Marquis Centennial Post Acute Rehab.

“There are no detail notes for this visit.”

“Resident 2 admitted to the facility in 12/2025 with diagnoses including hip fracture and anxiety. On 3/23/26 at 10:42 AM Resident 2 stated there was a CNA who was ""kind of rough"" with her/him told her/him to take her/himself to the bathroom and to not get out of bed until 6:00 AM. Resident 2 thought the incident occurred about a month ago. The facility's investigation dated 1/29/26 documented Resident 2 reported the allegation of abuse involving Staff 6 (CNA) to Staff 7 (SSD) on 1/29/26 at 4:00 PM. Staff 6 was sent home pending investigation.-á The Facility Reported Incident form was received by the State Agency on 1/30/26 at 2:13 PM. On 3/23/26 at 2:24 PM, Staff 7 stated Resident 2 told her that Staff 6 was abusive to her/him at 4:00 PM on 1/29/26. On 3/23/26 at 12:14 PM, Staff 6 denied abusing Resident 2 or any resident. On 3/24/26 at 1:13 PM, Staff 2 (DNS) stated the facility was made aware of the allegation of abuse at 4:00 PM on 1/29/26 and should have been reported to the State Agency within two hours and was not. -á Resident 2 admitted to the facility in 12/2025 with diagnoses including hip fracture and anxiety. On 3/23/26 at 10:42 AM Resident 2 stated there was a CNA who was ""kind of rough"" with her/him told her/him to take her/himself to the bathroom and to not get out of bed until 6:00 AM. Resident 2 thought the incident occurred about a month ago. The facility's investigation dated 1/29/26 documented Resident 2 reported the allegation of abuse involving Staff 6 (CNA) to Staff 7 (SSD) on 1/29/26 at 4:00 PM. Staff 6 was sent home pending investigation.-á The Facility Reported Incident form was received by the State Agency on 1/30/26 at 2:13 PM. On 3/23/26 at 2:24 PM, Staff 7 stated Resident 2 told her that Staff 6 was abusive to her/him at 4:00 PM on 1/29/26. On 3/23/26 at 12:14 PM, Staff 6 denied abusing Resident 2 or any resident. On 3/24/26 at 1:13 PM, Staff 2 (DNS) stated the facility was made aware of the allegation of abuse at 4:00 PM on 1/29/26 and should have been reported to the State Agency within two hours and was not. -á Resident was assessed for physical and psychological effects, none noted. Resident placed on alert for latent effects. FRI was submitted on 1/30 by DNS. No other residents identified as having the potential to be affected. CNA was immediately suspended following the allegation and remained suspended through the investigation. CNA's employment was terminated on 2/5/2026. Administrator and DNS will provide education to staff regarding abuse reporting at 2/10 all staff meeting. DNS was in serviced on reporting timelines to ensure FRI's are reported in a timely manner. Any allegations of abuse will be reported within 2 hours per the regulation. Allegations will be audited weekly for timely FRI submission over a period of 4 weeks, followed by monthly audits for 60 days. Administrator will monitor for ongoing 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.”

“There are no detail notes for this visit.”

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

“3. On 8/18/25 at 12:10 PM and 8/20/25 at 7:37 AM Resident 3GÇÖs room was observed with scratches of missing paint on the wall to the right of her/his bed. Resident 3 stated she/he was bothered by the scratches on the wall.-á-á On 8/20/25 at 11:16 AM Staff 1 (Administrator) and Staff 8 (Maintenance Director) acknowledged the scratching of missing paint on Resident 3GÇÖs wall and it required attention. , 2. Resident 17 was admitted to the facility in 7/2025 with diagnoses including pneumonia (inflammation and fluid in your lungs caused by bacterial, viral or fungal infection). The 7/22/25 Admission MDS indicated Resident 63 was cognitively intact. On 8/18/25 at 10:05 AM, Resident 17 stated the shower room residents used was covered in mold. -á Resident 17 reported to staff a black substance on the floor in the shower room. Resident 17 was worried about the health risks when the shower room was used. Resident 17 stated the shower room was dirty and dangerous and thought the black substance would kill anyone who used it.-á -á Resident 17 stated staff attempted to clean the black substance with a towel, but the floor was still dirty. On 8/18/25 at 10:05 AM, the shower rooms were observed. The shower in the east hall was unkept. A gray and white substance was observed along the walls. The shower faucet was covered in a goldish brown substance and was rusty. The tile on the floor was peeled off and the floor was black and slimy. The shower drain lid was loose. The shower drain was covered in a black substance. The black substance was a mixture of hair and black liquid. The bottom baseboard around the door inside the shower room had a deep dent. The baseboard was peeled with unpainted sections. The white rack shelf on the wall was covered in a brown rusty substance and clean linen were stored on top of the white shelf. The handle to turn on the water was wiggly. The fan inside the shower room was covered in gray and black lint. On 8/18/25 at 10:20 AM, The south hall shower roomGÇÖs fans were observed covered in dark gray and black lint.-á On 8/19/25 at 2:39 PM, Staff 16 (CNA) stated Resident 17 showed her the black substance on the floor in the shower room during her/his shower. Staff 16 attempted to clean the substance using a towel, which became stained during the process. The floor was also noted to be stained. Staff 16 stated Resident 17 was concerned about the black substance. Staff 16 acknowledged the black and rusty color throughout the shower walls and on the floor. Staff 16 stated the faucet to turn on the water was loose. She stated the handle was loose and was unable to adjust the temperature safely. On 8/20/25 at11:27 AM, Staff 1 (Administrator) acknowledged the shower room was unkept. Staff 8 (Housekeeping/Laundry/Maintenance Director) stated the shower was audited once a month. Staff 8 stated the shower handle in the shower room continued to break. Staff 8 stated the fans in the shower rooms were replaced a couple of months ago. -á -á -á -á -á , 1. Observations of the facility's general environment from 8/18/25 through 8/22/25 identified the following issues: -Eight of eight hanging light fixtures in the dining room contained multiple dead insects visibly trapped inside the covers. -Two visibly dusty portable oscillating fans, positioned on each side of the dining room tables and approximately six feet away from the seated residents, were actively blowing air toward them.-á -Nine of nine floor vents in the dining room were coated in thick layers of dust, debris and visible cobwebs. -A visibly dirty floor fan placed on top of a refrigerator was operating and blowing air across multiple zones in the kitchen including the coffee maker station, an area with dirty dishes and a clean area containing a rack with sanitized pitchers, food containers and cutting boards. -A ceiling vent in the south hallway, just outside room 131, showed a significant buildup of dust and cobwebs. On 8/20/25 at 11:16 AM Staff 1 (Administrator) and Staff 8 (Maintenance Director) acknowledged the identified concerns needed to be addressed. -á -á -á -á -á -á -á -á -á -á -á -á -á -á -á -á -á -á -á -á -á -á 3. On 8/18/25 at 12:10 PM and 8/20/25 at 7:37 AM Resident 3GÇÖs room was observed with scratches of missing paint on the wall to the right of her/his bed. Resident 3 stated she/he was bothered by the scratches on the wall.-á-á On 8/20/25 at 11:16 AM Staff 1 (Administrator) and Staff 8 (Maintenance Director) acknowledged the scratching of missing paint on Resident 3GÇÖs wall and it required attention. 2. Resident 17 was admitted to the facility in 7/2025 with diagnoses including pneumonia (inflammation and fluid in your lungs caused by bacterial, viral or fungal infection). The 7/22/25 Admission MDS indicated Resident 63 was cognitively intact. On 8/18/25 at 10:05 AM, Resident 17 stated the shower room residents used was covered in mold. -á Resident 17 reported to staff a black substance on the floor in the shower room. Resident 17 was worried about the health risks when the shower room was used. Resident 17 stated the shower room was dirty and dangerous and thought the black substance would kill anyone who used it.-á -á Resident 17 stated staff attempted to clean the black substance with a towel, but the floor was still dirty. On 8/18/25 at 10:05 AM, the shower rooms were observed. The shower in the east hall was unkept. A gray and white substance was observed along the walls. The shower faucet was covered in a goldish brown substance and was rusty. The tile on the floor was peeled off and the floor was black and slimy. The shower drain lid was loose. The shower drain was covered in a black substance. The black substance was a mixture of hair and black liquid. The bottom baseboard around the door inside the shower room had a deep dent. The baseboard was peeled with unpainted sections. The white rack shelf on the wall was covered in a brown rusty substance and clean linen were stored on top of the white shelf. The handle to turn on the water was wiggly. The fan inside the shower room was covered in gray and black lint. On 8/18/25 at 10:20 AM, The south hall shower roomGÇÖs fans were observed covered in dark gray and black lint.-á On 8/19/25 at 2:39 PM, Staff 16 (CNA) stated Resident 17 showed her the black substance on the floor in the shower room during her/his shower. Staff 16 attempted to clean the substance using a towel, which became stained during the process. The floor was also noted to be stained. Staff 16 stated Resident 17 was concerned about the black substance. Staff 16 acknowledged the black and rusty color throughout the shower walls and on the floor. Staff 16 stated the faucet to turn on the water was loose. She stated the handle was loose and was unable to adjust the temperature safely. On 8/20/25 at11:27 AM, Staff 1 (Administrator) acknowledged the shower room was unkept. Staff 8 (Housekeeping/Laundry/Maintenance Director) stated the shower was audited once a month. Staff 8 stated the shower handle in the shower room continued to break. Staff 8 stated the fans in the shower rooms were replaced a couple of months ago. -á -á -á -á -á”

“Resident 36 was admitted to the facility in 5/2024 with diagnoses including dysphagia (difficulty in swallowing).-á The Annual MDS dated 5/16/25 indicated Resident 36 was cognitively impaired for decision-making and independent for eating and drinking after set-up. On 7/23/25 Resident 36 returned from the hospital with orders for mildly thickened liquids. Resident 36's 7/23/25 Nutrition Care Plan did not include the current mildly thickened fluid status. On 8/19/25 at 11:36 AM Resident 36 was observed with a large plastic cup of liquid within reach on her/his bedside table. Staff 13 (CNA) confirmed the cup in Resident 36GÇÖs room contained thin liquids.-á On 8/21/25 at 11:28 AM a white paper cup was observed on the residentGÇÖs nightstand. Staff 26 (CNA) confirmed the cup contained thin liquids. On 8/19/25 at 12:01 PM, 8/21/25 at 11:15 AM, & 8/21/25 at 11:15 AM, Staff 28 (CNA), Staff 21 (CNA), and Staff 27 (CNA) stated they were unaware Resident 36 was on mildly thickened liquids. On 8/21/25 at 1:00 PM Staff 5 (RNCM) stated the care plan did not reflect the physician orders for mildly thickened liquids. Staff 5 stated the care plan was used to inform direct care staff of the residentGÇÖs care needs, led some staff to believe resident was on thin liquid.-á Resident 36 was admitted to the facility in 5/2024 with diagnoses including dysphagia (difficulty in swallowing).-á The Annual MDS dated 5/16/25 indicated Resident 36 was cognitively impaired for decision-making and independent for eating and drinking after set-up. On 7/23/25 Resident 36 returned from the hospital with orders for mildly thickened liquids. Resident 36's 7/23/25 Nutrition Care Plan did not include the current mildly thickened fluid status. On 8/19/25 at 11:36 AM Resident 36 was observed with a large plastic cup of liquid within reach on her/his bedside table. Staff 13 (CNA) confirmed the cup in Resident 36GÇÖs room contained thin liquids.-á On 8/21/25 at 11:28 AM a white paper cup was observed on the residentGÇÖs nightstand. Staff 26 (CNA) confirmed the cup contained thin liquids. On 8/19/25 at 12:01 PM, 8/21/25 at 11:15 AM, & 8/21/25 at 11:15 AM, Staff 28 (CNA), Staff 21 (CNA), and Staff 27 (CNA) stated they were unaware Resident 36 was on mildly thickened liquids. On 8/21/25 at 1:00 PM Staff 5 (RNCM) stated the care plan did not reflect the physician orders for mildly thickened liquids. Staff 5 stated the care plan was used to inform direct care staff of the residentGÇÖs care needs, led some staff to believe resident was on thin liquid.-á Resident #36 care plan updated to reflect MD order for thickened liquids. All residents on thickened fluids are potentially impacted. 100% audit has been completed to ensure Care plan reflects MD orders for thickened liquids. Nursing staff were in-serviced to update and review resident Careplan /Kardex with any fluid thickening changes per physician orders. DNS or designee will audit those residents identified to have thickened liquids to ensure care plan matches MD orders weekly for 4 weeks, then monthly for 90 days. Results of audits to be reviewed at facility QAA committee meeting, to ensure ongoing compliance. Resident #36 care plan updated to reflect MD order for thickened liquids. All residents on thickened fluids are potentially impacted. 100% audit has been completed to ensure Care plan reflects MD orders for thickened liquids. Nursing staff were in-serviced to update and review resident Careplan /Kardex with any fluid thickening changes per physician orders. DNS or designee will audit those residents identified to have thickened liquids to ensure care plan matches MD orders weekly for 4 weeks, then monthly for 90 days. Results of audits to be reviewed at facility QAA committee meeting, to ensure ongoing compliance. There are no detail notes for this visit.”

“1. On 8/21/25 at 9:38 AM observations of the facilityGÇÖs East unit refrigerator revealed the following items: an undated plastic container with a meal ticket on top dated 8/11/25, a plastic container dated 8/11/25, an undated container of spaghetti, and an undated container of rice with mixed vegetables. -á On 8/21/25 at 9:45 AM, Staff 9 (Dietary Manger) stated housekeeping was responsible for the maintenance of facility unit refrigerators. -á On 8/21/25 at 11:40 AM, Staff 34 (Housekeeper) stated she was unaware of the polices for food storage in facilityGÇÖs unit refrigerators. -á On 8/21/25 at 11:49 AM, Staff 8 (Maintenance Director) stated a designated housekeeper cleaned the facilityGÇÖs unit refrigerators once a week and was also expected to discard food items that were undated or were more than three days old. -á Staff 8 further stated the last time the East unit refrigerator was cleaned was on 8/14/25 and was next scheduled to be cleaned on 8/25/25 as the designated housekeeper was away. -á On 8/22/25 at 9:57 AM and 10:01 AM, Staff 1 (Administrator) stated the East unit refrigerator was used for resident food items and was cleaned by housekeeping every 72 hours. Staff 1 stated she expected housekeeping to ensure food items found in the East unit refrigerator were dated and discarded appropriately after three days. -á 2. On 8/18/25 at 9:29 AM during a tour of the facilityGÇÖs kitchen, a covered container of ice was observed with an ice scoop located inside. When asked, Staff 32 (Dietary Aide) stated inside the covered container was used to prepare ice water for residents.-á -á -á On 8/20/25 at 11:20 AM during meal tray service, Staff 33 (Dietary Aide) was observed using an ice scoop without gloves to prepare cups of ice water and proceeded to place the ice scoop back inside the container, on top of the ice, when not in use. -á On 8/20/25 at 1:17 PM Staff 33 confirmed she placed the ice scoop inside the container of ice when not in use and was unaware of an alternative process. -á On 8/20/25 at 1:44 PM Staff 9 (Dietary Manager) stated kitchen staff were expected to store the ice scoop separate from the container of ice when they prepared ice water for residents.”

“2. Resident 1 admitted to the facility in 2015 with a diagnosis including bladder obstruction. Resident 1GÇÖs 6/1/25 Quarterly MDS revealed she/he required an indwelling (urine) catheter. On 8/18/25 at 10:30 AM, 8/19/25 at 11:56 AM, 2:19 PM and 2:24 PM, and 8/20/25 at 2:46 PM, Resident 1 was observed to sit in her/his wheelchair in the activity room. Resident 1 had a urine catheter bag under her/his wheelchair with the tubing from the bag and up the left pant leg. The catheter tubing was on the floor and multiple staff passed by the resident. On 8/20/25 at 1:24 PM Staff 30 (CNA) stated Resident 1GÇÖs urine catheter tubing should not touch the floor while the resident was it her/his wheelchair. Staff 30 stated if she observed Resident 1's catheter tubing on the floor she would pick it up immediately.-á On 8/20/25 at 3:11 PM Staff 4 (Resident Care Manager/LPN) confirmed Resident 1GÇÖs urine catheter tubing was on the floor. Staff 4 stated she expected staff to ensure Resident 1's catheter tubing was not on the floor. , The facility's 3/2024 Isolation- Categories of Transmission-Based Precautions Policy specified the following: Residents with open complex wounds that require a dressing are included in EBP (enhanced barrier precautions) per CDC guidelines. PPE (personal protective equipment) is donned prior to high contact activity like bathing and wound care. 1.Resident 18 was admitted to the facility in 7/2025 with diagnoses including cerebral infarction (A lack of blood flow to the brain). The 7/31/25 Care Plan indicated EBP was initiated on 8/20/25.-á On 8/18/25 through 8/21/25 from 9:00 AM to 4:00 PM no signs were posted outside Resident 18GÇÖs room to indicated staff were to follow EBP. On 8/18/25 at 10:04 AM, Resident 18 was observed in her/his wheelchair in her/his room with the left leg elevated. Resident 18 wore a hinged knee brace on her/his left leg. The leg was wrapped with abdominal gauze dressing. The left foot was swollen, and the skin was purple and red. On 8/18/25 at 10:06 AM, Resident 18 stated she/he always wore a hinged knee brace and had a facility acquired wound behind her/his left calf Resident 18 stated staff performed wound care in her/his room several times during the week. Resident 18 stated PT removed the brace in her/his room to rub her/his leg.-á On 8/20/25 at 9:00 AM, Staff 15 (CNA) stated she did not wear PPE prior to providing a bed bath because Resident 18 was not on enhanced barrier precautions. On 8/20/25 at 9:36 AM, Staff 18 (LPN) stated Resident 18 had a wound to the back of her/his calf and wound care was provided on Monday, Tuesday and Wednesday. Staff 18 stated she did not wear EBP because the resident's wound was not infected.-á-á On 8/20/25 at 11:09 AM, Staff 4 (RNCM) stated Resident 18 had a wound with fluid and drainage oozing from the site, but was contained within the dressing. Staff 4 stated staff were not required to don PPE because the amount of drainage from the wound was light and the fluid was contained. On 8/20/25 at 12:17 PM, Staff 14 (Regional Nurse Consultant) stated Resident 18 had a wound and staff were required to don PPE when high activities like a bed bath and wound care were performed. Staff 18 acknowledged Resident 18GÇÖs medical record was updated on 8/20/25 and enhanced barrier precaution was initiated. -á -á -á 2. Resident 1 admitted to the facility in 2015 with a diagnosis including bladder obstruction. Resident 1GÇÖs 6/1/25 Quarterly MDS revealed she/he required an indwelling (urine) catheter. On 8/18/25 at 10:30 AM, 8/19/25 at 11:56 AM, 2:19 PM and 2:24 PM, and 8/20/25 at 2:46 PM, Resident 1 was observed to sit in her/his wheelchair in the activity room. Resident 1 had a urine catheter bag under her/his wheelchair with the tubing from the bag and up the left pant leg. The catheter tubing was on the floor and multiple staff passed by the resident. On 8/20/25 at 1:24 PM Staff 30 (CNA) stated Resident 1GÇÖs urine catheter tubing should not touch the floor while the resident was it her/his wheelchair. Staff 30 stated if she observed Resident 1's catheter tubing on the floor she would pick it up immediately.-á On 8/20/25 at 3:11 PM Staff 4 (Resident Care Manager/LPN) confirmed Resident 1GÇÖs urine catheter tubing was on the floor. Staff 4 stated she expected staff to ensure Resident 1's catheter tubing was not on the floor. The facility's 3/2024 Isolation- Categories of Transmission-Based Precautions Policy specified the following: Residents with open complex wounds that require a dressing are included in EBP (enhanced barrier precautions) per CDC guidelines. PPE (personal protective equipment) is donned prior to high contact activity like bathing and wound care. 1.Resident 18 was admitted to the facility in 7/2025 with diagnoses including cerebral infarction (A lack of blood flow to the brain). The 7/31/25 Care Plan indicated EBP was initiated on 8/20/25.-á On 8/18/25 through 8/21/25 from 9:00 AM to 4:00 PM no signs were posted outside Resident 18GÇÖs room to indicated staff were to follow EBP. On 8/18/25 at 10:04 AM, Resident 18 was observed in her/his wheelchair in her/his room with the left leg elevated. Resident 18 wore a hinged knee brace on her/his left leg. The leg was wrapped with abdominal gauze dressing. The left foot was swollen, and the skin was purple and red. On 8/18/25 at 10:06 AM, Resident 18 stated she/he always wore a hinged knee brace and had a facility acquired wound behind her/his left calf Resident 18 stated staff performed wound care in her/his room several times during the week. Resident 18 stated PT removed the brace in her/his room to rub her/his leg.-á On 8/20/25 at 9:00 AM, Staff 15 (CNA) stated she did not wear PPE prior to providing a bed bath because Resident 18 was not on enhanced barrier precautions. On 8/20/25 at 9:36 AM, Staff 18 (LPN) stated Resident 18 had a wound to the back of her/his calf and wound care was provided on Monday, Tuesday and Wednesday. Staff 18 stated she did not wear EBP because the resident's wound was not infected.-á-á On 8/20/25 at 11:09 AM, Staff 4 (RNCM) stated Resident 18 had a wound with fluid and drainage oozing from the site, but was contained within the dressing. Staff 4 stated staff were not required to don PPE because the amount of drainage from the wound was light and the fluid was contained. On 8/20/25 at 12:17 PM, Staff 14 (Regional Nurse Consultant) stated Resident 18 had a wound and staff were required to don PPE when high activities like a bed bath and wound care were performed. Staff 18 acknowledged Resident 18GÇÖs medical record was updated on 8/20/25 and enhanced barrier precaution was initiated. -á Resident #1 catheter tubing is secured properly when out of bed. Resident #18 was placed on EBP. Facility will audit all residents with complex wounds to ensure they are on EBP. Facility will audit all residents with catheters to ensure tubing is stored properly while out of bed. DNS will in-service staff on infection control for resident’s catheter tubing. DNS will in-service RN RCM’s and LN on EBP criteria and care planning. DNS or designee will audit new admissions for presence of complex wounds and ensure proper EBP are in place weekly for 4 weeks, then monthly for 90 days. DNS or designee will audit new admissions for use of a catheter to ensure proper storage of tubing when out of bed weekly for 4 weeks, then monthly for 90 days. Results of audits to be reviewed at facility QAA committee meeting, to ensure ongoing compliance. Resident #1 catheter tubing is secured properly when out of bed. Resident #18 was placed on EBP. Facility will audit all residents with complex wounds to ensure they are on EBP. Facility will audit all residents with catheters to ensure tubing is stored properly while out of bed. DNS will in-service staff on infection control for resident’s catheter tubing. DNS will in-service RN RCM’s and LN on EBP criteria and care planning. DNS or designee will audit new admiss”

“Resident 8 was admitted to the facility in 4/2025 with diagnoses including generalized anxiety disorder and malnutrition. -á Resident 8GÇÖs 7/21/25 Quarterly MDS revealed the resident was cognitively intact. -á On 8/18/25 at 10:38 AM, Resident 8 stated the foot board of her/his bed was broken and had not been fixed. -á A review of maintenance work orders from 7/1/25 through 8/18/25 revealed no evidence a request was submitted for Resident 8's foot board to be repaired.-á -á On 8/19/25 at 2:43 PM, Resident 8 was observed placing pressure on the left side of the foot board, which was unsecured and elevated the right side of the bed. The resident stated the foot board was broken since 8/11/25.-á -á On 8/19/25 at 3:13 PM, Staff 16 (CNA) stated she was aware Resident 8GÇÖs foot board was broken on 8/11/25 when she noticed it was no longer secured to the bedframe after the resident used it to assist herself/himself with a transfer. Staff 16 stated she reinserted the foot board into the bedframe, but it remained unsecured if too much pressure was applied. Staff 16 was unaware if maintenance was notified of the broken foot board. -á On 8/20/25 at 3:48 PM, Staff 31 (Nursing Assistant) stated she noticed a week prior the foot board was not secured to the bedframe and reinserted it. Staff 31 stated she did not notify maintenance of the broken foot board. -á On 8/21/25 at 10:35 AM Staff 8 (Maintenance Director) stated staff were expected to report broken furniture and equipment in residentsGÇÖ rooms as an electronic maintenance request during their shift. Resident 8 was admitted to the facility in 4/2025 with diagnoses including generalized anxiety disorder and malnutrition. -á Resident 8GÇÖs 7/21/25 Quarterly MDS revealed the resident was cognitively intact. -á On 8/18/25 at 10:38 AM, Resident 8 stated the foot board of her/his bed was broken and had not been fixed. -á A review of maintenance work orders from 7/1/25 through 8/18/25 revealed no evidence a request was submitted for Resident 8's foot board to be repaired.-á -á On 8/19/25 at 2:43 PM, Resident 8 was observed placing pressure on the left side of the foot board, which was unsecured and elevated the right side of the bed. The resident stated the foot board was broken since 8/11/25.-á -á On 8/19/25 at 3:13 PM, Staff 16 (CNA) stated she was aware Resident 8GÇÖs foot board was broken on 8/11/25 when she noticed it was no longer secured to the bedframe after the resident used it to assist herself/himself with a transfer. Staff 16 stated she reinserted the foot board into the bedframe, but it remained unsecured if too much pressure was applied. Staff 16 was unaware if maintenance was notified of the broken foot board. -á On 8/20/25 at 3:48 PM, Staff 31 (Nursing Assistant) stated she noticed a week prior the foot board was not secured to the bedframe and reinserted it. Staff 31 stated she did not notify maintenance of the broken foot board. -á On 8/21/25 at 10:35 AM Staff 8 (Maintenance Director) stated staff were expected to report broken furniture and equipment in residentsGÇÖ rooms as an electronic maintenance request during their shift. Resident #18’s bed was replaced on 8/20/25 while survey team was in the facility. Environmental Service Director will audit all resident beds to ensure that they are in functioning properly. Nursing staff will be in-serviced on reporting maintenance issues via electronic TELS  application. Environmental Services Director or designee will audit resident beds for maintenance issues weekly for 4 weeks, then monthly for 90 days. Results of audits to be reviewed at facility QAA committee meeting, to ensure ongoing compliance. Resident #18’s bed was replaced on 8/20/25 while survey team was in the facility. Environmental Service Director will audit all resident beds to ensure that they are in functioning properly. Nursing staff will be in-serviced on reporting maintenance issues via electronic TELS  application. Environmental Services Director or designee will audit resident beds for maintenance issues weekly for 4 weeks, then monthly for 90 days. Results of audits to be reviewed at facility QAA committee meeting, to ensure ongoing 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.”

“The facility's Criminal Records Check for Nursing Facilities in Oregon policy dated 6/2021, indicated the following: -The facility must periodically verify the status of all staff members by conducting routine audits and updating records as required by DHS (Department of Human Services). -Background checks for employees providing direct patient care will be completed at a minimum of every 2 years. 1. On 8/19/25 at 2:13 PM, during a review of background checks with Staff 7 (Staffing/Human Resources) for three randomly selected staff employed two or more years revealed the following: -Staff 10 (Medical Records), hire date 7/14/2010, required a criminal background recheck on 1/5/2025 which was not completed. -Staff 13 (CNA), hire date 11/28/2022, required a criminal background recheck on 4/11/2025 which was not completed. Staff 13 worked with residents and did not have a current criminal background check in place. On 8/20/25 at 8:30 AM, Staff 1 (Administrator) acknowledged Staff 10 and Staff 13's criminal background checks were not completed on 1/5/25 and 4/11/25 as required. Staff 1 stated she expected all staff to have current background checks in place. 2. On 8/19/25 at 2:21 PM Staff 7 was observed to access the state data base for criminal background information. On 8/19/25 at 2:45 PM a request was made for Staff 7 to provide her QED certificate. Staff 7 stated her certification ended in 3/2022. On 8/20/25 at 8:33 AM, Staff 1 acknowledged Staff 7 was not in compliance, as her QED certification was not current at the time of review. The facility's Criminal Records Check for Nursing Facilities in Oregon policy dated 6/2021, indicated the following: -The facility must periodically verify the status of all staff members by conducting routine audits and updating records as required by DHS (Department of Human Services). -Background checks for employees providing direct patient care will be completed at a minimum of every 2 years.”

“There are no detail notes for this visit.”

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

“The facilityGÇÖs current undated Friendship House (Memory Care Community) Disclosure Statement Program Overviewed revealed the environment at Friendship House was safe and as non-restrictive as possible allowing a maximum sense of freedom for the person. The physical design allowed for wandering both inside and outside the facility. An outdoor walkway was designed to allow for a safe wandering path. Residents were to be free to wander about the common area and outside secured yard. On 8/19/25 at 12:43 PM a resident was observed to try to open the door to the outside secured courtyard and she/he was unable. Staff redirected the resident back to the activity room area. On 8/19/25 at 2:13 PM, 8/20/25 at 9:25 AM, 12:25 PM and 3:00 PM, the two doors to the secure outdoor courtyard in the Memory Care Community were observed to be locked. The doors were locked with slide locks in the upper right corner of the doors. On 8/20/25 at 12:57 PM Staff 29 (CNA) stated the doors to the Memory Care CommunityGÇÖs secured outdoor courtyard were always locked and the staff took residentGÇÖs outside. On 8/20/25 at 1:41 PM two residents were overheard to talk with each other and stated they wanted to go outside and it would be nice to go outside when the weather was nice. There was no staff in the immediate area to assist them to go outside to the secured courtyard area.-á On 8/21/25 at 1:47 PM a resident stated she/he wanted to go outside. It was observed to be sunny outside with an outside temperature of 80 degrees. No staff were present or assisted the resident to go outside to the secured courtyard area. On 8/20/25 at 1:50 PM Staff 30 (CNA) stated the residents who lived in the Memory Care Community were only able to go outside with staff assistance and the doors were kept locked. On 8/21/25 at 1:57 PM Staff 1 (Administrator) confirmed the doors to the Memory Care CommunityGÇÖs secured outdoor courtyard were kept locked and residents could go outside with staff assistance only. The facilityGÇÖs current undated Friendship House (Memory Care Community) Disclosure Statement Program Overviewed revealed the environment at Friendship House was safe and as non-restrictive as possible allowing a maximum sense of freedom for the person. The physical design allowed for wandering both inside and outside the facility. An outdoor walkway was designed to allow for a safe wandering path. Residents were to be free to wander about the common area and outside secured yard. On 8/19/25 at 12:43 PM a resident was observed to try to open the door to the outside secured courtyard and she/he was unable. Staff redirected the resident back to the activity room area. On 8/19/25 at 2:13 PM, 8/20/25 at 9:25 AM, 12:25 PM and 3:00 PM, the two doors to the secure outdoor courtyard in the Memory Care Community were observed to be locked. The doors were locked with slide locks in the upper right corner of the doors. On 8/20/25 at 12:57 PM Staff 29 (CNA) stated the doors to the Memory Care CommunityGÇÖs secured outdoor courtyard were always locked and the staff took residentGÇÖs outside. On 8/20/25 at 1:41 PM two residents were overheard to talk with each other and stated they wanted to go outside and it would be nice to go outside when the weather was nice. There was no staff in the immediate area to assist them to go outside to the secured courtyard area.-á On 8/21/25 at 1:47 PM a resident stated she/he wanted to go outside. It was observed to be sunny outside with an outside temperature of 80 degrees. No staff were present or assisted the resident to go outside to the secured courtyard area. On 8/20/25 at 1:50 PM Staff 30 (CNA) stated the residents who lived in the Memory Care Community were only able to go outside with staff assistance and the doors were kept locked. On 8/21/25 at 1:57 PM Staff 1 (Administrator) confirmed the doors to the Memory Care CommunityGÇÖs secured outdoor courtyard were kept locked and residents could go outside with staff assistance only. All residents have the potential to be impacted by this citation. Memory care rear courtyard will remain unlocked during day time hours to ensure residents have access without staff assistance. Nursing staff will be in-serviced on resident use of courtyard area. Administrator or designee will audit memory care rear courtyard to ensure doors are unlocked during daytime hours weekly for 4 weeks, then monthly for 90 days. Results of audits to be reviewed at facility QAA committee meeting, to ensure ongoing compliance. All residents have the potential to be impacted by this citation. Memory care rear courtyard will remain unlocked during day time hours to ensure residents have access without staff assistance. Nursing staff will be in-serviced on resident use of courtyard area. Administrator or designee will audit memory care rear courtyard to ensure doors are unlocked during daytime hours weekly for 4 weeks, then monthly for 90 days. Results of audits to be reviewed at facility QAA committee meeting, to ensure ongoing compliance. There are no detail notes for this visit.”

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“Based on interview and record review it was determined the facility failed to provide a written Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) in a timely fashion for 1 of 3 sampled residents (#47) reviewed for Beneficiary Protection Notification. This placed residents at risk for unknown financial liabilities. Findings include: Resident 47 was admitted to the facility in 2/2024 with diagnoses including dementia (loss of cognitive functioning) and emphysema (a lung condition that causes shortness of breath). A review of resident 47's 4/1/24 quarterly MDS revealed she/he had impaired short- and long-term memory loss and moderately impaired decision-making skills. On 5/1/24 at 2:27 PM Staff 10 (Admission Director) stated Resident 47's last covered day of Medicare Part A services was 4/1/24. A review of Resident 47's medical record revealed the facility provided Resident 47's representative with a Notice of Medicare Non-Coverage on 4/1/24. On 5/3/24 at 10:37 AM Staff 1 (Administrator) stated, "We should be giving residents 48 hour notice so they are aware of the change." This Plan of Correction constitutes the facilitys written allegation of compliance for the deficiency cited in the CMS 2567. However, the submission of this plan is not an admission that a deficiency exists. The Plan of Correction is prepared and executed solely because it is required by federal and state law. This response and Plan of Correction does not constitute an admission or agreement by the provider of the facts alleged or set forth in the statement of deficiencies. Resident #47 is no longer on Med A stay. Resident #47 has been given a late ABN notice. All residents coming off Medicare A stay and remaining in facility as ICF level of care are potentially impacted by this citation. Administrator will in-service Admissions Coordinator SNF ABN requirements. Weekly audits will be completed for 4 weeks, then monthly for 90 days to ensure ongoing compliance with ABN notification for residents coming off Med A stays and remaining in facility. Results of audits will be reported in facility QA committee meetings. There are no detail notes for this visit.”

“Based on observation, interview and record review it was determined the facility failed to protect the resident's right to be free from physical abuse by another resident for 2 of 5 sampled residents (#s 34 and 29) reviewed for abuse. This placed residents at risk for abuse. Findings include: 1. Resident 34 was admitted to the facility in 1/2020 with diagnoses including history of traumatic brain injury and mental disorder due to a known physiological (related to the body) condition. Resident 34's 1/27/20 Socially Inappropriate Behavior Care Plan indicated the following: -The resident may get too physically close to others and talk nonstop to them. -The resident required reminders and encouragement to provide a safe distance between her/himself and others. -The resident may need to be redirected away from others should she/he talk too much, make negative/inappropriate statements, become an irritant to others or make inappropriate accusations towards others. Resident 34's 4/5/22 Quarterly MDS revealed the resident was severely cognitively impaired. Resident 47 was admitted to the facility in 6/2023 with diagnoses including dementia with psychotic disturbance and PTSD (post-traumatic stress disorder: a mental health condition triggered by a terrifying event, causing flashbacks, nightmares and severe anxiety). Resident 47's 6/12/23 Social Services Admission Assessment revealed the resident took quetiapine (an atypical antipsychotic used to treat schizophrenia, psychosis and bipolar disorder) for behaviors and sertraline (an antidepressant) for PTSD. Resident 47's 6/18/23 Admission MDS indicated the resident was severely cognitively impaired. Resident 47's 6/19/23 Care Plan indicated the following: -The resident was a veteran. -The resident experienced poor insight and safety awareness. a. A 7/2/23 Resident to Resident Event Assessment and Staff Questionnaire revealed the following: -Resident 47 and Resident 34 walked down the hall towards their rooms when Resident 34 stated "I have the right to be outside" to which Resident 47 responded with "don't come at me with that attitude." -Resident 47 pushed Resident 34 at chest level which caused Resident 34 to fall backwards and land on her/his left side. -Resident 34 sustained a superficial left elbow and left knee abrasion (a rub or wearing off of the skin) as a result of this incident. -Resident 47 visited with her/his spouse in the courtyard prior to the incident. -Resident 34 walked out to the courtyard despite staff encouragement to wait inside until Resident 47 finished her/his visit. On 4/29/24 at 10:51 AM Resident 47 was observed in the dining room sitting in her/his wheelchair. The resident was unable to answer any questions regarding the incident that occurred on 7/2/23. On 4/29/24 at 10:57 AM Resident 34 was observed in her/his room seated in a chair. The resident was unable to answer any questions regarding the incident that occurred on 7/2/23. On 4/30/24 at 9:32 AM Witness 1 (Spouse) stated when Resident 47 admitted to the facility she/he did not want anyone near her/him and would lash out at others who came into her/his space. Witness 1 stated Resident 47 did not like Resident 34 because she/he would try to insert her/himself into their family situations. On 5/1/24 at 11:10 AM Staff 26 (CNA) stated Resident 47 and Resident 34 had issues prior to the incident that occurred on 7/2/24. Staff 26 stated Resident 47 did not like that Resident 34 would speak to Witness 1, and because of this, she tried to distract Resident 34 if she knew Witness 1 was visiting. On 5/1/24 at 2:06 PM Staff 20 (RN) stated on 7/2/23 Resident 34 went outside to the courtyard while Witness 1 and Resident 47 visited despite asking Resident 34 to remain inside until their visit was finished. Staff 20 stated later on, and after Witness 1 left the facility, both residents walked down the hall when Resident 34 "started in about [her/his] right to be outside" following which Resident 47 stated "I am not going to let anybody talk to me like that and I am not going to put up with that." Staff 20 stated Resident 47 then placed her/his hands on Resident 34's chest and pushed her/him down. Staff 20 stated Resident 34 sustained minor injuries from the incident and was tearful. On 5/2/24 at 8:58 AM Staff 18 (LPN) stated Resident 47 was "irritated with [Resident 34] because of [her/his] attention-seeking behaviors" prior to the incident on 7/2/23, which was why she would "not sit them together at the same table." On 5/2/24 at 11:46 AM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged the findings of this investigation. Staff 1 confirmed Resident 47 pushed Resident 34 and Resident 34 sustained two abrasions as a result of the altercation. b. Resident 34's 7/4/23 Care Plan revealed the following: -The resident was not to sit at the same table or close to Resident 47 unless provided with one-to-one supervision. -The resident had a history of making uninvited/unwanted verbal accusations towards Resident 47 as well as threats of physical harm to others. Resident 47's 8/1/2023 Care Plan revealed the following: -Resident 34 may have trauma as a result of her/his experience in the military. -Trauma triggers included loud noises, fast movements from others and other resident behaviors. -The resident experienced physical aggression and abusive behavior, including pushing and shoving others as well as grabbing body parts of others (ie: shoulders, neck and arms). -Staff were to be cognizant (aware) of staff and other residents not invading her/his personal space. -If aggressive, staff were to try and remove the resident from the area and provide an individualized program with low stimulus. Resident 47's 8/30/23 Behavior Assessment indicated the resident's mental status could change throughout the day and she/he frequently presented with confusion and delusional thinking. The assessment also indicated the resident would occasionally exhibit aggressive posturing and verbalizations towards other residents, staff and environmental stimuli, such as loud noises or other resident behaviors. A 10/15/23 Resident to Resident Event Assessment revealed the following: -Resident 34 was in the dining room watching television when she/he was approached by Resident 47. -Resident 47 accused Resident 34 of being a thief and then grabbed Resident 34 around the neck and put her/his hand over Resident 34's face. -Two staff members immediately intervened and separated the residents. -Resident 34 was not injured. -Prior to this event, Resident 47 appeared sad and confused. -Resident 47 may have confused the voice on the television for Resident 34. On 4/29/24 at 10:51 AM Resident 47 was observed in the dining room sitting in her/his wheelchair. The resident was unable to answer any questions regarding the incident that occurred on 10/15/23. On 4/29/24 at 10:57 AM Resident 34 was observed in his room seated in a chair. Resident 34 could not recall any issues or altercations with other residents and stated she/he felt safe in the facility. On 5/1/24 at 11:10 AM Staff 26 (CNA) stated she was present during the altercation that occurred between Resident 34 and 47 in 10/2023. Staff 26 stated at the time of the incident in 10/2023, both residents were in the dining room watching television. Staff 26 stated Resident 47 put her/his hand on Resident 34's walker, Resident 34 stated "it [was] mine, don't take it" and then Resident 47 was instantly up on her/his feet and put Resident 34 in a choke hold with her/his right arm and put her/his left hand over the resident's face. Staff 26 stated she helped to "pry" Resident 47's arms off of Resident 34 and separated the residents. Staff 26 stated Resident 34 had "red marks on the left side of [her/his] neck and on the right side of [her/his] forehead" after the altercation. On 5/1/24 at 2:51 PM Staff 28 (Agency CNA) stated she worked on 10/15/23 and was told during shift change that Resident 47 "did not have a good attitude that day.”

“Based on observation, interview and record review the facility failed to conduct a new/accurate Level I PASARR when the facility became aware of indicators of a serious mental illness diagnoses and failed to complete a referral for a Level ll PASARR (Pre-Admission Screening and Resident Review) for 1 of 5 residents (# 46) reviewed for medications. This placed residents with a mental health disorder at risk for delayed care, emotional distress related to mental illness and lack of services to attain their highest practicable well-being. Findings include: Resident 46 admitted to the facility in 6/2023 with diagnoses including Psychotic Disorder with delusions (mental condition), Delusional Disorder (serious mental condition making it difficult to tell what is real), Dementia with behaviors, Post Traumatic Stress Disorder, Major Depressive Disorder and anxiety. A PASARR 1 (no indication of a serious mental illness) was completed from the hospital upon admission on 6/23/23 for Resident 46. Resident 46's current care plan directed staff with interventions for the following behavioral concerns: - Delusions; - Physical aggression; -Verbal aggression; - Socially inappropriate behaviors; - Resistive coming out of room; - Paranoid/ repetitiveness/demanding/anxious behavior; - History of suicidal behavior; - Wander/ elopement risk. Progress Behavioral notes reviewed from 4/3/24 to 5/2/24 revealed 12 occasions when Resident 46 slammed doors, yelled at others and made negative statements. Review of Resident 46's health record provided no evidence needed to complete a correct Level l PASARR or to make a referral for a Level ll PASARR for behavioral services. On 5/1/24 from 7:49 AM to 2:16 PM Resident 46 was observed on multiple occassions to self isolate in her/his room. On 5/3/24 at 10:59 AM Staff 1 (Administrator) stated she worked closely with the Social Services staff to complete the Level ll PASARR referrals. Staff 1 acknowledged Resident 46's Level l PASARR was coded incorrectly. Staff 1 acknowledged she would expect Resident 46 to be identified as a person who needed a Level ll PASARR with the dignoses and behaviors she/he experienced and a referral should be initiated. No additional information was provided. Level II referral will be made for resident #46. All residents with serious mental illness, not identified correctly by hospital prior to admit, may be impacted by this citation. 100% audit of all new admissions in last 60 days, who are still currently in facility has been completed  referral to PASARR 2 will be made, as indicated. Administrator will in-service social services staff on PASARR criteria and level II referrals. Administrator will in-service Admissions director for review of possible serious illness, missed by hospital PASARR  to ensure level 2 referral is made. Admin, or designee, will audit newly admitted residents with evidence of/ or possible serious mental disorders, intellectual disability, or related conditions- as defined by PASARR 2 requirements. Facility will initiate referral for level II as indicated. Audit to be completed weekly for 4 weeks, then monthly for 90 days and refer to level II if indicated. There are no detail notes for this visit.”

“Based on observation, interview and record review it was determined the facility failed to develop a person centered comprehensive care plan for 1 of 1 resident (#53) reviewed for communication. This placed residents at risk for unmet care needs. Findings include: Resident 53 was admitted to the facility in 3/2024 with diagnoses including non-traumatic subarachnoid hemorrhage (intracranial bleeding) and type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). A review of Resident 53's 3/26/24 Admission MDS revealed she/he had moderate cognitive impairment and needed an interpreter to communicate with her/his doctor or facility staff. Resident 53's care plan dated 3/28/24 indicated her/his primary languages were "Chinese/Taiwanese/Cantonese" and she/he had impaired communication skills related to a language barrier. On 5/1/24 at 10:06 AM Resident 53 was observed in the dining room speaking loudly in Chinese to Staff 22 (CNA). Staff 22 removed a cup of liquid from the table and stated as she walked away, "I don't know what she means." Staff 22 returned to the table with a cup of hot tea and Resident 53 was heard to verbalize in Chinese. Staff 22 was observed to shrug her shoulders and walked away. On 5/1/24 at 10:30 AM Staff 22 said "It's trial and error" when communicating with Resident 53. Staff 22 said she never saw a translator and said she thought it was an app for use on a tablet. On 5/2/24 at 11:08 AM Staff 22 stated Resident 53 did not have a communication board. She entered Resident 53's room and found a three-ring binder with communication pictures at her/his bedside. She looked through the images depicting care needs, emotions, questions, and responses and stated, "These are all good. It has emotions and actions." Staff 22 stated she did not know Resident 53 had it. Staff 22 stated, "It is not in [her/his] care plan." No evidence was found in Resident 22's care plan to indicate the communication binder was available as a communication aide. On 5/2/24 at 11:15 AM Staff 5 (RNCM) stated Resident 53 spoke a specific dialect which the voice translation app did not recognize. She confirmed Resident 53's care plan was not revised when she/he received the communication binder. On 5/2/24 at 11:54 AM Staff 12 (SSD) stated she expected Resident 53's communication binder to be added to her/his care plan so it was visible in the Kardex for staff to use it as a communication aide. On 5/3/24 at 10:32 AM Staff 1 (Administrator) stated she expected communication aides to be included in residents' care plans so staff know to use them. Resident #53s care plan has been updated to reflect use of communication binder. SSD will audit for other residents with language barriers and update care plans accordingly. DNS will in-service RCM and SSD staff on language barriers and Person-Centered comprehensive care planning. DNS or designee will audit Residents with language barriers, for person centered communication care plans to ensure tools are care planned and available. Audits will be weekly X4 and then monthly x 90 days to ensure ongoing compliance. Results of audits to be reported to facility QA committee. There are no detail notes for this visit.”

“Based on interview and record review it was determined the facility failed to follow physician orders for 1 of 5 sampled residents (#47) reviewed for unnecessary medications. This placed residents at risk for unmet needs. Findings include: Resident 47 was admitted to the facility in 6/2023 with diagnoses including heart failure. Resident 47's 4/2024 Physician Orders directed the following: -Obtain daily weights for heart failure, every day shift. -Notify physician if the resident gained three pounds in 24 hours or five pounds in a week. A review of Resident 47's 4/2024 Weight Summary revealed the following days without a recorded weight: -4/2/24 -4/3/24 -4/4/24 -4/5/24 -4/8/24 -4/9/24 -4/12/24 -4/17/24 -4/18/24 -4/19/24 -4/20/24 -4/26/24 -4/30/24 On 5/3/24 at 8:30 AM Staff 19 (CNA) stated Resident 47 was to be weighed daily and she/he rarely refused. On 5/3/24 at 8:33 AM Staff 18 (LPN) stated Resident 47 was weighed daily because she/he had heart failure and the resident "did not typically refuse." Staff 18 stated nurses were expected to document in the resident's progress notes the reason why a weight was not obtained for a resident with an order for scheduled weights. Staff 18 reviewed Resident 47's electronic record and confirmed the weights and progress notes with a reason as to why the weights were not obtained were missing on the days noted above. Staff 18 stated CNAs did not always inform her when they were unable to obtain Resident 47's weights, so she did not always know to write a progress note. On 5/3/24 at 9:11 AM Staff 2 (DNS) stated she thought Resident 47 was cooperative with being weighed and she/he was to be weighed daily. Staff 2 stated nurses were expected to notify Resident 47's physician on those occasions when a weight was not obtained in order to receive further instructions. Staff 2 reviewed Resident 47's clinical record and confirmed weights were not completed according to the resident's physician's orders. Resident # 47s daily weights have been discontinued per physicians orders. Facility with audit residents with physician orders for daily weights which include weight change notification parameters, to ensure notification has been made, as indicated. DNS will in-service licensed nursing staff on daily weight protocol and provider notification when applicable. DNS or designee will audit residents with daily weight orders to ensure protocol andprovider notification is completed as indicated weekly for 4 weeks and monthly for 90 days. Results of audit will be presented to QA committee to ensure ongoing compliance. There are no detail notes for this visit.”

“Based on observation, interview and record review it was determined the facility failed to ensure staff followed the care plan related to fall safety and provide sufficient supervision to prevent a fall for 2 of 2 sampled residents (#s 306 and 47) reviewed for accidents. This failure resulted in resident 306 having a fall with serious injury including a left shoulder fracture, a rib fracture and periprosthetic fracture involving the left greater trochanter (fracture of a previously-repaired hip) which required emergency medical services and treatment at the hospital. Findings include: 1. Resident 306 was admitted to the facility 1/2023 with diagnoses including right leg fracture and right shoulder fracture. A review of Resident 306's 1/17/23 admission MDS revealed she/he was cognitively intact and required extensive assistance from two or more staff to transfer on and off the toilet. Resident 306's care plan dated 1/11/23 directed caregivers to provide her/him with "two person stand pivot physical assist" to transfer and to encourage her/him not to ambulate without assistance. On 5/1/24 at 5:28 PM Staff 25 (Agency CNA) stated on 5/7/23 she responded alone to Resident 306's call for assistance. Staff 25 stated Resident 306 told her she wanted to use the commode in her/his bathroom. Staff 25 stated she asked Resident 306 what she needed to do to help her/him and Resident 306 told her she/he only needed her/his cane. Staff 25 stated she offered to get her/his wheelchair but Resident 306 told her she was only there to help with her/his pants. Staff 25 stated Resident 306 "walked to the bathroom," leaned forward to lock the door to the adjoining resident room and fell forward hitting her/his head and landing on her/his left side. On 5/1/24 at 6:06 PM Resident 306 stated Staff 25 assisted her/him to the bathroom using a manual wheelchair on 5/7/23 without the assistance of any other caregiver. She/he stated Staff 25 did not provide her/him with a gait belt to transfer. Resident 306 stated she/he stood up to transfer to the commode in her/his bathroom, tried to lock the door to the adjoining bathroom and fell forward hitting her/his head and landing on her/his left side. Resident 306 stated, "I think she was pulling the wheelchair out when I was trying to do that and it tripped me." On at 5/1/24 5:38 PM Staff 27 (LPN) stated she worked with Resident 306 on 5/7/23 and Staff 25 provided care alone for her/him at the time of the fall. Staff 27 stated she expected CNAs to consult residents' care plans or Kardex before working with the resident and the "Kardex tells how they transfer, ambulate and toilet. That is what they should be following." Staff 27 reported they called 911 because she/he was in an awquard position and they were not confident they could get her up and the paramedics "could assess [her/him] for other injuries." A review of Resident 306's hospital notes revealed she/he was sent to the emergency departement on 5/7/23 after she/he fell in the facility. Resident 306 was sent back to the facility but then returned and was admitted to the hospital on 5/9/23 and treated for anemia and the following injuries she/he sustained as a result of the fall on 5/7/23: -Left shoulder fracture -5th rib fracture -periprosthetic fracture involving the left greater trochanter (fracture of a previously-repaired hip) Resident 306's Hospital Discharge Summary indicated she/he was discharged from the hospital and returned to the facility on 5/12/24. A review of the facility's internal investigation completed by Staff 1 on 5/12/23 revealed Staff 25 did not follow Resident 306's care plan at the time of the fall. On 5/3/24 at 10:28 AM Staff 1 stated she expected CNAs to follow residents' care plans and Staff 25 knew where to find Resident 306's transfer status but did not follow it. , 2. Resident 47 was admitted to the facility in 6/2023 with diagnoses including dementia with a behavioral disturbance. Resident 47's 6/18/23 Admission MDS revealed the resident was severely cognitively impaired and not steady when moving from a seated to a standing position or when walking. The MDS also revealed the resident experienced a fall in the month prior to her/his admission to the facility, a fall in the two to six months prior to her/his admission to the facility and a fracture related to a fall in the six months prior to her/his admission to the facility. a. A review of Resident 47's clinical record revealed the resident experienced a fall in her/his room on 2/9/24 and 2/16/24 as a result of a failed attempt to self-transfer. Resident 47's 2/2024 Care Plan revealed the resident was at risk for falls related to her/his cognitive impairment, history of falls, lack of impulse control and unsteady gait (a person's manner of walking). The Care Plan indicated the resident was not to be left unsupervised in her/his room while awake as [Resident 47] may attempt to self-transfer to/from bed/wheelchair. Resident 47's 4/13/24 Fall/Post Fall Assessment revealed the following: -The resident experienced a fall at 2:30 AM in the resident's room. -The resident was in bed prior to the fall and found two feet from the transfer surface to the location of the fall. -A CNA found the resident with her/his hands resting on her/his roommate's bed with her/his right knee on the ground. -The resident was unable to provide a description of the fall event. -The new preventative plan was to perform frequent checks. The following questions from the Assessment were left unanswered: -When [was the resident] last visually observed? -When [was the resident] last toileted? -When [was the resident] last offered fluids? -When [was the resident] last repositioned? On 5/1/24 at 12:33 PM Staff 16 (LPN) stated she completed Resident 47's Fall/Post Fall Assessment on 4/13/24. Staff 16 stated she usually asked the resident's assigned CNA questions regarding care provided prior to a resident's fall but failed to do so in the case of Resident 47's fall on 4/13/24. Staff 16 stated staff typically checked on Resident 47 every few hours on night shift, and when Resident 47 was awake, she/he required "eyes on [her/him] at all times" because she/he was at risk for falls. On 5/1/24 at 2:37 PM Staff 17 (CNA) stated Resident 47 was considered a high fall risk and she usually checked on her/him around 11:30 PM to 12:00 AM and again around 2:00 AM. Staff 17 stated she found Resident 47 on 4/13/24 in her/his room "kneeling down on one knee at [her/his] roommate's bed" and could not recall when she last visually observed Resident 47, last toileted Resident 47, last offered Resident 47 fluids or last repositioned Resident 47 prior to this fall. Staff 17 stated she was not asked to provide any of these details at any point after the fall. On 5/2/24 at 8:58 AM Staff 18 (LPN) stated when Resident 47 was in bed, she expected CNAs to walk by the resident's room about every 10 minutes because she/he was "a huge fall risk." Staff 18 stated "sometimes [Resident 47] would stand up and the pressure light [would] not go off so it [was] really important staff [walked] the halls." On 5/2/24 at 12:09 PM Staff 2 (DNS) was informed of the findings of this investigation and stated "doing rounds [was] the best way to prevent a resident from having falls." Staff 2 stated she expected staff to be "peeking in resident rooms at least every 30 minutes" when doing walking rounds at night. b. Resident 47's 4/30/2024 Care Plan revealed the resident was at risk for falls related to her/his cognitive impairment, history of falls, lack of impulse control and unsteady gait (a person's manner of walking). The Care Plan indicated the resident was not to be left unsupervised in her/his room (while awake) as [Resident 47] may attempt to self-transfer to/from bed/wheelchair and a pressure sensitive call light [was] to be placed between the bed fitted sheet and draw sheet to the left side of the resident when in bed for a fall intervention. A review of Resident 47's cl”

“Based on observation, interview and record review it was determined the facility failed to perform post-dialysis assessments on 1 of 1 sampled residents (#33) reviewed for dialysis. This placed residents at risk for unidentified complications related to dialysis treatment. Findings include: Resident 33 was admitted to the facility in 6/2019 with diagnoses including end stage renal disease (kidney dysfunction). A 2/16/22 Physician Order stated nursing staff were to assess Resident 33's vital signs and write a progress note when she/he returned to the facility from dialysis. A 4/2/24 Quarterly MDS indicated Resident 33 had normal cognitive function. On 4/30/24 at 12:15 PM Resident 33 stated her/his vitals and port site (dialysis access site) are often not checked by facility staff after she/he returned from dialysis. Review of 4/2024 progress notes revealed no post-dialysis assessments were completed for Resident 33 on: -4/15/24, -4/17/24, -4/19/24, -4/22/24, -4/24/24 and -4/26/24. On 5/3/24 at 10:11 AM Staff 21 (LPN) stated post-dialysis assessments were to be performed immediately after a resident returns from dialysis. Staff 21 stated these assessment included checking respiratory rate, heart rate, blood pressure and the port site for any abnormalities. Staff 21 stated these assessments were documented in progress notes. On 5/3/24 at 10:14 AM Staff 2 (DNS) confirmed post-dialysis assessments were not performed and documented immediately upon Resident 33's return to the facility from dialysis on the dates listed above. Resident # 33 care plan/POC documentation has been updated to contain post dialysis assessment verification requirements. RCMs will audit other residents receiving dialysis to ensure Care plan /POC documentation in place to verify post dialysis assessment requirements. DNS will Inservice licensed nurse and RCMS staff of post dialysis assessment requirements documented in POC, per care plan. DNS or designee will audit dialysis residents care plans for follow up tasks being in place and complete as scheduled weekly for 4 weeks and monthly for 90 days. There are no detail notes for this visit.”

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

“*********************** 411-085-0320     Residents ' Rights: Charges and Rates Refer to F582 *********************** 411-085-0360     Abuse Refer to F600 *********************** 411-070-0043     Pre-Admission Screening and Resident Review Refer to F644 *********************** 411-086-0060     Comprehensive Assessment and Care Plan Refer to F656 *********************** 411-086-0110     Nursing Services: Resident Care Refer to F684 and F698 *********************** 411-086-0140     Nursing Services: Problem Resolution and Preventive Care Refer to F689 *********************** A follow-up survey was conducted on 7/8/24 to verify correction of the deficiencies noted from the licensure and complaint (Intake# 36352, 38791, 41034, 41410, 41614, 42218, 43325, 44783, 45651 and 46379) survey dated 5/3/24. These deficiencies are corrected as of 6/20/24.”

“The findings of the memory care unit community 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 survey conducted on 7/8/24 are documented in this report. It was determined the facility was in compliance with OAR 411 Division 57.”

“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.”