Lebanon Veterans Home.

“There are no detail notes for this visit.”

“There are no detail notes for this visit.”

“There are no detail notes for this visit. There are no detail notes for this visit.”

“Resident 13 was admitted to the facility in 2023 with diagnoses including anxiety and heart failure.-á -á From 7/23/23 through 7/9/25, Interdisciplinary Care Conference notes revealed Resident 13 would look for a copy of her/his advance directive. The 10/15/24 care conference reflected Resident 13 would look for a copy of the document and expressed interest in receiving assistance with completing it. A review of Resident 13's medical record revealed no indication staff assisted Resident 13 with completing an advance directive. -á On 9/8/25 at 11:33 AM, Staff 22 (Social Service Designee) acknowledged no one followed up on Resident 13GÇÖs request to complete an advance directive.-á -á Resident 13 was admitted to the facility in 2023 with diagnoses including anxiety and heart failure.-á -á From 7/23/23 through 7/9/25, Interdisciplinary Care Conference notes revealed Resident 13 would look for a copy of her/his advance directive. The 10/15/24 care conference reflected Resident 13 would look for a copy of the document and expressed interest in receiving assistance with completing it. A review of Resident 13's medical record revealed no indication staff assisted Resident 13 with completing an advance directive. -á On 9/8/25 at 11:33 AM, Staff 22 (Social Service Designee) acknowledged no one followed up on Resident 13GÇÖs request to complete an advance directive.-á -á Summary of Deficiency: Failure to obtain and assist with completing advance directives for Resident #13, leaving resident preferences unaddressed. 1. Corrective Action for Residents Found to be Affected Resident #13 in the survey received immediate corrective interventions. Documentation was updated in EMR and families were notified as appropriate. Residents who are their own responsible party were provided with a blank advance directive and policy. Family was provided with a copy of the blank advance directive and policy. 2. How Other Residents Potentially Affected Will Be Identified Conducted facility-wide audits to identify other residents at risk. Results were reviewed by the interdisciplinary team and corrective measures applied as needed. 3. Measures or Systemic Changes to Ensure Non-Recurrence - Relevant policies reviewed and revised. - Social Services Director re-educated Social Service Designees with documented competencies. - Tools (checklists, new monitoring forms) introduced. - Department leadership is responsible for ongoing enforcement. 4. Monitoring to Ensure Ongoing Compliance - Targeted audits 3 times per week for 8 weeks. - Benchmarks set at 100% compliance. - Results presented at QAPI. - Additional interventions are implemented if compliance is not sustained. 5. Responsible Party Appropriate department leadership (Social Services Director and or Designees) 6. Completion Date October 28, 2025 Summary of Deficiency: Failure to obtain and assist with completing advance directives for Resident #13, leaving resident preferences unaddressed. Resident #13 in the survey received immediate corrective interventions. Documentation was updated in EMR and families were notified as appropriate. Residents who are their own responsible party were provided with a blank advance directive and policy. Family was provided with a copy of the blank advance directive and policy. Conducted facility-wide audits to identify other residents at risk. Results were reviewed by the interdisciplinary team and corrective measures applied as needed. - Relevant policies reviewed and revised. - Social Services Director re-educated Social Service Designees with documented competencies. - Tools (checklists, new monitoring forms) introduced. - Department leadership is responsible for ongoing enforcement. - Targeted audits 3 times per week for 8 weeks. - Benchmarks set at 100% compliance. - Results presented at QAPI. - Additional interventions are implemented if compliance is not sustained. Appropriate department leadership (Social Services Director and or Designees) October 28, 2025 There are no detail notes for this visit.”

“On 9/3/25 at 10:41 AM on Delta 3 the following were observed: -á -The carpet between the fireplace and the dining room had three large brown stains that were approximately one foot in diameter. -á -The carpet in front of the recliners located by the television had dark brown stains that were approximately four feet long by one foot wide. -á -The carpet between the dining room and Room 305 had a dark brown stain approximately one- and one-half feet in diameter. -á On 9/3/25 at 10:45 AM Staff 8 (CNA) stated the carpets were cleaned approximately two weeks prior but the brown spots resurfaced a few days later.-á On 9/8/25 at 10:10 AM Staff 9 (Housekeeping Manager) stated the stains surrounded the dining room for at least two years. The carpet was cleaned at least every two weeks, but the stains were not able to be removed. -á On 9/3/25 at 10:45 AM Staff 8 (CNA) stated the carpets were cleaned approximately two weeks prior but the brown spots resurfaced a few days later.-á On 9/8/25 at 10:10 AM Staff 9 (Housekeeping Manager) stated the stains surrounded the dining room for at least two years. The carpet was cleaned at least every two weeks, but the stains were not able to be removed. Summary of Deficiency: Failure to maintain a clean, comfortable homelike environment (dirty/stained carpets in the Delta 3 unit). 1. Corrective Action for Residents Found to be Affected This citation does not name any specific residents. 2. How Other Residents Potentially Affected Will Be Identified Conducted a Delta-wide audits to identify other areas at risk. Results were reviewed by interdisciplinary team and corrective measures applied as needed. 3. Measures or Systemic Changes to Ensure Non-Recurrence - Replacing all common area carpets in Delta 3. - Staff re-educated on all floor cleaning competencies. - Department leadership is responsible for ongoing enforcement. 4. Monitoring to Ensure Ongoing Compliance - Delta-wide targeted audits 3 times per week for 8 weeks. - Benchmarks set at 100% compliance. - Results presented at QAPI. - Additional interventions are implemented if compliance is not sustained. 5. Responsible Party Appropriate department leadership (Administrator or Environmental Services Director and or Designees) 6. Completion Date October 28, 2025 Summary of Deficiency: Failure to maintain a clean, comfortable homelike environment (dirty/stained carpets in the Delta 3 unit). This citation does not name any specific residents. Conducted a Delta-wide audits to identify other areas at risk. Results were reviewed by interdisciplinary team and corrective measures applied as needed. - Replacing all common area carpets in Delta 3. - Staff re-educated on all floor cleaning competencies. - Department leadership is responsible for ongoing enforcement. - Delta-wide targeted audits 3 times per week for 8 weeks. - Benchmarks set at 100% compliance. - Results presented at QAPI. - Additional interventions are implemented if compliance is not sustained. Appropriate department leadership (Administrator or Environmental Services Director and or Designees) October 28, 2025 There are no detail notes for this visit.”

“Resident 68 was admitted to the facility in 9/2025 with a diagnosis of dementia.-á Resident 68's care plan initiated 12/12/24 revealed she/he had a history of wandering into other residents' rooms. Staff were to attempt to redirect Resident 68 before she/he entered another resident's room and offer food.-á Resident 135 was admitted to the facility in 4/2023 with a diagnosis of dementia.-á Resident 135's care plan initiated 12/28/23 revealed she/he had verbal and physical aggression. Interventions included to not invade Resident 135's space and staff were to monitor her/him when in close proximity of other residents.-á An 8/28/25 Resident to Resident /Staff Assessment form revealed on 8/28/25 at 5:10 PM CNAs witnessed Resident 68 walk into Resident 135's room while Resident 135 was in the dining room eating. Resident 135 stood up from the dining table, went into her/his room, and started to speak to Resident 68. Resident 135 then looked toward the dining room at staff, pushed Resident 68 ""hard"" which caused Resident 68 to fall. Resident 68 did not hit her/his head when she/he fell and did not sustain an injury.-á On 9/5/25 at 4:27 PM Staff 10 (CNA) stated Resident 68 wandered into other residents' rooms and did not have boundaries. Staff usually redirected her/him out of other residents' rooms. On 8/28/25 Resident 135 was eating dinner in the dining room when Resident 68 walked into Resident 135's room. Resident 135 finished eating and walked into her/his room and started to talk to Resident 68. The conversation was in normal tones and did not appear to be a concern. Resident 135 looked toward the dining room, then looked back at Resident 68 and pushed Resident 68 causing her/hm to fall. Staff 10 stated it was difficult to read Resident 135's mood. Some days Resident 135 was happy and other days she/he woke up upset. Staff 10 stated she did not intervene and initially just observed the interaction. Staff 10 stated the care plan indicated staff were to monitor Resident 135 from a distance because she/he did not like when people were in her/his ""bubble."" On 9/8/25 at 8:40 AM Staff 36 (CNA) stated Resident 135 was usually very sweet and friendly but over the last few months she/he became very angry and unpredictable. Resident 135 could be in a normal interaction with a resident and in just a second would change into a different person. Staff had to distract Resident 135 when she/he became aggressive. Staff 36 stated you never knew what Resident 135 would do, at times she/he allowed residents in her/his room and other times it upsets her/him. Staff 36 stated on 8/28/25 initially Resident 135 did not seem to be upset Resident 68 was in her/his room, but all of a sudden her/his voice changed. Staff 36 stated when she/he heard Resident 135's voice change she/he headed to Resident 135's room but it was too late, and Resident 135 pushed Resident 68. Resident 68 was not upset and was not hurt.-á On 9/5/25 at 1:08 PM Staff 11(LPN Resident Care Coordinator) stated Resident 68 wandered, and on 8/28/25 she/he wandered into Resident 135's room. Staff 11 acknowledged the care plan directed staff to be in close proximity when Resident 135 was with other residents.-á Resident 68 was admitted to the facility in 9/2025 with a diagnosis of dementia.-á Resident 68's care plan initiated 12/12/24 revealed she/he had a history of wandering into other residents' rooms. Staff were to attempt to redirect Resident 68 before she/he entered another resident's room and offer food.-á Resident 135 was admitted to the facility in 4/2023 with a diagnosis of dementia.-á Resident 135's care plan initiated 12/28/23 revealed she/he had verbal and physical aggression. Interventions included to not invade Resident 135's space and staff were to monitor her/him when in close proximity of other residents.-á An 8/28/25 Resident to Resident /Staff Assessment form revealed on 8/28/25 at 5:10 PM CNAs witnessed Resident 68 walk into Resident 135's room while Resident 135 was in the dining room eating. Resident 135 stood up from the dining table, went into her/his room, and started to speak to Resident 68. Resident 135 then looked toward the dining room at staff, pushed Resident 68 ""hard"" which caused Resident 68 to fall. Resident 68 did not hit her/his head when she/he fell and did not sustain an injury.-á On 9/5/25 at 4:27 PM Staff 10 (CNA) stated Resident 68 wandered into other residents' rooms and did not have boundaries. Staff usually redirected her/him out of other residents' rooms. On 8/28/25 Resident 135 was eating dinner in the dining room when Resident 68 walked into Resident 135's room. Resident 135 finished eating and walked into her/his room and started to talk to Resident 68. The conversation was in normal tones and did not appear to be a concern. Resident 135 looked toward the dining room, then looked back at Resident 68 and pushed Resident 68 causing her/hm to fall. Staff 10 stated it was difficult to read Resident 135's mood. Some days Resident 135 was happy and other days she/he woke up upset. Staff 10 stated she did not intervene and initially just observed the interaction. Staff 10 stated the care plan indicated staff were to monitor Resident 135 from a distance because she/he did not like when people were in her/his ""bubble."" On 9/8/25 at 8:40 AM Staff 36 (CNA) stated Resident 135 was usually very sweet and friendly but over the last few months she/he became very angry and unpredictable. Resident 135 could be in a normal interaction with a resident and in just a second would change into a different person. Staff had to distract Resident 135 when she/he became aggressive. Staff 36 stated you never knew what Resident 135 would do, at times she/he allowed residents in her/his room and other times it upsets her/him. Staff 36 stated on 8/28/25 initially Resident 135 did not seem to be upset Resident 68 was in her/his room, but all of a sudden her/his voice changed. Staff 36 stated when she/he heard Resident 135's voice change she/he headed to Resident 135's room but it was too late, and Resident 135 pushed Resident 68. Resident 68 was not upset and was not hurt.-á On 9/5/25 at 1:08 PM Staff 11(LPN Resident Care Coordinator) stated Resident 68 wandered, and on 8/28/25 she/he wandered into Resident 135's room. Staff 11 acknowledged the care plan directed staff to be in close proximity when Resident 135 was with other residents.-á Summary of Deficiency: Failure to protect Resident #68 from physical abuse by another resident (#135), despite a known history of aggression. 1. Corrective Action for Residents Found to be Affected Residents cited in the survey received immediate corrective interventions. Documentation was updated in EMR, and families were notified as appropriate. 2. How Other Residents Potentially Affected Will Be Identified All Delta residents are at risk. Behavior care plan audits will be conducted by Interdisciplinary care team. Residents at risk were reviewed by interdisciplinary team and corrective measures applied as needed. 3. Measures or Systemic Changes to Ensure Non-Recurrence - Relevant policies reviewed and revised. - All Staff re-educated on facility policy and will be educated on location and access to care plans/Kardex. - Department leadership is responsible for ongoing enforcement. 4. Monitoring to Ensure Ongoing Compliance - Baseline audit of all Delta resident behavior care plans/Kardex. Ongoing behavior care plan audits upon admissions, quarterly care conferences, change of condition, and as needed. - Benchmarks set at 100% compliance. - Results presented at QAPI. - Additional interventions are implemented if compliance is not sustained. 5. Responsible Party Appropriate department leadership (DON or Social Services Director and or Designees) 6. Completion Date October 15, 2025 Summary of Deficiency: Failure to protect Resident #68 from physical abuse by another resident (#135), despite a known history of aggression. Residents cited in the”

“Resident 123 was admitted to the facility in 2/2024 with a diagnosis of dementia and stroke. a. A Behavioral Management Program Policy and Procedure last updated 8/2014 revealed all non-pharmacological interventions were to be exhausted and acute medical conditions including pain and environmental factors were to be ruled out prior to obtaining any orders for psychoactive medications.-á Resident 123's 9/16/24 physician visit note revealed she/he was sitting at the exit door waiting to visit her/his spouse. Resident 123 appeared to be in good spirits. Staff did not report concerns. Staff previously reported on 8/19/24 Resident 123 kicked a staff when she/he was unable to leave the facility.-á Resident 123's Interdisciplinary Care Conference forms revealed: -10/2/24 Resident 123 visited her/his spouse on campus and enjoyed eating meals with her/him. -12/26/24 staff reported Resident 123 was agitated and hit staff. Resident 123 was frustrated from her/his inability to visit her/his spouse. Resident 123's 3/10/25 External Visit indicated Resident 123 had ""worsening behaviors."" Staff reported after Resident 123 visited her/his spouse, she/he appeared to be calm and content. The note indicated Resident 123 was on daily oxycodone (narcotic pain medication) for pain. The use of Seroquel (antipsychotic medication) was discussed with family and agreed with implementation. -á Resident 123's physician orders dated 3/10/25 revealed Seroquel was to be administered at bedtime. Resident 123's 3/2025 MAR revealed she/he was administered Seroquel at bedtime from 3/11/25 for ""agitation/behaviors."" Resident 123's clinical record revealed laboratory tests were not obtained prior to the initiation of Seroquel on 3/11/25.-á On 9/9/25 at 9:47 AM Staff 11 (LPN Resident Care Coordinator) stated Resident 123 was angry and depressed because she/he was not able to visit her/his spouse. Staff 12 (LPN Resident Care Coordinator) stated the antipsychotic was not appropriate for use and her/his behaviors did not improve.-á On 9/8/25 at 2:40 PM Staff 2 (DNS) stated Resident 123 sat by the door and wanted to see her/his spouse. The staff tried to assist the resident, but she/he hit and banged on the door. Resident 123 and her/his spouse were on different sleep schedules, and it was difficult for Resident 123 to understand the reason she/he could not visit her/his spouse. Staff 2 acknowledged labs were not obtained until 3/27/25, after the Seroquel was started. Staff 2 also indicated the Seroquel did not work. b. Resident 123's 6/24/25 Psychotropic Pharmacy Review form revealed she/he was on Seroquel (antipsychotic). Resident 123's care plan initiated on 2/29/24 was not updated to include the use of Seroquel and to monitor for side effects of the medication.-á Resident 123's clinical record did not indicate she/he was monitored for side effects of Seroquel.-á On 9/5/25 at 1:22 PM Staff 11 (LPN Resident Care Coordinator) stated a care plan for Seroquel was not developed and there was no monitoring for the side effects of the antipsychotic.-á Resident 123 was admitted to the facility in 2/2024 with a diagnosis of dementia and stroke. a. A Behavioral Management Program Policy and Procedure last updated 8/2014 revealed all non-pharmacological interventions were to be exhausted and acute medical conditions including pain and environmental factors were to be ruled out prior to obtaining any orders for psychoactive medications.-á Resident 123's 9/16/24 physician visit note revealed she/he was sitting at the exit door waiting to visit her/his spouse. Resident 123 appeared to be in good spirits. Staff did not report concerns. Staff previously reported on 8/19/24 Resident 123 kicked a staff when she/he was unable to leave the facility.-á Resident 123's Interdisciplinary Care Conference forms revealed: -10/2/24 Resident 123 visited her/his spouse on campus and enjoyed eating meals with her/him. -12/26/24 staff reported Resident 123 was agitated and hit staff. Resident 123 was frustrated from her/his inability to visit her/his spouse. Resident 123's 3/10/25 External Visit indicated Resident 123 had ""worsening behaviors."" Staff reported after Resident 123 visited her/his spouse, she/he appeared to be calm and content. The note indicated Resident 123 was on daily oxycodone (narcotic pain medication) for pain. The use of Seroquel (antipsychotic medication) was discussed with family and agreed with implementation. -á Resident 123's physician orders dated 3/10/25 revealed Seroquel was to be administered at bedtime. Resident 123's 3/2025 MAR revealed she/he was administered Seroquel at bedtime from 3/11/25 for ""agitation/behaviors."" Resident 123's clinical record revealed laboratory tests were not obtained prior to the initiation of Seroquel on 3/11/25.-á On 9/9/25 at 9:47 AM Staff 11 (LPN Resident Care Coordinator) stated Resident 123 was angry and depressed because she/he was not able to visit her/his spouse. Staff 12 (LPN Resident Care Coordinator) stated the antipsychotic was not appropriate for use and her/his behaviors did not improve.-á On 9/8/25 at 2:40 PM Staff 2 (DNS) stated Resident 123 sat by the door and wanted to see her/his spouse. The staff tried to assist the resident, but she/he hit and banged on the door. Resident 123 and her/his spouse were on different sleep schedules, and it was difficult for Resident 123 to understand the reason she/he could not visit her/his spouse. Staff 2 acknowledged labs were not obtained until 3/27/25, after the Seroquel was started. Staff 2 also indicated the Seroquel did not work. b. Resident 123's 6/24/25 Psychotropic Pharmacy Review form revealed she/he was on Seroquel (antipsychotic). Resident 123's care plan initiated on 2/29/24 was not updated to include the use of Seroquel and to monitor for side effects of the medication.-á Resident 123's clinical record did not indicate she/he was monitored for side effects of Seroquel.-á On 9/5/25 at 1:22 PM Staff 11 (LPN Resident Care Coordinator) stated a care plan for Seroquel was not developed and there was no monitoring for the side effects of the antipsychotic.-á Summary of Deficiency: Failure to prevent unnecessary use of psychotropic drugs (Resident #123 initiated on Seroquel without indication; monitoring not completed). 1. Corrective Action for Residents Found to be Affected IDT Care plan audit to ensure monitoring for efficacy/adverse side effects and appropriate non-pharmacological interventions. 2. How Other Residents Potentially Affected Will Be Identified Facility-wide audits were conducted to identify other residents at risk. The interdisciplinary team has reviewed results and corrective measures applied as needed. 3. Measures or Systemic Changes to Ensure Non-Recurrence - Relevant policies reviewed and revised. - Staff re-educated on the psychotropic medication policy, ongoing monitoring of adverse side effects, and efficacy. - A Performance improvement plan was initiated by the medical director, focusing on anti-psychotic medications. Department leadership is responsible for ongoing enforcement. 4. Monitoring to Ensure Ongoing Compliance - Baseline care plan audit of all residents receiving psychotropic medications. -Facility will monitor all new or changed psychotropic medication orders to ensure they are care planned appropriately. Benchmarks set at 100% compliance. - Results presented at QAPI. - Additional interventions are implemented if compliance is not sustained. 5. Responsible Party Appropriate department leadership (DON or Social Services Director and or Designees) 6. Completion Date October 28, 2025 Summary of Deficiency: Failure to prevent unnecessary use of psychotropic drugs (Resident #123 initiated on Seroquel without indication; monitoring not completed). IDT Care plan audit to ensure monitoring for efficacy/adverse side effects and appropriate non-pharmacological interventions. Facility-wide audits were conducted to identify other residents at risk. The ”

“2. Resident 74 was admitted to the facility in 1/2025 with diagnoses including urinary tract infection and cancer. -á Review of physician orders revealed Resident 74 was placed on Enhanced Barrier Precautions (EBP) on 4/23/25 due to chronic ulcers on the right ankle and heel. No end date was documented. -á On 9/2/25 at 1:52 PM, Resident 74 stated her/his shoulder wound was basically healed, but she/he still had wounds on her/his leg. -á On 9/3/25 at 11:30 AM, a nurses note indicated there was no wound on Resident 74's right lateral foot so no wound care was provided; the wound was resolved.-á -á From 9/2/25 through 9/5/25 observations revealed staff were not implementing EBP for Resident 74. -á On 9/8/25 at 7:06 AM, Resident 74's care plan was reviewed and EBP was listed on the care plan. -á On 9/8/2025 10:55 AM, Staff 5 (Infection Control RN) reported Resident 74's catheter was removed and her/his wounds were resolved. Staff 5 stated Resident 74's pressure ulcer resolved on 8/19/25 and the care plan was not updated. -á On 9/9/25 at 8:20 AM, Staff 2 (DNS) confirmed Resident 74 was placed on EBP for wounds which since resolved, and confirmed the care plan was not updated.-á -á -á -á -á -á -á -á , 1. Resident 9 was admitted to the facility in 10/2020 with a diagnosis of dementia.-á -á Resident 9's 4/11/25 Annual MDS revealed she/he had decreased ROM and a left-hand contracture.-á -á On 9/8/25 at 9:47 AM Resident 9 was observed in the dining area with a soft lamb wool Velcro wrap to the left hand. -á -á Resident 9's Care Plan initiated 10/2020 did not have a Velcro wrap on the care plan.-á -á -á On 9/4/25 at 9:18 AM Staff 28 (CNA) stated Resident 9 had a contracture and her/his fingers were hard to bend at times, and she/he had her/his wrap for quite a while.-á-á -á On 9/8/25 at 12:04 PM Staff 12 (LPN Resident Care Coordinator) stated staff used to place a towel in her/his hand to prevent her/his hand from forming a tight grip due to her/his contracture but she/he pulled the towel out. Staff 12 stated she ordered a new soft splint approximately one month ago but did not update the care plan.-á -á 2. Resident 74 was admitted to the facility in 1/2025 with diagnoses including urinary tract infection and cancer. -á Review of physician orders revealed Resident 74 was placed on Enhanced Barrier Precautions (EBP) on 4/23/25 due to chronic ulcers on the right ankle and heel. No end date was documented. -á On 9/2/25 at 1:52 PM, Resident 74 stated her/his shoulder wound was basically healed, but she/he still had wounds on her/his leg. -á On 9/3/25 at 11:30 AM, a nurses note indicated there was no wound on Resident 74's right lateral foot so no wound care was provided; the wound was resolved.-á -á From 9/2/25 through 9/5/25 observations revealed staff were not implementing EBP for Resident 74. -á On 9/8/25 at 7:06 AM, Resident 74's care plan was reviewed and EBP was listed on the care plan. -á On 9/8/2025 10:55 AM, Staff 5 (Infection Control RN) reported Resident 74's catheter was removed and her/his wounds were resolved. Staff 5 stated Resident 74's pressure ulcer resolved on 8/19/25 and the care plan was not updated. -á On 9/9/25 at 8:20 AM, Staff 2 (DNS) confirmed Resident 74 was placed on EBP for wounds which since resolved, and confirmed the care plan was not updated.-á -á -á -á -á -á -á -á -á On 9/8/25 at 12:04 PM Staff 12 (LPN Resident Care Coordinator) stated staff used to place a towel in her/his hand to prevent her/his hand from forming a tight grip due to her/his contracture but she/he pulled the towel out. Staff 12 stated she ordered a new soft splint approximately one month ago but did not update the care plan.-á -á Summary of Deficiency: Failure to update and revise care plans (Resident #9 contracture wrap not included Resident #74 infection precautions not updated when wounds resolved). 1. Corrective Action for Residents Found to be Affected Residents cited in the survey received immediate corrective interventions. Updated documentation in EMR, and families were notified as appropriate. 2. How Other Residents Potentially Affected Will Be Identified All residents will be audited for therapeutic adaptive equipment and isolation precautions. We will educate the Interdisciplinary Team on the new care plan checklist. 3. Measures or Systemic Changes to Ensure Non-Recurrence - Relevant policies reviewed and revised. - All Staff re-educated on facility policy and will be educated on location and access to care plans/Kardex. - Tools (care plan checklist) introduced. - Department leadership is responsible for ongoing enforcement. 4. Monitoring to Ensure Ongoing Compliance - Baseline audit of all therapeutic devices and isolation precaution care plans/Kardex. - 8 random care plans will be audited once weekly for four weeks, monthly 2 times. - Benchmarks set at 100% compliance. - Results presented at QAPI. - Additional interventions implemented if compliance not sustained. 5. Responsible Party Appropriate department leadership (DON and or Designees) 6. Completion Date October 28, 2025 Summary of Deficiency: Failure to update and revise care plans (Resident #9 contracture wrap not included Resident #74 infection precautions not updated when wounds resolved). Residents cited in the survey received immediate corrective interventions. Updated documentation in EMR, and families were notified as appropriate. All residents will be audited for therapeutic adaptive equipment and isolation precautions. We will educate the Interdisciplinary Team on the new care plan checklist. - Relevant policies reviewed and revised. - All Staff re-educated on facility policy and will be educated on location and access to care plans/Kardex. - Tools (care plan checklist) introduced. - Department leadership is responsible for ongoing enforcement. - Baseline audit of all therapeutic devices and isolation precaution care plans/Kardex. - 8 random care plans will be audited once weekly for four weeks, monthly 2 times. - Benchmarks set at 100% compliance. - Results presented at QAPI. - Additional interventions implemented if compliance not sustained. Appropriate department leadership (DON and or Designees) October 28, 2025 There are no detail notes for this visit.”

“Resident 135 was admitted to the facility in 4/2023 with diagnoses including dementia. An 4/27/25 incident report indicated Resident 135 was found on the floor in the activity room. According to the incident report, Resident 135 took 10 minutes to fully arouse, was unable to follow simple commands, and her/his right pupil was not responding to light at first. The on-call doctor was notified as well as the residentGÇÖs Power of Attorney (POA) and it was decided to keep Resident 135 in the facility and monitor her/his neurological status closely. The 4/27/25 Neurological Flow Sheet indicated checks were to be completed every 15 minutes for an hour, every 30 minutes for two hours, every hour for four hours, every four hours for 16 hours, and every eight hours for 48 hours. The 4/27/25 Neurological Flow Sheet for Resident 135 was incomplete with missing assessment areas and stopped after three hours. On 9/8/25 at 3:11 PM, Staff 21 (LPN) stated on 4/27/25 Resident 135 was found in the activity room laying on the ground with a pillow under her/his head. Staff 21 stated it took approximately an hour for Resident 135 to get back to baseline neurologically after the fall. On 9/8/25 at 3:11 PM, Staff 11 (RNCM) stated neurological checks were to be initiated after an unwitnessed fall or a head injury. Staff 11 stated neurological checks were to be completed every 15 minutes for an hour, every 30 minutes for two hours, every hour for four hours, every four hours for 16 hours, and every eight hours for 48 hours. -áStaff 11 acknowledged Resident 135GÇÖs neurological checks were incomplete with missing assessment areas. Staff 11 acknowledged the neurological checks stopped after every 30-minute checks and was to be continued until completed. Resident 135 was admitted to the facility in 4/2023 with diagnoses including dementia. An 4/27/25 incident report indicated Resident 135 was found on the floor in the activity room. According to the incident report, Resident 135 took 10 minutes to fully arouse, was unable to follow simple commands, and her/his right pupil was not responding to light at first. The on-call doctor was notified as well as the residentGÇÖs Power of Attorney (POA) and it was decided to keep Resident 135 in the facility and monitor her/his neurological status closely. The 4/27/25 Neurological Flow Sheet indicated checks were to be completed every 15 minutes for an hour, every 30 minutes for two hours, every hour for four hours, every four hours for 16 hours, and every eight hours for 48 hours. The 4/27/25 Neurological Flow Sheet for Resident 135 was incomplete with missing assessment areas and stopped after three hours. On 9/8/25 at 3:11 PM, Staff 21 (LPN) stated on 4/27/25 Resident 135 was found in the activity room laying on the ground with a pillow under her/his head. Staff 21 stated it took approximately an hour for Resident 135 to get back to baseline neurologically after the fall. On 9/8/25 at 3:11 PM, Staff 11 (RNCM) stated neurological checks were to be initiated after an unwitnessed fall or a head injury. Staff 11 stated neurological checks were to be completed every 15 minutes for an hour, every 30 minutes for two hours, every hour for four hours, every four hours for 16 hours, and every eight hours for 48 hours. -áStaff 11 acknowledged Resident 135GÇÖs neurological checks were incomplete with missing assessment areas. Staff 11 acknowledged the neurological checks stopped after every 30-minute checks and was to be continued until completed. Summary of Deficiency: Failure to complete required neurological assessments after a fall (Resident #135), leaving head injury risk unmonitored. 1. Corrective Action for Residents Found to be Affected Residents cited in the survey-initiated immediate education for staff for all future neurological evaluations for unwitnessed falls. 2. How Other Residents Potentially Affected Will Be Identified Conducted facility-wide audits to identify other residents at risk. The interdisciplinary team reviewed results, and corrective measures were applied as needed. 3. Measures or Systemic Changes to Ensure Non-Recurrence - Relevant policies reviewed and revised. - Staff re-educated with documented competencies. Educate all staff on the importance of timely completion of neurological checks when there is an unwitnessed fall/head strike. - Tools (neurological evaluations) reviewed. - Department leadership is responsible for ongoing enforcement. 4. Monitoring to Ensure Ongoing Compliance Review initiation and progress of mandatory neurological checks in clinical meeting working business days. - Daily monitoring during clinical meetings for 30 days. Weekly times two. Monthly times two. Quarterly thereafter. - Benchmarks set at 100% compliance. - Results presented at QAPI. - Additional interventions are implemented if compliance is not sustained. 5. Responsible Party Appropriate department leadership (DON and or Designees) 6. Completion Date October 28, 2025 Summary of Deficiency: Failure to complete required neurological assessments after a fall (Resident #135), leaving head injury risk unmonitored. Residents cited in the survey-initiated immediate education for staff for all future neurological evaluations for unwitnessed falls. Conducted facility-wide audits to identify other residents at risk. The interdisciplinary team reviewed results, and corrective measures were applied as needed. - Relevant policies reviewed and revised. - Staff re-educated with documented competencies. Educate all staff on the importance of timely completion of neurological checks when there is an unwitnessed fall/head strike. - Tools (neurological evaluations) reviewed. - Department leadership is responsible for ongoing enforcement. Review initiation and progress of mandatory neurological checks in clinical meeting working business days. - Daily monitoring during clinical meetings for 30 days. Weekly times two. Monthly times two. Quarterly thereafter. - Benchmarks set at 100% compliance. - Results presented at QAPI. - Additional interventions are implemented if compliance is not sustained. Appropriate department leadership (DON and or Designees) October 28, 2025 There are no detail notes for this visit.”

“2. Resident 74 was admitted in 1/2025 with diagnoses including stroke, cognitive communication deficit, and a history of repeated falls. -á A fall risk assessment dated 6/19/25 identified Resident 74 as confused, with multiple diagnoses and medications, and a history of falls. -á The 5/13/25 revised care plan required Resident 74 to have two-person assistance with a mechanical sit-to-stand lift for transfers. -á On 9/5/25 at 6:42 AM, Staff 7 (CNA) entered Resident 74GÇÖs room with a sit-to-stand lift with the resident observed in bed. -á At 6:55 AM, Staff 7 exited the room with the sit-to-stand lift. No other staff were observed in the room during the transfer. Resident 74 was in her/his electric wheelchair. At 8:30 AM, Staff 7 stated if a resident was care planned for two staff, she should have another staff member present during the transfer, and she did not have another staff present during Resident 74's transfer. Staff 7 stated she was confused about whether all sit-to-stand transfers required two staff or only some. -á On 9/9/25 at 8:20 AM, Staff 2 (DNS) stated she expected staff to follow residentsGÇÖ care plans. Staff 2 confirmed all sit-to-stand lift transfers required two staff. , 1. Resident 9 was admitted to the facility in 10/2020 with a diagnosis of dementia.-á Resident 9's 4/13/25 Post Fall Assessment revealed on 4/13/25 at 6:25 PM she/he had a witnessed fall in the dining room. Resident 9 was in her/his wheelchair, was ""wiggling"" her/his legs, leaned to the left, fell to the floor, and sustained a forehead laceration. The assessment indicated the armrest was not properly latched after staff transferred her/him into the chair with a mechanical lift.-á On 9/8/25 at 10:25 Staff 12 (LPN Resident Care Coordinator) verified staff did not latch Resident 9's wheelchair armrest correctly and her/his movement and lack of trunk control, caused her/him to fall out of the wheelchair when she/he leaned to the left.-á -á -á 2. Resident 74 was admitted in 1/2025 with diagnoses including stroke, cognitive communication deficit, and a history of repeated falls. -á A fall risk assessment dated 6/19/25 identified Resident 74 as confused, with multiple diagnoses and medications, and a history of falls. -á The 5/13/25 revised care plan required Resident 74 to have two-person assistance with a mechanical sit-to-stand lift for transfers. -á On 9/5/25 at 6:42 AM, Staff 7 (CNA) entered Resident 74GÇÖs room with a sit-to-stand lift with the resident observed in bed. -á At 6:55 AM, Staff 7 exited the room with the sit-to-stand lift. No other staff were observed in the room during the transfer. Resident 74 was in her/his electric wheelchair. At 8:30 AM, Staff 7 stated if a resident was care planned for two staff, she should have another staff member present during the transfer, and she did not have another staff present during Resident 74's transfer. Staff 7 stated she was confused about whether all sit-to-stand transfers required two staff or only some. -á On 9/9/25 at 8:20 AM, Staff 2 (DNS) stated she expected staff to follow residentsGÇÖ care plans. Staff 2 confirmed all sit-to-stand lift transfers required two staff.”

“1. -á Resident 3 was admitted to the facility in 11/2019 with diagnoses including post-traumatic stress disorder (PTSD). A 11/19/19 care plan indicated Resident 3 had a history of trauma related to childhood deprivation and abuse. The goal indicated Resident 3 would identify individual strengths by the review date. An intervention indicated Resident 3 needed assistance, supervision, and support to identify precipitating factors and stressors. A review of Resident 3GÇÖs medical record revealed no indication of a completed trauma screen. On 9/9/25 at 8:21 AM, Staff 30 (Social Service Designee) stated usually upon admission she completed a trauma screen to identify specific types of trauma and triggers for the trauma. With that information she put the type of trauma and triggers in the residentsGÇÖ care plan. Staff 30 stated she was unaware Resident 3 did not have a trauma screen to identify triggers of her/his diagnosis of PTSD and the triggers for Resident 3GÇÖs PTSD were not on the care plan. On 9/9/25 at 10:46 AM Staff 2 (DNS) stated every resident was to have a trauma screen completed to identify types of trauma and triggers. Staff 2 stated the information obtained in the trauma screen was to be placed on the residentsGÇÖ care plan, so staff were aware of the type of trauma and triggers to watch for. 2. -á Resident 11 was admitted to the facility in 1/2020 with diagnoses including post-traumatic stress disorder (PTSD). On 9/5/25 at 1:54 PM, Staff 31 (CNA) stated Resident 11 was aggravated at times and just wanted to be left alone sometimes. On 9/5/25 at 2:00 PM, Staff 32 (LPN) stated Resident 11 got aggravated at times and she was unsure what made her/him get aggravated. On 9/9/25 at 9:51 AM, Staff 33 (Social Service Designee) stated he was unable to locate a completed trauma screen for Resident 11. A review of Resident 11GÇÖs medical record revealed no indication of a completed trauma screen or a PTSD care plan. On 9/9/25 at 10:46 AM Staff 2 (DNS) stated every resident was to have a trauma screen completed to identify types of trauma and triggers. Staff 2 stated the information obtained in the trauma screen was to be placed on the residentsGÇÖ care plan, so staff were aware of the type of trauma and triggers to watch for. -á”

“Observations of the Direct Care Staff Daily Reports (DCSDR) from 9/2/25 through 9/8/25: -On 9/3/25 at 7:00 AM, the DCSDR posted was dated 9/2/25. It did not include evening or night shift staff numbers or hours, -On 9/4/25 at 7:11 AM, the DCSDR posted was dated 9/3/25. It did not include evening or night shift staff numbers or hours, -On 9/5/25 at 6:07 AM, the DCSDR posted was dated 9/4/25. It did not include evening or night shift staff numbers or hours, -On 9/8/25 at 6:45 AM, the DCSDR posted was dated 9/7/25. It did not include evening or night shift staff numbers or hours, -á On 9/9/25 at 8:16 AM, 10:34 AM and 11:04 AM Staff 2 (DNS) stated they needed to improve the timing of documenting evening shift and night shift information on the DCSDR.-á Observations of the Direct Care Staff Daily Reports (DCSDR) from 9/2/25 through 9/8/25: -On 9/3/25 at 7:00 AM, the DCSDR posted was dated 9/2/25. It did not include evening or night shift staff numbers or hours, -On 9/4/25 at 7:11 AM, the DCSDR posted was dated 9/3/25. It did not include evening or night shift staff numbers or hours, -On 9/5/25 at 6:07 AM, the DCSDR posted was dated 9/4/25. It did not include evening or night shift staff numbers or hours, -On 9/8/25 at 6:45 AM, the DCSDR posted was dated 9/7/25. It did not include evening or night shift staff numbers or hours, -á On 9/9/25 at 8:16 AM, 10:34 AM and 11:04 AM Staff 2 (DNS) stated they needed to improve the timing of documenting evening shift and night shift information on the DCSDR.-á Summary of Deficiency: Failure to post complete daily nurse staffing information (evening and night shifts missing from posted reports 9/2–9/8/25). 1. Corrective Action for Residents Found to be Affected No other residents were identified to be impacted by this practice. 2. How Other Residents Potentially Affected Will Be Identified All residents/families and visitors have the potential to be impacted by this deficiency. 3. Measures or Systemic Changes to Ensure Non-Recurrence - CMS/DHS regulation review. - Monday through Friday not including holidays staffing department will post day and evening shift numbers. Staffing will communicate with Bravo Noc shift nurse with the staffing data to fill out and sign form for Noc shift. The staffing department will communicate with Bravo nurses on weekends and holidays for all three shifts. Staff re-educated with documented competencies. - Department leadership responsible for ongoing enforcement. 4. Monitoring to Ensure Ongoing Compliance -Audit daily for one week, weekly for 8 weeks. - Benchmarks set at 100% compliance. - Results presented at QAPI. - Additional interventions implemented if compliance not sustained. 5. Responsible Party Appropriate department leadership (DON or Staffing and or Designees) 6. Completion Date October 28, 2025 Summary of Deficiency: Failure to post complete daily nurse staffing information (evening and night shifts missing from posted reports 9/2–9/8/25). No other residents were identified to be impacted by this practice. All residents/families and visitors have the potential to be impacted by this deficiency. - CMS/DHS regulation review. - Monday through Friday not including holidays staffing department will post day and evening shift numbers. Staffing will communicate with Bravo Noc shift nurse with the staffing data to fill out and sign form for Noc shift. The staffing department will communicate with Bravo nurses on weekends and holidays for all three shifts. Staff re-educated with documented competencies. - Department leadership responsible for ongoing enforcement. -Audit daily for one week, weekly for 8 weeks. - Benchmarks set at 100% compliance. - Results presented at QAPI. - Additional interventions implemented if compliance not sustained. Appropriate department leadership (DON or Staffing and or Designees) October 28, 2025 There are no detail notes for this visit.”

“-á -á -á 1. Resident 3 was admitted to the facility in 11/2019 with diagnoses including arterial fibrillation (an irregular heartbeat). A review of Physician Orders revealed an 8/29/25 order for warfarin (a blood thinning medication). A review of Resident 3GÇÖs care plan revealed no evidence of a blood thinning medication care plan or monitoring for adverse side effects of blood thinning medications. On 9/9/25 at 8:40 AM Staff 14 (RCM) stated adverse side effects for warfarin should be listed in a warfarin care plan. Staff 14 acknowledged Resident 3 had no care plan for blood thinning medications and no monitors in place to monitor for adverse side effects of blood thinning medications. On 9/9/25 at 10:52 AM Staff 2 (DNS) acknowledged Resident 3 was not care planned for blood thinners and had no monitors in place to monitor for adverse side effects of blood thinners. 2. -á Resident 4 was admitted to the facility in 2/2025 with diagnoses including heart failure. A review of Physician Orders revealed an 4/10/25 order for furosemide (a diuretic medication used to treat heart failure by removing excess fluid from the body). A review of Resident 4GÇÖs weights revealed the following: -+ -á-á-á-á-á-á 7/19/25 218 lbs. -+ -á-á-á-á-á-á 8/28/25 229 lbs. -+ -á-á-á-á-á-á 8/30/25 228.2 lbs. -+ -á-á-á-á-á-á 9/7/25 229.2 lbs. A review of Resident 4GÇÖs care plan revealed no evidence of a diuretic medication care plan. On 9/8/25 at 2:33 PM, Staff 17 (CNA) stated Resident 4 had a little weight gain but was unsure how much. Staff 17 stated Resident 4 had some edema (swelling) in her/his feet and used compression socks for the edema. On 9/8/25 at 2:48 PM, Staff 19 (LPN) stated she was unsure if Resident 4 had any weight gain or if Resident 4 took any diuretics. Staff 19 stated Resident 4 had edema to both legs, and the physician was to be notified for a weight gain of five pounds or more in three days. On 9/9/25 at 9:07 AM, Staff 20 (RNCM) stated Resident 4GÇÖs weight gain was not identified until this interview. Staff 20 acknowledged Resident 4 did not have a care plan for diuretic medications and was not being monitored for weight gain. On 9/9/25 at 10:42 AM, Staff 2 (DNS) stated a resident diagnosed with heart failure and taking a diuretic was to be monitored for weight gain and the doctor was to be notified for a gain of two to three pounds. Staff 2 stated Resident 4 should have had a head-to-toe assessment to see if the weight gain was related to heart failure and fluid retention. Staff 2 stated Resident 4 needed to be monitored for weight gain. -á -á -á -á -á 1. Resident 3 was admitted to the facility in 11/2019 with diagnoses including arterial fibrillation (an irregular heartbeat). A review of Physician Orders revealed an 8/29/25 order for warfarin (a blood thinning medication). A review of Resident 3GÇÖs care plan revealed no evidence of a blood thinning medication care plan or monitoring for adverse side effects of blood thinning medications. On 9/9/25 at 8:40 AM Staff 14 (RCM) stated adverse side effects for warfarin should be listed in a warfarin care plan. Staff 14 acknowledged Resident 3 had no care plan for blood thinning medications and no monitors in place to monitor for adverse side effects of blood thinning medications. On 9/9/25 at 10:52 AM Staff 2 (DNS) acknowledged Resident 3 was not care planned for blood thinners and had no monitors in place to monitor for adverse side effects of blood thinners. 2. -á Resident 4 was admitted to the facility in 2/2025 with diagnoses including heart failure. A review of Physician Orders revealed an 4/10/25 order for furosemide (a diuretic medication used to treat heart failure by removing excess fluid from the body). A review of Resident 4GÇÖs weights revealed the following: -+ -á-á-á-á-á-á 7/19/25 218 lbs. -+ -á-á-á-á-á-á 8/28/25 229 lbs. -+ -á-á-á-á-á-á 8/30/25 228.2 lbs. -+ -á-á-á-á-á-á 9/7/25 229.2 lbs. A review of Resident 4GÇÖs care plan revealed no evidence of a diuretic medication care plan. On 9/8/25 at 2:33 PM, Staff 17 (CNA) stated Resident 4 had a little weight gain but was unsure how much. Staff 17 stated Resident 4 had some edema (swelling) in her/his feet and used compression socks for the edema. On 9/8/25 at 2:48 PM, Staff 19 (LPN) stated she was unsure if Resident 4 had any weight gain or if Resident 4 took any diuretics. Staff 19 stated Resident 4 had edema to both legs, and the physician was to be notified for a weight gain of five pounds or more in three days. On 9/9/25 at 9:07 AM, Staff 20 (RNCM) stated Resident 4GÇÖs weight gain was not identified until this interview. Staff 20 acknowledged Resident 4 did not have a care plan for diuretic medications and was not being monitored for weight gain. On 9/9/25 at 10:42 AM, Staff 2 (DNS) stated a resident diagnosed with heart failure and taking a diuretic was to be monitored for weight gain and the doctor was to be notified for a gain of two to three pounds. Staff 2 stated Resident 4 should have had a head-to-toe assessment to see if the weight gain was related to heart failure and fluid retention. Staff 2 stated Resident 4 needed to be monitored for weight gain. -á -á Summary of Deficiency: Failure to monitor drug regimens appropriately (Resident #3 on warfarin without monitoring; Resident #4 on furosemide without monitoring). 1. Corrective Action for Residents Found to be Affected Residents cited in the survey received immediate corrective interventions. Updated documentation was put in EMR, and families were notified as appropriate. Resident #4’s primary care physician reviewed the diagnosis and resolved CHF. Created a care plan for lower extremity edema. 2. How Other Residents Potentially Affected Will Be Identified Conduct a facility-wide baseline care plan audit to identify other residents at risk. The interdisciplinary team reviewed the results and applied corrective measures as needed. 3. Measures or Systemic Changes to Ensure Non-Recurrence - Relevant policies reviewed and revised. - LN’s re-educated on high-risk medication care planning. - We will utilize monthly pharmacy consultant medication regimen reviews. - Department leadership responsible for ongoing enforcement. 4. Monitoring to Ensure Ongoing Compliance - Baseline audit of all residents’ high-risk medication care plans/kardex. Ongoing high-risk care plan audits upon admissions, quarterly care conferences, change of condition, and as needed. - Benchmarks set at 100% compliance. - Results presented at QAPI. - Additional interventions implemented if compliance is not sustained. 5. Responsible Party Appropriate department leadership (DON and or Designees) 6. Completion Date October 28, 2025 Summary of Deficiency: Failure to monitor drug regimens appropriately (Resident #3 on warfarin without monitoring; Resident #4 on furosemide without monitoring). Residents cited in the survey received immediate corrective interventions. Updated documentation was put in EMR, and families were notified as appropriate. Resident #4’s primary care physician reviewed the diagnosis and resolved CHF. Created a care plan for lower extremity edema. Conduct a facility-wide baseline care plan audit to identify other residents at risk. The interdisciplinary team reviewed the results and applied corrective measures as needed. - Relevant policies reviewed and revised. - LN’s re-educated on high-risk medication care planning. - We will utilize monthly pharmacy consultant medication regimen reviews. - Department leadership responsible for ongoing enforcement. - Baseline audit of all residents’ high-risk medication care plans/kardex. Ongoing high-risk care plan audits upon admissions, quarterly care conferences, change of condition, and as needed. - Benchmarks set at 100% compliance. - Results presented at QAPI. - Additional interventions implemented if compliance is not sustained. Appropriate department leadership (DON and or Designees) October 28, 2025 There are no detail notes for thi”

“2. During an observation of the resident medication storage cabinets in the Charlie House 100 unit on 9/5/25 at 6:05 PM, the following was found in room 107: - One box of Ondansetron 4mg tablets with an expiration date of 8/2025. -á On 9/5/25 at 6:05 PM, Staff 34 (LPN) acknowledged the expired medication and stated the expectation for resident medications was for nursing staff to remove and replace medications before they expired. -á -á On 9/8/25 at 5:28 PM, Staff 2 (DNS) acknowledged the expired medications and stated the expectation for resident medications in the medication cabinets was they were not expired while in use. -á 3. During an observation of the resident medication storage cabinets in the Charlie House 200 unit on 9/5/25 at 6:25 PM, the following was found in room 202: - One tube of triple antibiotic ointment with an expiration date of 7/2025. -á On 9/5/25 at 6:25 PM, Staff 35 (LPN) acknowledged the expired medication and stated the expectation was for all expired medications to be removed from resident storage cabinets. -á On 9/8/25 at 5:28 PM, Staff 2 (DNS) acknowledged the expired medications and stated the expectation for resident medications in the medication cabinets was they were not expired while in use. , 1. -á -á -á n-á -á 1. On 9/5/25 at 3:03 PM, an open bottle of Prednisolone 1% eye drops was observed with Staff 19 (LPN) in the medication storage in room 309. The bottle of Prednisolone had an open date which was unreadable and was dispensed on 6/13/25. Staff 19 stated eye drops were expired after being open for 30 days. On 9/5/25 at 3:05 PM, an open bottle of acetaminophen was observed with Staff 19 in the medication storage in room 307 which expired in 2/2025. Staff 19 stated medications were to be destroyed when they were expired. On 9/5/25 at 3:14 PM, two open insulin pens (an injection device that allows you to deliver preloaded insulin into the body) were observed with Staff 19 in the medication storage in room 309. Both pens did not have an open date on them and were dispensed on 7/1/25. Staff 29 stated insulin pens were expired after being open for 28 days. On 9/5/25 3:19 PM, Staff 20 (RNCM) stated medications needed to be removed from medication storage when expired. Staff 20 stated eye drops were to be labeled when opened and discarded after 30 days. Staff 20 stated insulin pens were to be labeled when opened and discarded after 30 days. 2. During an observation of the resident medication storage cabinets in the Charlie House 100 unit on 9/5/25 at 6:05 PM, the following was found in room 107: - One box of Ondansetron 4mg tablets with an expiration date of 8/2025. -á On 9/5/25 at 6:05 PM, Staff 34 (LPN) acknowledged the expired medication and stated the expectation for resident medications was for nursing staff to remove and replace medications before they expired. -á -á On 9/8/25 at 5:28 PM, Staff 2 (DNS) acknowledged the expired medications and stated the expectation for resident medications in the medication cabinets was they were not expired while in use. -á 3. During an observation of the resident medication storage cabinets in the Charlie House 200 unit on 9/5/25 at 6:25 PM, the following was found in room 202: - One tube of triple antibiotic ointment with an expiration date of 7/2025. -á On 9/5/25 at 6:25 PM, Staff 35 (LPN) acknowledged the expired medication and stated the expectation was for all expired medications to be removed from resident storage cabinets. -á On 9/8/25 at 5:28 PM, Staff 2 (DNS) acknowledged the expired medications and stated the expectation for resident medications in the medication cabinets was they were not expired while in use.”

“1. On 9/2/25 at 11:55 AM, Resident 130 stated the ground up food was completely unpleasant. -á On 9/3/25 at 8:12 AM, Resident 15 stated the food was tasteless, and always cold.-á -á On 9/3/25 at 10:09 AM, Resident 2 stated the food was not palatable and she/he did not like to eat it. -á During an observation of the lunch meal service on 9/5/25 at 12:24 PM, a meal of lemon pepper tuna, rice pilaf, and broccoli was served to residents of the Charlie 200 house. The meal service also included an alternate texture option for the lemon pepper tuna. The temperatures of the meal components when delivered from the kitchen were as follows: - Lemon pepper tuna: 160 degrees F. - Rice pilaf: 149 degrees F. - Broccoli: 135 degrees F. The broccoli was reheated in the microwave multiple times until it reached a temperature of 165 degrees F. - Mechanical soft texture (ground up) lemon pepper tuna: 125 degrees F. This tuna was placed in an oven set to 200 degrees F until served. Throughout the meal service the following were observed: - The lemon pepper tuna, rice pilaf, and broccoli were kept in separate foil covered metal containers on the kitchen counter and were opened repeatedly while being served. - All plates of food were reheated in the microwave prior to serving them to the residents. On 9/5/25 at 12:45 PM, Staff 37 (CNA) stated the residents' plates were microwaved nearly every lunch and dinner service to get the food warm enough to serve. The surveyor test meal was served at 12:47 PM directly after the last resident meal. The texture of the lemon pepper tuna was rubbery, the mechanical soft texture tuna was dry, the rice pilaf was dry and crunchy, and the broccoli was mushy and unpalatable. The lemon pepper tuna, the mechanical soft texture tuna, and the rice pilaf were lukewarm to touch, and the broccoli was cold. The following temperatures were noted: - Lemon pepper tuna: 121 degrees F. - Mechanical soft texture lemon pepper tuna: 136 degrees F. - Rice pilaf: 123 degrees Fahrenheit. - Broccoli: 87 degrees Fahrenheit. On 9/5/25 at 3:20 PM, Staff 6 (Dietary Manager) stated the drop in temperatures for resident meals was a known issue, and the facility administration was working on a plan of correction. Further education was forthcoming for staff. She stated the required holding temperature for most foods was 140 degrees F, and staff were instructed to use the oven set to 200 degrees F or the microwave to bring resident food up to the proper temperature before serving. On 9/5/25 at 5:06 PM, Staff 1 (Administrator) acknowledged the drop in temperatures and the unpleasantness of the surveyor test tray. He stated the drop in resident meal temperatures was a known issue, and the administrative team was working on a correction plan. , -á 2. On 9/5/25 at 11:39 AM, the posted lunch menu included lemon pepper tuna. -á On 9/5/25 at 11:49 AM, the meal cart was delivered to the Alpha 200 house. The tuna was placed in the oven. Staff 7 (CNA) removed the tuna from the oven, and it was observed at a temperature of 131 F. Staff 7 referenced a temperature guide for the food and stated it was close to the required temperature for other meats. -á On 9/5/25 at 12:16 PM, after all other meals were delivered to residents a test tray was sampled, and the tuna was lukewarm. -á -á On 9/5/25 at 12:28 PM, Staff 6 (Dietary Manager) stated the required holding temperature was 140 F. Staff were instructed to return food to the oven uncovered or use a microwave if temperatures were below the threshold.”

“During an observation of the COVID precautions in the Charlie House 100 unit on 9/3/25 at 10:25 AM, it was noted the frosted glass door to the unit did not have signage, PPE (Personal Protective Equipment), trash cans, or hand sanitization supplies on either side of the door. -á On 9/4/25 at 11:26 AM, Staff 5 (Infection Control RN) stated units with active COVID outbreaks were to have signage, PPE, trash cans, and hand sanitization supplies for staff and visitors on all doors to the unit. -á During an observation of the COVID precautions in the Charlie House 100 unit on 9/4/25 at 12:57 PM, two visitors were seen exiting the unit through the frosted glass door. The two visitors removed their masks after exiting, put the masks in their pockets, and opened multiple doors with their hands while exiting the building. -á During an observation of the COVID precautions in the Charlie House 100 unit on 9/5/25 at 6:55 PM, a staff member was observed to exit the unit through the frosted glass door, take off their mask, walk across the lobby to throw the mask away, and then sanitize their hands. -á On 9/8/25 at 3:21 PM, Staff 5 stated staff and visitors were not supposed to use the frosted glass door to the Charlie House 100 unit. He stated he did not put any signage, PPE, trash cans, or hand sanitization supplies by that door because it was not supposed to be used by anyone. -á On 9/8/25 at 5:28 PM, Staff 2 (DNS) acknowledged the lack of COVID precautions for the frosted glass door on the Charlie House 100 unit. She stated the expectation for any unit during a COVID outbreak was for signage, PPE, trashcans, and hand sanitization supplies to be at every door for that unit. During an observation of the COVID precautions in the Charlie House 100 unit on 9/3/25 at 10:25 AM, it was noted the frosted glass door to the unit did not have signage, PPE (Personal Protective Equipment), trash cans, or hand sanitization supplies on either side of the door. -á On 9/4/25 at 11:26 AM, Staff 5 (Infection Control RN) stated units with active COVID outbreaks were to have signage, PPE, trash cans, and hand sanitization supplies for staff and visitors on all doors to the unit. -á During an observation of the COVID precautions in the Charlie House 100 unit on 9/4/25 at 12:57 PM, two visitors were seen exiting the unit through the frosted glass door. The two visitors removed their masks after exiting, put the masks in their pockets, and opened multiple doors with their hands while exiting the building. -á During an observation of the COVID precautions in the Charlie House 100 unit on 9/5/25 at 6:55 PM, a staff member was observed to exit the unit through the frosted glass door, take off their mask, walk across the lobby to throw the mask away, and then sanitize their hands. -á On 9/8/25 at 3:21 PM, Staff 5 stated staff and visitors were not supposed to use the frosted glass door to the Charlie House 100 unit. He stated he did not put any signage, PPE, trash cans, or hand sanitization supplies by that door because it was not supposed to be used by anyone. -á On 9/8/25 at 5:28 PM, Staff 2 (DNS) acknowledged the lack of COVID precautions for the frosted glass door on the Charlie House 100 unit. She stated the expectation for any unit during a COVID outbreak was for signage, PPE, trashcans, and hand sanitization supplies to be at every door for that unit. Summary of Deficiency: Failure to ensure infection control standards during COVID outbreak in Charlie House 100, missing signage, PPE, and sanitation stations at a door. 1. Corrective Action for Residents Found to be Affected Residents cited in the survey received immediate corrective interventions. Updated documentation in EMR, and families were notified as appropriate. 2. How Other Residents Potentially Affected Will Be Identified Facility-wide audits were conducted to identify other residents at risk. Results were reviewed by interdisciplinary team and corrective measures applied as needed. 3. Measures or Systemic Changes to Ensure Non-Recurrence - Relevant policies reviewed and revised. - Infection preventionist or Designee will ensure that all interior doors leading to a house with active COVID will have appropriate signage, PPE, and garbage cans. All exterior doors that lead to a house with active COVID will have appropriate signage. - Department leadership responsible for ongoing enforcement. 4. Monitoring to Ensure Ongoing Compliance -During outbreaks IP, or designee will monitor postings and PPE supply. - Benchmarks set at 100% compliance. - Results presented at QAPI. - Additional interventions implemented if compliance not sustained. 5. Responsible Party Appropriate department leadership (IP nurse and or Designees). 6. Completion Date October 28, 2025 Summary of Deficiency: Failure to ensure infection control standards during COVID outbreak in Charlie House 100, missing signage, PPE, and sanitation stations at a door. Residents cited in the survey received immediate corrective interventions. Updated documentation in EMR, and families were notified as appropriate. Facility-wide audits were conducted to identify other residents at risk. Results were reviewed by interdisciplinary team and corrective measures applied as needed. - Relevant policies reviewed and revised. - Infection preventionist or Designee will ensure that all interior doors leading to a house with active COVID will have appropriate signage, PPE, and garbage cans. All exterior doors that lead to a house with active COVID will have appropriate signage. - Department leadership responsible for ongoing enforcement. -During outbreaks IP, or designee will monitor postings and PPE supply. - Benchmarks set at 100% compliance. - Results presented at QAPI. - Additional interventions implemented if compliance not sustained. Appropriate department leadership (IP nurse and or Designees). October 28, 2025 There are no detail notes for this visit.”

“There are no detail notes for this visit. There are no detail notes for this visit.”

“There are no detail notes for this visit.”

“There are no detail notes for this visit. There are no detail notes for this visit.”

“A 7/2/25 Delta Courtyards Policy revealed the facility was to provide residents access to a secured outdoor space and walkways which allowed residents to enter and return without staff assistance. Doors could be locked during the night and during adverse events, inclement weather (below 35 degrees F or above 95 degrees F), scheduled maintenance or to ""address resident issues with shared courtyards."" Observations revealed the following: On 9/2/25 at 3:25 PM the Delta 1 patio door was observed to be locked. A sign on the door indicated the door was open daily from 10:00 AM to 12:00 PM.-á On 9/3/25 at 10:41 AM the Delta 2 patio door was locked.-á On 9/4/25 at 10:14 AM the Delta 2 patio door was locked. A sign on the door indicated the door was open from 8:00 AM to 10:00 AM. No inclement weather was observed.-á On 9/4/25 at 10:27 AM Staff 10 (CNA) stated the patio door was on a set schedule to lock on Delta 1 and Delta 2 due to a resident with behaviors. Staff 10 stated currently the weather was not too hot outside for the residents. On 9/4/25 at 10:34 AM Staff 27 (CNA) stated the doors were set to automatically lock. The doors were unlocked for two hours. Delta 1's and Delta 2's doors did not unlock at the same time.-á On 9/8/25 at 11:59 AM Staff 12 (LPN Resident Care Coordinator) stated the residents had a right to go outside. Maintenance set up a timer to lock the doors at specified times. If a resident wanted to go outside and the doors were locked, they were assisted outside by staff. Staff 12 stated the doors were currently locked due to a resident who was able to walk from Delta 2 though the courtyard to Delta 1 and had a history of inappropriate behaviors with other residents. The doors were locked for safety reasons.-á On 9/8/25 at 2:40 PM Staff 2 (DNS) acknowledged the patio doors were locked, and the temperature did not exceed 95 degrees F. A 7/2/25 Delta Courtyards Policy revealed the facility was to provide residents access to a secured outdoor space and walkways which allowed residents to enter and return without staff assistance. Doors could be locked during the night and during adverse events, inclement weather (below 35 degrees F or above 95 degrees F), scheduled maintenance or to ""address resident issues with shared courtyards."" Observations revealed the following: On 9/2/25 at 3:25 PM the Delta 1 patio door was observed to be locked. A sign on the door indicated the door was open daily from 10:00 AM to 12:00 PM.-á On 9/3/25 at 10:41 AM the Delta 2 patio door was locked.-á On 9/4/25 at 10:14 AM the Delta 2 patio door was locked. A sign on the door indicated the door was open from 8:00 AM to 10:00 AM. No inclement weather was observed.-á On 9/4/25 at 10:27 AM Staff 10 (CNA) stated the patio door was on a set schedule to lock on Delta 1 and Delta 2 due to a resident with behaviors. Staff 10 stated currently the weather was not too hot outside for the residents. On 9/4/25 at 10:34 AM Staff 27 (CNA) stated the doors were set to automatically lock. The doors were unlocked for two hours. Delta 1's and Delta 2's doors did not unlock at the same time.-á On 9/8/25 at 11:59 AM Staff 12 (LPN Resident Care Coordinator) stated the residents had a right to go outside. Maintenance set up a timer to lock the doors at specified times. If a resident wanted to go outside and the doors were locked, they were assisted outside by staff. Staff 12 stated the doors were currently locked due to a resident who was able to walk from Delta 2 though the courtyard to Delta 1 and had a history of inappropriate behaviors with other residents. The doors were locked for safety reasons.-á On 9/8/25 at 2:40 PM Staff 2 (DNS) acknowledged the patio doors were locked, and the temperature did not exceed 95 degrees F. Summary of Deficiency: Access to secured outdoor space and walkways which allow residents to enter and return without staff assistance, except when indicated by OAR 411-057-0170(5)(e). 1. Corrective Action for Residents Found to be Affected Immediately upon identification of the deficiency, the Delta 1 and Delta 2 patio doors were reprogrammed to remain unlocked during all daytime hours, except during inclement weather, scheduled maintenance, or emergent safety events consistent with OAR 411-057-0170(5)(e). Staff immediately assisted any residents requesting outdoor access until corrective programming was completed. The resident previously identified as exhibiting unsafe behaviors was provided an individualized care plan with enhanced supervision interventions rather than restricting outdoor access for all residents. As of October 1, all residents on Delta 1 and Delta 2 halls have unassisted access to secured outdoor courtyards. 2. How Other Residents Potentially Affected Will Be Identified The Maintenance Director conducted a facility-wide audit of all secured outdoor courtyards and walkways on October 15th, 2025. No additional areas were found with inappropriate lock schedules. All residents have been confirmed to have unassisted access to outdoor areas as required. 3. Measures or Systemic Changes to Ensure Non-Recurrence Facility will prohibit scheduled door-lock programming during non-inclement weather hours. Locks may only be engaged under conditions explicitly permitted in OAR 411-057-0170(5)(e). Individualized Care Planning: Any resident with behavioral or safety concerns will have a care plan developed through the Interdisciplinary Team (IDT). Delta Neighborhood-wide Memory Care access will not be restricted for one resident. Maintenance Procedures: Maintenance staff have been instructed and retrained to discontinue automatic lock scheduling. All programming changes must be approved by the Administrator or DNS. Staff Training: On October 14th, 2025, all staff will be re-educated on resident rights related to outdoor access, OAR 411-057-0160(g) requirements, and proper procedures for managing individual resident risks without restricting others. 4. Monitoring to Ensure Ongoing Compliance Weekly Maintenance Director Audits: Maintenance Director or Designee will inspect each secured outdoor courtyard weekly for 8 weeks, then monthly thereafter. Compliance with outdoor access will be a standing agenda item at the monthly QAPI Committee meeting. 5. Responsible Party Appropriate department leadership (Administrator or Maintenance or Designees) 6. Completion Date October 28, 2025 Summary of Deficiency: Access to secured outdoor space and walkways which allow residents to enter and return without staff assistance, except when indicated by OAR 411-057-0170(5)(e). Immediately upon identification of the deficiency, the Delta 1 and Delta 2 patio doors were reprogrammed to remain unlocked during all daytime hours, except during inclement weather, scheduled maintenance, or emergent safety events consistent with OAR 411-057-0170(5)(e). Staff immediately assisted any residents requesting outdoor access until corrective programming was completed. The resident previously identified as exhibiting unsafe behaviors was provided an individualized care plan with enhanced supervision interventions rather than restricting outdoor access for all residents. As of October 1, all residents on Delta 1 and Delta 2 halls have unassisted access to secured outdoor courtyards. The Maintenance Director conducted a facility-wide audit of all secured outdoor courtyards and walkways on October 15th, 2025. No additional areas were found with inappropriate lock schedules. All residents have been confirmed to have unassisted access to outdoor areas as required. Facility will prohibit scheduled door-lock programming during non-inclement weather hours. Locks may only be engaged under conditions explicitly permitted in OAR 411-057-0170(5)(e). Individualized Care Planning: Any resident with behavioral or safety concerns will have a care plan developed through the Interdisciplinary Team (IDT). Delta Neighborhood-wide Memory Care access will not be restricted for one resident. Maintenan”

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“Based on interview and record review it was determined the facility failed to provide risk and benefits for the use of an antipsychotic medication to a resident/responsible party before administration and communicate changes in ROM services for 2 of 6 sampled residents (#s 80 and 118) reviewed for medications and positioning. This placed residents and responsible parties at risk for lack of appropriate information. Findings include: 1. Resident 80 admitted to the facility in 2020 with diagnoses including multiple sclerosis (disease of the central nervous system) and degeneration of the spine. A 1/10/24 Restorative Assessment and Referral indicated to utilize a standing frame (a device which allows an impaired individual to stand) for Resident 80 three times each week for 10 minutes for improved quality of life. Precautions required two staff present for set-up and one staff present during standing. A 2/29/24 revised Restorative Assessment and Referral indicated Resident 80 was to direct the frequency of the use of the standing frame. A 3/6/24 revised Task indicated staff were to facilitate Resident 80's ability to stand in the standing frame as needed for improved quality of life. On 4/25/24 and 4/27/24 the document indicated Resident 80 refused the standing frame and the task was not offered any additional days from 4/3/24 through 5/2/24. A 3/12/24 Interdisciplinary Care Conference indicated assistance would be provided to Resident 80 to have access to the standing frame per her/his request. Staff 5 (Resident Care Manager) was not in attendance. On 4/29/24 at 11:03 AM Resident 80 stated facility staff were to provide assistance to allow her/him to be in the standing frame three days each week, but the therapy was no longer offered by staff. On 5/1/24 at 9:01 AM Staff 12 (CNA) stated because Resident 80's standing frame task was PRN, staff no longer provided the standing frame service unless she/he asked. On 5/2/24 at 12:28 PM Staff 5 stated Resident 80 was able to advocate for herself/himself and could ask to use the standing frame. On 5/2/24 at 2:53 PM Resident 80 stated she/he was not aware she/he needed to ask staff to provide the standing frame service since the service was routine in the past. Resident 80 stated she/he only refused the standing frame services when she/he was too tired. On 5/3/24 at 9:42 AM Staff 2 (DNS) stated she trusted Resident 80's statement if she/he indicated she/he was not notified of the changes to her/his standing frame services. Staff 2 stated Resident 80 should be informed when changes were made to her/his therapy service plan. For individual- #80-expired- has been verbally notified that FMP is PRN and knows to ask if he wants to be in the standing frame. Updated care plan to reflect task. Will be placed under mobility in CP. #118-expired-Consent was received prior to resident expiration. For others affected- All residents are at risk. Changes / Interventions- Facility wide Audit of the FMP programs and Psychotropics consents. Care plans to be updated as necessary. Audit weekly of the FMP program and psychotropic consents x4 weeks and then monthly x2. Education- All LN’s; RCM’s; Therapy; Social Services department will receive education on resident’s rights to be informed of any changes in treatments and medication consents. A copy of residents' rights will be provided at the June resident council. QAPI Monitoring for compliance There are no detail notes for this visit.”

“Based on interview and record review it was determined the facility failed to notify a resident's physician of a change in condition for 1 of 3 sampled residents (#36) reviewed for UTIs. This placed residents at risk for delayed treatment. Findings include: Resident 36 admitted to the facility in 2021 with a diagnoses including dementia, urinary retention, and an irregular heart beat. A 2/2024 annual CAA indicated Resident 36 had a diagnosis of dementia, was able to communicate, transfer to the toilet, and was incontinent of urine. Resident 36's 3/2024 MAR revealed she/he was administered a blood thinner daily. Progress Notes revealed the following: -2/24/24 Resident 36 was observed to have small amounts of red-tinged urine during her/his incontinent care. The resident denied pain or painful urination. The not indicate the resident would be monitored. There was no indication Resident 36's physician was notified of the red-tinged urine. -2/25/24 Resident 36 did not have red or pink-tinged urine or discharge. -2/26/24 through 3/8/29 revealed Resident 36's urinary status was not assessed. -3/9/24 at 5:46 PM a note by Staff 23 (Agency RN) indicated the resident continuously took her/himself to the bathroom. Resident 36 reported a stomach ache at approximately 2:30 PM and was administered an antacid which was noted to be effective. The resident was also noted to have a small amount of blood on her/his incontinent brief and genitalia. Resident 36 reported she/he had to "pee every time." Staff were to monitor the resident. There was no indication Resident 36's physician was notified of the blood, abdominal pain, or frequent urination. -3/10/24 at 7:11 AM a note revealed Resident 36 reported "stomach cramping" which was alleviated with PRN medication. -3/10/24 at 11:13 AM revealed Resident 36 had "severe" abdominal pain, was "shaking", and "crying." The note indicated the pain could be from bowel care. The resident's physician was not able to be reached and the resident was transported to the hospital. A 3/12/24 hospital Orders At Discharge form revealed the resident was admitted to the hospital on 3/10/24 and was diagnosed with urinary retention, UTI with hematuria (blood in urine), and sepsis (potentially life-threatening complication of an infection) with sudden onset of kidney failure without septic shock (a serious condition when the body does not respond to an infection which causes a dramatic drop in blood pressure that can damage other organs). On 5/1/24 at 12:30 PM Staff 23 stated at times when a resident had symptoms of a UTI it was difficult for staff to obtain orders from the physician for UAs. Staff 23 stated she did not recall the note she wrote on 3/9/24, would review the note, and provide additional information if able. No additional information was provided. On 5/2/24 at 3:00 PM Staff 32 (LPN) stated if a resident had blood in her/his urine it could be signs of a UTI. Staff should also look at the medications the resident was administered and if the resident was on a blood thinner it could be related to the medication and the physician should be notified. The physician may or may not order a UA or other labs but staff should still notify the physician. On 5/2/24 at 4:33 PM Staff 2 (DNS) reviewed Resident 36's clinical record and stated during 2/24/24 through 3/8/24 she was not able find information to indicate Resident 36's physician was notified of the blood on the genitalia on 2/24/24 or 3/9/24. Staff 2 acknowledged the resident's blood could have been from the blood thinner or a possible UTI. Staff 2 stated she would provide documentation if Resident 36's physician was notified. No additional information was provided. For individual- #36- Provider notified. For others affected- All residents are at risk. Changes / Interventions-Facility wide audit of 24-hour reports will be auditing for appropriate provider notification Daily x2 weeks. Weekly x2. Monthly x2. Education- All nurses will be educated on appropriate and timely notification and documentation to the providers. QAPI Monitoring for compliance There are no detail notes for this visit.”

“Based on interview and record review it was determined the facility failed to provide timely Notice of Medicare Non-Coverage (NOMNC) for 1 of 1 sampled resident (#248) reviewed for notices. This placed residents at risk for lack of appeal information. Resident 248 was admitted to the facility in 2024 with diagnoses including heart attack and dehydration. A NOMNC documented the last covered day as 4/3/24. The NOMNC was signed by Resident 248 on 4/2/24. On 5/2/24 at 2:44 PM Staff 4 (Social Services Designee) confirmed the notice was not provided in the required timeframe to Resident 248. For individuals- #248-Discharged For others affected- All residents who are receiving services under Medicare Part A, B and Medicare Managed insurance. Changes / Interventions-Audit to identify those receiving services under Medicare Part A, B and Medicare Managed insurance who will require a NOMNC (Notification Of Medicare Non-Coverage). Audit weekly x4. Monthly x2. Education- Utilization Review team will be educated on patient liability notice standards. QAPI Monitoring for compliance There are no detail notes for this visit.”

“Based on interview and record review it was determined the facility failed to develop a sufficient grievance policy and a timely grievance response for 1 of 4 sampled resident (#128) reviewed for activities. This placed residents at risk for unaddressed concerns and grievances. Findings include: A 12/2023 revised facility Grievances policy indicated staff were to assist residents with the grievance process, a resolution to a grievance was "as soon as possible", and the policy did not indicate a reasonable expected timeframe for the facility to complete the review of grievances. The facility policy neglected to include that a resident had the right to file a grievance orally or anonymously and obtain a written decision. An 4/12/24 hand-written letter from Resident 128 to Staff 6 (Recreation Director) indicated dissatisfaction with recent rule changes to a game activity because of her/his "skills" for the game. The letter also indicated activity staff were "prejudice" against Resident 128. On 4/29/24 at 10:00 AM Resident 128 stated she/he filed a complaint about activities and received no communication about her/his concerns since the letter was written (15 days ago). On 5/1/24 at 10:09 AM Staff 3 (Assistant Administrator) stated he (the Grievance Officer) did not read Resident 128's letter until 4/28/24. Staff 3 stated Staff 8 (Social Service Designee) observed Resident 128's letter on 4/12/24 when Resident 128's letter was shared by Staff 6. Staff 3 stated there was a delay in response to Resident 128 due to a team effort to determine the best way to handle information in the letter. On 5/1/24 at 12:43 PM Staff 8 stated he believed Resident 128's 4/12/24 letter was written to express her/his feelings and Staff 8 did not consider the letter a grievance because it was not on the grievance form. On 5/1/24 at 4:40 PM and 5/3/24 at 10:39 AM Staff 3 indicated a late conversation with Resident 128 regarding her/his concerns with activities was conducted on 5/1/24 and the facility Grievance policy was insufficient when updated in 12/2023. For individual- #128- Social Services and Assistant Administrator met with resident on 5/2/24 and grievance was resolved to resident’s satisfaction. For others affected- All residents are at risk. Changes / Interventions- OVHL policy and procedure updated to reflect regulation. Audit grievance log weekly x4. Monthly x2. Education- Education to updated grievance policy provided in May 2024 All Staff meeting. QAPI Monitoring for compliance There are no detail notes for this visit.”

“Based on interview and record review, it was determined the facility failed to ensure residents were free from sexual and physical abuse for 2 of 5 sampled residents (#s 38 and 108) reviewed for abuse by Resident 139 and Resident 141. This placed residents at risk for abuse. Findings include: 1. Resident 38 admitted to the facility in 2018 with diagnoses including panic disorder, dementia, and PTSD (Post-Traumatic Stress Disorder). Resident 141 admitted to the facility in 2024 with a diagnosis of Alzheimer's Disease. An 10/11/23 Annual MDS indicated Resident 38 was rarely understood. An 4/4/24 Investigation revealed on 4/4/24 while Resident 38 was on a video call with Witness 1 (Family Member), Resident 141 was sitting next to Resident 38 and reached over and rubbed Resident 38's chest area. Witness 1 stated, "Keep your hands to yourself". Staff moved Resident 38 into her/his wheelchair to the nurses' station to complete the video call. Resident 141 was escorted back to her/his unit. The facility substantiated sexual abuse. On 5/1/24 at 10:10 AM Witness 1 stated Resident 38 was seated in a recliner while engaged in a video call with her. Witness 1 stated she saw a hand and forearm reach across and touch Resident 38's chest and was rubbing the area. Witness 1 yelled at Resident 141 and Resident 141 quit. On 5/2/24 at 7:49 AM Staff 17 (CNA) stated she was in a resident's room and Resident 141 was sitting next to Resident 38. Staff 17 stated she heard Witness 1 state "leave [her/him] alone." Resident 141 touched Resident 38's chest two times. Staff 17 stated she stood between the two recliners until Resident 38 could be removed from the area. On 5/3/24 at 8:57 AM Staff 21 (RCM) confirmed the facility substantiated sexual abuse by Resident 141 to Resident 38. 2. Resident 108 admitted to the facility in 2024 with diagnoses including depression. Resident 139 admitted to the facility in 2023 with diagnoses including dementia, psychotic disturbance, mood disturbance, anxiety, and PTSD (Post-Traumatic Stress Disorder). A 2/15/24 care plan indicated Resident 108 had a history of trauma to remain safe and stable. A 2/22/24 Annual MDS indicated Resident 108 had a BIMS score of 11 indicating moderate cognitive impact. A Nurse's Note on 4/17/24 at 8:30 PM indicated Resident 108 was struck by a thrown object on the side of her/his face. No injuries were identified on Resident 108, and the staff would continue to monitor her/him for any abnormalities. An 4/18/24 Investigation report revealed on 4/18/24 (incident occurred 4/17/24) around 7:30 PM Resident 139's behaviors escalated, she/he went into the kitchen and picked up a hand-held game in its packaging. Resident 139 threw the game into Resident 108's room and struck Resident 108 on the left side of her/his face. On 5/2/24 at 7:31 AM Staff 15 (CNA) stated around 7:30 PM on 4/17/24 she witnessed Resident 139's behaviors escalate, and she/he was upset. Resident 139 was yelling, Resident 108's door was open, and Resident 139 threw a handheld game into the room. Staff 15 went into the room and Resident 108 stated the game hit her/him in the face. On 5/1/24 at 12:21 PM Staff 14 (CNA) stated on 4/17/24 he observed Resident 139 pick up a hand-held game and throw it into Resident 108's room. Staff 14 stated he heard a sound of impact and Resident 108 reported to him that she/he was struck in the head by the game. Staff 14 did not get a chance to observe Resident 108's head at the time as he was attempting to keep other residents safe from 108's behaviors. On 5/3/24 at 8:54 AM Staff 40 (RCM) stated the facility did not substantiate abuse during the investigation. The facility determined Resident 139's PTSD was triggered, and she/he was agitated and did not believe Resident 139 was aware of her/his actions. For individual – #38, #141, #108, and #139 care plans were reviewed and updated. Residents haven’t verbalized or demonstrated ongoing psychological harm evidenced by continuing their daily routines and activities. For others affected – All residents are at risk. Changes / Interventions- Facility will review all allegations of abuse, resident to resident, and resident to staff assessments for the past three months. Care plans will be reviewed and updated as needed. Random daily observations will be completed in memory care unit for 2 weeks, weekly x2 weeks, and monthly x2 months of to ensure residents are safe, comfortable, and free of any signs of abuse or neglect. Education- Education on abuse is provided to all staff upon hire, annually, and as needed. Abuse training initiated on May 14th, 2024, all staff meeting. QAPI Monitoring for compliance There are no detail notes for this visit.”

“Based on interview and record review it was determined the facility failed to timely investigate abuse for 1 of 3 sampled residents (#38) reviewed for abuse. This placed residents at risk for abuse and neglect. Findings include: Resident 38 admitted to the facility in 2018 with diagnoses including panic disorder, dementia, and PTSD (Post-Traumatic Stress Disorder). Resident 141 admitted to the facility in 2024 with a diagnosis of Alzheimer's Disease. An 4/4/24 Investigation revealed an investigation timeframe 4/4/24 through 4/10/24. On 4/4/24 while Resident 38 was on a video call with Witness 1 (Family Member) Resident 141 was sitting next to Resident 38 and reached over and rubbed Resident 38's chest area. Witness 1 stated "Keep your hands to yourself." The facility determined sexual abuse was substantiated. On 5/3/24 at 8:57 AM Staff 21 (RCM) confirmed the investigation was not completed timely. Refer to F600 For individual- #38’s and resident # 141’s care plan has been updated. For others affected – All residents are at risk. Changes / Interventions – Anytime the facility submits a facility reported incident the leadership team will coordinate investigations and ensure timely completion. Education – All staff educated on the abuse policy procedure in May 2024. All abuse allegations will be reported and reviewed at the weekly risk management meeting to ensure that the investigation protocol has been followed and investigations are completed timely. QAPI Monitor for compliance There are no detail notes for this visit.”

“Based on interview and record review it was determined the facility failed to document and conduct a Significant Change MDS assessment within the required timeframe for 1 of 5 sampled residents (#118) reviewed for nutrition. This placed residents at risk for unassessed needs. Findings include: Resident 118 admitted to the facility in 2023 with diagnoses including diabetes, pressure ulcer and dementia. A 9/13/24 Admission MDS revealed Resident 118's BIMS score was 15 which indicated she/he was cognitively intact. There were no concerns with Resident 118's mood and she/he did not have any behaviors. Resident 118 was frequently incontinent of bowel and had occasional pain presence with PRN pain medications. Resident 118 had one Stage 3 (a deep wound that has broken through the top two layers of skin into the fatty tissue) pressure ulcer and moisture associated skin breakdown. Medications administered to Resident 118 included insulin and antidepressants. A 3/13/24 Quarterly MDS revealed Resident 118's BIMS was nine which indicated moderate cognitive impairment. Resident 118 felt down, depressed or hopeless two to six days during the look back period. Behaviors included physical symptoms towards others such as hitting or kicking, verbal behaviors such as threatening others, and behavioral symptoms not directed toward others such as pacing. Resident 118 also rejected care one to three days. Resident 118 was always incontinent of bowel. Pain levels were frequent pain with scheduled and PRN pain medications with a pain presence of eight on a one to 10 scale. Resident 118 had one Stage 4 (a deep wound that impacts muscle, tendons, ligaments, and bone) pressure ulcer and moisture associated skin breakdown. Medications administered to Resident 118 included insulin, antipsychotic, antianxiety, anticoagulant, and opioid medications. There was no documentation found in Resident 118's clinical records to indicate a significant change assessment was considered or ruled out. On 5/3/24 at 7:35 AM Staff 21 (RCM) stated she did not know why a significant change assessment was not completed for Resident 118. For individual- #118-expired. For others affected- All residents are at risk. Changes / Interventions-MDS audit tool to be reviewed to ensure significant changes not required. Daily x2 weeks. Weekly x2. Monthly x2. Education- Education will be provided to IDT team on requirements for significant change MDS. QAPI Monitor for compliance There are no detail notes for this visit.”

“Based on observation, interview, and record review it was determined the facility failed to revise care plan interventions for 3 of 8 sampled residents (#s 38, 101 and 121) reviewed for accidents, pressure ulcers and position and mobility. This placed residents at risk for unmet needs. Findings include: 1. Resident 38 admitted to the facility in 2018 with diagnoses including Parkinson's disease. A current care plan dated 2/14/22 indicated Resident 108 had a problematic manner of ineffective coping with interventions including taking Resident 108 on walks. An 4/10/24 Quarterly MDS indicated walking 10 feet was not attempted due to medical conditions or safety concerns. An 4/30/24 Abnormal Involuntary Movement Scale indicated Resident 38 could not sit in a chair without leaning back. Resident 38 could only stand with two persons with maximum assistance for balance and she/he twisted her/his feet. On 5/3/24 at 8:57 AM Staff 21 (RCM) stated Resident 38 declined in her/his abilities, no longer walked, and the care plan did not reflect their current abilities. 2. Resident 121 admitted to the facility in 2024 with diagnoses including cramp and spasm disorder, and anxiety. A 3/2/24 Admission MDS indicated Resident 121 had a BIMS score of 11 indicating moderate cognitive impairment. Resident 121 had a history of falls. A current care plan dated 3/18/24 indicated Resident 121 was at risk for falls with interventions including a fall mat at the bedside and in the bathroom. Resident 121 was to have commonly used items within reach. Physical therapy was to evaluate and treat for gait and proper assistive equipment. Staff were to remind Resident 121 to use the call light for assistance and place a sign to remind Resident 121 to use the call light near her/his clock in the bedroom, and near the call light in the bathroom. An 4/15/24 Post Fall Assessment revealed Resident 121 was found on the floor. Resident 121 had a history of falls with interventions that were effective were she/he was switched from using double canes for walking to using a walker and to have room and bed sensors. No documentation was found in Resident 121's care plan to include the use of room and bed sensors for fall interventions. , 3 . Resident 101 admitted to the facility in 2021 with a diagnosis of dementia. A 5/2023 annual MDS indicated Resident 101 was assessed to identify activities which were very important which included being with people and being in fresh air. A Care Plan updated 6/8/23 revealed the resident enjoyed bird watching out her/his window. Resident 101's clinical record revealed she/he moved to her/his current room 6/28/23. On 5/1/24 at 12:03 PM Resident 101 was observed in her/his recliner next to the window. The window blinds were shut. On 5/1/24 at 3:00 PM Staff 41 (CNA) stated Resident 101 loved to go to outside and to the casino. Staff 41 stated Resident 101 did not like her/his window blinds open. Staff 41 also stated if the blinds were opened the resident told staff to shut the blinds. Staff 101 stated when Resident 101 lived in a different part of the facility the resident used to bird watch from her/his window. Staff 41 stated since the resident moved to her/his current room the resident did not like to watch the birds from her/his window. On 5/2/24 at 11:20 AM Staff 6 (Recreational Director) indicated the care plan may not have been updated to reflect the resident's current preferences. For individuals- #38, #121 and #101 care plans have been updated. For others affected- All residents are at risk. Changes / Interventions- Facility wide audit of all resident fall, mobility and recreation care plans to ensure accuracy. IDT will continue with weekly audits x 4 weeks. Monthly x2. Education- Care Plan revision education will be provided to IDT team. QAPI Monitor for compliance There are no detail notes for this visit.”

“Based on interview and record review it was determined the facility failed to ensure dependent residents received required assistance with ADLs for 1 of 4 sampled residents (#80) reviewed for ADLs. This placed resident at risk for inadequate personal hygiene. Findings include: Resident 80 admitted to the facility in 2020 with diagnoses including multiple sclerosis (disease of the central nervous system) and degeneration of the spine. An 10/23/23 revised care plan indicated Resident 80 required one staff to assist with bathing. 3/2024 and 4/2024 shower calendars for Resident 80 indicated the resident received one shower during the week on 3/6/24, 4/18/24, 4/25/24, and 4/29/24. No showers were provided on any Sundays and Resident 80 was to receive her/his showers at night. The 3/12/24 Quarterly MDS indicated Resident 80 required substantial to maximum assistance for bathing. On 4/29/24 at 10:57 AM and 5/1/24 at 11:33 AM Resident 80 stated she/he received no Sunday shower as expected and only one shower during the week for the last 30 days due to lack of staff. Resident 80 indicated she/he filed a grievance related to lack of showers but concerns related to her/his showers continued. On 5/1/24 at 9:01 AM Staff 12 (CNA) indicated Resident 80 was the only resident who requested showers at night to help relax her/his muscles and it was difficult to get her/his shower task completed. Staff 12 stated Staff 11 (CNA) was often left to work alone at night over the last two months due to lack of staffing. On 5/2/24 at 2:33 PM Staff 27 (CNA) stated Resident 80 often informed her no shower was provided earlier in the week and nurses were aware. Staff 27 stated because Resident 80's shower required staff assistance for one hour, she sometimes was not able to complete Resident 80's make-up shower. On 5/2/24 at 4:48 PM Staff 3 (Assistant Administrator) confirmed he spoke with Resident 80 about her/his shower concern in 1/2024 and expected Resident 80 to be provided a follow-up shower if weekend showers were missed. On 5/3/24 at 9:42 AM Staff 2 (DNS) and Staff 22 (Assistant DNS) acknowledged Staff 7 (Staffing Coordinator) received direction that the same resident unit should not always be required to work short-handed when the expectations for the facility staffing model were not met. Staff 2 acknowledged teamwork was necessary for Resident 80 to receive two showers weekly and it did not occur. For individual #80- Shower schedule has been changed per resident preference and updated on his/her care plan. For others affected- All residents are at risk. Changes / Interventions-Facility wide audits will be completed to determine time and day of shower preference, with Care Plans being updated as necessary. Audit shower sheets daily for completion for 2 weeks. Weekly x2. Monthly x2. Education- All staff will be educated on bathing schedules and required documentation. QAPI Monitor for compliance There are no detail notes for this visit.”

“Based on interview and record review it was determined the facility failed to monitor a resident for a change of condition, make a urology appointment, and follow physician orders for 2 of 8 sampled residents (#s 36 and 118) reviewed for UTIs and medications. This placed residents at risk for delayed care and unmet needs. Findings include: 1. Resident 36 admitted to the facility in 2021 with a diagnosis of dementia. a. A 2/2024 annual CAA indicated Resident 36 had a diagnoses of dementia, was able to communicate, was able to transfer to the toilet, and was incontinent of urine. Resident 36's 3/2024 MAR revealed she/he was administered a blood thinner daily. Progress Notes revealed the following: -2/24/24 Resident 36 was observed to have small amounts of red-tinged urine during her/his incontinent care. The resident denied pain or painful urination. The not indicate the resident would be monitored. -2/25/24 Resident 36 did not have red or pink-tinged urine or discharge. -2/26/24 through 3/8/29 revealed Resident 36's urinary status was not assessed. -3/9/24 at 5:46 PM a note by Staff 23 (Agency RN) indicated the resident continuously took her/himself to the bathroom. Resident 36 reported a stomach ache at approximately 2:30 PM and was administered an antacid which was noted to be effective. The resident was also noted to have a small amount of blood on her/his incontinent brief and genitalia. Resident 36 reported she/he had to "pee every time." Staff were to monitor the resident. -3/10/24 at 7:11 AM a note revealed Resident 36 reported "stomach cramping" which was alleviated with PRN medication. -3/10/24 at 11:13 AM revealed Resident 36 had "severe" abdominal pain, was "shaking", and "crying." The note indicated the pain could be from bowel care. The resident's physician was not able to be reached and the resident was transported to the hospital. A 3/12/24 hospital Orders At Discharge revealed the resident was admitted to the hospital on 3/10/24 and was diagnosed with urinary retention, UTI with hematuria (blood in urine), and sepsis (potentially life-threatening complication of infection) with sudden onset of kidney failure without septic shock (a serious condition when the body does not respond to an infection which causes a dramatic drop in blood pressure that can damage other organs). On 5/2/24 at 4:33 PM Staff 2 (DNS) reviewed Resident 36's clinical record and stated during 2/24/24 through 3/8/24 she did not see Resident 36's physician was notified of the blood on the genitalia on 2/24/24 or 3/9/24. Staff 2 acknowledged the resident's blood could have been from the blood thinner or a possible UTI. Staff 2 also stated she expected staff to monitor the resident each shift for at least 72 hours to ensure the resident did not have continued bleeding or additional symptoms of a UTI. b. Resident 36's After visit Summary revealed the resident was hospitalized from 3/10/24 through 3/12/24 and orders included the resident was to be seen by urology (Physician who specializes in conditions related to the urinary system). Resident 36's 4/15/24 facility NP visit note revealed the resident was sent to the hospital and was identified to have UTI and a "Referral to urology was sent" for urinary retention (bladder does not empty completely after urinating). Review of Resident 36's record revealed no documentation a referral to urology was completed. On 5/2/24 at 3:30 PM a request was made to Staff 40 (RNCM) to provide documentation a referral was made. No additional information was provided. , 2. Resident 118 admitted to the facility in 2023 with diagnoses including pressure ulcer and diabetes. A 4/2024 MAR instructed staff to administer one fourth a cup of Kefir (fermented milk with probiotic effects on blood sugar, cholesterol, and digestion) two times a day for 14 days with a start date of 4/12/24, and a discontinue of 4/25/24. Eighteen times the MAR referred the reader to administration notes, and six times it was documented as administered. The 4/12/24, 4/13/24, 4/18/24, and 4/19/24 Medication Administration Notes indicated Kefir was not available. On 5/3/24 at 7:35 AM Staff 21 (RCM) stated staff should notify the physician when Kefir was unavailable. For individual- #36- RCM reached out to provider and family regarding urology referral and both parties declined. #118-expired. For others affected- All residents are at risk. Changes / Interventions- Referral coordinator and social service department will process and follow up on referrals. Daily review of the missed documentation and 24-hour report x2 weeks. Weekly x2. Monthly x2. Education- All nurses will be educated on appropriate and timely notification and documentation to the providers. QAPI Monitor for compliance There are no detail notes for this visit.”

“Based on observation, interview, and record review it was determined the facility failed to accurately assess pressure ulcers for 2 of 5 sampled residents (#s 59 and 118) reviewed for pressure ulcers. This placed residents at risk for worsening wounds. Findings include: 1. Resident 59 admitted to the facility in 3/2017 with diagnoses including paraplegia (the inability to voluntarily move the lower parts of the body). A review of Resident 59's care plan revealed a 1/21/24 care plan for a moisture associated wound (inflammation of the skin caused by moisture) to her/his sacrum. A review of a 1/22/24 Wound Evaluation revealed Resident 59 had moisture assoicated damage to her/his sacrum. The Wound Evlauation stated the wound was 12 cm X 8.14 cm with 90% dead tissue on the wound bed. A review of a 1/29/24 Wound Evaluation revealed Resident 59 had an unstageable pressure wound (wound caused by pressure with full thickness tissue loss with exposed bone, tendon, or muscle; dead tissue may be present on some parts of the wound bed; often includes tissue damage beneath the skin) on her/his sacrum. The Wound Evaluation stated the wound was 12.88 cm X 9.56 cm with a 1.4 cm depth and 80% dead tissue on the wound bed. A review of a 2/4/24 Wound Evaluation revealed Resident 59 had moisture associated damage to her/his sacrum. The Wound Evaluation stated the wound was 16.1 cm X 9.04 cm with a 2.4 cm depth and 3.2 cm tunneling under the skin and 80% dead tissue on the wound bed. A review of a 4/29/24 Wound Evaluation revealed Resident 59 had a Stage 4 pressure wound (wound caused be pressure with full thickness tissue loss with exposed bone, tendon, or muscle; dead tissue may be present on some parts of the wound bed; often includes tissue damage beneath the skin) on her/his sacrum. The Wound Evaluation stated the wound was 12.76 cm X 16.57 cm with 10% dead tissue. On 5/1/24 at 10:47 AM Staff 38 (LPN) stated Resident 59 had the sacrum pressure ulcer since 1/2024. On 5/1/24 at 10:47 AM a wound was observed on Resident 59's sacrum with Staff 38. The wound was observed to have full thickness tissue loss with a mixture of pale pink and red tissue through much of the wound with scattered dead tissue and undermining (erosion underneath the outwardly visible wound margins resulting in more extensive damage beneath the skin surface). Resident 59's wound met the definition of a Stage 4 pressure ulcer. On 5/1/24 at 2:56 PM Staff 9 (RCM) stated Resident 59's wound to her/his sacrum started on 1/14/24 as an unstageable pressure wound. Staff 9 stated the wound worsened and on 2/4/24 Resident 59 was admitted to the hospital for wound debridement (surgical removal of dead tissue). On 5/2/24 at 9:44 AM Staff 9 and Staff 13 (RCM) stated Resident 59 had a stage 4 pressure wound to her/his sacrum. Staff 9 and 13 acknowledged Resident 59's sacrum wound was incorrectly assesed as moisture associated damage and Resident 59's stage 4 pressure wound to her/his sacrum was not on the care plan. For individuals- #59- Skin and wound app has been updated to proper wound staging. #118-expired For others affected- All residents are at risk. Changes / Interventions- Facility wide audit in weekly wound care meeting to ensure all wounds are staged correctly. Nursing leadership will review all pressure wounds weekly. Education- Wound care certified nurses to present education on proper wound staging. QAPI Monitor for compliance There are no detail notes for this visit.”

“Based on observation, interview and record review it was determined the facility failed to assess and care plan a resident's ability to transfer from a reclining chair and timely investigate a fall for 2 of 8 sampled residents (#s 121 and 142) reviewed for dementia care and accidents. This placed residents at risk for falls. Findings include 1. Resident 142 admitted to the facility with a diagnosis of dementia. A 3/25/24 admission MDS indicated Resident 142 walked without assistive devices. The assessment indicated she/he and had a fall prior to and one fall after admission to the facility. Resident 142's risk factors for falls included medication side affects which could cause confusion and dizziness. The resident also had insomnia and was often awake for many hours at a time placing the resident at risk for falls. A care plan initiated 3/18/24 revealed Resident 142 was at risk for falls and the resident was to wear non-skid socks and call staff for assistance. On 4/30/24 at 12:52 PM Resident 142 was observed in a recliner with her/his eyes shut, she/he was covered with blankets, and her/his legs were elevated on the recliner leg rests. Resident 142 was not observed to attempt to get out of the recliner. On 5/2/24 at 12:08 PM Staff 21 (RNCM) stated the recliners had remote controls to elevate the leg rests, there should always be one staff in the common area, and if a resident needed assistance to stand staff should be able to intervene. Staff 21 acknowledged many residents in the memory care unit were not able to use the remote control to adjust the recliner leg rests. Staff 21 stated Resident 142 was not not assessed to determine if she/he was able to use the remote, and acknowledged if the resident attempted to transfer out of the chair with the leg rests elevated it would increase the resident's risk for falls. Staff 21 stated the care plan did not direct staff to ensure leg rests were down if staff were not in the common area and the resident was asleep. On 5/2/24 at 1:25 PM Resident 142 was observed in a recliner with her/his legs elevated on the recliner leg rests. Resident 142 was covered with blankets and her/his eyes were shut. Resident 142 was then observed to attempt to transfer out of the recliner but was not able to lower the leg rests. Resident 142 swung her/his legs over the leg rests and attempted to get out of the chair. Staff 18 (CNA) was then observed to assist the resident with the recliner remote to lower the leg rests and assisted the resident to stand. Resident 142 was observed to be unsteady when she/he initially stood and then was able to walk to the dining room table. Staff 18 stated in general they always tried to have one staff member in the common area, but there were times when all the staff were assisting other residents and may not be available. Staff 18 stated Resident 142 was not able to use the remote to lower the recliner leg rests without staff providing verbal assistance and directions, but was able to stand if the leg rests were down. , 2. Resident 121 admitted to the facility in 2024 with diagnoses including anxiety, and cramp and spasm disorder. An 4/15/24 Post Fall Assessment revealed Resident 121 was found on the floor. The investigation was completed on 4/22/24. An 4/23/24 Post Fall Assessment revealed Resident 121 reported a fall in the bathroom. The investigation was completed on 5/1/24. On 5/3/24 at 9:09 AM Staff 40 (RCM) confirmed the 4/15/24 and 4/23/24 fall investigations were not completed timely. For individuals- #142-#121- Care plan were updated with current requirements of care. For others affected- All memory care residents are at risk. Changes / Interventions- Audit all memory care residents for safe use of recliners and timely completion of assessments. Audit memory care residents for recliner safety daily x2 weeks. Weekly x2. Monthly x2. Audit all opened fall assessments for timely completion daily x2 weeks. Weekly x2. Monthly x2. Education- Educate staff for proper/safe recliner use per individual care plans. All RCM’s/Social Service Designee’s will be educated to complete post fall assessments in a timely manor. QAPI Monitor for compliance There are no detail notes for this visit.”

“Based on observation, interview, and record review it was determined the facility failed to obtain orders for oxygen for 1 of 1 sampled resident (#86) reviewed for respiratory care. This placed residents at risk for impaired respiratory status. Findings include: Resident 86 admitted to the facility in 12/2022 with diagnoses including chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems). A review of Resident 86's care plan revealed a 3/3/23 care plan for as-needed oxygen. An 4/8/24 Progress Note revealed Resident 86 received oxygen due to respiratory difficulties and shortness of breath. On 4/29/24 at 10:42 AM an oxygen concentrator was observed by Resident 86's bed. Resident 86 stated she/he used oxygen a couple of times a week, usually in the evenings. A 5/1/24 review of Resident 86's medical record revealed no evidence of oxygen orders. On 5/2/24 at 8:45 AM Staff 30 (CNA) stated Resident 86 used oxygen as needed or requested. On 5/2/24 at 9:41 AM Staff 13 (RCM) acknowledged Resident 86 used oxygen as needed but had no orders for oxygen. For individual- #86- Oxygen orders received from provider. For others affected- All residents are at risk. Changes/Interventions- Facility wide visual audit for oxygen use and related orders. Audit one neighborhood day x2weeks. Audit all neighborhoods Monthly x2. Daily x2 weeks, weekly x2. Monthly x2. Education- Nurses will be educated on process of initiating standing Oxygen orders. QAPI Monitoring for compliance There are no detail notes for this visit.”

“Based on interview and record review it was determined the facility failed to ensure residents were free from significant medication errors for 1 of 5 sampled residents (#118) reviewed for medications. This placed residents at risk of jeopardized health status. Findings include: Resident 118 admitted to the facility in 2023 with diagnoses including partial intestinal obstruction. A signed 3/11/24 physician's order instructed staff to administer Loperamide (to treat diarrhea) by mouth in the morning for diarrhea with a start date of 12/14/23. The physician order also instructed staff to administer Senna (to treat constipation) by mouth in the morning for constipation with a start date of 2/14/23. 2/2024, 3/2024 and 4/2024 MARs instructed staff to administer Loperamide by mouth in the morning for diarrhea with a start date of 12/14/23. The physician order also instructed staff to administer Senna by mouth in the morning for constipation with a start date of 2/14/23. Resident 118 was administered both medications daily as follows: -2/14/24 through 2/23/24, and 2/25/24 through 2/29/24; -3/1/24 through 3/5/24, 3/7/24 through 3/13/24, 3/15/24, and 3/17/24 through 3/31/24. -4/1/24 through 4/12/24, 4/14/24 through 4/17/24 and 4/21/24 through 4/24/24. An 4/2024 Documentation Survey Report revealed from 4/8/24 through 4/12/24 Resident 118 did not have a bowel movement (five days). An 4/13/24 Nurses Note indicated Resident 118 was on alert since she/he did not have a bowel movement for five days. Resident 118 was provided a suppository. An 4/14/24 Medication Administration Note indicated Resident 118 was administered Miralax for bowel care as she/he did not have a bowel movement for three days. On 4/15/24 a Medication Administration Note indicated Resident 118 was administered Miralax for bowel care which was effective. On 5/3/24 at 7:40 AM Staff 21 (RCM) stated Resident 118 should not have both Loperamide and Senna administered at the same time and the Loperamide should be a PRN administration. Staff 21 stated the order was put in clinical records incorrectly and was considered a medication error. For Individual-118-expired. 2) For others affected- All residents are at risk for this. 3) Changes/Interventions- Audit all residents who have orders for loperamide to ensure not taking laxatives time. Audit for dual use of loperamide and laxatives daily x 2 weeks. Weekly x 2 weeks. Monthly x 2 months. 4) Education- All nurses will be educated on proper use of bowel medications. 5) QAPI Monitor for compliance. There are no detail notes for this visit.”

“Based on interview and record review it was determined the facility failed to ensure resident records were complete and accurate for 1 of 5 sampled residents (#118) reviewed for medications. This placed residents at risk for unmet needs Findings include: Resident 118 admitted to the facility in 2023 with a diagnosis of diabetes. A 3/11/24 signed physician order instructed staff to administer insulin (regulates level of blood sugar) injection three times a day for diabetes with a start date of 10/22/23. An 4/2024 Diabetic Orders report instructed staff to administer insulin injection three times a day for diabetes. The following dates and times were documented Resident 118 was sleeping and was not administered her/his insulin 4/1/24 5:00 PM, 4/13/24 7:00 AM, 4/14/24 7:00 AM, 4/16/24 12:00 PM, 4/21/24 12:00 PM, and 4/23/24 12:00 PM. On 5/3/24 at 7:35 AM Staff 21 (RCM) stated the dates listed above were marked in error and Resident 118 was administered her/his medication as physician ordered. For individual- #118-expired For others affected- All insulin dependent residents. Changes / Interventions- Facility wide audit of all May 2024 insulin documentation for accuracy. Daily x2 weeks. Weekly x2 weeks. Monthly x2 months. Education- All nurses will be educated on proper documentation of any insulin that is not administered. QAPI Monitor for compliance There are no detail notes for this visit.”

“Based on observation, interview, and record review it was determined the facility failed to practice proper infection control procedures for 1 of 5 sampled residents (#59) reviewed for pressure ulcers and sanitize resident care equipment for 1 of 3 halls. This placed residents at risk for infection. Findings include: 1. Resident 59 admitted to the facility in 3/2017 with diagnoses including paraplegia (the inability to voluntarily move the lower parts of the body). A review of an 4/29/24 Wound Evaluation revealed Resident 59 had a Stage 4 pressure ulcer (wound caused by pressure with full thickness tissue loss with exposed bone, tendon, or muscle; dead tissue may be present on some parts of the wound bed; often includes damage underneath the skin) on her/his sacrum. On 5/1/24 at 10:47 AM Staff 38 (LPN) was observed performing Resident 59's wound care with Staff 37 (CNA). Staff 38 was observed emptying Resident 59's catheter bag, he removed his gloves, and put on new clean gloves. Staff 38 was not observed performing hand hygiene and stated he was not aware he had to perform hand hygiene after removing gloves and before applying clean gloves. Staff 36 stated she was not aware of the need to perform hand hygiene after gloves were removed. On 5/1/24 at 2:56 PM Staff 9 (RCM) stated staff were expected to perform hand hygiene after taking off gloves, prior to applying new gloves. For individual- #59- Staff member has been educated on proper hand hygiene. All vital sign machines have disinfectant wipes on them. For others affected- All residents are at risk. Changes / Interventions- Facility wide hand hygiene education was provided at all staff meeting of May 2024. IP nurse will Audit 4 wound treatments per week x2 weeks. 2 treatments per week x2 weeks. 1 treatment per week for x2 weeks. To ensure proper hand hygiene techniques. During these audits, the auditor will ensure vitals machines have sanitizing wipes. Education- All staff were educated on sanitizing equipment between use during all staff meeting in May 2024. QAPI Monitor for compliance There are no detail notes for this visit.”

“There are no detail notes for this visit. There are no detail notes for this visit.”

“Based on interview and record review, it was determined the facility failed to post accurate and complete staffing information for 1 of 1 facility reviewed for staffing. This placed residents and visitors at risk for incomplete and inaccurate staffing information. Findings include: A review of the Direct Staff Daily Reports (DCSDR) from 4/1/24 through 5/1/24 revealed the number of scheduled staff instead of the number of staff who actually worked for that particular shift. On 5/1/24 at approximately 8:15 AM the 4/30/24 DCSDR was posted for the public and revealed no staffing data was entered for the night shift. On 5/3/24 at 10:09 AM Staff 2 (DNS) was informed of the incomplete or inaccurate DCSDRs. The example of the 4/30/24 posting was presented to Staff 2 who acknowledged the DCSDR sheets were not consistently reviewed and corrected to reflect the actual staff working during the current shift. Staff 2 confirmed their current system needed same shift review by the staff. -Signature stamps no longer in use, wet signatures only. -DHS staffing sheets are updated 2 times daily. OVHL operates with 12-hour shifts. Education- Education provided to NOC and Weekend shift nurses. On completing DHS staffing sheets accurately. -Staffing coordinator audits previous day’s staffing sheets for accuracy. -QAPI Monitor for compliance. There are no detail notes for this visit.”

“************************ OAR 411-085-0310 Residents' Rights: Generally Refer to F552 and F585 ************************ OAR 411-086-0130 Nursing Services: Notification Refer to F580 ************************ OAR 411-085-0320 Residents' Rights: Charges and Rates Refer to F582 ************************ OAR 411-085-0360 Abuse Refer to F600 and F610 ************************ OAR 411-086-0060 Comprehensive Assessment and Care Plan Refer to F637 and F657 ************************ OAR 411-086-0110 Nursing Services: Resident Care Refer to F677, F684, F695 and F760 ************************ OAR 411-086-0140 Nursing Services: Problem Resolution and Preventive Care Refer to F686 and F689 ************************ OAR 411-086-0300 Clinical Records: Refer to F842 ************************ OAR 411-085-0330 Infection Control and Universal Precautions Refer to F880 ************************ There are no detail notes for this visit.”

“The findings of the state licensure and memory care unit health survey conducted from 4/29/24 to 5/3/24 are documented in this report. The survey was conducted to determine compliance with OAR 411 Division 57. For additional information refer to Form CMS 2567 dated 5/3/24. Abbreviations possibly used in this document: ADL:     activities of daily living bid:              twice a day BIMS:    Brief Interview for Mental Status CAA:     Care Area Assessment CBG:     capillary blood glucose or blood sugar cm:               centimeter CMA:     Certified Medication Aide CNA:     Certified Nursing Assistant CPR:     Cardiopulmonary Resuscitation DNS:     Director of Nursing Services F:                Fahrenheit FRI:              Facility Reported Incident HS or hs:        hour of sleep LPN:              Licensed Practical Nurse MAR:     Medication Administration Record mcg:              microgram MDS:     Minimum Data Set mg:               milligram ml:               milliliters O2 sats:         oxygen saturation in the blood OT:               Occupational Therapist PCP:     Primary Care Physician PO:               by mouth, orally PRN:     as needed PT:               Physical Therapist RA:               Restorative Aide RAI:              Resident Assessment Instrument RD:               Registered Dietitian ROM:     range of motion RN:               Registered Nurse RNCM:    Registered Nurse Care Manager SA:               State Agency SLP:              Speech Language Pathologist TAR:     Treatment Administration Record tid:              three times a day UA:               Urinary Analysis UTI:              Urinary Tract Infection The findings of the state licensure and memory care unit health revisit survey conducted on 7/11/24 to 7/11/24 are documented in this report. It was determined the facility was in compliance with OAR 411 Division 57. These deficiencies are corrected as of 6/18/24.”

“Based on observation, interview, and record review it was determined the facility failed to provide health care services in accordance with the licensing rules of the facility. Findings include: OAR 411-085-0310 Residents' Rights: Generally (F552) OAR 411-086-0130 Nursing Services: Notification (F580) OAR 411-085-0360 Abuse (F600 and F610) OAR 411-088-0050 Right to Return from Hospital (F625) OAR 411-086-0060 Comprehensive Assessment and Care Plan (F637 and F657) OAR 411-086-0110 Nursing Services: Resident Care (F760 and F684) OAR 411-086-0140 Nursing Services: Problem Resolution and Preventive Care (F686 and F689) OAR 411-086-0300 Clinical Records (F842) Cross Reference POC for F552-residents Rights: Generally Cross Reference POC for- F580- Nursing Services Notification Cross Reference POC for-F600 and F610- Abuse Cross Reference POC for-F625- Right to return from Hospital Cross Reference POC for-F637 and F657- Comprehensive Assessment and Care Plan Cross Reference POC for-F760 and F684-Nursing Services: Resident Care Cross Reference POC for-F686 and F689-Nursing Services: Problem Resolution and Preventative Care. Cross Reference POC for- F842-Clincal Records There are no detail notes for this visit.”

“Based on observation and interview it was determined the facility failed to provide memory care residents access to a secure and safe outdoor space for 2 of 2 memory care courtyards. This placed residents at risk to not be able to walk outside at will and be at risk for elopement and injury. Findings include: 1. Multiple observations on 4/29/24 and 5/1/24 revealed the patio doors to the shared Delta 100 and 200 patio and the Delta 300 patio were locked. Badge access was the only way to open the doors. On 5/1/24 at 2:27 PM Staff 42 (CNA) stated the doors on the 300 hall were locked for a few months. There were about five to six residents who liked to go outside and attempted to open the doors. Staff 42 stated when able she went outside with the residents when they attempted to open the doors. On 5/1/24 at 2:45 PM Staff 40 (RNCM) stated the doors were temporarily locked due to a few resident-related incidents which occurred in the memory care units. Staff 40 acknowledged the doors were to be unlocked during the day unless there was inclement weather. Staff 40 stated when a resident exited the doors the staff were alerted via the computer system. 2. On 5/1/24 at 2:15 PM two dining room chairs were observed by the Delta 100 patio door. The chairs were easily pulled with the use of one hand. One two-tiered cart on wheels which was approximately three feet in height was observed by the Delta 200 hall patio door and one dining room chair which was easily pulled with the use of one arm. By the 100 patio door there were two plastic planters which were broken and had sharp edges when touched. The Delta 300 patio area had an area in which there was an approximately six inch gap between the bottom of the fence and the ground. On 5/1/24 at 2:27 PM Staff 42 (CNA) stated at one time maintenance used to keep the memory care patios well maintained but she did not see anyone work on the patio area for a long time. Staff 42 stated there were about five to six residents who to liked to go outside and attempted to open the doors but could not because the doors were locked. Staff 42 stated when able she went outside with the residents. On 5/1/24 at 2:45 PM Staff 40 (RNCM) acknowledged the cart and chairs could be moved and a resident could move them near the fence to elope. Staff 40 also acknowledged both patios were not maintained and the sharp edges could place residents at risk for injury. For individual- No resident identified For others affected- All residents in Delta/Memory care are at risk. Changes/Interventions- 6-inch gap at bottom of the fence has been fixed. The broken planter beds have been removed. Times have been set for automatic lock and unlock of memory care patio doors. Patio availability times from 8am to 6pm. Access to patios will be restricted during inclement weather. This task will be completed by June 18th, 2024. Signs will be placed on memory care patio doors as a reminder to not bring indoor furniture outside. Audit for memory care furniture will be completed 5 days a week. Memory care staff will check patios during shift change to complete assignment forms which includes patio audit. Audit for appropriate landscaping conditions x1 a week for 1 month, 1x a month for 1 month. Education- Educate memory care staff during house meetings along with read and signs. Education will be done during June all staff meetings. QAPI Monitor for compliance. There are no detail notes for this visit.”

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“There are no detail notes for this visit.”

“Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 07/31/2023 and 08/06/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.”

“Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 07/17/2023 and 07/23/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.”