Every finding on record at Pilot Butte Rehabilitation Center

Based on interview and record review it was determined the facility failed to investigate allegations of verbal abuse for 4 of 5 sampled residents (#s 15, 16, 18, and 19) reviewed for verbal abuse. This placed residents at risk for further abuse. Findings include:1. Resident 15 was admitted to the facility in 12/2024 with diagnoses including depression and muscle wasting. A Grievance Form dated 2/3/26 documented Resident 15 had been verbally abused by Resident 17. Resident 17 had called Resident 15 pussy and faggots and making threats. The form noted Resident 17 denied name-calling and threats and had been advised to request a staff member when upset. Further documentation indicated Resident 17 had improved and that lashing out had decreased. There was no documented evidence the facility conducted a thorough investigation to determine whether verbal abuse had occurred. On 6/24/26 at 10:09 AM Staff 16 (Social Services Director) stated no formal investigation was completed. On 6/24/26 at 11:43 AM Staff 1 (Administrator) stated when the facility received a resident grievance form, interviews should be conducted with both staff and residents and document the information on a progress note or on the grievance form. Staff 1 provided no additional information to show a thorough investigation had been completed. 2. Resident 16 was admitted to the facility in 8/2022 with diagnoses including stroke. A Grievance Form dated 2/3/26 documented Resident 17 had verbally abused Resident 16, calling her/him pussy and faggots and making threats. Resident 17 denied name-calling and threats and had been advised to request a staff member when upset. Further documentation indicated Resident 17 had improved and lashing out had decreased. Recommended actions included continued monitoring. There was no documented evidence the facility conducted a thorough investigation to determine whether verbal abuse had occurred. On 6/24/26 at 10:09 AM, Staff 16 (Social Services Director) stated no formal investigation was completed. On 6/24/26 at 11:43 AM, Staff 1 (Administrator) stated when the facility received a resident grievance form, interviews should be conducted with both staff and residents and document the information on a progress note or on the grievance form. Staff 1 provided no additional information to show a thorough investigation had been completed. 3. Resident 18 was admitted to the facility in 9/2022 with diagnoses including stroke. A Grievance Form dated 3/13/26 documented Resident 18 was extremely uncomfortable due to Resident 17's actions. Resident 17 had been yelling curse words and vile names at residents and staff. The documented action had been to continue education and therapy and complete care planning for Resident 17. A Behavior Note dated 3/13/26 documented Resident 17 was upset about the dining room seating arrangement and had screamed homophobic slurs at residents and refused to calm down. On 6/23/26 at 12:07 PM, Staff 43 (CNA) stated she had not heard anything from administration related to the grievance. There was no documented evidence the facility conducted a thorough investigation to determine whether verbal abuse had occurred. On 6/24/26 at 11:43 AM, Staff 1 (Administrator) stated when the facility received a resident grievance form, interviews should be conducted with both staff and residents and document the information on a progress note or on the grievance form. Staff 1 provided no additional information to show a thorough investigation had been completed. 4. Resident 19 was admitted to the facility in 7/2025 with diagnoses including depression and stroke. A Grievance Form dated 3/13/26 documented Staff 43 (CNA) had been advocating for Resident 19 due to verbal abuse from Resident 17. Resident 19 had been moved to different seating and had felt alienated from other resident because of being accused of taking Resident 17's dining room spot. Resident 19 had been tired of being called foul names. A separate Grievance Form dated 3/13/26 documented Resident 17 had been screaming and yelling and had claimed Resident 19 took her/his spot. Resident 20 had been tired of seeing Resident 19 being insulted and bullied. A Behavior Note dated 3/13/26 documented Resident 17 had been upset about the dining room seating arrangement, screamed homophobic slurs at residents and refused to calm down. On 6/17/26 at 8:11 AM, Witness 10 (anonymous resident) stated she/he had heard Resident 17 calling Resident 19 a faggot. There was no documented evidence the facility conducted a thorough investigation to determine whether verbal abuse had occurred. On 6/23/26 at 12:07 PM, Staff 43 confirmed she had completed the 3/13/26 grievance for Resident 19. Staff 43 stated Resident 17 entered the dining room and saw Resident 19 was seated in a spot Resident 17 considered her/his own. Resident 17 called Resident 19, a gay little faggot. Staff 43 stated Resident 19 had been tearful. Staff 43 stated she had not heard any response related to the outcome of the grievance. On 6/24/26 at 11:43 AM, Staff 1 (Administrator) stated when the facility received a resident grievance form, interviews should be conducted with both staff and residents and document the information on a progress note or on the grievance form. Staff 1 provided no additional information to show a thorough investigation had been completed.

Based on interviews and record review, it was determined the facility failed to protect the residents' right to be free from verbal abuse by another resident for 4 of 5 sampled residents (#s 15, 16, 18, and 19) reviewed for verbal abuse. This placed residents at risk for further abuse. Findings include:1. Resident 15 was admitted to the facility in 12/2024 with diagnoses including depression and muscle wasting. Resident 17 was admitted to the facility in 12/2025 with diagnoses including traumatic brain injury, brain damage and adjustment disorder. Resident 15's Annual MDS dated [DATE] indicated she/he was cognitively intact. Resident 17's admission MDS dated [DATE] indicated she/he was moderately cognitively impaired. A Grievance Form dated 2/3/26 documented Resident 15 had been verbally abused by Resident 17. Resident 17 had called Resident 15 pussy and faggots and making threats. The form noted Resident 17 denied name-calling and threats and had been advised to request a staff member when upset. Further documentation indicated Resident 17 had improved and that lashing out had decreased. Recommended actions included continued monitoring. Resident 17's Care Plan dated 3/18/26 documented a risk for behavior symptoms including outbursts of yelling and cursing when redirected or educated. Interventions included approaching resident in a calm manner, reapproaching later if agitated or uncooperative, and keeping Resident 17 in a supervised area when out of bed. On 6/15/26 at 1:34 PM, Resident 15 stated Resident 17 cursed at her/him about once a month. Resident 15 stated the cursing did not make her/him feel good and made her/him uncomfortable. Resident 15 also stated the verbal behavior made her/him feel uncomfortable when directed at staff. On 6/23/26 at 8:12 AM, Staff 35 (CNA) stated on 2/3/26 Resident 17 said a lot of nasty things and had cursed at Resident 15. Staff 35 stated Resident 17 was so loud the whole facility knew what was happening and attempts had been made to stop the resident.On 6/24/26 at 10:09 AM, Staff 16 (Social Services Director) stated she followed up with Resident 15 about her/his grievance concern and educated Resident 15 about Resident 17's difficulty controlling verbal outburst. Staff 16 stated she did not have an opinion on whether the 2/3/26 incident constituted verbal abuse and stated it would depend on the residents' feelings. On 6/24/26 at 11:43 AM, Staff 1 (Administrator) stated Resident 17 had been vocal in public spaces and directed verbal interactions toward staff rather than residents. Residents had become upset and had complained about Resident 17. Staff 1 stated residents who were interviewed did not indicate they had been verbally abused by Resident 17. 2. Resident 16 was admitted to the facility in 8/2022 with diagnoses including stroke. Resident 17 was admitted to the facility in 12/2025 with diagnoses including traumatic brain injury, brain damage and adjustment disorder. Resident 16's MDS dated [DATE] indicated she/he was cognitively intact. Resident 17's admission MDS dated [DATE] indicated she/he was moderately cognitively impaired. A Grievance Form dated 2/3/26 documented Resident 17 had verbally abused Resident 16, calling her/him pussy and faggots and making threats. Resident 17 denied name-calling and threats and had been advised to request a staff member when upset. Further documentation indicated Resident 17 had improved and that lashing out had decreased. Recommended actions included continued monitoring. Resident 17's Care Plan dated 3/18/26 documented she/he was at risk for behavior symptoms with verbal outbursts of yelling and cussing when Resident 17 was redirected or educated. Interventions included approach resident in a calm manner, re-approach later if agitated or uncooperative. Resident 17 was to be in a supervised area when out of bed. On 6/15/26 at 1:26 PM, Resident 16 stated Resident 17 had threatened to attack her/him. Resident 17 called her/him derogatory statements. Resident 16 stated it pisses her/him off because it brought up bad memories from childhood. On 6/23/26 at 8:12 AM, Staff 35 (CNA) stated on 2/3/26 Resident 17 said a lot of nasty things and had cursed at Resident 16. Staff 35 stated Resident 17 was so loud the whole facility knew what was happening and attempts had been made to stop the resident. On 6/24/26 at 10:09 AM, Staff 16 (Social Services Director) stated she followed up with Resident 16 about her/his grievance concern and educated Resident 16 about Resident 17's difficulty controlling verbal outburst. Staff 16 stated she did not have an opinion on whether the 2/3/26 incident constituted verbal abuse and stated it would depend on the residents' feelings. On 6/24/26 at 11:43 AM Staff 1 (Administrator) stated Resident 17 had been vocal in public spaces and directed verbal interactions toward staff rather than residents. Residents had become upset and had complained about Resident 17. Staff 1 stated residents who were interviewed did not indicate they had been verbally abused by Resident 17. 3. Resident 18 was admitted to the facility in 9/2022 with diagnoses including stroke. Resident 17 was admitted to the facility in 12/2025 with diagnoses including traumatic brain injury, brain damage and adjustment disorder. Resident 17's admission MDS dated [DATE] indicated she/he was moderately cognitively impaired. Resident 18's MDS dated [DATE] indicated she/he was cognitively intact. A Grievance Form dated 3/13/26 documented Resident 18 was extremely uncomfortable due to Resident 17's actions. Resident 17 had been yelling curse words and vile names at residents and staff. The documented follow-up action was to continue educating, therapy and care planning for Resident 17. A Behavior Note dated 3/13/26 documented Resident 17 was upset about the dining room seating arrangement and had screamed homophobic slurs at residents and refused to calm down. Resident 17's Care Plan dated 3/18/26 documented she/he was at risk for behavior symptoms with verbal outbursts of yelling and cussing when Resident 17 was redirected or educated. Interventions included approach resident in a calm manner and re-approach later if agitated or uncooperative. Resident 17 was to be in a supervised area when out of bed. Resident 18's revised care plan documented the resident had declining health status, with interventions to include promoting a calm, quiet environment. A Behavior Note dated 6/13/26 documented Resident 17 had been kicking and screaming at residents and had called them names. On 6/17/26 at 8:09 AM, Resident 18 stated Resident 17 was verbally abusive. Resident 17 had told her/him I'm going to knock your ass, sometime in the second week of 6/2025. Resident 18 stated she/he had not felt safe in the facility due to Resident 17's behaviors. On 6/23/26 at 12:07 PM, Staff 43 (CNA) stated on 3/13/26, in the dining room with multiple residents present a resident had been placed in a seat where Resident 17 considered her/his spot. Staff 43 stated Resident 17 had yelled, you gay little faggot, at a resident. On 6/24/26 at 8:27 AM, Staff 15 (LPN) stated on 3/13/26 Resident 17 had been yelling at Resident 18 and another resident. Staff 15 did not recall specific words but stated Resident 17 had used many colorful words. On 6/24/26 at 11:43 AM, Staff 1 (Administrator) stated Resident 17 had been vocal in public spaces and directed verbal interactions toward staff rather than residents. Residents had become upset and had complained about Resident 17. Staff 1 stated residents who were interviewed did not indicate they had been verbally abused by Resident 17. 4. Resident 19 was admitted to the facility in 7/2025 with diagnoses including depression and stroke. Resident 17 was admitted to the facility in 12/2025 with diagnoses including traumatic brain injury, brain damage and adjustment disorder. Resident 17's admission MDS dated [DATE] indicated she/he was moderately cognitively impaired. A Grievance Form dated 3/13/26 documented Staff 43 (CNA) had been advocating for Resident 19 due to verbal abuse from Resident 17. Resident 19 had been moved to different seating and had felt alienated from other resident because of being accused of taking Resident 17's dining room spot. Resident 19 had been tired of being called foul names. A separate Grievance Form dated 3/13/26 documented Resident 17 had been screaming and yelling and had claimed Resident 19 took her/his spot. Resident 20 had been tired of seeing Resident 19 being insulted and bullied. A Behavior Note dated 3/13/26 documented Resident 17 had been upset about the dining room seating arrangement, screamed homophobic slurs at residents and refused to calm down. Resident 17's revised care plan dated 3/18/26 documented she/he was at risk for behavior symptoms with verbal outbursts of yelling and cussing when Resident 17 was redirected or educated. Interventions included approach resident in a calm manner, re-approach later if agitated or uncooperative. Resident 17 was to be in a supervised area when out of bed. Resident 19's Significant Change MDS dated [DATE] indicated she/he was severely cognitively impaired. On 6/17/26 at 8:11 AM, Witness 10 (Resident) stated she/he had heard Resident 17 calling Resident 19 a faggot. On 6/23/26 at 12:07 PM, Staff 43 confirmed she had completed the 3/13/26 grievance for Resident 19. Staff 43 stated Resident 17 entered the dining room and Resident 19 had been seated in a spot Resident 17 considered her/his own. Resident 17 stated to Resident 19, you gay little faggot. Staff 43 stated Resident 19 had been tearful. Staff 43 removed Resident 19 because attempting to remove Resident 17 would have escalated the situation. Resident 19 had been placed by the nurse's station outside the dining room, and she/he had appeared sad after leaving the dining room. Staff 43 stated she had not heard any response related to the outcome of the grievance. On 6/24/26 at 8:27 AM, Staff 15 (LPN) stated on 3/13/26 Resident 17 had been yelling at Resident 19 and another resident. Staff 15 did not remember specific words but stated Resident 17 used many colorful words. On 6/24/26 at 11:43 AM, Staff 1 (Administrator) stated Resident 17 had been vocal in public spaces and directed verbal interactions toward staff rather than residents. Residents had become upset and had complained about Resident 17. Staff 1 stated residents who were interviewed did not indicate they had been verbally abused by Resident 17.

Based on interview and record review it was determined the facility failed to report to the State Survey Agency an allegation of verbal abuse for 4 of 5 sampled residents (#s 15, 16, 18, and 19) reviewed for verbal abuse. This placed residents at risk for continued abuse. Findings include:1. Resident 15 was admitted to the facility in 12/2024 with diagnoses including depression and muscle wasting. A 2/3/26 Grievance Form documented Resident 15 was verbally abused by Resident 17 and was called pussy and faggots. Resident 17 also threatened physical assault to Resident 15. There was no documented evidence Resident 15's report of being verbally abused by Resident 17 was reported to the State Survey Agency for the incident on 2/3/26. On 6/24/26 at 11:43 AM, Staff 1 (Administrator) stated she did not feel the allegation of verbal abuse rose to the level to report to the State Agency. 2. Resident 16 was admitted to the facility in 8/2022 with diagnoses including stroke. A 2/3/26 Grievance Form documented Resident 16 was verbally abused by Resident 17 and was called pussy and faggots. There was no documented evidence Resident 16's report of being verbally abused by Resident 17 was reported to the State Survey Agency for the incident on 2/3/26. On 6/24/26 at 11:43 AM, Staff 1 (Administrator) stated she did not feel the allegation of verbal abuse rose to the level to report to the State Agency. 3. Resident 18 was admitted to the facility in 9/2022 with diagnoses including stroke. A 3/13/26 Grievance Form documented Resident 18 was extremely uncomfortable by Resident 17's actions. Resident 17 was yelling curse words and vile names at residents and staff. A Behavior Note dated 3/13/26 documented Resident 17 was upset about the seating arrangement in the dining room. Resident 17 screamed homophobic slurs at other residents and refused to calm down. On 6/24/26 at 8:27 AM, Staff 15 (LPN) stated on 3/13/26 Resident 17 was yelling at Resident 18 and another resident. Staff 15 did not remember specific words but stated Resident 17 used many colorful words. There was no documented evidence Resident 18's report of being verbally abused by Resident 17 was reported to the State Survey Agency for the incident on 3/13/26. On 6/24/26 at 11:43 AM, Staff 1 (Administrator) stated she did not feel the allegation of verbal abuse rose to the level to report to the State Agency. 4. Resident 19 was admitted to the facility in 7/2025 with diagnoses including depression and stroke. A Grievance Form dated 3/13/26 documented Staff 43 (CNA) had been advocating for Resident 19 due to being verbally abused by Resident 17. Resident 19 had been tired of being called foul names. On 6/23/26 at 12:07 PM, Staff 43 stated Resident 17 called Resident 19 a gay little faggot. There was no documented evidence the 3/13/26 Grievance Report of Resident 19 being verbally abused by Resident 17 was reported to the State Survey Agency. On 6/24/26 at 11:43 AM. Staff 1 (Administrator) stated she did not feel the allegation of verbal abuse rose to the level to report to the State Agency.

Based on interview and record review, it was determined the facility failed to ensure residents were free from misappropriation of property for 3 of 3 sampled residents (#s 8, 18, and 21) reviewed for misappropriation. This placed residents at risk for missed medications and an increase in pain. Findings include:1. Resident 8 was admitted to the facility in 2/2024 with diagnoses including complex pain syndrome and anxiety disorder. A 12/23/25 Narcotic Log (pg. 1) for Resident 8 indicated lorazepam 0.5 mg one tablet every two hours as needed for anxiety was ordered. Staff documented the medication was administered 11 times from 12/23/26 through 1/7/26 and Staff 3 (LPN) administered the medication 10 of those times. Resident 8's 12/2025 and 1/2026 MARs included lorazepam 0.5 mg, one tablet every two hours as needed for anxiety and oxycodone every four hours as needed for chronic pain. Staff documented the medication had been administered 11 times from 12/23/25 through 1/7/266, and Staff 3 administered the medication 10 of those times. Staff documented oxycodone had been administered 50 times from 12/23/26 through 1/7/26, and Staff 3 administered the medication 26 of those times. A Facility Reported Incident Form (FRI) dated 1/8/26 was submitted to the State Survey Agency, which alleged that Staff 3 (LPN) had administered narcotic medications to certain residents more frequently than other staff. An undated FRI Investigation included a review of facility narcotic logs, which indicated Staff 3 was the nurse who had administered narcotic medications and had not allowed the CMA to administer the narcotics. Staff 3 was suspended pending investigation and later resigned. Two CMAs reported concerns with Staff 3's behavior which included frantic disposal of medications which made confirmation of wasted medications difficult. Some residents asked for pain medications when documentation showed they had already received pain medications. During the audit it was noted an issue did occur related to the documentation of the disposal of medications and the facility could not account for medications within the narcotic log. On 6/22/26 at 9:46 AM, Staff 3 stated she would not provide a statement. On 6/23/26 at 11:42 AM, Staff 37 (CMA) stated a lot of medications were administered at night by Staff 3 and he was uncertain why a resident would need medication while they were sleeping. Staff 37 stated Resident 8 was administered lorazepam during the night and Resident 8 always slept through the night. On 6/23/26 at 10:46 AM, Staff 38 (CMA) stated she was the one who reported the concern. She had reported the concern around 11/2025, and an audit was completed and the concern continued so she reported the concern again. Staff 38 stated she was uncomfortable to count with Staff 3 because her behaviors were erratic. Staff 38 stated there were pages with an X on them but no documentation of where the medication was. She informed hospice because Resident 8 was an eight out of 10 pain and it was documented she/he was getting more medications at night but still in pain. On 6/24/26 at 11:35 AM, Staff 1 (Administrator) stated the facility had determined misappropriation of Resident 8's medications occurred. 2. Resident 18 was admitted to the facility in 2/2024 with diagnoses including phantom limb syndrome with pain. A Facility Reported Incident Form (FRI) dated 1/8/26 was submitted to the State Survey Agency, which alleged that Staff 3 (LPN) had administered narcotic medications to certain residents more frequently than other staff. A Medication Audit Reconciliation Narrative dated 1/13/26 documented all medication carts were audited and reconciled. All narcotic counts were reviewed and verified. During the audit two pages had been removed from the narcotic book and the corresponding medication cards for the entries could not be accounted for Resident 18's Percocet. An undated FRI Investigation included a review of facility narcotic logs, which indicated Staff 3 was the nurse who had administered narcotic medications and had not allowed the CMA to administer the narcotics. Staff 3 was suspended pending investigation and later resigned. Two CMAs reported concerns with Staff 3's behavior which included frantic disposal of medications which made confirmation of wasted medications difficult. Some residents asked for pain medications when documentation showed they had already received pain medications. During the audit it was noted an issue did occur related to the documentation of the disposal of medication and the facility could not account for medications within the narcotic log. On 6/22/26 at 9:46 AM, Staff 3 stated she would not provide a statement. On 6/22/26 at 8:30 AM and 6/24/26 at 11:35 AM, Staff 1 (Administrator) stated the facility had determined misappropriation of Resident 18's medications. Resident 18 had two narcotic log pages torn out of the logbook and her/his Percocet medication was unaccounted for. 3. Resident 21 was admitted to the facility in 12/2025 with diagnoses including palliative care and chronic pain. A 12/2025 MAR indicated to administer morphine tablet every four hours for moderate to severe pain. On 12/25/25 Resident 21 was documented as having morphine administered four times with three of these times administered by Staff 3 (LPN). A Facility Reported Incident Form (FRI) dated 1/8/26 was submitted to the State Survey Agency, which alleged that Staff 3 (LPN) had administered narcotic medications to certain residents more frequently than other staff. A Medication Audit Reconciliation Narrative dated 1/13/26 documented all medication carts were audited and reconciled. All narcotic counts were reviewed and verified, during the audit two pages had been removed from the narcotic book and the corresponding medication cards for the entries could not be accounted for Resident 21's morphine. An undated FRI Investigation included a review of facility narcotic logs, which indicated Staff 3 was the nurse who had administered narcotic medications and had not allowed the CMA to administer the narcotics. Staff 3 was suspended pending investigation and later resigned. Two CMAs reported concerns with Staff 3's behavior which included frantic disposal of medications which made confirmation of wasted medications difficult. Some residents asked for pain medications when documentation showed they had already received pain medications. During the audit it was noted an issue did occur related to the documentation of the disposal of medication and the facility could not account for medications within the narcotic log. On 6/23/26 at 10:46 AM, Staff 38 (CMA) stated she was the one who reported the concern. She had reported the concern about around 11/2025, and an audit was completed and the concern continued so she reported again. Staff 38 stated she was uncomfortable to count with Staff 3 because her behaviors were erratic. A couple of morphine narcotic books were crossed out but no one had signed off on the medication for them to be destroyed. Staff 38 thought Staff 3 and Staff 37 had destroyed the medications. On 6/24/26 at 11:35 AM, Staff 1 (Administrator) stated the facility had determined misappropriation of Resident 21's medications. The deficient practice was identified as Past Noncompliance based on the following: On 1/18/26, the deficient practice was identified by the facility and was corrected when the facility completed a root cause analysis of the incident and determined there was misappropriation of medications. The Plan of Correction included: 1. Staff educated on medication administration, medication count, disposal and storage of medications. 2. Police report placed for potential crime.3. Staff 3 resignation accepted.4. Pharmacy consulted to perform a medication cart audit.5. Narcotic audits to be completed weekly for four months, then monthly for three months. Audits would be brought to QAPI for review and education opportunities.

Based on interview and record review, it was determined the facility failed to ensure community resources were in place for a safe and orderly discharge for 1 of 3 sampled residents (#4) reviewed for discharge. This placed residents at risk for an unsafe discharge. Findings include:Resident 4 was admitted to the facility in 1/2026 with diagnoses including mild cognitive impairment and second-degree burns to lower limbs. a. Resident 4's Care Plan dated 1/30/26 indicated the discharge destination was a shelter, noting she/he had been homeless. Interventions included planning with community resources to support independence post-discharge. A Social Services Note dated 4/1/26 documented Resident 4 had been informed that her/his discharge plan was unsafe, that the resident understood, and the resident was her/his own responsible party and had chosen to proceed. A Discharge summary dated [DATE] indicated reason for Resident 4's discharge was Medicaid had been denied and that Resident 4 had been discharged to houseless. It documented multiple discussions regarding safety concerns and noted Resident 4's continued intention to live in her/his vehicle. A home care referral was completed, and services would include physical, occupational, and speech therapy. A Discharge Summary MDS dated [DATE] indicated Resident 4 was cognitively intact and required supervision or touching assistance with walking 10 feet. There was no documented evidence in Resident 4's clinical record that a home health care referral was completed as indicated in the Discharge Summary. A Physical Therapy Discharge Summary signed 4/3/26 documented Resident 4 would ambulate 200 feet over uneven pavement using a front wheel walker with modified independent. On 3/20/24 Resident 4 completed 200 feet two times over uneven pavement with a front-wheel walker and stand by assistance. At the time of therapy discharge on [DATE], testing Resident 4's ability to ambulate 200 feet over uneven pavement was not completed prior to discharge. On 4/6/26 the State Survey agency received a complaint indicating Resident 4 had admitted to the facility for burns sustained to her/his legs from a propane heater living in her/his vehicle. The resident discharged back to her/his truck and fell and sustained a spine fracture and skull fracture. A 4/13/26 hospital Discharge Summary indicated Resident 4 was admitted to the hospital on [DATE] with a shattered neck break, closed fracture of the forehead and closed fracture to odontoid (small bony peg on the second neck bone to help turn the head side to side.) Resident 4 was found on the ground outside of her/his vehicle on 4/3/26. On 6/16/26 at 10:51 AM and on 6/17/26 at 7:58 AM, attempts to contact Resident 4 were unsuccessful. On 6/18/26 at 8:47 AM, Witness 9 (Transitional Care Advisor for Home Health Care) stated no home health services referral was received for Resident 4's 4/2/26 discharge. On 6/24/26 at 10:00 AM, Staff 16 (Social Services Director) stated usually emails would go back and forth for home health services referrals. Staff 16 stated Resident 4 was questioned about moving into her/his vehicle and Resident 4 had the right to make bad choices and it was not in her control. No email exchanges with home health were provided. On 6/24/26 at 11:25 AM, Staff 1 (Administrator) stated if a discharge summary indicated a resident was referred to home health services, she would expect the referral to be placed. Resident 4 was admitted to the facility in 1/2026 with diagnoses including displaced fracture of second cervical vertebra, fracture of vault of skull, and fracture of the neck. b. A 4/17/26 admission MDS indicated Resident 4 was moderately cognitively impaired. A 5/24/26 Physician Communication form from Staff 25 (RN) to the physician documented Resident 4 wished to discharge because of money concerns. Staff 25 documented that Resident 4 did not appear cognitively able to live independently and had confusion. A physician response dated 5/27/26 indicated Resident 4 discharged before she/he could be seen and Resident 4 left against medical advice. The physician had told Resident 4 not to discharge until she/he was cleared by neurosurgery. A 5/25/26 Physician Progress note indicated Resident 4 was upset and wanted to leave against medical advice. Resident 4 did not have a safe discharge plan and appeared confused intermittently during discussion. Resident 4 had a history of mild cognitive impairment. It was recommended Resident 4 stay at the facility until she/he was cleared by the neurosurgeon rather than leaving the facility against medical advice. There was no documented evidence in Resident 4's clinical record that she/he signed leaving the facility against medical advice or a referral for home health services was completed. A 5/26/26 Discharge Summary documented anticipated discharge date was 5/27/26 and was a resident driven discharge. Discharge was to a business parking lot. Resident 4 was a fall risk and no longer wished to move forward with liquidating assets to obtain Medicaid. Resident 4 was aware that it meant she/he had to discharge from the facility. Functional level of status was toileting hygiene maximal assistance of one-person and moderate assistance of one person for bathing and dressing. Home care equipment none, home care referral was completed for physical and occupational therapy. Resident 4 would follow up on her/his own for future appointments. A 5/27/26 Discharge Notice and Order Request indicated Resident 4 needed physical and occupational therapy. Nursing and social services were needed. Additional nursing instructions were for neck brace management and medication management. On 6/16/26 at 10:51 AM and on 6/17/26 at 7:58 AM, attempts to contact Resident 4 were unsuccessful. On 6/16/26 at 12:01 PM, Witness 8 (Friend) stated Resident 4 was confused and her/his mind is not at all there. Witness 8 stated Resident 4 was living in an RV park and a person who works at the park had checked in with her/him. On 6/18/26 at 8:47 AM, Witness 9 (Transitional Care Advisor for Home Health Care) stated no home health services referral was received for Resident 4's 5/27/26 discharge. Witness 9 stated a medical agency had reached out to her not the facility. Witness 9 stated she personally never spoke with Resident 4. On 6/17/26 at 8:47 AM, on 6/18/26 at 9:43 AM, and on 6/24/26 at 11:25 AM, Staff 1 (Administrator) stated if a discharge summary indicated a resident was referred to home health services, she would expect the referral to be placed. Staff 1 stated Staff 16 (Social Services Director) was unavailable during Resident 4's second discharge and Staff 1 did not document notes. Staff 1 stated Resident 4 did not want to get rid of her/his assets. Witness 8 had informed her that Resident 4 would be on Witness 8's property in a fifth wheel trailer. Staff 1 stated Resident 4 did not discharge against medical advice, and it was a coordinated discharge with the physician.

Based on observations, interview and record review it was determined the facility failed to maintain safe water temperatures for 1 of 2 halls ([NAME] Falls Hall). This placed residents at risk for burns. Findings include:An undated Water Temperature Instructions sheet for logging facility water audits revealed: Test the water at various locations thought the facility. For burn prevention the domestic water temperatures were to be kept below 120 degrees Fahrenheit. 1.Resident 9 was admitted to the facility in 7/2025 with a diagnosis of anxiety. Resident 9's 6/22/25 Quarterly MDS revealed she/he was cognitively intact.On 9/16/25 at 2:42 PM with Staff 38 (Maintenance Director) Resident 9's sink water was observed to be 123.3 degrees F. Staff 38 stated he checked the water weekly but usually did the audits in the morning, and the water temperatures were never that high. On 9/17/25 at 7:48 AM Resident 9 stated she/he lovedthe hot water.On 9/16/25 at 3:36 PM Staff 1 (Administrator) stated the water audits should not be done at the same time each week to ensure the water temperature variances were identified throughout the day and temperatures should be below 120 degrees F. 2. Resident 16 was admitted to the facility in 9/2022 with a diagnosis of diabetes. Resident 16's 7/1/25 Quarterly MDS Revealed she/he was cognitively intact.On 9/16/25 at 2:42 PM with Staff 38 (Maintenance Director) Resident 9's sink water was observed to be 123.3 degrees F. Staff 38 stated he checked the water weekly but usually did the audits in the morning, and the water temperatures were never that high. On 9/17/25 at 7:48 AM Resident 16 stated she/he loved the hot water.On 9/16/25 at 3:36 PM Staff 1 (Administrator) stated the water audits should not be done at the same time each week to ensure the water temperature variances were identified throughout the day and temperatures should be below 120 degrees F. 3. Resident 19 was admitted to the facility in 8/2025 with a diagnosis of a stroke. Resident 19's 8/5/25 admission MDS revealed she/he was cognitively intact.On 9/16/25 at 2:29 PM with Staff 38 (Maintenance Director) Resident 19's sink water was observed to be 132.1 degrees F. Staff 38 stated he checked the water weekly but usually did the audits in the morning, and the water temperatures were never that high. On 9/17/25 at 8:03 AM Resident 19 stated she liked the water hot.On 9/16/25 at 3:36 PM Staff 1 (Administrator) stated the water audits should not be done at the same time each week to ensure the water temperature variances were identified throughout the day and the temperatures should be below 120 degrees F. 4. Resident 26 was admitted to the facility in 7/2025 with a diagnosis of a stroke. On 9/16/25 at 2:35 PM with Staff 38 (Maintenance Director) Resident 2's sink water was observed to be 124.7 degrees F. Staff 38 stated he checked the water temperatures weekly but usually did the audits in the morning, and the water temperatures were never that high. On 9/16/25 at 3:36 PM Staff 1 (Administrator) stated the water audits should not be done at the same time each week to ensure the water temperature variances were identified throughout the day and the temperatures should be below 120 degrees F. On 9/16/25 at 3:33 PM Staff 28 (LPN) stated residents did not report hot water concerns and usually staff had to let the water run for a while for the water to become warm enough for residents to shower. On 9/16/25 at 3:35 PM Staff 21 (CNA) stated residents usually reported the water was not warm enough. On 9/17/25 Resident 26 was not available for an interview. 5. Resident 32 was admitted to the facility in 10/2024 with a diagnosis of heart disease. Resident 32's 8/5/25 Quarterly MDS revealed she/he wascognitively impaired.On 9/16/25 at 2:35 PM with Staff 38 (Maintenance Director) Resident 32's sink water was observed to be 124.7 degrees F. Staff 38 stated he checked the water temperatures weekly but usually did the audits in the morning, and the water temperatures were never that high.On 9/16/25 at 3:33 PM Staff 28 (LPN) stated residents did not report hot water concerns and usually staff have to let the water run for a while for the water to become warm enough for residents to shower. On 9/16/25 at 3:35 PM Staff 21 (CNA) stated residents usually reported the water was not warm enough. On 9/16/25 at 3:36 PM Staff 1 (Administrator) stated the water audits should not be done at the same time each week to ensure the water temperature variances were identified throughout the day and the temperatures should be below 120 degrees F. 6. Resident 33 was admitted to the facility in 8/2024 with a diagnosis of liver disease. Resident 33's 8/11/25 Annual MDS revealed she/he was cognitively intact.On 9/16/25 at 2:29 PM with Staff 38 (Maintenance Director) Resident 33's sink water was observed to be 132.1 degrees F. Staff 38 stated he checked the water weekly but usually did the audits in the morning, and the water temperatures were never that high. On 9/16/25 at 3:36 PM Staff 1 (Administrator) stated the water audits should not be done at the same time each week to ensure the water temperature variances were identified throughout the day and the temperatures should be below 120 degrees F.On 9/17/25 at 8:57 AM Resident 33 stated the staff assisted her/him with the water, and she/he did not have any concerns with the temperatures. 7. Resident 52 was admitted to the facility in 9/2025 with a diagnosis of respiratory failure. Resident 52's 9/16/25 admission MDS Revealed she/he was moderately cognitively impaired.On 9/16/25 at 2:35 PM with Staff 38 (Maintenance Director) Resident 52's sink water was observed to be 124.7 degrees F. Staff 38 stated he checked the water weekly but usually did the audits in the morning, and the water temperatures were never that high. On 9/16/25 at 3:36 PM Staff 1 (Administrator) stated the water audits should not be done at the same time each week to ensure the water temperature variances were identified throughout the day and the temperatures should be below 120 degrees F. 8. Resident 54 was admitted to the facility in 9/2025 with a diagnosis of heart failure. Resident 54's 9/13/25 admission MDS revealed she/he was cognitively intact. On 9/16/25 at 2:34 PM with Staff 38 (Maintenance Director) Resident 54's sink water was observed to be 129.4 degrees F. Staff 38 stated he checked the water weekly but usually did the audits in the morning, and the water temperatures were never this high. On 9/16/25 at 3:36 PM Staff 1 (Administrator) stated the water audits should not be done at the same time each week to ensure the water temperature variances were identified throughout the day.On 9/16/25 at 3:33 PM Staff 28 (LPN) stated residents did not report hot water concerns and usually staff have to let the water run for a while for the water to become warm enough for residents to shower. On 9/16/25 at 3:35 PM Staff 21 (CNA) stated residents usually reported the water was not warm enough. Resident 54 was not available to be interviewed.On 9/16/25 at 3:36 PM Staff 1 (Administrator) stated the water audits should not be done at the same time each week to ensure the water temperature variances were identified throughout the day. 9. Resident 55 was admitted to the facility in 9/2025 with a diagnosis of heart disease.Resident 55's 9/14/25's admission MDS revealed she/he was cognitively intact.On 9/16/25 at 2:29 PM with Staff 38 (Maintenance Director) Resident 55's sink water was observed to be 132.1 degrees F. Staff 38 stated he checked the water weekly but usually did the audits in the morning, and the water temperatures were never that high. On 9/16/25 at 3:36 PM Staff 1 (Administrator) stated the water audits should not be done at the same time each week to ensure the water temperature variances were identified throughout the day and the temperatures should be below 120 degrees F. On 9/17/25 at 8:59 AM Resident 55 stated she/he did not think the water was too hot and the temperature wasjust fine. 10. Resident 58 was admitted to the facility in 9/2025 with a diagnosis of a hip fracture.Resident 58's 9/10/25 admission Profile indicated she/he had some short-term memory issues but was ableto communicate without difficulty.On 9/16/25 at 2:29 PM with Staff 38 (Maintenance Director) Resident 58's sink water was observed to be 132.1 degrees F. Staff 38 stated he checked the water weekly but usually did the audits in the morning, and the water temperatures were never that high. On 9/17/25 at 8:55 AM Resident 58 stated she/he did not have concerns with the water being too hot.On 9/16/25 at 3:36 PM Staff 1 (Administrator) stated the water audits should not be done at the same time each week to ensure the water temperature variances were identified throughout the day and the temperatures should be below 120 degrees F.

Based on observation and interview the facility failed to ensure proper hand hygiene and sanitary surfaces for 1 of 1 kitchen. This placed residents at risk for cross-contamination. Findings include:On 9/15/25 at 11:29 AM, Staff 19 (Dietary Manager) picked up and sorted meal tickets with gloved hands and then picked up bread without washing his hands and changing gloves. On 9/15/25 at 11:30 AM, Staff 19 opened the walk-in cooler with gloved hands and then handled raw foods without washing his hands and donning clean gloves.On 9/15/25 at 11:31 AM, Staff 20 opened the walk-in cooler and removed condiments with his bare hands and then touched clean dishes without washing his hands and donning gloves.On 9/17/25 at 11:12 AM, Staff 19 picked up a clipboard with gloved hands then picked up cooked meat without washing his hands and donning clean gloves. On 9/17/25 at 11:28 AM, Staff 19 stated CNAs help residents complete meal tickets each morning. Staff 19 stated the tickets were a contaminated surface. On 9/17/25 at 11:31 AM, Staff 19 took a meal ticket with gloved hands and placed it on a cutting board and after plating the food, placed the ticket on the tray and picked up the next ticket, placing it on the cutting board. On 9/17/25 at 11:49 AM, Staff 19 sorted meal tickets with gloved hands then placed a quesadilla on the same cutting board, cut it, and placed it on a plate without washing his hands or changing gloves. On 9/17/25 at 12:59 PM, Staff 19 stated he was aware he should not touch items in the kitchen that are not sanitized with gloved hands without washing his hands and donning clean gloves. On 9/18/25 at 12:45 PM, Staff 19 stated the kitchen staff had not been using proper hand hygiene while preparing and plating resident meals. On 9/18/25 at 1:05 PM, Staff 20 stated he was aware the walk-in cooler handle and the meal tickets were contaminated surfaces, and he acknowledged touching both with gloved hands and not washing his hands or changing his gloves afterward. On 9/19/25 at 10:33 AM, Staff 1 (Administrator), Staff 15 (Regional VP) and Staff 11 (Regional Director of Clinical Operations) acknowledged the facility failed to practice proper hand hygiene.

Based on observation, interview and record review it was determined the facility failed to follow infection control standards for 2 of 2 sampled residents (#s 1 and 24) reviewed for hospice and transmission-based precautions. This placed residents at risk for exposure to, and contraction of, infectious diseases. Findings include:1. Resident 24 was admitted to the facility in 8/2025 with a diagnosis of cellulitis (infection of the skin). Resident 24's Care Plan initiated 8/29/25 revealed she/he was used a walker with transfers and was to be supervised. Resident 24 had a history of a drug-resistant organism in her/his urine, was at times incontinent, and had cellulitis to her/his leg requiring precautions during high contact activities. On 9/17/25 at 9:20 AM a Contact Isolation sign was observed outside of Resident 24's door. The sign directed staff to put on a gown and gloves prior to entering the resident's room. Staff 36 was observed to enter Resident 24's room after putting on a disposable gown and gloves. Resident 24 exited the room and Staff 36 followed her/him after she removed her gloves and performed hand hygiene. Staff 36 did not remove her disposable gown. Staff 36 stated she did not remove the gown because she did not want Resident 24 to walk down the hall without assistance. On 9/18/25 at 12:21 PM Staff 14 (IP) stated staff should have removed the gown prior to exiting the room. 2. Resident 1 was admitted to the facility in 6/2025 with diagnoses including chronic kidney disease, and disorders of the bladder. The facility's Transmission-Based Precautions Policy and Procedure revised 11/2024, indicated the following: Enhanced Barrier Precautions (EBP) were implemented alongside standard precautions to reduce transmission of multidrug-resistant organisms (germs that resist treatment with multiple antibiotics). EBP required targeted use of glove and gowns during high-contact resident care activities such as transferring and device care, including urinary catheter use. PPE included gloves and gown prior to the high-contact care. Face protection (mask, goggles, or face shield) may also be needed if there was risk for splash or spray. a. A 6/25/25 care plan indicated Resident 1 was at risk for infection due to a history of aspiration (inhaling food or fluid into the lungs), pneumonia, indwelling catheter (tube placed in the bladder to drain urine), and a history of multiple UTIs. Interventions included to implement EBP during high-contact care activities such as transferring, and urinary catheter care. On 9/17/25 at 9:17 AM, Staff 13 (CNA) and Staff 12 (CNA) were observed assisting Resident 1 with a transfer using a mechanical lift. Both staff wore gloves; no other PPE was observed. On 9/17/25 at 9:26 AM, Staff 13 and Staff 12 stated they understood EBP applied to changing briefs or emptying a catheter, and they would wear full PPE during those tasks. They did not believe gowns were required for transferring Resident 1 with a mechanical lift. On 9/17/25 at 9:27 AM, the EBP sign posted next to Resident 1's room indicated all health care personnel must wear gloves and gown for high contact resident care activities including bathing, transferring, changing linens, assisting with toileting and providing hygiene. On 9/19/25 at 7:14 AM, Staff 11 (Regional Director of Clinical Operations) stated staff were expected to follow the EBP sign and policy for using the proper PPE while caring for a resident. b. On 9/18/25 at 2:01 PM, Staff 18 (Hospice RN) was overheard informing Resident 1 her/his catheter was leaking, and she was going to turn on the light to change the catheter. Staff 18 was observed wearing gloves but no gown. At 2:19 PM, Staff 18 removed her gloves; no gown was observed. Staff 18 confirmed she changed Resident 1's catheter and wore only gloves. She acknowledged a gown should be worn during catheter care. On 9/19/25 at 7:14 AM Staff 11 (Regional Director of Clinical Operations) stated staff were expected to follow the EBP sign and policy for using the proper PPE while caring for residents.

Based on interview and record review it was determined the facility failed to report allegations of neglect and abuse timely for 3 of 4 sampled residents (#s 21, 47, and 51) reviewed for abuse and neglect. This placed residents at risk for neglect and abuse. Findings include:1. Resident 21 was admitted to the facility 8/25/25 with diagnoses including pelvic fracture. On 9/15/25 at 3:52 PM, Resident 21 stated she/he reported an allegation of abuse by Staff 33 (RN) and Staff 34 (CNA) that occurred on 9/7/25. The resident alleged an RN, and a CNA gave her/him a suppository against her/his will. Resident 21 also alleged Staff 34 forcefully placed her hand on the resident's hip to hold her/him down. Resident 21 stated she/he spoke to Staff 2 (DNS) and Staff 1 (Administrator) about the incident and wanted to file a grievance. The facility reported the alleged abuse to the State Agency on 9/16/25. On 9/16/25 at 7:53 AM, Staff 2 stated she and Staff 1 spoke with the resident and the staff involved when they learned of the incident 9/8/25. Staff 2 stated she did not take further action. On 9/19/25 at 10:33 AM, Staff 1 (Administrator), Staff 15 (Regional VP) and Staff 11 (Regional Director of Operations) stated allegations of abuse should be reported to the state agency within 2 hours. 2: Resident 51 was admitted to the facility in 8/2023 with diagnoses including infection. On 4/28/25 Resident 51 reported she/he had been verbally and physically abused by Staff 24 (CNA). Staff 2 (DNS) and Staff 3 (former Administrator) learned of the alleged abuse on 4/28/25 at 12:15 PM and a FRI was submitted to the State Agency on 4/28/25 at 3:49 PM. Resident 51 was not available for interview. Staff 2 was not available for interview. An attempt to interview Staff 24 on 9/16/25 was not successful. Attempts to interview Staff 3 on 9/18/25 were not successful. On 9/18/25 at 8:30 AM, Staff 21 (CNA) stated she was assisting Staff 24 to provide care for Resident 51 on 4/27/25. Staff 21 stated Staff 24 handled the resident roughly while placing a chuck (a device used to help reposition a resident) under the resident. She stated Staff 24 told Resident 51 she/he was not exactly easy to move when Resident 51 objected to the rough handling by Staff 24. Staff 21 stated Staff 24 then jerked the chuck under the resident to reposition her/him without counting (a method used to be sure staff reposition the resident in unison). The resident told Staff 24 he was hurting her/him. Staff 21 stated Staff 24 ignored the resident and left the room after repositioning her/him without providing additional care. On 9/19/25 at 10:27 AM, Staff 16 (Social Services Director) stated Resident 51 informed her on 4/28/25 Staff 24 had been abusive to her/him while providing care. On 9/19/25 at 10:33 AM, Staff 1 (Administrator), Staff 15 (Regional VP) and Staff 11 (Regional Director of Operations) stated allegations of abuse should be reported to the state agency within 2 hours and stated facility records showed the alleged abuse was not reported timely. 3. Resident 47 was admitted to the facility in 4/2024 with diagnoses including quadriplegia, Amyotrophic Lateral Sclerosis (ALS, a progressive disease which affects physical function). A facility reported incident dated 10/3/24 at 10:00 AM indicated on 10/2/24 at 12:00 PM, Staff 4 (CNA) reported Staff 5 did not provide care to Resident 47 during the night shift on 10/1/24. Attempts to interview Staff 4 on 9/16/25 and 9/18/25 were unsuccessful. On 9/16/25 at 11:07 AM, Staff 6 (Former Nurse's Aide Student) stated she observed Staff 5 enter Resident 47's room and turn off the call light during night shift on 10/1/24 without providing care or services. Staff 6 reported the concern to Staff 2 between 6:00 AM and 7:00 AM on 10/2/24. Staff 2 was not available for interview. On 9/19/25 at 7:19 AM, Staff 1 (Administrator) stated she would expect staff to report an allegation of neglect to the State agency within 24 hours if no major injury occurred.

Based on interview and record review it was determined the facility failed to follow physician orders and failed to monitor a resident for a change of condition for 3 of 5 sampled residents (#s 2, 5, and 8) reviewed for medications. This placed residents at risk for unmet care needs. Findings include:1. Resident 2 was admitted to the facility in 9/2022 with a diagnosis of heart disease. Per Mayo Clinic: Hypokalemia (low potassium) symptoms of irregular heart rhythms were the most worrisome complication of very low potassium levels, particularly in people who have heart disease Resident 2's 8/11/25 Basic Metabolic Panel results revealed her/his potassium level was 2.7 (normal range 3.4-4.9). Resident 2's Progress Notes revealed:-On 8/11/25 Resident 2 was seen by her/his physician at the medical clinic and laboratory samples were obtained. -On 8/12/25 her/his physician called the facility with orders to transport Resident 2 to the local emergency department due to a critically low potassium level. The note indicated Resident 2 refused to be transported to the hospital due to the cost of the transportation. -On 8/13/25 at 8:42 AM Resident 2 was transported to the hospital for a critically low potassium level.-On 8/13/25 at 5:03 PM Resident 2 was admitted to the hospital with a diagnosis of NSTEMI (Non-ST-elevation Myocardial Infarction/type of heart attack where a partial blockage of the artery reduces blood flow to the heart causing muscle damage). Resident 2's clinical record revealed no documentation Resident 2's physician was informed the resident was not sent to the emergency department per physician orders on 8/12/25 and there was no documented monitoring of the resident after she/he refused to go to the hospital. On 9/17/25 at 3:49 PM Staff 31 (LPN) stated Resident 2's physician called the facility and provided orders to send Resident 2 to the emergency room due to a critically low potassium level. When the emergency medical technicians arrived, they informed Resident 2 the cost of the transport would likely not be covered with insurance, and she/he would need to pay for transportation. Resident 2 did not want to pay for transportation. Staff 31 stated she did not call the physician to inform him the orders were not implemented. On 9/17/25 at 3:06 PM Staff 32 (LPN Patient Care Coordinator) stated there was no indication the staff communicated with Resident 2's physician that orders to send Resident 2 to the emergency room were not followed and verified there was no monitoring of Resident 32 until she/he was transported to the hospital the following day, despite being at risk for complications related to low potassium levels. 2. Resident 5 was admitted to the facility in 9/2024 with a diagnosis of kidney disease. Resident 5's 9/2/25 Order Summary Report revealed she/he had dialysis on Mondays, Wednesdays, and Fridays from 6:00 AM to 9:00 AM. Orders also included Resident 5 was to be administered Aspirin (non-steroidal anti-inflammatory) daily, calcium acetate (binds with phosphate in food) with meals daily, midodrine (treats low blood pressure) every Monday, Wednesday, and Friday, Allopurinol (treats gout) daily, omeprazole (treats acid reflux) daily, and a multivitamin (supplement) daily.Resident 5's 8/2025 and 9/2025 MAR revealed she/he did not receive Allopurinol on 8/6/25, 8/11/25, 8/15/25, 9/3/25, and 9/15/25, midodrine on 8/6/25, 8/11/25, 8/27/25, 9/3/25, and 9/15/25, multivitamin on 8/6/25, 8/11/25, 8/27/25, 9/3/25, and 9/15/25, omeprazole on 8/6/25, 8/27/25, 9/1/25, 9/3/25, calcium acetate 8/6/25 AM dose, 8/22/25 AM dose, 8/27/25 AM dose, 8/29/25 AM dose, 9/3/25 AM dose, 9/10/25 AM dose, 9/12/25 AM dose, and 9/15/25 AM dose, and Aspirin on 8/6/25, 8/11/25, 8/27/25, 9/3/25, and 9/15/25. On 9/18/25 at 3:06 PM Staff 14 (Assistant DNS) stated Resident 5 had dialysis early mornings on Monday, Wednesday, and Friday, and staff often did not provide the medications as ordered on dialysis days. 3. Resident 8 was admitted to the facility in 2/2024 with a diagnosis of dementia. Resident 8's 9/2/25 Order Summary Report revealed she/he was to be administered Bisacodyl (laxative) tablets PRN if she/he did not have a bowel movement for two days. Resident 8's bowel record from 8/20/25 through 9/18/25 revealed she/he did not have a bowel movement for two days from 8/20/25 through 8/23/25, 9/5/25 through 9/7/25, and 9/15/25 though 9/17/25. Resident 8's 8/2025 and 9/2025 MAR revealed she/he was not administered Bisacodyl after not having a bowel movement for two days on 8/22/25, 9/1/25, 9/7/25, and 9/17/25. On 9/18/25 at 8:44 AM Staff 35 (RN) stated the night shift staff ran a bowel report for all residents. If a resident did not have a bowel movement for three days bowel care was initiated. On 9/18/25 at 3:06 PM Staff 14 (Assistant DNS) stated the facility's bowel protocol was to provide bowel care after a resident did not have a bowel movement for three days. Staff 14 verified staff did not follow Resident 8's physician orders for bowel care which were to be administered if she/he did not have a bowel movement for two days.

Based on interview and record review it was determined the facility failed to provide residents with a written bed hold notification, including reserved bed hold payment, at the time of transfer to the hospital and notify the Ombudsman for 1 of 2 sampled residents (# 6) reviewed for hospitalization and discharge. This placed residents at risk for lack of knowledge regarding their choices and potential financial responsibilities. Findings include:Resident 6 was admitted to the facility in 1/2025 with diagnoses including kidney failure.A review of Resident 6's clinical record revealed she/he was transferred to the hospital on [DATE]. No evidence was found in the clinical record to indicate a written notice of the facility's bed hold policy was provided to the resident or her/his representative. No documentation was found indicating the Ombudsman was notified of the transfer.On 9/18/25 at 8:47 AM, Staff 11 (Regional Director of Clinical Operations) and Staff 14 (Assistant Director of Nursing Services) verified a written bed hold notification was not provided to Resident 6 or her/his representative at the time of transfer to the hospital, and the Ombudsman was not notified of the transfer.

Based on interview and record review it was determined the facility failed to protect the residents' right to be free from neglect and protect the residents' rights to be free from verbal and physical abuse by Staff 24 for 2 of 4 sampled residents (#s 47 and 51) reviewed for neglect and abuse. This placed residents at risk for abuse and neglect. Findings include: Resident 47 was admitted to the facility in 4/2024 with diagnoses including quadriplegia, Amyotrophic Lateral Sclerosis (ALS, a progressive disease which affects physical function). A care plan dated 4/23/24 directed staff to encourage Resident 47 to reposition frequently for pressure relief. The Documentation Survey Report 10/1/24 indicated Resident 47 was not repositioned on the night shift. The Alleged Neglect investigation dated 10/2/24 revealed Staff 2 (DNS) was notified Resident 47 did not receive care during the night shift on 10/1/24. Resident 47 stated Staff 5 (Former CNA) was useless, entered the room, turned off the call light, and did not provide care. Resident 47 also reported she/he was not offered any hydration or toileting. Due to ALS, Resident 47 was unable to eat or hydrate independently. On 9/16/25 at 8:14 AM, Staff 5 stated Resident 47 did receive care the night of 10/1/25. On 9/16/25 at 8:25 AM, Staff 8 (CNA) stated Resident 47 was very upset on the morning of 10/2/24. Staff 5 reported she could not assist Resident 47 due to back issues. On 9/16/25 at 11:07 AM, Staff 6 (Former Nurse's Aide Student) stated she saw Staff 5 enter Resident 47's room and turn off the call light. Staff 5 then told Staff 6 not to enter the room, saying she would take care of it. Staff 6 reported the concern to Staff 2 on the morning of 10/2/24. On 9/16/25 at 11:12 AM, Staff 7 (CNA) stated she did not go into Resident 47's room because Staff 5 was assigned to her/his room. On 9/16/25 at 11:43 AM, Staff 9 stated she came in the morning of 10/2/24 and Resident 47 complained about night shift from 10/1/24 not taking care of her/him. Staff 6 told her Staff 5 kept turning off Resident 47's call light. On 9/19/25 at 7:17 AM, Staff 1 (Administrator) stated staff were expected to provide care and services and not neglect residents. 2: Resident 51 was admitted to the facility in 8/2023 with diagnoses including infection. On 9/18/25 at 8:30 AM, Staff 21 (CNA) stated she was assisting Staff 24 (CNA) to provide care for Resident 51 on 4/27/25. Staff 21 stated Staff 24 was rough with the resident while placing a chuck (a device used to help reposition a resident) under the resident. She stated Staff 24 told Resident 51 she/he was not exactly easy to move when Resident 51 objected to the rough treatment by Staff 24. Staff 21 stated Staff 24 then jerked the chuck under the resident to reposition him without counting (a method used to be sure staff reposition the resident in unison) and the resident told Staff 24 he was hurting him. Staff 21 stated Staff 24 ignored the resident and left the room after repositioning her/him without providing the resident additional care. On 9/19/25 at 10:27 AM, Staff 16 (Social Services Director) stated Resident 51 informed her on 4/28/25 that Staff 24 had been abusive to her/him while providing care. A review of the investigation 5/1/25 by Staff 3 (former Administrator) and Staff 2 (DNS) revealed the facility could not rule out abuse to Resident 51 by Staff 24. Resident 51 was not available for interview. An attempt to interview Staff 24 on 9/16/25 was not successful. Staff 2 was not available for interview. Attempts to interview Staff 3 on 9/18/25 were not successful. On 9/19/25 at 10:33 AM, Staff 1 (Administrator), Staff 15 (Regional VP) and Staff 11 (Regional Director of Clinical Operations) acknowledged Resident 51 was abused by Staff 24.

Based on observation, interview and record review it was determined the facility failed to inform residents of the risks and benefits of psychotropic medication use for 2 of 5 sampled residents (#6 and 36) reviewed for medications and dementia. This placed residents at risk for being uniformed. Findings include: Resident 6 was admitted to the facility in 1/2025 with diagnoses including depression and bipolar disorder. A Physician's order revealed Resident 6 received Depakote (a mood stabilizer) daily. Review of the clinical record revealed no evidence the risks and benefits of Depakote were discussed with her/him. On 9/18/25 at 8:47 AM, Staff 11 (Regional Director of Clinical Operations) and Staff 14 (Assistant Director of Nursing Services) verified the risks and benefits were not reviewed with Resident 6. 2. Resident 36 was admitted to the facility in 8/2022 with diagnoses including dementia. Resident 36 had a responsible party who made her/his medical decisions. A review of the resident's clinical record on 9/16/25 revealed an order for Depakote Sprinkles (a medication used to impact agitation and mood) on 8/21/25. A review of the resident's MAR revealed the first dose of Depakote Sprinkles was administered on 8/22/25. No record of informed consent by the resident representative was found during the initial record review completed 9/16/25. Further review of the clinical record on 9/18/25 revealed a Psychotropic Medication Consent dated 9/18/25. On 9/18/25 at 3:21 PM, Staff 26 (RN) stated she did not know she needed to obtain informed consent from the resident representative before administering Depakote Sprinkles. On 9/18/25 at 3:34 PM, Staff 14 (RN/Assistant DNS) stated staff were required to obtain informed consent from the resident or resident representative prior to administering a psychotropic medication.

Based on interview and record review it was determined the facility failed to ensure a resident was safe from elopement for 1 of 1 sampled resident (#1) reviewed for elopement. This failure was determined to be an immediate jeopardy situation due to the facility failed to follow the Resident 1's care plan and provide adequate supervision, which resulted in Resident 1's elopement from the facility. Findings include: Resident 1 admitted to the facility on ,d+[DATE] for a 5-day respite stay with diagnoses including Alzheimer's Disease, dementia, anxiety disorder and restlessness. On 9/5/24 at 11:53 AM, Witness 1 (Family) stated on 8/15/24 she was notified Resident 1 was found in the middle of a roundabout, confused and carrying a teddy bear by a local law enforcement officer. The officer notified Resident 1's family. Witness 1 stated Resident 1 told her she/he wanted to leave the facility so when someone opened the door, she/he walked out. The 8/12/24 BIMS (an assessment tool used to assess cognition) revealed Resident 1 had severe cognitive impairment. The 8/12/24 Ambulation Care Plan revealed Resident 1 was independent with ambulation. The 8/13/24 Behavior Care Plan revealed Resident 1 was at risk for behavior symptoms related to elopement due to dementia, sun downs (the emergence or worsening of symptoms, like agitation, confusion or aggressiveness, in the late afternoon or early evening) and her/his first time away from home. Interventions included to encourage Resident 1 to remain in a supervised area when out of bed, monitor every 15 minutes and to redirect when wandering. The 8/13/24 Elopement Evaluation revealed Resident 1 was at risk for elopement. The 8/13/24 Progress Note revealed Resident 1 was confused, wandered throughout the facility and was exit seeking. The 8/14/24 Progress Note revealed Resident 1 wandered around the facility trying to get out and stated she/he wanted to go home. Resident 1 attempted to open each door she/he approached, all she/he thought of was to leave and was a high elopement risk. The 8/28/24 Facility Investigation revealed Resident 1 was at the facility for a five day respite stay, was ambulatory, could almost run if [she/he] want to, went to every door in the facility to try and get out, set off two alarms, needed frequent visual checks and was a high risk for elopement and falls. On 8/15/24, Staff 6 (CNA) last observed Resident 1 between 5:30 PM and 5:45 PM when the resident walked back and forth in the hallway, appeared agitated and excited and stated, I want to go home. I am going home today. The investigation further indicated Witness 2 (Visitor) observed Resident 1 in the lobby when Resident 1 sat down and began to talk out loud to herself/himself. Resident 1 abruptly stood up and stated she/he was going for a walk and followed another visitor out the door. The investigation summary indicated Staff 5 (CNA) last saw the resident at 6:30 PM in her/his room and Witness 2 observed her/him in the lobby between 7:00 PM and 7:15 PM. Resident 1 was found in the street by a police officer at approximately 7:30 PM and the facility staff was notified of the elopement at 7:45 PM when Resident 1 was returned to the facility by the police officer. Per record review the distance from the facility to where the resident was found was approximately 1.8 miles. Per Google Earth and Mapquest, the resident would have walked alongside a four lane highway, crossed the highway, walked along a busy street and transversed through three roundabouts before she/he was found in the third roundabout by the local police. Record review revealed 30-minute visual checks were in place from 8/13/24 at 6:45 AM through 8/15/24 at 3:30 PM. Resident 1's visual checks stopped nearly four hours before she/he eloped on 8/15/24 after 7:00 PM. In addition, Resident 1's care plan of 15-minute checks was not followed. On 9/5/24 at 10:56 AM, Staff 5 stated she was the last person to observe Resident 1 at 6:30 PM, when she attempted to wake up the resident for dinner. This was 30-45 minutes before Resident 1's elopement. Staff 5 further stated, after a while, the police came saying she was missing. On 9/5/24 at 11:20 AM, Staff 8 (CNA) stated Resident 1 was very confused, stayed by the door and was exit seeking the entire time at the facility. If staff attempted to redirect her/him, Resident 1 would get very angry, shake, grind her/his teeth and then immediately begin to exit seek again out all of the doors. On 9/6/24 at 11:46 AM, Staff 9 (CNA) stated Resident 1 was exit-seeking and pulling on the doors, but did not see any staff redirect her/him and did not redirect Resident 1 herself. On 9/5/24 at 12:37 PM, Staff 12 (CNA) stated Resident 1 was exit-seeking from the moment she/he woke up and constantly tried to find a way out using any of the four doors. Staff 12 further stated all staff were aware of the exit seeking behavior but did not redirect Resident 1 unless she/he was at the main entry door. Staff 12 stated not all staff on evening and night shift were aware of the care planned safety checks so the checks did not always get done. On 9/5/24 at 12:20 PM, Staff 2 (DNS) and Staff 4 (Admission Nurse/Resident Care Manager) verified Resident 1 was a high risk for elopement. Staff 2 stated Resident 1's care plan should have had individualized interventions in place to prevent elopement and acknowledged there was no documented evidence Resident 1's care plan was followed by encouraging her/him to remain in a supervised area when out of bed, monitoring her/his location every 15 minutes and redirecting when she/he wandered. Staff 2 stated the every 30 minute monitoring fell off at 3:30 PM on 8/15/24 because staff were unaware of the need to do this. Staff 2 acknowledged Resident 1 was found approximately two miles away from the facility by a local law enforcement officer and staff were unaware of the elopement until 7:45 PM when the resident was brought back to the facility. Staff 2 stated, she/he picked a time that was a good time when all the staff were busy. On 9/5/24 at 2:05 PM, Staff 1 (Administrator) and Staff 2 (DNS) were notified of the Immediate Jeopardy (IJ) situation and provided a copy of the IJ template related to the facility's failure to put into place individualized care plan interventions and to follow the residents care plan to prevent elopement. On 9/5/24 at 4:17 PM, an acceptable facility IJ removal plan was submitted by the facility. The plan indicated the facility would implement the following actions: *Current residents identified as elopement risks would have their care plans reviewed to reflect person centered care. *All current residents would be reassessed for risk of elopement. Any identified residents' plan of care would be updated to include individualized, personalized interventions. *The elopement book would be updated to include any newly identified residents. *All facility staff would be educated on the residents identified at risk for elopement and their individualized care plan interventions as well as procedures to initiate if a resident eloped. Education would be completed by 9/6/24 at 2:30 PM. Staff who were on leave or under COVID restrictions would be required to complete the education prior to returning work. *Daily audits would be completed starting 9/6/24 by the Interdisciplinary Team (IDT) to ensure residents were properly identified for elopement risk, elopement care plans were individualized, and staff followed care plan elopement interventions. Any identified issues would be immediately corrected. *Daily audits would continue for 14 days, then weekly for three months. Results of the audits would be presented to the QAPI team. The IJ was removed on 9/6/24 at 2:00 PM, as confirmed by onsite verification by the survey team on 9/9/24.

Based on observation, interview, and record review it was determined the facility failed to provide therapeutic diets to 3 of 4 (#s 2, 23, and 28) sampled residents reviewed for food. This placed residents at risk for unmet nutritional needs. Findings include: 1. Resident 2 admitted to the facility in 2024 with diagnoses including end stage kidney disease and diabetes. A 5/24/24 Summary of Care Document for Resident 2 included discharge orders for a diabetic diet. On 5/29/24 at 2:53 PM Staff 4 (Dietary Manager) stated residents who required diabetic diets were individually interviewed to determine what level of diet compliance each resident wanted and Resident 2's preferences were added to her/his meal ticket to reflect her/his requests. Staff 4 acknowledged there were no prescribed recipes used or portion control guideline for staff preparing meals to follow for therapeutic diets including residents who required a diabetic diet. On 5/29/24 at 3:50 PM Staff 13 (RD) acknowledged the facility approved therapeutic diets, which included a diabetic diet, should be printed and followed. 34703 2. Resident 23 admitted to the facility in 2024 with a diagnosis of malnutrition. A 2/2/24 Admission MDS indicated Resident 23 was cognitively intact. An 4/23/24 physician order indicated Resident 23 was to have nutritionally enhanced meals. A review of Resident Council minutes dated 4/22/24 revealed residents were not receiving what they ordered at mealtimes. On 5/29/24 at 9:13 AM Resident 23 was observed sitting in her/his bedroom with a plate of one small pancake and a small sausage patty, and there were no beverages. Resident 23 stated she/he always ordered oatmeal for breakfast but never received it. On 5/29/24 at 12:30 PM Staff 4 (Dietary Manager) stated if a resident did not complete a meal order the facility prepared whatever was on the menu. Staff 4 acknowledged he was aware Resident 28 always wanted fruit but sometimes it was not provided. 3. Resident 28 admitted to the facility in 2023 with diagnoses including diabetes. A 5/10/24 Significant Change MDS indicated the resident was cognitively intact. A physician order dated 10/12/23 revealed Resident 28 was to receive a CCHO (low carbohydrate) diet related to her/his diagnosis of diabetes. On 5/28/24 at 10:42 AM Resident 28 stated she/he was a diabetic and was not to receive extra carbohydrates. Resident 28 stated she/he marked out carbohydrates on her/his meal order but still received the carbohydrates, and did not receive the fruit she/he ordered. On 5/29/24 at 12:30 PM Staff 4 (Dietary Manager) stated if a resident did not complete a meal order the facility prepared whatever was on the menu. Staff 4 acknowledged he was aware Resident 28 always wanted fruit but sometimes it was not provided.

Based on observation and interview it was determined the facility failed to maintain comfortable temperature levels for 1 of 2 (Pine Meadow Hall) halls observed for environment. This placed residents at risk for uncomfortable temperatures. Findings include: Resident 26 admitted to the facility in 2024 with diagnoses including ALS (a nervous system disease). On 5/28/24 at 10:17 AM Resident 26 stated her/his room and the hall were too cold and made her/his body hurt. Resident 26 stated she/he reported this to management and nursing staff, but nothing was done to resolve the temperature issue. On 5/30/24 at 10:39 AM Staff 15 (CNA) and Staff 16 (CNA) stated Pine Meadow Hall was cold and residents complained about it. Multiple random observations from 5/28/24 through 5/31/24 revealed Resident 26's room and Pine Meadow Hall were cold. The thermostat for the hall was set to 68 degrees. On 5/30/24 at 1:04 PM Staff 14 (Maintenance Director) stated he tested the temperature in residents' rooms but did not document the results or complete audits. Staff 14 stated he was aware of Resident 26's complaints of being cold, but he kept the thermostats at 74 degrees. On 5/30/24 at 1:10 PM Staff 2 (DNS) verified the thermostat in Pine Meadow Hall was set for 68 degrees and should be set for 71 degrees to 81 degrees to keep residents comfortable, and acknowledged she was aware Resident 26 complained of the hall and her/his room being cold.

Based on observation, interview, and record review it was determined the facility failed to ensure beard restraints were worn during meal preparation for 1 of 1 sampled kitchen reviewed for sanitary food practices. This placed residents at risk for contaminated food. Findings include: A review of the facility's policy Dietary Dress Code dated 1/2024 revealed beards must be clean, well-groomed and must be completely covered with a beard covering. On 5/28/24 at 8:10 AM Staff 4 (Dietary Manager) and Staff 26 (Cook) were observed preparing food in the kitchen without beard restraints. Staff 4 indicated he was not aware staff had to wear beard coverings. On 5/29/24 at 12:01 PM Staff 13 (RD) acknowledged staff were to wear beard restraints while working in the kitchen.

Based on observation, interview and record review it was determined the facility failed to ensure meals were palatable, attractive, and at an appetizing temperature for 1 of 1 kitchen and 3 of 4 sampled residents (#s 9, 11 and 23) reviewed for food quality. This placed residents at risk for unmet nutritional needs. Findings include: 1. Resident 9 admitted to the facility in 2023 with diagnoses including cancer. An 10/10/23 Significant Change MDS indicated the resident was cognitively intact. On 5/28/24 at 11:23 AM Resident 9 stated the food was always cold and the meat was chewy. On 5/30/24 at 12:35 PM a test tray was delivered to surveyors. The plate warmer was cool to touch, the meat was hard, and the rice was lukewarm. On 5/30/24 at 12:37 PM Staff 2 (DNS) and Staff 3 (Regional RN) acknowledged the food was not hot and the meat was hard. 2. Resident 23 admitted to the facility in 2024 with a diagnosis of malnutrition. A 2/2/24 Admission MDS indicated Resident 23 was cognitively intact. On 5/29/24 at 1:03 PM Resident 23's lunch had raw hamburger in the taco casserole. On 5/29/24 at 1:05 PM Staff 4 (Dietary Manager) verified the hamburger was raw. On 5/30/24 at 12:35 PM a test tray was delivered to surveyors. The plate warmer was cool to touch, the meat was hard, and the rice was lukewarm. On 5/30/24 at 12:37 PM Staff 2 (DNS) and Staff 3 (Regional RN) acknowledged the food was not hot and the meat was hard. 26991 3. Resident 11 admitted to the facility in 2023 with a diagnosis of surgical infection. An 4/6/24 quarterly MDS revealed Resident 11 was able to answer questions but had moderate cognitive impairment. On 5/28/24 at 10:07 AM Resident 11 stated she/he ate in her/his room and the food was cold by the time it arrived. On 5/30/24 at 12:35 PM a test tray was delivered to surveyors. The plate warmer was cool to touch, and the rice was lukewarm. On 5/30/24 at 12:37 PM Staff 2 (DNS) acknowledged the food was not hot.

Based on interview, and record review it was determined the facility failed to obtain consent to administer medication for 1 of 5 (#16) sampled residents reviewed for unnecessary medications. This placed residents at risk for uninformed care. Findings include: Resident 16 admitted to the facility in 12/2019 with diagnoses including dementia, restlessness and agitation. A review of Resident 16's Physician Orders revealed an 4/11/24 order for buspirone (a medication in the anxiolytic drug class used to treat anxiety). A review of Resident 16's medical record revealed an 4/11/24 signed consent for buspirone listed as an antidepressant medication. The consent went over the risks and benefits for an antidepressant medication. On 5/30/24 at 4:03 PM Staff 2 (DNS) stated buspirone was an anxiolytic medication, not an antidepressant medication. Staff 2 acknowledged Resident 16 and her/his representative were not given informed consent for buspirone.

Based on interview and record review it was determined the facility failed to evaluate a resident's choice for bathing for 1 of 1 sampled resident (#18) reviewed for choices. This place residents at risk for lack of honored choices. Findings include: Resident 18 admitted to the facility in 2023 with diagnoses including stroke and anxiety. The 3/4/24 Quarterly MDS indicated Resident 18 required partial to moderate assistance for bathing and was cognitively intact. A 11/29/24 care plan indicated to provide Residents 18's bathing according to his/her preferences two times a week. The Task: Shower form for Resident 18 indicated the following: -On 5/1/24 at 9:30 PM the resident refused her/his shower. -On 5/4/24 at 8:30 PM the resident refused her/his shower. -On 5/11/24 at 9:54 PM the resident refused her/his shower. On 5/28/24 at 9:23 AM Resident 18 stated she/he refused showers because staff offered showers at night when she/he wanted to be in bed. Resident 18 stated she was told by CNAs her/his showers were scheduled at night. Resident 18 requested a different time for bathing and no changes were made to her/his bathing schedule. On 5/29/24 at 8:39 AM Staff 5 (Resident Care Manager) stated an investigation regarding Resident 18's shower refusals was not started as expected. Staff 5 acknowledged Resident 18 should be aware an alternative shower schedule was available.

Based on observation, interview and record review it was determined the facility failed to follow physician orders and provide care and services to promote the healing of pressure ulcers for 1 of 2 sampled residents (#1) reviewed for pressure ulcers. Resident 1 developing a facility acquired unstageable pressure ulcer. Findings include: Resident 1 was admitted to the facility in 2017 with diagnoses including paraplegia (paralysis of the lower body) and a Stage IV (a deep wound that reaches bone, ligaments or muscles) pressure ulcer of the sacral region (region between the bottom on the spine and the tailbone). a. A 9/7/21 physician order indicated to float Resident 1's heels and apply soft boots to both lower extremities at all times. A 9/17/21 care plan indicated Resident 1 was to use pillows for repositioning to reduce pressure and wear soft boots while in bed. A 11/29/22 New Pressure ulcer investigation revealed Staff 4 (LPN) observed Resident 1 with no boots on and a large thick scab on her/his right heel. Resident 1 stated they never put my boots on. A 11/30/22 Initial Skin Ulcer Assessment indicated Resident 1 had an unstageable facility acquired pressure ulcer to her/his right heel with 100 percent eschar (a collection of dead tissue that is flush with the skin) that measured 3.0 cm x 4.0 cm. The 1/20/23 Annual MDS indicated Resident 1 had one Stage IV wound on admission and one facility acquired unstageable wound. On 2/23/23 at 10:08 AM Staff 4 stated on 11/29/22 she observed Resident 1 did not wear her/his soft boots and during the investigation nurses informed her that because the soft boots were not working CNAs were informed not to put them on Resident 1. On 2/23/23 at 2:56 PM Staff 7 (RN) stated in 11/2022 Resident 1 had soft boots that exposed her/his heel to the pressure of the bed so Staff 7 stated she chose not to use pillows but dangled Resident 1's foot off the edge of the bed. On 2/24/23 at 5:13 PM Staff 3 (DNS) stated Resident 1's care plan should be followed and match her/his physician's order to avoid pressure ulcers. b. The 10/5/22 Admission History and Physical hospital notes indicated Resident 1 had a stable sacral region (area between the bottom of the spine and he tailbone) pressure ulcer to the bone with no infections and no drainage. The 10/12/22 Weekly Skin Ulcer Measurement Wound Evaluation revealed Resident 1's Stage IV wound on the coccyx (tailbone) had a wound bed that contained 100 percent granulation (part of the wound healing process in which new skin is formed) and measured 1.5 cm x 2.2 cm and was 0.3 cm in depth. The 10/2022 TAR indicated beginning on 10/14/22 Resident 1's sacral wound was to be cleansed with wound cleaner, patted dry, skin prepped, a collagen pad applied to the wound bed and covered with an absorbent dressing every day. The 12/15/22 Weekly Skin Ulcer Measurement Wound Evaluation revealed Resident 1's Stage IV coccyx wound bed contained 90 percent granulation with ten percent slough (dead tissue), small drainage, maceration (skin associated with improper wound care) and measured 1.6 cm x 3 cm and was 0.3 cm in depth. The 1/26/23 revised care plan indicated Resident 1's pressure ulcers were to show signs of healing, declines in the skin were to be reported to the physician and the resident was to be educated on the importance of changing positions and turning to avoid pressure ulcers. The 2/2023 TAR indicated the 10/14/22 order for Resident 1's sacral wound treatment was not changed. The 2/15/23 Weekly Skin Ulcer Measurement Wound Evaluation revealed no significant changes during the week to Resident 1's coccyx wound and the wound measured 1.5 cm x 2.5 cm x 0.5 cm in depth. A 2/15/23 physician visit progress note revealed Resident 1's Stage IV coccyx pressure ulcer had dressing present (the wound was not observed). During random observations from 2/20/23 at 1:24 PM to 2/24/23 at 10:18 AM Resident 1 was observed on a pressure relief air mattress in bed with pillows under her/his feet and at her/his side. Resident 1 indicated she/he preferred to remain in bed. On 2/23/23 at 10:08 AM Staff 4 (LPN) stated she often completed Resident 1's wound evaluations, Resident 1's treatment for her/his coccyx was discussed during morning meetings and Staff 4 agreed there was no noticeable improvements to the resident's coccyx wound since 10/2022. Staff 4 stated the facility was not as aggressive as possible with Resident 1's wound care due to the lack of a permanent DNS since 7/2022 and acknowledged Resident 1's coccyx wound was just left without further consideration. Staff 4 stated Resident 1's coccyx wound and wound interventions were discussed with her/him many times and an updated risk benefit document was needed since it was last signed in 2019. On 2/24/23 at 5:13 PM Staff 3 (DNS) acknowledged since Resident 1's wound healing stalled in the healing process she would involve the physician and look for different options.

Based on observation, interview and record review it was determined the facility failed to ensure residents were provided adequate and appropriate assistance to prevent injury during transfers for 2 of 3 sampled residents (#s 9 and 57). Resident 9 experienced delayed treatment, increased pain, sustained a bone fracture, and required hospitalization . Findings include: 1. Resident 9 was a long term resident of the facility with [DIAGNOSES REDACTED]. The resident's care plan with an initiation date of 6/25/15 indicated the resident had contractures of both knees and was unable to fully extend her/his legs. The resident required two person extensive assistance for toileting, and required a mechanical lift-hoyer with 2 person total assist. An update on 9/14/15 indicated the resident required two person assistance for EZ Lift (sit to stand lift) with gait belt stabilizing at ankles or may use Hoyer. A revision for transfers was noted on 3/28/16 and stated resident requires Mechanical Lift-hoyer with 2 person total assist by staff. On 4/15/16 it was noted EZ lift or hoyer for transfers. EZ lift preferred method for toileting. Use hoyer lift if fatigued. The resident was noted to yell out I'm falling, You're breaking my leg when repositioned and transferred. A facility Incident Report dated 4/20/16 indicated the resident was lowered to the floor on 4/19/16 by Staff 4 (CNA). The investigation stated the resident was being transferred with the EZ lift when her/his legs moved out of position, the resident was lowered to the bed and began to slide to the floor when she/he was detached from the lift. Staff 4 stated she assisted the resident to the floor. The investigation indicated the bed was in the low position. The resident was lifted off the floor by Staff 4 and 5 (CNA) using the Hoyer lift with no nurse assessment. The resident was subsequently found to have a leg fracture two days later. Review of April 2016 progress notes (PNs) showed no documentation from 4/13/16 through 4/19/16. On 4/20/16 at 8:38 am the resident was noted to have pain in her/his knees related to a fall the previous day. The resident was unable to communicate the exact location of pain, but yelled out her/his legs hurt. There was some increased swelling to the right ankle noted. The physician was notified and stated he would see the resident the following day. At 11:45 pm it was noted a CNA reported increased bruising of the resident's right ankle. The right ankle was swollen and bruised to the outer lower aspect with dispersed bruising noted above the ankle. PNs on 4/21/16 indicated the resident was seen by the physician, X-rays were obtained that showed a leg fracture and the resident was sent to the hospital for further evaluation. An X-ray report of the right ankle dated 4/21/16 showed a displaced distal fibular fracture, the shaft of the fibula was displaced two bone widths. The report further indicated the bones were diffusely osteopenic (lower than normal bone density). A Hospital History and Physical dated 4/21/16 indicated the resident had an obvious lower left extremity deformity secondary to a mechanical ground level fall. The resident was noted to have had an X-ray earlier in the day significant for a distal right tibula/fibula fracture. On 4/22/16 it was noted the resident was quite demented and admitted to the hospital for a nasty Tib/Fib Fx (fracture). The resident was not a candidate for surgery, but was treated conservatively with a splint/brace for healing of the fracture. The resident readmitted to the nursing facility on 4/23/16. Interviews conducted 6/28/16 through 6/30/16 between 8:00 am and 3:30 pm revealed: Staff 4 stated at the time of the incident on 4/19/16 she had placed the resident in the sit to stand lift and began to lift the resident into a standing position. The resident's legs began to twist to the side so Staff 4 sat the resident back on the edge of the bed, which was approximately 2-2.5 feet in height. The resident's feet were flat on the floor. As Staff 4 began to move the sit to stand lift out of the way the resident started to slide off the bed, so she held onto the resident and assisted the resident to the floor. Staff 4 was the only aide in the room prior to the resident being placed on the floor. After the resident was lowered to the floor Staff 4 obtained a second aide and they lifted the resident off the floor using the Hoyer lift. Staff 4 stated she did not report the incident to the nurse and the resident was not assessed prior to lifting the resident off the floor. Staff 4 stated she frequently transferred the resident without another staff assisting; the only time she consistently utilized two staff with Resident 9 was on night shift. Staff 5 indicated Staff 4 came and told her the resident was on the floor and she needed help to transfer the resident. Staff 5 stated Staff 4 said it was not a fall and the resident was carefully lowered to the floor. Staff 5 indicated they used the Hoyer lift to get the resident up and into the wheelchair. The resident normally called out and was anxious with transfers so when the resident called out during the transfer it seemed within her/his norm. Staff 5 knew the nurse needed to be informed of any resident incident, but she just didn't think about it until the next day when the resident was not within her/his normal self. Staff 5 further indicated she normally transferred/positioned the resident with two staff as the resident did not provide much assistance, was painful and fearful. Staff 5 stated it was safer to use two staff to transfer the resident. Staff 10 (RNCM) indicated she would not transfer the resident on her own but some of the long term aides could do on their own. Staff 10 stated she was unsure if the resident was care planned for a one or two person transfer at the time of the injury, but facility policy indicated minimum two staff for Hoyer transfers and minimum of one for sit to stand transfers. The comfort level of the staff and the resident's needs were a huge factor in how many staff were needed for care. Staff 10 further indicated it was up to the aides to determine if they needed one or two staff to complete a transfer with the resident. When the resident's multiple anxieties/fears, knee contractures, tendency for the resident's legs to tip to the left, dementia and inability to provide more than minimal assistance were discussed with Staff 10 she agreed it did not seem a good plan to transfer the resident alone. Staff 3 (RN) indicated the resident had some increased pain and bruising on 4/19/16, but they were unaware of any incident at that time. The resident was always difficult to determine pain because she/he called out with any movements. Staff 3 treated the resident for pain because of the difficulty in assessing the resident and the resident was acting out of her/his baseline. Staff 3 could not explain why she had no nursing notes documented on 4/19/16. Staff 3 indicated as far as she knew the resident was a two person transfer with the EZ Lift. The resident was very anxious with transfers and movement and the resident was unable to straighten her/his legs independently. Staff 3 stated it was safer for the resident and the staff to have two staff present during transfers to help with positioning of the resident's legs. Staff 6 (RN) indicated the resident was a two person assist for transfers prior to the fall and remained a two person after the fall. The resident was very frightful with transfers prior to the injury on 4/19/16, had contractures in both knees and very poor cognition. Staff 6 stated the resident required the two staff for stability, to help reassure and redirect the resident as much as possible. Staff 20 (PT Manager) indicated a hoyer lift transfer was always two staff assist, and in general a sit to stand lift could be utilized with one staff. However, the use of one staff versus two depended on the staff proficiency/comfort and the resident. Staff 20 worked with the resident and aides on different options for transfers in April 2016 prior to the fall, but he could not recall what determination nursing made for the number of staff required for the sit to stand lift. Staff 8 (CNA) indicated the resident always complained and called out with any movement even prior to the fracture. The resident frequently yelled out during any movement and especially during transfers. The resident was very fearful of any transfer and would become very anxious and upset. The resident would normally calm down once the transfer/movement was completed. Staff 8 stated she always used two staff to transfer the resident. She felt it was safer due to the resident's fear, limitations and cognition. Staff 8 indicated on 4/19/16 before they knew there was an incident or anything was wrong the resident had whimpered a lot with transfers and yelled you broke my leg. The resident did not normally whimper with transfers, that was not her/his normal behavior. Staff 7 (RN) indicated nothing was reported to her on 4/19/16, but she did notice the resident was calling out more. The resident appeared twisted while sitting in her/his chair so Staff 7 and Staff 20 repositioned the resident to try and make her/him more comfortable. The resident always called out, was anxious and stated pain with transfers, but the resident seemed more painful. Staff 7 stated the morning of 4/20/16 the previous nurse mentioned the resident was given pain medication during the night which was out of the resident's baseline. Staff 7 was questioning what was going on with the resident when Staff 5 overheard and reported what she knew about the incident from 4/19/16. The resident should not have been moved without a nursing assessment. Staff 7 was not sure if the resident was care planned for one or two staff assistance with transfers at the time of the fall. Staff 7 frequently told staff if they were not comfortable with a one person transfer for any resident to obtain a second staff. She always encouraged staff to err on the side of safety. Staff 9 (CNA) indicated the resident was always anxious with transfers and movement even prior to the incident on 4/19/16. The resident can sometimes be calmed, but other times was inconsolable. Staff 9 had used the sit to stand lift with the resident and only one staff on several occasions. One of the resident's legs wanted to turn out but if you held the leg in place against the knee pad on the lift until the resident put weight on it, then the leg would not turn out. Staff 9 stated on other occasions the resident might be more tired or more anxious and she would utilize a second staff member for transfers; it varied with the resident's condition. Staff 2 (DNS) stated she had no issue with CNA staff determining whether one or two staff were needed for transfers related to Resident 9. Staff 2 stated there were several staff who were very proficient and able to complete a one person transfer without issue. Staff 2 was unable to provide any additional information to clarify if the resident was care planned for a one or two person transfer prior to the fracture. 2. Resident 57 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. On 6/29/16 at 9:05 am Resident 57 was observed sitting in his wheel chair and manipulating a gait belt that was attached to a transfer pole in the physical therapy room. The resident proceeded to attempt self transfer from her/his wheelchair using the gait belt and transfer pole. Resident 57 became unstable and attempted to sit back down in her/his wheelchair. The residents wheelchair was not in a locked position and rolled out from underneath the resident causing her/him to fall down onto her/his bottom. On 6/29/16 at 9:30 am Staff 15 (PT) confirmed that Resident 57 could work independently when in the therapy room, but staff should supervise and make sure her/his wheelchair is in a locked position for safety purposes. Staff 16 (OT) stated that Resident 57 had cognitive impairments and that staff should make sure the wheelchair was in a locked position during therapy treatments in the therapy room. On 6/29/16 an incident report was completed and indicated Resident 57 reported that she/he lost her/his balance while trying to self-transfer to a mat table using a transfer pole in the therapy room. The resident's wheelchair was not locked and the resident fell back onto her/his bottom. On 6/29/16 at 12:26 pm Staff 7 (RN) confirmed staff should cue to help remind the resident to lock her/his brakes and check to make sure Resident 57's brake were in a locked position for safety purposes.

Based on interview and record review it was determined facility staff failed to report a resident fall, and obtain professional assessment prior to transferring a resident post fall for 1 of 3 sampled residents (#9) reviewed for accidents. Resident 9 experienced delayed treatment, increased pain, sustained a bone fracture, and required hospitalization . Findings include: The Oregon State Board of Nursing Standards and Authorized Duties for the Certified Nursing Assistant states OAR [PHONE NUMBER] Conduct Unbecoming a Nursing Assistant .(3) Conduct related to client safety and integrity: (a) Failing to take action to preserve or promote a person's safety based on nursing assistant knowledge, skills, and abilities; .(c) Failing to report changes in a person's status from the last assessment made by the registered nurse; (d) Jeopardizing the safety of a person under the CNA's care; . Resident 9 was a long term resident of the facility with [DIAGNOSES REDACTED]. The resident's care plan with an initiation date of 6/25/15 indicated the resident had contractures of both knees and was unable to fully extend her/his legs. The resident required two person extensive assistance for toileting, and required a mechanical lift-hoyer with 2 person total assist. A revision date for transfers was noted as 3/28/16. On 4/15/16 it was noted EZ lift or hoyer for transfers. EZ lift preferred method for toileting. Use hoyer lift if fatigued. A facility Incident Report dated 4/20/16 indicated the resident was lowered to the floor on 4/19/16 by Staff 4 (CNA). The investigation stated the resident was being transferred with the EZ lift (sit to stand lift) when her/his legs moved out of position, the resident was lowered to the bed and began to slide to the floor when she/he was detached from the lift. Staff 4 stated she assisted the resident to the floor. The resident was lifted off the floor by Staff 4 and Staff 5 (CNA) using the Hoyer lift. There was no licensed nurse notification or assessment prior to moving the resident off of the floor. Progress Notes (PNs) on 4/21/16 indicated the resident was seen by the physician, X-rays were obtained that showed a leg fracture and the resident was sent to the hospital for further evaluation. Interviews conducted on 6/28/16 and 6/29/16 between 8:00 am and 3:30 pm revealed: Staff 4 stated at the time of the incident on 4/19/16 she had the resident ready for the day, sitting at the edge of the bed, connected the sling behind the resident and attached to the lift. Staff 4 started to raise the resident up with the sit to stand lift but the resident's legs started to move out of place. The resident was lowered back to a seated position on the edge of the bed. When Staff 4 moved the lift out of the way the resident began to tip backwards and slide forward onto the floor. Staff 4 held on to the resident and assisted the resident to the floor. Staff 4 then obtained a second aide and they lifted the resident off the floor using the Hoyer lift. Staff 4 stated she did not report the incident to the nurse and the resident was not assessed prior to lifting the resident off the floor. Staff 4 did not count the incident as a fall so she did not think the nurse needed to be told. Staff 4 stated she frequently transferred the resident without another staff assisting; the only time she consistently utilized two staff with Resident 9, was on night shift Staff 5 indicated on 4/19/16 Staff 4 came and told her the resident was on the floor and she needed help to transfer the resident. Staff 5 stated Staff 4 said it was not a fall and that the resident was carefully lowered to the floor. Staff 5 indicated they used the Hoyer lift to get the resident up and into the wheelchair. The resident normally called out and was anxious with transfers so when the resident called out during the transfer it seemed within her/his baseline. Staff 5 knew the nurse needed to be informed of any resident incident, but she just didn't think about it at the time. The resident seemed within her/his norm and it all happened so fast. After Resident 9 was assisted back into the wheelchair, Staff 5 returned to her assigned residents. The following day, 4/20/16, Staff 5 was assigned to Resident 9 and the resident was not within her/his baseline. Staff 5 told the nurse, Staff 7 (RN) what happened. Staff 7 indicated on 4/19/16 the resident showed indications of increased pain. The resident appeared twisted while sitting in her/his chair so Staff 7 and Staff 20 (PT Manager) repositioned the resident to try and make her/him more comfortable. No incidents were reported to Staff 7 on 4/19/16. Staff 7 stated on the morning of 4/20/16 it was reported to her the resident was medicated for pain during the night; this was not the resident's baseline. Staff 5 approached Staff 7 and reported what she knew about the incident that occurred on 4/19/16. The resident should not have been moved without a nursing assessment. Staff 7 contacted the physician on 4/20/16 to report the incident as well as the resident's increased pain the day after the fall. Staff 2 (DNS) indicated the incident on 4/19/16 was not reported to the charge nurse and no assessment was done of the resident prior to the resident being transferred back to the wheelchair from the floor. Refer to F-323

Based on interview and record review it was determined the facility failed to ensure staff timely reported a fall, and obtain professional assessment prior to transferring a resident post fall for 1 of 3 sampled residents (#9) reviewed for accidents. Resident 9 experienced delayed treatment, increased pain, sustained a fracture, and required hospitalization . Findings include: Resident 9 was a long term resident of the facility with [DIAGNOSES REDACTED]. The resident's care plan with an initiation date of 6/25/15 indicated the resident had contractures of both knees and was unable to fully extend her/his legs. The resident required two person extensive assistance for toileting, and required a mechanical lift-hoyer (a mechanical lift which cradles the resident in a sling) with 2 person total assist. A revision date for transfers was noted as 3/28/16. On 4/15/16 it was noted EZ lift (a mechanical sit to stand lift) or hoyer for transfers. EZ lift preferred method for toileting. Use hoyer lift if fatigued. A facility Incident Report dated 4/20/16 indicated the resident was lowered to the floor on 4/19/16 by Staff 4 (CNA). The investigation stated the resident was being transferred with the EZ lift when her/his legs moved out of position, the resident was lowered to the bed and began to slide to the floor when she/he was detached from the lift. Staff 4 stated she assisted the resident to the floor. The resident was lifted off the floor by Staff 4 and 5 (CNA) using the Hoyer lift with no nurse assessment. The resident was subsequently found to have a leg fracture two days later. Review of April 2016 progress notes (PNs) showed no documentation from 4/13/16 through 4/19/16. On 4/20/16 at 8:38 am the resident was noted to have pain in her/his knees related to a fall the previous day. The resident was unable to communicate the exact location of pain, but yelled out her/his legs hurt. There was some increased swelling to the right ankle noted. The physician was notified and stated he would see the resident the following day. At 11:45 pm it was noted a CNA reported increased bruising of the resident's right ankle. The right ankle was swollen and bruised to the outer lower aspect with dispersed bruising noted above the ankle. PNs on 4/21/16 indicated the resident was seen by the physician, the resident was transported out of the facility for an X-ray. The X-ray showed a leg fracture and the resident was sent to the hospital for further evaluation. A Hospital History and Physical dated 4/21/16 indicated the resident had an obvious lower left extremity deformity secondary to a mechanical ground level fall. The resident was noted to have had an X-ray earlier in the day significant for a distal right tibula/fibula fracture. On 4/22/16 it was noted the resident was quite demented and admitted to the hospital for a nasty Tib/Fib Fx (fracture). The resident was not a candidate for surgery, but was treated conservatively with a splint/brace for healing of the fracture. The resident readmitted to the nursing facility on 4/23/16. Interviews conducted on 6/28/16 and 6/29/16 between 8:00 am and 3:30 pm revealed: Staff 4 stated at the time of the incident on 4/19/16 she started to raise the resident into a standing position with the sit to stand lift. The resident's legs started to move out of the knee pad on the lift and the resident started to slip downwards. Staff 4 indicated she lowered the resident back onto the edge of the bed with her/his feet flat on the floor. Staff 4 moved the sit to stand lift out of the way and the resident tipped backwards and began to slide to the floor. Staff 4 held on to the resident and assisted the resident to the floor. Staff 4 then obtained a second aide and they lifted the resident off the floor using the Hoyer lift. Staff 4 stated she did not report the incident to the nurse and the resident was not assessed prior to lifting the resident off the floor. Staff 4 stated she did not count the incident as a fall, the resident seemed fine to her so she did not think about telling the nurse. Staff 5 indicated on 4/19/16 Staff 4 came and told her the resident was on the floor and she needed help to transfer the resident. Staff 4 reported to Staff 5 the resident had not fallen but was carefully lowered to the floor. Staff 5 indicated they used the Hoyer lift to get the resident up and into the wheelchair. The resident normally called out and was anxious with transfers so when the resident called out and expressed pain during the transfer it seemed within her/his baseline. Staff 5 understood the nurse needed to be informed of any resident incident, but it didn't occur to her at the time of the fall on 4/19/16. The resident seemed within her/his usual self. Staff 5 did not report the incident to the nurse. Staff 5 returned to her assigned residents after she assisted with the transfer of Resident 9 off the floor and back into the wheelchair. On the following day, 4/20/16, Staff 5 was assigned to Resident 9. The resident was not her/his usual self and appeared more painful with and without movement. Staff 5 told the nurse, Staff 7 (RN) what had occurred on the morning of 4/19/16. Staff 8 (CNA) stated the resident was always anxious and would call out during transfers. Staff 8 was unsure of the specific date but she did see some swelling that she showed the nurse. The resident had more pain and whimpered a lot during transfers which was not her/his usual behavior. Staff 8 stated this occurred before anyone knew the resident had fallen or was injured. Staff 7 indicated nothing was reported to her on 4/19/16, but she did notice the resident was calling out more. The resident appeared twisted while sitting in her/his chair so Staff 7 and Staff 20 (PT Manager) repositioned the resident to try and make her/him more comfortable. The resident always called out, was anxious and stated pain with transfers, but the resident seemed more painful. Staff 7 stated the morning of 4/20/16 the previous nurse mentioned the resident was given pain medication during the night which was not the resident's baseline. Staff 7 was approached by Staff 5 who reported what she knew about the incident from 4/19/16. The second aide involved, Staff 4, did not report any information to Staff 7 on her own. The resident should not have been moved without a nursing assessment. Staff 7 contacted the physician to report the incident as well as the resident's increased pain. Staff 2 (DNS) indicated the incident on 4/19/16 was not reported to the charge nurse and no assessment was done of the resident prior to the resident being transferred back to the wheelchair from the floor. Refer to F-281 and F-323