were not on the wheelchair. Staff 3 stated she put the new intervention onto the IRCP to always use the foot pedals when transporting the resident because the resident was no longer strong enough to hold up her/his feet due to CHF and the need for constant oxygen. Staff 3 stated she talked with all the staff about the importance of this intervention and the staff voiced their understanding. Staff 3 stated Staff 4 was present for the inservice. Staff 3 stated the resident denied she/he told the CNA not to use the foot pedals. Staff 3 stated Staff 4 did not follow the resident's care plan. On 12/12/12 at 2:35 pm, Staff 4 (CNA) stated he had toileted Resident 1 before taking her/him to the dining room for dinner. Staff 4 stated the foot pedals were attached but were in the up position and the resident wanted to hold her/his feet up. Staff 4 stated the care plan was not in the holder in the resident's room at that time, "not until yesterday." Staff 4 was asked, during interview, if he looked at the copy in the notebook at the nurse's station, Staff 4 did not answer. On 12/12/12 at 3:10 pm, Staff 5 (CMA) stated all residents had an IRCP in their room in the closet. Staff 5 stated there was also a copy in a notebook on the counter of the nurse's station. Staff 5 stated if the resident was new and the nurse was not sure how a resident was transferred/transported he would go directly to the therapy department. On 12/12/12 at 3:25 pm, Staff 6 (RN) stated Resident 1 complained of increased pain after the accident on 12/7/12. Staff 6 stated the resident received routine pain medication for chronic pain and had prn Tylenol or oxycodone for breakthrough pain. Staff 6 stated he assisted with Resident 1 after the fall occurred and medicated the resident for breakthrough pain due to injuries from the fall. Staff 6 confirmed the resident had a care plan in the closet in her/his room and a copy was at the desk. On 12/12/12 at 3: 30 pm, Staff 3 (RNCM) confirmed during interview that Resident 1 had an increase use of prn pain medication after the fall of 12/7/12. The prn medication had not been used prior to the fall according to the December 2012 MAR. On 12/12/12 at 3:45 pm, Staff 7 (CNA) stated he knew there were IRCPs in all resident rooms as well as in the notebook at the nurse's desk. According to the medical record on 12/12/12, during the evening shift, the resident had an Xray taken of her/his left wrist due to pain. The results indicated a sprain and the physician ordered a splint to be worn. On 12/13/12 at 9:48 am, Staff 8 (Graduate Nursing Assistant, GNA) stated she knew Resident 1 used the foot pedals "all the time." On 12/13/12 at 9:55 am, Staff 10 (CNA) stated the resident was care planned for using foot pedals and used them all the time. Staff 10 stated she never had Resident 1 refuse to use the foot pedals. On 12/13/12 at 10:00 am, Staff 11 (LPN) stated the resident was care planned to use foot pedals since the fall in October 2012. Staff 11 stated she never had a CNA come to her and say the resident did not want to use her/his foot pedals. On 12/13/12 at 10:05 am, Resident 1 confirmed during interview she/he was seen by her physician and a portable Xray was taken of her/his left wrist. The physician stated the wrist was sprained and a splint was ordered. The physician stated the CT scan confirmed there was no fracture of the jaw. Resident 1 stated the wrist was painful and also pointed to her/his forehead (where the lump was located) and stated her/his head hurt. On 12/13/12 the findings of the facial CT scan were reviewed. The resident's physician signed the results and wrote "noted, no fracture."

1. Based on interview and record review it was determined that the facility failed to assess for pain for 1 of 2 sampled residents (#265) who fell at the facility. The lack of nursing assessment lead to uncontrolled pain and a delay of hospitalization for a [MEDICAL CONDITION]. Findings include: Resident 265 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Nurses' notes dated 8/17/10 at 6:05 pm documented Resident 265 was found sitting upright on the floor of her room. The resident denied hitting her/his head and no red or open areas were noted. The resident stated that s/he was trying go to the commode and that s/he used the call light. The resident's walker was not found near her/him and the call light was not on when the staff found her/him on the floor. The staff assisted the resident to the commode and then assisted her/him back to bed. The resident was noted to be slightly confused and had a delay in "processing information." The facility notified the physician by fax of the fall. An interdisciplinary team note dated 8/17/10 documented that at the time of the incident Staff 25 (LPN) performed passive range of motion on the resident who had no pain at the time. The resident was assisted up to the commode with two staff members using a gait belt. The resident was noted to bear weight on her/his right leg, pivot transfer, and to "swing legs into bed and adjust self." The resident denied pain or discomfort and "no facial grimace noted." Resident 265's August 2010 MAR indicated [REDACTED]. At 12:20 am the medication was identified on the MAR indicated [REDACTED]. The MAR indicated Not gone but better". A NN dated 8/18/10 at 4:00 am revealed the resident had been "very painful this shift. unable to relieve completely.... pain in right inner thigh." The resident stated that the pain was due to a fall the day before. The NN indicated nursing staff would "continue to assess." There was no documented physical assessment of the resident's right hip/leg status. On 8/18/10 at 4:30 am the MAR indicated severe right inner leg pain." There was no effectiveness of the medication recorded. At 8:30 am the MAR indicated [REDACTED]. The 8/18/10 9:45 am NN revealed the resident complained of right hip pain, the facility sent a fax to Family Nurse Practitioner (FNP). On 8/18/10 at 4:00 pm the resident was examined by the FNP. The FNP documented the resident had "right hip, pelvis, and thigh pain", her/his right leg was externally rotated and s/he was unable to move or bend her/his leg. The FNP gave the facility orders to send the resident to the hospital for evaluation of right hip/pelvis. On 4/5/12 at 2:00 pm Staff 1, DNS and Staff 26 (Corporate RN ) agreed the lack of timely assessment resulted in delay of hospitalization . 2. Based on interview and record review it was determined the facility failed to ensure that physician orders [REDACTED]. This put the resident at risk of receiving improper care. Resident 266 was hospitalized with pneumonia, had staples that had not been removed and an increase in the stage of the pressure ulcers. Findings include: a. Resident 266 was admitted to the facility in September 2011 with [DIAGNOSES REDACTED]. The facility's Daily Skilled Nurse's Notes dated 9/14/11 from the day shift noted, "lung sounds w/crackles throughout, pt able to cough up phlegm." The note indicated the resident received oxygen at 2 liters/minute. According to a physician's orders [REDACTED]." There was no evidence in the record that the "now" dose had been given. The resident's 2011 September MAR indicated [REDACTED] According to facility records Resident 266 was seen and assessed by a Family Nurse Practitioner (FNP) on 9/15/11. The FNP's note indicated the resident had "crackles in her/his bilateral lungs." A nurse's note dated 9/15/11 at 10:45 am indicated the resident was experiencing shortness of breath with increased congestion. According to that nurse's note the resident was transported to a local emergency room via ambulance at 11:00 am for evaluation. The resident was admitted to the hospital. A chest x-ray dated 9/15/11 indicated the resident had "extensive left upper lobe infiltrate (pneumonia)." On 4/5/12 at 1:45 pm Staff 11 (RNCM) confirmed the [MEDICATION NAME] was not available and the resident should have been sent to the hospital. b. The facility's Initial Data Collection form dated 9/3/11 indicated Resident 266 was admitted with multiple staples in the three incisions in her/his bilateral thighs. Resident 266 was not in the facility long enough to have a completed comprehensive assessment. On admission to the facility, physician orders [REDACTED]. The staples should have been removed on 9/6/11. The order to remove the staples was not transcribed onto the TAR. According to a progress note dated 9/15/11 Resident 266 was seen and assessed by a Family Nurse Practitioner (FNP) on 9/15/11. The FNP's note indicated the resident's incisions were clean and dry and had staples in place. On 4/5/12 at 1:45 pm, Staff 11 (RNCM) reviewed the resident's chart and agreed there were orders to remove the staples. The staples were not removed while Resident 266 was in facility. c. According to the facility's Initial Data Collection form dated 9/3/11 Resident 266 had three stage two pressure ulcers on her/his coccyx. The resident's admission orders [MEDICATION NAME] to cleft of buttocks bid & prn for incontinence." There was no evidence in the record that this order had been transcribed onto the TAR. According to the facility's Skin Care Progress Sheet the ulcers on the coccyx were measured on 9/3/11 and 9/10/11. The assessments described the ulcers as red with a pink open area in the middle. The 9/11 TAR indicated that [MEDICATION NAME] once per shift" was started on 9/12/11. According to a hospital clinic encounter form dated 9/15/11, Resident 266 had three Stage 3 pressure ulcers on her/his left buttock. On 4/5/12 at 1:45 pm Staff 11 (RNCM) reviewed the record and agreed that the treatment for [REDACTED].

Based on observations, interviews and record review it was determined the facility failed to provide an appropriate assistive device to prevent a resident fall resulting in a leg fracture for 1 of 4 sampled residents (#1). Findings include: Resident 1 was admitted to the facility in 2011 with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Review of an Assessment Of Risk For Falls form dated 2/9/11 revealed the resident was at high risk for falls due to cognitive status, decreased mobility, maximum assistance needed for transfers, blindness and incontinence. Review of the comprehensive care plan dated 2/14/11 revealed no documentation the resident was a fall risk and fall interventions used by staff to reduce the potential for falls. Review of a Care Area Assessment (CAA) dated 2/21/11 revealed the resident was at risk for falls due to antidepressant medication use, incontinence, visual impairment and pain. The assessment indicated the resident had not attempted self transfers from the bed or wheelchair and had no falls. Review of the In Room Care Plan dated 2/22/11 revealed the resident used a wheelchair with leg rests and foot pedals for ambulation. The care plan did not indicate the resident was at risk for falls and safety interventions included a low bed, bed against the wall and bed canes. Review of a NN dated 2/26/11 at 4:15 pm revealed the resident had left the facility for dialysis via a local medical transport company. At 5:45 pm the facility received a call from a local hospital, the resident had arrived at dialysis, slipped out of a wheelchair and complained of right leg pain. At 9:00 pm the facility received a call from a local hospital the resident was treated for [REDACTED]. Review of a hospital x-ray report dated 2/26/11 revealed the resident was diagnosed with [REDACTED]. Review of a phone note from the local medical transport company dated 2/17/11 revealed Staff 10 (RN) was contacted at the facility and the resident "on more than one occasion cl (client) has or is at risk of sliding out of (her/his) wheelchair on return from dialysis." The medical transport company was informed by Staff 10 the facility would call on 2/18/11 and "discuss safety concerns and solutions." No documentation could be located the facility had contacted the local medical transport company on 2/18/11 regarding the resident's safety concerns. Review of a phone note from the local medical transport company dated 2/24/11 revealed Staff 11 (Social Services) was contacted at the facility and the resident had "behavior and safety issues multiple times cl (client) slipping out of wheelchair." The note indicated Staff 11 would "research different chair and will ensure snug lap belt in the mean time." Observations on 3/21/11 at 8:30 am revealed the resident had two wheelchairs in the resident's room. One wheelchair was a tilt-in space chair with a seatbelt and the other wheelchair had no seatbelt. In an interview on 3/21/11 at 8:30 am the resident indicated having a fall from the wheelchair on the way into the dialysis center. The resident did not remember what day the fall occurred and said the fall did not happen at the facility. In an interview on 3/21/11 at 9:45 am Staff 2 (CNA) said the resident had two wheelchairs and no longer used the wheelchair without the seatbelt. Staff 2 said the resident went to dialysis three times a week on Tuesday, Thursday and Saturday and now used the tilt-in-space wheelchair with the seatbelt. In an interview on 3/21/11 at 10:15 am Staff 4 (CNA) said the resident used the wheelchair without a seatbelt prior to the resident's fall on 2/26/11 and now used the tilt-in-space wheelchair with a seatbelt. In an interview on 3/21/11 at 12:50 pm Staff 6 (RNCM) said the resident was admitted with a personal wheelchair which did not have a seatbelt. Staff 6 said on 2/26/11 the resident went to dialysis in the personal wheelchair. In an interview on 3/22/11 at 9:22 am Witness 1 (Operations Manager for the local medical transport company) said the resident was transported from the facility to dialysis on 2/10/11, 2/12/11, 2/15/11, 2/17/11, 2/19/11, 2/22/11 and 2/26/11. Witness 1 said the resident had slipped out of the wheelchair during transport into the dialysis center on 2/26/11. Witness 1 said the driver's report any problems with resident transport to a manager and the facility would be contacted regarding the issue. In a interview on 3/23/11 at 12:20 pm Staff 6 (RNCM) stated she was not notified by facility staff the resident was having problems slipping out of the wheelchair during transport to dialysis. Staff 6 said the local medical transport company had requested the resident have a seatbelt on the wheelchair after the resident fell on [DATE]. In an interview on 3/23/11 at 2:45 pm Witness 3 (Manager at the local medical transport company) indicated the facility was contact on 2/17/11 and 2/24/11 regarding the resident slipping in the wheelchair during transport to dialysis. In an interview on 3/24/11 at 7:45 am Staff 12 (Restorative Aid) said the resident started using the wheelchair with a seatbelt two to three days after the resident fell . In interviews on 3/24/11 at 10:20 am Staff 11 (Social Services) said the local medical transport company had contacted her prior to the resident's fall regarding the resident slipping in the wheelchair and the local medical transport company had requested the facility use a wheelchair with a seatbelt. Staff 11 indicated there was no documentation of the phone conversation with the local medical transport company and indicated she had told Staff 6 about the issue. Staff 6 (RNCM) said the local medical transport company had not contacted her and was not aware of any problems with the resident slipping in the wheelchair prior to 2/24/11. In an interview on 3/24/11 at 11:38 am Staff 10 (RN) said the local medical transport company had contacted him at least two weeks prior to the resident's fall. Staff 10 said there was no documentation he spoke with the local medical transport company and indicated Staff 6 was notified the resident was having a problem slipping out of the wheelchair.

Based on observation, interview and record review it was determined the facility failed to provide cares within the scope of practice for 1 of 1 sampled residents (#3) by implementing an intervention of Barco boots without a physician's order or evaluation. Resident 3 experienced multiple Stage 2 pressure ulcers from the Barco boots. Findings include: Oregon State Board of Nursing, Nurse Practice Act, [PHONE NUMBER] Conduct Derogatory to the Standards of Nursing Defined (1) (a) Developing, modifying, or implementing standards of nursing practice/care which jeopardize patient safety and (4) (a) Performing acts beyond the authorized scope of the level of nursing for which the individual is licensed. Resident 3 was readmitted to the facility in 2008 with [DIAGNOSES REDACTED]. It causes weakness and atrophy, or wasting, of the muscles with paralysis of voluntary movements and eventual death.) The Quarterly Review/Summary dated 7/21/10 indicated the resident had advanced ALS and was dependent on staff for all ADLs, transfers and mobility. The resident's body was "rigid throughout." Untimed NN of 10/4/10 indicated "Blisters intact to bilat (bilateral) heels. Appear to be resolving." A fax dated 10/4/10 at 11:45 am indicated the resident "had foot support boots last month. Boots have been D/c (discontinued) et (and) heels are floated to promote resolution of blisters." Departmental Notes dated 10/4/10 at 12:02 pm indicated the resident "had Barco boots (an orthopedic foot support that held the foot at a neutral position or right angle) applied to provide support for his feet. On 9-28-2010 it was noted that both of his heels had intact blisters on them. At that time the nurse removed the boots and floated the heels. Blisters appear to be due to the boots." Review of the clinical record revealed no physician's order to evaluate for foot support, no order to treat for foot support, no order for Barco boots and no order to discontinue the Barco boots. Following the NN dated 10/4/10 of the bilateral blisters to the resident's heels, there were no additional NN regarding the resident's pressure ulcers. The Problem Focused Visit Note dated 10/6/10 written by Witness 1 (FNP/Family Nurse Practitioner) indicated the resident had "3 cm blisters bilateral heels. 2nd and 3rd pedal digits (toes) of left foot with 0.5 x 0.5 cm stage 2 decubes (pressure ulcers)." A Stage 2 pressure ulcer is a partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue). It may also present as an intact or open/ruptured blister. In an interview on 10/19/10 at 12:15 pm Staff 3 (RNCM) stated the pressure ulcers on the resident's heels came from the Barco boots. Staff 3 was unaware of the Stage 2 pressure ulcers on the resident's toes. Observation on 10/19/10 at 12:20 pm revealed Staff 3 assessed the resident's feet. The resident had bilateral plantar flexion contractions (downward pointing toes). Staff 3 noted the resident had bilateral heel ulcers, pressure areas on two toes of the left foot and five areas of non-intact skin on the right foot. In an interview on 10/20/10 at 10:45 am Staff 3 stated Staff 8 (RNCM) suggested the Barco boots for the resident. In an interview on 10/20/10 at 11:52 am Staff 8 (RNCM) stated she asked the PT for Barco boots for the resident but the PT did not evaluate the resident. Staff 8 stated the resident wore the boots for approximately two and a half days. In an interview on 10/20/10 at 2:15 pm Staff 11 (PT) stated he had not evaluated the resident for Barco boots. When asked if Barco boots would be appropriate for a resident with plantar flexion contractions, Staff 11 replied, "Probably not." In an interview on 10/20/10 at 2:30 pm Witness 1 (FNP) stated she had not ordered the Barco boots. Witness 1 stated the Barco boots were the start of the resident's foot problems and added the resident was "very rigid and I don't think they would be appropriate." Refer to F 314 regarding the resident's pressure ulcers.

Based on observation, interview and record review it was determined the facility failed to prevent pressure ulcers for 1 of 4 sampled residents (#3) with pressure ulcers. Resident 3 developed multiple, avoidable Stage 2 pressure ulcers. Findings include: Resident 3 was readmitted to the facility in 2008 with [DIAGNOSES REDACTED]. It causes weakness and atrophy, or wasting, of the muscles with paralysis of voluntary movements and eventual death.) The Pressure Ulcer RAP dated 4/14/10 indicated the resident had "no skin issues at this time." The comprehensive Care Plan reviewed and updated 7/20/10 indicated the resident was at risk for skin breakdown due to ALS and decreased mobility. Planned interventions included a pressure relieving mattress, nutrition and skin risk assessments as needed and skin checks with bathing. The In Room Care Plan initially dated 7/20/10 revealed an undated, unsigned addition of "Barco foot support when in bed." The addition was crossed off and marked "d/c" or discontinue. An unsigned addition dated 10/4/10 indicated staff were to "float heels." The Quarterly Review/Summary dated 7/21/10 indicated the resident had advanced ALS and was dependent on staff for all ADLs, transfers and mobility. The resident's body was "rigid throughout." The resident "has not had any pressure sore areas this past quarter." A Visit Note dated 9/1/10, written by Witness 1 (FNP/Family Nurse Practitioner) indicated the resident's skin was "intact with no evidence of rashes, bruises, breakdown or abrasions." The facility Skin Policy and Procedure dated 11/20/09 indicated when skin breakdown occurred the licensed nurse was to: examine the wound, get treatment orders from the physician, notify the family and physician, make out a Skin Care Progress Worksheet, place the resident on 24 hour report and initiate and complete an incident report. The RNCM was to assess and investigate the cause of the breakdown, determine interventions needed, change the care plan and implement interventions. Additionally, the RNCM was to notify the DNS, Administrator and Registered Dietitian. The October 2010 Physician order [REDACTED]. The first was for "Moisturizer to bilateral feet qd" and the second was to "Monitor for breakdown (of the skin) qd." The October 2010 TAR indicated neither order was signed as implemented from 10/1/10 through 10/18/10. Untimed NN of 10/4/10 indicated "Blisters intact to bilat (bilateral) heels. Appear to be resolving." A fax dated 10/4/10 at 11:45 am indicated the resident "had foot support boots last month. Boots have been D/c (discontinued) et (and) heels are floated to promote resolution of blisters." Departmental Notes dated 10/4/10 at 12:02 pm indicated the resident "had Barco boots (an orthopedic foot support that held the foot at a neutral position or right angle) applied to provide support for his feet. On 9-28-2010 it was noted that both of his heels had intact blisters on them. At that time the nurse removed the boots and floated the heels. Blisters appear to be due to the boots." An entry on the October 2010 TAR, dated 10/4/10, indicated staff were to "Monitor blisters on bilat (bilateral) heels until resolved" to be done on each shift. The order was signed as completed on 40 of 43 shifts. An order dated 10/13/10 indicated the right heel was to be dressed with [MEDICATION NAME] Thin, a dressing that was absorbent but kept the wound moist, that was to be changed every 5 days. The Problem Focused Visit Note dated 10/6/10 written by Witness 1 (FNP) indicated the resident had "3 cm blisters bilateral heels. 2nd and 3rd pedal digits (toes) of left foot with 0.5 x 0.5 cm stage 2 decubes (pressure ulcers)." A Stage 2 pressure ulcer is a partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue). It may also present as an intact or open/ruptured blister. The plan was to "Float heels, Keep toes free of blankets and open to air." Observations on 10/18/10 at 9:55 am during the initial tour of the survey revealed the resident lying in bed with bilateral side rails and oxygen by nasal canula. Staff 3 (RNCM) stated the resident seemed to be able to track with his eyes and could clamp down his teeth, otherwise the resident was unable to move. The resident was covered with a sheet, including his feet. In an interview on 10/19/10 at 12:15 pm Staff 3 (RNCM) stated the pressure ulcers on the resident's heels came from the Barco boots. Staff 3 was unaware of the Stage 2 pressure ulcers on the resident's toes and unaware of the orders to keep bedding off the resident's toes and the toes open to the air. Observation on 10/19/10 at 12:20 pm revealed Staff 3 removed the sheet that covered the resident's feet and assessed them. The resident had bilateral plantar flexion contractions (downward pointing toes) and the heels were floated. Staff 3 noted the resident had bilateral heel ulcers, pressure areas on two toes of the left foot and five areas of non-intact skin on the right foot. In an interview on 10/20/10 at 10:45 am Staff 3 (RNCM) stated Staff 8 (RNCM) had suggested the Barco boots for the resident and the resident had not been assessed or fitted for the boots by the PT. Staff 3 added the Barco boots had a fixed angle and were not adjustable. Staff 3 stated she did a full body audit on Resident 3 and prepared nine Skin Care Progress Sheets for the resident's wounds. Staff 3 acknowledged no skin sheets for the resident's pressure ulcers were prepared when blisters were noted on 10/4/10. Review of the Skin Care Progress Sheets revealed five were dated 10/19/10, four were undated and all were unsigned. Resident 3's wounds included: an unstageable pressure ulcer on the left third toe caused by the "Barco Boots," an unstageable pressure ulcer on the bottom of the left second toe, a Stage 2 pressure ulcer on the left heel caused by "Barco Boots," an unstageable pressure ulcer on the right heel caused by "pressure from Barco Boots," a Stage 2 pressure ulcer on the right great toe caused by "pressure from Barco Boots," a Stage 2 pressure ulcer on the right foot second toe caused by "pressure from Barco Boot," a Stage 2 pressure ulcer on the right foot third toe caused by "pressure from Barco Boots," a Stage 2 pressure ulcer on the right fourth toe caused by "pressure from Barco Boots," and a Stage 2 pressure ulcer on the right foot at the base of the fifth toe caused by "pressure from Barco." In an interview on 10/20/10 at 11:52 am Staff 8 (RNCM) stated the resident had increased "foot drop" that was noted during Restorative Aide sessions. Staff 8 stated she asked the PT for Barco boots for the resident but the PT had not evaluated the resident. Staff 8 stated the resident wore the boots for approximately two and a half days. In an interview on 10/20/10 at 2:15 pm Staff 11 (PT) stated he remembered Staff 8 had asked for Barco boots for a resident. Staff 11 stated he had not evaluated Resident 3. Staff 11 was asked who evaluated residents for appropriateness and fit of devices such as Barco boots and answered, "I don't know, I guess that would be nursing." When asked if Barco boots would be appropriate for a resident with plantar flexion contractions, Staff 11 replied, "Probably not." In an interview on 10/20/10 at 2:30 pm Witness 1 (FNP) stated she had not ordered the Barco boots. Witness 1 stated she was in the facility seeing residents every week and the Barco boots were put on Resident 3 and discontinued between her usual visits and without her knowledge. Witness 1 added it was "sad because his skin was in really good condition." Witness 1 stated the Barco boots were the start of the resident's foot problems and added the resident was "very rigid and I don't think they would be appropriate."