Avamere Health Services of Rogue Valley

1. On 8/19/25 at 8:03 AM, Resident 84 stated her/his room was very cold and at night she/he wore two pairs of socks on her/his feet, sweatpants, a sweatshirt, and socks on her/his hands to stay warm. Resident 84 was observed in the wheelchair, had a blanket around her/his shoulders. At this time a staff entered the room and asked Resident 84 if she/he was still cold.-áOn 8/19/25 at 3:29 PM, Staff 17 (Maintenance Director) stated he checked temperatures in the resident rooms weekly and would expect resident rooms to be between 72 and 78 degrees. Staff 17 was asked to check the room temperature in Resident 84's room. Temperatures obtained were 64 degrees, 65 degrees, and-áthe area around the air conditioner vent in Resident 84's room was 54 degrees.-áOn 5/19/25 at 3:44 PM, Staff 1 (Administrator) acknowledged the temperature in Resident 84's room.-á2. On 8/18/25 at 2:48 PM, room 210GÇÖs hot water in the restroom was turned on and became very hot within 10 seconds. The resident in room 210 confirmed she/he did not go into the restroom.On 8/19/25 at 3:29 PM, Staff 17 (Maintenance Director) stated the water temperature in the resident rooms were not to exceed 120 degrees. Staff 17 stated he checked five resident rooms per week. The temperature of the hot water in Room 210 was checked and revealed to be 132 degrees.-áOn 8/19/25 at 3:44 PM, Staff 1 (Administrator) stated the water temperature should not exceed 120 degrees. On 8/20/25 at 2:35 PM, Staff 17 was asked to check the water temperature for multiple rooms and the public restroom in the 300 hall. It was found to be 142 degrees.-á

Resident 14 was admitted to the facility in 6/2025 with diagnoses including alcohol abuse and seizures.On 8/18/25 at 2:41 PM, Resident 14 stated she/he received a NOMNC (Notice of Medicare Non-Coverage) from the Social Service Director and a nurse. Resident 14 stated the nurse told her/him the facility was not a homeless shelter. Resident 14 stated she/he felt belittled by the comment, and she/he notified the administrator via email but did not hear back from the administrator. Resident 14 provided a copy of a NOMNC signed on 8/6/25 by Staff 4 (Social Service Director) and Staff 19 (LPN Infection Preventionist).On 8/20/25 at 2:20 PM, Staff 1 provided an email between Resident 14 and himself sent from Resident 14 on 8/7/25 with a subject line Formal Complaint Regarding Improper Notice, Coercion, and Staff Conduct. Item 3 of the email stated while Resident 14 was receiving a NOMNC the nurse, stated, GÇ£'This isnGÇÖt a homeless shelterGÇÖ. I asked, GÇÿDo you think IGÇÖm homeless?GÇÖ To which she smirked but did not respond. This type of comment is not only demeaning but reflects an unprofessional and prejudiced tone that should have no place in a care setting. Regardless of intent, the remark was belittling and left a lasting emotional impact.GÇ¥-á Staff 1 replied to Resident 14 on 8/12/25, GÇ£Regarding items 3 and 4: I will address this concern with the staff member involved. We do not have a nurse by that name working here, could you clarify her name?GÇ¥On 8/20/25 at 2:45 PM, Staff 1 (Administrator) stated he received an email from Resident 14 regarding a staff complaint. Staff 1 stated Resident 14 never got back to him with the staffGÇÖs name, so an investigation was not completed.On 8/22/25 at 10:01 AM, Staff 1 acknowledged he should have asked Resident 14 when he did not receive a reply to the email. Staff 1 also acknowledged Resident 14GÇÖs email was an allegation of verbal abuse, and it should have been reported to the State Agency.

Resident 14 was admitted to the facility in 6/2025 with diagnoses including alcohol abuse and seizures.On 8/18/25 at 2:41 PM, Resident 14 stated she/he received a NOMNC (Notice of Medicare Non-Coverage) from the Social Service Director and a nurse. Resident 14 stated the nurse told her/him the facility was not a homeless shelter. Resident 14 stated she/he felt belittled by the comment, and she/he notified the administrator via email but did not hear back from the administrator. Resident 14 provided a copy of a NOMNC signed on 8/6/25 by Staff 4 (Social Service Director) and Staff 19 (LPN Infection Preventionist).On 8/20/25 at 2:20 PM, Staff 1 provided an email between Resident 14 and himself sent from Resident 14 on 8/7/25 with a subject line Formal Complaint Regarding Improper Notice, Coercion, and Staff Conduct. Item 3 of the email stated while Resident 14 was receiving a NOMNC the nurse stated, GÇ£'This isnGÇÖt a homeless shelterGÇÖ. I asked, GÇÿDo you think IGÇÖm homeless?GÇÖ To which she smirked but did not respond. This type of comment is not only demeaning but reflects an unprofessional and prejudiced tone that should have no place in a care setting. Regardless of intent, the remark was belittling and left a lasting emotional impact.GÇ¥-á-áStaff 1 replied to Resident 14 on 8/12/25, GÇ£Regarding items 3 and 4: I will address this concern with the staff member involved. We do not have a nurse by that name working here, could you clarify her name?GÇ¥On 8/20/25 at 2:45 PM, Staff 1 (Administrator) stated he received an email from Resident 14 regarding a staff complaint. Staff 1 stated Resident 14 never got back to him with the staffGÇÖs name, so an investigation was not completed.On 8/22/25 at 10:01 AM, Staff 1 acknowledged he should have asked Resident 14 when he did not receive a reply to the email. Staff 1 also acknowledged Resident 14GÇÖs email was an allegation of verbal abuse, and the allegation should have been investigated to rule out abuse.

Resident 6 admitted to the facility in 3/2025 with diagnoses including dementia.-áA comprehensive care plan dated 5/21/25 revealed Resident 6 had a behavior monitor in place, with behaviors of agitation, fabricating stories, and anxiety. The behavior monitor identified the following triggers: history of growing up in an alcoholic environment, dealing with physical/mental changes, and roommate issues. There was no additional behavior care plan.A 5/28/25 progress note revealed Resident 6 had hallucinations.-á-áA 6/18/25 progress note revealed Resident 6 was very confused and argumentative with CNA staff.-áA 6/26/25 Quarterly MDS revealed Resident 6 had verbal behaviors towards others.-áA 7/16/25 progress note revealed Resident 6 often called out, had difficulty sleeping, displayed agitation with staff and other residents, and displayed agitation surrounding meals. The progress note also indicated television noise and commercials caused Resident 6's behaviors. The progress note also revealed Resident 6 made comments about hitting and raping staff.-á-áA 7/30/25 progress note revealed Resident 6 accused the staff of attempting to kill her/him.-áA 7/31/25 progress note revealed Resident 6 stated the facility staff tried to kill her/him with food and made death threats towards staff.-áAn 8/15/25 progress note revealed Resident 6 yelled at a CNA and was triggered after seeing the color yellow.-áIn an interview on 8/19/25 at 7:51 AM Resident 6 became fixated on food preferences and stated she/he should kill the facility cook but was afraid of God. Resident 6 made multiple statements of how she/he could kill others.On 8/20/25 at 8:40 AM, Staff 12 (CMA) stated Resident 6 threatened staff, yelled for care, and became upset if the staff were not in the room immediately.-áOn 8/21/25 at 8:12 AM, Staff 9 (CNA) stated Resident 6 was very religious, made statements about going to hell, made derogatory statements towards women, and what Resident 6 watched on television affected how she/he acted.-áOn 8/21/25 at 8:15 AM, Staff 13 (LPN) stated Resident 6 made sexual comments, stated she/he would rape the CNA staff, and her/his behaviors were affected by which television show she/he watched.On 8/21/25 at 10:41 AM, Staff 10 (CNA) stated Resident 6 became easily frustrated, could be verbally abusive, and made statements of killing others but would also say she/he was ""Godly."" Staff 10 also stated she recently picked up on Resident 6's mood being affected by what was on the television, but that was not in the care plan.On 8/21/25 at 3:24 PM Staff 4 (Social Services Director) stated Resident 6 became agitated with certain things, including roommates. Staff 4 stated Resident 6 fabricated stories and what she/he watched on television affected how she/he acted, such as a military movie resulting in Resident 6 talking about killing. Staff 4 reviewed Resident 6's care plan and stated the care plan did not address all of her/his behaviors.On 8/21/25 at 4:09 PM Staff 2 (DNS) reviewed Resident 6's care plan and confirmed it would be appropriate for the care plan to address her/his current behaviors.-á

On 8/18/25 at 9:23 PM, Witness 3 (Family) stated she was in the facility for 72 hours with Resident 1 and family cleaned and inserted the resident's dentures because staff did not assist the resident.-á-áOn 8/20/25 at 8:58 AM, Resident 1 was observed with mouth odor and the resident stated she/he wore her/his dentures overnight. -áOn 8/21/25 at 1:03 PM, Staff 15 (LPN-Resident Care Manager) confirmed Resident 1's dentures were to be cleaned in the morning and evenings and removed at night. Staff 15 expected staff to communicate resident care concerns to ensure adjustments were made for Resident 1's oral care hygiene.-á-á

On 8/19/25 at 9:47 AM, Resident 67 was sitting in her/his room with no television on. Staff 30 (Activities Director) entered Resident 67's room and provided the resident an activity calendar with no further discussion.-áOn 8/19/25 at 10:14 AM, Staff 30 acknowledged she was behind on activity assessments which resulted in an incomplete assessment for Resident 67.On 8/21/25 at 1:03 PM Staff 15 (LPN-Resident Care Manager) acknowledged the lack of staff education related to activities and confirmed Resident 67 required additional staff engagement to meet her/his need for socialization and activities.On 8/22/25 at 10:37 AM, Staff 27 (CNA) stated, at times, Resident 67 declined reading materials and they were unsure where to chart activities for residents.-á

1. Resident 5 was admitted to the facility in 7/2025 with diagnoses including stroke, hip fracture, and dementia.An 8/13/25 revised care plan indicated Resident 5 was at high risk for falls and instructed staff to place fall mats on each side of her/his bed.-áOn 8/19/25 at 2:20 PM, Resident 5 was observed in bed with no fall mats at her/his bedside.-áOn 8/20/25 at 2:05 PM, Witness 2 (Family) stated she visited Resident 5 routinely and no fall mats were used for Resident 5.-áOn 8/20/25 at 6:48 PM, Staff 26 (CNA) stated she provided care for Resident 5 and was unaware fall mats were indicated in her/his care plan.-áOn 8/21/25 at 11:45 AM, Staff 24 (LPN) stated she was not aware Resident 5 was to have fall mats in place because it was not on the TAR.-áOn 8/21/25 at 1:03 PM, Staff 15 (LPN-Resident Care Manager) expected staff to utilize fall mats as indicated in the care plan.On 8/22/25 at 11:22 AM, no fall mats were in place while Resident 5 was in bed.-áOn 8/22/25 at 11:36 AM, Staff 2 (DNS) confirmed staff were to use fall mats for Resident 5.2. Resident 13 was admitted to the facility in 7/2025 with diagnoses including sepsis (severe reaction to infection in the body) and respiratory failure.A 7/5/25 care plan for falls indicated to place Resident 13's bed in the lowest position, except during care.-áThe 7/9/25 Admission MDS indicated Resident 13 was admitted with generalized weakness, some disorganized thinking, was assessed to have a BIMS score of 14 (cognitively intact) and was dependent on staff for toileting.-áOn 8/19/25 at 8:32 AM, Resident 13 was observed lying crosswise on her/his bed with the bed in an elevated position.On 8/22/25 at 10:07 AM, Resident 13's bed was in an elevated position, the resident was positioned lying across the bed with her/his feet within one foot of the floor. Resident 13 indicated she/he required staff assistance.-áOn 8/22/25 at 10:24 AM, Staff 28 (CNA) stated Resident 13 ""always"" positioned herself/himself in the bed in unsafe positions and refused to keep her/his bed in the low position. Staff 28 stated nursing staff were not informed.On 8/22/25 at 10:37 AM, Staff 27 (CNA) stated he told nurses ""four to five times"" about his concern related to Resident 13's positioning in bed. Staff 27 confirmed Staff 15 (LPN-Resident Care Manager) was not informed.On 8/22/25 at 11:27 AM, Staff 2 (DNS) expected information about Resident 13's positioning and bed position to be communicated to Staff 15. Staff 2 acknowledged Resident 13's care plan was not updated to address her/his bed placement and she/he needed a care plan revision to address appropriate fall risk interventions.

Resident 55 was admitted to the facility on 7/31/25 with diagnoses including falls and Multiple Sclerosis (an autoimmune disease of the brain and spinal cord where the bodyGÇÖs immune system attacks the protective area around nerve cells causing damage that disrupts communication between the brain and body).A 7/31/25 Physician Order revealed Resident 55 had orders for a regular diet.A review of Resident 55GÇÖs weights revealed the following:-+-á7/31/25 146.8 lbs. (weight was struck out for being inaccurate)-+ 8/4/25 131.8 lbs.-+ 8/5/25 128 lbs.-+ 8/11/25 123.6 lbs.-+ 8/12/25 124.2 lbs.An 8/13/25 Progress Note revealed Resident 55 had a 5.8% weight loss.On 8/18/25 at 12:39 PM, Resident 55 stated she/he did not eat much due to the food being, ""terrible."" Resident 55 stated she/he was not sure if she/he lost weight.A review of Resident 55GÇÖs medical record revealed no evidence of supplements or other interventions for weight loss.On 8/21/25 at 12:49 PM, Staff 25 (CNA) stated Resident 55 did not have much of an appetite, but at times requested a snack.Resident 55's weight was documented on 8/21/24 as 123.2 lbs.On 8/21/25 at 1:07 PM, Staff 31 (LPN) stated she was not sure if Resident 55 lost weight.On 8/21/25 at 1:27 PM, Staff 5 (RD) stated Resident 55GÇÖs weight was on 8/12/25 showed significant weight loss. Staff 5 stated Resident 55 was to be seen in the Nutrition at Risk meeting on 8/21/25. Staff 5 acknowledged Resident 55 had no interventions or supplements in place for weight loss.On 8/21/25 at 4:54 PM, Staff 15 (LPN Resident Care Manager) stated between Resident 55GÇÖs weight on 8/4/25 and 8/12/25, she/he showed significant weight loss. Staff 15 stated an assessment of Resident 55GÇÖs significant weight loss was completed on 8/21/25 and Staff 5 ordered a nutritional supplement for Resident 55 to be started on 8/22/25. Staff 15 stated her expectation for residents with significant weight loss was for them to be assessed, reviewed by the IDT in the Nutritional at Risk meeting, and weight loss prevention interventions put in place within the same week the significant weight loss occurred.On 8/22/25 at 10:40 AM, Staff 2 (DNS) acknowledged there were 12 days between Resident 55GÇÖs significant weight loss and assessment, and having interventions put in place. Staff 2 stated she expected interventions to prevent any further weight loss to be put in place quicker than 12 days.

Resident 10 was admitted to the facility in 2017 with diagnoses including chronic pain.-áA 7/9/25 Progress Note revealed the resident requested she/he be prescribed lidocaine patches to manage her/his pain. The request was also documented in the Provider Communications Notebook by Staff 22 (former LPN-Resident Care Manager).-áA review of the 8/2025 Pain Level Summary revealed Resident 10 reported pain levels of 3 to 6 (moderate to severe) on 9 of 21 days reviewed.-áOn 8/19/25 at 8:44 AM, Resident 10 stated she/he regularly experienced severe pain.On 8/21/25 at 12:22 PM, Staff 23 (Medical Director) stated she was not aware Resident 10 requested lidocaine patches. Staff 23 stated she and the nurse practitioner reviewed the Provider Communications Notebook during each visit to the facility.-áOn 8/22/25 at 11:30 AM, Staff 2 (DNS) stated she was unable to locate any documentation from the Provider Communications Notebook of Resident 10's request for lidocaine patches.-áOn 8/22/25 at 12:05 PM, Staff 1 (Administrator) and Staff 2 (DNS) confirmed nursing staff should document residents' medication needs in the Provider Communications Notebook and follow up if they do not receive a response from the provider.-á

On 8/18/25 at 12:13 PM, an observation was made with Staff 18 (LPN) of a bottle of antifungal powder in an unlocked precaution cart outside room 213. Staff 18 stated the antifungal powder should be locked in the treatment cart.On 8/19/25 at 11:05 AM, an observation was made with Staff 18 of a bottle of antifungal powder located in room 202 on a small table near the bed. Staff 18 stated the antifungal powder should be locked in the treatment cart.On 8/21/25 at 8:28 AM, an observation was made with Staff 16 (RN) of a bottle of antifungal powder located in room 108 on the overbed table. Staff 16 stated the antifungal powder should be locked in the treatment cart.On 8/21/25 at 8:45 AM, Staff 2 (DNS) stated antifungal powder should be locked in the treatment cart.-á

Resident 27 was admitted to the facility in 1/2025 with diagnoses including dementia.A 2/6/25 progress note revealed Resident 27's diet was downgraded due to loose dentures.A 2/13/25 progress note revealed Resident 27 did not want to get up for meals as she/he was having trouble with her/his dentures.A 3/21/25 progress note revealed Resident 27 did not want other people to see her/his top dentures because they always fell down while eating.A Care Plan revised 4/21/25 revealed Resident 27 wore upper dentures.A 5/27/25 social service progress note revealed an attempt to make a dental appointment for Resident 27.-á-áA 6/20/25 Care Conference Information evaluation revealed Resident 27 was concerned about her/his dentures not fitting and had a dental appointment coming up.-áOn 8/19/2025 at 7:49 AM, Resident 27 was observed eating in her/his room. Resident 27's dentures appeared to not fit well and moved while she/he talked and ate.On 8/21/25 at 8:09 AM, Staff 9 (CNA) stated Resident 27 liked to seclude her/himself due to of being self-conscious about her/his dentures.-áOn 8/21/25 at 10:46 AM, Staff 10 (CNA) stated Resident 27's dentures have been loose since she/he admitted to the facility and the dentist appointment was still being worked on.-áOn 8/21/25 at 3:35 PM, Staff 4 (Social Services Director) stated she was made aware of Resident 27's need for a dental appointment and first reached out to a dentist on 5/27/25. She also confirmed Resident 27's dentures still did not fit and she/he was self-conscious.-áOn 8/21/25 at 4:11 PM, Staff 2 (DNS) reviewed Resident 27's records and confirmed there was delay in arranging the dental appointment.-á

2. On 8/18/25 at 11:56 AM, Staff 32 (CNA) was observed walking into room 203, a room on contact precautions, without a gown or gloves. Staff 32 acknowledged she did not wear a gown or gloves when delivering the tray to room 203, she stated she did not touch the resident. The contact precaution sign indicated staff were to where a gown and gloves upon entering room. Staff 32 acknowledged the sign said to wear a gown and gloves before entering the room, and stated, GÇ£well okGÇ¥ and walked away.On 8/20/25 at 8:40 AM, Staff 19 (IP) stated staff were expected to follow the signage posted outside resident rooms.3. Resident 47 was admitted to the facility in 8/2023 with diagnoses including depression.The 7/24/25 Annual MDS indicated Resident 47 had a stage 4 pressure wound (a wound caused by pressure that has gone through all layers of skin and fat to reach down to muscle, bone, or tendon) on her/his coccyx which was present upon admission.On 8/18/25 at 2:08 PM, Resident 47 stated she/he had a pressure wound.On 8/21/25 at 10:42 AM, Resident 47GÇÖs pressure wound dressing change was observed with Staff 31 (LPN). The pressure wound was located on Resident 47GÇÖs coccyx and the wound appeared to meet the criteria of a stage 4 pressure wound. Staff 31 gathered the wound care supplies, completed hand hygiene, donned a gown and gloves, and entered Resident 47GÇÖs room. Staff 31 set up the dressing supplies on Resident 47GÇÖs bed. While wearing the same gloves, Staff 31 cleaned Resident 47GÇÖs wound, applied the clean dressing, reached into her pocket, retrieved a pen, dated and signed Resident 47GÇÖs dressing, and put the pen back into her pocket. Staff 31 then removed her gloves, gown, and washed her hands.On 8/21/25 at 10:51 AM, Staff 31 stated she completed hand hygiene before starting Resident 47GÇÖs wound care and after completing the wound care. Staff 31 stated she did not change her gloves during Resident 47's wound care. Staff 31 stated this was how she always completed wound care.On 8/21/25 at 10:55 AM, Staff 19 (IP) stated she expected hand hygiene to be completed, new gloves applied after and in between dirty and clean steps during wound care. Staff 19 stated Staff 31 should have completed hand hygiene, donned gown and gloves, entered Resident 47GÇÖs room, set up wound care supplies, removed soiled gloves, completed hand hygiene, applied new gloves, cleaned the wound, removed soiled gloves, completed hand hygiene, applied new gloves, applied clean dressing, removed soiled gloves, completed hand hygiene, applied new gloves, retrieved pen out of her pocket, dated wound, returned pen to pocket, removed soiled gloves and gown, and completed hand hygiene.1. On 8/18/25 at 12:35 PM, signage was posted outside Room 104 and instructed all staff who assisted the resident in Bed A to wear gowns and gloves during high-contact (frequent physical interaction) activities, including resident transfers.On 8/18/25 at 12:36 PM, Staff 29 (PT) was observed transferring the resident in Bed A from the bed to a wheelchair without wearing a gown or gloves. Staff 29 stated she did not wear personal protective equipment (PPE) because she did not handle the residentGÇÖs catheter.On 8/20/25 at 8:40 AM, Staff 19 (IP) stated therapy staff were provided with a list of residents on transmission-based precautions. Staff 19 reported therapy staff were expected to reference the list and follow signage posted outside resident rooms to ensure appropriate PPE use.

A review of the facility's PBJ Staffing Report dated 8/12/25 revealed an alert for low weekend staffing for the first quarter of 2025.-áA review of Direct Care Daily Staffing Reports for weekends during the first quarter of 2025 and 7/19/25 through 8/18/25 revealed the facility failed to maintain CNA staffing ratios for the following dates: 2/2/25, 2/16/25, 2/28/25, 3/8/25, 7/19/25, and-á7/28/25.On 8/22/25 at 10 AM, Staff 22 (Scheduling Coordinator) confirmed the facility did not meet the minimum CNA staffing ratio for the identified days.-á-á-á

Based on interview and record review it was determined the facility failed to ensure residents were treated with dignity for 1 of 4 sampled residents (#52) reviewed for dignity. This placed residents at risk for lack of self-worth. Findings include:

Resident 52 was admitted to the facility in 2024 with a diagnosis of pernicious anemia (inability of the body to absorb vitamin B12; left untreated it can cause irreversible damage to the nervous system).

A 3/23/24 admission MDS revealed Resident 52 was cognitively intact.

On 4/15/24 at 1:17 PM and 4/17/24 at 11:47 AM Resident 52 stated she/he took medication which was required to prevent her/his health from significantly declining. The side affects of the medication made her/him feel ill for up to four hours after it was administered and she/he preferred to take the medication in the morning. One Thursday morning Resident 52 asked the nurse when her/his medication could be administered. The nurse's response was that she had the medication in her pocket and would administer the medication when the nurse wanted to administer it. Resident 52 stated the nurse's response hurt her/his feelings.

On 4/16/24 at 6:42 PM Staff 26 (LPN) stated she worked with Resident 52 but denied any verbal interactions with the resident about administering the medication on her time and not the resident's preferred time.

On 4/16/24 at 7:04 PM Staff 42 (LPN) stated Resident 52 reported Staff 26 spoke to her/him in a manner which was not very nice. The resident reported she/he felt like she/he was an inconvenience to Staff 26. Staff 42 stated she did not report the resident's concern to management because she did not feel it was verbal abuse.

On 4/17/24 at 8:04 AM and 10:26 AM Staff 2 (DNS) stated if a resident reported to staff they were not spoken to in a dignified manner it should be reported to management. Management should investigate the incident and educate staff as needed. Staff 2 stated she spoke to Staff 26 and Staff 26 acknowledged when Resident 52 requested her/his medication Staff 26 responded "I'll get to it when I get to it."

Based on interview and record review it was determined the facility failed to treat residents with respect for 1 of 1 sampled resident (#63) reviewed for abuse and call lights. This placed residents at risk for lack of dignified treatment. Findings include:

Resident 63 admitted to the facility in 2023 with diagnoses including kidney failure and difficulty walking.

A 11/19/23 Admission MDS indicated Resident 63 was cognitively intact.

A 12/15/23 FRI indicated staff yelled at Resident 63, and refused to assist her/him with cares. The FRI included the resident had significant care needs and depended on staff for assistance.

On 4/18/24 at 11:23 AM Witness 5 (Complainant) indicated Resident 63 stated staff yelled at her/him all the time.

An Incident report dated 12/15/23 included the following:
-Staff 7 (CNA) and Staff 48 (CNA) were bathing Resident 63's roommate. Resident 63 asked Staff 7 if she/he could have a shower later in the day. Staff 7 stated he would try to do a shower for her/him in the afternoon.

Resident 63 stated later she/he asked Staff 48 for a shower and Staff 48 stated "you're going to have to wait, I'm here to take care of your roommate. You are not even elderly, you need to get your fat ass up, I don't even know why you are here". Resident 63 stated Staff 49 called her/him "a bitch" and she/he spoke with a nurse about it, but the nurse stated "suck it up."

On 12/15/23 Resident 63 left the facility for a dialysis appointment. When the resident returned from her/his appointment she/he stated to Staff 26 (LPN) she/he was going home and wanted her/his medications. Staff 26 explained if the resident left she/he would leave AMA (against medical advice) because there was not a physician order for discharge. Resident 63 stated Staff 26 told her/him "I'm not giving you shit." Resident 63 responded she/he was concerned about dying if she/he did not have her/his medications and Staff 26 stated "Go home and die." Resident 63 stated she/he left the facility. Staff 26 stated she returned with AMA paperwork but the resident left the facility.

A Final Investigation dated 12/19/23 indicated management was notified of the 12/15/23 incident and staff involved were placed on suspension. Staff 10 (LPN Unit Manager) indicated the resident left AMA due to being yelled at by staff.

On 4/18/24 at 8:09 AM Staff 26 stated she remembered the resident but did not remember her/him being yelled at by staff.

On 4/18/24 at 8:05 AM Staff 49 (CNA) stated she did not yell at Resident 63.

Based on interview and record review it was determined the facility failed to address with resident council grievances for 1 of 1 resident council reviewed for grievances. This placed residents at risk for unmet needs. Findings include:

An 4/17/24 review of resident council notes revealed a Bi-Monthly Resident Counsel Questions form was completed on 4/10/24 which revealed the following concerns:

-Residents did not feel they were treated respectfully by staff.
-Residents did not feel staff listened to their needs or responded timely.
-Residents did not feel staff followed up with them when they had a concern or issue.
-Residents felt staff retaliated when they expressed concerns.
-Residents stated staff did not answer their call lights within 10 minutes.
-Residents felt the noise level in the facility was unacceptable.
-Residents stated the facility did not offer snacks at bedtime and when requested.
-Residents stated the food did not taste good and it was cold.
-Residents stated lost items were not replaced by the facility.
-Residents did not feel there were enough activities to interest them.
-Residents stated they did not receive showers timely.

During a resident council meeting on 4/17/24 at 11:00 AM residents stated the facility staff did not respond to concerns indicated on the 4/10/24 Bi-Monthly Resident Counsel Questions.

On 4/19/24 at 8:34 AM Staff 21 (Activity Director) stated the Bi-Monthly Resident Counsel Questions form process was initiated on 4/10/24. Staff 21 stated she did not forward a completed copy of the Bi-Monthly Resident Counsel Questions to anyone.

On 4/19/24 at 8:51 AM Staff 1 (Administrator) stated he did not receive a copy of the 4/10/24 Bi-Monthly Resident Counsel Questions. Staff 1 stated he should receive a copy of the form as soon as it is completed and grievances should be addressed within five days. Staff 1 acknowledged the grievances on the 4/10/24 Bi-Monthly Resident Counsel Questions form were not addressed.

Based on observation and interview it was determined the facility failed to maintain a homelike environment for 1 of 1 facility reviewed for environment. This placed residents at risk for living in an unkempt environment. Findings include:

Observations of the facility's general environment and residents' rooms from 4/15/24 through 4/19/24 identified the following issues:

-Room 111 had a missing floorboard in the center of the room.
-Room 204 had a large chunk of the bathroom door missing which exposed the inside material of the door and there was missing paint.
-Room 215-B had wall damage with missing paint behind the bed and along the wall where the bathroom was located.
-Room 218-A had wall damage with missing paint along the wall to the left of the residents bed.
-Lights were not working on the 200 hall outside rooms 204 and 216.
-A small round table in the smoking area had sharp and jagged edges that were approximately 18 inches long.
-The double doors at the end of the 100 hall had multiple cobwebs, residual tape and splatter marks covering them.
-A ceiling tile outside Room 209 was damaged with a thick layer of what appeared to be different shades of brown mold.
-The transition strip in the large dining room had corners that did not line up and sections of the strip were torn and peeling.
-On Hall 100 where mechanical lifts were stored the carpet along the entryway was torn and tattered and there were gaps along the transition strip.
-On Hall 100 there was approximately three to four feet of tattered carpet at the nurse's station.
-On Hall 200 there were two areas near the fire doors with approximately 12 inches of black tape holding the carpet together.
-On Hall 200 near the nurses' station there were two areas with approximately 12 inches of black tape holding the carpet together.
-The main entryway had a large section of carpet that was loose with waves/wrinkles in it.

On 4/18/24 at 8:21 AM Staff 1 (Administrator) and Staff 44 (Maintenance Director) acknowledged the identified above concerns needed to be addressed.

2. Resident 29 admitted to the facility in 2024 with a diagnosis of dementia.

A 1/25/24 Complaints/Grievances form revealed Witness 9 (Family Member) did not want Staff 43 (Night shift LPN) to work with Resident 29. The form indicated it would be difficult for the other nurse on the night shift to provide Resident 29 care if Staff 43 worked on the hall where Resident 29 resided. The form indicated a plan would be coordinated with Staff 2 (DNS) to ensure Resident 29 felt safe.

A 1/27/24 Progress Note revealed Witness 9 requested Staff 43 not work with Resident 29. The note indicated the "...nurse passed this message along."

Resident 29's Progress Notes revealed Staff 43 documented the following:
-1/27/24 Resident 29 walked in the hall with her/his walker without assistance.
-2/8/24 Staff 43 was called to Resident 29's room due to the resident's fall.
-2/23/24 Resident 29 was on alert for a non-injury fall
-3/8/24 Resident 29 was on alert for a non-injury fall and she/he did not report pain.
-3/23/24 Resident 29 did not have a bowel movement and denied abdominal pain.
-3/29/24 Resident 29 did not have a bowel movement and denied abdominal pain
-4/5/24 Resident 29 was administered milk of magnesia (laxative)

On 4/15/24 at 4:55 PM Witness 9 stated she filled out a Grievance form and spoke to staff and informed them she did not want Staff 43 to work with Resident 29 but Staff 43 continued to care for the resident.

On 4/17/24 at 7:37 AM Staff 43 stated Resident 29 had dementia and was more confused when she/he first admitted to the facility. At the end of 1/2024 Resident 29 alleged she pushed the resident which caused her/him to fall. Staff 43 stated she tried to communicate with Resident 29, it agitated the resident, and then the resident reported to Witness 9 she/he was upset with Staff 43. Staff 43 stated she was told not to provide care to Resident 29 and the other night nurse would provide care to Resident 29. Staff 43 stated at times she still provided care and administered medications to Resident 29.

On 4/17/24 at 11:47 AM Staff 10 (LPN Unit Manager) stated Staff 43 was to only work with Resident 29 on an emergency basis, but acknowledged Staff 43 continued to administer medications and provide routine care which was documented in Resident 29's clinical record.








, Based on interview and record review it was determined the facility failed to ensure grievances were resolved or resolutions sustained for 2 of 3 sampled residents (#s 7 and 29) reviewed for grievances and care planning. This placed residents at risk for unresolved concerns. Findings include:

The facility's Grievance Policy dated 5/2000 stated: "It is the policy of this facility to ensure that all residents and their family members are afforded the opportunity to express their concerns and suggest changes in facility policy formally, in writing if they desire without the fear of restraint, interference, coercion, discrimination or reprisal. Additionally, the nursing facility will listen to and act promplty upon grievances and recommendations received from resident, family and advocacy groups."

1. Resident 7 admitted to the facility in 10/2017 with diagnoses including type 2 diabetes and major depressive disorder.

On 10/12/23 a public complaint was received which indicated Resident 7 expressed concerns about nursing staff throwing her/his food away and the facility administration refusing to follow up on a grievance that was submitted.

On 4/16/24 at 12:11 PM Staff 14 (Social Services Director) stated if a resident reported a concern a grievance was initiatied within five days. Staff 14 stated she did not have a paper grievance for Resident 7 regarding staff throwing food away without the resident's permission, and Resident 7 submitted grievances often via emails to Staff 1 (Administrator).

On 4/17/24 at 11:00 AM Staff 1 confirmed an email was sent to him from Resident 7 regarding her/his food being thrown away and a grievance was not started or completed related to Resident 7's concerns.

Based on observation, interview, and record review it was determined the facility failed to ensure residents were free from abuse for 1 of 1 sampled resident (#19) reviewed for abuse. This placed residents at risk for abuse. Findings include:

Resident 19 was admitted to the facility in 8/2020 with diagnoses including post laminectomy syndrome (a condition in which a person continues to feel pain after back surgery).

An 8/22/23 MDS indicated Resident 19 was cognitively intact.

A 9/9/23 Progress Note stated Resident 19 was subjected to physical aggression when she/he ignored Resident 1. Resident 1 "yanked" on Resident 19's hair. Both residents were separated, and Resident 19 was placed on alert charting.

A review of a 9/9/23 care plan revealed Resident 1 had a resolved care plan for physical aggression toward another resident.

A 9/13/23 Brief Interview for Mental Status (BIMS) Evaluation indicated Resident 1 was cognitively intact.

On 4/18/24 at 8:05 AM Resident 1 stated, when asked about the 9/2023 incident with another resident, "I do not remember the incident, but it sounds like something I would do. I'm sorry, but I have a temper."

Random observations from 4/15/24 through 4/18/24 revealed Resident 19 was either outside or sat in the hall in front of her/his room. Resident 19 and Resident 1 were not observed interacting.

On 4/18/24 at 7:56 AM Resident 19 stated in 9/2023 she/he was sitting in Resident 1's spot in the hallway and Resident 1 went up to her/him and said she/he was in her/his spot. Resident 19 ignored Resident 1. Resident 19 stated Resident 1 scooted forward and yelled "I know you can hear me", and then Resident 1 pulled Resident 19's hair. Resident 19 stated staff separated them. Per Resident 19 she/he had no pain or injuries related to the incident.

On 4/19/24 at 8:41 AM Staff 1 (Administrator) and Staff 2 (DNS) agreed Resident 1 pulled Resident 19's hair. No further information was provided.

Based on interview and record review it was determined the facility failed to assess a resident for a significant change in condition for 1 of 4 sampled residents (#6) reviewed for falls. This placed residents at risk for unmet care needs. Findings include:

Resident 6 admitted to the facility in 8/2023 with diagnoses including infection and pressure ulcer of the lower spine.

Resident 6's 12/14/23 Physician Order indicated the resident was referred to hospice services.

Resident 6's Census log indicated the resident started hospice services on 12/20/23.

A review of Resident 6's MDS records indicated a Significant Change MDS was not completed after the resident started hospice services.

On 4/18/24 at 11:06 AM Staff 19 (LPN Unit Manager) reviewed Resident 6's MDS records. Staff 19 stated a Significant Change MDS was required if a resident started hospice services. Staff 19 confirmed a Significant Change MDS was not completed for Resident 6.

Based on observation, interview, and record review it was determined the facility failed to ensure care plans were revised to accurately reflect the needs of residents for 1 of 1 sampled resident (#7) reviewed for care plans. This placed residents at risk for unmet needs. Findings include:

Resident 7 admitted to the facility in 10/2017 with diagnoses including diabetes and major depressive disorder.

A Care Plan initiated on 9/20/23 revealed the resident was to use her/his call light, walkie talkie or to call the nurses' station by phone if staff assistance was needed.

A 2/9/24 Quarterly MDS revealed Resident 7 was cognitively intact.

A Kardex (brief overview of each resident) dated 4/15/24 revealed staff were to encourage Resident 7 to use her/his call light for her/his needs and to ensure all staff were able to attend to her/his needs.

A 3/18/24 Alert Note revealed Resident 7 was reminded staff could not hear or see the call light from the hall the resident was on and for Resident 7 to use her/his call bell system or walkie talkie that was implemented.

On 4/17/24 at 3:16 PM Staff 39 (CNA) stated Resident 7 used a call bell system or walkie talkie to request staff assistance as needed. Staff 39 stated she carried a walkie talkie in her pocket so Resident 7 could communicate with her at any time.

An observation on 4/17/24 at 3:21 PM revealed Resident 7 used her/his walkie talkie to ask Staff 39 for assistance in her/his room.

On 4/17/24 at 3:56 PM Staff 17 (LPN) stated Resident 7 used the call bell system or walkie talkie to communicate with staff for assistance. Staff 17 stated Resident 7 was aware to use her/his call bell system or walkie talkie because the call light could not be seen or heard from the location of Resident 7's room. Staff 17 stated he kept the walkie talkie with him during his shift so he could easily communicate with Resident 7.

On 4/18/24 at 10:16 AM Staff 19 (LPN Unit Manager) reviewed Resident 7's care plan and stated it did not accurately reflect how the resident was to call for staff assistance. Staff 19 stated Resident 7 was aware staff could not hear or see her/his call light from her/his room location and she/he was to use the call bell system or walkie talkie the facility provided.

On 4/18/24 at 10:34 AM Staff 2 (DNS) stated Resident 7 was instructed to not use her/his call light due to the location of her/his room and to use the other two devices that were provided to her/him for staff assistance. Staff 2 stated she expected care plans to be updated with any changes.

2. Resident 52 was admitted to the facility in 2024 with a diagnosis of pernicious anemia (inability of the body to absorb vitamin B12; left untreated it can cause irreversible damage to the nervous system).

An 4/2024 MAR revealed Resident 52 was to be administered Folic Acid 400 micrograms QD for vitamin B12 deficiency. The MAR indicated the Folic Acid was not administered from 4/13/24 through 4/16/24.

Progress Notes revealed the following:
-4/13/24 Folic Acid-dose on order
-4/14/24 Folic Acid-waiting on pharmacy to deliver
-4/15/24 Folic Acid-waiting on pharmacy to dispense
-4/16/24 Folic Acid-waiting on pharmacy to dispense

On 4/17/24 at 3:50 PM Staff 10 (LPN Unit Manager) stated Folic Acid 400 micrograms was an over-the-counter medication which was available in the central supply closet and should have been administered.

, Based on interview and record review it was determined the facility failed to ensure residents received medications as prescribed, were monitored for medication side effects and provide wound care as ordered for 4 of 14 sampled residents (#s 8, 52, 58 and 59) reviewed for dignity, medications, and pressure ulcers. This placed residents at risk for an ineffective medication regimen and worsening wounds. Findings include:

1. Resident 8 admitted to the facility in 2018 with diagnoses including depression and irregular heartbeat.

A 2/22/24 revised care plan indicated the following:
-Resident 8 was on anticoagulant therapy and was at risk for bleeding. Interventions included monitoring, documenting, and reporting to the physician any anticoagulant complications.
-Resident 8 was on antidepressant medications to reduce sexual behaviors toward staff. Interventions included monitoring the side effects of antidepressant medication and its effectiveness.

An 4/2024 MAR instructed staff to administer Zoloft (for treating depression) every morning for depressive disorder and apixaban (an anticoagulant) for an irregular heartbeat.

No documentation was found in clinical records Resident 8's anticoagulant and antidepressant medication side effects were monitored and documented daily.

On 4/19/24 at 8:01 AM Staff 1 (Administrator) and Staff 2 (DNS) stated Resident 8's monitoring for anticoagulant and antidepressant medication should be in the physician's orders and monitored daily.

, 3. Resident 58 admitted to the facility in 4/2023 with diagnoses including an infection in a right foot wound.

On 9/11/23 a public complaint was received alleging Staff 15 (LPN) failed to complete wound care and falsified records by signing the wound care as complete.

A review of Resident 58's 8/2023 TAR indicated her/his dressing change to the right great toe was not completed on 8/24/23 and 8/25/23.

A review of Resident 58's 8/2023 Progress Notes revealed the dressing change to the right great toes was passed to the next shift on 8/24/23 and 8/25/23. No evidence was located which indicated Resident 58's dressing was changed on 8/24/23 and 8/25/23.

A review of Resident 58's 8/2023 Progress notes revealed on 8/26/23 it was discovered Resident 58's right great toe dressing was not changed for two days, 8/24/23 and 8/25/23, and it was noted there were maggots found in the wound and the wound had increased redness around it.

A review of Resident 58's 8/28/23 Wound Evaluation indicated there was increased redness around the wound.

A review of Resident 58's 8/2023 MAR revealed on 8/30/23 Resident 58 began Keflex (an antibiotic) for her/his wound.

An 8/30/24 Order Note stated new orders for an antibiotic were received due to redness around the wound.

On 4/15/24 at 6:34 PM Witness 4 (Complainant) stated she was unable to complete Resident 58's wound care on 8/24/23 and 8/25/23 and she notified the next shift. Witness 4 stated Staff 15 did not complete Resident 58's wound care the days before 8/24/23 but signed it as completed.

On 4/16/24 at 6:15 PM Witness 3 (Complainant) stated they were informed Resident 58's wound care was not completed for two days which resulted in maggots being in the wound and a wound infection.

On 4/17/24 at 9:04 AM Staff 15 stated she changed Resident 58's dressing to her/his right great toe on 8/23/24 and there were no maggots present. Staff 15 denied signing wound care was completed when it was not.

On 4/19/24 at 8:41 AM Staff 2 (DNS) stated she was aware maggots were found in Resident 58's right great toe wound on 8/26/24. Staff 2 acknowledged Resident 58's wound care was not completed on 8/24/23 and 8/25/23 and Resident 58 was started on antibiotics on 8/30/24 related to her/his right great toe wound. Staff 2 denied any increased redness around the wound and stated the wound did not worsen.

4. Resident 59 admitted to the facility in 7/2018 with diagnoses including a pressure injury (wound caused by pressure) to the sacrum region (the large, triangle-shaped bone in the lower spine that forms part of the pelvis).

On 9/11/23 a public complaint was received alleging Staff 15 (LPN) failed to complete wound care and falsified records by signing the wound care was completed in 5/2023.

A review of Resident 59's 5/2023 TAR revealed blank entries related to Resident 59's sacral wound care on 5/19/23 and 5/20/23.

A review of Resident 59's 5/2023 Progress Notes revealed no evidence her/his sacral wound dressing was changed on 5/19/23 and 5/20/23.

On 4/15/24 at 6:34 PM Witness 4 (Complainant) stated Staff 15 did not complete Resident 59's wound care in 5/2023, but Staff 15 signed on the TAR the wound care was completed.

On 4/17/24 at 9:04 AM Staff 15 stated if she was unable to complete wound care she passed the wound care task to the next shift and informed management. Staff 15 denied signing wound care as completed when it was not.

On 4/19/24 at 8:41 AM Staff 2 (DNS) stated she expected wound care to completed as ordered. Staff 2 acknowledged missed documentation on 5/19/23 and 5/20/23 for Resident 59's sacral wound care. Staff 2 and Staff 35 (Regional Nurse Consultant) acknowledged there was no indication wound care was completed for Resident 59's sacrum wound on 5/19/23 and 5/20/23.

Based on observation, interview, and record review it was determined the facility failed to maintain water temperatures below 120 F for 3 of 4 resident bathrooms (Room 104, 108, 111) reviewed for hot water and follow care plan interventions, assess for care plan effectiveness, identify and implement new fall interventions and provide adequate supervision needed to prevent falls for 1 of 4 sampled residents (#6) reviewed for falls. This placed residents at risk for injury. Findings include:

1. On 4/17/24 from 10:55 AM through 12:02 PM with Staff 44 (Maintenance Lead) the following bathroom water temperatures were obtained:

-Room 104 123 F
-Room 108 125 F
-Room 111 121 F

Resident 26 and Resident 29 resided in Room 104 and both required staff assistance for toileting transfers.

Resident 20 and Resident 52 resided in Room 108, both were cognitively intact. Resident 52 was independent for toileting and Resident 20 required one staff assistance for toileting transfers.

Room 111 was currently empty.

On 4/17/24 at 12:30 PM Staff 1 (Administrator) indicated the water heater was new, acknowledged the water temperature was greater than 120 F in Rooms 104, 108, and 111, and Staff 44 would adjust and monitor the water temperatures.

, 2. Resident 6 admitted to the facility in 8/2023 with diagnoses including infection and pressure ulcer of the lower spine.

Resident 6's 8/28/23 Admission MDS revealed the resident had no cognitive impairments and required extensive assistance of two or more persons for transferring and toileting. Resident 6 had no falls within the last two to six months (prior to admission) and no falls since her/his admission.

Resident 6's Fall CAA indicated Resident 6 was at risk for falls due to prescribed psychotropic medications (medications affecting a person's mental state), the need for staff assistance with balance and mobility and the need for staff to monitor Resident 6 for safety.

Resident 6's 11/28/23 Quarterly MDS revealed the resident had no cognitive impairments and required supervision or touch assistance for transferring and toileting. Resident 6 had two or more falls since admission.

Resident 6's 2/28/24 Quarterly MDS revealed the resident had moderate cognitive impairments and required substantial/maximal assistance for transferring and toileting. The resident was frequently incontinent of urine and occasionally incontinent of bowel and was not on a toileting program. Resident 6 had two or more falls since the last assessment.

From 8/24/23 through 4/15/24 31 fall risk evaluations were completed. Resident 6 was identified to be at a moderate to high fall risk.

Resident 6's current Care Plan indicated the resident was at risk for falls related to impaired mobility, muscle weakness, wasting, atrophy and pain. The following fall prevention measures were in place:

-Call light within reach at all times; initiated 8/25/23.
-Notify family/responsible party of any fall; initiated 8/25/23.
-Notify Resident 6's physician of any fall; initiated 8/25/23.
-Keep bed in lowest position except during care; initiated 8/29/23.
-Physical Therapy/Occupational Therapy evaluation and/or treatment as needed; initiated 8/29/23.
-Mobility bed canes to bilateral sides of the bed; initiated 8/30/23, revised 3/19/24.
-Monitor for decline or improvement; initiated 8/30/23.
-Frequently remind Resident 6 to use the call light for any assistance; initiated 9/1/23, revised 1/1/24.
-Education given to therapy staff to come to the nursing station to report any falls; initiated 9/21/23.
-Keep the wheelchair in a locked position, centered on Resident 6's left side; initiated 9/21/23.
-Resident 6 was to wear non-skid foot wear at all times; initiated 10/2/23.
-Frequent rounding; initiated 10/13/23.
-Nightstand moved closer to Resident 6's bed with all personal items within reach; initiated 10/28/23.
-Continue to remind and encourage the resident to ask for assistance multiple times during the shift; initiated 10/14/23, revised 1/31/24.
-Staff to remind Resident 6 frequently to ask for assistance and use her/his call light to transfer out of bed; initiated 11/10/23.
-Keep Resident 6's door open at all times except during care; initiated 11/13/23.
-Ensure Resident 6 had her/his soda pop and snacks within wheelchair accessibility so she/he could reach them; initiated 11/15/23.
-Therapy to evaluate cushion in electric wheelchair; initiated 12/30/23.
-Fall mats on both sides of the bed for safety; initiated 2/5/24.
-Staff to anticipate Resident 6's needs; initiated 2/5/24.

From 10/12/23 through 4/19/24 Resident 6 experienced 30 falls in the facility. Fall investigations revealed the following:

-10/12/23 at 8:30 PM: Resident 6 had an unwitnessed fall in her/his bathroom due to self-transferring without assistance. New fall care plan intervention: staff to educate Resident 6 on self-transferring and need to ask for assistance.

-10/26/23 at 2:42 PM: Resident 6 had an unwitnessed fall in her/his room due to self-transferring without assistance. Interventions: continue to educate and encourage Resident 6 to use the call light for assistance with transferring and to keep her/his non-skid socks on at all times.

No new fall care plan interventions were put into place.

-10/28/23 at 9:30 PM: Resident 6 had an unwitnessed fall in her/his room due to reaching for something on her/his nightstand and falling. The resident did not ask for help when self-transferring. New fall care plan intervention: Resident 6's nightstand was moved closer to her/his bed so all personal items were within reach.

-11/10/23 at 3:55 AM: Resident 6 had an unwitnessed fall in her/his room while getting up to reach for a can of soda pop. New fall care plan intervention: ensure Resident 6 had her/his soda pop and snacks within wheelchair accessibility so she/he could reach them.

-11/12/23 at 4:35 PM: Resident 6 fell when being transferred by two CNA staff due the resident's legs being weak and giving out. New fall care plan intervention: Resident 6 was changed to a two person mechanical lift until Physical Therapy evaluated the resident.

-11/19/23 at 1:15 PM: Resident 6 had an unwitnessed fall in her/his room and was found at the end of her/his bed. No interventions were documented.

No new fall care plan interventions were put into place.

-12/25/23 at 10:17 PM: Resident 6 had an unwitnessed fall while self-transferring to her/his power wheelchair. Interventions: Continue to remind Resident 6 to use the call light. New fall care plan intervention: therapy to look at Resident 6's wheelchair cushion.

-1/1/24 at 3:00 AM: Resident 6 had an unwitnessed fall while self-transferring into her/his power wheelchair. Interventions: continue to encourage Resident 6 to use the call light for assistance.

No new fall care plan interventions were put into place.

-1/25/24 at 9:33 PM: Resident 6 had a fall while her/his family member assisted the resident with a transfer from the toilet. Interventions: education given to family to let staff transfer resident.

No new fall care plan interventions were put into place.

-1/26/24 at 5:23 PM: Resident 6 had an unwitnessed fall while attempting to self-transfer to the bathroom. Interventions: continue to encourage Resident 6 to use the call light for assistance.

No new fall care plan interventions were put into place.

-1/28/24 at 7:01 PM: Resident 6 had an unwitnessed fall in her/his bathroom. Interventions: continue to remind and encourage Resident 6 to ask for assistance, multiple times during the shift.

No new fall care plan interventions were put into place.

-2/4/24 at 3:20 AM: Resident 6 had an unwitnessed fall in her/his room while standing up and self-ambulating to reach her/his soda pop. Interventions: education provided to Resident 6 to use her/his call light for assistance, ensure call light remained within reach and bed was in lowest position.

Resident 6's care plan was not followed as the resident's soda pop was not within reach. No new fall care plan interventions were put into place.

-2/5/24 2:30 AM: Resident 6 had an unwitnessed fall and was found on her/his back on the floor at the foot of her/his bed. Interventions: encourage Resident 6 to use the call light for assistance and place the bed in the lowest position. New fall care plan intervention: Fall mats to be placed on both sides of the bed for safety.

-2/10/24 at 3:00 PM: Resident 6 had an witnessed fall while self-transferring from her/his wheelchair to the bed. Interventions: continue to remind and encourage Resident 6 to ask for assistance, multiple times during the shift.

No new fall care plan interventions were put into place.

-2/13/24 at 5:51 PM: Resident 6 had an unwitnessed fall while she/he attempted to walk to her/his bathroom. Interventions: encourage Resident 6 to ask for assistance for transfers and other care needs. Continue to regularly round on Resident 6.

No new fall care plan interventions were put into place.

-2/16/24 at 5:00 PM: Resident 6 had an unwitnessed fall while she/he attempted to self-transfer from her/his bed to her/his wheelchair. Interventions: education provided to Resident 6 to use her/his call light to ask for assistance, ensure call light remained within reach, the bed was in the lowest position and continue frequent rounding on Resident 6.

No new fall care plan interventions were put into place.

-2/25/24 2:00 PM: Resident 6 had an unwitnessed fall in her/his room and was found on the floor leaning on her/his wheelchair. Interventions: continue encouragement and reminders for Resident 6 to use the call light for assistance and the resident to be rounded on when up in a chair.

No new fall care plan interventions were put into place.

-3/9/24 6:00 AM: Resident 6 had an unwitnessed fall and was found on her/his right side on the floor by her/his bed. At the time of the incident there was no fall mat in place. Interventions: ensure fall mats were in place, education was provided to the nurse regarding facility protocols when a fall occurred, continue to educate and encourage Resident 6 to use the call light.

Resident 6's care plan was not followed as no fall mats were in place. No new fall care plan interventions were put into place.

-3/16/24 12:42 PM: Resident 6 had an unwitnessed fall in her/his room and was found on the floor leaning on her/his wheelchair after self-transferring. Interventions: encouragement provided to Resident 6 to use the call light for assistance.

No new fall care plan interventions were put into place.

-3/18/24 9:35 AM: Resident 6 had an unwitnessed fall in her/his bathroom while she/he attempted to look in the bathroom mirror to trim her/his beard. Interventions: encouragement provided to Resident 6 to use the call light for assistance.

No new fall care plan interventions were put into place.

-3/18/24 10:45 AM: Resident 6 had an unwitnessed fall due to self-transferring. The resident was found on the ground between the foot of the bed and a table and appeared to be sleeping. Interventions: encouragement provided to Resident 6 to use the call light for assistance.

No new fall care plan interventions were put into place.

-3/18/24 9:53 PM: Resident 6 had an unwitnessed fall in front of her/his bathroom. Interventions: encourage Resident 6 to use the call light for assistance.

No new fall care plan interventions were put into place.

-3/30/24 11:45 PM: Resident 6 had an unwitnessed fall and was found in her/his room on the floor next to her/his bed due to self-transferring. Interventions: encouragement provided to Resident 6 to use the call light for assistance and ensure fall mats were in place.

No new fall care plan interventions were put into place.

-4/2/24 3:51 AM: Resident 6 had an unwitnessed fall and was found on the floor next to her/his bed due to self-transferring. Interventions: encourage Resident 6 to call for assistance and continue to place fall mats to the sides of the bed.

No new fall care plan interventions were put into place.

-4/5/24 1:44 PM:Resident 6 had an unwitnessed fall and was found in the bathroom in the hallway near Staff 19's (LPN Unit Manager) office due to self-transferring. Interventions: encourage Resident 6 to use the call light for assistance and round on Resident 6 frequently.

No new fall care plan interventions were put into place.

-4/10/24 6:38 AM: Resident 6 had an unwitnessed fall and was found laying on the floor mat next to her/his bed due to self-transferring. Interventions: fall mats placed to both sides of Resident 6's bed and call light placed within reach.

No new fall care plan interventions were put into place.

Resident 6's Progress Notes from 4/10/24 through 4/19/24 revealed the resident experienced additional falls on 4/12/24, twice on 4/14/24 and once on 4/19/24. None of Resident 6's 30 falls resulted in injuries.

Observations from 4/15/24 through 4/19/24 between the hours of 8:07 AM and 4:06 PM revealed the following concerns:

-Resident 6's room was the last room at the end of the unit with minimal staff activity or traffic.
-Resident 6 did not use her/his call light to call for assistance.
-Resident 6 was often up in her/his wheelchair and alone in her/his room.
-Resident 6 attempted to stand up while in her/his wheelchair, at times, while no staff were around.
-Resident 6 was not checked on by staff for up to one hour at times.

The facility failed to follow care plan interventions, re-assess current interventions and develop new interventions to ensure Resident 6 was adequately supervised.

On 4/15/24 at 1:39 PM Witness 6 (Family) stated Resident 6 fell "all of the time, every day and sometimes several times a day." Witness 6 stated Resident 6 was usually found on her/his floor or in her/his bathroom. Witness 6 reported staff talked about moving Resident 6 by the nurses' station over a month ago but nothing happened.

On 4/16/24 at 2:38 PM Staff 17 (LPN) stated Resident 6 was a high fall risk. Staff 17 reported Resident 6 would benefit from being closer to the nurses' station but there were no appropriate beds to accommodate Resident 6 at the current time. Staff 17 stated the resident fell frequently due to self-transferring and he checked on Resident 6 when he did his rounds. Staff 17 stated on 3/28/24, Resident 6 left the facility without being seen by staff and was located at a restaurant near the facility.

On 4/16/24 at 2:54 PM Staff 38 (CNA) stated Resident 6 was confused, unpredictable and unable to use her/his call light. Staff 38 stated Resident 6 had many falls due to self-transferring and he checked on her/him a minimum of every two hours. Staff 38 stated staff tried to remind Resident 6 not to get up but she/he did not remember. Staff 38 stated Resident 6 continued to fall despite fall preventions being in place.

On 4/17/24 at 2:32 PM Staff 4 (CNA) stated Resident 6 was "unsuccessful" using the call light so she/he required checks at least every two hours. Staff 4 stated Resident 6 was a high fall risk and fell "a lot" and she worried about her/him. Staff 4 stated Resident 6 would benefit from being closer to the nurses' station where there was more staff activity.

On 4/18/24 at 10:52 AM Staff 19 (LPN Unit Manager) reported Resident 6 had many falls because she/he self-transferred. Staff 19 stated Resident 6 needed to have "round-the-clock rounding, all of the time, as frequently as possible." Staff 19 stated Resident 6 did not use her/his call light and had many falls, often on evening or night shift, because she/he was not being rounded on frequently enough and her/his room was at the end of the unit where she/he could not be seen. Staff 19 reviewed Resident 6's current fall care plan interventions and confirmed there were no new fall interventions attempted for several months and the team needed to reassess Resident 6 and determine other fall interventions to try because she did not want to see the resident continue to fall and get injured.

Based on observation, interview, and record review the facility failed to maintain healthy parameters of nutritional status for 3 of 6 residents (#s 32, 60 and 358) reviewed for nutrition. This placed residents at risk for weight loss. Findings include:

1. Resident 32 admitted to the facility in 2023 with diagnoses including stroke and dementia.

An 10/3/23 MDS indicated Resident 32 had moderate cognitive impairment. No dietary issues were noted, and she/he was working with ST and currently weighed 142 pounds.

An 10/2023 MAR instructed staff to administer a nutritional supplement three times a day with a discontinuation date of 10/30/23.

An 10/28/23 Order Note indicated the supplement appeared to cause gastrointestinal upset.

A Weight Summary Review revealed Resident 32 weighed 148 pounds on 9/29/23 and 135 pounds on 10/30/23. (Eight percent weight loss)

No documentation was found in Resident 32's clinical record for a Nutritional Assessment after an eight percent weight loss.

On 4/19/24 at 7:46 AM Staff 1 (Administrator) and Staff 2 (DNS) stated there was usually a report which was created to review weight loss and Resident 32 should have been discussed by the Nutrition At Risk committee.

2. Resident 60 admitted to the facility in 2023 with diagnoses including severe protein-calorie malnutrition.

A 11/13/23 hospital Clinical Nutrition Follow-up indicated Resident 60 had a weight loss greater than 7.5 percent in the last three months with severe body fat and muscle mass depletion. Recommendations and interventions included changing the food supplement to a strawberry bene-protein shake three times a day with meals. Weight on 1/13/23 was 123 pounds.

The MAR from 11/18/23 through 11/30/23 instructed staff to obtain weight daily on the day shift before breakfast and notify the physician of any weight gain. On 11/18/23 Resident 60's weight was documented at 135 pounds, on 11/20/23 her/his weight was documented at 114. On 11/24/23, 11/25/23, and 11/29/23 it was documented as "NA." From 11/26/23 through 11/28/23 and 11/30/23 there was no documentation weights were obtained.

The 12/2023 MAR instructed staff to obtain weight daily on the day shift before breakfast and notify the physician of any weight gain. On 12/1/23 and 12/30/23 there was no documentation of Resident 60's weight was obtained. On 12/10/23, 12/14/23, and 12/15/23 the MAR referred the reader to order notes.

Physician orders signed on 12/30/23 instructed staff to provide a nutritonal supplement three times a day with a start date of 11/27/23 and to obtain weight daily on the day shift before breakfast with a start date of 11/18/23.

Order Notes reviewed for 12/10/23, 12/14/23, and 12/15/23 did not have documentation of why Resident 60's weight was not obtained.

On 4/19/24 at 7:51 AM Staff 1 (Administrator) and Staff 2 (DNS) stated when there was a large discrepancy in weight staff may be weighing in a wheelchair and not taking off the weight of the wheelchair. Staff 2 stated education may be needed for staff.
, 3. Resident 358 admitted to the facility in 3/2024 with diagnoses including adult failure to thrive.

A 3/26/24 Nutrition Assessment from the hospital stated Resident 358's eating was inadequate with an average intake of 33% of meals, and Resident 358's most recent weight on 2/29/24 was 220 lbs.

An 4/4/24 Nutrition at Risk Assessment indicated Resident 358 was at risk for nutritional deficits due to malnutrition, inadequate intake and wounds.

An 4/12/24 Nutrition at Risk Assessment indicated Resident 358's intake declined but she/he accepted 100% of the nutritional interventions.

A review of Resident 358's 4/2024 MAR revealed 4/4/24 orders for a nutritional supplement, Med Pass 2.0, twice a day, and an 4/12/24 order to increase Med Pass 2.0 to three times a day.

On 4/15/24 at 1:40 PM Resident 358 was observed sitting in bed with lunch on the tray table over her/his bed. Resident 358's food was untouched. The food tray was observed in front of Resident 358 until 2:58 PM. Resident 358's CNA Task charting indicated on 4/15/24 at 1:33 PM, Resident 358 consumed 0-25% of lunch.

On 4/16/24 at 8:15 AM Resident 358 was observed sleeping in bed, her/his covered breakfast tray was located on the bedside table to the right side of the bed. Resident 358's CNA Task charting indicated she/he consumed 0-25% of breakfast.

On 4/16/24 at 3:01 PM Staff 17 (LPN) stated Resident 358 often refused meals and alternate meals.

An 4/16/24 review of Resident 358's weights revealed a weight of 142.8 lbs. on 3/29/24 and a weight of 191 lbs on 4/2/24. The 3/29/24 weight was struck out due to a technical error on 4/2/24.

On 4/17/24 at 12:00 PM Resident 358's covered lunch tray was observed on the bedside table, Resident 358 was not observed in the room until 1:16 PM. At 1:16 PM staff set up Resident 358's lunch and left the room. Resident 358's CNA Task charting indicated at 1:00 PM Resident 358 consumed 0-25% of her/his lunch.

On 4/18/24 at 7:53 AM Resident 358 was observed sitting in a wheelchair eating breakfast. At 8:00 AM Staff 18 (CNA) asked Resident 358 if she/he was done eating. Resident 358 replied she/he could "not eat now." CNA Task charting indicated Resident 358 consumed 0-25% of breakfast.

On 4/18/24 at 12:06 PM Staff 19 (LPN Unit Manager) stated Resident 358 had a lot of missed weights due to refusals and Staff 19 confirmed the refusals were not documented. Staff 19 stated Resident 358's average meal intake was 33% and she/he should have been offered a replacement meal when she/he ate less than 50% of her/his meal. Staff 19 confirmed there was no documentation for meal replacements and Resident 358 lost weight since the last weight at the hospital prior to admission.

On 4/18/24 at 12:38 PM Staff 20 (LPN) stated Resident 358 did not eat well during meals at times, but stated Resident 358 was offered snacks throughout the day. Staff 20 stated bedtime snacks were offered and charted in the CNA Tasks, but there was no documentation of the snacks offered throughout the day. Staff 20 confirmed bedtime snacks were charted once since Resident 358 admitted to the facility.

An 4/19/24 review of CNA Task charting from 3/29/24 through 4/18/24 revealed Resident 358 consumed 76-100% of the meal eight times, consumed 51-75% of the meal 10 times, consumed 26-50% of the meal 20 times and consumed 0-25% of the meal 23 times.

An 4/19/24 review of CNA Meal Replacement task charting revealed, from 3/29/24 through 4/18/24, Resident 358 consumed a meal replacement once on 4/16/24 at 1:00 PM and she/he consumed 50% of the meal replacement.

An 4/19/24 review of Resident 358's weights revealed on 4/19/24 Resident 358 weighted 192 lbs.

On 4/19/24 at 8:41 AM Staff 2 (DNS) confirmed Resident 358 had two weights since admission. Staff 35 (Regional Nurse Consultant) stated, per policy, weights should be obtained upon admission, then weekly for four weeks, and then monthly. Staff 2 stated if a resident consumed less than 50% of their meal she expected the alternate meal to be offered. Staff 2 confirmed Resident 358 ate on average less than 50% of meals with an alternate meal being offered once, and Resident 358 lost weight since admission.

Based on observation, interview, and record review it was determined the facility failed to ensure ongoing communication with the dialysis center for 1 of 2 sampled residents (#63) reviewed for rehab. This placed residents at risk for dialysis complications. Findings include:

Resident 63 admitted to the facility in 2023 with diagnoses including chronic kidney disease and was dependent on dialysis (a procedure to remove waste products from the blood when the kidneys stop working).

Resident 63's care plan for renal failure dialysis, revised on 11/15/23, indicated the resident's scheduled dialysis days were Monday, Wednesday, and Friday.

A review of the resident's clinical record revealed a 11/21/23 document related to dialysis communication. There were no forms from 11/22/23 through 12/15/23 between the facility and the dialysis provider.

On 4/19/23 at 8:39 AM Staff 10 (LPN Unit Manager) indicated there was one dialysis communication form in Resident 63's clinical record. Staff 10 stated the form was an important document and used for communication between the dialysis center and the facility.

On 4/19/23 at 9:34 AM Staff 2 (DNS) stated she would look for the missing dialysis communication documentation. No further information was provided.

4. Resident 160 was admitted to the facility in 2023 with diagnosis including shoulder replacement.

A 8/12/23 Admission MDS indicated Resident 160 was cognitively intact and required supervision or touching assistance from staff for toileting.

A 9/7/23 FRI indicated on 8/27/23 Resident 160 had her/his call light on for 45 minutes and needed to use the restroom. Resident 160 indicated she/he heard Staff 36 (Former CNA) talking in the hallway. Resident 160 stated Staff 36 came into her/his room, turned around and left without attending to the resident's needs. Resident 160 stated Staff 36 did not return to assist her/him.

On 4/18/24 at 8:09 AM Staff 27 (CNA) stated she remembered Staff 39; she did not answer her resident's call lights or other resident's call lights.

On 4/18/24 at 9:14 AM Staff 1 (Administrator) and Staff 2 (DNS) stated Staff 39 (Former CNA) worked in the facility for years and had multiple warnings and write ups related to resident care and not answering call lights. Staff 36 was terminated.


, Based on observation, interview, and record review it was determined the facility failed to have adequate staff available to timely meet the needs of residents for 3 of 18 sampled residents (#s 32, 60 and 160) and for 2 of 3 wings (Wings 1 and 2). This placed residents at risk for unmet needs. Findings include:

1. A 2/7/24 Quality Assurance Resident Council note indicated call light wait times were too long. The 2/12/24 Response Form indicated the facility followed the state minimum CNA staffing requirements.

A 3/6/24 Resident Council Department Response Form indicated the residents felt they needed more nurses and there were not enough which affected their care. The facility's response was they staffed to meet the state minimum staffing requirements.

An 4/10/24 Bi-Monthly Resident Counsel Questions form revealed the questions if residents felt staff answered call lights within a 10-minute time frame, and if the resident counsel felt the facility was staffed well enough to meet the needs of the residents, to which the answer to both was documented as no.

An 4/10/24 Resident Council Department Response Form indicated the facility needed more CNAs on the evening shift because staff was working with residents who were "sundowning" (a neurological phenomenon associated with increased confusion and restlessness in people with delirium or dementia). The facility response was the facility staffed to meet or exceed the state minimum staffing requirements on all three shifts.

On 4/15/24 interviews were conducted revealing the following:

-11:28 AM Resident 1 stated she/he had to activate the call light long before she/he had to urinate as after 2:00 PM call light wait times were 10 minutes to an hour. Resident 1 stated she/he fell because she/he took herself/himself self to the bathroom. One night no CNAs ever came after activating the call light.
-11:51 AM Resident 44 stated she/he was a dissatisfied consumer as she/he had chronic bowel issues, and she/he would be on the bedpan after activating the call light for up to 30 to 45 minutes. At times staff gathered and just gossiped and did not answer call lights.
-1:21 PM Resident 31 stated she/he had to wait up to 30 minutes for her/his call light to be answered and stated the facility needed more staff.
-1:26 PM Resident 52 stated the call light wait time was approximately one to one and a half hours for a response on all shifts.
-1:35 PM Resident 37 stated it took an hour and a half to get assistance and on 4/15/24 she/he had to wait 40 minutes. At times staff came in to the room, turned off the call light, and then did not come back. Resident 37 stated at times she/he was in pain, and she/he had to wait an hour. Resident 37 stated it depended on who was working and not the time of day.
-1:36 PM Resident 36 stated the facility was always short of staff. In the middle of the night she/he heard hear her/his roommate in pain and activated her/his call light, but waited an hour for a response.
-1:42 PM Resident 6 stated it took "forever" for staff to respond to call lights. Resident 6 stated she/he would go down the hall to try and find someone to help but could not find anyone. Resident 6 stated it happened a lot on the evening shift around 7:00 PM and ,at times, she/he saw staff talking at the nurses' station and not answering call lights.
-1:51 PM Resident 50 stated during the night she/he had to wait for care, she/he was a two-person assist and there were not always two staff members available to help. Resident 50 stated she/he, at times, had incontinent episodes because she/he could not wait any longer for assistance.
-2:13 PM Resident 29 stated at night and on the weekends when she/he activated her/his call light it took a long time for staff to respond. Resident 29 stated at times she/he had incontinent episodes because she/he had to wait too long.
-2:24 PM Resident 34 stated there was not enough staff on day and evening shifts, and residents had to wait a long time for their call lights to be answered.
-2:25 PM Resident 308 stated she/he had to call out for help one night because her/his call light was not answered. Resident 308 stated she/he did not feel the facility had enough nurses.
-5:24 PM Resident 26 stated call light wait times were over 15 minutes. Resident 26 stated the facility needed more CNAs and nurses during the day.

On 4/16/24 at 7:35 AM Resident 8 stated her/his call light wait times were mostly over half an hour.

On 4/17/24 at 5:45 AM Staff 3 (CNA) stated from 10/2023 through 12/2023 the facility was short-staffed approximately six out of seven days a week and she worked a lot of double shifts. Residents complained of long call light wait times up to 20 to 30 minutes.

On 4/18/24 at 9:30 AM Staff 8 (CNA) stated that call light wait times went over 20 minutes.

On 4/18/24 at 10:56 AM Staff 4 (CNA) stated at times she took lunch break, and when she came back her assigned residents' call lights were on for over 20 minutes. Staff 4 stated residents activated their call light when on a bedpan and did not have timely follow up. Residents who were continent had incontinent episodes and their dignity was affected because of a long call light wait times.

On 4/18/24 at 1:00 PM Staff 11 (CNA) stated residents complained of long call light wait times "very much" and she observed residents who were left on a bedside commode for long periods of time, and a couple of residents had incontinent episodes when they were continent because staff did not attend to timely.

On 4/19/24 at 7:46 AM Staff 1 (Administrator) and Staff 2 (DNS) stated the expectation for call light response was five to 10 minutes and to check on the residents every couple of hours.

2. Resident 32 was admitted to the facility in 2023 with diagnoses including stroke and dementia.

A 9/29/23 care plan indicated Resident 32 was incontinent of bowel and bladder with interventions including an incontinent program to toilet upon rising, before meals, after meals, at bedtime, and PRN.

An 10/23/23 MDS indicated Resident 32 had moderate cognitive impairment and was occasionally incontinent of bowel and bladder. Resident 32 was normally aware of her/his need to go to the bathroom and staff assisted her/him with toileting and incontinent care needs.

A review of the Direct Care Staff Daily Reports from 10/22/23 through 11/22/23 revealed the facility did not have sufficient CNA staff to meet the state minimum CNA staffing requirements on the following days: 10/28/23 day shift, 10/29/23 day shift,11/12/23 day shift, and 11/24/23 night shift.

On 11/22/23 a public complaint was received which indicated Resident 32 was left in a soiled brief for an extended period. A family member visited daily and observed Resident 32 sitting in wet brief because not enough staff were available to assist, and stated call light wait times were longer than 20 minutes.

On 4/17/24 at 5:45 AM Staff 3 (CNA) stated from 10/2023 through 12/2023 the facility was short-staffed approximately six out of seven days a week and she worked a lot of double shifts. Residents complained of long call light wait times up to 20 to 30 minutes.

On 4/18/24 at 9:16 AM Witness 1 (Family Member) confirmed Resident 32 was left in a soiled brief for an extended period of time.

On 4/18/24 at 10:56 AM Staff 4 (CNA) stated at times she went on lunch break and when she came back her assigned residents' call lights were on for over 20 minutes. Staff 4 stated residents activated their call light when on a bedpan and there was no timely response. Staff 4 stated she found Resident 32 in a soaked brief, and she/he complained to her about having to wait a long time for assistance.

On 4/19/24 at 7:46 AM Staff 1 (Administrator) and Staff 2 (DNS) stated the expectation for call light response was five to 10 minutes and to check on the residents every couple of hours.

3. Resident 60 was admitted to the facility in 2023 with diagnoses including anxiety, a pressure ulcer to the right buttock, and muscle weakness.

A review of the Direct Care Staff Daily Reports from 11/15/23 through 11/14/23 revealed the facility did not have sufficient CNA staff to meet the state minimum CNA staffing requirements on the following days: 11/24/23 night shift, 11/26/23 evening shift, 12/1/23 night shift, 12/3/23 evening shift, and 12/7/23 night shift.

A 11/15/23 care plan indicated Resident 60 was incontinent of bowel and bladder and was at risk for skin impairment. Interventions included an incontinent program to toilet upon rising, before meals, after meals, at bedtime, and PRN. Resident 60 used briefs for dignity.

A 11/18/23 Nursing Care Note indicated Resident 60 called the police for help. The note indicated Resident 60 wanted staff to always stay in her room. The note indicated Resident 60 used her/his call light multiple times and each time it was answered timely. The note indicated the facility would do frequent checks on the night of 11/18/23.

A 11/19/23 MDS indicated Resident 60 had moderate cognitive impairment and was frequently incontinent of bladder and always incontinent of bowel. Resident 60 was at risk for skin impairment and was dependent on staff for assistance with toileting.

A Documentation Survey Report for 11/2023 indicated no documentation of assistance with toileting hygiene for the day shift on 11/22/23 and the night shift on 11/23/23.

A public complaint was received on 12/14/23 which indicated Resident 60 was lying in urine and she/he attempted to reach staff by phone, but no one answered. Resident 60 called Witness 2 (Family Member) and Witness 2 stayed on the phone with Resident 60 until staff came and assisted Resident 60. This occurred two nights in a row and Resident 60 ended up calling 911. Police came to the facility for a welfare check.

On 4/16/24 at 12:03 PM Witness 2 confirmed call light wait times of up to an hour and staff standing around and talking with multiple lights on at the nurses' station.

On 4/17/24 at 5:45 AM Staff 3 (CNA) stated from 11/2023 through 12/2023 the facility was short-staffed approximately six out of seven days a week and she worked a lot of double shifts. Residents complained of long call light wait times up to 20 to 30 minutes.

On 4/17/24 at 10:28 AM Staff 6 stated in 11/2023 the facility was short-staffed and she had to work very fast. Staff 6 stated it was overwhelming and stressful and residents thought staff were ignoring them.

On 4/18/24 at 10:56 AM Staff 4 (CNA) stated at times she would go on lunch and when she came back her assigned residents' call lights were on for over 20 minutes. Staff 4 stated residents would activate their call light when on a bedpan and not have it answered timely. Staff 4 stated she had found Resident 60 in a soaked brief and if she/he would push her/his call light a lot it was because her/his needs were not met.

On 4/19/24 at 7:46 AM Staff 1 (Administrator) and Staff 2 (DNS) stated the expectation for call light response was five to 10 minutes and to check on the residents every couple of hours.

Based on interview, and record review, it was determined the facility failed to post accurate and complete staffing information for 1 of 1 facility reviewed for staffing. This placed residents at risk for incomplete and inaccurate staffing information. Findings include:

A review of the Direct Care Staff Daily Reports (DCSDR) from 11/23/23 through 12/15/23 revealed no staff hours were documented on eight days, census was documented only one day, and the number of staff was not documented two days out of 23 days reviewed.

On 4/19/24 at 7:39 AM Staff 1 (Administrator) and Staff 2 (DNS) stated they were not aware of the issues with the DCSDR reports. Staff 2 stated the Staffing Coordinator was newer to the facility during the above reviewed time period.

Based on interview and record review it was determined the facility failed to ensure a resident's medication was available for administration for 1 of 4 sampled residents (#52) reviewed for dignity. This placed residents at risk for an ineffective medication regimen. Findings include:

Resident 52 was admitted to the facility in 2024 with a diagnosis of pernicious anemia (inability of the body to absorb vitamin B12; left untreated it can cause irreversible damage to the nervous system).

A 3/23/24 admission MDS revealed Resident 52 was cognitively intact. Resident 52 had a severe degeneration of her/his spinal cord due to a vitamin B12 deficiency.

On 4/15/24 at 1:17 PM and 4/17/24 at 11:47 AM Resident 52 stated she/he took vitamin B12 daily, which was required to prevent her/his health from significantly declining. Resident 52 stated it was like life or death to her/him if she/he missed the medication. Resident 52 stated the facility did not have her/his vitamin B12 available to administer.

An 4/2024 MAR revealed vitamin B12 was not administered on 4/15/24.

An 4/15/24 Progress Note indicated staff waited for the pharmacy to dispense the medication.

On 4/18/24 at 10:21 AM Staff 10 (LPN Unit Manager) stated the pharmacy did not send the resident her/his medication because it was not common to administer the medication daily. The order was initially clarified when Resident 52 was admitted to the facility but the pharmacy failed to document the clarification in the resident's record, and therefore there was another delay in sending the medication and Resident 52 missed a dose of her/his vitamin B12.

Based on observation, interview, and record review it was determined the facility failed to ensure residents were assessed prior to prescription and use of psychotropic medications for 1 of 6 sampled residents (#29) reviewed for unnecessary medications. This placed residents at risk for over-sedation. Findings include:

Resident 29 admitted to the facility on 1/19/24 with a diagnosis of mild dementia without behaviors.

Progress Notes revealed the following:
-1/19/24 Resident 29 admitted to the facility and was noted to have some short-term memory loss.
-1/20/24 Resident 29 was alert, oriented, followed commands, had some forgetfulness, no unwanted behaviors, and slept through the night. The resident was noted to be adjusting well.
-1/20/24 at 11:50 PM Resident 29 was found on the floor. The resident was at her/his baseline mental status.
-1/21/24 and 1/22/24 Resident 29 was assessed to have no injury from her/his fall.
-1/22/24, 1/23/24, and 1/25/24 Resident 29's mood was pleasant with no unwanted behaviors.
-1/25/24 Resident 29's daughter was notified Seroquel (antipsychotic medication used to treat bipolar disorder [mood swings from depressive lows to manic highs] and schizophrenia [disorder affecting a person's ability to behave clearly]) was added at HS.

Review of Resident 29's 1/2024 MAR revealed Seroquel was administered once on 1/25/24 and was then discontinued.

Resident 29's record did not have an assessment or rationale for starting the medication on 1/25/24 or for stopping the medication after 1/25/24.

Progress notes from 1/25/24 to 3/6/24 revealed the following:
-1/26/24 Resident 26 was assessed after a fall and cursed at the nurse, denied the fall and later apologized to the nurse for cursing.
-1/27/24 Resident 29 walked in the hall on the evening/night shift without assistance and was easily redirected back to her/his room.
-2/2/24 Resident 29 participated with therapy, did not have unwanted behaviors and slept at night.
-2/8/24 Resident 29 had an unwitnessed fall in her/his room. The resident walked in halls without assistance and staff were able to redirect the resident back to her/his room.
-2/11/24 on night shift, Resident 29 stood without assistance and staff redirected the resident.
-2/17/24 evening shift Resident 29 walked without assistance. Staff provided education, provided the resident blocks and a snack which "distracted" the resident from self-ambulating.
-2/27/24 Resident 29 was found kneeling on the floor and the resident stated she/he was cleaning the floor.
-3/6/24 Resident 29 participated in her/his RA program.

A 2/2/24 psychologist Progress Note revealed Resident 29 was assessed and the resident reported difficulty sleeping due to the environment. The resident stated she/he had some depression, had good family support, wanted to go home but realized she/he required more support, and moving to a higher level of care would be appropriate. A recommendation was made for an increase in melatonin (sleep aid) for sleep. The progress note did not indicate the resident was assessed for behaviors the facility was not able to be manage.

A 3/2024 MAR revealed on 3/6/24 Resident 29 was started on Seroquel, was administered the medication every night, and on 3/20/24 was started on Nuplazid (treats Parkinson's related psychosis [mental disorder with a disconnection from reality]) and was administered the medication every morning. The MAR also indicated Resident 29 was started on an antibiotic on 3/28/24.

Resident 29's clinical record did not have an assessment for the initiation of the Seroquel or Nuplazid.

On 4/15/24 at 1:57 PM Witness 9 (Family) stated in 1/2024 the facility started the resident on Seroquel for no reason. Witness 9 stated the facility staff called in 1/2024 and stated they reported Resident 29 got up at night and fell and then they started the Seroquel. Witness 9 stated she was upset, came into the facility, and wanted the medication to be stopped. Witness 9 stated she wanted Resident 29's neurologist to monitor the resident's medications due to the resident's Parkinson's disease.

On 4/16/24 at 2:42 PM Resident 29 was observed in her/his room playing dominos with her/his roommate. Resident 29 explained the rules of dominos to the surveyor.

On 4/16/24 at 2:50 PM Staff 47 (CNA) stated at times Resident 29 was confused but was easily redirected. Resident 29 at times needed safety reminders to not walk without assistance and at times stated to staff to "get away from me" but otherwise the resident did not have behaviors. Resident 29 liked to color and colored for hours, liked to put art on the wall, and showed staff what she/he created. Resident 29 also liked to talk to her/his roommate.

On 4/17/24 at 1:47 PM Staff 10 (LPN Unit Manager) stated after the Seroquel was initially started in 1/2024 Witness 9 was very upset. Witness 9 came in to the facility and Staff 10 spoke to Witness 9 about Resident 29's dementia diagnosis. Staff 10 stated Witness 9 was not aware the resident had a diagnosis of dementia. Witness 9 wanted the resident's neurologist to assist with any psychotropic medication management due to the resident's diagnosis of Parkinson's disease. On 3/5/24 Resident 29 went to her/his neurologist and was started on Seroquel and Nuplazid. The resident's clinical record did not contain the neurologist's assessment or rationale for the psychotropic medications. Staff 10 acknowledged the resident's record did not contain information to indicate Resident 10 had delusions, hallucinations or behaviors which staff were not able to redirect with non-pharmacological interventions prior to 1/25/24 or prior to the restart of the Seroquel and Nuplazid in 3/2024. A request was made for an assessment or rationale for the initiation of Seroquel and Nuplazid. No additional information was provided.

On 4/17/24 at 4:02 PM Staff 20 (IP/LPN) stated Resident 29 was more confused when she/he was first admitted to the facility in 1/2024 but seemed to improve. Staff 20 stated Resident 29 had quite a few falls. After one of the falls at the end of 3/2024 Resident 29 reported knee pain and was sent to the hospital for evaluation. At the hospital the resident denied knee pain and the resident was tested and diagnosed to have a UTI. Resident 29 was started on antibiotics. Staff 20 was not able to identify Resident 29's behaviors which would warrant initiating psychotropic medications. Staff 20 also stated it was unclear if the resident's condition improved because she/he was treated for the UTI or was started on the psychotropic medications.

Based on interview and record review it was it was determined the facility failed to ensure a medication error rate of less than 5%. The facility administration error rate was 7% with two errors in 27 opportunities. This placed residents at risk for an ineffective medication regimen. Findings include:

1. Resident 303 admitted to the facility in 2024 with a diagnosis of a low functioning thyroid.

Epocrates Online (web based pharmacy resource) revealed levothyroxine (hormone replacement)should be taken 15 to 60 minutes before breakfast with a full glass of water at the same time daily.

Resident 303's 4/6/24 admission MDS indicated she/he was cognitively intact.

On 4/16/24 at 7:30 AM Staff 15 (LPN) was observed to administer levothryoxine to Resident 303. Resident 303 was observed eating breakfast and stopped to take her/his medications including the levothyroxine.

On 4/16/24 at 2:58 PM Resident 303 stated when she/he was at home, she usually did not take levothyroxine with food. Resident 303 stated she/he took the levothyroxine as soon as she/he woke up, even before she/he drank her/his coffee. Resident 303 stated since admission to the facility the staff administered the medication with food.

On 4/17/24 at 10:00 AM Staff 10 (LPN Unit Manager) stated the medical director felt the benefits outweighed the risks if a resident took thyroid medications with food as long as the resident took the medication with food and the resident's labs were monitored. By providing the levothyroxine with breakfast it allowed the resident to sleep and not be woken at 6:00 AM. Staff 10 stated she reviewed medications with residents at the 72 hour conference but did not ask the residents about their medication administration time preferences for medications such as levothyroxine. Staff 10 acknowledged if a resident was a long-term resident, administering levothyroxine with food and monitoring labs could be effective, but for a resident on the skilled unit and only in the facility for a short period of time such as Resident 303, changing the resident's medication regimen might not be therapeutic. A request was made to Staff 10 to provide scientific data to support administering levothyroxine with food. No additional information was provided.

2. Resident 30 admitted to the facility in 2024 with a diagnosis of diabetes

On 4/16/24 at 7:54 AM Staff 45 (LPN) was observed to administer Resident 30 her/his medications. Cranberry D-Mannose (supplement to prevent UTIs) was not administered.

On 4/17/24 at 9:22 AM Staff 45 stated she/he did not administer Resident 30 her/his Cranberry D-Mannose because it was not available in the supply closet.

On 4/17/24 at 9:22 AM with Staff 45 and staff 46 (Central Stores) one bottle of Cranberry D-Mannose was observed on the shelf. Staff 45 stated she looked in the supply closet and only saw plain cranberry supplement. Staff 45 stated she did not see the Cranberry D-Mannose on the higher shelf.

Based on observation, interview, and record review it was determined the facility failed to ensure menus were followed for 2 of 4 sampled residents (#s 8 and 40) reviewed for food. This placed residents at risk for unmet food preferences. Findings include:

1. Resident 8 admitted to the facility in 2018 with diagnoses including diabetes.

An 4/17/24 breakfast menu ticket revealed poached eggs, toast, link sausage, cream of wheat, and two percent milk.

On 4/17/24 at 7:51 AM Resident 8 stated she/he received scrambled eggs instead of poached eggs and did not receive any drinks.

On 4/19/24 at 7:54 AM Staff 1 (Administrator) and Staff 2 (DNS) stated they expected the kitchen to provide Resident 8 what was on her/his menu ticket.

2. Resident 40 was admitted to the facility in 2023 with diagnoses including adult failure to thrive.

An 4/17/24 breakfast menu ticket revealed Resident 40 circled hash brown patty, grapes, two eggs over easy, and coffee. The lunch menu ticket indicated a hamburger on a bun. The bun portion was crossed out and a handwritten "English muffin" was in place of the bun. Additionally, chopped tomatoes, chocolate ice cream, and a small apple juice were indicated.

On 4/17/24 at 7:33 AM, 7:35 AM, and 7:36 AM Staff 9 (CNA) was in Resident 40's room assisting with breakfast set up, Resident 40 stated she/he wanted bacon, her/his roommate had bacon and her/his food was wrong. Staff 9 stated she could take the unwanted food off Resident 40's plate. Staff 9 stated Resident 40 wanted a hash brown patty and bacon, but bacon was not on the breakfast meal ticket. Resident 40 stated she/he was supposed to get a hash brown patty instead of tater tots.

On 4/17/24 at 12:24 PM Resident 40 was observed with a hamburger and a hamburger bun, chopped tomatoes, and two English muffins with what appeared to be peanut butter spread in between the two pieces of English muffin. No chocolate ice cream was observed on the lunch tray. Resident 40 stated she/he did not get her/his ice cream.

On 4/19/24 at 7:54 AM Staff 1 (Administrator) and Staff 2 (DNS) stated they expected the kitchen to provide Resident 40 what was on the meal ticket. Staff 1 stated if the kitchen ran out of hashbrown patties it was simple to make them using tater tots.

Based on observation, interview, and record review it was determined the facility failed to provide assistive devices for 1 of 5 sampled residents (#8) reviewed for nutrition. This placed residents at risk for unmet needs. Findings include:

Resident 8 admitted to the facility in 2018 with diagnoses including diabetic neuropathy (damage or disease affecting the nerves).

An 4/3/24 care plan indicated Resident 8 was at nutritional risk with interventions including adaptive equipment of a two-handle cup and a lip plate.

An 4/17/24 breakfast menu ticket revealed the following adaptive equipment: a lip plate and a two-handle cup.

On 4/17/24 the following occurred:
-7:46 AM Staff 4 (CNA) brought out a small plastic cup with a white liquid out of Resident 8's room.
-7:51 AM Resident 8 stated she/he did not know where her/his milk was, and she/he did not receive any drinks with breakfast.
-7:55 AM Staff 4 stated she took Resident 8's milk because her/his cup did not have an adaptive handle on it.
-7:58 AM Staff 4 came out of the kitchen with Resident 8's cup with adaptive handles on it.
-12:43 PM Resident 8 was observed sitting in a wheelchair with a lunch tray in front of her/him with a cup of white liquid with no adaptive handles.
-12:46 PM Staff 4 stated the kitchen neglected to provide Resident 8 with a cup with adaptive handles for lunch.

On 4/19/24 at 8:00 AM Staff 1 (Administrator) and Staff 2 (DNS) stated it was expected for the kitchen to read the menu tickets and provide Resident 8 with her/his care planned adaptive meal equipment.

Based on observation, interview, and record review it was determined the facility failed to handle and prepare food in a sanitary manner for 1 of 1 kitchen reviewed for sanitary practices. This placed residents at risk for food-borne illness. Findings include:

On 4/17/24 at 8:24 AM the beverage carts for Wing 1 and Wing 2 were observed with dirty coffee pots which were used for the residents. Staff 28 (Dietary Services Manager) acknowledged the coffee pots needed deep cleaning.

On 4/17/24 at 11:45 AM the following was observed during preparing and plating food from the kitchen's steam table for lunch:
-Staff 31 (Dietary Aide) performed a temperature check on all food. The food was within normal limits except for the potato salad which was 51 degrees and needed to be 41 degrees. No further checking was performed for the potato salad.
-Staff 31 was observed touching the food with utensils and his gloved hands, he then stepped away from the steam table to retrieve tongs and did not perform hand hygiene or don new gloves. Staff 31 left the steam table twice to retrieve food from the refrigerator and was observed to open the refrigerator with his gloved hand, retrieve a tote with ice, uncover bowls of potato salad and close the refrigerator door with his gloved hand. Staff 31 did not change his gloves or complete hand hygiene during the above observations. He then returned to the steam table, removed hamburger buns from a bag, placed them on a tray for delivery to a resident and then continued to handle food using utensils and his gloved hands. Staff 31 left the steam table to retrieve cheese slices from the refrigerator, touched his nose and watch, removed his gloves, and tossed one glove on top of the tote of ice with uncovered potato salad.
-Staff 31 had a beard and mustache but only wore a surgical facemask which did not restrain all his beard or mustache.

On 4/17/24 at 12:56 PM Staff 31 acknowledged "There was a break in infection control" and he should have changed his gloves, performed hand hygiene, worn a beard restraint and checked the temperature again for the potato salad before it was served to residents.

Based on interview and record review it was determined the facility failed to ensure records were accurate for 1 of 6 sampled residents (#44) reviewed for unnecessary medications. This placed residents at risk for inaccurate treatment. Findings include:

Resident 44 was admitted to the facility in 12/2023 with diagnoses including high blood pressure.

Resident 44's 12/19/23 Physician Order indicated the resident was to receive lisinopril (medication to treat high blood pressure) one time a day and the medication was to be held for systolic blood pressure (pressure in the arteries when the heart beats) below 110 and diastolic blood pressure (pressure in the arteries when the heart rests between beats) below 60.

Resident 44's 3/2024 and 4/2024 MARs indicated the resident's blood pressure was documented as "NA" on 3/27/24, 4/1/24, 4/5/24, 4/8/24, 4/9/24, 4/15/24 and 4/16/24.

On 4/18/24 at 10:32 AM Staff 19 (LPN Unit Manager) and Staff 22 (CMA) reviewed Resident 44's physician order and 3/2024 and 4/2024 MARs. Staff 19 stated Resident 44's blood pressure readings needed to be documented on the MAR where "NA" was marked. Staff 22 stated he took Resident 44's blood pressure readings prior to administering her/his lisinopril on the dates marked "NA", but did not document the readings as required. Staff 19 stated her expectation was Resident 44's blood pressure readings were documented as instructed.

Based on interview and record review it was determined the facility failed to monitor antibiotic use for 1 of 1 resident (#1) reviewed for antibiotic stewardship. This placed residents at risk for unnecessary medications. Findings include:

Resident 1 admitted to the facility in 7/2013 with diagnoses including infection due to urinary catheter, and a history of multi-drug-resistant organisms (MDRO).

An 4/16/24 review of Resident 1's care plan revealed a 2/9/23 care plan for enhanced barrier precautions related to a history of MDRO infections and a 2/18/24 care plan for chronic urinary tract infections.

A review of Resident 1's 2/2024 MAR revealed an order for cephalexin (an antibiotic) for a urinary tract infection which started on 2/17/24 and ended on 2/25/24.

A 2/16/24 urine analysis lab indicated Resident 1 had a small number of bacteria in her/his urine.

On 4/16/24 Staff 2 (DNS) acknowledged there was no culture and sensitivity completed with the urinalysis to determine the correct antibiotic for Resident 1.

On 4/19/24 at 8:41 AM Staff 2 acknowledged Resident 1 completed the ordered antibiotic treatment from 2/17/24 through 2/25/24. Staff 2 stated an antibiotic time-out should have occurred but was not completed 48 hours after starting the antibiotic.

Based on interview and record review, it was determined the facility failed to complete reference checks for 1 of 5 staff (#12) reviewed for hiring practices. This placed residents at risk for unqualified staff. Findings include:

Two Verbal Employee Reference forms dated 4/1/20 were provided for Staff 12's references with documentation in "other remarks" as "rehireable."

An Employee Detail report revealed Staff 12 was hired on 3/13/24.

On 4/18/24 at 12:38 PM Staff 1 (Administrator) stated Staff 12 was on the schedule and working, he was transferred from another facility and he did not know Staff 12 required new reference checks.

Based on interview and record review it was determined the facility failed to ensure background checks were completed for newly hired staff for 1 of 5 newly hired sampled staff (#12) reviewed for background checks. This placed residents at risk for abuse. Findings include:

An Employee Detail report revealed Staff 12 was hired on 3/13/24.

On 4/18/24 at 10:10 AM Staff 37 (HR and Payroll) was unable to locate Staff 12's background check.

An Oregon Background Check Unit Notification letter revealed Staff 12's Preliminary Fitness Determination was 4/18/24.

On 4/18/24 at 12:38 PM Staff 1 (Administrator) stated Staff 12 was on the schedule and working, he was transferred from another facility and he did not know Staff 12 required a new background check.

Based on interview and record review it was determined the facility failed to ensure state minimum CNA staffing requirements were maintained for 27 of 261 shifts reviewed for staffing. This placed residents at risk for delayed treatment and unmet care needs. Findings include:

A review of the Direct Care Staff Daily Reports from 10/22/23 through 11/22/23, 11/23/23 through 12/15/23, and 3/14/24 through 4/14/24 revealed the facility did not have sufficient CNA staff to meet the minimum CNA staffing requirements on the following days and shifts:

-10/28/23 day shift
-10/29/23 day shift
-11/12/23 day shift
-11/24/23 night shift
-11/26/23 evening shift
-12/1/23 night shift
-12/3/23 evening shift
-12/5/23 day shift
-12/7/23 night shift
-3/14/24 night shift
-3/21/24 evening shift
-3/23/24 day and night shift
-3/28/24 evening shift
-3/30/24 day shift
-4/1/24 day shift
-4/5/24 evening shift
-4/6/24 day shift
-4/7/24 day and evening shift
-4/8/24 evening shift
-4/9/24 day and evening shift
-4/10/24 evening shift
-4/11/24 day and evening shift
-4/13/24 evening shift

On 4/19/24 at 7:38 AM Staff 1 (Administrator) and Staff 2 (DNS) stated the lack of sufficient CNA staff was usually the result of staff calling off for work.

***************************************
OAR 411-085-0310 Residents' Rights: Generally
        
        
        

Refer to F550, F557, F565 and F585
****************************************
OAR 411-087-0100 Physical Environment: Generally

Refer to F584
****************************************
OAR 411-085-0360 Abuse

Refer to F600
****************************************
OAR 411-086-0060 Comprehensive Assessment and Care Plan

Refer to F637 and F657
****************************************
OAR 411-086-0110 Nursing Services: Resident Care

Refer to F684, F698 and F759
*****************************************
OAR 411-086-0140 Nursing Services: Problem Resolution and Preventive Care

Refer to F689, F692 and F758
***************************************
OAR 411-086-0100 Nursing Services: Staffing

Refer to F725 and F732
******************************************
OAR 411-086-0260 Pharmaceutical Services

Refer to F755
******************************************
OAR 411-086-0250 Dietary Services

Refer to F803, F810 and F812
****************************************
OAR 311-086-0300 Clinical Records

Refer to F842
***************************************
OAR 411-086-0330 Infection Control and Universal Precautions

Refer to F881
****************************************

Based on interview and record review it was determined the facility failed to ensure grievances were resolved for residents in a timely manner for 2 of 3 sampled residents (#s 1 and 9) reviewed for grievances. This placed residents at risk for unresolved concerns. Findings include:

A Lost Item Policy last revised 9/2004 revealed the facility would make every effort to ensure resident belongings were protected and to recapture lost items or to make restitution should a lost item not be recovered. After the lost item was reported as missing and not recovered, within three business days, the form was to be forwarded to the administrator to determine if further action was needed. The facility was to communicate with the resident within five business days after the social service staff received the form back from the administrator.

1. Resident 1 was admitted to the facility in 2022 with diagnoses including diabetes.

A 3/12/23 Complaints/Grievance form revealed Resident 1 reported a full pack of cigarettes was missing. Staff went to the store for the resident and bought cigarettes with the resident's money.

A 6/3/23 quarterly MDS indicated Resident 1 was cognitively intact.

On 7/25/23 at 6:10 PM Resident 1 stated on one occasion the facility lost her/his cigarettes and the facility did not replace them. She/he had to use her/his own money.

On 7/26/23 at 2:28 PM Staff 1 (Administrator) stated staff should have replaced the cigarettes and not uses the resident's money.

2. Resident 9 was admitted to the facility in 2022 with diagnoses including heart failure.

A 5/18/23 quarterly MDS indicated Resident 9 was cognitively intact.

A 6/19/23 Lost or Damaged Items form revealed the resident reported one gray windbreaker and one blanket was missing. The form was updated on 7/19/23 indicating family and staff looked for the items, the items were not found and the resident would be reimbursed if needed.

On 7/25/23 at 5:24 PM Resident 9 stated she/he received a really nice blanket for a Christmas present in 2022 and after the item was reported missing in 6/2023 she/he did receive a response from the facility if the blanket would be replaced. Resident 9 stated the missing jacket was replaced with an unlined windbreaker and not a jacket of the same quality.

On 7/27/23 at 11:36 AM Staff 1 indicated if an item was replaced it should be of similar quality and was not aware the blanket was not yet replaced.

Based on interview and record review it was determined the facility failed to ensure a resident was not abused for 1 of 3 sampled residents (#3) reviewed for abuse. This placed residents at risk for injury. Findings include:

Resident 3 was admitted to the facility in 2016 with diagnoses including dementia.

A FRI dated 4/13/23 revealed Staff 2 (CNA) used force while she assisted Resident 3 with incontinent care. Resident 3 did not turn when Staff 2 requested the resident to turn, therefore Staff 2 reported she used the sheet to roll the resident "hard". At the time of the incident Staff 2 stated she was irritated and frustrated and knew it was "wrong". Resident 9 was interviewed at the time of the incident and reported a staff person "threw" her/him over several times and it was upsetting but denied ongoing fear.

On 7/28/23 at 9:50 AM Staff 2 acknowledged she used force to turn Resident 3 during incontinent care by using a turn sheet. Staff 2 stated it was during last rounds, she was not able to find anyone to help her and she "tugged hard" on the turn sheet. Staff 2 stated it was wrong to use force to turn the resident. The resident stated it hurt but did not sustain an injury.

On 7/26/23 at 3:57 PM Staff 3 (LPN Resident Care Manager) stated the facility substantiated the allegation of abuse related to the forceful manner in which Staff 2 provided care to Resident 3.

Based on interview and record review it was determined the facility failed to report an allegation of abuse for 1 of 3 sampled residents (#1) reviewed for abuse. This placed residents at risk for abuse. Findings include:

Resident 1 was admitted to the facility in 2022 with diagnoses including diabetes.

A Significant event form dated 2/27/23 revealed Resident 1 reported a staff member stated the only way Resident 1 would leave the facility would be in a body bag. Resident 1 did not find the comment funny. The form did not indicate the state agency was notified of the incident.

On 7/26/23 at 11:14 AM Staff 3 (LPN Resident Care Manager) stated if a resident made a comment which could potentially be verbal abuse, the incident should be reported to the state agency. Staff 3 indicated the resident was not able to identify who made the comment and it could have been a resident. Staff 3 stated the resident had dark humor and often joked with staff and other residents and a comment could have been made in a joking manner, but it was not determined who made the comment. Staff 3 acknowledged incidents were to be reported to the state agency if abuse was not immediately able to be ruled out and this incident was not reported.

Based on interview and record review it was determined the facility failed to develop a baseline care plan reflective of mobility needs for 1 of 4 sampled residents (#6) reviewed for transfer status. This placed residents at risk for falls. Findings include:

Resident 13 was admitted to the facility 7/24/23 with diagnoses including a history of falls.

A Kardex (CNA guide to resident specific care) revealed the resident's transferring status required two staff with "all" transfers and the resident required "one" staff with transfers using a walker.

On 7/26/23 at 4:37 PM Staff 5 (CNA) stated she was assigned to work with Resident 13 and was told the resident required one person stand by assist for transfers. Staff 5 reviewed the Kardex and confirmed the resident's transfer status had conflicting information and she would need to clarify with the nurse.

On 7/26/23 at 4:49 PM Staff 4 (LPN Resident Care Manager) reviewed the resident's Kardex and acknowledged the resident's transferring status had conflicting information and staff would not be able to easily determine if the resident required one or two staff for transfers. Staff 3 stated the person who created the baseline care plan did not correct the auto-generated data and the resident in fact required one assist for transfers and not two.

Based on interview and record review it was determined the facility failed to ensure care plans were revised for 1 of 3 sampled residents (#4) reviewed for ADLs. This placed residents at risk for care plans not reflective of current care needs. Findings include:

Resident 4 was admitted to the facility in 2017 with diagnoses including diabetes.

Resident 4's Care Plan indicated she/he was to have enhanced barrier precautions related to wound care. The care plan was initiated on 12/22/22. The goal was to prevent the spread of infections. Gloves and gowns were to be worn during care including toileting.

On 7/26/2023 at 10:25 AM Staff 6 (CNA) was observed to provide Resident 4 incontinent care. Staff 5 wore gloves but did not wear a gown.

On 7/27/23 at 10:23 AM Staff 3 (LPN Resident Care Manager) stated at one time Resident 4 had an open wound and was on enhanced barrier precautions. The resident's wound healed and the care plan was not updated to reflect the resident's current status.

Based on interview and record review it was determined the facility failed to ensure residents were monitored after allegations of abuse for 2 of 3 sampled residents (#s 1 and 5). This placed residents at risk for unidentified psychosocial harm. Findings include:

1. Resident 1 was admitted to the facility in 2022 with diagnoses including depression.

A Significant incident report form dated 2/27/23 revealed Resident 1 reported a staff member told her/him the only way the resident was going to leave the facility was in a body bag. The resident did not feel the comment was funny.

Progress notes revealed the resident was not monitored for behavioral or mood changes after the 2/27/23 reported incident.

A 3/3/23 psychological progress note revealed the resident was assessed for depression and for reports that a staff member made a comment to the resident about leaving the facility in a body bag. The resident was upset about the comment but the comment did not contribute to increased depression.

On 7/26/23 at 11:14 AM Staff 3 (LPN Resident Care Manager) stated if staff were to monitor residents after allegations of abuse to ensure there were no psychosocial changes. Staff 3 indicated the staff did not monitor Resident 1.

2. Resident 5 was admitted to the facility in 2023 with diagnoses including a pelvic fracture.

A Progress Note dated 5/29/23 revealed the resident was upset and reported a CNA threw a bedside commode toward her/his bed and the told the resident she/he needed to stop making staff change her/his incontinent brief. The resident reported the CNA raised his voice and told her/him to get out of bed. There were no notes after the 5/29/23 note to indicate if the staff monitored the resident to ensure there were no psychosocial outcome related to the reported incident.

On 7/27/23 at 11:28 AM Staff 1 (Administrator) and Staff 7 (DNS) stated if a resident reported abuse the staff should monitor the resident for psychosocial outcome even if the the allegation was not substantiated. A request was made for documentation to indicate staff monitored the resident after the alleged incident on 5/29/23. No additional information was provided.

***************
OAR 411-085-0310 Residents' Rights: Generally

Refer to F585
***************
OAR 411-085-0360 Abuse

Refer to F600 and F609
***************
OAR 411-086-0040 Admission of Residents

Refer to F655
***************
OAR 411-086-0060 Comprehensive Assessment and Care Plan

Refer to F657
***************
OAR 411-086-0110 Nursing Services: Resident Care

Refer to F684
***************

Based on interview and record review it was determined the facility failed to protect the resident's right to be free from physical abuse by a resident for 1 of 2 sampled residents (#36) reviewed for resident-to-resident abuse. This placed residents at risk for abuse and psychosocial harm. Findings include:

Resident 36 admitted to the facility in 6/2022 with diagnoses including blood clot to the lungs and weakness.

A 12/21/22 Quarterly MDS revealed Resident 36 had a BIMS score of 15, indicating she/he was cognitively intact.

Resident 13 admitted to the facility in 5/2015 with a diagnosis including schizophrenia and had a BIMS score of 15, indicating she/he was cognitively intact.

The facility's 1/17/23 investigation revealed Resident 36 reported to Staff 18 she/he was kicked in the left shin by Resident 13. Staff 18 (CMA) assessed Resident 36 for injury and immediately reported the incident to Staff 26 (LPN/charge nurse). There were no witnesses. Upon re-assessment by Staff 26, it was indicated Resident 36 had a slight bruise on her/his left shin. Resident 36 stated she/he had no pain and felt safe. The investigation revealed Resident 13 refused to be interviewed on the day of the incident. On 1/18/23 Staff 3 (Regional Nurse Consultant) interviewed Resident 13. Resident 13 acknowledged kicking Resident 36 but did not intend to hurt her/him.

On 1/18/23 Witness 3 (Clinical Psychologist) interviewed Resident 36 for psycho-social harm (emotional and psychological wellbeing). Witness 3's interview revealed Resident 36 reported "slight anxiety" and avoidance of Resident 13. Resident 36 denied significant residual effects from the incident and stated, "I move on from things." Witness 3 concluded there was no significant evidence of psycho-social harm.

On 2/24/23 at 8:55 AM Staff 3 confirmed the resident-to-resident incident occured.

Based on interview and record review it was determined the facility failed to revise a care plan for 1 of 1 sampled resident (#15) reviewed for pressure ulcers. This placed residents at risk for unmet care needs. Findings include:

Resident 15 was admitted to the facility in 2018 with diagnoses including Parkinson's Disease (a brain disorder that affects movement).

In 2019 Resident 15's family provided a document which contained information related to a mental health diagnoses. The document was scanned into Resident 15's electronic health record.

An ankle wound was identified on 6/24/22. Orders were received for treatment. The care plan was to be revised to include the nurses were to ensure Resident 15 wore protective boots at all times and discouraged the use of shoes.

A review of the 2/2023 comprehensive care plan identified interventions for daily weights, weights per physician order, an air mattress, pressure ulcer care and cognitive problems due to dementia.

The care plan was not revised to include any interventions related to an ankle ulcer and the need for protective boots at all times, to discourage the use of shoes, clarification of how often Resident 15's weights were to be monitored or a mental health diagnoses for which she/he was being treated.

On 2/23/23 at 3:01 PM Staff 27 (Resident Care Manager LPN) was asked about the revisions to the care plan. No additional information was provided.

Based on interview and record review it was determined the facility failed to provide a qualified professional to direct the activities program for 1 of 1 facility reviewed for activities. This placed residents at risk for unmet activity needs. Findings include:

On 2/23/23 at 10:39 AM Staff 16 (Activity Director) stated she had been in the activities position since 8/2022 and did not have an activities certificate. She reported working with Staff 1 (Administrator) to initiate the appropriate certification for her position.

A review of the 11/2022 through 2/2023 resident council minutes and the 2/2023 activity schedule revealed Resident 16 was the Activity Director.

On 2/23/23 at 3:06 PM Staff 1 stated Staff 16 was hired for activities and had been in the position since 8/2022. Staff 1 acknowledged Staff 16 was not currently certified.

Based on interview and record review it was determined the facility failed to reassess causes and interventions and provide medications for 1 of 1 sampled resident (#15) reviewed for pressure ulcers. This placed residents at risk for inappropriate wound care and infections. Findings include:

1. Resident 15 was admitted to the facility in 2018 with diagnoses including Parkinson's Disease (a brain disorder that affects movement) and diabetes.

a. Medical records indicated Resident 15 had interventions in place in 2021 to avoid shoes, wear protective boots and instructed licensed nurses to ensure the boots were in place at all times due to previous foot wounds.

On 6/24/22 a new wound to Resident 15's ankle was identified and determined to be caused by a shoe. The wound was noted to have a scab.

An order dated 6/24/22 instructed staff to apply Betadine (an iodine solution used to protect against infection) twice a day until resolved and to notify the physician if the wound worsened.

On 9/14/22 a Skin/Wound note identified an open area on Resident 15's right ankle previously observed to be a scab. The wound was determined to be a Stage 3 (full thickness tissue destruction) caused by pressure and contained slough (dead tissue).

There was no evidence in the medical record the facility considered whether the protective boots or the resident's behavior contributed to the ankle wound, whether the ankle wound was referred to the wound clinic for delayed healing prior to opening up or interventions were re-evaluated and potential causes were investigated for the worsening of the ankle wound.

On 2/23/23 at 3:01 PM Staff 27 (Resident Care Manager LPN) stated she was aware the wound started at the facility and was being followed by the wound clinic. Staff 27 did not provide any additional information.

b. A medication order dated 12/12/22 from the wound clinic instructed staff to provide Amoxicillin (antibiotic) prior to weekly wound clinic visits due to a history of heart valve replacement.

The 1/2023 MAR revealed the Amoxicillin was administered for the entire month.

The 2/2023 MAR documented one dose of Amoxicillin was administered from 2/1/23 through 2/22/23.

On 2/24/23 at 9:23 Staff 3 (Regional Nurse Consultant) stated the order was confusing and thought it should be written differently. No additional information was provided.

6. Resident 39 was admitted to the facility in 2022 with diagnoses including high blood pressure.

On 2/20/23 at 10:56 AM Resident 39 was asked about smoking. Resident 39 stated she/he was allowed to smoke independently. When asked about storage of her/his smoking materials Resident 39 patted her/his chest and said "right here in my pocket."

On 2/21/23 at 1:07 PM Staff 28 (CNA) was asked about smoking at the facility and stated Resident 39 was an independent smoker. Staff 28 added when a resident was independent they kept their smoking materials but if a resident required supervision their smoking materials were locked up at the nurses' station.

On 2/22/23 at 8:27 AM Resident 39 was observed to turn in her/his smoking materials to the charge nurse.

On 2/22/23 at 8:31 AM Resident 39 was asked about turning in her/his smoking materials and stated she/he normally kept them in a pocket but this recently changed and she/he gave them to the charge nurse.

On 2/23/23 at 3:55 PM the facility smoking practice was discussed with Staff 3 (Regional Nurse Consultant) and she stated the facility had identified a problem. Staff 3 state all smoking materials were to be locked up when not in use.

, Based on observation, interview and record review it was determined the facility failed to ensure residents' environment remained free from accident hazards and smoking materials were stored securely for 5 of 5 sampled residents (#s 10, 12, 22, 27 and 39) reviewed for accidents. This placed residents at risk for accidents. Findings include:

1. Resident 10 was admitted to the facility in 2018 with diagnoses including diabetes and weakness.

A 2/23/21 comprehensive care plan indicated Resident 10 was at moderate risk for falls and she/he had a history of falls. Interventions included fall mats on both sides of Resident 10's bed.

On 2/20/23 at 11:01 AM, 2/22/23 at 7:36 AM and 11:15 AM Resident 10 was in bed with one fall mat up against the wall and the other mat was in the middle of the room approximately five feet away from her/his bed.

On 2/22/23 at 11:25 AM Staff 8 (CNA) stated Resident 10's care plan interventions for fall prevention were to have her/his bed in the lowest position and to have fall mats on both sides of the bed. Staff 8 stated Resident 10 had not fallen for a long time and the fall mats did not always get placed next to her/his bed.

On 2/22/23 at 12:51 PM Resident 10 was in bed and no fall mat was observed on the window side of the bed.

On 2/23/23 at 9:46 AM Resident 10 was in bed and two fall mats were placed one on top of the other approximately five feet from her/his bed.

On 2/23/23 at 11:35 AM Staff 19 (Resident Care Manager LPN) confirmed Resident 10 should have fall mats on both sides of her/his bed.

2. Resident 12 was admitted to the facility in 2/2023 with diagnoses including diabetes, and absence of right leg.

A 2/20/21 comprehensive care plan indicated Resident 12 was at moderate risk for falls. Interventions included padded fall mats on both sides of the bed.

On 2/20/23 at 11:01 AM, 2/22/23 at 7:36 AM, and 11:15 AM a fall mat was observed to be approximately five feet away from Resident 12's bed. No fall mat was on the other side of the bed.

On 2/22/23 at 12:51 PM no fall mats were observed on Resident 12's side of the room.

On 2/23/23 at 11:35 AM two fall mats were observed one on top of the other in the center of the room. Staff 19 (Resident Care Manager LPN) observed the mats and confirmed Resident 12 should have fall mats on both sides of her/his bed.

, 4. Resident 27 admitted to the facility in 3/2023 with diagnoses including dementia and nicotine dependence.

A 7/12/22 care plan revealed Resident 27 could smoke safely and independently without adaptation or supervision. Staff were to check Resident 27's clothing for burns, complete smoking assessment, educate her/him where the designated smoking area was and review acknowledgement of safety risks with resident.

An 8/29/22 Smoking Resident Statement of Agreement signed by Resident 27 revealed the following:
-Resident 27 was deemed a safe and independent smoker.
-All smoking materials were to be always locked up when not being used.

A 10/4/22 Smoking Resident Statement of Agreement signed by Resident 27 revealed she/he agreed to abide by the facility smoking policy which included putting her/his smoked cigarettes in the ash tray and smoking in the established smoking area.

A 12/16/22 Quarterly MDS indicated Resident 27's BIMS score was 13 (cognitively intact).

On 2/20/23 at 10:37 AM Resident 27 was observed self-propelling out to the smoking area and she/he had her/his cigarettes and lighter inside her/his jacket that was visible. Resident 27 made her/his way out to the designated smoking area, was observed lighting her/his own cigarette.

On 2/20/23 at 12:00 PM Resident 27 was observed in her/his room eating lunch and her/his cigarettes and lighter were on the bed side table while Resident 27 ate lunch.

On 2/20/23 at 1:25 PM Resident 27 stated she/he was an independent smoker and "always" kept her/his cigarettes and lighter with her/him. Resident 27 stated she/he went to the designated smoking area to smoke and was told by staff to not to smoke close to the building or exit doors.

On 2/22/23 at 6:43 PM Staff 20 (CNA) stated Resident 27 was an independent smoker, kept her/his cigarettes and lighter with her/him at "all times." Staff 20 stated Resident 27 was able to smoke in the designated area and she/he "never" turned her/his smoking materials in.

On 2/23/23 at 10:42 AM Staff 19 (Resident Care Manager LPN) stated Resident 27 was re-educated on 2/23/23 regarding her/his cigarettes being returned to the nurses' station when she/he completed smoking.

On 2/23/23 at 3:56 Staff 1 (Administrator), Staff 2 (DNS) and Staff 3 (Regional Nurse Consultant) were present for an interview. Staff 3 stated residents who were deemed safe to smoke independently smoke in the designated smoking area. Staff 2 stated Resident 27 was to pick up and return her/his smoking materials to the nurses' stations. Staff 1, Staff 2 and Staff 3 acknowledged there were inconsistencies regarding the smoking policy and procedure with staff and residents.

5. Resident 22 admitted to the facility in 8/2020 with diagnoses including chronic pain and nicotine dependence.

A 3/2/21 care plan revealed Resident 22 was able to smoke safely and independently without adaptation or supervision. Staff were to check Resident 22's clothing for burns, complete a smoking assessment, educate her/him as to where the smoking area was and review the acknowledgement of safety risks with resident. Staff were to educate Resident 22 to turn her/his smoking materials into the nurses' station in a secured box.

A 11/21/22 Quarterly MDS indicated Resident 22's BIMS score was 15 indicating she/he was cognitively intact.

An 8/29/22 Smoking Resident Statement of Agreement signed by Resident 22 revealed the following:
-Resident 22 was deemed a safe and independent smoker.
-All smoking materials were to be always locked up when not being used.

On 2/22/23 at 12:00 PM Staff 21 (CNA) stated Resident 22 was independent to smoke and "always" carried her/his cigarettes with her/him. Staff 21 indicated Resident 22 had a personal lock box in her/his room but Resident 22's smoking materials were not always locked up after use but Resident 22 kept them with her/him.

On 2/22/23 at 6:43 PM Staff 20 (CNA) stated Resident 22 was independent to smoke, kept her/his cigarettes and lighter with her/him at "all times." Staff 20 stated Resident 22 was able to smoke in the designated area and Resident 22 did not always lock her/his smoking materials in her/his secure lock box.

On 2/23/23 at 10:42 AM Staff 19 (Resident Care Manager LPN) stated Resident 22 was an independent smoker and had a secure lock box in her/his room to store smoking materials. Staff 19 stated staff were expected to remind Resident 22 to place her/his smoking materials in the secure lock box when done smoking.

On 2/23/23 at 3:56 Staff 1 (Administrator), Staff 2 (DNS) and Staff 3 (Regional Nurse Consultant) were present for an interview. Staff 3 stated residents who were deemed safe to smoke independently smoke in the designated smoking area. Staff 2 stated Resident 22 was to lock her/his smoking materials in her/his secure lock box when done smoking. Staff 1, Staff 2 and Staff 3 acknowledged there were inconsistencies regarding the smoking policy and procedure with staff and residents.

, 6. Resident 12 admitted to the facility in 4/2020 with diagnoses including peripheral vascular disease (circulatory condition) and diabetes.

The 12/19/22 Quarterly MDS revealed Resident 12 had a BIMS score of 15, indicating she/he was cognitively intact.

An 4/23/22 Smoking Safety Evaluation was conducted, and the facility deemed Resident 12 safe to smoke independently.

An 8/29/22 Smoking Resident Statement of Agreement signed by Resident 12 revealed she/he agreed to abide by the facility smoking policy which included the following:
-Resident 12 was deemed a safe and independent smoker.
-All smoking materials were to be always locked up when not being used.

The Resident's 12/24/22 care plan revealed Resident 12 was able to smoke safely and independently, without adaptation or supervision. Staff were to check Resident 12's clothing for burns, complete smoking assessment, educate her/him where the designated smoking area was and review acknowledgement of safety risks with the resident.

An 2/11/23 Smoking Safety Evaluation was conducted, and the facility deemed Resident 12 safe to smoke independently.

In an interview on 2/22/23 at 11:38 AM Resident 12 stated she/he was an independent smoker. Resident 12 stated her/his cigarettes and lighter were kept at the nurse's station in a locked box and the nurse would give her/him the cigarettes and lighter when she/he was ready to go out and smoke. Resident 12 stated she/he was "supposed" to return the cigarettes and lighter back to the nurse's station when she/he was done smoking but sometimes would keep the cigarettes and lighter on her/him and return them at the end of the day.

On 2/22/23 at 11:43 AM Staff 35 (CMA) stated Resident 12 was "pretty good" about returning her/his cigarettes and lighter and she had no concerns regarding Resident 12 smoking.

On 2/23/23 at 8:40 AM Staff 36 (LPN/charge nurse) showed the surveyor the smoking materials lock box at the nurse's station. The surveyor observed Resident 12's name written on the cigarettes and lighter in the lock box.

On 2/23/23 at 3:56 PM Staff 3 (Regional Nurse Consultant) stated residents who were deemed safe to smoke independently smoke in the designated smoking area. Staff 3 stated the expectation was for independent smokers to return their smoking materials after each smoking session to the nurse's station to be locked up. Staff 3 stated if the independent smokers did not comply with the smoking policy, they were re-evaluated and re-educated. If the residents continued not to comply, they risked losing their smoking privileges.

On 2/24/23 at 9:20 AM Resident 12 was observed smoking in the designated smoking area.

On 2/24/23 at 9:27 AM Resident 12 was observed entering the facility from the designated smoking area and showed the surveyor her/his zippered waist pack with her/his smoking materials. Resident 12 recalled the rules of the facility smoking policy but did not return her/his smoking materials to the nurse. Resident 12 stated she/he would "try" to turn them in afterwards, and she/he "did not care what the administration said about it."

During observations on 2/24/23 at 9:32 AM and 10:37 AM, Resident 12 did not return her/his smoking materials to the nurses' station. Resident 12 returned to her/his room with her/his smoking materials in her/his zippered waist pack.

Based on observation, interview and record review it was determined the facility failed to monitor and assess weight loss for 1 of 2 sampled residents (#24) reviewed for nutrition. This placed residents at risk for weight loss. Findings include:

Resident 24 was admitted to the facility in 2022 with diagnoses including (sepsis) a blood infection.

Resident 24's hospital records indicated a weight of 297 pounds.

A facility admission weight dated 9/22/22 indicated Resident 24 weighed 295 pounds.

Another weight dated 9/22/22 of 265 pounds was recorded in the medical record and the previous weight of 295 pounds was crossed out by a nurse on 1/23/23 which indicated an error in the electronic record.

An RD assessment dated 9/27/22 indicated Resident 24's intake was meeting her/his caloric needs and recommended a no added salt diet.

Additional weights recorded:
-9/30/22 295 pounds
-10/4/22 295 pounds
-10/5/22 295 pounds
-10/15/22 241 pounds
-12/19/22 234 pounds
No additional weights recorded until:
-1/22/23 208 pounds
-1/29/23 218 pounds
-2/8/23 220 pounds

A Nutrition at Risk (NAR) note dated 11/9/22 indicated Resident 24 had better acceptance of meals and twice a day ordered supplements.

A NAR note dated 1/4/23 indicated Resident 24's weight was trending back up and she/he would be discontinued from NAR.

A RD Assessment dated 1/12/23 for significant changes documented a weight of 234 pounds. Food intakes met most needs with recommendations to reweigh the resident to ensure accuracy, refer to SLP for food textures and ensure the amounts of the supplements consumed were documented.

A NAR note dated 1/25/23 indicated Resident 24 had weight loss due to COVID-19 infection and decreased food intake. The recommendation was to increase the supplements to three times a day.

On 2/22/23 at 8:06 AM Resident 24 was asked about breakfast. Resident 24 stated it was "gone" and described eating French toast, sausage, hot cereal, fruit and a protein drink. Resident 24 was asked about weight loss and stated it was her/his "fault." Resident 24 explained her/his weight got out of control and was only eating what was provided by the facility. Resident 24 added, "I put myself on a diet."

There was no evidence in the medical record to indicate the facility discussed Resident 24's weight loss or desire to lose weight with her/him.

On 2/23/23 at 11:42 AM Staff 27 (Resident Care Manager LPN) stated Resident 24 started on NAR in 11/2022. Staff 27 added she could not find evidence Resident 24 was seen in NAR prior to her/his return to facility in 11/2022. Staff 27 stated the weights were "terrible".

On 2/24/23 at 9:13 Staff 3 (Regional Nurse Consultant) stated the weights were "crazy". NAR was stopped initially in 1/2023 because her/his wounds had healed and weight was trending up. Staff 3 stated when she noticed Resident 24's weights decreased she restarted her/him on NAR again. Staff 3 added Resident 24 had COVID-19 and was very sick. Staff 3 stated she could not find any additional information related to weight loss.

Based on observation, record review and interview it was determined the facility failed to have adequate staff available to meet the needs of residents for 1 of 3 wings (Wing 2). This placed residents at risk of unmet needs. Findings include:

1. On 2/22/23 at 11:25 AM Staff 8 (CNA) stated a couple of residents complained of long call light wait times. Staff 8 stated at times answering call lights in a timely was difficult such as during shift changes and meal times.

During observations on 2/23/22 at 10:09 AM room 210 A's call light was on. The call light monitor at the nurses' station indicated the light was on for 23 minutes and 41 seconds. The call light monitor was observed cotinuously until 10:25 AM whenthe light was on for 35 minutes.

At 10:26 AM the call light monitor indicated room 217's call light was on for 19 minutes. Staff 1 (Administrator) also observed 217's call light time of 19 minutes.

In an interview on 2/24/23 at 10:05 AM with Staff 1, Staff 2 (DNS) and Staff 3 (Regional Nurse Consultant) confirmed staffing shortages were a concern.

, 2. Resident 9 admitted to the facility on 10/2017 with diagnoses including morbid obesity and chronic pain.

A progress note on 11/21/22 indicated Resident 9 waited for approximately 30 minutes for a CNA to assist her/him with ADL care. The note indicated Resident 9 utilized the phone instead of contacting staff through a walkie talkie.

On 2/20/23 at 11:42 AM Resident 9 stated her/his ADL care needs were not met and staff took "forever" to provide her/him with personal-care because of long call light wait times. Resident 9 stated on 11/26/22 during night shift she/he waited over 30 minutes for the bedpan to be removed and assisted with personal-care. Resident 9 stated it was an "on-going concern."

On 2/21/23 at 12:00 PM Staff 21 (CNA) stated on 11/26/22 he worked the night shift and Resident 9 waited for over 20 minutes for personal-care because she/he would only allow females to provide personal-care.

On 2/21/23 at 9:35 AM Staff 23 (Former-LPN) stated she recalled the incident 11/26/22, during night shift and Resident 9 waited for mpre than 20 minutes to receive personal-care because she/he only wanted female staff to provide personal-care and waited for the nurses to assist with her/his personal-care.

On 2/21/23 at 1:09 PM Staff 22 (Former-LPN) stated she recalled the incident on 11/26/22 because she provided personal-care for Resident 9 and removed the bedpan from underneath the resident. Staff 22 stated Resident 9 waited "maybe" 20 minutes because she/he would only allow female staff to provide personal-care.

On 2/23/22 at 2:35 PM Staff 1 (Administrator) and Staff 3 (Regional Nurse Consultant) stated staff were expected to answer call lights as quickly as possible and acknowledged call light wait times greater than 20 minutes.

Based on interview and record review it was determined the facility failed to ensure the required annual CNA training and annual performance reviews were completed for 3 of 5 sampled CNA staff (#s 12, 13, and 14) reviewed for staffing. This placed residents at risk for unmet needs. Findings include:

On 2/21/23 at 10:47 AM Staff 15 (HR and Payroll) provided the most recent performance reviews for Staff 12 (CNA), Staff 13 (CNA) and Staff 14 (CNA).
- Staff 12 was hired on 4/21/18, the provided performance review was dated 1/17/22.
- Staff 13 was hired on 7/19/21, the facility was unable to provide a performance review.
- Staff 14 was hired on 3/26/14, the facility was unable to provide a performance review.

On 2/21/23 at 10:51 AM Staff 15 acknowledged the performance evaluations were not completed annually for Staff 13 and stated she would look for additional documentation for performance reviews and records to show training requirements were met.

On 2/24/23 at 10:50 AM Staff 15 (Human Resources and Payroll) provided training certificates for Staff 11, Staff 12, Staff 13 and Staff 14.
-Staff 12 was hired on 4/21/18, records revealed from 4/21/21 through 4/22/22 Staff 12 did not receive any training.
-Staff 13 was hired on 7/19/21, records revealed from 7/19/21 through 7/19/22 Staff 13 attended 1.25 hours of training.
- Staff 14 was hired on 3/26/14, records revealed from 3/26/21 through 3/26/22 Staff 14 attended 3 hours of training.

Based on observation and interview it was determined the facility failed ensure food was labeled and stored in a way to minimize food spoilage, failed to maintain a clean and sanitary environment for the kitchen refrigerator and ensure dishwasher chemical solution was maintained at correct concentration for 1 of 1 kitchen reviewed for sanitary conditions. This placed residents at risk of foodborne illness. Findings include:

1. On 2/20/23 at 8:37 AM the walk-in refrigerator and walk-in freezer in the facility's kitchen were observed to contain the following improperly stored items and unsanitary conditions:
-15 to 20 individual 1-ounce cups filled with mayonnaise, covered with lids not dated
-Three cake deserts individually wrapped not dated.
-One chocolate pudding covered not dated.
-Three individually wrapped sandwiches not dated.
-Three ketchups, three mustards, one barbeque sauce (approximately eight ounces half full) and one Italian dressing with a fill date of 1/18/22 but no discard date found.
-The walk-in refrigerator ceiling had multiple dust particles (gray and black all over the ceiling and on the adjacent wall across from the internal fan).
-The walk-in freezer had packages of asparagus, pearl white onions and brussel sprouts that were freezer burnt. The pearl white onions were opened and not dated.
-A package of frozen polish dogs was not dated and freezer burnt.

On 2/20/23 at 8:45 AM Staff 30 (Cook) stated all the food in the walk-in refrigerator with no dates on the packages should have been dated or discarded on 2/19/23. Staff 30 stated the ketchup, mustard and barbeque sauces had not been used in some time but should be refilled once a month. Staff 30 stated maintenance was responsible for cleaning the refrigerator fans and ceilings. Staff 30 stated the food in the walk-in freezer that was freezer burnt should have been thrown out.

On 2/22/23 at 10:31 AM Staff 32 (Dietary Manager) stated all the food in the walk-in refrigerator was to be covered, labeled and if not, was to be discarded. At 10:35 AM Staff 32 observed and acknowledged the dust particles on the ceiling and adjacent to the fan in the walk-in refrigerator and stated maintenance was responsible for cleaning the ceiling and fan once a month.

2. In an observation and interview on 2/20/23 at 8:51 AM Staff 31 (Dietary Aide) was washing dishes and indicated the facility utilized a low temperature dishwasher. The temperature log sheets were hanging on the wall adjacent to the dishwasher.

The sanitizer Dish Machine Log 2/2023 revealed the following:
*Staff were to record wash temperature, test sanitizer with test strip, ensure appropriate PPM (parts per million) was reached and record PPM and if PPM was not reached mark corrective action taken). Maintain this log for each month. Report any inappropriate temperatures or sanitizing issues to the supervisor immediately for corrective actions.

-2/1/23: No PPM recorded for breakfast, lunch or dinner.
-2/2/23: No PPM recorded for breakfast, lunch or dinner.
-2/3/23 No PPM recorded for lunch or dinner.
-2/4/23: No PPM recorded for breakfast, lunch or dinner.
-2/5/23: No wash temperature completed and no PPM recorded for breakfast, lunch or dinner.
-2/9/23: No wash temperature completed and no PPM recorded for breakfast.
-2/10/23: No wash temperature completed and no PPM recorded for breakfast.
-2/18/23: No wash temperature completed and no PPM recorded for dinner.

On 2/20/23 at 8:55 AM Staff 31 stated staff were expected to record the dishwasher temperature for each meal and test the PPM to ensure the low temperature dishwasher reached appropriate temperatures and chemical sanitation.

On 2/22/23 at 10:31 AM Staff 32 (Dietary Manager) acknowledged the Sanitizer Dish Machine Logs were not completed accurately for 2/2023.

Based on interview and record review it was determined the facility failed to ensure medical records were complete, accurate and readily accessible for 1 of 5 sampled residents (#15) reviewed for medications. This place residents at risk for unmet care needs. Findings include:

Resident 15 was admitted to the facility in 2018 with diagnoses including Parkinson's Disease and dementia.

In 2019 information was provided to the facility about Resident 15's mental health diagnosis. The information was not included or readily accessible in the record.

Resident 15 had orders dated 2/1/23 for Seroquel and Abilify (anti-psychotic medications).

The 2/2023 MAR indicated Resident 15 received one dose of Abilify for the month and the Seroquel was administered daily.

On 2/21/23 at 2:39 PM Staff 4 (Social Services) acknowledged she was involved in behavior and psychotropic medication review. Staff 4 stated the Seroquel was new and Resident 15's family wanted her/him to take it for bipolar disorder. Staff 4 added Resident 15 had dementia without behavioral disturbances but she was not aware of Resident 15's bipolar disorder.

On 2/23/23 at 3:01 PM Staff 27 (Resident Care Manager LPN) stated Resident 15's family was involved in the medications. Staff 27 stated the Seroquel was used for dementia but the family said Resident 15 was bipolar. Staff 27 stated she was not aware of any information related to Resident 15's bipolar disorder being provided to the facility.

Based on observation and interview it was determined the facility failed to ensure there was a functioning and audible call light system for 1 of 3 wings (Wing 2) reviewed for call lights. This placed residents at risk for unmet needs. Findings include:

1. During an observation on 2/21/23 at 7:10 AM Resident 36 activated her/his call light but the display outside the room did not activate. Resident 36 stated she/he requested Resident 32 activate her/his call light because her/his call light was not working. At 7:10 AM Staff 1 (Administrator) had Resident 36 activate her/his call light and was observed outside the room and revealed a red flashing light which indicated the call light in the bathroom was activated. Staff 1 stated when Resident 36 activated her/his call light the white light should activate outside of the room even if the bathroom light was activated.

2. On 2/20/23 at 1:19 PM room 209's call light was activated and the audible sound at the nurses' station was heard at a low level when standing next to the nurses' station. A staff member turned the call light monitor's sound up to a higher level.

On 2/22/23 at 7:38 AM Staff 9 (LPN Charge Nurse) stated the call light monitor could not be heard well on Wing 2 and staff would "keep an eye on it."

On 2/23/23 observations on Wing 2 were as follows:
-8:04 AM Resident 27's call light was activated and there was no audible sound from the nurses' station.
-9:37 AM no call lights were observed activated on Wing 2 and an audible sound was heard at the nurses' station.
-10:09 AM Resident 2's call light was activated with no audible sound from the nurses' station.
-10:26 AM Staff 1 increased the volume on the call light monitor.

On 2/24/23 at 8:43 AM room 211 call light was activated while standing next to the nurses' station and no audible sound was heard from the call light monitor.

In an interview on 2/24/23 at 10:05 AM with Staff 1, Staff 2 (DNS) and Staff 3 (Regional Nurse Consultant), Staff 1 stated he would have maintenance look at the system.

Based on observation and interview it was determined the facility failed to ensure required postings were available for 1 of 1 facility reviewed for required postings. This placed residents at risk for lack of posted information. Findings include:

On 2/24/23 at 8:00 AM observations of required postings revealed the Administrator's license was not posted as required. Staff 1 (Administrator) was asked about his license and he pointed to the wall. Staff 1 was reminded his administrator's license was required to be posted along with the facility license. Staff 1 stated he would post his license.

Based on interview and record review it was determined the facility failed to verify a CNA license for 1 of 5 sampled staff (#11) reviewed for staffing. This placed residents at risk for care from unqualified staff and abuse. Findings include:

A review of Staff 11's (CNA) records revealed Staff 11's license expired on 11/17/22.

On 2/21/23 at 10:52 AM Staff 15 (Human Resources and Payroll) stated Staff 11 was on the schedule working with residents.

On 2/21/23 at 12:18 PM Staff 1 (Administrator) confirmed Staff 11's license was expired.

On 2/22/23 at 11:43 AM Staff 11 stated he worked with residents and his license was currently expired.

Based on interview and record review it was determined the facility failed to ensure background checks were completed for newly hired staff for 1 of 5 sampled staff (#29) reviewed for background checks. This placed residents at risk for abuse. Findings include:

Background checks were requested from Staff 15 (Human Resources and Payroll) on 2/23/23 for Staff 29 (LPN) for a hire date of 1/27/23.

On 2/23/23 at 10:45 AM Staff 15 stated Staff 29's background check was still in process and was not completed.

Based on interview and record review it was determined the facility failed to provide on-site Registered Dietician visits for 1 of 1 facility reviewed for nutrition services. This placed residents at risk for unmet nutritional needs. Findings include:

On 2/7/23 at 9:27 AM Staff 32 (Kitchen Manager) stated the previous Registered Dietician only worked remotely and the facility hired Staff 33 (Registered Dietitian) in 1/2023 and she worked remotely.

A review of the facility staff list revealed Staff 33 was the facility's Registered Dietian.

On 2/9/23 at 11:42 AM Staff 1 (Administrator) confirmed the previous Registered Dietician and Staff 33 worked remotely and he was not aware an RD was required to be physically in the building on a regular basis.

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OAR 411-085-0360 Abuse

Refer to F600
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OAR 411-86-060 Comprehensive Assessment and Care Plan

Refer to F657
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OAR 411-086-0230 Activity Services

Refer to F680
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OAR 411-086-0140 Nursing Services: Problem Resolution & Preventive Care

Refer to F686, F689 and F692
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OAR 411-086-0100 Nursing Services: Staffing

Refer to F725 and F727
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OAR 411-086-0310 Administration: Employee Orientation & In-Service Training

Refer to F730
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OAR 411-086-0250 Dietary Services

Refer to F812
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OAR 311-086-0300 Clinical Records

Refer to F842
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411-087-0440 Physical Environment: Nurse Call System

Refer to F919
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