Every finding on record at Marquis Springfield

Based on observation, interview and record review the facility failed to ensure a homelike environment for 1 of 1 facility reviewed for environment. This placed residents at risk for not having a homelike environment. Findings include: 1. Resident 74 was admitted to facility in 2015 with a diagnosis of type 2 diabetes mellitus. Resident 74's Annual MDS Assessment completed in 10/2025 indicated a BIMS of 15 (cognitively intact).On [DATE] at 10:23 AM, several rooms on the north hall, including Resident 74's room, were observed to have linoleum floors that appeared stained and dirty. On [DATE] at 9:42 AM. Resident 74 stated the floor in his room looked pretty bad. She/he stated the facility needed to do a better job caring for the floor. 2. A walk-through of the facility conducted [DATE] at 10:00 AM revealed the following items: - Hallway carpets were excessively worn, stained or torn in 5 of 5 halls utilized by residents. There was a divot in the hallway outside rooms [ROOM NUMBERS] that created a tripping hazard. -Door and casings were significantly scratched, marred and stained for 44 of 55 resident rooms observed. - room [ROOM NUMBER] contained warped, bubbling carpet - 13 of 16 rooms in the north hall contained stained linoleum. - rooms [ROOM NUMBERS] had worn, marred or chipped paint. room [ROOM NUMBER] had an unrepaired hole in the wall. - room [ROOM NUMBER] contained chipped linoleum. - In a small activity room utilized by residents 1 of 3 hanging lights had burnt-out bulbs and 3 of 3 hanging lights were unclean and/or contained debris. - In the main dining room, the Formica countertop on the beverage counter had large areas where the subsurface showed through and a closet door next to one of the entrances that was stained or dirty. In the large entryway the transition piece was broken. On [DATE] at 11:57 PM, Resident 32 was observed self-propelling down the hall between room [ROOM NUMBER] and 53. Resident 32 stated the carpet needed cleaning because it looked like someone bled to death on the floor. During a walk-through of the facility conducted on [DATE] at 9:30 AM, Staff 6 (Plant Operations Manager) stated he was aware of the needed repairs. He stated he had no comprehensive plan for building maintenance. On [DATE] at 12:35 PM, Staff 1 (Administrator) stated she was aware there were significant building maintenance items that needed to be addressed.

Based on observation, interview, and record review it was determined the facility failed to ensure residents had an accessible bathroom call light for 2 of 3 sampled residents (#s 38 and 83) reviewed for accidents. This placed residents at risk for the inability to call for assistance. Findings include: 1. Resident 38 was admitted to the facility in 11/2024 with a diagnosis of dementia. On 12/29/25 at 12:42 PM Resident 38's bathroom was observed without a call light cord to access if she/her fell to the ground. On 1/2/26 at 10:32 AM Staff 6 (Maintenance) stated if a resident room did not have a call light cord the staff were to notify him, and he would provide a cord. Staff 6 stated he was not notified Resident 38 did not have a bathroom call light cord. On 1/5/26 at 10:28 AM Staff 1 (Administrator) stated she and Staff 4 (DNS) did audits to ensure residents' bathrooms had call light cords. Staff 1 stated the staff were to notify maintenance in person or via the facility online communication system if a resident needed a new call light cord. 2. Resident 83 was admitted to the facility in 11/2024 with a diagnosis of UTI. Resident 83's 11/23/25 admission MDS revealed she/he was cognitively intact. On 12/29/25 at 12:42 PM Resident 83's bathroom was observed without a call light cord to access if she/he fell to the ground. On 1/2/26 at 10:32 AM Staff 6 (Maintenance) stated if a resident room did not have a call light cord the staff were to notify him, and he would provide a cord. Staff 6 stated he was not notified Resident 38 did not have a bathroom call light cord. On 1/5/26 at 10:28 AM Staff 1 (Administrator) stated she and Staff 4 (DNS) did audits to ensure residents' bathrooms had call light cords. Staff 1 stated the staff were to notify maintenance in person or via the facility online communication system if a resident needed a new call light cord.

Based on observation interview and record review it was determined the facility failed to ensure an insulin open date was documented for 1 of 1 sampled resident (#17) observed to receive insulin during medication administration observation. This placed residents at risk for ineffective medication regimen. Findings include: Resident 17 was admitted to the facility in 9/2025 with a diagnosis of diabetes. Resident 17's 12/31/25 Active Orders included staff were to administer Lispro (fast acting insulin) with meals. On 12/31/25 at 7:41 AM Staff 8 (LPN) was observed to prepare Insulin Lispro for Resident 17. The Lispro insulin did not have an open date, and Staff 8 stated all insulin was to be dated when first opened. On 12/31/25 at 8:41 AM Staff 9 (LPN Resident Care Manager) stated insulin should be dated when opened. Staff stated the 12/2025 pharmacy receipt binder did not have a receipt for Resident 17's Lispro insulin and she was not able to determine when the Lispro was potentially first used. On 12/31/25 9:00 AM Witness 1 (Pharmacy Technician) stated the Lispro insulin was sent to the facility on [DATE]. On 12/31/25 at 10:42 AM and 12:05 PM Staff 2 (RN Consultant) stated all insulin was to be dated when opened. Staff 2 stated Lispro was good for 28 days after it was opened and at room temperature.

Based on interview and record review it was determined the facility failed to follow physician orders and implement non-pressure injury interventions for 1 of 3 sampled residents (#77) reviewed for edema. This placed residents at risk for fluid overload and worsening wounds. Findings include: Resident 77 was admitted to the facility in 12/2025 with a diagnosis of heart disease. a. Resident 77's 12/19/25 Orders Detail revealed staff were to obtain daily weights and notify her/his medical provider if she/he had more than a three-pound weight gain in 24 hours or a five-pound weight gain in one week. Resident 77's weight log revealed the following dates when she/he had more than a three-pound weight gain in 24 hours:-12/18/25 272 pounds-12/19/25 275.8 pounds-12/20/25 279.4 pounds Resident 77's clinical record did not have documentation to indicate her/his medical provider was notified of the three-pound weight gain on 12/19/25 and 12/20/25. On 1/2/26 at 1:44 PM Staff 5 (RNCM) verified Resident 77's medical provider was not notified on 12/19/25 or 12/20/25 per physician orders when she/he had a weight gain. On 1/5/26 at 11:29 AM Staff 4 (DNS) stated if a resident had an order to notify her/his medical provider staff were to use the online communication tool which was linked to a resident's progress notes. b. Resident 77's 12/29/25 Progress Note revealed a CNA and nurse observed blood on Resident 77's bed sheets. Resident 77 was assessed to have hit her/his left great toe and Resident 1 reported she/he was not able to feel her/his feet and did not know what happened. On 1/2/26 at 12:00 PM Staff 7 (LPN) stated if a new skin issue was identified a skin event was to be initiated, the resident was to be monitored, and treatment was to be initiated. On 1/2/2026 1:44 PM Staff 5 (RNCM) stated skin treatments and monitoring were not initiated on the 12/2025 TAR on 12/29/25. On 1/5/26 at Staff (DNS) stated if a new skin issue was identified. Staff were to initiate a Skin Event form, an investigation was completed to ensure care and services were provided related to the skin injury, and a root cause analysis was completed to prevent future injuries.

Based on observation, interview and record review the facility failed to provide meaningful activities designed to meet the interests of the resident for 1 of 1 resident (# 14) reviewed for mood. This placed residents at risk for decreased quality of life. Findings include:Resident 14 was admitted to the facility in 8/2025 with diagnoses including cerebral infarction (stroke). On 12/29/25 at 10:49 AM, Resident 14 stated she/he liked to read prior to his stroke. During observations 12/29/25 through 12/31/25 Resident 14 was observed in awake and in her/his bed without engaging in any activity. A review of Resident 14's clinical record revealed the following, In the past, I enjoyed reading a lot. Further review of the resident's Progress Notes revealed a nursing note dated 8/27/25 with the following, The stroke took my vision, and I am unable to read .I used to be an avid reader. A review of the resident's Activities Care Plan revealed the resident had no activities related to books. On 1/3/26 at 10:50 AM Staff 11 (CNA) stated Resident 14 spent most of his time in her/his bed or listening to television. On 1/3/26 at 11:06 AM, Staff 12 (CNA) stated Resident 14 didn't talk much or ask for things and was often just lying in her/his bed looking out the window. Staff 12 stated Resident 14 often seemed bored and could be irritable. On 1/5/26 at 11:08 AM, Staff 17 (Activities Director) stated a resident who expressed an interest in reading should have been offered audio books and it should be noted in the resident's clinical record if they do not want an activity. On 1/6/26 at 12:35 PM, Staff 1 (Administrator) stated the facility had options for audio books for residents and Resident 14 should have been offered audio books.

Based on interview and record review it was determined the facility failed to ensure residents were given bed hold information for 2 of 2 sampled residents (#s 2 and 31) reviewed for hospitalization. This placed residents at risk for lack of information and unexpected financial costs. Findings include: 1. The facility Bed Hold Policy with an unknown revision date indicated facility staff were to complete an Oregon Notice of Transfer or Discharge and Bed Hold form with each resident transfer and ensure the resident had the paperwork when they transferred out of the facility. Resident 2 admitted to the facility in 10/2025 with diagnoses including an infection to the left leg and diabetes. An 10/12/25 admission MDS indicated Resident 2 was cognitively intact. A review of Resident 2's medical record revealed she/he transferred to the hospital on [DATE]. No information was found in Resident 2's medical record to indicate a bed hold was explained, offered, or given to Resident 2 when she/he left the facility. On 1/5/26 at 12:04 PM, Staff 16 (LPN) stated nursing staff were expected to fill out the Oregon Notice of Transfer or Discharge and Bed Hold form and send with residents when they were transferred to the hospital. She stated she was unaware if Resident 2 received an Oregon Notice of Transfer or Discharge and Bed Hold form when she/he transferred to the hospital. On 1/5/26 at 1:50 PM, Staff 4 (DNS) stated the expectation for the Oregon Notice of Bed Hold and Transfer form was for the resident to have the form when they left the facility or soon thereafter. She acknowledged no documentation could be found regarding a bed hold being explained, offered, or given to Resident 2 when she/he transferred to the hospital. 2. Resident 31 was admitted to the facility in 11/2025 with diagnoses including heart failure and respiratory failure. The 12/4/25 admission MDS revealed Resident 31's BIMS assessment score was 15 (cognitively intact). A 12/17/25 Oregon Notice of Transfer or Discharge and Bed Hold form revealed Resident 31 was transferred to the hospital due to a change of condition. The form revealed the resident would inform family of her/his transfer to the hospital. The form included details about the bed hold policy but did not indicate if the information related to the bed hold policy was discussed with the resident. On 12/29/25 at 4:22 PM, Resident 31 stated no bed hold information was discussed or paperwork provided to her/him related to the bed hold policy at the time of her/his 12/17/25 hospital transfer. On 1/2/26 at 2:33 PM and 4:03 PM, Staff 10 (LPN) and Staff 13 (RN) stated nurses completed the nursing portion of the Oregon Notice of Transfer or Discharge and Bed Hold form. Staff 10 and Staff 13 did not know how residents were to obtain the information once the nursing information was completed. On 1/2/26 at 4:22 PM, Staff 14 (Hospital Liaison) stated nursing staff were to provide a copy of the Oregon Notice of Transfer or Discharge and Bed Hold form to residents when they transferred out of the facility. On 1/5/26 at 11:32 AM, Staff 1 (Administrator) expected staff to review the bed hold policy with residents at discharge or soon after discharge. Staff 1 acknowledged Resident 31's Oregon Notice of Transfer or Discharge and Bed Hold form was incomplete and was to include information when the bed hold information was discussed with the resident. On 1/5/26 at 1:44 PM, Staff 4 (DNS) expected staff to provide a copy for the Oregon Notice of Transfer or Discharge and Bed Hold form to the resident or family at the time of discharge and acknowledged follow-up with Resident 31 did not occur once she/he returned from the hospital.

Based on interview and record review it was determined the facility failed to ensure a resident's skin injury was investigated for 1 of 3 sampled residents (#77) reviewed for non-pressure skin injury. This placed residents at risk for worsening wounds. Findings include: Resident 77 was admitted to the facility in 12/2025 with a diagnosis of heart disease. An Abuse Investigations policy last revised on 10/15/20 revealed if an injury of unknown source was reported an investigation was to be completed. At a minimum staff were to review documents, medical records, interview staff who identified the incident, the resident and any staff who may have been in contact with the identified resident. Resident 77's 12/24/25 admission MDS revealed she/he was cognitively intact. Resident 77's 12/29/25 Progress Note revealed a CNA and nurse observed blood on Resident 77's bed sheets. Resident 77 was assessed to have hit her/his left great toe and Resident 1 reported she/he was not able to feel her/his feet and did not know what happened. On 12/29/25 at 11:27 AM Resident 77 stated her/his toe was bleeding, staff stated she/he bumped it on something but stated she/he did not hit her/his foot on anything. Resident 1's clinical record revealed there was no investigation related to the left great toe skin injury. On 1/2/26 at 12:00 PM Staff 7 (LPN) stated if a new skin issue was identified a skin event was to be initiated. On 1/2/26 at 10:57 AM Staff 2 (RN Consultant) indicated the Skin Event form and investigation was not started on 12/29/25. On 1/5/26 at 11:49 AM Staff 4 (DNS) stated if a new skin issue was identified staff were to initiate a Skin Event form, an investigation was completed to ensure care and services were provided related to the skin injury, and a root cause analysis was completed to prevent future injuries. Refer to F684 example (b) for additional information.

Based on observation, interview and record review the facility failed to ensure residents did not display increased anger, withdrawal or depressive behaviors for 1 of 1 resident (# 14) reviewed for mood. This placed residents at risk for unidentified depression. Findings include: Resident 14 was admitted to the facility in 8/2025 with diagnoses including cerebral infarction (stroke). Resident 14's MDS completed 9/2025 revealed a BIMS score of 15 (cognitively intact) and a PQH9 score of 00 (not depressed).A 10/14/25 progress note revealed the resident was tearful and asked about options for therapy since she/he was discharged from physical therapy due to lack of progress and indicated the resident expressed frustration about not being able to go home. The resident had been described as pleasant and cooperative in previous notes. A progress note dated 10/15/25 revealed the resident declined her/his shower despite multiple attempts by staff to offer a shower. Resident 14's progress notes did not reveal any previous declinations of care. A progress note dated 10/19/25 revealed the resident called her/his mother believing she/he was scheduled to discharge and would be able to go home. A second progress note dated 10/19/25 revealed the resident had been tearful and upset and spoke of going home during her/his shower and was alert charted for depression for 1 week. A progress note dated 10/22/25 revealed the resident declined multiple offers of a shower or a bed bath. A progress note date 10/28/25 revealed the resident continued to express sexualized feelings toward the female CNA. A progress note date 10/29/25 revealed the resident refused showers and became irritable with staff. The clinical record revealed no previous documentation of irritable behavior toward care providers by the resident. A progress note date 11/5/25 revealed the resident refused offers of a shower by multiple staff members. A progress note dated 11/11/25 revealed the resident continued to express sexualized feelings toward the female CNA. Progress notes dated 11/11/25 revealed the resident was agitated, restless and confused. A progress note dated 11/12/25 revealed the resident was irritable and declined to have her/his weight taken or to shower. On 11/17/25 progress notes revealed the resident remained fixated on the female CNA who had been removed from his care team due to previously documented behaviors. A progress note dated 11/26/25 revealed the resident was irritable and refused bowel care and multiple offers of showers. The resident was described as unmotivated and avoiding eye contact. A progress note dated 11/30/25 revealed the resident refused to get out of bed. A progress note dated 12/4/25 revealed the resident refused her/his independent exercise therapy despite multiple offers. A progress note dated 12/17/25 revealed the resident was tearful during a provider visit related to wanting to gain strength. On 12/29/2025 at 10:49 AM, Resident 14 stated she/he felt depressed and suicidal and wanted to go home. Resident 14 stated she/he had not spoken to staff about feeling depressed or suicidal. Resident 14 presented with a flat affect and appeared uninterested in answering questions. On 1/3/26 at 10:50 AM, Staff 11 (CNA) described Resident 14 as not being very expressive and she/he needed to be checked on frequently as she/he would not ask for care. On 1/3/26 at 11:04 AM, Staff 12 (CNA) described Resident 14 as seeming to struggle with depression and sometimes tearful. On 1/5/26 at 9:28 AM, Staff 14 (RNCM) stated there was no indication in Resident 14's clinical record she/he had been assessed for depression or offered mental health therapy. On 1/5/26 at 9:37 AM, Staff 3 (Social Services Assistant) stated he had discussed mental health therapy with Resident 14 and the resident had declined. Staff 3 stated he had not requested the resident be evaluated by a practitioner for depression.On 1/5/25 at 1:00 PM, Staff 4 (DNS) stated she would want a practitioner to assess a resident if there were cumulative behaviors noticed by staff such as declining cares and changes in behavior or mood. Staff 4 stated declinations of assessment or treatment by residents should be documented in the resident's clinical record.

Based observations, interviews, and record review it was determined the facility failed to maintain healthy nutrition status for 3 of 7 sampled residents (#s 12, 13, and 96) reviewed for pressure ulcers, tube feeding, and nutrition. This placed residents at risk for impaired nutrition. Findings include: Resident 12 was admitted to the facility on [DATE] with diagnoses including diaphragmatic hernia without obstruction (a condition in which an abdominal organ moves through an opening in the diaphragm into the chest area) and esophageal obstruction (functional impairment of swallowing due to a blockage in the esophagus). The 10/7/25 Hospital Discharge Summary orders indicated the facility dietitian was to manage Resident 12's tube feed. Staff were to administer Jevity 1.2 at a continuous rate of 30 (ml/hour), (advanced G-tube feeding formula) administered at 10 ml every 12 hours, advancing to a goal 55 ml/hour, for a total of 1,320 ml over 24 hours. On 10/7/25 Resident 12 weighed 117.2 pounds. The 10/7/25 nutrition care plan indicted Resident 12 was at risk for impaired nutrition, was monitored during Nutrition at Risk (NAR) meetings, had a G-tube (feeding tube that goes straight into the stomach), and was coded NPO (nothing by mouth). Staff were to refer to dietitian for evaluation and recommendations. Resident 12's goal was to maintain or increase weight. A 10/7/25 enteral feed order indicated staff were to administer Jevity 1.2 55 ml per hour via G-tube, 660 ml every 12 hours, for a total of 1,320 ml per 24 hours starting at 7:00 PM. Review of the 10/2025 MAR revealed staff administered the following: On 10/7/25 at 7:00 PM, staff documented NA (not administered). On 10/11/25 at 7:00 PM staff administered 548 ml. On 10/12/25 at 8:00 AM staff administered 548 ml and at 7:00 PM staff administered 569 ml. On 10/13/25 at 7:00 PM staff documented NA (not administered). The resident missed approximately 1,961 kcal compared to the prescribed order for these dates and feedings. A 10/7/25 enteral feed order indicated staff were to administer via G-tube 255 ml water via G-tube every 12 hours, total 510 ml every 24 hours, tube feed goal 55 ml per hour starting at 7:00 PM. Review of the 10/2025 MAR revealed staff administered the following: On 10/7/25 at 7:00 PM, staff documented NA. On 10/8/25: 510 ml administered at 8:00 AM. On 10/9/25: 510 ml administered at 8:00 AM. On 10/11/25: 191 ml administered at 7:00 PM. On 10/12/25: 198 ml administered at 7:00 PM. On 10/13/25: staff documented NA. On 10/18/25: 210 ml administered at 8:00 AM and 201 ml administered at 7:00 PM. On 10/19/25: 217 ml administered at 7:00 PM. On 10/20/25: 152 ml administered at 7:00 PM. On 10/21/25: 240 ml administered at 8:00 AM and 500 ml at 7:00 PM. On 10/27/25: 170 ml administered at 8:00 AM and 0 ml at 7:00 PM. On 10/28/25: 188 ml administered at 8:00 AM and 170 ml at 7:00 PM. On 10/29/25: 91 ml administered at 8:00 AM. The resident missed approximately 911 ml of prescribed water. On 10/8/25 Resident 12 weighed 115.0 pounds. The 10/8/25 Dietary admission Assessment indicated Resident 12 was not NPO and the resident did not have problems with swallowing or chewing. The assessment indicated the resident recently gained or lost weight. Resident 12 reported she/he lost a lot of weight but it did not include documentation of the resident's usual body weight or nutritional goals. No documentation was found in the medical record to indicate the care plan included the resident's preferences and goals. On 10/9/25 Resident 12 weighed 111.0 pounds. On 10/10/25 Resident 12 weighed 105.8 pounds. A 10/10/25 Nutrition Weight Note indicated Resident 12 had a 5.1 percent weight loss since admission and the dietitian was to review the resident's tube feed orders to determine if they needed adjustment. Resident 12 was to be reviewed during NAR. A 10/10/25 physician order indicated Resident 12 was referred to palliative care for a consult due to severe protein malnutrition and G-tube status. A 10/10/25 Nutrition Weight Note indicated the dietitian reviewed Resident 12's current tube feed orders and recommended increasing the resident's formula due to weight loss. On 10/10/25 a dietitian referral indicated a request to change current Jevity 1.2 at 55 ml/hour over 12 hours to Jevity 1.5 ml/hour over 24 hours, with 175 ml free water flush every six hours to provide a total of 1,980 kcal, 84 grams of protein, and 2,050 ml. Meeting 100 percent of the estimated kcal needs, protein needs, and fluid needs. The 10/14/25 Dietitian Assessment indicated Resident 12 required tube feeding was seen for weight monitoring. Estimated nutritional needs indicated the resident needed 1695-1940 kcal per day. The current order provided 1584 kcal per day. Updated orders were requested on 10/10/25. On 10/22/25 Staff 20 (RN/RCM) reviewed and signed the Dietitian Assessment. Staff 20 indicated Resident 12's orders were updated on 10/17/25 and the Resident 12's care plan was reviewed and updated. The 10/16/25 Weight Nutrition at Risk Assessment indicated Resident 12 had significant weight loss. The facility sent a recommendation to increase Resident 12's g-tube formula to the Gastroenterologist, however, they declined to address recommendations until resident was seen in December 2025. The assessment also noted that the dietitian needed to resend the 10/10/25 G-tube feeding orders with clarification. The assessment indicated current interventions are not appropriate. No documentation was found in the resident's medical record to indicate the order was implemented. On 10/17/25 Resident 12 weighed 104.2 pounds. On 10/17/25 Staff 10 (RD) sent a second referral with recommendations to update Resident 12's current G-tube orders. The recommendation was to change from Jevity 1.2 at 55 ml/hour over 24 hours to Jevity 1.5 ml/hour over 24 hours with 75 ml free water flush every six hours providing a total of 1,980 kcal, 84 grams of protein, and a total of 1,515 ml. Meeting 100 percent of the estimated kcal needs, protein needs, and fluid needs. A 10/22/25 external feeding order instructed staff to administer Jevity 1.5 via G-tube 55 ml per hour via continuous 24-hour G-tube feeding pump. Staff to document amount received per shift. Review of the 10/2025 MAR revealed staff administered the following: On 10/22/25: 440 ml AM shift. On 10/23/25: 265 ml AM shift, 350 ml PM shift and 510 ml night shift. On 10/24/25: 155 ml AM shift, 497 ml PM shift and night shift. On 10/25/25: 345 ml AM shift, 300 ml PM shift and 460 ml night shift. On 10/26/25: 359 ml AM shift, 460 ml PM shift and 440 ml night shift. On 10/27/25: 440 ml AM shift,188 ml PM shift and night shift. On 10/28/25: 540 AM shift, 365 ml PM shift and 440 ml night shift. On 10/29/25: 620 ml AM shift, 580 ml PM shift and 544 ml night shift. On 10/30/25: 300 ml AM shift. The resident missed approximately 2,378 kcal compared to the physician order. On 10/24/25 Resident 12 weighed 106.4 pounds. A 10/30/25 enteral feed order indicated staff were to administer Jevity 1.5 via G-tube 55 ml over 24 hours continuous via pump. Staff to document total amount received. Start on 10/30/25 at 3:00 PM and end on 10/31/25 at 2:37 PM. The 10/2025 MAR revealed the following: On 10/30/25 PM shift documented NA and night shift did not document total received. On 10/31/25 Resident 12 weighed 104.6 pounds. On 10/31/25 no documentation was provided to indicate total received. The resident missed approximately 1,949 kcal compared to the physician order. A 10/31/25 enteral feed order indicated staff were to administer Jevity 1.5 via G-tube 65 ml per hour from 1400- 1000 via pump every shift. Staff to document total received. End date 11/10/25. No documentation was found on the 10/2025 and 11/2025 MAR to indicate the total received: On 11/7/25 Resident 12 weighed 103.8 pounds. A 11/7/25 Nutritional Weight Note indicated per RCM weight loss may be due to missed feeding. Staff to continue monitoring weekly Weight loss continued to be significant and increased by 1 precent. A 11/10/25 enteral feed order indicated staff were to administer Jevity 1.5 via G-tube 65 ml per hour from 11:00 AM through 3:00 PM. Staff document total formula received. End date 12/24/25. The 11/2025 MAR revealed staff documented the total formula received for the resident 16 out of 60 scheduled feeding opportunities. The 12/2025 MAR revealed the following shift with 0 ml formula administered: PM shift: 12/1/25, 12/3/25 through 12/9/25, 12/15/25, 12/18/25, 12/22/25 and 12/23/25. A 11/13/25 Nutritional Weight Note indicated Resident 12's weight loss continued but was slowly decreasing. Will plan to continue the current plan of care unless RCM's has different insights on the tolerance of tube feed. On 11/14/25 Resident 12 weighed 102.7 pounds. On 11/21/25 Resident 12 weighed 103.4 pounds. A 11/25/25 Nutritional Weight Note indicated the dietitian will request additional milliliters from pump due to continued weight loss. On 11/28/25 Resident 12 weighed 103.6 pounds. On 12/5/25 Resident 12 weighed 106.2 pounds. On 12/12/25 Resident 12 weighed 110.8 pounds. A 12/22/25 Nutritional Weight Note indicated that, based on calculations, Resident 12 should be getting 1,957 ml of G-tube formula over 24 hours. A 12/24/25 eternal feed order indicated staff were to disconnect the resident from tube feeding at 7:00 AM or when total of 1,200 cc Isosource 1.5 had been administered. Staff to document amount received. Review of the 12/2025 MAR revealed staff administered the following: On 12/25/25: 1164 ml administered. On 12/28/25: 1051 ml administered. On 12/29/25: 1051 ml administered. On 12/30/25: 1180 ml administered. The resident missed approximately 531 kcal compared to the physician order. On 12/31/25 Resident 12 weighed 120.4 pounds. On 12/29/25 at 11:56 AM, Resident 12 reported she/he underwent surgery several months prior and had a feeding tube in place. The resident stated she/he was NPO and was becoming increasingly hungry every day. The resident further reported she/he lost more than 40 pounds within the past year. Resident 12 stated she/he did not recall being assessed regarding her/his feeding tube or having discussions related to nutritional goals. The resident expressed a desire to gain weight and stated she/he would be comfortable weighing 120 pounds. On 12/31/25 at 2:30 PM, Staff 15 (NP) stated she was aware of Resident 12's significant weight loss and severe protein malnutrition and would have expected the dietitian to follow up regarding nutritional needs. Staff 15 confirmed she would expect orders to be followed up within a couple of days. On 12/30/25 at 3:03 PM, Staff 10 (RD) stated she initially submitted a recommendation to increase Resident 12's G-tube feeding on 10/10/25. The order was returned on 10/17/25 due to inaccurate calculations. Staff 10 resubmitted the recommendations on 10/17/25 but it was not approved until 10/22/25. Resident 12's new order was not implemented until 10/24/25. Staff 10 acknowledged the order was not followed in a timely manner. Staff 10 requested retraining on 12/22/25 however this training had not occurred. Staff 10 further stated Resident 12's nutritional goals did not include an ideal weight, interventions were not effective, and the facility failed to meet the resident's nutritional needs. On 12/31/25 at 10:35 AM, Staff 13 (LPN) stated she was not aware of Resident 12's history of weight loss or of the resident's ideal weight. Staff 13 further stated she did not recall the last time she was provided education regarding tube feeds. On 1/5/26 at 9:38 AM, Staff 14 (RCM) stated Resident 12 was reviewed during weekly NAR meetings and she was aware of Resident 12's significant weight loss. Staff 14 acknowledged Resident 12's G-tube orders were not followed up on in a timely manner. Staff 14 further stated she was not aware of the dietitian's recommended retraining related to G-tube feeding. On 1/5/26 at 10:13 AM, Staff 4 (DNS) acknowledged staff failed to meet the resident's nutritional goals related to monitoring, following dietary orders, and G-tube feeding practices. 2. Resident 13 was admitted to the facility in 11/2025 with diagnoses including diabetes. A review of weights revealed the following: 11/21/25 233 lbs. 12/4/25 236.8 lbs. 12/9/25 220 lbs. 12/12/25 221.1 lbs. 12/18/25 222.6 lbs. 12/29/25 221.2 lbs. On 1/5/26 at 8:49 AM, Staff 10 (RD) stated Resident 13 had a significant weight loss on 12/9/25. Staff 10 stated Resident 13's weight loss was identified on 12/18/25 and Resident 13 was assessed for weight loss on 12/29/25. Staff 10 stated it was beneficial for Resident 13 to lose weight, but the weight loss was too rapid. Staff 10 stated she recommended nutritionally enhanced meals but stated the RCM did not want any interventions. Staff 10 stated she makes recommendations, and the RCMs choose whether to follow those recommendations. On 1/5/25 at 9:11 AM Staff 5 (RN RCM) stated Resident 13 had significant weight loss on 12/9/25. Staff 5 stated Resident 13's weight loss was identified on 12/24/25 and Resident 13 was assessed for weight loss on 12/29/25. Staff 5 stated there were no recommendations from the RD due to the weight loss. Staff 5 stated Resident 13's provider had not been notified of the weight loss. Staff 5 stated it was expected for weight loss to be identified, and the provider should be notified at the time of the weight loss. Staff 5 stated it was expected weight loss was to be assessed within the week of weight loss. Staff 5 acknowledged Resident 13's weight loss was not identified, assessed, and the provider was not notified in a timely manner. On 1/5/25 at 12:02 PM, Staff 4 (DNS) stated weights were reviewed every morning during the clinical meeting. Staff 4 stated when a resident had significant weight loss it was expected the RD would follow up with the resident, recommendations be put in place, the care plan updated, and the provider notified within the week of the identified weight loss. Staff 4 acknowledged Resident 13's weight loss was not identified and assessed timely and acknowledged Resident 13's provider had not been notified of the weight loss. 3. Resident 96 was admitted to the facility in 12/2025 with diagnoses including acute kidney failure and protein-calorie malnutrition. A 12/19/25 physician order indicated the diet for Resident 96 was to include 75 grams of protein. A 12/26/25 Dietitian Assessment revealed Resident 96 received no supplements, the resident ate 60% of her/his meals and received 42 grams of protein daily based on Staff 12's (RD) calculations. Staff 12 recommended Resident 96 receive increased calories and protein to meet her/his nutritional requirements, and the recommendation would be discussed with Staff 5 (RNCM). The assessment was not complete and required additional information from Staff 5. The 12/30/25 admission MDS revealed Resident 96's BIMS assessment score was 15 (cognitively intact) and she/he received dialysis (a treatment to filter waste products and excess fluid from the blood). On 12/30/25 at 4:03 PM, Resident 96 stated she/he received dialysis three times weekly and did not want breakfast before she/he left. On 1/5/26 at 10:50 AM and 12:50 PM, Staff 5 stated he was unaware Resident 96 required additional nutritional resources. On 1/5/26 at 11:02 AM, Staff 12 stated she was to communicate the nutritional concerns of residents during morning meeting. Staff 12 stated she neglected to communicate concerns related to Resident 96's nutritional status until 12/29/25 and followed her communication with an email on 12/30/25 to Staff 5. On 1/5/26 at 1:39 PM, Staff 4 (DNS) stated an improved system of communication was needed. Staff 4 expected assessments to be completed within seven days and acknowledged Resident 96's nutritional interventions were not implemented timely.

Based on record review and interview the facility failed to provide residents with a risk benefit assessment for 1 of 1 resident (# 74) assessed for food. This place residents at risk for uninformed choices. Findings include:Resident 74 was admitted to the facility in 2015 with diagnoses including diverticulitis. On 12/29/25 at 10:15 AM Resident 1 stated she/he was lactose intolerant kept getting food items containing dairy products with her/his meals. Resident 74 stated she/he takes Lactaid (a medication to treat lactose intolerance) before each meal however, she/he still will experience loose stools from the dairy products. An entry in the clinical record dated 2/15/23 revealed the resident was lactose intolerant. Physician orders dated 9/2024 for revealed an order for Lactaid. On 1/3/26 at 10:50 AM, Staff 11 (CNA) stated she often reminded Resident 74 her/his loose stools were related to eating foods containing dairy, but the resident continued to eat the foods she/he preferred. On 1/3/26 at 11:06 AM, Staff 12 (CNA) stated Resident 74 frequently experiences loose stools when she/he consumes dairy products. Staff 12 stated Resident 74 continues to eat dairy products. On 1/5/26 at 9:12 AM, Staff 10 (RD) stated she was aware Resident 74 took Lactaid so she assumed she/he was aware of the consequences of eating lactose-containing foods. Staff 10 stated she had not done a dietary assessment of Resident 74. On 1/5/26 at 9:19 AM, Staff 5 (RNCM) stated Resident 74 experienced significant diarrhea from eating foods containing lactose. Staff 5 stated Resident 74 was noncompliant with her/his dietary recommendations, but Staff 5 had not completed a Declination of Treatment (a risk/benefit analysis) with Resident 74 related to lactose. On 1/5/26 at 1:00 PM, Staff 4 (DNS) stated staff should have completed a Declination of Treatment with Resident 74 related to her/his lactose intolerance.

Based on observations, interviews, and record review it was determined the facility failed to ensure medications were not left at a resident's bedside, residents were monitored after an aspiration event, and fall interventions were in place for 3 of 7 sampled residents (#s 5, 43 and 83) reviewed for accidents and nutrition. This placed residents at risk for accidental poisoning, aspiration, and at risk for injuries from falls. Findings include: 1.Resident 5 admitted to the facility in 11/2025 with diagnoses including weakness and scoliosis. On 12/29/25 at 10:39 AM, Resident 5 stated she/he rolled out of bed several times since admission in 11/2025. Resident 5 was observed lying in bed and fall mats were observed rolled up in the corner of the room. A 11/23/25 Progress Note revealed Resident 5 had fallen while trying to take her/himself to the bathroom and fall mats were placed as an intervention. A review of Resident 5's care plan revealed a 11/25/25 care plan for fall mats at bedside. Multiple observations made from 12/29/25 through 1/2/26 revealed Resident 5's fall mats were rolled in the corner of the room. On 1/5/26 at 11:02 AM, Resident 5's room was observed with Staff 14 (RCM) and Staff 14 confirmed there were no fall mats at the bedside. Resident 5 stated the fall mats were not being used anymore. Staff 14 acknowledged Resident 5 was care planned for fall mats at the bedside and staff were expected to follow the care plan. On 1/5/26 at 11:52 AM, Staff 4 (DNS) stated staff were expected to follow residents' care plans and Resident 5 should have had fall mats at the bedside per care plan. An 11/2016 facility Alert Charting-Clinical Assessment indicated the nurse shall assess and document identified changes in condition of residents, as identified. The facility policy is to assure the adequate monitoring and appropriate interventions for all residents whenever a change of condition, or incident occurs. Alert charting is used to identify residents who require monitoring, assessment and documentation in the clinical record at least once a shift, or as determined by the RCM. 2. Resident 43 was admitted to the facility in 1/2024 with diagnoses including kidney failure and falls. A Progress Note dated 12/25 indicated Resident 43 had a piece of meat caught in her/his throat. She/he was able to clear the meat with a cough, burp, and drinking fluids. Resident 43 stated she/he had recent issues with meat and harder vegetables getting caught in her/his throat. Resident 43 was agreeable to trying chopped meats and an extra side of gravy with all meals. On 12/16/25 at 9:29 AM, Staff 13 (LPN) stated she wrote the Progress note related to Resident 43 having food stuck in her/his throat. She stated she placed the resident on alert, notified the RCM and reported to the next shift. On 12/29/25 at 10:31 AM, Resident 43 stated she/he recently had meat and vegetables caught in her/his throat. She/he stated staff had not spoken to her/him regarding the food stuck in her/his throat. On 1/5/26 at 9:09 AM, Staff 20 (CNA) stated she remembered a while back Resident 43 stated her/his food was getting stuck in her/his throat, but Staff 20 had not notified the nurse. On 1/5/26 at 9:11 AM, Staff 21(LPN) stated on 12/16/25 Resident 43 had an incident of food getting stuck in her/his throat. Staff 21 stated Resident 43 eats in her/his room and is not monitored. Staff 21 acknowledged Resident 43 should have been placed on alert so staff could monitor her/his eating and observe for aspiration. Staff 21 stated Resident 43 should have been placed on alert to keep an eye on how she/he performed on a new diet. On 1/5/26 at 12:19 PM, Staff 4 (DNS) stated she was not aware of the incident with Resident 43. Staff 4 stated her expectation was to place Resident 43 on alert and monitor for aspiration, the physician called, RCMs notified, Registered Dietitian notified, and therapy notified to evaluate Resident 43's diet and risk of aspiration. 3. Resident 83 was admitted to the facility in 11/2025 with a diagnosis of a UTI. Resident 83's 11/21/25 admission MDS revealed she/he was cognitively intact. On 12/29/25 at 12:53 PM anti-fungal powder was observed on Resident 83s bedside table. On 12/30/25 at 1:21 PM Staff (LPN) stated the powder was not to be at the bedside. Resident 83 stated she did not use the powder. On 12/31/25 at 10:43 AM Staff 2 (RN Consultant) stated medications were not to be kept at the bedside without physician orders, an assessment of a resident's ability to administer the medication and a lock box to store the medication.

Based on interview and record review it was determined the facility failed to ensure the influenza vaccine was offered to residents for 1 of 5 (#13) sampled residents reviewed for vaccinations. This placed residents at risk for influenza infection. Findings include: The facility Vaccination of Residents policy with a 5/2021 revision date indicated all residents were to be offered vaccinations that helped in preventing disease and all vaccination information was to be recorded in the resident's medical record. Resident 13 was admitted to the facility in 11/2025 with diagnoses including diabetes and urinary tract infection. A 11/27/25 admission MDS indicated Resident 13 was cognitively intact.During a review of Resident 13's medical record no information was found to indicate the influenza (flu) vaccine was offered for the 2025 flu season (October 2025 through May 2026). On 1/5/26 at 1:50 PM, Staff 4 (DNS) stated the expectation for resident flu vaccinations was for all residents to be offered the flu vaccine each flu season. She acknowledged Resident 13 was not offered the influenza vaccine for the 2025 flu season.

Based on interview and record review it was determined the facility failed to follow medication parameters for 1 of 5 sampled residents (#5) reviewed for medications. This placed residents at risk for side effects to medications. Findings include:Resident 5 was admitted to the facility in 11/2025 with diagnoses including hypertension (elevated blood pressure).A review of Physician Orders revealed a 12/12/25 order for Aldactone 12.5 mg twice a day (a medication to help remove extra fluid from the body) for fluid retention hold for systolic blood pressure (top number) less then 115 or hold for diastolic blood pressure less than 70 (bottom number).A review of Resident 5's 12/2025 MAR revealed Aldactone was documented as given with a diastolic blood pressure less than 70:12/19/25 at 1:00 PM 124/6212/20/25 at 1:00 PM 122/6012/21/25 at 7:00 AM 128/6812/24/25 at 7:00 AM 128/6812/24/25 at 1:00 PM 132/6812/25/25 at 7:00 AM 130/6012/26/25 at 1:00 PM 128/6012/28/25 at 1:00 PM 128/6012/31/25 at 7:00 AM 126/6612/31/25 at 1:00 PM 124/66 A review of Resident 5's 1/2026 MAR revealed Aldactone was documented as given with a diastolic blood pressure less than 70:1/1/26 at 7:00 AM 126/661/1/26 at 1:00 PM 120/641/2/26 at 7:00 AM 132/68On 1/2/26 at 9:23 AM, Staff 18 (CMA) stated Resident 5's Aldactone order indicated the medication was to be held when the diastolic blood pressure was less than 70. Staff 18 stated she administered Resident 5 the Aldactone on 12/31/25 at the 7:00 AM and 1:00 PM doses, on 1/1/26 at the 7:00 AM and 1:00 PM doses, and on 1/2/26 at the 7:00 AM dose. Staff 18 stated the Aldactone should have been held on the above dates due to the diastolic blood pressure less than 70. On 1/2/26 at 9:37 AM, Staff 2 (Regional Nurse Consultant) stated Resident 5's Aldactone order indicated the medication was to be held when Resident 5's blood pressure was less than 70. Staff 2 stated on the above dates and times, Resident 5's Aldactone should have been held per orders.On 1/2/25 at 12:15 PM, Staff 7 (LPN) stated Resident 5's order for Aldactone indicated the medication was to be held when Resident 5's blood pressure was less than 70. Staff 7 stated she administered Resident 5 on 12/25/25 at 7:00 AM and on 12/26/25 at 1:00 PM. Staff 7 stated the Aldactone should have been held on the above dates due to the diastolic blood pressure less than 70.On 1/5/26 at 7:49 AM, Staff 19 (CMA) stated she gave Resident 5 her/his medications on 12/20/25 and 12/21/25. Staff 19 stated if the documentation indicated the medication was administered then she administered the medication.On 1/5/26 at 11:52 AM, Staff 4 (DNS) stated it was expected staff follow orders and hold medications when the order indicated the medication be held.

Based on interview and record review it was determined the facility failed to protect residents' rights to be free from misappropriation of property by staff for 4 of 4 sampled residents (#101, 102, 103 and 104) reviewed for misappropriation of property. Findings include: 1. Resident 101 was admitted to the facility in 2024, with diagnoses including cancer of the colon and frontal lobe of the brain. A Police Department Incident/Investigation Report dated 10/28/24, indicated the department received a report from the facility regarding possible theft of narcotic medication. On the night of 10/23/24 Staff 3 (Agency LPN) oversaw resident medications on the facility's South Hall and a resident complained to day shift staff she/he did not receive her/his narcotic pain medication and was in pain. Several other residents also complained about not getting their medications. Staff 2 (DNS) began an investigation and multiple medication administration and documentation discrepancies were found specifically with narcotic medications. All the concerns involved Staff 3. A progress note by Staff 4 on 10/24/2024 at 3:07 AM, indicated she called the pharmacy requesting verification of any remaining for Resident 101's oxycodone. Staff 4 called the on-call nurse practitioner to request an order for the resident's medication to ensure Resident 101 was medicated prior to the resident leaving for her/his chemotherapy treatment in the morning. Staff 4 called the pharmacy for authorization to pull the medication from the facility's Pyxis machine (computerized medication dispensing system that helps clinicians safely and efficiently provide the correct medications to the right patients at the right time), then gave the medication to Staff 3 to administer. Staff 4 did not watch Staff 3 administer the medication. The pharmacy Med Bank Report from the Pyxis machine for the early morning hours of 10/24/24 contained the following electronically generated medication information: On 10/24/24 at 4:42 AM, oxycodone was removed for Resident 101 by Staff 4. Resident 101's 10/2024 MAR indicated the resident was administered the following dose of medication on 10/24/24: Oxycodone narcotic pain medication by Staff 3 at 4:00 AM. Staff 3 documented she administered Resident 101's oxycodone medication at 4:00 AM but the medication was not pulled from the Pyxis machine until 4:42 AM. Staff 3 could not have administered the medication before it was available. On 12/3/24 at 12:53 PM Resident 101, stated on 10/23/24 around 11:00 PM she/he requested pain medication and Staff 3 (LPN) told her/him there was no oxycodone (narcotic pain medication) for her/him in the medication cart and she gave her/him Tylenol and a muscle relaxant. Staff 3 told the resident she would let the day shift nurse figure out the oxycodone medication issue in the morning. The resident stated she/he knew the oxycodone medication; it was a smaller pill than her/his other medications and helped her/him to sleep. The Tylenol and muscle relaxant the nurse administered did not help her/him to sleep. The resident stated she/he had increased pain from not receiving the oxycodone and could not sleep that night. On 12/4/24 at 8:30 AM, Staff 4 (LPN) stated two CNAs came to tell her a resident was asking for pain medication and had been asking for quite a while. Staff 4 went to check with Staff 3 to see why she did not give the resident her/his oxycodone medication. Staff 3 stated she gave the resident Tylenol. Staff 4 then told Staff 3 the resident needed her/his oxycodone and if there was no current oxycodone on the cart, she just had to call the on-call physician and get a script called into the pharmacy. Staff 3 told her she was going on a break. Staff 4 stated she told Staff 3 it was neglect to leave a resident in pain. Staff 4 decided she needed to step in to assist the resident and she called the on-call physician, got an order, called the pharmacy for an authorization, pulled the medication from the Pyxis machine (Emergency Kit), and gave the medication to Staff 3 to administer to the resident. In the morning the resident stated she/he did not get the medication and Staff 3 had told her/him she was going to leave it for the day shift to figure out. On 12/4/24 at 8:50 AM, Staff 5 (CNA) stated the evening of 10/23/24 the facility had a scheduled downtime for the computer system from 11:00 PM to 1:15 AM. She reminded Staff 3 about the downtime so Staff 3 could check on her residents before the computer went down. Staff 5 stated Staff 3 did not do so and stated she was not going to look at the PRN sheet (for medications) until after the downtime. Staff 5 stated she had written down a PRN request for Resident 101 for oxycodone because the resident was very painful. When she answered the resident's call light at 1:30 AM the resident said Staff 3 had still not administered the oxycodone. Staff 5 stated she went to the nurse on the other hall to request assistance for the resident. On 12/5/24 at 8:24 AM, Staff 3 (LPN) stated she had computer issues on the evening shift of 10/23/24. Staff stated the computer system kept crashing and probably didn't save her documentation. She remembered Resident 101 had requested pain medication. She told the resident she was waiting for authorization from the pharmacy. Staff 3 stated she made a call to the on-call physician to get the order, then she had to call the pharmacy for an authorization. She said she got the authorization in the middle of the night but did not remember what time it arrived. Staff 3 stated she thought she gave Resident 101 Tylenol and maybe an ice pack. Then Staff 4 pulled the medication from the Pyxis machine and handed it to Staff 3 to administer. Staff 3 stated she thought it was normal for one nurse to just hand medication to another nurse. Staff 3 stated she signed the medication into the narcotic book. The On-Call Physician Log report for the facility indicated Staff 4 was the only person to make a call to the on-call telephone line on 10/24/24. Staff 3 claimed she had completed the steps necessary to get the resident's pain medication but the record showed she did not call the on-call physician for an order for Resident 101 or any other resident. On 12/5/24 at 9:50 AM, Staff 2 (DNS) stated when Staff 3 told the resident she/he would have to wait for pain medication until the day shift nurse came in to figure it out, she was not following standard nursing practice. Staff 2 stated Staff 3 reported she had made the arrangements to get the medication from the Pyxis machine for the resident but Staff 3 did not. Staff 2 also stated other staff reported they were unable to find Staff 3 at numerous times during the shift, she took a lot of breaks, and she met with someone in a van out in the parking lot during the night. Staff also found two medication cups Staff 3 labeled for residents in the trash of a bathroom that was not located in an area where Staff 3 should have disposed of them. Staff 2 acknowledged the oxycodone for Resident 101 was documented as administered by Staff 3 before it was available to administer. Staff 2 stated she had reported the concerns to OSBN and Law Enforcement. 2. Resident 102 was admitted to the facility in 2024, with diagnoses including end stage renal disease and traumatic amputation of the right lower leg. Resident 102 was alert and oriented. A Police Department Incident/Investigation Report dated 10/28/24, indicated they received a report from the facility regarding possible theft of narcotic medication. Multiple medication administration and documentation discrepancies were found, specifically with narcotic medications, and all the concerns involved Staff 3 (Agency LPN). The pharmacy Med Bank Report from the Pyxis machine (computerized medication dispensing system that helps clinicians safely and efficiently provide the correct medications to the right patients at the right time) for the early morning hours of 10/24/24 contained the following medication information: On 10/24/24 at 3:53 AM, oxycodone was removed by Staff 4. Resident 102's 10/2024 MAR indicated the resident was administered the following dose of medication on 10/24/24: oxycodone narcotic pain medication by Staff 3 at 3:48 AM. Staff 3 documented she administered Resident 102's oxycodone medication at 3:48 AM but the medication was not pulled from the Pyxis machine until 3:53 AM. Staff 3 could not have administered the medication before it was available. On 12/4/24 at 10:04 AM, Resident 102 stated no one gave her/him oxycodone on the night shift of 10/23/24 to 10/24/24. Resident 102 stated the bandage came off her/his wound and the linens rubbing on her/his stump was so painful it was a 9 out of 10 on the pain scale. The resident was adamant no one gave her/him any oxycodone. The nurse gave him Tylenol only and it did not help very much. The resident stated they gave her/him something stronger starting the next day. On 12/5/24 at 8:24 AM, Staff 3 stated they had to pull the oxycodone for the resident from the Pyxis machine. Staff 3 stated Staff 4 pulled it and she administered it. Staff 3 stated she put it in a med cup with the Tylenol, the oxycodone was small and the room was dark so maybe the resident didn't see it. On 12/5/24 at 9:50 AM, Staff 2 (DNS) stated Resident 102 was very alert and oriented. It was not remotely possible that she/he would have missed the oxycodone medication in the cup. Staff 2 acknowledged Staff 3 documented she had administered the medication before it was even available. Staff 2 added Staff 3 documented she gave the medication at 3:48 AM and then documented it was effective at 3:53 AM, which is not an adequate amount of time to determine effectiveness. 3. Resident 103 was admitted to the facility in 2019, with diagnoses including metabolic encephalopathy (neurological disorder that occurs when the brain is affected by a chemical imbalance in the blood), and Alzheimer's disease. A Police Department Incident/Investigation Report dated 10/28/24, indicated they received a report from the facility regarding possible theft of narcotic medication. Multiple medication administration and documentation discrepancies were found specifically with narcotic medications and all the concerns involved Staff 3 (LPN). Resident 103's 10/24/2024 MAR indicated at 3:00 AM Resident 103 was marked as sleeping so did not receive her/his scheduled dose of Tramadol (narcotic pain medication). The 10/2024 Narcotic Log book page #043 for Resident 103 indicated one dose of Tramadol was pulled by Staff 3 at 3:00 AM. The page did not contain any documentation of what happened to the medication when it was not administered to the resident because she/he was sleeping. The medication should have been destroyed by Staff 3 with the assist of another nurse to verify destruction. The dose of Tramadol was not found by staff. A pharmacy Disposal of Controlled Drugs in a Long-Term Care facility report dated 10/2024 for Resident 103 verified the dose of Tramadol pulled by Staff 3 on 10/24/24 at 3:00 AM had not been destroyed. On 12/5/24 at 8:24 AM, Staff 3 (LPN) stated if she pulled the medication, but the resident was sleeping, maybe she administered it later or taped it in the book? There was no documentation found in the medical record to indicate what happened to the medication. On 12/5/24 at 9:07 AM, Staff 2 (DNS) stated the Narcotic Log showed Staff 3 pulled the medication at 3:00 AM but she also charted the resident was sleeping at 3:00 AM so she did not administer the medication. Standard nursing practice indicated if a nurse pulled a medication, that nurse should administer the medication, or the nurse should destroy the medication with a second nurse as a witness. Staff 2 stated you do not save the medication for later and you do not tape the medication in the narcotic book. No evidence was found to show the medication, which had not been administered, was destroyed and Staff 2 stated they did not find the medication in the facility. 4. Resident 104 was admitted to the facility in 2024, with diagnoses including heart failure, respiratory failure, and peripheral vascular disease (disorder of the blood which can cause pain, cramping, aching, or burning in the legs and feet.) A Police Department Incident/Investigation Report dated 10/28/24, indicated they received a report from the facility regarding possible theft of narcotic medication. Multiple medication administration and documentation discrepancies were found, specifically with narcotic medications, and all the concerns involved Staff 3 (Agency LPN). Resident 104's 10/2024 MAR indicated on 10/24/24 at 12:09 AM, Staff 3 administered a dose of oxycodone to the resident and the medication was effective. Then at 1:00 AM (50 minutes later) Staff 3 documented she administered a dose of Tylenol. Both doses were documented as administered on the MAR during times the one-to-one sitter stated the resident was asleep. A written statement by Staff 7 (LPN) indicated when she heard report on 10/24/24 at 6:30 AM she asked if Resident 104 had received any pain medication on the night shift and was told by the CNA the resident slept all night. On 12/4/24 at 1:08 PM, Staff 6 (CNA) stated he was the one-to-one sitter with Resident 104 on the night shift of 10/23/24. He worked from 10 PM to 6 AM. He never saw Staff 3 administer any medications to Resident 104 and the resident slept through the night. Staff 6 stated the nurse did come by the hall twice but was only looking for the other nurse and Staff 3 never entered the resident's room. On 12/5/24 at 8:24 AM, Staff 3 stated she administered medication one time during the night shift to Resident 104. She stated she administered the medication while the female CNA went to the bathroom. She also stated the female CNA was on the shorter side and had short, cropped hair. Staff 3 concluded she was in the room with her (female CNA). On 12/5/24 at 9:07 AM, Staff 2 (DNS) acknowledged Staff 3 documented she administered pain medication to Resident 104 but there was a male caregiver assigned as a one-to-one sitter to Resident 104 who reported the nurse never entered the resident's room during the night shift and the resident slept through the night.

Based on interviews and record reviews it was determined the facility failed to report a reasonable suspicion of a crime to the State Survey Agency for 4 of 4 sampled residents (#s 101,102, 103 and 104) reviewed for misappropriation of property. This placed residents at risk for further misappropriation of property and incomplete investigations. Findings include: A Police Department Incident/Investigation Report dated 10/28/24 indicated they received a report from the facility regarding possible theft of narcotic medication. A Complaint Form dated 10/23/24 at 10:00 PM to 10/24/24 at 6:00 AM (the night shift) submitted by the facility to the Oregon State Board of Nursing indicated a possible diversion of medications had occurred. On the morning of 10/24/24 the medication aides reported several narcotics had been incorrectly signed out and medications were signed out of the narcotic book but not documented as administered on the eMAR (electronic MAR) by Staff 3 (LPN). There were discrepancies in Staff 3's charting of narcotics. Interviews with residents determined some residents had only received Tylenol for pain relief and not their oxycodone medications. The residents were alert and oriented. An investigation was completed and found other discrepancies. All the concerns found were linked to Staff 3. A report was filed with Law Enforcement. On 12/03/24 at 12:15 PM Staff 2 (DNS) indicated they did not report the concerns to the State Survey Agency, but had reported to OSBN and the local law enforcement agency. Staff 2 stated she felt there may not be enough evidence to prove the diversion of medications. Staff 2 stated she did have concerns with Staff 3's handling of narcotic medications and there were multiple documentation issues which raised her suspicions which included when Staff 3 stated she gave PRN Tylenol at the same time she gave PRN narcotic pain medication. Normally you would administer the Tylenol, and if it was not effective, then administer the narcotic. It did not make sense to give both medications at the same time. On 12/4/24 at 3:17 PM Staff 1 (Administrator) and Staff 2 acknowledged they should have reported to the State Survey Agency.

Based on observation and interview it was determined the facility failed to ensure resident dining environments were homelike, and resident shower rooms were clean for 1 of 2 dining rooms and 5 of 5 shower rooms reviewed for environment. This placed residents at risk for lack of homelike environment and an unsanitary environment. Findings include: 1. Observations on 7/30/24 at 9:25 AM and 8/1/24 at 10:01 AM revealed five individual shower rooms for residents. All five shower rooms were observed to have a heater vent, a small heater unit on the wall, and a ceiling fan. All of them were covered in cobwebs and had dust particle build-up on the exterior and inside (approximately quarter-inch thick dust particles) for each of the three separate components (ceiling fan, heater vent and small heater). On 8/1/24 at 9:32 AM Staff 20 (Housekeeper) stated housekeepers were responsible for cleaning all five shower rooms, which included dusting the ceiling fans, vents and heaters. Staff 20 stated she was unable to clean the accumulated dust particles inside the heater, vent and ceiling fan and would refer the task to Staff 3 (Maintenance Director) to clean. On 8/01/24 12:14 PM Staff 3 acknowledged the thick dust particle buildup in all five shower rooms (including the ceiling fan, heater vent and small heater). Staff 3 indicated he did not normally clean the ceiling fans or heaters unless the motors stopped working. Staff 3 stated it never crossed his mind to clean the heater vents. Staff 3 stated all five showers would be cleaned and dusted. 50927 2. On 7/29/24 at 1:06 PM lunch was observed in the main dining room. Six of 12 residents were served food on trays and no food or drinks were removed from the trays. On 7/31/24 at 1:03 PM lunch was observed in the main dining room. Eleven of 12 residents were served food on trays at the table. On 7/31/24 at 2:10 PM Staff 8 (Dietary Manager) stated the facility's protocol was to serve meals on the trays they were delivered on. Staff 8 further stated, I started here as a cook right before Covid and we have always done it that way. On 7/31/24 at 2:30 PM Staff 8 stated he checked the protocol and acknowledged staff were not to serve meals on trays to residents.

Based on observation, interview and record review it was determined the facility failed to ensure residents were treated with dignity for 1 of 1 sampled resident (#137) reviewed for dignity, 3 of 15 residents (#s 2, 15 and 39) reviewed for assisted dining. This placed residents at risk for lack of dignity. Findings include: 1. Random observations on 7/30/24 from 12:20 PM through 12:50 PM (30 minutes) revealed Staff 19 (CNA) was in the Willamette dining room and Residents 2, 15 and 39 were all seated at the same table for lunch. Staff 19 stood or walked around the table to assist each each of the residents with their lunch meal. On 7/30/24 at 1:13 PM Staff 19 stated the three residents in the Willamette dining room needed assistance and cueing when eating their meals. Staff 19 acknowledged she stood and should have been seated to assist Residents 2, 15 and 39 with their meals. On 8/1/24 at 4:30 PM Staff 2 (DNS) stated she expected all staff to sit with residents who required assistance with eating. Staff 2 stated Staff 19 spoke with her regarding the 7/30/24 dining incident and acknowledged she was supposed to be seated when assisting Residents 2, 15 and 39 with their meals. 34324 2. Resident 179 admitted to the facility in 2024 with diagnoses including neurogenic bladder. Resident 179's 7/25/24 Care Plan indicated the use of an indwelling catheter related to a neurogenic bladder. Observations made on 7/29/24 at 10:50 AM, 11:40 AM, 12:59 PM and 7/30/24 at 12:00 PM revealed Resident 179 laying in bed with her/his room door open. Resident 179's exposed catheter bag contained urine, had no privacy cover and was visible from the hallway. On 7/30/24 at 12:07 PM Staff 2 (DNS) stated residents with catheters were to have a privacy bag or a flap covering the catheter. Staff 2 acknowledged there was no privacy bag or flap covering Resident 179's catheter bag and the resident's catheter was visible from the hallway.

Based on interview and record review it was determined the facility failed to comprehensively assess a resident's needs related to nutrition for 2 of 3 sampled residents (#s 17 and 42) reviewed for nutrition. This placed residents at risk for unmet nutritional needs and weight loss. Findings include: 1. Resident 17 admitted to the facility in 5/2024 with diagnoses including diabetes, end stage renal disease, and dependence on renal dialysis. The 5/15/24 Admission MDS Nutritional Status CAA did not include Resident 17's history, current nutritional status, or plan of care. On 8/1/24 at 1:15 PM Staff 2 (DNS) acknowledged the 5/15/24 Admission MDS Nutrition CAA was not comprehensive and did not include Resident 17's history, current nutritional status, or plan of care. 50928 2. Resident 42 was admitted to the facility on [DATE] with the diagnoses including fracture of the right femur, malignant neoplasm of the lung and type 2 diabetes. Resident 42's Admission MDS dated [DATE], Section V: Care Area Assessment (CAA) Summary identified resident's Nutritional Status CAA triggered for further assessment. There was no documentation in the resident's medical record indicating the Nutritional Status CAA was completed or notes referring to where an assessment could be found. On 8/1/24 at approximately 3:00 PM Staff 2 (DNS) confirmed the nutritional status CAA was blank and Resident 42's nutritional needs were not assessed.

Based on observation, interview and record review it was determine the facility failed to ensure a residents call light was within reach for 1 of 2 sampled residents (#25) reviewed for physical environment. This placed residents at risk for lack of ADL assistance. Findings include: Resident 25 was admitted to the facility in 11/2017 with diagnoses including dementia and depression. The Quarterly MDS dated [DATE], revealed Resident 25 had a BIMS score of 15, which indicated the resident was cognitively intact. On 7/29/24 at 1:07 PM Resident 25 stated she/he needed assistance to move her/himself in bed and was not sure where the call light was located. Observations on 7/29/24 from 1:08 PM through 3:09 PM revealed Resident 25's call light was on the left side of her/his bed, on the floor, out of reach. Staff entered Resident 25's room at 1:18 PM, repositioned her/him, and took the resident's lunch tray, but did not ensure her/his call light was within reach. On 7/29/24 at 3:09 PM Staff 16 (CNA) entered the room and acknowledged Resident 25's call light was on the floor and out of reach. Staff 16 stated Resident 25 did not get out of bed and needed her/his call light for assistance. Staff 16 stated staff were expected to ensure call lights were within reach at all times. On 8/1/24 at 4:30 PM Staff 2 (DNS) stated she expected all staff to ensure residents' call lights were not on the floor and were accessible to residents at all times. Staff 2 acknowledged Resident 25's call light was out of reach for an extended period of time.

Based on interview and record review it was determined the facility failed to provide information related to financial responsibilities for 1 of 3 sampled residents (#14) reviewed for Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN). This placed residents at risk for unforeseen financial responsibilities. Findings include: Resident 14 admitted to the facility in 4/2024 and received Medicare services from 4/26/24 through 6/28/24. Resident 14 received and signed the NOMNC (Notice of Medicare Non-Coverage) on 6/26/24. Although the resident remained in the facility, there was no evidence the resident received a SNFABN providing information on the resident's financial liability. On 7/31/24 at 4:16 PM Staff 5 (Social Service Director) acknowledged Resident 14 did not receive the SNFABN form and did not receive information about financial responsibilities after discharging from Medicare services while remaining in the facility.

Based on interview and record review it was determined the facility failed to ensure the resident had constant supervision and physical assistance for toileting. The resident fell experienced increased pain, decreased ability to stand and was subsequently identified with a displaced fracture (complete separation of the bone). Findings include: Resident 4 was admitted to the facility in 2016 with [DIAGNOSES REDACTED]. The 6/1/16 MDS associated Care Area Assessment Worksheets indicated the resident was admitted to the facility after a fall at home. The Resident was on the floor for many hours before she/he was found and transported to the hospital for evaluation and treatment. The worksheet indicated the resident had an upcoming planned cervical spine (neck) surgery and was admitted to the facility for therapy until surgery was performed. The resident was identified to be alert and oriented to self and place but was forgetful. The resident had decreased strength to the legs, had poor balance, pain to the left shoulder and left hip and had decreased safety awareness. The resident was assessed to not be able to walk or transfer without staff assistance. The Care Plan initiated on 5/25/16 indicated the resident was at risk for falls and interventions included the resident was to have a call light within reach. The Care Plan also indicated the resident had functional and physical limitations related to urinary incontinence. The resident was to have one person constant supervision and physical assist for safety with toileting. Therapy Daily Treatment Notes from 5/30/16 through 6/8/16 were reviewed. On 5/30/16 the resident was documented to walk 100 feet with a front wheel walker and minimal assistant to prevent lateral leaning. On 5/31/16 the resident walked in the hallway for 50 feet with the use of a front wheel walker and a knee brace for left lower leg support. On 6/2/16 the resident walked for 20 feet in the hall with moderate assistance. On 6/3/16 the resident was documented to walk 75 feet with a front wheel walker with minimal assistance. The 6/6/16 note did not indicate the resident walked. The resident was documented to do balance activities for sitting and transfer training. The Progress Notes from 5/25/16 through 6/10/16 were reviewed. On 5/26/16 the note indicated the resident's pain was well managed. The 5/30/16 at 3:32 am note indicated the resident requested pain medication but refused Tylenol. The 5/30/16 at 9:14 pm note, 5/31/16 at 2:37 am, 7:43 am and 10:00 pm notes indicated the resident did not have new pain. The 6/1/16 at 7:39 am and 4:34 pm notes indicated the resident did not have increased pain. The 6/2/16, 6/3/16, and 6/4/16 notes indicated the resident did not have pain and/or an increase in pain. The 6/5/16 Fax to Witness 7 (Resident 4's Nurse Practitioner) indicated the resident reported abdominal discomfort when the resident was administered Tylenol (non-narcotic pain medication). Witness 7 responded on 6/6/16 with orders for oxycodone every 12 hours PRN pain. The 6/7/16 Progress Note at 5:33 am indicated at 4:10 am staff heard Resident 4 call for help. The resident was found on the floor by a CNA. The resident was on her/his left side near the wall. The resident reported 10 out of 10 pain (zero is no pain, 1-3 is little pain, 4-6 is moderate pain and 7-10 is severe pain) to the left hip and shoulder. The June 2016 MAR indicated the resident took oxycodone for the first time after the fall on 6/7/16 at 4:28 am for a pain level of 10 out of 10. The medication was documented as effective. The 6/7/16 Therapy Daily Treatment Note for physical therapy indicated the resident reported being very sore and a nerve block was performed to the left knee for 8 out of 10 knee pain due to a recent fall onto the left side. The 6/8/16 therapy note indicated the resident was very sore and needed additional time to mend. The resident rode the omnicycle (stationary therapy bicycle) for ten minutes. On 7/18/16 at 2:12 pm Staff 28 (CNA) indicated Resident 4 seemed to have more pain after the 6/7/16 fall and was more difficult to transfer. The 6/8/16 at 3:40 am and 7:36 am Progress Note indicated the resident had decreased range of motion to the left side and orders for x-rays were obtained due to the resident's increased pain and less movement of the left side. The 6/8/16 Significant Findings Report for the x-rays included the interpretation of the left hip x-ray. Findings indicated there appeared to be shortening of the femoral neck (bone/area between the top of the leg bone and the ball and socket hip joint) without a definite fracture line. The comments included Question occult fracture of the femoral neck. Additional imaging is recommended. The 6/8/16 Fax to Witness 7 (Resident 4's Nurse Practitioner) sent by Staff 21 (LPN) indicated all x-rays obtained came back with no identified fractures. The fax included a request for an additional x-ray of the neck. The fax did not include information to indicate the left hip possibly had an occult fracture and additional imaging was recommended. On 7/12/16 at 10:15 am Witness 7 indicated he was not notified of the hip x-ray results and the recommendation for additional imaging studies. Witness 7 indicated he reviewed the x-ray after the resident was discharged from the facility and there was a potential hair line fracture. Witness 7 indicated if he was notified of the possible fracture he would have ordered additional imaging studies and ordered the resident to be non-weight bearing pending the results of the imaging studies. Witness 7 indicated continued falls and the resident's continued use of the left leg could cause a hairline fracture to worsen. The June 2016 MAR indicated on 6/8/16 the resident was administered pain medication at 2:31 am for a pain level of 10 out of 10 and the pain medication was documented as effective. The 6/9/16 at 12:44 am Progress Noted indicated the resident had pain including pain to the left hip. An ice pack was offered to the resident but the resident refused the ice pack. The note indicated the resident accepted pain medication. The June 2016 MAR indicated on 6/9/16 the resident was administered oxycodone at 12:52 am for a pain level of 5 out of 10 and the medication was documented as effective. The 6/9/16 Therapy Daily Treatment note for Physical Therapy identified the resident had a left leg discrepancy (one leg is shorter than the other leg) which contributed to the resident's poor balance. The 6/10/16 at 12:45 am note indicated a CNA transferred the resident to the bedside commode, left the room for linens and the resident fell before the CNA returned. The statement signed on 6/15/16 by Staff 17 (CNA) indicated she transferred the resident to the bedside commode. The resident's bed required dry linens and Staff 17 left the room for less than one minute. The resident was found on the floor on the left side. The Resident Abuse Investigation Report Form signed by Staff 20 (DNS) on 7/6/16 included Staff 17 did not follow Resident 4's Care Plan. On 7/19/16 at 3:21 pm Staff 17 indicated she was aware Resident 4 was a fall risk and the resident's Care Plan instructed staff not to leave the resident alone for toileting. Staff 17 indicated the resident reported she/he needed to have a bowel movement. Staff 17 indicated she did not think the resident would be done toileting before she returned with dry linens. Staff 17 provided the resident the call light before leaving the room but the resident fell before she returned to the room. On 7/18/16 at 11:00 am Staff 19 (RNCM) indicated Resident 4 was not safe to be left alone when toileting and the resident's Care Plan reflected the resident was to have constant supervision. Resident 4 was left unattended on 6/10/16. The June 2016 MAR indicated on 6/10/16 at 1:15 am the resident was administered oxycodone and the medication was documented as not effective. The resident was then administered Tylenol at 1:53 am and was effective. On 7/7/16 at 12:15 pm Staff 10 (LPN) indicated she worked on 6/10/16 the day the resident fell from the bedside commode. The resident had back and neck pain and she administered Resident 4 oxycodone. The oxycodone was not effective so she administered the resident Tylenol. The Tylenol was effective for the pain. Staff 10 indicated the resident was able to transfer and bear weight after the fall. The PT notes for 6/10/16 electronically signed at 9:12 am indicated the resident reported 8.5 out of 10 pain to the left hip and thigh when the resident moved the left leg. The note electronically signed at 10:23 am by Staff 25 (Physical Therapy Assistant) indicated the resident had severe motor planning issues (ability to move feet) and did not follow commands for transfers and pre-walking exercises. The note indicated the resident's RNCM and nursing staff were notified of the resident's condition and imaging studies were to be obtained to rule out potential fracture to the left leg. On 7/18/16 at 4:25 pm Staff 25 indicated on 6/10/16 Resident 4 had significant difficulty moving the legs. The resident was painful and was not able to bear weight on the left side. Staff 25 was aware the resident fell on the night shift and felt the resident's symptoms reflected a possible hip fracture. Staff 25 informed the nursing staff of his assessment and the nursing staff were to communicate with the physician to obtain x-rays to rule out a fracture. The Late Entry Progress Note dated 6/10/16 at 9:00 pm indicated the resident had at scheduled pre-operative appointment at 1:00 pm on 6/10/16. The resident was sent to the hospital emergency room after the appointment for increased pain. The Declaration signed by Witness 8 (Orthopedic Surgeon) on 7/27/16 indicated Resident 4 fell at home before 5/25/16 and x-rays were not obtained after the fall. The resident was also noted to fall on 6/8/16 at the facility. Witness 8 reviewed the resident's 6/8/16 left hip x-rays and identified the resident to have a impacted fracture (one fragment part is driven into another part) and the fracture was minimally displaced. Witness 8 indicated it was possible the impacted fracture seen on the 6/8/16 imaging study occurred prior to the admission to the facility. Even assuming that the impacted fracture became more displaced as a result of the June 10 fall, it likely did not change the treatment options. The surgical option identified by Witness 8 was a hip pinning surgery (bones are realigned and secured with rods/screws/pins/or plates). The 6/10/16 at 12:54 pm Clinic Progress Note indicated the resident reported increased pain down the left leg into the knee after the fall on 6/10/16. The resident was instructed to go to the emergency room . The 6/10/16 hospital medical Consultation report indicated the resident reported 9.5 out of 10 pain to the left hip. The resident reported she/he was not able to move the left leg during transfers. The Clinic physician recommended the resident to go to the emergency room for evaluation of the left leg. The resident was identified to have a displaced hip fracture that may have been sustained after a fall at the facility. The left hip was not examined because of the resident's pain. The 6/11/16 Operative Report indicated the resident x-ray revealed a displaced femoral neck fracture but quite good bone quality. The report indicated the resident's femoral head (top of leg bone) was replaced with an implant. The form received on 8/1/16 from Witness 9 (Resident 4's hospital Orthopedic Surgeon) indicated a minimally displaced hip fracture could be repaired with a pinning. Witness 9 also indicated a hemi-arthoplasty was the only option for Resident 4's 6/10/16 x-ray findings because the resident's hip was displaced. The hospital records indicated the resident was discharged from the hospital on [DATE]. On 7/14/16 at 11:37 am, on 7/15/16 at 4:00 pm and on 7/19/16 at 10:27 am Staff 23 (Administrator) indicated Resident 4 was admitted to the facility and had left hip pain. Staff 23 acknowledged Resident 4 had falls at the facility and the resident's 6/7/16 x-rays identified a possible occult fracture and the facility did not notify the resident's physician of the recommendation of follow-up imaging studies. Staff 23 acknowledged the resident continued to participate in therapy and acknowledged therapy identified Resident 4 had symptoms of a left hip fracture after the 6/10/16 fall.

Based on observation, interview and record review it was determined the facility failed to initiate interventions and provide supervision to ensure a safe environment for 1 of 2 sampled residents (#231) at risk for elopement. Resident 231 was identified on 7/14/14 as a wander risk and needed 24/7 supervision. Resident 231 left the faciity on [DATE] without staff knowledge. Resident 231 received insulin and left the facility prior to being served breakfast. The resident was located 1.4 miles away from the facility by staff and was returned to the facility with a CBG of 21 (normal range 90-130), tired and hungry. This placed the resident in immediate jeopardy and constituted substandard quality of care. Findings include: Resident 231 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a local hospital discharge summary dated 7/14/14 revealed the resident was admitted for rehabilitation services due to a "severe" traumatic brain injury. The summary indicated the resident would continue to require 24/7 supervision due to the resident's "severe" cognitive impairment. The note also indicated the resident continued to be unsafe and had poor safety awareness. Review of a hospital care transfer form dated 7/14/14 revealed the resident was to be transferred to the facility for skilled nursing care and was to receive daily physical and occupational therapy. The form indicated the resident was alert, oriented, confused, had impaired memory and was a "wander risk". Physician orders [REDACTED]. Review of a Nursing Admission assessment dated [DATE] at 4:02 pm revealed the resident was admitted post brain injury, memory was "ok", comprehended surroundings and understood what was being said. The assessment indicated the resident had a history of [REDACTED]. The assessment also indicated the resident was alert and oriented to person, place and time and suffered from short term memory loss at times. There was no analysis regarding the hospital discharge summary which indicated the resident needed 24/7 supervision and had poor safety awareness. Review of an initial care plan dated 7/14/14 revealed the resident had a cognitive deficit, related to a brain trauma, characterized by a deficit in memory, judgement, decision making and thought process. The care plan did not identify the resident was at risk for wandering or potential elopement from the facility and there were no staff interventions in place regarding supervision of the resident. Review of a nurse's note dated 7/14/14 at 9:26 pm revealed staff were notified the resident was found in a driveway across the street from the facility by a neighborhood pedestrian. The resident told staff she/he exited the facility through the front door, was looking for her/his sister and had not known where she/he was at. The resident was escorted back to the facility and placed on alert charting for possible elopement. Review of an elopement/incident assessment dated [DATE] at 9:30 pm revealed the resident was not seen from 9:00 pm to 9:26 pm. The assessment indicated the resident had a history of [REDACTED]. The resident was found safe, unharmed, appeared confused and in no distress. The assessment did not include an analysis of how the resident left the facility and what interventions were put into place to keep the resident safe from elopement. Review of a nurse's note dated 7/14/14 at 10:47 pm revealed the resident spent most of the night wandering the facility. The note indicated the resident attempted to open the front door next to the north nurse's station multiple times and was redirected by staff. Review of an elopement/incident assessment dated [DATE] revealed the resident was a wanderer and had poor safety awareness. The assessment indicated the resident left the faciity on [DATE] and was either let out of the facility by visitors or the resident was able to read the posted exit code, use the key pad and let herself/himself out. The assessment also indicated the resident did not "look like a resident" and the resident did not remember leaving the facility. The plan was to have the resident wear a name badge with the facility's address and phone number written on the badge. The care plan was updated 7/16/14 and staff were to have the resident wear a name badge with the facility's address and phone number. Review of a nurse's note dated 7/16/14 at 1:00 pm revealed the resident appeared forgetful and wandered the facility throughout the day. Review of a nurse's note, late entry dated 7/18/14 at 6:10 am, revealed the resident was found by staff walking outside the facility with a walker. The note indicated the resident wore the elopement risk badge. The resident was returned to the facility and was placed in front of the nurse's station so staff could keep an eye on the resident while staff passed medications and meal trays to residents. The note did not indicate additional staff interventions were added to the care plan. Review of a CBG summary dated 7/18/14 at 6:28 am revealed the resident's blood sugar level was 119. Review of a July 2014 MAR revealed the resident received Lispro insulin in the morning on 7/18/14 at 7:00 am. Review of a medication administration note dated 7/18/14 at 9:00 am revealed the resident was out of the facility and no medication was given. Review of a nurse's note dated 7/18/14 at 10:07 am revealed the resident was escorted back to the facility and the resident's CBG was 21 (hypoglycemic/ low blood sugar). The resident was administered glucose two times and was given a sandwich and orange juice. The note indicated the resident received insulin prior to elopement from the facility and prior to breakfast. The resident's CBG was checked 10 minutes later and it was 81. The note also indicated on last check the resident was no longer shakey (symptom of low blood sugar) and CBG was 110. Review of a late entry nurse's note dated 7/18/14 at 10:48 am revealed Staff 9 (RNCM) was notified upon arrival to the facility the resident eloped. The resident was in the facility while meal trays were passed between 7:00 am and 7:30 am. Staff 5 (CNA) saw the resident walk towards the main dining room, west of the north nurse's station and Witness 1 (Nursing Student) and Witness 2 (Student Nurse) were informed staff the resident exited the back door near the atrium. A search was initiated and local authorities, family, the resident's physician, DNS and the administrator were notified. The note indicated the resident was returned to the facility by a staff and the resident was wearing the elopement badge. On 7/18/14 at 8:00 am Staff 13 (LPN), Witness 1 (Nursing Student) and Witness 2 (Nursing Student) were observed at the north nurse's station. Staff 13 was overheard talking on the phone and stated local authorities had been notified the resident had left the facility. On 7/18/14 at 8:10 am it was observed the back door near the atrium had a keypad next to the door and the door was locked. A note above the keypad indicated the code needed to unlock the door. In interview on 7/18/14 at 8:25 am Witness 1 (Student Nurse) indicated she saw the resident around 6:30 am. Witness 1 said she saw the resident enter the code to the back door near the atrium and leave the facility. She did not know she/he was a resident at the time and did not see a name badge. Witness 1 said the resident walked around the facility and re-entered through the front door. Witness 1 said around 7:30 am Staff 6 (LPN) was informed by Staff 5 (CNA) the resident was missing. Witness 1 said facility staff did a search of the building, outside the building and the surrounding neighborhood. Witness 1 said the facility was aware the resident had a history of [REDACTED]. In an interview on 7/18/14 at 8:45 am Staff 4 (CNA) said she arrived at the facility at 5:55 am and noticed the resident inside the building near the back door near the atrium. Staff 4 said the resident was wearing a name badge which indicated the resident resided at the facility. Staff 4 said the student nurses and facility staff entered through the door at that time and she was informed the resident was missing around 7:15 am. In an interview on 7/18/14 at 9:00 am Staff 5 (CNA) said as she passed meal trays around 7:30 am she noticed the resident standing at the west end of the north hallway. Staff 5 said she finished passing meal trays to the north hall and the resident's room. Staff 5 then asked a student nurse about the resident who was not in his/her room and was told the resident had gone outside. Staff 5 looked for resident outside and could not find the resident. Staff 5 said the resident had a history of [REDACTED]. Staff 5 said the resident had been exit seeking the previous night. In an interview on 7/18/14 at 9:15 am Witness 2 (Student Nurse) said she saw the resident at 6:45 am by the back door near the atrium. She saw the resident again around 7:15 am and did not know if he was a resident or a visitor to the facility. Witness 2 indicated she did not see a name badge on the resident and the resident was not using a walker or cane. Witness 2 said the first time she saw the resident, around 6:45 am, her/his gait was steady but when she saw the resident the second time at 7:15 am she/he looked unsteady and noticed she/he was wearing a badge. Witness 2 said the facility had not informed her the resident was an elopement risk. Witness 2 was told by Staff 6 this was the first time the resident eloped. On 7/18/14 at 9:30 am the resident was observed sitting near the north nurse's station being assessed by Staff 6 (LPN). Staff 6 was observed administering glucose to the resident. In an interview on 7/18/14 at 9:30 am Staff 6 indicated the resident's CBG was 21 when resident returned to the facility. The resident had not eaten prior to leaving the facility. At 9:48 am Staff 6 said the resident was administered Lispro insulin at 6:30 am. In an interview on 7/18/14 at 9:42 am Staff 7 (CNA) said the resident's meal tray was brought to the resident's room at 7:30 am. The resident was not in the room and did not eat prior to the elopement. In an interview on 7/18/14 at 10:45 am Staff 8 (Receptionist) said she found the resident at 9:00 am on the front lawn of her house, 1.4 miles from the facility, picking grass. Staff 8 said she called the facility to verify the resident was missing and kept the resident at her house until the resident was picked up. Staff 8 said Staff 6 picked up the resident and brought the resident back to the facility. Staff 8 said the resident was tired and did have an elopement badge on. Staff 8 said the resident did stand at the front door of the facility at times and she never saw the resident use the key pad. In an Interview on 7/18/14 at 11:45 am Staff 9 (RNCM) said the resident was admitted to the facility post brain injury and had cognitive deficits, slow speech and short term memory loss. Staff 9 had not seen the hospital care transfer form or hospital discharge summary which indicated the resident wandered and needed 24/7 supervision until 7/15/14. Staff 9 said she verbally told staff to keep an eye on the resident after the first elopement. Staff 9 said the elopement badge was added to the care plan and no other elopement interventions were in place. Staff 9 acknowledged the badge would not prevent the resident from leaving the facility. Staff 9 said the badge would alert staff and others the resident was not to leave the facility. If the resident left the facility the badge would alert people to contact the facility when the resident was found. Staff 9 said the admitting nurses, Staff 11 (LPN) and Staff 12 (LPN) were responsible for initiating the resident's care plan and having interventions in place for elopement concerns if the RNCM was not available. In an interview on 7/18/14 at 12:00 pm Staff 10 (Administrator) said the elopement badge was the routine intervention for residents at risk for elopement. Staff 10 acknowledged the appropriate state agency was not notified of the resident's elopement on 7/14/14 per facility policy. In an interview on 7/18/14 at 12:15 pm Staff 29 (Community Liaison) indicated she talked to the local hospital discharge coordinator prior to the resident's admission to the facility and was told the resident liked to walk and wandered. Staff 29 said because the resident had a brain injury she asked the hospital if the resident was at risk for elopement and the hospital said the resident was not an elopement risk. Any information from the hospital was given to the RNCM or DNS and did not feel the resident was "a complicated case". In an interview on 7/18/14 at 12:40 pm Staff 11 (LPN) said he assisted Staff 12 (RN) with the resident's admission to the facility. Staff 11 reviewed the hospital transfer form and medication orders and acknowledged the resident was a wander risk but was not at risk to leave the facility. Staff 11 told the resident to ask staff if the resident wanted to go outside. Staff 11 said he completed the initial care plan for the resident and felt the resident was not at risk for elopement. After the resident eloped on 7/14/14 he informed staff to be aware the resident left the facility and did not update or revise the care plan with interventions to prevent the resident from future elopments. In an interview on 7/18/14 at 12:49 Staff 12 (RN) said she completed the resident's physical assessment on admission to the facility and did review the hospital transfer form. Staff 12 was not aware the resident was at risk for elopement. In an interview on 7/18/14 at 1:00 pm Staff 10 (Administrator) was informed the resident was not provided adequate supervision to ensure a safe environment which resulted in the resident eloping from the facility on three occasions. Resident 231 was identified on 7/14/14 as a wander risk and needed 24/7 supervision. Resident 231 left the faciity on [DATE] without staff knowledge. Resident 231 received insulin and left the facility prior to being served breakfast. The resident was located 1.4 miles away from the facility by staff and was returned to the facility with a CBG of 21 (normal range 90-130), tired and hungry. The immediate jeopardy was abated on 7/18/14 at 2:30 pm when the survey team received an acceptable plan of correction. 2. Based on observation and interview it was determined the facility failed to ensure a maintenance door alarm functioned to ensure residents did not elope for 1 of 1 maintenance doors. This placed residents at increased risk for elopement. Findings include: Observation on 7/22/14 at 9:39 am revealed the maintenance door with a sign that read "Disable alarm before passing through. Reset Alarm Upon Return". The door also had a door scope. When you looked into the scope a person could see beyond the closed door. On 7/22/14 at 9:48 am, with another surveyor standing in the hall by the maintenance door, this surveyor walked out of the maintenance door. The doorbell chimed twice. This surveyor walked through an unlocked gate located beyond the maintenance door and walked to the main road. This surveyor then returned to the building through the door located by medical records. At 9:51 am this surveyor returned to the maintenance door. The surveyor standing in the hall reported staff did not check the maintenance door after it chimed to ensure a resident did not leave the building. On 7/22/14 at 11:34 am Staff 24 (Assistant DNS) acknowledged the maintenance door chimed twice when the door was opened. After the alarm chimed two times the chime stopped. Staff 24 stated the door alarm was not set properly. The alarm should sound with a loud continuous alarm that needed to be disarmed manually by entering a code. The continuous alarm alerted staff to look to see if residents left the facility.