Every finding on record at Portland Health and Rehabilitation

Based on interview and record review, it was determined the facility failed to effectively respond to resident council concerns expressed at 3 of 3 resident council meetings reviewed for facility response to Resident Council concerns. This placed residents at risk for unmet needs concerning issues of resident care and lessened quality of life. Findings include: The facility's 1/2017 Resident Council Policy revealed the facility was expected to communicate a response and/or decisions to the Resident Council by the next meeting.During the 2/25/26 at 11:08 AM Resident Council meeting the residents stated they did not feel heard about their concerns or suggestions. The Resident Council stated they did not receive a response from administration or departments regarding the concerns or suggestions they reported.A 2/25/26 review of the Resident Council/Family Council Department minutes revealed the following from the Resident Council meetings concerns: -12/12/25, residents expressed concern for food quality, personal money access and no responses were provided to the Resident Council;-1/14/26, residents expressed concern for requested spices for food, laundry return and no responses were provided to the Resident Council;-2/16/26, residents expressed concern for wanting spices for their food and no response was provided to the Resident Council.On 2/25/26 at 12:52 PM Staff 23 (Activity Director) confirmed the lack of responses to the Resident Council concerns. Staff 23 stated she assisted the residents with Resident Council and there was not any form of communication for facility departments with Resident concerns.On 2/25/26 at 1:08 PM Staff 1 (Administrator) acknowledged the lack of response to the Resident Council concerns as a council. Staff 1 acknowledged all Resident Council concerns should be appropriately addressed in written form and given to the Resident Council to review.

Based on interview and record review it was determined the facility failed to have a system in place to deliver mail on Saturdays for 1 of 1 Resident Council reviewed. This placed residents at risk for lack of timely written communications. Findings include:On 2/25/26 at 11:08 AM during the Resident Council group interview, residents stated their mail was not delivered on Saturdays.On 2/25/26 at 12:52 PM Staff 23 (Activity Director) stated the MOD (manager of the day) delivered mail on Saturdays.On 2/25/26 at 1:00 PM Staff 3 (RNCM) stated she sometimes worked on Saturdays as the MOD and she never delivered mail to the residents.On 2/25/26 at 1:04 PM Staff 8 (RN) stated he worked as the MOD on Saturdays at times and never passed mail to residents.On 2/25/26 at 1:15 PM Staff 1 (Administrator) stated he expected the MOD delivered mail on Saturdays and acknowledged there was no other system in place to deliver mail to residents on Saturdays.

Based on interview and record review it was determined the facility failed to monitor residents and follow physician orders for 6 of 13 sampled residents (#'s 37, 48, 55, 62, 63, and 68) reviewed for abuse, staffing, and death. This placed residents at risk for unidentified concerns and unmet care needs. Findings include: 1. The facility's 9/30/25 Abuse Allegation investigation revealed Resident 37 alleged a resident of the opposite sex entered her/his room on 9/29/25 and touched her/his chest and abdominal region. The investigation identified Resident 68 to be the alleged perpetrator, but the facility was not able to collaborate Resident 37's allegation of abuse. a. Resident 37 was admitted to the facility in 9/2025 with a diagnosis of spinal fracture. Resident 10/1/25 admission MDS revealed she/he had severe memory impairment. Resident 37's Progress notes revealed the following:-9/30/25 during a care conference Resident 37 reported an allegation of abuse and was moved to another room to separate her/him from the alleged perpetrator. -10/1/25 (There was no assessment related to the alleged allegation of abuse and Resident 37's psychosocial status).-10/2/25 Resident 37 was assessed to be confused at times and worked with therapy. (There was no assessment related to the alleged allegation of abuse and Resident 37's psychosocial status.)-10/3/25 Resident 37 was assessed for physical, emotional distress and behavioral changes. No changes were identified. -10/4/25 Resident 37 was assessed to be alert and oriented, able to make needs known, and had limited ROM. (There was no assessment related to the alleged allegation of abuse and Resident 37's psychosocial status.) On 2/23/26 at 10:30 AM Resident 37 stated a resident of the opposite sex came into her/his room and lifted her/his shirt. Resident 37 stated the incident scared her/him and she/he stopped eating in the dining room. On 2/26/26 at 9:41 AM Staff 24 (RN) stated if a resident had a change of condition staff were to place a resident on alert charting. Alert charting was to be completed each shift (every eight hours) and the note should address the area of concern being monitored. The alert charting was to be done for at least 72 hours but longer if needed. RN On 2/26/26 at 4:06 PM Staff 2 (DNS) stated he would expect a resident's alert charting to be completed every shift for at least 72 hours, and it was to be specific to the concern identified. b. Resident 68 was admitted to the facility in 9/2025 with a diagnosis of facial fractures. Resident 68's 10/1/25 Montreal Cognitive Assessment revealed she/he had severe cognitive impairment. Resident 68's Progress Notes revealed: -10/1/25 Resident 68's discharge plan was to return home. (There was no assessment to ensure staff monitored Resident 68 to ensure she/he did not enter other resident rooms.)-10/2/25 there was no progress note documented. -10/3/25 Resident 68 was assessed to be irritable, and her/his medical status was monitored. (There was no assessment to ensure staff monitored Resident 68 to ensure she/he did not enter other resident rooms.) On 2/26/26 at 9:41 AM Staff 24 (RN) stated if a resident had a change of condition, or needed to be monitored, staff were to place a resident on alert charting. Alert charting was to be completed each shift (every eight hours) and the note should address the area of concern being monitored. The alert charting was to be done for at least 72 hours but longer if needed. On 2/26/26 at 4:06 PM Staff 2 (DNS) stated he would expect staff would monitor a potential perpetrator in an investigation. A resident's alert charting to be completed every shift for at least 72 hours and it was to be specific to the concern identified. 2. Resident 48 was admitted to the facility in 1/2025 with a diagnosis of pressure ulcer. The facility's 10/21/25 Allegation of Sexual Inappropriate Behavior investigation revealed Resident 48 alleged Resident 68 entered her/his room and touched her/his thigh without consent. Resident 48 was placed on 1:1 supervision and Resident 48 was placed on alert charting. Resident 48's 10/14/25 Quarterly MDS and 1/13/26 Annual MDS revealed she/he was cognitively intact. Resident 48's Progress Notes revealed the following:-10/21/25 Resident 48 reported a resident of the opposite sex entered her/his room, asked Resident 48 to touch the intruder's hand, and the other resident touched her/his thigh twice. Staff were immediately notified. -10/22/25 a progress note was not documented-10/23/25 Resident 48 was monitored due to invasion of privacy by another resident. Resident 48 was guarded and worried.-10/24/25 Resident 24 was assessed for her/his nationality, language, and need for ADL assistance. (There was no assessment related to the alleged allegation of abuse and Resident 37's psychosocial status.) On 2/23/26 at 10:05 AM Resident 48 stated Resident 68 came in her/his room and Resident 68 rubbed her/his legs. Resident 48 stated it upset her/him for about a month but was now over it. On 2/26/26 at 9:41 AM Staff 24 (RN) stated if a resident had a change of condition, or needed to be monitored, staff were to place a resident on alert charting. Alert charting was to be completed each shift (every eight hours) and the note should address the area of concern being monitored. The alert charting was to be done for at least 72 hours but longer if needed. On 2/24/26 at 1:46 PM and 2/26/26 at 4:06 PM Staff 2 (DNS) stated he completed the investigation related to this incident would expect staff would monitor and document on a resident every shift for at least 72 hours and it was to be specific to the concern identified. 3. Resident 55 was admitted to the facility in 9/2021 with a diagnosis of heart disease. Resident 55's 12/4/25 Order Details report revealed zinc oxide (treats skin irritations) was to be applied every two hours. Resident 55's 12/2025 TAR revealed zinc oxide was applied every two hours on most shifts. Resident 55's 1/2026 and 2/2026 TAR did not include staff were to apply zinc every two hours. On 2/26/26 at 11:19 AM Staff 17 (CNA) stated the CNAs applied barrier cream to Resident 55's skin every two hours. The nurses had to apply the medicated cream. On 2/26/26 at 2:29 PM AM Staff 9 (RN) stated if a resident required zinc oxide cream to be applied it was documented on the TAR. On 2/26/26 at 4:21 PM Staff 2 (DNS) stated Zinc oxide was a medicated cream, and the licensed nurses were to administer the medication. Staff 2 acknowledged the order was not on the current TARs and was not documented as administered. 4. Resident 62 was admitted to the facility in 1/2026 with a diagnosis of seizures. Resident 62's 1/26/26 Progress Note by Staff 3 (RNCM) revealed staff observed her/him at the nurse's station and she/he was shaking and was unresponsive. The note indicated a CNA stated that [she/he] did this again yesterday . Resident 62's clinical record did not have an assessment of shaking or unresponsiveness on 1/25/26. On 2/27/26 at 11:11 AM Staff 3 stated she did not recall the CNA who reported Resident 62 had a shaking and unresponsive event on 1/25/26. Staff 3 stated if a resident had a change in condition the CNA should report to the nurse and the nurse should document an assessment. On 2/27/26at 11:25 AM Staff 2 (DNS) stated if a resident had a change of condition the CNA was to report to the nurse, the physician was to be notified, and the resident was to be monitored. 5. Resident 63 was admitted to the facility in 12/2025 with diagnoses of kidney disease and heart failure. Resident 12/4/25 hospital Physician Discharge Orders included Resident 62 was to be weighed upon admission to the facility and daily. Staff were to call the physician if Resident 63 gained three pounds in more than 24 hours or five pound in five days. Resident 62's weight log revealed the following: -12/625 202 pounds.-12/8/25 209.4 pounds.-12/925 209 pounds.-12/10/25 207 pounds.-12/1125 223 pounds.-12/15/25 200 pounds.-12/16/25 200.2 pounds.-12/17/25 200 pounds.-12/19/25 200.2 pounds.-12/20/25 209.2 pounds.-12/23/25 211.4 pounds. Resident 63's clinical record did not have documentation to indicate her/his physician was notified of weight gains per orders on 12/8/26, 12/11/25, and 12/20/25. On 2/26/26 at 4:26 PM Staff 2 (DNS) stated Resident 63 was on dialysis and weight fluctuations were expected. Staff did not call the physician with weight gain per physician orders but should have clarified the order due to dialysis related weight fluctuations.

Based on observation and interview it was determined the facility failed to ensure medications and biologicals were secured and accessible only to authorized personnel for 2 of 3 facility halls observed for secure medication cart. This placed residents at risk for misappropriation of medications and adverse medication consequences. Findings include:1. On 2/25/26 at 12:16 PM an unattended medication storage cart in the [NAME] Hall was observed to have unlocked drawers. Two staff members and a visitor were observed to walk past the unlocked medication storage cart. On 2/25/26 at 12:20 AM Staff 10 (RN) opened the closed door in room [ROOM NUMBER], approached the unlocked medication storage cart and locked it. Staff 10 confirmed the drawer had been left unlocked and unattended while she was in room [ROOM NUMBER]. The medication storage cart was inspected, and Staff 10 confirmed the cart contained residents' prescribed medications, insulin vials and insulin needles. Staff 10 confirmed the medication carts were to remain locked when left unattended. On 2/25/26 at 2:58 PM Staff 2 (DNS) confirmed medication carts were to be locked when left unattended by the licensed nurse. 2. On 2/24/26 at 11:32 AM an unattended medication storage cart in the [NAME] Hall was observed to have an opened drawer. The medication storage cart was locked, but the drawer had not been fully closed which allowed access to the contents of the drawer. The drawer was inspected and found to contain insulin vials and insulin needles. On 2/24/26 at 11:33 AM two staff members were observed walking by the medication storage cart and no action taken by either staff member. On 2/24/26 at 11:39 AM Staff 9 (RN) approached the cart and confirmed the drawer had not been fully closed and therefore was left unlocked while unattended. Staff 9 stated the drawer contained insulins vials, syringes, and glucometers. Staff 9 confirmed medication carts were to remain locked when left unattended. On 2/25/26 at 2:58 PM Staff 2 (DNS) confirmed medication carts were to be locked when left unattended. 3. On 2/26/26 at 1:04 PM a medication cart was observed unlocked on the North Hall. The nurse was not in view of the cart. On 2/26/26 at 1:11 PM Staff 11 (LPN) confirmed the cart was left unlocked and unattended. On 2/25/26 at 2:58 PM Staff 2 (DNS) confirmed medication carts were to be locked when left unattended.

Based on observation, interview, and record review it was determined the facility failed to implement Enhance Barrier Precautions for 2 of 2 sampled residents (#s 11 and 48) reviewed for pressure ulcers. This placed residents at risk for cross contamination. Findings include:1. Resident 11 was admitted to the facility in 10/2025 with a diagnosis of pressure ulcer. Resident 11's 2/26/26 Weekly Skin Evaluation revealed she/he had a pressure ulcer to the left buttock which was first observed on 3/27/25. On 2/25/26 at 10:56 AM Staff 4 (RNCM) was observed to begin pressure ulcer care. Staff 4 performed hand hygiene and put on gloves. Prior to removing Resident 11's dressing, this surveyor asked Staff 4 if she/he was to wear a gown. Staff 4 stated she did not need to wear a gown and only needed to use gloves. Resident 11's ulcer was observed to not have signs of infection. On 2/26/26 at 9:11 AM and 2/27/26 at 12:07 PM Staff 8 (Infection Preventionist) stated residents with chronic wounds that did not have significant drainage were on standard precautions (use of gloves, gowns, masks and eye protection based on the anticipated risk of exposure to fluids). Staff 8 stated residents with chronic wounds should be on EBP (Enhance Barrier Precautions) but Resident 11 did not have EBP in place. On 2/26/26 at 3:59 PM Staff 2 (DNS) stated residents with chronic wounds should be in EBP. 2. Resident 48 was admitted to the facility in 1/2025 with a diagnosis of pressure ulcer. Resident 48's 1/13/26 Annual MDS revealed she/he was cognitively intact. On 2/23/26 at 2:40 PM and 02/25/2026 at 3:25 PM Resident 48's room was observed with no signage and no PPE (Personal Protective Equipment) by her/his room to indicate she/he was on EBP (Enhance Barrier Precautions). Resident 48 stated staff did not use gowns when they performed wound care. Resident 48 declined to have this surveyor observe wound care. On 2/26/26 at 1:50 PM Staff 4 (RNCM) stated Resident 48 was admitted to the facility in 1/2025 with a pressure ulcer. Staff stated she did not wear a gown when she/he did wound care. On 2/26/26 at 9:11 AM and 2/27/26 at 12:07 PM Staff 8 (Infection Preventionist) stated residents with chronic wounds that did not have significant drainage were on standard precautions (use of gloves, gowns, masks and eye protection based on the anticipated risk of exposure to fluids). Staff 8 stated residents with chronic wounds should be on EBP but Resident 48 did not have EBP in place. On 2/26/26 at 3:59 PM Staff 2 (DNS) stated residents with chronic wounds should be in EBP.

Based on observation, interview, and record review it was determined the facility failed to complete a comprehensive assessment for 2 of 7 sampled residents (#s 2 and 48) reviewed for pressure ulcer and unnecessary medications. This placed residents at risk for adverse side effects and worsening wounds. Findings include: 1. Resident 2 was admitted to the facility in 11/2025 with a diagnosis of dementia with behavioral disturbances. Resident 2's 11/2025 MAR revealed she/he was administered olanzapine (antipsychotic medication) for delusions, risperidone (antipsychotic medication) for delusions, and sertraline (antidepressant) for mood disorder. Resident 2's 11/18/25 admission MDS and associated CAA indicated she/he used psychotropic medications but there was no analysis of findings including her/his medical condition, history, and rationale for the continued use of psychotropic medications. On 2/27/26 at 8:59 AM Staff 16 (MDS Coordinator) reviewed the 11/18/26 admission MDS and verified she did not address Resident 2's mental health diagnosis, history or psychotropic medications, and the goal of treatment or did not direct the reader to the documentation to support her rationale for developing a care plan and the goal of treatment. On 2/27/26 at 11:35 AM Staff 2 (DNS) sated the CAAs should have an analysis of the use of the psychotropic medications. 2. Resident 48 was admitted to the facility in 1/2025 with a diagnosis of pressure ulcer. Resident 48's 1/28/25 hospital Discharge Summary revealed she/he had a sacral pressure ulcer with tunneling with osteomyelitis (bone infection). Resident 48 was discharged to the facility for wound care. Resident 48's 1/13/26 Annual MDS and CAAs revealed she/he was identified to have a pressure ulcer. The analysis of findings included information related to her/his nutrition. there was no information related to Resident 48's pressure ulcer, if the pressure ulcer was chronic and if it was expected to heal. On 2/27/26 at 8:59 AM Staff 16 (MDS Coordinator) reviewed the 1/13//26 admission MDS and CAAs and verified she did not address Resident 48's pressure ulcer or refer to documentation to support the rationale for developing a care plan and the goal of treatment. On 2/27/26 at 11:35 AM Staff 2 (DNS) sated the CAAs should have an analysis of Resident 48's care as related to the pressure ulcer.

Based on interview and record review it was determined the facility failed to ensure residents were not abused for 3 of 7 sampled residents (#s 48, 65 and 66) reviewed for abuse. This placed residents at risk for abuse and diminished psychosocial well-being. Findings include:The facility's update 2022 Freedom from Abuse, Neglect, Corporal Punishment, Involuntary Seclusion, Mistreatment, Misappropriation of Resident Property, and Exploitation Policy statement included each resident has the right to be free from abuse including verbal, physical and sexual. The abuse definition included the willful infliction of intimidation resulting in mental anguish. 1. Resident 6 was admitted to the facility in 2020 with diagnoses including epilepsy (neurological disorder) and dementia. Resident 65 was admitted to the facility in 2024 with diagnoses including a stroke and depression. Resident 66 was admitted to the facility in 2025 with diagnoses including heart failure and depression. Review of a 9/25/25 incident report documented on 9/25/25 Resident 6, Resident 65 and Resident 66 tried to exit the facility for the smoking break. Resident 6 stated she/he believed Resident 65 bumped her/his wheelchair which led to a confrontation. Review of a written statement on 9/25/25 documented Resident 6 stated in the morning while attempting to exit for the smoking break, she/he felt Resident 65 push her/his wheelchair and said to hurry up. Resident 6 stated Resident 65 yelled at her/him and then she/he yelled back Get away from me, don't touch me you fucking bitch. You touch me again and I'll kill you. Review of a written statement from Resident 65 on 9/25/25 documented she/he stated that morning Resident 6 called her/him a fucking bitch, tried to hit her/him and then Staff 11 (LPN) pulled her/him away just in time. Review of a written statement from Resident 66 on 9/25/25 documented that morning she/he waited to exit for a smoking break when Resident 6 stood up and took a swing at Resident 65 and called her/him a bitch. Resident 6 then turned to Resident 66 and said, You're a little bitch too, I bet I could beat your ass. It was documented Resident 66 stated the incident made her/him afraid. Resident 66 discharged from the facility 9/30/25 and her/his phone was not in service on 2/25/26. On 2/25/26 at 3:35 PM Witness 2 (Family Member) stated Resident 66 was not able to take phone calls. Resident 65 discharged from the facility 1/10/26, calls were placed on 2/24/26 and 2/25/26 but were unsuccessful. On 2/24/26 at 12:14 PM Resident 6 stated she/he did not recall the incident. On 2/26/26 at 12:01 PM Staff 11 recalled the incident between Resident 6, Resident 65 and Resident 66 on 9/25/25. Staff 11 noticed Resident 6 being aggressive towards Resident 65. Resent 6 motioned as if she/he was going to hit Resident 65 so he separated the two residents. Staff 11 recalled them yelling at each other but was not able to recall the verbiage used. On 2/26/26 at 12:28 PM Staff 2 (DNS) confirmed his written investigation and conclusion of Resident 6 verbally and physically threatened Resident 65 and verbally threatened Resident 66 on 9/25/25. Staff 2 stated he expected all residents to be free from abuse. 2. Resident 48 was admitted to the facility in 1/2025 with a diagnosis of pressure ulcer. Resident 48's 10/14/25 quarterly MDS and 1/13/26 Annual MDS revealed Resident 48 was cognitively intact. Resident 68's 10/1/25 Montreal Cognitive Assessment revealed she/he had severe cognitive impairment. The facility's 10/21/25 Allegation of Sexual Inappropriate Behavior investigation revealed on 10/21/25 Staff 27 (CNA) heard Resident 48 call out. Staff 27 entered Resident 48's room and observed Resident 68 in her/his wheelchair. Resident 48 reported to Staff 27 Resident 68 touched her/his thigh inappropriately. Resident 68 denied the interaction. Resident 68 was removed from Resident 48's room and was placed on 1:1 supervision. On 2/23/26 at 10:05 AM Resident 48 stated Resident 68 came in her/his room and Resident 68 rubbed her/his hands on Resident 48's legs. Resident 48 stated it upset her/him for about a month but was now over it. On 2/24/26 at 1:46 PM Staff 3 (RNCM) stated prior to Resident 68 entering Resident 48's room, Resident 68 was usually at the nurse's station and not going into other resident rooms. On 2/24/26 at 6:15 PM and 2/26/26 at 3:31 PM telephone messages were left for Staff 27. A return call was not received. On 2/26/26 at 4:07 PM Staff 2 (DNS) stated Resident 68 touched Resident 48 in a nonconsensual manner.

Based on observation, interview, and record review it was determined the facility failed to ensure pressure ulcer care was provided to promote healing and physician orders were followed for 2 of 2 sampled residents (#s 11 and 48) reviewed for pressure ulcers. This placed residents at risk for delayed healing. Findings include: 1. Resident 11 was admitted to the facility in 10/2025 with a diagnosis of osteomyelitis (bone infection) and pressure ulcer. Resident 11's 2/3/26 Order Details revealed her/his ulcer was to be cleaned with wound cleanser, a full package, one gram of collagen powder was to be applied to the wound bed, a calcium alginate sheet was to be lighted packed, and then covered with a border dressing. On 2/25/26 at 10:56 AM Staff 4 (RNCM) was observed to perform pressure ulcer care to Resident 11's sacral pressure ulcer. The care included:-Wound cleanser was applied to clean gauze.-The ulcer periphery and wound bed was cleaned.-The ulcer was dried with clean gauze.-After gloves were removed, hand hygiene was performed, and new gloves were applied. -A collagen sheet was applied to the ulcer base.-Calcium alginate was placed on top of the collogen sheet.-A border dressing was applied to hold the calcium alginate and collagen in place. On 2/27/26 at 11:04 AM Staff 4 stated the facility had both powder and sheets of collagen. Staff 4 stated the powder was usually used for deeper wounds and the order should be clarified. Staff 4 acknowledged used the sheet and not the powder.On 2/26/26 at 3:59 PM Staff 2 (DNS) stated if orders needed to be changed, the physician was to be notified. 2. Resident 48 was admitted to the facility in 1/2025 with a diagnosis of pressure ulcer. Resident 48's Order Review History Report revealed coccyx (tailbone) wound care orders were last updated on 12/23/26. Resident 48's coccyx Weekly Skin Evaluations revealed the following wound status: -1/6/26 improved-1/13/26 improved-1/20/26 unchanged-1/27/26 unchanged-2/3/26 unchanged-2/10/26 unchanged-2/17-26 unchanged-2/24/26 unchanged On 2/25/26 at 3:25 PM Resident 48 declined to have wound care observed. On 2/26/26 at 1:14 PM Staff 3 (RNCM) stated pressure ulcers were monitored weekly. Standard of practice was to change treatment if the ulcer did not improve over a two-week period of time. On 2/26/26 at 1:50 PM Staff 10 (RN/Wound Nurse) stated Resident 48 was admitted to the facility in 2025 and her/his ulcer was larger. Staff 10 stated she called the physician for change in wound care if the ulcer worsened. Staff 10 stated the ulcer currently had a small opening but was two cm deep. On 2/26/26 at 4:07 PM Staff 2 (DNS) stated the last order change for Resident 48's coccyx ulcer was in 12/2025. Staff 2 stated if there was no change staff should ask for a physician to assess the wound and provide additional recommendations if needed.

Based on interview and record review it was determined the facility failed to perform pre and post dialysis assessments on 1 of 1 resident (#3) reviewed for dialysis. This placed residents at risk for inadequate monitoring. Findings include:The facility's Dialysis Policy from 3/2025 states the facility provides ongoing monitoring of the dialysis access site and utilizes a Dialysis Flow Sheet to document resident specific dialysis care including monitoring of the catheter and fistula.Resident 3 was admitted to the facility in 1/2026 with diagnoses including chronic kidney disease.Physician orders from 1/29/26 included Resident 3 had a fistula (a connection port used to access blood vessels during dialysis) in her/his chest and she/he was to receive dialysis services three times a week.A 2/9/26 admission MDS cognitive assessment determined Resident to have no cognitive limitations.Review of records from 1/2026 and 2/2026 revealed Resident 3 received dialysis treatment on 1/28/26, 2/9/26, and 2/18/26. No record was found of pre or post dialysis assessments being completed for Resident 3 on those dates.On 2/25/26 at 8:45 AM Resident 3 stated staff did not perform any formal checks after she/he returned from dialysis.On 2/25/26 at 11:02 AM Staff 20 (RN) stated when a resident received dialysis treatments, they were assessed and a pre and post dialysis form was completed. This form included full vitals, port site appearance inspection and review of any information provided by the dialysis center.On 2/25/26 at 3:41 PM Staff 3 (RNCM) confirmed pre and post dialysis assessments had not been performed on Resident 3. Staff 3 stated these forms included a guide of specific areas to be inspected and documented to ensure proper dialysis monitoring was performed on Resident 3 prior to and after she/he returned from a dialysis appointment.

Based on interview and record review it was determined the facility failed to ensure a resident or representative understood an arbitration agreement before signing for 2 of 3 sampled residents (#s 3 and 21). This placed residents at risk for inability to resolve concerns in court. Findings include: 1. Resident 3 was admitted to the facility in 1/2026 with a diagnosis of kidney disease. Resident 3's 1/29/26 State Arbitration Agreement form revealed on 1/29/26 she/he signed to accept the agreement. Resident 3's 2/3/26 admission MDS revealed she/he was cognitively intact. On 2/25/226 at 10:33 AM Resident 3 stated she/he was really sick when she/he admitted to the facility and did not recall all events. Resident 3 stated she/he did not know what an arbitration agreement entailed. Resident 3 stated if she/he knew the agreement meant she/he waived her/his right to file a lawsuit, she/he would not have signed the agreement. On 2/25/26 at 10:00 AM Staff 5 (Business Office Manager) stated she reviewed an arbitration agreement with a resident if she/he was cognitively intact and as soon after admission to the facility as possible. Staff 5 stated Resident 3 often stated she/he did not understand what she/he was told even after the information was reviewed with her/him. On 2/25/26 at 12:25 PM Staff 21(Regional Admissions Director) stated staff were to ensure residents were cognitively intact prior to signing an arbitration agreement and involve family when needed. Staff 21 also stated staff were to ensure residents understood what an arbitration agreement meant prior to signing. 2. Resident 21 was admitted to the facility in 1/24/26 with a diagnosis of heart failure. Resident 21's clinical record revealed Witness 1 (Family) was her/his emergency contact. Resident 21's 1/30/26 admission MDS revealed she he was moderately cognitively impaired. On 2/25/26 at 9:21 AM Resident 21 stated she/he did not sign admission paperwork, and Witness 1 may have signed an arbitration agreement. Resident 21 called Witness 1 (via phone) and Witness 1 stated the facility was notified Resident 21 was not to sign any papers without his knowledge. Witness 1 stated he did not know what an arbitration agreement meant and stated if it waived Resident 21's right to file a lawsuit, he would not have allowed Resident 21 to sign the agreement. On 2/25/26 at 10:00 AM and 2/25/26 at 12:25 PM Staff 5 (Business Office Manager) stated she reviewed the arbitration with a resident if she/he was cognitively intact and as soon as the resident was available after admission to the facility. Staff 5 stated Witness 1 did not want Resident 21 to sign any paperwork without him first reviewing the information. Staff 5 acknowledged Resident 21 signed the arbitration agreement on 1/26/26 and she/he had moderate cognitive impairment. On 2/25/26 at 12:25 PM Staff 21(Regional Admissions Director) stated staff were to ensure residents were cognitively intact prior to signing an arbitration agreement and involve family when needed. Staff 21 also stated staff were to ensure residents understood what an arbitration agreement meant prior to signing.

Based on interview and record review, it was determined that the facility failed to ensure care was provided in a manner that maintained resident dignity for 1 of 7 residents (#67) reviewed for abuse. This placed residents at risk for undignified care. Findings include:Resident 67 was admitted to the facility in 6/2024 with diagnoses including hemiplegia (loss of movement and/or sensation in half of the body), depression, and anxiety.An 8/14/25 Annual MDS assessment determined Resident 67 had normal cognitive function.An 8/6/25 facility investigation report included the following statements from Resident 39, Resident 67, Staff 12 (LPN), and Staff 22 (CNA):- Resident 39 was in a shared room with Resident 67 and witnessed the incident. Resident 39 stated Staff 22 entered and exited Resident 67's room loudly. When confronted about slamming the door, Staff 22 and Resident 67 raised their voices at each other to which Resident 67 became upset.- Resident 67 stated Staff 22 was moving quickly around Resident 67's room and slammed the door upon exit. Resident 67 asked Staff 22 why he slammed the door to which Staff 22 responded and asked, What are you going to do about it?- Staff 12 stated he observed Staff 22 and Resident 67 cursing at each other inside Resident 67's room as well as at the nurse's station when Resident 67 was filling out a grievance form.- Staff 22 stated Resident 67 was talking to Staff 22 with attitude and cursing at him regarding closing the door loudly. Staff 22 stated Resident 67 threatened to hit him to which Staff 22 asked Resident 67 what are you going to do? Resident 67 then stated she/he was going to file a complaint on Staff 22. Staff 22 responded by saying, do what you want. I don't even care. I'm not working with disrespectful residents like [her/him] no more.An 8/11/25 Incident Report concluded the incident between Resident 67 and Staff 22 was a verbal dispute provoked by both Resident 67 and Staff 22.On 2/24/26 at 12:09 PM Resident 67 stated Staff 22 was moving quickly and slamming doors on 8/4/25. Resident 67 stated he told Staff 22 to leave the room. Resident 67 stated Staff 22 said something like, what are you going to do about it. Resident 67 stated her/his [NAME] was hurt more than anything after how Staff 22 interacted with her/him.On 2/24/26 at 12:24 PM Resident 39 stated after Staff 22 had slammed the door, Resident 67 was upset. Resident 39 stated she/he recalled Staff 22 talking back to Resident 67 disrespectfully.On 2/24/26 at 12:37 PM Staff 12 (LPN) stated he witnessed the incident between Resident 67 and Staff 22. Staff 12 stated he overheard two people shouting at each other and he had to intervene. Staff 12 stated Staff 22 was very rude towards Resident 67 who was initially upset but did not appear bothered the following day.On 2/24/26 and 2/25/26 attempts to communicate with Staff 22 were made but were unsuccessful. On 2/27/26 at 11:21 AM Staff 5 (Business Office Manager/Human Resources) stated Resident 67 tended to be explosive and confrontational, but Staff 22 should not have matched Resident 67 behavior and treated Resident 67 disrespectfully. Staff 5 stated Staff 22's behavior was unprofessional.On 2/27/26 at 11:48 AM Staff 2 (DNS) confirmed the incident which occurred on 8/6/25 and Staff 22's behavior with slamming the door and yelling back at Resident 67 was unprofessional and undignified.

Based on interview and record review it was determined the facility failed to assist residents to formulate and obtain an advance directive for 2 of 3 sampled residents (#s 26 and 48) reviewed for advance directives. This placed residents at risk for healthcare decisions to conflict with resident wishes. Findings include: 1. Resident 26 was admitted to the facility in 1/2026 with diagnoses of esophageal obstruction (blockage of esophagus) and dysphagia (difficulty swallowing). A review of Resident 26's clinical record revealed no documentation of an advance directive and no evidence the resident was provided written information regarding the right to formulate one. On 2/26/26 at 8:30 AM, Resident 26 stated she/he had not completed an advance directive and had not been offered the opportunity to formulate one. On 2/26/26 at 1:44 PM, Staff 5 (Business Office Manager/Human Resources) stated residents without an advance directive were offered a blank advance directive during their initial care conference. Staff 5 confirmed Resident 26 had not been offered the opportunity to complete an advance directive. On 2/26/26 at 4:20 PM, Staff 1 (Administrator) stated it was the facility's responsibility to ensure residents were informed of their right to formulate an advance directive upon admission and the process should be completed in accordance with required guidelines. 2. Resident 48 was admitted to the facility in 1/2025 with a diagnosis of pressure ulcer. Resident 48's 1/13/26 Annual MDS revealed she/he was cognitively intact. Resident 48's Care Plan revealed she/he did not have an advance directive, and staff were to offer advance directive information at least quarterly. On 2/25/26 at 8:07 AM Resident 48 stated she/he had an advance directive. On 2/26/26 at 1:00 PM Staff 5 (Business Office Manager) stated Resident 48 had an advance directive, but her/his facility did not obtain a copy. On 2/26/26 at 4:20 PM, Staff 1 (Administrator) stated it was the facility's responsibility to ensure residents were informed of their right to formulate an advance directive upon admission and the process should be completed in accordance with required guidelines.

Based on observation, interview, and record review it was determined the facility failed to assess the use of a physical restraint for 1 of 2 sampled resident (#12) reviewed for positioning and mobility. This placed residents at risk for inappropriate use of a restraint. Findings include:Resident 12 was admitted to the facility in 1/2021 with diagnoses of stroke and dementia. A 1/14/26 Annual MDS assessment indicated Resident 12 had no physical restraints in place and was able to make herself/himself understood and was able to understand others. A 1/23/26 Morse Fall Scale assessment indicated Resident 12 had a history of falls and exhibited impaired balance while standing. The assessment identified Resident 12 as being at high risk for falls. A 1/28/26 Care Plan indicated Resident 12 had impaired mobility and was at high risk for falls. Planned interventions included placement of the bed against the wall, bed in low position, monitor for seizure activity, and placement of a mattress on the floor next to the bed while the resident was in bed. The Care Plan did not include the use of wedges intended to prevent the resident from exiting or falling out of bed. On 2/23/26 at 3:31 PM and on 2/25/26 at 8:56 AM Resident 12's room was observed with a sign posted above the bed which stated, Please ensure body pillow is in place before leaving room to protect the resident from falling out of bed. Two wedges (positioning cushions described by staff to prevent the resident from rolling or falling out of bed) were observed in her/his room propped up against a wall. Record review did not identify a physician order, documented assessment, evaluation for potential restraint use, informed consent, or care plan interventions addressing the use of wedges to prevent the resident from falling out of bed. On 2/25/26 at 10:13 AM, Staff 14 (CNA) stated it was not a body pillow that was used, it was wedges. Staff 14 stated the wedges were used to keep Resident 12 from falling out of bed and were used each time the resident was in bed. On 2/25/26 at 10:35 AM, Staff 18 (CNA) stated staff provided most cares for Resident 12 and confirmed it was not a body pillow used, but wedges. Staff 18 stated the wedges were used at night to prevent the resident from falling out of bed. On 2/25/26 at 3:23 PM, Staff 10 (RN) stated she was aware staff utilized wedges for Resident 12 while in bed to prevent her/him from rolling out. Staff 10 confirmed there was no physician order, no documented assessment, and no care plan intervention addressing the use of the wedges.On 2/25/26 at 4:03 PM, Staff 4 (RNCM) acknowledged Resident 12 utilized wedges rather than a body pillow and confirmed there was no documented assessment evaluating the devices for potential restraint use, no physician order, and no care plan interventions in place. On 2/25/26 at 4:43 PM, Staff 2 (DNS) acknowledged there was no physician order, no documented evaluation, no informed consent, and no care plan interventions related to the use of wedges. Staff 2 stated it was his expectation that positioning devices are not utilized without proper assessment, consent and care plan documentation.

Based on observation, interview, and record review it was determined the facility failed to obtain a baseline assessment for 1 of 5 sampled residents (#2) reviewed for unnecessary medications. This placed residents at risk for unidentified adverse medication side effects. Findings include: Resident 2 was admitted to the facility in 11/2025 with a diagnosis of dementia. Resident 2's admission orders included she/he was to be administered Risperdal (antipsychotic medication) and olanzapine (antipsychotic medication).Resident 2's clinical record revealed an AIMS (Abnormal Involuntary Movement Scale) was not completed until 2/18/26, three months after she/he was admitted to the facility and antipsychotic therapy was initiatedOn 2/24/26 at 12:38 PM Resident 2 was observed without abnormal involuntary movements. On 2/26/26 at 1:09 PM Staff 3 (RNCM) stated an AIMS was to be completed when a resident was first started on an antipsychotic medication and then every six months. Staff 3 acknowledged Resident 2's AIMS was not completed timely. On 2/26/26 at 3:56 PM Staff 2 (DNS) sated if a resident was administered an antipsychotic medication, the AIMS was to be completed when the medication was initiated in order to obtain a baseline assessment.

Based on interviews and record review it was determined the facility failed to report allegations of abuse within the mandated timeframe for 3 of 4 sampled residents (#s 6, 65 and 66) for 1 of 5 FRI reports reviewed for abuse. This placed residents at risk for further abuse. Findings include:The facility's revised 2022 Freedom from Abuse, Neglect, Corporal Punishment, Involuntary Seclusion, Mistreatment, Misappropriation of Resident Property and Exploitation revealed it was expected for the facility to immediately report all suspected and/or allegations of abuse in accordance with state and federal law. The policy defined immediately to mean as soon as possible but no later than two-hours after an allegation of abuse was made.On 9/26/25 at 11:09 AM, the state agency (SA) received a FRI for a 9/25/25 at 9:00 AM alleged abuse with Resident 6, Resident 65 and Resident 66.On 2/26/26 at12:28 PM Staff 2 (DNS) stated on 9/26/25 he completed the FRI and sent it to the SA and he was not aware of any other attempts to contact the SA within the required two-hour timeframe.On 2/26/26 at 12:41 PM, Staff 1 (Administrator) confirmed the 9/26/25 FRI for allegations of abuse was submitted to the SA late and he expected all allegations of abuse to be reported to the SA within the required two-hour reporting timeframe.

Based on interview and record review it was determined the facility failed to provide a bed hold policy for 1 of 1 sampled resident (#62) reviewed for hospitalization. This placed residents at risk for not being informed of their right to return to the facility. Findings include: Resident 62 was admitted to the facility in 1/2026 with a diagnosis of seizures. Resident 62's 1/26/26 Progress Note revealed she/he sat at the nurse's station, was observed to have tremors, and was unresponsive. Resident 62 was transported to the hospital for evaluation and treatment. Resident 62's clinical record did not have documentation to indicate a bed hold policy was provided to Resident 62 or her/his representative. On 2/27/26 at 11:11 AM Staff 3 (RNCM) stated Resident 62 was not stable when she/he was transported to the hospital. Staff 3 stated she did not notify Resident 62's representative of the bed hold policy. On 2/27/2026 at 11:53 AM Staff 1 (Administrator) stated the facility residents were not required to pay to hold their bed. All residents were allowed to return from a hospitalization, even without a bed hold notification.

Based on observation, interview, and record review it was determined the facility failed to ensure dependent residents received required assistance with ADL care for 2 of 2 sampled residents (#s 12 and 32) reviewed for ADL care. This placed residents at risk for lack of personal hygiene. Findings include:1. Resident 12 was admitted to the facility in 1/2021 with diagnoses of stroke and dementia.Resident 12's Annual MDS dated [DATE] indicated the resident was dependent on staff for personal hygiene and grooming.A review of Resident 12's care plan dated 1/19/26 revealed no interventions addressing facial hair removal or grooming preferences. Resident 12 was observed on 2/24/26 at 9:14 AM and on 2/25/26 at 8:55 AM with a significant amount of visible chin hair. On 2/24/26 at 9:16 AM, Resident 12 stated she/he did not want to have facial hair and would like staff to take care of her/his unwanted hair. On 2/25/26 at 10:13 AM, Staff 14 (CNA) observed Resident 12 's facial hair and stated her/his facial hair is really long. On 2/25/26 at 10:35 AM, Staff 18 (CNA) observed Resident 12's facial hair and stated her/his chin hair is long and needs to be shaved.On 2/25/26 at 3:09 PM, Staff 10 (RN) stated there were no care plan interventions addressing Resident 12's facial hair and acknowledged she had observed facial hair on Resident 12's chin. On 2/25/26 at 4:27 PM, Staff 2 (DNS) stated he was unaware Resident 12 had long chin hairs and acknowledged it was not proper ADL care. Staff 2 stated the expectation was for residents to be offered grooming on shower days and as needed. 2. Resident 32 was admitted to the facility in 12/2024 with diagnoses of fracture and legal blindness. Resident 32's annual MDS dated [DATE] indicated Resident 32 was dependent on staff for ADL care related to toileting and hygiene. A review of Resident 32's care plan dated 12/18/25 indicated she/he was dependent on staff for toileting and required assistance with toilet transfers, including setup and clean-up. A 9/2/25 Facility Reported Incident revealed morning staff found Resident 32 on 8/31/25 soiled with a bowel movement. The resident's brief and bed linens were saturated with fecal matter, and the floor surrounding the bed was also soiled.On 2/26/26 at 9:11 AM, Staff 12 (LPN) stated he worked the morning of 8/31/25 and observed Resident 32's bedding and the surrounding floor covered in feces. Staff 12 stated he had never observed Resident 32 in that condition before. On 2/26/26 at 9:27 AM, Staff 13 (Medical Records/CNA) stated on the morning of 8/31/25, she observed Resident 32 with feces present on the bed, floor, sleepwear, and on one of the resident's legs. Staff 13 stated it appeared the resident had been left soiled for an extended period of time. On 2/26/26 at 12:15 PM, Staff 15 (Former CNA) stated he worked the morning shift on 8/31/25. Staff 15 reported when he checked on Resident 32, the resident's bed and surrounding floor were soiled. Staff 15 stated the resident required a full bedding change and a head-to-toe shower. On 2/26/26 at 12:52 PM, Staff 2 (DNS) stated he was aware of the incident on the morning of 8/31/25. Staff 2 acknowledged Resident 32 was found in a soiled condition, with feces on the bed, floor, and on her/his sleepwear, as documented in the Facility Reported Incident. Staff 2 stated it was his expectation residents requiring ADL assistance, received care consistent with their individualized care plans. On 2/27/26 at 9:11 AM, Staff 19 (Former CNA) stated he worked the night shift beginning on 8/30/25. Staff 19 stated he was unaware Resident 32 was incontinent and required assistance with toileting. Staff 19 confirmed he did not provide incontinent care for Resident 32 during his shift or the morning of 8/31/25.

Based on interview and record review it was determined the facility failed to provide resident centered activities for 1 of 1 sampled resident (#7) reviewed for activities. This placed residents at risk for diminished psychosocial well-being and quality of life. Findings include: Resident 7 was admitted to the facility in 2019 with diagnoses including anxiety and dysphagia following cerebral infarction (difficulty swallowing following a stroke). The 9/25/25 Annual MDS revealed Resident 7 was cognitively impaired, speech was unclear and rarely understood and she/he was dependent on staff for all ADL and mobility needs. Resident 7 enjoyed watching television, to sit in the lobby, listen to music and individualized visits.Resident 7's 10/25/25 Activity Quarterly Progress Note Review revealed she/he enjoyed listening to music, to go outside for fresh air when the weather was good, to watch birds and staff fill the bird feeder outside her/his room window, make phone calls to family, sensory visits and one to one individualized visits. On 2/23/26 at 1:31 PM Resident 7 was observed to lie in bed with her/his body slightly tilted to the right. Residents 7's television was parallel to the wall, on her/his left side of the bed and playing a Western television program with no volume. Resident 7's room was observed with no music devices, no leisure opportunities or supplies, no family pictures or room decorations were visible.On 2/24/26 at 12:10 PM and 2:13 PM Resident 7 was observed in her/his bed with the room divider curtain pulled around the bed, the television was parallel to the wall and not visible from her/his bed and a Western television program was on but the resident was unable to hear the program. The resident's roommate had on a news program and the news program was heard in the room. No other leisure opportunities were visible.On 2/25/26 at 8:47 AM Staff 25 (CNA) stated she obtained the information to care for a resident from the Kardex (care plan for direct care). She stated Resident 7 did not get up and she/he only liked to watch television.On 2/25/26 at 12:37 PM Resident 7 was observed in bed with her/his room divider curtains slightly split a little. The television had a Western program on, three copied pictures were taped to the resident wall and the pictures were of different sceneries. No music was playing and the resident window blinds were closed.On 2/27/26 at 9:36 Staff 26 (CNA) stated she was aware of Resident 7's activity interest from the Kardex. Staff 26 stated the resident mostly liked to watch television. No other activities or leisure interests were shared.Resident 7's 2/27/26 Kardex revealed she/he preferred activities, enjoyed one-to-one visits, visits, art, music, animals, movies and the outdoors. Resident 7 enjoyed listening to music, go outside when weather is nice, bird watching out her/his window, to call her/his family and sensory visits.On 2/26/26 at 9:23 AM Resident 7 was observed sleeping in her/his bed with the room divider curtains drawn, window blinds were closed, no music opportunities and the television had a Western program playing.On 2/27/26 at 9:29 AM Resident 7 was asked if she/he liked Western television programs and the resident stated No. Resident 7 was asked if she/he was bored and the resident stated yes.On 2/27/26 at 9:45 AM Staff 23 (Activity Director) stated she documented Resident 7's activities on the Record of One-on-One Activities forms. Staff 23 stated she did not have a set schedule to provide one to one visits for Resident 7 but she did have two days a week she scheduled for herself to provide one to one visits to all residents in the facility. Staff 23 acknowledged Resident 7 did not like Western programs and she/he did not have any music or other leisure opportunities in her/his room. Staff 23 confirmed Resident 7 had not attended any group activities in over a year and Resident 7 was dependent on staff to assist with leisure opportunities.Record review of Resident 7's Record of One-on-One Activities documentation on 2/27/26 at 10:17 AM revealed the following activities for 1/2026 and 2/2026:-1/6/26, read her/him part of book;-1/8/26, read her/him part of book;-1/15/26, listened to music and watched birds;-1/20/26, read her/him part of book;-1/22/26 read her/him part of book;-2/5/26, read her/him part of book;-2/10/26, read her/him part of book;-2/12/26, bird watching;-2/17/26 listened to music;-2/19/26, read her/him part of book.On 2/27/26 at 11:24 AM Staff 1 (Administrator) expected Resident 7 to have more opportunities for individual activities designed to meet her/his interests and support her/his physical, mental and psychosocial well-being.

Based on observation, interview, and record review, it was determined that the facility failed to provide care in accordance with professional standards and failed to ensure care needs were met for 3 of 3 sampled residents (#s 1, 3 and 5) reviewed for call lights. This placed residents at risk for unmet care needs. Findings include: 1. Resident 5 was admitted to the facility in 2/2024 for diagnoses including congestive heart failure and surgical aftercare.Resident 5's care plan dated 2/26/24 indicated she/he needed moderate assistance with ADLs such as dressing, bathing, toileting hygiene and transfers.On 3/6/24 the State Survey Agency (SSA) received a complaint which stated Resident 5 had waited over 45 minutes the morning of 3/6/24 for help with personal care.On 7/9/25 at 11:21 AM Witness 1 (Complainant) stated when Resident 5 was at the facility, she/he would activate the call light and CNA staff would come in, turn off the call light and ask what she/he needed. Resident 5 made her/his specific request and was told the staff would get the nurse but nobody came. She/he would use the call light again, staff would come back, ask what she/he needed, would leave and the resident would wait even longer, up to one and a half hours.2. Resident 3 was admitted to the facility in 9/2024 with diagnoses including acute transverse myelitis (inflammation of the spinal cord, which causes nerve damage) and diabetes mellitus.Resident 3's care plan revealed she/he needed moderate assistance with ADLs such as dressing, bathing, and toileting hygiene.On 10/25/24, the SSA received a complaint which stated Resident 3's call light was not answered for over 20 minutes on 10/25/24, and CNA staff were never to be found when residents needed assistance.On 7/10/25 at 2:03 PM, Resident 3 stated call light response times varied anywhere from 15 minutes to over an hour and occurred on all shifts. Resident 3 recalled an incident last fall on NOC shift where a cognitively impaired resident came into her/his room and started going through her/his things. She/he stated nobody responded to the call light, so she/he had to start screaming to get a staff into her/his room. She/he stated long call light times had been an issue since she/he was admitted to the facility.3. Resident 1 was admitted to the facility in 3/2025 with diagnoses including hypertension and atrial fibrillation.Resident 1's care plan revealed she/he needed substantial assistance with ADLs such as dressing, bathing, toileting, hygiene and transfers.On 3/11/25, the SSA received a complaint which stated Resident 1's call light was not answered timely, and she/he had to wait over half an hour for assistance.On 7/10/25 at 9:00 AM, Witness 4 (Complainant) stated she was the resident's authorized representative. She stated Resident 1 frequently called her upset because she/he had activated the call light, needed help with incontinence care, and staff would turn her/his call light off and leave the room without assisting the resident. Witness 4 stated she spoke to the DNS about the issue and was told they would work on it.Resident 1's Nursing Note dated 3/12/25 at 2:48 PM noted Staff 2 (DNS) talked to the resident and the resident mentioned long call light response time, especially when she/he wanted to use the bathroom, and that she/he has not been cleared yet to ambulate to the bathroom by herself/himself. Call light response time was addressed with the staff.Review of Resident Council notes from 11/2024 to 5/2025 indicated the following call light concerns: -11/19/24: Call lights taking hours, frequently saying they will return and do not. Seeing staff on phones and not working.-12/18/24: NOC shift call lights.-1/22/25: NOC shift call lights. (Resident name) ostomy bag breaking, waiting 4+ hours on it being changed. Response to call lights are very long. CNAs on phones. CNA's passing off things to next shift and not addressing.-2/19/25: NOC shift nurses/CNAs not answering call lights. Aides on phone, not being responsive. Call light audits to be done.-3/20/25: Call light times.night staff absent. Showers/bed baths not being done.-4/16/25: Call light times NEED TO BE ADDRESSED. ‘I'll be right back' is trending.-5/21/25: Call light times still an issue.Interviews with residents revealed the following concerns:On 7/9/25 at 12:43 PM, Resident in room [ROOM NUMBER] stated she/he activated the call light over an hour ago, wanted something to eat, and had not had breakfast or lunch.On 7/10/24 at 12:24 PM, Resident in room [ROOM NUMBER] stated call lights were an ongoing issue. She/he verified the ostomy bag statement from the 1/2025 Resident Council meeting and stated it sometimes took hours for staff to respond to call lights, and it occurred on all shifts. The resident stated she/he had waited two hours for a response time in the past six weeks and stated staff know my situation (bed bound and has an ostomy bag); they should at least come down and tell me they're working on it. It has not improved at all. I shouldn't have to lie in poop for two hours.On 7/11/25 at 10:45 AM, the Resident Council President stated call light times had gotten worse, but had always been an issue at the facility.On 7/11/25 at 12:52 PM, Resident in room [ROOM NUMBER] stated call light times were over an hour. The resident stated she/he spilled a water bottle and got water all over the floor early this morning. She/he told staff about it, and they still haven't cleaned or mopped the floor. A pillow was observed on the floor with water stains on the pillow. The resident stated, I put that down there to soak up the water, and it's still there. On 7/10/25 at 1:33 PM, Staff 10 (CNA) stated it was an expectation that call lights be answered immediately.On 7/10/25 at 3:49 PM, Staff 11 (CNA) stated she was able to answer call lights timely, but if staff were giving residents showers or cares it could take longer. On 7/10/25 at 4:10 PM, Staff 12 (LPN) stated call light response times depended on whether other residents were receiving showers or other care. He also stated that response times took longer during meal tray pass. On 7/11/25 at 11:30 AM, Staff 2 (DNS) was informed of the findings of long call light wait times and provided no additional information.

Based on interview and record review, it was determined that the facility failed to implement care plan interventions for aspiration precautions for 1 of 3 sampled residents (#6) reviewed for respiratory services and aspiration precautions. This placed residents at risk for a lack of nutritional assistance and aspiration. Findings include: Resident 6 was admitted to the facility in 7/2025, with diagnoses including chronic respiratory failure and congestive heart failure.Resident 6's care plan dated 7/4/25 revealed she/he was on aspiration precautions and required one-to-one supervision for all meals.On 7/10/25 at 1:10 PM, Resident 6 was overheard calling out for staff in her/his room. Upon entering the resident's room, a meal tray with partially eaten food was observed on the resident's bedside table. No staff were observed present in the room with Resident 6. After the state surveyor exited the resident's room, Staff 6 (Speech Therapist) was observed to enter the resident's room and assist the resident to her/his care conference.On 7/10/25 at 1:40 PM, Staff 6 stated she was Resident 6's speech therapist. She confirmed the resident was supposed to be a one-to-one supervision while eating and stated she observed the meal tray in Resident 6's room with no staff present.On 7/10/25 at 1:48 PM, Staff 9 (CNA) stated he was Resident 6's assigned CNA. He was unaware of the resident's care plan interventions for supervised eating and stated he had not worked with the resident before that shift.On 7/11/25 at 11:18 AM, Staff 4 (RCM) confirmed Resident 6 was on aspiration precautions and required one-to-one supervision for all meals.

Based on observation, interview and record review it was determined the facility failed to ensure residents' change of condition was assessed timely for 2 of 2 residents (#s 8 and 22) reviewed for skin conditions. This failure resulted in Resident 8 experiencing untreated and significant pain, sustaining multiple fractures and receiving treatment at the hospital. Findings include: 1. Resident 8 was readmitted to the facility in 10/2018 with diagnoses including hemiplegia (a severe or complete loss of strength or paralysis on one side of the body) and hemiparesis (a mild or partial loss of strength on one side of the body) following a stroke. a. Resident 8's 1/7/24 Quarterly MDS Assessment revealed the resident was usually able to make her/himself understood and understand others, experienced upper and lower extremity impairment on one side of her/his body and required substantial-to-maximal assistance with transfers. A review of Resident 8's clinical record revealed the following: -On 2/25/24 at 6:59 AM a Progress Note written by Staff 34 (Former LPN) indicated the resident experienced increased pain to her/his right knee, the knee was painful to the touch and the resident refused to move it. Staff 34 contacted the resident's provider to request an order for PRN Tylenol (pain reliever used to treat minor aches and pains). The note indicated Staff 34 would pass this information on to the day shift nurse to follow up. -On 2/25/24 at 11:16 AM a Progress Note indicated an X-ray was to be completed stat due to symptoms and per the provider's verbal orders. -On 2/25/24 at 11:20 AM the resident received her/his first dose of PRN Tylenol for ankle pain rated as a four out of 10. -On 2/25/24 at 2:21 PM X-ray results were reported to the resident's provider which indicated the resident had fractures involving the distal fibula (the lower end of the fibula bone in the leg) and the medial malleolus (the bony prominence on the inner side of the ankle). -On 2/26/24 at 1:21 AM a Progress Note written by Staff 34 stated the resident possibly hit her/his right ankle and the facility was waiting for the provider to review the X-ray results. -On 2/26/24 at 3:09 PM a Progress Note written by Staff 35 (LPN) indicated a call was placed to the resident's provider as Staff 35 was concerned about the resident's right ankle and leg pain and noted the resident was unable to move her/his right leg. Non-emergency transportation was called as the resident agreed to go to the emergency department for evaluation. -On 2/26/24 at 3:20 PM the resident received PRN Tylenol for ankle pain rated as a nine out of 10. -On 2/26/24 at 3:42 PM a Progress Note indicated the resident was transported to the hospital. 2/26/24 to 2/27/24 Emergency Department Provider Notes indicated the resident experienced significant pain in the right ankle and her/his ankle required splinting (a medical procedure that involves immobilizing the ankle joint with a rigid device to treat injuries or other conditions) in the emergency department. A 3/1/24 Injury of Unknown Origin Investigation of Resident 8's distal fibula and medial melleolus fractures revealed the following: -On 2/25/24 the resident complained her/his right ankle hurt. -An unidentified nurse assessed the resident's ankle on 2/25/24 and noted it to be swollen and tender to the touch. -The resident confirmed her/his ankle was injured and indicated the injury occurred in the last couple days. -Immediate actions included: an X-ray was completed, the resident's provider was notified of the X-ray results, the resident was placed on alert charting and the facility waited for further orders from the provider. The investigation did not indicate any times for these action items. -The resident declined to go to the hospital at this time. The investigation did not indicate what time the resident was offered to go to the hospital, if the resident was informed she/he had fractured multiple bones or if the resident was re-offered the opportunity to go to the hospital. No evidence was found in Resident 8's clinical record to indicate any pain relief alternatives were offered or provided to the resident following the resident's first documented report of pain on 2/25/24 at 6:59 AM until she/he received Tylenol at 11:20 AM on 2/25/24 or any action was taken by the facility between 2/25/24 at 2:21 PM through 2/26/24 at 3:09 PM following the receipt of the X-ray that confirmed the resident experienced multiple fractures. On 10/23/24 at 2:53 PM Resident 8 was observed in her/his room in her/his wheelchair. Resident 8 was able to answer yes or no questions and confirmed she/he broke her/his ankle during a transfer from her/his wheelchair to bed when she/he was assisted by an unidentified staff person in 2/2024. Resident 8 further confirmed she/he experienced a great deal of pain during this time period, indicated she/he reported her/his pain to multiple staff and it took a long time until any one at the facility realized she/he was hurt. On 10/28/24 at 3:31 PM Staff 37 (CNA) stated she assisted Resident 8 with restorative exercises on Friday, 2/23/24, and at this time, the resident was great. Staff 37 stated she worked as a CNA on Saturday, 2/24/24, and recalled Resident 8 did not get out of bed for either breakfast or lunch on this day, which was unusual for the resident as she/he was usually always up and in her/his wheelchair by 5:00 AM. Staff 37 stated she asked Staff 5 (CNA), the resident's assigned day shift CNA on 2/24/24, about Resident 8 and was told the resident did not feel well. On 10/28/24 at 3:51 PM Staff 5 stated she recalled Resident 8 was totally fine on 2/23/24. Staff 5 stated she was the resident's assigned day shift CNA on 2/24/24, and when she started her shift, the resident complained her/his foot hurt and she/he would not let me do anything with [her/his] leg. Staff 5 stated the resident would yell no, no, no any time she tried to touch her/his leg know and she let the nurse know immediately. Staff 5 stated Resident 8 was normally a a very active resident and on 2/24/24 she/he refused to be touched or do anything. Staff 5 stated she reported this change of condition to multiple nurses on 2/24/24 many, many times. On 10/29/24 at 10:08 AM Staff 35 (LPN) stated she worked evening shift on 2/25/24. Staff 35 stated she asked CNAs how long Resident 8 had been in pain and nobody gave me answers. Staff 35 stated she had worked with Resident 8 for years and knew she/he was not her/himself and she/he just seemed like she/he was in pain. Staff 35 stated she was not told much about what happened and she did not know when Resident 8's injury occurred. Staff 35 stated she recalled asking the resident if she/he wanted to go to the emergency room to which she/he was agreeable. On 10/29/24 at 11:00 AM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged the findings and confirmed Resident 8's change of condition was not addressed timely. b. Resident 8's 8/11/23 Care Plan revealed the following: -Staff were to ask the resident yes or no questions in order to determine her/his needs. -The resident required extensive assistance from one staff with dressing and personal hygiene and extensive assistance from one-to-two staff with showers. -CNAs were to monitor for changes in skin integrity during dressing, personal care and showers and alert the licensed nurse immediately of any changes. An 8/14/23 Progress Note revealed the following: -Staff 36 (CNA) reported to the nurse Resident 8's right fifth toe was black. -The nurse assessed Resident 8's fifth toe and noted the black area covered the entire bottom of her/his toe and the wound measured approximately 1.5 cm long and 1 cm wide. -Staff 36 observed a red blister on Resident 8's fifth toe last week and didn't tell anyone then. -Staff 36 was educated on the importance of reporting abnormal skin impairments right away. An 8/14/23 Incident and Investigation determined the facility failed to ensure identification of a skin issue and provide needed care and services in a timely manner. On 10/23/24 at 2:50 PM Resident 8 was observed in her/his room and sat in her/his wheelchair. The resident was able to indicate through yes or no questions her/his toe was black months ago but was unable to provide any additional details about this skin impairment. On 10/28/24 at 7:43 AM Staff 36 stated she recalled she assisted Resident 8 with range of motion in 2/2024 when she noticed the resident's right fifth toe was a different color. Staff 36 stated the toe really looked different and was black the second time she observed it a few days later. Staff 36 stated she thought she informed a nurse of the resident's toe discoloration after her initial observation but could not recall for sure but stated she did report it to Staff 18 (Former DNS) after her second observation. On 10/29/24 at 11:00 AM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged the findings and did not provide any additional information. 2. Resident 22 was admitted to the facility in 11/2022 with diagnoses including stroke. Resident 22's 9/2024 and 10/2024 Physician's Orders revealed the following: -All wounds must be evaluated by the physician or NP at first opportunity. -The resident was to receive a weekly skin evaluation and each skin impairment was to be evaluated. Resident 22's 9/24/24 Weekly Skin Evaluation identified the resident to have self-inflicted scratches and dry scabs all over her/his bilateral upper extremities. The evaluation did not indicate if the resident's physician or NP was notified of the wounds or if a treatment was to be implemented. Resident 22's Weekly Skin Evaluations from 9/30/24 through 10/22/24 made no mention of the resident's bilateral upper extremity wounds, including any measurements, number of wounds or whether or not they had improved, worsened or stayed the same. Resident 22's 10/3/24 Potential/Actual Impairment to Skin Integrity Care Plan indicated weekly treatment documentation of skin breakdown was to include the width, length and depth of the skin impairment as well as any other notable changes or observations. Resident 22's 10/10/24 Annual MDS Assessment revealed the resident was able to make her/himself understood and understood others without difficulty and received application of nonsurgical dressings and ointments/medications other than to her/his feet. The CAAs revealed the resident recently had open skin on her/his left shin area which was partially due to her/his scratching, a wound culture was completed that indicated the wound was positive for Methicillin-resistant Staphylococcus aureus (MRSA, a type of bacteria that is resistant to certain antibiotics and an infection that can be serious and difficult to treat, especially if left untreated), the resident was treated with antibiotics and she/he refused several doses. On 10/23/24 at 11:33 AM Resident 22 was observed in her/his room in bed. The resident's arms were observed to have numerous scattered scabs, some of which were opened and revealed streaks of blood. Resident 22 stated she/he was recently treated with antibiotics for a staph infection related to the wounds on her/his legs. Resident 22 stated the scabs on her/his arms had been there for weeks, the scabbing on her/his arms looked like the wounds on her/his legs, her/his arms itched regularly and the facility was not doing anything to treat the scabs on her/his arms. On 10/24/24 at 12:28 PM Witness 8 (Family Member) stated he discussed Resident 22's leg and arm wounds with Staff 4 (LPN Resident Care Manager) in 9/2024 but thought only the leg wounds were addressed. Witness 8 wondered if the continued itching and scabbing of the resident's arms was a result of an allergic reaction but never got a resolution. On 10/25/24 at 10:11 AM Staff 5 (CNA) stated the scabs on Resident 22's arms had been there for at least a month and the resident complained about and scratched them. Staff 5 stated she reported these scabs to the nurse and was not sure if anything was done. On 10/25/24 at 10:34 AM Staff 23 (CNA) stated she noticed the resident's arms were scratched up really bad about a week or two ago and stated she reported this to the nurse. On 10/25/24 at 11:07 AM Staff 31 (LPN) observed Resident 22's arms and confirmed the resident had scattered scabbing throughout her/his bilateral upper extremities. Staff 31 stated the resident did not have these scabs the last time she worked with the resident last month and the scabbing had not been reported to her. Staff 31 stated a resident's physician or NP was to be notified in the case of any new skin issue in order to obtain a treatment. Staff 31 reviewed the resident's electronic record and stated it did not look like the doctor had been notified of the resident's arm wounds. On 10/25/24 at 2:52 PM Staff 4 observed Resident 22's arms. Staff 4 stated she was not aware of the resident's arm wounds and neither was the resident's physician. On 10/25/24 at 3:28 PM Staff 33 (NP) stated she was not aware of any new skin issues for Resident 22, including any wounds or scabs on her/his arms. On 10/25/24 at 3:42 PM Staff 2 (DNS) confirmed the wounds on Resident 22's arms had not been reported to the resident's physician or NP and were not being monitored or treated and should have been.

Based on observation, interview and record review it was determined the facility failed to assess for care plan effectiveness, identify and implement new fall interventions or provide adequate supervision needed to prevent falls for 3 of 3 sampled residents (#s 40, 48 and 108) reviewed for falls. This failure resulted in Resident 108's hospitalization and placed residents at risk for falls and injury. Findings include: 1. Resident 108 was admitted to the facility in 9/2023 with diagnoses including cancer, severe protein-calorie malnutrition, abnormal weight loss, chronic fatigue, and weakness. Resident 108's 9/9/23 Admission MDS indicated she/he was cognitively intact and while she/he moved about her/his room and facility, she/he required supervision with the assistance of one other person. The MDS indicated Resident 108 experienced falls prior to admission to the facility. Review of Resident 108's 9/2/23 care plan indicated she/he was a high risk for falls. The care plan directed staff to provide a safe environment free from clutter or spills, adequate and glare-free light, a reachable call light which worked, encouragement to participate in activities, physical therapy, and have her/his bed in a low position. The 9/2/23 Visual Bedside Individual Service Plan (bedside care plan) indicated Resident 108 was independent with ambulation, used a wheelchair and mobility was with a wheelchair which required one person to assist with mobility. A 10/4/23 at 1:25 PM Progress Note revealed Resident 108 walked independently in the hallway and fell face-forward. The resident was transported to the hospital. A 10/4/23 at 8:59 PM Progress Note revealed Resident 108 returned from the hospital with a fractured orbital wall (break in one or more of the eye socket bones), which was swollen, bruised with a small laceration (cut). Review of Resident 108's 10/4/23 fall investigation provided was not a thorough investigation or assessment of the fall. The investigation was not completed until 10/13/23 (three days after discharge). No fall care plan revisions were found as completed or implemented. A 10/5/23 at 8:57 PM Progress Note revealed Resident 108 tripped and fell walking in the hallway. The resident acquired 1 cm bilateral scrapes on both knees. Review of Resident 108's 10/5/23 fall investigation provided was not a thorough investigation or assessment of the fall. The investigation was not completed until 10/15/23 (five days after discharge). No fall care plan revisions were found as completed or implemented. Review of a 10/6/23 fall investigation revealed Resident 108 fell in her/his room and was found on the floor. The resident believed the wheelchair brakes did not work and the facility found one of the brakes was loose and the facility repaired the wheelchair brake. No evidence of the 10/6/23 fall was found in the resident's electronic health record, progress notes or alert charting, no revision of care plan interventions, the investigation was not a thorough investigation or assessment of the fall. The investigation was completed 10/15/23 (five days after discharge). A 10/10/23 at 3:02 AM Progress Note revealed Resident 108 was found on the floor next to her/his bed face-forward and bled from her/his nose and mouth. Resident 108 was sent to the hospital. On 10/11/23 at 12:59 AM Staff 4 (LPN) received a phone call from the hospital to inform the facility Resident 108 passed away in the hospital. No evidence was found to reflect Resident 108's care plan interventions were revised prior to her/his discharge. The fall investigations were not timely, did not identify all known, foreseeable and unforeseeable accident hazards in her/his environment. No evidence was found of a plan for attempts to reduce fall risks or identify possible assistance to prevent an avoidable accident. On 10/29/24 at 9:51 AM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged the lack of care plan revisions for Resident 108's falls. Staff 1 and Staff 2 acknowledged the fall investigations were not comprehensive and were completed after the resident's discharge to the hospital. Staff 1 and Staff 2 would expect thorough fall investigations and care plan revisions for falls to be completed and implemented timely. No additional information was provided. 41458 2. Resident 40 was readmitted to the facility in 5/2024 with diabetes, pneumonia and metabolic encephalopathy (brain dysfunction caused by an underlying illness or organs not working well). From 5/30/24 through 10/16/24, 10 fall risk assessments were completed. Resident 40 was identified to be at high risk for falling on all assessments. Resident 40's 5/30/24 Fall Care Plan, with revisions on 6/10/24, 9/17/24, 9/30/24, 10/14/24, 10/22/24 and 10/23/24, indicated the resident was a high fall risk due to gait/balance problems and impaired cognition. The following fall precautions were in place: -Anticipate and meet the resident's needs. Initiated 5/30/24. -Be sure the resident's call light was within reach and encourage the resident to use it for assistance. Initiated 5/30/24. Revised 9/30/24. -Ensure the resident was wearing appropriate footwear such as rubber soled shoes or non-skid socks when ambulating or mobilizing in her/his wheelchair. Initiated 5/30/24. Revised 6/10/24. -Follow facility fall protocol. Initiated 5/30/24. -PT evaluation and treatment as ordered or PRN. Initiated 5/30/24. -Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter or remove any potential causes, if possible. Provide education to the resident/family/caregivers/IDT (interdisciplinary team) as to causes. Initiated 5/30/24. -The resident needed a safe environment with even floors free from spills and/or clutter, adequate glare free light, a working and reachable call light and personal items within reach. Initiated 5/30/24. Revised 6/10/24. -For no apparent acute injury, determine and address causative factors of the fall. Initiated 9/17/24. -Provide one-to-one activities that promote exercise and strength building where possible. Provide one-to-one activities if bed bound. Initiated 9/17/24. -PT consultation for strength and mobility. Initiated 9/17/24. -The resident had frequent falls due to self-transferring. Initiated 9/30/24. -Place a full sized mattress on the floor by Resident 40's bed when she/he was in bed. The bed was to be in the lowest position. Initiated 10/14/24. Revised 10/23/24. -Keep Resident 40's wheelchair out of her/his view. Initiated 10/14/24. -Enhanced activities for fall prevention. Initiated 10/22/24. Resident 40's 8/4/24 Significant Change MDS indicated Resident 40 had moderately impaired cognition and the resident required substantial to maximal assistance for bed mobility and standing. Resident 40's 10/10/24 Discharge with Return Anticipated MDS indicated Resident 40 had short term memory deficits, severe impairment making decisions regarding tasks of daily life and required substantial to maximal assistance for bed mobility and partial to moderate assistance for standing. From 7/12/24 through 10/16/24, Resident 40 sustained 12 non-injury falls in the facility. Fall investigations revealed the following: -7/12/24 at 4:50 AM: Resident 40's fall investigation revealed Resident 40 was found kneeling on the floor in front of her/his bed. The report indicated Resident 40 tried to pick something up off the floor. According to the report, at the time of the fall, the resident required one person assistance for standing, had a fall mat, high/low bed and the bed was against the wall. The resident was reminded that staff needed to pick up items if she/he dropped them. No new fall care plan interventions were put into place. -9/17/24 at 4:00 AM: Resident 40's fall investigation revealed Resident 40 was found on the floor in her/his room, next to her/his bed. The resident's bed was in the lowest position, she/he had on non-skid socks and the call light was by the resident but not activated. The resident was educated regarding the importance of using the call light. -9/26/24 at 7:00 AM: Resident 40's fall investigation revealed the resident was found sitting on the floor in her/his room leaning on the right side of her/his bed. Resident 40 was alert with confusion and exhibited impulsivity with poor safety judgement. No new fall care plan interventions were put into place. -9/26/24 at 9:55 PM: Resident 40's fall investigation revealed the resident was found on the floor in her/his room on the right side of her/his bed. The resident was wearing non-skid socks. No new fall care plan interventions were put into place. -9/29/24 at 12:40 PM: Resident 40's fall investigation revealed the resident was found on her/his floor. The resident's bed was in the lowest position and the resident was wearing non-skid socks. Resident 40 tried to transfer herself/himself to the wheelchair. Resident 40's call light was within reach and the area was free from clutter. The resident was very confused. No new fall care plan interventions were put into place. -10/5/24 at 7:35 AM: Resident 40's fall investigation revealed the resident was found down on her/his room floor. The resident was wearing non-skid socks and the lights were on in her/his room. The resident had impaired memory, gait and balance. Resident 40 had a history of self-transferring. No new fall care plan interventions were put into place. -10/7/24 at 8:30 PM. Resident 40's fall investigation revealed the resident was found on the floor in her/his room very close to the bed. The resident's bed was in the lowest position and she/her wore non-skid socks. The resident had impaired memory and a history of self-transferring. No new fall care plan interventions were put into place. -10/10/24 at 7:00 AM: Resident 40's fall investigation revealed the resident was found on the floor in her/his room leaning against the bed. The resident had on non-skid socks and the lights were on in her/his room. The call light was within reach and the area was free of clutter. Resident 40 had a history of self-transferring and impaired gait/balance. No new fall care plan interventions were put into place. -10/14/24 at 11:00 AM: Resident 40's fall investigation revealed the resident was found on the floor in her/his room by the bed after attempting to self-transfer. Resident had on non-skid socks and the floor was dry. A new intervention was identified to have Resident 40's wheelchair put away and out-of-sight to prevent the resident from self-transferring. -10/14/24 at 2:48 PM: Resident 40's fall investigation revealed the resident was found on the floor in her/his room. The resident wore non-skid socks, the fall mat was in place, the resident's bed was in the lowest position and the call light was within reach and not activated. Resident 40 indicated via pointing that she/he was attempting to reach her/his wheelchair. A new intervention was care planned to have a full sized mattress next to Resident 40's bed while she/he was in bed. Resident 40's care plan was not followed as her/his wheelchair was supposed to be put away and out-of-sight to prevent the resident from self-transferring. -10/14/24 at 11:26 PM: Resident 40's fall investigation revealed the resident was found sitting on the floor mat by her/his bed. The resident had on non-skid socks, the room was free of clutter and Resident 40's call light was within reach. A new intervention was care planned for Activities to develop a structured activities plan for the resident. -10/16/24 at 12:05 PM: Resident 40's fall investigation revealed the resident was found on the floor in her/his room, attempting to get to her/his wheelchair which was located on the other side of the room. The resident had multiple falls due to attempts to self-transfer in her/his room. Resident 40's care plan was not followed as her/his wheelchair was supposed to be put away and out-of-sight to prevent the resident from self-transferring. No new fall care plan interventions were put into place. Random observations from 10/23/24 through 10/29/24 between the hours of 7:30 AM and 3:30 PM revealed the following concerns: -Resident 40 was in her/his wheelchair in her/his room being interviewed by the State surveyor and attempted to get up from the wheelchair without assistance. -Resident 40 was observed multiple times resting in her/his bed, at times appearing to be asleep and other times awake, with the curtains drawn which resulted in staff being unable to visualize the resident from the hallway. -On two separate observations, Resident 40 was observed in her/his bed with her/his wheelchair parked next to the end of the bed, visible to the resident. -Resident 40 was not observed engaged in one-to-one or group activities during any observations. On 10/25/24 at 9:30 AM Staff 22 (CNA) stated Resident 40 fell a lot so he tried to keep the resident up. He stated if the resident was in bed then he put the full sized mattress next to the bed. Staff 22 stated he did not see Resident 22 engaged in group or one-to-one activities. On 10/25/24 at 9:41 AM and 10:44 AM Staff 5 (CNA) reported Resident 40 liked to have meals in the dining room and then get back into bed. Staff 5 stated Resident 40 had many falls and her/his fall precautions included having a full sized mattress at the resident's bedside and ensuring the resident's bed was in the lowest position. At 10:44 AM, Staff 5 entered Resident 40's room and the resident was sitting on the edge of the bed with her/his wheelchair parked at the end of the bed, in full view. Staff 5 acknowledged that Resident 40's wheelchair was supposed to be put away, out-of-sight. On 10/25/24 at 10:13 AM Staff 23 (CNA) stated Resident 40's falls always occurred in her/his room. Staff 23 stated she had not seen any one-to-one activities occurring with Resident 40 and thought the resident liked activities such as playing volleyball and painting. Staff 23 stated the resident was supposed to have a fall mat at the bedside and the wheelchair should be out-of-sight but sometimes co-workers aren't doing things right which resulted in Resident 40 falling. Staff 23 stated Resident 40 did not use the call light to summon assistance. On 10/28/24 at 8:05 AM Staff 25 (RN) stated Resident 40 was at risk for falling and had many falls because the resident attempted to get to her/his wheelchair and fell . Staff 25 stated Resident 40's wheelchair was supposed to be put away and out-of sight. Staff 25 entered Resident 40's room and confirmed the resident's wheelchair was parked at the end of the resident's bed, in full view, and the wheelchair was not supposed to be in her/his sight. On 10/28/24 at 9:31 AM Staff 14 (Activities Director) stated Resident 40 rarely went to group activities and doing one-to-one activities with the resident was not a frequent thing. On 10/28/24 at 10:40 AM Staff 4 (LPN Care Manager) stated Resident 40 was a frequent faller and will try to stand-up and go right down. Staff 4 stated Resident 40 was supposed to be engaged in group or one-to-one activities and have her/his wheelchair out-of-sight. Staff 4 stated Resident 40 did not use her/his call light. Staff 4 reviewed Resident 40's falls and acknowledged staff did not consistently follow the resident's care plan including providing group and one-to-one activities and ensuring the resident's wheelchair was out-of-sight when she/he was in bed. Staff 4 confirmed there were multiple falls where no new fall care plan interventions were identified or implemented. Staff 4 stated she expected other care plan interventions to be attempted and put into place. On 10/28/24 at 2:34 PM Staff 1 (Administrator) stated he was aware Resident 40 experienced frequent falls. Staff 1 stated they needed to do more root cause analysis regarding the resident's falls and look into what else we can do to prevent the falls. Refer to F679. 47000 3. Resident 48 was admitted to the facility in 5/2024 with diagnoses including traumatic subdural hemorrhage (condition that occurs when blood pools between the skull and the brain after a head injury). Resident 48's 9/24/24 Significant Change in Status MDS Assessment revealed the resident was cognitively intact and had not experienced any falls since her/his prior assessment. Resident 48's 10/18/24 Fall Investigation revealed the resident experienced a non-injury fall out of bed on 10/18/24. The investigation concluded a perimeter mattress (a mattress with raised edges used to help prevent residents from rolling out of bed) to define bed perimeter would be implemented to reduce the risk of the resident rolling out of bed. Resident 48's 10/21/24 At Risk for Falls Care Plan indicated the following: -The resident was considered a high risk to fall related to a history of falls. -The resident's bed was to be kept at an appropriate height. -A perimeter mattress was to be placed on the resident's bed when it became available. Random observations of Resident 48 from 10/23/24 at 12:35 PM through 10/25/24 at 9:26 AM revealed the resident to be in her/his room in bed. The resident laid on a regular mattress and her/his bed was at approximately waist height and no fall mats were observed on the ground. The resident was unable to answer any questions about her/his care. On 10/25/24 at 10:05 AM Staff 5 (CNA) stated she was unsure if Resident 48 was considered at risk to fall or if the resident had experienced any recent falls. On 10/25/24 at 10:34 AM Staff 23 (CNA) stated she thought Resident 48 was considered at risk to fall but was not aware of any recent falls or interventions. On 10/28/24 at 11:48 AM Staff 4 (LPN Care Manger) stated Resident 48 fell out of bed on 10/18/24, following which she ordered a perimeter mattress for the resident's bed to help with safety. Staff 4 stated staff were supposed to use wedges to help keep the resident safe until the perimeter mattress arrived at the facility but she did not care plan the use of wedges. On 10/28/24 at 12:14 PM Staff 2 (DNS) stated the facility's interdisciplinary team determined a perimeter mattress was the best intervention to implement following the resident's fall on 10/18/24. Staff 2 stated the resident's bed was to be kept in a low position when occupied with a fall mat in place until the perimeter mattress was put in place. Staff 2 confirmed these temporary safety interventions should have been care planned and were not.

1. Based on interview and record review it was determined the facility failed to ensure a resident had a care plan developed to ensure adequate supervision was in place to prevent elopement for 1 of 3 sampled residents (#2) reviewed for elopement. Resident 2 exited the building, fell and sustained a fracture. Findings include: Resident 2 was admitted to the facility in 2016 with [DIAGNOSES REDACTED]. The facility Elopement/Wandering policy updated on 7/2014 indicated Based on the results of the Elopement/Exit-Seeking Evaluation, care plan interventions to manage wandering and/or exit seeking behaviors are initiated/implemented. The care plan addresses the resident's wandering behavior, potential to exit Center and/or episodes of elopement and the measures taken to manage those behaviors. The 9/22/16 hospital Discharge Orders did not include Resident 2 was at risk for elopement. The 9/22/16 Nursing Admission Evaluation indicated Resident 1 was confused. The form indicated the resident did not verbalize the intent or desire to leave the facility. The 9/23/16 Elopement/Exit Seeking Evaluation by Staff 7 (RNCM) indicated Resident 2 was at risk to elope. The resident was cognitively impaired, had a lack of safety awareness and received medication that could increase agitation. On 8/1/17 via email a Care Plan was provided by Staff 1 (DNS) to indicate a Care Plan was initiated on 9/22/16 and identified Resident 2 as an elopement risk. Interventions included to see bedside care plan. On 8/3/17 at 10:38 am Staff 7 (RNCM) indicated after a resident was admitted to the facility the initial Nursing Admission Evaluation form initially addressed if the resident was at risk for elopement. The information could be obtained from medical records or family members. If the resident was at risk to elope or had a desire to leave the facility a care plan was developed to alert staff to be aware of the risk. Staff 7 indicated in addition to the Nursing Admission Evaluation an Elopement Assessment was completed to determine if the resident was at risk for elopement. Staff 7 acknowledged she completed the Elopement Evaluation on 9/23/16 and identified Resident 2 to be at risk for elopement. The Care Directive form (initial bedside care plan with resident specific interventions) initiated on 9/22/16 by Staff 7 and updated one day after the resident eloped on 9/26/16 by Staff 1 (DNS) indicated Resident 2 was a high elopement risk and staff were to redirect the resident from exits and assist to activities and provide socialization. On 8/4/17 at 11:00 am Staff 7 (RNCM) indicated she initiated the Care Directive on 9/22/16 upon Resident 2's admission to the facility. Staff 7 indicated she did not initially document on the Care Directive to identify Resident 2 was an elopement risk. Staff 7 indicated Staff 1 updated the care plan on 9/26/16 after Resident 2 eloped. The interventions on the form were specific interventions including to re-direct the resident from exits. The 9/23/16 evening shift Interdisciplinary Progress Note indicated the resident was alert and up and moving around, the resident was confused but stayed safe. The 9/25/16 day shift Interdisciplinary Progress Note indicated the resident was outside and yelled for help. Resident 1 was found on the ground with the wheelchair off to the side. The resident had an abrasion to the right elbow. The 9/25/16 evening shift note indicated the resident continued to have pain and was sent to the hospital for evaluation. The resident was diagnosed with [REDACTED]. The resident was placed in an arm sling until the resident was able to follow up with the orthopedic physician. The Elopement Occurrence report indicated on 9/25/16 Staff 11 (CNA) saw Resident 2 in the lobby at 11:20 am. Resident 2 was found outside at 11:30 am. The report indicated Staff 13 (LPN) found the resident outside on the ground. On 8/4/17 at 9:40 am Staff 11 indicated after he was informed Resident 2 was outside on the ground he asked another CNA to assist him with Resident 2. Resident 2 reported she/he wanted fresh air. The resident was not able to tell staff how she/he left the building and which exit was used. Staff 11 acknowledged the Elopement Occurrence report indicated Staff 11 saw Resident 2 in the lobby 10 minutes before the resident was found outside. Staff 11 indicated he did not remember if the resident was in the lobby. Staff 11 indicated the lobby area was a busy area and staff were usually present. Staff 11 indicated if a resident at risk for elopement and was by the lobby he would alert other staff. Staff 11 did not recall if he did or did not alert staff. Staff 11 also indicated he was not sure if Resident 2 was in the Elopement book but knew Resident 2 was at risk to elope because the resident always tried to do tasks independently and staff had to intervene. On 8/2/17 at 8:46 am Staff 10 (CNA assigned to Resident 2 on 9/25/16) indicated she did not remember what was on Resident 2's in-room care plan. Staff 10 indicated when Resident 2 was first admitted to the facility the resident required extensive assistance for mobility. If the resident wanted to go somewhere staff assisted the resident in the wheelchair. Staff 10 indicated if a resident was at risk for elopement the resident was identified in a book located in the charting room. Staff 10 also indicated if a resident was at risk to elope the information was also located on the in-room care plan. If a resident was at risk to elope the resident was not to be near the front door lobby area. If the resident was by the lobby the staff were to escort the resident to another area of the facility to ensure the resident did not leave the building and to ensure family or other residents did not let the resident out the front door. On 8/4/17 Staff 13 indicated she did not recall the specific events regarding the elopement of Resident 2. Staff 13 indicated if a resident was identified to be at risk for elopement staff were to redirect the resident from the lobby to an area supervised by staff. The 9/25/16 Interdisciplinary Progress Note indicated Resident 2 fell in the morning and had severe back pain. The resident verbalized to staff that her/his pain was becoming unbearable. The resident's physician was called and the resident was sent to the hospital emergency department for evaluation. The hospital performed an x-ray and the resident had a fractured shoulder. 2. Based on observation, interview and record review it was determined the facility failed to ensure fall preventions interventions were implemented for 1 of 3 sampled residents (#8) reviewed for falls. This placed residents at risk for injury. Findings include: Resident 8 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. The 7/7/17 Fall assessment indicated Resident 8 was a high risk for falls. 7/7/17 ADL Plan of Care indicated the resident was at risk for falls. interventions to prevent falls included Resident 1's wheelchair was to be kept out of the resident's sight when she/he was in bed. Observation on 7/19/17 at 10:40 am Resident 8 was observed in bed. The resident's left side of the bed was against the wall. The resident's wheel chair was approximately 10 feet from the head of the bed. The wheel chair was within line of sight of Resident 8. On 7/19/17 at 10:50 am Staff 1 (DNS) acknowledged the wheelchair was within sight of Resident 8 and should not be within sight.