Marquis Autumn Hills Memory Care

Findings Resident 3 Review of Resident 3's (R3) electronic health records indicated the facility admitted the resident on 12/31/24 with diagnoses including bipolar disorder (serious mental illness characterized by extreme mood swings), dementia with behavioral disturbance, and traumatic brain injury. R3's Minimum Data Set (MDS-assessment tool) dated 1/2/26 documented residentGÇÖs brief interview for mental status was 99 indicating the interview was not completed or was stopped before completion, had severely impaired cognitive skills for decision making, exhibited physical behavioral symptoms directed towards others, verbal behavioral symptoms directed towards others (e.g., screaming at others), and other behavioral symptoms not directed towards others (e.g., pacing, rummaging, disrobing in public, or verbal/vocal symptoms like screaming, disruptive sounds) for 1 to 3 days during the past 7 days. In addition, R3GÇÖs behavior significantly interfered with the resident's participation in activities or social interactions, significantly intruded on the privacy or activity of others, significantly disrupted care or living environment. The MDS documented that R3 wandered daily and the residentGÇÖs wandering significantly intruded on the privacy or activities of others. The above behaviors were the same compared to prior assessments. R3 resided in the secured unit of the facility. -á Review of R3GÇÖs care plan in place at the time of 11/16/25 incident, documented wandering behavior, initiated on 6/24/25, identifying-á that resident GÇ£can create undesired situations by wandering into co-residentGÇÖs rooms uninvited and need redirected 10 x per dayGÇ¥ with interventions GÇ£to see behavior monitoring services for specific interventions that included call my son, bring me a cup of black coffee, take me out to the courtyard for a walk, bring my devotion book, 1:1/reassure (1 staff provided direct supervision to 1 resident), redirect, assist to quiet area, give food and/or fluids, -ásecured unit, psychotropic medication plan of care, and take me for walks.GÇ¥ Resident 4 Review of Resident 4's (R4) record indicated the facility admitted the resident on 2/29/24 with diagnoses including vascular dementia with behavioral disturbance, restlessness and agitation, schizoaffective disorder (mental health condition with mood disorder symptoms). -áR4's Minimum Data Set (MDS-assessment tool) dated 2/6/26 -ádocumented residentGÇÖs brief interview for mental status was 11 of 15 indicating cognition was moderately impaired, had delusions, and exhibited verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) for 1 of 3 days during the past 7 days. R4 resided in the secured unit of the facility. -á Review of facilityGÇÖs Investigation Summary and Conclusion: Resident to Resident 11/16/25, undated, documented that: *On 11/16/25 at 4:05 PM R3 entered or attempted to enter R4GÇÖs room. R4 quickly approached R3 and pushed his front wheeled walker (FWW) into R3GÇÖs leg GÇ£4 or 5 timesGÇ¥ as staff was trying to get to them and separate them. Staff report R3 yelled in pain when the FWW was pushed into her and was limping as staff separated the residents. R3 sustained a swollen right knee that was painful to palpitation as well as swelling that was bruised below and medial to the right kneecap. On call provider was notified of injuries and R3 was sent to the Emergency Department (ED) for evaluation. ED x-rays of the tibia/fibula did not show a fracture. ED diagnosis was contusion right leg. Order was obtained to apply ice packs. *The summary also documented that when awake, R3 constantly wanders around the unit, ambulating independently, up and down the hallway, around the common room, as well as entering co-residentGÇÖs rooms despite doors being closed. If staff is able to get R3 to sit, R3 wonGÇÖt stay much longer than 10 minutes. R3 talks incessantly, usually word salad (unintelligible, extremely disorganized speech or writing-ágenerally manifested as a symptom of a mental disorder)-á. The wandering and talking does irritate the more cognizant co-residents, staff do their best to redirect R3 to a diversional activity, offer snack or fluids or take her for a walk outside. For the past month, R3GÇÖs nighttime hours of sleep range from 0 hours to 6.5, mostly 4 hours or less. Staff have observed increased periods of agitation, resident banging on the secure door demanding to get out and quickly slipping through the door if it is open. When agitated, R3 is difficult to re-direct. R3 exhibited daily wandering into resident rooms, despite redirection attempts. Behavior had been consistent across multiple assessments. R3 had been involved in 2 previous Resident to Resident incidents. The first when R3 would not leave a co-residentGÇÖs personal space; the co-resident then slapped R3. The second was when a co-resident became frustrated over a non-related incident and approached R3, who was ambulating in the hallway, and pushed his FWW toward her. When interviewed one hour after the incident, R3 was unable to answer questions about the incident coherently. *The summary also documented that R4 was previously infatuated with a hospice aide to where the facility had to ask to have the aide reassigned. At that time, R4 was convinced the aide had been murdered by R3 (whom R4 began calling GÇ£that guyGÇ¥ and GÇ£that hermaphroditeGÇ¥ (organism possessing both male and female reproductive organs). When interviewed two hours after the incident, R4 was lying in bed watching tv. When asked what happened he stated, GÇ£that guy was laying in my bedGÇ¥ GÇ£that guy is still stirring things upGÇ¥. R4 then became agitated. R4 would not answer if he had been bumped into R3 with his walker, if he was injured or scared, or if he said anything to her. *Review of Certified Nursing Assistant (CNA) 12GÇÖs statement documented she witnessed GÇ£R4 was walking around hallway using his walker, R3 was by his room door trying to enter his room. R4 was yelling at R3 not to come to his room, he does not want to see her.GÇ¥ Review of R3GÇÖs behavior monitoring and intervention documented on *11/16/25 at 1:17 PM, resident was agitated and wandering with interventions of redirection, remove from situation, provide calm environment, reapproach, toilet with same/unchanged outcome. *11/16/25 at 4:02 PM, resident had disruptive sounds, agitated, anxious, restless, wandering with interventions of provide calm environment with same/unchanged outcome. Review of R3GÇÖs progress notes documented R3 continued to experience the effects of R4 hitting her leg up to six days after the incident: *11/16/25 provider documented that -áR3 opened the door of R4 which upset R4 who hit R3 on her legs multiple times using his walker. ResidentGÇÖs right leg was swollen, resident was screaming in pain, scheduled medication given. Order placed for ice pack to swollen right leg. *11/16/25 at 6:45 PM, resident left facility to hospital. *11/17/25 at 2:32 AM, resident came back to the facility from the hospital. *11/20/25 at 5:19 AM, bruising still noted to right leg, swelling has gone down. Resident stated that her leg hurts. *11/21/25 at 4:45 AM, bruising still noted to right leg, swelling has gone down. *11/22/25 at 5:22 AM, bruising still noted to right leg, swelling has gone down. Observation on 04/06/2026 at 2:49 PM showed R3 wandering up and down the hallways of the secured unit, making several loops, while loudly saying word salad (verbalizing random and unrecognized words (for example saggy baggy, pickle) loudly while walking. There were stop signs on Rooms #2, 6, and 8 and a picture of a horse on R3GÇÖs door. R3 was observed entering Room #3. After several seconds, Certified Medication Assistant (CMA) 3 entered Room #3 and asked resident to come out of the room and walked resident out of the room. CMA3 stated that R3 walks up and down the hallway and when she doesnGÇÖt see R3 in the hallway, it means R3 was in a resident's room. CMA3 stated that R3 goes into all residentGÇÖs rooms and opens their doors and stated that the other residents don't like R3 going into their rooms. The Social Services Director (SSD) approached R3 and asked R3 if she wanted to go outside in the courtyard. R3 said, GÇ£Yes.GÇ¥ During an interview on 04/06/2026 at 3:02 PM Certified Nursing Assistant (CNA) 4 stated that R3 had been entering other residentsGÇÖ rooms GÇ£since last yearGÇ¥ and that staff would often have to search for her when she wandered into rooms, noting that other residents would become GÇ£angry, upset, and irritatedGÇ¥ when this occurred. R4 doesn't like it when she goes in his room, he will yell GÇ£get out of my room.GÇ¥ CNA4 stated that we just her walk, we try to keep an eye on her as much as we can and but it is hard when someone is on break because that leaves one staff by themselves. GÇ£We do what we can, but we can only do so much.GÇ¥ During an interview on 04/06/2026 at 3:15 PM Certified Medication Assistant (CMA) 3 stated that R3 entered other residentsGÇÖ rooms daily (1GÇô2 times per day) and that the behavior had increased over the past 3GÇô6 months, with interventions such as stop signs during last couple months (after 11/16/25 incident) which was not helping. The residents with the stop signs on their doors (R4 had a sign on his door) are not ok with R3 going into their rooms and they yell at her. Observation on 04/07/2026 at 9:15 AM showed R3 wandering up and down the hallways of the secured unit, making several loops, while loudly saying word salad. R3 approached several residents while loudly saying word salad in their faces. Other residents would frown and move away from R3. R3 continued to loudly say word salad. During an interview on 04/07/2026 at 9:21 AM, CNA18 stated that R3GÇÖs behaviors would GÇ£get other residents worked up,GÇ¥ and that while staff attempted to redirect her, there was no structured monitoring plan. CNA18 indicated R3 would wander everywhere, and she would scream at people sometimes. Any minute she can go into someone's room. R4 is very particular about his space. -áEven in the dining room, when R3 approaches his room, he will yell when she is outside and she won't go in his room. R3 has no space boundaries, she'll comes right up to your face. During a concurrent interview and record review on 04/07/2026 at 3:24 PM Registered Licensed Nurse (LN) 3 stated that on 11/16/2025 he was called by CNA12 when R4 hit R3 after R3 entered or attempted to enter R4GÇÖs room. Review of LN3GÇÖs progress note dated 11/16/25 at 5:19 PM documented GÇ£CNA stated that [R3] was opening the door of [R4]GǪ..[R4] was walking using his walker toward his room, and [R4] was upset and hit resident [R3] on [R3GÇÖs] legs multiple times using his walker. CNA called the Nurse to the unit and the nurse saw that resident's right leg was swollen. Resident was screaming with pain, scheduled pain medication given.GÇ¥ Observation on 4/07/2026 at 3:28 PM showed R3 wandering up and down the hallways of the secured unit, making several loops, while loudly saying word salad. During an interview on 4/07/2026 at 3:30 PM CNA12 stated that she was caring for R3 during the 11/16/25 incident. CNA12 stated that the incident happened before dinner. R4 was walking down the hallway with his walker, as he normally walks about 150 feet every morning and evening. R3 had been in an agitated mood throughout the day, yelling more than usual. There were two CNAs scheduled, as usual, and the other CNA was on break at the time. I was in the living roomGÇöas requiredGÇöand positioned near the entry so I could monitor R3. She walked with her walker toward R4GÇÖs room, opened his door, and went inside. R4 was approaching his room when I saw him knock over her walker and begin striking her legs with his own walker. He was shouting at her. His walker is large and heavy, with a basket attached to the front. I immediately ran over to separate them. R3 was inside his room, and the basket from R4GÇÖs walker had fallen off and was on the floor. R3 was screaming, saying she was in pain, and her shin appeared swollen. R4 then went into his room and closed the door. By the time I reached them, I saw him hit her twice with his walker. CNA12 stated that R3GÇÖs behaviors were ongoing and that she GÇ£should have a 1:1 all the time.GÇ¥ Observation on 04/08/2026 at 11:15 AM showed R3 wandering up and down the hallways of the secured unit, making several loops, while loudly saying word salad. During an interview on 04/08/2026 at 11:25 AM Social Services Director (SS) stated that R3 entered R4GÇÖs room, R3 was in R4GÇÖs space, and when R3 attempts to go into other residentGÇÖs room, the other residentGÇÖs get upset and tell her to get out. Staff are supposed to redirect R3. During an interview on 04/08/2026 at 1:09 PM Director of Nursing (DON) stated that R3GÇÖs behaviors of entering other residentsGÇÖ rooms were baseline and longstanding, that other residents reacted negatively, and that interventions such as door signage were implemented after the incident, not before. DON further stated that R3 was more agitated at that time probably related to pain as R3 had tooth abscess at that time. DON stated that the incident happened at 5:37 PM and there would have been 2 CNAs who were busy helping to take residents into the dining room and setting up for dinner at that time. DON further stated that R4 doesn't like anyone in his room, he has space boundaries. R3 doesnGÇÖt have any space boundaries and she crosses that space. DON stated that when R3 is observed going towards a residentGÇÖs room, staff should redirect her and offer food/fluids. R4 pushed his walker into R3 to get her out of his room, he wanted to get her out. DON stated this was not abuse because R4GÇÖs response was reflexive and abuse is intent. When informed the federal definition of abuse does not require intent and asked if R4GÇÖs actions were deliberate/willful or accidental, DON stated that it was willful. The DON further confirmed there was no defined monitoring schedule, no assigned staff responsibility, and no routine documentation of supervision. During an interview on 04/09/2026 at 1:36 PM Administrator stated that abuse was defined as behavior used to exert power or control resulting in physical, emotional, or psychological harm. She stated that GÇ£willfulGÇ¥ means a deliberate act and not accidental, and confirmed that intent to harm is not required to determine abuse under federal regulations. When asked about Resident #3GÇÖs behaviors prior to the 11/16/25 incident, the Administrator stated the resident exhibited wandering behaviors, including walking up and down the hallway and requiring redirection to common areas. She confirmed that the resident entered other residentsGÇÖ rooms and that staff were aware of this behavior. The Administrator indicated that in the past couple of months, the residentGÇÖs behaviors had decreased; however, the resident continued to exhibit nonsensical speech and wandering. The Administrator described interventions in place prior to the incident as: redirecting the resident to common areas, providing engagement activities such as listening to the radio, reading, writing, spiritual activities, gardening, walking with staff, taking the resident outside to the courtyard. The Administrator stated that staff could redirect the resident out of other residentsGÇÖ rooms, but acknowledged that the resident was not on 1:1 supervision, there was no staff specifically assigned to monitor the resident, monitoring was described as line-of-sight when possible but not consistently defined. When asked why more structured interventions or supervision were not implemented earlier, the Administrator stated she was GÇ£not sure.GÇ¥ The Administrator further reported that immediately after the incident, the facility separated the residents, posted stop signs on doors, and placed a visual cue (horse image, as R3 loved horses) on the residentGÇÖs door. During an interview on 04/13/2026 at 12:31 PM Administrator confirmed that the QAPI AD HOC meeting was on 10/22/25 prior to 11/16/25 resident-to-resident altercation. The QAPI AD HOC interventions were to increase engagement during high-risk times (between meals) -áthrough the use of snack carts between meals to redirect and engage residents, increased availability of tabletop and individualized activities, environmental modifications to reduce stimulation and crowding. When asked how it could be determined that the QAPI AD HOC interventions were fully effective when a resident-to-resident altercation occurred in the early evening between meals time within 30 days of implementation, Administrator stated that it was really challenging with memory care unit residents, it happened really quickly, staff intervened quickly and it was an unpredictable event. Facility policy Preventing Resident Abuse, revised 10/2022, documented the facility will not condone any form of resident abuse with the goal to achieve and maintain an abuse-free environment. Signs of physical abuse includes bruises, abrasionsGǪGÇ¥

F600- A PASARR Level II evaluation was completed for Resident #3 on 4/15/26. Recommended interventions will be implemented immediately upon receipt and incorporated into the resident’s care plan. Resident #4 was re-evaluated by IDT and has been successfully transitioned to an ICF bed on an unlocked unit where the risk of resident wandering into his room is minimized. 100% of residents in secured memory care unit are potentially impacted. All facility staff were re-inserviced on abuse prevention, including willful intent, resident-to-resident incidents, resident centered interventions to reduce risk of resident-to-resident events and mandatory reporting requirements IDT will be in-service on evaluation and revaluation of interventions to reduce resident to resident occurrences., including resident centered interventions to reduce risks Admin and DNS with IDT team will audit any future resident to resident encounters to ensure effective new interventions were implemented to reduce likelihood of res-to-res events.  Audits will be done daily M-F Weekly x 4 weeks and monthly x90 days. Results of audits will be reviewed in QA to ensure ongoing compliance

Findings include: Review of the Admission Record revealed that R21 was admitted to the facility on 08/14/25 with diagnoses which included unspecified dementia, mild, with other behavioral disturbance (early-stage cognitive decline where memory/thinking problems are present but not yet severe, the specific cause (e.g., AlzheimerGÇÖs vs vascular) is not determined, and notable behaviors occur), chronic obstructive pulmonary disease, unspecified (a progressive, long-term lung disease that causes obstructed airflow, making it difficult to breathe), and repeated falls. The Admission Record revealed the resident was his own representative. Review of the residentGÇÖs record did not provide evidence that a Healthcare Power of Attorney (HPOA) had been established. An Order Summary Report dated 08/11/25 revealed a handwritten note on the right, bottom of the page which included, GÇ£Admit to the secure unit.GÇ¥ The note was signed and dated by the provider. No rationale was indicated. Review of the residentGÇÖs record provided no evidence of documentation which related to the clinical criteria met for placement on the secured/locked unit or documentation that reflected whether placement in the secured/locked area was the least restrictive approach that was reasonable to protect the resident and assure his health and safety. A nursing Admission Assessment dated 08/14/25 indicated the resident had been admitted for dementia with behaviors. The portion of the assessment completed by the Registered Nurse/Resident Care Manager (RN/RCM) included that the resident was confused about the reason for admission to the facility and questioned his placement on a dementia care unit. According to the documentation, the resident perceived his care as minimal and did not agree with the dementia diagnosis. GÇ£Adjustment is expected to be challenging given his prior independence in an Assisted Living Setting (ALS)GǪGÇ¥ An elopement care plan initiated on 08/15/25, related to wandering, wanting to go home, and cognitive impairment had a goal for the resident not to leave the secured environment unattended or without staff knowledge. Interventions included placement on the secured GÇ£Friendship HouseGÇ¥ unit. The admission Minimum Data Set (MDS) assessment dated 08/25/25 revealed that the resident scored 13 on the Brief Interview for Mental Status (BIMS) assessment, suggesting intact cognition. Behaviors included verbal behavioral symptoms directed toward others which occurred 4 to 6 days out of the 7-day lookback period, with no wandering noted. A Resident to Resident Event Assessment dated 09/22/25 included a Social Service section which stated R21 was not currently receiving mental health services at that time. A Resident to Resident Event Assessment dated 10/23/25 included a Medical/Clinical Review which stated that, GÇ£[R21] has dementia and spends most of his time in the common room, where he watches TV with the other residents. He is easily irritated by co-residents who are talking in the common room or walking around.GÇ¥ GÇ£[R21] also has a diagnosis of depression, which can affect his social engagement and motivation. This depression may increase the risk of non-compliance with treatment or care routines. [R21GÇÖs] vitamin B-12 anemia can result in irritation and agitation.GÇ¥ The Assessment Summary portion of the document included, GÇ£Since his admission, [R21] has expressed dissatisfaction with his situation, stating that he wishes to leave the facility and asserting that he does not have dementia. He believes he should not be in a Memory Care facilityGǪGÇ¥ The summary further stated, GÇ£GǪ he is adamant about his desire for independence, including living elsewhere and socializing with friendsGǪGÇ¥ Review of the quarterly MDS dated 11/21/25 revealed the resident reported feeling down, depressed, or hopeless. Review of the residentGÇÖs medical record for November 2025 provided no evidence of a quarterly assessment for ongoing placement on the secured unit. Review of the Quarterly Multidisciplinary Care Conference meeting notes dated 12/18/25 included the following attendees: the Social Services Director (SSD/Resident Care Manager (RCM), the Director of Nursing Services (DNS), with the residentGÇÖs brother and sister attending via phone. The justification for the resident not being in attendance was noted as, GÇ£Due to cognitive impairment, resident would not benefit from being part of this meeting.GÇ¥ The Discharge Planning portion of the notes indicated, GÇ£Family requests resident continue at the Friendship House [secured unit] for Long-term care.GÇ¥ The IDT recommendation included, GÇ£Resident does not desire discharge, continues to need and benefit from nursing facility placement.GÇ¥ The quarterly MDS assessment dated 02/20/26 revealed the resident scored 15 on the BIMS assessment, indicating intact cognition. His behaviors included verbal behavioral symptoms directed toward others occurred 4 to 6 days out of the 7-day lookback period and the resident refused care 1 to 3 days out of the 7-day lookback period. Per the assessment, no wandering had occurred since the prior assessment. Review of the residentGÇÖs medical record for February 2026 provided no evidence of a quarterly assessment for ongoing placement on the secured unit. Review of the Medical Center Discharge Summary dated 03/05/26 included that the resident had been seen, principally, for frequent falls. In the section titled, GÇ£? DementiaGÇ¥ revealed, GÇ£B12 GÇ£220GÇ¥ [indicating low levels of vitamin B-12] suggesting possible reversible source of memory and gait impairment. Started B12 1000 micrograms (mcg) injection on 03/01, repeat on 03/03, plan weekly x 4 weeks, Hope to see improvement in 2-4 weeks.GÇ¥ Under the Social Support section of the document, it was reported that R21 stated that he wanted his friend/roommate from his previous residence to be his medical decision maker and POA. GÇ£The resident said he had paperwork to that effect, but we havenGÇÖt seen it.GÇ¥ On 03/12/26 at 9:15 PM a Behavior Note included that the resident was GÇ£always angry about care.GÇ¥ The note continued stating the resident was GÇ£always argumentative and disrespectful.GÇ¥ On 03/13/26 at 4:23 PM a Social Service Note included that the resident asked the SSD to contact his caseworker because he was GÇ£sick of living in this hellhole.GÇ¥ Review of a Multidisciplinary Care Conference meeting note dated 03/17/26 revealed the SSD and DNS/RCM were in attendance. The residentGÇÖs brother and sister attended via phone. According to the documentation, the justification for the resident not to be in attendance and/or participating in the resident-centered care planning process was noted as, GÇ£Due to cognitive impairment, resident would not benefit from being a part of this meeting.GÇ¥ The discharge plan per IDT recommendation was for the resident to continue at the Friendship house for long-term care. The IDT recommendation included, GÇ£Resident does not desire discharge, continues to need and benefit from nursing facility placement.GÇ¥ In an IDT Progress Note dated 03/21/26 at 1:27 PM R21 expressed to Occupational Therapist that he would like to transfer to a VeteranGÇÖs Home. On 03/21/26 at 2:32 PM an IDT Progress Note included that at his appointment with a new VA Primary Care Physician (PCP) on 03/19/26, the residentGÇÖs paperwork indicated a positive suicide screen and that the resident was having suicidal thoughts. According to the note, the resident was reminded about the VA crisis line he could talk to at any time if he desired. R21 was placed on alert and staff updated to monitor for suicidal statements or attempts to harm himself. However, review of the residentGÇÖs comprehensive care plan did not provide evidence of a plan to address his suicidal ideation. Review of the residentGÇÖs medical record did not reveal evidence of a referral for psychiatric services. An anticipated discharge plan initiated on 04/03/26 related to LTC at the Friendship House for secured environment had a goal for the residentGÇÖs needs to continue to be met per the plan of care. Interventions included, GÇ£I do not want to talk to someone about the possibility of leaving this facility and returning to live and receive services in the community.GÇ¥ A care plan focused on sadness/depression initiated on 04/03/26 related to the diagnosis of depression. The goal for the plan was for the resident to choose to do tasks that would help him meet his goals on a daily basis. Interventions included GÇ£Medication as per MD.GÇ¥ On 04/06/26 at 3:06 PM, during an interview, R21 stated that he was not here [on the secured dementia unit] of his own choice and felt he did not belong here. An Encounter Note dated 04/07/26 at 00:00 included that the resident had made it clear that he would like to be discharged from the facility. Per the note, the provider discussed R21GÇÖs GÇ£negative attitudeGÇ¥ with him, and the resident GÇ£basically statedGÇ¥ that his attitude was his attitude and that if he has to stay here that he will, GÇ£make life hell for everyone.GÇ¥ On 04/08/26 at 8:37 AM an interview was conducted with a Certified Nursing Assistant (CNA18). He stated that he thought R21 had been placed on the secured unit because he had tried to leave the facility in the past and because of his behaviors. He stated that the resident did not want to be here and that the loud residents with dementia made him agitated. When asked if he thought R21 was appropriately placed on the unit, CNA18 smiled, looked down, and would not answer the question. On 04/08/26 at 8:45 AM R21 was observed sitting in the day room watching television. Another resident was observed as she walked into the room. The other resident was noted to speak continuously and in a very loud voice. She was observed approaching other residents in the room, placing her walker closely in front of them, leaning over so her face was just inches away, and intrusively speaking phrases such as, GÇ£Saggy, baggy!GÇ¥ and GÇ£Are we going yet?GÇ¥ R21, who appeared agitated, yelled, GÇ£Be quiet!GÇ¥, GÇ£Give it a rest!GÇ¥, GÇ£Shut up!GÇ¥ and GÇ£Go away!GÇ¥ Staff were observed to redirect the other resident to another area of the facility. However, the other resident was noted to engage in this behavior throughout the day. During an interview with the SSD conducted on 04/08/26 at 8:58 AM, she stated that R21GÇÖs brother was his representative. However, she stated that to her knowledge, the residentGÇÖs brother had not completed the necessary legal procedures to obtain authorization for placing R21 on the secured unit. She stated that the residentGÇÖs family wanted him here because he was a high fall risk, and for his own safety reasons. She stated, GÇ£We never want to hold him here against his will. He has expressed that he does not want to be here before.GÇ¥ When asked what the legal process was for a representative to have authorization to act on the residentGÇÖs behalf, she stated that she would GÇ£get back to you on that.GÇ¥ She stated that the residentGÇÖs BIMS were 15 out of 15, that he was cognitively intact, and had not had the diagnosis of mild dementia for very long. When asked if the resident had the right to seek exit, she stated, GÇ£Yes, of course. He has the right to be treated with dignity and respect and to make his own decisions. We shouldnGÇÖt hold him here against his will.GÇ¥ When asked if the resident was being held against his will, she stated she didnGÇÖt feel like it. She stated that it was her job to protect his rights. When asked if she thought the residentGÇÖs rights were being violated, she stated, GÇ£When you put it that way, yeah.GÇ¥ On 04/08/26 at 9:15 AM an interview was conducted with the facilityGÇÖs Administrator. She stated that the resident had come to the facility for long-term care, and that he was admitted directly to the GÇ£Friendship HouseGÇ¥ for memory care. She stated that his primary diagnosis was dementia with other behavioral disturbances. She stated that the resident had BIMS of 15, GÇ£indicating he had some cognitive decline.GÇ¥ After clarification, she stated that the resident was cognitively intact. When asked if the resident was a ward of the court, she stated, GÇ£No, he is his own guarantor.GÇ¥ When asked if the resident was mentally incapacitated, she stated, GÇ£No.GÇ¥ She stated, GÇ£He has the right to leave the facility.GÇ¥ When asked if the facility had the authority to hold R21 on the secured unit against his will, she stated, GÇ£No.GÇ¥ On 04/08/26 at 9:52 AM an interview was conducted with the DNS/RCM. When asked about R21, she stated the resident was very stubborn, difficult to redirect, did what he wanted, and disregarded doctorGÇÖs orders, and that he had that right. She stated that the resident made his own decisions and was his own representative. She stated that he had normal cognition and that he had the right to leave the facility Against Medical Advice (AMA) when he wanted to. When asked if there was any documentation indicating the facility had the authority to keep the resident on the secured unit against his will, she stated she did not know that she would have to find that out. She stated that R21 had made several calls to the Ombudsman, telling them he did not want to be here, and that he does not belong here. When asked if the facility had any clinical justification to keep the resident on the secured unit, she stated GÇ£No,GÇ¥ not that she was aware of. GÇ£Honestly, I donGÇÖt know.GÇ¥ When asked if she thought keeping him on the secured unit was a violation of R21GÇÖs rights, she stated, GÇ£Yeah.GÇ¥ An interview was attempted by calling the Ombudsman; however, the call was not returned. During a phone interview with the residentGÇÖs provider conducted on 04/08/26 at 11:38 AM, he stated that the main reason the resident was on the secured unit was because he didnGÇÖt want to be here and he had dementia issues. He stated that the resident had significant issues with being in this facility, but that he thought R21 would GÇ£go off and do things that werenGÇÖt good for him,GÇ¥ and, GÇ¥he would get himself into trouble if he was not supervised.GÇ¥ He stated that the residentGÇÖs brother was GÇ£peripherally involvedGÇ¥ with the residentGÇÖs care. He stated that R21 has had several episodes of heart failure and that he was not compliant with his fluid restriction. He stated that R21 refused to sleep in his room, and that he sat for days in the dining room. When asked if R21 was an incapacitated adult, a danger to himself or others, or if there were any other considerations which would deem him unfit to make his own decisions, he stated that he would have to talk with the DNS about that. He stated that he realized that the resident was really unhappy here, and that he needed to GÇ£spruce himself upGÇ¥ so he could get out of here. He stated that he thought adult foster care was probably the best thing for him. He stated that the resident was not a danger to himself, other than being obstructive to his own care. He stated that the resident had BIMS of 15 and was his own representative, and stated, GÇ£Maybe he would be better off at their residential facility with a general population and a little more freedom.GÇ¥ When asked if it had been a violation of the residentGÇÖs rights to place him on the secured unit, he stated, GÇ£Yeah, thatGÇÖs a hard one. I really donGÇÖt want to answer that question.GÇ¥ During a follow-up interview and concurrent record review conducted on 04/09/26 at 8:29 AM with the facility Administrator, she stated that she had not been in her current position when R21 was admitted, but she gathered that he had been sent to the facility for placement on the secured unit related to his history of frequent falls. When asked if placement on the least restrictive unit had been attempted first, she stated that GÇ£a least restrictive option was not tried first.GÇ¥ When asked whether ongoing assessments for continued placement on the secured unit had been conducted, she reviewed the residentGÇÖs record and stated that she did not see ongoing assessment for continued placement on the unit. She stated that quarterly reviews should have been completed. She stated that the facility had conducted Care Conferences with the SSD/RCM, DNS, the residentGÇÖs family, and (she thought) the resident was involved. She stated that if the family held POA, they might choose to conduct the conference without the resident present. When asked if the resident had designated a POA, she stated there was no POA in place. GÇ£At this time, he is his own representative and should be invited to his care conferences.GÇ¥ On 04/09 26 at 9:53 AM a follow-up interview was conducted with the SSD. She stated that Care Planning Conferences were conducted quarterly, about every 90 days. She stated that residents who represent themselves are invited to come, and the residentGÇÖs family may come if the resident gives permission. She stated R21GÇÖs family was very involved and that the residentGÇÖs sister had requested that R21 not come to the meetings. She stated that for the conference conducted on 09/12/25, she thought they invited the R21 to come, GÇ£but he was really upset, and just wanted out of here,GÇ¥ so only the brother and sister attended the meeting. She stated that after placement, the resident had been very upset because he felt that he had just been dropped off here and no one had told him anything. For the care conference held on 03/16/26, she stated that the resident was not invited because he had just come back from the hospital and was sleeping a lot. When asked, she said the resident represented himself and the family couldn't exclude him from his care conference. On 04/09/26 at 11:28 AM an interview with R21 was conducted. He stated that he was not expecting to be put on this unit. GÇ£I hate it. If I had a memory problem it would be great, but I donGÇÖt.GÇ¥ He stated that the doctor had not explained the rationale for placing him on the unit. He stated they loaded him on a bus and dropped him there. They told him it was because heGÇÖd had some falls. He stated this experience had affected him GÇ£horribly.GÇ¥ GÇ£I shouldnGÇÖt be here, legally.GÇ¥ He stated that he was not free to go anytime he wanted. GÇ£The doors are locked. I donGÇÖt have any rights here when it comes to movement.GÇ¥ When asked about the experience, he stated, GÇ£It sucks. There is nothing pleasant about being told what to do and when you can do it.GÇ¥ He stated, GÇ£They took control of my life, and I find that very offensive.GÇ¥ 04/13/26 at 9:07 AM a phone interview was conducted with the residentGÇÖs family member. She stated that the resident had not been happy about being placed on the secured unit and that he would probably rather be in assisted living. She stated that the resident had been in the facility for 6-7 months and that it had been GÇ£pretty obvious that he was non-compliant because he doesnGÇÖt want to be there.GÇ¥ When asked whether the resident had set up a Healthcare Power of Attorney, she stated GÇ£I donGÇÖt know. I thought my brother was his POA.GÇ¥ When asked it R21 was appropriate for the secured facility, she stated that she could not answer that. She stated that he wanted his freedom. When asked if R21 seemed more depressed by living on the secured unit, she stated, GÇ£Absolutely.GÇ¥ Review of the undated Friendship House Disclosure Statement included the Friendship House philosophy was to provide an atmosphere that promotes independence, dignity, privacy, choice and continued opportunity for family and community involvement while meeting the unique needs of each resident. Specific objectives included to ensure that each resident achieves and maintains the maximum level of independence possible, to develop and maintain a care plan that provides an approach for care that meets each residentGÇÖs unique needs, and maintains a home-like atmosphere that supports freedom, dignity and choice for residents in the least restrictive wayGǪ The interdisciplinary team members will review the residentGÇÖs appropriateness to remain on the Friendship House Unit each time they conduct the residentGÇÖs quarterly assessment. The resident must meet specific criteria to remain on a secured unit. Review of the facility policy titled, Abuse, Neglect and Exploitation GÇô Clinical Protocol, updated 10/05/22, included, GÇ£AbuseGÇ¥ means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.GÇ¥

Resident # 21-SSD to schedule a care conference to include Resident to discuss placement options including transition to ICF bed in facility. On 4/8/26 Resident #21 was given a tour and offered a bed on the ICF unit by Admin and DNS. Resident declined move to the ICF unit.   We will continue to coordinate discharge planning including resident and family. Any resident who does not meet criteria for the secured memory care unit is potentially impacted. 100% audit of all memory care residents will be completed by IDT to ensure Memory care criteria are met. Placement/discharge care plan to be updated to reflect results of audit, as indicated VP of clinical services will Inservice IDT team on secured memory unit criteria for placement and Quartey review of placement. Admin will audit new admission placement and post care conference to ensure criteria is meet weekly x 4 weeks and monthly x90 days. Auding findings will be discussed in QA to ensure ongoing compliance.

Review of R24's ""Admission Record,"" located in the electronic medical record (EMR) under the ""Profile"" tab, revealed R24 was admitted to the facility on 12/18/24 with diagnoses including vascular dementia and anxiety. -á Review of R24's annual ""Minimum Data Set (MDS),"" located in the EMR under the ""MDS"" tab, with an Assessment Reference Date (ARD) of 01/19/26, revealed R24 had a -áStaff Assessment for Mental Status (SAMS)"" which indicated R24 had long and short-term memory problems. The ""MDS"" also indicated R24 received hospice services. -á Review of R24's ""Order Summary Report,"" revealed an order, dated 10/18/25, for lorazepam (anti-anxiety) oral concentrate 2 mg/ml (milligrams/milliliters), .25 ml every 4 hours as needed (PRN) for anxiety, restlessness, and dyspnea (sensation of difficulty breathing). -á Review of R24's ""Care Plan Report,"" located in the EMR under the ""Care Plan"" tab, revealed a care plan, dated 12/11/25, that indicated R24 had psychotropic medication due to anxiety. -á Review of ""Pharmacist's Recommendation to Prescriber,"" dated 11/03/25 and located in the EMR under ""Documents"" tab, revealed ""Findings/Recommendations: [R24] has an order for the following PRN [pro-re-nata, as needed] psychotropic medication: for lorazepam oral concentrate 2 mg/ml, .25 ml every 4 hours as needed for anxiety, restlessness, and dyspnea. CMS requires a 14 day stop on all PRN psychotropic medications unless the prescriber documents clinical rationale for continued use and proves a new duration for use on the continued order.GǪPrescribers Comments patient has prn psychotropics as end-of-life meds. Given the nature of-á [R24's] disease process and end of life and decline, this is still very much appropriate. PRN need in perpetuity."" -á During an interview on 04/09/26 at 10:46 AM, the Director of Nursing (DON),-á stated all PRN psychotropic medications should have a stop date on them. -á Review of facility policy titled,"" Psychoactive Medication Management & Chemical-Restraint Prevention,"" dated 04/25/25, specified ""to ensure every resident of (sic) free from chemical restraints and that all psychoactive (psychotropic) medications are prescribed, administered, monitored, and discontinued in according with CMS regulations at F605 Chemical Restraint. GǪ PRN order for any psychotropic drug are limited to 14 days unless the prescriber re-evaluates the resident and documents rationale and a specific duration."" , Findings Resident 9 Review of Resident 9's (R9) electronic health records documented the facility admitted the resident on 3/16/22-á with diagnoses including anoxic brain injury (condition that occurs when the brain is deprived of oxygen), dementia, depression, encephalopathy (disease or dysfunction of the brain, affecting its normal function) and delusions (fixed, false belief not shared by others that the resident holds even in the face of evidence to the contrary). R9's Minimum Data Set (MDS-assessment tool) dated 2/2726 documented residentGÇÖs brief interview for mental status (BIMS) was 9 of 15 indicating moderate cognitive impairment. Review of R9GÇÖs current Medication Administration Record (MAR) and physicianGÇÖs orders documented: * Lorazepam Tablet (anti-anxiety) 0.5 MG *Controlled Drug* Give 1 tablet sublingually (under tongue) every 5 minutes as needed for Single dose SL w/onset of seizure CALL 911 if 1st dose ineffective- May repeat every 5 minutes up to 3 doses. CALL 911 if 1st dose ineffective- Continued Lifelong for emergent treatment of possible seizures. Start date was 3/12/24. GÇ£IndefiniteGÇ¥ was shown in the GÇ£End dateGÇ¥ section of the order details. Review of R9GÇÖs current care plan, MAR, physician orders and medication regimen review from Sept 2025 did not show documented practitioner specified duration for continuation of Lorazepam beyond 14 days. During an interview on 04/08/2026 at 1:09 PM Director of Nursing (DON) read R9GÇÖs Lorazepam order and stated it was for seizures. DON confirmed Lorazepam was a psychotropic medication and there was no end date for the medication which was started on 3/12/24, more than 14 days ago. During an interview on 04/09/2026 at 3:01 PM Administrator stated that staff should be following facilityGÇÖs policy which state as needed psychotropic medications orders should have a specified duration. Re view of facility policy Psychoactive Medication Management & Chemical-Restraint Prevention, dated 4/25/25, PRN (as needed) orders for any psychotropic drug are limited to 14 days unless the prescriber re-evaluates the resident and documents rationale and a specific duration. Anxiolytics (anti-anxiety medications) were defined as psychoactive/psychotropic Medications.

#9 Updated clinical justification from provider for Lorazepam received for use to treat active seizure disorder. Stop date has been clarified with provider for the PRN use of Lorazepam. #24 Reviewing with hospice prescriber potential DC or clarification of the duration to be indefinite duration. Stop date has been clarified with Hospice provider for the PRN Ativan use. All residents on PRN psychotropic medications for treatment of mood or behavior, are potentially impacted. 100% audit of residents on PRN psychotropic medications has been completed to ensure duration of use is specified by provider. Psychoactive medication  P&P as been updated. DNS, RCM and licensed staff have been inserviced on the PRN 14 day end date and prescriber clinical justifications, as indicated for longer durations. DNS will audit all new PRN psychoactive weekly X4 monthly x 90 days to ensure end dates are provided. Results of audits will be reviewed by facility QAPI committee, to ensure ongoing compliance.

Findings include: For R6: Review of the Admission Record revealed R6 was admitted to the facility on 08/02/23 with diagnoses which included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance (indicates a diagnosis of dementia where the type (e.g., AlzheimerGÇÖs, vascular) and severity (mild, moderate, severe) are unknown, and the resident shows no significant behavioral or psychological symptoms), and anxiety. An Interdisciplinary (IDT) Progress Note dated 11/09/25 at 6:20 AM revealed the resident appeared to be very confused that morning after care. According to the note, he couldnGÇÖt follow direction, was unable to make a full sentence, was mumbling, and looking at staff and unable to say anything. He refused to have vital signs taken. The Director of Nursing Services (DNS) notified the provider and received an order to send the resident to the hospital for further evaluation of the mental status change. 911 was called and the resident left the facility at 6:35 AM with paramedics. Per the note, the family would be notified. Review of R6GÇÖs medical record provided no evidence of a written Notice of Transfer/Discharge or a bed hold notice. On 04/09/26 at 1:20 PM the facility Administrator stated she was unable to locate the Notice of Transfer or bed hold notice for this hospitalization. During an interview conducted on 04/09/26 at 2:14 PM, the Director of Nursing Services stated that the process was for the bed hold to be provided in the packet when the resident goes out. She stated that the facility would notify the family verbally, by phone. On 04/09/26 at 2:37 PM an interview was conducted with the Director of Social Services. She stated that the facility process was to hold the residentGÇÖs bed for 14 days, per policy. She stated that she was not sure whether the resident/family/representative would receive a written notice of the transfer or the bed hold policy. Review of the facility's Bed Hold Policy, undated, included, a Transfer Notice is completed in the Transfer Notice and Bed Hold Policy Assessment in [the electronic record]. The reason for the transfer is included in the notice by the Licensed Nurse at the time of transfer... The Transfer Notice and Bed Hold Policy will be included in the packet sent with the resident to the transfer location. The requirement is met if the resident's copy of the notice of transfer and bed hold is sent with the papers accompanying the resident to the hospital. , Findings Resident 37 Review of Resident 37's (R37) record indicated the facility admitted the resident on 8/16/23 with diagnoses including dementia. On 11/25/25, had a planned discharge to a residential care facility. Review of R37GÇÖs discharge notes stated that discharge was due to a required lowered level of care. R37's discharge Minimum Data Set (MDS-assessment tool) dated 11/25/25 documented resident was discharged home/community on 11/25/25. R37's record did not include documentation that a written notice of discharge was provided to resident/representative. During a concurrent interview and record review on 04/08/2026 at 1:02 PM Director of Nursing (DON) stated that when residents are discharged the facility provides a green Oregon pamphlet that gives residents the right to return to the facility and includes their appeal rights and information on advocacy agencies. DON reviewed R37GÇÖs records and confirmed there was no evidence that resident was provided with this information. During an interview 04/08/2026 at 12:59 PM Administrator stated that when residents are sent to their residential care facility side of the campus, this is considered a discharge home. During an interview on 04/10/2026 at 11:28 AM Administrator stated that written notice provided to R37GÇÖs for 11/25/25 discharge was not found, but a discharge notice should have been sent. Review of facility policy Notice Transfer Discharge TD, dated 5/2010, documented -áGÇ£our facility shall provide a resident and/or the residentGÇÖs representative with a thirty (30) day written notice of an impending transfer of discharge. The notice will provide the reason for transfer of discharge, the effective date of the transfer or discharge, the location to which the resident is being transferred or discharged, the name, address, and telephone number of the state long-term care ombudsman, the name, address, and telephone number of each individual or agency responsible for the protection and advocacy of mentally ill or development disabled individuals (as applies); and the name, address, and telephone number of the state health department agency that has been designated to handle appeals of transfers and discharge notices.GÇ¥

1. 100% audit completed of residents that were transferred to hospital in the last 30 days. 2. DNS to inservice LN and RCM to be on Oregon Notice of Transfer or Discharge and Bed Hold requirement to be completed at time of discharge to emergency department or acute care directly. 3. DNS to monitor transfers to acute weekly x4 weeks and monthly x90 days for compliance 4. Reports of audit will be reported and monitored at QA to ensure ongoing compliance is attained

Findings Preadmission Screening and Resident Review (PASARR) GÇ£is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. PASARR requires that 1) all applicants to a Medicaid-certified nursing facility be evaluated for serious mental disorder (SMI) and/or intellectual disability (ID); 2) be offered the most appropriate setting for their needs (in the community, a nursing facility, or acute care setting); and 3) receive the services they need in those settings. Individuals identified with SMI or ID indicators are referred for GÇ£PASARR Level IIGÇ¥. PASARR Level II evaluation will confirm the identification of SMI/ID and determine if specialized services are required. Review of Resident 4's (R4) electronic health records indicated the facility admitted the resident on 2/29/24 with diagnoses including vascular dementia with behavioral disturbance, restlessness and agitation, schizoaffective disorder (mental health condition with mood disorder symptoms). R4's Minimum Data Set (MDS-assessment tool) dated 5/12/25 documented GÇ£noGÇ¥ response to question GÇ£Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? Review of R9GÇÖs record documented a PASARR Level II evaluation, dated 11/11/24, under PASRR Level II Determination section of the evaluation, it showed the resident meet PASRR Level II criteria for a serious mental illness. The MDS, dated 5/12/25, coding was inconsistent with the residentGÇÖs PASARR Level II evaluation, which confirmed the resident had been evaluated under the Level II process and determined to have a serious mental illness. During concurrent interview and record review on 04/08/2026 at 11:44 AM, the Business Office Manager (BOM) confirmed he completed the MDS section A which included the PASARR section by obtaining information from PASARR forms in the medical record. After review of R4GÇÖs PASARR documentation and MDS, BOM confirmed the MDS coding was inaccurate and that the response should have been GÇ£YesGÇ¥ to reflect the residentGÇÖs PASARR Level II status. BOM stated that the facility uses the Resident Assessment Instruction (RAI) as their policy and the MDS should be accurate. During an interview on 04/09/2026 at 3:01 PM Administrator stated that R4GÇÖs MDS was inaccurate and her expectation is the MDS is accurate. Review of Long-Term Care Facility Resident Assessment Instrument 3.0 UserGÇÖs Manual Version 1.20.1, dated October 2025, documented GÇ£The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that (1) the assessment accurately reflects the residentGÇÖs status.GÇ¥

Resident #9 MDS was corrected. 100% of residents with PASRR level 2 needs are potentially impacted. 100% audit of MDS has been completed. Medical Records and SSD have been inserviced on the coding for Section A PASARR. SSD to audit MDS completed weekly to ensure PASSR coding is correct. Weekly x 4 weeks and monthly x90 days. Results of audits will be reviewed by facility QAPI committee, to ensure ongoing compliance.

Findings Preadmission Screening and Resident Review (PASARR) GÇ£is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. PASARR requires that 1) all applicants to a Medicaid-certified nursing facility be evaluated for serious mental disorder (SMI) and/or intellectual disability (ID); 2) be offered the most appropriate setting for their needs (in the community, a nursing facility, or acute care setting); and 3) receive the services they need in those settings. Individuals identified with SMI or ID indicators are referred for GÇ£PASARR Level IIGÇ¥. PASARR Level II evaluation will confirm the identification of SMI/ID and determine if specialized services are required. Review of Resident 3's (R3) electronic health records indicated the facility admitted the resident on 12/31/24 with diagnoses including bipolar disorder (serious mental illness characterized by extreme mood swings) and dementia with behavioral disturbance, and traumatic brain injury. Review of the R3GÇÖs PASARR Level I screening completed prior to admission, dated 12/31/24, indicated GÇ£no serious mental illness.GÇ¥ There was no evidence in the record that the Level I findings were reviewed for accuracy or reconciled with the residentGÇÖs documented diagnoses. Review of R3GÇÖs records did not reflect documented evidence the facility referred R3 to the State-designated PASARR authority for a Level II evaluation after identifying the residentGÇÖs bipolar disorder. During a concurrent interview and record review on 04/08/2026 at 11:25 AM Social Services Director (SS) reviewed R3GÇÖs PASARR level 1 and confirmed it indicated no serious mental illness. SS and surveyor reviewed OregonGÇÖs Department of Human Services Form 0460INS GÇô Instructions for Form 0460, Pre-Admission Screening/Resident Review (PASRR) Level I, dated 01/08, located at https://sharedsystems.dhsoha.state.or.us/DHSForms/Served/se0460ins.pdf . Based on review of the form, SS stated that R3 met the conditions for SMI identification which included 1) mental health diagnosis, 2) mental health diagnosis resulted in significant impaired functioning within the past 3-6 months, and 3) due to mental health diagnosis sustained a significant disruption to their living situation within the past 2 years. These conditions were present prior to nursing home admission. SS stated that the facility should have referred R3 for PASARR level 2 evaluation. SS further stated that when residents are admitted, the facility evaluates the residents and completes a level 2 if needed, this should have been done for R3, but it was not. During an interview on 04/09/2026 at 3:01 PM Administrator stated that R3 had a history of SMI and acknowledged that a Level II referral should have been initiated. Review of facilityGÇÖs Pre-Admission Screening & Resident Review (PASRR) Protocol GÇô Oregon, undated, documented if a person starts to exhibit any behaviors related to SMIGǪthen start with Level 1 PASSR and request a Level II. -á

Resident #3 PASSAR has been completed. Any resident requiring a PASSAR level 2 upon admit is potentially impacted 100% audit has been completed, and a referral to PASSAR has been done as indicated. VP of Clinical services has inserviced IDT on admission requirements for PASSAR level 2, for any with SMI or IDD. Admin to complete audits to occur weekly x 4 weeks and monthly x90 days. Results of audits will be reviewed by facility QAPI committee, to ensure ongoing compliance.

Findings-á -á 1. Review of R1's ""Admission Record,"" located in the electronic medical record (EMR) under the ""Profile"" tab, revealed R1 was admitted to the facility on 07/25/24 with diagnoses including anxiety disorder, pneumonitis, and dementia. -á Review of R1's quarterly ""Minimum Data Set (MDS),"" located in the EMR under the ""MDS"" tab, with an Assessment Reference Date (ARD) of 01/23/26, revealed R1 had a ""Brief Interview for Mental Status (BIMS)"" score of four out of 15, which indicated R1 had severely impaired cognition. -á Review of R1's ""Care Plan Report,"" located in the EMR under the ""Care Plan"" tab, revealed a care plan, dated 07/25/24, indicating R1 was at risk for falls related to cognitive impairment, a history of falls, and use of psychotropic medications. An intervention, dated 03/16/26, instructed staff to ensure R1 had a nonskid mat under his reclining chair. -á During an observation and interview with R1 on 04/06/26 at 3:24 PM, R1 attempted to stand and there were no nonslip mats on his floor. R1 stated he had never had anything on his floor. -á During an observation on 04/07/26 at 3:47 PM, there was no nonslip mat under R1's recliner or anywhere on the floor. -á During an interview on 04/06/26 at 3:47 PM, Certified Medication Assistant (CMA) 1, confirmed there was no mat on the floor. He stated if there were any fall interventions they would be listed on KARDEX (quick reference tool used by staff to summarize patients care needs, medication, and daily requirements). -á Review of R1's KARDEX, dated 04/08/26, located in the EMR under the ""Care Plan"" tab, revealed ""provide nonskid (sic) mat under reclining chair."" -á During an interview on 04/08/26 at 3:11 PM, Certified Nursing Aide (CNA) 8 he stated after reviewing the KARDEX R1 should have a nonslip mat under his recliner and it was not there. -á During an interview on 04/09/26 at 10:46 AM, the Director of Nursing (DON) stated all fall interventions that are on the care plan should be put in place for the resident. R1 should have a nonslip mat under his recliner. -á 2. Review of R33's ""Admission Record,"" located in the electronic medical record (EMR) under the ""Profile"" tab, revealed R33 was admitted to the facility on 05/12/25 with diagnoses including depression, unspecified dementia, and dysphagia, oropharyngeal phase. -á Review of R33's quarterly ""Minimum Data Set (MDS),"" located in the EMR under the ""MDS"" tab, with an Assessment Reference Date (ARD) of 03/13/26, revealed R33 had a ""Brief Interview for Mental Status (BIMS)"" score of three out of 15, which indicated R33 had severely impaired cognition. -á Review of R33's ""Care Plan Report,"" located in the EMR under the ""Care Plan"" tab, revealed a care plan, dated 05/22/25, that indicated R33 had potential for or had impaired nutrition related to cognitive impairment, knowledge deficit, and sedentary lifestyle. An intervention instructed staff to ensure R33 was supervised or was provided oversite and needed encouragement and cueing with meals and snacks. R33 needed assistance when fatigued and staff should ensure R33 is sitting up for meals in chair or wheelchair. -á During an observation on 04/06/26 at 1:33 PM, in R33's room on the bedside table revealed the food on R33's tray was observed untouched. Her silverware was still wrapped in a napkin. R33's milk, prune juice, and water were still covered with the plastic lid. The bedside table was observed next to the bed and R33 was also observed lying in her bed, sleeping through her meal. No staff was observed assisting or prompting R33 throughout the meal. -á During an observation on 04/06/26 at 1:59 PM, R33's meal tray was observed in the tray cart, and the meal was untouched. -á Review of R33's ""POC [point of care] Response History,"" located in the EMR under the ""Task"" tab, dated 03/28/26 to 04/10/26, revealed R33 consumed zero to 25% of her meal on 04/06/26 during the lunch meal service. -á During an observation on 04/07/26 at 1:22 PM, in R33's room, Certified Nurse Aide (CNA)14 was observed setting R33's tray up for lunch on her bedside table. CNA14 ensured all food and drink lids were off and silverware was unwrapped from the napkin, available to use. R33 was observed in her bed. CNA14 prompted R33 to eat, R33 took one bite and set her spoon back on the plate. After CNA14 ensured R33 was set up for lunch, she left the room. When CNA14 left R33's room, R33 laid back on her bed. Staff were not observed assisting R33 again during the meal. -á During an interview on 04/07/26 at 1:23 PM, CNA14 stated staff make sure R33 is set up to eat in her room. -á During an observation on 04/07/26 at 1:59 PM, R33's meal tray was observed in the tray cart, the meal was observed to have less than 25% consumed. -á Review of R33's ""POC Response History,"" located in the EMR under the ""Task"" tab, dated 03/28/26 to 04/10/26, revealed R33 consumed zero to 25% of her meal on 04/07/26 during the lunch meal service. -á During an interview on 04/08/26 at 11:48 AM, the Registered Dietician (RD) stated R33 is care planned to have assistance and supervision. She added it was limited but she would expect staff to ensure R33 is set up to eat her meal and prompting her to eat throughout the meal. The RD stated she would also expect staff to get R33 in a chair or wheelchair to eat her meals. She added R33 does not like to eat in the dining room as it can be overstimulating for R33 so staff should be setting her up in the hall to eat her meals. -á During an interview on 04/09/26 at 10:46 AM, the Director of Nursing (DON) confirmed care plans should be followed. She stated if R33's care plan advised staff R33 needed assistance and supervision with meals then she expected staff to provide the proper assistance and supervision. -á Review of facility policy titled, ""Care Plans- Person Centered Comprehensive,"" dated 10/2024, specified ""An individualized Person-centered comprehensive care plan that includes objectives and goals to meet the resident's medical, nursing, mental and psychological needs is developed for each resident based on the resident strengths, needs and preferences.""

R1 non skid pad is in front of recliner. R 33 is receiving feeding assistance as necessary. Residents that have non skid pad or feeding assistance are potentially impacted by this citation. Inservice provided to all staff 4/13/26 regarding following Kardex for fall matts and non-skid matts. RCM to audit to ensure fall matts and feeding assistance are followed Weekly x 4 weeks and monthly x90 days. Results of audits will be reviewed by facility QAPI committee, to ensure ongoing compliance.

Findings include: Review of the Admission Record revealed that R21 was admitted to the facility on 08/14/25 with diagnoses which included unspecified dementia, mild, with other behavioral disturbance (early-stage cognitive decline where memory/thinking problems are present but not yet severe, the specific cause (e.g., AlzheimerGÇÖs vs vascular) is not determined, and notable behaviors occur), and repeated falls. The Admission Record revealed the resident was his own representative. Review of the residentGÇÖs record did not provide evidence that a Healthcare Power of Attorney (HPOA) had been established. An Order Summary Report dated 08/11/25 revealed a handwritten note on the right, bottom of the page which included, GÇ£Admit to the secure unit.GÇ¥ The note was signed and dated by the provider. No rationale was indicated. Review of the residentGÇÖs record provided no evidence of documentation of the clinical criteria met for placement on the secured/locked unit or documentation that reflected whether placement in the secured/locked area was the least restrictive approach that was reasonable to protect the resident and assure his health and safety. An admission Minimum Data Set (MDS) assessment dated 08/25/25 revealed that the resident scored 13 on the Brief Interview for Mental Status (BIMS) assessment, suggesting intact cognition. Behaviors included verbal behavioral symptoms directed toward others which occurred 4 to 6 days out of the 7-day lookback period, with no wandering noted. Review of the Quarterly Multidisciplinary Care Conference meeting notes dated 12/18/25 included the following attendees: the Social Services Director (SSD/Resident Care Manager (RCM), the Director of Nursing Services (DNS), with the residentGÇÖs brother and sister attending via phone. The justification for the resident not being in attendance was noted as, GÇ£Due to cognitive impairment, resident would not benefit from being part of this meeting.GÇ¥ The Discharge Planning portion of the notes indicated, GÇ£Family requests resident continue at the Friendship House [secured unit] for Long-term care.GÇ¥ The IDT recommendation included, GÇ£Resident does not desire discharge, continues to need and benefit from nursing facility placement.GÇ¥ The quarterly MDS assessment dated 02/20/26 revealed the resident scored 15 on the Brief Interview for Mental Status, indicating intact cognition. His behaviors included verbal behavioral symptoms directed toward others occurred 4 to 6 days out of the 7-day lookback period and the resident refused care 1 to 3 days out of the 7-day lookback period. Per the assessment, no wandering had occurred since the prior assessment. Review of a Multidisciplinary Care Conference meeting note dated 03/17/26 revealed the SSD and DNS/RCM were in attendance. The residentGÇÖs brother and sister attended via phone. According to the documentation, the justification for the resident not to be in attendance and/or participating in the resident-centered care planning process was noted as, GÇ£Due to cognitive impairment, resident would not benefit from being a part of this meeting.GÇ¥ The discharge plan per IDT recommendation was for the resident to continue at the Friendship house for long-term care. The IDT recommendation included, GÇ£Resident does not desire discharge, continues to need and benefit from nursing facility placement.GÇ¥ During a follow-up interview and concurrent record review conducted on 04/09/26 at 8:29 AM with the facility Administrator, she was asked whether ongoing assessments for continued placement on the secured unit had been conducted, she reviewed the residentGÇÖs record and stated that she did not see ongoing assessment for continued placement on the unit. She stated that quarterly reviews should have been completed. She stated that the facility had conducted Care Conferences with the SSD/RCM, DNS, the residentGÇÖs family, and she thought the resident was involved. She stated that if the family held POA, they might choose to conduct the conference without the resident present. When asked if the resident had designated a POA, she stated there was no POA in place. GÇ£At this time, he is his own representative and should be invited to his care conferences.GÇ¥ On 04/09 26 at 9:53 AM a follow-up interview was conducted with the SSD. She stated that Care Planning Conferences were conducted quarterly, about every 90 days. She stated that residents who represent themselves are invited to come, and the residentGÇÖs family may come if the resident gives permission. She stated R21GÇÖs family was very involved and that the residentGÇÖs sister had requested that R21 not come to the meetings. She stated that for the conference conducted on 09/12/25, she thought they invited the R21 to come, GÇ£but he was really upset, and just wanted out of here,GÇ¥ so only the brother and sister attended the meeting. She stated that after placement, the resident had been very upset because he felt that he had just been dropped off here and no one told him anything. For the care conference held on 03/16/26, she stated that the resident was not invited because he had just come back from the hospital and was sleeping a lot. When asked, she said the resident represented himself and the family couldn't exclude him from his care conference. Review of the facility policy titled, Care Plans- Person Centered Comprehensive, revised 10/2024, included an individualized Person-centered comprehensive care plan that includes objectives and goals to meet the residentGÇÖs medical, nursing, mental and psychological needs is developed for each resident based on the resident strengths, needs and preferences. Our facilityGÇÖs Care Planning/Interdisciplinary Team, in coordination with the resident, resident representative develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain in alignment with resident goals for admission and desired outcomes. -á -á

Resident 21 Care conference has been scheduled to include resident and care planning decisions. All residents have the right to be invited to care conferences and to participate in care plan decision making, as able. IDT staff to be in-serviced on resident right to attend Care conference. Admin to100% audit of care conference attendees Weekly x 4 weeks and monthly x90 days. Results of audits will be reviewed by facility QAPI committee, to ensure ongoing compliance.

Findings Review of Resident 3's (R3) electronic health records indicated the facility admitted the resident on 12/31/24 with diagnoses including bipolar disorder (serious mental illness characterized by extreme mood swings), dementia with behavioral disturbance, and traumatic brain injury. R3's Minimum Data Set (MDS-assessment tool) dated 1/2/26 documented residentGÇÖs brief interview for mental status was 99 indicating the interview was not completed or was stopped before completion, had severely impaired cognitive skills for decision making, exhibited physical behavioral symptoms directed towards others, verbal behavioral symptoms directed towards others (e.g., screaming at others), and other behavioral symptoms not directed towards others (e.g., pacing, rummaging, disrobing in public, or verbal/vocal symptoms like screaming, disruptive sounds) for 1 to 3 days during the past 7 days. The MDS documented that R3 wandered daily and the residentGÇÖs wandering significantly intruded on the privacy or activities of others. The above behaviors were the same compared to prior assessments. R3 resided in the secured unit of the facility. Review of R3GÇÖs care plan in place at the time of 11/16/25 incident, documented wandering behavior, initiated on 6/24/25, identifying that resident GÇ£can create undesired situations by wandering into co-residentGÇÖs rooms uninvited and need redirected 10 x per dayGÇ¥. Record review indicated an elopement risk assessment was completed upon admission, dated 1/2/25, with a risk score of 42, indicating a high potential to leave the facility without permission. Review of R3GÇÖs multi-disciplinary meetings, dated 1/21/26, documented behaviors included anxious, repetitive motions/questions, restless, pacing, panic, inappropriate toileting, spending time back and forth from room to common room, and entering resident's rooms. There was no documented evidence that elopement risk was reassessed. Review of R3GÇÖs progress notes and elopement assessments did not show any subsequent elopement reassessment during the past 15 months, despite continued and frequent wandering behaviors. Review of R3GÇÖs behavior monitoring and interventions report, dated 3/10/26 to 4/8/26, documented resident wandered six times during this time period. Observation on 04/06/2026 at 2:49 PM showed R3 wandering up and down the hallways of the secured unit, making several loops, while loudly saying word salad. R3 verbalized random and unrecognized words (saggy baggy, pickle, word salad) loudly while walking. There were stop signs on Rooms #2, 6, and 8 and a picture of a horse on R3GÇÖs door. R3 was observed entering Room #3. After several seconds, Certified Medication Assistant (CMA) 3 entered Room #3 and asked resident to come out of the room and walked resident out of the room. CMA3 stated that R3 walks up and down the hallway and when she doesnGÇÖt see R3 in the hallway, it means R3 was in a resident's room. CMA3 stated that R3 goes into all residentGÇÖs rooms and opens the door and stated that the other residents don't like R3 going into their rooms. The Social Services Director (SSD) approached R3 and asked R3 if she wanted to go outside in the courtyard. R3 said yes. During an interview on 04/06/2026 at 3:02 PM Certified Nursing Assistant (CNA) 4 stated that R3 had been entering other residentsGÇÖ rooms GÇ£since last yearGÇ¥ and that staff would often have to search for her when she wandered into rooms, noting that other residents would become GÇ£angry, upset, and irritatedGÇ¥ when this occurred. During an interview on 04/06/2026 at 3:15 PM Certified Medication Assistant (CMA) 3 stated that R3 entered other residentsGÇÖ rooms daily (1GÇô2 times per day) and that the behavior had increased over the past 3GÇô6 months, with interventions such as stop signs during last couple months (after 11/16/25 incident) not helping. The residents with the stop signs on their doors (R4 had a sign on his door) are not ok with R3 going into their rooms and they yell at her. Observation on 04/07/2026 at 9:15 AM showed R3 wandering up and down the hallways of the secured unit, making several loops, while loudly saying word salad. R3 approached several residents right up their face while loudly saying word salad. Other residents would frown and move away from R3. R3 continued to loudly say word salad. During an interview on 04/07/2026 at 9:21 AM CNA18 stated that R3 would wander everywhere, she would scream at people sometimes. Observation on 04/07/2026 at 2:41 PM showed R3 wandering the hallways of the secured unit with her walker. During an interview on 04/07/2026 at 2:41 PM CNA18 stated that R3 wandered the hallways constantly in the secured unit. CNA18 stated that R3 can't open the doors at either end of the hallways, both doors required codes to be entered to open the door. CNA18 stated that if R3 sees someone exiting the doors leading to the other unit, R3 will try to follow them out, so we have to be careful when exiting doors. CNA18 pointed to the camera above the staff room near the exit door which was pointed down the hallway. CNA18 confirmed R3 di did not wear a wander guard alarm that alerts staff if she were to exit the unit. Observation on 4/07/2026 at 3:28 PM showed R3 wandering up and down the hallways of the secured unit, making several loops, while loudly saying word salad. During an interview on 04/08/2026 at 10:05 AM CNA20 stated that R3 wanders and is at risk for elopement. R3 knocks at the exit door to the other unit and tries to get out. CNA20 further stated that if someone opens the door, R3 follows them, that's why R3 knocks on the door. Observation on 04/08/2026 at 11:15 AM showed R3 wandering up and down the hallways of the secured unit, making several loops, while loudly saying word salad. During an interview on 04/08/2026 at 11:25 AM Social Services Director (SS) stated that R3 entered R4GÇÖs room, R3 was in R4GÇÖs space, and when R3 attempts to go into other residentGÇÖs room, the other residentGÇÖs get upset and tell her to get out. Staff are supposed to redirect R3. SS stated that R3 would bang on secured doors leading to the other nursing unit. During an interview on 04/08/2026 at 1:09 PM Director of Nursing (DON) stated that R3GÇÖs behaviors of wandering and entering other residentsGÇÖ rooms were baseline and longstanding. DON stated that the elopement risk assessments are completed upon admission, but the facility does not routinely reassess elopement risk after admission even when behaviors persist or change. DON reviewed R3GÇÖs elopement risk assessment, dated 1/2/25, completed on admission and confirmed the facility had not reassessed several risk factors since admission such as previous attempts to leave, exit-seeking behaviors, shadowing staff, statements that resident wanted to go home or adjustment issues. During an interview on 04/09/2026 at 3:01 PM Administrator stated that R3 wanders but is not an elopement risk. Administrator stated that she hasnGÇÖt heard or seen R3 knocking on -áICFGÇÖs (non-secured nursing unit) door or following staff when they exit. When informed of observations of R3 pulling on exit door handles and staff reporting resident following staff when they exit, Administrator stated that R3 is not necessarily following staff out the door to exit. Administrator reviewed admission elopement risk assessment, dated 1/2/25, and stated that this was the only assessment completed but reassessments should have been done because the current assessment does not reflect residentGÇÖs current status, for example, resident has not voiced desire to exit and is not watching the exit doors. Review of facility policy Elopement Risk Assessment, dated 5/1/22, documented GÇ£E lopement is by definition- A resident who leaves the premises, or safe area, without authorization and/or any necessary supervision required to do so. -áTypically, these residents have some cognitive deficits, substance abuse/with impaired judgement, where leaving the facility without supervision would be deemed unsafeGǪ.assessment is completed by day 3 after admission. Residents with history of wandering were considered indications for elopement risk assessmentGǪ. Additional Elopement Risk assessment to be completed if the resident has a change in behavior in exit seeking/elopement type behaviors that were previously not present and/or change in cognitive status that would change the risk factors in the Elopement Risk assessment previously completed.GÇ¥ Please also see F600.

R3 Elopement Risk Reassessed Resident #3 Care plan for resident specific interventions for wandering or elopement seeking has been reviewed and updated.  Resident is in a secure memory care unit designed for residents with exit seeking and wandering. The Stop signs have not been effective for Resident #3 as she has no awareness, these will be removed. IDT revaluated person-centered interventions to reduce potential conflict with others. All residents with intrusive wandering have the potential to be effected by this. 100% audit of residents with intrusive wandering have been reviewed, CP interventions update as indicated. Re-Inservice provided to memory care staff regarding person centered approaches diversional activity for intrusive wandering residents. Activities director to do Random audit post meal when congested for intervention and redirections weekly X4 x then monthly 90 days. Results of audits will be reviewed by facility QAPI committee, to ensure ongoing compliance.

Findings -á Review of R1's ""Admission Record,"" located in the electronic medical record (EMR) under the ""Profile"" tab, revealed R1 was admitted to the facility on 07/25/24 with diagnoses including anxiety disorder, pneumonitis, and dementia. -á Review of R1's quarterly ""Minimum Data Set (MDS),"" located in the EMR under the ""MDS"" tab, with an Assessment Reference Date (ARD) of 01/23/26, revealed R1 had a ""Brief Interview for Mental Status (BIMS)"" score of four out of 15, which indicated R1 had severely impaired cognition. -á Review of R1's ""Physician Orders,"" located in the EMR under the ""Orders"" tab, revealed the following order, dated 02/04/26, oxygen 2 l/min (liters/minute) via nasal cannula as needed for oxygen saturation less than 90% on room air. -á During an observation on 04/06/65 at 12:19 PM, an oxygen cylinder in an oxygen cart with tubing and cannula hanging over the handle of the cart; the cannula touching the floor. -á During an interview on 04/06/26 at 12:19 PM, R1 stated the oxygen was left ""just hanging there like that."" -á During an observation on 04/08/26 at 1:25 PM, an oxygen cylinder in an oxygen cart with tubing and cannula hanging over the handle of the cart; the cannula touching the floor. -á During an interview on 04/08/26 at 1:52 PM, Licensed Practical Nurse/Licensed Nurse (LN) 8 confirmed the oxygen tubing and cannula were hanging over the cart. She added the tubing and cannula should be stored in a bag when the resident is not using it. She stated it is an infection control issue. -á Review of the facility policy titled, ""Departmental (Respiratory Therapy)- Prevention of Infection GÇô Level I,"" dated 02/2014, specified ""The purpose of this procedure is to guide prevention of infection associated with respiratory therapy task and equipment, including ventilators, among residents and staff. Infection Control Considerations Related to Oxygen AdministrationGǪkeep the oxygen cannula and tubing in used PRN [pro-re-nata, as needed] in a plastic bag when not in use.""

R1 canister and canula removed from room, as not in use. Currently no other resident is on 02. DNS designee will audit weekly x4 x then monthly X 90 days . Results of audits will be reviewed by facility QAPI committee, to ensure ongoing compliance.

Findings -á Review of R33's ""Admission Record,"" located in the electronic medical record (EMR) under the ""Profile"" tab, revealed R33 was admitted to the facility on 05/12/25 with diagnoses including depression, unspecified dementia, and dysphagia, oropharyngeal phase. The face sheet also listed an allergy to dairy. -á Review of R33's quarterly ""Minimum Data Set (MDS),"" located in the EMR under the ""MDS"" tab, with an Assessment Reference Date (ARD) of 03/13/26, revealed R33 had a ""Brief Interview for Mental Status (BIMS)"" score of three out of 15, which indicated R33 had severely impaired cognition. -á Review of R33's ""Care Plan Report,"" located in the EMR under the ""Care Plan"" tab, revealed a care plan, dated 05/22/25, that indicated R33 had potential for or had impaired nutrition related to cognitive impairment, knowledge deficit, and sedentary lifestyle. An intervention instructed staff to provide diet according to the physician's order. -á Review of R33's ""Order Summary Report,"" dated 04/09/26, revealed an order, dated 05/12/25, which indicated ""Regular DietGǪNo milk or other dairyGǪ"" -á During an observation on 04/06/26 at 1:33 PM, in room R33's on her bedside table, the drinks provided on her tray included milk, juice, and water. -á During an interview on 04/06/26 at 1:34 PM, Certified Medication Assistant (CMA)3 confirmed R33 did receive milk with her lunch. -á During an observation on 04/07/26 at 1:22 PM, in room R33's on her bedside table, the drinks provided on her tray included milk. -á During an observation on 04/08/26 at 8:12 AM, in room R33's on her bedside table, the provided drinks on her tray included milk. -á During an interview on 04/08/26 at 8:12 AM, Certified Medication Assistant (CMA)3 confirmed R33 received milk and prune juice with her breakfast. -á -á Review of R33's tray ticket, provided by the facility and dated 04/08/26, specified ""Allergies: Dairy Free."" The ticket went on to read ""Breakfast Wed [Wednesday]-4/8/26GǪMilk Whole 8 FL [fluid] OZ [ounces]."" -á During an interview on 04/08/26 at 12:36 PM, Dietary Aide (DA)3 stated all meal tickets are double checked by her to make sure what is on the tray is correct. She added when the resident is not supposed to have milk, they would not receive milk. -á During an interview on 04/08/26 at 12:40 PM, the Certified Dietary Manager (CDM) stated if the resident's meal ticket indicates they should not receive milk, that should be honored. -á Review of facility policy titled, ""Food Allergies and Intolerances,"" dated 08/2017, specified ""Residents with food allergies and/or intolerances will be identified upon admission and steps will be taken to prevent resident exposure to the allergies. GǪResidents with food intolerances and allergies will be offered appropriate substitutions for foods that they cannot eat.""

Resident 33 is not receiving milk products. Any resident with a milk allergy is potentially impacted. 100% residents with milk allergy has been audited, to ensure allergy reflected on tray card. All staff in-service 4/13. Dietary staff in-service 4/24 Dietary Manager will do 100% audit  Weekly x 4 weeks and monthly x90 days. Results of audits will be reviewed by facility QAPI committee, to ensure ongoing compliance.

Findings During the initial tour of the kitchen on 04/06/26 between 11:16 AM to 11:36 AM the following were observed: Refrigerator: -Pasteurized process cheese, sliced, in cellophane, dated 04/06/26 and no additional dates-á -Eight white cheese slices, in cellophane, were dated 04/06/26 but had no additional dates. -An opened bag of ""Arrezzio Shredded Cheese,"" five pounds, opened with no dates.-á -Bowl of rice, covered with cellophane, with no dates. -Metal bowl, covered with cellophane, labeled ""Egg"" with no dates. Freezer: -Plastic bag of eight (out of 12) frozen waffles with no label and no dates. During an interview on 04/06/26 at 11:26 AM, the Certified Dietary Manager (CDM) stated they reference the poster that is in the dry storage for the end dates of items. He acknowledged the items did not have a used by date on them, they only had the dates the items were opened.-á During an observation and interview on 04/07/26 at 9:11 the Activity Director (AD) was observed in the kitchen, next to the steam table, with no hair restraint. The AD confirmed she was not wearing a hair restraint while in the kitchen. During an observation and interview on 04/07/26 at 1:11 PM, Housekeeper (HK)5 was observed carrying folded towels in the kitchen, walking through the entire kitchen, without a hair restraint. HK5 confirmed she was not wearing hair restraint.-á During an interview on 04/08/26 at 11:28 AM, the Certified Dietary Manager (CDM) stated all staff that enter the kitchen should wash their hands and wear a hair restraint. He added no matter who they were all staff needed to wear a hair restraint if they entered the kitchen.-á Review of facility policy titled ""Storage of Frozen and Refrigerated Foods,"" dated 08/12/19, specified ""The Food and Nutrition Services Department will store frozen and refrigerated food according to policy guidelines and state regulations. GǪFoods need to be labeled with name of the product and expiration or discard date it removed from the original packaging."" Review of facility policy titled ""Employee Cleanliness,"" dated 02/25, specified ""All Food and Nutrition Services department employees will be dressed appropriately and will practice good hygiene. GǪ A hairnet, hat or bouffant disposable cap must be worn and must cover hair completely including bangs.""-á

All undated refrigerated items have been disposed of. All undated freezer items have been disposed of. All residents are potentially impacted by this citation. Dietary staff inserviced on P&P of dating food 4/24. All staff inserviced 4/13 on hairnet requirements in the kitchen. Dietary Manager to audit dates on food weekly x4 x monthly 90 days and ongoing audits per facility policy.  Dietary manager to random audit Hairnet usage weekly x4 x monthly X 90 days.

Findings During an interview and joint record review on 04/10/2026 at 11:28 AM of 7/30/25, 9/25/25, 11/12/25, 2/11/26 Facility QAPI agenda with listed individuals who attended the meeting. *The Medical Director or designee was not shown on the attendee list for 7/30/25, 9/25/25, 11/12/25 and 2/11/26 meetings. *The Infection Preventionist was now shown on the attendee list for 7/30/25, 9/25/25, 11/12/25 meetings. The Administrator confirmed the Medical Director or designee and the Infection Preventionist was not shown as attending the above meetings. The Administrator further stated that the Medical Director usually attends virtually and meetings are often scheduled when he is available. The Administrator stated that she will check and get back to surveyor if Medical Director attended these meetings. Review of email dated Friday, April 10, 2026 at 1:03 PM Administrator confirmed Infection Preventionist did not attend meetings prior to 2/11/26 when Director of Nursing received her specialized infection certification and fulfilled role of Infection Preventionist. No further information was provided about Medical DirectorGÇÖs attendance at QAPI meetings.

QAPI meeting has been scheduled for 4/28 to include Medical director or NP and IPC. Admin and DNS has been re-inserviced on the attendee requirements for QAPI meetings. Admin- Audits to be done Quarterly after each QA meeting for attendance for 6 months. Results of audits will be reviewed by facility QAPI committee, to ensure ongoing compliance.

Findings Review of facility Marquis Water Management Program GÇô Legionella, dated 4/23/28, documented: *t he Maintenance Director maintains documentation that describes the facilityGÇÖs water system. A copy is kept in the Emergency Preparedness (EPP) binder. *A risk assessment will be conducted by the water management team annually to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facilityGÇÖs water systemsGǪ.this includes clinical equipmentGǪmedical devices and other equipment utilized in the facility that can spread Legionella through aerosols or aspirationGǪThis facilityGÇÖs entire population is at risk. *Based on the risk assessment, control points (locations in the water systems where a control measure can be applied) will be identified. The list of identified points shall be kept in the water management program. * Control measures will be applied to address potential hazards at each control point. A variety of measures may be used, including physical controls, temperature management, disinfectant level control, visual inspections, or environmental testing for pathogens. The measures shall be specified in the water management program action plan. *Testing protocols and acceptable ranges (control limits) will be established for each control measure. Review of CDCGÇÖs Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings, dated 9/30/25, described key steps included describe the building water system using text and flow diagrams, identify areas where legionella could grow and spread, decide where control measures should be applied and how to monitor them, establish ways to intervene when control limits are not met, make sure the program is running as designed and is effective, document and communicate all activities. During concurrent interview and record review on 04/08/2026 at 12:54 PM-áMaintenance Director provided GÇ£Building Water Systems Flow Diagram, undated, of the facility building which described the building water system and flow of water. When asked to provide identified areas of the building where legionella could grow or spread and the control measures to monitor these areas, Maintenance Director shook his head and stated that he did not have this. Maintenance Director further stated that he did not know the ideal temperature for Legionella growth and provided water temperature logs (temps between 105-120 degrees) for 11/22/25, 11/29/25, 12/2/25, 12/8/25, 12/31/25, and 1/7/26 which were used for resident comfort, so residents donGÇÖt burn themselves. The Maintenance Director could not identify areas where legionella could grow and spread, provide control measures or parameters to monitor these identified areas, or state interventions to address if/when data was outside of the established parameters to ensure an effective water management program was implemented. During an interview on 04/09/2026 at 3:01 PM Administrator stated that her expectation was the facility had an effective water management program to prevent the growth and spread of Legionella. Surveyor informed Administrator of concerns with review of the facilityGÇÖs water management program, no additional information was provided by the facility.

Maintenance Director in-serviced on Water Management Program to Reduce Legionella Growth and Spread in Buildings A risk assessment analysis and facility inspection for potential areas of growth and spread of water-borne pathogens was conducted by the Administrator and Maintenance Director and determined there are currently no potential areas for growth or contamination. These findings were shared with the Infection Preventionist. Administrator initiated engagement with a qualified third-party water management vendor specializing in Legionella prevention to provide ongoing oversight, consultation, and documentation review per contract. Ongoing infection surveillance to identify potential waterborne illness. Admin to audit water system monitoring results weekly for four (4) weeks, then monthly for ninety (90) days. Review of findings during Quality Assurance and Performance Improvement (QAPI) meetings, with additional corrective actions implemented as needed.

Findings -á Review of facility policy Pneumococcal Vaccine, dated 10/20/20, documented GÇ£all residents will be offered Pneumococcal vaccinations to aid in preventing pneumococcal infections (e.g., pneumonia)GǪ.Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccination, and when indicated, will be offered the vaccine within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. Assessments of pneumococcal vaccination status for prior pneumococcal vaccination will be conducted within five (5) working days of the residentGÇÖs admission if not conducted prior to admissionGǪ.Administration of the pneumococcal vaccine or revaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination.GÇ¥ Review of facility policy Influenza and COVID19 Vaccine, dated 10/20/20, documented GÇ£all residentsGǪ.who have no medical contraindications to the vaccine will be offered the influenza vaccine annuallyGǪ.per state/CDC guidelines to encourage and promote the benefits associated with vaccinations against influenzaGǪ.Between October 1 st and March 31 st each year, the influenza vaccine shall be offered to residentsGǪ, unless the vaccine is medically contraindicated or the residentGǪhas already been immunizedGǪGÇ¥ -á Review of the CDC's Pneumococcal Vaccine Timing for Adults, dated March 2025, showed there were four types of pneumococcal vaccines available in the United States: pneumococcal conjugate vaccines (PCV15, PCV20, and PCV21) and pneumococcal polysaccharide vaccine (PPSV23). For adults 65 years or older who have not previously received any pneumococcal vaccine, CDC recommends you give 1 dose of PCV20 or PCV21. If PCV15 is used, this should be followed by a dose of PPSV23 at least one year later. For adults 65 years or older who have only received PPSV23, CDC recommended 1 dose of PCV20 or PCV21 one year after PPSV23. The PCV15 dose should be administered at least one year after the most recent PPSV23 vaccination. For adults 65 years or older who have only received PCV13, CDC recommended PCV20 or PCV21 one year after PCV13. For adults 65 years or older who have only received PCV13 or PPSV23 after age 65 years old, CDC recommended PCV20 or PCV21 at least five years after PCV13 or PPSV23.-á -á -á Resident 20 -á Review of Resident 20's (R20) electronic health records indicated the facility admitted the resident on 2/5/24 and was over 90 years old.-á -á Review of R20's records, under Immunizations tab showed receipt of PPSV23 on 12/19/24. There was no pneumococcal consent after 12/19/24. -á Review of CDC Pneumococcal Vaccine Recommendations showed R20 was 50 years or older, had a prior dose of PPSV23, no prior or unknown doses of PCV13 with the recommendation to give one dose of PCV15, PCV20, or PCV21 at least one year after the last dose of PPSV23. There was no documented evidence that R20 was offered or declined PCV15, PCV20, or PCV21. -á -á -á Resident 26 -á Review of Resident 26's (R26) electronic health records indicated the facility admitted the resident on 6/27/19 and was over 70 years old.-á -á Review of R26's records, under Immunizations tab showed PCV13 was refused on 10/6/20. There was no pneumococcal consent after 10/6/20.-á -á Review of CDC Pneumococcal Vaccine Recommendations showed R26 was 50 years or older, had no prior doses of pneumococcal with the recommendation to give one dose of PCV15, PCV20, or PCV21. There was no documented evidence that R26 was offered or declined PCV15, PCV20, or PCV21. -á -á -á Resident 31 -á Review of Resident 31's (R31) electronic health records indicated the facility admitted the resident on 10/8/25 and was over 80 years old.-á -á Review of R31's records, under Immunizations tab showed PPSV23 was received on 9/20/18 (before 65 yrs old) and PCV13 on 10/25/16. There was no pneumococcal consent after 10/8/25.-á -á Review of CDC Pneumococcal Vaccine Recommendations showed R31 was 50 years or older, had received PPSV23 before 65 years old and PCV13 with recommendation to give one dose of PCV15, PCV20, or PCV21. There was no documented evidence that R31 was offered or declined PCV15, PCV20, or PCV21. -á Resident 32 -á Review of Resident 32 (R32) electronic health records indicated the facility admitted the resident on 2/3/26 and was over 70 years old.-á -á Review of R32's records, under Immunizations tab showed PCV13 was received on 10/10/16 and PPSV23 on 9/15/13. R32 received influenza on 11/11/21. There was no pneumococcal or influenza consent after 2/3/26. -á-á -á Review of CDC Pneumococcal Vaccine Recommendations showed R32 was 50 years or older, had received PPSV23 after 65 years old and PCV13 with recommendation to give one dose of PCV15, PCV20, or PCV21. There was no documented evidence that R32 was offered or declined PCV15, PCV20, or PCV21. -á -á During an interview on 04/08/2026 at 2:21 PM-áDirector of Nursing (DON) stated that she was also the facilityGÇÖs Infection Preventionist (IP) and when residents are admitted influenza, COVID19, and pneumococcal immunizations are reviewed and residents/families are offered these vaccinations. If resident/family are interested in receiving vaccinations, the physician is contacted to determine which pneumococcal series is indicated. DON reviewed R20GÇÖs records and stated that she did not recall if she asked the physician about residentGÇÖs pneumococcal immunization or not, or what they said.-áDON stated that she did not see documentation that resident was offered, received or declined pneumococcal and it was not shown on the residentGÇÖs immunization which means the resident did not receive it. DON stated that it looks like it got missed. DON reviewed R26, R31, R32GÇÖs records and confirmed residents were not offered pneumococcal and influenza vaccination when admitted, but should have. -á During an interview on 04/09/2026 at 3:01 PM Administrator stated that her expectation and the facilityGÇÖs policy was residents are offered pneumococcal and influenza vaccinations at the time of admission.

F0883- Resident #32 no longer resides in facility Resident #20, #26, #31 Pneumococcal Consent reviewed and administered as indicated. 100% of residents potentially impacted. 100% audit has been completed on pneumococcal vaccinations. VP of clinical service provided Inservice to DNS and RCM on vaccination consents and administration process upon Admission. Pneumococcal Vaccine audits to be completed by Medical Records  Weekly x 4 weeks and monthly x90 days.  follow up to DNS/IPC at time of audit. Results of audits will be reviewed by facility QAPI committee, to ensure ongoing compliance.

Findings Review of CDC ""Staying Up To Date-áwith COVID-19 Vaccines"", dated 11/19/25, https://www.cdc.gov/covid/vaccines/stay-up-to-date.html , documented GÇ£CDC recommends a 2025-2026 COVID-19 vaccine for people ages 6 months and older based on individual-based decision-makingGǪGetting the 2025-2026 COVID-19 vaccine is especially important if youGǪ..are living in a long-term care facilityGǪ.GÇ¥ Review of facility policy Influenza and COVID19 Vaccine, dated 10/20/20, documented GÇ£all residentsGǪ.who have no medical contraindications to the vaccine will be offered the influenza vaccine annually and the COVID19 vaccinations per state/CDC guidelines to encourage and promote the benefits associated with vaccinations against influenzaGǪ.Between October 1 st and March 31 st each year, the influenza vaccine shall be offered to residentsGǪ, unless the vaccine is medically contraindicated or the residentGǪhas already been immunizedGǪCOVID 19 vaccinations will be offered to all residents upon admitGǪdepending on vaccination availability.GÇ¥ -á Resident 20 -á Review of Resident 20's (R20) electronic health records indicated the facility admitted the resident on 2/5/24 and was over 90 years old.-á -á Review of R20's records, under Immunizations tab showed receipt of COVID19 on 11/9/21. Review of R20GÇÖs COVID 19 vaccination form, dated 10/22/24, showed verbal consent was obtained from residentGÇÖs representation to receive COVID 19 vaccination. Review of Medication Administration for October 2024 did not show resident received COVID 19 vaccine. -á Resident 21 -á Review of Resident 21's (R21) electronic health records indicated the facility admitted the resident on 9/14/25 and was over 70 years old.-á -á Review of R21's records, under Immunizations tab showed receipt of COVID19 on 2/9/23. There was no COVID 19 consent after 9/14/25. -á-á -á Resident 26 -á Review of Resident 26's (R26) electronic health records indicated the facility admitted the resident on 6/27/19 and was over 70 years old.-á -á Review of R26's records, under Immunizations tab showed COVID 19 vaccination was pending with date PCV13 was refused on 10/6/20. Review of R26GÇÖs COVID 19 vaccination form, dated 10/23/24, showed verbal consent was obtained from residentGÇÖs representation to receive COVID 19 vaccination. Review of Medication Administration for October 2024 did not show resident received COVID 19 vaccine. -á -á Resident 31 -á Review of Resident 31's (R31) electronic health records indicated the facility admitted the resident on 10/8/25 and was over 80 years old.-á -á Review of R31GÇÖs records, under Immunizations tab showed COVID 19 vaccination was received on 11/10/23. R31 had a physicianGÇÖs order, dated 10/8/25, for GÇ£COVID 19 vaccinations to be administered IM (intramuscularly) per manufacturerGÇÖs instructions with resident or resident representative consentGÇ¥. -áThere was no COVID 19 consent after 10/8/25. -á-á-á -á -á-á-á-á-á-á-á-á-á-á-á-á-á-á-á-á-á-á-á-á-á-á Resident 32 -á Review of Resident 32 (R32) electronic health records indicated the facility admitted the resident on 2/3/26 and was over 70 years old.-á -á Review of R32's records, under Immunizations tab did not show any COVID 19 vaccinations. R32 had a physicianGÇÖs order, dated 2/3/26, for GÇ£COVID 19 vaccinations to be administered IM (intramuscularly) per manufacturerGÇÖs instructions with resident or resident representative consentGÇ¥. -áThere was no COVID 19 consent after 2/3/26. -á-á-á-á -á During an interview on 04/08/2026 at 2:21 PM-áDirector of Nursing (DON) stated that she was also the facilityGÇÖs Infection Preventionist (IP) and when residents are admitted influenza, COVID19, and pneumococcal immunizations are reviewed and residents/families are offered these vaccinations. If resident/family are interested in receiving vaccinations. DON reviewed R20GÇÖs records and stated that she did not see documentation that resident was offered, received or declined covid 19 vaccination and it was not shown on the residentGÇÖs immunization which means the resident did not receive it. DON stated that it looks like COVID 19 immunizations were not offered in 2025 and 2026 although there were no COVID 19 vaccine supply issues. We should have offered it, but we didnGÇÖt. During an interview on 04/09/2026 at 3:01 PM Administrator stated that her expectation and the facilityGÇÖs policy was residents are offered COVID 19 vaccinations at the time of admission.

F0887 Resident #32 no longer resides in facility. Resident #20, #21, #26, #31  100% of residents COVID vaccination have been follow up. 100% audit has been completed on COVID 2025/26 vaccines. In servicing by VP clinical service for DNS and RCM on vaccination consents on Admission, with MDS process. COVID Vaccine audits to be completed by Medical Records  Weekly x 4 weeks and monthly x90 days, follow up to DNS/IPC at time of audit. Results of audits will be reviewed by facility QAPI committee, to ensure ongoing compliance.

Resident 16 was admitted to the facility on 1/12/26 with diagnoses including vascular dementia with agitation and depression. A 1/12/26 physician order revealed Resident 16 was prescribed quetiapine 75 MG (an antipsychotic medication) twice daily. A review of Resident 16GÇÖs medical record revealed no indication an Abnormal Involuntary Movement Scale (AIMS) (used to identify if symptoms/side effects of psychoactive medication use were present) assessment was completed. On 2/26/26 at 3:58 PM Staff 2 (RNCM/DNS/IP) stated Resident 16 was already on an antipsychotic medication upon admission, so her understanding was Resident 16 did not require an AIMS completed until six months after admission. On 2/26/26 at 4:10 PM Staff 11 (Regional RN Consultant) stated Resident 16 required an AIMS assessment completed upon admission and every six months as the resident received antipsychotic medication. Staff 11 confirmed Resident 16 did not have an AIMS completed upon admission. -á

1. AIMS assessment completed for resident #16 2. 100% audit of all residents on antipsychotic medication completed to ensure current AIMS assessment has been completed. 3. RCM and DNS to be in-serviced on requirement that AIMS be completed on admission 4. Medical Records to monitor new admissions with orders for antipsychotic medications weekly x4 weeks and monthly x90 days for compliance with completion of AIMS assessment.  Corrections to be made at time of audit completion. 5. Reports of audit will be reported and monitored at QA to ensure ongoing compliance is attained

Resident 5 was admitted to the facility in 4/2024 with diagnoses including diabetes and heart disease. A review of Resident 5GÇÖs clinical record revealed she/he was transferred to the hospital on the following dates: 11/19/25, 11/29/25, 12/2/25, 12/21/25, and 2/10/26. No evidence was found in Resident 5GÇÖs clinical record to indicate written notice of the facilityGÇÖs bed hold policy was provided to the resident or her/his representative when she/he was transferred to the hospital. On 2/26/26 at 3:47 PM Staff 10 (LPN Resident Care Manager) stated upon transfer to the hospital, the charge nurse was to open an assessment in the residentGÇÖs medical record and provide the resident with a bed hold notification. On 2/27/26 at 10:01 AM Staff 2 (RNCM/DNS/IP) confirmed a written bed hold notification was not provided to Resident 5 or her/his representative at the time of transfer to the hospital on the specified dates. -á

1. 100% audit completed of residents that were transferred to hospital in the last 30 days. 2. DNS to inservice LN and RCM to be on Oregon Notice of Transfer or Discharge and Bed Hold requirement to be completed at time of discharge to emergency department or acute care directly. 3. DNS to monitor transfers to acute weekly x4 weeks and monthly x90 days for compliance 4. Reports of audit will be reported and monitored at QA to ensure ongoing compliance is attained

Resident 9 was admitted to the facility on 3/16/22 with diagnoses including delusional disorders. The 2022 Marquis Standards of Care indicated the following: -Staff were required to change residents' clothing each day.-á -Staff were required to shave residents as needed.-á The 10/2025 Care Plan indicated the following: -Resident 9 required supervision and assistance to complete dressing. -Ensure clothing and footwear was clean. -Provide assistance with dressing after resident attempted each step.-á -Pick out a couple appropriate outfits and offer me choices. The Kardex indicated Resident 9 required constant supervision with cueing and minimal physical assistance during shaving. The 11/2025 Quarterly MDS indicated Resident 9 had a BIMS score of 6 which indicated the resident was cognitively severely impaired.-á The 2/25/26 Medical Record indicated Staff 9 (CNA) provided assistance to complete personal hygiene.-á From 2/24/26 through 2/26/26 from 8:00 AM to 4:00 PM, Resident 9 was observed wearing the same blue sweater, sweatpants and socks. Resident 9's beard was long with white and brown hair. Resident 9's mustache was thick and overgrown down to her/his top lip.-á -á On 2/24/26 at 1:27 PM, Resident 9 acknowledged her/his long beard and stated she/he had not shaved. Resident 9 stated she/he allowed staff to shave her/his beard.-á On 2/25/26 at 9:11 AM, Resident 9 was resting in bed. Resident 9 stated he was unsure when she/he last changed clothes or shaved her/his beard.-á On 2/25/26 at 1:30 PM, Resident 9 was observed leaving the facility for an outing and was wearing the same clothes she/he wore all day the previous day.-á -á On 2/26/26 at 9:44 AM, Staff 9 stated Resident 9 was independent and cooperative. Staff 9 stated Resident 9 required staff to set up personal hygiene supplies including clothes daily. Staff 9 stated she was unable to shower her/him or set up supplies because she was busy with other residents.-á On 2/26/26 at 10:01 AM Staff 7 (RN) stated Resident 9 was redirectable, cooperative and did not refuse care. Staff 7 stated Resident 9 was able to complete daily personal hygiene independently. Staff 7 stated she expected staff to set up personal hygiene supplies, including clothing daily. Staff 7 stated staff notified her if residents refused care. Staff 7 stated Resident 9 did not refuse personal hygiene assistance during the week.-á -á On 2/26/26 at 11:23 AM, Staff 2 (RNCM/DNS/IP) stated she monitored the medical electronic system to ensure personal hygiene tasks were completed and followed up with staff if incomplete documentation was observed. Staff 2 stated Resident 9 was cooperative and redirectable and did not refuse care. Staff 2 stated she felt disturbed to hear Resident 9 was wearing the same clothes for the last three days because she/he was redirectable and completed personal hygiene.-á

1. Resident #9 hygiene was addressed immediately upon notification 2. All residents have the potential to be impacted by this citation 3. Nursing Staff to be in service on Resident Standards of Care and notifying LN/RCM/DNS of refusal by resident 4. DNS, or designee, to audit weekly x4 weeks and monthly x90 days for personal hygiene and addressing needs being met. 5. Reports of audit will be reported and monitored at QA to ensure ongoing compliance is attained.

The facilityGÇÖs 1/2016 Assessment for Ability to Make Use of Electric Call System policy instructed facility staff to assess residents for call light use at admission and when a significant change occurred. The policy instructed facility staff to document identified call light safety risks in the residentGÇÖs record. a. Resident 20 was admitted to the facility in 2/2024 with diagnoses including unspecified dementia. Resident 20GÇÖs 8/30/25 revised care plan revealed she/he used a pressure sensitive call light pad.-á b.-áResident 21 was admitted to the facility in 8/2025 with diagnoses including unspecified dementia and repeated falls. Resident 21GÇÖs 2/14/26 revised care plan did not include information related to call light use.-á-á c.-áResident 26 was admitted to the facility in 6/2019 with diagnoses including Alzheimer's disease. Resident 26GÇÖs 8/18/23 Call Light Safety Assessment revealed the resident was aware and able to use a call light.-á On 2/23/26 at 10:26 AM, 2/24/26 at 8:25 AM, and 2/25/26 at 9:25 AM Residents 20, Resident 21, and Resident 26 were observed to have their call lights unplugged from the call light box in their rooms, and no alternative means to call for assistance. On 2/24/26 at 2:21 PM Staff 9 (CNA) stated residents were to have functional call lights and stated she did not know why Resident 20, Resident 21, and Resident 26 did not have functional call lights. She stated staff were always present in the unit and the residents without functional call lights were either independent with care or sought out staff when they needed assistance.-á On 2/25/26 at 10:24 AM Staff 7 (RN) stated every resident was supposed to have a functional call light. She stated she did not know the reason Resident 20, Resident 21, or Resident 26 did not have functional call lights. Staff 7 stated the staff did regular rounding to check on residents and were close enough to hear residents yelling for help. On 2/25/26 at 11:00 AM Staff 8 (Maintenance Director) stated he was notified of new admission call light placement needs before a resident was admitted to the facility and stated he was notified through an internal facility system for broken or missing call lights. Staff 8 stated he painted Resident 26GÇÖs room on 2/22/26, removed the call light, and forgot to replace it. He stated Resident 21 should have a functional call light but could not identify why one was not in place. Staff 8 stated Resident 20GÇÖs call light was removed when he replaced the batteries in the call light box on 2/24/26. Staff 8 acknowledged the lack of functional call lights for Residents 20, 21 and 26.-á On 2/26/26 at 1:32 PM Staff 2 (DNS) acknowledged functional call lights were required for all residents.

1. Resident #20 was call light was addressed immediately upon notification. Residents #21and 26 have been evaluated for call light use and safety has been addressed. 2. All Residents in MCU are potentially impacted, 100% audit of all residents in MCU completed for call light use and/or need for a call light alternative to be identified based on call light safety assessment. 3. All staff will be in serviced on protocol for communication of maintenance of call light function concerns. 4. Admin, or designee to audit new move-ins weekly x4 weeks and monthly x90 days in the MCU for call light safety assessment. 5. Reports of audit will be reported and monitored at QA to ensure ongoing compliance is attained.

a. Staff 3GÇÖs (Human Resources Coordinator) QED certification showed an approval date of 11/23/21. On 2/26/26 at 2:40 PM, Staff 3 and Staff 1 (Administrator) acknowledged QED recertification was required every three years and confirmed they did not complete the required recertification on time.-á b. Staff 4GÇÖs (Housekeeper) 2/9/24 Final Fitness Determination (FFD) indicated an expiration date of 2/9/26.-á On 2/26/26 at 2:45 PM, Staff 1 (Administrator) was unable to provide documentation to indicate Staff 4GÇÖs required two-year criminal history check was completed or was in process prior to the expiration date. c. Staff 5GÇÖs (Cook) 2/15/24 Final Fitness Determination (FFD) indicated an expiration date of 2/15/26.-á On 2/26/26 at 2:47 PM, Staff 1 (Administrator) acknowledged Staff 5's FFD was expired and she provided documentation that indicated Staff 5GÇÖs required two-year criminal history check was initiated on 2/23/26, eight days after the expiration date.-á d. On 2/26/26 at 2:40 PM, Staff 1 (Administrator) and Staff 3 were interviewed regarding the facilityGÇÖs system to ensure active supervision of staff hired under preliminary status pending Background Check Unit (BCU) approval. Staff 1 and Staff 3 stated they did not have a policy in place related to active supervision of new employees with pending BCU approval.-á-á -á

A. Staff 3’s QED recertification was completed upon identification of the lapse.  Administrator has verified that Staff 3’s QED status is now active and current. Staff 3 (Staffing Director) has been re-inserviced on recertification requirements for QED qualifications. A digital tracking log has been implemented to monitor Staff 3’s QED Certification expiration with automatic alerts 90, 60, and 30 days before expiration. Admin and Staffing Director are responsible to monitor for ongoing compliance. Reports of audit will be reported and monitored at QA to ensure ongoing compliance is attained B. Active Supervision policy in-service provided to all staff. All preliminary hired staff will be identified on Facilities “welcome board” until clearance of background check. Welcome board posted at nursing station in facility in easily visible area Admin to monitor new preliminary hired staff weekly x4 and monthly x90 days to ensure ongoing compliance Reports of audit will be reported and monitored at QA to ensure ongoing compliance is attained C. Staff 4 and 5 criminal history check has been updated. 100% audit of all current staff completed by QED and Admin to verify FFD expiration dates. Admin inserviced Staffing director on QED requirements for every 2 your background checks. A centralized spreadsheet was implemented as an FDD renewal tool to track FFD expirations Admin will run weekly review X4 week and monthly X 90 days to ensure no employee approaches expiration without renewal in process Reports of audit will be reported and monitored at QA to ensure ongoing compliance is attained

Resident 20 was admitted to the facility in 2/2024 with diagnoses including unspecified dementia.-á The Annual MDS dated 7/11/25 revealed Resident 20 spoke Korean, needed or wanted an interpreter, and it was somewhat important to her/him to participate in her/his favorite activities, religious services and things with groups of people. Resident 20GÇÖs 8/2025 revised care plan indicated the facility was to offer the resident a variety of in-room, group, and independent activities, which included watching baseball (United States and international), news in her/his native language on YouTube, jazz music, and large print reading activities in her/his native language.-á Resident 20GÇÖs activity tracking form from 1/27/26 through 2/24/26 showed no documentation of music, entertainment, reading material, news, hospitality cart, electronic devices, or baseball related activities were offered to Resident 20.-á On 2/23/26 at 9:53 AM and 11:41 AM, 2/24/26 at 1:45 PM and 3:00 PM, 2/26/26 at 9:22 AM, 9:44 AM, and 10:07 AM Resident 20 was not offered or engaged in any care planned activities. Resident 20GÇÖs room did not have a television or large print reading materials. On 2/24/26 at 2:21 PM Staff 9 (CNA) stated Staff 8 (Activity Director) held group activities but invited only those residents she knew liked the specific activity.-á She stated other staff engaged residents when they had time, but this was difficult due to the behavior and care needs residents required most days on the unit.-á On 2/25/26 at 10:24 AM Staff 7 (RN) stated Resident 20 usually watched television in the Common Room, which usually consisted of geographic or nature shows.-á She stated she was unaware of the resident engaging in activities in her/his native language beyond a monthly outing to the Asian Center. On 2/26/26 at 12:50 PM Staff 8 stated she had not offered to set Resident 20 up to watch baseball since the 2025 United States baseball playoffs, watch programs in her/his native language, or listen to music.-á She confirmed she had not provided Resident 20 with reading material in her/his native language since at least 12/2025.

Resident 20 received an immediate reassessment of activity needs, preferences, cultural considerations, and language needs. Resident 20 activity care plan has been updated to reflect person centered activities. All residents and especially ESL residents are potentially impacted by this citation. 100% audit of residents with ESL activity care plans have been reviewed and updated, as indicated to support person centered activities. Activities director inservice provided to ensure compliance with person centered activity planning, including cultural and language appropriate engagement. Admin or designee to monitor ongoing compliance weekly x4 weeks and monthly x90 days for person centered activity programming with ESL in the  MCU. 6. Reports of audit will be reported and monitored at QA to ensure ongoing compliance is attained

Based on interview and record review it was determined the facility failed to honor the resident's right to be free from physical abuse from other residents for 1 of 6 sampled residents (#2) reviewed for abuse. This placed residents at risk for physical abuse. Findings include: Resident 2 admitted to the facility in 3/2025 with diagnoses including Alzheimer's disease. Resident 2's 3/17/25 Admission MDS revealed she/he had a BIMS of 9, which indicated moderate cognitive impairment. Resident 3 admitted to the facility in 8/2023 with diagnoses including dementia. Resident 3's 2/24/25 Quarterly MDS revealed she/he had a BIMS of 12, which indicated moderate cognitive impairment. An 4/19/25 facility Investigation Summary and Conclusion revealed on the morning of 4/19/25 Resident 2 and Resident 3 were in their shared room asleep when Resident 2 woke up and turned on the overhead light. Resident 3 woke up and became angry, swore at Resident 2, and pushed her/him back onto her/his bed. Resident 3 then went to the common television room to complain about the overhead light being on. The facility moved the residents to different rooms. Neither resident was injured during the incident. Resident 2's 4/19/25 Resident to Resident Event Assessment revealed Resident 2 was interviewed after the incident and stated Resident 3 cursed at her/him when the bedroom light was turned on. Resident 2 stated Resident 3 then shoved her/him hard onto the bed and attacked her/him because she/he turned on the light. Resident 2 stated the incident scared her/him and she/he complained of left shoulder pain later in the day. Resident 3's 4/19/25 Resident to Resident Event Assessment revealed Resident 3 was interviewed after the incident and stated Resident 2 stood over her/his bed yelling and Resident 3 then pushed Resident 2 onto her/his bed. On 5/15/25 at 7:51 AM Staff 6 (CNA) stated she worked on 4/19/25 and recalled the incident between Resident 2 and Resident 3. Staff 6 stated she found Resident 3 screaming about pushing Resident 2 because she/he turned the light on. Resident 2 was very scared and wanted to be out of the shared room. The two residents were then separated. On 5/15/25 at 1:25 PM Resident 3 stated she/he and Resident 2 had many issues because they shared a room and Resident 2 turned the light on every night. Resident 3 stated on 4/19/25 Resident 2 woke her/him up when she/he turned the light on. Resident 3 stated the two residents then went back and forth turning the light on and off until she/he shoved Resident 2 onto the bed. On 5/15/25 at 1:32 PM Resident 2 stated Resident 3 was upset because she/he said the light was in her/his face and then Resident 3 shoved Resident 2 down on the bed. Resident 2 stated she/he was afraid at the time but felt safe now because the facility moved her/him out of the shared room. Resident 2 stated she/he felt abused by Resident 3 and no longer interacted with her/him. On 5/15/25 at 4:51 PM Staff 11 (LPN) stated on 4/19/25 she was called to the room Resident 2 and Resident 3 shared. Staff 11 stated Resident 3 was upset and stated she/he pushed Resident 2 because Resident 2 turned on the light. Staff 11 stated Resident 2 was upset and reported being scared. On 5/15/25 at 2:50 PM Staff 2 (DNS) stated she investigated the 4/19/25 event and concluded the incident met the definition of abuse. The deficient practice was identified as Past Noncompliance based on the following: On 4/19/25, the deficient practice was identified by the facility and was corrected when the facility implemented the following to prevent further incidents of resident to resident abuse: 1. Resident 2 and Resident 3 were separated, 2. The facility implemented auditing through alert charting, 3. The facility reviewed and updated Resident 2 and Resident 3's care plans.

******************************** OAR 411-086-0360 Abuse Refer to F600 ********************************

Based on interview and record review it was determined the facility failed to inform residents of the risks and benefits of psychotropic medication use for 1 of 5 sampled residents (#9) reviewed for medications. This placed residents at risk for being uniformed of psychotropic medication. Findings include: Resident 9 was admitted to the facility in 8/2024 with the diagnoses including vascular dementia. The 10/22/24 Physician Orders revealed an order for Duloxetine (antidepressant)to be administered daily. The medical record revealed no evidence risk and benefit information for Duloxetine was reviewed with Resident 9. On 10/24/24 at 11:05 AM Staff 6 (LPN Resident Care Manager Support) acknowledged risk and benefit information related to the use of Duloxetine was not provided to Resident 9.

1. Informed psychoactive consent completed for resident #9. 2. 100% audit of all residents receiving psychoactive medications to ensure informed consents completed. 3. Policy and procedure reviewed and continues to be appropriate. 4. Licensed nurses, Resident Care Manager, and Social Service Director inserviced on policy and procedure for psychoactive informed consent. 5. Audits are completed weekly X4 weeks and then monthly X 90 day by DNS or designee. Results of audits to be reviewed by facility QA committee, to ensure ongoing compliance attained.

Based on interview and record review it was determined the facility failed to assess significant weight loss for 1 of 2 sampled residents (#11) reviewed for nutrition. This placed residents at risk for additional weight loss. Findings include: Resident 11 admitted to the facility in 5/2023 with diagnoses of vascular dementia and malnutrition. A 5/2/23 Nutrition Care Plan revealed Resident 11 was at risk for impaired nutrition due to severe malnutrition and vascular dementia with a goal of Resident 11 maintaining or increasing her/his weight to above 167 pounds. The interventions for Resident 11 included a referral to a dietitian for evaluation and recommendations as needed. A 5/12/24 Dietitian Assessment revealed Resident 11 weighed 157.4 pounds and weight gain was beneficial. A 7/23/24 Provider Progress Note revealed Resident 11 weighed 164.9 pounds, her/his weight was stable for the last six months, no additional interventions were put in place. An 8/21/24 Provider Progress Note revealed Resident 11 weighed 164.8 pounds, her/his weight was stable for the last six months, no additional interventions were put in place. A 9/24/24 Provider Progress Note revealed Resident 11 weighed 156.4 pounds, her/his weight was down 10 pounds over the last month and seven pounds over the last six months. No additional interventions were put in place. A review of the 7/2024 through 10/2024 Progress Notes revealed no additional assessments of Resident 11's weight loss. An 10/11/24 Quarterly MDS indicated Resident 11 did not have weight loss and weighed 159 lbs. An 10/11/24 Summary Dietary revealed Resident 11 currently weighed 158.6 pounds, and over the last 180 days Resident 11 had significant weight loss. An 10/17/24 Summary Nursing assessment did not address Resident 11's weight loss. Resident 11's Weights and Vitals Summary revealed the following weights: - 4/12/24: 178.3 pounds - 7/12/24: 164.4 pounds - 9/13/24: 157 pounds - 10/11/24: 158 pounds - 10/14/24: 157.4 pounds - 10/18/24: 152.4 pounds - 10/23/24: 150 pounds On 10/22/24 at 2:48 PM Staff 6 (Resident Care Manager Support) reviewed Resident 11 and stated she did not identify weight loss on the 10/11/24 MDS but confirmed Resident 11 did have over a 10 percent weight loss in the last six months. Staff 6 stated when weight loss was identified she was to notify the provider, the family, make a registered dietitian referral, and add the resident to the Nutrition at Risk list. On 10/23/24 at 9:52 AM Staff 10 (Registered Dietitian) stated she was last at the facility on 10/18/24 and did not see Resident 11. Staff 10 stated she expected to be notified of any significant weight loss. Staff 10 confirmed she did not assess Resident 11 since 5/2024, but her/his goal was to maintain or increase her/his weight. Staff 10 stated the facility should have notified her of Resident 11's weight loss. Staff 10 stated when notified of a resident with significant weight loss she assessed her/him to see what else was going on. Staff 10 stated Resident 11 had a diagnosis of congestive heart failure so the facility needed to ensure the weight loss was not fluid related. On 10/24/24 at 11:23 AM Staff 3 (Regional RN) stated when weight loss was identified the staff were to make a referral to the registered dietitian, add the resident to nutrition at risk, and do a nutrition and weight assessment; Staff 3 confirmed these interventions were not in place for Resident 11.

1. Nutritional assessment completed for resident #11. 2. 100% audit of all resident completed to identify additional significant weight loss. 3. Policy and procedure for significant weight loss reviewed and continue to be appropriate. 4. Licensed nurses, Resident Care Manager, Dietary Manager and Registered Dietician inserviced on policy for significant weight loss. 5. Audits are completed weekly X4 weeks and then monthly X 90 day by DNS or designee. Results of audits to be reviewed by facility QA committee, to ensure ongoing compliance attained.

Based on observation, interview, and record review it was determined the facility failed to ensure medication storage areas were secured and free of expired medication for 1 of 1 medication cart and 1 of 1 medication storage room reviewed for safe medication storage. This placed residents at risk for misappropriation of medications, adverse medication consequences and diminished treatment efficacy. Findings include: The facility's Storage of Medication Policy, revised 5/2010, stated, "The Facility shall store all drugs and biologicals in a safe, secure, and orderly manner." 1. On 10/21/24 at 1:49 PM the Intemediate Care medication cart outside of Room 17 was unlocked and unattended. On 10/21/24 at 1:53 PM Staff 4 (CMA) confirmed the cart was unlocked and unattended. On 10/24/24 at 1:00 PM Staff 1 (Administrator) was informed of these findings. No Additional information was provided. 2. On 10/24/24 at 7:44 AM a multidose bottle of Lorazepam (a controlled antianxiety medication) was found in the locked medication refrigerator with an expiration date of 7/21/24. On 10/24/24 at 7:44 AM Staff 5 (LPN) confirmed the Lorazepam was expired. On 10/24/24 at 1:00 PM Staff 1 (Administrator) was informed of these findings. No Additional information was provided.

F761: Expired Medications 1. Expired medication destroyed. 2. Audit completed to identify other medication expiration dates. 3. Policy and Procedure reviewed and continue to be appropriate. 4. Inservice of Certified Medication Aides, Licensed Nurses and Resident Care Managers on storage of expired medications. 5. Audits are completed weekly X4 weeks and then monthly X 90 day by DNS or designee and/or Pharmacy nurse consultant. Results of audits to be reviewed by facility QA committee, to ensure ongoing compliance attained. F761: Safe Storage 1. Employee leaving medication cart unattended and unlocked educated regarding safe storage of medications. 2. Policy and procedure reviewed and continues to be appropriate. 3. All licensed nurses and Certified Medication Aides inserviced on safe storage of medications. 4. Audits are completed weekly X4 weeks and then monthly X 90 day by DNS or designee. Results of audits to be reviewed by facility QA committee, to ensure ongoing compliance attained.

Based on observation, interview, and record review it was determined the facility failed to implement Enhanced Barrier Precautions for 1 of 1 facility reviewed for infection control. This placed residents at risk for exposure to infections. Findings include: The facility's undated "Isolation - Categories of Transmission-Based Precautions" policy indicated Enhanced Barrier Precautions were to be used for residents with catheters and complex wounds. On 10/21/24 Staff 1 (Administrator) provided a list of residents with catheters which included Residents 2, 8, and 14. On 10/22/24 at 12:38 PM Resident 2 and Resident 14's rooms were observed with no signage to indicate they were on Enhanced Barrier Precautions. At this time Staff 8 (CNA) stated there were no residents with precautions on the hall. On 10/22/24 at 2:10 PM Resident 8's room was observed with no signage to indicate she/he was on Enhanced Barrier Precautions. On 10/22/24 at 2:16 PM Staff 2 (DNS) stated the facility implemented Enhanced Barrier Precautions for Resident 2, Resident 8, and Resident 14 due to catheter use. Staff 2 stated there were no signs or indicators about Enhanced Barrier Precautions on the resident rooms at this time because the facility was waiting for blue sticker dots be delivered. Staff 2 further stated the facility did not store PPE in the hallways, but it was available to staff in the "spa". Staff 2 went to the "spa" on the ICF hall to show the PPE storage and discovered the hospital gowns were not stored there. Staff 7 (CNA) offered assistance to Staff 2 and stated none of the residents on the ICF hall had precautions of any kind. Staff 2 told Staff 7 the facility were to follow Enhanced Barrier Precautions for all residents with an indwelling catheter. Staff 7 stated she was not aware and the facility staff were not doing that. Staff 2 then confirmed the facility did not implement Enhanced Barrier Precautions.

1. Residents #2, 8 and 14 placed on Enhanced Barrier Precautions during the survey. 2. Audit of all residents to identify others who meet criteria for Enhanced Barrier Precautions completed. 3. Policy and Procedure reviewed and continues to be appropriate. 4. All staff inserviced on criteria and use of Enhanced Barrier Precautions. 5. Audits are completed weekly X4 weeks and then monthly X 90 day by DNS or designee. Results of audits to be reviewed at facility QA committee, to ensure ongoing compliance attained.

Based on interview and record review it was determined the facility failed to offer pneumococcal immunizations for 1 of 5 sampled residents (#27) reviewed for immunizations. This placed residents at risk for lack of vaccination. Findings Include: Resident 27 admitted to the facility in 2/2024 with diagnoses including chronic pain. Resident 27's immunization records did not indicate if she/he was assessed for, offered, or declined a pneumococcal vaccination following admission to the facility. On 10/24/24 at 12:06 PM Staff 3 (Regional RN) stated the medical record showed no documentation the facility offered a pneumococcal vaccination to Resident 27.

1. Resident #27 will be offered Pneumococcal vaccination. 2. 100% audit of all residents completed to ensure all residents have been offered pneumococcal vaccination. 3. Policy and Procedure reviewed and continues to be appropriate. 4. Inservice of Resident Care Managers, Licensed Nurses on Pneumococcal vaccination policy and procedure. 5. Audits of new admissions completed weekly X4 weeks then monthly X 90 days by DNS or designee. Results of audits to be reviewed by facility QA committee to ensure ongoing compliance attained.

**************************** OAR 411-085-0310 Resident Rights: Generally Refer to F552 **************************** OAR 411-086-0140 Nursing Services: Problem Resolution & Preventative Care Refer to F692 and F883 **************************** OAR 411-086-0260 Pharmaceutical Services Refer to F761 **************************** OAR 411-086-0330 Infection Control and Universal Precautions Refer to F880 ****************************

Based on interview and record review it was determined the facility failed to ensure the administrator completed 10 hours of dementia training. This placed residents at risk for lack of dementia specific care. Findings include: Review of the current Course Completion records revealed Staff 1 (Administrator) did not complete ten hours of dementia training. On 10/24/24 at 10:46 AM Staff 1 stated he did not have 10 hours of dementia training.

Residents Affected: All resident on the secured memory care. Corrective Action: 1. Administrator has completed 10 hours of dementia training. 2. Policy and Procedure reviewed and continues to be appropriate. 3. Inservice of the OAR required 10-hours dementia specific training with administrator. 4. Audit annually of required training for Dementia will be completed by Staffing.

Based on observation, interview and record review it was determined the facility failed to ensure 1 of 3 sampled residents (#9) had individually identifiable rooms. This placed residents at risk for not being able to locate their rooms. Findings include: Resident 9 was admitted to the facility in 8/2024 with diagnoses including vascular dementia. On 10/21/24 at 10:45 AM Resident 9's room was observed to have an empty shadow box at her/his room entrance. No other individualized identification was visible to assist Resident 9 in locating her/his room. On 10/24/24 at 9:41 AM Staff 11 (Activity Director) acknowledged Resident 9 did not have an individually identified resident room.

1. Resident #9s room was updated to be have name clearly visible and identifiable. 2. 100% audit of all residents room on the secured unit to ensure rooms are individually identifiable. 3. Policy and Procedure reviewed and continues to be appropriate. 4. Inservice of Activity Director on resident rooms policy and procedure. 5. Audits of new admissions completed weekly X4 weeks then monthly X 90 days by Administrator or designee. Results of audits to be reviewed by facility QA committee to ensure ongoing compliance attained.

The findings of the state licensure and memory care unit health survey conducted from 10/21/24 through 10/24/24 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 10/24/24. 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

A follow-up survey was conducted on 12/18/24 to verify correction of the deficiencies noted from the memory care community health survey dated 10/24/24. These deficiencies are corrected as of 12/13/24.

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 04/08/2024 and 04/14/2024, 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 interview and record review it was determined the facility failed to ensure residents were free from physical abuse for 1 of 15 sampled residents (#2) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 2 was admitted to the facility in 1/2024 with diagnoses including dementia. Resident 2's most recent MDS assessment dated 1/29/24 revealed no BIMS score, which indicated she/he had severe cognitive impairment. Resident 2 had no behavioral issues documented. Resident 1 was admitted to the facility in 3/2022 with diagnoses including dementia and delusional disorder. Resident 1's most recent MDS assessment dated 3/1/24 revealed a BIMS score of 9, which indicated she/he had moderate cognitive impairment. Behaviors documented were physical and verbal symptoms directed toward others which placed other residents at significant risk of physical injury. Interventions were to remove her/him from the area and provide low stimulus diversional activities. On 2/23/24 the facility submitted a report which revealed on 2/23/24, Resident 1 was observed by staff standing over Resident 2 holding Resident 2's wrist. Resident 2 was lying on the couch in the living room. The residents were separated and Resident 2 was observed to have scratches on her/his face. On 4/8/24 at 1:20 PM Staff 7 (CNA) confirmed he was working the day of the incident. He stated Resident 1 needed close supervision due to her/his behaviors which included physical aggression toward other residents. Staff 7 stated he was on break when the incident occurred. On 4/10/24 at 11:57 AM Staff 6 (CNA) confirmed she was working the day of the incident. She stated she was in the living room with the residents and walked across the hall to wash her hands, then heard Resident 2 yelling. She ran into the living room and observed Resident 1 standing over Resident 2, who was lying on the couch. She observed Resident 1's hands to be on Resident 2's face. Staff 6 separated the residents and reported the incident to the charge nurse. Staff 6 stated she observed two skin tears on Resident 2's face as a result of Resident 1 grabbing Resident 2's face. On 4/8/24 and 4/9/24 both residents were observed and had no recall of the incident. On 4/10/24 at 1:30 PM, Staff 1 (Administrator) and Staff 2 (DNS) were notified of the investigative findings and provided no further information.

Tag: F600  Free from Abuse and Neglect Residents Affected: Resident #1  Supervision in place during periods of increased agitation to prevent further resident to resident altercation with Resident #2. Care plans updated as indicated. All residents on the secured memory care unit are potentially affected by this citation. Corrective Action for Potentially Impacted Residents: Education provided to all staff working on the secured unit to ensure appropriate and continuous supervision and oversight is provided to all residents, in the event of any scheduled breaks or absence from the floor. Staff is to ensure supervisor is notified and coverage is secured before leaving the memory care unit. In-service date (April 30th, 2024) to all staff regarding expectation around scheduled and unscheduled breaks the unit. In-service also includes resident to resident altercations and prevention of abuse. Admin, or designee, will conduct random audits of common areas of secured unit to observe for adequate supervision, audits to be completed weekly x4 weeks and then monthly x 90 days to ensure ongoing compliance. Results of audits to be reported to facility QA committee

Based on interview and record review it was determined the facility failed to act upon complaints of hip pain and rule out significant injury after multiple falls for 1 of 3 sampled residents (#3) reviewed for falls. As a result, Resident 3 experienced prolonged pain over a period of four weeks, and a delay in diagnosis of hip fracture requiring hospitalization and surgery. The hip fracture was not diagnosed until 8/5/23, 31 days after her/his fall on 7/4/23. Findings include: Resident 3 was admitted to the facility in 3/2023, with diagnoses including stroke and dementia. Resident 3's care plan dated 2/28/23 noted she/he was was a fall risk due to impaired mobility, gait unsteadiness and decreased safety awareness due to her/his cognitive impairment. The care plan indicated Resident 3 had experienced falls in 3/2023 and 6/2023. Resident 3's Progress Notes revealed she/he experienced three falls on 7/4/23, 7/8/23 and 7/9/23. The 7/4/23 Post Fall Assessment revealed Resident 3 attempted to stand, fell and hit her/his head and hip and reported pain in her/his back, left side of her/his head, left hip and right shoulder. The 7/8/23 Post Fall Assessment revealed Resident 3 attempted to stand, fell and complained of pain in her/his left hip. The facility provider was notified and ordered a hip and spine x-ray. The 7/9/23 Post Fall Assessment revealed Resident 3 attempted to self transfer, fell from the chair she/he was seated in and was observed to slide to the floor by staff. Resident 3 complained of pain "everywhere." On 7/11/23, a progress noted written by Staff 3 (RCM) stated the x-ray was canceled by the service provider. Resident 3's 7/2023 and 8/2023 Progress Notes documented the following dates she/he experienced pain: - 7/4/23 at 6:31 PM: "Resident complained of pain" - 7/4/23 at 8:59 PM: Resident had a non witnessed fall this evening. Resident stated she/he hit her/his head and hip...Resident also complained of pain to lower lateral left back and right shoulder. - 7/5/23 at 2:34 AM: "Resident complained of pain all over." - 7/5/23 at 12:46 PM: "Resident this morning complained of discomfort from fall, resident just had scheduled medication." - 7/6/23 at 2:10 PM: "Post fall, no injuries noted, complained of leg pain." - 7/7/23 at 1:15 AM: Resident complained of pain in her/his legs. - 7/7/23 at 10:54 AM: Resident states only pain is related to her/his legs especially during wound care. - 7/8/23 at 10:38 AM: "Medication given for leg pain per LN (licensed nurse). 6/10 pain scale." - 7/8/23 at 1:05 PM: "Resident took a shower today, complained of legs burning after shower...There is some increased generalized weakness, accompanied by general aches/pains after shower." - 7/8/23 at 3:12 PM: Resident had a fall this afternoon during shift change. Resident was following another resident and lost her/his balance and fell in the common area. She/he did not hit her/his head, but does complain of pain in her/his left hip where she/he fell. - 7/9/23 at 4:42 AM: Resident was sleeping in the living room tonight...she/he tried to stand on her/his own and slid off the chair...Pain pill given for complaints of generalized pain. - 7/10/23 at 7:45 AM: "Resident complained of 6/10 pain." - 7/11/23 at 7:46 AM: "Resident complained of pain." - 7/12/23 at 12:23 PM: "Post multiple falls, resident per baseline, noted pain in legs." - 7/14/23 at 4:18 PM: "Resident complained of back pain." - 7/15/23 at 9:41 AM: "Resident complained of pain per LN 7/10." - 7/16/23 at 8:24 AM: "Resident complained of leg pain 6/10 per LN." - 7/16/23 at 12:51 PM: "Resident was pulling at Unna boots, complained of burning on the right leg." - 7/17/23 at 8:30 AM: "Resident complained of leg pain." - 7/18/23 at 1:51 AM: "Resident complained of pain in her/his legs. - 7/19/23 at 1:51 AM: Resident complained of pain in her/his legs." - 7/19/23 at 4:57 AM: Resident appeared to be restless, she/he complained of pain in her/his legs. - 7/20/23 at 1:34 AM: Resident complained of pain in her/his legs. - 7/20/23 at 5:20 AM: Resident refused to sleep in her/his bed. She/he stated that she/he was uncomfortable in bed..she/he complained of pain in her/his legs. - 7/21/23 at 2:15 AM: Resident complained of pain in her/his legs. - 7/21/23 at 4:44 AM: Resident appeared to be restless/anxious all NOC. She/he was given a snack, complained of pain in her/his legs. - 7/22/23 at 5:40 AM: "Please rule out pain as contributing factor; complaint of pain when Unna boots had to be reapplied." - 7/22/24 at 10:28 AM: "Resident complained of burning leg pain once during shift." - 7/22/23 at 11:11 AM: "Resident complained of pain in both legs." - 7/24/23 at 1:03 AM: Resident complained of pain in her/his legs. - 7/24/23 at 9:31 AM: "Resident complained of pain in both legs." - 7/24/23 at 12:42 PM: "Resident up this morning, calling out for help constant, pain medications have been offered for legs pain." - 7/25/23 at 9:07 AM: "Complained of leg pain." - 7/26/23 at 7:40 AM: "Resident complained of pain 6/10 per LN." - 7/27/23 at 1:30 AM: Resident complained of pain in her/his legs. - 7/27/23 at 9:55 AM: "PRN Administration was ineffective. Continue complaints of back pain." - 7/27/23 at 10:02 AM: "Resident complained of leg pain per LN." - 7/28/23 at 1:30 AM: Resident complained of pain in her/his legs. - 7/28/23 at 4:21 PM: "Resident complained of lower back pain." - 7/28/23 at 8:11 PM: "Resident was observed restless this evening, frequently standing, grimacing, complained of leg pain." - 7/29/23 at 11:24 AM: "Complained of leg pain." - 7/29/23 at 4:50 PM: "Resident had complaint of back pain." - 7/29/23 at 7:35 PM: "Resident expressed pain when staff raised legs to install new dressings." - 7/30/23 at 3:14 AM: Resident is complaining of her/his legs are burning and her/his back hurts. Medicated with PRN Norco at 11:30 PM, appears to have no effect...at this time she/he appears anxious, continuously asking us to not hurt her/him or why we hate her/him. - 7/30/23 at 12:57 PM: "Resident awake all morning, constant asking for assist, crying out, trying to walk without assist in dining." - 7/31/23 at 1:43 AM: Resident complained of pain in her/his legs. - 7/31/23 at 12:19 PM: "Complained of back pain." - 7/31/23 at 11:58 PM: Resident complained of pain in her/his legs. - 8/1/23 at 7:39 AM: "Resident complained of pain 8/10 per LN." - 8/2/23 at 5:51 AM: Increase complained of pain noted,..resident slept on and off throughout the NOC complaining of pain in her/his legs. - 8/2/23 at 8:24 AM: "Report stated that patient didn't sleep well last night due to pain. Made multiple changes to RX for pain on 8/1/23, but she/he no longer has any PRN pain RX. Messaged nurse practitioner to request possible PRN." - 8/2/23 at 8:29 PM: Resident has been uncomfortable, grimacing, calling out in pain in her/his left hip and leg off and on for several hours. Occasionally re-directable but she/he returns to complaints of pain after a few minutes. She/he does not want to lay down, she/he will not keep her/his legs elevated. Family is very worried that the current dose/frequency of medication is not effective, they note she/he is rarely vocal about pain. - 8/2/23 at 10:14 PM: "PRN did not control pain, resident continues to call out, wince in pain, is tense, restless." - 8/3/23 at 5:40 AM: Resident has been up all shift in her/his wheelchair...continues to call out, try to get up unassisted and call out in pain. She/he told this LN her/his pain is in the lower back, left hip or left leg at different times..She/he had her/his PRN dose at 2030 but continues to complain of pain. - 8/3/23 at 2:23 PM: Resident was re-evaluated and it was determined current pain regimen was ineffective..Resident was sitting in her/his wheelchair, again identifying that her/his bilateral lower extremities were in pain. - 8/3/23 at 3:39 PM: "New orders to start oxycodone [a pain medication] 5 mg every 6 hours scheduled and Norco 5/325 BID for breakthrough pain. There is to be 3 hours between the oxycodone and Norco doses." - 8/4/23 at 2:58 AM: "Resident appeared to be restless when assisted to bed at the beginning of this shift complaining of back pain and leg pain." - 8/4/23 at 1:53 PM: "Resident anxious at times, asking staff to sit with her/him. Complaint of back pain." - 8/4/23 at 10:37 PM: "Resident started fidgeting, complained of left hip pain, restless, calling out for help...Received order for left hip x-ray STAT." - 8/5/23 at 2:06 AM: "X-ray results: Acute Superiorly Displaced Subcapital Fracture of the Left Femoral Neck - Orders to send to ED for evaluation and treatment." Resident 3's 7/2023 MAR documented she/he was administered PRN Norco (a pain medication) 5/325 mg a total of 42 doses on the following dates: -On 7/1/23 - 1 time; -On 7/3/23 - 1 time; -On 7/4/23 - 2 times; -On 7/5/23 - 1 time; -On 7/6/23 - 1 time; -On 7/7/23 - 1 time; -On 7/8/23 - 1 time; -On 7/9/23 - 1 time; -On 7/10/23 - 2 times; -On 7/11/23 - 1 time; -On 7/14/23 - 1 time; -On 7/15/23 - 1 time; -On 7/16/23 - 2 times; -On 7/17/23 - 1 time; -On 7/18/23 - 1 time; -On 7/19/23 - 1 time; -On 7/20/23 - 1 time; -On 7/21/23 - 2 times -On 7/22/23 - 2 times; -On 7/23/23 - 2 times; -On 7/24/23 - 2 times -On 7/25/23 - 1 time; -On 7/26/23 - 1 time; -On 7/27/23 - 2 times; -On 7/28/23 - 2 times; -On 7/29/23 - 3 times; -On 7/30/23 - 2 times; -On 7/31/23 - 3 times. Staff 3 was not available for interview during the survey period. On 4/8/24 at 9:23 AM, Witness 2 (Complainant) stated Resident 3 complained of pain while in the facility after she/he experienced several falls. Witness 2 stated she had to yell to facility staff over the phone to get x-rays and this was when the hip fracture was discovered. On 4/9/24 at 1:10 PM, Staff 1 (Administrator) and Staff 2 (DNS) stated the x-rays should have been rescheduled immediately after the service provider initially canceled on 7/11/23.

Tag: F684  Quality of Care Resident Affected: Resident 3  has been discharged. Residents with indicators of possible injury and ordered x-rays are potentially impacted by this citation. DNS has in-serviced licensed nurses on timeliness of follow up for ordered radiology post falls. DNS, or designee, will audit weekly X 4 weeks, then monthly X 90 days any follow testing needs post falls for residents, to ensure ongoing compliance. Areas of concern to be addressed directly and results of audits to be reported to facility QA committee

******************************************* OAR 411-085-0360: Abuse Refer to F600 ******************************************* OAR 411-086-0110: Nursing Services: Resident Care Refer to F684 *******************************************

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 04/01/2024 and 04/07/2024, 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 03/04/2024 and 03/10/2024, 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 07/31/2023 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 02/21/2022 and 02/27/2022, 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 11/15/2021 and 11/21/2021, 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.