Regency Gresham Nursing and Rehabilitation Center

Resident 98 was admitted to the facility in 7/2025 with diagnoses including congestive heart failure and anxiety.-á Resident 98's Significant Change MDS dated 8/26/25 indicated the resident was dependent on staff for personal hygiene and grooming.-á Resident 98 was observed on 9/15/25 at 10:45 AM, 9/16/25 at 8:50 AM and on 9/18/25 at 8:40 AM with a significant amount of visible facial hair.-á On 9/15/25 at 11:00 AM Resident 98 stated she/he did not want to have facial hair and would like staff to take care of her/his facial hair. Resident 98 stated she/he relied on staff to shave unwanted facial hair.-á On 9/18/25 at 8:43 AM, Staff 27 (CNA) stated her morning routine included reviewing the shower schedule for residents assigned to her each day, which included shaving residents. Staff 27 indicated she did not routinely assess or offer shaving assistance to resident with facial hair but waited for residents to request to be shaved.-á On 9/18/25 at 8:47 AM, Staff 24 (CNA) stated he obtained information to care for Resident 98 from the Kardex (bedside care plan) and acknowledged Resident 98 had a noticeable amount of facial hair.-á On 9/18/25 at 8:53 AM, Staff 9 (LPN) stated the facility's process for shaving residents was to complete shaving on their scheduled shower days. Staff 9 acknowledged she had noticed Resident 98's facial hair and stated she/he should have been care planned for her/his shaving needs.-á On 9/18/25 at 10:27 AM Staff 2 (DNS) stated it was her expectation for Resident 98 to have her/his shaving preferences followed.-á

F699 Residents #49 and 68 were assessed for trauma. The care plans for residents #49 and 68 were clarified to include trauma triggers and resident specific interventions. Current medical records were audited for those residents who have dx PTSD or hx of trauma. Identified residents were interviewed and their care plans updated. Re-education will be provided to applicable staff on Trauma Informed Care and appropriate care planning for trauma. Routine audits of residents with trauma will be conducted by DNS/designee weekly for 4 weeks, then quarterly to determine that current care plans are specific and resident focused r/t trauma informed care. Results will be reported to QAPI for follow up if indicated. Resident #98 was assisted with shaving her facial hair on 9/18/25. Care plan updated to reflect resident’s preferences. Current resident medical records were audited for those dependent on staff for shaving to determine that current care plan/Kardex reflected residents’ needs/preferences. Re-education will be provided to applicable staff regarding shaving of dependent residents. Routine audits of identified dependent residents who need assistance with shaving will be conducted by DNS/designee weekly for 4 weeks, then quarterly. Results will be reported to QAPI for follow up if indicated.

2. Resident 49 was admitted to the facility in 8/2025 with diagnoses including PTSD (Post Traumatic Stress Disorder.-á Resident 49's 9/11/25 Admission MDS revealed the resident was able to make her/himself understood and understand others without difficulty.-á No evidence was found in Resident 49's clinical record to indicate an assessment of the resident's trauma was completed or a care plan was developed to address the resident's potential trauma triggers.-á On 9/15/25 at 1:35 PM Resident 49 stated she/he had a diagnosis of PTSD. Resident 49 stated the facility had not asked her/him about any history of trauma or potential triggers.-á On 9/17/25 at 12:32 PM Staff 25 (CNA) stated she was unaware Resident 49 had PTSD because it was not listed on her/his Kardex (bedside care plan). Staff 25 further stated she did not know if Resident 49 had any specific triggers related to PTSD. On 9/17/25 at 12:59 PM Staff 9 (LPN) stated there were no specific triggers listed on Resident 49's care plan. Staff 9 stated the care plan was not resident-specific and it should have been.-á On 9/17/25 at 1:42 PM Staff 3 (Social Services Director) acknowledged the omission of Resident 49's potential triggers from the care plan was an oversight. Staff 3 stated she was aware of the resident's diagnosis of PTSD but did not ensure the specific triggers were identified or incorporated into the care plan.-á On 9/17/25 at 2:35 PM Staff 2 (DNS) stated Resident 49 should have been assessed upon admission for her/his diagnosis of PTSD, including identification of her/his potential triggers.-á -á , The facilityGÇÖs revised 10/2022 Trauma Informed Care Policy procedure was to screen residents upon admission for trauma-informed care needs which included identifications of triggers and history of trauma. Staff were directed to utilize family/friends/responsible parties for history, triggers and interventions. Interventions for care planning were expected to include triggers for trauma. -á 1.Resident 68 was admitted to the facility in 3/2025 with a diagnosis including PTSD (Post Traumatic Stress Disorder). -á Resident 68GÇÖs 3/28/25 Admission MDS assessed her/him as cognitively intact, with a diagnosis including PTSD. -á On 9/15/25 at 12:00 PM Resident 68 acknowledged her/his diagnosis of PTSD and stated yelling may trigger a negative response for her/him. -á No evidence was found in Resident 68's clinical record to indicate an assessment of the residentGÇÖs trauma triggers were completed or a care plan was developed to address the resident's potential for re- traumatization. -á On 9/17/25 at 1:00 PM Staff 11 (LPN) did not state any triggers for Resident 68. -á On 9/18/25 at 11:13 AM Staff 3 (Social Services Director) acknowledged Resident 48 did not have potential triggers identified for her/his trauma diagnoses. Staff 3 did not assess, or care plan interventions related to Resident 68GÇÖs triggers. -á On 9/18/25 at 12:50 PM Staff 15 (CNA) and at 12:57 PM Staff 16 (CNA) were unaware if Resident 68 had any triggers related to her/his PTSD. -á On 9/19/25 at 2:18 PM Staff 1 (Administrator) confirmed he expected facility staff to assess all residents for trauma informed care at admission and triggers were to be identified and care planned to decrease the potential for re-traumatization. -á -á

F699 Residents #49 and 68 were assessed for trauma. The care plans for residents #49 and 68 were clarified to include trauma triggers and resident specific interventions. Current medical records were audited for those residents who have dx PTSD or hx of trauma. Identified residents were interviewed and their care plans updated. Re-education will be provided to applicable staff on Trauma Informed Care and appropriate care planning for trauma. Routine audits of residents with trauma will be conducted by DNS/designee weekly for 4 weeks, then quarterly to determine that current care plans are specific and resident focused r/t trauma informed care. Results will be reported to QAPI for follow up if indicated.

Resident 6 was admitted to the facility in 2012 with diagnoses including hypertension (high blood pressure). A review of physician orders revealed a 2/6/25 order for Metoprolol Succinate ER (a medication used to treat hypertension) with directions to hold if the blood pressure was below 100/60 or the heart rate was below 60 beats per minute and a 7/12/25 order for Prazosin HCL (a medication used to treat hypertension) with directions to hold if the blood pressure was below 100/60. A review of the 9/2025 MAR revealed on 9/18/25 Resident 6GÇÖs blood pressure was 106/54 and her/his Metoprolol Succinate ER was documented as given by Staff 20 (CMA). On 9/18/25 at 12:39 PM, Staff 20 stated she had given Resident 6 Metoprolol Succinate ER during the morning pass. Staff 20 acknowledged Resident 6GÇÖs blood pressure was 106/54 and the Metoprolol should have been held. A review of the 9/2025 MAR revealed Prazosin was documented as given by Staff 19 (CMA) with the following blood pressures: -+ -á-á-á-á-á-á On 9/5/25, 122/56 -+ -á-á-á-á-á-á On 9/10/25, 110/56 -+ -á-á-á-á-á-á On 9/12/25, 106/56 -+ -á-á-á-á-á-á On 9/14/25, 132/56 A review of the 8/2025 MAR Revealed Metoprolol Succinate ER was documented as given by Staff 19 with the following blood pressures: -+ -á-á-á-á-á-á 8/3/25, 104/56 -+ -á-á-á-á-á-á 8/31/25, 122/56 A review of the 8/2025 MAR revealed Prazosin was documented as given by Staff 19 with the following blood pressures. -+ -á-á-á-á-á-á 8/7/25, 138/56 -+ -á-á-á-á-á-á 8/8/25, 118/56 -+ -á-á-á-á-á-á 8/10/25, 118/56 -+ -á-á-á-á-á-á 8/12/25, 112/56 -+ -á-á-á-á-á-á 8/17/25, 116/56 -+ -á-á-á-á-á-á 8/27/25, 110/56 On 9/18/25 at 2:16 PM, Staff 19 stated when she held a medication, she would put a note into the progress notes indicating why the medication was held. Staff 19 acknowledged the above blood pressures and stated, GÇ£some days I probably held the medications and some days I didnGÇÖt.GÇ¥ A review of Resident 6GÇÖs Progress Notes revealed no indication Metoprolol Succinate ER or Prazosin was held on the above dates. On 9/19/25 at 10:20 AM, Staff 2 (DNS) stated staff were expected to follow physicianGÇÖs orders and hold blood pressure medications when indicated based on the physician order. Staff 2 acknowledged on the above dates, Resident 6GÇÖs blood pressures were below the ordered parameters for giving the medications and stated the medications should have been held. -á

F757 Medication error report was completed for identified resident. Resident’s medication orders were re-evaluated by provider and order parameters were updated. Current medical records were audited for other residents receiving blood pressure medications that require hold parameters to determine medications were administered according to the order. Re-education will be provided to applicable staff on the five rights of medications administration with a focus on hold parameters. Routine audits of medication passes will be completed weekly to ensure medications are being administered per order by DNS/designee weekly for 4 weeks, then quarterly. Results will be reported to QAPI for follow up if indicated.

On 9/18/25 at 8:41 AM, an observation was made in the 300-hall medication cart with Staff 21 (CMA). An open bottle of calcium citrate plus vitamin D was observed in the medication cart with an expiration of 8/2025. On 9/18/25 at 8:52 AM, Staff 22 (LPN Resident Care Manager) acknowledged the expired bottle of calcium citrate plus vitamin D and stated medications were to be discarded when expired. On 9/18/2025 at 10:04 AM, Medication Storage Room 1 was observed with Staff 26 (Infection Preventionist), the following expired medication were observed: -+ -á-á-á-á-á-á Major Bisacodyl Suppositories with an expiration of 4/2025. -+ -á-á-á-á-á-á Good Sense Hemorrhoidal Suppositories with an expiration of 11/2024. -+ -á-á-á-á-á-á Antifungal cream with an expiration of 11/2024. -+ -á-á-á-á-á-á Hydrogel with an expiration of 10/2024. -+ -á-á-á-á-á-á Instant toothache oral pain relief gel with an expiration of 6/2025. On 9/18/2025 at 10:04, Staff 26 acknowledged the expired medications and stated he was not auditing the over-the-counter medications for expiration dates, but GÇ£I suppose I should beGÇ¥ On 9/19/2025 at 10:26 AM, Staff 2 (DNS) acknowledged the expired medications and stated medications in the supply rooms and medication carts are expected to be discarded when expired.

F 761 Expired medications were removed from med storage areas on 9/18/25. Medication rooms and med carts were audited to ensure all medications were not expired. Re-education will be provided to applicable staff on disposing of medications (prescription and OTC) that have reached their expiration date. Routine audits of medication storage rooms and medications carts will be conducted by DNS/designee weekly for 4 weeks, then quarterly. Results will be reported to QAPI for follow up if indicated.

Review of the US FDA 2022 Food Code indicated the following: -Food prepared and held cold must be clearly marked with date prepared or by day which the food shall be consumed or discarded. -Food must be labeled with a use-by date if stored for at least 24 hours.-á -Time/temperature control for safety foods must be stored within refrigeration units and held at temperatures of 41 degrees F or below.-á The facility's Food and Safety Sanitation policy, dated 2023, revealed the following:-á -Perishable foods with expiration dates should be used prior to the use-by date on the package. -All time and temperature control for safety foods, including leftovers, should be labeled, covered and dated when stored.-á -Refrigerated food should be stored at or below 41 degrees F.-á 1. On 9/15/25 at 9:09 AM, a brief kitchen tour was completed and revealed the following regarding the non-produce kitchen refrigerator:-á -A container of meat spread was unlabeled and undated and was not marked with a use-by date. -á -A large pan of orange gelatin was uncovered, unlabeled and undated and was not marked with a use-by date. -A five-gallon container of yellow liquid was unlabeled and undated and was not marked with a use-by date. -A five-gallon container of orange liquid was unlabeled and undated and was not marked with a use-by date.-á On 9/15/25 at 9:28 AM, Staff 4 (Dietary Manager) confirmed the items identified in the non-produce kitchen refrigerator were not properly labeled and dated.-á 2. On 9/16/25 at 3:20 PM, the second-floor unit resident and nourishment refrigerator was reviewed and revealed the following:-á -A container of meat spread and a brown paper bag containing food items, marked WK, were unlabeled and undated.-á On 9/16/25 at 3:20 PM, Staff 23 (CMA) confirmed the items identified in the second-floor unit resident and nourishment refrigerator were not properly labeled and dated.-á On 9/17/25 at 8:38 AM, Staff 4 stated all food in the resident and nourishment unit refrigerators needed to be labeled, dated and discarded if expired.-á 3. On 9/17/25 at 8:19 AM, the Main Dining Room resident refrigerator was reviewed and revealed the following:-á -A 16-ounce paper cup of brown liquid was unlabeled and undated.-á -A partially filled bottle of Coke with initials JW was undated.-á -A small plastic container of light orange colored dressing was unlabeled and undated.-á -A pint container of an orange-colored food substance with #13 written on it was unlabeled and undated.-á -A black plastic take-out container with food was unlabeled and undated.-á -An opened 64-ounce container of vanilla coffee creamer was unlabeled and undated. -A gray striped container with food was unlabeled and undated.-á -A glass container of red liquid was unlabeled and undated.-á -A container of yogurt had a use-by date of 7/6/25.-á -An opened container of sour cream was undated.-á -A pitcher of orange liquid dated 9/13/25 had no use-by date.-á -An opened package of smoked salmon was undated and had no use-by date.-á -A plastic container of shriveled grapes dated 8/12/25 and a plastic container of mushy cantaloupe dated 8/25/25 was marked with a resident's name.-á -An opened strawberry parfait cup dated 9/12/25 had no used-by date.-á -A take-out container of Chinese food was unlabeled and undated.-á -A plastic container with a blue lid and one with a red lid (containing food) was unlabeled and undated.-á -A 56-ounce opened container of vanilla coffee creamer was unlabeled and undated.-á -There was no temperature monitoring log observed for this refrigerator.-á On 9/17/25 at 8:48 AM, Staff 4 confirmed the items identified in the Main Dining Room resident refrigerator were not properly labeled and dated and expired items were not discarded. In addition, Staff 4 stated refrigerators needed to be monitored for proper temperature control to ensure foods and liquids were being stored at 41 degrees F or less.-á 4. On 9/17/25 at 8:48 AM, the first-floor resident and nourishment refrigerator was reviewed and revealed the following:-á -Three opened containers of ice cream were unlabeled and undated.-á -Prepackaged cheese and meat sticks belonging to a resident were expired.-á -Five individual prepackaged hummus containers belonging to a resident were expired.-á -The last temperature monitoring log was dated July 2024.-á On 9/17/25 at 8:48 AM, Staff 4 confirmed the items identified in the first-floor resident and nourishment refrigerator were not properly labeled and dated and expired items were not discarded. In addition, Staff 4 stated refrigerators needed to be monitored for proper temperature control to ensure foods and liquids were being stored at 41 degrees F or less.-á -á -á -á -á -á -á -á -á -á -á -á -á -á

F 812 On 9/15/25, the unlabeled and undated food in the kitchen was disposed of. On 9/16/25, the unlabeled and undated food on second floor was disposed of. On 9/17/25, the unlabeled and undated food on the main floor was disposed of. Food storage areas were audited for undated and unlabeled food to ensure no other food items are undated. All refrigerator temp logs were audited to ensure accuracy and completion. Re-education provided to applicable staff regarding dating food items and temperature logs. Routine audits of food storage areas and temperature logs will be conducted by the Administrator/designee to determine that no other food items are undated, and logs are kept up to date weekly for 4 weeks, then quarterly. Results will be reported to QAPI for follow up if indicated.

Resident 49 was admitted to the facility in 8/2025 with diagnoses including PTSD (Post Traumatic Stress Disorder) and urine retention.-á Resident 49's 9/5/25 Catheter Evaluation revealed she/he required an indwelling urine catheter.-á On 9/15/25 at 1:41 PM, 9/17/25 at 8:40 AM and on 9/18/25 at 8:25 AM Resident 49 was observed in bed or in her/his wheelchair with her/his catheter bag and tubing in direct contact with the floor.-á On 9/17/25 at 8:42 AM, Staff 25 (CNA) stated Resident 49's catheter bag and tubing should not touch the floor. Staff 25 stated if she observed the catheter bag and tubing on the floor, she would pick it up. On 9/17/25 at 8:50 AM and on 9/18/25 at 8:27 AM, Staff 9 (LPN) confirmed Resident 49's catheter bag and tubing was on the floor. Staff 9 stated the bag should be kept off the floor and below the level of the bladder to prevent infection and ensure proper drainage.-á On 9/17/25 at 9:08 AM, Staff 2 (DNS) stated she expected Resident 49's catheter bag and tubing be kept off the floor at all times.

F 880 Resident #49’s catheter bag was changed and secured to w/c appropriately. Resident #49 discharged on 9/25/25. Current residents with catheters were audited to ensure we were keeping the catheter bags/tubing off the floor. Re-education will be provided to applicable staff regarding infection control r/t catheter bags/tubing and proper positioning. Routine audits of residents with catheters will be conducted by DNS/designee to determine that catheters are being kept off the floor weekly for 4 weeks, then quarterly. Results will be reported to QAPI for follow up if indicated.

Based on observation and interview it was determined the facility failed to ensure residents were aware of the right to review survey results for 2 of 2 floors and failed to make survey results were readily accessible for 1 of 2 floors reviewed for resident rights. This placed residents and the public at risk for not being informed of the facility's survey history. Findings include: On 6/27/24 at a resident meeting at 2:00 PM residents asked if they were allowed to know the results of the current survey when it was completed. None of the 8 residents attending were aware there was a copy of the survey results located on the first floor near the elevator. Residents further stated most second floor residents could not easily access the first floor without assistance from staff. On 6/28/24 at 2:00 PM no accessible survey results were observed on second floor. On 6/28/24 at 2:00 PM Staff 14 (Activities Director) stated there used to be a place by the nurses station on the second floor where the results of the survey were available in the past, but she believed it disappeared during a remodel. Staff 14 stated she did not think most residents were aware there were results of the survey available to residents. On 6/28/24 at 2:35 PM Staff 1 (Administrator) stated survey results were available by the first-floor entrance, which "everyone uses for admission, appointments, outings." Staff 1 stated there was no copy on the second floor in the past six years. Staff 1 also stated if residents on the second floor wanted to see a copy of the survey results, "They can ask staff."

F- 577 The resident council will be educated on the location of the survey results on 7/31/24. A second copy of the survey results was placed in a high-visibility area on the 2nd floor on 6/28/24. Re-education will be provided to applicable staff regarding the location of the survey results. Routine audits of the location of the survey results will be conducted by the Administrator/designee to determine that they remain intact (weekly for 4 weeks, then quarterly). Results will be reported to QAPI for follow up if indicated.

Based on interview and record review it was determined the facility failed to ensure resident representatives were informed in writing of changes in financial coverage for 1 of 4 sampled residents (#340) reviewed for advance beneficiary notification. This placed residents and their representatives at risk for unknown financial liabilities and lack of knowledge regarding the right to appeal the decision. Findings include: Resident 340 was admitted to the facility for skilled care in 2/2023 with diagnoses including Alzheimer's disease. Resident 340's 3/2/23 Psychosocial History and Discharge Plan revealed the resident's family assisted her/him with decision-making and the resident was unable to make serious medical decisions for her/himself. Resident 340's 3/10/23 Admission MDS revealed the resident was severely cognitively impaired. Resident 340's undated Admission Record (a document in a patient's electronic health record that summarizes important details, including patient identification, allergies and contact information) identified Witness 2 (Family Member) as the resident's Emergency Contact #1, Care Conference Person, Power of Attorney (POA) and Representative Payee (a person or organization who receives Social Security or SSI [supplemental security income] benefits for anyone unable to manage his/her own benefits). Although Resident 340 was identified as severely cognitively impaired in assessments, a Notice of Medicare Non-Coverage (NOMNC) form was provided by facility staff and signed by the resident on 3/28/24. The form indicated the resident's covered services were scheduled to end on 3/30/23. According to the resident's health record, Resident 340 remained in the facility after 3/30/23 as a private pay resident after that date. No evidence was found in the resident's health record to indicate Witness 2 was provided with a NOMNC, her right to appeal the determination or notification of any other financial liabilities, including an advanced beneficiary notification. On 6/25/24 at 2:51 PM Witness 2 stated she informed Staff 12 (Social Services Director) on 2/27/23 she was Resident 340's POA and was responsible for making all medical and financial decisions for the resident. Witness 2 stated the facility never provided her with a NOMNC for Resident 340. Witness 2 stated she found out months later that the resident signed the form per request of the facility and accrued a bill ever since. On 6/26/24 at 3:00 PM Staff 12 (Social Services Director) stated Witness 2 was involved in Resident 340's care and was her/his POA. On 6/26/24 at 3:44 PM Staff 1 (Administrator) stated he issued Resident 340 the NOMNC and was present when the resident signed the form. Staff 1 stated he typically did not have a resident with a diagnosis of dementia sign the form but he did it in this case "in the essence of time." Staff 1 stated he did not notify Witness 2 he had Resident 340 sign the form.

F- 582 Resident #340 was discharged on 5/31/2023. Notices of Medicare non-coverage for the past 30 days were audited for documentation of notification to appropriate responsible parties. Re-education will be provided to applicable staff regarding documentation of notification to appropriate responsible parties. Routine audits of notifications of Medicare non-coverage will be conducted by Administrator/designee to determine that documentation of notification to appropriate responsible parties is complete (weekly for 4 weeks, then quarterly). Results will be reported to QAPI for follow up if indicated.

Based on observation and interview it was determined the facility failed to maintain a homelike and comfortable environment for 2 of 3 halls reviewed for environment. This placed residents at risk for living in an unkempt and uncomfortable environment. Findings include: 1. Observations of the facility's general environment and residents' rooms from 6/24/24 through 7/1/24 identified the following issues: -Room 19 had wall damage behind the bed with missing paint and exposed drywall; -Room 23 had wall damage behind the bed with missing paint, exposed drywall, several brown spots on the ceiling and a fan with dirty blades; -Room 25 had wall damage on the right side of the bed with missing paint and exposed drywall; -Room 36 had damage to the lower portion of the door with sharp/jagged edges; -Room 50 had wall damage to the left of the door with missing paint and exposed drywall; -Room 55 had lower wall damage on two walls including behind the bed with missing paint/drywall and a stained/dirty privacy curtain; -Room 62 had wall damage behind the bed with missing paint and exposed drywall; -The 300 hall had a broken picture frame on the wall with sharp/jagged edges; -An overhead light was burned out in the dining room, as well as between rooms 27-28 and between rooms 39-40. On 7/1/24 at 9:26 AM Staff 1 (Administrator) and Staff 6 (Maintenance Director) acknowledged the identified concerns needed to be addressed. , 2. Resident 16 was admitted to the facility in 6/2024 with diagnoses including a right foot wound. Resident 16's 6/6/24 Admission MDS revealed the resident was cognitively intact. On 6/25/24 at 9:46 AM Resident 16 was observed in her/his room in bed with a blanket covering the length of her/his body. Resident 16 stated her/his room was "freezing" and her/his children brought extra comforters because the room was so cold. Resident 16 stated she/he complained to facility staff that the room was too cold on the day she/he admitted to the facility. Resident 16 stated an unidentified staff member "blocked the vent" in the room approximately five to seven days after she/he reported the temperature issue but the room was still cold. Resident 16 further stated she/he did not shower in the bathroom because it was "excessively cold." On 6/26/24 at 9:22 AM Resident 16 was observed in her/his room in bed with a blanket covering the length of her/his body and wearing a hat. Resident 16 stated she/he often wore a hat in her/his room to keep warm and she/he preferred to keep the door to the bathroom closed at all times "so the cold air would not blow into [her/his] room." The Surveyor entered the resident's bathroom and felt cold air blowing. On 6/26/24 at 9:59 AM Staff 23 (CNA) stated Resident 16 complained about her/his room being cold "a couple of times," and when the resident did, Staff 23 stated she added the resident's concern to the maintenance book and offered the resident an extra blanket. Staff 23 stated Resident 16's room was known to be "really bad" when it came to temperatures. Staff 23 stated Resident 16's room temperatures "fluctuated a lot" and the room was sometimes "really, really hot" and sometimes "really, really cold." On 6/26/24 at 10:09 AM Staff 6 (Maintenance Director) stated it was his practice to continue checking the temperatures of rooms with temperature complaints even after he felt the issue was addressed in order to ensure that the concern was resolved. Staff 6 stated Resident 16's room had a long history of temperature complaints but he did not take regular temperature readings of Resident 16's room. Staff 6 stated he was not aware Resident 16 complained that her/his room and bathroom were cold. At that time, Staff 6 took temperature readings of the resident's room and bathroom. The temperature reading to the left of the resident's head of bed was 69 degrees and the temperature in the resident's bathroom was 65 degrees. On 6/26/24 at 11:23 AM Staff 1 (Administrator) acknowledged the findings and stated resident room temperatures were determined according to resident preferences.

F- 584 The walls with missing paint/exposed drywall for RMs 19, 23, 25, 50, 55, and 62 were corrected on 7/8-11/24. The stains and dusty fan in RM 23 were corrected on 7/8/24. The damage to the door in RM 36 was corrected on 7/10/24. The soiled privacy curtain in RM 55 was corrected on 7/12/24. The damaged picture frame in the 300 hall was corrected on 7/22/24. The 3 lightbulbs in the overhead lights were replaced on 7/17/24. Resident 16s RM was audited to determine that the temp was acceptable to the resident and within range on 7/9/24. Re-education will be provided to applicable staff regarding procedure to address wall damage, temperature ranges, privacy curtains, and lightbulb replacement. Routine audits of wall damage, temperature ranges, privacy curtains, and lightbulb replacement will be conducted by Administrator/designee to determine that areas are clean and comfortable (weekly for 4 weeks, then quarterly). Results will be reported to QAPI for follow up if indicated.

Based on interview and record review it was determined the facility failed to ensure the Office of the State Long Term Care Ombudsman was notified of resident hospitalizations for 3 of 3 sampled residents (#s 40, 87 and 339) reviewed for hospitalization. This placed residents at risk for lack of advocacy by the Ombudsman's office. Findings include: 1. Resident 40 was admitted to the facility in 12/2023 with diagnoses including dementia and heart disease. Resident 40's 2/26/24 Discharge MDS indicated the resident was discharged to an acute care hospital. Review of Resident 40's health record revealed no documentation to indicate the state/local Ombudsman was notified Resident 40 was discharged to a hospital. On 7/1/24 at 11:02 AM Staff 1 (Administrator) stated the facility did not notify the Ombudsman of discharged residents. , 2. Resident 87 was admitted to the facility in 5/2024 with a diagnosis of spinal cord compression. A 5/23/24 Nursing Note indicated Resident 87 was sent to the hospital. No evidence was found in the resident's clinical record to indicate the Office of the State Long Term Care Ombudsman was notified of Resident 87's hospitalization. On 7/1/24 at 10:35 AM Staff 13 (Social Services) stated she was unaware the Office of the State Long Term Care Ombudsman's office was to be notified when a resident was sent to the hospital. On 7/1/24 at 10:46 AM Staff 1 (Administrator) stated the facility did not send out written hospital notifications to the Office of the State Long Term Care Ombudsman. , 3. Resident 339 was admitted to the facility in 6/2024 with diagnoses including congestive heart failure. A 6/17/24 Progress Note indicated Resident 339 was sent to the hospital. No evidence was found in Resident 339's health record to indicate a copy of the resident's transfer notice was sent to a representative of the Office of the State Long-Term Care Ombudsman for the hospitalization. On 7/1/24 at 10:35 AM Staff 13 (Social Services Director) stated she was unaware a representative of the Office of the State Long-Term Care Ombudsman was to be notified when a resident was hospitalized. On 7/1/24 at 11:02 AM Staff 1 (Administrator) confirmed the facility did not send a copy of the transfer notice to a representative of the Office of the State Long-Term Care Ombudsman for Resident 339's hospitalization.

F- 623 The notification to the Ombudsman for residents #40, #87 and #339 were sent on 7/1/24. Resident medical records were audited for resident transfers within the last year to determine that the Long-Term Care Ombudsman has been notified of the prior resident transfers. Re-education will be provided to applicable staff regarding procedure to notify the Long-Term Care Ombudsman of resident transfers. Routine audits of notification to the Ombudsman of resident transfers will be conducted by Administrator/designee to determine that reports have been submitted (weekly for 4 weeks, then quarterly). Results will be reported to QAPI for follow up if indicated.

Based on interview and record review it was determined the facility failed to provide residents with a written notice of the facility's bed hold policy at the time of transfer to the hospital for 1 of 3 sampled residents (#40) reviewed for hospitalization and discharge. This placed residents at risk for lack of knowledge regarding their choices and potential financial responsibilities. Findings include: Resident 40 was admitted to the facility in 12/2023 with diagnoses including dementia and heart disease. Resident 40's 2/26/24 Discharge MDS indicated the resident was discharged to an acute care hospital. Review of Resident 40's health record revealed no documentation to indicate the resident was notified of or provided a copy of the facility's bed hold policy prior to her/his 2/26/24 discharge. On 7/1/24 at 9:54 AM Staff 2 (DNS) confirmed a bed hold policy was not provided to Resident 40 when she/he transferred to a hospital.

F- 625 The notification of bed hold policy for transfer 2/26/24 was documented in the clinical record for resident¿¿¿¿¿ #40 on 7/16/24. Resident medical records were audited for transfers to the hospital in the last 30 days to determine that notification of bed hold policy was documented in the clinical record. Re-education will be provided to applicable staff regarding documentation of notification of bed hold policy in the clinical record. Routine audits of documentation of notification of bed hold policy in the clinical record will be conducted by DNS/designee (weekly for 4 weeks, then quarterly). Results will be reported to QAPI for follow up if indicated.

Based on interview and record review it was determined the facility failed to revise and update a care plan intervention for clothing preferences and call light use for 1 of 2 sampled residents (# 45) reviewed for care planning. This placed residents at risk for unmet of care needs. Findings include: Resident 45 admitted to the facility in 11/2023 with diagnoses including paralysis and infection. Resident 45's 2023 comprehensive care plan indicated she/he preferred to get dressed in a shirt even when she/he stayed in bed. Resident 45's comprehensive care plan further indicated her/his call light was to be within reach and Resident 45 was encouraged to use it. Observations made from 6/24/24 through 6/27/24 revealed Resident 45 wore a hospital gown throughout the day. On 6/27/24 at 9:29 AM Staff 26 (CNA) and Staff 27 (LPN) stated Resident 45 rarely used her/his call light. When Resident 45 wanted something she/he yelled for assistance. Staff 26 stated Resident 45 preferred to wear a hospital gown. Staff 26 stated Resident 45 did not seem to have a preference between shirt or gown. On 6/28/24 at 10:57 AM Staff 28 (CNA) stated 2 years ago Resident 45 used her/his call light consistently and showed a preference for shirts. Staff 28 stated currently she did not see her/him use a call light and stated Resident 45 did not have a preference of clothing. On 6/28/24 at 11:00 AM Staff 29 (CNA) and Staff 30 (CNA) stated Resident 45 rarely ever used her/his call light. Staff 29 and Staff 30 stated she/he called out for assistance. Staff 29 and Staff 30 stated Resident 45 did not express a preference for wearing a shirt or hospital gown. On 6/28/24 at 11:52 AM Staff 25 (RN) Stated Resident 45 wore a shirt or one of the hospital gowns. Staff 25 stated Resident 45 did not really use her/his call light. Staff 25 stated when Resident 45 really needed something she/he yelled. Staff 25 confirmed Resident 45's care plan was not updated for her/his changed needs.

F- 656 The care plan for resident #45 was clarified on 7/16/24 to include that he does not wear pants and is unable to use the call light. Current resident medical records were audited for those with dressing interventions related to specific clothing preferences and inability to use a call light to determine that current status was clearly described. Re-education will be provided to applicable staff regarding documentation of dressing interventions related to specific clothing preferences and inability to use a call light in the care plan. Routine audits of dressing interventions related to specific clothing preferences and inability to use a call light will be conducted by DNS/designee to determine that current status is clearly described (weekly for 4 weeks, then quarterly). Results will be reported to QAPI for follow up if indicated.

Based on observation, interview and record review it was determined the facility failed to ensure foods were labeled and stored in a way to minimize food spoilage and cross contamination for 1 of 1 kitchen and 1 of 3 snack/resident refrigerators reviewed for sanitary food storage. This placed residents at risk for potential infections related to foodborne pathogens. Findings include: Review of the US FDA 2022 Food Code revealed: -food prepared and held cold must be clearly marked with date prepared or by day which the food shall be consumed or discarded with a maximum of seven days. Observation on 6/24/24 at 9:12 AM of the following items placed on the dishwashing station by Staff 21 (Cook): -An undated plastic container of macaroni with red meat sauce. -A container of whipped topping dated 6/7. -A container of undated gelatin. Observation of the kitchen on 6/24/24 at 9:12 AM revealed the following: Freezer: -An open plastic bag with three waffles dated 4/16/24. -An undated open plastic bag of five garden burgers with freezer burn. -A box of undated garlic bread sticks. - A large piece of wrapped meat with no date. Walk-in refrigerator: -A box of individually wrapped Danish rolls dated 3/30. The box instructions directed if frozen, thaw overnight and serve. -A partially open plastic container of whipped topping dated 5/25. -An open undated plastic bag of five white slices of cheese. On 6/24/24 at 9:39 AM Staff 21 confirmed the items she placed on the dishwasher station were removed from the refrigerator and should have been removed from the refrigerator prior to that day. On 6/24/24 at 9:40 AM Staff 16 (Dietary Manager) confirmed the items in the freezer and refrigerator where not stored or labeled correctly and were past the date to serve. Staff 16 threw away items. Staff 16 stated the box of Danish rolls were frozen but did not know when they were pulled from the freezer. Observation on 6/27/24 at 8:33 AM of the station two snack/resident refrigerator with an undated or labeled plate with a blue lid of an uneaten lunch meal from 6/24/24 (baked pasta, broccoli and a roll). On 6/27/24 at 8:40 AM Staff 1 (Administrator) removed the undated and unlabeled plate of food from the station two snack/resident refrigerator. Staff 1 acknowledged he expected all food in the refrigerator to be labeled and dated. Staff 1 acknowledged the finding of the kitchen observations and stated he expected all food to be labeled, dated and discarded by the expiration date.

F- 812 The undated food was disposed of on 6/24/24. The food storage area was audited for undated food to determine that no other food items are undated on 7/23/24 Re-education provided to applicable staff regarding dating food items. Routine audits of food storage areas will be conducted by the Administrator/designee to determine that no other food items are undated (weekly for 4 weeks, then quarterly). Results will be reported to QAPI for follow up if indicated.

******************** 411-085-0030 Required Postings Refer to F577 ******************** 411-085-0320 Residents ' Rights: Charges and Rates Refer to F582 ******************** 411-087-0100 Physical Environment: Generally Refer to F584 ******************** 411-087-0450 Heating & Ventilation System Refer to F584 ******************** 411-088-0080 Notice Requirements Refer to F623 ******************** 411-088-0050 Right to Return from Hospital Refer to F625 ******************** 411-086-0060 Comprehensive Assessment and Care Plan Refer to F656 ******************** 411-086-0110 Nursing Services: Resident Care Refer to F684 ******************** 411-086-0250 Dietary Services Refer to F812 ********************

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 08/21/2023 and 08/27/2023, 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 observation, interview and record review it was determined the facility failed to accommodate resident needs for 2 of 6 sampled residents (#s 21 and 77) reviewed for environment. This placed residents at risk for lack of accommodation of needs and preferences. Findings include: 1. Resident 77 was admitted to the facility in 2022 with diagnoses including muscle wasting, falls and edema. Resident 77's care profile indicated Resident 77 was her/his own responsible party. An 10/15/22 care plan indicated Resident 77 was a high fall risk. The care plan indicated she/he had edema to both legs with interventions including to elevate her/his legs. An 4/3/23 Alert Note indicated the family came in to visit with Resident 77 and her/his family member stated the physician "recommended" Resident 77 sleep in the bed at an angle. Resident 77 was currently using the recliner to sleep. Resident 77 stated she/he "would try" to sleep in the bed. An 4/3/23 Skilled Services Note indicated the family wanted Resident 77 back in bed. Maintenance was aware and planned to remove the recliner and replace it with a bed on 4/4/23. An 4/4/23 Quarterly MDS indicated Resident 77's BIMS score was 13 which indicated she/he was cognitively intact. 4/12/23 and 4/13/23 Skilled Service Notes indicated Resident 77 was supposed to sleep in the bed and keep her/his lower extremities elevated. Resident 77 was non-compliant with this and slept in her/his wheelchair. On 4/20/23 at 6:01 AM Staff 19 (CNA) stated Resident 77 slept in her/his wheelchair at night. On 4/20/23 at 5:59 AM Resident 77 was observed in her/his wheelchair with eyes closed and a blanket on her/his lap. Multiple medical supplies and other items were on Resident 77's bed. On 4/20/23 at 11:17 AM Resident 77 stated she/he "loved" the recliner but was told the physician ordered the bed. Resident 77 stated she/he tried the bed once, but it was very painful to be in, so she/he slept in the wheelchair. On 4/20/23 at 10:42 AM Staff 11 (Patient Care Coordinator) stated the facility encouraged Resident 77 to use her/his bed and Resident 77's family member requested removal of the recliner. On 4/21/23 at 11:02 AM Staff 2 (DNS) indicated the facility would speak with the therapy department to see if it was okay for Resident 77 to use her/his recliner to sleep in. , 2. Resident 21 was admitted to the facility in 2021 with diagnoses including aftercare following surgical amputation and diabetes. A 3/7/23 revised care plan indicated Resident 21 was cleared to transfer to and from the toilet with limited assist of one staff. No additional details regarding her/his toilet use were provided. The 4/2023 Documented Survey Report indicated from 4/1/23 through 4/18/23 Resident 21 was continent and independent for toileting during evening and night times for 31 of 36 opportunities. On 4/17/23 at 2:57 PM Resident 21 stated she/he transferred herself/himself on and off the toilet from her/his wheelchair so she/he wanted her/his own option to clean the common bathroom/shower room toilet independently before use. Resident 21 stated she/he bought herself/himself a toilet brush which often disappeared from the bathroom and also utilized an alternative bathroom if the shower/bathroom near her/his room was occupied. On 4/19/23 at 9:49 AM the shower/bathroom near Resident 21's room was observed to have a shower chair in front of the sink with no available paper towels or toilet paper for resident use. On 4/19/23 at 9:50 AM Staff 5 (CNA) stated Resident 21 chose to use the toilet independently and did not use the call light to ask for any assistance in the shower/bathroom. Staff 5 stated she often cared for Resident 21 and knew the resident was particular about germs but unaware of her/his intent to clean the bathroom or her/his need for toileting supplies. Staff 5 revealed the bathroom was routinely cleaned only after showers but she and other CNAs were capable to assist Resident 21 with the cleaning of the toilet if informed. On 4/19/23 at 10:20 AM Staff 25 (Housekeeper) stated she supplied Resident 21 with toilet paper because paper products often went missing from the shower/bathrooms due to a resident who liked to take them. Staff 25 stated she did not believe anyone else knew she supplied Resident 21 with her/his own supply of toilet paper and provided it for about five months. On 4/19/23 at 1:47 PM Staff 6 (LPN) stated she was aware Resident 21 needed to carry her/his own toilet paper because of another resident who removed them from the shower/bathroom. Staff 6 stated she was surprised that not all CNAs were aware of Resident 21's toileting needs. On 4/19/23 at 2:18 PM Staff 26 (CNA) observed with the surveyor an alternate shower/bathroom near Resident 21's room where shower chairs impeded access to the sink and toilet. Staff 26 stated she was unaware residents ever needed to use the toilet independently in that room and extra shower chairs were often stored in that location. On 4/19/23 at 4:53 PM Staff 24 (CNA) stated she was aware Resident 21 needed a clear walkway in the shower/bathroom for toileting. On 4/21/23 at 10:09 AM Staff 2 (DNS) stated the shower room/bathroom cleaning was a process and the room may be dirty if any independent resident needed to use the toilet. Staff 2 also stated because of the current demolition of a storage area extra shower chairs were stored in the shower/bathroom. Staff 2 stated she was unaware of missing toilet paper and paper towels in the shower/bathrooms and confirmed Resident 21 needed toilet paper with her/him to use toilet.

The recliner for resident #77 was provided. Resident #21 was offered a room change to a room with a more private bathroom and care plan was updated to reflect his specific preferences. Residents were interviewed to determine that sleeping and toileting preferences are being met. Re-education will be provided to applicable staff regarding accommodation of resident preferences for toileting and sleeping. Routine interviews of 5 sampled residents will be conducted by DNS/designee to determine that resident preferences for toileting and sleeping are being met (weekly for 4 weeks, then quarterly). Results will be reported to QAPI for follow up if indicated.

Based on interview and record review it was determined the facility failed to provide written information to residents concerning the right to formulate an advance directive for 5 of 6 sampled residents (#s 30, 41, 55, 59 and 399) reviewed for advance directives. This placed residents at risk for not having their health care decisions honored. Findings include: Records reviewed for Residents 30, 41, 55, 59 and 399 revealed no documentation of an advance directive or documentation to indicate the residents were informed of or provided written information concerning their right to formulate an advance directive. On 4/20/23 at 12:35 PM Staff 27 (Social Services Coordinator) stated she asked about a POLST (Physician Orders for Life Sustaining Treatment) upon admission but not advance directives. Staff 27 stated the facility had no process for discussing advance directives upon admission and was unable to provide documentation to verify residents were notified of their right to formulate an advance directive or to ensure a copy was obtained if a resident had an advance directive. On 4/20/23 at 2:11 PM Staff 1 (Administrator) confirmed Staff 27 did not follow through with assisting residents to formulate an advance directive.

The opportunity to complete Advanced Directives was documented for residents #30, 41, 55, 59, and 399. Current residents were offered the opportunity to complete an Advanced Directive and responses were documented in the clinical record. Re-education will be provided to applicable staff regarding the Advanced Directive/POLST policy. Routine audits of documentation regarding preferences for Advanced Directives/POLST will be conducted by NHA/designee to determine that reviews were documented (weekly for 4 weeks, then quarterly). Results will be reported to QAPI for follow up if indicated.

Based on interview and record review it was determined the facility failed to ensure a resident's missing personal property was adequately addressed for 1 of 2 sampled residents (#67) reviewed for personal property. This placed residents at risk for loss of personal items. Findings include: Resident 67 was admitted to the facility in 2022 with diagnoses including stroke. A 3/28/23 Quarterly MDS revealed Resident 67 had a BIMS of 15 and was cognitively intact. A 5/18/21 Resident's Personal Property Record indicated Resident 67 had two pairs of jeans. On 4/17/23 at 3:04 PM and 4/19/23 at 4:47 PM Resident 67 stated almost one year ago she/he had four pairs of jeans, but now only had two pairs of jeans for some time. Resident 67 stated all CNAs knew about the missing jeans, there was no follow-up to her/his concern and she/he was never shown a Grievance Form or Missing Item Report form to complete. On 4/19/23 at 4:53 PM Staff 24 (CNA) stated for about three months she was aware of Resident 67's missing jeans, thought the process was already documented and as a result provided no follow-up or additional reporting for lost items. On 4/20/23 at 3:19 PM Staff 3 (Patient Care Coordinator) stated around nine months ago Resident 67's brother bought two new pairs of jeans for the resident. Staff 3 stated Resident 67 indicated around that time the jeans went missing but Staff 3 immediately found the jeans, labeled them, but did not update the resident's inventory. Staff 3 stated she was unaware Resident's 67 jeans were still missing. Staff 3 confirmed Resident 67's inventory should have been updated to include four pairs of jeans, CNAs should have offered Resident 67 a Grievance Form or Missing Item Report form and inform Staff 3 the missing jeans issue continued. On 4/21/23 at 8:55 AM Resident 67 stated Staff 2 (DNS) found one additional pair of jeans in her/his room yesterday (three total) but still wanted the fourth pair of jeans found. Resident 67 stated no Missing Item Report was completed at that time and Staff 2 indicated she would follow up with the missing fourth pair of jeans.

The missing pants for resident #64 were located, a missing item form was completed with the resident, and personal property record for resident #64 was updated. Current residents were interviewed to determine that they had no unresolved missing items. Re-education will be provided to applicable staff regarding completion of a missing item form and adding new items to personal property records. Routine audits of missing item reports will be conducted by NHA/designee to determine that there are no unresolved missing items (weekly for 4 weeks, then quarterly). Results will be reported to QAPI for follow up if indicated.

Based on observation, interview and record review it was determined the facility failed to revise care plans for 4 of 13 sampled residents (#'s 21, 28, 49 and 52) reviewed for communication, environment and ADLs. This placed residents at risk for lack of person-centered care. Findings include: 1. Resident 21 was admitted to the facility in 2021 with diagnoses including aftercare following surgical amputation and diabetes. A 3/7/23 revised care plan indicated Resident 21 was cleared to transfer to and from the toilet with limited assist of one staff. No additional details regarding her/his toilet use was provided. The 4/2023 Documented Survey Report indicated from 4/1/23 through 4/18/23 Resident 21 was continent and independent for toileting during evening and night times for 31 of 36 opportunities. On 4/17/23 at 2:57 PM Resident 21 stated she/he transferred herself/himself on and off the toilet from her/his wheelchair so she/he wanted her/his own option to clean the common bathroom/shower room toilet independently before use. Resident 21 stated she/he bought herself/himself a toilet brush which often disappeared from the bathroom and also utilized an alternative bathroom if the shower/bathroom near her/his room was occupied. On 4/19/23 at 9:49 AM the shower/bathroom near Resident 21's room was observed to have a shower chair in front of the sink with no available paper towels or toilet paper for resident use. On 4/19/23 at 9:50 AM Staff 5 (CNA) stated Resident 21 chose to use the toilet independently and did not use the call light to ask for any assistance in the shower/bathroom. Staff 5 stated she often cared for Resident 21 and knew the resident was particular about germs but unaware of her/his intent to clean the bathroom or her/his need for toileting supplies. Staff 5 revealed the bathroom was routinely cleaned only after showers but she and other CNAs were capable to assist Resident 21 with the cleaning of the toilet if informed. Staff 5 stated the care plan was not updated for Resident 21's needs or wants related to toileting. On 4/19/23 at 10:20 AM Staff 25 (Housekeeper) stated she supplied Resident 21 with toilet paper because paper products often went missing from the shower/bathrooms due to a resident who liked to take them. Staff 25 stated she did not believe anyone else knew she supplied Resident 21 with her/his own supply of toilet paper and provided it for about five months. On 4/19/23 at 1:47 PM Staff 6 (LPN) stated she was aware Resident 21 needed to carry her/his own toilet paper because of another resident who removed them from the shower/bathroom. Staff 6 was surprised not all CNAs were aware of Resident 21's toileting needs, acknowledged the information was not on the resident's care plan and stated residents' care plans were updated by the Resident Care Manager. On 4/19/23 at 2:18 PM Staff 26 (CNA) observed with the surveyor an alternate shower/bathroom near Resident 21's room where shower chairs impeded access to the sink and toilet. Staff 26 stated she was unaware residents ever needed to use the toilet independently in that room and extra shower chairs were often stored in that location. On 4/19/23 at 4:53 PM Staff 24 (CNA) stated she was aware Resident 21 needed a clear walkway in the shower/bathroom for toileting but the information was not in the care plan. On 4/20/23 at 3:50 PM Staff 3 (Patient Care Coordinator) stated she completed some care plan updates but an RN was responsible for the oversight of the care plan. Staff 3 acknowledged Resident 21 often provided her/his own care by her/his choice including independent toileting in the shower/bathroom and her/his care plan should be updated to be more person-centered. 2. Resident 28 was admitted to the facility in 2015 with diagnoses including end stage renal disease (kidney failure) and diabetes. The 1/13/23 Annual MDS and Nutrition CAA indicated Resident 28 received dialysis and was at risk for nutritional deficits related to renal dialysis which occurred three times per week. A 3/6/23 Order Summary indicated Resident 28's dialysis appointment time was for 11:30 AM and pick-up time was from 10:32 AM until 11:02 AM with a return time of 4:15 PM. A care plan printed on 4/18/23 indicated to send meals or snacks with Resident 28 to dialysis. On 4/18/23 at 11:10 AM and 4/19/23 at 9:32 AM Resident 28 stated she/he often did not eat breakfast and food was not sent with her/him to dialysis due to increased precautions at dialysis over the last three years. Resident 28 stated sometimes she/he had lower blood sugar in the afternoon because she/he missed lunch due to the dialysis schedule. Resident 28 stated she/he often had to wait for food when she/he returned in the afternoon from dialysis. On 4/19/23 at 1:47 PM Staff 6 (LPN) confirmed no food was sent with Resident 28 to dialysis and at breakfast the resident received extra food because of the dialysis schedule. On 4/21/23 at 10:09 AM Staff 2 (DNS) confirmed food was no longer allowed at dialysis and acknowledged Resident 28's care plan needed to be updated to meet her/his individual needs. , 3. Resident 49 was admitted to the facility in 2020 with diagnoses including dementia. A care plan revised 10/5/21 revealed Resident 49 spoke Ukrainian and Russian only, understood some English words, staff were to use a communication board to help with communication and were to provide a translator as necessary. The care plan did not indicate how to contact a translator for Resident 49. On 4/21/23 at 8:08 AM Staff 32 (CNA) stated she occasionally worked with Resident 49 because she was able to speak Russian with her/him. Staff 32 stated the other facility staff did not have a way to communicate with Resident 52. On 4/21/23 at 8:41 AM Resident 49 was in bed, a communication board or information about a translator tool was not observed in the room. Resident 49 did not respond when spoken to. On 4/21/23 at 8:43 AM Staff 33 (CNA) stated she spoke slowly to Resident 49, she/he understood sometimes and the facility did not have a translation tool to use to communicate with Resident 49. On 4/21/23 at 10:07 AM Staff 28 (RNCM) stated Resident 49 could understand some English, some facility staff were able to speak to Resident 49 in Ukrainian and the facility utilized a translator tool, but the staff were required to get approval from the administrator prior to each use. On 4/21/23 at 10:07 AM Staff 1 (Administrator) stated the facility had translation services to communicate with Resident 49, but this was not included in the care plan and he was going to distribute information regarding the service to the staff. Staff 1 also stated some facility staff spoke Resident 49's native language and were able to speak with the resident. Resident 49's care plan was reviewed with Staff 1 and he confirmed there was nothing related to the translation services, that family was available to assist in translating and the care plan did not include staff who were able to communicate with Resident 49. 4. Resident 52 was admitted to the facility in 1/2023 with diagnoses including stroke. Resident 52's communication care plan revised 1/12/23 revealed Resident 52 had aphasia (inability to speak) following a stroke and staff were to speak to her/him on an adult level, speak clearly and slower than normal and anticipate the resident's needs. On 4/19/23 at 11:30 AM Resident 52 was interviewed and was able to respond appropriately to questions. Resident 52 spoke slowly but was able to convey her/his message using simple words. On 4/20/23 at 4:20 PM Staff 31 (CNA) stated Resident 52 was able to speak but needed time to respond. On 4/21/23 at 8:48 AM Staff 33 (CNA) stated Resident 52's communication improved significantly since she/he admitted to the facility. Staff 33 stated Resident 52's improved communication was not addressed on the care plan and updates were not added to the care plan. On 4/21/23 at 10:11 AM Staff 28 (RNCM) reviewed Resident 52 and stated her/his communication improved since she/he admitted to the facility. Staff 28 reviewed the care plan and confirmed the care plan was not revised to indicate how Resident 52's communication changed and did not include information on how to communicate with her/him.

The care plans for residents #21, 28, 49, and 52 were updated. Resident medical records were audited for updated dialysis, communication, and toileting care plans. Re-education will be provided to applicable staff regarding care planning needs and preferences. Routine audits of dialysis, communication, and toileting care plans will be conducted by DNS/designee (weekly for 4 weeks, then quarterly). Results will be reported to QAPI for follow up if indicated.

Based on observation, interview and record review it was determined the facility failed to provide ADL care for 1 of 6 sampled residents (#55) reviewed for ADLs. This placed residents at risk for poor hygiene. Findings include: Resident 55 was admitted to the facility in 2021 with diagnoses including stroke with right sided hemiparesis (paralysis). The 3/23/23 care plan indicated Resident 55 was totally dependent on one staff for personal hygiene. Observations on 4/17/23 through 4/19/23 during day and evening shifts revealed Resident 55 had dried dark brown and tan substances under her/his left hand fingernails and whiskers on her/his chin. On 4/18/23 at 10:36 AM Resident 55 stated staff did not offer to clean her/his nails or shave her/his chin. Resident 55 stated she/he did not appreciate the whiskers on her/his face and had to wait until shower day to have them shaved. On 4/19/23 at 12:08 PM Staff 2 (DNS) acknowledged Resident 55's nails were dirty and needed to be cleaned and there were whiskers on her/his chin.

Resident #55s fingernail was cleaned at the time of discovery and facial hair was shaved. Residents who are dependent for shaving facial hair and fingernail cleaning were reviewed to determine that care preferences and needs are being met. Re-education will be provided to applicable staff regarding fingernail cleaning and removing facial hair. Routine audits of residents who are dependent for shaving facial hair and fingernail cleaning will be conducted by DNS/designee to determine that care is being delivered per resident preference. (Weekly for 4 weeks, then quarterly). Results will be reported to QAPI for follow up if indicated.

Based on interview and record review it was determine the facility failed to follow physician's orders and implement timely interventions after an injury for 1 of 2 sampled residents (#21) reviewed for abuse. This placed residents at risk for lack of adequate care. Findings include: Resident 21 was admitted to the facility in 2021 with diagnoses including aftercare following surgical amputation and diabetes. A 1/23/23 physician Discharge Instructions After Shoulder Surgery indicated Resident 21 was to wear her/his sling at all times except when showering, dressing and when doing her/his exercises. Resident 21's arm was also non-weight bearing with no lifting, pushing or pulling with the operative arm and her/his arm was to be kept at her/his side when the sling was not worn. A 2/3/23 Nursing Note indicated Resident 21 did not wear her/his sling because she/he believed the physician gave her/him different orders. A 2/8/23 Nursing Note indicated Resident 21 complained of increased right shoulder pain after Staff 4 (CNA) turned her/him using her/his right shoulder. The 2/2023 MAR indicated twice on 2/8/23 and once on 2/9/23 oxycodone (narcotic pain medication) was requested by Resident 21 due to elevated pain. Prior to 2/8/23 oxycodone was requested only once on 2/1/23. A 2/13/23 Incident Report indicated Resident 21 stated Staff 4 did not know not to touch her/his shoulder during turning and a voicemail was received on 2/9/23 to confirm the physician wanted Resident 21 to wear the sling at all times except for bathing, dressing and exercises. A 2/16/23 initiated care plan (seven days after the facility received clarification of physician orders) indicated Resident 21 was to have her/his right arm in a sling at all times unless bathing, dressing or during exercise per physician orders (there was no indication in the care plan related to no pulling or pushing of the resident's arm since orders received on 1/23/23). On 4/19/23 at 10:40 AM Staff 4 stated he assisted Resident 21 with turning because her/his call light was on but did not look at Resident 21's care plan prior to providing her/his care. On 4/19/23 at 1:47 PM Staff 6 (LPN) stated she evaluated Resident 21 at the time of the 2/8/23 incident and started alert charting for three days on 2/14/23 after speaking to Staff 3 (Patient Care Coordinator). Staff 6 stated Staff 4 was an agency staff at the time of the incident so viewing a care plan prior to providing care would be a nursing standard and even more important. On 4/20/23 at 3:50 PM Staff 3 (Patient Care Coordinator) confirmed she initiated, followed up and completed the investigation dated 2/13/23 and all information on the dates of the 2/8/23 incident came from Resident 21. On 4/21/23 at 11:28 AM Staff 28 (RNCM) confirmed care plans should be updated timely according to physician orders.

The care plan for resident #21 was updated to include the arm sling on the CNA Kardex on 2/16/23. Resident medical records were audited for physician orders for arm slings to determine that the information is included on the Kardex. Re-education provided to applicable staff regarding documentation of arm slings on the Kardex and reading the Kardex prior to caring for residents. Routine audits of orders for arm slings will be conducted by DNS/designee to determine that information is included on the Kardex (weekly for 4 weeks, then quarterly). Results will be reported to QAPI for follow up if indicated.

Based on observation, interview and record review it was determined the facility failed to provide respiratory care and services for 1 of 3 sampled residents (#13) reviewed for respiratory services. This placed residents at risk for unmet respiratory needs. Findings include: 1. a. Resident 13 was admitted to the facility in 2023 with diagnoses including respiratory failure and sleep apnea. A 2/27/23 care plan indicated Resident 13 had alteration of respiratory status with interventions including provide oxygen therapy as physician ordered and provide oxygen via nasal cannula at two to four liters per minute with a goal to keep oxygen levels above 92 percent. A review of the TAR from 4/1/23 through 4/21/23 instructed staff to monitor Resident 13's oxygen saturation (how much oxygen in the blood) as needed and to keep oxygen saturations above 92 percent PRN. There was no documentation on the TAR Resident 13 was administered oxygen or how many liters per minute were provided. An O2 Sats Summary report revealed from 4/1/23 through 4/21/23 Resident 13 was on oxygen via a nasal cannula 44 instances and on room air 13 instances when her/his oxygen saturation levels were checked. A 4/7/23 Nurse Practitioner's Encounter Note indicated Resident 13 was on two liters per minute of oxygen. On 4/21/23 at 7:44 AM Resident 13 was in her/his room and was observed with a nasal cannula in place receiving oxygen. On 4/21/23 at 9:14 AM Staff 18 (CNA) stated Resident 13 sometimes wore her/his oxygen in bed during the day. On 4/21/23 at 10:55 AM Staff 2 (DNS) stated the liters per minute should be indicated on the TAR and she expected staff to document when Resident 13 was administered oxygen. b. A review of the 3/13/23, 4/7/23 and 4/11/23 Nurse Practitioner's Encounter Notes indicated for Resident 13 to use a CPAP (Continuous Positive Airway Pressure) machine nightly. A 4/4/23 Secure Conversations Note indicated Resident 13 mentioned she/he used a "Bipap" (Bi-level Positive Airway Pressure) machine at home and when she/he was at the hospital and it was care planned for her/him to be on droplet precautions when she/he was using her/his CPAP machine, but there was no CPAP machine. Observations from 4/17/23 through 4/21/23 revealed no CPAP machine in Resident 13's room. On 4/17/23 at 11:50 AM and 4/21/23 at 7:44 AM Resident 13 was in her/his room and reported she/he wore oxygen at night, she/he used to use a CPAP machine at home, but did not know why the facility did not give her/him a CPAP machine. On 4/21/23 at 10:55 AM Staff 2 (DNS) stated if a resident did not actively have a CPAP machine, they had to get another sleep study completed. Staff 2 stated she did not know if Resident 13 had a CPAP machine previously or if the facility could obtain the CPAP machine for her/him.

The oxygen order for resident #13 was modified to include liters per minute on 5/2/23. Resident #13 did not have a physician order for CPAP use and when asked stated that she did not wish to use a CPAP now. Resident medical records were audited for oxygen orders to determine that liters per minute was included in each order. Resident medical records were audited for CPAP orders to determine that devices were available for use. Re-education will be provided to applicable staff regarding oxygen order entry. Routine audits of oxygen order entry and CPAP devices will be conducted by DNS/designee to determine that liters per minute is included in orders and CPAP devices are available for use as ordered (Weekly for 4 weeks, then quarterly). Results will be reported to QAPI for follow up if indicated.

Based on interview and record review it was determined the facility failed to provide sufficient staffing to meet the needs of residents for 3 of 6 sampled residents (#s 197, 203 and 297) reviewed for staffing. This placed residents at risk for unmet needs. Findings include: 1. Resident 197 was admitted to the facility in 2022 with diagnoses including heart failure, weakness and difficulty walking. A 5/30/22 Admission MDS indicated Resident 197 had a BIMS of 15 indicating she/he was cognitively intact. Resident 197 required extensive assistance from one person with toileting. A Documentation Survey Report from 6/1/22 through 6/25/22 revealed out of 25 opportunities on evening shift Resident 197 did not receive toileting assistance eight instances. A Tek-Care Report (call light time log) for Resident 197's room from 6/1/22 through 6/15/22 revealed the following call light wait times over 20 minutes: -6/1/22: 4:23 PM 50 minutes, 5:56 PM 31 minutes. -6/2/22: 1:03 AM 26 minutes, 1:58 am 23 minutes, 4:48 AM 21 minutes. -6/5/22: 10:37 AM 29 minutes. -6/11/22: 5:39 AM 45 minutes. -6/12/22: 2:34 AM 21 minutes, 12:57 PM 42 minutes. -6/15/22: 6:37 AM 39 minutes. Review of Direct Care Staff Daily Reports from 6/1/22 through 6/25/22 revealed the facility did not meet the state minimum CNA staffing ratios on the following days: -6/10/22 day shift. -6/11/22 night shift. -6/12/22 day shift and evening shift. -6/18/22 night shift. -6/19/22 day shift. -6/24/22 day shift and night shift. -6/25/22 day shift. On 4/18/23 at 8:27 AM Witness 4 (Complainant) reported call light times were long throughout the day in 6/2022 and Resident 197 had incontinent episodes because of waiting too long. On 4/21/23 at 10:46 AM Staff 2 (DNS) stated she did not receive reports the residents had concerns with call light wait times. Staff 2 stated she expected call light wait times to be under 15 minutes and in general did not remember staffing concerns in 6/2022. 2. Resident 203 was admitted to the facility in 2022 with diagnoses including muscle wasting and a history of falling. Review of Direct Care Staff Daily Reports from 9/15/22 through 10/1/22 revealed the facility did not meet the state minimum CNA staffing ratios on the following days: -9/15/22 day shift. -9/21/22 day shift. -9/25/22 night shift. -9/26/22 day shift. -10/1/22 day shift. A Tek-Care Report (call light time log) for Resident 203 from 9/28/22 through 10/1/22 revealed the following call light wait times over 20 minutes: -9/30/22: 4:33 AM night shift 28 minutes, 10:17 PM 24 minutes. -10/10/22: 6:40 AM 20 minutes. On 4/18/23 at 12:44 PM Witness 6 (Complainant) stated Resident 203 reported concerns with staffing and had to wait for call lights to be answered timely. On 4/21/23 at 10:46 AM Staff 2 (DNS) stated she did not receive reports residents had concerns with call light wait times. Staff 2 stated she expected call light wait times to be under 15 minutes. 3. Resident 297 was admitted to the facility in 2022 with diagnoses including fracture to the right leg and muscle weakness. An 8/8/22 Admission MDS indicated Resident 297 had a BIMS of 15 indicating she/he was cognitively intact. Resident 297 required extensive assistance with two persons assist with toileting. Review of Direct Care Staff Daily Reports from 9/15/22 through 10/1/22 revealed the facility did not meet the state minimum CNA staffing ratios on the following days: -9/15/22 day shift. -9/21/22 day shift. -9/25/22 night shift. -9/26/22 day shift. -10/1/22 day shift. A Tek-Care Report (call light time log) for Resident 297's bed from 9/28/22 through 10/1/22 revealed the following call light wait times over 20 minutes: -9/30/22: 10:06 AM 27 minutes, 6:54 PM 24 minutes, 8:00 PM 39 minutes -10/1/22: 12:41 AM 54 minutes, 9:56 AM 24 minutes. On 4/18/23 at 12:44 PM Witness 6 (Complainant) stated on 10/1/22 she and Resident 203 returned to the facility and Resident 297 (Resident 203's roommate) was agitated. Resident 297 reported she/he had to wait for staff to assist with incontinent care which was an ongoing concern. The facility told Resident 297 there was not enough staff. On 4/21/23 at 10:46 AM Staff 2 (DNS) stated she did not receive reports the residents had concerns with call light wait times. Staff 2 stated she expected call light wait times to be under 15 minutes.

The identified residents had been discharged to the community prior to survey inspection. Staffing schedules were reviewed for accuracy to determine that staffing requirements are met according to minimum staffing ratios. Re-education provided to applicable staff regarding minimum staffing ratios and strategies to mitigate staffing shortages. Routine audits of staffing ratios will be done by the Administrator weekly x4 weeks to ensure staffing ratios are being met and sufficient efforts are being made to mitigate any staffing shortages. Results will be reported to QAPI for follow up if indicated.

Based on interview and record review it was determined the facility failed to ensure minimum CNA staffing requirements were maintained for 12 of 41 days reviewed. This placed residents at risk for lack of timely care. Findings include: A review of the DCSDRs (Direct Care Staff Daily Reports) from 6/1/22 through 6/25/22 and 9/15/22 through 10/1/22 revealed the facility did not have sufficient CNA staff to meet the minimum CNA to resident staffing ratios for 12 of 41 days. On 4/21/23 10:46 AM Staff 2 (DNS) indicated in general she did not remember staffing concerns in 6/2022.

The identified residents had been discharged to the community prior to survey inspection. Staffing schedules were reviewed for accuracy to determine that staffing requirements are met according to minimum staffing ratios. Re-education provided to applicable staff regarding minimum staffing ratios and strategies to mitigate staffing shortages. Routine audits of staffing ratios will be done by the Administrator weekly x4 weeks to ensure staffing ratios are being met and sufficient efforts are being made to mitigate any staffing shortages. Results will be reported to QAPI for follow up if indicated.

*************************************** OAR 411-086-0360 Resident Furnishings, Equipment Refer to F558 *************************************** OAR 411-086-0040 Admission of Residents (Advanced Directive) Refer to F578 ************************************** OAR 411-085-0310 Resident Rights: Generally Refer to F584 ************************************** OAR 411-086-0060 Comprehensive Assessment and Care Plan Refer to F657 *************************************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F677, F684 and F695 *************************************** OAR 411-086-0100 Nursing Services: Staffing Refer to F725 ***************************************

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 11/21/2022 and 11/27/2022, 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 interview and record review it was determined the facility failed to follow the physician orders for blood pressure medication for 1 of 5 sampled residents (#1) reviewed for medications. This placed residents at risk for adverse medication effects. Findings include: The facility's 1/2022 General Dose Preparation and Medication Administration policy directed "staff should verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident." Resident 1 was admitted to the facility in 1/2020 with diagnoses including cerebral infarction (stroke) and hypertension (high blood pressure). On 4/26/22 at 1:10 PM Witness 4 (Complainant) stated while Resident 1 resided in the facility in 2020, she/he received the incorrect dose of blood pressure medication for several days and Witness 4 believed it was double the ordered dose. Resident 1's 1/31/20 Admission Orders included an order for metoprolol tartrate (medication used to treat high blood pressure) 25 mg, take 0.5 tablet by mouth twice daily for high blood pressure. Review of Resident 1's 1/2020 MAR revealed the order for metoprolol tartrate 25 mg, 0.5 tablet by mouth twice daily had a corresponding check mark with staff initials which indicated the medication was administered. A 2/5/20 Physician Notification, written by Staff 31 (Former Staff) indicated Resident 1 received metoprolol tartrate 25 mg for five days (evening dose) on 1/31/20 through 2/4/20 rather than the 12.5 mg dose ordered. The Physician Notification indicated Resident 1's [blood pressure] was "96/54 - 118/76 from 1/31 - 2/5" and [heart rate] was "60-99 [beats per minute] 1/31 - 2/5." The provider's response included, "noted, [blood pressure and heart rate] reviewed. [Resident 1] tolerated higher dose without bradycardia (low heart rate) and [systolic blood pressure] mostly greater than 100. Return to the 12.5 mg dosing for now." A 2/6/20 progress note written by Staff 4 (Patient Care Coordinator LPN) indicated he spoke with Resident 1's family related to the medication error. On 5/2/22 at 11:07 AM Staff 4 acknowledged he wrote the progress note regarding the medication error. Staff 4 stated he could not recall the incident and did not provide additional information or details surrounding the medication error. On 5/3/22 at 2:44 PM Staff 1 (Administrator) and Staff 2 (DNS) were notified of the findings of this investigation. Staff 2 questioned if Resident 1 experienced a negative outcome and acknowledged the resident had hypotension (low blood pressure).

On 2/5/2020, facility staff identified that the dosage dispensed by pharmacy on for Resident #1 required tablets to be split by facility staff. The medications were sent back to the pharmacy and new cards with half tabs were received. The physician was notified and Resident #1's vital signs were monitored. Physician reviewed vital signs on 2/6/2020 and documented that he/she was without bradycardia and SBPs mostly >100. Resident was discharged on 2/19/2020. Resident orders for half tablets were reviewed and compared to dispensed cards to determine that no additional whole tablets were dispensed for orders stating half tablets. Re-education will be provided to applicable staff regarding comparing orders for half tablets with medications dispensed and the 5 Rights. Routine audits of orders for half tablets will be conducted by DNS/designee to determine that no additional concerns are identified (weekly for 4 weeks, then quarterly). Results will be reported to QAPI for follow up if indicated.

The findings of the recertification health survey conducted 07/05/22 are documented in this report. It was determined the facility was in substantial compliance with 42 CFR Part § 483 Requirements for Long Term Care Facilities.

Based on observation, interview and record review it was determined the facility failed to ensure the Direct Care Staff Daily Reports (DCSDR) were complete for 35 of 87 days reviewed for staffing. This placed residents and visitors at risk for lack of staffing information. Findings include: Observations were made from 4/25/22 through 4/28/22 between the hours of 6:00 AM and 3:45 PM. During these observations, the DCSDR were incomplete. Examples include: - The 4/25/22, 4/26/22, 4/27/22 and 4/28/22 hours worked column by the RN, LPN, CNA and NA were blank for all shifts; - The 4/26/22 day shift census was blank; - The 4/27/22 day, evening and night shift census was blank; - The 4/27/22 evening shift RN, LPN, CNA and NA number of staff column was blank; - The 4/28/22 day shift census was blank. Review of the 2/2022, 3/2022 and 4/2022 DCSDR revealed 31 days in 3/2022 where the hours worked column by the RN, LPN, CNA and NA was blank or incomplete and four days in 4/2022 where the hours worked column was blank and the census was not documented. On 5/2/22 at 10:21 AM and 10:54 AM Staff 6 (LPN) and Staff 22 (Staffing Development Coordinator) stated the station one shift nurse filled out the DCSDR information at the beginning of each shift. On 5/3/22 at 2:44 PM Staff 1 (Administrator) and Staff 2 (DNS) were notified of the findings of this investigation. Staff 1 acknowledged the requirement for the DCSDR to be completed when posted and stated the facility's practice was to reconcile the DCSDR the following day.

The identified Direct Care Staff Daily Reports were completed on 5/3/22. Direct Care Staff Daily Reports were audited for the prior 6 months to determine that required data has been recorded. Re-education will be provided to applicable staff regarding the process for completion of Direct Care Staff Daily Reports. Routine audits of Direct Care Staff Daily Reports will be conducted by Administrator/designee to determine that required data was recorded (weekly for 4 weeks, then quarterly). Results will be reported to QAPI for follow up if indicated.

The findings of the recertification health survey conducted 07/05/22 are documented in this report. It was determined the facility was in substantial compliance with 42 CFR Part § 483 Requirements for Long Term Care Facilities.

Based on interview and record review it was determined the facility failed to ensure residents were free from significant medication errors for 1 of 2 sampled residents (#10) identified with a medication error. As a result, Resident 10 received two blood pressure medications, a cholesterol medication, a heartburn medication, a rheumatoid arthritis medication, and an anti-seizure medication on 6/12/21 and required admission to the hospital for monitoring. The facility identified the noncompliance and immediately initiated a plan of correction which resulted in staff awareness and education to ensure accurate identification of residents and no further medication errors occurred. This incident was identified as meeting the criteria for past noncompliance. Findings include: The facility's 1/2022 General Dose Preparation and Medication Administration policy directed "staff should verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident." Resident 10 admitted to the facility in 6/2021 with diagnosis including hepatic encephalopathy, increased edema of lower extremities, heart failure and diabetes. On 6/12/21 at 6:30 PM Staff 33 (Former Staff) erroneously administered leflunomide (a rheumatoid arthritis drug) 20 mg, metoprolol (a blood pressure drug) 25 mg (3 tabs), atorvastatin (a cholesterol drug) 20 mg, hydralazine (a blood pressure drug) 50 mg (2 tabs), famotidine (a heartburn drug) 20 mg, gabapentin (an anti-seizure drug) 400 mg. Staff 33 evaluated Resident 10 and notified Staff 12 (LPN) and the resident. The physician directed Staff 12 to monitor Resident 10 for adverse side effects and send the resident to the hospital for monitoring. In an interview on 4/29/22 at 8:44 AM Staff 33 stated on 6/12/21 she administered incorrect medications to Resident 10. She stated she realized her error and immediately reported to Staff 12 and Staff 2 (DNS). Staff 33 stated she was distracted and inadvertently walked into the wrong resident room and administered medications to the wrong resident. Staff 33 stated she received immediate education after the incident, was reeducated on medication administration, received in-service training on The Five Rights of Medication Administration and had a competency checklist done. On 4/29/22 at 10:00 AM Staff 2 confirmed the medication error occurred and Resident 10 was sent to the hospital for evaluation. Staff 2 stated a quality assurance process was immediately implemented which included placement of identification bands on newly admitted residents, STOP signs created for carts to visually cue people to not disturb CMAs and additional staff was hired to handle phone calls and assist visitors. Additionally, training and reeducation took place and skills audits were conducted to ensure medication pass competency of CMA and LPN staff. In an interview on 5/2/22 at 5:44 PM Staff 12 stated on 6/12/21 Staff 33 erroneously administered leflunomide, metoprolol, atorvastatin, hydralazine, famotidine and gabapentin to Resident 10. Staff 12 stated she immediately evaluated Resident 10 and notified the physician and the resident. Staff 12 stated Resident 10 was sent to the hospital due to low blood pressure and for blood pressure monitoring and to be evaluated. Interviews conducted from 4/25/22 through 5/2/22 between the hours of 8:00 AM and 4:30 PM with Staff 1 (Administrator) , Staff 2, Staff 3 (Nurse Practitioner), Staff 12, Staff 8 (RN), Staff 4 (Patient Care Coordinator/LPN), Staff 10 (LPN), Staff 6 (LPN), Staff 9 (LPN), Staff 13 (LPN), Staff 15 (CMA), Staff 16 (CMA) and Staff 14 (LPN). All staff interviewed were aware of the five rights of medication administration and stated it was expected and proper procedure to identify the resident with a picture, name band, name and date of birth before administering medications. The situation met the criteria for past noncompliance as follows: 1. The incident indicated noncompliance at F760 2. The noncompliance occurred after the exit date of the last standard recertification survey (5/6/19) and before the date of this survey (4/25/22) 3. There was sufficient evidence the facility corrected the noncompliance and was in substantial compliance with F760 as evidenced by: -No deficient practice found at F760 with additional sampled residents. -Evidence the deficient practice was identified by the facility, brought to quality assurance and a plan of correction was implemented on 7/8/21 to continue use of identification bands on newly admitted residents, place STOP signs on carts for visual cues to not disturb CMAs and hire additional staff to handle phone calls and assist visitors. -DNS, RN, LPN and CMA interviews indicated knowledge and awareness of expectations and protocol to accurately identify residents. On 5/3/22 at 2:44 PM Staff 1 (Administrator) and Staff 2 (DNS) were notified of the findings of this investigation.

Based on interview and record review it was determined the facility failed to ensure minimum CNA staffing ratios were maintained for 25 of 85 days and the use of NAs did not exceed more than 25% of the CNA staffing ratios for 14 of 85 days reviewed for staffing. This placed residents at risk for delayed assistance and unmet care needs. Findings include: Review of the 2/2022, 3/2022 and 4/2022 Direct Care Staff Daily Reports (DCSDR) revealed the following days the minimum CNA staffing ratios were not met: 2/1/22 day shift was short one CNA and evening shift was short one CNA; 2/7/22 evening shift was short one CNA and night shift was short one CNA; 2/19/22 evening shift was short one CNA; 2/20/22 night shift was short one CNA; 2/27/22 night shift was short two CNAs; 3/4/22 night shift was short one CNA; 3/5/22 evening shift was short one CNA; 3/11/22 evening shift was short one CNA; 3/12/22 evening shift was short one CNA; 3/13/22 evening shift was short one CNA; 3/20/22 night shift was short one CNA; 3/24/22 evening shift was short one CNA; 3/30/22 night shift was short one CNA; 4/1/22 day shift was short one CNA; 4/2/22 evening shift was short one CNA; 4/3/22 night shift was short two CNAs; 4/9/22 night shift was short three CNAs 4/10/22 night shift was short one CNA; 4/11/22 day shift was short three CNAs; 4/15/22 day shift was short one CNA; 4/17/22 evening shift was short one CNA and night shift was short one CNA; 4/18/22 day shift was short one CNA; 4/24/22 day shift was short two CNAs; 4/25/22 evening shift was short one CNA; 4/26/22 day shift was short one CNA. Review of the 2/2022, 3/2022 and 4/2022 DCSDRs revealed the following days when the facility's use of NAs exceeded the 25% maximum ratio: 2/5/22 - evening shift 50% 2/6/22 - evening shift 40% 2/12/22 - evening shift 40% 2/13/22 - evening shift 50% 2/19/22 - evening shift 50% 2/27/22 - evening shift 40% 3/5/22 - evening shift 30% 3/13/22 - evening shift 30% 3/20/22 - evening shift 70% 3/27/22 - evening shift 60% 4/2/22 - evening shift 50% 4/3/22 - evening shift 50% 4/10/22 - evening shift 30% 4/23/22 - evening shift 40% On 5/2/22 at 3:00 PM Staff 22 (Staffing Development Coordinator) reviewed the 2/2022, 3/2022 and 4/2022 DCSDR and confirmed the minimum CNA staffing ratios were not met and NAs exceeded the 25% maximum ratio on the dates listed. On 5/3/22 at 2:44 PM Staff 1 (Administrator) and Staff 2 (DNS) were notified of the findings of this investigation.

No specific residents were identified as being negatively affected. Staffing schedules were reviewed for accuracy to determine that staffing requirements are met according to minimum staffing ratios. Re-education to applicable staff regarding OAR for staffing ratios. Routine audits of will be done by the Administrator weekly x4 weeks to ensure staffing ratios are being met. Results will be reported to QAPI for follow up if indicated.

************************************** OAR 411-085-0110 Nursing Services: Resident Care Refer to F684 and F760 ************************************** OAR 411-086-0100 Nursing Services: Staffing Refer to F732 **************************************

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 04/25/2022 and 05/01/2022, 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.