Every finding on record at Rivers Edge Rehabilitation and Care

Based on observation, interview, and record review it was determined the facility failed to provide a clean and well-maintained homelike environment for 3 of 7 sampled residents (#s 5, 27, and 28) and 2 of 5 resident hallways reviewed for environment. This placed residents at risk for lack of a homelike environment. Findings include: 1. Resident 28 was admitted to the facility in 11/2025. On 6/1/26 at 12:10 PM, Witness 2 (Family Member) stated she/he was dissatisfied with the cleanliness and condition of Resident 28's room: the blinds were broken, there was a hole in the window frame leading directly to the outside, the floor was frequently dirty, and the resident's fall mat was dirty and sticky. Witness 2 stated the broken blinds and window frame hole were both present when the resident moved into the room, and she/he had spoken to the previous maintenance director about the need for repair. Resident 28's room was observed to have accumulated dirt and dust on the floor, particularly around the furniture and under the window. The window blinds were coated with dust and five of the slats were broken. There was a hole in the bottom left corner of the window frame that led directly to the outside, big enough for a fingertip to poke through. Resident 28's fall mat was soiled with large brown stains and sticky spots. On 6/2/26 at 3:54 PM Staff 12 (Housekeeping Manager) acknowledged Resident 28's room and fall mat were dirty and needed to be cleaned. Staff 12 stated the blinds were difficult to clean since they were broken. On 6/4/26 at 8:55 AM Staff 8 (Maintenance Director) stated he was aware of the broken blinds, but not the window frame hole in Resident 28's room. Staff 8 stated repairs such as broken blinds and a hole in the window frame required immediate repair. On 6/4/26 at 10:59 AM Staff 1 (Administrator) stated repairs to blinds and windows were to be made as soon as the damage occurred, and all staff members were responsible for reporting repair needs to maintenance. 2. Resident 5 was admitted to the facility in 2023. On 6/1/26 at 11:24 AM, Resident 5 stated several months ago she/he requested maintenance move the pictures hanging behind her/his bed to a location where she/he could see them, and the light next to the door was not working, but neither request was addressed. Observations of Resident 5's room revealed pictures were hung behind the resident's bed where she/he could not see them, and the light next to the door did not work. Resident 5's floor was dirty with accumulated dust and debris. Next to the resident's dresser on the floor was a dirty sock, a tube of cream, various pieces of plastic packaging, and a pair of nail clippers. The resident's bed was angled away from the wall and the area between the wall and bed was dirty and dusty. The area under Resident 5's wheelchair had sticky red spots and visible dirt. On 6/2/26 at 3:54 PM Staff 12 (Housekeeping Manager) acknowledged Resident 5's room was dirty and needed to be cleaned. A 6/3/26 Work Order Report revealed a work order for moving Resident 5's pictures and fixing the light in her/his room was generated on 5/18/26 and closed on 5/22/26. On 6/4/26 at 9:13 AM Staff 8 (Maintenance Director) stated he was unaware of Resident 5's previous request to have her/his pictures moved or that the light in the room did not work. Staff 8 was unable to give a reason why the work order was closed when the work was not completed. 3. Resident was admitted to the facility in 12/2025. On 6/1/26 at 12:31 PM, Resident 27 stated the toilet in her/his room did not flush, would run continuously at times, and required manual adjustment. Resident 27 stated staff were aware of the issue, but it was not repaired. On 6/3/26 at 3:26 PM, Staff 11 (CNA) stated Resident 27's toilet was frequently clogged, and she had informed the prior maintenance director about the issue twice in the past. A 6/3/26 Work Order Report revealed a work order to address Resident 27's malfunctioning toilet was generated on 4/10/26 and closed on 5/27/26. On 6/4/26 at 9:00 AM, Staff 8 (Maintenance Director) stated he was unaware of an issue with Resident 27's toilet and was unable to give a reason why the work order was closed when the work was not completed. 4. Upon the 6/1/26 survey entrance, observed several handrail end cap pieces were missing from handrails in resident areas. On 6/3/26 the facility implemented an improvised repair by covering the handrail ends caps with a plastic foam material and black tape. The application of tape created crevices between the layers, and portions of the tape protruded at angles where it was folded. The handrail closest to the dining room was not fully covered with tape, leaving an exposed area of the plastic foam. On 6/3/26 at 2:28 PM Staff 12 (Housekeeping Manager) was observed wiping the handrails but not the taped areas. On 6/4/2026 at 9:17 AM observed taped areas were peeling. Staff 12 stated the peeling tape resulted in an uncleanable surface.

Based on observation, interview and record review it was determined the facility failed to ensure kitchen staff wore appropriate hair restraints during meal preparation, provide a sanitary kitchen environment and ensure proper hand hygiene practices were followed for 1 of 1 facility kitchen reviewed for sanitation. This placed residents at risk for unsanitary foods and food-borne illness. Findings include:The facility's undated Food Preparation and Service policy indicated:-Food preparation staff are to adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illnesses.-Bare hand contact with food is prohibited. Gloves are worn when handling food directly and changed between tasks. Disposable gloves are single-use items and discarded after each use.-Food and nutrition services staff wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food.1. On 6/3/26 at 11:29 AM, Staff 9 (Cook) was observed working in the kitchen without a hair restraint. Staff 9's hair was pulled back into a braid, which was observed swinging onto the front of her shoulder while she actively prepared food items for lunch.On 6/3/26 at 11:30 AM, Staff 7 (Dietary Director) stated Staff 9 forgot to replace her hair restraint after returning from lunch break. Staff 7 stated he believed a hair restraint was required only when the employee's hair was not pulled back and contained.On 6/4/25 at 10:35 AM, Staff 6 (Regional Dietary Director) stated hair restraints were to be worn at all times while working in the kitchen.2. Observation of the facility's kitchen on 6/3/26 between 12:00 PM and 12:30 PM, revealed the following:-Staff 9 (Cook) opened the refrigerator and removed a bag of salad. Staff 9 opened the bag without gloves and used her bare hands to dish out the salad. Staff 9 returned the bag of salad to the refrigerator.-Staff 9 picked up a biscuit with bare hands, cut into pieces, and placed them onto a plate.-Staff 9 picked up pre-made sandwiches with bare hands and placed them on plates.On 6/3/26 at 12:28 PM, Staff 7 (Dietary Director) acknowledged Staff 9 did not properly follow guidelines for handling ready to eat food.On 6/4/26 at 10:35 AM, Staff 6 (Regional Dietary Director) stated staff are expected to use utensils or gloves when handling ready-to-eat food items.3. On 6/4/26 at 10:20 AM, during interview with Staff 6 (Regional Dietary Director) and Staff 7 (Dietary Director), black tape was observed wrapped around the edge of the metal table used to hold clean dishes from the dishwasher. Staff 7 stated the tape was applied after the table was damaged. Staff 6 acknowledged the tape created a surface that could not be adequately cleaned and stated the tape needed to be removed.

Based on observation and interview it was determined the facility failed to ensure the facility was free from pests for 1 of 1 sampled facility reviewed for environment. This placed residents at risk for a lack of sanitary conditions. Findings include: The facility's 5/2008 Pest Control policy indicated:-This facility maintains an on-going pest control program to ensure the building is kept free of insects and rodents.-Windows are screened at all times.On 6/1/26 at 12:13 PM observed an open bathroom window without a screen in room [ROOM NUMBER]. No insects were observed at that time.On 6/1/26 from 5:47 PM to 6:21 PM, during dinner in the main resident dining room, a window without a screen was open and a mosquito, unidentified large bug, and a fly were observed. Staff 14 (Social Services Director) closed the window and stated it was due to insects getting in through the window. Five windows in the dining room did not have screens. On 6/2/26 at 9:36 AM, a fly was observed on the surveyor's computer while in the south hall.On 6/3/26 at 12:50 PM, a fly was observed in Staff 3's (LPN Resident Care Manager) office.On 6/4/26 at 9:00 AM, Staff 8 (Maintenance Director) stated he was aware several screens needed to be replaced or repaired and stated he was conducting an audit of all window screens the following week.On 6/4/26 at 1:22 PM, Staff 1 (Administrator) stated screens were required to be in place on all windows as part of the facility's pest control policy and acknowledged the facility had several missing or damaged screens.

Based on interview and record review it was determined the facility failed to ensure a resident's bowel care was held per physician orders and labs were monitored for 2 of 5 sampled residents (#2 and 4) This placed residents at risk for dehydration. Findings include: 1. Resident 2 was admitted to the facility in 7/2023 with a diagnosis of a genetic disorder characterized by chronic constipation. Resident 2's 7/2/24 Order Details revealed she/he was to be administered MiraLAX (laxative) every morning for constipation hold for loose stools. Resident 2's bowel care record from 5/5/26 through 6/3/26 revealed on 5/23/26 and 5/24/26 she/he had two loose each day. Resident 2's 5/2026 MAR revealed MiraLAX (was not held on 5/23/24, 5/24/26, or 5/26/26. On 6/3/26 atn12:34 PM Staff 21 (CMA) stated if a resident had an order to hold bowel medications for loose stools the medication should not be administered if a resident had a loose stool. Staff 21 stated CNAs notified her if a resident had a loose stool. On 6/3/26 at 3:43 PM Staff 2 (DNS) verified bowel care was not held when Resident 2 had loose stools. The information for loose stools was also on the bowel list which was printed daily and staff were to review the list prior to administering bowel care medications. 2. Resident 4 was admitted to the facility in 12/2023 with a diagnosis of kidney disease. Epocrates.com (web-based pharmacy resource) revealed interactions included the use of torsemide and sertraline. The combination of these two medications could increase the risk of low sodium levels and sodium levels should be monitored. National Library of Medicine defines low blood sodium as levels lower than 135. Resident 4's Labs report from 2/2025 through 3/15/25 revealed on 3/5/25 her/his sodium level was low at 130. Resident 4's 6/2026 MAR included she/he was administered torsemide (removes excess fluid) and sertraline (antidepressant) daily. On 6/4/26 at 2:20 PM Staff 3 (LPN Resident Care Manager) stated Resident 4 often had her/his laboratory tests obtained during dialysis. Staff 3 verified Resident 4's last documented sodium level was on 3/5/25. On 6/4/26 at 4:16 PM Staff 2 (DNS) stated each resident's physician provided standing orders for routine laboratory tests. Staff 2 stated Resident 4 did not have standing orders for routine laboratory tests, verified on 3/5/25 her/his sodium was low, and no additional sodium levels were ordered or obtained after 3/2025.

Based on observation, interview, and record review it was determined the facility had a medication error rate of greater than 5%. The facility error rate was with 32 percent with 8 errors in 25 opportunities. This placed resident at risk for adverse medication regimen. Findings include: Resident 16 was admitted to the facility in 4/2026 with a diagnosis including diabetes. Resident 16's 4/27/26 admission MDS revealed she/he was cognitively intact On 6/2/26 at 8:56 AM Staff 19 (CMA) was observed to prepare Resident 16's medications, enter Resident 16's room, place her/his medicine cup with the prepared medications on her/his computer table, then Staff 19 exited her/his room. The medications which were left on the bedside table included: -amlodipine (treats high blood pressure)-atorvastatin (anti-lipid)-disulfiram (treats alcohol use disorder)-Biktarvy (anti-viral medication)-vitamin B12 (Supplement)-Farxiga (treats heart failure)-metformin (treats diabetes)-multvitamin (supplement)-Omeprozole (treats reflux disease)After Staff 19 left the room, this surveyor asked if Resident 16 was assessed to self-administer medications. Staff 19 stated Resident 16 did not have an assessment to leave medications at bedside, returned to her/his room, and requested Resident 16 to consume the medications. On 6/3/26 at 3:43 PM Staff 2 (DNS) stated medications were not to be left at the bedside unless a resident was assessed to be safe, had orders to leave at the bedside, and was reflected on the care plan. Staff 2 acknowledged leaving medications at the bedside was considered a medication error.

Based on interview and record review it was determined the facility failed to ensure allegations of abuse were reported timely for 1 of 6 sampled residents (#45) reviewed for accidents and abuse. This placed residents at risk for continued abuse. Findings include: The facility's Abuse Prevention Policy and Procedure, dated 6/12/18, indicated:-All incidents, accidents, and injuries of unknow origins such as bruising or skin tears, and resident-to-resident contacts will be identified through the 24-hour report and an incident report in order to initiate an investigation. The Administrator and the Director of Nursing will be notified.-Mandated Reporters are to immediately report to their onside supervisor and the State Hotline number be they have reasonable cause to believe abuse, neglect, involuntary seclusion, abandonment, or financial exploitation has occurred, or when they have reason to suspect an incident is sexual or physical assaults. The Director of Nursing and/or Administrator shall be immediately notified of all allegations of abuse and neglect. Resident 45 was admitted to the facility in 7/2018 with a diagnosis of respiratory failure. Resident 45's 1/1/26 Progress Note revealed she/he alleged abuse and psychosocial harm. Resident 45 reported two CNAs assisted her/him to reposition in bed and her/his back was injured because the CNAs overdid it. Resident 45's 1/1/26 Event-Other investigation form revealed on 1/1/26 a handwritten note by Staff 17 (CNA) was found on the Resident Care Manager's floor. The note indicated on 12/30/25 Resident 45 was heard screaming in pain. Resident 45 reported staff caused her/him to be in pain by assisting her/him in bed when she/he did not need to be repositioned. On 6/4/26 at 2:38 PM Staff 17 stated if a resident reported abuse she/he notified the charge nurse. Staff 17 stated on 12/30/25 when Resident 45 reported abuse she/he reported to Staff 18 (Former RN) and also wrote a note to the Resident Care Manager. On 6/4/2026 9:59 AM Staff 1 (Administrator) stated staff should have reported Resident 45's allegation of abuse on 12/30/25 and the facility did not report to the state within the required time frame.On 6/5/26 at 10:37 AM Staff 18 stated on 12/30/25 she was not notified of Resident 45's allegation of abuse. Staff 18 stated if she/he was notified, she would have reported to management.

Based on observation, interview and record review it was determined the facility failed to ensure the MDS was coded accurately related to oxygen and non-invasive mechanical ventilator for 1 of 3 sampled residents (#7) reviewed for respiratory care. This placed residents at risk for inaccurate assessments. Findings include:The facility's undated Quarterly Assessments policy revealed quarterly MDS assessments were conducted to track the resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status were monitored. Resident 7 was admitted to the facility in 7/2022 with diagnosis including obstructive sleep apnea, chronic respiratory failure with hypoxia and hypercapnia (the body's tissues do not receive enough oxygen and the lungs cannot effectively remove carbon dioxide leading to dangerous carbon dioxide buildup in the blood), and Chronic Obstructive Pulmonary Disease (COPD)A review of the 4/25/26 Quarterly MDS revealed the resident was not using oxygen or a BiPAP (Bilevel Positive Airway Pressure that delivers pressurized air through a mask providing two pressure levels: a higher pressure for inhaling and a lower pressure of exhaling). The physician order, last signed on 5/31/26, revealed an order with a start date of 2/5/26 indicating Resident 7 was to receive continuous oxygen at two Liters per minute through nasal cannula (NC) or bled into the BiPAP.On 6/1/26 at 1:38 PM Resident 7 was observed with a NC placed in her/his nostrils and received oxygen through a portable oxygen machine. Resident 7 stated she/he required the use of continuous oxygen. Resident 7 stated while she/he was in bed she/he received oxygen through the BiPAP machine bled through from the oxygen concentrator and while up in the wheelchair received oxygen through the portable oxygen machine and the NC.On 6/4/26 at 12:12 PM Staff 5 (MDS Coordinator) stated he was an offsite MDS Coordinator that went to the facility once a week. Staff 5 stated he collected information for each section of the MDS through the resident's physicians order, progress notes and any documentation uploaded into the resident's medical record. Staff 5 acknowledged Resident 7 required continuous oxygen, used a BiPAP and he coded the 4/25/26 Quarterly MDS inaccurately. On 6/4/26 at 2:08 PM Staff 2 (DNS) acknowledged Resident 7's 4/25/26 Quarterly MDS was coded inaccurately related to oxygen and BiPAP use.

Based on interview and record review it was determined the facility failed to provide PRN insulin per physician orders for 1 of 5 sampled residents (#4) reviewed for unnecessary medications. This placed residents at risk for elevated blood sugars. Findings include: Resident 4 was admitted to the facility in 12/2023 with a diagnosis of diabetes. Resident 4's 6/24/25 Physician Orders revealed Insulin Lispro (fast acting insulin) was to administer every two hours PRN CBG greater than 400. Resident 4's PRN Insulin Lispro was not to be administered within two hours of her/his scheduled Lispro which was to be administered after meals. Resident 4's 5/2026 DAR (Diabetic Administration Record) revealed her/his CBG was greater than 400 on 5/1/26 at 1:00 PM, 5/7/26 at 9:00 AM, 5/12/26 at 12:00 PM and 6:26 PM, and 5/26/26 at 8:25 AM. Resident 4's DAR revealed staff did not administer the PRN Insulin Lispro. Resident 4's clinical record did not have documentation to indicate on 5/1/26, 5/7/26, 5/12/26, and 5/26/26 her/his CBG was rechecked after the CBGs were greater than 400. On 6/4/26 at 2:04 PM Staff 4 (RN Regional Consultant) verified in 5/2026 Resident 4's CBG was greater than 400 on four occasions and there was no documentation to indicate her/his CBG was rechecked or PRN insulin Lispro was administered.

Based on observation, interview and record review it was determined the facility failed to ensure aspiration precautions were followed for 2 of 5 sampled resident (#s 38 and 44) reviewed for accidents. This placed residents at risk for adverse outcomes related to aspiration. Findings include: 1. Resident 38 was admitted to the facility in 9/2025 with a diagnosis of dysphagia (difficulty swallowing). Resident 38's 9/10/25 Speech Therapy Evaluation and Plan of Treatment revealed she/he had minimal signs of dysphagia but due to her/his cognitive status and confusion, she/he was not able to follow instructions for swallowing strategies. Resident 38 was assessed to not have signs of aspiration. Recommendations included she/he was to have close supervision for oral intake and be upright for meals. Resident 38's 9/10/25 in-room Aspiration Precautions Information sheet (posted above Resident 38's head of bed) did not instruct staff to provide supervision for meals. Resident 38's 2/23/26 Aspiration Precautions information sheet (located in the dining room in a binder) revealed she/he was to be provided 1:1 monitoring while eating. Resident 38's 3/25/26 Order Details revealed she/he was to have 1:1 supervision for meals with small bites and sips. On 6/1/26 at 4:20 PM Resident 38 was observed in bed with her/his eyes shut. Two cups of fluids within arm's reach were observed on Resident 38's bedside table. On 6/1/26 at 4:22 PM Staff 20 (CNA) stated Resident 38 was able to eat independently. Staff 20 reviewed Resident 38's in-room Aspiration Precautions Information sheet and stated Resident 38 was able to eat and drink without supervision. If Resident 38 was assessed to need 1:1 supervision staff would need to be with the resident while she/he consumed food and fluids. On 6/1/26 at 4:52 PM and 6:02 PM Staff 3 (LPN Resident Care Manager) stated a resident's in-room Aspiration Precautions Information sheet and the sheet located in the dining room should contain the same information. Staff 3 stated 1:1 supervision meant there should not be drinks within reach in a resident's room and staff were to be present with all intakes. On 6/1/26 at 5:32 PM Staff 25 (CNA) stated if a resident had aspiration precautions a sign was placed in a resident's room with instructions. Staff 25 stated Resident 38 was able to eat and drink independently and did not require 1:1 supervision. On 6/2/26 at 11:27 AM Staff 2 (DNS) stated the most current information for residents' aspiration precautions was located in the dining room. If a resident's Aspiration Precautions Information sheet indicated a resident was to be provided 1:1 supervisor, no food or drinks were to be left within reach at the bedside unless specified on the form. 2.Resident 44 was admitted to the facility in 5/2026 with diagnoses including pneumonia. Resident 44's health record indicated resident had a BIMS score of nine, indicating a moderate cognitive deficit. Resident 44's 5/22/26 care plan and admission orders indicated Resident 44 was a high aspiration risk and required one on one supervision for all eating and drinking. On 6/1/26 at 1:42 PM, Resident 44 was observed asleep in bed. Two cups were located on the bedside table within reach of the resident. One cup without a lid contained juice, and a second cup with a lid contained water. On 6/1/26 at 2:55 PM, Staff 16 (Restorative Aide) stated Resident 44 required one to one supervision during all meals, and Resident 44 was not to be left unsupervised, were to cue the resident during meals and assist with all food and liquid intake as needed. Staff 16 stated she never witnessed the resident chocking or coughing during meals. On 6/1/26 at 3:41 PM, Resident 44 stated she/he did not have a history of choking while consuming liquids. On 6/1/26 at 3:56 PM, Staff 3 (LPN Resident Care Manager), stated Resident 44 required one to one supervision during all meals and required staff to be present to monitor and assist with eating and liquids as needed. Staff 3 stated fluids should not be left at the bedside unless the fluids were well out of reach of the resident. On 6/1/26 at 4:16 PM, Resident 44 was observed awake in bed. Two cups were located on the bedside table within reach of the resident. One cup without a lid contained juice, and a second cup with a lid which contained water. The resident did not reach for any fluids on his bedside table. On 6/1/26 at 3:55 PM Staff 27 (CNA) stated she worked with the resident who had poor vision and was to be taken to the dining room for assistance with all meals. Staff 27 stated she would refer to the Kardex (a quick guide for CNAs to provide care to residents) but was unaware the resident required one to one supervision and was not to have liquids at bedside. On 6/1/26 at 4:22 PM, Staff 26 (CNA) stated she was aware Resident 44 was not to drink from a straw but was unaware the residents required one to one supervision and was not to have fluids at her/his bedside. On 6/2/26 at 11:27 AM, Staff 2 (DNS) and Staff 4 (RN Regional Consultant) stated Resident 44 required one to one supervision which meant staff to be present for all food and liquid intake and fluids were not to be kept at the bedside unless they were placed out of reach.

Based on observation, interview, and record review it was determined the facility failed to maintain oxygen equipment for 1 of 3 sampled residents (#7) reviewed for oxygen therapy. This placed residents at risk for increased risk for respiratory failure. Findings include: Resident 7 was admitted to the facility in 7/2022 with diagnosis including obstructive sleep apnea, chronic respiratory failure with hypoxia and hypercapnia (the body's tissues do not receive enough oxygen and the lungs cannot effectively remove carbon dioxide leading to dangerous carbon dioxide buildup in the blood), and Chronic Obstructive Pulmonary Disease (COPD)A review of the 7/23/26 Annual MDS revealed Resident 7 had a BIMS of 15 indicating she/he was cognitively intact and it revealed Resident 7 utilized oxygen.The physician order, last signed on 5/31/26, revealed an order with a start date of 2/5/26 indicating Resident 7 was to receive continuous oxygen at two Liters per minute through nasal cannula (NC) or bled into the BiPAP.A review of 6/2026 TAR revealed to clean the oxygen concentrator and filter every Tuesday night shift starting on 2/10/26. On 6/2/26 this task was documented as completed by Staff 15 (LPN).Observations on 6/1/26 at 1:23 PM, 6/2/26 at 3:27 PM, and 6/3/26 at 8:50 AM revealed the external vent on the back of the oxygen concentrator to have a layer of dust when touched with a finger.On 6/1/26 at 1:38 PM Resident 7 stated she/he required the use of continuous oxygen. Resident 7 stated while she/he was in bed she/he received oxygen through the BiPAP machine bled through from the oxygen concentrator and while up in the wheelchair received oxygen through the portable oxygen machine and the NC.On 6/2/26 at 3:48 Staff 24 (CNA) stated Resident 7 received continuous oxygen and only the nurses cleaned the exterior of the oxygen concentrator machines. On 6/3/26 at 8:56 AM Staff 15 stated Resident 7's oxygen concentrator did not have a filter to clean, and she did not clean the exterior of the oxygen concentrator as nursing didn't do that.On 6/3/26 at 9:28 AM Staff 2 (DNS) stated she expected the charge nurse to wipe down the exterior of the oxygen concentrator, including the vent on the back. Staff 2 observed Resident 7's oxygen concentrator and acknowledged it had a layer of dust that should not be there.

Based on interview and record review it was determined the facility failed to ensure a resident had transporation for dialysis for 1 of 1 sampled residents (#4) reviewed for dailysis. This placed residents at risk for fluid retention. Findings include: Resident 4 was admitted to the facility in 12/2023 with a diagnosis of kidney disease. Resident 4's [DATE] Annual MDS revealed she/he was cognitively intact. On [DATE] at 11:09 AM Resident 4 stated she/he did not go to dialysis on [DATE] because the facility did not set up transportation. On [DATE] at 4:12 PM Staff 14 (Social Services Director) stated the company that provided Resident 4 transportation to dialysis had a contracted schedule which needed to be renewed every 90 days. The contract was not renewed prior to expiration and Resident 4 missed dialysis on [DATE]. On [DATE] at 4:16 PM DNS stated the facility should always ensure the transportation contract was renewed before it expired to ensure a resident did not miss dialysis.

Based on interview and record review it was determined the facility failed to provide dementia training for 5 of 5 sampled staff (#s 4, 9, 21, 22, and 23) reviewed for dementia training. This placed residents with dementia at risk of not receiving appropriate care and services to attain or maintain their highest practicable self. Findings include: A review of the facility's in-service records revealed dementia training was not completed by Staff 4 (CNA), Staff 9 (CNA), Staff 21 (CNA), Staff 22 (CNA), and Staff 23 (CNA) within the last 12 months. On 3/3/25 at 1:59 PM, Staff 1 (Administrator) confirmed the reviewed staff did not complete dementia training within the last 12 months.

Based on observation, interview, and record review it was determined the facility failed to ensure resident equipment, resident windows, walls, and bathroom lighting were in good working order and water was hot for 4 of 8 sampled residents (#s 6, 13, 22, and 26) reviewed for environment. This placed residents at risk for an unhomelike environment. Findings include: 1. Resident 6 was admitted to the facility in 12/2024 with diagnoses including dementia. On 2/26/25 at 12:00 PM, Resident 6's bathroom was observed to be dim with the light on. On 3/3/25 at 10:23 AM, Resident 6's bathroom was observed to be dark with the lights on. On 3/3/25 at 10:25 AM, Staff 13 (CNA) stated Resident 6 used the bathroom. Staff 13 stated the light had been dim for at least a week. On 3/3/25 at 10:38 AM Staff 5 (Maintenance Director) confirmed the bathroom light was dim and it was unsafe for a resident to go in there with the dim light. On 3/3/25 at 12:28 PM Resident 6 stated she/he took her/himself to the bathroom and had a difficult time seeing her/his way around in the bathroom. 50897 2. Resident 13 admitted to facility in 11/2023 with diagnoses including congestive heart failure (a progressive heart disease that affects pumping action of the heart muscles). A 12/2024 Annual MDS assessment revealed Resident 13 had a BIMS of 15 (cognitively intact). On 2/24/25 at 10:00 AM and on 2/27/25 at 10:08 AM, Resident 13 stated her/his walls were damaged from the bed scraping on the wall and she/he brought it up to maintenance several times but they were not repaired. Resident 13 sated the condition of the walls in her/his room bothered her/him because they were not repaired. On 3/3/25 at 9:28 AM, Staff 5 (Maintenance Director) stated it was hard to get repair completed due to rooms were occupied and he could not paint rooms with residents in the room. On 3/3/25 at 1:46 PM, Staff 1 (Administrator) stated she recognized walls in disrepair were not a homelike environment for residents. 26991 3. Resident 22 was admitted to the facility in 2023 with a diagnosis of diabetes. A 12/18/24 annual MDS revealed Resident 22 was cognitively intact. On 2/24/25 at 4:52 PM, Resident 22's bathroom window was observed to have a crack which extended from the left side and spread to the right side. Resident 22's water in her/his sink was checked for one minute and it was cool to the touch. On 2/27/25 at 2:09 PM, with Staff 6 (Business Office Manager) Resident 22's sink water was tested and it was 59 degrees F. On 2/27/25 at 2:31 PM, Resident 22 stated her/his water was cold and her/his window was cracked since she/he was admitted to the facility. On 2/27/25 at 2:35 PM, Staff 1 (Administrator) stated staff performed a weekly water check but the form they filled out did not include the temperatures which were taken so she could not verify the location or temperatures. Staff 1 verified the cracked window and cold water temperatures were identified on 2/24/25. On 3/3/25 at 10:51 AM, Staff 5 (Maintenance Director) stated a pump was out therefore the hot water was not being pushed to rooms including Resident 22's room. 42270 4. Resident 26 admitted to the facility in 12/2023 with diagnoses including heart failure. A 12/23/24 Annual MDS revealed Resident 26 had a BIMS of 15 which indicated she/he was cognitively intact. On 2/24/25 at 5:18 PM Resident 26 stated there was a time her/his bed had been stuck with the head up for ten days. A 2/3/25 Physical Therapy note revealed Resident 26's bed was stuck in a high position with the head and knee elevated which resulted in Resident 26 being unable to get out of bed and unable to roll in the bed. A 2/5/25 Physical Therapy note revealed Resident 26's bed was broken and stuck in a high position. A 2/6/25 Physical Therapy note revealed resident 26's bed was broken and she/he could not get in and out of the bed safely. A 2/7/25 progress note revealed Resident 26 reported to Staff 7 (Social Services Director) concerns about her/his bed being broken and not yet repaired. Resident 26 stated she/he was not able to get out of bed because the bed was stuck too high and it was difficult to have a bowel movement due to the bed being at a tilt. A 2/7/25 progress note revealed Resident 26's bed controller was fixed. On 2/26/25 at 8:56 AM, Staff 9 (CNA) stated she recalled Resident 26's bed being broken and stated it was broken for around three days. Staff 9 stated Resident 26 was stuck with one side of the head up and the other side down so she/he was stuck laying sideways and could not get out of the bed during this time. Staff 9 stated the facility management was aware of the broken bed. On 2/27/25 at 11:13 AM, Staff 7 (Social Services Director) stated she was made aware of Resident 26's bed not working on 2/7/25 and the bed was repaired later that day. Staff 7 did not know how long the bed was stuck but stated Resident 26 was laying flat with part of the the top of the bed swaying down. Staff 7 stated Staff 5 (Maintenance Director) and Staff 1 (Administrator) were notified and the bed was repaired the same day she was notified of it. On 2/27/25 at 2:32 PM, Staff 5 (Maintenance Director) stated he was aware of Resident 26's bed being broken and stated it was stuck at a level that she/he could not get out of bed. Staff 5 stated the bed was broken for a couple days.

Based on observation and interview it was determined the facility failed to store food in a sanitary manner for 1 of 1 resident refrigerator reviewed for food safety. This placed residents at risk for foodborne illnesses. Findings include: On 2/27/25 at 12:53 PM, a resident room refrigerator was observed with Staff 12 (Food Service Director) and observed the following: -An undated plate of meatballs. -An undated, uncovered bowel of pears. -A container of cottage cheese dated 2/12/25. -A sandwich dated 2/21/25. -An undated desert. -Two partial gallons chocolate milk with an expiration date of 2/7/25. -A jar of salsa with an expiration date of 2/20/25. -An open container of hot dogs with an expiration date of 1/16/25. -An open container of cole slaw with an expiration date of 2/20/25. -An open container of bologna with an expiration date of 2/18/25. -A green canister dated 11/14/23 with an unknown powder in it. -An undated pitcher with blue liquid in it labeled bowel prep with a resident's name on it. Staff 12 stated anything provided by the kitchen was dated and should be thrown out three days after that date, all other food needs to be thrown out by the expiration date. Staff 12 stated medications should not be stored in the resident's refrigerator and the dietary aid was responsible for cleaning out the resident's refrigerator monthly.

Based on interview and record review it was determined the facility failed to ensure residents were offered pneumonia vaccines for 5 of 5 sampled residents (#s 19, 22, 26, 38, and 39) reviewed for vaccines. This places residents at risk for pneumonia. Findings include: 1. Resident 19 was admitted to the facility in 9/2022 with a diagnosis of Parkinson's disease. Resident 19's clinical record revealed she/he was eligible for, but was not offered a pneumonia vaccine. On 2/27/25 at 11:02 AM and at 11:26 AM, Staff 2 (DNS) verified resident 19 was eligible to receive a pneumonia vaccine. A request was made for Staff 2 to provide documentation a pneumonia vaccine was offered to Resident 19. No additional information was provided. 2. Resident 22 was admitted to the facility in 12/2024 with a diagnosis of diabetes. Resident 22's clinical record revealed she/he was eligible for, but was not offered a pneumonia vaccine. On 2/27/25 at 11:02 AM and at 11:26 AM, Staff 2 (DNS) verified Resident 22 was eligible to receive a pneumonia vaccine. A request was made for Staff 2 to provide documentation a pneumonia vaccine was offered to Resident 22. No additional information was provided. 3. Resident 26 was admitted to the facility in 12/2023 with a diagnosis of kidney failure. Resident 26's clinical record revealed she/he was eligible for, but was not offered a pneumonia vaccine. On 2/27/25 at 11:02 AM Staff 2 (DNS) verified Resident 28 was eligible to receive a pneumonia vaccine. A request was made for Staff 2 to provide documentation a pneumonia vaccine was offered to Resident 26. No additional information was provided. 4. Resident 38 was admitted to the facility in 8/2024 with a diagnosis of a stroke. Resident 38's clinical record revealed she/he was eligible for, but was not offered a pneumonia vaccine. On 2/27/25 at 11:02 AM Staff 2 (DNS) verified Resident 38 was eligible to receive a pneumonia vaccine. A request was made to Staff 2 to provide documentation a pneumonia vaccine was offered to Resident 38. no additional information was provided. 5. Resident 39 was admitted to the facility in 9/2024 with a diagnosis of seizures. Resident 39's clinical record revealed she/he was eligible for, but was not offered a pneumonia vaccine. On 2/27/25 at 11:02 AM Staff 2 (DNS) verified Resident 39 was eligible to receive a pneumonia vaccine. A request was made to Staff 2 to provide documentation a pneumonia vaccine was offered to Resident 39. No additional information was provided.

Based on interview and record review it was determined the facility failed to provide bowel care and failed to follow physician orders for medication parameters for 3 of 5 sampled residents (#s 9, 22, and 24) reviewed for medications. This placed residents at risk for constipation and adverse medication regimen. Findings include: 1. Resident 9 was admitted to the facility in 6/2022, with a diagnosis of dementia. A bowel record dated 1/29/25 through 2/27/25 revealed Resident 9 had a bowel movement on 2/1/25 and did not have another bowel movement until 2/7/25. A 2/2025 MAR revealed Senna (laxative) was administered on 2/4/25 and the results of the administration were unknown. Progress Notes from 1/29/25 through 2/7/25 did not include an assessment related to Resident 9's lack of bowel movement. On 2/27/25 at 9:18 AM, Staff 10 (CMA) stated every day a bowel sheet was printed for all residents. If a resident did not have a bowel movement for three days, bowel care was initiated. On 2/27/25 at 9:18 AM, Staff 8 (LPN) stated if a resident refused bowel care the nurse was to document in the resident's Progress Notes an assessment and the rationale bowel care was not provided. On 2/28/25 at 9:36 AM, Staff 2 (DNS) verified bowel care was to be administered if a resident did not have a bowel movement for three days. A nurse was to document an assessment if a resident stated they did not require bowel care. Staff 2 verified Resident 9 did not have a bowel movement for five days and there was no documented nursing assessment. 2. Resident 22 was admitted to the facility in 12/2023, with a diagnosis of depression. A bowel record dated 1/29/25 through 2/25/25 revealed Resident 22 had a bowel movement on 2/2/25 and did not have another bowel movement until 2/6/25. Resident 22 also was documented to have a bowel movement on 2/21/25 and did not have another bowel movement until 2/25/25. Resident 22's 2/2025 MAR revealed she/he did not have PRN bowel care medications ordered. Resident 22's Progress notes from 2/2/25 through 2/25/25 revealed no bowel assessments. On 2/27/25 at 9:18 AM, Staff 10 (CMA) stated every day a bowel sheet was printed for all residents. If a resident did not have a bowel movement for three days, bowel care was initiated. On 2/27/25 at 9:18 AM, Staff 8 (LPN) stated if a resident refused bowel care the nurse was to document in the resident's Progress Notes an assessment and the rationale bowel care was not provided. On 2/28/25 at 9:36 AM, Staff 2 (DNS) verified bowel care was to be administered if a resident did not have a bowel movement for three days. A nurse was to document an assessment if a resident stated they did not require bowel care. Staff 2 stated Resident 22 was very independent, was able to use the bathroom without assistant, and staff may not have documented all of Resident 22's bowel movements. Staff 2 verified Resident 22 did not have a bowel movement for four days on two occasions, there were no PRN bowel care orders initiated and administered from the standing orders, and there were no nursing assessments in the resident's clinical records. 47001 3. Resident 24 was admitted to the facility in 10/202,4 with diagnoses including heart failure. A 10/31/24 physician order for Lasix (a diuretic medication) indicated to hold the medication for a systolic blood pressure (SBP) less then 110. A review of Resident 24's 2/2025 MARs revealed the following: -On 2/4/25 the blood pressure was 109/62 and the MAR was signed as administered. -On 2/6/25 the blood pressure was 108/60 and the MAR was signed as administered. -On 2/12/25 the blood pressure was 98/59 and the MAR was signed as administered. -On 2/14/25 the blood pressure was 96/50 and the MAR was signed as administered. -On 2/17/25 the blood pressure was 99/62 and the MAR was signed as administered. -On 2/19/25 the blood pressure was 102/60 and the MAR was signed as administered. -On 2/21/25 the blood pressure was 108/59 and the MAR was signed as administered. -On 2/25/25 the blood pressure was 108/61 and the MAR was signed as administered. On 2/27/25 at 1:31 PM, Staff 10 (CMA) stated Resident 24 received Lasix if she did not put a hold note in the progress notes. A 2/27/25 review of Resident 24's 2/2024 Progress Notes revealed no evidence of Staff 10 holding Resident 24's Lasix. On 3/3/25 at 10:28 AM, Staff 2 (DNS) stated based on Resident 24's blood pressure parameters, her/his Lasix should have been held for the identified days in 2/2025.

Based on interview, observation and record review it was determined the facility failed to follow resident rights for 2 of 2 sampled residents (#s 13 and 26) reviewed for resident rights and incontinence care. This placed residents at risk for lack of dignity. Findings include: 1. Resident 13 admitted to facility in ,d+[DATE], with diagnoses including congestive heart failure (a progressive heart disease that affects pumping action of the heart muscles). A ,d+[DATE] Annual MDS assessment revealed Resident 13 had a BIMS of 15 (cognitively intact). A review of Resident Council notes from ,d+[DATE] revealed Resident 13's concerns about leaking briefs had been discussed at Resident Council and the facility response recorded was they would work to ensure the most appropriate product was used and supply an incontinence pad for Resident 13's wheelchair. A review of Resident 13's ,d+[DATE] care plan revealed no changes were made related to incontinence. On [DATE] at 10:05 AM, Resident 13 stated her/his brief leaked when she/he urinated. Resident 13 stated she/he preferred to participate in activities but mostly stayed in her/his room because she/he did not want to be embarrassed by her/his brief leaking. On [DATE] at 11:50 AM, Resident 13 was observed wheeling down the facility hall with a wet peri area. On [DATE] at 8:15 AM, Staff 17 (CNA) stated he occasionally noticed Resident 13 with leaking briefs. Staff 17 stated Resident 13 used to attend activities frequently but now seemed to mostly stay in her/his room. On [DATE] at 9:27 AM, Resident 13 was observed in her/his wheelchair in the hallway and a strong smell of urine from the resident. On [DATE] at 9:57 AM, Staff 4 (CNA) stated she was aware Resident 13 sometimes had leaking briefs and correct application of her/his briefs was critical to prevent leakage. On [DATE] at 12:22 PM, Staff 3 (LPN/Resident Care Manager) stated she was responsible for care planning for Resident 13. She stated she was not aware of Resident 13's issues with leaking briefs and staff should have informed her Resident 13's briefs were leaking. On [DATE] at 1:07 PM, Staff 2 (DNS) stated she was aware Resident 13 had brought up the issue of leaking briefs. Staff 2 stated CNA staff determined moderate briefs were sufficient for Resident 13 and she thought the issue had been resolved. 42270 2. Resident 100 admitted to the facility in ,d+[DATE], with diagnoses including heart failure. A [DATE] progress note written at 12:31 AM revealed Resident 100 passed away on [DATE] at 12:30 AM. A [DATE] progress note written at 11:59 AM revealed Resident 100's body was picked up at 11:45 AM. Resident 26 admitted to the facility in ,d+[DATE] with diagnoses including heart failure. A [DATE] Annual MDS revealed Resident 26 had a BIMS of 15 which indicated she/he was cognitively intact. A [DATE] progress note revealed Resident 26 was upset over her/his roommate passing away and the body being left in their room for several hours after death. A review of the medical record revealed no documentation staff offered to move Resident 26 out of the room or move Resident 100's body out of the shared room while they waited for her/him to be picked up. On [DATE] at 11:45 AM, Resident 26 stated she/he was upset because Resident 100 was left in their shared room after her/his death. On [DATE] at 12:41 PM, Staff 7 (Social Services Director) stated she recalled the incident and stated Resident 26 should have been put on alert following the death of the roommate and being left in the room for multiple hours with Resident 100's body. Staff 7 stated she did not know if Resident 26 was offered to move out of the room while the body was in the room and stated she would have been upset if she was left in a room with a deceased resident for over 11 hours. On [DATE] at 1:27 PM, Staff 3 (LPN Resident Care Manager) stated at the time of Resident 100's death Resident 26 was not moved to another room and Resident 26 was not placed on alert charting following the death of her/his roommate.

Based on interview and record review it was determined the facility failed to ensure a resident or resident's representative was provided the risk and benefits information for psychotropic medications prior to administration for 1 of 5 sampled residents (#9) reviewed for medications. This placed residents at risk for lack of informed consent. Findings include: Resident 9 was admitted to the facility in 6/2022 with a diagnosis of depression. A 1/17/25 hospice Certification and Plan of Care revealed Resident 9 was admitted to hospice services on 1/17/25. Orders indicated Abilify (an antipsychotic medication) was to be administered daily, Cymbalta (an antidepressant medication) was to be administered daily, and lorazepam (an antianxiety medication) was to be administered PRN for restlessness. Review of Resident 9's clinical record revealed no evidence of consent forms for the administration of Abilify, Cymbalta, or lorazepam. On 2/27/25 at 9:18 AM, Staff 8 (LPN) stated consents for psychotropic medications were to be obtained from residents prior to medication administration. On 2/27/25 at 11:42 AM, Staff 3 (LPN Resident Care Manager) stated hospice should have obtained consents for the psychotropic medications upon admission to hospice services. Staff 3 stated she did not see the consents for the medications in Resident 9's clinical record. On 2/28/25 at 9:36 AM, Witness 2 (Hospice Director) stated hospice staff reviewed general admission consent and treatment plans upon admission to hospice services. Hospice did not go over the risk and benefits of psychotropic medications unless the facility provided a specific form and notified hospice staff to include the education in the admission process.

Based on interview and record review it was determined the facility failed to follow up on grievances for 1 of 4 sampled residents (# 26) reviewed for staffing. This placed residents at risk for not having their needs addressed. Findings include: Resident 26 admitted to the facility in 12/2023 with diagnoses including heart failure. A 12/23/24 Annual MDS revealed Resident 26 had a BIMS of 15 which indicated she/he was cognitively intact. A 5/14/24 progress note revealed Resident 26 complained to Staff 7 (Social Services Director) about long call light times. Staff 7 told Resident 26 she would address the issue. A 5/24/24 progress note revealed Resident 26 complained to Staff 7 about long call light times and her/his room not being clean. Staff 7 told Resident 26 she would report the concerns to the appropriate people. A 5/29/24 progress note revealed Resident 26 complained to Staff 7 about food issues and long call light times. Staff 7 told Resident 26 she would report the concerns to the appropriate department. A 6/3/24 progress note revealed Resident 26 complained to Staff 7 about the night shift not doing a good job, long call light times, and rude staff. Staff 7 told Resident 26 she would report this to the administrator and resident care manager. A review of the medical record revealed no documented follow up to the concerns. A review of the grievance binder revealed no grievances related to the concerns. On 2/28/25 at 12:28 PM Staff 7 (Social Services Director) stated when Resident 26 made complaints about staffing and call lights she reported the concerns to nursing and did nothing else with it. On 2/28/25 at 12:57 PM Staff 3 (LPN Resident Care Manager) stated when she followed up with Resident 26 she would just have a conversation and encouraged her/him that there was never a problem with staffing. On 2/28/25 at 1:15 PM Staff 29 (Regional Nurse Consultant) and Staff 2 (DNS) stated going forward the facility planned to follow the grievance process when there were concerns expressed to staff and Staff 2 stated she was unaware of Resident 26's concerns identified in the progress notes. On 2/28/25 at 3:57 PM Resident 26 reviewed the concerns she/he expressed and stated the facility did not resolve them and had not gotten back to her/him about the concerns.

Based on interview and record review it was determined the facility failed to protect the resident's right to be free from physical abuse by another resident for 1 of 3 sampled residents (#39) reviewed for abuse. This placed residents at risk for injury related to abuse. Findings include: Resident 39 was admitted to the facility in 9/2024 with diagnoses including post traumatic stress disorder (PTSD). Resident 20 was admitted to the facility in 11/2024 with diagnoses including PTSD. On 1/18/25 a Facility Reported Incident (FRI) was received by the State Survey Agency, which alleged Resident 20 hit Resident 39 on the head several times. Resident 39's 1/18/25 Progress Note indicated she/he reported to the nurse she/he was hit by Resident 20 on the top of the head several times. The facility's investigation dated 1/20/25, revealed Resident 39 and Resident 20 were in the dining room. Resident 39 was on her/his phone when Resident 20 asked Resident 39 to turn her/his phone down. Resident 39 stated she/he did turn her/his phone down, Resident 20 stated Resident 39 refused to turn her/his phone down. Resident 20 went over to Resident 39 and hit Resident 39 on the head several times. The residents were separated and assessed, no injuries noted. The police were notified and Resident 39 pressed charges against Resident 20. Both residents were placed on alert charting and no further incidents occurred. The facility substantiated abuse. On 2/28/25 at 10:09 AM, Staff 11 (LPN) stated on 1/18/25 Resident 39 went to the nurse's station and reported Resident 20 hit Resident 39 on the head several times after Resident 20 asked Resident 39 to turn down the volume on her/his phone. Staff 11 stated the residents were separated and Resident 39 was assessed for injury, no injuries noted. The police were notified and Resident 39 pressed charges against Resident 20. Staff 11 stated Resident 20 did not like loud noises and would yell if something in the environment was too loud. Staff 11 stated Resident 20 had no previous physical behaviors and had no physical behaviors since the incident on 1/18/25. On 2/28/25 at 1:33 PM, Staff 3 (LPN/Resident Care Manager) stated on 1/18/25 there was an incident with Resident 39 and Resident 20. Staff 3 stated Resident 39 was watching a video on her/his phone without using her/his headphones, which irritated Resident 20. Staff 3 stated Resident 20 hit Resident 39 on the head several times. Staff 3 stated Resident 20 usually had verbal behaviors and the incident on 1/18/25 was the only time Resident 20 had physical behaviors. Resident 20 acknowledged the incident occurred and that it was abuse.

Based on interview and record review it was determined the facility failed to ensure Resident 1 was free from non-consensual sexual contact for 1 of 1 sampled resident (#1) reviewed for sexual abuse. This failure was determined to be an immediate jeopardy situation because the facility failed to investigate and report allegations of sexual abuse and follow Resident 1's care plan to ensure Resident 1's safety which resulted in physical injury and mental distress. Findings include: Resident 1 admitted to the facility in 6/2022 with diagnoses including Huntington's disease (a condition that leads to progressive degeneration of nerve cells in the brain which affects movement, cognitive functions, and emotions) and anxiety. The 12/28/22 Quarterly MDS revealed Resident 1 had a BIMS score of 6 which indicated severe cognitive impairment. a. The 7/6/22 Cognitive Loss Care Plan indicated Resident 1 had impaired decision making skills which could lead to poor choices. The 11/26/22 5:30 AM Progress Note indicated Resident 1 had occasional restlessness during the night, was resistive to cares, required two person staff assistance for cares and bloody discharge was noted in her/his brief. The 11/26/22 Progress Note indicated Staff 5 (Agency LPN) was summoned to resident room via CNA d/t [due to] copious amounts of blood in brief, on sheets and the floor .in addition to increased agitation and inconsolable behaviors. Staff 5 noted Resident 1 to have more frequent movements while screaming out unintelligible statements. Resident 1 was very resistive to exam and very guarded with genitals locking [her/his] legs closed at first. Resident 1 allowed Staff 5 to examine her/him when the male CNA stepped away. Resident 1 was noted to have copious amounts of bright red blood expelling from her/his vaginal area and had swelling and abrasions to the internal labia and vaginal vault. Resident 1 was unable to give a definitive response as to if sexual activity occurred with her/his significant other. When questioned the resident responded I didn't want it. Maybe I did. It was rough. No, nothing happened. When questioned by Staff 5, Resident 1 was unable to vocalize if any foreign bodies were utilized. Resident 1 was severely agitated when EMS arrived. Resident 1's brief was changed prior to her/his transfer to the hospital and noted to be full of bright red blood. Staff 5 noted Resident 1's agitation increased with any male persons present which was a new behavior. Staff 5 indicated Witness 8 (Resident 1's Boyfriend) visited the prior evening and after Witness 8's departure staff noted increased resistance to cares and blood in Resident 1's brief. The 11/26/22 Hospital Records indicated Resident 1 was evaluated in the emergency room for reported painful intercourse the night before. Resident 1's last menstrual period was two years prior. A pelvic exam was performed which revealed no evidence of trauma and minimal bleeding. Lab work and a pelvic ultrasound was completed with no findings of concern. Multiple etiologies of the vaginal bleeding were considered, findings were most consistent for mild local trauma however vaginal bleeding in a postmenopausal person must be considered. Resident 1 was to follow-up with an OB/GYN in one to two weeks. [There was no evidence the hospital was informed of a possible sexual assault and a sexual assault kit was not completed. A full work-up for vaginal bleeding of unknown origin was completed. The hospital records provided conflicting accounts of trauma.] Progress Notes revealed Resident 1 was on alert charting upon return from the hospital for vaginal bleeding but did not include monitoring for bruising around the breasts, genital area or inner thighs which could be further indication of a sexual assault. The 12/2/22 Facility Investigation revealed the ED [Emergency Department] notes stated that it was probably bleeding after menopause but could not definitively say for sure and referred to OB/GYN for follow-up. The investigation further revealed it is difficult to say if for sure the sexual encounter happened and the resident can be a poor historian. Immediate action to keep Resident 1 safe was to keep the room door open when Resident 1 visited with Witness 8 and provide frequent checks. The investigation indicated one OB/GYN declined to schedule the appointment due to Resident 1's Huntington's chorea (involuntary jerking or writhing) movements and the inability to conduct a pelvic exam. Resident 1's provider would follow-up and perform the pelvic exam once the proper equipment was ordered and received. The 12/15/22 Provider Notes indicated Resident 1 was seen for an initial psychological visit for depression and to evaluate Resident 1's cognition. [There was no evidence of ongoing depression.] There was no evidence in Resident 1's medical record of a history of vaginal bleeding. There was no evidence another OB/GYN was contacted or her/his provider completed a pelvic exam as ordered by the ED physician. There was no evidence in facility records the equipment needed for a pelvic exam was ordered. On 2/2/23 at 11:52 AM Staff 1 (Administrator) verified Resident 1's follow-up pelvic exam was not completed and the facility did not have the equipment needed. On 2/3/23 at 2:00 PM Staff 5 (Agency LPN) stated Resident 1 had fresh blood and pea to quarter sized clots in her/his brief. Resident 1's outer labia was very red and there was some redness/irritation around the vaginal vault; and said, It looked like it was traumatized. Staff 5 stated Witness 8 was rough around the edges, could be foul, belligerent, carry alcohol and smelled of alcohol. Staff 5 stated she worked at the facility since 8/2022 and Resident 1 never had vaginal bleeding prior to the 11/26/22 incident. On 2/9/23 at 9:57 AM Staff 1 stated the facility did not report the 11/26/22 incident to law enforcement and she contacted two people from the State of Oregon (Witnesses 5, Operations and Policy Analyst and 6, Interim Program Manager) who told her she did not have to report the incident. Staff 1 stated she had no nursing background and did not know why after the 11/26/22 incident Resident 1 was only on alert charting for vaginal bleeding, did not include monitoring for bruising around the breasts, genital area or inner thighs and verified Resident 1 had not been tested for any sexually transmitted diseases. Staff 1 verified the facility did not follow-up with an OB/GYN as ordered by the hospital physician and further stated the facility could not restrain Resident 1 like the hospital was allowed to do. Staff 1 acknowledged the 11/26/22 progress note indicated Resident 1 had increased agitation, trauma to the genital area, blood and a change in behavior when around males; all of which were indications of sexual abuse. On 2/9/23 at 4:00 PM Witness 5 and Witness 6 were interviewed. Witness 5 stated she instructed Staff 1 to notify local law enforcement. Witness 6 stated he discussed the situation with Witness 5, agreed the facility needed to notify local law enforcement and did not communicate directly with the facility. On 2/15/23 at 5:02 PM Witness 7 (ED Physician) stated Resident 1's transfer to the hospital was not reported as an alleged sexual assault. Witness 7 stated if it had a full sexual assault exam would have been completed including getting samples, testing for sexually transmitted diseases and having law enforcement involvement. Witness 7 stated it would have been a completely different exam and the vaginal ultrasound would not have been ordered unless the sexual assault exam warranted it. Witness 7 stated, 100% we would never restrain [anyone] for a pelvic exam and further stated performing the pelvic exam on Resident 1 was no trouble. b. The 7/6/22 Cognitive Loss Care Plan indicated Resident 1 had impaired decision making skills which could lead to poor choices. A 12/2/22 revised intervention instructed staff to determine if decisions made by the resident endangered the resident or others and to intervene if necessary. It further indicated to provide supervision as needed by leaving the room door open when Witness 8 (Resident 1's Boyfriend)visited. The current care plan as of 2/9/23 did not indicate a visitor restriction was in place. A 12/31/22 at 1:38 AM Progress Note indicated Resident 1 had a large amount of blood in her/his brief after Witness 8 had visited with the room door closed. A 12/31/22 at 12:52 PM Progress Note revealed Resident 1 had a small amount of blood in her/his brief. Progress notes revealed Resident 1 was placed on alert charting for vaginal bleeding only. There was no evidence in the medical record the family or physician was notified, the root cause of the resident's bleeding was assessed by nursing staff, the resident was evaluated by a physician or a facility investigation was completed. On 2/3/23 at 2:00 PM Staff 5 (Agency LPN) stated the facility used a lot of agency staff and few regular facilty staff. Staff 5 stated there was never education for agency staff such as where to read care plans, how to read them, or if any resident needed something specific. Staff 5 stated it was really scary to be an agency nurse at this facility. On 2/8/23 at 9:53 AM Staff 2 (LPN Resident Care Manager) stated Resident 1 did not have any vaginal bleeding prior to the 11/26/22 incident and had none since the 12/31/22 incident. Staff 2 verified Resident 1 had no incidents of vaginal bleeding since Witness 8 was banned from the building. On 2/9/23 at 9:57 AM Staff 1 (Administrator) stated she did not complete a FRI or formal facility investigation of the 12/31/22 incident. Staff 1 stated she did not report the 12/31/22 incident to law enforcement because she contacted two people from the State of Oregon (Witnesses 5, Operations and Policy Analyst and 6, Interim Program Manager) who told her she did not have. Staff 1 verified Resident 1's care plan instructed staff to leave the resident room door open when Witness 8 visited yet Resident 1's 12/31/22 progress note revealed Resident 1's door was shut during the visit. Staff 1 stated the nursing staff believed the vaginal bleeding was her/his menstrual cycle because Resident 1 told staff it was her/his period and the events were approximately four weeks apart. [Resident 1 has severe cognitive impairment and her/his last menstrual period was 2 years prior per hospital records.] Staff 1 stated she had no nursing background and did not know why after the 12/31/22 incident Resident 1 was only on alert charting for vaginal bleeding, did not include monitoring for bruising around the breasts, genital area or inner thighs and verified Resident 1 was not tested for any sexually transmitted diseases. Staff 1 stated Witness 8 was banned from the facility but acknowledged this information was not on Resident 1's care plan. Staff 1 further stated this information was posted at the nurses station. When asked to show this surveyor where the posting was, Staff 1 was unable to locate the posting. After several minutes of looking for the posting Staff 1 found the posting on the bulletin board in the staff break room. Staff 1 agreed if a new agency nurse worked at the facility they would not have this information at the beginning of their shift. On 2/9/23 at 4:00 PM Witness 5 and Witness 6 were interviewed. Witness 5 stated she instructed Staff 1 to notify local law enforcement. Witness 6 stated he discussed the situation with Witness 5, agreed the facility needed to notify local law enforcement and did not communicate directly with the facility. On 2/15/23 at 10:52 AM the facility was notified of the Immediate Jeopardy (IJ) situation and an immediacy removal plan was requested. On 2/15/23 at 1:21 PM the facility submitted an acceptable immediacy removal plan which would abate the IJ situation. The immediacy removal plan included the following: *The boyfriend of Resident 1 is no longer allowed in the building as the police have restricted him from the building. The resident is two person care. A sign has been placed at the nurse's station for all staff to see. A care conference was done with the daughter to talk with her about the resident's cognition. *The facility will interview current residents within 48 hours to ensure they feel safe in the facility and with visitors. Will assess by an RN the five out of the six females with severe and moderate cognitive impairment for ability to consent within 48 hours. One female already has a guardian in place. *Care plan will be updated for Resident 1 within 48 hours. *Facility will in-service all staff starting today to reeducate them on the importance of abuse and reporting abuse within the next 48 hours and as they come on shift. *DNS/Designee will audit progress notes weekly. *Each care plan will be updated to reflect any visitor exemptions and signage will be placed at the nurse's station today. *Agency book will be updated, and a sign will be placed at the nurses' station, so agency know where to find the agency book. *Regional Nursing Consultant will reeducate the Administrator on the importance of abuse and reporting abuse within the next 48 hours. *Will continue interviewing residents at random per MDS schedule to ensure all residents are interviewed each quarter. If blood appears in resident's brief again MD will be notified, resident will be interviewed and assessed. If needed, police will be called and resident will be sent to the ER, and a FRI will be submitted. On 2/17/23 at 3:14 PM it was determined through staff interviews and review of facility documentation revealed all aspects of the POC were implemented and completed.

Based on interview and record review it was determined the facility failed to ensure residents were free from sexual abuse for 1 of 3 sampled residents (#2) reviewed for abuse. This failure, Resident 1's sexual abuse of Resident 2, was determined to be an Immediate Jeopardy (IJ) situation. Findings include: Resident 1 admitted to the facility in 2011 with [DIAGNOSES REDACTED]. A review of Resident 1's medical record revealed Resident 1 had a BIMs (cognitive assessment) score of 1 which indicated severe cognitive impairment. A 6/25/19 care plan revealed Resident 1 had a history of [REDACTED]. A review from 6/25/19 through 10/2/19 revealed Resident 1 made sexually inappropriate comments on 8/28/19 and requested sexual favors on 9/4/19 and had no documented incidents of sexual abuse. Resident 2 was admitted to the facility in 2014 with [DIAGNOSES REDACTED]. A review of Resident 2's medical record revealed Resident 2 had severely impaired cognitive skills which affected her/his daily decision making and was rarely/never understood. On 9/30/19 at 12:59 PM a FRI (Facility Reported Incident) was received by the State Survey Agency which reported sexual abuse between two residents. On 9/28/19 Staff 5 (CNA) witnessed Resident 1 attempt to put her/his hands up Resident 2's shirt, escorted Resident 1 back to her/his room, educated her/him the behavior was not appropriate and reported the incident to Staff 6 (LPN). On 9/29/19 Resident 1 was observed pinching (Resident 2's) nipples. Staff 5 informed Resident 1 this behavior was not appropriate, escorted Resident 1 back to her/his room, questioned why Resident 1 did what she/he did and Resident 1 responded I like it. The FRI further revealed Resident 2 was not able to give consent. The Abuse Investigation revealed on 9/28/19 Resident 1 attempted to put her/his hands up Resident 2's shirt. Staff immediately intervened and escorted Resident 1 back to her/his room and educated her/him that behavior was not appropriate. On 9/29/19 Resident 1 was observed with Resident 2 pinching (her/his) nipples. Resident 1 was escorted back to her/his room and educated on inappropriate touching. A review of Resident 1's medical record revealed no indication she/he was the perpetrator in any inappropriate sexual touching incident on 9/28/19. A 9/29/19 progress note revealed Resident 1 was caught touching another res (resident) inappropriately. A review of Resident 2's medical record revealed no indication she/he was the victim of sexual abuse on 9/28/19 or 9/29/19. On 10/2/19 at 10:40 AM Staff 7 (LPN) stated she received a verbal report of alleged sexual abuse at the start of her day shift on 9/30/19 and immediately began to review all resident documentation, interview staff and reported the allegation to Staff 2 (DNS). On 10/2/19 at 11:15 AM and 1:13 PM Staff 5 stated she observed Resident 1 in the hallway at approximately 10:00 AM with her/his hands in the area of Resident 2's pants attempting to place her/his hand up Resident 2's shirt, verified she immediately intervened, escorted Resident 1 to her/his room and instructed Resident 1 the behavior was not appropriate. Staff 5 stated she reported the incident to Staff 6 (LPN) and verified there were no other staff in the vicinity who witnessed the incident. On 9/29/19 Staff 5 stated she observed Resident 1 in the hallway at approximately 10:00 AM with her/his hand reaching up and touching Resident 2's breast. Staff 5 verified she immediately intervened, escorted Resident 1 to her/his room, instructed Resident 1 the behavior was not appropriate, questioned Resident 1 why she/he did what she/he did, Resident 1 responded because I like it and stated she reported the incident to Staff 6. Staff 5 stated no care plan interventions changed for Resident 1 or Resident 2 on 9/28/19 or 9/29/19. On 10/2/19 at 11:25 AM Staff 6 stated on 9/28/19 she did not see anything for sure but as she and Staff 5 walked down the hall she thought she saw Resident 1 touching another resident so hollered Hey. Staff 6 stated since she was unsure if anything happened she did not report or document the incident. Staff 6 further stated on 9/29/19 Staff 5 reported the allegation of abuse between Resident 1 and Resident 2. Staff 6 verified she documented a progress note on 9/29/19 for Resident 1, did not revise Resident 1 or Resident 2's plan of care because the CNAs already were aware of Resident 1's behaviors and did not report the 9/28/19 and 9/29/19 incidents to the facility management. Staff 6 stated she attempted to notify Staff 2 (DNS) on 9/29/19 but was unable to contact her. Staff 6 stated she did not notify Resident 1 or Resident 2's physician or responsible parties of the 9/28/19 and 9/29/19 incidents. On 10/3/19 at 12:43 PM Witness 3 (Family of Resident 2) stated she was not informed by the facility of any incidents which happened over the previous weekend. On 10/2/19 at 1:33 PM and 2:20 PM Staff 1 (Administrator) and Staff 2 stated on 9/30/19 it was reported to them on 9/28/19 at approximately 10:00 AM Resident 1 was observed by Staff 5 to attempt to put her/his hand under Resident 2's shirt, Staff 5 intervened, provided reality orientation to Resident 1 and reported the incident to Staff 6. Staff 1 and Staff 2 further stated on 9/29/19 at approximately 10:00 AM Resident 1 approached Resident 2 and was observed to perform a squeezing motion to Resident 2's left breast. Staff 1 and Staff 2 verified Staff 5 reported both the 9/28/19 and 9/29/19 incidents to Staff 6 who did not follow the abuse reporting procedure and did not report the incidents to the facility management. Staff 1 and Staff 2 verified they would expect to see documentation in both Resident 1 and Resident 2's progress notes for the 9/28/19 and 9/29/19 sexual abuse incidents, verified documentation was not completed, and verified no care plan changes or interventions for Resident 1 or Resident 2 were completed at the time of either incident. Staff 2 verified the initial report of the allegation of Resident 1's sexual abuse of Resident 2 was verbally given to her the morning of 9/30/19 by Staff 7 and she received no phone calls from any facility staff on 9/28/19 or 9/29/19. Staff 1 and 2 verified no safety interventions were put into place to ensure the safety of Resident 2 and all female residents after the 9/28/19 sexual abuse incident. Staff 1 acknowledged the 9/28/19 and 9/29/19 incidents between Resident 1 and Resident 2 met the definition of sexual abuse. On 10/3/19 at 10:05 AM the facility was informed of the identified Immediate Jeopardy for the failure to ensure residents were free from sexual abuse. Some situations of abuse do not result in an observable physical injury or the psychosocial effects of abuse may not be immediately apparent. Other residents may not be able to speak due to a medical condition and/or cognitive impairment, cannot recall what had occurred or may not express outward signs of physical harm, pain or mental anguish. Utilizing the reasonable person concept, it was reasonable to assume with Resident 2's [DIAGNOSES REDACTED]. The facility failed to provide supervision and monitoring to ensure the safety of Resident 2 and other female residents after the 9/28/19 sexual abuse allegation was reported by Staff 5 to Staff 6 on 9/28/19. On 9/29/19 Resident 1 sexually abused Resident 2. After the incident on 9/29/19 Staff 6 failed to report the additional allegation of abuse which continued to place all vulnerable residents at risk for abuse. An IJ Abatement Plan was requested. On 10/3/19 at 12:05 PM the IJ Abatement Plan, was received and approved. The Plan included: Immediate Action: 1) Resident 1 would not be in the hallway unattended or out of eyesight from staff. 2) Resident 1 would not be in the dining room with females unattended and would not eat at a dining room table with other female residents. 3) Care plans were updated for both Resident 1 and Resident 2 and both residents were placed on alert to monitor for adverse side effects from the 9/28/19 and 9/29/19 events. 4) Pharmacy was requested to complete a medication review for Resident 1. 5) PASSRII requested for Resident 1. 6) Alternative placement was pursued for Resident 1. Staff Education: All staff would be re-educated on the Abuse Policy and Procedure by the end of business 10/3/19. The education placed a strong emphasis on what abuse was, who reports abuse and how to determine if abuse was reported by reviewing the log in the FRI Reporting Binder. Staff Changes: Staff 6 was immediately suspended for failure to recognize abuse and report abuse. Termination of employment would occur on 10/4/19. On 10/3/19 at 2:55 PM observation, interview and record review verified the IJ Abatement Plan immediate actions were in place, Staff 6 was suspended pending termination and the staff education was initiated. On 10/4/19 at 10:38 AM the IJ Abatement Plan was reviewed for implementation. Observations, record reviews and staff interviews were confirmed the Plan was completed.

Based on interview and record review it was determined the facility failed to report allegations of attempted sexual abuse for 2 of 3 sampled residents (#s 1 and 2) reviewed for abuse. These failures, determined to be an Immediate Jeopardy (IJ) situation, resulted in recurrent sexual abuse by Resident 1 to Resident 2 on 9/29/19. Findings include: Resident 1 admitted to the facility in 2011 with [DIAGNOSES REDACTED]. A review of Resident 1's medical record revealed Resident 1 had a BIMs (cognitive assessment) score of 1 which indicated severe cognitive impairment. A 6/25/19 care plan revealed Resident 1 had a history of [REDACTED]. A review from 6/25/19 through 10/2/19 revealed Resident 1 made sexually inappropriate comments on 8/28/19 and requested sexual favors on 9/4/19 and had no documented incidents of sexual abuse. Resident 2 was admitted to the facility in 2014 with [DIAGNOSES REDACTED]. A review of Resident 2's medical record revealed Resident 2 had severely impaired cognitive skills which affected her/his daily decision making and was rarely/never understood. On 9/30/19 at 12:59 PM a FRI (Facility Reported Incident) was received by the State Survey Agency which reported sexual abuse between two residents. On 9/28/19 Staff 5 (CNA) witnessed Resident 1 attempt to put her/his hands up Resident 2's shirt, escorted Resident 1 back to her/his room, educated her/him the behavior was not appropriate and reported the incident to Staff 6 (LPN). On 9/29/19 Resident 1 was observed pinching (Resident 2's) nipples. Staff 5 informed Resident 1 this behavior was not appropriate, escorted Resident 1 back to her/his room, questioned why Resident 1 did what she/he did and Resident 1 responded I like it. The FRI further revealed Resident 2 was not able to give consent. The 9/30/19 Abuse Investigation revealed the 9/28/19 and 9/29/19 allegations of abuse were not reported to the facility management until 9/30/19. A review of Resident 1 and Resident 2's medical record revealed no evidence the 9/28/19 and 9/29/19 alleged sexual abuse incidents were reported to the facility management. On 10/2/19 at 11:15 AM and 1:13 PM Staff 5 stated she reported the 9/28/19 and 9/29/19 incidents to Staff 6 and verified there were no other staff in the vicinity who witnessed the incidents. On 10/2/19 at 11:25 AM Staff 6 stated on 9/28/19 she did not see anything for sure but as she and Staff 5 walked down the hall she thought she saw Resident 1 touching another resident so hollered Hey. Staff 6 stated since she was unsure if anything happened she did not report the incident. Staff 6 further stated on 9/29/19 Staff 5 reported to her the allegation of abuse between Resident 1 and Resident 2 and verified she did not report the 9/28/19 and 9/29/19 incidents to the facility management. Staff 6 stated she attempted to notify Staff 2 (DNS) on 9/29/19 but was unable to contact her. On 10/2/19 at 10:40 AM Staff 7 (LPN) stated she received a verbal report of alleged sexual abuse at the start of her day shift on 9/30/19 and immediately began to review all resident documentation, interview staff and reported the allegation to Staff 2. On 10/2/19 at 1:33 PM and 2:20 PM Staff 1 (Administrator) and Staff 2 verified Staff 5 reported both the 9/28/19 and 9/29/19 incidents to Staff 6 who did not follow the abuse reporting procedure and did not report the incidents to the facility management. Staff 2 verified the initial report of the allegation of Resident 1's sexual abuse of Resident 2 was verbally given to her the morning of 9/30/19 by Staff 7 and she received no phone calls from any facility staff on 9/28/19 or 9/29/19. Staff 1 acknowledged the 9/28/19 and 9/29/19 incidents between Resident 1 and Resident 2 met the definition of sexual abuse. Staff 2 verified the FRI was not submitted to the State Survey Agency in the required timeframe because Staff 6 did not follow the abuse reporting guidelines and inform the facility management. On 10/3/19 at 10:05 AM the facility was informed of the identified Immediate Jeopardy for the failures to report the 9/28/19 and 9/29/19 allegations of abuse. Staff 6 failed to implement the facility abuse reporting policy and procedure for the instances of sexual abuse of Resident 2 on 9/28/19 and 9/29/19 and further failed to protect all vulnerable female residents from the reoccurrence of sexual abuse. This failure created an environment where sexual abuse could and did reoccur. An IJ Abatement Plan was requested. On 10/3/19 at 12:05 PM the IJ Abatement Plan, was received and approved. The Plan included: Immediate Action: 1) Resident 1 would not be in the hallway unattended or out of eyesight from staff. 2) Resident 1 would not be in the dining room with females unattended and would not eat at a dining room table with other female residents. 3) Care plans were updated for both Resident 1 and Resident 2 and both residents were placed on alert to monitor for adverse side effects from the 9/28/19 and 9/29/19 event. 4) Pharmacy was requested to complete a medication review for Resident 1. 5) PASSRII requested for Resident 1. 6) Alternative placement was pursued for Resident 1. Staff Education: All staff would be re-educated on the Abuse Policy and Procedure by the end of business 10/3/19. The education placed a strong emphasis on what abuse was, who reports abuse and how to determine if abuse was reported by reviewing the log in the FRI Reporting Binder. Staff Changes: Staff 6 was immediately suspended for failure to recognize abuse and report abuse. Termination of employment would occur on 10/4/19. On 10/3/19 at 2:55 PM observation, interview and record review verified the Plan's immediate actions were in place, the staff changes were in progress and the staff education was initiated. On 10/4/19 at 10:38 AM the Plan was reviewed for implementation. Observations, record reviews and staff interviews were confirmed the Plan was completed. Refer to F600.

Based on observation, interview and record review it was determined the facility failed to develop and implement interventions to reduce fall and tripping hazards for 2 of 3 sampled residents (#s 18 and 31) who were reviewed for accidents. This resulted in Resident 31 falling and sustaining a facial laceration which required sutures at the hospital. Findings include: 1. Resident 31 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. Resident 31's 9/3/15 Falls CAA indicated the resident's fall risks included weakness, cognitive impairment and questionable safety awareness. The resident was alert and aware of her/his surroundings, ambulated independently without assistive devices and had good balance. A 2/1/16 Event Report indicated the resident tripped and fell in the courtyard after a smoke break. The resident had facial bleeding, 911 was called and the resident was transported to the emergency department for further evaluation and treatment. The resident was face down on the cement with one shoe off her/his foot laying near her/him. The resident was confused and had a laceration with uncontrolled bleeding. There was an uneven spot in the sidewalk near where the resident fell . The area was corded off and was to be repaved for the safety of all residents. On 2/9/16 at 9:23 am Resident 31 was observed with a laceration to the left eye brow, bruising around the left eye with red patches in the white of the eye and bruising to the left of the lips. The resident stated staff told her/him that she/he fell . On 2/9/16 at 11:06 am Staff 2 (RNCM) stated Resident 31 tripped and fell in the courtyard on 2/1/16. The resident went to the hospital for sutures to the left eyebrow. At the time of the incident the resident did not know what happened. On 2/11/16 at 8:25 am the sidewalk in the courtyard had numerous cracks in the cement and areas where the concrete was buckled. The cracks and buckled areas were patched with cement. Some of the patches appeared older than others and were crumbling or jutted above the surrounding surface and created a tripping hazard. Areas where the cement was buckled were patched in an attempt to create a smooth transition from one section to another. These transitions were too short in length to no longer be a tripping hazard. None of the transitions or patches were painted with a high visibility paint color to alert residents of the potential hazards. The section of sidewalk where Resident 31 fell was buckled and cement patching created a peak several inches higher than the surrounding surface. The area was taped off to prevent residents from using that section of sidewalk. On 2/11/16 at 9:39 am Staff 1 (Administrator) was shown the condition of the courtyard sidewalk. She stated the sidewalk had been that way for the seven to eight years she had been at the facility. She stated they had not considered painting the transitions to help residents identify them. She acknowledged they had painted the transitions in front of the facility. She stated it was a constant battle to continually patch the cracks and it was hard in the winter because the cement did not want to set. Staff 1 acknowledged the taped off area was where Resident 31 fell . 2. Resident 18 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. Progress Notes dated 2/5/16 through 2/7/16 indicated Resident 18 complained of dizziness and was sent out of the facility for observation and testing. The resident returned to the facility on [DATE] from the emergency room with no abnormal findings. The resident was placed on alert charting to monitor her/him. On 2/7/16 the resident became dizzy while standing and was assisted by two CNAs to use a urinal. The resident fell and sustained a skin tear on the back of the right hand. Resident 18's care plan indicated to assist the resident to the toilet as needed and assist with transfers. The care plan did not indicate the resident was supposed to be standing while using the urinal or specifically how the resident was to be assisted with transfers. The facility's care plan binder contained Resident 18's Care Plan but did not have a Resident Status Sheet (an abbreviated care plan used by the aides to provide resident care). A 2/7/16 Event Report indicated Resident 18 was standing with a walker to use a urinal with the assistance of two aides. The resident became dizzy, lost balance and fell . The report indicated staff were following the care plan when Resident 18 fell (the resident's care plan did not provide staff with direction on how to properly transfer and toilet the resident). On 2/8/16 at 11:33 am Resident 18's posterior right hand had a large bruise with scabbing. On 2/10/16 Staff 4 (CNA) stated staff were assisting Resident 18 with transfers using two aides and a front wheel walker. Staff 4 acknowledged the care plan did not indicate to use two aides and a front wheel walker for transfers. On 2/10/16 at 9:57 am and 12:57 pm Staff 3 (DNS) acknowledged Resident 18's care plan did not indicate how staff were to assist the resident with transfers and toileting. Staff 3 acknowledged the Event Report which indicated staff were following the care plan was not accurate.

Based on observation, interview and record review it was determined the facility failed to provide supervision to esnure an environment free of accident hazards for 1 of 3 residents (#42) who smoked independently. Resident 42 was identified to smoke independently on 5/7/2013 although he had a [DIAGNOSES REDACTED]. This placed the resident at risk for immediate jeopardy and constituted substandard quality of care. Findings include: Resident 42 was admitted to the facility in 4/2013 with [DIAGNOSES REDACTED]. The resident was known to be a smoker upon admission to the facility. Smoking Safety assessment dated [DATE] listed cognitive factors/[DIAGNOSES REDACTED]. The assessment also listed psychiatric factors/[DIAGNOSES REDACTED]. The conclusion for Resident 42's assessment was to be supervised while smoking. Resident 42 signed the facility rules for supervised smoking. Care Plan dated 5/7/2013 noted Resident was independent with smoking and had a key to box for storage of cigarettes and lighters outside. Smoking Safety assessment dated [DATE] did not list the cognitive factors/[DIAGNOSES REDACTED]. The psychiatric factors/ [DIAGNOSES REDACTED]. The conclusion on the assessment deemed Resident 42 an independent smoker. The Indpendent Smoker Agreement dated 5/9/2013 was signed by Resident 42 which outlined the facility rules regarding smoking independently which included forfeiture of privileges if they were broken. Residents were not allowed to keep a lighter in their pocket or in the facility, it was to be kept in the lock box in the smoking gazebo. Progress Note dated 5/17/2013, noted Resident 42 fell forward hitting the left side of his face on the wall, resident had no recall of what happened. The facility concluded that the resident had a black out or seizure event. Progress Note dated 5/21/2013 noted Resident 42 had been outside smoking and witnesses stated that he suddenly fell . Facility concluded that the resident had a seizure with a black out. Progress Note dated 5/31/2013 noted Resident was outside smoking and suddenly fell on his side. The facility concluded the fall appeared to be related to his balance and seizure concerns. Progress Note dated 6/10/2013 noted Resident 42 had a fall during a grand mal seizure and was sent to the emergency room for evaluation due to the duration of the seizure. Progress Note dated 6/17/2013 noted Resident 42 was outside smoking at the gazebo and suddenly fell face forward onto a rail. A witness statement reported "that he fell like a tree making no attempt to stop himself." Progress Note dated 6/19/2013 noted Resident 42 was with a physical therapist in the hall and fell face first to the floor. The Progress Note concluded the resident had another seizure and blacked out causing a laceration to his chin and abrasion bruise to outer right side of eye. Progress Note dated 6/28/2013 noted Resident 42 was outside walking back from the smoking gazebo when he/she stumbled and fell forward. Resident had an abrasion to his left cheek and shin, the laceration appeared to need stitches and 911 was called to assess for an emergency room visit. The facility concluded that the resident appeared to black out and had a long history of seizures. Nurses Note dated 7/23/2013 Resident 42 was found in room having a seizure on bed seizure lasted about 1 minute." Was up walking later and stumbled but caught himself, resident refused an assessment." Smoking Safety Assesment update on 7/24/2013 noted Resident 42 adhered to smoking rules and remained appropriate to smoke independently with no additional comments. A quarterly review of Resident 42 dated 7/24/2013 noted: He is an independent smoker and has adhered to rules and regulations. There have been no "smoking" related accidents. However he has had several seizures/falls while out smoking. On 8/19/2013 at 10:20 am, Resident 42 was observed outside the facility with a red lighter in his hand, headed toward the outside smoking area. On 8/20/2013 at 10:23 am, Resident 42 was observed in the facility hallway with a red lighter in his hand, headed toward the outside smoking area. On 8/20/13 at 1:10 pm, Resident 42 was observed smoking alone in the gazebo located outside the facility. Resident 42 stated that the lock box he used was number 1 and that he kept his cigarettes in the lock box and his key and lighter with him in his pocket. He stated that he does light his own cigarettes. On 8/20/13 at 2:23 pm, Staff 2, RNCM stated Resident 42 was supervised while smoking initially after admission to the facility, due to his confusion. Staff 2 further stated that his medical condition which included seizures (epilepsy) and dementia had not changed. Staff 2 reviewed Smoking assessment dated [DATE] and 5/9/2013. Staff acknowledged that the medical [DIAGNOSES REDACTED]. Staff 2 stated that Resident 42 liked his independence. Staff 2 also acknowledged Resident 42 would be a safety risk if he had a seizure while smoking. On 8/20/2013 at 2:19 pm, Staff 8, CNA stated Resident 42 was not assisted to smoke and it is not care planned. Staff 8 stated that she had concerns about safety due to Resident 42's epilepsy. On 8/20/2013 at 3:54 pm, Staff 1 DNS, and Staff 3, Administrator were informed Resident 42 stated that he had a lighter in his pocket. Staff 1 and Staff 2, RNCM acknowledged Resident 42's seizure acitivty/falls as he walked to the gazebo, during smoking at the gazebo and after smoking. The facility acknowledged the Smoking assessment dated [DATE] did not include the same [DIAGNOSES REDACTED]. The immediate jeapardy was abated on 8/20/2013 at 6:32 pm when the survey team received the plan of correction.