Every finding on record at Laurelhurst Post Acute & Rehabilitation

Based on observation and interview it was determined the facility failed to maintain resident rooms and equipment for 2 of 2 rooms (Room #s 361 and 370) and 1 of 2 Units (ICF-Intermediate Care Facility) reviewed for environment and resident council. This placed residents at risk for injury. Findings include: 1. On 6/23/26 at 9:25 AM room [ROOM NUMBER] was observed to have three areas of missing laminate on the sink counter. Each missing laminate area was less than or equal to 0.5 inches in diameter and were rough when touched.On 6/26/26 at 7:59 AM 13 (CNA) stated when he entered room [ROOM NUMBER], the room door opened inward, and the door blocked the sink. Staff 13 stated if he noticed missing laminate he would notify maintenance, but he never saw the missing laminate in room [ROOM NUMBER]. On 6/26/26 at 9:03 AM Staff 14 (Maintenance Director) stated when facility maintenance was required, staff were to notify him, and then he would assign the task to his staff. Staff 14 stated he was not aware of the missing laminate, the edges needed to be dremmeled to be smooth to prevent potential skin injury. 2. On 6/23/26 at 9:23 AM with Staff 5 (CNA) room [ROOM NUMBER]'s laminate sink counter was observed to have a large piece of laminate missing. The missing laminate piece was approximately eight inches long by two inches high and was rough to touch. Staff stated he never noticed the missing laminate, but if he did, he would notify maintenance. On 6/26/26 at 9:03 AM Staff 14 (Maintenance Director) stated when facility maintenance was required, staff were to notify him, and he would assign the task to his staff. Staff 14 stated he was not aware of the missing laminate, the edges needed to be dremmeled smooth to prevent potential skin injury. 3. Resident 104 was admitted to the facility in 6/2023 with a diagnosis of a stroke. Resident 104's Care Plan revised on 1/28/25 revealed she/he was to use a cane for mobility. Resident 104's 3/27/26 Quarterly MDS revealed she/he was cognitively intact. On 6/25/26 at 2:00 PM during a Resident Council Meeting, Resident 104 stated when she/he was weighed on the ICF wheelchair scale, the support towel (collapsable column) was really loose, and it made her/him feel off balanced. On 6/26/2026 7:59 AM with Staff 13 (CNA) the ICF scale on the third floor was observed to have a support column. The support column, when touched, was loose and moved approximately one inch forward and back. Staff 13 stated the support column was loose for about six months. On 6/26/26 at 9:53 AM Staff 14 (Maintenance Director) stated staff were to notify him if facility maintenance needed to be completed. Staff 14 stated no one informed him the scale column on the ICF was loose.

Based on observation, interview and record review it was determined the facility failed to monitor temperatures in the medication refrigerators for 3 of 3 medication refrigerators. This placed residents at risk for receiving medications with reduced efficacy. Findings include:The undated PharMerica Refrigerator Temperatures indicated CDC recommends Twice Daily Temps if Vaccines are Present 1.On 6/25/26 at 9:15 AM, the medication room refrigerator temperature logs for the second floor were reviewed for 6/1/26 through 6/25/26 and revealed no temperatures were recorded for 6/1/26 through 6/25/26 for the day shift and 6/3/26, 6/22/26, 6/23/26 temperatures were not recorded for the night shift. On 6/25/26 at 9:15 AM, Staff 6 (LPN) stated the day shift nurses, and night shift nurses were supposed to document the temperature of the refrigerator, and verified vaccines were present in the refrigerator. 2.On 6/25/26 at 9:23 AM, the medication room refrigerator temperature logs for the third floor were reviewed for 6/1/26 through 6/25/26 and revealed no temperatures were recorded for 6/1/26 through 6/25/26 for the day shift and 6/7/26 and 6/25/25 for the night shift. On 6/25/26 at 9:23 AM, Staff 3 (LPN) stated the day shift nurses and night shift nurses were supposed to document the temperature of the refrigerator, and verified vaccines were present in the refrigerator. 3.On 6/25/26 at 9:30 AM, the medication room refrigerator temperature logs for the fourth floor were reviewed for 6/1/26 through 6/25/26 and revealed no temperatures were recorded for 6/1/26, 6/2/26, 6/5/26, 6/14/26, 6/15/26, 6/16/26 through 6/22/26, and 6/25/26 for the day shift and 6/7/26, and 6/2/26, 6/6/26, 6/10/26, 6/12/26, 6/14/26, and 6/16/26 through 6/18/26 for the evening shift. On 6/25/26 at 9:30 AM, Staff 6 (RN) stated the day shift nurses, and evening shift nurses were supposed to document the temperature of the refrigerator, and verified vaccines were present in the refrigerator. RN Staff 6 stated if the temperatures were out of parameters (measurable factors that help define a system), staff should notify the Director of Nursing Services (DNS) immediately. On 6/25/26 at 9:38 AM, Staff 2 (DNS) confirmed day shift nurses, and night shift nurses were responsible for checking the temperatures of the refrigerators in the medication storage rooms and documenting temperatures. Staff 2 stated her expectation was for the documents to be filled out and accurate and if the temperatures were out of parameters she should be notified immediately.

Based on observation, interview and record review it was determined the facility failed to prepare and handle food in a sanitary manner in 3 of 4 resident refrigerators reviewed for food service. This placed residents at risk for foodborne illness. Findings include:1. On 6/25/26 at 9:54 AM, observation was made of the ICF (Intermediate Care Facility) 3 resident refrigerators. The following food items were found unlabeled and undated: hot dogs, buns, pizza snacks, pickles, potato salad and a cup of melted ice cream. On 6/25/26 at 9:55 AM, Staff 25 (CNA) stated she was unsure of the process when a resident brought food in from an outside source, but thought staff were required to date and label residents' food. Staff 25 stated she was unsure how long food could remain in the refrigerator. On 6/25/26 at 11:02 AM, Staff 2 (DNS) observed food items that were unlabeled and undated and confirmed residents' food was required to be labeled and dated, and staff were expected to follow proper labeling and dating procedures. 2. On 6/25/26 at 10:55 AM, observations were made of the ICF (Intermediate Care Facility) 4 resident refrigerators. The following food items were found unlabeled and undated: feta cheese, lean cuisines, chicken and vegetable dumplings, two large boxes of hot pockets, olives and broccoli. On 6/25/26 at 10:56 AM, Staff 26 (CNA) stated CNAs were responsible for labeling and dating residents' food and kitchen staff was responsible for ensuring food was not expired. On 6/25/26 at 11:02 AM, Staff 2 (DNS) observed food items that were unlabeled and undated and confirmed residents' food was required to be labeled and dated, and staff were expected to follow proper labeling and dating procedures. 3. On 6/25/26 at 11:08 AM, observations were made of the SNF (Skilled Nursing Facility) 1 resident refrigerators. The following foods were observed unlabeled and undated: three boxes of lean cuisines meals, a pint of Ben & Jerry's ice cream, yogurt, and an opened undated Red Bull. On 6/25/26 at 11:09 AM, Staff 2 (DNS) observed food items that were undated and unlabeled and confirmed residents' food was required to be labeled and dated, and staff were expected to follow proper labeling and dating procedures. On 6/25/26 at 11:15 AM, Staff 27 (Dietary Aid) stated he was trained to check refrigerators to ensure food was dated and labeled. Staff 27 stated he was not trained to check freezer items for dating, labeling, or expiration. Staff 27 stated he checked all refrigerators the previous day and did not observe any items requiring removal. On 6/25/26 at 11:18 AM, Staff 28 (Cook) stated he checked the resident's refrigerator and freezers daily and was unaware of any foods that needed to be removed. On 6/25/26 at 11:19 AM, Staff 23 (Dietary Manager) stated the expectation was for staff to check resident refrigerators and freezers daily and remove any food that was not dated or labeled.

Based on interview and record review it was determined the facility failed to ensure a resident's grievance was completed timely for 1 of 13 sampled residents (#39) who attended resident council meeting. This placed residents at risk for unresolved concerns. Findings include: Resident 39 was admitted to the facility in 3/2025 with a diagnosis of cancer. Resident 39's 3/26/26 Quarterly MDS revealed she/he was cognitively intact. Resident 39's Grievances included the following: -On 4/4/26 Resident 39 reported concerns related to staffing and food services. A follow up to this grievance was not completed until 5/6/26.-On 4/18/16 Resident 39 reported concerns related to another resident's behaviors. A follow up to this grievance was not completed until 4/30/26.-On 5/22/26 Resident 39 reported concerns related to the manner other residents accessed an ice machine. A follow up was not completed until 6/1/26.On 6/25/26 at 2:00 PM Resident 39 stated she /he filed three grievances, and it took almost one month before Staff 1 (Administrator) provided her/him with the written resolution. Resident 39 stated she/he was provided the completed grievances on 6/25/26.On 6/26/26 at 10:12 AM Staff 1 stated when a resident filed a grievance the department which conducted the investigation was to provide a resolution to a resident within a week. Staff 1 stated she did not provide Resident 39 timely resolutions.

Based on interview and record review it was determined the facility failed to follow physician orders and clarify physician orders for 3 of 7 sampled residents (#s 6, 90, and 136) reviewed for dialysis and nutrition. This placed residents at risk for worsening conditions. Findings include: 1 Resident 6 was admitted to the facility in 5/2026 with diagnoses including asthma and diabetes. A review of Resident 6's weight record revealed Resident 6 had a 17-pound weight gain increasing from 169 pounds on 5/18/26 to 186 pounds on 5/22/26. A 5/22/26 Progress Note revealed Resident 6's provider was notified of an increase in bilateral leg edema. A 5/22/26 Provider Progress Note indicated the plan for Resident 6 was, new orders for furosemide (a medication to decrease water retention), new orders for labs, and a new order for a chest x-ray. A 5/26/26 Provider Progress Note revealed Resident 6 had a new diagnosis of heart failure. A 6/25/26 review of Resident 6's medical record revealed no evidence the chest x-ray was completed. On 6/26/26 at 11:07 AM, Staff 11 (RN) stated Resident 6 was having increased leg edema and received orders for furosemide and to elevate her/his legs. Staff 11 stated she did not review the provider's notes; the RNCM was responsible for reviewing provider notes. Staff 11 was unable to locate an order for the chest x-ray on 5/22/26 or chest x-ray results. On 6/26/26 at 12:32 PM, Staff 12 (RNCM) stated her process was to review provider's notes and to clarify any orders if necessary. Staff 12 stated she missed the provider's note on 5/22/26 related to the chest x-ray. Staff 12 stated the provider should have been notified and asked for clarification on whether they wanted the chest x-ray completed for Resident 6. On 6/26/26 at 12:59 PM, Staff 2 (DNS) stated RNCMs were required to review provider notes and reach out for clarification. Staff 2 stated her expectation would have been for staff to reach out to the provider for clarification regarding Resident 6's chest x-ray order. 2 Resident 131 was admitted to the facility on [DATE] with diagnoses including end stage renal disease with dialysis, high blood pressure, and immunodeficiency due to post kidney transplant. A 6/15/26 care plan review indicated Resident 131's medications were to be held on dialysis days per order. A review of Resident 131's medical record revealed no evidence of orders to hold medications on dialysis days. A review of the 6/2026 MAR revealed the following medications were held on 6/16/26, 6/18/26, 6/20/26, and 6/23/26 due to Resident 131 being at dialysis: calcium acetate (a medication that binds phosphate), torsemide (a diuretic medication), Protonix (a medication to lower stomach acid), nifedipine (a medication used to treat high blood pressure), aspirin, NPH insulin (a long acting insulin), finasteride (a medication used to treat enlarged prostates), lactobacillus (a probiotic) Nystatin swish and swallow (a medication used to treat oral yeast), and multiple vitamins. The 6/2026 MAR also revealed Resident 6 had not received Envarsus (a medication used to help prevent organ rejection) four times. On 6/24/26 at 2:50 PM, Staff 2 (DNS) stated Resident 131 did not have orders to hold medications on dialysis days. Staff 2 stated the provider was not notified of the missed medications. Staff 2 stated staff were expected to give medications as ordered, clarify any questions with the provider, and notify the provider for any missed medications. 3. Resident 90 was admitted to the facility in 7/2021 with a diagnosis of kidney disease. Resident 90's Progress Notes revealed the following: -5/1/26 note written by Staff 17 (LPN) indicated Resident 90 reported burning with urination and was concerned about a possible UTI. The note indicated Resident 90's physician was to be notified and she/he would be monitored.-5/2/26-5/4/26 there were no notes.-5/5/26 Resident 90's physician was notified of a need for a narcotic refill. -5/6/26 and 5/7/26 Resident 90 was assessed to have no signs of infection to her/his toe. (There were no notes related to monitoring Resident 90 for signs of a possible UTI.)-5/8/26 staff notified Resident 90's physician that she/he had a low blood pressure of 78/40 and reported blurred vision. Resident 90 was transported to the hospital. Resident 90's clinical record did not reveal documentation Resident 90's physician was notified of her/his reports of burning with urination or a possible UTI. Resident 90's 5/8/26 hospital History and Physical revealed she/he reported having signs of a UTI for about two days, with increased frequency and incontinence. Resident 90 was identified to be retired health care worker and recognized [her/his] symptoms well. Resident 90's 5/11/26 hospital Discharge Summary revealed she/he was admitted to the hospital with altered mental status and pain with urination and was diagnosed with a UTI. On 6/25/26 at 7:58 PM Staff 17 stated she wrote the 5/1/26 note related to Resident 90 reports of burning with urination. Staff 17 acknowledged Resident 90's clinical record did not indicate her/his physician was notified and staff did not monitor her/him for a possible UTI after 5/1/26. On 6/26/26 at 11:04 AM Staff 2 (DNS) stated if residents had burning with urination, their physician was to be notified, and staff were to monitor the resident every shift to assess for a possible UTI. Staff 2 indicated Resident 90's UTI diagnosis and treatment were delayed.

Based on interview and record review it was determined the facility failed to ensure residents received appropriate pain management for 1 of 5 sampled residents (#78) reviewed for pain. This placed residents at risk for pain and discomfort. Findings include:Resident 78 was admitted to the facility on [DATE] with diagnoses including aftercare following knee replacement surgery and pain.The 6/11/26 Hospital Discharge Instructions indicated staff were to administer oxycodone PRN (1-3 tablets of 5 mg-15 mg oxycodone) and Tylenol 500 mg at bedtime. The last documented administration of oxycodone 5 mg occurred on 6/11/26 at 8:42 AM.The 6/11/26 at 9:52 PM, admission Nursing Collection Tool revealed Resident 78 reported sharp left knee pain with a pain level of five, affecting sleep, social activities, physical activity, mobility, and emotions.The 6/12/26 at 1:20 PM, MAR revealed Resident 78 received oxycodone 5 mg and reported pain level of nine. (approximately 18 hours later)The 6/15/25 Pain care plan indicated Resident 78 was prescribed opioid medications for pain. The goal was to remain free from complications related to opioid use. Staff were to administer pain medications as ordered.On 6/22/26 at 12:00 PM, Witness 1 (Friend) and Witness 2 (Friend) stated Resident 78 arrived at the facility on 6/11/26 at approximately 9:00 PM, following knee surgery and was in a lot of pain. Witness 1 further stated Resident 78 did not receive pain medication until the following day 6/12/26, which was a concern due to her/his discomfort.On 6/22/26 at 3:42 PM, Resident 78 stated she/he was discharged from the hospital following knee surgery and arrived at the facility on 6/11/26 at approximately 9:00 PM. Resident 78 stated her/his pain increased after arrival and reported a pain level of greater than six. Resident 78 stated staff told her/him they did not have her/his pain medication available, and the resident did not receive pain medication until the following day, and her/his knee was painful. On 6/24/26 at 6:57 PM, Staff 10 (CNA) stated Resident 78 arrived from the hospital after having knee surgery and reported her/his pain level was a seven out of 10 and she/he was uncomfortable. Staff 10 reported the concern to the nurse and overheard the nurse advising the resident that her/his pain medications were not available.On 6/25/26 at 8:39 AM, Witness 3 (Pharmacists) stated staff did not order Resident 78's oxycodone until 6/12/26. Witness 3 stated the facility first requested authorization to access oxycodone from the Pyxis (automated medication dispensing system requiring pharmacy authorization for medication access) on 6/12/26 at approximate 10 AM, however, staff did not pull the medication at that time. Witness 3 stated the same staff requested authorization again on 6/12/26 at approximately 1:12 PM. Staff pulled one 5 mg oxycodone tablet. Witness 3 further stated the pharmacy delivered Resident 78's oxycodone on 6/12/26 at approximately 2:00 PM.On 6/25/26 at 10:16 AM, Staff 11 (RN) confirmed Resident 78 had an order for oxycodone at the time of admission and the facility should have had the medication on hand. Staff 11 stated she contacted the pharmacist to request oxycodone from the Pyxis machine. Staff 11 stated only one tablet was available and the resident declined the medication because the resident wanted her/his full prescribed dose. Staff 11 stated she offered ice to the resident for her/his knee discomfort, which the resident accepted while waiting for her/his pain medication. Staff 11 confirmed she did not document the resident's refusal of the half dose of pain medication and did not notify the physician of the resident knee pain. Staff 11 stated she did not assess Resident 78 for pain and on 6/12/26 Resident 78's pain level increased from seven to a nine.On 6/26/26 at 11:31 AM, Staff 12 (RNCM) confirmed nurses were required to assess and address pain at admission. Staff 12 confirmed Resident 78 was admitted after 8:00 PM, on 6/11/26 following hospital discharge and had not received pain medication until 6/12/26 the next day. Staff 12 confirmed admission documentation reflected Resident 78 expressed sharp left knee pain with a pain level of five. Staff 12 stated nursing staff were expected to offer pain medication, document if a resident refused and notify the physician. Staff 12 confirmed Resident 78 did not receive pain medication until after 1:00 PM, the following day, at which time Resident 78's pain level was reported as nine out of 10. Staff 12 further stated oxycodone should have been available via Pyxis and was unaware the Pyxis did not have the full dose needed for Resident 78.

Based on interview, and record review it was determined the facility failed to monitor dialysis port and failed to care plan dialysis port for 1 of 1 sampled resident (#131) reviewed for dialysis. This placed residents at risk for dialysis related complications. Findings include: Resident 131 was admitted on [DATE] with diagnoses including end stage renal disease.A review of Resident 131's care plan revealed a 6/14/26 care plan for peritoneal dialysis (a process to filter blood using the lining of the stomach), a 6/14/26 care plan to use enhanced barrier precautions due to the peritoneal dialysis catheter, a 6/15/26 care plan indicating dialysis access was through the peritoneal catheter, and a 6/17/26 care plan for peritoneal dialysis catheter care. No information was found on the care plan regarding Resident 131's dialysis port.On 6/22/26 at 2:50 PM, Resident 131 stated she/he was doing peritoneal dialysis at home, but at the facility Resident 131 stated she/he was doing hemodialysis (a medical procedure that uses machines to filter the blood) through a chest port. Resident 131 stated staff did not check her/his chest port.A review of Resident 131's medical record revealed no indication 131's chest port was being monitored.On 6/26/26 at 10:53 AM, Staff 11 (RN) stated Resident 131 had a chest port which she checked on dialysis days. Staff 11 stated there was no order to check the chest port, she just knew it needed done.On 6/26/26 at 12:28 PM, Staff 12 (RNCM) stated Resident 131 did not have orders to monitor the chest port and was not care planned to monitor the chest port. Staff 12 stated staff were expected to check the chest port every shift, and this should be documented in the TAR.On 6/26/26 at 12:51 PM, Staff 2 (DNS) acknowledged Resident 131 did not have orders to monitor the chest port and was not care planned for monitoring of the chest port. Staff 2 stated staff were expected to monitor the chest port before and after dialysis and every shift. Staff 2 stated this should be documented in the TAR and on the care plan.

Based on observation, interview, and record review it was determined the facility failed to assess a resident prior to implementing bedrails for 1 of 4 sampled residents (#54) reviewed for accidents. This placed residents at risk for entrapment. Findings include: Resident 54 was admitted to the facility in 11/2025 with a diagnosis of a stroke with paralysis to the left side. Resident 54's 11/28/29 Device/Mattress Safety Observation form revealed the type of device was a bed rail, but the form did not identify the length of the rail. The form indicatedResident 54 was able to move in bed but was not able to transfer independently, and the rail was not a restraint. There was no additional information related to the placement of the rail. Resident 54's 11/29/26 Order Details revealed she/he was to have bilateral one quarter rails for mobility. The order instructions included staff were to monitor Resident 54 for entrapment. Resident 54's 12/2/26 admission MDS revealed she/he had moderate cognitive impairment, was able to make her/his needs known, but had difficulty learning new information. Resident 54 was assessed to not attempt to get out of bed by her/himself due to left side paralysis. Resident 54 was also assessed to have increased confusion and hallucinations. Resident 54's Care plan updated on 1/2/26 indicated she/he required assistance with ADLs and used one quarter side rails for bed mobility. Resident 54's 6/4/26 Quarterly MDS revealed she/he was severely cognitively impaired. Resident 54's 6/15/26 side rail consent revealed she/he consented to the use of side rails. On 6/22/26 at 1:30 PM Resident 54 was observed with one quarter rails which were located bilaterally. The rails were located bilaterally at middle of the mattress. Resident 54's right leg was observed over the rail on the left side of the bed. A CNA entered the room and shut the door. On 6/24/26 9:08 AM Staff 22 (CNA) stated Resident 54 at times attempted to get out of bed without assistance, hallucinated, and had rails positioned in the middle of the bed. Staff 22 stated Resident 54 was often found in bed in varying positions and at times had one leg over the bed rail. On 6/24/2026 9:36 AM Staff 15 (CNA) stated Resident 54 was always moving her/his legs in bed. On 6/25/26 at 10:12 AM Staff 16 (RA) stated Resident 54's mental status varied each day, some days she/he was very coherent and other days she/he hallucinated. Staff 16 stated Resident 54 was able to move her right side, could use the rail to reposition, and in the past was observed with her/his right leg over the rail. On 6/24/26 at 9:18 AM Staff 21 (LPN Resident Care Manager) stated rails were usually used by residents to assist with bed mobility. The rail placement was near the head of the bed. Staff 21 stated if the rails were longer, like quarter or half rails, the rails at times could extend from the head of the bed down to a resident's rib cage area. On 6/25/26 at 11:00 AM with Staff 21 Resident 54 was observed in bed with the rail placement in the middle of the bed (aligned with Resident 54's ribs to buttock region.) Staff 21 acknowledged if Resident 54 attempted to swing her/his right leg over the edge of the bed, the rails would inhibit her/his movement. Resident 54 was asked if she/he liked the rails, and she/he stated she/he hated the rails; they hurt her/his knees, and she/he am always hitting the rails. On 6/26/26 at 10:48 AM Staff 2 (DNS) stated the facility usually used assist/mobility bars. Staff 2 stated Resident 54 was busy in her/his bed and moved a lot. Staff 2 stated the rails were generally located at the head of the bed and there was no clear assessment or rationale for Resident 54's rail placement to be in the middle of the bed.

Based on interview and record review it was determined the facility failed to ensure x-rays were obtained as ordered for 1 of 2 sampled residents (#128) reviewed for change of condition. This placed residents at risk for delayed treatment. Findings include: Resident 128 was admitted to the facility in 2/2026 with a diagnosis of a pelvic fracture. Progress Notes revealed the following:-3/1/26 Resident 128's physician was notified Resident 128 had an unwitnessed fall; her/his oxygen saturation was 85 percent on room air; oxygen was applied and her/his oxygen levels increased to 93 percent. -3/1/26 Resident 128's physician response included stat (to be done immediately) chest x-ray. Resident 128's clinical record did not have x-rays obtained on 3/1/26.On 6/25/26 at 9:24 AM Staff 18 (RN) stated if an x-ray was ordered stat, the order was to be completed the day it was ordered. If the x-ray technician was not able to come to the facility, the physician was to be notified. On 6/26/26 at 10:32 AM Staff 2 (DNS) stated stat orders were to be obtained within four to six hours. Staff 2 stated if the orders were not able to be obtained within four to six hours the physician was to be notified. Staff 2 stated there was no x-ray obtained on 3/1/26 and no indication staff called the physician.

Based on observation, interview, and record review it was determined the facility failed to ensure menus were followed for 1 of 5 sampled residents (#78) observed during dining observations. This place residents at risk for lack of honored preferences and nutrition. Findings include: Resident 78 was admitted to the facility on [DATE] with diagnoses including aftercare following knee replacement surgery and pain.The 6/11/26 physician order revealed Resident 78 was allergic to gluten (a protein found in wheat, barley, and rye) and required a gluten free diet. On 6/12/26 a Change of Diet indicated Resident 78 was allergic to gluten, melon, carrots, and bananas. The 6/15/26 Food care plan indicated Resident 78 had Celiac disease (a condition in which eating gluten causes damage to the small intestine) and required a gluten free diet. The 6/22/26 admission Dietary Profile indicated Resident 78 had a regular diet, gluten allergy, and required a gluten free diet. On 6/22/26 at 11:54 AM, Resident 78 stated staff asked about her/his food preferences and allergies sometime after admission; however, staff did not appear to understand Celiac disease and which foods contained gluten. Resident 78 stated she/he was served foods inconsistent with her/his dietary needs for approximately four days despite notifying nursing and dietary staff. Resident 78 stated friends brought food to the facility because the kitchen kept serving her/him meals with gluten. Resident 78 expressed concerns of the dietary staffs understanding of Celiac disease and what foods she/he could consume. On 6/22/26 at 12:00 PM, Witness 1 (Friend) and Witness 2 (Friend) stated they brought food to Resident 78 because the facility continued to serve foods inconsistent with the resident's dietary needs related to Celiac disease. They stated Resident 78 described the experience as distressing and expressed concerns regarding the facility's meal service. On 6/25/26 at 10:16 AM, Staff 11 (RN) stated Resident 78 had Celiac disease and was served foods inconsistent with the resident's dietary needs on multiple occasions. Staff 11 stated dietary staff told her they had not received a dietary slip identifying the residents' gluten free diet. Staff 11 stated for the first couple days the resident's meal ticket did not indicate a gluten free diet and she returned Resident 78's breakfast because it was not gluten free. Staff 11 stated Resident 78 expressed concerns that consuming gluten could cause diarrhea and abdominal pain. On 6/26/26 at 1:32 PM, surveyors requested both a regular and alternative test tray. Surveyors observed the meal was not consistent with the posted menu, as beef stroganoff was served with orzo instead of the listed egg noodles. On 6/26/26 at 1:42 PM, Staff 23 (Dietary Manager) confirmed the meal served was not consistent with the posted menu and confirmed the menu was not followed as indicated.

Based on observation, interview, and record review it was determined the facility failed to provide palatable food to 2 of 5 residents (#s 19 and 78) reviewed for food. This placed residents at risk for weight loss and reduced quality of life. Findings include: 1. Resident 19 was admitted to the facility in 10/2025 with diagnoses including depression and anxiety.The 3/26/26 resident Council minutes revealed residents expressed concerns food lacked flavor and was not palatable. The 5/6/26 Quarterly MDS indicated Resident 19 was cognitively intact.On 6/23/26 at 9:14 AM, Resident 19 stated the food was too salty, did not look good, and was not good to eat.On 6/24/26 at 10:54 AM, Staff 24 (Cook) stated sometimes residents complained about cold food. Staff 24 stated every floor had a microwave that staff used to heat up the residents' food but then the food did not taste good.On 6/24/26 at 11:10 AM, Staff 23 (Dietary Manager) stated she was unaware of recent food complaints but was aware residents expressed concerns in the past about food being cold and not palatable. On 6/26/26 at 1:32 PM, surveyors requested both a regular and an alternative test tray. Surveyors received a quesadilla and steamed broccoli. The quesadilla was tough to chew along the edges, the cheese was not melted, and the broccoli was cold. Additionally, the tray included beef stroganoff with rice and a dinner roll. The beef stroganoff was bland and lacked flavor.On 6/26/26 at 1:42 PM, Staff 23 confirmed the food was cold and not palatable. Staff 23 also stated the beef stroganoff was bland and would have been improved with sour cream.2. Resident 78 was admitted to the facility on [DATE] with diagnoses including aftercare following knee replacement surgery and pain.On 6/22/26 at 11:54 AM, Resident 78 stated the food did not always taste good.On 6/24/26 at 11:10 AM, Staff 23 (Dietary Manager) stated she was unaware of recent food complaints but was aware residents expressed concerns in the past about food being cold and not palatable. On 6/26/26 at 1:32 PM, surveyors requested both a regular and an alternative test tray. Surveyors received a quesadilla and steamed broccoli. The quesadilla was tough to chew along the edges, the cheese was not melted, and the broccoli was cold. Additionally, the tray included beef stroganoff with rice and a dinner roll. The beef stroganoff was bland and lacked flavor.On 6/26/26 at 1:42 PM, Staff 23 confirmed the food was cold and not palatable. Staff 23 also stated the beef stroganoff was bland and would have been improved with sour cream.

Based on observation, interview, and record review it was determined the facility failed to ensure EBP (Enhance Barrier Precautions) were followed for 2 of 4 sampled residents (#s 9 and 28) reviewed for tube feeding and pressure ulcers. This placed residents at risk for cross contamination. Findings include: 1. Resident 9 was admitted to the facility in 5/2025 with a diagnosis of a stroke. Resident 9's Care Plan initiated 11/11/25 revealed she/he was to be in EBP related to her/his tube feeding. Interventions included gowns and gloves were to be worn with high contact tasks including bathing and personal hygiene. On 6/24/26 at 7:30 AM Resident 9's door was observed to be shut. Staff 19 (CNA) opened Resident 9's door and stepped out and summoned Staff 7 (LPN). Staff 19 was observed to be wearing scrubs and was not wearing a gown or gloves. Staff 19 then reentered Resident 9's room and shut the door. On 6/24/26 at 7:37 AM Staff 19 stated she assisted Resident 9 with personal hygiene and bathing. Staff 19 stated she wore a cloth gown, took it off to summon Staff 7 (LPN), reentered the room, and put on a clean cloth gown to continue assisting Resident 9 with personal hygiene. On 6/24/26 at 8:12 AM Staff 7 (LPN) stated if a resident was to have EBP, staff were to wear a disposable gown. Staff 7 stated she did not observe Staff 19 to wear a gown while providing care. On 6/24/26 at 10:24 AM Staff 20 (Infection Preventionist) stated when a resident was to have EBP staff were to wear nonpermeable disposable gowns, and not a cloth gown when providing high contact tasks. On 6/26/26 at 4:30 PM Staff 2 (DNS) stated staff were not to wear a cloth gown when providing high contact tasks when a resident was in EBP. 2.Resident 28 was admitted to the facility in 1/2026 with diagnoses including pressure ulcers, chronic lower extremity wounds, and MDRO (multidrug resistant organisms, germs that have become resistant to multiple antibiotics). A 6/2021 Center for Disease Control Consideration for Use of Enhanced Barrier Precautions (EBP) in Skilled Nursing Facilities identified that EBP was an approach of targeted gown and glove use for residents with wounds, regardless of the multidrug-resistant organism status of the resident, due to the common existence of organisms in nursing facilities. The 6/4/26 care plan included EBP related to chronic bilateral lower extremity wounds, and right rear thigh wounds. EBP was in place, gowns, gloves donned during the following care: dressing, bathing, showering, personal hygiene, brushing teeth, changing linens, changing briefs, assisting with toileting, wound care, and dressing changes. Strict hand hygiene before gloving and after glove removal was required. On 6/2/25 at 1:32 PM, an EBP sign, with instructions to don gown and gloves, was observed in the hall and outside the door of Resident 28's room. A supply of gowns was observed near the door. Random observations from 6/22/26 through 6/24/26 on day and evening shifts, multiple staff were observed entering Resident 28's room without PPE. On 6/23/26 at 8:35 AM Resident 28's EBP sign had been removed. On 6/25/26 at 2:34 PM Staff 6 (RN) entered Resident 28's room to perform wound care to her/his feet. Staff 6 did not perform hand hygiene. Staff 6 donned gloves but not a gown. Resident 28 had an open area to her/his toes and heel. Staff 6 stated she/he was not aware she/he needed to wear a gown for wound care. On 6/26/26 at 12:18 PM Staff 20 (Infection Preventionist) stated the physician orders were still active for Resident 28 to be on EBP, and she did not know why staff removed the EBP sign and PPE. Staff 20 stated there were still orders

Based on observation, interview and record review it was determined the facility failed to ensure a call light was accessible to a resident for 1 of 13 residents (#54) reviewed for staffing. This placed residents at risk for delayed care. Findings include: Resident 54 was admitted to the facility in 11/2026 with a diagnosis of a stroke. Resident 54's Care Plan revised 3/25/26 indicated she/he was at risk for falls and staff were to remind her/him to activate the call light for assistance. Observation on 6/23/26 at 8:23 AM revealed Resident 54's call light was not within reach. Staff 1 (Administrator) entered Resident 54's room and secured her/his call light within her/his reach. On 6/24/26 at 9:12 AM Resident 54 was observed in bed. Resident 54's call light was not on her/his bed. Staff 7 (LPN) entered Resident 54's room and located her/his call light under her/his bed. Staff 7 indicated the call light was to be secured to Resident 54's sheets or gown so she/he could reach it. On 6/24/26 at 9:36 AM Staff 15 (CNA) stated Resident 54 was able to activate the call light. On 6/26/26 at 10:48 AM Staff 2 (DNS) stated residents were to have their call lights within reach.

Based on interview and record review it was determined the facility failed to provide nutritional supplements as ordered for 4 of 5 residents (#s 305, 306, 307 and 308) reviewed for nutritional supplements. This placed residents at risk for weight loss and inadequate nutrition. Findings include:1. Resident 306 was admitted to the facility in 10/2024 with diagnoses including dysphagia (difficulty swallowing) and malnutrition.A physician order from 6/27/25 included 120 ml of Medpass 2.0, a nutritional supplement, to be provided to Resident 306 three times a day between meals.Review of the 10/2025 MAR revealed 9, which indicated the medication was unavailable, was entered on 10/12/25, 10/13/25, 10/14/25, 10/15/25, 10/20/25, 10/21/25, 10/22/25, 10/24/25, 10/25/25, 10/26/25 and 10/27/25 for Medpass 2.0. On 10/30/25 at 9:40 AM Staff 23 (Dietary Manager) stated she was responsible for ordering Medpass 2.0 and confirmed there was a delay in administrative approval for the order she submitted on 10/24/25. Staff 23 stated the order she submitted on 10/24/25 had not been approved by administration until 10/27/25. Staff 23 stated the Medpass 2.0 supplies had been insufficient on previous orders during 10/2025 due to food order budget restrictions from administration. Staff 23 stated the insufficient supply of Medpass 2.0 was due to having been limited to ordering one pack of Medpass 2.0 but was required to order 2 packs of the nutritional supplement. She stated the order approval delay on 10/24/25 and previous order restrictions resulted in Medpass 2.0 being unavailable for Resident 306 on 11 days during 10/2025.On 10/31/25 at 10:29 AM Staff 27 (LPN) stated the Medpass 2.0 supplement was unavailable just about every day since the transition of ownership. Staff 27 stated she checked throughout the facility to locate a supply but was unable to locate the Medpass 2.0. On 11/3/25 at 2:02 PM Staff 2 (DNS) stated the 9 notation on the MAR indicated the Medpass 2.0 supplement was not available. Staff 2 confirmed Resident 306 did not receive Medpass 2.0 as ordered on 10/12/25, 10/13/25, 10/14/25, 10/15/25, 10/20/25, 10/21/25, 10/22/25, 10/24/25, 10/25/25, 10/26/25 and 10/27/25.2. Resident 307 was admitted to the facility in 4/2021 with diagnoses including Parkinson's disease and malnutrition.An 8/12/15 cognitive assessment determined Resident 307 had normal cognitive function.A physician order from 8/20/25 included 120 ml of Medpass 2.0, a nutritional supplement, to be provided to Resident 307 three times a day between meals.Review of the 10/2025 MAR revealed 9, which indicated the medication was unavailable, was entered on 10/24/25, 10/25/25, 10/26/25 and 10/27/25 for Medpass 2.0.On 10/30/25 at 9:40 AM Staff 23 (Dietary Manager) stated she was responsible for ordering Medpass 2.0 and confirmed there was a delay in administrative approval for the order she submitted on 10/24/25. Staff 23 stated the order she submitted on 10/24/25 had not been approved by administration until 10/27/25. She stated this delay resulted in the supplement being unavailable for Resident 307 on 10/24/25, 10/25/25, 10/26/25 and 10/27/27.On 10/31/25 at 10:29 AM Staff 27 (LPN) stated the Medpass 2.0 supplement was unavailable just about every day since the transition of ownership. Staff 27 stated she checked throughout the facility to locate a supply, but it is usually not available. On 11/3/25 at 1:58 PM Resident 307 stated she/he did not receive a nutritional supplement on 10/24/25, 10/25/25, 10/26/25 and 10/27/25.On 11/3/25 at 2:02 PM Staff 2 (DNS) stated the 9 notation on the MAR indicated the Medpass 2.0 supplement was not available. Staff 2 confirmed Resident 307 did not receive Medpass 2.0 as ordered on 10/24/25, 10/25/25, 10/26/25 and 10/27/25.3. Resident 305 was admitted to the facility in 4/2023 with diagnoses including stroke, dementia and failure to thrive.A physician order from 1/5/24 included 120 ml of Medpass 2.0, a nutritional supplement, to be provided to Resident 305 four times a day due to her/his failure to thrive.Review of the 10/2025 MAR revealed 9, which indicated the medication was unavailable, was entered on 10/25/25, 10/26/25 and 10/27/26 for Medpass 2.0.A purchase order from the dietary department, dated 10/24/25, indicated Medpass 2.0 was submitted for approval on 10/24/25 but was not approved until 10/27/25.On 10/30/25 at 9:40 AM Staff 23 (Dietary Manager) stated she was responsible for ordering Medpass 2.0 and confirmed there was a delay in administrative approval for the order she submitted on 10/24/25. She stated this delay resulted in the supplement being unavailable for Resident 305 on 10/25/25, 10/26/25 and 10/27/27.On 10/31/25 at 10:29 AM Staff 27 (LPN) stated the Medpass 2.0 supplement was unavailable just about every day since the transition of ownership. Staff 27 stated she checked throughout the facility to locate a supply, but it is usually not available. On 11/3/25 at 2:02 PM Staff 2 (DNS) stated the 9 notation on the MAR indicated the Medpass 2.0 supplement was not available. Staff 2 confirmed Resident 305 did not receive Medpass 2.0 as ordered on 10/25/25, 10/26/25 and 10/27/25.4. Resident 308 was admitted to the facility in 9/2014 with diagnoses including dysphagia (difficulty swallowing) and hemiplegia (loss of motor function on one side of the body).A physician order from 8/15/23 included 118 ml of Medpass 2.0, a nutritional supplement, to be provided to Resident 308 three times a day between meals.A 10/1/15 cognitive assessment determined Resident 308 had normal cognitive function.Review of the 10/2025 MAR revealed 9, which indicated the medication was unavailable, was entered on 10/24/25, 10/25/25, 10/26/25 and 10/27/25 for Medpass 2.0.On 10/30/25 at 9:40 AM Staff 23 (Dietary Manager) stated she was responsible for ordering Medpass 2.0 and confirmed there was a delay in administrative approval for the order she submitted on 10/24/25. She stated this delay resulted in the supplement being unavailable for Resident 305 on 10/24/25, 10/25/25, 10/26/25 and 10/27/27.On 10/31/25 at 10:29 AM Staff 27 (LPN) stated the Medpass 2.0 supplement was unavailable just about every day since the transition of ownership. Staff 27 stated she checked throughout the facility to locate a supply, but it is usually not available. On 11/3/25 at 1:53 PM Resident 308 stated she/he did not recall receiving a nutritional supplement on 10/24/25, 10/25/25, 10/26/25 and 10/27/25.On 11/3/25 at 2:02 PM Staff 2 (DNS) stated the 9 notation on the MAR indicated the Medpass 2.0 supplement was not available. Staff 2 confirmed Resident 308 did not receive Medpass 2.0 as ordered on 10/24/25, 10/25/25, 10/26/25 and 10/27/25.

Based on interview and record review it was determined the facility failed to provide care in a timely manner for 1 of 3 residents (#303) reviewed for ADLs and transfers. This placed residents at risk for pain and discomfort related to delayed care. Findings include:Resident 303 was admitted to the facility in 2021 with diagnoses including breast cancer and congestive heart failure. A 9/23/25 Quarterly MDS revealed Resident 303 had a BIMS score of 15 which indicated the resident was cognitively intact.Resident 303's 9/2025 care plan revealed she/he required two-person assistance for bed mobility and transfers and was incontinent of bowel and bladder.A grievance was submitted by Resident 303 on 9/28/25 regarding the delay in being assisted to bed on the evening of 9/27/25. The grievance indicated Resident 303 stated she/he preferred to go to bed around 5:00 PM but was not assisted until approximately 9:00 PM. The resident reported she/he was aware there was only one CNA working on her/his floor that evening and expressed this was a staffing failure and totally unsafe. Resident 303 further stated she/he was in pain from being up in her/his wheelchair for so long. The grievance was reviewed by Staff 3 (Former Administrator), who acknowledged the incident occurred and verified staffing shortages contributed to the delay. On 10/30/25 at 12:35 PM Resident 303 stated she/he preferred to go to bed between the hours of 4:30 PM and 5:00 PM each evening to rest, watch television or use her/his computer. Resident 303 stated on the evening of 9/27/25, she/he was not assisted to bed until approximately 9:00 PM. Resident 303 stated her/his legs became painful from sitting in her/his wheelchair for an extended period, and she/he was drenched in urine by the time she/he was transferred to bed and changed. On 10/31/25 at 5:44 AM Staff 7 (RN) stated the facility was short staffed on the evening of 9/27/25. Staff 7 confirmed Staff 9 (CNA) worked alone for approximately four hours on the evening of 9/27/25. Staff 7 further stated Resident 303 complained her/his legs were hurting and had soaked through her/his brief. Staff 7 stated the resident appeared frustrated from the long wait that evening.On 10/31/25 at 2:36 PM Staff 9 (CNA) stated he worked alone for approximately four hours during the evening shift on 9/27/25. Staff 9 stated he was responsible for 20 residents, including several who required two-person assistance for transfers and care. Staff 9 further stated he was unable to assist Resident 303 to bed at her/his requested time because he was covering the floor without additional CNA support. Staff 9 stated at approximately 9:00 PM, he and the charge nurse were able to transfer Resident 303 to bed and provide incontinence care. Staff 9 indicated the resident told him she/he was sore from sitting for an extended period and her/his brief was soaked and her/his pants were damp.On 10/31/25 at 3:06 PM Staff 5 (Resident Care Manager/LPN) stated she was aware the facility was short-staffed on the evening of 9/27/25 because Resident 303 informed her. Staff 5 confirmed Staff 9 worked alone for approximately four hours, caring for 20 residents, seven of whom required two-person assistance. Staff 5 stated Resident 303 was not assisted to bed per her/hisrequest and preferences due to not having adequate staffing on 9/27/25.On 11/3/25 at 3:41 PM Staff 2 (DNS) confirmed the facility was short-staffed on the evening of 9/27/25 and acknowledged the incident involving Resident 303 occurred. Staff 2 stated it was her expectation Resident 303's needs and preferences were honored.

Based on interview and record review it was determined the facility failed to ensure a safe discharge for 1 of 3 sampled residents (#1) reviewed for discharges. This placed residents at risk for an unsafe discharge and potential rehospitalization. Findings include:Resident 1 was admitted to the facility on 4/2024, with diagnoses including fibular fracture.Resident 1's 4/15/24 Discharge Care Plan indicated the resident was anticipated to discharge home. Social Services was to arrange support services such as home health (HH) caregiver support, PT, and OT.A 6/12/24 Physician Note revealed the resident would benefit from HH, PT, and OT after discharge.A 6/12/24 Social Services Note revealed a referral was sent to a Home Health agency.A 6/14/24 Social Services Note revealed Resident 1 decided to remain at the facility and had paid for two weeks in advance.Resident 1's 6/19/24 Discharge Summary revealed the resident was discharged from the facility on 6/19/24 without a HH referral.On 9/5/25 at 1:57 PM, Staff 16 stated she did not recall what happened with the Home Health referral for Resident 1.On 9/8/25 at 9:38 AM, Witness 10 (Home Health) stated the agency received a referral for Resident 1 on 6/12/24 with the discharge planned for 6/14/24. The agency called Staff 16 on 6/14/24 as the referral was not complete and was informed that Resident 1 was no longer planning to discharge and to cancel the referral.On 9/8/25 at 12:25 PM, Resident 1 stated Staff 16 knew she/he planned to discharge home on 6/19/24. Resident 1 stated she/he was without caregiver supports until she/he arranged services and supports through her/his physician. Resident 1 stated her/his family member had to quit two jobs in order to provide ADL care until home health caregiver support services were in place. On 9/8/25 at 1:45 PM, Staff 1 (Administrator) and Staff 2 (DNS) acknowledged Resident 1 discharged home without a home health referral for caregiver support, PT, and OT services.

Based on observation, interview and record review it was determined the facility failed to properly dispose of expired medications for 3 of 3 medication storage rooms, 4 of 5 medication carts, and 1 of 3 medication storage refrigerators. This placed residents at risk for lack of medication efficacy and adverse reactions from expired medications. Findings include: The facility's Storage of Medications policy with revision date 11/2020 did not address vials of medications but indicated outdated medications were to be destroyed by the facility. The manufacturer insert indicated a multi-dose vial of Tuberculin should be dated when opened and thrown away after 30 days to avoid oxidation and degradation. During a review of the fourth-floor medication storage room on 3/11/25 at 3:24 PM, the following expired medication was found: - One box of nicotine transdermal 14mg patches with an expiration date of 2/2025. On 3/11/25 at 3:33 PM, Staff 27 acknowledged the transdermal patches were expired and not discarded. Staff 27 stated the expectation was for expired medications to be discarded. During a review of the third-floor medication cart on 3/11/25 at 3:52 PM, the following expired medications were found: - One bottle of saline nasal spray with an expiration date of 1/2025. - One bottle of liquid geri tussin (cough suppressant) with an expiration date of 10/2024. - One bottle of liquid acid reducer with an expiration date of 2/2025. On 3/11/25 at 3:59 PM, Staff 28 acknowledged the medications were expired and the expectation was expired medications were to be destroyed. Staff 28 admitted not knowing the facility's medication storage policy. During a review of the second-floor medication storage room on 3/11/25 at 4:05 PM, the following expired medications were found: - One bottle of vitamin C 250mg tablets with an expiration date of 2/2025. - One tube of Vitamin A&D Ointment with an expiration date of 12/2024. - One tube of triple antibiotic ointment with an expiration date of 1/2025. On 3/11/25 at 4:16 PM, Staff 16 acknowledged the medications were expired and the expectation was expired medications were to be destroyed. Staff 16 admitted not knowing the facility's medication storage policy. During a review of the second-floor medication cart on 3/11/25 at 4:21 PM, the following expired medication was found: - One bottle of liquid geri tussin with an expiration date of 9/2024. On 3/11/25 at 4:28 PM, Staff 16 acknowledged the medications were expired and the expectation was expired medications were to be destroyed. Staff 16 admitted not knowing the facility's medication storage policy. During a review of the skilled unit first-floor medication storage room on 3/13/25 at 10:05 AM, the following expired medications were found: - Two open and used multi-dose vials of Tuberculin (solution used in testing for Tuberculosis) with no open dates. - One bottle of sodium chloride tablets with an expiration date of 2/2025. On 3/13/25 at 10:25 AM, Staff 17 acknowledged the medications were expired and the expectation was for expired medications to be destroyed or sent back to the pharmacy. During a review of the skilled unit first-floor medication cart on 3/13/25 at 10:31 AM, the following expired medication was found: - One bottle of vitamin C 250mg tablets with an expiration date of 2/2025. On 3/13/25 at 10:40 AM, Staff 17 acknowledged the medications were expired and the expectation was for expired medications to be destroyed or sent back to the pharmacy. During a review of the skilled unit second-floor medication cart on 3/13/25 at 10:43 AM, the following expired medication was found: - One bottle of vitamin C 250mg tablets with an expiration date of 2/2025. On 3/13/25 at 10:50 AM, Staff 29 acknowledged the medications were expired and the expectation was for expired medications to be destroyed and order replacements if needed. Staff 16 admitted not knowing the facility's medication storage policy. On 3/13/25 at 3:56 PM, Staff 3 stated the expectation was for all staff handling medications to know and follow the medication storage policy. She stated the facility policy was to destroy expired medications and order replacements if needed. She stated Tuberculin multi-dose vials should be dated when opened and thrown away after 28 days.

Based on observation, interview and record review it was determined the facility failed to ensure food was labeled and stored in a manner to minimize spoilage and cross contamination for 1 of 1 kitchen and 3 of 3 dining room refrigerator units and freezers reviewed for sanitary conditions. This placed residents at risk for foodborne illness and unappetizing meals. Findings include: The facility's Preventing Foodborne Illness - Food Handling Policy dated ,d+[DATE] revealed the following: - Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized. The facility's Personal Food Storage dated ,d+[DATE] revealed the following: - Food or beverage brought in from outside sources for storage in facility pantries, refrigeration units, or personal room refrigeration units will be monitored by designated staff for food safety. - Designated facility staff will be assigned to monitor individual room storage and refrigeration units for food or beverage disposal. 1. The following items were observed in the facility's main kitchen: On [DATE] at 9:22 AM, the refrigerator had an unlabeled plastic wrapped stainless steel container filled with filets of a white product. On [DATE] at 9:25 AM, the freezer had a package of unlabeled and undated frozen red patties, which possibly was ground beef. On [DATE] at 11:28 AM, the dry storage room had cans of dented apple pie filling, black beans, and diced peaches. There was an unlabeled and undated open bag of croutons. On [DATE] at 9:30 AM, Staff 4 (Dietary Manager) acknowledged the unlabeled product in the plastic wrapped stainless steel container and stated the frozen red patties were veggie patties. Staff 4 stated food items were expected to be labeled and dated with the date they were prepared or opened. On [DATE] at 11:31 AM, Staff 4 acknowledged the dented cans and stated the dented cans were expected to be taken out of the pantry and placed into the office. Staff 4 acknowledged the bag of opened croutons and could not decipher the writing on the bag. Staff 4 reiterated the expectations of labeling and dating opened packages with the date the package was opened. 2. On [DATE] at 11:56 AM, the second floor Intermediate Care Facility (ICF) unit freezer had an unopened package of frozen purple Ube steamed buns unlabeled, undated and expired on [DATE]. On [DATE] at 11:58 AM, Staff 25 (CNA) was unable to confirm who the package belonged to and acknowledged the expiration date. On [DATE] at 3:42 PM, Staff 18 (LPN Resident Care Manager) confirmed the expired package in the freezer and stated dietary staff were responsible for cleaning out and monitoring the contents in the refrigerator. On [DATE] at 4:00 PM, Staff 20 (CNA) stated it was the responsibility of staff to take resident food items from the resident, label a name or room number onto the item, date any open or unopened product, and staff were to place item into the unit refrigerator. On [DATE] at 10:50 AM, Staff 4 (Dietary Manager) stated dietary staff restocked and checked refrigerators daily and were expected to throw away expired product from the unit refrigerators. 3. The following sign was posted on the third floor refrigerator door: - Attention Staff: Please date all containers when opened. From [DATE] at 1:04 PM to [DATE] at 10:16 AM, the following items were observed on the third floor of the ICF building: Third Floor ICF Refrigerator: - An opened container of vanilla nutritional supplement, not dated. - A tumbler with blue cap filled with white liquid, not labeled or dated. - A plastic container with red chunks of product, not labeled or dated. - An opened container of sour cream, not dated. Third Floor ICF Freezer: - A glass container of frozen blueberries, not labeled or dated. - Homemade popsicles held in their plastic popsicle mold, not labeled or dated. On [DATE] at 3:52 PM, Staff 19 (CNA) acknowledged the unlabeled and undated items in the refrigerator and freezer. Staff 19 stated not all CNAs cleaned out the refrigerators. On [DATE] at 3:42 PM, Staff 18 (LPN Resident Care Manager) stated dietary staff were responsible for cleaning out and monitoring the contents in the refrigerator. On [DATE] at 4:00 PM, Staff 20 (CNA) stated it was the responsibility of staff to take resident food items from the resident, label a name or room number onto the item, date any open or unopened product, and staff were to place item into the unit refrigerator. On [DATE] at 10:50 AM, Staff 4 (Dietary Manager) stated dietary staff restocked and checked refrigerators daily and were expected to throw away expired product from the unit refrigerators. 4. The following sign was posted on the fourth floor refrigerator door: - Attention Staff: Please date all containers when opened. From [DATE] at 1:15 PM to [DATE] at 10:10 AM, the following items were observed on the fourth floor of the ICF building's refrigerator: - A clear cup of white liquid with plastic wrap covering the top, not labeled or dated. - An opened container of thickened white liquid, not dated. The packaging stated to discard four days after opening. - An opened container of thickened juice, with no date which was opened. There was a date of ,d+[DATE] on the bottom of the container. On [DATE] at 4:00 PM Staff 20 (CNA) stated it was the responsibility of staff to take resident food items from the resident, label a name or room number onto the item, date any open or unopened product, and staff were to place item into the unit refrigerator. On [DATE] at 10:45 AM, Staff 4 (Dietary Manager) stated the date on the bottom of the thickened liquids were to indicate the date in which the liquid was delivered to the facility. Staff 4 stated when staff opened the containers, the expectation was for staff to immediately write the date visibly onto the container, as to not create a health hazard for residents. Staff 4 stated dietary staff restocked and checked refrigerators daily and were expected to throw away expired product from the unit refrigerators.

Based on observation, interview and record review it was determined the facility failed to assess residents for safe self-administration of medication for 2 of 2 sampled residents (#s 65 and 69) reviewed for self-administering medication. This placed residents at risk for an unsafe medication regimen. Findings include: 1. Resident 65 admitted to the facility in 4/2024 with diagnoses including kidney failure. Resident 65's 1/6/25 Quarterly MDS assessed her/him with a BIMS score of 15, which indicated the resident was cognitively intact. Resident 65's 3/11/25 Physician Orders included an order for Zinc Oxide External Paste 20 % which directed staff to apply to [genital area] topically two times a day for skin care, for three days and apply to affected areas topically as needed for skin care. An order for Hydrocortisone External Cream 2.5 % directed staff to apply to affected areas topically as needed for skin care, apply BID with Ketoconazole (antifungal medication) when skin folds were flared. On 3/11/25 at 9:27 AM, 12:34 PM, 3:30 PM and 3/12/25 at 8:49 AM, Resident 65 was observed to lay in her/his bed with one tube of the Zinc Oxide External Paste and two tubes of the Hydrocortisone External Cream on her/his window seal. Resident 65 stated the tubes were there for the past several months, she/he used the cream as needed and sometimes on her/his neck when it itched. Resident 65's health record showed no evidence she/he was assessed to self-administer the Zinc Oxide External Paste or Hydrocortisone External Cream. On 3/12/25 at 9:20 AM, Staff 7 (LPN/Resident Care Manager) confirmed and removed the tube of Zinc Oxide External Paste and two tubes of the Hydrocortisone External Cream from Resident 69's her/his window seal. Staff 7 stated Resident 65 was not assessed to self-administer the creams and she would expect a nurse to complete an assessment before allowing any resident to keep over-the-counter medications at their bedside. 2. Resident 69 admitted to the facility in 2/2025 with a diagnoses including dementia and diabetes. A 3/3/25 Admission MDS assessed Resident 69 with a BIMS score of 15, which indicated the resident was cognitively intact. On 3/10/25 at 10:13 AM, Resident 69 requested her/his cough drops from her/his bedside dresser drawer. Resident 69 stated she/he sucked on her/his cough drops often. On 3/11/25 at 12:53 PM and 3/13/25 at 8:55 AM Resident 69 was observed with three packs of Fisherman's Friend extra strong cough drops at bedside, packs were within her/his reach and she/he was sucking on something. Review of Resident 69's health record reveal no indication she/he was safe to self-administer cough drops from bedside. On 3/13/25 at 9:16 AM Staff 8 (LPN/Resident Care Manager) stated she was unaware Resident 69 used cough drops while in the facility and removed the cough drops from her/his room. Staff 8 stated she expected residents to be assessed by a licensed nurse for safe self-administration of cough drops and for the cough drops to be kept locked up. Staff 8 confirmed Resident 69 did not have a self-administration assessment completed to ensure Resident 69 was safe with the cough drops.

Based on interview and record review it was determined the facility failed to ensure residents were free from misappropriation for 1 of 1 residents (#357) reviewed for misappropriation. This placed residents at risk for lack of medication efficacy and loss of property. Findings include: Resident 357 admitted to the facility in 9/2024 with diagnoses including hip fracture and lung disease. A 9/20/24 physician order instructed staff to administer Oxycodone (a pain reliever) one to two tablets every four hours as needed for pain. A 9/24/24 Admission MDS revealed Resident 357 had a BIMS score of 14, which indicated the resident was cognitively intact, and Resident 357 had frequent pain and received PRN pain medications. A review of Resident 357's clinical record revealed the following: -Discharge paperwork dated 10/9/24 indicated Resident 357 took home 56 Oxycodone tablets. -Discharge Summary dated 10/9/24 indicated Resident 357 took home all medications. -Narcotic logbook records dated 10/9/24 and 10/11/24 revealed Resident 357 signed both pages indicating she/he took home all their 112 Oxycodone tablets. -A facility destruction log dated 10/11/24 indicated 56 of Resident 357's Oxycodone were destroyed by two facility staff. On 3/10/25 at 12:49 PM, Resident 357 stated she/he discharged from the facility on 10/9/25 with her/his belongings including all their medications in a stapled paper bag. Resident 357 stated when she/he arrived home the Oxycodone tablets she/he signed for were not in the bag with the other medications. Resident 357 stated she/he placed a call to the facility on [DATE] and spoke to Staff 15 (LPN) to report the missing Oxycodone. Resident 357 stated Staff 15 informed the resident she placed the Oxycodone in the stapled paper bag sent home with Resident 357. On 3/10/25 at 5:09 PM, and on 3/12/25 at 9:41 AM, Staff 15 stated she discharged Resident 357 on 10/9/24. She stated during the discharge conversation she went over all Resident 357's medications, and signed a form with Resident 357 showing all medications were sent home including 56 Oxycodone. Staff 15 stated Resident 357 called her a few hours after she/he discharged to report the 56 Oxycodone were not in the stapled paper bag sent home with her/him. Staff 15 stated she told Resident 357 to look again and call her back. Staff 15 stated Resident 357 did not call her back and she did not report the missing Oxycodone to upper management. On 3/12/25 at 10:11 AM, Staff 17 (CMA) stated she was aware Resident 357 called the facility on 10/9/24 to report she/he was missing 56 Oxycodone. Staff 17 stated she did not report the missing pain medications to upper management and was unsure why the Oxycodone were destroyed by facility staff. On 3/12/25 at 1:45 PM, Staff 14 (RNCM) stated she unaware of the missing Oxycodone until 3/10/25. Staff 14 acknowledged the 56 Oxycodone were not sent home with Resident 357 and was unsure why the 56 Oxycodone were destroyed by the facility staff. On 3/12/25 at 1:53 PM, Staff 3 (DNS) stated she was unaware of the missing Oxycodone until 3/11/25. Staff 3 acknowledged all 112 Oxycodone belonged to Resident 357 and should have been sent home with the resident. Staff 2 stated she was unsure why 56 Oxycodone were destroyed by facility staff.

Based on interview and record review it was determined the facility failed to protect the resident's right to be free from abuse by staff for 1 of 3 residents (#40) reviewed for abuse. This resulted in skin tears, increased anxiety and post-traumatic stress disorder (PTSD) for Resident 40. Findings Include: Resident 40 was admitted to the facility in 2019 with diagnoses including depression. Resident 40's 9/27/22 cognitive assessment indicated normal cognitive function. An incident report dated 12/6/22 indicated Resident 40 was upset regarding the noise early in the morning and asked Staff 27 (Agency LPN) and Staff 29 (Agency CNA) to be quiet while looking through the curtain to her/his roommate's side. Staff 29 told Resident 40 to stay on her side of the room and pushed Resident 40 back into her/his section using the armrests of Resident 40's wheelchair which Resident 40's arms were resting on. This resulted in a 2.75 cm x .72 cm skin tear on her/his left outer forearm and a 3.56 cm x 2.1 cm skin tear on the back of her/his right hand. A 12/7/22 at 11:52 AM Progress Note indicated the resident became distressed and tearful stating 'I feel like I'm getting worse emotionally. I'm going to have a breakdown. I'll take whatever you want to give' regarding medications. A 12/8/22 at 9:33 AM Progress Note indicated Resident 40 was reported to have experienced night terrors and was unable to sleep. Staff 26 reported Resident 40 was in distress when the 12/6/22 abuse incident was discussed. A 12/15/22 Progress Note indicated on 12/13/22 Resident 40 was prescribed prazosin (a medication used to reduce nightmares and general symptoms of PTSD) due to new onset of nightmares and diagnosis of PTSD. On 10/30/23 at 2:38 PM Resident 40 recalled the incident consistent with the incident report and stated she never wanted to see Staff 29 ever again. Resident 40 stated she/he experienced increased anxiety after the incident. On 11/2/23 at 3:51 PM Staff 27 (Agency LPN) stated she witnessed the 12/6/22 incident. Staff 27 stated Staff 29 forcefully pushed Resident 40 backwards into her/his room using the wheelchair armrest while her/his arms were on the armrests. Resident 40 reacted after the incident by yelling, look at what he did . I'm bleeding. Staff 27 stated Resident 40's skin was torn back on both arms and required immediate wound cleaning and bandaging. Staff 27 stated Resident 40 was very vocal and very upset after the incident. Staff 27 stated Resident 40's stress and anxiety continued for two to three weeks after the incident repeatedly saying, make sure he never comes back. Look what he did. Attempts to contact Staff 29 (Agency CNA) were unsuccessful. On 11/1/23 3:51 PM Staff 28 (LPN) confirmed Resident 40 was abused by Staff 29 which resulted in skin tears and triggered the resident's PTSD.

Based on observation, interview and record review it was determined the facility failed to follow care plan interventions, assess for care plan effectiveness, identify and implement new fall interventions and provide adequate supervision needed to prevent falls for 1 of 1 sampled resident (#57) reviewed for falls. This failure resulted in the resident having eight falls in ten months, one with serious injury, which resulted in the resident sustaining a fractured hip requiring surgery. Findings include: Resident 57 was admitted to the facility in 2020 with diagnoses including anxiety, depressive disorder and schizo-affective disorder (a mental health disorder). Resident 57's 7/3/23 Quarterly MDS indicated the resident had no cognitive impairments. Resident 57 required supervision for walking in her/his room, the hallway and for toilet transfers. Resident 57 was not on a toileting program. Resident 57's 8/27/23 5 Day MDS indicated the resident had severe cognitive impairment and required extensive assistance of two people for toileting and transfers. The resident was not steady moving from a seated to standing position, walking was unsteady and she/he was only able to stabilize herself/himself with staff assistance. Resident 57 was not on a toileting program. Resident 57's 10/3/23 Quarterly MDS indicated the resident had no cognitive impairment. The resident required supervision to touch assistance when moving from a sitting to standing position and during toilet transfers. Resident 57 was not on a toileting program. From 1/13/23 through 10/31/23, 11 fall risk evaluations were completed. Resident 57 was typically identified to be at a moderate to high fall risk. Resident 57's current Care Plan indicated the resident was at risk for falls related to cognitive problems, deconditioning, gait/balance problems, history of falls, history of self-transferring and self-ambulating. The following fall preventions were in place: -Ensure call light was within reach. Initiated 12/23/20. Revised 1/29/21. -Encourage resident to wear non-skid footwear at all times. Initiated 2/5/21. -Encourage resident to use a front wheeled walker (FWW) when ambulating for safe mobility per therapy. The resident self-ambulated despite reminders to ask for assistance without walker. Initiated 12/24/20. Revised 8/21/23. -One person assistance with transfers with FWW. Initiated 12/24/20. Revised 10/11/23. -The resident required one person supervision with FWW for toilet transfers; however, [she/he] self toileted and did not ask for assistance. If already in the bathroom provide frequent checks. Initiated 12/24/20. Revised 11/1/23. -The resident was sensitive to bright lights and often closed [her/his] eyes while trying to ambulate down the hallway. The resident had sunglasses. Encourage [her/him] to wear the sunglasses when up ambulating. Provide frequent reminders of this and to call for assistance. Initiated 4/5/21. -Review and update fall risk assessments quarterly, post any falls and PRN. Initiated 4/5/21. -Rule out potential causes of fall such as infection, medication side effects, diagnoses related and environmental. Initiated 4/5/21. -Do not leave [the resident] unsupervised in the bathroom or on the beside commode. Initiated 9/27/23. On 11/1/23 this intervention was discontinued and the level of supervision was decreased to frequent checks when in the bathroom. -Keep bed in the lowest position except during care. Initiated 9/27/23. -Mobility bars/bed cane. Initiated 9/27/23. -PT/OT evaluation and/or treatment if indicated. Initiated 9/27/23. -The resident required two person assistance with transfers. Initiated 9/27/23. -FWW for all ambulation. Initiated 9/27/23. -Use gait belt with all transfers. Initiated 9/27/23. From 1/10/23 through 10/28/23, Resident 57 experienced eight falls in the facility, one with serious injury which resulted in a fractured hip requiring surgical intervention. Fall investigations revealed the following: -1/10/23 at 6:35 PM Fall Investigation revealed Resident 57 fell in her/his room and sustained a 2 cm X 15 cm scratch on the left forearm and a skin tear on the fourth left finger. Resident stated she/he was going to the bathroom to take a shower. Summary: Resident continued with limited safety awareness and obsessive behaviors regarding taking showers. The resident continued to be at risk for falling. Falls may not be preventable. No new fall care plan interventions were put in place. -1/21/23 at 1:30 PM Fall Investigation revealed Resident 57 fell in her/his room while going to the sink to wash her/his hands. Resident 57 reported her/his legs became weak which contributed to the fall. The resident was ambulating without assistance. Summary: The resident had another fall. The resident has photosensitivity. Dark sunglasses were recommended but the resident no longer chose to wear them. Falls may be unavoidable. No new fall care plan interventions were put in place. -1/23/23 at 11:42 PM Fall Investigation revealed Resident 57 was found on the floor by her/his door in a sitting position. The nurse was called to come to the unit from the third floor to assess Resident 57. The resident reported she/he was trying to go to the bathroom and bumped into something. Summary: Resident 57 has had multiple falls to and from the bathroom. As per previous documentation, falls may be unavoidable due to resident's choices and mental health issues. -8/19/23 at 3:08 PM Fall Investigation revealed Resident 57 walked from the dining room unassisted and without a walker. Resident 57 was observed by a CNA down the hallway, zig-zagging across the hallway. The resident fell on to her/his right side. Resident 57 was known to have a gait imbalance and ambulated without assistance. Resident 57 was unable to walk after the fall and was sent to the hospital for an evaluation. Resident 57 sustained a hip fracture which required surgical intervention. Summary: Resident 57 self-ambulated from her/his room, to the dining room and on the way back to her/his room the resident fell . Resident 57 was supposed to be ambulating with SBA (stand by assistance) of 1 person with a FWW. Resident 57's care plan was not followed as she/he was supposed to have SBA with a FWW in order to ambulate in the hallway. No new fall care plan interventions were put in place. -9/18/23 at 11:01 AM Fall Investigation revealed Resident 57 was found down on the bathroom floor. Resident 57 stated she/he lost her/his balance. Resident 57 was assisted to the toilet and then back to her/his chair. Summary: Resident 57 had a history of falls. Her/his last fall resulted in a right hip fracture. The resident's medications increased her/his risk of falls. Resident 57 frequently covered her/his eyes due to light sensitivity and self-toileted. The resident had dark sunglasses; the resident did not use the call light. Falls were unavoidable. Will add frequent offers to toilet in the task and frequent checks. -9/26/23 at 2:45 PM Fall Investigation revealed Resident 57 was found in the doorway to her/his bathroom. Patient ambulated without assistance. Summary: The resident had a history of falls related to toileting. Resident 57 had medications that increased the risk of falls. Resident 57 was sensitive to light and had dark sunglasses. The resident did not use the call light. The resident had a history of self-toileting. Falls were determined to be unavoidable. Will add frequent offers to toilet in the tasks as well as frequent checks. Will schedule toileting before and after meals. -10/5/23 at 4:24 PM Fall Investigation revealed Resident 57 fell coming from her/his bathroom. The resident's walker was next to the toilet in the bathroom. The resident ambulated without assistance. Summary: The resident had a history of falls. Resident 57 exhibited impulsive/compulsive behaviors. Resident 57 frequently covered her/his eyes due to being sensitive to light and had dark sunglasses to help her/him ambulate more safely. The resident did not use the call light and had a history of self-toileting. Falls were determined to be unavoidable. No new fall care plan interventions were put in place. -10/28/23 at 7:30 PM Fall Investigation revealed Resident 57 attempted to transfer from her/his bed to the wheelchair and fell . Resident 57 stated her/his legs were too weak and she/he was unable to make it to the bed. The resident was transferring and ambulating without assistance. On 11/1/23, the care plan intervention, which directed staff not to leave the Resident 57 unsupervised while in the bathroom or on the commode, was discontinued and the supervision level was reduced to provide frequent checks on Resident 57 when she/he was in the bathroom. The facility failed to follow care plan interventions, re-assess current interventions and develop new interventions to ensure Resident 57 was adequately supervised and her/his falls were unavoidable. Resident 57 experienced eight falls from 1/10/23 to 10/28/23 and on 8/19/23 Resident 57 fell sustaining a fractured right hip. Resident 57 required surgical intervention to repair her/his broken hip. Random observations between 10/30/23 through 11/3/23 between the hours of 7:30 AM and 9:30 PM revealed the following concerns: -Resident 57 sat for hours on her/his bed with her/his privacy curtains drawn. Resident 57 was not visible from the hallway as staff passed by her/his room. -Staff frequently walked by Resident 57's room without checking on her/him. -No staff were observed using a gait belt with Resident 57 and her/his bed was never in the lowest position as per the care plan. -Staff did not provide two person assistance with transfers as per the care plan. -Resident 57 did not use a call light. -Resident 57 was never observed wearing her/his sunglasses. -Resident 57 was observed self-ambulating in her/his room and to/from the bathroom without staff noticing. In addition, the following concerns were observed: On 11/1/23 at 8:51 AM Resident 57 stood up and ambulated to the bathroom with Staff 6 providing SBA with a FWW. Staff 6 did not use a gait belt. Staff 6 left the resident in the bathroom and was picking up breakfast trays. At 9:11 AM Resident 57 exited the bathroom, walked to the sink and then returned to her/his bathroom without assistance. No staff were in the area to visualize Resident 57 ambulating from the bathroom. On 11/1/23 at 1:24 PM Resident 57 was standing at the door to her/his room yelling for assistance. A CNA intervened and walked the resident back to her/his bed then left the room. At 1:27 PM Resident 57 again ambulated to the door without assistance or using her/his FWW. The resident again yelled for assistance from the doorway. On 11/2/23 between 2:31 PM and 3:31 PM Resident 57 was observed ambulating with her/his FWW to the bathroom. During this time, Resident 57 ambulated to the bathroom, exited the bathroom, washed her/his hands at the sink and returned to her/his bed without staff noticing. No staff checked on the resident during this hour observation. On 11/1/23 at 9:33 AM Staff 4 (Agency RN) reported Resident 57 often fell because she/he had weak legs and got up on her/his own, a lot. She reported the resident did not have much space in her/his room which may contribute to her/his falls. Staff 6 stated staff were supposed to check on Resident 57 every time they passed by her/his room. Staff 6 reported the resident never used her/his call light. On 11/1/23 at 9:44 AM Staff 6 (CNA) stated it was difficult to provide adequate supervision to Resident 57 because there were only three CNA staff scheduled on day shift for 24-26 residents. On 11/1/23 at 10:53 AM Staff 7 (CNA) stated staff were supposed to check on Resident 57 every time they walked by the room but sometimes they were too busy to provide the level of oversight the resident needed. On 11/2/23 at 7:55 AM Staff 8 (LPN) reported Resident 57 had multiple falls due to self-transferring and ambulating without assistance. Staff 8 stated the resident's falls were a result of her/his psychotropic medications and light sensitivity. Staff 8 stated Resident 57 had sunglasses but the resident did not use them. She reported the resident required SBA of one person with a FWW for all ambulation. Staff 8 stated on 8/19/23, Resident 57 ambulated from her/his room all the way to the dining room without anyone noticing her/him until the CNA on the other end of the hallway saw him zig-zagging down the hallway without assistance. The resident fell , was sent to the hospital and diagnosed with a fractured hip. Staff 8 stated there were two CNAs working the evening Resident 57 fell and they were both in rooms helping other residents. On 11/2/23 at 9:08 AM Staff 10 (CNA) stated she worked the evening shift on 8/19/23 when Resident 57 fell . Staff 10 stated as she exited a different resident's room, she observed Resident 57 down the hallway, zig-zagging across the hall. She stated the resident was ambulating unassisted and without a FWW and fell . Staff 10 stated she screamed for help and it took some time before the nurse came. Staff 6 stated they had to wait for the CMA to return from a different floor before they were able to get Resident 57 off of the floor. On 11/3/23 at 12:19 PM Staff 3 (RNCM) stated Resident 57 had multiple falls. Staff 3 stated the resident did not utilize her/his call light for assistance. She reported staff were supposed to provide SBA with FWW for ambulation and complete frequent checks which she defined as peaking around Resident 57's curtain every time a staff member walked by the room. Staff 3 stated the only intervention that would keep Resident 57 safe would be one-to-one supervision but the facility could not provide that level of supervision because the facility did not have the staff. Staff 3 reported she did not complete an analysis of Resident 57's falls to determine any trends but was aware the resident typically fell when going to or from the bathroom. Staff 3 acknowledged the facility was responsible for keeping Resident 57 safe and the facility was not providing adequate supervision for Resident 57. On 11/3/23 at 2:09 PM and 11/6/23 at 10:04 AM Staff 2 (DNS) confirmed on 8/19/23 staff did not follow Resident 57's care plan which resulted in the resident sustaining a fractured hip requiring surgical intervention. Staff 2 acknowledged the level of supervision was not adequate to meet Resident 57's needs. She stated she needed to really drill down with Staff 3 and complete an analysis of Resident 57's falls and determine interventions with the assistance of the interdisciplinary team. Refer to F725.

1. Based on observation, interview and record review it was determined the facility failed to ensure sufficient staffing to meet resident care needs for 1 of 1 facility reviewed for sufficient and competent staffing. This failure resulted in Resident 57 having eight falls in ten months, one with serious injury which resulted in the resident sustaining a fractured hip requiring surgery. Findings include: The facility's 2/2017 Staffing Policy indicated the following: -The facility provided sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. -Staffing numbers and the skill requirements of direct care staff were determined by the needs of the residents based on each resident's plan of care. Resident 57 was admitted to the facility in 2020 with diagnoses including anxiety, depressive disorder and schizo-affective disorder (a mental health disorder). Resident 57's 7/3/23 Quarterly MDS indicated the resident had no cognitive impairments. Resident 57 required supervision for walking in her/his room, the hallway and for toilet transfers. Resident 57 was not on a toileting program. Resident 57's 8/27/23 5 Day MDS indicated the resident had severe cognitive impairment. Toileting and transfers required two person extensive assistance. The resident was not steady moving from a seated to standing position, walking was unsteady and she/he was only able to stabilize herself/himself with staff assistance. Resident 57 was not on a toileting program. Resident 57's 10/3/23 Quarterly MDS indicated the resident had no cognitive impairment. The resident required supervision to touch assistance when moving from a sitting to standing position and during toilet transfers. Resident 57 was not on a toileting program. From 1/10/23 through 10/31/23, 11 fall risk evaluations were completed. Resident 57 was typically identified to be at a moderate to high fall risk. Resident 57's 1/10/23 through 10/31/23 fall investigations revealed the resident experienced eight falls. On 8/19/23, Resident 57 sustained a right hip fracture which required surgical intervention: -1/10/23 (evening shift), 1/21/23 (day shift), 1/23/23 (night shift), 8/19/23 (evening shift), 9/18/23 (day shift), 9/26/23 (evening shift), 10/5/23 (evening shift), and 10/28/23 (evening shift). Random observations between 10/30/23 and 11/3/23 revealed the following concerns: -From 10/30/23 through 11/6/23 between the hours of 7:30 AM to 9:30 PM Resident 57 had her/his privacy curtains pulled and was not visible from the hallway on all observations. -On 10/31/23 at 1:37 PM a second floor resident smelled strongly of urine. -On 11/1/23 at 8:25 AM a call light was on in room [ROOM NUMBER] and the resident was yelling for help -On 11/1/23 between 8:51 AM and 9:11 AM Resident 57 ambulated to the bathroom, exited the bathroom, washed her/his hands at the sink and returned to her/his bed without assistance or being noticed by staff. -On 11/1/23 at 1:24 PM Resident 57 was standing at the door to her/his room yelling for assistance. A CNA intervened and walked the resident back to her/his bed then left the room. At 1:27 PM Resident 57 again ambulated to the door without assistance or using her/his FWW. The resident again yelled for assistance from the doorway. -On 11/2/23 between 2:23 PM and 2:47 PM the two second floor ICF evening CNAs were helping a resident who required two-person assistance with transfers, back to bed. No staff were visualized in the hallway for 24 minutes. -On 11/2/12 between 2:31 PM and 3:31 PM Resident 57, identified as a high fall risk (with a history of multiple falls), walked with her/his FWW to the bathroom, exited the bathroom and returned to her/his bed, unnoticed. During the 60 minute observation, no staff checked on the resident despite being care planned for frequent checks. -On 11/2/23 at 8:34 PM the call light in room [ROOM NUMBER] was activated for 34 minutes. No staff were visualized on the floor. -On 11/3/23 at 7:49 AM a strong urine smell was detected around room [ROOM NUMBER]. Interviews with staff revealed the following concerns: -On 11/1/23 at 9:44 AM Staff 6 (CNA) stated it was difficult to provide adequate supervision to the high fall risk residents, including Resident 57, because there were only three CNA staff scheduled on day shift for 24 to 26 residents. -On 11/1/23 at 10:53 AM Staff 7 (CNA) stated the second floor ICF unit had very heavy care residents and some behavioral residents, too. Staff 7 stated it was hard to provide oversight to high risk fall residents. Staff 7 stated staff were supposed to check on Resident 57 every time they walked by the room but sometimes they were too busy to provide the level of supervision the resident needed. Staff 7 stated the unit had at least 10 residents who required two-person assistance with transfers so often two staff were in a resident's room at one time. On 11/2/23 at 7:55 AM Staff 8 (LPN) stated on 8/19/23, Resident 57 ambulated from her/his room all the way to the dining room without anyone noticing her/him until the CNA on the other end of the hallway saw her/him zig-zagging down the hallway without assistance. The resident fell , was sent to the hospital and diagnosed with a fractured hip. Staff 8 stated there were two CNAs working the evening Resident 57 fell and they were both helping other residents. -On 11/2/23 at 8:31 AM Staff 9 (CNA) stated she typically worked day shift and was assigned the second floor ICF unit. Staff 9 stated the unit usually had 25 to 26 residents and only three CNAs scheduled on day shift. Staff 9 stated once in a while a float CNA was assigned to the unit but that did not occur very often. Staff 9 stated she notified the union regarding her staffing concerns. Staff 9 stated CNAs were unable to adequately supervise residents, unable to complete nail care when giving showers and unable to spend the time needed with residents because of low staffing. -On 11/2/23 at 9:08 AM Staff 10 (CNA) stated staffing was a big issue. Staff 10 stated agency staff were utilized almost every shift and they did not know the residents. Staff 10 stated she was typically assigned 12 to 13 residents on evening shift because only two CNAs were usually assigned on each ICF unit for evening shift. Staff 10 stated the facility determined staffing based on the State minimum staffing ratios and not to the acuity needs of the residents. Staff 10 stated it was difficult to provide good care. She reported some residents took a long time to care for so call light response times were often 30 minutes or more which made residents mad so they got up on their own and got hurt. Staff 10 stated she worked the evening shift on 8/19/23 when Resident 57 fell . Staff 10 stated as she exited a different resident's room, she observed Resident 57 down the hallway, zig-zagging across the hall. She stated the resident was ambulating unassisted and without a FWW and fell . Staff 10 stated she screamed for help and it took some time before the nurse came. Staff 10 stated they had to wait for the CMA to return from a different floor before they were able to get Resident 57 off of the floor. -On 11/2/23 at 8:39 PM Staff 40 (CNA) stated the second floor ICF unit had residents who required very heavy care. She stated there were usually two CNA staff assigned on the evening shift and there were many residents who required two-person assistance with transfers so two CNAs were often in residents' rooms at the same time. Staff 40 stated oftentimes the day shift did not have time to get residents requiring two-person assistance back to bed on their shift so it made it very busy on the evening shift. Staff 40 stated sometimes showers had to be bumped and there were times when she was too busy to take breaks. -On 11/2/23 at 8:40 PM Staff 41 (CNA) stated on the evening shift, third floor ICF unit there were several heavy care residents that required two-person assistance but due to staffing issues two people were often not available to provide the needed assistance which was dangerous. -On 11/2/23 at 8:52 PM Staff 18 (CNA) stated this evening, she spent over one hour trying to track down a resident's dinner tray. She stated the facility staffed float CNAs the past few days because the State was at the facility but usually they did not have float staff assigned or if there was a float staff assigned they were often pulled to cover call-ins. Staff 18 stated on the evening of 11/1/23, there was a resident on the second floor covered in feces, two different times, and the other CNA on duty was not available to help because she took frequent breaks which left Staff 18 running all night. Staff 18 stated a male resident in a wheelchair tracked her down to yell at her because the call light response times were so delayed. -On 11/2/23 at 8:53 PM Staff 16 (Agency CNA) stated this was the second time he worked at the facility and he was assigned a float position covering the second, third and fourth ICF floors. He reported when he arrived, he received a report regarding his second floor residents but not the third or fourth floor residents. Staff 16 stated he did not have access to the electronic health records until around 5:00 PM so he was unsure of the residents' needs, precautions or which residents were high fall risks. Staff 16 stated there was no way to communicate between the floors and no way to know when call lights were activated on his other units. On 11/2/23 at 10:11 AM Staff 13 (Staffing Coordinator) and Staff 14 (Staffing Assistant) reported staffing was determined based on the State minimum staffing ratios and not to the acuity needs of the residents. Staff 13 reported the ICF floors had high acuity residents and many residents required two-person assistance for transfers, one-to-one assistance with feeding and several residents were determined to be high fall risks. Staff 13 and Staff 14 reported staffing was not adequate on ICF units and the day and evening shifts would benefit from at least one additional CNA staff on each unit. Staff 13 stated staff from the Skilled unit asked for additional staffing help but she was unable to provide the requested help. Staff 13 stated she did not check agency staff competencies so she did not know if agency staff were competent to work in the nursing home setting but she tries them out and if they are not good then she blocks them. Staff 13 stated there was no formal orientation for agency staff but they used to have orientation notebooks at each nursing station. Staff 13 stated each floor nurse was responsible for orienting agency staff. On 11/3/23 at 12:19 PM Staff 3 (RNCM) stated the only intervention that would keep Resident 57 safe would be one-to-one supervision but the facility could not provide that level of supervision because the facility did not have the staff. Staff 3 acknowledged the facility was responsible for keeping Resident 57 safe and the facility did not provide adequate supervision to Resident 57. On 11/3/23 at 2:09 PM and 11/6/23 at 10:04 AM Staff 2 (DNS) confirmed on 8/19/23 staff did not follow Resident 57's care plan which resulted in the resident sustaining a fractured hip requiring surgical intervention. Staff 2 acknowledged the level of supervision was not adequate to meet Resident 57's needs. On 11/6/23 at 9:21 AM Staff 1 (Administrator) and Staff 2 (DNS) reported the facility staffed according to the State minimum staffing ratios and not to the acuity needs of the residents. Staff 1 and Staff 2 stated the facility did not review agency staff's competencies but assumed they were competent to work in the nursing home setting because they were licensed. 32543 2. Based on interview and record review it was determined the facility failed to respond timely to residents' call lights for 1 of 3 sampled residents (#192) reviewed for staffing. This placed residents at risk for unmet care needs and accidents. Findings include: Resident 192 was admitted to the facility in 2023 with diagnoses including neck fracture. A review of Resident 192's call light response time record from 1/20/23 through 2/28/23 revealed call light wait times of 20 minutes or greater on the following dates: - 1/26/23 at 3:12 PM for 28 minutes. - 1/26/23 at 8:35 PM for 28 minutes. - 1/27/23 at 7:00 PM for 20 minutes. - 1/28/23 at 9:36 AM for 24 minutes. - 1/30/23 at 8:56 PM for 27 minutes. - 2/1/23 at 4:08 AM for 21 minutes. - 2/1/23 at 7:07 PM for 21 minutes. - 2/2/23 at 7:57 AM for 27 minutes. - 2/4/23 at 5:26 AM for 22 minutes. - 2/4/23 at 5:32 PM for 22 minutes. - 2/4/23 at 8:25 PM for 42 minutes. - 2/7/23 at 8:36 PM for 22 minutes. - 2/8/23 at 9:48 PM for 30 minutes. - 2/16/23 at 10:24 AM for 21 minutes. - 2/16/23 at 10:27 PM for 21 minutes. - 2/17 /23 at 9:05 AM for 21 minutes. - 2/18/23 at 3:44 PM for 30 minutes. - 2/27/23 at 3:22 PM for 21 minutes. - 2/27/23 at 6:36 PM for 21 minutes. On 11/3/23 at 12:05 PM Resident 192's call light record was reviewed with Staff 2 (DNS) who stated a 20 minute call light wait time was at the top of what they would like to see.

Based on interview and record review it was determined the facility failed to ensure a resident received adequate supervision to prevent a fall for 1 of 3 sampled residents (#1) reviewed for falls. This put residents at risk for potentially avoidable incidents. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A public complaint was received on 5/3/18 which indicated the resident was left unattended on the bedside commode and fell . Witness 1 (Complainant) indicated the resident previously experienced a fall at her/his memory care facility, sustained a [MEDICAL CONDITION] and was hospitalized . The resident was discharged from the hospital to the nursing facility. Witness 1 stated within three hours of admission to the nursing facility the resident was left on the bedside commode, fell and sustained a 2-3 inch laceration which required stitches. A nursing facility form labeled HOSPITAL REPORT dated 4/14/18 at 3:30 PM indicated the resident had a right [MEDICAL CONDITION], was forgetful with dementia and had mixed continence/incontinence. The resident was noted to be weight bearing as tolerated and required two person transfer assistance to the commode. A hospital discharge summary dated 4/14/18 indicated the resident had severe dementia and previously resided in a memory care facility where she/he sustained a fall with a resulting [MEDICAL CONDITION]. The resident stabilized and was discharged to a skilled nursing facility for continued physical therapy with the plan to return to her/his previous memory care facility. A facility admission nursing data base with an effective date of 4/14/18 indicated the resident was oriented to person and lethargic. The resident's prior level of function was marked as dependent and the resident was admitted related to a ground level fall with a [MEDICAL CONDITION]. The assessment indicated the resident had three falls in the last month and 4-5 falls in the last six months per the resident's family. A facility incident investigation dated 4/14/18 at 7:41 pm indicated the resident fell from the bedside commode and cut her/his head. The resident was observed attempting to self transfer out of the bed and Staff 4 (CNA) assisted the resident to the bedside commode at the resident's request. Staff 4 left the room to get clean bedding for the resident and when he returned the resident was on the ground and other staff were present. A witness statement from Staff 4 stated he gave the resident the call light and told her/him not to transfer back to bed until he returned. The investigation indicated no abuse or neglect was suspected. The resident's care plan dated 4/16/18 indicated the resident had an ADL performance deficit related to confusion, dementia and musculoskeletal impairment. The resident required two staff assistance to use the toilet and to transfer. The resident was noted to have experienced an actual fall with serious injury. The resident was noted to have a recent [MEDICAL CONDITION] and a history of falls. The resident's undated kardex (CNA care plan) indicated the resident was not to be left unsupervised in the bathroom or on the bedside commode, keep the bed in the locked position at all times and the resident was to wear non-skid foot wear at all times. The resident required two staff assistance for transferring, mobility and toilet use. No care plan information prior to 4/16/18 was located. A hospital after visit summary dated 4/14/18 indicated the resident was treated for [REDACTED]. The resident was started on antibiotics for the UTI and had three staples in place to the [MEDICAL CONDITION]. The resident's staples were to be removed in 10-14 days. The resident's (MONTH) (YEAR) MAR indicated [REDACTED]. No medications were documented on 4/14/18. The resident received one dose on 4/15/18 for a pain level of 3, two doses on 4/16/18 for a pin level of 7 in the morning and a pain level of 4 in the early evening. The resident continued to receive one dose of [MEDICATION NAME] each day for pain level varying from 5-9. The resident's pain was rated on a pain scale of 0-10, 0 being no pain and 10 being extreme pain. A nursing progress note dated 4/14/18 at 1:20 PM indicated the resident was admitted with a [DIAGNOSES REDACTED]. The resident's prior level of function was dependent. The resident arrived via a wheelchair and was transferred with the assistance of two staff. The resident was oriented x1 (person) had adequate hearing and clear speech. The resident was additionally noted as always incontinent of bowel and bladder. A nursing progress note dated 4/15/18 at 7:19 AM indicated the resident was admitted on late evening shift; initial contact with the resident was following a fall at 7:40 pm on 4/14/18. The resident was found on the floor on her/his back after attempting to get up form the commode without assistance. The resident sustained [REDACTED]. Interviews conducted 5/31/18 through 6/1/18 between 8:30 AM and 1:30 PM showed: Staff 4 (CNA) indicated he was not familiar with the resident or her/his care plan at the time of the fall. Staff 4 stated he did not check the care plan as he was in a hurry. When he entered the room the resident was already trying to get out of bed. Staff 4 offered the resident the bedpan but the resident requested the bedside commode. Staff 4 assisted the resident to the commode and then left the room for just a moment to get new bedding. When he returned the resident was on the ground and other staff were present. Staff 4 stated he should have checked the care plan and stayed with the resident because he was not familiar with the resident. Staff 4 thought the resident would be ok for a few minutes. Staff 7 (RNCM) indicated the resident arrived late in the day and it was determined the report from the hospital was not an accurate picture of the resident. The resident's care plan was not done within the first 24 hours which was their rule of thumb; the care plan information was all dated 4/16/18. Staff 7 stated it appeared both admission nurses completed the resident's admission which was not the normal procedure. Staff 4 (CNA) did not have a good understanding of the resident and after putting the resident on the bedside commode he left the room and the resident fell . Staff 7 indicated when the resident returned from the hospital, after the fall, a sitter was instituted to stay with the resident at all times. The resident was more confused, combative and made repeated attempts to get up on her/his own. Staff 7 was not sure what happened with the initial care information for the resident. Staff 6 (RN) indicated he had no interaction with the resident prior to the fall on 4/14/18. Staff 6 stated he had not received any information or reports about the resident and was unsure how long the resident was at the facility prior to the fall. CNA staff came and reported the resident was on the ground so he went to assess the resident. The resident's vital signs were stable but did have bleeding from the back of her/his head. Staff 6 was concerned about a bleed so the resident was sent to the hospital for a CT scan and evaluation. The resident returned to the facility several hours later with staples in place to the back of her/his head. Staff 8 (RN) indicated he was not working at the time the resident was admitted on Saturday 4/14/18. When he returned on 4/15/18 he was told the resident's admission needed to be completed so he finished the needed items. Staff 8 stated the resident answered questions but seemed confused so he contacted the resident's son for much of the information. Staff 5 (RN) indicated 4/14/18 was a very busy day with multiple admissions; Resident 1 admitted later in the day but she could not remember exactly when. She heard a loud noise and headed to the resident's room. The resident was on the floor with her/his brief around her/his knees and was found to have a wound to the back of the head. Staff 5 stated the physician was notified, the resident was sent to the hospital for evaluation and returned to the facility a few hours later with staples in place. Staff 5 stated prior to the resident's admission the hospital reported the resident was oriented only to person and had a [MEDICAL CONDITION]. The hospital did not report any behaviors. Staff 5 further indicated she was working on other admissions and did not interact with the resident prior to responding to the resident's fall. Staff 5 stated when a new admission was scheduled she normally reported the resident's basic information such as orientation, transfer status, continence and any other safety items to the charge nurse and CNAs prior to the resident arriving at the facility. Staff 5 was unsure if her reports regarding the resident were passed on to the evening shift staff. Staff 5 indicated the resident should not have been left alone on the bedside commode based on her/his orientation status and [MEDICAL CONDITION].

Based on interview and record review it was determined that the facility failed to assess and document the health status of 1 of 3 sampled residents (#1) who experienced falls. Resident 1 experienced a change of condition which included a [MEDICAL CONDITION] with ongoing pain. Findings include: The Oregon State Board of Nursing (OSBN) April 15, 2011 Scope of Practice for Registered Nurses [PHONE NUMBER] (2) (A) Collect objective and subjective data from observations, examinations, interviews, and written records in an accurate and timely manner as appropriate to the client's health care needs and context of care; (B) Documenting nursing interventions and responses to care in an accurate, timely, thorough, and clear manner(D) Anticipating and recognizing changes or potential changes in client status; Identifying signs and symptoms of deviation from current health status. Resident 1 was admitted to the facility with [DIAGNOSES REDACTED]. Resident 1 was essentially non-verbal and communicated primarily with gestures. The resident was dependent for ADLs and was non-ambulatory. The resident propelled herself/himself in her/his wheelchair with the use of her/his left arm. On 4/25/11 at 8:45 pm, the resident fell out of her/his wheelchair sustaining a right [MEDICAL CONDITION] and a hematoma of the right temple. Staff 3, RN performed the assessment following the fall. The Incident Report (IR) and the NN described a 2 x 2 cm bruise of the right temple and the resident's neurological status. The IR and the NN did not include an assessment of the resident's range of motion of her/his extremities, did not include if external rotation or shortening of the extremities were present or if there was any bruising or swelling. On 4/26/11 at 7:30 am the ADL Flowsheet revealed the resident was in her/his wheelchair and was returned to bed as she/he complained of pain. Staff 7, LPN wrote an entry in the NN at 9:05 am and revealed a family member requested an x-ray. Staff 7 documented in the NN at 9:45 am that the resident complained of pain of the right hip with movement. An assessment of the right lower extremity or right hip area was not documented. Staff 7 documented in the NN at 1:15 pm the resident again complained of right hip pain with provision of care and, "Noted some swelling of right hip, without bruising or redness." On 4/26/11 at 4:00 pm the NN revealed an x-ray of the resident's right hip was done. At 6:00 pm the x-ray revealed a right [MEDICAL CONDITION]. The resident was transported to the hospital at 7:10 pm. The ER report revealed the resident's right leg was externally rotated. "Possible worsening of mental status with acute [MEDICAL CONDITION], urinary tract infection and head trauma from a fall. The patient clearly landed with some force on the right side of (her/his) head." In interview on 5/19/11 at 10:50 am, Staff 2, RNCM, stated an assessment should have been completed at the time of the incident. In interview on 5/19/11 at 1:15 pm, Staff 7 stated she did not do an assessment to determine if the right leg was externally rotated, if there was shortening and only noted "some swelling." In interview on 5/19/11 at 3:00 pm, Staff 3 stated she was the charge nurse on 4/25/11 the evening of the fall. She stated she performed a complete assessment of the resident following the fall and did not document her findings. An Incident Analysis Report of 4/28/11 written by Staff 2 indicated Staff 3 did not find any external rotation or shortening of the resident's right lower extremity on 4/25/11. Staff 3 confirmed she did not document an assessment related to the right hip and leg immediately following the fall on 4/25/11. Refer to F 323

Based on interview and record review it was determined that the facility failed to provide the necessary assistive devices for 1 of 3 sampled residents (#1) who experienced falls. Resident 1 sustained a right temple hematoma and right hip fracture. Findings Include: Resident 1 was admitted to the facility with [DIAGNOSES REDACTED]. The resident was essentially non verbal, dependent for ADLs and non-ambulatory. The resident was able to propel in her/his wheelchair with the use of the left arm. The 2/27/11 Quarterly MDS revealed the resident was at risk for falls related to right sided [DIAGNOSES REDACTED], weakness, medical [DIAGNOSES REDACTED]. The resident did not have a history of attempting to rise from her/his wheelchair without assistance. The resident fell from her/his wheelchair on 12/8/10 and a non-skid pad was placed beneath the wheelchair cushion. On 3/25/11 the resident experienced a fall from her/his bed. The care plan was revised and included a bed alarm with floor pads on both sides of the bed. An IR of 4/25/11 revealed at approximately 8:45 pm the resident was found on the floor in her/his room at the head of the bed with the wheelchair at her side. The resident was found on her/his right side and had a right temple hematoma which measured 2 x 2 cm. The IR and the NN did not include an assessment of the resident's range of motion of the lower extremities, if external rotation was present, if shortening of an extremitiy was noted or if there was any bruising or swelling of the right hip. It was found during the fall investigation that the foot rests had been removed from the resident's wheelchair prior to the fall. On 4/26/11 the ADL flowsheet revealed the resident was up in her/his wheelchair and complained of pain at 7:30 am and was returned to bed. The NN of 9:05 am revealed a (family member) requested an x-ray be done. A NN at 9:45 am revealed the resident complained of pain of her right hip with movement. An assessment was not done of the right lower extremity or of the right hip area. NN at 1:15 pm revealed the resident complained of right hip pain with care provided. "Noted some swelling right hip, without bruising or redness." On 4/26/11 the NN revealed an x-ray of the right hip was done at 4:00 pm. At 4:10 pm the NN revealed staff requested the resident to transfer to a bedside commode but the resident refused. At 6:00 pm the x-ray report revealed the resident had a right hip fracture. The resident was transported to the hospital at 7:10 pm. The 4/26/11 ER report revealed the resident's right leg was externally rotated. "Possible worsening of mental status with acute hip fracture, urinary tract infection and head trauma from a fall. The patient clearly landed with some force on the right side of (her/his) head." In interview on 5/19/11 at 10:50 am, Staff 2, RNCM, stated an assessment of the right hip was not documented until 4/28/11 following the x-ray report of 4/26/11. "The assessment should have been done at the time of the incident." Staff 2 wrote an Incident Analysis on 4/28/11 and included contributing factors to the fall. "When (the resident) leans forward with (her/his) feet in the elevated foot rests her body positioning is more balanced." In interview on 5/19/11 at 1:15 pm, Staff 7, LN, stated she was the day charge nurse on 4/26/11. She reported the resident did not want her/his right leg moved as it was painful. She stated she did not assess the resident to determine if there was external rotation or other signs and symptoms of a possilbe fracture. She documented in the NN on 4/26/11 at 1:15 pm that there was some swelling of the right hip and the hip area was without bruising or redness. In interview on 5/19/11 at 2:00 pm, Staff 8, PT, stated the resident always had foot rests in place. She reported the resident was very small and the foot rests brought her/his knees higher and pushed her/his hips back to a more secure angle. She stated it was standard practice if a resident did not propel themselves in a wheelchair using their feet they were to have foot rests. "Without the footrests it posed risks of getting their legs caught and falling out of the wheelchair." In interview on 5/19/11 at 2:50 pm, Staff 5, CNA, stated she found the resident on the floor and called for the nurse. "We lifted (her/him) back to bed using a sheet. I saw a bruise on (her/his) right temple." In interview on 5/19/11 at 3:00 pm, Staff 3, RN, stated she was the charge nurse on the evening of the fall on 4/25/11. Staff 3 reported she performed a complete assessment of the resident at the time of the fall but did not document her findings on the IR or the NN. "I never realized the CNA had taken the foot rests off. If I had known I would not have left them off." Staff 3 reported the resident always had the foot rests in place when she/he was up in the wheelchair. The Incident Analysis reported Staff 3 saw the resident at 8:30 pm and asked the resident if she/he wanted to go to bed and the resident refused. In interview on 5/19/11 at 3:15 pm, Staff 4, CNA, stated the resident was in her/his wheelchair and he placed the resident at the head of her/his bed and turned the television on. He reported the resident pointed at the knob at the side of the wheelchair which adjusts the foot rests. He stated he removed the foot rests and she/he stopped pointing. He reported that when he removed the foot rests the resident's feet did not touch the floor and her/his legs were dangling. The 5/3/11 hospital discharge summary revealed the resident was not a candidate for surgery based on her/his comorbidities. The report indicated the the resident's head trauma may have played a role in her/his ongoing altered mental status. The report revealed pain control was the main issue during her/his hospitalization . "The odds are this hip fracture will be a terminal event, or will soon lead to medical complications [REDACTED]. .

Based on observation, interview, and record review, it was determined that the facility failed to thoroughly investigate, report to facility administration and State agencies, four incidents involving 3 of 13 sampled residents (#'s 1, 8 & 12) to rule out abuse/neglect. The failure of the facility to identify and investigate incidents to rule out abuse/neglect resulted in immediate jeopardy to the three residents. Findings include: Review of the facility's Abuse Investigations policy and procedures indicated that "all reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by community management." Review of the facility's Abuse Prevention Program policy and procedures defined neglect as "a failure or omission on the part of a care giver to provide the care, supervision, and services necessary to maintain the physical and mental health of a resident." On 3/15/11 at 3:46 pm, following consultation with State Agency Survey Supervisors, the surveyors informed Staff 1, Director of Operations, that the failure of the facility to ensure that their policies and procedures regarding abuse and neglect were followed constituted a situation of immediate jeopardy to the residents. Surveyors requested a plan of correction, to immediately protect residents from harm, be developed and implemented. On 3/15/11 at 4:45 pm, a plan of correction was provided by the facility to ensure that their policies and procedures regarding abuse and neglect were followed. It was accepted by the survey team. The immediate jeopardy was abated on 3/15/11 at 4:54 pm. 1a. Resident 8 was admitted in 1/2010 with [DIAGNOSES REDACTED]. The resident's 12/30/10 NN indicated the resident had "some blood on her brief". When the resident was checked, it was noted that there was "blood on brief and vagina". The note also indicated that the resident complained of "pain/discomfort to area". There was no documented evidence that an investigation had been initiated to rule out abuse. During interviews on 3/15/11 at 10:30 am and 12:30 pm, Staff 16, LPN, stated that on 12/30/10, a CNA (Staff 16 could not recall which one) informed her of some blood that was observed in the resident's brief and vaginal area. Staff 16 stated that she checked the resident's peri-area for any open areas and did not notice any open areas. According to Staff 16, this was the first time she could recall the resident having blood in her vaginal area. Staff 16 further stated that there was a small amount of blood that was observed and that the cause of the bleeding was never determined. When asked if an investigation had been initiated, she replied that she did not initiate one, but immediately had informed the resident's physician and Staff 6, RNCM. During interview on 3/15/11 at approximately 3:00 pm, Staff 6, RNCM, stated that she was informed of the resident's vaginal bleeding on 12/30/10. When asked if the resident's vaginal bleeding would be something that would be investigated or reported, she replied, "don't need to report it, because it is medical, why should it be reported." She then stated that there was "a small, trace amount of blood" and that "maybe she was having her period, because that can happen to women after [MEDICATION NAME]." When asked about any follow up, she replied that she examined the resident and asked the resident if anyone had hurt her and that the resident replied no. Staff 6 acknowledged that she had not documented this. When asked if she had considered abuse as a possibility, Staff 6 replied that she had not. When asked about the facility's policy and procedures regarding reporting, Staff 6 stated that she did not know the facility's policy and procedures regarding reporting and did not have a copy of the policies in her office. When asked what she would report and investigate, she replied "it would depend on the resident". During interview on 3/15/11, at 3:20pm, Staff 2, DNS, stated that she had just been informed that day, by Staff 6, of the resident's vaginal bleeding incident. When asked if she would have investigated this incident, she replied that she would have definitely investigated this incident in order to rule out abuse. Staff 2 stated that she was not made aware of the resident's vaginal bleeding until 3/15/11, and if she had known, she would have spoken to the resident and checked for any signs/symptoms of abuse. During interview on 3/16/11 at 3:50 pm, Staff 6 stated that abuse was not her first thought. She described Resident 8 as "alert and 100% oriented". She further stated that based on her findings and speaking to the resident, she did not believe that it warranted an investigation of abuse. Staff 6 acknowledged that there was no documentation of her assessment. b. Resident 8 had a 12/30/10 NN, which indicated that during wound rounds, the resident was observed to have a Stage 3 pressure sore. The note also indicated that the resident had "chronic excoriation to buttocks reported to be worsening - likely r/t (related to) res (resident) sitting in w/c (wheelchair) on roho (air) cushion found last wk (week) to have air loss & sitting on metal on w/c". There was no documented evidence that an investigation had been initiated to rule out abuse or neglect. During interviews on 3/15/11 at approximately 3:00 pm, and 3/16/11 at 1:25 pm, Staff 6, RNCM, verified that when she was told about the Roho cushion being low, it had actually been discovered sometime prior to her being notified on 12/30/10. Staff 6 stated that a charge nurse was told by a CNA, that there was air loss in the resident's Roho cushion that the resident sat on while in her electric wheelchair. She then stated that the charge nurse did not document this information or do any follow up intervention and that the resident continued to sit on the cushion. Staff 6 was unsure as to exactly when the charge nurse was made aware of deflated Roho cushion and only stated that it had occurred sometime in the week prior to 12/30/10. Staff 6 could not recall the CNA who had informed the charge nurse. When asked if there was any investigation initiated, Staff 6 replied "no" and did not give a reason as to why an investigation was not initiated. 2. Resident 12 was admitted to the facility in 10/2010 and had [DIAGNOSES REDACTED]. The resident's 10/31/10 NN disclosed that a family member had exhibited rough behavior towards the resident, including pulling the resident up on the arms and "slapping" the resident's hands, asking if the resident could feel it and "then pulling". It was noted that when the charge nurse requested the family member not to do those things, the family member kept repeating, "did you hear that? Mommie wants you to sit there & rot". It was further documented in the NN, "At this point no longer beneficial to continue conversation & simply asked for (family member) to wait for PT..." It was further identified in the 10/31/10 NN, that the family member was observed feeding the resident at a rate too fast for the resident to completely swallow. There was no documented evidence that an investigation had been initiated to rule out abuse. In interview on 3/15/11 at 11:38 am, Staff 21, LPN, stated that the family member had been told by physical therapy to not do this, but had been pulling the resident up by the arms and slapping the resident's hands while they were on the walker. Staff 21 stated that it "felt abusive" to her, but did not think the family member was actually abusive to the resident. Staff 21 reported the incident to Staff 4, RNCM, and was told to document what had happened. In interview on 3/15/11 at 11:22 am, Staff 4 stated that she did not recall the incident. In interview on 3/15/11 at 3:23 pm, Staff 2, DNS, stated that the incident "was abuse" and should have been investigated. 3. Resident 1 was admitted in 2/2011, with [DIAGNOSES REDACTED]. Review of the resident's Admission Assessment completed on 2/14/11, coded that the resident had "clear comprehension" with regard to the ability to understand others and coded that the resident was able to be "understood" with regard to the ability to express ideas and wants. For the resident's cognitive assessment, the resident was able to complete the Brief Interview for Mental Status (BIMS), a test for cognitive recall, registration and temporal orientation. The resident had a total score of 15 (based on a range of 0 to 15, with 15 being the highest level of cognition). Review of the resident's Rehab Progress Grid and Record of Services Provided note dated 3/4/11, documented the following: "pt (patient) declined using AE (adaptive equipment) due to frustration with staff/[MEDICAL CONDITION] change/soiled bed...pt was seen by drs (doctors) as pt cannot change [MEDICAL CONDITION] independently as pt was for [AGE] years before surgery." On 3/10/11 at 9:00 am, a Quality of Life Assessment interview was completed with the resident. During the interview, the resident was asked to share how the resident felt with regard to staff and how staff had been providing care. The resident stated that although she/he can take care of the [MEDICAL CONDITION] bag, she/he still needed a little help, but "they (staff) don't want to be bothered by it" and stated that "I'm stern about it and tell them (staff) they have to help me." When asked if the resident had reported this to staff, the resident stated, that she/he had told staff, but could not remember their names. In interview on 3/10/11 at 10:09 am, when asked if the resident had ever complained about care, Staff 11, Certified Occupational Therapist Assistant (COTA), stated that yes, about a couple of weeks ago. Staff 11 stated that the resident's call light was on, staff went went into the resident's room and saw the resident in the resident's bathroom. Staff 11 further stated that the resident was very upset and that the resident told Staff 11 that she/he needed help with her/his [MEDICAL CONDITION] and that the aide had told the resident that they (CNA) would be right back. Staff 11 stated that she had to go back to get the CNA. Staff 11 further stated that the resident was very sweet, but then began to become "grumpy" about her/his care. Staff 11 stated, "I could understand...her/his complaints were legitimate." In interview on 3/10/11 at 10:38 am, Staff 12, COTA, was asked about the resident's care and cognition. Staff 12 stated that the resident's cognition was good, alert and oriented x 3. Staff 12 further stated that last week the resident complained about staff care of the resident's [MEDICAL CONDITION] and stated that the resident's new surgery had made it difficult to care for the [MEDICAL CONDITION]. Staff 12 stated that the resident had told her that the resident was "really upset, frustrated and angry." Staff 12 stated, "I would have been too" and that the resident doesn't get tearful, but was definitely "frustrated" and "disgusted." Staff 12 stated that the resident had told her that she/he had soiled the bed, however staff had only observed a small brown spot on the resident's bed linen. When asked how long ago the resident had told Staff 12 about this incident, Staff 12 referred to her therapy notes and stated that it had been on 3/4/11. In interview on 3/10/11 at 1:59 pm, Staff 13, CNA, was asked about her knowledge of the resident. Staff 13 stated that the resident was easy to care for, but wanted collaboration with aides. When asked to explain what Staff 13 meant by collaboration with aides, Staff 13 stated that the resident wanted aides to understand that the resident needed assistance and had been frustrated with certain aides. Staff 13 stated that the aides didn't understand that the resident needed help with the [MEDICAL CONDITION]. When asked if Staff 13 had mentioned the resident's concerns to anyone, staff stated that she had talked to Staff 3, RNCM, about the aides not assisting the resident with the [MEDICAL CONDITION]. ln interview on 3/11/11 at 9:03 am, Staff 15, RN, was asked if she knew of any concerns made by the resident. Staff 15 stated that the resident had made complaints that aides were rushed and that the resident felt rushed with assistance of the [MEDICAL CONDITION] and care of it. Staff 15 further stated that mostly the resident complained of aides not assisting with the resident's [MEDICAL CONDITION]. When asked if Staff 15 remembered an incident that occurred on 3/4/11, where the resident had been frustrated with care, staff stated that she had not heard of the incident. In interview on 3/11/11 at 11:13 am, Staff 12, COTA, was asked if she had told anyone about the 3/4/11 incident with the resident. Staff 12 stated that she told Staff 10, Rehab Services Director. In interview on 3/11/11 at 11:17 am, Staff 10, Rehab Services Director, when asked if Staff 12 had told her anything about the resident being upset with care on 3/4/11, stated "I don't recall." In a follow-up interview on 3/16/11 at 4:02 pm, Staff 10, clarified her previous interview and stated that she had recalled Staff 12 reporting to her about the resident's [MEDICAL CONDITION] not sealing properly. In interview on 3/11/11 at 1:30 pm, Staff 3, RNCM, stated that the resident had told her about being frustrated with having different aides and with staff not assisting with her/his [MEDICAL CONDITION]. When asked if Staff 3 heard of an incident involving the resident's [MEDICAL CONDITION] care on 3/4/11, Staff 3 stated that she had not. In a follow-up interview on 3/16/11 at 4:02 pm, Staff 3, also clarified her previous interview and stated that there was an instance where it was true the resident was having problems with an aide (CNA) and that the aide had asked her why the resident needed ostomy assistance when the resident had been independent. Staff stated that she did explain to that aide the reason for the resident's [MEDICAL CONDITION] assistance. In interview on 3/15/11 at 3:25 pm, Staff 2, DNS, was informed of the resident's frustration with care of the [MEDICAL CONDITION]. Staff 2 stated that there was a "break" in communication between staff. When asked what were Staff 2's expectations on the shared information, Staff 2 stated that she would talk to the resident and would investigate. Through interviews it was revealed that staff members had knowledge of the resident's frustration with certain CNAs not assisting with the resident's [MEDICAL CONDITION] care. There was no documented evidence that facility staff identified the resident's concerns, particularly made on 3/4/11, as possible neglect of care, and no documented evidence that the facility initiated a thorough investigation to determine if neglect had occurred with regards to the care of the resident's [MEDICAL CONDITION].

Based on observation, interview, and record review, it was determined that the facility failed to implement their policies and procedures to investigate incidents to ensure the protection of 3 of 13 sampled residents (#'s 1, 8 & 12). Findings include: Review of the facility's Abuse Investigations policy and procedures indicated that "all reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by community management." Review of the facility's Abuse Prevention Program policy and procedures defined neglect as "a failure or omission on the part of a care giver to provide the care, supervision, and services necessary to maintain the physical and mental health of a resident." 1a. Resident 8 was admitted in 1/2010 with [DIAGNOSES REDACTED]. The resident's 12/30/10 NN indicated the resident had "some blood on her brief". There was no documented evidence that an investigation had been initiated to rule out abuse. During interviews on 3/15/11 at 10:30 am and 12:30 pm, Staff 16, LPN, stated that on 12/30/10, a CNA (Staff 16 could not recall which one) informed her of some blood that was observed in the resident's brief and vaginal area. When asked if an investigation had been initiated, she replied that she did not initiate one, but immediately had informed the resident's physician and Staff 6, RNCM. During interview on 3/15/11 at approximately 3:00 pm, Staff 6, RNCM, stated that she was informed of the resident's vaginal bleeding on 12/30/10. When asked if the resident's vaginal bleeding would be something that would be investigated or reported, she replied, "don't need to report it, because it is medical, why should it be reported." When asked if she had considered abuse as a possibility, Staff 6 replied that she had not. When asked about the facility's policy and procedures regarding reporting, Staff 6 stated that she did not know the facility's policy and procedures regarding reporting and did not have a copy of the policies in her office. When asked what she would report and investigate, she replied "it would depend on the resident". During interview on 3/15/11, at 3:20pm, Staff 2, DNS, stated that she had just been informed that day, by Staff 6, of the resident's vaginal bleeding incident. When asked if she would have investigated this incident, she replied that she would have definitely investigated this incident in order to rule out abuse. b. Resident 8 had a 12/30/10 NN, which indicated that during wound rounds, the resident was observed to have a Stage 3 pressure sore. The note also indicated that the resident had "chronic excoriation to buttocks reported to be worsening - likely r/t (related to) res (resident) sitting in w/c (wheelchair) on roho (air) cushion found last wk (week) to have air loss & sitting on metal on w/c". There was no documented evidence that an investigation had been initiated to rule out abuse or neglect. During interviews on 3/15/11 at approximately 3:00 pm, and 3/16/11 at 1:25 pm, Staff 6, RNCM, verified that when she was told about the Roho cushion being low, it had actually been discovered sometime prior to her being notified on 12/30/10. When asked if there was any investigation initiated, Staff 6 replied "no" and did not give a reason as to why an investigation was not initiated. 2. Resident 12 was admitted to the facility in 10/2010 and had [DIAGNOSES REDACTED]. The resident's 10/31/10 NN disclosed that a family member had exhibited rough behavior towards the resident, including pulling the resident up on the arms and "slapping" the resident's hands, asking if the resident could feel it and "then pulling". It was noted that when the charge nurse requested the family member not to do those things, the family member kept repeating "did you hear that? Mommie wants you to sit there & rot". It was further documented in the NN, "At this point no longer beneficial to continue conversation & simply asked for (family member) to wait for PT..." It was further identified in the 10/31/10 NN, that the family member was observed feeding the resident at a rate too fast for the resident to completely swallow. There was no documented evidence that an investigation had been initiated to rule out abuse. In interview on 3/15/11 at 11:38 am, Staff 21, LPN, stated that it "felt abusive" to her, but did not think the family member was actually abusive to the resident. In interview on 3/15/11 at 3:23 pm, Staff 2, DNS, stated that the incident "was abuse" and should have been investigated. 3. Resident 1 was admitted in 2/2011, with [DIAGNOSES REDACTED]. Review of the resident's Admission Assessment completed on 2/14/11, coded that the resident had "clear comprehension" with regard to the ability to understand others and coded that the resident was able to be "understood" with regard to the ability to express ideas and wants. On 3/10/11 at 9:00 am, during interview, the resident stated that although she/he can take care of the [MEDICAL CONDITION] bag, she/he still needed a little help, but "they (staff) don't want to be bothered by it" and stated that "I'm stern about it and tell them (staff) they have to help me." When asked if the resident had reported this to staff, the resident stated, that she/he had told staff, but could not remember their names. In interview on 3/10/11 at 10:09 am, Staff 11, Certified Occupational Therapist Assistant (COTA), stated that about a couple of weeks ago, the resident was very upset and told Staff 11 that she/he needed help with her/his [MEDICAL CONDITION] and that the aide had told the resident that they (CNA) would be right back. Staff 11 further stated that the resident was very sweet, but then began to become "grumpy" about her/his care. Staff 11 stated, "I could understand...her/his complaints were legitimate." In interview on 3/10/11 at 10:38 am, Staff 12, COTA, stated that last week the resident complained about staff care of the resident's [MEDICAL CONDITION]. Staff 12 stated that the resident had told her that the resident was "really upset, frustrated and angry." Staff 12 stated "I would have been too" and that the resident doesn't get tearful, but was definitely "frustrated" and "disgusted." In interview on 3/10/11 at 1:59 pm, Staff 13, CNA, stated that the aides didn't understand that the resident needed help with the [MEDICAL CONDITION]. When asked if Staff 13 had mentioned the resident's concerns to anyone, staff stated that she had talked to Staff 3, RNCM, about the aides not assisting the resident with the [MEDICAL CONDITION]. ln interview on 3/11/11 at 9:03 am, Staff 15, RN, was asked if she knew of any concerns made by the resident. Staff 15 stated that the resident had made complaints that aides were rushed and that the resident felt rushed with assistance of the [MEDICAL CONDITION] and care of it. Staff 15 further stated that mostly the resident complained of aides not assisting with the resident's [MEDICAL CONDITION]. In interview on 3/11/11 at 1:30 pm, Staff 3, RNCM, stated that the resident had told her about being frustrated with having different aides and with staff not assisting with her/his [MEDICAL CONDITION]. In interview on 3/15/11 at 3:25 pm, Staff 2, DNS, was informed of the resident's frustration with care of the [MEDICAL CONDITION]. When asked what were Staff 2's expectations on the shared information, Staff 2 stated that she would talk to the resident and would investigate. Through interviews it was revealed that staff members had knowledge of the resident's frustration with certain CNAs not assisting with the resident's [MEDICAL CONDITION] care. There was no documented evidence that facility staff identified the resident's concerns and no documented evidence that the facility initiated a thorough investigation to determine if neglect had occurred with regards to the care of the resident's [MEDICAL CONDITION]. Refer to F225

1. Based on observation, interview and record review, it was determined that the facility failed to ensure that the resident environment remained free from accident hazards for 3 of 3 cognitively impaired sampled resident (#'s 10, 23 & 24) in regards to water temperatures exceeding 120 degrees. The failure of the facility to ensure that accident hazards, due to water temperatures exceeding 120 degrees resulted in immediate jeopardy for three cognitively impaired residents, who were identified as able to access the water independently. Findings include: On 3/9/11 at 10:53 am, during environmental review, the water temperature in room 272 was recorded at 126 degrees. As a result, the surveyors used the State agency therometer to measure the water tempertures throughout the ICF and skilled buildings. Hot water temperatures were recorded to exceed 120 degrees in multiple areas, including resident rooms. Facility staff were interviewed and identified three cognitively impaired residents who were able to access the water independently. a. Resident 23 was admitted in 5/2005, with [DIAGNOSES REDACTED]. In interview on 3/9/11 at 11:19 am, Staff 25, RN, stated that Resident 23 was able to access the water independently. On 3/9/11 at 11:42 am, the water temperature in Resident 23's room was recorded at 130 degrees. In interview on 3/9/11 at 1:58 pm, Staff 26, CNA, stated that Resident 23 could be very confused and had observed the resident independently accessing the water in the sink, including rinsing dentures. Staff 26 stated that she has had to adjust the water temperature in resident's rooms and has reported excessive water temperatures to maintenance. b. Resident 10 was admitted in 12/2010, with [DIAGNOSES REDACTED]. On 3/9/11 at 12:03 pm, the water temperature in Resdent 10's room was recorded at 132 degrees c. Resident 24 was admitted in 10/2004, with [DIAGNOSES REDACTED]. On 3/9/11 at 12:05 pm, the water temperature in Resident's 24's room was recorded at 130 degrees. In interview on 3/9/11 at 2:00 pm, Staff 21, LPN, and Staff 30, LPN, were asked what residents were cognitively impaired and could ambulate or use their wheel chair to access the water in their rooms. Staff 21 and Staff 30 identified Residents 10 and 24 as being cognitively impaired and able to access the water independently in their rooms. In interview on 3/9/11 at 12:30 pm, Staff 9, Environmental Services Manager, stated that a laser thermometer was used to test the water temperatures throughout the campus. Staff 9 was asked how often the facility's laser thermometer was tested and calibrated. She replied that she was unsure. When asked what the manufacture's recommended, she replied that the thermometer was at least 5 years old and that they did not have the manufacture's instruction manual anymore. In interview on 3/9/11 at 2:05 pm, Witness 1, Plumber, stated that the outgoing water temperature for the ICF building was too high, measuring at 130 degrees. In interview on 3/9/11 at approximately 3:00 pm, Staff 7, Environmental Services Director, was asked if the laser thermometer used by the facility was working accurately/correctly, in which she replied no. On 3/9/11 at 2:35 pm, following consultation with State Agency Survey Supervisors, the surveyors informed Staff 1, Director of Operations, that the failure of the facility to ensure that accident hazards, due to water temperatures exceeding 120 degrees for three cognitively impaired residents who were identified as able to access the water independently, constituted immediate jeopardy. Surveyors requested a plan of correction, to immediately protect the residents from harm, be developed and implemented. On 3/9/11 at 4:30 pm, a plan of correction was provided by the facility that immediately protected the three cognitively impaired residents from accidents and/or injuries and developed a monitoring system for acceptable water temperatures. It was accepted by the survey team. The immediate jeopardy was abated on 3/9/11 at 4:37 pm. 2. Based on observation, interview and record review, it was determined that the facility failed to assess the use of side rails for 4 of 6 sampled residents (#s 4, 5, 7 & 13) with side rail use. Findings include: a. During observations on 3/8 and 3/9/11, Resident 5 was observed to have bilateral half side rails in place when in bed. There was no documented assessment of the risks vs. benefits of the side rail use. In interview on 3/11/11 at 6:58 am, Staff 5, RNCM, stated that there had been no assessment of the side rails completed. b. Resident 7 had [DIAGNOSES REDACTED]. During observations on 3/9 and 3/10/11, Resident 7 was observed to have bilateral side rails in place when in bed. There was no documentation in the resident's record to assess the use of the side rail and to assess whether the use of the side rail was a restraint and/or safety hazard. During interview on 3/16/11 at 1:15 pm, Staff 6, RNCM, acknowledged that the resident did have side rails on her bed and that she did not complete an assessment of the use of the side rails. c. Resident 13 was admitted in 04/2010 with [DIAGNOSES REDACTED]. During observations on 3/9 and 3/10/11, Resident 13 was observed to have bilateral side rails in place when in bed. There was no documentation in the resident's record to assess the use of the side rail and to assess whether the use of the side rail was a restraint and/or safety hazard. During interview on 3/16/11 at 1:00 pm, Staff 6, RNCM, acknowledged that the resident did have side rails on her bed and that she did not complete an assessment of the use of the side rails. d. Resident 4 was admitted to the facility in 2/2011, with [DIAGNOSES REDACTED]. Observations on 3/10/11 at 10:25 am and 1:47 pm, observed the resident's right half side rail up. Review of the resident's record revealed no assessment had been completed to assess the use of the half side rail and to assess whether the use of the side rail could be a restraint and/or safety hazard. In interview on 3/15/11 at 10:45 am, Staff 3, RNCM, was asked if there had been an assessment completed for the use of the resident's half side rail. Staff 3 stated that there was no assessment and was not aware that the resident had a half side rail in use.

Based on two immediate jeopardies that placed the facility into Substandard Quality of Care in the areas of Resident Behavior and Facility Practices and Quality of Care, it was determined that the facility was not administered by the management team in an effective and efficient manner. Findings include: 1. Administration failed to monitor and follow up on ensuring that current abuse policies and procedures were followed. Review of the facility's last Abuse Prevention Program in-service completed on 11/22/10, indicated numerous employees had not attended or received the abuse prevention program training. In a follow-up interview on 3/15/11 at 2:30 pm, Staff 28, Human Resources, stated that those who attended the Abuse Prevention in-service on 11/22/10 or received the training materials afterwards, signed the attendance sheet. If the sheet was not signed, that staff member did not receive the training. Refer to F226. 2. Administration failed to ensure that management staff were knowledgeable in regards to the use and maintenance of equipment. On 3/9/11, the facility failed to ensure that accident hazards, due to water temperatures exceeding 120 degrees which resulted in immediate jeopardy for three cognitively impaired residents, who were identified as able to access the water independently. In interview on 3/9/11 at 12:30 pm, Staff 9, Environmental Services Manager, stated that the laser thermometer was used to test the water temperatures throughout the campus. Staff 9 was asked how often the facility's laser thermometer was tested and calibrated. She replied that she was unsure. When asked what the manufacture's recommended, she replied that the thermometer was at least 5 years old and that they did not have the manufacture's instruction manual anymore. In interview on 3/9/11 at 2:05 pm, Witness 1, Plumber, stated that the outgoing water temperature for the ICF building was too high, measuring at 130 degrees. In interview on 3/9/11 at approximately 3:00 pm, Staff 7, Environmental Services Director, was asked if the laser thermometer used by the facility was working accurately/correctly, in which she replied no. Refer to F323