Every finding on record at Village Health Care

Based on observation, interview and record review it was determined the facility failed to comprehensively assess a resident for the use of an electric wheelchair and develop new interventions to reduce the risk of falls for 2 of 4 sampled residents (#s 3 and 73) reviewed for accidents. This failure resulted in Resident 73 sustaining a five-centimeter laceration (a jagged wound or cut in the flesh) to her/his right anterior (toward the front) lower leg, multiple leg fractures and a brief syncopal episode (fainting or passing out) secondary to blood loss. Findings include: The facility's 1/2025 Physical Restraints and Enablers/Devices Policy indicated a Device Evaluation was completed prior to a device being initiated. The resident and/or representative is provided risks/benefits of device use and consent obtained prior to its implementation. The individual service plan is updated to identify device use and identifies other interventions put into place addressing medical symptoms, environmental safety and psychosocial concerns. The facility's 1/2025 Fall Management Policy indicated the following:-The licensed nurse updates care plans reflecting individualized interventions in an attempt to reduce or prevent falls. -A systematic review of current interventions is completed post fall and a root cause is identified.-Should a new intervention be implemented, previous interventions are reviewed for discontinuation to determine if they were ineffective. 1. Resident 73 was admitted to the facility in 3/2025 with diagnoses including weakness and lymphedema (a chronic condition characterized by painful, long-lasting swelling caused by a buildup of lymph fluid in the body's soft tissues). Resident 73's 10/7/25 Care Plan revealed the following: -The resident required assistance for bed mobility, transferring and locomotion related to an above-the-knee amputation to her/his left leg. -The resident required one-to-two-person physical assistance from staff with a slide board (a medical mobility aid used to help people transfer between seated surfaces) for transfers. Resident 73's 2/23/26 Annual MDS revealed the resident was cognitively intact, experienced lower extremity impairment on one side, required supervision or touch assistance for bed-to-chair transfers and used a manual wheelchair for mobility. A 4/17/26 Equipment Related Incident Form revealed the following:-Resident 73 maneuvered a newly issued electric wheelchair in her/his room in a confined space near the bed.-At approximately 3:30 PM, the resident's assigned CNA responded to her/his call light and found the resident seated in her/his electric wheelchair with a large pool of blood on the floor beneath the resident. -A nurse was notified, entered the resident's room, noted active bleeding from the right anterior lower leg and applied pressure. -The resident was pale and lethargic. -The resident was sent to the emergency department, and she/he sustained a five-centimeter laceration to her/his right anterior lower leg, a fracture to her/his right tibia (the large, strong bone located in the front part of your lower leg, running from just below the knee to the ankle) and fibula (the slender long bone on the outer side of your lower leg, running parallel to the tibia from just below the knee to the ankle) and a brief syncopal episode secondary to blood loss. -The resident reported her/his thumb slipped off of the control, which caused the electric wheelchair to continue forward into the resident's bed where the resident's right leg hit the metal bed frame. -The resident received an anticoagulant (a medication that prevents or slows down the clotting of blood) which contributed to significant bleeding from the injury. A 4/19/26 Hospital Discharge Summary revealed the following:-Resident 73 required supplemental oxygen in the emergency department as she/he experienced acute hypoxemic respiratory failure (a sudden inability of the respiratory system to adequately oxygenate the blood) following a scooter accident. -The resident sustained fractures to her/his right tibia and fibula and required laceration repair. -The resident's oxycodone (a powerful, semi-synthetic opioid analgesic prescribed to treat moderate-to-severe chronic pain) was increased due to acute pain secondary to the fractures. No evidence was found in Resident 73's clinical record to indicate she/he had been assessed to safely operate an electric wheelchair. On 6/1/26 at 11:03 AM and 6/2/26 at 1:33 PM, Resident 73 was observed in her/his room in bed. Resident 73 stated she/he was informed by Staff 27 (Former Director of Rehabilitation) she/he was to receive an electric wheelchair on 4/17/26 between 2:00 PM to 2:30 PM. Resident 73 stated the electric wheelchair arrived as scheduled accompanied by Witness 4 (Electric Wheelchair Representative). Resident 73 stated Staff 29 (CNA) helped transfer her/him from a manual wheelchair into the electric wheelchair, following which she/he went around the facility in the electric wheelchair with Witness 4 walking alongside. Resident 73 stated Witness 4 showed her/him how things worked on the chair, but not as much as he should have. Resident 73 stated she/he did not know how to use that chair, including how to stop it. After Witness 4 left the facility, Resident 73 stated she/he returned to her/his room, could not stop the electric wheelchair, and as a result, bumped into the metal part of the bed and kept pushing. Resident 73 stated blood was gushing out of my leg, she/he activated her/his call light and went to sleep. Resident 73 stated, I thought I was going to die. On 6/2/26 at 1:13 PM, Witness 5 (Family) stated he was informed by Resident 73 she/he was going to receive her/his new electric wheelchair on 4/17/26. Witness 5 stated he was informed by Staff 1 (Administrator) that residents were to receive training on operating an electric wheelchair prior to receiving one in order to ensure the resident knew how to operate it, but Resident 73 did not receive training by therapy services. Witness 5 stated the electric wheelchair incident that occurred on 4/17/26 was near fatal and derailed the resident's life. On 6/2/26 at 2:06 PM and 2:38 PM, Staff 27 stated it was the facility's policy a resident did not use an electric wheelchair independently until therapy completed an assessment, which included the residents' ability to transfer on-and-off the electric wheelchair, use the controls to safely navigate their environment and to prove they were safe. Staff 27 stated Resident 73's electric wheelchair was to be delivered to the facility by the end of 4/2026, but she did not know the exact date of delivery. Staff 27 stated Resident 73's electric wheelchair arrived on 4/17/26 but after she had left the facility. Staff 27 stated Staff 30 (Physical Therapist) was in the facility when the resident's electric wheelchair arrived, but because the therapy department was located in the back of the facility, there was no way for a therapist to know the electric wheelchair arrived unless someone let them know. Staff 27 stated nurses usually let the therapy department know when an electric wheelchair arrived, and if the assessment could not be completed upon arrival, the electric wheelchair was held in the therapy department until the assessment was completed. Staff 27 stated Resident 73 was not assessed for the use of the electric wheelchair prior to its use and she/he should have been. On 6/2/26 at 2:59 PM and 6/4/26 at 3:18 PM, Staff 29 (CNA) stated Resident 73 informed her a couple days before or maybe the day prior to she/he was going to receive a new electric wheelchair on 4/17/26. Staff 29 stated she was unaware of any policy related to residents receiving new electric wheelchairs and/or the need for an assessment prior to use. Staff 29 stated she assisted Resident 73 into the electric wheelchair on 4/17/26. Staff 29 stated the resident was in the chair a while before she responded to the resident's call light around 3:00 PM. Staff 29 stated the resident was passed out and there was blood all over when she entered the room. On 6/2/26 at 3:28 PM, Witness 4 stated he arrived at the facility on 4/17/26 at 2:30 PM to deliver Resident 73's electric wheelchair. Witness 4 stated the receptionist at the front desk checked me in and pointed me in the direction of the resident's room. Witness 4 stated an unidentified staff person assisted the resident into the electric wheelchair. Witness 4 stated the resident test drove the electric wheelchair throughout the facility, greeting a handful of staff along the way. Witness 4 stated he went over documents with the resident and spoke with Staff 18 (Maintenance Director) regarding how to charge the electric wheelchair prior to leaving the facility. On 6/3/26 at 8:20 AM, Staff 18 stated he was unaware Resident 73's electric wheelchair was delivered on 4/17/26, and electric wheelchairs were to be stored in the therapy department until an assessment by a therapist was completed. On 6/3/26 at 8:33 AM, Staff 28 (Director of Rehabilitation) stated therapy assessments of electric wheelchairs were to be completed prior to a resident getting into the chair. Staff 28 stated he expected staff to notify the therapy department if they observed a new electric wheelchair in the facility so it could be removed from use until appropriately screened for safety. On 6/3/26 at 8:40 AM, Staff 31 (Receptionist) stated she observed Resident 73 in the electric wheelchair on 4/17/26 along with Witness 4 but was away from her desk when the resident's electric wheelchair was delivered. Staff 31 stated she did not notify any staff on 4/17/26 that the resident's electric wheelchair arrived but guessed the charge nurse for that day was probably notified. On 6/3/26 at 9:09 AM, Staff 26 (CNA) stated new electric wheelchairs were supposed to be parked in the therapy department until the resident was authorized to use it. Staff 26 stated she had never seen a new electric wheelchair arrive at the facility, but if she did, she would notify a nurse. On 6/3/26 at 9:03 AM, Staff 11 (CNA) stated she knew the week prior to the electric wheelchair's arrival on 4/17/26 that it was coming. Staff 11 stated Resident 73 informed her of its arrival date, and she assumed other staff were aware. On 6/3/26 at 9:53 AM, Staff 13 (LPN) stated she worked evening shift on 4/17/26 and was told during shift report Resident 73 was to receive a new electric wheelchair on this day. Staff 13 stated after the electric wheelchair arrived on 4/17/26, she introduced herself to Witness 4 but did not inform any additional staff the electric wheelchair arrived as she thought everyone was already aware. Staff 13 stated she did not ask Witness 4 to notify her when he was done showing the resident the electric wheelchair as she expected he would come and let us know how [she/he] did. Staff 13 stated she entered the resident's room after being informed by CNAs that there had been an incident and the resident had passed out. Staff 13 stated the resident was drowsy when she entered the room, Staff 2 (DNS) applied pressure to the resident's leg because she/he was bleeding a lot, and she called 911. On 6/3/26 at 10:13 AM, Staff 2 stated she expected the therapy department to be notified as soon as an electric wheelchair arrived at the facility so an assessment and training could be completed to ensure the resident was safe to use the device. Staff 2 stated she expected staff to inform therapy or management staff that Resident 73's electric wheelchair had arrived on 4/17/26 and prior to her/him being transferred into the chair, and they were not notified until after the incident occurred. On 6/3/26 at 10:25 AM, Staff 30 (Physical Therapist) stated she worked on 4/17/26 but was not notified Resident 73's electric wheelchair was delivered. Staff 30 stated she was unsure of the process of what to do if an electric wheelchair showed up for a resident, but stated if she was notified, she would not leave the electric wheelchair with the resident and would talk to someone at the facility to find out the process. On 6/3/26 at 10:32 AM, Staff 1 (Administrator) stated he expected staff to notify the therapy team that an electric wheelchair arrived at the facility prior to a resident getting into the device so a safety evaluation could be completed. Staff 1 stated he was unaware Resident 73 and other staff were aware of the exact delivery date and time for the electric wheelchair. Staff 1 further stated he expected any staff who were aware Resident 73's electric wheelchair was in the facility to have notified the therapy team, and they did not. 2. Resident 3 was admitted to the facility in 3/2026 with diagnoses including a right total hip replacement with deep hardware removal and post-traumatic osteoarthritis of right hip. Review of Resident 3's Morse Fall Scale assessments dated 3/16/26 and 4/7/26 revealed Resident 3 was a high risk for falls. Review of Resident 3's Occupational Therapy (OT) evaluation dated 3/13/26 revealed the resident's SLUMS (a test to assess an individual's cognition) score was 16 out 30 which indicated the resident had cognitive impairment. The resident required maximal assistance with toileting and moderate assist with transfers. Review of Resident 3's 3/14/26 Physical Therapy (PT) evaluation revealed Resident 3's Short Physical Performance Battery (an objective tool designed to measure balance, lower limb strength, and functional mobility) score was zero which indicated the resident was at high risk for falls and increased risk of mobility disability. The resident required touch assistance when walking using a front wheeled walker (FWW). A progress note dated 3/29/26 indicated Resident 3 required one to two staff to assist with transfers using a FWW and indicated the resident had been transferring and toileting themselves without assistance. The progress note indicated Resident 3 was reminded she/he had not been cleared to be independent and needed to use her/his call light for assistance. Review of Resident 3's Fall incident reports revealed the following: - On 3/31/26 Resident 3 fell after getting up on her/his own. Resident 3 requested to be sent to the hospital and was found to have a right femur fracture which required surgical repair. The incident report indicated the facility had been providing Resident 3 with education to ask for assistance due to getting up on her/his own. No new interventions were listed but the resident was encouraged to ask for assistance. - On 5/12/26 Resident 3 fell after getting up on her/his own and sustained a skin tear on her/his right elbow. The resident had not used her/his call light and was re-educated to call for assistance to prevent re-injury. Resident 3's care plan dated 3/24/26 revealed the resident was at risk for falls and instructed facility staff to encourage the resident to use the call light for assistance, to ensure the resident wore non-skid socks when up, and to provide one person to assist with toileting and transferring. The care plan was revised on 3/25/26, 4/25/26, and 6/2/26 but did not include new or amended fall prevention interventions. On 6/1/26 at 11:00 AM Resident 3 stated she/he did not know why she/he fell but believed she/he was approved to walk and transfer independently. Observations made on 6/1/26 at 11:00 AM, 6/2/26 at 8:15 AM, 6/3/26 at 8:53 AM, and 6/4/26 at 8:52 AM revealed Resident 3 was not wearing non-skid socks. On 6/3/26 at 8:53 AM Resident 3 was observed to push her/his call light and observed the bedside commode had crumpled toilet paper and yellow liquid in the bowl. The resident stated she/he wanted staff to empty the bedside commode and confirmed she/he had used the commode without assistance because she/he believed she/he was cleared to do so independently. On 6/3/26 at 9:33 AM Staff 22 (CNA) stated she believed Resident 3 was independent to transfer and use the toilet on her/his own and was not at risk for falls. Staff 22 confirmed Resident 3 had not asked for assistance before using the bedside commode earlier. Staff 22 stated she had not reviewed Resident 3's Kardex (a quick, easy-to-read care plan for CNAs) before working with Resident 3. After reviewing the Kardex, Staff 22 confirmed Resident 3 was not cleared to complete her/his cares independently. On 6/4/26 at 10:09 AM Staff 20 (RN) stated staff educated Resident 3 to use the call light to ask for assistance, but the education did not prevent Resident 3 from self-transferring and falling. On 6/4/26 at 11:04 AM Staff 24 (Former Director of Rehabilitation) confirmed Resident 3 was at high risk for falls and was often non-compliance with asking for assistance. Staff 24 stated the facility discussed Resident 3's non-compliance multiple times during morning department manager meetings and weekly skilled services review meetings. Staff 24 stated she did not recall what interventions were put in place but would have recommended frequent checks and moving Resident 3 closer to the nursing station. On 6/5/26 at 8:36 AM Staff 2 (DNS) stated she determined the effectiveness of fall interventions by monitoring for the absences of no new falls and the team would discuss alternative strategies. Staff 2 stated she was aware of Resident 3's falls and stated the resident's confirmed current fall preventions interventions were ineffective and no new interventions were not discussed or implemented.

Based on observation, interview and record review it was determined the facility failed to monitor temperatures in the medication refrigerators for 3 of 3 medication refrigerators. This places residents at risk for receiving ineffective medications or vaccinations. Findings include:On 6/5/26, the CDC requires facilities to monitor temperatures in medication refrigerators to maintain a temperature between 36 and 46 degrees Fahrenheit (F).On 6/4/26 at 1:13PM, Staff 3 (Regional Director of Clinical Operations) provided the temperature logs for three medication refrigerators.A review of Station 1's medication temperature log for 5/2026 revealed missing temperatures on 5/1/26, 5/2/26, 5/8/26, 5/11/26, 5/14/26, 5/15/26, 5/16/26, 5/17/26, 5/22/26, and 5/29/26 (10 days).A review of Station 2's medication temperature log for 5/2026 revealed missing temperatures on 5/1/26, 5/2/26, 5/3/26, 5/4/26, 5/5/26, 5/9/26, 5/10/26, 5/16/26, and 5/17/26 (nine days).A review of Station 3's medication temperature log for 5/2026 revealed missing temperatures on 5/1/26, 5/2/26, 5/3/26, 5/4/26, 5/5/26, 5/6/26, 5/8/26, 5/9/26, 5/10/26, 5/16/26, 5/17/26, and 5/24/26 (12 days).On 6/5/2026 at 8:43 AM, Staff 1 (Administrator) stated staff were expected to check the medication refrigerators daily. Staff 1 confirmed the missing temperatures and stated the facility did not have a back-up temperature monitoring system on the days with blank temperatures.

Based on observation, interview and record review it was determined the facility failed to ensure residents were allowed to retain and use personal possessions for 1 of 1 sampled resident (#50) reviewed for edema. This placed residents at risk for diminished quality of life. Findings include:The facility's Notice of Resident Rights Under Oregon State Law policy, dated 7/2025 indicated residents had the right to keep and use personal clothing and possessions as space permitted unless to do so infringed on other residents' rights and unless medically contraindicated. Resident 50 was admitted to the facility in 9/2025 with diagnoses including chronic respiratory failure with hypoxia (an ongoing long-term condition where the respiratory system cannot adequately oxygenate the blood), COPD (a group of progressive long-term lung conditions that cause irreversible damage to the airways), dependence on oxygen, anxiety and insomnia. Resident 50's 9/5/25 Social Services admission and History Evaluation indicated the resident slept in a wheelchair because it helped her/him to breathe better. Resident 50's 9/8/25 admission MDS indicated the resident was cognitively intact, had shortness of breath or trouble breathing when lying flat and Resident 50 was at risk for pressure ulcers. Resident 50's 9/29/25 Cardiology follow-up note indicated the resident's legs continued to be swollen and the resident had not received her/his recliner chair but was supposed to receive it today. Resident 50's 2/17/26 Care Conference indicated the resident and her/his daughter inquired about needing a reclining chair, the business office would follow-up with Staff 1 (Administrator) and Staff 1 and Staff 2 (DNS) would look into purchasing a reclining chair for the resident. Resident 50's 4/2026, 5/2026 and 6/2026 TARs indicated the resident consistently became short of breath when lying flat or avoided lying flat to prevent shortness of breath. Multiple observations from 6/1/26 through 6/5/26 between the hours of 8:00 AM and 4:30 PM revealed Resident 50 sat in a non-reclining, manual wheelchair when awake and while sleeping. On 6/1/26 at 9:43 AM, 6/2/26 at 2:42 PM and 6/4/26 at 3:26 PM, Resident 50 stated she/he slept in a manual wheelchair since her/his admission to the facility and was in a wheelchair 24 hours a day, seven days a week. Resident 50 stated she/he did not sleep in her/his bed because she/he was unable to breathe when in bed and was afraid because her/his oxygen levels dropped into the 70's (severe hypoxia) when in bed. Resident 50 stated she/he was supposed to elevate her/his legs, but it was difficult to do while sitting in a wheelchair. Resident 50 stated she/he asked to bring her/his own recliner chair from home but was told no because it was made of fabric and could be an infection control issue. Resident 50 stated she/he was provided with a Geri-chair (a medical chair for resident's requiring frequent assistance from a caregiver for daily activities and transport) approximately two months ago but she/he could not recline the chair, independently, and had to call for assistance thus did not want to use the Geri-chair. Resident 50 stated she/he wanted her/his own recliner chair because she/he could operate the recliner independently. On 6/2/26 at 1:46 PM, Witness 1 (Family) stated Resident 50 asked to bring her/his recliner chair to the facility and it was denied because it wasn't leather. Witness 1 stated Resident 50 never slept in a bed because the resident had too much trouble breathing and the resident needed a recliner chair so she/he could breathe better and elevate her/his legs. Witness 1 stated the facility brought the resident a Geri-chair but Resident 50 could not independently recline the chair and wanted her/his own recliner chair. Witness 1 stated the last she heard anything about Resident 50's recliner chair was at least two months ago. On 6/3/26 at 1:24 PM, Witness 2 (Friend) stated approximately two months ago, she spoke with Staff 1 about bringing Resident 50's recliner chair to the facility and she was told no. Witness 2 stated Resident 50 wanted her/his own recliner chair and I hate to see [her/him] sitting in the wheelchair all of the time. Witness 2 stated the facility brought the resident a Geri-chair but Resident 50 barely fit in it and was unable to independently operate the chair so the resident did not want to use it. On 6/4/26 at 8:32 AM, Staff 8 (CNA) stated Resident 50 always sat and slept in her/his wheelchair. Staff 8 stated one time Resident 50 tried to sleep in her/his bed, but it was too hard for the resident to breathe, and she/he got scared so bad and would only sleep in her/his manual wheelchair. On 6/4/26 at 9:02 AM, Staff 10 (CNA) stated Resident 50 sat and slept in her/his wheelchair all of the time because the resident felt if she/he laid down, she/he would die. Staff 10 stated she tried to have Resident 50 lay in bed, but the resident was too afraid. On 6/4/26 at 9:38 AM, Staff 12 (CNA) stated Resident 50 had anxiety and she/he only sat in her/his wheelchair. Staff 12 stated Resident 50 reported if she/he got into bed, she/he would suffocate. On 6/4/26 at 12:58 PM, Staff 4 (LPN Care Manager) stated Resident 50 always sat in her/his wheelchair because she was not comfortable sleeping in her/his bed. Staff 4 stated Resident 50 had edema in her/his legs because the resident was not properly elevating her/his legs. Staff 4 stated Resident 50 wanted to bring her/his own recliner chair into the facility, but Staff 1 denied the request. On 6/4/26 at 1:14 PM and 2:51 PM, Staff 1 confirmed he denied Resident 50's request to bring her/his own recliner chair into the facility and acknowledged there was adequate space for the recliner chair in Resident 50's room and no residents' rights would be infringed upon unless the recliner chair became unsanitary. Staff 1 stated he did not feel the resident's own recliner chair was appropriate because it was, potentially, an infection control concern. Staff 1 stated he was aware the resident had been sitting and sleeping in her/his wheelchair since the resident admitted in 9/2025. Staff 1 stated around the end of 2/2026, he attempted to order a recliner chair for Resident 50 but accidently ordered a Geri-chair which did not work for the resident because she/he could not independently operate the chair. Staff 1 continued to state Resident 50 could not bring her/his recliner chair to the facility and no additional follow-up was conducted by Staff 1. On 6/5/26 at 11:33 AM, Staff 3 (Regional Director of Clinical Operations) stated it was her expectation the facility reviewed and offered all options to Resident 50 to ensure the resident had the accommodations she/he needed.

Based on observation, interview and record review it was determined the facility failed to ensure residents could access their closets independently for 1 of 1 sampled residents (#23) reviewed for accommodation of needs. This placed residents at risk for inability to access personal belongings. Findings include: Resident 23 was admitted to the facility in 12/2025 with diagnoses of right and left knee replacements and difficulty walking. Resident 23's quarterly MDS dated [DATE] identified the resident as having intact cognitive function, used a walker and wheelchair for mobility, and required set up and supervision with transfers and walking. A care plan dated 4/1/26 revealed Resident 23 utilized a wheelchair and required one person assistance with walking. Observations of Resident 23's room on 6/1/26 at 10:48 AM. 6/3/26 at 9:45 AM, and 6/4/26 at 3:02 PM revealed Resident 23 and the roommate's beds were positioned directly facing each other. Each bed was centered on its assigned wall beneath the overbed light. The headboards were pushed against the walls, and the footboards were approximately 20 to 24 inches apart from the other. The closets were located in the corner on the far wall. On 6/3/24 at 9:45 AM Resident 23 was observed attempting to maneuver her/his wheelchair between the two beds but the wheels caught against the foot boards preventing Resident 23 to access her/his closet.On 6/1/26 at 10:48 AM Resident 23 stated she/he could not access her/his closet when in her/his wheelchair because the wheels would become caught on the foot boards of the two beds because they were too close. Resident 23 stated she/he was not supposed to walk on her/his own yet but she/he did not want to have to ask staff and instead would hold onto the footboard to walk to the closet or use the bed remote to raise the bed all the way up to make more room for the wheelchair to fit between the two beds when attempting to get to her/his closet. Resident 23 stated staff were notified multiple times she/he could not access her/his closet, but no changes were made to the room. On 6/3/26 at 9:14 AM Staff 16 (CNA) stated Resident 23 only accessed her/his closet in the morning by transferring out of bed on the closet side of the bed and did not go to the closet after that to his knowledge. Staff 16 stated Resident 23 was independent with walking and thought she/he could probably get through the space between the beds if she/he wanted to.On 6/4/26 at 9:55 AM Staff 17 (CNA) stated Resident 23 was independent with walking in her/his room but also used a wheelchair. Staff 17 stated Resident 23's wheelchair did not fit between the two beds, so the resident would lock her/his wheelchair and walked on her/his own to access the closet. Staff 17 confirmed she was not aware Resident 23 was not yet cleared to walk unassisted and had not reported the wheelchair could not fit between the beds. On 6/4/26 at 10:09 AM Staff 20 (RN) stated he did know if Resident 23 had difficulty accessing her/his closet.On 6/4/26 at 3:02 PM Staff 1 (Administrator) and Staff 18 (Maintenance Director) entered Resident 23's room and confirmed the footboards were too close together and a wheelchair would not fit between them. Staff 1 stated he felt the current layout of Resident 23's room would not meet the required minimum square footage around beds and Resident 23 should not have been required to put her/himself at risk of falling to access her/his closet.

Based on interview and record review, it was determined the facility failed to provide a written bed-hold notice at the time of hospital transfer for 1 of 1 resident (#76), provide residents with the necessary written documentation related to hospital transfer and discharge and did not notify the Long-Term Care Ombudsman for 2 of 3 residents (#s76 and 78) reviewed for hospitalization and discharge. This placed residents at risk for lack of being informed, financial responsibilities and Ombudsman advocacy. Findings include: The facility's 5/2025 Bed Hold Policy indicated: The resident and/or representative is informed of the Bed Hold Policy in writing upon admission, transfer, or leave of absence. Upon transfer or discharge, the nursing department provides the resident and/or resident representative with a copy of the Notice of Bed Hold Policy. The facility's 5/2025 Transfer and Discharge Policy indicated: The facility sends a copy of the notice to the State Long-Term Ombudsman.1. Resident 76 was admitted in 4/2026 with diagnoses including streptococcal infection (bacterial infection) and respiratory failure.Resident 76's admission Profile indicated she/he was responsible for themselves.Review of Resident 76's clinical record revealed she/he was transferred to the hospital on 4/26/26. No evidence was found in Resident 76's clinical record to indicate the resident or resident representative was provided with a written Notice of Bed Hold Policy at the time of transfer and no evidence to indicate the State Long-Term Care Ombudsman was notified of the discharge. On 6/3/26 at 1:28 PM, Staff 24 (LPN) stated bed-hold information was provided to residents or resident representatives when residents were transferred to the hospital. On 6/5/26 at 12:26 PM, Staff 1 (Administrator) confirmed the facility did not provide a written Notice of Bed Hold Policy for Resident 76 at the time of the hospital transfer.2. Resident 78 was admitted in 3/2026 with diagnoses including surgical aftercare and morbid obesity.Resident 78's admission Profile indicated she/he was responsible for themselves.Review of Resident 78's clinical record revealed she/he was discharged from the facility following leaving against medical advice (AMA). No evidence was found in Resident 78's clinical record to indicate the State Long-Term Care Ombudsman was notified of the discharge.On 6/5/26 at 12:26 PM, Staff 1 (Administrator) verified the State Long-Term Care Ombudsman had not been notified of Resident 76 or Resident 78's transfer/discharge events.

Based on interview and record review it was determined the facility failed to follow physician orders for 1 of 5 sampled residents (#7) reviewed for unnecessary medications. This placed residents at risk for adverse side effects to medications. Findings include:Resident 7 was admitted to the facility in 4/2024 with diagnoses including hypertension (high blood pressure) and heart failure.A 11/21/25 order for metoprolol succinate (a medication used to treat hypertension) indicated the medication was to be held if the pulse was less than 55 beats per minute (bpm).A review of the 5/2026 and 6/2026 MAR revealed no documentation on the MAR of Resident 7's pulse.A review of the pulse record revealed no pulse was taken on 5/1/26, 5/3/26, 5/11/26, 5/14/26, 5/24/26, 5/26/26, 5/27/26, 5/30/26, and 6/1/26.A review of the pulse record revealed Resident 7's pulse was taken after the medications were administered on 5/7/26, 5/8/26, 5/10/26, 5/15/26, and 5/31/26.A review of the pulse record revealed Resident 7's pulse was less than 55 and metoprolol succinate was administered on 5/12/26, 5/18/26, 5/22/26, 5/25/26, and 5/29/26.On 6/4/26 at 10:24 AM, Staff 14 (CMA) stated Resident 7 had orders for metoprolol succinate, hold if her/his pulse was less than 55. Staff 1 stated she should have checked Resident 7's pulse prior to administering the metoprolol, but Staff 7 stated she could not remember if she checked Resident 7's pulse prior to giving her/his medication.On 6/4/26 at 12:28 PM, Staff 2 (DNS) stated the MAR was not triggering for Resident 7's pulse to be taken prior to the metoprolol succinate being given. Staff 2 stated it was the expectation for staff to follow physician order, check Resident 7's pulse prior to administering the metoprolol succinate, and to hold the medication if resident 7's pulse was less than 55 bpm.

Based on interview and record review it was determined the facility failed to ensure a resident's ordered pain medication was available to the resident 17 out 186 dose administration opportunities for 1 of 1 sampled residents (#56) reviewed for pain management. This placed residents at risk for uncontrolled pain. Findings include: Resident 56 admitted to the facility in 11/2021 with diagnoses including chronic pain syndrome.Resident 56's Annual MDS dated [DATE] revealed the resident was cognitively intact, frequently experienced pain in the previous five days, and reported a nine out of ten on a pain scale (a scale indicating a person's pain level where zero equals no pain).Review of Resident 56's clinical records revealed a physician order for Aspercreme Lidocaine Cream 4%, which was active since 3/9/26, instructed the facility to administer the pain medication to the resident's neck and left shoulder two times per day for pain. Review of Resident 56's 3/2026 Treatment Administration Record (TAR), 4/2026 TAR, 5/2026 TAR, and 6/2026 TAR revealed the resident had not been administered Aspercreme Lidocaine Cream 4% on the following dates:- 3/5/26 AM Dose- 3/5/26 PM Dose- 3/6/26 AM Dose- 3/6/26 PM Dose- 4/21/26 AM Dose- 5/11/26 PM Dose- 5/20/26 AM Dose- 5/26/26 AM Dose- 5/27/26 AM Dose- 5/28/26 AM Dose- 5/29/26 AM Dose- 5/29/26 PM Dose- 5/30/26 AM Dose- 5/30/26 PM Dose- 5/31/26 AM Dose- 5/31/26 PM Dose- 6/1/26 AM Dose On 6/1/26 at 11:22 AM Resident 56 stated the facility had run out of the ordered lidocaine cream for her/his left shoulder pain multiple times with the most recent time occurring the week prior. Resident 23 stated she/he did not know why the facility kept running out of medications and without it her/his left shoulder pain was not managed. On 6/4/26 at 10:05 AM Staff 19 (CMA) stated nurses administered creams. Staff 19 stated to ensure residents did not run out of medication the expectation was to check the supply regularly and submit a request to have the medication refilled when the supply started to become low. On 6/4/26 at 10:09 AM Staff 20 (RN) stated when Aspercreme Lidocaine 4% was running low the expectation was to notify Staff 21 (Central Supply) since it was an OTC cream. Staff 20 confirmed Resident 56 missed multiple doses of Aspercreme due to the medication running out but the medication running out but was unsure as to why the facility did not have any available for residents. On 6/4/26 at 3:09 AM Staff 21 stated he checked the medication supply room daily to verify available stock so he could order out of stock supplies. Staff 21 confirmed Aspercreme Lidocaine 4% had run out multiple times because the facility switched vendors and the new vender did not carry Aspercreme Lidocaine 4%, so he relied on Amazon.com and local stores to purchase the pain cream but the stores did not consistently have it in stock. Staff 2 stated Staff 21 was responsible for monitoring and tracking medications that required refills, including Aspercreme. Staff 21 stated she/he was unaware Resident 56 had missed doses of her/his Aspercreme and the medication should not have run out.

Based on interview and record review it was determined the facility failed to offer pneumococcal immunizations for 2 of 5 sampled residents (#s 7 and 56) reviewed for immunizations. This placed residents at risk for pneumonia. Findings include:Review of the facility's Pneumococcal Vaccine policy, dated 6/19/25, instructed the facility to follow the Centers for Disease Control (CDC) Pneumococcal Vaccine Timing for Adults guide to determine appropriate vaccination and cadence. Review of the CDC's Pneumococcal Vaccine Timing for Adults, dated March 2025, revealed there were four types of pneumococcal vaccines available in the United States: pneumococcal conjugate vaccines (PCV15, PCV20, and PCV21) and pneumococcal polysaccharide vaccine (PPSV23). For adults 65 years or older who have not previously received any pneumococcal vaccine, CDC recommends you give 1 dose of PCV20 or PCV21. If PCV15 is used, this should be followed by a dose of PPSV23 at least one year later. For adults 65 years or older who have only received PPSV23, CDC recommended 1 dose of PCV20 or PCV21 one year after PPSV23. The PCV15 dose should be administered at least one year after the most recent PPSV23 vaccination. For adults 65 years or older who have only received PCV13, CDC recommended PCV20 or PCV21 one year after PCV13. For adults 65 years or older who have only received PCV13 or PPSV23 after age [AGE] years old, CDC recommended PCV20 or PCV21 at least five years after PCV13 or PPSV23. a. Resident 56 was admitted to the facility in 11/2021 with diagnoses including chronic obstructive pulmonary disease and asthma. Review of Resident 56's clinical records revealed the resident last received the PPSV23 on 2/27/23 with no documentation of pneumococcal consent after 2/23/24. There was no documented evidence that Resident 56 was offered or declined PCV15, PCV20, or PCV21.On 6/5/26 at 8:15 AM Resident 56 stated she would have wanted to have been offered the pneumococcal vaccination. b. Resident 7 was admitted to the facility in 4/2024 with diagnoses including chronic heart failure and diabetes.Review of Resident 7's clinical records revealed the resident last received the PCV13 on 7/17/17. There was no pneumococcal vaccination consent after 7/17/17. There was no documented evidence that Resident 7 was offered or declined PCV20 or PCV21.Resident 7's 4/30/26 Quarterly MDS indicated the resident had severe cognitive impairment. On 6/4/26 12:46 PM Staff 15 (Infection Preventionist) stated she developed a tracking system when she took over the position approximately ten months early and found residents were past due for vaccinations. Staff 15 was aware Resident 7 and Resident 56 were due for pneumococcal vaccinations but had not offered the vaccination. Staff 15 stated she struggled completing the past due vaccinations because of being pulled to other nursing and staffing coordination related tasks.On 6/5/26 at 8:36 AM Staff 2 (DNS) confirmed knowing Staff 15 was working on past due vaccinations but did not confirm knowing specific residents. Staff 15 stated her expectation was residents are offered pneumococcal vaccinations when due.

Based on observation, interview, and record review it was determined the facility failed to implement proper safety protocols for bathing equipment, which contributed to a fall for 1 of 3 sampled resident (#1) reviewed for falls. This placed resident at risk for injury. Findings include:Resident 1 was admitted to the facility in 2/2025 with diagnoses including spinal stenosis (spinal canal narrowing resulting in pain, numbness, or weakness) and chronic kidney disease. A care plan dated 9/9/25 revealed Resident 1 required partial to moderate assistance with bathing and bathing transfer tasks.A Fall Without Fracture Incident Report dated 11/10/25 completed by Staff 4 (RN) stated Resident 1 received assistance from Staff 8 (NA Student) with transporting her/him back to her/his room in a rolling shower chair. When Staff 8 attempted to cross over the transition strip to Resident 1's room, the rolling shower chair got stuck in the transition strip on the floor of the door frame. Staff 8 attempted to lift the rolling shower chair from the backrest which resulted in the backrest becoming detached. The loss of the back support resulted in Resident 1 falling backwards onto the floor. Staff 4 assessed Resident 1 found no injury, assisted her/him to stand and then walked her/him to bed. On 2/3/26 at 1:11 PM Resident 1 stated she/he recalled falling out of the shower chair and stated she/he was afraid immediately after the incident. Resident 1 stated staff assessed her/him and assisted her/him back to bed after determining no injury had occurred. Resident 1 stated she/he did not experience a significant increase in pain after the fall. On 2/3/26 at 1:27 PM Staff 6 (Maintenance Director) demonstrated how the backrest became detached from the rolling shower chair used on 11/10/25. Staff 6 stated the backrest becoming detached was a design flaw, which he addressed after the incident on 11/10/25 by securing the pipes together with screws to prevent them from detaching easily.On 2/3/26 at 3:50 PM Staff 8 stated she assisted with Resident 1's shower on 11/10/25. Staff 8 stated she assisted Resident 1 to her/his room after the shower. When they arrived at the doorway, Resident 1 reported she/he was usually assisted in backwards to her/his room because of the transition strip. Staff 8 reported Resident 1's rolling shower chair became stuck in the transition strip. To dislodge the stuck wheel, Staff 8 pulled up on the backrest of the wheelchair which resulted in the backrest being removed and Resident 1 falling to the floor. Staff 8 stated Resident 1 experienced pain and cried after the incident but stated she/he did not experience increased pain after the fall. On 2/4/26 at 10:54 AM, Staff 7 (CNA) stated she was the shower aide on 11/10/25 and directed Staff 8 to assist Resident 1 back to his/her room. Staff 7 stated she did not witness the fall but reported Resident 1 mentioned a minimal increase in back pain after the fall and that there was no indication of injury after she/he was assessed.On 2/4/26 at 11:12 AM Staff 4 stated she assessed Resident 1 after the incident for injury. Resident 1 showed no signs of major injury and was able to stand and walk to her/his bed without any major injury. On 2/4/26 at 12:12 PM Staff 2 (DNS) confirmed Resident 1 experienced a fall due to incorrect and unsafe techniques used by Staff 8.

Based on interview and record review, it was determined the facility failed to re-evaluate preventative interventions in the presence of new pressure ulcers for 1 of 3 (#1) sampled residents reviewed for skin issues. This placed residents at risk for developing new pressure ulcers. Findings include:Resident 1 admitted to the facility in 4/2024, with diagnoses including hemiplegia and hemiparesis following cerebral infarction.Resident 1 no longer resided in the facility and could not be observed or interviewed.Resident 1's 4/21/25 care plan revealed Resident 1 had potential impairment to skin integrity related to history of CVA (stroke) with left sided deficits/neglect, impaired mobility, poor insight to limitations, incontinence, history of weight loss and other comorbidities. Interventions included avoid scratching, keep body parts from excessive moisture, keep fingernails short, follow facility protocols for treatment of injury, identify and document potential causative factors and eliminate/resolve where possible, off load when in bed, frequent repositioning while in wheelchair and clean after each incontinence episode. Resident 1's 6/12/25 Weekly Skin Audit revealed Resident 1 developed a small, superficial open area on his/her left buttock.Resident 1's 8/29/25 Weekly Skin Audit revealed Resident 1 developed moisture-associated skin damage to his/her coccyx.Resident 1's 9/12/25 Weekly Skin Audit revealed Resident 1 developed un unstageable pressure wound to his/her heel.A review of Resident 1's clinical record found no documented evidence that the facility re-evaluated resident's current care plan interventions to ensure the effectiveness of her/his interventions to prevent additional pressure ulcers.On 10/30/25 at 10:09 AM, Staff 13 (RN) stated weekly skin audits are completed on a shower day and a nurse looks over the resident's skin from head to toe. Staff stated she recommended a pressure reducing air mattress at some point and notified the RCM and DNS of this recommendation but did not document it. She stated on 8/29/25 she contacted Resident 1's provider about the new skin issue on his/her coccyx but did not work with Resident 1 again and did not follow up for a recommendation. On 11/3/25 at 8:58 AM, Staff 16 (LPN/Resident Care Manager) stated when a resident had skin breakdown, additional interventions should be implemented but were not for Resident 1. On 11/3/25 at 10:11 AM, Staff 2 (DNS) stated additional interventions should have been developed and implemented to prevent Resident 1's skin breakdown.

Based on interview and record review it was determined the facility failed to ensure residents were free from significant medication errors for 1 of 3 sampled residents (#3) reviewed for medications. As a result, Resident 3 experienced significant clinical symptoms (increased swelling of the extremities, lowered oxygen levels and shortness of breath) related to the medication error and had a 10-day hospitalization stay. Findings include: Resident 3 admitted to the facility in 1/2025 with diagnoses including chronic obstructive pulmonary disease (damage to the airways and air sacs in the lungs which make it difficult to breathe) and congestive heart failure (a weakened heart condition the causes fluid buildup in the feet, arms, lungs and other organs). Resident 3's 1/10/25 nursing notes indicated she/he was alert and oriented and was able to make her/his needs known. On 2/4/25, the facility submitted a report to the State Survey Agency which revealed Resident 3 did not receive her/his lasix (a diuretic which reduces fluid buildup), which resulted in her/his hospitalization and the facility had initiated an investigation. On 2/7/25, the facility sent additional information which confirmed Resident 3 did not receive lasix for four days due to a charting error on the resident's MAR. Physician orders dated 1/11/25 for Resident 3 revealed she/he was to be administered 40 mg of lasix once a day from 1/11/25 through 1/22/25. Resident 3's Nursing Note dated 1/22/25 revealed she/he had a new order for lasix to be administered two times a day for five days due to the resident's complaints of increased swelling in her/his lower extremities. Resident 3's 1/23/25 Nursing Note indicated for the resident's new order to be implemented, her/his original order needed to be stopped. Resident 3's 1/2025 MAR revealed she/he did not receive her/his lasix from 1/27/25 through 1/30/25. An MD provider note dated 1/31/25, indicated Resident 3 had reported shortness of breath and swelling in her/his legs. The note indicated the resident had not been administered lasix from 1/27/25 through 1/31/25 and was a medication error. Resident 3 was re-started on her/his medication on 1/31/25. Resident 3's 2/2/25 Nursing Note revealed she/he was observed to have continued shortness of breath, increased respiratory rate, lower than normal oxygen levels and swelling in her/his legs. The resident was sent to the ED at approximately 9:00 AM and diagnosed with acute hypoxemic respiratory failure (a serious condition where the lungs fail to deliver enough oxygen to the blood, leading to a deficiency of oxygen in the body). Hospital discharge records dated 2/12/25 revealed Resident 3 was admitted to the ED on 2/2/25, and was diagnosed with hypoxemic respiratory failure. Resident 3 was admitted to the ICU and received 5-6 liters of oxygen (baseline oxygen was 2 liters), prednisone (a steroid medication used to treat inflammation), and was volume overloaded on her/his physical exam. Resident 3's BNP (brain natriuretic peptide, a protein hormone produced by the heart's ventricles in response to stress and pressure, which rise when heart failure is experienced) was elevated above normal levels and the report concluded the heart failure was due to medication non-adherence. On 5/21/25 at 2:31 PM, Staff 5 confirmed she received new orders from the provider to start a lasix burst which consisted of taking the medication twice a day for five days. She attempted to hold the once per day lasix order from 1/22/25 through 1/26/25. She was unable to place the medication on hold due to a glitch in the computer system and had to discontinue the medication. She stated she was going to be off for several days, so she spoke to the facility provider and the care manager regarding the medication change, as she was concerned about the glitch in the medication system. Staff 5 stated she placed the resident on alert for the new medication regimen and assumed the previous nurse manager or DNS would address the issue in their clinical rounds. Resident 3 was not interviewed due to discharging from the facility. On 5/22/25 at 11:28 AM, Staff 4 (Nurse Practitioner) stated a resident missing four days of lasix would constitute a significant medication error and could have significant, serious medical outcomes for residents. On 5/22/25 at 12:05 PM, Staff 1 (Administrator) and Staff 2 (DNS) were notified of the investigative findings and provided no additional information.

Based on observation, interview and record review it was determined the facility failed to ensure proper hand hygiene and infection control practices were followed during CBG monitoring for 1 of 1 sampled resident (#22) reviewed for dialysis and failed to ensure enhanced barrier and transmission based precautions were followed for 1 of 1 facility reviewed for infection control precautions. This placed residents at risk for infections, communicable diseases and cross-contamination. Findings include: 1. The Lippincott Manual of Nursing Practice, 10th edition, Fundamentals of Standard Precautions for Hand Hygiene indicated hand hygiene is the single most recommended measure to reduce the risk of transmitting micro-organisms. Hand hygiene should be performed between patient contacts; after contact with blood, body fluids, secretions and excretions, and contaminated equipment or articles; before donning and after removing gloves is vital for infection control. The American Health Care Association National Infection Prevention Forum Tips for Meeting the Cleaning and Disinfecting of Blood Glucose Meters Requirements in Skilled Nursing Facilities, undated, indicated the following: -Place a barrier under the blood glucose meter when in a resident 's room or when placed on top of the medication cart to avoid spread of microorganisms and contamination of surfaces and other equipment or supplies. -Place clean and dry paper towel(s) under the blood glucose meter before placing it on a resident's table or on top of the medication cart. -Perform hand hygiene immediately after removal of gloves and before touching other medical equipment or supplies intended for use with other persons. Resident 22 was admitted to the facility in 1/2025 with diagnoses including diabetes and end-stage renal disease. Resident 22's 1/2025 MAR indicated the resident had CBGs monitored before each meal and at bedtime. On 1/27/25 at 12:04 PM Staff 11 (RN) entered Resident 22's room with CBG supplies including a lancet (a sharp device used to prick a finger to obtain a blood droplet for testing), small square gauze, alcohol prep pad and a glucometer and placed them on the resident's dirty bedside table. No barrier was utilized on Resident 22's bedside table to prevent contamination. Staff 11 left Resident 22's room and returned two minutes later. Staff 11 then donned gloves (without completing hand hygiene), pricked Resident 22's finger, wiped off a small drop of blood using the gauze pad and placed the second drop of blood onto a test strip which was inserted into the shared glucometer. On 1/27/25 at 12:06 PM Staff 11 completed CBG monitoring, exited Resident 22's room, returned to the medication cart, placed the glucometer on the cart (without a barrier), removed his gloves, donned new gloves (without completing hand hygiene) and disinfected the glucometer. Staff 11 then placed the disinfected glucometer back on the medication cart. The medication cart was not disinfected and no barrier was utilized to prevent contamination. Staff 11 then removed his gloves, donned new gloves (without completing hand hygiene), removed a syringe and a vial of insulin from the medication cart and drew up Resident 22's insulin injection. Staff 11 placed the syringe on the medication cart. The medication cart was not disinfected and no barrier was utilized to prevent contamination. Staff 11 then removed his gloves, donned a new pair of gloves (without completing hand hygiene) and entered Resident 22's room. He placed the syringe with insulin on the resident's dirty bedside table, prepped the resident's skin using an alcohol prep pad and gave Resident 22 her/his insulin injection. Resident 22's table was not disinfected and no barrier was utilized to prevent contamination. On 1/27/25 at 1:09 PM Staff 11 stated he typically utilized paper towels as a barrier on a resident's bedside table and the medication cart but did not do so today because he was behind in his scheduled duties. Staff 11 stated he typically completed hand hygiene after removing dirty gloves and before donning clean gloves but he forgot to complete appropriate hand hygiene today because he was stressed from being behind in his schedule. On 1/31/25 at 11:10 AM Staff 2 (DNS) stated staff were expected to complete hand hygiene after removing dirty gloves and before donning clean gloves and a barrier should have been used on Resident 22's dirty bedside table and the medication cart prior to placing clean supplies down. Staff 2 stated clean supplies should never be placed on a dirty surface and hand hygiene should always be completed between gloving. 46053 2. The CDC's website titled Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes dated 6/28/24 indicated the following: -Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs). -Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). The facility's March 26, 2024 Enhanced Barrier Precautions (EBP) policy and procedure indicated the following: -EBPs are initiated to reduce transmission of multidrug resistant organisms (MDRO) employing targeted gown and glove use during high contact resident care activities. -EBPs are indicated for residents with MDRO, wounds, or indwelling medical devices. On 1/27/25 the facility had 14 residents who had MDRO, wounds or indwelling medical devices which required Enhanced Barrier Precautions (EBP). On 2/3/25 at 12:32 PM Staff 2 (DNS / Infection Preventionist) verified the following residents met the requirements for EBPs: -Resident 1 -Resident 13 -Resident 14 -Resident 21 -Resident 26 -Resident 30 -Resident 35 -Resident 36 -Resident 38 -Resident 64 -Resident 220 -Resident 221 -Resident 271 -Resident 318 Random observations from 1/27/25 through 1/28/25 between the hours of 8:00 am and 4:30 PM revealed all 14 identified residents requiring EBPs had no EBP signage to notify staff they were on EBPs and no PPE supplies were observed outside any of the listed residents' rooms. On 1/28/25 at 2:06 PM Staff 15 (CNA) was observed to exit Resident 318's room and Resident 21's room. She stated she did not wear a gown or mask when she provided hands-on care to these residents. She stated she only had to wear a gown and a mask if the residents had flu-like symptoms. On 1/28/25 at 4:16 PM Staff 3 (RN/RCM) stated she expected staff to follow Enhanced Barrier Precautions when providing high-contact direct cares for residents with a catheter, a nephrostomy, a urostomy, a picc line or other points of entry that could place the resident at risk. Staff 3 acknowledged the facility did not currently have signage or PPE kits at residents' doors whose conditions indicated the use of enhanced barrier precautions. She stated, I expect it. It is standard of practice. On 2/3/25 at 10:47 AM Staff 15 (Regional [NAME] President) acknowledged the facility was not following Enhanced Barrier Precautions and stated, PPE should be in the carts outside the rooms for anyone that meets the EBP criteria. Hands on care would require full PPE to protect the point of entry and everyone involved. 43691 3. According to the CDCs Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007), droplet precautions include use of a mask for mouth and nose protection and eye protection to prevent transmission of respiratory droplets which can transmit infection, including influenza, between individuals. Resident 270 was readmitted to the facility in 1/2025 which diagnoses including influenza. A progress note from 1/19/25 at 3:34 AM reported Resident 270 had returned from the hospital with diagnoses including influenza and droplet precautions were to be followed. On 1/27/25 at 1:29 PM a cart containing PPE was observed outside Resident 270s room. No sign which indicated what type of precautions were to be followed was observed outside of the room. On 1/27/25 at 1:29 PM Staff 16 (LPN) and Staff 8 (RA/CNA) were asked what precautions were to be followed for Resident 270. Staff 16 stated she was not sure. Staff 8 stated enhanced barrier precautions were to be followed for Resident 270. On 1/27/25 at 1:44 PM housekeeping staff was observed inside Resident 270's room wearing a surgical mask and gloves, but no eye protection. Verbal communication was attempted with this staff member which was unsuccessful. On 1/27/25 at 1:49 PM Resident 270's precautions were reviewed with Staff 2 (DNS). Staff 2 stated droplet precautions should have been followed for Resident 270 until she/he was reassessed and physician orders had been updated. On 1/27/25 at 2:02 PM Staff 2 and Staff 15 (Regional [NAME] President) confirmed a sign outside of Resident 270's room should have been present to communicate what precautions were to be followed for Resident 270. Staff 2 also confirmed a resident should have been assessed prior to changes being made in infection control practices.

Based on interview and record review it was determined the facility failed to ensure residents were notified their of rights both orally and in writing on an ongoing basis for 1 of 1 facility reviewed for Resident Council. This placed residents at risk for not being informed of their rights. Findings include: On 1/30/25 at 11:00 AM the Resident Council members stated they were not informed of resident rights on an ongoing basis, were unsure if any were posted in the facility, or where to obtain the resident rights. Record review of Resident Council Meeting minutes for 11/12/24, 12/10/24 and 1/17/25 revealed no evidence resident rights were provided to, or reviewed with, residents during the meetings or by any other method. On 1/30/25 at 12:27 PM Staff 1 (Administrator) stated he believed resident rights were reviewed through Resident Council and was not aware of any other method used to relay resident rights. Staff 1 acknowledged this finding and no additional information was provided.

Based on interview and record review it was determined the facility failed to have a system in place to deliver mail on Saturdays for 1 of 1 Resident Council reviewed. This placed residents at risk for lack of timely written communications. Findings include: On 1/30/25 at 11:00 AM during the Resident Council group interview, residents stated their mail was not delivered on Saturdays. Review of 11/20024 through 1/2025 resident activity participation charts revealed no evidence mail was delivered to residents on Saturdays. On 1/30/25 at 1:10 PM, Staff 1 (Administrator) confirmed there was no system in place to deliver mail to residents on Saturdays.

Based on interview and record review it was determined the facility failed to comprehensively assess 3 of 7 sampled residents (#s 15, 18 and 33) reviewed for medications, ROM and behaviors. This placed residents at risk for unassessed needs and a lack of a person-centered care plan. Findings include: 1. Resident 15 was admitted to the facility in 2019 with diagnoses including major depression, schizophrenia, post traumatic stress disorder and anxiety disorder. An annual MDS assessment dated [DATE] indicated the resident had mild cognitive impairment with a BIMS of 13. According to the MDS the resident was prescribed daily psychotropic medication including antianxiety, antipsychotic, and antidepressant medication. Under the CAA for psychotropics, the analysis of findings was limited to a list of psychiatric diagnoses, a list of the prescribed psychotropic medications, and a statement that psychotropic meds have been included in [the resident's] Care Plan as a preventative measure. Care Plan will be updated if changes in risk factors. There was no evidence of a review of the indicators and supporting documentation, no description of the problem such as targeted behaviors, how the mental health diagnosis manifested or presented or specific risk factors associated with the use of psychotropic medications. The CAAs for falls, nutrition, and functional ability all followed the same pattern. On 1/31/25 at 10:50 AM Staff 2 (DNS) confirmed the CAAs did not include an analysis of the triggered concerns. 2. Resident 33 was admitted in 11/2021 with diagnoses including stroke and hemiplegia (paralysis on one side of the body). The resident's annual MDS dated [DATE] identified the resident to be cognitively intact with a BIMS of 15. Under preferences the MDS identified that it was important to the resident that they make choices and stay active. Under the Functional Abilities section the resident was identified to have a ROM impairment on one side and used a walker and wheelchair for mobility. The MDS identified the resident to experience occasional pain and to have received no restorative services in the past seven days. The Functional Abilities CAA described the resident to be at risk for ADL inabilities and identified a list of diagnoses that could impact mobility. The CAA indicated ADLs have been included in [resident's] care plan as a preventative measure. Care plan will be updated if change in risk factors. Noted--Pt has RA program. The CAA lacked an analysis of the resident's current level of function, goals, or level of participation in the RA program. The CAA did not identify what potential negative outcome was to be prevented by including ADLs in the resident's care plan. On 1/31/25 at 10:57 AM Staff 2 (DNS) confirmed the CAA lacked an analysis of findings to ensure a person-centered care plan. 38140 3. Resident 18 admitted to the facility in 2023 with a diagnoses including major depression. Resident 18's 11/15/24 Quarterly MDS indicated no symptoms of little interest in doing things, depressed mood, feeling down or hopeless. A 11/20/24 Social Services Evaluation revealed Resident 18 appeared to have had a decline in her/his mood and affect. Resident 18's health record revealed no assessment for the analysis, cause or contributing factors for a decline in her/his mood and affect. Resident 18's 1/3/25 Re-Admission MDS assessed her/him with moderately impaired cognition with diagnoses including major depression. Resident 18 was assessed with no behaviors exhibited. No CAA was completed to comprehensively assess the resident's mood and behaviors. On 2/3/25 at 9:11 AM Staff 2 (DNS) confirmed Resident 18's health record did not accurately assess and include a description of the specific behaviors documented by Social Services, the MDS lacked through assessment for Resident 18's mood and behaviors and lacked a CAA with an analysis of findings.

Based on observation, interview and record review it was determined the facility failed to provide an ongoing person-centered activity program for 4 of 4 sampled dependent residents (#s 17, 24, 57 and 269) reviewed for activities. This placed residents at risk of a decline in psychosocial well-being and diminished quality of life. Findings include: 1. Resident 57 was admitted to the facility in 12/2024 with diagnoses including stroke, schizophrenia and dementia. Resident 57's 1/4/25 Admission MDS revealed the resident had short and long term memory problems and the resident was severely impaired to make decisions regarding tasks of daily living. Resident 57 liked listening to music, reading books/newspapers or magazines, doing things in groups of people, participating in favorite activities and participating in religious activities or practices. A review of Resident 57's health record revealed no evidence an Activities care plan was completed. The facility's Activity Calendar revealed the following scheduled activities: -1/27/25 9:30 AM: Sit and Be Fit 10:30 AM: Bingo 11:30 AM: Screen Time 2:00 PM: Wii Sports -1/28/25 9:30 AM: Sit and Be Fit 10:15 AM: Coffee and Chat 2:00 PM: Crafting DIY Squirrel Feeder -1/29/25 9:30 AM: Sit and Be Fit 10:30 AM: Bingo 2:00 PM: Chinese New Year Celebration with Chinese Appetizers -1/30/25 9:30 AM: Sit and Be Fit 10:15 AM: Coffee and Chat 11:00 AM: Gospel Sing Along with [NAME] and [NAME] 2:00 PM: Uno -1/31/25 9:30 AM: Sit and Be Fit 10:30 AM: Bingo 2:00 PM: Friday Matinee Everything, Everywhere, All at Once Resident 57's Activity Participation Log from 12/30/24 through 1/30/25 indicated Resident 57 participated in one independent activity on 1/25/25. Random observations of Resident 57 conducted from 1/28/25 through 1/30/25 between the hours of 9:15 AM and 2:46 PM revealed the resident was mostly up in her/his wheelchair, often alone in her/his room but at times in the hallway or sitting in the 200 unit dining area. The resident had one paperback novel and a blue, hard covered book observed in her/his room. The resident had no TV on, no music playing and no newspapers or magazines in her/his room. Resident 57 was not observed engaged in any group activities, including a live music performance observed on 1/28/25, and no one-on-one activities occurred in Resident 57's room. On 1/29/25 at 3:08 PM Witness 1 (Family) reported Resident 57 loved to walk and be outside in the sunshine. Witness 1 reported Resident 57 was very artistic, liked books, was very religious and enjoyed nice, soft music. Witness 1 stated recently, when she came to visit, she found Resident 57 sitting alone in her/his wheelchair in her/his semi-dark room, with the door closed. Witness 1 stated Resident 57 was not being engaged in activities. On 1/30/25 at 9:05 AM Staff 7 (CNA) reported Resident 57 enjoyed listening to live music. Staff 7 stated she did not see Resident 57 engaged in group or one-on-one activities and the resident did not have anything in her/his room to do. On 1/30/25 at 11:03 AM Staff 9 (Activity Director/Social Service Director) confirmed Resident 57 did not have an Activity care plan completed. Staff 9 stated she was unaware of Resident 57's activity preferences and no activities program was developed for the resident. Staff 9 stated the activities program began to fall off around mid-December. Staff 9 stated she was unable to get to many of the newly admitted residents so other residents, including Resident 57, were without a developed activities program. On 1/31/25 at 11:14 AM Staff 2 (DNS) stated she expected to see activity plans in place for all residents but especially for residents with dementia or behavioral issues. 38140 2. Resident 17 was admitted to the facility in 2021 with diagnoses including stroke and Aphasia (language disorder that affects a person's ability to communicate). Resident 17's 10/13/24 Annual MDS revealed the resident experienced severely impaired cognition. Resident 17 liked listening to music, doing things in groups of people, pets, participating in favorite activities and participating in religious activities or practices. On 1/27/25 at 1:11 PM Witness 4 (Family) stated Resident 17 enjoyed watching television, listening to music, especially jazz, classical and the oldies. Witness 4 stated Resident 17 had a radio in her/his room but they had not seen the radio since last spring. A review of Resident 17's current care plan directed staff to complete the following: - Assist patient to/from activity area. -Coordinate with nursing/therapy staff to get patient up for activities of choice. -Arrange for resident to attend group activities. -Encourage resident to eat in common dining area. -Seat resident near others as desired. -Explain activity events offered. Narrate as need for understanding and success. -Invite resident to activities and encourage participation. -Schedule one-on-one activity for resident one to two times per week. -Approaches may include braiding her/his hair, read aloud, watch television with commentary. No resident centered care plan interventions were found in Resident 17's health record. The facility's Activity Calendar revealed the following scheduled activities: -1/27/25 9:30 AM: Sit and Be Fit 10:30 AM: Bingo 11:30 AM: Screen Time 2:00 PM: Wii Sports -1/28/25 9:30 AM: Sit and Be Fit 10:15 AM: Coffee and Chat 2:00 PM: Crafting DIY Squirrel Feeder -1/29/25 9:30 AM: Sit and Be Fit (one resident in attendance) 10:30 AM: Bingo (12 residents in attendance) 2:00 PM: Chinese New Year Celebration with Chinese Appetizers -1/30/25 9:30 AM: Sit and Be Fit 10:15 AM: Coffee and Chat 11:00 AM: Gospel Sing Along with [NAME] and [NAME] 2:00 PM: Uno -1/31/25 9:30 AM: Sit and Be Fit 10:30 AM: Bingo 2:00 PM: Friday Matinee Everything, Everywhere, All at Once Resident 17's Activity Participation Log from 12/30/24 through 1/30/25 indicated Resident 17 participated in one in room activity on 1/25/25. Random observations of Resident 17 were conducted from 1/27/25 through 1/30/25 between the hours of 8:24 AM and 3:32 PM. Resident 17 was observed to lie in bed with curtains pulled around her/his bed, her/his television turned off, no music played and her/his room was often dark. At times, Resident 17's roommate's television was on but not visable to Resident 17 as cutians were pulled. Resident 17 was not observed engaged in any group activities, including a live music performance observed on 1/28/25, and no one-on-one or diversional activities were observed in Resident 17's room. On 1/30/25 at 1:34 PM Staff 9 (Activity Director/Social Service Director) confirmed the lack of activities provided for Resident 17. Staff 9 stated in room activities had not been provided recently and staff did not get Resident 17 out of bed to attend group activities. Staff 9 stated she was not aware Resident 17 enjoyed television or had a radio to listen to in her/his room. On 1/31/25 at 9:51 AM Staff 2 (DNS) stated she expected activity care plans to be resident centered, implemented and an activity program to be in place for all residents. 3. Resident 24 was admitted to the facility in 2022 with diagnoses including chronic kidney disease and diabetes. Resident 24's 11/1/24 Annual MDS revealed the resident was cognitively intact. Resident 24 liked the news, listening to music, animals, reading books/newspapers or magazines, doing things in groups of people, fresh air outdoors, participating in favorite activities and participating in religious activities or practices. A review of Resident 24's 1/28/25 care plan directed staff to complete the following: -Assist her/him to and from activity area -Coordinate with nursing/therapy staff to get patient up for activities of choice Invite and encourage her/him to participate in activities of her/his interest. -Offer one-on-one activity in room or other resident preferred location, one time a week by way of crafting, conversation, television viewing and prayer as tolerated. No resident centered care plans were found in Resident 24's health record. The facility's Activity Calendar revealed the following scheduled activities: -1/27/25 9:30 AM: Sit and Be Fit 10:30 AM: Bingo 11:30 AM: Screen Time 2:00 PM: Wii Sports -1/28/25 9:30 AM: Sit and Be Fit 10:15 AM: Coffee and Chat 2:00 PM: Crafting DIY Squirrel Feeder -1/29/25 9:30 AM: Sit and Be Fit (one resident in attendance) 10:30 AM: Bingo (12 residents in attendance) 2:00 PM: Chinese New Year Celebration with Chinese Appetizers -1/30/25 9:30 AM: Sit and Be Fit 10:15 AM: Coffee and Chat 11:00 AM: Gospel Sing Along with [NAME] and [NAME] 2:00 PM: Uno -1/31/25 9:30 AM: Sit and Be Fit 10:30 AM: Bingo 2:00 PM: Friday Matinee Everything, Everywhere, All at Once Resident 24's Activity Participation Log from 12/30/24 through 1/30/25 indicated Resident 24 participated in one independent activity on 1/25/25. Random observations of Resident 24 conducted from 1/27/25 through 1/30/25 between the hours of 8:21 AM and 3:30 PM revealed the resident was asleep or watched television in her/his bed with the divider curtain pulled to the foot of the right side of bed. Resident 24 was not observed engaged in any group activities, including a live music performance observed on 1/28/25, and no one-on-one activities were observed in Resident 24's room. On 1/30/25 at 1:34 PM Staff 9 (Activity Director/Social Service Director) confirmed the lack of activities provided for Resident 24. Staff 9 stated in room activities had not been provided recently and staff did not get Resident 24 out of bed to attend group activities. On 1/31/25 at 9:51 AM Staff 2 (DNS) stated she expected to see resident centered activity plans and an activity program in place for all residents. 43691 4. Resident 269 was admitted to the facility in 1/2025 with diagnoses including congestive heart failure. Review of Resident 269's records revealed no assessment of activity preferences had been completed. On 1/27/25 at 10:29 AM Resident 269 stated she/he had not been asked about activity preferences and had not been invited to participate in any activities. On 1/29/25 at 2:00 PM a music activity was overheard occurring in the main dining room of the facility. Resident 269 was not observed at the activity. On 1/30/25 at 10:06 AM Resident 269 stated she/he heard the music activity the previous day but had not been invited to the activity and would have been interested in attending. On 1/30/25 at 10:48 AM Staff 9 (Activity Director/Social Service Director) stated an activity assessment was to be completed on residents within five days of their admission to the facility. On 1/31/25 at 11:27 AM Staff 2 (DNS) confirmed an activity assessment had not been completed for Resident 269 to determine activity preferences and Resident 269 had not been invited to activities.

Based on interview and record review it was determined the facility failed to provide evidence a designated licensed nurse (LN) served as a charge nurse to provide the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 of 1 facility reviewed for staffing. This placed the residents at risk for unmet needs. Findings include: The facility's Direct Care Staff Daily Reports revealed from 1/1/25 through 1/27/25, 36 out of 81 shifts were without LN coverage to serve as a charge nurse as follows: -1/1/25; day shift. -1/2/25; day, evening and night shifts. -1/3/25 day shift. -1/6/25; day, evening and night shifts. -1/8/25; night shift. -1/9/25; day and night shifts. -1/10/25; night shift. -1/14/25; day, evening and night shifts. -1/15/25; night shift. -1/17/25; evening and night shift. -1/20/25; day, evening and night shifts -1/21/25; day, evening and night shifts. -1/22/25; day, evening and night shifts. -1/23/25; evening and night shifts. -1/24/25; day, evening and night shifts. On 1/30/25 at 9:42 AM Staff 17 (Staffing Coordinator) confirmed the dates and shifts the facility did not meet the LN coverage on the shifts identified. No additional information was provided. An interview on 1/30/25 at 9:56 AM with Staff 1 (Administrator) confirmed the facility was unaware if an LN was staffed on the shifts provided. No additional information was provided.

Based on interview and record review it was determined the facility failed to ensure an RN was available for at least eight consecutive hours per day seven days per week for 9 of 27 days reviewed for staffing. This placed residents at risk for lack of timely RN assessments and care. Findings include: Review of the Direct Care Staff Daily Reports from 1/3/25 through 1/27/25 revealed no RN coverage was available for at least eight consecutive hours per day on the following days: -1/2/25. -1/6/25. -1/13/25. -1/14/25. -1/17/25. -1/20/25. -1/21/25. -1/22/25. -1/24/25. On 1/30/25 at 9:42 AM Staff 17 (Staffing Coordinator) acknowledged the facility lacked RN coverage on the identified days on the Direct Care Staff Daily Reports. No additional information was provided. On 1/30/25 at 9:56 AM Staff 1 (Administrator) acknowledged the facility's failure to meet RN coverage for eight consecutive hours per day on the dates provided. No additional information was provided.

Based on observation, interview and record review it was determined the facility failed to ensure residents were treated with dignity for 1 of 1 sampled resident (# 3) and 1 of 1 facility reviewed for dignity and dining. This placed residents at risk for lack of dignity. Findings include: 1. Resident 3 was admitted to the facility in 10/2014 with diagnoses including adult failure to thrive, abnormal weight loss and anxiety. Resident 3's 12/20/24 Annual MDS revealed the resident had no cognitive impairments and had impairments of both upper extremities. Observations of Resident 3 during breakfast and lunch meals from 1/28/25 through 1/30/25 revealed the following: -1/28/25 at 8:52 AM: Resident 3 received two glasses of juice served in plastic medication glasses and cereal served in a medium sized paper bowl. -1/28/25 at 12:48 PM: Resident 3 received two glasses of juice served in plastic medication glasses. -1/29/25 at 8:23 AM: Resident 3 received two glasses of juice served in plastic medication glasses. -1/30/25 at 8:37 AM: Resident 3 received two glasses of juice served in Styrofoam glasses. On 1/28/25 at 8:52 AM and 12:48 PM Resident 3 stated she/he received paper, plastic and Styrofoam dishware for at least the past two months. She/he stated it was difficult to feed herself/himself because the paper, plastic and Styrofoam dishware was not sturdy enough which resulted in spilled food and drinks. On 1/28/25 at 12:55 PM Staff 4 (CNA) reported residents, including Resident 3, were served with plastic or Styrofoam glasses because the regular glassware kept getting lost or the kitchen ran out of regular dishware. On 1/29/25 at 8:25 AM Staff 5 (CNA) stated the residents were served with plastic or Styrofoam glasses for the past couple of months and was not sure why the kitchen did not provide regular dishware. On 1/29/25 at 8:34 AM Staff 6 (Dietary Manager) stated he was new in his role as dietary manager and was unaware the residents were being served drinks and food with plastic and Styrofoam dishware. Resident 3 spoke with Staff 6 and told him plastic and Styrofoam dishware did not work with her/his hands. Staff 6 confirmed Resident 3 was being served drinks in plastic and Styrofoam glasses and that was not dignified or home-like. 2. Random observations of the facility during breakfast and lunch on 1/28/25 through 1/29/25 revealed the following: -Multiple residents who were served meals in their rooms and both dining rooms were served drinks in plastic medication or Styrofoam glasses. -Plastic medication and Styrofoam glasses were observed on the all of the beverage service carts. On 1/28/25 at 8:52 AM and 12:48 PM Resident 3 stated she/he received paper, plastic and Styrofoam dishware for at least the past two months. She/he stated it was difficult to feed herself/himself because the paper, plastic and Styrofoam dishware was not sturdy enough which resulted in spilled food and drinks. On 1/28/25 at 12:55 PM Staff 4 (CNA) reported residents, including Resident 3, were served with plastic or Styrofoam glasses because the regular glassware kept getting lost or the kitchen ran out of regular dishware. On 1/29/25 at 8:25 AM Staff 5 (CNA) stated the residents were served with plastic or Styrofoam glasses for the past couple of months and was not sure why the kitchen did not provide regular dishware. On 1/29/25 at 8:34 AM Staff 6 (Dietary Manager) stated he was new in his role as dietary manager and was unaware the residents were being served drinks and food with plastic and Styrofoam dishware. Staff 6 completed a walk-through of the facility and confirmed multiple residents were being served drinks in plastic and Styrofoam glasses and that was not dignified or home-like.

Based on interview and record review it was determined the facility failed to inform residents and/or the residents' responsible party of the risks and benefits, and to ensure consent was obtained for the use of psychotropic medications for 1 of 5 sampled residents (# 220) reviewed for unnecessary medications. This placed residents at risk for lack of informed consent. Findings include: The facility's Informed Consent for Psychotropic Drugs, dated 9/2017, revealed the licensed nurse was to: -Discuss the rationale/benefits for the orders as directed by the physician. -Discuss the potential risk factors (side effects/symptoms) of taking the prescribed drug. -Review the content with the resident and obtain their signature if they agreed to take the prescribed drug. Resident 220 was admitted to the facility in 1/2025 with diagnoses including generalized anxiety disorder. Resident 220's 1/2025 MAR revealed the resident received the following psychotropic medications as ordered by her/his physician: -Citralopram Hydrobromide (a medication to treat depression and panic attacks) one time a day for generalized anxiety. -Aprazolam (a medication to treat anxiety) every 12 hours as needed for anxiety. Review of Resident 220's health record revealed no documentation to indicate the resident or her/his representative was informed of the risks and benefits of citralopram and aprazolam and no evidence the resident consented to receive the medications. On 1/30/25 at 12:47 PM Staff 2 ( DNS) stated it was her expectation nursing staff reviewed the risks and benefits of psychotropic medications with residents prior to the residents taking the medications and confirmed Resident 220 received citralopram and aprazolam without consent being obtained.

Based on interview and record review it was determined the facility failed to ensure care plan interventions were followed for 1 of 3 sampled resident (#7) reviewed for accidents. The facility's failure resulted in Resident 7 sustaining serious bodily injury. The facility identified the noncompliance and immediately initiated a plan of correction which resulted in disciplinary action and additional fall prevention training with instructions to follow the care plan for all staff. This incident was identified as meeting the criteria for past noncompliance. Resident 7 admitted to the facility 9/15/20 with diagnoses including left [CONDITION(S)] and dementia. The 9/22/20 Five Day MDS revealed Resident 7 had had a fall in the last month, a fall in the past two to six months, and a fracture which was related to a fall within the past six months. The toileting section was assessed as an extensive assist. Residents 7's care plan initiated on 9/15/20 for toileting included the intervention to not leave Resident 7 unsupervised on the toilet; one-person physical assist and used the commode. A 9/23/20 progress note by Staff 15 (RN), revealed a CNA notified her Resident 7 was found on the floor in her/his room. Staff 15 went to the resident's room and found Resident 7 laying on her/his right side on the floor. Resident 7 reported pain and injury to right hip and x-rays were ordered for the right hip. A 9/24/20 progress note identified the right hip x-ray showed a subcapital impaction fracture (neck and head of femur where the broken ends of bone were jammed together) with mild displacement. The physician was notified and Resident 7 was transferred to the hospital. On 9/24/20 at 4:16 PM, Staff 12 (CNA) was interviewed for the investigation of the incident. Staff 12 reported she was assigned to care for Resident 7. Staff 12 reported Resident 7 asked to use the commode and she transferred the resident to the commode per the care plan. While Resident 7 was on the commode, Staff 12 became aware of another resident who needed help. Staff 12 left Resident 7 on the commode unattended and did not let another staff assist the other resident. When she returned to Resident 7's room, other staff were in the room and Resident 7 was on the floor. The investigation report revealed Staff 12 acknowledged she did not follow the care plan. On 5/18/21 at 12:44 PM, Staff 2 (DNS) confirmed Staff 12 did not follow Resident 7's care plan on 9/23/20. Staff 2 reported Staff 12 had not other incidents since 9/23/20. Staff 2 revealed the facility immediately took steps to counsel and monitor Staff 12. In addition, all staff attended a training on fall prevention, which was completed on 9/30/20. The situation met the criteria for past noncompliance as follows: 1. The incident indicated noncompliance for F689. 2. The noncompliance occurred after the exit date of the last standard recertification survey 11/14/19 and before the date of this survey 5/10/21. 3. There was sufficient evidence the facility corrected the noncompliance and was in substantial compliance with F689 as evidenced by: - No deficient practice was found at F689 with additional sampled residents. - Evidence the deficient practice was identified by the facility, the facility took immediate action to immediately counsel and monitor the staff responsible and trained all staff for fall risk and prevention. The Fall Risk Patients! training material was signed by 65 staff and indicated the training was completed by 9/30/20. - DNS, RCM, and CNA interviews indicated knowledge and awareness of fall prevention and directions to follow residents care plans.

Based on interview and record review the facility failed to clarify a Physician's order for a [MEDICATION NAME] burst for 1 of 3 sampled residents (#1) who were reviewed for steroid use. As a result the resident experienced adverse side effects when the medication was discontinued without a medication taper. Findings include: Resident 1 was admitted to the facility 12/12/12 with [DIAGNOSES REDACTED]. A Physician's visit note, dated 2/5/13, identified the resident complained of an exacerbation of [DIAGNOSES REDACTED] with increased weakness and pain. The note indicated the resident was on chronic steroid therapy for [DIAGNOSES REDACTED] and the plan was to increase the resident's [MEDICATION NAME] dose from 10 mg daily to a "40 mg dose for about 6 weeks and then begin a slower taper." The note identified the facility should schedule a follow-up appointment with the resident's Rheumatologist to see if he had further recommendations. On 2/5/13 at 3:38 pm the Physician, documented in a facility progress note, the resident's [MEDICATION NAME] was increased to 40 mg daily for "2 weeks and reassess." A signed Physician's Telephone Order, dated 2/5/13, identified an order to increase the resident's [MEDICATION NAME] to 40 mg daily for two weeks related to a [DIAGNOSES REDACTED] flare up. On 2/5/13 at 3:56 pm a progress note, documented by Staff 3, RN, the resident's [MEDICATION NAME] was increased from 10 mg to 40 mg for two weeks. On 2/13/13 at 1:20 pm a progress note identified the resident was seen by the Rheumatologist and came back with a new order but no orders related to the [MEDICATION NAME] therapy. The resident's February 2012 MAR indicated [REDACTED]. and the 40 mg dose was initiated on 2/6/13 and administered daily through 2/19/13. The MAR indicated [REDACTED]. Lippincott Williams & Wilkins' 2013 Nursing Drug Handbook, Nursing Considerations, page 1118, identified [MEDICATION NAME] should be gradually reduced in dosage after long-term therapy. On 2/27/13 at 6:42 pm a progress note identified the resident complained of generalized pain and the resident's family was concerned the resident's [MEDICATION NAME], which had been taken daily for [DIAGNOSES REDACTED], was discontinued. The note indicated the resident was transported to the hospital. The hospital's Discharge Summary indicted the resident was admitted on [DATE] and discharged on [DATE] with Discharge [DIAGNOSES REDACTED]." The summary identified the resident had been on [MEDICATION NAME] and "pulsed" to an increased dose of 40 mg daily for [DIAGNOSES REDACTED]. Once the pulse was done, the [MEDICATION NAME] was "accidentally stopped" rather than returning to the usual dose which "likely led to [MEDICAL CONDITION]." In interview on 4/2/13 at 10:15 am Witness 3, Physician, reported the resident had a [DIAGNOSES REDACTED]. Witness 3 stated the resident complained of increased pain related to a [DIAGNOSES REDACTED] exacerbation and stated to Witness 3 the Rheumatologist would normally increase the [MEDICATION NAME] dosage during flare ups. Witness 3 reported she ordered an increase in the resident's [MEDICATION NAME] to 40 mg daily and the plan was to reassess after two weeks to see the resident's response to the increase and to determine if the resident should stay at the higher dose or be titrated down. Witness 3 reported she was on vacation at the end of the two week [MEDICATION NAME] burst and the resident was scheduled to see the Rheumatologist during the two week period. Witness 3 stated she assumed the Rheumatologist would assess the resident's [DIAGNOSES REDACTED] treatment and make recommendations related to the [MEDICATION NAME] burst and dosage, however, he did not document any orders related to [DIAGNOSES REDACTED]. Witness 3 stated when she returned from vacation the resident was in the hospital because the resident's [MEDICATION NAME] was discontinued without first tapering it down. In interview on 4/2/13 at 10:46 am Staff 2, RNCM, reported Resident 1 had increased pain and the Physician ordered a trial increase in the resident's [MEDICATION NAME] for two weeks and then wanted the dosage reassessed. Staff 2 stated the nurse should have put in a nursing order to reassess the [MEDICATION NAME] dosage on 2/19/13 and contact the Physician for additional orders when it ended. Staff 2 confirmed the resident's 40 mg [MEDICATION NAME] burst was discontinued without additional orders. Staff 2 reported it was everyone's responsibility to ensure a steroid taper was done. On 4/2/13 at 11:30 am Resident 1 was observed lying in bed and could not recall events leading up to the hospitalization on [DATE]. In interview on 4/2/13 at 11:35 am Staff 1, DNS, reported [MEDICATION NAME] should be tapered down and confirmed Lippincott Williams & Wilkins' Nursing Drug Handbook which identified, under Nursing Considerations, [MEDICATION NAME] should have a gradual reduction in dosage after long-term use. In interview on 4/3/13 at 11:30 am Witness 2, family, reported Resident 1 had been on [MEDICATION NAME] for 30-[AGE] years for [DIAGNOSES REDACTED] which is a rare [DIAGNOSES REDACTED] disorder that affects the muscles. Witness 2 reported at the end of February the resident was progressively getting weaker and more confused. Witness 2 stated she spoke with the facility on 2/27/13 and asked them to contact the Physician to increase the resident's [MEDICATION NAME] dosage, however, the facility reported the resident's [MEDICATION NAME] was discontinued on 2/19/13. Witness 2 reported the facility didn't taper the resident back down to the 10 mg maintenance dose after the increase and the resident was hospitalized and diagnosed with [REDACTED]. In interview on 4/4/13 at 3:35 pm Staff 3, RN, confirmed the resident's 40 mg [MEDICATION NAME] burst was discontinued after two weeks with no tapering orders. She reported residents receiving a [MEDICATION NAME] burst should have tapering orders.

Based on interview and record review it was determined the facility failed to follow standards of practice for licensed nurses by not responding timely when a resident (#1) took other resident's medications. Resident 1 required hospitalization as a result of ingesting other resident's [MEDICATION NAME] (blood thinner). Findings include: According to the Oregon State board of Nursing Nurse Practice Act: "Scope of Practice Standards for All Licensed Nurses [PHONE NUMBER] (1) Standard related to the licensed nurse responsibilities for client advocacy. The licensed nurse: (b) intervenes on behalf of the client to identify changes in health status, to protect, and promote and optimize health, and to alleviate suffering." Resident 1 was admitted to the facility in early 2011 with numerous [DIAGNOSES REDACTED]. On 3/29/11 at 8:55 am Resident 1 was observed in a wheelchair in the hallway next to Station 3. Resident 1 was asked by the surveyor if he/she had taken [MEDICATION NAME] cards from a cart and acknowledged that he/she did take six to eight medication cards from a cart but did not know what they were. The resident offered no more information. Review of an incident report completed by Staff 5 (RN) on 3/14/11 revealed that on 3/11/11, "(Witness 2, former Staff RN)) came to me at about 2000 - 2030 (8:00 - 8:30 pm) on 3/11/11, & she (Witness 2) told me all of her [MEDICATION NAME] (blood thinner medication) cards were missing..." A search was conducted and two bubble pack cards of [MEDICATION NAME] were found in Resident 1's room. The resident denied "taking those pills." On 3/29/11 at 1:02 pm Staff 5 (RN) was interviewed and asked by the surveyor why she had filled out the incident report instead of Witness 2 (former Staff RN) since Witness 2 was responsible for maintaining the [MEDICATION NAME] in a locked cart. Staff 5 said she filled out the incident report because Resident 1 resided in the section of the facility that she was assigned to. She said she did not fill out an incident report until two days later until told to do so by Staff 3 (RNCM). She said she did not chart in the NN or place Resident 1 on alert status (for risk for bleeding related to possible ingestion of [MEDICATION NAME]). Review of NN dating from 3/11/11 through 3/13/11 revealed no documentation regarding Resident 1 haven taken [MEDICATION NAME] bubble pack cards and there were no notations the resident was exhibiting symptoms of bleeding. There was no documentation the physician, Staff 1 (DNS) or Staff 3 (RNCM) had been notified [MEDICATION NAME] cards had been missing. On 3/14/11 at 9:00 am NN revealed Resident 1 was having "excessive bleeding" to the amputation sites on both lower extremities. The resident's vital signs were documented as normal. An attempt to contact the physician was unsuccessful so the Adult Nurse Practitioner was contacted and orders were received to send the resident to the hospital. an order for [REDACTED]. An investigation by Staff 3 (RNCM) on 3/14/11 revealed she was notified on 3/14/11 at 7:30 am that Station 3 was missing all their [MEDICATION NAME] cards and 2 [MEDICATION NAME] cards had been found in Resident 1's room. On 3/29/11 at 12:22 pm Staff 3 (RNCM) was interviewed and said Staff 4 (LPN) called her at 7:30 am because Resident 1 was bleeding from surgical wounds and self scratching. Staff 4 said she was told in (daily shift change report) Resident 1 had taken some [MEDICATION NAME] cards. Staff 3 said she was told when she arrived to the facility at 7:45 am that all of the [MEDICATION NAME] cards were missing from Station 3. Staff 3 said she found 13 missing [MEDICATION NAME] cards and instructed Staff 4 to send the resident to the ER and Staff 1 (DNS) and Staff 2 (Administrator) were notified. Staff 3 said this was the first time she had been notified that Resident 1 had taken [MEDICATION NAME] cards from the treatment cart. She said at that point Staff 1 (DNS) took over the investigation after she (RNCM) had completed hers. On 3/14/11 Staff 1 (DNS) received a written report from Witness 2 (former Staff RN) regarding the [MEDICATION NAME] cards that had been taken by Resident 1. Witness 2 acknowledged leaving and not locking the treatment cart where the [MEDICATION NAME] cards were kept while she was checking in medications from Witness 1 (pharmacy delivery staff). Review of an investigation completed by Staff 1 on 3/14/11 revealed it was brought to her attention upon arrival to the facility on [DATE] that Resident 1 was exhibiting signs of excessive bleeding. The physician was notified, a PT/INR (lab test to determine blood coagulation time) was drawn and an ambulance called. It was determined, "A total of 11 cards and/or labels were found in (Resident 1's) room during the course of searching and cleaning. Four cards were empty. No one witnessed (Resident 1) taking the medication, but (his/her) excessive bleeding is enough to suspect. (Resident 1) is not a reliable historian. This appears to be an isolated incident... All nursing has (sic) been inserviced regarding regarding the cart and proper communication. The nurses who worked on the weekend of this incident have been disciplined and educated regarding communication, notification of issues, and proper documentation...No resident went without [MEDICATION NAME] because each has several cards. I believe the nurses who care for (Resident 1) would have placed (him/her) on alert or notified the RCM, MD and/or DNS had they thought (Resident 1) actually ingested pills." During three interviews with Staff 1 on 3/26/11 between 9:00 am and 11:20 am Staff 1 acknowledged, as in her investigation, that proper documentation and notification of appropriate disciplines did not occur. Review of the Hospital Admission History and Physical revealed Resident 1 had blood on both sides of the mouth and blood soaked bandages on both lower extremity amputation sites. Lab tests revealed an INR greater than 10 (critical level). The plan was for the resident to receive fresh frozen plasma, Vitamin K and packed red blood cells (to reverse the effects of over anticoagulation from [MEDICATION NAME] ingestion). Resident 1 returned to the facility on [DATE] with no further complications. Refer to F-tag 329

Based on interviews and record review it was determined the facility failed to prevent a resident (#1) from receiving other resident's medications. Resident 1 received other resident's [MEDICATION NAME] (blood thinner) resulting in bleeding and hospitalization . Resident 1 was admitted to the facility in early 2011 with numerous [DIAGNOSES REDACTED]. Review of the March 2011 MAR indicated [REDACTED]. On 3/29/11 at 8:55 am Resident 1 was observed in a wheelchair in the hallway next to Station 3. Resident 1 was asked by the surveyor if he/she had taken [MEDICATION NAME] cards from a cart and acknowledged that he/she did take six to eight medication cards from a cart but did not know what they were. The resident offered no more information. Review of an incident report completed by Staff 5 (RN) on 3/14/11 revealed that on 3/11/11, "(Witness 2, former Staff RN)) came to me at about 2000 - 2030 (8:00 - 8:30 pm) on 3/11/11, & she (Witness 2) told me all of her [MEDICATION NAME] (blood thinner medication) cards were missing..." A search was conducted and two bubble pack cards of [MEDICATION NAME] were found in Resident 1's room. The resident denied "taking those pills." On 3/29/11 at 1:02 pm Staff 5 (RN) was interviewed and asked by the surveyor why she had filled out the incident report instead of Witness 2 (former Staff RN) since Witness 2 was responsible for maintaining the [MEDICATION NAME] in a locked cart. Staff 5 said she filled out the incident report because Resident 1 resided in the section of the facility that she was assigned to. She said she did not fill out an incident report until two days later until told to do so by Staff 3 (RNCM). She said she did not chart in the NN or place Resident 1 on alert status (for risk for bleeding related to possible ingestion of [MEDICATION NAME]). Review of NN dating from 3/11/11 through 3/13/11 revealed no documentation regarding Resident 1 haven taken [MEDICATION NAME] bubble pack cards and there were no notations the resident was exhibiting symptoms of bleeding. There was no documentation the physician, Staff 1 (DNS) or Staff 3 (RNCM) had been notified [MEDICATION NAME] cards had been missing. On 3/14/11 at 9:00 am NN revealed Resident 1 was having "excessive bleeding" to the amputation sites on both lower extremities. The resident's vital signs were documented as normal. An attempt to contact the physician was unsuccessful so the Adult Nurse Practitioner was contacted and orders were received to send the resident to the hospital. an order for [REDACTED]. An investigation by Staff 3 (RNCM) on 3/14/11 revealed she was notified on 3/14/11 at 7:30 am that Station 3 was missing all their [MEDICATION NAME] cards and 2 [MEDICATION NAME] cards had been found in Resident 1's room. On 3/29/11 at 12:22 pm Staff 3 (RNCM) was interviewed and said Staff 4 (LPN) called her at 7:30 am because Resident 1 was bleeding from surgical wounds and self scratching. Staff 4 said she was told in (daily shift change report) Resident 1 had taken some [MEDICATION NAME] cards. Staff 3 said she was told when she arrived to the facility at 7:45 am that all of the [MEDICATION NAME] cards were missing from Station 3. Staff 3 said she found 13 missing [MEDICATION NAME] cards and instructed Staff 4 to send the resident to the ER and Staff 1(DNS) and Staff 2 (Administrator) were notified. Staff 3 said this was the first time she had been notified that Resident 1 had taken [MEDICATION NAME] cards from the treatment cart. She said at that point Staff 1 (DNS) took over the investigation after she (RNCM) had completed hers. On 3/14/11 Staff 1 (DNS) received a written report from Witness 2 (former Staff RN) regarding the [MEDICATION NAME] cards that had been taken by Resident 1. Witness 2 acknowledged leaving and not locking the treatment cart where the [MEDICATION NAME] cards were kept while she was checking in medications from Witness 1 (pharmacy delivery staff). Review of an investigation completed by Staff 1 on 3/14/11 revealed it was brought to her attention upon arrival to the facility on [DATE] that Resident 1 was exhibiting signs of excessive bleeding. The physician was notified, a PT/INR (lab test to determine blood coagulation time) was drawn and an ambulance called. It was determined, "A total of 11 cards and/or labels were found in (Resident 1's) room during the course of searching and cleaning. Four cards were empty. No one witnessed (Resident 1) taking the medication, but (his/her) excessive bleeding is enough to suspect. (Resident 1) is not a reliable historian. This appears to be an isolated incident... All nursing has (sic) been inserviced regarding regarding the cart and proper communication. The nurses who worked on the weekend of this incident have been disciplined and educated regarding communication, notification of issues, and proper documentation...No resident went without [MEDICATION NAME] because each has several cards. I believe the nurses who care for (Resident 1) would have placed (him/her) on alert or notified the RCM, MD and/or DNS had they thought (Resident 1) actually ingested pills." During three interviews with Staff 1 on 3/26/11 between 9:00 am and 11:20 am Staff 1 acknowledged, as in her investigation, that proper documentation and notification of appropriate disciplines did not occur. Review of the Hospital Admission History and Physical revealed Resident 1 had blood on both sides of the mouth and blood soaked bandages on both lower extremity amputation sites. Lab tests revealed an INR greater than 10 (critical level). The plan was for the resident to receive fresh frozen plasma, Vitamin K and packed red blood cells (to reverse the effects of over anticoagulation from [MEDICATION NAME] ingestion). Resident 1 returned to the facility on [DATE] with no further complications.

Based on interview and record review it was determined the facility failed to store medication in a locked compartment that was not assessable to unauthorized personnel or residents. Resident 1 required hospitalization for treatment of [REDACTED]. Findings include: Resident 1 was admitted to the facility in early 2011 with numerous [DIAGNOSES REDACTED]. On 3/29/11 at 8:55 am Resident 1 was observed in a wheelchair in the hallway next to Station 3. Resident 1 was asked by the surveyor if he/she had taken Coumadin cards from a cart and acknowledged that he/she did take six to eight medication cards from a cart but did not know what they were. The resident offered no more information. Review of an incident report completed by Staff 5 (RN) on 3/14/11 revealed Witness 2 (former staff RN) reported to her on 3/11/11 that all of her Coumadin cards were missing and saw a "gentleman wheeling a W/C (wheelchair), going by and grabbing all Coumadin cards..." A search revealed Resident 1 was found to have two Coumadin bubble pack medication cards. Resident 1 denied "taking those pills." Review of a statement documented by Witness 2 on 3/14/11 revealed she acknowledged leaving a treatment cart containing Coumadin medication cards unlocked while checking in other medications from Witness 1 (pharmacy delivery driver). On 3/29/11 at 11:12 Witness 1 was interviewed by telephone and said he saw a resident open a cart and pull out medication cards and told the nurse (Witness 2). On 3/14/11 Staff 1 (DNS) received a written report from Witness 2 regarding the Coumadin cards that had been taken by Resident 1. In the report Witness 2 acknowledged leaving the treatment cart containing Coumadin unlocked at about 9:00 pm while checking in other medications delivered by Witness 1 (pharmacy delivery driver). Witness 2 documented she was told by Witness 1 that he saw a "man in a W/C open my drawer & take some meds. (medications) out." A search was conducted and three Coumadin cards were found in Resident 1's room in the trash. The resident was asked where the rest of the Coumadin cards were but did not offer any answer. At 10:00 pm Witness 2 asked all CNA staff to look in resident's rooms for any "med cards in trash or on the floor." No additional medication cards were found. In her report Witness 2 reported not calling the RNCM or DNS. Review of an "Investigation of (Resident 1) and missing Coumadin:" completed by Staff 3 (RNCM) on 3/14/11 revealed, "I was notified the am on 3/14/11@ 7:30am that it was reported that Station 3 was missing all of their Coumadin cards and 2 cards had been found in (Resident 1's) room..." The resident was asked if he/she had taken any medication that was not given to him/her and denied doing so. 911 was called to transport the resident to the hospital. After Resident 1 had left the facility Staff 3 continued to search for any missing Coumadin. She found a manilla envelope in the resident's second bedside table drawer containing three empty Coumadin cards and notified Staff 1 (DNS) and Staff 2 (Administrator). Staff 3 then went back to Resident 1's room, picked up the resident's pillow case and four cards containing Coumadin fell out. She delivered the Coumadin cards to Staff 1. She sent "blood covered linens" to the laundry where another empty Coumadin card was found. Staff 3 delivered the Coumadin card to Staff 1. Staff 3 then contacted the hospital ER to notify them of "our suspicions." On 3/29/11 at 12:22 pm Staff 3 (RNCM) was interviewed and reported she was called at home by Staff 4 (LPN) on 3/14/11 at 7:30 am and told Resident 1 was bleeding from "surgical wounds and self inflicted scratches." Staff 4 said she learned during report that Resident 1 had taken Coumadin cards from the treatment cart. Staff 3 said that when she arrived to the facility at 7:45 am she was told all the Coumadin cards were missing from Station 3. Staff 3 said 13 (Coumadin) cards were missing. She said she had Staff 4 send Resident 1 to the hospital ER and notified Staff 1(DNS) and Staff 2 (Administrator). Review of investigation completed by Staff 1(DNS) on 3/14/11 revealed a total of 11 Coumadin cards and/or labels were found in Resident 1's room during the course of searching and cleaning; four of the Coumadin cards were empty. "No one witnessed (Resident 1) taking the medication, but (his/her) excessive bleeding is enough to suspect...." "All nursing staff has been inserviced regarding the cart and proper communication. The nurses who worked on the weekend of this incident have been disciplined and educated regarding communication, notification of issues, and proper documentation...." "No resident went without Coumadin because each has several cards. I believe the nurses who cared for (Resident 1) would have placed (him/her) on alert or notified the RCM (RNCM), MD, and/or DNS had they thought (Resident 1) actually ingested the pills." On 3/29/11 at 9:00 am Staff 1 said Witness 2 acknowledged leaving the treatment cart containing Coumadin cards unlocked while working with Witness 1. Review of NN dated 3/14/11 at 9:30 am revealed Resident 1 was sent to the hospital ER as a result of excessive bleeding to the amputation sites at the right leg and left foot. Review of the hospital History and Physical report dated 3/14/11 revealed Resident 1 obtained 11 coumadin cards with each card containing up to 14 pills per card, with a variation of 2.5 to 5 mg tablets. The calculated dose the resident may have received was 520 mg. The physical revealed the resident to have bleeding from a tooth and "bilateral feet." Lab tests revealed the resident's. "INR (lab test to determine blood coagulation time) greater than 10, (critically high) with suspected Coumadin overdose. The resident required administration of plasma, vitamin K and packed red blood cells to reverse bleeding from the effects the ingestion of Coumadin. Refer to F-tag 329