Every finding on record at Independence Health and Rehabilitation

Based on interview and record review, it was determined the facility failed to ensure a controlled substance was not administered without a physician's order for 1 of 3 sampled residents (#4) reviewed for medication administration. This placed residents at risk of receiving medications without a physician's order and experiencing adverse side effects. Findings include: Resident 4 was admitted to the facility in 10/2025 with diagnoses including atrial fibrillation, osteoarthritis, and anxiety disorder. Resident 4's care plan, initiated 11/9/25, included the following interventions:-ADL self-care performance deficit related to dementia.-Resident experienced pain.-Monitor and document for side effects of pain medication.-Provide non-pharmacological pain interventions, including offering heat or cold packs and repositioning. Resident 4's 11/2025 Physician Orders included:-Tramadol HCl (an opioid pain medication) 50 mg by mouth every 12 hours as needed for pain.-Acetaminophen 325 mg by mouth every 4 hours as needed for pain.-Ice or heat application for 20 minutes every hour as needed for pain.-Morphine sulfate (an opioid pain medication) oral concentrate 0.25 ml by mouth every hour as needed for pain. A 5/21/26 Quarterly MDS assessment indicated Resident 4 had a BIMS score of 11, indicating moderate cognitive impairment. A FRI dated 5/28/26 documented Staff 15 (former RN) administered edible marijuana to Resident 4, which was not ordered by the resident's physician. Resident 4's 5/29/26 Nursing Progress Notes documented the following:-At 12:47 AM, Resident 4 was placed on alert for psychosocial harm related to allegations of abuse. The resident slept intermittently throughout the shift with no complaints.-At 11:57 AM, Resident 4's representative was notified a nurse had given the resident marijuana edibles and possible alcohol, and the resident was being monitored for adverse effects. The representative expressed appreciation for the notification.-At 4:39 PM, Resident 4 remained on alert for psychosocial harm related to the allegations. The resident was up in a wheelchair for part of the day socializing with other residents. No concerns related to the allegation were noted, and staff continued monitoring. On 7/29/26 at 11:37 AM, Staff 9 (Social Services Director) stated she was not present when the incident occurred; however, she visited with Resident 4 in the days following the incident and observed no apparent side effects. On 7/29/26 at 3:00 PM, Staff 1 (Administrator) and Staff 2 (Director of Nursing Services) stated Staff 14 (LPN) reported witnessing Staff 15 provide Resident 4 with edible marijuana. They interviewed Staff 15, who admitted providing Resident 4 with marijuana edibles. Staff 15 was immediately placed on administrative leave while the facility conducted an investigation. Following the investigation, Staff 15's employment was terminated, and a report was made to the Oregon State Board of Nursing. Their investigation did not identify evidence Staff 15 had provided marijuana or any other non-prescribed substances to additional residents. The facility also provided education to staff regarding professional standards, abuse prevention, and following physician orders. Staff 1 and Staff 2 acknowledged the facility was ultimately responsible for resident safety and acknowledged any staff providing residents with substances not ordered by a physician was unacceptable. Attempts were made to interview Staff 15 on 7/30/26 at 8:58 AM 7/31/26 at 9:42 AM, but were unsuccessful. On 7/30/26 at 9:05 AM, Staff 14 stated Staff 15 was providing her with orientation training on the date of the incident. Staff 14 stated when she entered Resident 4's room she observed Staff 15 cutting what appeared to be candy into smaller pieces. When Staff 14 questioned Staff 15, Staff 15 stated the candy was edible marijuana gummies and acknowledged providing them to Resident 4. Staff 14 observed Staff 15 place the pieces of the gummies within Resident 4's reach. Staff 14 stated she believed Staff 15's actions were inappropriate and reported the incident to facility management the following day. The deficient practice was identified as Past Noncompliance based on the following: On 5/28/26, the deficient practice was identified by the facility and was corrected when the facility completed an investigation and determined Staff 15 provided a controlled substance to Resident 4. The Plan of Correction included: -Staff 15 was terminated from employment.-Resident 4 was assessed for adverse reactions to marijuana substance and put on alert monitoring for psychosocial harm.-Facility led investigation to ensure no other residents had been provided with marijuana substances.-Facility wide re-education was provided regarding professional standards, abuse prevention, and following physician orders.

Based on interview and record review it was determined the facility failed to ensure staff provided care and services according to professional standards for 1 of 3 sampled residents (#4) reviewed for medication administration. This placed residents at risk for unsafe medication administration. Findings include:OAR [PHONE NUMBER]Scope of Practice Standards for All Licensed Nurses(1) Standards related to the licensee's responsibility for safe nursing practice. The licensee shall:(a) Practice within the laws and rules governing the practice of nursing at the level the nurse is licensed. OAR [PHONE NUMBER]Scope of Practice Standards for Registered Nurses(1) The Board recognizes that the scope of practice for the registered nurse encompasses avariety of roles, including, but not limited to:(a) Provision of client care;(2) Standards related to the RN's responsibility for ethical practice, accountability for services provided, and competency. The RN shall: (b) Be knowledgeable of the professional nursing practice and performance standards and adhere to those standards; (c) Be knowledgeable of the Oregon statutes and regulations governing RN practice and practice within those legal boundaries. Resident 4 was admitted to the facility in 10/2025 with diagnoses including osteoarthritis, mild cognitive impairment, and anxiety disorder. Resident 4's 11/9/25 Care Plan included the following interventions:-ADL self-care performance deficit related to dementia. -Resident experienced pain. -Monitor and document for side effects of pain medication. -Provide non-pharmacological pain interventions, including offering heat or cold packs and repositioning. Resident 4's 11/2025 Physician Orders included:-Tramadol HCl (an opioid pain medication) 50 mg by mouth every 12 hours as needed for pain. -Acetaminophen 325 mg by mouth every 4 hours as needed for pain. -Ice or heat application for 20 minutes every hour as needed for pain. -Morphine sulfate (an opioid pain medication) oral concentrate 0.25 mL by mouth every hour as needed for pain. A 5/21/26 Quarterly MDS assessment indicated Resident 4 had a BIMS score of 11, indicating moderate cognitive impairment. A FRI dated 5/28/26 documented Staff 15 (former RN) administered edible marijuana to Resident 4, which was not ordered by the resident's physician. On 7/29/26 at 3:00 PM, Staff 1 (Administrator) and Staff 2 (DNS) stated Staff 14 (LPN) reported she witnessed Staff 15 providing Resident 4 with edible marijuana. Staff 15 was immediately placed on administrative leave during the investigation. Staff 15 was later terminated and reported to the OSBN. Staff 15 was interviewed and stated she had provided Resident 4 with edible marijuana and had not provided it to other residents. The facility identified no other residents received marijuana substances from Staff 15 and education was provided to all staff regarding professional standards. Attempts were made to interview Staff 15 on 7/30/26 at 8:58 AM and 7/31/26 at 9:42 AM, but were unsuccessful. On 7/30/26 at 9:05 AM, Staff 14 stated she was receiving orientation from Staff 15 on the date of the incident. While in Resident 4's room, Staff 14 observed Staff 15 cut up what appeared to be candy. When Staff 14 questioned Staff 15, Staff 15 stated the candy was edible marijuana gummies and acknowledged she was providing them to Resident 4. Staff 15 then placed the pieces of the gummies within Resident 4's reach. Staff 14 stated she was confused by Staff 15's actions, believed they were inappropriate, and reported the incident to facility management the following day. The deficient practice was identified as Past Noncompliance based on the following: On 5/28/26, the deficient practice was identified by the facility and was corrected when the facility completed an investigation and determined Staff 15 provided a controlled substance to Resident 4. The Plan of Correction included: -Staff 15 was terminated from employment. -Resident 4 was assessed for adverse reactions to marijuana substance and put on alert monitoring for psychosocial harm. -Facility led investigation to ensure no other residents had been provided with marijuana substances. -Facility wide re-education was provided regarding professional standards, abuse prevention, and following physician orders. Refer to F684

Based on observation, interview, and record review it was determined the facility failed to maintain essential kitchen equipment for 1 of 1 kitchen reviewed for kitchen services. This placed residents at risk for food borne illnesses. Findings include:The 12/5/07 manufacturer specifications for the Ecolab Model ES-2000 indicated the dishwasher required a minimum wash and rinse temperature of 120 degrees Fahrenheit and a recommended temperature of 140 degrees Fahrenheit.On 5/7/26 at 12:17 PM, an observation of the facility kitchen revealed the dishwasher temperature gauge was hazed and unreadable. Staff 16 (Registered Dietician) acknowledged the gauge was unreadable. She stated Dietary Manager was on vacation. She was unsure of the dishwasher's status and requested maintenance assistance.A review of the May 2026 dishwasher log did not include temperature monitoring.On 5/7/26 at 12:24 PM, Staff 15 (Maintenance Supervisor) acknowledged the temperature gauge was unreadable and needed to be replaced. Staff 15 stated the dishwasher temperature was tested with a thermometer on a regular basis but could not provide a temperature record.On 5/7/26 at 12:32 PM, observed Staff 15 use a temperature probe to test the water in the dishwasher and the temperature read 134 degrees Fahrenheit.On 5/7/26 at 12:44 PM, Staff 14 (Dietary Aide) stated she monitored the chemical levels of the dishwasher every morning and between meals but did not monitor the dishwasher temperature. On 5/7/26 at 1:32 PM, Staff 1 (Administrator) stated the facility did not have a temperature record log for the dishwasher and stated the temperature of the dishwasher was to be checked daily.

Based on interview and record review it was determined the facility failed to offer a COVID-19 vaccine for 3 of 5 sampled residents (#s 4, 6, and 14) reviewed for immunizations. This placed residents at risk for COVID-19. Findings include: 1. Resident 4 was admitted to the facility in 2024 with diagnoses included multiple sclerosis (an autoimmune disease which affects the central nervous system). A review of Resident 4's immunization record revealed no documentation she/he was offered or received a COVID-19 vaccine in 2025.On 5/8/26 at 3:13 PM Staff 3 (Assistant Director of Nurses/LPN Resident Care Manager) stated she reviewed Resident 4's documentation and confirmed there was no evidence Resident 4 was offered or received a COVID-19 vaccine.2. Resident 6 admitted to the facility in 2025 with diagnoses including osteomyelitis (bone infection). A review of Resident 6's immunization record revealed she/he did not have documentation of a COVID-19 vaccine in 2025.A review of Resident 6's medical record revealed a 11/4/25 Multi-Vaccine Consent Form signed by Resident 6, and the COVID-19 vaccine was neither accepted nor declined. On 5/8/26 at 3:13 PM Staff 3 (Assistant Director of Nurses/LPN Resident Care Manager) confirmed Resident 6 did not receive an updated COVID-19 vaccine and the consent form was not completed.3. Resident 14 admitted to the facility in 2025 with diagnoses including kidney failure.A review of Resident 14's immunization record revealed no documentation she/he received a COVID-19 immunization in 2025.A 12/18/25 Multi-Vaccine Consent Form signed by Resident 14 revealed she/he consented to receive a COVID-19 immunization. On 5/8/26 at 2:03 PM Staff 3 (Assistant Director of Nurses/LPN Resident Care Manager) reviewed Resident 14's medical record and confirmed she/he did not receive a COVID-19 immunization.

Based on observation and interview it was determined the facility failed to store food in a sanitary manner for 1 of 1 kitchen reviewed for food safety. This placed residents at risk for foodborne illnesses. Findings include:On 5/4/26 at 9:34 AM, a brief kitchen tour was completed and revealed the following:-An opened bag of cereal in dry storage was unlabeled and undated.-An opened container of ranch dressing in the refrigerator was undated.-An open bag containing eight boiled eggs in the refrigerator was unlabeled and undated.-An open block of cheese in the refrigerator was loosely wrapped and undated.On 5/4/26 at 9:36 AM, Staff 13 (Cook) stated staff were to date food products when opened and add a use-by date. Staff 13 confirmed the open items were undated and stated she would discard them.On 5/7/26 at 11:38 AM, Staff 16 (Registered Dietician) stated staff were to date any food product immediately when opened and discard any items found without dates.

Based on observation, interview and record review it was determined the facility failed to implement measures to prevent the spread of infection related to catheter positioning, hand hygiene, and Enhanced Barrier Precautions for 1 of 1 staff member (Staff 8) reviewed during a random observation and 3 of 11 sampled residents (#s 4, 8, and 29) reviewed for infection control. This placed residents at risk for infections. Findings include: 1. On 5/4/26 at 1:32 PM, Resident 4's catheter was observed to be attached to her/his bed with part of the catheter resting on the floor. On 5/6/26 at 11:59 AM Resident 4 was observed with part of the catheter attached to the bed and part of it rested on the floor. On 5/6/26 at 9:00 AM Staff 21 (CNA) observed Resident 4's catheter and confirmed it rested on the floor. On 5/6/26 at 10:29 AM Staff 9 (CNA) observed Resident 4's catheter and confirmed it rested on the floor. Staff 9 stated a barrier between the catheter and the floor was required. Staff 9 raised Resident 4's bed slightly and placed a basin under the catheter. On 5/8/26 at 1:32 PM Staff 4 (LPN Infection Preventionist) stated resident catheter bags were not to rest on the floor. 2. A 4/2024 CDC Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multi-drug-resistant Organisms document indicated Enhanced Barrier Precautions (EBP) was recommended when high-contact care was provided to residents with indwelling medical devices (tubes inserted into the body). On 5/6/26 at 9:24 AM, Staff 12 (CNA) was observed to assist Resident 8 into her/his bathroom. Resident 8 was observed to have an indwelling catheter. Staff 12 donned gloves, assisted Resident 8, doffed the gloves, and exited the room. Staff 12 did not don a gown while providing care to Resident 8. On 5/6/26 at 9:30 AM, Staff 12 stated he escorted Resident 8 to the bathroom and emptied her/his catheter bag. Staff 12 stated he wore gloves while he provided the care and a gown was not needed for that activity. On 5/8/26 at 11:35 AM, Staff 2 (DNS) and Staff 3 (Assistant Director of Nurses/LPN Resident Care Manager) stated staff were to follow Enhance Barrier Precautions when providing high-contact care for Resident 8. Staff 3 stated high-contact care included any contact with Resident 8's catheter or catheter bag. 3. On 5/7/26 at 7:55 AM, Staff 8 (LPN) was observed at the medication cart on the west hallway, Staff 8 dropped a cotton ball on the floor, disposed of it in a garbage can, and then placed the lid on top of the insulin pen without completing hand hygiene. On 5/7/26 at 7:77 AM Staff 2 (DND) stated nursing staff were expected to complete hand hygiene prior to returning items to the medication cart. 4. A 4/2024 CDC Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent the Spread of Multi-drug-resistant Organisms indicated, Enhanced Barrier Precautions (EBP) was recommended when high-contact care was provided to residents with indwelling medical devices (tubes inserted into the body). On 5/4/26 at 1:20 PM Resident 29 was observed in her/his room with a PICC (long flexible tube inserted into the upper arm and advanced until the tip rests just above the heart) line on her/his right arm. On 5/4/26 at 1:29 PM Resident 29 stated staff did not wear PPE when they administered IV medications or provided PICC care. On 5/7/26 at 8:35 AM Staff 4 (IP/LPN) was observed disconnecting Resident 29's IV medication from her/his PICC line and began to complete a flush protocol (the insertion of saline fluid to prevent blockages) to the resident's PICC line without donning a gown. On 5/7/26 at 8:43 AM, Staff 4 stated she did not need to don a gown for Resident 29's flush protocol and staff were not required to follow EBP when they provided high-contact care to the resident because she/he did not have open wounds. On 5/11/26 at 12:50 PM, Staff 2 (DNS) stated she expected residents with PICC lines to be placed on EBP in the facility. Staff 2 stated nursing staff were expected to don a gown and gloves when high contact care was provided to Resident 29, which included interventions for her/his PICC/

Based on interview and record review it was determined the facility failed to provide influenza and pneumococcal vaccines for 3 of 5 sampled residents (#s 4, 6, and 14) reviewed for immunizations. This placed residents at risk for influenza and pneumonia. Findings include: 1 Resident 4 was admitted to the facility in 2024 with diagnoses included multiple sclerosis (an autoimmune disease which affects the central nervous system). A review of Resident 4's immunization record revealed no documentation she/he was offered or received an influenza vaccine in 2025.On 5/8/26 at 3:13 PM Staff 3 (Assistant Director of Nurses/LPN Resident Care Manager) stated she reviewed Resident 4's documentation and confirmed there was no evidence Resident 4 was offered or received an influenza vaccine.2. Resident 6 admitted to the facility in 2025 with diagnoses including osteomyelitis (bone infection). A review of Resident 6's immunization record revealed she/he received a PCV 13 in 2017.A review of the CDC Pneumococcal Vaccine Recommendations revealed Resident 6 required another dose of a pneumococcal vaccine to be current.A review of Resident 6's medical record revealed a 11/4/25 Multi-Vaccine Consent Form signed by Resident 6 but was incomplete and pneumococcal vaccines were neither accepted nor declined. On 5/8/26 at 3:13 PM Staff 3 (Assistant Director of Nurses/LPN Resident Care Manager) confirmed Resident 6 did not receive an updated Pneumococcal vaccine and the consent form was not completed thoroughly.3. Resident 14 admitted to the facility in 2025 with diagnoses including kidney failure.A review of Resident 14's immunization record revealed no documentation she/he received a influenza immunization in 2025.A 12/18/25 Multi-Vaccine Consent Form signed by Resident 14 revealed she/he consented to receive an influenza immunization. On 5/8/26 at 2:03 PM Staff 3 (Assistant Director of Nurses/LPN Resident Care Manager) reviewed Resident 14's medical record and confirmed she/he did not receive an influenza immunization.

Based on observation, interview and record review it was determined the facility failed to ensure a catheter bag was properly placed for 1 of 1 sampled residents (#8) reviewed for urinary catheters. This placed residents at risk of urinary tract infections. Findings include: Resident 8 was admitted in 2/2025 with diagnoses including pneumonia (lung infection).The 2/6/26 Annual MDS indicated Resident 8 was cognitively intact and an indwelling urinary catheter was in place.Resident 8's Care Plan, revised on 12/17/25, identified the presence of an indwelling urinary catheter. Care Plan Interventions included to change from a leg bag to drain bag for day and night use and encourage proper positioning of the catheter and drainage bag.Multiple observations on 5/4/26 through 5/6/26 between 9:00 AM to 4:00 PM revealed Resident 8 sat in a wheelchair with the catheter drainage bag placed on her/his wheelchair seat, above the bladder, between the resident's leg and the arm rest.On 5/6/26 at 9:03 AM Staff 10 (CNA) stated Resident 8 frequently placed the catheter bag above her/his bladder and staff were expected to remind her/him to reposition the bag below the bladder.On 5/6/26 at 9:30 AM Staff 12 (CNA) was observed assisting Resident 8 with care. Resident 8's catheter bag was positioned on the wheelchair, above the bladder, between her/his leg and the armrest. Staff 12 stated Resident 8 frequently placed the catheter bag in that location and he did not remind the resident to move it below his/her bladder.On 5/6/26 at 9:53 AM Resident 8's catheter bag was observed to be on the seat of the wheelchair, above the bladder, between her/his leg and the armrest. Staff 8 (LPN) stated Resident 8's catheter bag was not in the proper position and the proper placement required the bag to remain below the bladder. Staff 8 stated Resident 8 needed to wear a leg bag when out of bed and when she/he refused, staff were expected to remind Resident 8 to position the catheter drainage bag below her/his bladder on the outside of the wheelchair.On 5/8/26 at 11:35 AM Staff 2 (DNS) stated Resident 8's catheter bag was to remain below her/his bladder at all times and staff were expected to assist the resident with maintaining proper placement.

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 2 of 5 sampled residents (#s 4 and 43) reviewed for unnecessary medications. This placed residents at risk for uninformed about their medications. Findings include: 1. Resident 4 admitted to the facility in 2024 with diagnoses including depression. Resident 4's physician orders revealed a 1/6/26 order for citalopram (an antidepressant). A review of Resident 4's medical record revealed no indication she/he was informed in advance of the risks and benefits of citalopram. On 5/11/26 at 1:19 PM Staff 2 (DNS) confirmed Resident 4 was not informed of the risks and benefits of citalopram. 2. Resident 43 was admitted to the facility in 5/2026 with diagnoses including esophageal obstruction (narrowed esophagus). Resident 43's 5/2/26 Physician Orders indicated the resident was prescribed clonazepam (antianxiety medication) for anxiety. Review of Resident 43's medical record revealed no indication the resident was informed in advance of the risks and benefits of clonazepam. On 5/8/26 at 11:35 AM, Staff 2 (DNS) acknowledged Resident 43 was not informed of the risks and benefits for the use of clonazepam.

Based on observation, interview and record review it was determined the facility failed to ensure residents had unsoiled clean linens for 1 of 3 linen closets reviewed for environment. This placed residents at risk for a lack of a homelike environment. Findings include:On 5/6/26 at 10:26 AM the left lower corner of the east hall linen closet was observed to have multiple black spots. On 5/6/26 at 11:10 AM Staff 11 (CNA) stated there was a mold odor in the east linen closet at times. Staff 11 opened the east linen closed and confirmed there appeared to be mold in the lower left corner of the closet with multiple blankets touching the black spots on the wall. Staff 11 removed the blankets and sent them to laundry. On 5/6/26 at 12:03 PM Staff 15 (Maintenance Supervisor) stated he was unaware of any concerns with mold in the east linen closet. Staff 15 looked in the linen closed and confirmed there was mold in the lower left corner.

Based on interview and record review it was determined the facility failed to complete a Significant Change MDS within the required timeframe for 1 of 1 sampled resident (#6) reviewed for hospice. This placed residents at risk for unassessed hospice needs. Findings include: Resident 6 admitted to the facility in 11/2025 with diagnoses including osteomyelitis (an infection in the bone). A 4/21/26 Progress Note revealed Resident 6 admitted to hospice services on 4/21/26. A Significant Change MDS assessment dated [DATE] was completed on 5/7/26, 17 days after Resident 6 admitted to hospice. On 5/8/26 at 10:55 AM Staff 18 (MDS Coordinator) reviewed Resident 6's Significant Change MDS and confirmed it was not completed within 14 days after Resident 6 was admitted to hospice.

Based on observation, interview and record review it was determined the facility failed to provide personal care for 1 of 4 sampled residents (#34) reviewed for ADLs. This placed residents at risk for not receiving grooming. Findings include:Resident 34 was admitted to the facility on [DATE] with diagnoses including schizophrenia and major depressive disorder. The 4/22/26 admission MDS indicated Resident 34 had a BIMS score of 14, which indicated the resident was cognitively intact, and required staff assistance with personal care, which included shaving.On 5/4/26 at 11:27 AM Resident 34 was observed in her/his room with facial hair that was long and thick. Resident 34 stated she/he preferred short facial hair, but staff did not offer to trim or shave her/his facial hair since admission into the facility.On 5/6/26 at 1:56 PM Staff 10 (CNA) stated she worked with Resident 34 on 5/5/26 but did not offer to shave or trim the resident's facial hair. On 5/6/26 at 2:16 PM Staff 6 (CNA) stated she provided care to Resident 34 during her shift but did not offer to shave or trim the resident's facial hair. Staff 6 stated residents were provided assistance to shave or trim facial hair on scheduled bathing days.On 5/7/26 at 10:08 AM Staff 17 (CNA) stated residents bathed two times a week in the facility and she offered to shave or trim residents' facial hair on their scheduled bathing days. Staff 17 confirmed she offered and assisted Resident 34 with bathing since her/his admission but did not offer to shave or trim the resident's facial hair. On 5/7/26 at 10:30 AM Staff 8 (LPN) stated Resident 34 was timid and reluctant to communicate her/his needs to staff. Staff 8 stated she was unaware of Resident 34's facial hair or personal care preferences.On 5/11/26 at 12:08 PM Staff 3 (Assistant Director of Nurses/LPN Resident Care Manager) stated she expected staff to offer to shave or trim residents' facial hair as needed based on their preference or on their scheduled bathing days. Staff 3 stated Resident 34 was in the facility a sufficient length of time for her/his facial hair preferences to be known and accommodated by staff.

Based on interview and record review it was determined the facility failed to provide PRN bowel medication for 1 of 5 sampled residents (#34) reviewed for unnecessary medications. This placed residents at risk for unmet bowel care needs. Findings include:The facility's Bowel Protocol policy dated 5/2025 stated if a resident does not have a bowel movement for three days, the nurse administers the physician ordered bowel program.Resident 34 admitted to the facility on [DATE] with diagnoses including chronic idiopathic constipation. A review of Resident 34's Physician Orders dated 4/17/26 included sennoside 8.6 mg and polyethylene glycol 3350 powder, for constipation on a PRN basis. The Physician Orders also indicated the resident was to receive Milk of Magnesia for constipation on a PRN basis after three days of no bowel movement.A review of Resident 34's bowel record indicated the resident had no bowel movement from 4/21/26 to 4/24/26 (four days). A review of Resident 34's 4/2026 MAR revealed no indication the resident received or refused PRN medications for constipation from 4/21/26 to 4/24/26. On 5/11/26 at 10:29 AM Staff 7 (LPN) stated Resident 34 went three days without a bowel movement in 5/2026 but she was unaware if the resident went three or more days without a bowel movement in 4/2026. On 5/11/26 at 12:18 PM Staff 3 (Assistant Director of Nursing/LPN Resident Care Manager) confirmed the resident went four days without a bowel movement from 4/21/26 to 4/24/26 and did not receive PRN constipation medications. Staff 3 stated nursing staff were expected to offer and administer Resident 34 one of her/his three ordered PRN constipation medications on 4/24/26.

Based on interview and record reviewed it was determined the facility failed to implement wound care interventions as ordered for 1 of 1 sampled resident (#40) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers. Findings include: Resident 40 was admitted to the facility in 3/2026 with diagnoses including leg amputation and pressure ulcers.A 3/27/26 physician order indicated staff were to perform wound care to the pressure ulcers on Resident 40's back every day shift.Progress Notes on 4/6/26 and 4/10/26 indicated wound care was not completed, and staff passed the treatment on to the next shift.On 4/22/26, a complaint was received which indicated Resident 40 was admitted to the facility on [DATE] with multiple unstageable pressure ulcers to her/his back. Witness 3 (Complainant) indicated staff did not always provide wound care, the wounds worsened, and the resident was sent to the hospital.On 5/7/26 at 11:28 AM, Staff 19 (CMA) stated Resident 40 had a bariatric bed and mattress, but she/he liked to stay on her/his back and did not get out of bed as often as she/he should have.On 5/7/26 at 11:53 AM, Staff 3 (Assistant Director of Nursing / Licensed Practical Nurse Resident Care Manager) stated Resident 40 was given a bariatric bed upon admission due to her/his weight and not being able to fit in a standard bed. Staff 3 stated she ordered an air mattress which came four days later. Staff 3 stated she spoke with Resident 40 multiple times regarding repositioning off her/his back and getting out of bed more, but the resident did not always comply.On 5/11/26 at 9:57 AM, Staff 7 (LPN) and Staff 18 (MDS Coordinator) stated Resident 40 was to have dressing changes to her/his back daily but on 4/6/26 and 4/10/26 the dressings were not changed. Staff 7 stated the dressing changes were supposed to be passed on to the next shift, but they were not completed on the next shift either.

Based on observation, interview and record review it was determined the facility failed to ensure physician orders were followed to prevent accidental choking for 1 of 5 sampled resident (#43) reviewed for unnecessary medications. This placed residents at risk for adverse outcomes related to aspiration. Findings include:Resident 43 was admitted to the facility in 5/2026 with diagnoses including esophageal obstruction (narrowed esophagus).Resident 43's 5/1/26 Care Plan indicated she/he required enteral nutrition (tube feeding) related to esophageal obstruction and was to remain NPO (nothing by mouth).Resident 43's 5/1/26 Physician's Orders stated Resident 43 was NPO.On 5/7/26 at 1:34 PM, Witness 2 (Family Member) stated Resident 43 was served juice at breakfast and was now coughing.On 5/7/26 1:54 PM, Resident 8 was observed sitting upright in bed, coughing, and attempting to spit up phlegm.On 5/7/26 at 1:55 PM, Staff 8 (LPN) stated Resident 43 was served juice at breakfast by a CNA. Staff 8 stated Resident 43 consumed approximately half of a sip of juice before it was removed, Resident 43 was evaluated and the incident was reported to the administrator.A 5/7/26 Progress Note indicated Resident 43 consumed five milliliters of juice orally. Resident 43's lungs sounded free and clear of any liquid, the physician was notified, and Resident 43 was placed on alert.A 5/7/26 Incident Report revealed Resident 43 was provided juice by Staff 9 (CNA). Staff 9's written statement indicated she did not see Resident 43's tube feed and provided her/him with juice. Staff 9 wrote the juice was removed the minute she was told Resident 43 could not have it.On 5/8/26 at 10:39 AM, Staff 2 (DNS) stated Staff 9 (CNA) served Resident 43 orange juice while passing fluids prior to breakfast service. Staff 2 stated Resident 43's physician orders and care plan were not followed.On 5/8/26 at 12:44 PM and 5:29 PM, attempts to contact Staff 9 were unsuccessful.

Based on observation and record review it was determined the facility failed to post complete staffing information for 1 of 1 facility reviewed for required staff postings. This placed residents and the public at risk for incomplete and inaccurate staffing information. Findings include:Observations of the Direct Care Staff Daily Reports posted at the facility entrance revealed the evening shift section was left blank on the following dates and times:-5/4/2026 at 2:52 PM-5/5/26 at 3:58 PM-5/6/26 at 3:45 PMOn 5/6/26 at 3:48 PM Staff 8 (LPN) stated the charge nurse was responsible to complete and post the Direct Care Staff Daily Reports at the start of each shift. Staff 8 stated the evening shift started at 2:00 PM and confirmed she did not complete the 5/6/26 evening shift section of the Direct Care Staff Daily Report. On 5/11/26 at 12:46 PM Staff 2 (DNS) stated she was aware of prior incidents when the evening shift section of the Direct Care Staff Daily Reports was not completed and posted timely. Staff 2 stated she expected the charge nurse to complete and post the evening shift section of the Direct Care Staff Daily Reports within the first hour of the shift and acknowledged it was not completed as required from 5/4/26 to 5/6/26.

Based on interview and record review it was determined the facility failed to ensure a resident was transferred as care planned for 2 of 2 sampled residents (#s 2 and 31) reviewed for falls. this placed residents at risk for injury. Findings include: 1. Resident 2 admitted to the facility in 1/2007 with diagnoses including dementia (a group of symptoms affecting cognition, memory and social relationships) and hemiplegia following cerebral infarction (paralysis of one side of the body following a stroke caused by a blood clot in the brain). Resident 2 was non-verbal and unable to be interviewed due to dementia. A review of the Physician Encounter note dated 8/25/24 revealed the resident was transported to the emergency department following a fall on 8/25/24. Resident 2 was diagosed at the hospital with a fracture of the right femural neck (a break in the bone that connects the ball of the hip to the thigh bone). A review of the resident's care plan indicated Resident 25 required the assistance of two caregivers for toileting and personal care. In an interview on 2/12/25 at 5:02 PM Staff 25 (Former Agency CNA) stated he had not reviewed Resident 2's care plan and was not aware Resident 2 required two caregivers for personal care. Staff 25 stated he worked with Resident 25 on several shifts. Staff 25 stated while performing an end-of-shift brief change Staff 25 briefly turned away from the resident and the resident fell to the floor. In an interview on 2/15/25 at 7:02 PM Staff 27 (LPN) stated she was seated at the nurses station which was very near Resident 2's room when the fall occurred. Staff 27 stated the shift was fully staffed and all staff working night shifts were frequently reminded to ask for help from the nurse if another CNA was not available to assist with resident care. Staff 27 said it would have been easy for Staff 25 to request her assistance with Resident 2. In an interview on 2/18/25 at 9:54 AM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged Staff 25's failure to follow Resident 2's care plan which caused Resident 2 to experience an avoidable fall and injury. 26991 2. Resident 31 was admitted to the facility in 7/2023 with a diagnosis of a stroke. A care plan initiated 1/21/24 revealed Resident 31 required the assistance of two people to transfer from a bed to wheelchair. A 7/10/24 annual MDS revealed Resident 31 had a stroke, was weak on one side and was at risk for falls. A 12/10/24 quarterly MDS revealed Resident 31 was cognitively intact. A 12/25/24 Fall without fracture investigation revealed on 12/25/24 at 6:50 PM a CNA assisted Resident 31 to transfer from her/his bed to a chair without additional staff to assist. Resident 31 became weak, the CNA lowered her/him to the floor, and she/he did not sustain an injury. Prior to the fall Resident 31 informed the CNA she/he only required one staff to transfer from the bed to wheelchair. The investigation indicated the CNA who transferred Resident 31 at the time of the fall did not review her/his care plan prior to the transfer. On 2/9/25 at 10:46 AM Resident 31 stated a few months prior she/he fell when one staff attempted to transfer her/him alone. On 2/11/25 at 11:48 AM Staff 20 (Agency CNA) stated she never worked with Resident 31 until 12/25/24. On 12/25/24 she received a report from the previous shift on the resident's ability to eat, transfer, and toileting status. Staff 20 stated the resident was in bed and called for help to get out of bed, when she looked for staff to assist her, she was not able to find anyone. Resident 31 rang two additional times and the third time she/he used her/his call light the resident stated she/he only needed one person to assist her/him with transfers. Resident 31 was alert, was very persistent, so she attempted to transfer her/him by herself prior to looking at the care plan. During the transfer Resident 31 became weak, she eased the resident to the floor, and she/he did not sustain an injury. Staff 20 verified she did not check the care plan prior to transferring Resident 31 and she was later informed the resident required the assistance of two people to transfer. On 2/12/25 at 9:23 AM Staff 2 (DNS) verified Resident 31 was not transferred as care planned and fell .

Based on observation and interview it was determined the facility failed to maintain a comfortable interior for 2 of 2 residents (#29 and 35) and 1 of 1 hall reviewed for a homelike environment. This placed residents at risk for an unhomelike environment. Findings include: 1.Resident 297 was admitted to the facility in 12/2024 with a diagnosis of varicose veins of left lower extremity. A 12/5/24 MDS revealed Resident 297 was cognitively intact. On 2/12/25 at 9:20 AM, Resident 35's room was observed with an unpainted area behind the headboard with drywall exposed. On 2/12/25, Resident 29 stated when she/he moved into the room the wall had been in disrepair for a while. In an interview on 2/12/25 at 2:56 PM, Staff 17 (CNA) stated she was aware of the wall damage in the hallway to include torn drywall with missing paint. Residents' rooms also had drywall exposed and paint missing behind the headboards. Staff 17 acknowledged it should be repaired. In an interview on 2/18/25 at 10:33 AM, Staff 12 (Maintenance Director) Stated the wall had been down for two months from ongoing water damage. He acknowledged the wall in the hallway and residents' rooms had drywall exposed and walls in disrepair without paint. 26991 2. Resident 20 was admitted to the facility in 8/2020 with a diagnosis of heart failure. A 12/17/24 quarterly MDS revealed Resident 20 was cognitively impaired. On 2/9/25 at 2:43 PM when Resident 20's bathroom light was turned on, the bathroom fan was activated, and the fan motor made a very loud, metal rattling noise. On 2/11/25 at 3:37 PM Staff 12 (Maintenance Director) verified Resident 20's bathroom fan rattled when activated. On 2/12/24 at 3:13 PM and 2/18/25 at 9:29 AM Staff 1 (Administrator) stated he was not notified by residents of noisy bathroom fans. Staff 1 stated staff did not report the concern which then created an unhomelike environment. On 2/18/25 at 9:07 AM Resident 20 stated the fan was loud and was like that for years. 3. Resident 31 was admitted to the facility in 7/2023 with a diagnosis of a stroke. A 12/23/24 quarterly MDS revealed Resident 31 was cognitively intact. On 2/9/25 at 10:55 AM in Resident 31's bathroom, dry wall, which was cut, not patched, and not repainted, was observed behind the toilet near the water shut off valve. The area was cut in the shape of a square and each side was approximately nine inches long. On 2/11/25 at 3:53 PM Resident 31 stated she/he did not use the bathroom. On 2/13/25 at 8:14 AM and 2/14/25 at 8:28 AM Staff 12 (Maintenance Director) stated the facility pipes frequently leaked. Staff 12 stated the leak in Resident 5's room occurred approximately two months ago and he had not repaired the wall. On 2/14/25 at 8:28 AM Staff 1 (Administrator) stated the facility had several leaks from the water pipes and the dry wall repairs should be completed promptly to ensure a quality living environment for the residents. 4. Resident 38 was admitted to the facility in 12/2024 with a diagnosis of a fractured skull. A 1/2/25 admission MDS revealed Resident 38 had moderate cognitive impairment. On 2/10/25 at 10:13 AM when Resident 38's bathroom light was turned on, the bathroom fan was activated, and the fan generated a loud, metal rattling noise. Resident 38 was in bed, approximately 12 feet from the bathroom, and stated the fan was loud. The dry wall behind the toilet near the shut off valve was cut, not patched, and not repainted. The area was cut in the shape of a square and each side was approximately six inches long. On 2/13/25 at 8:14 AM and 2/14/25 at 8:28 AM Staff 12 (Maintenance Director) stated he did not recall when the leak occurred and knowledged the dry wall was cut in Resident 38's room. On 2/12/24 at 3:13 PM, 2/14/25 at 8:28 AM, and 2/18/25 at 9:29 AM Staff 1 (Administrator) stated the facility had several leaks from the water pipes. Staff 1 stated the dry wall repairs should be completed promptly to ensure a quality living environment for the residents. Staff 1 stated he was not notified by residents of noisy bathroom fans and staff did not report the concern creating an unhomelike environment. 5. Resident 19 was admitted to the facility in 9/2020 with a diagnosis of kidney failure. A 12/5/24 quarterly MDS revealed Resident 19 was cognitively intact. On 2/9/25 at 11:13 AM when Resident 19's bathroom light was turned on, the bathroom fan was activated, and the fan generated a loud, metal rattling noise. Resident 19 stated the fan was really loud and laughed. On 2/11/25 at 3:37 PM Staff 12 (Maintenance Director) acknowledged Resident 19's fan rattled. On 2/14/25 at 8:28 AM Staff 1 (Administrator) stated he was not notified by residents of noisy bathroom fans and staff did not report the concern creating an unhomelike environment. 6. Resident 11 was admitted to the facility in 12/2018 with a diagnosis of heart disease. A 1/10/25 annual MDS revealed Resident 11 was cognitively intact. On 2/12/25 at 2:00 PM and on 2/18/25 at 9:18 AM with Staff 14 (CNA) when entering the [NAME] Hall shower room, the room was cold. When the fan was activated, cold air was pushed down from the ceiling. Staff 14 stated she notified Staff 12 (Maintenance Director). Staff 14 stated the [NAME] Hall shower room was always cold and residents had to be transported to the East Hall for showers. On 2/12/25 at 3:00 PM Resident 11 stated when the fan was turned on in the west shower room the air was cold and chilly. Resident 11 stated she/he had to take a shower on the other end of the hall (East Hall) and was transported there half ass naked. On 2/13/25 08:14 AM via text Staff 12 reported the [NAME] Hall shower fan was installed incorrectly, and was pulling air down from the outside and was not pulling the air up.

Based on interview and record review it was determined the facility failed to obtain and implement PASARR (Preadmission screening and resident review/screens for serious mental illness and or intellectual disability) and findings timely for 1 of 1 sampled resident (#19) reviewed for PASARR. This placed residents at risk for lack of mental health resources. Findings include: Resident 19 was admitted to the facility in 9/2020 with mental health diagnoses and a serious visual impairment. A 2/15/24 Resident Review PASRR II (Screening for mental illness) form revealed Resident 19 was at risk for self-endangering, heard voices, and was agoraphobic (fear of open spaces or crowded places/fear of leaving one's own home). A mental health evaluation was indicated and was to be completed within 14 days. A 2/22/24 PASRR Level II Evaluation revealed Resident 19 had mental health diagnoses, dementia, and depression. Recommendations made after the evaluation included: -consider increasing her/his Abilify (antipsychotic medication) -make a referral to a psychiatric prescriber for medication management -inquire if Resident 19 would enjoy listening to books -contact agencies and resources for peer support and support for the visually impaired On 2/10/25 at 2:51 PM and 2/10/25 3:49 PM with Staff 15 (Business Office Manager) and Staff 3 (LPN Resident Care Manger) Staff 3 and Staff 15 stated Resident 19 was agoraphobic and it was initially very difficult for her/him to attend her/his medical appointments. Over time resident 19 developed a routine and improved with attending appointments, but if her/his routine was altered she/he was set off. In 2024 Resident 19 was noncompliant with fluid restrictions and she/he was still noncompliant, she/he at times made delusional comments, and talked to people who were not visible to others. Staff 15 stated the evaluation which was completed in 2/2024 was sent to the facility but some of the information was not correct and a revised copy was requested by the facility. Staff 3 and Staff 15 stated the facility did not receive a revised copy. On 2/11/25 09:17 AM Witness 2 (MA LPC/Licensed Professional Counselor with a Masters degree stated the PASARR assessments were usually sent to the facility within one month after the evaluation was completed. Witness 2 stated she would e-mail, fax, or mail a copy of the evaluation to the facility. Witness 2 stated she was not notified by the facility they did not have the results of the evaluation. On 2/11/25 at 10:30 AM Staff 5 (Social Services) stated she was the contact person for the PASARR evaluations. After the assessments were completed, the assessments were sent to her. If she did not receive the assessment she would communicate with the mental health evaluator until she received the report. After she received the report the interdisciplinary team reviewed the recommendations and discussed the findings with the resident's physician which, if any, interventions would be appropriate for the resident. On 2/11/25 12:02 PM Staff 2 (DNS) stated the facility failed to ensure the results of the PASARR were obtained, reviewed, and implemented if indicated. On 2/12/25 07:34 AM Staff 16 (Activities) stated she was familiar with Resident 19 but was not aware of recommendations from a PASARR assessment including audio books or resources for the visually impaired.

Based on observation, interview, and record review, it was determined the facility failed to provide care and services for skin wounds for 1 of 1 sampled resident (#8) reviewed for non-pressure skin wounds. This placed residents at risk for worsening wounds. Findings include: The 1/2025 facility's Skin Integrity policy indicated the following for residents: The nurse establishes a plan of care based on risk factors (factors that increase the chance of a problem). The resident's skin is inspected daily with completion of ADLs, with changes reported to the nurse. Ongoing evaluation continues weekly for a full body skin audit (an examination). -For skin impairment identified with admission (abrasion, bruise, burn, excoriation, pressure sore, rash, skin tear, surgical wound etc.) the nurse would complete the following: Document the skin impairment, including measurements of size, color, presence of odor, exudates (fluid), and presence of pain associated with the skin impairment in the weekly wound evaluation for surgical, pressure, burns, and venous stasis ulcer (a sore on the leg caused by poor blood flow). -Bruises, skin tears and abrasions are monitored on the TAR weekly until resolved. - Notify the resident/representative of the skin condition and treatment plan. -Implement interventions and document them on resident's care plan. Wounds are evaluated weekly by center clinicians. Arterial, pressure, stasis and venous ulcer, significant surgical wounds and burns are evaluated, measured and the findings documented in the medical record. This evaluation include pain associated with the wound during wound care. Resident 8 was admitted to the facility in 5/2024 with diagnoses including contusion (bruising) of right lower leg, and an open wound to right lower leg. A 5/9/24 care plan revealed Resident 8 had potential impairment to the skin due to abrasion, edema (swelling), and immobility. Interventions included following facility protocols for treatment of the injury, monitoring, and documenting the location, size, and treatment of the skin injury and reporting any abnormalities, failures to heal, signs of infection, and maceration (softening). An 8/9/24 Nursing Progress Note revealed Resident 8's right leg wound had exposed tendon and measured seven centimeters by three and half centimeters. An 8/9/24 Emergency Department (ED) summary indicated Resident 8 was admitted to the ED with a right leg wound for the past three months. Resident 8 informed the ED staff that the facility staff took off her/his wound vacuum and noted her/his tendons were exposed. Resident 8 experienced increased pain when the wound vacuum (device used to help wounds heal) was removed and it was recommended to transfer Resident 8 to the ED. Resident 8 had a wound infection, worsening of necrotic (dead tissue) wound, sepsis (a severe infection) and need for wound debridement (removal of dead tissue). An 8/8/24 Surgical Consultation revealed Resident 8 had an open wound to the right front lower leg. She/he developed a hematoma (a collection of blood) on 5/2/24 and the overlying skin and subcutaneous (under the skin) tissue became necrotic, and she/he underwent debridement on 6/11/24. Resident 8's wound was managed by a wound vacuum and on 8/9/24 the dressing was changed, and the wound was found to have necrotic tissue that was malodorous (had a bad smell.) No documentation was found in the clinical record to indicate Resident 8's right lower leg was assessed weekly for size, color, presence of odor, exudates, treatment, and presence of pain. A 9/4/24 signed physician order instructed staff to provide wound care on Mondays, Wednesdays and Fridays. To remove wound vacuum and all dressings and gauze. Cleanse with saline and hibicleanse, border skin with dressing, apply foam or nonstick dressing over tendon, fill wound with foam, plastic drape to cover and seal. A 9/2024 TAR instructed staff to change the wound vacuum dressing three times a week on Mondays, Wednesdays, and Fridays, with a start date of 8/30/24 and a discontinue date of 11/5/24. The 9/4/24 physician orders were not found on the TAR. On 9/27/24, there was no documentation that treatment was completed by Staff 9 (Former LPN). On 2/11/25 at 8:31 AM Staff 6 (LPN) completed a dressing change on Resident 8's right leg open wound. Resident 8 had some facial grimacing during the dressing change. The wound was pink with no odor and was approximately 12 centimeters in length by 7.5 centimeters width. On 2/12/25 at 9:13 AM Staff 9 stated he did not remember if he completed wound care on Resident 8 on 9/27/24. Staff 9 stated the facility ran out of wound treatment supplies in 9/2024 and there may not have been supplies to complete the treatment. On 2/13/25 at 9:23 AM Staff 8 (LPN) stated the RCM usually completed the wound assessments. If the RCM could not complete the assessment, it would be delegated to another staff member. On 2/14/25 at 11:42 AM Staff 1 (Administrator) stated the 9/4/24 signed physician order which was not entered and initiated on the TAR. Staff 1 also indicated there was no evidence treatment was completed on 9/23/24. On 2/18/25 at 7:42 AM Staff 2 (DNS) and Staff 3 (MDS Coordinator-RCM) stated it was expected Resident 8 had weekly wound evaluations of her/his right leg wound.

Based on interview and record review it was determined the facility failed to perform weekly physician ordered skin audits, accurately and routinely assess a pressure ulcer, perform ordered wound treatment and pressure reduction intervention, promptly notify the physician of a nonhealing pressure ulcer, clarify pressure ulcer treatment orders and promptly initiate new treatment orders for 1 of 3 sampled residents (#1) reviewed for pressure ulcers. This resulted in Resident 1 developing an avoidable unstageable pressure ulcer; and placed other residents at risk for worsening pressure ulcers, delayed treatment and delayed healing. Findings include: CMS Appendix PP defined the following pressure ulcer stages: - Stage 1 Pressure Injury: Non-blanchable [DIAGNOSES REDACTED] of intact skin Intact skin with a localized area of non-blanchable [DIAGNOSES REDACTED] (redness). In darker skin tones, the PI may appear with persistent red, blue, or purple hues. The presence of blanchable [DIAGNOSES REDACTED] or changes in sensation, temperature, or firmness may precede visual changes. Color changes of intact skin may also indicate a deep tissue PI (see below). - Stage 2 Pressure Ulcer: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. This stage should not be used to describe moisture associated skin damage including incontinence associated [MEDICAL CONDITION], intertriginous [MEDICAL CONDITION] (inflammation of skin folds), medical adhesive related skin injury, or traumatic wounds (skin tears, burns, abrasions). - Stage 3 Pressure Ulcer: Full-thickness skin loss Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the wound bed, it is an Unstageable PU/PI. - Unstageable Pressure Ulcer: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) should only be removed after careful clinical consideration and consultation with the resident's physician, or nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws. If the slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer will be revealed. If the anatomical depth of the tissue damage involved can be determined, then the reclassified stage should be assigned. The pressure ulcer does not have to be completely debrided or free of all slough or eschar for reclassification of stage to occur. Resident 1 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The resident no longer resided at the facility. An Interdisciplinary Progress Notes dated 3/6/17 indicated Resident 1's left foot and leg were tender. The resident was administered [MEDICATION NAME] which was helpful. An Interdisciplinary Progress Notes dated 3/7/17 indicated Resident 1 had an open sore on the left outer foot near the little toe which measured 1.3 cm by 1.3 cm with bloody drainage and a warm, swollen, painful foot. The assessment failed to indicate the depth or cause of the wound. A review of Resident 1's clinical record revealed no Weekly Skin Evaluations from 3/7/17 through 5/25/17. A Weekly Skin Evaluations dated 5/26/17 indicated Resident 1 had a Stage 2 wound on the left foot with a yellow wound bed which measured 2.6 cm by 1.4 cm and 0.2 cm deep. A review of Resident 1's clinical record revealed no Weekly Skin Evaluations from 5/31/17 through 6/14/17. A Weekly Skin Evaluations dated 6/27/17 indicated Resident 1 had a Stage 1 wound on the left foot with pink/beefy red wound bed and measured 2.3 cm by 2.5 cm and 0.1 cm deep slightly oblong in shape. A review of Resident 1's clinical record revealed no additional Weekly Skin Evaluations identified as Resident 1's left foot wound. A review of Resident 1's Interdisciplinary Progress Notes dated 3/7/17 through 11/10/17 revealed no routine, consistent, accurate and comprehensive assessments of the resident's left foot pressure ulcer. Resident 1's Care Plan for Impaired Tissue Integrity with an initial date of 3/15/17 included the following interventions: - Administer medications and treatments related to impaired tissue as ordered. - Monitor impaired tissue regularly noting characteristics including measurements of impaired tissue and effectiveness of treatment. A Facsimile Transmission Nurses Station dated 3/7/17 notified the physician Resident 1 had an open wound on the left outer foot near the small toe which measured 1.3 cm by 1.3 cm with bloody drainage and a swollen, painful foot. The facility cleaned the wound and placed a foam dressing. The facility requested treatment orders. The physician replied on 3/7/17 with Continue dressing changes. Notify by phone if not improving. Off set pressure to area. The order failed to indicate specifically what kind of dressing changes to continue and how often. No documentation was found in the resident's clinical record to indicate the facility clarified the treatment orders. A Facsimile Transmission Nurses Station dated 4/29/17 indicated the resident's left foot wound was tender and not healing. The facility requested orders for [MEDICATION NAME] (medical grade honey used for wound treatment) and cover with a foam dressing daily. The physician agreed to the request on 5/3/17. (This was four days after the request was made by fax instead of by phone as ordered on [DATE].) A Facsimile Transmission Nurses Station dated 5/5/17 indicated the resident continued to have a Stage 2 pressure ulcer to the left outer foot. The facility requested orders for wound cleanser, Santyl (enzymatic ointment which digests collagen in necrotic tissue) to the wound bed and cover with foam dressing for one week then discontinue the Santyl and continue the remainder of the treatment until the wound was healed. The physician agreed to the request on 5/9/17 which was four days after the facility requested new treatment orders. An Interdisciplinary Progress Notes dated 5/14/17 indicated an order to change the left foot wound treatment to Santyl for one week was noted and faxed to the pharmacy. An Interdisciplinary Progress Notes dated 5/16/17 indicated the new treatment with Santyl was started. Resident 1's left foot wound bed was red with scabbing. There was increased warmth to the surrounding skin and it was very painful to touch. The assessment failed to provide measurements of the wound. This was seven days after the new treatment order was received from the physician. A review of Resident 1's clinical record revealed no explanation or rationale for the four day delay in obtaining new, more aggressive, treatment orders or the seven day delay in the implementation of those new orders once received from the physician. An Interdisciplinary Progress Notes dated 5/18/17 indicated Resident 1's left foot wound bed was yellow with some redness around the edges, a moderate amount of bloody drainage and slight foul odor. The left foot was very painful to touch. The assessment failed to provide measurements of the wound. An Interdisciplinary Progress Notes dated 5/24/17 indicated Resident 1's left foot wound bed continued to be covered with yellow slough (a wound bed covered with slough would indicate the wound was unstageable), no drainage, no odor, no redness and no warmth. The area remained tender to touch. The assessment failed to provide measurements of the wound. An Interdisciplinary Progress Notes dated 5/28/17 indicated Resident 1's left foot wound measured 1.8 cm by 1.5 cm was full thickness with no depth. (Full thickness tissue loss would indicate the wound was a Stage 3 pressure ulcer) An Interdisciplinary Progress Notes dated 6/13/17 indicated the physician examined Resident 1's left foot and planned sharps intervention (no additional explanation was provided). An Interdisciplinary Progress Notes dated 6/14/17 indicated the physician would come to the facility on [DATE] to debride (removal of dead tissue) Resident 1's left foot wound. An Interdisciplinary Progress Notes dated 6/16/17 indicated the physician debrided Resident 1's left foot wound. No description of the procedure or results were provided. An Interdisciplinary Progress Notes dated 6/21/17 indicated Resident 1 was reviewed for pressure ulcer. The resident had an unstageable pressure ulcer to the left outer leg which was still being debrided. The wound was possibly infected and the physician was considering antibiotics. An Interdisciplinary Progress Notes dated 7/20/17 indicated Resident 1's left foot was healing and the bandage reduced to standard band-aid. A review of Resident 1's clinical record revealed no physician's order for a treatment change including a band-aid. An Interdisciplinary Progress Notes dated 7/20/17 indicated the charge nurse was educated to use only physician ordered wound covering. An Interdisciplinary Progress Notes dated 7/21/17 indicated Resident 1's left foot wound was looking better but the use of a bandage too large for the wound caused damage to the surrounding tissue and the wound had regressed overall. It was recommended to change the covering bandage to a smaller one. A review of Resident 1's clinical record revealed no indication the physician was contacted and a smaller bandage requested. An Interdisciplinary Progress Notes dated 8/31/17 indicated there was no open area visible (to the left foot wound). Staff would continue to cover the wound with a band-aid, leaving the wound open to air to reduce moisture. An Interdisciplinary Progress Notes dated 9/4/17 indicated Resident 1's left foot wound measured 1.2 cm by 1.0 cm and was full thickness wound, there was dark red above the wound with tenderness. No additional information was provided to explain the change in wound condition noted on 8/31/17. An Interdisciplinary Progress Notes dated 9/6/17 indicated the physician was faxed with a request to change the wound treatment to leave the wound open to air due to improvement. A review of Resident 1's monthly (MONTH) through (MONTH) (YEAR) TARs revealed ordered weekly skin assessments were not completed or were not correctly documented on 2/10/17, 2/17/17, 2/14/17, 3/3/17, 3/31/17, 4/7/17, 4/28/17, 6/30/17, 7/7/17, 8/4/17, 8/11/17, 8/18/17, 8/25/17 and 9/29/17. Resident 1's (MONTH) (YEAR) TAR indicated to continue dressing changes to the left foot near the small toe and foam dressing. Notify the physician by phone if not improving. The treatment was not completed on 3/8/17, 3/9/17, 3/20/17 3/26/17 and 3/27/17. The TAR further indicated to keep pressure off of the wound which was not completed 11 times from 3/8/17 through 3/29/17. A review or Resident 1's clinical record revealed no physician's order for a foam dressing. Resident 1's (MONTH) and (MONTH) (YEAR) TARs indicated to change the dressing to the left foot wound daily. The type of dressing and procedure was not indicated. Resident 1's monthly (MONTH) through (MONTH) (YEAR) TARs indicated ordered treatment to the left foot wound was not completed on 6/7/17, 6/28/17 through 6/30/17, 7/12/17, 7/13/17, 7/14/17, 7/24/17, 7/27/17, 7/28/17, 8/28/17, 9/25/17 through 9/29/17, 10/9/17 and 10/10/17. Resident 1's (MONTH) (YEAR) TAR revealed no treatment for [REDACTED]. On 2/23/18 at 11:05 AM Staff 4 (LPN) stated Resident 1 had a Stage 2 pressure ulcer on the foot which cleaned up to a Stage 1 or better. She stated the resident was frequently repositioned and the resident was compliant with positioning. She stated the wound got worse at one point but was not infected. On 3/28/18 at 11:12 AM the concerns related to Resident 1's left foot wound including skin assessments, wound assessments, missing treatments, prompt physician notification, clarification of treatment orders and prompt initiation of treatment orders were discussed with Staff 2 (Regional RN) and Staff 10 (DNS). The chart documentation was presented for their review and they verified the concerns. Staff 2 and Staff 10 were requested to provide any clarifying documentation. On 3/30/18 at 9:29 AM Staff 10 stated there was no additional documentation.

Based on interview and record review it was determined the facility failed to promptly notify the physician of a resident's severe weight loss, lack of food and fluid intake for four days and change in condition for 1 of 3 sampled residents (#1) reviewed for change in condition. This resulted in Resident 1 experiencing a sever weight loss and a delay in receiving a transfer to an acute care setting for emergent treatment. Findings include: Resident 1 was readmitted to the facility in 2017 with [DIAGNOSES REDACTED]. A review of Resident 1's Weight Record revealed the following: - On 9/27/16 Resident 1's weight on admission to the facility was 205 pounds. (The Weight Record failed to indicate if the weights were in pounds or kilograms. On 10/27/17 at 11:09 am Staff 5 (assistant DNS) stated the weights were in pounds.) - On 6/15/17 the resident weighed 186 pounds. - On 6/20/17 the resident weighed 185 pounds. - On 6/29/17 the resident weighed 182 pounds. - On 7/11/17 the resident weighed 170. This was a loss of 12 pounds, or 6.6% body weight, in 12 days and a loss of 16 pounds, or 9.6% body weight, in 26 days. This was a severe weight loss. - On 7/12/17 a reweigh confirmed the resident weighed 170 pounds. A review of Resident 1's 7/2017 Meal Monitor Flow Sheet indicated no food or fluid intake was documented between dinner on 7/2/17 and dinner on 7/6/17. A review of Resident 1's clinical record revealed no indication the physician was notified of the resident's severe weight loss identified on 7/11/17 and the resident did not consume any food or fluid at meals between dinner on 7/2/17 and dinner on 7/6/17. A Facsimile Transmission Nurses Station form dated 7/16/17 addressed to Resident 1's physician indicated the resident refused medications three times that week due to nausea. The resident was refusing fluids and the facility was concerned about the resident's fluid deficit. The facility requested lab orders for a BMP (basic metabolic panel) and a UA (urinalysis). The physician responded on 7/18/17 with Noted. Patient eval in ER. On 10/30/17 at 12:26 pm Staff 6 (DNS) stated the physician was not notified of Resident 1's weight loss and lack of intake between 7/2/17 and 7/6/17. Staff 6 acknowledged Resident 1's physician was notified by fax on 7/16/17 and responded via fax on 7/18/17 to send the resident to the emergency room for evaluation. Staff 6 stated if a nurse is concerned about a resident they should call the physician. Refer to F-325

Based on interview and record review it was determined the facility failed to ensure a resident maintained acceptable nutritional parameters for 1 of 3 sampled residents (#1) reviewed for change in condition. This resulted in Resident 1 experiencing a severe, unplanned weight loss. Findings include: Resident 1 was readmitted to the facility in 2017 with [DIAGNOSES REDACTED]. A Nutritional Note Progress Notes dated 3/26/17 indicated Resident 1's intakes for breakfast were 76%; intakes for lunch were 79%; and intakes for dinner were 72%. Resident 1's Care Directive Form (the bedside care plan used by staff for the provision of care) revised on 2/17/17, 5/11/17 and 8/7/17 did not indicate the amount of assistance the resident needed with meals. Resident 1's Care Plan: Nutrition Hydration Status reviewed on 5/24, 8/2/17 and 8/16/17 included the following: Goals: - The resident would not have an unplanned significant weight loss or gain. - The resident would consume 75% of meals and more than 75% of the fluids provided at meals. Interventions: - Monitor the resident's meal intake and offer a substitute or supplement if 50% or less of the meal is consumed. - Weigh the resident per facility protocol. - Refer the resident to the Registered Dietitian as appropriate. A review of Resident 1's Weight Record revealed the following: - On 9/27/16 Resident 1's weight on admission to the facility was 205 pounds. (The Weight Record failed to indicate if the weights were in pounds or kilograms. On 10/27/17 at 11:09 am Staff 5 (assistant DNS) stated the weights were in pounds.) - On 6/15/17 the resident weighed 186 pounds. - On 6/20/17 the resident weighed 185 pounds. - On 6/29/17 the resident weighed 182 pounds. - On 7/11/17 the resident weighed 170. This was a loss of 12 pounds, or 6.6% body weight, in 12 days and a loss of 16 pounds, or 9.6% body weight, in 26 days. This was a severe weight loss. - On 7/12/17 a reweigh confirmed the resident weighed 170 pounds. - On 7/19/17 the resident weighed 170.6 pounds. (Resident 1 was sent to the hospital on [DATE] and was not in the facility on 7/19/17) A review of Resident 1's 7/2017 Meal Monitor Flow Sheet from breakfast on 7/1/17 through breakfast on 7/18/17 indicated the resident refused all breakfast food, fluids, alternates and supplements. The resident ate 10% of lunch on two days, drank 480 ml of fluids over 17 days and otherwise refused food and fluids. The resident ate between 40-100% of dinner on five out of 17 days and drank a total of 1000 ml of fluids on six out of 17 days. The resident's intake was not documented nine times. No food or fluid intake was documented between dinner on 7/2/17 and dinner on 7/6/17. An Interdisciplinary Progress Notes dated 7/10/17 indicated Resident 1 lost weight but it was expected because she/he was refusing breakfast. The resident was eating 10% of lunch and 16% of dinner. It was recommended to schedule the resident's anti-nausea medications 30 minutes before meals. On 6/6 the resident's weight was 188.2 pounds and on 6/29 it was 182 pounds. The note did not indicate over what period of time the resident's meal intake percentages were from or how they were calculated. The note provided no rationale for the resident's anti-nausea medication or scheduling it 30 minutes before meals. The note did not indicate why a current weight was not used for the nutrition review. A review of Resident 1's clinical record revealed no indication the physician was notified of the resident's severe weight loss identified on 7/11/17 and the resident did not consume any food or fluid at meals between dinner on 7/2/17 and dinner on 7/6/17. A Facsimile Transmission Nurses Station form dated 7/16/17 addressed to Resident 1's physician indicated the resident refused medications three times that week due to nausea. The resident was refusing fluids and the facility was concerned about the resident's fluid deficit. The facility requested lab orders for a BMP (basic metabolic panel) and a UA (urinalysis). The physician responded on 7/18/17 with Noted. Patient eval in ER. An Interdisciplinary Progress Notes dated 7/16/17 indicated Resident 1 was not her/his self and was sleepy and sedated. The resident complained of pain in the left arm. The resident refused all her/his night time medications and had poor food and fluid intake. An Interdisciplinary Progress Notes dated 7/17/17 at 1230 indicated Resident 1's physician was updated on the resident's recent decline. The note did not indicate specifically when the physician was updated and what specific information was conveyed to the physician related to the resident's decline. An Interdisciplinary Progress Notes dated 7/17/17 AM indicated Resident 1 had poor food and fluid intake and had refused all meals and fluids for four days. The resident refused to go to the hospital. An Interdisciplinary Progress Notes dated 7/18/17 at 8:00 am indicated Resident 1 refused medications and food. The resident refused to go to the hospital. An Interdisciplinary Progress Notes dated 7/18/17 at 11:00 am indicated Resident 1 requested to go to the hospital. A hospital Progress Notes dated 7/29/17 indicated Resident 1 had acute kidney failure. The resident likely had [MEDICAL CONDITION] which worsened from poor oral intake. A hospital Discharge Summaries dated 7/31/17 indicated Resident 1 was admitted to the hospital because she/he was not eating and was more confused for two to three days. An initial evaluation in the emergency department showed the resident had acute kidney failure, a potassium level of 6.1 (normal is 3.6 to 5.2) and evidence of a UTI. The resident was suspected to have [MEDICAL CONDITION] but the stage was unknown (patients with kidney disease are at increased risk of high potassium level due to decreased potassium excretion from the kidneys). The resident was treated with IV (intravenous) fluids. On 10/27/17 at 11:09 am Staff 5 (assistant DNS) acknowledged Resident 1's Care Directive Form did not indicate the amount of assistance the resident needed with meals, the resident's intake was not documented nine times between 7/1/17 and 7/18/17, the meal monitoring indicated the resident had no intake between dinner 7/2/17 and dinner 7/6/17 and the Registered Dietician was not present at the 7/10/17 nutrition review. On 10/30/17 at 12:26 pm Staff 6 (DNS) stated the physician was not notified of Resident 1's weight loss and lack of intake between 7/2/17 and 7/6/17. Staff 6 acknowledged a current weight was not used for the 7/10/17 nutrition review. Staff 6 stated Resident 1's 7/11/17 weight and 7/12/17 reweigh were not communicated to the dietary manager for follow up at the nutrition review. Staff 6 stated the following nutrition review was scheduled for 7/19/17 with the Registered Dietitian but the review was not done. Staff 6 acknowledged Resident 1's physician was notified by fax on 7/16/17 and responded via fax on 7/18/17 to send the resident to the emergency room for evaluation. Staff 6 stated if a nurse is concerned about a resident they should call the physician.

Based on interview and record review it was determined the facility failed to follow physician's orders to obtain laboratory tests, assess and monitor bruising, for 1 of 3 sampled residents (#3) reviewed for change in condition. This resulted in Resident 3 requiring medication and treatment to stop the bleeding from a laceration in the emergency room secondary to a fall at the facility. Subsequently Resident 3 was readmitted to the hospital and required additional medication to stop internal bleeding and a blood transfusion. Findings include: Resident 3 was readmitted to the facility in 2017 with [DIAGNOSES REDACTED]. A faxed physician order dated 8/17/17 increased Resident 3's [MEDICATION NAME] (anti-coagulant) dose to 5 mg four days a week and 2.5 mg three days a week. The resident's INR (a lab test which indicates how long it takes for the blood to clot and is used by the physician when determining a therapeutic dose of [MEDICATION NAME]) was to be rechecked in two weeks. A faxed physician order dated 9/1/17 indicated Resident 3 was to continue the current dose of [MEDICATION NAME] and have her/his INR rechecked on 9/5/17. A review of Resident 3's clinical record revealed no documentation the resident's INR was rechecked on 9/5/17. In an e-mail dated 10/24/17 at 1:23 pm Staff 5 (Assistant DNS) indicated the facility did not have Resident 3's INR rechecked on 9/5/17 as ordered by the physician. On 10/27/17 Staff 5 acknowledged Resident 3 was administered the same dose of [MEDICATION NAME] from 9/5/17 through 9/26/17 when the resident went to the hospital. An Interdisciplinary Progress Notes dated 9/26/17 at 6:00 am indicated Resident 3 fell and sustained a 6-8 cm laceration to the right elbow. A gauze pressure bandage was applied. The resident complained of severe pain in right hip. The resident was sent to the emergency room . Hospital ED Provider Notes dated 9/26/17 indicated the Resident 3 fell and sustained a right arm laceration. The laceration required six stitches. Despite a replacement dressing the resident's repaired wound continued to bleed. The resident's INR was supratheraputic (too high) at 6.0 and the resident was administered vitamin K (used to treat an overdose of [MEDICATION NAME]), the wound was unroofed by removing the overlying skin, a gel foam and pressure dressing were applied. An Interdisciplinary Progress Notes dated 9/26/17 PM indicated Resident 3 was placed on alert charting and hourly checks. An Interdisciplinary Progress Notes dated 9/27/17 at 12:25 pm indicated Resident 3 was very sore in the hip area. Her/his right hip was swollen, bruised and warm to the touch. A review of Resident 3's clinical record revealed no alert charting nurse's notes for evening shift on 9/27/17 and day shift on 9/28/17. On 10/27/17 at 11:09 am Staff 5 (Assistant DNS) stated when a resident is on alert charting there was supposed to be a chart note for every shift. She acknowledged the missing alert charting on 9/27/17 and 9/28/17. An Interdisciplinary Progress Notes dated 9/29/17 at 4:00 am indicated Resident 3 complained of severe pain, vomited green fluid and had several small episodes of vomiting. The resident's right hip bruise was 7 cm by 5 cm, firm and raised with diffuse bruising. An Interdisciplinary Progress Notes dated 9/30/17 N(NAME) indicated Resident 3 was very confused and tearful. The resident screamed and cried with rolling in bed because her/his right hip was bruised and swollen. An Interdisciplinary Progress Notes dated 10/1/17 days indicated Resident 3 was given 60 ml of a supplement which she/he vomited. The resident had extensive right hip bruising which radiated into the thigh with slight yellowing at the edges. An Interdisciplinary Progress Notes dated 10/1/17 PM indicated Resident 3 was sent to emergency room for a mental status change and poor intake over five days. A hospital H&P dated 10/1/17 indicated Resident 3 was diagnosed with [REDACTED]. The resident's hemoglobin (blood protein which carries oxygen) level was 6.0 (normal is 12 to 15.5), RBC (red blood cell count) level was 1.87( normal is 3.90 to 5.03) and hematocrit (the percentage of red blood cells in the blood) level was 18.4 (normal is 34.9 to 44.5). Imaging indicated the resident had a 10 cm likely hematoma (an abnormal collection of blood outside the blood vessels) in the resident's right hip. The resident was administered intravenous vitamin-K and packed red blood cells.

Based on observation, interview and record review it was determined the facility failed to ensure that an assisstive devise was in place to prevent an accident or to provide a safe environment for 2 of 7 sampled residents (#s 8 and 10) who were reviewed. Resident 10 experienced a fractured ankle. Findings include: 1. Resident 10 had lived at the facility since 2005 with [DIAGNOSES REDACTED]. Resident 10's in-room care plan dated 9/1/10 directed staff to strap the resident's left foot to his foot rest with a soft fleece strap. This prevented the resident's paralyzed foot from dragging on the floor. A facility incident report dated 11/15/10 revealed that at dinner on 11/15/10 Witness 4 (Resident 10's family member) reported to the LN that Resident 10's ankle was very swollen. Facility nursing notes (NN) dated 11/15/10 documented Resident 10 went out of the facility for x-rays. On 11/16/10 NN documented the resident had fractured his left ankle. He returned to the facility on [DATE] with a splint. The facility Event Investigation Final Summary dated 11/19/10 concluded Resident 10 must have hurt his foot when moving through the facility in his wheelchair without his left foot rest. On 3/9/11 at 2:25 pm Staff 1 (Administrator) explained that the maintenance staff and Witness 4 agreed to remove the left foot rest the day of the incident to have it cleaned and painted. A written statement by the Activity Director dated 11/18/10 stated that on 11/15/10 he kept Resident 10's left foot elevated while being moved from the dining room, after a Resident Council meeting. The statement documented the resident was left at the nurses station. On 3/9/11 at 5:19 pm Witness 4 stated the foot rest was off for six to eight hours the day of the incident. Witness 4 felt the resident moved around dragging his foot or someone may have pushed the resident in his wheelchair without the foot rest. Witness 4 stated the foot rest was removed at the nurses station and the RNCM and DNS were there and aware the foot rest was removed. 2. Resident 8 was admitted to the facility in 2008 with [DIAGNOSES REDACTED]. The MDS dated [DATE] did not indicate the use of side rails or that the resident was dependent on staff for mobility or transfers. The Care Area Assessment (CAA) dated 1/18/11 indicated the resident had [DIAGNOSES REDACTED]." Resident 8's care plan dated 2/11/11 identified that the resident was at risk for falls due to muscle spasms. The care plan included directions to staff to have half side rails up when the resident was in bed per the resident's choice, to use two person mechanical lift for transfers and two person assistance for bed mobility. On 3/9/11 at 10:30 am the bilateral half side rails on the bed were loose and moved easily when touched. During observation of ADL care on 3/9/11 the resident had involuntary spasms when the CNAs turned her and/or repositioned her legs. The resident was unable to turn or reposition herself without staff assistance. On 3/9/11 at 8:45 am Resident 8 stated that she had spasms "all the time" and that the rails were put on because she fell when she first got there. She indicated that she "wanted them." On 3/9/11 at 12:00 pm Staff 13 (Maintenance) was questioned regarding his plan and procedure for checking that side rails were tight. He stated that he checked them every month and that there was a "log at the nurses' station" for maintenance concerns from staff. The maintenance log was reviewed on 3/9/11 at 12:15 pm and the resident's loose rails were not listed to be tightened for the previous month's time frame. During interview on 3/10/11 at 3:15 pm with Staff 3 (RNCM) and Staff 5 (Corporate RN), Staff 3 stated she was unaware that the resident's bed rails were loose and stated that the resident could only move her left arm. When questioned if the loose rails, the resident's inability to reposition self, and the resident's spasms put her at risk for injury or entrapment, Staff 3 did not respond but Staff 5 stated the loose rails were a safety concern and could pose an entrapment risk.