Every finding on record at Terraces of Boise, The

Based on Idaho State LTC Reporting Portal System, policy review, record review and staff interview, it was determined the facility failed to ensure resident's rights were protected to be free from misappropriation of residents' funds. This was true for 1 of 3 residents (Resident #39) whose record was reviewed for misappropriation. This deficient practice caused emotional and financial harm when Resident #39's personal finances were used by a facility staff member. Findings include: Resident #39 was admitted to the facility on [DATE] with multiple diagnoses including a left pubic fracture, dementia, and depression. Resident #39's admission MDS assessment dated [DATE], documented Resident #39 was cognitively intact. An I&A, dated 12/4/25, was submitted to the Idaho State LTC Reporting Portal System identifying a facility staff member had stolen $1900 from Resident #39.The report documented on 12/4/25 at 11:30 AM, the Executive Director (ED) was contacted by the Boise Police Department regarding the status of an ongoing investigation into suspected financial exploitation involving a former short-stay rehabilitation resident, [Resident #39]. The investigating officer reported the police department had obtained documentation confirming [CNA #2] had used [Resident #39's] credit card to pay their personal rent and utility bills.The I&A further documented, the June 2025 incident, when [Resident #39s] family notified the facility of unexplained and unauthorized activity on the resident's credit card statement. At the time of the family's concern, the resident had recently completed a short-stay rehabilitation stay at the facility from 6/1/25 through 7/2/25. The family expressed concern the activity may have occurred during the resident's stay but were unsure due to complex family dynamics. The ED immediately assisted the family in contacting law enforcement and filing a formal police report.On 12/4/25, law enforcement informed the ED they had secured evidence linking the unauthorized charges, totaling $1,900, directly to [CNA #2]. The ED informed the family of the findings and reaffirmed the facility does not tolerate any form of abuse, neglect, or exploitation. The family stated they would check with the credit card company to confirm whether fraud charges had been removed and would follow up with the ED. The Nursing Home Administrator (NHA) was alerted to the findings immediately.On 12/17/25 at 11:34 AM, the ED stated the facility was unaware any theft had happened regarding CNA #2. He stated Resident #39 had left the facility with his family prior to any police investigations.The ED continued, When the police notified the facility of the theft, we started our internal investigations, staff trainings, and resident reviews for any additional misappropriation which might have occurred. CNA #2 was found by the police, but we have no further information regarding the case. The ED also stated the facility has been in communication with the family to make reparations; however, we cannot do more until we file for the completed case report. When asked why the facility did not address the concerns when the family first notified the facility in June 2025, the ED stated he had directed the family to contact law enforcement to file a report since the family was not sure if the charges had come from the facility or their family. The facility did not conduct any internal facility investigations at the time of the original notification in June 2025.

Based on observation, the FDA Food Code, and staff interview, it was determined the facility failed to ensure food items were appropriately labeled, dated, and covered, dish racks and air condenser refrigerator fans were cleaned and sanitized. These deficiencies had the potential to affect the 36 residents who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. Findings include: Based on observation, the FDA Food Code, and staff interview, it was determined the facility failed to ensure food items were appropriately labeled, dated, and covered, and dish racks, air condenser refrigerator fans were cleaned and sanitized. These deficiencies had the potential to affect the 36 residents who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. Findings include: 1. The FDA Food Code Section 3-302.11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation documented, food shall be protected from cross contamination by separating raw animal foods during storage, preparation, holding, and display from raw ready-to-eat foods including other raw animal food such as fish. The FDA Food Code Section 3-501.17 Ready-to-Eat, TCS (time/temperature control for safety) food, date marking, documented marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded.On 12/18/25 at 4:18 PM, the following was observed in the walk-in meat refrigerator and freezer: Refrigerator: Salmon open and uncovered, stored below raw beef. Undated, unlabeled seared cooked beef stored below raw beef. Freezer: Open and undated chicken wings, chicken tenders, and frozen scones. Uncovered shrimp cocktail, cooling from recent cooking. On 12/18/25 at 4:22 PM, the Kitchen Manager stated the food should have been covered, labeled, and dated. He further stated cooked food should be stored above raw food, and raw fish should be stored above raw beef, and it was not. 2. The FDA Food Code Section 4-501.12 Cutting Surfaces documented cutting surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms (tiny living things including bacteria, viruses, and fungi) transmissible through food may build up or accumulate. These microorganisms may be transferred to foods that are prepared on such surfaces. On 12/18/25 at 4:25 PM, it was observed in the main kitchen a white cutting board with colored stains and pitting. On 12/19/25 at 9:39 AM, during a walk through of the storage areas for [NAME], Maple, and Redwood Houses, cutting boards in the 3 houses had discoloration and pitting in the middle of multicolored boards. On 12/19/25 at 10:04 AM, the Kitchen Manager stated the cutting boards were discolored and pitted and should have been replaced. 3. The FDA Food Code Section 4-602.11 Equipment Food-Contact Surfaces and Utensils documented microorganisms may be transmitted from a food to other foods by utensils, cutting boards, thermometers, or other food-contact surfaces. Food-contact surfaces and equipment used for time/temperature control for safety foods should be cleaned as needed throughout the day but must be cleaned no less than every 4 hours to prevent the growth of microorganisms on those surfaces. On 12/18/25 at 4:00 PM, the following was observed: The condenser fan covers in the walk-in produce refrigerator had a layer of dust blowing out from fans. The clean pot and pan drying rack next to the walk-in meat refrigerator and clean side of the dishwashing area had a layer of dust on the racks surrounding the clean pots, pans, and utensils. On 12/18/25 at 4:02 PM and 4:18 PM, the Kitchen Manager stated whenever covers are seen with dust, we will put in a work order for maintenance to remove them and we missed these fan covers. The kitchen manager also stated they had not cleaned or sanitized the dish drying racks in some time as they were working through the refrigerator racks first. We should have cleaned and sanitized these racks long before they developed a layer of dust. On 12/18/25 at 4:58 PM, during dinner tray line observation at [NAME] House, the following was observed: At 5:15 PM, [NAME] #1 placed food containers on top of the cutting board and knife used for chopping foods for mechanical chopped diets. At 5:17 PM, [NAME] #1 removed the food containers and chopped up vegetables and cooked chicken without cleaning or sanitizing the cutting board and knife. At 5:19 PM, [NAME] #1 placed a sauce container back onto the cutting knife, on top of the cutting board to serve sauce on top of the chicken and vegetables. He then placed the sauce container back into the heating cart. [NAME] #1 did not clean or sanitize the cutting board and knife. At 5:20 PM, [NAME] #1 placed a drinkable straw on the same cutting board as listed above, filled up the cup with liquid food, and then placed the drinkable straw into the cup which was then served to the resident. At 5:24 PM, [NAME] #1 placed the sauce container from the heating cart back on top of the flat surface of the cutting knife which was lying on the cutting board. He used the same knife to cut cooked noodles and chicken breast without sanitizing or cleaning between uses. [NAME] #1 then used the flat surface of the cutting knife to scoop up cut chicken breast and noodles onto a resident's plate, which was served. Cleaning and sanitation of the cutting board and knife was not observed for the duration of tray line which ended at 5:42 PM. On 12/18/25 at 5:45 PM, [NAME] #1 stated the containers are cleaned and sanitized prior to use. He stated the containers could have been placed elsewhere on the countertop, but he did not believe he was cross contaminating food contact surfaces since everything was cleaned and sanitized prior to use. When asked if the cutting board and knife should have been cleaned between uses, when the containers were placed on top of them, he stated they could have been, but it is not what he normally does. On 12/19/25 at 9:51 AM, the Kitchen Manager stated [NAME] #1 should have placed the sauce and food containers on the countertop, not on top of the cutting board and knife. He stated the cutting board, and knife should have been cleaned and sanitized after being used for holding the food and sauce containers.

Based on observation, record review, and staff interview it was determined the facility failed to ensure sanitary laundry services were provided to the residents, hand hygiene was performed by facility staff, and medication was stored appropriately. This deficient practice had the potential for harm if facility residents were provided laundry, staff cares, and medications which were not handled with appropriate sanitation practices. Findings include: 1. On 12/17/25 at 2:35 PM, it was observed in Redwood House's laundry room, Resident #18's laundry was left wet in the washing machine. On 12/17/25 at 2:37 PM, RN #1 stated Resident #18's laundry would not have been washed earlier than 10:00 AM as CNAs will sometimes do laundry during the day if a resident requires it. She stated, the facility has a shift change at 2:00 PM in the afternoon, so the laundry would not have been waiting wet more than 4 hours. RN #1 could not provide an exact time the laundry had been started as the day shift CNAs were no longer available and there is no tracking system to know which CNA started the load of laundry. On 12/17/25 at 2:45 PM, it was observed in [NAME] House's laundry room clothes were hanging from a rack on the clean and dirty sides of the laundry room. On 12/17/25 at 2:48 PM, CNA #3 stated, Clothes hanging up on either side of the laundry room would be considered by CNA's to be clean and just waiting to be taken to the resident's room. On 12/17/25 at 3:15 PM, it was observed in Maple House's laundry room, Resident #30's wet laundry was left sitting in the washing machine. On 12/17/25 at 3:15 PM, the Housekeeping Lead stated wet laundry should be changed within an hour. On 12/17/25 at 3:24 PM, the ED stated, The side with the washers is dirty - but clothes hanging next to the outer wall hanging up could be clean. However, the dirty side should only be for dirty clothes. He further stated there is no current way to tell when the washing machine was started or how long the laundry had been sitting in the washing machines ready to move to the dryer. The ED stated CNAs train other CNAs how to do residents laundry and they should not be hanging clothes on the dirty side if they are clean. On 12/17/25 at 4:59 PM, the DON/IP stated the change of shift (between day and afternoon) might make it longer between loads (wash to dryer) but the DON/IP would not expect wet laundry to wait more than 2 hours before moving it to the dryer. She further stated clean laundry should remain on the clean side of the laundry room, not on the dirty side. On 12/17/25 at 3:29 PM, staff were observed walking into the clean side door of the main laundry room with 2 bags of dirty linen. On 12/17/25 at 3:33 PM, the Housekeeping Lead stated the staff member should have walked into the dirty side with those laundry bags. She will need to be trained. 2. On 12/18/25 at 8:45 AM, RN #1 was observed for morning medication pass. RN #1 performed hand hygiene at 8:59 AM and began to prepare medications for Resident #43. At 9:12 AM, RN #1 entered Resident #43's room. No hand hygiene observed upon entrance to Resident #43's room. RN #1 administered medications to Resident #43, performed hand hygiene and exited the room. When asked when hand hygiene is performed, RN #1 stated, Before and after. It's difficult with a med cup and water in hand. When asked if RN #1 performed hand hygiene before entering resident #43's room RN #1 stated, I did not perform hand hygiene. 3. On 12/18/25 at 8:43 AM, five capsules were observed on top of the medication cart. There was no barrier between the five capsules and top of the medications cart, and LPN #1 was about 3-4 steps away from her medication cart talking to the ST. As soon as LPN #1 saw the surveyor, LPN #1 walked back to her cart and opened the capsule and placed them inside the pill pouch. On 12/18/25 at 9:11 AM, when asked about the capsules on top of the medication cart, LPN #1 stated she should have put the capsules inside the medication cup.

Based on observation, policy review, and staff interview it was determined the facility failed to ensure residents were treated with dignity when referring to resident's as feeders who require assistance when eating, as well as serving meals at the same time to residents sitting at the same table. This was true for 4 of 4 residents (#3, #13, #17, and #22) who were observed during dining. This deficient practice had the potential to create psychosocial harm to residents if resident's felt inferior by being referred to as feeders or not being served meals at the same time. Findings include:The Facility's Dignity Policy, revised February 2021, documented residents are to be cared for in a manner which promotes and enhances their sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Staff are expected to provide a dignified dining experience, and to always speak respectfully to residents.1. Resident #3 was admitted to the facility on [DATE] with multiple diagnoses including Alzheimer's, dementia, depression, ataxia (a lack of muscle control and coordination), and muscle weakness. Resident #13 was admitted to the facility on [DATE] with multiple diagnoses including dementia, brain bleed, repeated falls, and muscle weakness. Resident #17 was admitted to the facility on [DATE] with multiple diagnoses including dementia, muscle weakness, and dysphagia (difficulty swallowing). On 12/18/25 at 4:55 PM, before dinner service, the surveyor overheard CNA #2 orienting an agency CNA staff member. CNA #2 pointed to Resident #3, #13, and #17's table and referred to their table as a special table with feeders who would need additional help. At 5:35 PM, CNA #2 asked [NAME] #1 when the feeders table's meals would be ready to serve. On 12/18/25 at 5:55 PM, CNA #2 stated she should not be referring to resident's as feeders and she should not be pointing out that their table was special. 2. Resident #22 was admitted to the facility on [DATE] with multiple diagnoses including, Alzheimer's Disease (a progressive brain disorder that slowly destroys memory, thinking skills, and eventually the ability to carry out simple tasks), Osteoarthritis, and muscle weakness. On 12/15/25 Resident #22 was observed in the [NAME] dining room as follows: At 12:26 PM, Resident #22 was observed seated adjacent to Resident #41. Resident #41 was served her meal and eating while Resident #22 had not been served her plate. Resident #22 asked, Are we going to get our food? At 12:32 PM, Resident #22 told Resident #41 I have nothing to eat and Can I get more of this, pointing at her drinking glass. Glass was observed almost empty. At 12:36 PM CNA #1 served regular food minced and moist with mashed potatoes with gravy. Resident #22 started eating. At 12:44 PM, Resident #22 was served with another plate of minced and moist food which consisted of mashed potatoes and parmesan chicken pesto. On 12/15/25 at 1:14 PM, when asked why Resident #22 was not served her food at the same time as Resident #41, [NAME] #1 stated, the cook that was in charge of making special diets like minced and moist, forgot about it and had to get it from the kitchen upstairs. When asked if Resident #22 always eats in the [NAME] Dining Room, [NAME] #1 stated, Yes, she always eats in this dining room. On 12/16/25 at 2:33 PM, the RD stated residents sitting at the same table should be served their meals at the same time.

Based on observation, SOM Appendix PP, and staff interviews it was determined the facility failed to provide timely meals to residents when they had to wait more than 45 minutes to receive breakfast from the posted time. This was true for 7 of 15 residents (#3, #13, #14, #17, #22, #33 and #50) observed during dining service. This deficient practice created the potential for harm if residents did not receive their meal to avoid potential food-medication interactions, and psychosocial harm if not provided meals in a timely manner. Findings include:A review of the MDS Assessment, section GG, self care, documented Resident #33 required substantial/maximal assistance with eating, Resident's #3 and #13 were dependent for eating, Resident #17 required partial/moderate assistance, and Resident #14 required supervision or touching assistance. On 2/9/26 at 7:15 AM, a dining meal schedule was observed posted in the [NAME] dining room which documented a hot breakfast serviced started at 8:00 AM.Four staff members (1 LPN and 3 CNAs) were observed in the dining room.On 2/9/26 at 8:37 AM, the following was observed in the [NAME] dining room: At 8:37 AM, CNA #2 stated the residents were now seated in the dining room, and asked [NAME] #1 if he was ready to serve, to which he replied, Yes, and began serving the dining room residents. Between 8:49 AM and 8:56 AM, Resident #3, #14, #17, and #33 received their breakfast meals. At 8:57 AM, Resident #22 received her breakfast meal.At 9:10 AM, Resident #50 received her breakfast meal in her room.At 9:12 AM, Resident #14 was observed drinking syrup from a ramekin. The ramekin slipped from his hand onto his pants, when he began using a fork to eat the syrup off of his pants. At 9:13 AM, Resident #13 received his breakfast meal in his room. Support Staff #1 remained in Resident #13's room to assist him with breakfast.On 2/9/26 at 2:01 PM, the DON stated she was unaware meals needed to be delivered within 45-minutes of the posted mealtime. She believed the mealtime started whenever residents were ready to eat in the dining room.On 2/10/26 at 10:15 AM, CNA #3 stated many residents in [NAME] house require 1-2 staff to assist them in the morning. CNA #3 stated, When I arrive for my shift, I work from 6:00 AM until breakfast to get resident's up and ready, but it does take until after 8:00 AM to get the residents into the dining room. When asked if there were enough staff, CNA #3 stated it would be nice to have extra hands to assist with resident needs.On 2/10/26 at 11:30 AM, when asked if there were enough staff to attend to the needs of the [NAME] house residents during meal times, the administrator stated he had enough nursing staff. Cross-reference F550.

Based on observation, staff interview, and record review, it was determined the facility failed to ensure position change alarms were assessed as potential restraints and a consent from the residents' representative and physician's order were obtained prior to installation of the alarms. This was true for 2 of 3 residents (#14 and #22) reviewed for potential restraints. This deficient practice had the potential for harm if the position change alarms were improperly used and if resident's experienced physical deterioration due to lack of movement. Findings include:The State Manual Appendix PP issued 7/23/25, documented if the facility staff choose to implement alarms, they should document their use aimed at assisting the staff to assess patterns and routines of the resident. Use of these devices, like any care planning intervention, must be based on assessment of the resident and monitored for efficacy on an on-going basis.The facility's Falls and Fall Risk, Managing policy revised March 2018, documented:If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant.If underlying causes cannot be readily identified or corrected, staff will try various interventions based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable.The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling.The use of position alarm will be monitored for efficacy and staff will respond to alarms in a timely manner. 1.Resident #14 was admitted to the facility on [DATE], with multiple diagnoses including Alzheimer's disease with late onset, muscle weakness and hypertension.A Risk for Fall care plan documented Resident #14 had tab alarm, chair, pressure alarm bed as fall prevention device, initiated 8/21/24.Resident #14's record did not include documentation a least restrictive devices were attempted prior to him using the position change alarm. Also, his record did not include an assessment of him using the chair and bed alarm as a potential restraint.On 12/16/25 at 11:38 AM, 12/16/25 at 2:07 PM, and 12/17/25 at 11:14 AM Resident #14 was observed in his wheelchair with a tab alarm attached to the back of his wheelchair, clipped on the back of his shirt. 2. Resident #22 was admitted to the facility on [DATE] with multiple diagnoses including Alzheimer's disease, muscle weakness and hypertension.A Risk for Fall care plan documented Resident #22 had a tab alarm to her bathroom door and tag alarm to her wheelchair initiated 5/6/25.On 12/16/25 at 11:38 AM and 12/18/25 at 5:06 PM Resident #22 was observed in her wheelchair with a tab alarm attached to the back of her wheelchair and clipped on her shirt.Resident #22's record did not include documentation that least restrictive devices were attempted prior to her using the position change alarm. Her record did not include an assessment of her using the chair alarm as potential restraint.On 12/18/25 at 4:25 PM, when asked about Resident #14 and Resident #22 having a tab alarm attached on their wheelchair, the DON stated it comes with some sort of fall risk assessments, residents being impulsive, and sometimes as requested by their representatives. The least restrictive interventions were also used such as providing the resident with soft touch call light or placing them closer to the nurse's station, using the tab alarm was our last resort. When asked about the resident's assessment before placing the tab alarm, the DON stated there was no assessment, only the fall risk assessment was completed. The DON also stated they did not require a consent before placing the tab alarm on the residents.

Based on record review and staff and resident interview, it was determined the facility failed to ensure resident's missing personal item was investigated as potential misappropriation of resident's property. This was true for 1 of 1 resident (Resident #34) reviewed for misappropriation of personal property. This failure created the potential for Resident #34 to experience emotional distress due to the loss of a personal item with inherent value. Findings include:Resident #34 was admitted to the facility on [DATE] and readmitted [DATE], with multiple diagnoses including Parkinson's disease (a movement disorder that affects the nervous system), diabetes and hypertension.A Quarterly MDS assessment dated [DATE], documented Resident #34 was cognitively intact.On 12/16/25 at 9:36 AM, Resident #34 stated a ring which was given to her by her grandmother went missing. Resident #34 stated she reported it to the facility and was told they will look for it. Resident #34 stated she was told the ring had not been found yet, and they will keep looking for it.On 12/19/25 at 10:31 AM, when asked to describe her missing ring, Resident #34 stated the ring had three stones, an emerald stone in the middle and two diamonds on the side and set in gold.On 12/17/25 at 2:26 PM, the LSW stated Resident #34 asked her family member to bring the ring to the facility on her birthday at the end of July 2025, and it was reported missing two weeks after it was brought into the facility. The LSW stated they posted a picture of the ring in the facility and looked through Resident #34's room, as well as in the laundry but the ring was not found.An undated telephone text message provided by the ED documented, Also M103 [Resident #34's room] daughters in today and state they brought in a family heirloom ring (resident's grandmother's ring a diamond and emerald ring). They brought it in last Wednesday and on Friday resident told them she had lost it.On 12/17/25 at 3:40 PM the ED was asked if Resident #34's missing ring was investigated, the ED stated they put a signage of the missing ring in the facility for about a month and looked for it in her room and laundry room, but the ring was not found. When asked if CNAs who provided care to Resident #34 and other staff were interviewed, the ED stated, Yes. When asked for the documentation of what was done to look for Resident #34's ring, the ED stated they did look for the ring and staff were interviewed, but he did not have documentation of what they did to look for the missing ring. The ED stated there were no progress notes made and there should have been. He stated, We did all the right things except writing it down.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure resident's MDS assessments accurately reflected their status. This was true for 1 of 1 resident (Resident #6) whose MDS assessment was reviewed. This deficient practice had the potential for negative outcomes if Resident #6 was not assessed and/or monitored due to inaccurate assessments. Findings include:Resident #6 was admitted to the facility on [DATE] and readmitted [DATE] with multiple diagnoses, including heart disease, anemia, and hypertension.Resident #6's MDS assessments documented the following: admission assessment dated [DATE], he had no impairment on his upper and lower extremities Quarterly assessment dated [DATE], he had impairments on both sides of his upper and lower extremities.Resident #6 was observed on the following days as follows: 12/16/25 at 3:05 PM, able to move his both [NAME] while his wheelchair was being push by the staff. 12/17/25 at 10:52 AM, sitting in his wheelchair in the living room of [NAME] House during activity with other residents, with his hand supporting his chin.On 12/18/25 at 2:24 PM, when asked during telephone interview regarding Resident #6's Quarterly MDS assessment of his range of motion dated 9/15/25, the MDS nurse stated she would review the MDS and would call the surveyor back.On 12/18/25 at 4:08 PM, the MDS nurse called back and stated, Resident #6's Quarterly MDS assessment dated [DATE] was mistakenly coded as with impairment on both sides of his upper and lower extremities. The MDS nurse stated it should have been coded as no impairment.

Based on observation, record, policy review, and staff interviews, it was determined the facility failed to follow residents comprehensive centered care plans. This was true for 1 of 6 residents (Resident #22) reviewed for care plan implementation. This deficient practice had the potential for physical harm related to Resident #22's receiving beverages that did not meet her ordered dietary needs. Findings include:The facility's Care Plan policy, revised March 2022, documented care interventions are chosen after data gathering, considering the residents problem areas and their causes, and relevant clinical decisions. Resident #22 was admitted to the facility on [DATE] with multiple diagnoses including Alzheimer's disease, muscle weakness, dementia, depression, and anxiety.Resident #22's care plan, initiated 4/3/25, documented a diet order to include offering unsweetened or sugar-free beverages.On 2/9/26 the following observations were made:At 7:37 AM, CNA #2 provided Resident #22 with orange juice.At 8:33 AM, Support Staff #1 gave Resident #22 a second glass of orange juice.At 8:59 AM, Resident #22 received her breakfast and a third glass of orange juice.On 2/10/26 at 1:57 PM, the RD stated, Resident #22 is on a no sweetened beverage diet order. She should not have gotten orange juice.

Based on observation, record review, and staff interview it was determined the facility failed to ensure care plans were revised as needed. This was true for 1 of 13 residents (Resident #8) whose record was reviewed for care plan revision. This deficient practice created the potential for harm if the Resident #8 did not receive oxygen treatment as ordered. Findings include:Resident #8 was admitted to the facility on [DATE], and re-admitted on [DATE], with multiple diagnoses including sleep apnea and chronic obstructive pulmonary disease (an ongoing lung condition caused by damage to the lungs).A physician's order, dated 11/12/25, directed staff to provide oxygen at 2 LPM via nasal cannula, at all times for every shift.Resident #8's care plan, dated 11/12/25, directed staff to provide oxygen continuously at 2 LPM via nasal cannula and to provide oxygen monitoring and management.On 12/16/25 at 9:19 AM, Resident #8 was observed lying in bed without an oxygen nasal cannula.On 12/18/25 at 11:36 AM, Resident #8 was again observed lying in bed without an oxygen nasal cannula. When asked where her oxygen nasal cannula was, Resident #8 stated she had not been using it for some time. She did not remember the exact date.On 12/19/25 at 10:14 AM, the ADON stated Resident #8 had been receiving O2 via nasal cannula continuously; however, she had been weaned off it and was using room air with oxygen saturation vitals taken twice per day. The ADON stated the care plan and physician's order had not been updated to reflect the removal of the nasal cannula for room air. The care plan should have been updated to reflect Resident #8's current oxygen treatment.

Based on policy review, observation, and interview, it was determined the facility failed to ensure medications were administered according to professional standards of practice. This was true for 1 of 7 residents (Resident #42) observed during medication administrations. This failed practice created the potential for Resident #42 to experienced adverse effects when her medications were not administered according to physician's order. Findings include: The facility's Administering Medications policy revised April 2019 documented the individual administering the medication checks the label three times to verify the right resident, right medications, right dosage, right time, and right method (route) of administration before giving the medication.Resident 342 was admitted to the facility on [DATE], with multiple diagnose including inflammatory neuropathy (condition that affects the peripheral nerves, leading to symptoms such as weakness, numbness, and pain), anemia and hypertension.A physician's order documented Resident #42 was to receive the following medications: gabapentin 300 mg capsule, one capsule by mouth one time a day for pain, ordered 12/13/25 gabapentin 400 mg capsule, one capsule by mouth at bedtime for pain, ordered 12/12/25On 12/18/25 at 9:21 AM LPN #1 prepared and administered Resident #42's morning medications which included gabapentin 400 mg one capsule.On 12/18/25 at 9:45 AM, LPN #1 reviewed the physician's order of Resident #42's medications. LPN #1 stated she gave the 400 mg gabapentin to Resident #42. LPN #1 stated, I should have given the 300 mg gabapentin.

Based on observation, record review, and staff interview it was determined the facility failed to provide respiratory services. This was true for 1 of 1 resident's (Resident #8) who was reviewed for oxygen and respiratory services. This deficient practice had the potential for Resident #8 to experience shortness of breath when her physician's order was not followed. Findings include:Resident #8 was admitted to the facility on [DATE], and re-admitted on [DATE], with multiple diagnoses including sleep apnea and chronic obstructive pulmonary disease (a lung condition caused by damage to the lungs).A physician's order, dated 11/12/25, directed staff to provide Oxygen at 2 LPM via nasal cannula, at all times for every shift. On 12/16/25 at 9:19 AM, and on 12/18/25 at 11:36 AM, Resident #8 was observed lying in bed without oxygen via nasal cannula. Resident #8 stated she had not been using her oxygen for some time and did not know the exact date it stopped. On 12/19/25 at 10:14 AM, the ADON confirmed the facility was not currently providing 2 LPM of oxygen via nasal cannula at all times as per physician's orders.

Based on observation, record review, staff interview, and policy review, it was determined the facility failed to ensure medications were secured when they were unattended by staff and to ensure pharmacy labels matched the physician's order. This was true for 1 of 1 resident (Resident #30) whose medication administration was observed. This failed practice created the potential for harm if medications were taken by another resident and should Resident #30's Oxycodone (opioid pain medication) be administered at the wrong dose. Findings include: Resident #30 was admitted to the facility on [DATE], with multiple diagnoses including stage 4 pressure ulcers of left and right heels, and hypertension (high blood pressure).1.On 12/18/25 at 12:05PM, LPN #2 entered Resident #30's room with her medications on hand. Upon entering Resident #30's room, she stated she needed to use the restroom, LPN #2 requested help from CNA to assist Resident #30 to the restroom. LPN #2 exited room with medications in hand along with dirty dishes. Upon exiting Resident #30's room, LPN #2 was observed leaving a cup containing a white powder on top of the medication cart. LPN #2 brought dirty dishes to the kitchen and returned to the medication cart. LPN #2 then took the cup with the white powder into the kitchen and mixed it with water, LPN #2 walked back to the medication cart, placing the cup containing the white powder mixed with water on top of the medication cart when a male resident asked her what soup was being served for lunch. LPN #2 was observed leaving the cup containing the white powder mixed with water on top of the medication cart and returned to the kitchen to check the menu for the male resident.On 12/18/25 at 12:15 PM when asked about the cup containing the white powder mixed with water left on top of the medication cart when she went to the kitchen to check the menu, LPN #2 stated, no Miralax (laxative used to treat occasional constipation). When asked if nursing staff was supposed to leave Miralax on top of the medication cart, LPN #2 states, No.On 12/19/25 at 10:55 AM, when asked if nurses were to leave medications unattended on top of the medication cart, the DON stated, No. 2. The facility's Labeling of Medication Containers Policy revised April 2019, documented any medication packaging inadequately or improperly labeled are returned to the issuing pharmacy. A physician's order documented Resident #30 was to receive the following: Oxycodone HCl 5 mg tablet: 0.5 tablet by mouth twice daily [6 AM and 12 PM] Oxycodone HCl 5 mg tablet: 0.5 tablet by mouth twice daily as neededOn 12/18/25 at 12:20 PM, LPN #2 prepared and administered Resident #30's medication which included the Oxycodone. The Oxycodone IR pharmacy label documented Give 0.5 tablet by mouth four times daily as needed.On 12/18/25 at 12:35 PM, when asked about the physician's order for Resident #30's Oxycodone, LPN #2 stated Resident #30 had scheduled and as needed orders for Oxycodone. When asked if the order was the same on the pharmacy's label LPN #2 stated, No. When asked what the policy was for labeling when orders change, LPN #2 stated, put an order change sticker on it. No order change sticker was observed on the medication card.On 12/19/25 at 10:55 AM, when the DON was asked if physician orders and pharmacy card labels were to match, the DON stated, Yes it should, when a provider changes the order, the pharmacy should send a new card to match. The DON stated, if nursing staff finds a pharmacy label does not match the MAR the nurse is to call the pharmacy to get a new card dispensed.

Based on observation and staff interview, it was determined the facility failed to ensure kitchen equipment was clean and food was stored in a safe and sanitary manner. This deficency had the potential to affect the 36 residents who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. Findings include: FDA Food Code Section 4-602.11 Equipment Food-Contact Surfaces and Utensils: (E) Surfaces of utensils and equipment contacting food that is not time/temperature control for food shall be cleaned: (4) In equipment such as ice bins and beverage dispensing nozzles and enclosed components of equipment such as ice makers, cooking oil storage tanks and distribution lines, beverage and syrup dispensing lines or tubes, coffee bean grinders, and water vending equipment: (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold. FDA Food Code Section 6-501.14 (A) Documented cleaning ventilation systems intake and exhaust air ducts shall be cleaned so they are not a source of contamination by dust, dirt, and other materials. On 12/16/24 and 12/19/24, it was observed in the main kitchen walk-in refrigerator, the air conditioner fan covers were coated in a layer of dust with short strands of dust waving in the air current. On 12/19/24 it was observed the ice machine in the main kitchen had a layer of pink slime mold on the [NAME] side of the interior of the ice machine. On 12/19/24 at 11:42 AM, the Dietitian confirmed there was a layer of pink slime mold in the ice machine and stated she was unsure when the ice machine had last been serviced by the third party vendor. On 12/19/24 at 11:42 AM, the Maintenance Technician confirmed the ice machine in the main kitchen is serviced and cleaned quarterly by a third party. The last cleaning of the ice machine was on 11/26/24. The Maintenance Technician stated the walk-in refrigerator air conditioning covers are meant to be cleaned quarterly, and he was unsure why the air conditioning cover in question was not cleaned.

Based on observation, interview, and FDA Food Code review, it was determined the facility failed to ensure garbage was properly disposed of to minimize attracting insect and rodents. This deficient practice had the potential to affect all residents, staff, and visitors in the facility. Findings include: FDA Food Code Section 5-501.15 Outside Receptacles: (B) Receptacles and waste handling units for refuse and recyclables such as an on-site compactor shall be installed so that accumulation of debris and insect and rodent attraction and harborage are minimized and effective cleaning is facilitated around and, if the unit is not installed flush with the base pad, under the unit. On 12/19/24 it was observed in the facility garbage compactor area, various items of edible and non-edible refuse were spread around the ground near the garbage compactor. On 12/19/24 at 10:15 AM, the Dietitian stated she was unsure when the area around the garbage compactor had last been cleaned. On 12/19/24 at 11:48 AM, the Maintenance Technician and Administrator confirmed the garbage compactor area was cleaned every two weeks, after the compactor is emptied. The Maintenance Technician stated the area had been cleaned the previous week and was not scheduled to be cleaned until the following day.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure infection prevention measures were taken when reusable medical equipment was not disinfected between residents. These failures had the potential to impact residents in the facility by placing them at risk for cross contamination and infection. Findings include: The facility's Cleaning and Disinfection of Resident-Care Items and Equipment policy, revised 9/22, documented, resident care equipment, including reusable medical equipment will be cleaned and disinfected according to current Centers for Disease Control (CDC) recommedations. The CDC Website for Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, dated 4/12/24, accessed on 12/23/24 stated: Clean and reprocess (disinfect or sterilize) reusable medical equipment (e.g., blood glucose meters and other point-of-care devices, blood pressure cuffs, oximeter probes, surgical instruments, endoscopes) prior to use on another patient or when soiled. On 12/19/24, at 8:45 AM, LPN #1 was observed using the mobile vital signs machine to obtain blood pressure, pulse, and temperature readings on a resident. LPN #1 was observed to use the same machine to obtain blood pressure, pulse, and temperature readings on another resident. LPN #1 was not observed to clean or disinfect the equipment between the two residents. LPN #1 stated she cleaned the mobile vital signs machine once at the end of her shift. On 12/19/24 at 10:00 AM, CNA #1 stated the mobile vital signs machines were cleaned once a day by night shift staff. On 12/19/24 at 12:35 PM, the Administrator stated nursing staff are responsible to clean the mobile vital signs machines after each resident use.

Based on policy review I&A report review, record review and staff interview, it was determined the facility failed to ensure call lights were within residents' reach. This was true for 1 of 2 residents (Resident #49) reviewed for falls. This resulted in harm to Resident #49 when she fractured her left hip and left wrist. Findings include: The facility's Safety and Supervision of Residents policy, revised July 2017, documented the facility strived to make the environment as free from accidents and hazards as possible. It also stated the facility identified hazards and risks on an ongoing basis. This policy was not followed. 1. Resident #49 was initially admitted to the facility on [DATE], with multiple diagnosis including a tibia fracture. An MDS admission assessment, dated 11/28/23, documented Resident #49 required supervision or touching (cueing) assistance for upper body dressing and supervision or touching assistance when rolling left or right. Resident #49's care plan, dated 11/21/23, directed staff to anticipate Resident #49's needs and encourage her to use the call light for assistance. A facility I&A report, dated 12/5/23, documented staff responded to Resident #49's call light. When they entered the room Resident #49 was found on the left side of her bed on the floor. Resident #49 complained of pain to her left hip and left wrist. The report documented Resident #49 was reaching for a piece of chocolate on the nightstand when she fell out of bed. Vital signs were taken, and Resident #49 was sent to the hospital for further evaluation. The I&A report did not include staff interviews related to the fall or potential risks or hazards. On 12/13/23 at 8:32 AM, Resident #49 stated she was reaching for the call light on her nightstand when she rolled off the bed. She stated she looked down at her leg and noticed it looked a little off. Resident #49 stated she did not activate the call light until she was on the floor. She stated shortly after activating the call light a CNA and a nurse came in to help her. She stated the nurse acted promptly and sent her to the hospital after taking her vital signs. Resident #49 further stated no one on behalf of the facility asked her what occurred when she returned. On 12/13/23 at 5:01 PM, the DON stated Resident #49 was reassessed when she returned to the facility and moved to a room closer to the nurse's station as an intervention. She stated Resident #49 just rolled out of bed. The DON also stated she always spoke to staff about fall investigations as they collaborated and assessed the fall risk. On 12/13/23 at 6:26 PM, RN #2 stated Resident #49's call light was activated, and CNA #2 entered the room first then called for her. She stated she recalled walking into the room and observed Resident #49 laying on the left side of the bed with a swollen left wrist. RN #2 stated the call light was wrapped around the top drawer of the nightstand and the nightstand was pushed all the way back against the wall. She stated Resident #49 would have had to reach all the way back to activate the call light. RN #2 stated Resident #49 was in pain and difficult to understand but she noticed Resident #49 pointed up at the nightstand and she assumed Resident #49 was trying to reach for the bag of chocolates sitting on the nightstand. RN #2 stated Resident #49 could have been pointing to the call light, but she was not sure if CNA #2 placed it on the nightstand when she entered the room first. RN #2 stated she did not have a conversation with anyone in the facility to analyze for risk or hazards after the fall. On 12/13/23 at 6:29 PM, CNA #2 stated she responded to Resident #49's call light and immediately called RN #2. She also stated she observed the call light wrapped around the top drawer of the nightstand and Resident #49 was on the floor on the left side of her bed. The facility failed to ensure Resident #49 had access to her call light, resulting in a fall with injury.

Based on record review, and staff interview, it was determined the facility failed to ensure residents were monitored for side effects and offered non-pharmacological interventions prior to administering an opioid pain medication. This was true for 3 of 7 residents (#34, #49, and #102) reviewed for unnecessary medications. This failure created the potential for residents to experience adverse reactions due to a lack of appropriate monitoring or increased pain due to not offering non-pharmacological interventions. Findings include: 1. Resident #102 was admitted on [DATE], with multiple diagnoses including a fracture of his right femur. Resident #102 was prescribed Oxycodone Hcl 5mg (opioid medication), take 1 oral tablet by mouth every 6 hours as needed for moderate pain. Resident #102's MAR, dated 12/8/23 through 12/12/23, did not include documentation nonpharmacological pain interventions were attempted prior to the administration for Oxycodone for 8 of 8 administrations on the following dates and times: - 12/8/23 at 7:34 PM - 12/9/23 at 8:07 AM - 12/9/23 at 8:02 PM - 12/10/23 at 9:02 AM - 12/10/23 at 3:05 PM - 12/11/23 at 12:19 AM - 12/11/23 at 7:28 PM - 12/12/23 at 7:32 PM Resident #102's MAR, dated 12/8/23 through 12/12/23 did not include non-pharmacological interventions for pain or monitors for opioid side effects. 48402 2. Resident #34 was readmitted to the facility on [DATE], with multiple diagnoses including normal pressure hydrocephalus (NPH a condition caused by an abnormal buildup of cerebrospinal fluid in the cavities or spaces of the brain.) A physician order, dated 11/30/23, documented to administer 1 tablet of 5mg Oxycodone (opioid medication) to Resident #34 by mouth every 6 hours as needed for moderate pain. Resident #34's MAR, dated 11/30/23 through 12/12/23, did not include documentation non-pharmacological pain interventions attempted prior to the administration for Oxycodone for 4 of 4 administration on the following dates: - 12/3/23 at 1:56 AM - 12/3/23 at 12:21 PM - 12/5/23 at 7:26 AM - 12/10/23 at 11:37 AM Resident #34's MAR, dated 11/30/23 through 12/12/23, did not include non-pharmacological interventions for pain or monitors for opioid side effects. 3. Resident #49 was readmitted to the facility on [DATE], with multiple diagnoses including a left wrist fracture. A physician order, dated 12/9/23, documented to administer 1 tablet of 50 mg Tramadol (opioid medication) to Resident #49 by mouth every 6 hours as needed for pain. Resident #49's MAR, dated 12/1/23 through 12/31/23, documented Resident #49 may have ice pack wrapped in cloth and applied every hour as needed for pain, discomfort, or inflammation. Resident #49's MAR, dated 12/9/23 through 12/12/23, did not include documentation of non-pharmacological pain interventions attempted prior to the administration of Tramadol for 8 of 8 administrations on the following dates: - 12/10/23 at 2:30 AM -12/10/23 at 10:13 AM - 12/10/23 at 3:54 PM - 12/10/23 at 9:54 PM - 12/11/23 at 9:06 AM - 12/11/23 at 5:53 PM - 12/12/23 at 2:30 AM - 12/12/23 at 10:21 AM Resident #49's record did not include monitors for side effects of opioid medication. On 12/15/23 at 10:46 AM, the DON stated staff were to document non-pharmacological interventions in a progress note and nurses were expected to monitor for side effects of all medications.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure medications available for residents were labeled and dated; this was true for 2 of 3 medication storage rooms inspected. This failure created the potential for residents to receive medication used for another resident presenting a risk for cross-contamination or to receive expired medications with decreased efficacy. Findings include: The facility's Medication Storage policy, dated January 2023, documented the provider pharmacy dispenses medications in containers that meet the state and federal labeling requirements. Medications are to remain in these containers. Outdated or discontinued medications are immediately removed from stock. This policy was not followed. 1. On 12/11/23 at 3:23 PM, a blister pack of Lyrica (schedule 3 narcotic used to treat neuropathic pain) was observed in the Maple medication cart, narcotic box. The label on the Lyrica was handwritten, in red marker, with no expiration date. LPN #3 stated the Lyrica came from another health facility in a bottle. 2. On 12/11/23 at 3:36 PM, a vial of Tubersol (a clear, colorless solution used in the detection of infection with Mycobacterium tuberculosis) multidose vial was observed in the Maple medication storage room refrigerator with no opened date. The refrigerator contained a Prevnar vaccine (vaccine for pneumococcal disease) syringe that had expired. LPN #3 stated there was no opened date on the multidose vial or the box. She stated it should have been dated when it was opened, and it was good for 28 days after opening. LPN #3 stated the storage room was checked for expired medication routinely and the Prevnar vaccine should have been discarded when it expired. 3. On 12/11/23 at 4:04 PM, a Prevnar vaccine syringe was observed in the [NAME] medication storage refrigerator that was expired. LPN #1 stated the syringe should have been thrown out when it expired.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure food items were dated and labeled and hygiene practices followed. This failure had the potential to affect 43 of 43 residents residing in the facility who consumed food prepared by the facility at risk of adverse health outcomes, including food-born illnesses. Findings include: The facility's Food Storage policy, undated, documented food should include a date to indicate by which a ready-to-eat food should be consumed. It also stated left over food was to be stored in a covered container or wrapped carefully and securely. Each item was to be clearly labeled and dated before refrigerated and leftover food should be used within 3 days or discarded. This policy was not followed. 1. On 12/11/23 at 7:26 AM, during a main kitchen inspection, 7 of 32 opened seasoning containers did not have a use by date on the container. On 12/11/23 at 7:29 AM, the Chef stated he did not know if the seasonings were good. He stated they should have been dated. On 12/11/23 at 7:30 AM, food items were located with past use by dates, items had no use by date, and items were observed to be uncovered with no proper labeling as follows: In the main kitchen refrigerator the following items were located with past use by dates: - Horseradish dated 11/22 - Cocktail Sauce dated 10/7 - Chili Sauce dated 12/6 The use by dates did not include the year, however the Chef acknowledged they were outdated and removed them from the refrigerator. In the main kitchen refrigerator the following items were located undated: - Ground beef - Turkey Gravy - Pickle relish - Sweet peppers - Liquid egg yolk In the main kitchen the following food items were located uncovered and undated: - Frozen Brisket a jus sauce in the freezer - Ground beef in the refrigerator In the Maple kitchen refrigerator fruit was observed uncovered and undated. On 12/11/23 at 7:39 AM, the Chef stated the items should have been properly dated and covered and the past dated items should have been discarded. 3. The facility's Food Safety policy, undated, documented temperatures of the food would be monitored during preparation, serving, and holding and the temperatures would be documented. This policy was not followed. On 12/14/23 at 12:31 PM, a tray line observation was conducted in the Maple, [NAME], and Redwood kitchens. Two of 3 kitchens did not have documented temperatures of the food prior to serving. On 12/14/23 at 12:49 PM, Cook #1 stated she took the food temperatures but did not document them. On 12/14/23 at 5:15 PM, the Executive Chef stated he was unaware of the temperatures not being taken at the time of serving and holding. He also stated the temperatures should be taken on preparation, serving, and holding.

Based on record review, staff interview, and policy review, it was determined the facility failed to ensure residents did not develop avoidable pressure ulcers and promptly received wound care and interventions as ordered by the wound care physician. This was true for 1 of 3 residents (Resident #6) reviewed for pressure ulcers and resulted in harm to Resident #6 when she developed a Stage III pressure ulcer and placed her at risk of infection and/or further deterioration of the wound. Findings include: The National Pressure Ulcer Advisory Panel - 2016 Definitions define a Stage III pressure ulcer as a full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue (pink-red moist tissue that fills an open wound when it starts to heal) and epibole (rolled wound edges) are often present. Slough (dead or weakened tissue that is hard or soft in texture - usually black, brown, or tan in color) and/or eschar (non-viable yellow, tan, gray, green, or brown tissue) may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining (when the tissue under the wound edges becomes eroded, resulting in a pocket beneath the skin at the wound's edge) and tunneling (channels that extend from a wound into and through the tissue or muscle below) may occur. Fascia, muscle, tendon, ligament, cartilage or bone is not exposed. The facility's policy for Prevention of Pressure Ulcers, dated 2005, documented the following: * Use appropriate support surface in the resident's bed or chair. * Use pressure reducing or relieving devices as necessary. * Establish a turning and positioning schedule in bed and chair to meet the resident's needs. * Position with appropriate surfaces to protect bony prominences. Whenever possible, teach the resident to change position at regular intervals and shift weight in the wheelchair. Use supportive devices. *Assessment Guidelines included comorbid conditions, general condition of skin, urinary or fecal incontinence, hydration, bedfast, mobility status, limitation in range of motion, and refusal of care. * Equipment may include appropriate support surface for bed and chair, skin lotion, and pillows. This policy was not followed. Resident #6 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #6's care plan documented she was at risk for potential skin impairment related to decreased mobility, weakness, potential for nutritional decline and deficient, poor safety with movement and cognitive changes due to disease process, involuntary movement, and incontinence. The potential for skin impairment was added to the care plan on 6/28/18 Resident #6's Significant Change in Status MDS assessment, dated 8/8/20, documented she had problems with her short-term and long-term memory, and she required extensive assistance of 2 persons with bed mobility, transfers, personal hygiene, and toileting. The MDS documented she used a wheelchair, was at risk for developing pressure ulcers, and had no unhealed pressure ulcers at that time. Resident #6's care plan was not updated to address her need for increased assistance with bed mobility. Resident #6's Braden Scale for Predicting Pressure Ulcers, dated 8/8/20 at 11:45 AM, documented she was at high risk for developing a pressure ulcer. Resident #6's Weekly Skin Assessment, dated 8/27/20 at 4:46 PM, documented she had a new Stage III pressure wound measuring 3.1 by 1.3 cm. Resident #6's Progress Notes documented the following: * On 8/15/20 at 5:58 PM, Resident #6 was incontinent of 2 large, loose stools. The nurse continued to apply [MEDICATION NAME] ointment on Resident #6's bottom, which had blanchable redness and irritation from incontinence. There was an abraded area to the top of the natal cleft (the cleft between the buttocks) on the right side. * On 8/22/20 at 4:09 AM, Resident #6 had an excoriation on her coccyx (tailbone), and the nurse continued to apply a barrier cream. * On 8/24/20 at 1:16 AM, Resident #6 had a wound on her coccyx that she stated was painful. The wound was cleaned, a dressing was applied, and the nurse documented will contact md (medical doctor) for further assessment and orders. * On 8/24/20 at 9:23 PM, Resident #6 had an open area to her coccyx. The nurse documented will continue to apply a barrier cream and change dressings per md orders. Dressing changed per treatment orders. * On 8/25/20 at 11:35 AM, the nurse was unable to keep the dressing on Resident #6's coccyx wound. Resident #6 was agitated and uncooperative. *On 8/25/20 at 1:51 PM, a Progress Note documented by the NP stated she was asked to see Resident #6 due to a new coccyx wound/pressure sore. The note documented Resident #6 preferred to spend a lot of time on the floor and scooted on her buttocks or moved about in her wheelchair, and she was recently napping in bed frequently due to being ill with COVID-19. The NP documented Resident #6 had recovered from COVID-19 and was back in her original room. The note stated Resident #6's coccyx had a Stage III ulcer measuring 2 cm by 1 cm, it had mild oozing of blood, and there was a dressing over the area. The note documented an evaluation by the wound care physician was requested. The note further documented Resident #6 was at high risk for worsening wound due to inability to keep her off the floor. The wound care physician's consult was completed on 8/26/20. The wound care physician documented his comments and orders for treatment of [REDACTED]. The wound care physician documented Resident #6 had recently had COVID-19 and aspiration pneumonia and had a Stage III pressure ulcer on her right inner buttock. The orders included a Roho (inflatable) cushion, to turn (reposition while in bed) Resident #6 every 2 hours, and to keep the head of Resident #6's bed less than 30 degrees at all times. The wound care physician also ordered [MEDICATION NAME] (a wound cleanser) wet to dry dressing (a wet or moist gauze dressing put on the wound and a dry covering placed on top) twice per day with Venelex (an ointment used in wound care management to relieve pain, reduce odor, and promote healing) to the periwound (area surrounding the wound). The facility utilized an electronic medical record system. The wound care physician's active orders were not entered into the physician orders [REDACTED].#6's electronic medical record. Resident #6's record did not include documentation explaining the reason the wound care physician's orders [REDACTED].#6's electronic medical record. The wound care physician's orders [REDACTED]. a. Resident #6's electronic medical record included physician orders [REDACTED]. The dressing was ordered and started on 8/27/20, and it was entered again as ordered on [DATE] and started on 8/28/20. The order did not include the wound care physician's 8/26/20 orders for a wet to dry dressing to be changed twice daily and as needed, and the application of Venelex ointment to the periwound. Additionally, the order did not include Resident #6's need for a Roho cushion, to be turn every 2 hours, and to keep the head of Resident #6's bed at less than 30 degrees at all times. A Skilled Nursing Facility Note by the wound care physician, dated 9/2/20, documented staff was supposed to be using a [MEDICATION NAME] wet-to-dry dressing b.i.d. (twice a day) with Venelex to the periwound, but apparently has just been using Venelex to Resident #6's wound. The wound care physician again ordered a wet to dry dressing to be changed twice per day with Venelex to the periwound. The [MEDICATION NAME] was changed to acidic acid 0.25%. The electronic physician orders [REDACTED]. 8/26/20 order, to include Clean Stage III pressure ulcer to sacrum with Acetic Acid 0.25% wet to dry gauze, lightly coat [DIAGNOSES REDACTED] (redness) to peri skin with Venelex ointment, place and secure protective foam, b.i.d. and as needed. b. Resident #6's TARs for August and September 2020 documented to clean the Stage III pressure ulcer on her sacrum with wound cleanser, apply skin prep to the perimeter, apply Veneer ointment, apply protective foam, and secure and change the dressing daily and as needed. The TARs documented the order start date was 8/28/20 and was signed as completed by staff from 8/28/20 through 9/2/20. The ordered was discontinued on the TAR on 9/2/20. Resident #6's MARs for August and September 2020 documented Venelex Ointment was to be applied to her Stage III sacrum pressure ulcer one time a day. The order started on 8/28/20 and was signed as completed by staff from 8/28/20 through 9/2/20. The order was discontinued on the MAR indicated [REDACTED] The TARs and MARs from 8/28/20 through 9/2/20 were inconsistent. The TARs documented Veneer ointment was to be applied and the MARs documented Venelex ointment was to be applied. Resident #6's record did not include documentation staff sought clarification of the type of ointment to be applied to Resident #6's wound. c. A Skilled Nursing Facility Note by the wound care physician, dictated and transcribed on 8/26/20, documented an order for [REDACTED].#1 said she thought the pressure ulcer developed when Resident #6 was in the Linden House (also part of the same facility) due to having COVID-19. RN #1 said Resident #6 had been back in the Maple House (her original room) for over 24 hours when she discovered the pressure ulcer. RN #1 said Resident #6 spent a lot of time on the floor, and she had a cushion on her wheelchair, but she did not know what kind of cushion it was. RN #1 said she thought there was a cushion on Resident #6's bed because when she sat on the bed it felt like there was something more than a mattress, but it was not an air mattress. Resident #6 was not provided with a low air loss mattress as ordered by the wound care physician on 8/26/20. On 9/18/20 at 2:26 PM, LPN #3 said when Resident #6 was in the COVID-19 unit she was incontinent of urine and diarrhea, and she was on an antibiotic which always gave her diarrhea. LPN #3 said the DON was the one who discovered redness on Resident #6's bottom, and she applied barrier cream to Resident #6's bottom. LPN #3 said Resident #6 had a standard pressure reducing mattress with bolsters. LPN #3 said Resident #6 could reposition herself and would turn herself when she perked up, and staff repositioned her frequently when she was lethargic (sleepy or fatigued and sluggish). LPN #3 said Resident #6 declined rapidly after she went back to the Maple house, and the Roho cushion was obtained after there was some redness on her right buttock and after the wound developed. There was no documentation in Resident #6's record of initiation of the wound care physician's orders [REDACTED]. Resident #6's record did not include documentation of the reason(s) the wound care physician's orders [REDACTED]. On 9/18/20 at 4:01 PM, the DON said she believed the order for the wet to dry dressing was changed for Resident #6 because she could not keep the dressing on due to scooting on the floor. The DON said her expectation was for the nurse to follow the physician's orders [REDACTED]. On 9/18/20 at 5:45 PM, the DON said Resident #6's pressure ulcer did not originally present as a pressure ulcer. The DON said Resident #6 was on an antibiotic, had loose stools, and liked to scoot around on the floor. The DON said Resident #6's bottom was getting better with barrier cream when she left the COVID-19 unit, but she continued to scoot on the floor and she guessed that re-injured the area and caused it to worsen as her medical condition deteriorated.

Based on observation, record review, and staff interview, it was determined the facility failed to provide adequate supervision to meet resident needs. This was true for 2 of 4 residents (#11 and #16) reviewed for supervision and accidents. Resident #11 was harmed when staff failed to provide adequate supervision while the resident was in his room and he fell and sustained a rib fracture. Resident #16 was harmed when she sustained a [MEDICAL CONDITION] in her room falling from her bed. Findings include: 1. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An annual MDS assessment, dated 2/12/18, documented Resident #11 had moderate cognitive impairment and documented he experienced one fall with no injury. The previous quarterly MDS assessment, dated 11/27/17, documented Resident #11 experienced 2 or more non-injury falls. An undated care plan, documented Resident #11 had dementia and impaired cognitive function. An undated care plan, documented Resident #11 was at risk for falls with or without injury related to a recent [MEDICAL CONDITION], with right side [MEDICAL CONDITION], cognitive impairment, gait/balance problems, incontinence, poor communication/comprehension, and [MEDICAL CONDITION] med use and impulsivity, history of falls w/ (with) Fx (fracture). The care plan interventions were documented as follows: * Ensure Resident #11's call light was within reach and encourage him to use it as needed. Resident #11 had stopped utilizing his call light and would yell out for assistance. Staff were encouraged to reorient Resident #11 as needed. * Educate Resident #11 and his family on safety reminders and what to do if falls occur. * Ensure Resident #11's bed was in low position and at an appropriate height for transfers. * Ensure Resident #11 was wearing appropriate footwear when mobilizing in his wheelchair. * Ensure Resident #11's bedroom door is closed at night, to prevent him from closing the door himself. * Resident #11 utilized a side rail on the right side of his bed for a sense of security and a halo bar to the left side of his bed to aid in independence with bed mobility and transfers. * Pressure alarm to bed and wheelchair to alert staff of unsafe self-transfers and safety needs. Staff to ensure placement, turned on and functionality of the devices. * PT/OT were to evaluate Resident #11 and treat as ordered and PRN. Resident #11's clinical record documented the resident experienced 6 unwitnessed falls between 9/16/17 and 1/27/18 and 1 witnessed fall on 9/21/17. Resident #11's I&A Reports documented the following: * 9/16/17 - 11:19 AM: Resident #11 experienced an unwitnessed fall in another resident's bathroom. * 9/21/17 - 2:12 AM: Resident #11 was observed walking in his room unattended and before an CNA could assist him, he fell and landed on his right elbow. The I&A documented Resident #11 had disconnected his bed alarm to keep it from sounding. * 9/25/17 - 5:20 AM: Resident #11 experienced an unwitnessed fall from bed. The I&A documented his alarm was sounding with his back against his night stand. Resident #11 had multiple skin tears to his left elbow and left hand. A 9/25/17 at 9:09 AM, physician's orders [REDACTED]. A Radiology Interpretation Significant Findings, dated 9/25/17 at 11:02 AM, documented Resident #11 sustained a nondisplaced [MEDICAL CONDITION] rib. The report documented there was a question about a possible [MEDICAL CONDITION] rib in addition. A Nurse's progress note, dated 9/25/17 at 2:00 PM, documented Resident #11 sustained a fracture to his 3rd rib and a questionable fracture to his 4th rib. * 10/3/17 - 6:50 AM: Resident #11 experienced an unwitnessed fall from bed. The resident was assisted into a wheelchair. * 11/30/17 - 4:50 PM: Resident #11 experienced an unwitnessed fall from bed. The resident was found in his room with his back resting against the wall near his bathroom. Resident #11's bed alarm was not sounding at the time of the fall and did not appear plugged in. * 12/30/17 - 5:45 PM: Resident #11 experienced an unwitnessed fall from bed. The resident was found in his room with his upper body lying face down on the bed. The I&A documented he was trying to self-transfer. * 1/27/18 - 8:07 PM: Resident #11 experienced an unwitnessed fall from bed. The I&A documented Resident #11 was incontinent of urine and was trying to use the restroom. On 3/19/18 at 8:15 PM, Resident #11 was in his room with his door closed. On 3/20/18 at 8:39 AM, Resident #11 was observed in his wheelchair at the breakfast table with an alarm attached to the back of his wheelchair. Resident #11's wheelchair had a Wanderguard attached under his wheelchair. On 3/20/18 at 9:33 AM, Resident #11 was observed nearing the front door by himself and a proximity alarm sounded. Resident #11 stated he wanted to find his wife. Resident #11 made several attempts to leave the building to find his wife. CNA #1 approached Resident #11 and redirected him. On 3/20/18 at 11:01 AM, Resident #11 was observed sitting in his wheelchair staring out the window waiting for his wife to come. Resident #11 had an alarm on the back of his wheelchair and a Wanderguard under his chair. On 3/21/18 at 9:10 AM, Resident #11 was observed at the breakfast table with an alarm attached to the back of his wheelchair and Wanderguard under his chair. On 3/22/18 at 5:36 PM, Resident #11 was observed in the hallway near the front door and was turning off lights with no staff members around. Resident #11's chair alarm was not attached to the back of his wheelchair during the observation. On 3/21/18 at 10:25 AM, the DNS stated Resident #11's wife spent time with Resident #11 throughout the day. When asked what activities were provided when Resident's #11's wife was not available the DNS stated the staff encouraged activities such as reading, making bird houses, offered snacks, calling his wife, looking out the window, and sitting in the day room. The DNS stated Resident #11's falls had no pattern that the facility had identified. When asked what intervention were in place when he was in his room the DNS stated Resident #11 had alarms in place, his bed was in low position and he wore appropriate foot wear. The DNS stated Resident #11 could not consistently remember to utilize a call light and staff should check on him. When it was brought to the DNS's attention that Resident #11 had fallen consistently in his room she was asked for evidence of what changes had been made to Resident #11's care plan after each fall. The DNS stated if the falls were occurring in Resident #11's room then she would expect staff to open Resident #11's door for increased supervision. The DNS was unable to provide evidence of increase supervision. The facility failed to modify interventions including increasing supervision after each fall to try and prevent ongoing falls in Resident #11's room. 2. Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #16's Fall Risk Assessment, dated 1/31/18 documented she was a high risk for falls. A significant change MDS assessment, dated 2/19/18, documented Resident #16 had a moderate cognitive impairment and documented she had experienced no falls. The MDS documented Resident #16 did not use a bed alarm. The MDS documented Resident #16 required extensive assistance of one to two staff members for all cares. An undated care plan, documented Resident #16 was at risk for falls with or without injury related to confusion, gait/balance problems, incontinence, poor communication/comprehension, and psychoactive drug use, unaware of safety needs, (and) vision problems. The care plan interventions were documented as followed: * Staff were to anticipate and meet Resident #16's needs. * Ensure Resident #16's call light was within reach and encourage her to use it as needed. Resident #16 was confused and did not utilize her call light. Staff were to anticipate Resident #16's needs. * Staff were to ensure Resident #16's environment was safe. * Resident #16 required extensive assistance of two staff members for transferring and bed mobility. * Educate Resident #16 and her family on safety reminders and what to do if falls occur. * Pressure alarm to bed and wheelchair to alert staff of unsafe self-transfers and safety needs. Staff to ensure placement, turned on and functionality of the devices. * Ensure Resident #16's bed was at the appropriate height for transfers. * Ensure Resident #16 was wearing appropriate footwear when mobilizing in her wheelchair. * PT were to evaluate Resident #16 and treat as ordered and PRN. * Ensure Resident #16's call light, water, and remote control were within her reach. * Review her falls for possible root causes. Resident #16's clinical record documented the resident experienced 2 unwitnessed falls between 1/30/18 and 2/22/18. Resident #16's I&A Reports documented the following: * An I&A Report, dated 1/30/18 at 4:30 PM, documented Resident #16 experienced an unwitnessed fall from bed. The resident was assisted back into bed. The I&A documented Resident #16's bed alarm was on but did not sound when she moved off of her bed and towards her dresser. A follow up note to the 1/30/18 - 4:30 PM fall, dated 1/31/18 at 10:00 AM, documented Resident #16 was provided an interior design book and personalized activity blanket between scheduled activities. Resident #16's at risk for falls care plan, was revised at an unknown date, to include offering Resident #16 her an interior design book and personalized activity blanket between scheduled activities. * An I&A Report, dated 2/20/18 at 5:40 PM, documented Resident #16 experienced an unwitnessed fall from bed, where she sustained a hematoma to the side of her head and a skin tear to her left ear. The I&A documented a picture of Resident #16 between the bed and the window. The I&A documented Resident #16 was educated on her bed alarm placement. A follow up note for the 2/20/18 fall was not completed on the I&A. An Emergency Doctor Provider Notes, dated 2/20/18 at 7:11 PM, documented Resident #16 suffered an unwitnessed fall and it was assumed Resident #16 hit her head on either the window sill or her bed. The note documented the facility was unsure if Resident #16 lost consciousness or not. The note documented Resident #16 had a laceration to her left ear and a hematoma to the left side of her head. A Nurse's Note, dated 2/20/18, documented Resident #16 returned from the emergency room . The laceration appeared to extend from the edge of her ear flap to the inner aspect of the canal cartilage. Approximately 6 sutures seen. An undated care plan, documented Resident #16 had a fall with a laceration to the left ear and staff were to monitor Resident #16 per facility protocol for neurological assessments and assess her range of motion for 7 days and continue her at risk interventions. No new interventions were implemented. On 3/19/18 at 7:53 PM, Resident #16 was observed in bed with her bed flush against the wall under the window sill and bilateral 1/2 bed rails. Resident #16's bed was in low position, Resident #16's bedside table was next to her on the other side of her bed opposite the wall. On 3/20/18 at 4:30 PM, Resident #16 was observed in bed with her bed flush against the wall under the window sill and bilateral 1/2 bed rails. Resident #16's bed was in low position, Resident #16's bedside table was next to her on the other side of her bed opposite the wall. On 3/21/18 at 10:25 AM, the DNS and the ADON stated Resident #16 she had multiple falls and was admitted with a fall history. The DNS stated Resident #16 spent time in the dining room so staff could keep her in their line of sight. The DNS stated her room was close to the nurses station for more frequent observation opportunities. The DNS did not see patterns in Resident #16's falls. The DNS stated when she fell in her room they added a busy blanket and an interior design book. The DNS stated Resident #16's falls seemed to have decreased since she was placed on hospice. The DNS was unable to identify additional fall interventions initiated to keep Resident #16 safe.