Menlo Park Post Acute

Resident 9 was admitted to the facility on 7/2025 with diagnoses of ParkinsonGÇÖs disease and a joint fracture. -á On 5/20/26 at 11:23 AM, review of Resident 9GÇÖs clinical record found no evidence a SNFABN notice was provided to Resident 9. -á In an interview on 5/21/26 at 12:03 PM, Staff 8 (Social Services Director) stated she was unable to locate a SNFABN notice for Resident 9. -á In an interview on 5/21/26 at 12:43 PM, Staff 17 (Medical Records Associate) stated she was unable to locate a paper copy of a SNFABN notice for Resident 9. -á In an interview on 5/21/26 at 2:45 PM, Staff 9 (Business Office Manager) stated she had phone conversations with Resident 9GÇÖs representative regarding the end of Medicare coverage and transition to private pay status, however, was unable to provide documentation. Staff 9 stated Resident 9GÇÖs Medicare coverage ended on 9/23/25 and private pay began the same day.

Resident #9 is discharged from the facility. An audit of all current residents who experienced a Medicare benefit termination or transition to another payor source within the previous 90 days will be completed to verify that a SNFABN was issued, signed, and properly maintained in the medical record and business office file. The Social Services Director, Business Office Manager, and Medical Records staff were re-educated regarding SNFABN requirements, documentation standards, and record retention expectations. The Administrator or designee will audit 100% of Medicare coverage terminations weekly for four weeks, then monthly for two months, to ensure SNFABN completion and documentation. The results of these audits will be reviewed in QAPI for the need for further intervention.

Resident 6 admitted to the facility on 2/2/26 with diagnoses including end stage renal disease, unspecified conjunctivitis, perforated corneal ulcer, and dependence on renal dialysis. Resident 6's 2/8/26 comprehensive MDS assessment documented Resident 6 had a medically complex condition including perforated corneal ulcer in her/his right eye and conjunctivitis with bacterial agents as the disease.-á Resident 6's Care Plan initiated on 2/12/26 documented Resident 6 was at risk for complications related to a bilateral eye infection. Erythromycin (an antibiotic) eyedrops were initiated on 2/12/26.-á Resident 6's 2/12/26 Physician Orders included erythromycin ophthalmic ointment 5 mg to apply in left eye five times a day.-á-á Resident 6's 2/2026 MAR documented the following: -On 2/16/26 at 11:00 AM, medication was not given as resident was at dialysis by Staff 18 (CMA). -On 2/17/26 at 11:00 AM, medication was not given as resident was at dialysis by Staff 18. -On 2/18/26 at 11:00 AM, medication was not given as resident was at dialysis by Staff 18. -On 2/23/26 at 11:00 AM, medication was not given as resident was at dialysis by Staff 18. -On 2/23/26 at 1:00 PM, medication was not given as resident was absent from home by Staff 19 (CMA). -On 2/25/26 at 11:00 AM, medication was not given as resident was absent from home by Staff 19. -On 2/25/26 at 1:00 PM, medication was not given as resident was absent from home by Staff 19. -On 2/27/26 at 11:00 AM, medication was not given as resident was absent from home by Staff 19. There was no documented evidence Resident 6's provider was notified regarding the missed antibiotic eye medication. On 5/19/26 at 10:30 AM, Resident 6 stated she/he did not receive his/her eyedrops as ordered. On 5/21/26 at 11:06 AM, Staff 18 stated if any medications were due while Resident 6 was out of the facility for dialysis she would document on the MAR that Resident 6 was out of the facility. Staff 18 stated she did not communicate with the nurse about missing the antibiotic eye medication. On 5/21/26 at 12:01 PM, Staff 19 stated she could not recall if she notified the nurse the medications were due while Resident 6 was out of the facility for dialysis and was unsure whether the physician knew Resident 6 had missed doses of their antibiotic eye medication. On 5/21/25 at 1:00 PM and 5/22/26 at 9:34 AM, attempts were made to contact Staff 21 (LPN) were unsuccessful. On 5/22/26 at 10:19 AM, Staff 4 (LPN) stated Staff 18 and Staff 19 did not communicate with her on 2/16/26, 2/23/26 or 2/27/26 that Resident 6 had missed her/his antibiotic eye medication due to being out of the facility for dialysis. Staff 4 stated the medication aides should have communicated with her so she could contact the provider. On 5/22/26 at 10:48 AM, Staff 20 (RNCM) stated the CMAs should have communicated with the nurse about Resident 6 missing doses of the eye drops due to being out of the facility. On 5/22/26 at 11:14 AM, Staff 2 (DNS) stated the CMAs should have notified the charge nurse and charge nurse should have coordinated with the RNCM and provider to adjust Resident 6's medication schedule. -á

Resident #6  discharged from the facility An audit of all residents receiving medications while routinely attending dialysis, outside appointments  are reviewed to identify missed doses Education was provided to CMA’s and LNs to Report missed medications and medication refusals promptly . The Director of Nursing (DNS), RN Care Manager, or designee will audit all medication omissions related to appointments, dialysis, or refusals. These audits will be conducted weekly x4, monthly x2, or until compliance is achieved. The results of these audits will be reviewed in QAPI for the need for further intervention

2. Resident 47 was admitted to the facility in 1/2026 with diagnoses including end stage renal disease. A 1/31/26 physician order included 5 ml of guaifenesin (Musinex) to be administered by a clinician as needed for coughing. On 2/9/26 at 10:19 AM three medication containers were observed at Resident 47GÇÖs bedside table. No lock box was observed in Resident 47's room. Resident 47 stated she/he had those medications for a cough. Resident 47 stated other residents approached her/him and requested to receive a dose of those medications on multiple occasions. Review of Resident 47GÇÖs records on 2/10/26 revealed no assessment for self-administration of any medications was performed for Resident 47. On 2/13/26 at 11:24 AM Staff 35 (LPN) stated a self-administration assessment was to be completed prior to a medication being left in a resident's room. If determined safe to self-administer a specific medication, new orders were placed by a physician, and the resident was provided a lock box and key for safe storage of medication. On 2/13/26 at 11:35 AM Staff 6 (RNCM) stated a medication self-administration assessment was done on residents to determine if there were safe to self-administer any medication. Staff 6 stated a medication self-administration assessment was not completed on Resident 47. Staff 6 entered Resident 47's room and confirmed Musinex, Musinex PM, and two saline nasal rinses were on Resident 47GÇÖs bedside table and should not have been in Resident 47GÇÖs room as she/he was not safe to self-administer those medications. , The facility's Self-Administration of Medication policy dated 8/2024 included the following: - Medication at bedside is stored in closed, locked cupboards or drawers. This includes over the counter medications. - The RCM (Resident Care Manager) evaluates the resident's ability to self-administer medications using the Self Administration Evaluation form. No medications are stored at bedside nor self-administered until evaluation complete.-á - A physician order is obtained indicating the specific medications that resident is able to self-administer. - Drug storage is the responsibility of the nursing staff.-á - Medications are indicated on the MAR as self-administered. 1. Resident 13 was admitted to the facility in 10/2024 with a diagnosis of fracture of neck of left femur.-á The Quarterly MDS with an ARD of 12/2/25 revealed Resident 13 had a BIMS score of 15, which indicated the resident was cognitively intact. A review of Resident 13's clinical record revealed no self-administration of medication assessment was completed to determine the resident's ability to safely self-administer Senna (a laxative) and Tums (a chewable antacid).-á Observations on 2/9/26 at 12:57 PM and 2/10/26 at 9:33 AM revealed Resident 13 had one Tums tablet and one Senna pill inside of a small plastic cup on her/his bedside table.-á On 2/10/26 at 9:33 AM, Resident 13 stated staff had given her/him the Senna, but she/he did not want to take it and put it back in the plastic cup. Resident 13 stated she/he purchased Tums but also changed her/his mind about taking it.-á On 2/10/26 at 9:39 AM, Staff 12 (CMA) entered Resident 13's room and handed her/him a cup of medications with a cup of water. Observations revealed Staff 12 placed the cup of water next to the plastic cup containing the Tums and Senna and exited the room. On 2/10/26 at 1:56 PM, Resident 13 was observed exiting her/his room to use the restroom. At 2:00 PM, Resident 13 was observed walking with staff around the building. At 2:26 PM, Resident 13 was observed entering her/his room and the cup containing the Tums and Senna was still on her/his bedside table.-á On 2/10/26 at 2:51 PM, Staff 14 (CNA) stated she was unaware of Resident 13 being authorized to self-administer medications. She stated if medications were found on residents' bedside tables, she would inform the nurse. On 2/10/26 at 2:58 PM, Staff 15 (CNA) stated she was unaware of Resident 13 being authorized to self-administer medications. She stated if Resident 13 had medications at her/his bedside, she would let the nurse know. On 2/10/26 at 3:06 PM, Staff 13 (CMA) stated the process of giving medication to residents included ensuring residents completely swallowed oral medications safely prior to walking away from the resident. She stated if she saw any residents with a cup of medications on their bedside, she would inform the nurse. She was unaware of any residents who had authorization to self-administer their own medication.-á On 2/10/26 at 3:11 PM, Staff 11 (LPN) stated he expected staff to inform him of any resident who had medications at their bedside. He stated he did not know of any residents who had authorization to self-administer their own medication. At 3:16 PM, Staff 11 went into Resident 13's room and confirmed Resident 13 had one Tums and one Senna in a plastic cup on her/his bedside table. Staff 11 stated CMAs were expected to give medications and observe residents until all of the medications were gone and medications were not to be left unattended.-á On 2/12/26 at 4:02 PM, Staff 2 (DNS) stated she expected staff to remain with residents when residents took medications. She stated she expected staff to inform a nurse immediately if medications were found by a resident's bedside.

Resident #13 does not wish to self-administer his medications.  All medications were removed. Resident 47 does not wish to self-administer his medications.  All meds were removed from bedside. All rooms were evaluated for medications at bedside and medications were removed.  No other deficiencies were noted. Nurses and medication aides were educated to not leave medications at bedside.  All staff were educated to notify nurses or med aides if medications were found at bedside.  Nurses were educated to notify RCM if a resident wishes to self-administer medications DNS/Designee will randomly review resident rooms, and med passes to ensure meds are not left at bedside weekly x4, monthly x2, or until compliance is achieved. The results of these audits will be reviewed in QAPI to determine the need for further oversight.

Resident 64 was admitted to the facility in 2025 with diagnoses including heart failure. Resident 64GÇÖs 8/15/25 Admission MDS assessed her/him to be cognitively intact. Review of the 11/2025 Resident Council Meeting minutes revealed the council had a concern of GÇ£to much into personal business.GÇ¥ The 11/18/25 written response by Staff 8 (Social Services Director) revealed Resident 64 was GÇ£upset because call was placed to APS [Adult protective Services] regarding misappropriation of funds.GÇ¥ On 2/13/26 at 9:24 AM Staff 9 (Activity Director) acknowledged she assisted the residents with the Resident Council meetings. Staff 9 confirmed she read the written responses from the meeting minutes to the Resident Council out loud, exactly as written. Staff 9 confirmed Resident 64's name was written in the 11/2025 Resident Council meeting minutes. On 2/13/26 at 11:45 AM Staff 8 acknowledged Resident 64GÇÖs name was documented on the Resident Council meeting response she wrote. Staff 8 stated she was not aware the responses she wrote were read out loud to residents or that the residents had access to read her responses.-á On 2/13/26 at 11:32 AM Resident 64 stated she/he was at the 12/2025 Resident Council Meeting and felt angry that she/he heard her/his name read out loud to everyone in the meeting about the facility calling APS about her/him. On 2/13/26 at 12:16 PM Staff 1 (Administrator) stated he expected the Resident Council minutes to not include residentGÇÖs personal confidential information and it should not have been read out loud to the resident group. -á -á -á -á -á

Resident 64 was interviewed regarding the incident where her name was read aloud in resident council.  She is satisfied with the staff being educated for it Other resident council attendees were interviewed to ensure no one else had issues with privacy.  No other residents were affected. Activity Director was educated to not read names and personal information during the resident council meetings or in the presence of other residents Administrator/designee will do random interviews with resident council members to ensure no personal information is discussed weekly x4 monthly x2 or until compliance is achieved. The results of these audits will be reviewed in QAPI to determine the need for further oversight.

3. Resident 62 was admitted to the facility on 1/26/26 with diagnoses including third degree burns.-á The 2/1/26 Admission MDS was completed and signed on 2/10/26, two days past the fourteen-day completion timeframe.-á On 2/12/26 at 1:44 PM Staff 4 (LPN Resident Care Manager) confirmed the late MDS completion date.-á , 2. Resident 30 was admitted to the facility in 5/2024 with a diagnoses including heart failure. Resident 30GÇÖs 1/15/26 (Re-Admission) Admission MDS assessed her/him as cognitively intact with little to no interest in doing things. The Activities CAA summary only addressed activities as to GÇ£observe resident's acclimation to facility and will encourage and assist resident with activity programming as resident is accepting.GÇ¥ No other information was documented as assessed for the reasons for little to no interest in recreational, diversional or leisure interest. On 2/13/26 at 924 AM Staff 9 (Activity Director) stated she did not complete or contribute information for Resident 30's leisure and recreational activity preferences for the MDS. On 2/13/26 at 12:42 PM Staff 2 (DNS) expected the triggered Activities CAA in Resident 30GÇÖs 1/15/26 Admission MDS to fully assess the resident's activity needs and preferences. No additional information was provided. , 1. Resident 66 was admitted to the facility in 1/2021 with a diagnosis of an encounter for orthopedic aftercare following surgical amputation.-á Resident 66's 1/6/26 Annual MDS Assessment was listed in her/his health record as ""in progress"" and was not signed or submitted by the recertification survey exit date of 2/13/26.-á On 2/13/26 at 12:21 PM Staff 36 (RN, MDS Coordinator) acknowledged Resident 66's 1/6/26 Annual MDS Assessment was not completed within 14 days of the Assessment Review Date (ARD). Staff 36 stated the assessment was partially completed and not ready to be submitted. Staff 36 stated the assessment was ""a-ápriority"" but she did not know when she would be able to complete it and submit it.-á On 2/13/26 at 1:10 PM Staff 1 (Administrator) acknowledged the resident's assessment was not completed timely and he knew it was also an issue for other residents. Staff 1 stated he expected all residents' MDS Assessments to be completed timely because they were an important factor in developing and maintaining resident-centered care plans.

Resident 66 MDS was completed, exported, and accepted Resident 30 is discharged from the facility Resident 62 MDS was completed, exported, and accepted All other MDS that are in progress were reviewed to ensure timely completion and deficiencies were corrected All in progress MDS were reviewed to ensure the activity CAA is completed with a full assessment regarding activities of choice and preferences of participation. MDS coordinator and the activity director were educated on completion of CAAs. DNS/Designee will audit random MDS’s weekly x4 and monthly x2, or until compliance is achieved.  The results of these audits will be reviewed in QAPI to determine the need for further oversight.

1. Resident 12 was admitted to the facility in 7/2022 with a diagnosis of pneumonia.-á Resident 12's 1/6/26 Quarterly MDS was listed as in her/his health record as ""in progress"" and was not completed or signed by the recertification survey exit date of 2/13/26.-á On 2/13/26 at 12:21 PM Staff 36 (RN, MDS Coordinator) acknowledged Resident 12's 1/6/26 Quarterly MDS Assessment was not completed within 14 days of the Assessment Review Date (ARD). Staff 36 stated there were still sections of the assessment that she needed to complete before she submitted it.-á On 2/13/26 at 1:10 PM Staff 1 (Administrator) acknowledged the resident's assessment was not completed timely and he knew it was also an issue for other residents. Staff 1 stated he expected all residents' MDS Assessments to be completed timely because they were an important factor in developing and maintaining resident-centered care plans.-á 2. Resident 15 was admitted to the facility in 6/2025 with a diagnosis of multiple rib fractures.-á Resident 15's 12/22/25 Quarterly MDS Assessment was listed in her/his health record as ""in progress"" and was not completed or signed by the recertification survey exit date of 2/13/26.-á On 2/13/26 at 12:21 PM Staff 36 (RN, MDS Coordinator) acknowledged Resident 15's 1/6/26 Quarterly MDS Assessment was not completed within 14 days of the Assessment Review Date (ARD). Staff 36 stated the assessment was partially completed and not ready to be submitted. Staff 36 stated the assessment was ""a priority"" but she did not know when she would be able to complete it and submit it.-á On 2/13/26 at 1:10 PM Staff 1 (Administrator) acknowledged the resident's assessment was not completed timely and he knew it was also an issue for other residents. Staff 1 stated he expected all residents' MDS Assessments to be completed timely because they were an important factor in developing and maintaining resident-centered care plans.-á 3. Resident 26 was admitted to the facility in 4/2019 with a diagnosis of combined systolic (congestive) and diastolic (congestive) heart failure (a type of heart failure characterized by the heart being unable to contract and relax properly).-á Resident 26's 12/16/25 Quarterly MDS Assessment was submitted on 2/12/26 (58 days after the Assessment Review Date).-á On 2/13/26 at 12:21 PM Staff 36 (RN, MDS Coordinator) acknowledged Resident 26's 12/16/26 Quarterly MDS Assessment was not completed within 14 days of the Assessment Review Date (ARD). Staff 36 stated it was ""not ideal"" that Resident 26's 12/16/25 Quarterly Assessment was completed more than 14 days after the ARD.-á On 2/13/26 at 1:10 PM Staff 1 (Administrator) acknowledged the resident's assessment was not completed timely and he knew it was also an issue for other residents. Staff 1 stated he expected all residents' MDS Assessments to be completed timely because they were an important factor in developing and maintaining resident-centered care plans.-á 4. Resident 45 was admitted to the facility in 6/2021 with a diagnosis of ataxic gait (an unsteady, uncoordinated walking pattern caused by brain damage).-á Resident 45's 12/17/25 Quarterly MDS Assessment was listed in her/his health record as ""in progress"" and was not completed or signed by the recertification survey exit date of 2/13/26.-á On 2/13/26 at 12:21 PM Staff 36 (RN, MDS Coordinator) acknowledged Resident 45's 12/17/25 Quarterly MDS Assessment was not completed within 14-ádays of the Assessment Review Date (ARD). Staff 36 stated ""a fair amount"" of the assessment was partially completed but it was not ready to be submitted. Staff 36 stated she did not know when it would be ready to submit.-á On 2/13/26 at 1:10 PM Staff 1 (Administrator) acknowledged the resident's assessment was not completed timely and he knew it was also an issue for other residents. Staff 1 stated he expected all residents' MDS Assessments to be completed timely because they were an important factor in developing and maintaining resident-centered care plans.-á 5. Resident 51 was admitted to the facility in 10/2022 with a diagnosis of hemiplegia and hemiparesis (neurological conditions causing one-sided body weakness or paralysis) following a stroke.-á Resident 51's 1/6/26 Quarterly MDS Assessment was listed in her/his health record as ""in progress"" and was not completed or signed by the recertification survey exit date of 2/13/26.-á On 2/13/26 at 12:21 PM Staff 36 (RN, MDS Coordinator) acknowledged Resident 51's 1/6/26 Quarterly MDS Assessment was not completed within 14 days of the Assessment Review Date (ARD). Staff 36 stated the interviews were done but the part she was responsible for completing was not done yet. Staff 36 stated she-ádid not know when it would be ready to submit.-á On 2/13/26 at 1:10 PM Staff 1 (Administrator) acknowledged the resident's assessment was not completed timely and he knew it was also an issue for other residents. Staff 1 stated he expected all residents' MDS Assessments to be completed timely because they were an important factor in developing and maintaining resident-centered care plans.-á 6. Resident 67 was admitted to the facility in was admitted to the facility in 6/2019 with a diagnosis of dementia. Resident 67's 12/23/25 Quarterly MDS Assessment was listed in her/his health record as ""in progress"" and was not completed or signed by the recertification survey exit date of 2/13/26.-á On 2/13/26 at 12:21 PM Staff 36 (RN, MDS Coordinator) acknowledged Resident 67's 12/23/25 Quarterly MDS Assessment was not completed within 14 days of the Assessment Review Date (ARD). Staff 36 stated she was still waiting for additional data in order to submit the assessment. Staff 36 stated she did not have a timeline for the data or submission.-á On 2/13/26 at 1:10 PM Staff 1 (Administrator) acknowledged the resident's assessment was not completed timely and he knew it was also an issue for other residents. Staff 1 stated he expected all residents' MDS Assessments to be completed timely because they were an important factor in developing and maintaining resident-centered care plans.-á 7. Resident 80 was admitted to the facility in 5/2023 with a diagnosis of metabolic encephalopathy (a brain dysfunction caused by illness, organ failure or-áchemical imbalances that alter brain metabolism).-á Resident 80's 1/6/26 Quarterly MDS was listed in her/his health record as ""in progress"" and was not completed or signed by the recertification survey exit date 2/13/26.-á On 2/13/26 at 12:21 PM Staff 36 (RN, MDS Coordinator) acknowledged Resident 80's 1/6/26 Quarterly MDS Assessment was not completed within 14 days of the Assessment Review Date (ARD). Staff 36 stated the interviews were done but the part she was responsible for completing was not done yet. Staff 36 stated she did not know when it would be ready to submit.-á On 2/13/26 at 1:10 PM Staff 1 (Administrator) acknowledged the resident's assessment was not completed timely and he knew it was also an issue for other residents. Staff 1 stated he expected all residents' MDS Assessments to be completed timely because they were an important factor in developing and maintaining resident-centered care plans.

Resident’s 12, 15, 26, 45, 51, 67, and 80 all had their overdue MDS’s completed, exported and accepted. All other MDS that are in progress were reviewed to ensure timely completion and deficiencies were corrected MDS coordinator was educated on MDS completion deadlines and to notify DNS or Administrator if she is unable to complete them on time so assistance can be provided. DNS/Designee will audit random MDS’s to ensure they were completed timely weekly x4 and monthly x2, or until compliance is achieved.  The results of these audits will be reviewed in QAPI to determine the need for further oversight.

2. Resident 2 was admitted to the facility in 2024 with a diagnoses including major depression. Resident 2GÇÖs 10/14/25 Annual MDS assessed her/him as cognitively intact. Very important Activity preferences were identified as music, pets and going outside. It was important to do her/his favorite activities.-á On 2/9/26 at 4:01 PM Resident 2 stated she/he was very bored most of the time with only one activity offered in the morning for less than 30 minutes and sometimes an afternoon program. Resident 2 stated there was very little interaction or engagement in the activities offered. Resident 2 stated the facility had books available to read in the past but they had been removed. On 2/11/26 at 8:31 AM Resident 2 was observed in her/his room with the television on and she/he talked about the lack of planned activities today so she/he would figure out something to do today. On 2/12/26 at 1:16 PM Staff 17 (CNA) stated she/he read the Kardex care plan to get information to care for residents and acknowledged no activity preferences were on Resident 2's Kardex. A Kardex care plan dated 2/12/26 revealed Resident 2 had no activity interests or preferences on the Kardex care plan to inform staff of the residentGÇÖs activity preferences. On 2/13/26 at 9:24 AM Staff 9 (Activity Director) confirmed Resident 2 had no information to direct staff to assist the resident with activity preferences. Staff 8 acknowledged the lack of resident centered activity programming for Resident 2. On 2/13/26 at 12:31 PM Staff 1 (Administrator) stated he expected all residents to have individual activity programs to meet their interests both from groups and individual activities. 3. Resident 3 was admitted to the facility in 2023 with a diagnoses including anxiety. Resident 3GÇÖ s 3/13/25 Annual MDS assessed her/him as cognitively intact. Very important Activity preferences were identified as reading materials, music, pets, religion, doing things with groups of people, going outside, the news and doing her/his favorite activities. On 2/9/26 at 12:21 PM Resident 3 stated she/he was often bored and watched a lot of television for background noise. Resident 3 stated she/he missed the book cart and bookshelf to have access to reading materials. Resident 3 showed an Activity calendar for groups and stated the very little number of things offered were not engaging or interesting. On 2/11/26 at 11:33 AM Staff 9 (Activity Director) was observed to sit at a dining room table and put a puzzle together. Resident 3 nor any other residents were engaged in the puzzle. On 2/12/26 at 1:16 PM Staff 17 (CNA) stated she/he read the Kardex care plan to get information to care for residents and acknowledged no activity preferences were on Resident 3's Kardex. A Kardex care plan dated 2/12/26 revealed Resident 3 had no activity interests or preferences on the Kardex care plan to inform staff of the residentGÇÖs activity preferences. On 2/13/26 at 9:24 AM Staff 9 (Activity Director) acknowledged the lack of activity programming for Resident 3 and the resident liked to sit outside and watch television. On 2/13/26 at 12:31 PM Staff 1 (Administrator) stated he expected all residents to have individual activity programs to meet their interests both from groups and individual activities. 4. Resident 30 was initially admitted to the facility in 2024 with a diagnoses including depression. Resident 30GÇÖs 1/15/25 Admission MDS assessed her/him as cognitively intact. Very important Activity preferences were identified as music, pets, news, to go outside and do her/his favorite things. Its was somewhat important for Resident 30 to have access to books, religion and doing things with groups of people. On 2/9/26 at 10:01 AM Resident 30 stated she/he was bored at times and was very upset her/his television remote control did not work all the time when she/he wanted to have the television available. Resident 30 was observed to click on buttons on her/his remote control and the television did not turn on. On 2/12/26 at 1:16 PM Staff 17 (CNA) stated she/he read the Kardex care plan to get information to care for residents and acknowledged no activity preferences were on Resident 30's Kardex. A Kardex care plan dated 2/12/26 revealed Resident 30 had no activity interests or preferences on the Kardex care plan to inform staff of the residentGÇÖs activity preferences. On 2/13/26 at 9:24 AM Staff 9 (Activity Director) acknowledged the lack of activity programming for Resident 30 and she was not aware Resident 30 had difficulty with the television remote. Staff 8 stated the resident liked to talk some with her and watch television. On 2/13/26 at 12:31 PM Staff 1 (Administrator) stated he expected all residents to have individual activity programs to meet their interests both from groups and individual activities. 5. Resident 60 was initially admitted to the facility in 1/2026 with a diagnoses including spinal stenosis (narrowing of spinal canal causing pain). Resident 60GÇÖs 1/19/25 Admission MDS assessed her/him as cognitively intact. Very important Activity preferences were identified as reading/books, music, news, religion, going outside and doing things with groups of people. On 2/10/26 at 10:01 AM Resident 60 stated she/he was extremely bored and only had her/his cell phone for any distraction or entertainment. Resident 60 stated their family would come to visit to help break the boredom. Resident 60 stated she/he only went to therapy other wise she/he was in their room with no working television.-á On 2/10/26 at 3:18 PM Resident 60 was observed in her/his bed and looked at her/his person cell phone with no television on their side of room. Resident 60 had a small bag of popcorn which she/he received from the GÇ£group activityGÇ¥ which a person brought to her/him while in bed. On 2/12/26 at 1:16 PM Staff 17 (CNA) stated she/he read the Kardex care plan to get information to care for residents and acknowledged no activity preferences were on Resident 60's Kardex. A Kardex care plan dated 2/12/26 revealed Resident 60 had no activity interests or preferences on the Kardex care plan to inform staff of the residentGÇÖs activity preferences. On 2/13/26 at 9:24 AM Staff 9 (Activity Director) acknowledged the lack of activity programming for Resident 60 and she was not aware Resident 60 did not have a working television in her/his room. Staff 8 stated Resident 60 liked to look at her/his phone, go to therapy balloon group and food groups sometimes. On 2/13/26 at 12:31 PM Staff 1 (Administrator) stated he expected all residents to have individual activity programs to meet their interests both from groups and individual activities. . -á -á , The facility's undated Activities policy included the following:-á - Activity programs are designed to meet the interests of and support the physical, mental and psychosocial wellbeing of each resident. - ""Activities"" are considered any endeavor, other than routine ADLs, in which the resident participates, that is intended to enhance his or her sense of wellbeing and to promote or enhance physical, cognitive or emotional health. - Activities are not necessarily limited to formal activities being provided only by activities staff. - Other facility staff may also provide the activities. - Scheduled activities are posted on the resident bulletin board. Activity schedules are also provided individually to residents who cannot access the bulletin board (e.g., bed bound or visually impaired residents). - Residents are encouraged, but not required, to participate in scheduled activities. 1. Resident 20 was admitted to the facility in 1/2026 with diagnoses including blindness in left and right eyes and dysphagia following cerebral infarction (difficulty swallowing following a stroke).-á The 5-Day Admissions MDS with an ARD of 2/2/26 revealed Resident 20 had a BIMS score of 15, which indicated the resident was cognitively intact. The resident required extensive assistance with all ADLs, including always needing assistance with reading written materials.-á Resident 20's 1/2026 Activity Profile revealed it was very important to listen to music she/he liked and to go outside for fresh air when the weather was good. It also revealed Resident 20 found it somewhat important to do things with groups of people.-á Review of Resident 20's Care Plan initiated 2/10/26 indicated for staff to encourage Resident 20 to attend activities and to provide assistance as needed.-á On 2/9/26 at 10:53 AM, Resident 20 stated she/he did not know the facility had activities and she/he had not been invited to any activities. Observations of the activities calendar for 2/10/26 included music and ice cream at 11:00 AM and a popcorn social at 2:00 PM.-á On 2/10/26 at 2:06 PM, Resident 20 stated she/he was not invited to music and ice cream or to the popcorn social and was not aware of the activities. Observations of the activities calendar for 2/11/26 included Bingo at 2:00 PM. On 2/11/26 at 2:35 PM, Witness 2 (Family Member) took a folder out of Resident 20's drawer. Observations of the contents inside of the folder included crossword puzzles, wordsearches, coloring pages, and colored pencils. Witness 2 stated Resident 20 was given the folder when she/he first moved into the facility as independent activities. Witness 2 stated she/he was not sure how Resident 20 could utilize the materials, as Resident 20 was visually impaired.-á On 2/11/26 at 2:35 PM, Resident 20 stated she/he did not know the facility was playing Bingo at 2:00 PM and stated, ""I love Bingo.""-á On 2/12/26 at 9:27 AM, Staff 16 (CNA) stated residents were informed of activities when Staff 9 (Activities Director) announced the event on the overhead speaker and Staff 9 was the person who informed residents of activities that were available. Staff 16 stated Resident 20 liked to sleep all day.-á On 2/12/26 at 10:03 AM, Staff 17 (CNA) stated Staff 9 was responsible for giving out activities' schedules for the month and day to residents and Staff 9 informed residents by making announcements on the overhead speaker. Staff 17 stated if residents wanted to join an outing, residents would go to the front desk and sign their names on a sheet. Staff 17 was not aware of Resident 20's preferences but stated it could be found on her/his care plan.-á Observations of the activities calendar for 2/12/26 included an outing at 10:00 AM.-á On 2/12/26 at 3:12 PM, Resident 20 stated she/he did not know there was an outing for the activity. Resident 20 stated she/he would have liked to go if she/he knew about it. On 2/12/26 at 3:15 PM, Staff 9 stated she had informed Resident 20 to reach out to Staff 9 if she/he needed other activities. Staff 9 stated she passed out a reading material to residents each morning to inform residents of the day's activities, and she typically made an announcement on the overhead speaker 20-30 minutes before the start of the activity. Staff 9 stated she did not pass out the reading material to Resident 20, because she/he was typically asleep. Staff 9 acknowledged Resident 20 would not be able to see the reading material and stated she did not follow up throughout the day with Resident 20 to inform her/him of the day's activities. Staff 9 stated independent activities included crossword puzzles, newspapers, and coloring pages and were provided to residents, but acknowledged these items were inappropriate for Resident 20. Staff 9 stated she had not procured music or audiobooks for Resident 20 and had not spent much time with her/him.-á On 2/12/26 at 4:10 PM, Staff 1 (Administrator) stated he expected for Staff 9 and CNAs to inform residents of the activities for the day. Staff 1 stated he expected for residents to be provided with activities and supplied with items appropriate for their level of function.-á -á

Residents 2, 3, 20, and 60 were re-assessed for resident centered activity preferences and their care plans were updated.   Resident 30 discharged from the facility. All other residents were reviewed to ensure their activity care plans were resident centered.  Their care plans were updated accordingly. Activity director will interview residents regarding preferences of group activities to get their input before updating the activity calendar.  The activity calendar will be updated to include more activities that meet the interests of the residents who enjoy group activities. Activity director was educated that the activity program should support residents in their choice of activities, including group, individual, and independent activities, and be designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community.  These activities should be based on the comprehensive assessment and care plan and the resident’s preferences. Administrator/Designee will randomly interview residents regarding their activity preferences and to see if the activities meet their interests.  These interviews will be conducted weekly x4, monthly x2, or until compliance is achieved.  The results of these interviews will be reviewed in QAPI to determine the need for further oversight and intervention.

On 2/12/26 at 3:15 PM, Staff 9 (Activities Director) stated she was recently promoted to Activities Director and was not aware of any certifications, trainings, or qualifications required for the position. Staff 9 confirmed she was the person who planned the group and individual activities for residents. On 2/13/26 at 8:13 AM, Staff 1 (Administrator) confirmed Staff 9 had been the Activities Director since 12/2025 and did not have the appropriate certifications, trainings, or qualifications for the role.-á -á

The activity director was enrolled in a state approved training course and now has a mentor that will oversee the activity program until the course is completed. The administrator and HR director were educated on the need for a qualified professional to lead the activities program and what qualifications are required to meet the regulation. HR/Designee will ensure the training course is completed and the certificate is placed in the employee file.  Any issues will be communicated to the administrator and reviewed in QAPI for further interventions.

2. Resident 45 was admitted to the facility in 2021 with diagnoses including peripheral vascular disease. The 12/17/25 Quarterly MDS revealed a BIMS score of 15 indicating Resident 45 had intact cognition. The Care Plan, last reviewed 1/14/26, indicated Resident 45 was seen by podiatry for routine toenail care as needed. -á No evidence was found in Resident 45's clinical record podiatry care was provided. In an interview on 2/11/26 at 10:18 AM, Resident 45 stated she/he needed podiatry services for toenail care. The resident reported the podiatrist who visited the facility declined to complete toenail care the most recent time they came in due to payor issues. Resident 45 stated her/his toenails were so long she/he worried about breakage and infections. On 2/11/26 at 10:39 AM, Staff 8 (Social Services Director) confirmed the mobile podiatrist used by the facility no longer accepted Resident 45GÇÖs insurance plan. Staff 8 indicated all residents at the facility with that insurance plan had to begin going to podiatry appointments off site. Staff 8 confirmed on 2/12/26 at 12:18 PM she was unable to find documentation of podiatrist visits for Resident 45 from the past year. -á On 2/12/26 at 12:38 PM, Staff 34 (CNA) removed Resident 45GÇÖs shoes and socks at her/his request. -áResident 45GÇÖs toenails on both feet were observed as thick, yellowed, and very long. -áThe approximate length of most toenails was one half inch past the end of the toes. Staff 2 (DNS) acknowledged on 2/23/26 at 2:58 PM podiatry services had not been provided to Resident 45 per the care plan.-á , Resident 42 was admitted to the facility in 8/2025 with diagnoses including diabetes. The 11/24/25 Modified Quarterly MDS indicated Resident 42 had a BIMS score of 15 which indicated the resident was cognitively intact.-á The 9/5/25 Care Plan indicated the nursing staff completed nail trimming for Resident 42 and staff monitored skin conditions when care was provided and staff notified the nurse of any open areas or red skin areas.-á A review of Resident 42's Physician Orders on 2/2026 indicated the nurses checked fingernails and toenails once a week on bath days and trimmed the residents nails as needed. Resident 42 was scheduled for evening showers on Sunday and Wednesday. The 3/10/25 Skin & Wound Evaluation indicated Resident 42's right plantar foot wound was healed. An attached picture of Resident 42's right plantar foot indicated Resident 42's toenails were trimmed.-á The 2/2026 Documentation Survey Report indicated Resident 42 showered on 2/11/26.-á The 2/2026 MAR indicated Staff 29 (LPN) completed nail care on 2/11/26. The 2/2026 MAR indicated Resident 42 was not verbally or physically aggressive to other residents or staff.-á On 2/9/26 at 11:28 AM, Resident 42 was observed sitting in wheelchair and she/he was not wearing shoes. The resident had a left BKA (below the knee amputation) and on the right foot, the first three toes were amputated. Resident 42's foot was red, swollen and had a white substance around the foot and her/his two toenails were yellow and were overgrown and curved towards the bottom of her/his foot. Resident 42 stated staff didn't assess her/his foot and they didn't perform nail trimming. Resident 42 stated ""staff didn't care"" so why should she/he.-á On 2/12/26 at 9:35 AM, Resident 42 stated she/he showered yesterday evening and staff didn't offer to cut her/his toenails. Resident 42 stated she/he allowed staff to assist during showers and allowed staff to perform nail care when offered.-á On 2/12/26 at 1:26 PM, Staff 17 (CNA) stated the nurses perform nail care for residents with a diagnoses of diabetes. Staff 17 stated the nurses performed nail care after residents showered. On 2/12/26 at 1:50 PM, Staff 30 (CNA) stated Resident 42 showered, and he noticed Resident 42 had white stuff on her/his foot. Staff stated he tried to scrub it off with a towel, but the white substance didn't come all the way off. Staff 30 stated Resident 42's-foot didn't have too much redness but acknowledged Resident 42's toenails were deformed. Staff 30 stated he didn't report skin concerns because the foot didn't have discharge and open wounds. Staff 30 stated the nurses performed nail care after showers and was unsure if this was completed for Resident 42.-á On 2/12/26 at 3:48 PM, Staff 29, (LPN) stated he didn't assess Resident 42's foot because she/he refused weekly skin checks. Staff 29 stated he was unaware about any skin issues or concerns related to Resident 42's foot. Staff 29 stated he didn't perform nail care because Resident 42 refused. Staff 29 stated he did not report Resident 42's refusal of nail care or weekly skin checks to Staff 6 (RNCM). Staff 30 entered Resident 42's room and asked Resident 42 to assess her/his foot and she/he agreed. Staff 30 described Resident 42's nails overgrown but not having an ingrown nail. On 2/13/26 at 9:36 AM, Staff 6 stated residents had orders for weekly nail care. Staff 6 stated staff were expected to document nail care when it was completed and was unsure Resident 42 refused foot care.-á -á-á On 2/13/26 at 10:14 AM, Staff 2 (DNS) stated residents with a diabetic diagnoses received nail care by the podiatrist and the nursing staff. Staff 2 expected staff performed nail care on shower days.

Resident 42 nail care was completed Resident 45 podiatry appointment was scheduled on 02/24/26 which resident refused to go to, and appointment rescheduled to 03/17/2026.  Resident will be encouraged to attend Other residents were reviewed to ensure appropriate foot care was given. Education was provided to CNA’s and Licensed nurses regarding importance of weekly skin checks and nail care, reporting abnormal findings, the escalation process for refusals, and the requirement to notify RNCM of repeated refusals DNS/designee will audit random residents to ensure proper nail care was performed and weekly skin checks were completed and documented appropriately. These audits will be conducted weekly x4, monthly x2, or until compliance is achieved.  The results of these audits will be reviewed in QAPI for the need for further intervention.

A facility Trauma-Informed Care policy dated 8/2024 included the focus of four areas when care interventions are developed and strategies to support resident with trauma history. Those four areas include: -Realize the prevalence of trauma through education and training of care staff, -Recognize how trauma affects individuals through evaluation and identification of triggers, -Responding and putting knowledge into practice through development of resident=centered care planning, and -Resisting re-traumatization through avoiding identified triggers and making empathetic, reasonable modifications to the care approach and environment. 1. Resident 10 was admitted to the facility in 1/2026 with diagnoses including post-traumatic stress disorder (PTSD) and anxiety. An Admission MDS dated 1/12/26 revealed Resident 10 had a BIMS score of 15, which indicated the resident was cognitively intact.-á A Care Plan dated 1/12/26 stated Resident 14 had a diagnosis of PTSD but did not include resident specific information regarding triggers of her/his PTSD or what prevention techniques to address her/his PTSD if triggered. Review of Resident 10GÇÖs records from 1/10/26 through 2/9/26 revealed a Trauma Informed Care assessment had not been performed to determine specific and potential triggers for PTSD, techniques to prevent a response if triggers occurred, or care intervention to implement for the resident after her/his PTSD was triggered. On 2/9/26 at 10:18 AM Resident 10 was observed in her/his room and stated she/he had experienced a startled reflex on multiple occasions at the facility due to staff loudly knocking on her/his door and also had experienced night terrors. Resident 10 stated she/he had verbally told staff her/his PTSD was triggered by loud sudden noises like knocking on the door and she/he wished for them to lightly tap on the door before they entered.-á On 2/10/26 at 2:32 PM a CNA was observed knocking loudly on Resident 10GÇÖs door prior to entering Resident 10GÇÖs room. Resident 10 was overheard verbally responding to the knocks in a louder than conversational voice level. On 2/12/26 at 11:23 AM Staff 18 (CNA) stated Resident 10 did not like staff loudly knocking on her/his door. Staff 18 stated this information was gained from talking with Resident 10 and was not included in her/his records.-á On 2/12/26 at 11:38 AM Staff 11 (LPN) stated he learned about Resident 10GÇÖs PTSD triggers verbally from other staff members but did not have specific information on how to address Resident 10GÇÖs PTSD. On 2/12/26 at 12:38 PM Staff 8 (Social Services Director) stated assessing a resident with a diagnosis of PTSD was important to know how to manage a residentGÇÖs triggers and to prevent those triggers from impacting a resident. Staff 8 stated the information gained from a Trauma Informed Care assessment was to be included in a resident's care plan. Staff 8 confirmed a Trauma Informed Care assessment had not been completed on Resident 10. Staff 8 she was unaware of specific trigger related to Resident 10s PTSD. On 2/12/26 at 12:49 PM Staff 6 (RNCM) confirmed a Trauma Informed Care assessment had not been completed on Resident 10 to determine specific triggers and what action to take if Resident 10's PTSD was triggered. Staff 6 stated she was unaware a formal assessment was required to be completed for residents diagnosed with PTSD. -á , 2. Resident 3 admitted to the facility in 3/2023 with diagnoses including Post Traumatic Stress Disorder (PTSD) and anxiety. Reviewed of Resident 3GÇÖs health recorded revealed a Trauma Screen was completed on 8/22/24 and indicated the resident refused. No other Trauma Screen was found as completed. Resident 3GÇÖs 3/13/25 Annual MDS assessed her/him as cognitively intact and the medical diagnoses included anxiety and PTSD. Review of Resident 3GÇÖs health record revealed a 2/11/26 Care Plan with no indications to the PTSD triggers to ensure the resident, who was a trauma survivor, received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for the residentsGÇÖ experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization for Resident 3. No information was found in the health records to identify. On 2/11/26 at 5:45 AM Staff 36 (CNA) confirmed Resident 3 did not have any indications to triggers for possible re-traumatization or to escalate behaviors. Staff 36 could not provide triggers for the resident but stated Resident 30 would sometimes experience outbursts with yelling and throwing things. On 2/13/26 at 11:51 AM Staff 8 (Social Services Director) confirmed Resident 3 did not have any care plan interventions for possible re- traumatization. She was unaware of the need to assess and document trauma informed care prior to a week ago and had not been able to assess and care plan for all the residents. On 2/13/26 at 1:06 PM Staff 1 (Administrator) acknowledged Resident 3's care plan had not interventions related to her/his PTSD. Staff 1 expected residents care planned and staff to be aware of possible PTSD triggers to residents. -á -á

Resident 10 was re-interviewed for past trauma and potential triggers were identified.  His care plan was updated with interventions to prevent trauma. Resident #3 was assessed for any past traumas. The care plan and kardex was revised to include trauma-informed interventions and behavioral support strategies. Other residents were reviewed for trauma informed care assessments and any potential triggers and any deficiencies were corrected. Education provided to the Social Service team on trauma informed care including assessing residents for past traumas and identifying any triggers to prevent re-traumatization by Implementing individualized care plan interventions. Education to nurses/med aides/CNAs on trauma informed care including where to find the triggers and interventions to prevent them and reporting any triggers you find out to an IDT member to ensure they are care planned. DNS/designee will audit random new residents to ensure they were assessed for past traumas and that triggers are identified and care planned with interventions to prevent re-traumatization.  These audits will be conducted weekly x4, monthly x2, or until compliance is achieved.  The results of these audits will be reviewed in QAPI for the need for further intervention.

Resident 10 was admitted to the facility in 1/2026 with diagnoses including paraplegia (paralysis of the legs and lower body) and wounds.-á The 1/10/26 Care Plan identified ResidentGÇÖs 10GÇÖs pain would be relieved to a tolerable level as indicated by the resident.-á A 1/11/26 PhysicianGÇÖs Order was in place for Morphine Sulfate 10 MG/5 ML every six hours as needed for pain.-á The 1/16/26 Admission MDS revealed a BIMS score of 14 indicating the resident was cognitively intact . The resident received scheduled and PRN pain medications.-á The 1/2026 and 2/2026 MARs showed Staff 27 (CMA) administered PRN Morphine with a pain rating of zero seven times in the two-month period on 1/21/26, 1/22/26, 1/28/26, 1/29/26, 2/4/26, and 2/5/26. The 1/2026 and 2/2026 Progress Notes contained no additional assessment or justification for the dates associated with a pain rating of zero or why the morphine was administered to the resident. -á On 2/11/26 at 9:58 AM Staff 27-ástated she was able to administer pain medications with no pain assessment or nursing oversight. She did not recall administering PRN Morphine to Resident 10 with a pain rating of zero.-á On 2/12/26 at 1:50 PM Staff 6 (RNCM) -á stated Resident 10 identified a pain level of four or five as tolerable. Staff 6 stated the resident was always in pain and would never be at a pain rating of zero. Staff 6-ástated a pain rating assessment should always be conducted and reported to the licensed nurse when a resident requested pain medication. Administering PRN Morphine with a pain rating of zero was not appropriate.

Resident #10’s medical record was immediately reviewed. The resident’s pain management plan was reviewed and clarified to ensure PRN Morphine is administered only when clinically indicated and after an appropriate pain assessment. An audit of all residents currently receiving PRN narcotic pain medications was conducted to ensure a documented pain assessment is completed prior to administration. PRN medications are administered according to physician orders and clinical indications. Medication Aide and licensed nurse educated on proper pain assessment prior to PRN pain medication administration, pain management and PRN medication administration was reviewed and reinforced with nursing staff. The Director of Nursing or Designee will conduct weekly audits of PRN pain medication administrations for compliance weekly x4 monthly x2, or until compliance is achieved. The results of these audits will be reviewed in QAPI for the need for further intervention.

-á Resident 42 was admitted to the facility in 8/2025 with diagnoses including diabetes. The 9/5/25 Care Plan indicated Resident 42 had her/his own teeth and required assistance setting up when oral hygiene was performed.-á The 11/24/25 Modification of Quarterly MDS indicated Resident 42 had a BIMS score of 15 which indicated the resident was cognitively intact and Resident 42 did not have dental pain, discomfort and difficulty chewing.-á The 11/2025 Documentation Survey Report indicated Resident 42 was not verbally or physically aggressive to other residents or staff.-á A 11/21/25 Progress Note indicated Resident 42 was verbally aggressive with staff and reported toothache.-á A 11/25/25 Progress Note indicated Staff 31 (Social Services Assistant) called to make an emergent dental appointment but the clinic advised her to call back the following day and an appointment would be scheduled within 48 hours.-á-á On 2/9/26 at 11:28 AM, Resident 42 stated she/he felt neglected and felt the facility didnt care about her/him. Resident 42 stated she/he didnt have teeth on the top part of her/his mouth and had multiple missing teeth at the bottom part of her/his mouth. Resident 42 stated she/he had dental pain and discomfort back in 11/2025 and told staff. Resident 42 stated she/he was unable to chew her/his food. Resident 42 stated staff had not scheduled a dental appointment because they didn't care. Resident 42 stated she/he requested an emergent dental appointment in 11/2025 but staff didn't follow up.-á On 2/12/26 at 1:26 PM, Staff 17 (CNA) stated emergent dental appointments was scheduled quickly and residents were seen with in a couple of days. Staff 17 was unaware Resident 42 had dental concerns.-á On 2/12/26 at 1:50 PM, Staff 30 (CNA) stated he didn't provide oral care on 2/11/26 swing shift for Resident 42.-á 02/12/2026 3:48 PM Staff 29, (LPN) stated he didn't assess Resident 42's mouth to notice any dental concerns. Staff 29 stated Resident 42 had not expressed dental pain, discomfort or difficulty chewing. Staff 29 stated residents reporting dental pain and discomfort were scheduled an emergent dental appointment. Staff 29 stated social services scheduled emergent dental appointments within a couple of days. Staff 29 stated he encouraged oral hygiene and reminded residents to perform oral hygiene throughout the day and was unaware oral hygiene not occurring yesterday.-á On 2/12/26 at 3:57 PM, Staff 8 (Social Service Director) stated emergent dental appointments were scheduled within 24 hours upon request. Staff 8 stated dental concerns were discussed on a quarterly basis and she was unsure about the emergent appointment Resident 42 requested back in 11/2025.-á On 2/13/26 at 9:36 AM, Staff 6 (RNCM) stated she was unaware Resident 42 had dental pain and discomfort. Staff 6 stated she was not Resident 42's RCM back in 11/2025 so she didnt know about her/his dental concerns. Staff 6 stated staff helped Resident 42 set up supplies to perform oral hygiene. Staff 6 acknowledged Resident 42's request to see a dentist was not timely. -á -á On 2/13/26 at 10:14 AM, Staff 2 (DNS) stated residents who reported dental pain, discomfort and difficulty chewing were scheduled an emergent dental appointment immediately. Staff 2 acknowledged Resident 42's request to see a dentist was not timely.-á -á -á -á

Resident #42 was immediately assessed for dental pain and has no concerns and was scheduled to see his dentist on 03/13/26 All other residents were reviewed for dental concerns and appropriate action taken. Education for direct care staff to report dental pain or concerns to the provider and the IDT timely.  IDT is educated on dental services policy and follow through.  Dental concerns will be followed in the daily clinical meeting. DNS/designee will audit the dental referrals to ensure proper follow through weekly x4 monthly x2, or until compliance is achieved. The results of these audits will be reviewed in QAPI for further intervention.

The facility's Dishwashing policy dated 8/2024 included the following: - Do not run dishes through until machine has reached proper temperature for your specific machine. This may take multiple cycles. - Check for proper temperatures and pressure. Log Temps, if deficient, tell FNS Manager and/or Maintenance Director.-á The facility's Resident Food from Outside Source policy dated 8/2024 included the following: - Refrigerated food items from an outside source is stored in a container with the following information on it: date product was received, name of product, resident name and room number.-á - Refrigerated foods that are unlabeled or undated, when noted, is discarded. - Homemade items, restaurant leftovers, take out items, milk, cottage cheese and similar type items is discarded on day three.-á 1. On 2/11/26 at 10:21 AM, the dishwasher temperature log was observed to be blank for 2/11/26.-á On 2/11/26 at 10:21 AM, the dishwashing machine's temperature gauge was observed to be at 110*F and Staff 20 (Dietary Aide) was observed rinsing dirty dishes and loading them onto a rack. He stated the machine was a low temperature machine and confirmed the machine's current thermometer read was 110*F. Staff 20 stated the temperature was supposed to be at 120*F and confirmed the log for 2/11/26 was blank. He stated he usually checked the temperature before washing dishes and after washing dishes. From 10:21 AM to 10:31 AM, the temperature gauge remained at 110*F, Staff 20 completed three loads of dishes and was preparing a fourth load into the dishwasher.-á On 2/11/26 at 10:32 AM, Staff 7 (Dietary Director) confirmed the dishwasher was a low temperature machine and required the temperature to be at or above 120*F in order for the dishes and utensils to be considered sanitized. She stated staff did not touch the machine and did not have the ability to adjust it. On 2/11/26 at 10:40 AM, Staff 20 continued to unload and load the dishwasher with dirty dishes while the thermometer gauge remained at 110*F. On 2/11/26 at 11:03 AM, Staff 21 (Dietary Aide) inserted a thermometer into the water of the dishwashing machine, which read 111*F.-á On 2/11/26 at 11:09 AM, Staff 7 inserted a thermometer into the water of the dishwashing machine, which read 118*F. She confirmed the dishwasher was not at the temperature needed in order for the dishes and utensils to be appropriately sanitized. She stated when the temperature was not at 120*F or above, staff were expected to let her know immediately. On 2/12/26 at 4:02 PM, Staff 1 (Administrator) stated he expected the dishwasher to be at the appropriate level for dishes and utensils to be sanitized. He stated he expected for staff to inform management immediately when the temperature of the dishwasher was below it's appropriate level.-á 2. On 2/11/26 at 8:41 AM, the inside of the resident refrigerator (a refrigerator designated for residents' food only) was observed to have a bag with a resident's name and room number on it, but no date. On 2/12/26 at 8:58 AM, the inside of the resident refrigerator was observed to have a bag with a resident's name and room number on it, but no date. Inside of the bag included a container of watermelon, cantaloupe and honey dew melon in a pool of liquid, but no date or expiration; a rotisserie chicken inside of a bag with no date or expiration; and two slices of processed cheese enclosed in plastic packaging with no date or expiration.-á On 2/12/26 at 9:05 AM, Staff 22 (Dietary Aide) stated he checked the resident refrigerator each day but did not throw away any of the contents inside of the resident refrigerator. He stated it was the responsibility of CNAs and housekeeping to throw away resident items in the refrigerator. On 2/12/26 at 10:12 AM, Staff 18 (CNA) stated when residents or family brought in food from outside of the facility, CNAs were responsible to put the resident's name, room number, and date it was received on the container. She stated CNAs threw away spoiled food or after the third day after it was received. On 2/12/26 at 10:17 AM, Staff 19 (CNA) stated when residents wanted to store their own food in the refrigerator, CNAs were responsible for putting the resident's name, room number, and date it arrived on the container. She stated CNAs were not supposed to throw away anything and dietary staff were responsible for cleaning and throwing away food.-á On 2/12/26 at 10:20 AM, Staff 17 (CNA) stated CNAs were responsible for putting a resident's name, room number, and the day it was received onto the container when residents bring food from outside of the facility. She stated CNAs did not throw away any food from the resident refrigerator and it was the responsibility of kitchen or housekeeping staff to do so. On 2/12/26 at 10:28 AM, Staff 7 (Dietary Director) confirmed the resident refrigerator had an undated bag that contained the undated container of melons, undated rotisserie chicken and two undated slices of processed cheese. She stated it was the responsibility of CNAs to receive a resident's food from outside and to put their name, room number, and day it was received onto the container. Staff 7 stated she expected for dietary staff, CNAs and housekeeping to work together to ensure unlabeled food, expired food, and food that has been in the refrigerator for three days to be thrown out.-á On 2/13/26 at 8:18 AM, Staff 1 (Administrator) stated he expected for dietary staff, housekeeping and CNAs to work together to ensure unlabeled food, expired food, or food that has been in the resident refrigerator for three days to be thrown out.-á -á

The kitchen manager informed her staff to serve the meals on disposable trays and utensils until the dishwasher could be fixed.  The dish washer was serviced on 2/11/26 and fixed on 2/13/26 All dishes were re-washed to ensure appropriate sanitation before use Dietary staff were educated on proper temps and sanitation of dishes, taking and logging temperatures per policy, and what to do if the machine is not working properly and notify the dietary manager. Administrator/Designee will audit dishwasher temps and logs for compliance weekly x4 monthly x2, or until compliance is achieved. The results of these audits will be reviewed in QAPI for further intervention. The resident’s refrigerator was cleaned out, and all residents’ food was labeled and dated per policy. There are no other resident refrigerators. Staff were educated that refrigerated food items from an outside source is stored in a container with date received, name of product, resident, and resident room number on it.  Also educated on unlabeled items are discarded, and items that need to be thrown out on day 3. Administrator/Designee will audit resident refrigerators for compliance weekly x4 monthly x2, or until compliance is achieved. The results of these audits will be reviewed in QAPI for the need for further intervention.

On 2/9/26 at 9:24 AM, the facility's dumpsters were observed to be very full and the doors did not close to enclose the trash. On 2/10/26 at 9:18 AM, the facility's dumpsters were observed to be very full and had trash overflowing from the top. Two inside out gloves were observed on the concrete where the dumpsters were and one large trash bag was placed in front of the dumpsters.-á On 2/10/26 at 3:30 PM, the facility's dumpsters were observed to be very full, trash overflowing from the top and four large bags were in front of the dumpsters. The ground around the dumpsters was observed to have miscellaneous trash items. On 2/11/26 at 5:00 AM, the facility's dumpsters were observed to be very full, trash overflowing from the top and more than four large bags placed in front of the dumpsters. The ground around the dumpsters was observed to have miscellaneous trash items including inside out gloves.-á On 2/11/26 at 6:44 AM, Staff 7 (Dietary Director) stated the dumpsters were shared by all of the employees of the facility. On 2/11/26 at 7:59 AM, Staff 10 (Maintenance Director) stated the garbage was supposed to be collected six times per week, Monday through Saturday. He stated the garbage company was also supposed to pick up the bags off the ground. Staff 10 stated he was not sure what happened on 2/9/26 and 2/10/26, but he did not get a phone call from the garbage company. Staff 10 acknowledged garbage should be contained in their receptacles and off the ground. On 2/13/26 at 8:20 AM, Staff 1 (Administrator) stated he expected the garbage to be contained in the receptacles and off the ground and for staff to notify management when the dumpsters became too full.-á -á

The garbage dumpsters were emptied and the ground around them was picked up. The grounds outside the facility were walked and any trash was disposed of All staff educated on ensuring waste was properly contained in the dumpsters and the grounds around it are kept clean. The frequency to have the dumpsters emptied was increased.  The dumpster will be placed behind an enclosure to keep outside persons from dumping and rummaging through the containers.  Rounding for compliance will be increased by facility staff. Administrator/Designee will audit waste dumpster area for compliance weekly x4 monthly x2, or until compliance is achieved. The results of these audits will be reviewed in QAPI for the need for further intervention.

-á 2. During an 2/11/26 at 10:00 AM Residents Council meeting the residents expressed a concern they were not offered hand hygiene during the dining room meal services. During a 2/11/26 dining room observation from 11:33 AM to 12:00 PM no hand hygiene was offered to the residents in the dining room prior to receiving lunch. On 2/11/26 at 12:01 PM Resident 2, Resident 28 and Resident 80 were observed eating lunch in the dining room. The residents all stated they were not offered hand hygiene prior to the meal service and would have liked to have had clean hands to eat with during the meal. On 2/12/26 at 11:40 AM Staff 18 (CNA) stated the residents usually wash their hands in the morning and were not offered hand hygiene prior to serving lunch unless a resident requested to have their hands washed. During a 2/13/2026 at 12:42 PM Staff 2 (DNS) state she would expect the residents to be offered hand hygiene prior to eating a meal in the dining room. -á -á -á , The 8/1/24 Hand Hygiene policy and procedure specified hand hygiene was required before and after assisting a resident with personal care, after handling soiled or used linens, before applying gloves, and after removing gloves.-á 1.On 2/10/26 at 9:09 AM Staff 27 (CNA) was observed wearing gloves and providing cares to Resident 8 who was on contact precautions (infection-control measures used to prevent the spread of germs). These cares included touching the residentGÇÖs gown, legs and bedding, and combing her/his hair. Staff 27 placed the residentGÇÖs linens into a bag, removed her gloves, and exited the room using the gloves to carry the bag. Staff 27 was observed continuously as she dropped off the dirty linens, proceeded down the hall with the dirty gloves in hand, dropped the gloves into a garbage can, and then picked up clean gloves and started to put them on to enter a new room. At no point was hand hygiene performed.-á On 2/10/26 at 9:25 AM Staff 27 stated-áhand hygiene should be done as soon as gloves came off, but hand sanitizer was hard on her skin and she preferred to wear gloves instead of always using sanitizer.-á On 2/13/26 at 10:54 AM Staff 4 (Infection Preventionist) stated-áhand hygiene should be performed by staff after the removal of gloves and after disposal of garbage or dirty linens, before they went on to their next task. Staff 4 stated staff would need to wash their hands if they did not want to use hand sanitizer.-á

CNA was immediately educated on hand hygiene after removing gloves and before applying new gloves. CNAs were educated on offering hand hygiene to residents before meals are served. Other staff working that day were educated on hand hygiene policy and offering to provide hand hygiene to residents before meals. All staff will be re-educated on hand hygiene policy and offering hand hygiene to residents before meals.  Infection preventionist will increase rounding to ensure appropriate practices are occurring. DNS/Designee will audit compliance of appropriate hand hygiene and offering hand hygiene to residents before meals weekly x4 monthly x2, or until compliance is achieved. The results of these audits will be reviewed in QAPI for the need for further intervention.

Based on interview and record review it was determined the facility failed to inform residents and/or the residents' responsible party of the risks and benefits, and to ensure consent was obtained for the use of psychotropic medications for 2 of 5 sampled residents (#s 34 and 66) reviewed for unnecessary medications. This placed residents at risk for lack of informed consent. Findings include: The facility's Psychoactive Medications policy, dated 8/1/24, indicated risks and benefits of drug use and revealed informed consent was to be obtained from the resident/resident representative prior to administration of any psychoactive medication. 1. Resident 34 was admitted to the facility in 3/2023 with diagnoses including major depressive disorder. Resident 34's 10/2024 MAR revealed the resident received the following psychotropic medications as ordered by her/his physician: -Buspirone (a medication to treat anxiety), three times a day for anxiety. -Sertraline (a medication to treat depression), one time a day for major depression. -Clonidine (a medication to treat anxiety), every 6 hours as needed for anxiety. Review of Resident 34's health record revealed no documentation to indicate the resident or her/his representative were informed of the risks and benefits of buspirone, sertraline or clonidine and no evidence the resident consented to receive the medications. On 11/6/24 at 11:51 AM Staff 2 (Interim DNS) stated it was her expectation nursing staff reviewed the risks and benefits of psychotropic medications with residents prior to the residents taking the medications and confirmed Resident 34 received buspirone, sertraline and clonidine without consent being obtained. 2. Resident 66 was admitted to the facility in 10/2024 with diagnoses including major depressive disorder. Resident 66's 10/2024 MAR revealed the resident received the following psychotropic medication as ordered by her/his physician: -Quetiapine (a medication to treat major depressive disorder), one time a day at bedtime. Review of Resident 66's health record revealed no documentation to indicate the resident or her/his representative were informed of the risks and benefits of quetiapine and no evidence the resident consented to receive the medication. On 11/6/24 at 11:51 AM Staff 2 (Interim DNS) stated it was her expectation nursing staff reviewed the risks and benefits of psychotropic medication with residents prior to the residents taking the medication and confirmed Resident 34 received quetiapine without consent being obtained.

Resident #34 was informed of the risks and benefits of taking psychotropic medications and a consent was obtained for each medication Resident # 66 was informed of the risks and benefits of taking psychotropic medications and a consent was obtained for the medication All residents on psychotropic medications will be audited to ensure the risks and benefits were explained and that a consent was obtained. Any deficiencies will be corrected Licensed nurses will be educated on the need to obtain consent before the administration of psychotropic medications. New psychotropic drugs will be reviewed in clinical meeting to ensure a consent was obtained. DNS/Designee will perform random audits on residents with psychotropic medications to ensure consent was obtained weekly x4, monthly x2, or until compliance is achieved. Audits will be brought through QAPI for review

Based on observation and interview it was determined the facility failed to ensure a homelike environment for 1 of 1 facility reviewed for dining. This placed residents at risk for a lessened quality of life. Findings include: Observations on 11/5/24 through 11/8/24 between the hours of 8:00 AM and 12:35 PM revealed meals were served with plastic spoons, plastic glasses and Styrofoam cups. On 11/5/24 at 12:38 PM Resident 66 was eating lunch. Resident 66 held up a plastic spoon and stated, "they give us this crap to eat with." On 11/6/24 at 1:38 PM Staff 29 (CNA) stated residents usually received regular forks and knives but were given plastic spoons, plastic glasses and Styrofoam cups for at least the past month. Staff 29 stated this was not homelike. On 11/6/24 at 1:42 PM Staff 30 (Dietary Manager) stated the facility did not have enough glasses, cups or silverware for all of the meal service. Staff 30 stated plasticware and Styrofoam cups were not homelike. On 11/8/24 at 9:17 AM Staff 13 (Activities Director) confirmed multiple residents complained about paper and Styrofoam cups, plastic glasses and plastic utensils. Staff 13 reported the residents stated "it feels like a fast food restaurant" rather than a homelike environment when they received plastic and Styrofoam dishware and utensils.

Resident 66 will be provided with regular dishware and silverware for meals All residents will be provided with regular dishware and silverware for meals Additional dishware has been purchased for the facility. Dietary staff will be educated to use proper dishware with meals to create a homelike environment. The dietary manager will be educated to notify administrator when more dishware is needed to meet the PAR level needed for each meal. Administrator/Designee will audit random meals to ensure that proper dishware is being used when serving meals weekly x4 and monthly x2 or until compliance is achieved. Audits will be brought through QAPI for review

Based on observation, interview and record review it was determined the facility failed to protect the resident's right to be free from verbal abuse by a resident for 1 of 1 sampled residents (#19) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 19 admitted to the facility in 3/2024 with diagnoses including infection and anxiety disorder. A 10/10/24 Quarterly MDS revealed Resident 19 had moderate cognitive impairment. Resident 17 admitted to the facility in 10/2024 with diagnoses including amputation and obesity. A 10/23/24 Admission MDS revealed Resident 17 was cognitively intact. On 11/6/24 at 11:55 AM Resident 17 was observed to enter the doorway of Resident 19's room where she/he proceeded to yell and swear at Resident 19. Resident 17 told Resident 19 to "stop fucking yelling out" and to turn her/his damn tv down." The interaction was observed by Staff 13 (Activities Director), Staff 22 (Physical Therapy Assistant), Staff 21 (CMA) and Witness 1 (Family Member). On 11/6/24 at 12:02 PM Staff 22 stated he was doing a therapy session with Resident 17 when the resident unexpectedly stopped in the doorway of Resident 19's room and started shouting and cursing at Resident 19. Staff 22 stated he went into Resident 19's room to ask if she/he was ok. Staff 22 stated Resident 19 said she/he did not know what happened or why Resident 17 was screaming at her/him. On 11/7/24 9:29 AM Resident 19 stated a resident was at her/his doorway and was yelling at her/him. Resident 19 stated she/he felt scared and did not know why she/he had been yelled at. On 11/7/24 at 9:38 AM Staff 21 stated she observed Resident 17 in the doorway of Resident 19's room yelling at her/him. Staff 21 stated she went to get help from another staff member when Resident 17 was swearing at Resident 19 in an escalated voice. On 11/7/24 at 9:48 AM Staff 13 stated she was in a resident room across the hall when she heard Resident 17 yell at Resident 19 "your tv is too fucking loud and you are too loud." Staff 13 stated she went into Resident 19's room to make sure she/he was ok. Staff 13 stated Resident 19 said "she/he felt weird and she/he did not know why Resident 17 yelled at her/him." On 11/7/24 at 10:20 AM Resident 17 stated she/he stopped in the doorway of Resident 19's room and yelled at her/him. Resident 17 stated she/he yelled at resident 19 to "turn her/his damn tv down, used the f-word a few times, told the resident to use her/his damn call light and told the resident she/he was the rudest person in the building." Resident 17 also stated "I have a tendency to lose control of my emotions and I rage at times. Raging has been a part of my life since middle school." On 11/7/24 at 2:18 PM Witness 10 stated Resident 19 "had a bad day" the day of the incident. Witness 10 stated Resident 19's emotions run high sometimes and she/he rages. On 11/8/24 at 12:22 PM Staff 1 (Administrator) and Staff 2 (Interim DNS) were notified of the findings of this investigation. Staff 1 stated moving forward, Resident 17 was to let staff know when she/he was frustrated. Staff 1 stated it was his expectation to keep residents safe, protected and free from abuse at all times.

Residents were immediately separated. Resident 19 was placed on alert for psychosocial distress. Resident 17 was educated to alert staff if he had a disagreement with another resident so they can handle it. Other residents were interviewed to see if any other verbal abuse had occurred. No other residents were affected. Staff were educated on abuse policy including what to do if abuse occurs and who and when to report abuse Administrator/Designee will perform random resident and staff interviews regarding abuse and abuse reporting weekly x4 and monthly x2 or until compliance is achieved. Audits will be brought through QAPI for review

Based on interview and record review it was determined the facility failed to timely report an allegation of sexual abuse to the State Agency (SA) for 1 of 3 sampled residents (# 60) reviewed for abuse. This placed residents at risk for abuse. Findings include: The facility's 8/2024 Abuse Screening, Training, Identification, Investigation, Reporting and Protection policy directed the following: -Any suspicion of a crime requires notification of law enforcement and the State survey agency immediately by the person who first forms the suspicion of the crime for sexual abuse. -If, with the suspicion of a crime, there is abuse or a serious injury, the staff member must report the incident within 2 hours of forming the suspicion to law enforcement and the State survey agency. Resident 60 was admitted to the facility in 7/2024 with diagnoses including C-difficile infection (a bacterial infection in the colon). Resident 60's 10/15/24 Quarterly MDS indicated the resident had intact cognition. Resident 13 was admitted to the facility in 6/2024 with diagnoses including diabetes and alcohol induced cirrhosis of the liver (damage to the liver due to alcohol abuse). Resident 13's 9/24/24 Quarterly MDS indicated the resident had intact cognition. The facility's 10/27/24 FRI form, completed by Staff 24 (LPN) revealed the following: -Resident 60 alleged Resident 13 touched her/his genital area while she/he slept and upon waking, she/he asked the resident to leave and Resident 13 left the room. -On 10/27/24 around 7:00 AM, Staff 1 (Administrator) was notified by a nurse at the facility that Resident 60 reported being inappropriately touched by Resident 13. -Staff 25 (CNA) confirmed seeing Resident 13 exit Resident 60's room but did not see Resident 13 entering or in Resident 60's room. -Facility security cameras saw Resident 13 in the vacinity of Resident 60's room but did not see Resident 13 enter or exit Resident 60's room. -Resident 13 denied inappropriately touching Resident 60. -The SA was notified of the incident on 10/27/24 at 11:05 AM. On 11/4/24 at 9:54 AM Resident 60 stated she/he was in her/his room waiting for the wound care nurse to come and complete wound care treatment. Resident 60 stated she/he fell asleep and around 11:00 PM on 10/26/24 was awakened because Resident 13 was touching her/his "pubic hairs." Resident 60 stated Resident 13 was "shocked" when she/he woke up and Resident 13 quickly "disappeared." Resident 60 stated she/he activated her/his call light and Staff 25 (CNA) responded. Resident 60 stated she/he reported the alleged sexual abuse to Staff 25 who then reported the alleged sexual abuse to Staff 24. On 11/4/24 at 2:51 PM Staff 1 stated he was notified of Resident 60's alleged sexual abuse when he arrived to work on 10/27/24 and began working on the investigation around 7:00 AM. He stated it was his understanding that he had 24 hours to report an allegation of abuse unless there was serious bodily injury so he wanted to complete the investigation prior to notifying the SA. On 11/4/24 at 6:02 PM Staff 25 stated she arrived for her scheduled night shift assignment and was getting report when Resident 60 activated her/his call light. Staff 25 stated she walked towards Resident 60's room and noticed Resident 13 in her/his wheelchair, backing out of Resident 60's room. Staff 25 stated, initially, Resident 60 reported being upset because the wound care nurse had not shown up, so she informed Resident 60 she would notify the night shift charge nurse regarding the resident's concern. Staff 25 stated approximately five minutes later, Resident 60 activated her/his call light again. Staff 25 stated when she arrived in Resident 60's room, the resident told her that Resident 13 had put her/his hand up her/his brief and inappropriately touched her/him. Staff 25 stated she notified Staff 24 between 10:30 PM and 10:50 PM regarding Resident 60's alleged sexual abuse. Staff 25 stated Staff 24 spoke with Resident 60 between 11:00 PM on 10/26/24 and 12:00 AM on 10/27/24. On 11/4/24 at 7:36 PM Staff 24 stated around 12:30 AM on 10/27/24, Staff 25 informed her that Resident 60 wanted to speak with her. Staff 24 reported Resident 60 notified her that Resident 13 had touched her/him inappropriately on her/his upper thigh and "private area." Staff 24 stated she attempted to call a nurse manager but they were "unreachable" so she notified the nurse manager and Staff 1 "in the morning." Staff 24 stated she did not report the allegation of sexual abuse to law enforcement or the SA within two hours because she was not familiar with the timeframe for reporting abuse allegations. On 11/6/24 at 11:01 AM Staff 2 (Interim DNS) stated there was some confusion as to the required timeframe for reporting allegations of abuse so the allegation was not reported within the mandated timeframe. Staff 2 stated the expectation was any abuse allegations were reported to the SA immediately but no longer than two hours of the alleged incident.

The abuse allegation for Resident 60 was reported Other residents were interviewed to see if any other sexual assaults were reported Staff were educated that all abuse allegations must be reported immediately to the abuse coordinator and that any abuse allegations must be reported to the state agency immediately but no longer than 2 hours of the alleged incident. Administrator/Designee will audit any allegations of abuse to ensure timely reporting was completed weekly x4 and monthly x2, or until compliance is achieved. Audits will be brought through QAPI for review

Based on interview and record review it was determined the facility failed to ensure transfer notices with appeal rights were provided in writing to residents and their representatives, and to ensure the Office of the State Long-Term Care Ombudsman was notified of resident hospitalizations for 1 of 1 sampled resident (#73) reviewed for hospitalizations. This placed residents at risk for lack of information regarding their options, rights, and lack of advocacy from the Ombudsman Office. Findings include: Resident 73 was admitted to the facility in 9/2024 with diagnoses including complications of a foreign body accidentally left in the body following heart catheterization (a procedure that uses a catheter to diagnose and treat heart conditions). A review of Resident 73's health record revealed she/he was transferred to the hospital on 10/8/24. No evidence was found in Resident 73's health record to indicate a transfer notice with appeal rights was provided in writing to the resident or their representative upon transfer to the hospital, or that the Office of the State Long-Term Care Ombudsman was notified of the resident's transfer to the hospital. On 11/7/24 at 2:44 PM Staff 28 (Medical Records) indicated she was aware the Office of the State Long-Term Ombudsman needed to be notified when residents transferred to the hospital but she had not notified the Ombudsman's office of resident hospital transfers since 8/2024. On 11/7/24 at 2:50 PM Staff 2 (Interim DNS) stated the charge nurse was supposed to complete the written notification of transfer for residents transferring to the hospital and Staff 28 was to notify the Office of the State Long Term Care Ombudsman when residents transferred to the hospital. Staff 2 confirmed neither was completed when Resident 73 transferred to the hospital on 10/8/24.

Resident 73 was given a written notice of transfer with appeal rights and the Ombudsman’s office was notified of the transfer. All residents sent to the hospital in the past 30 days were reviewed to ensure they received the written notice of transfer. Any deficiencies were corrected. The Ombudsman’s office was notified of the transfers. Licensed nurses were educated on the need to provide the written notice of transfer with appeal rights to residents or resident representative upon an acute care transfer. The Medical records Director was educated on the need to notify the Ombudsman’s office of acute care transfers. DNS/Designee will review acute care transfers to ensure they were provided a written notice of transfer with appeal rights and that the ombudsman office was notified of the transfer weekly x 4 and monthly x2, or until compliance is achieved. Audits will be brought through QAPI for review

Based on interview and record review it was determined the facility failed to provide residents with a written notice of the facility's bed hold policy at the time of transfer to the hospital for 1 of 1 sampled resident (#73) reviewed for hospitalization. This placed residents at risk for lack of knowledge regarding their choices and potential financial responsibilities. Findings include: Resident 73 was admitted to the facility in 9/2024 with diagnoses including complications of a foreign body accidentally left in the body following heart catheterization (a procedure that uses a catheter to diagnose and treat heart conditions). A review of Resident 73's health record revealed she/he was transferred to the hospital on 10/8/24. No evidence was found in Resident 73's health record to indicate a written bed hold policy with reserved bed payment was provided to the resident or their representative upon transferring to the hospital on 10/8/24. On 11/7/24 at 2:50 PM Staff 2 (Interim DNS) stated the charge nurse was supposed to provide a written bed hold policy with reserved bed payment to the resident upon transfer to the hospital. Staff 2 confirmed Resident 73 did not receive a written bed hold policy when she/he transferred to the hospital on 10/8/24.

Resident 73 was offered a copy of the bed hold policy with reserved bed payment information All residents sent to the hospital in the past 30 days were reviewed to ensure they received a bed hold policy. Licensed nurses were educated that residents going to acute care needed to be provided a copy of the bed hold policy with reserved bed payment information. DNS/Designee will review acute care transfers to ensure they were provided a copy of the bed hold policy with reserve bed payment weekly x 4 and monthly x2, or until compliance is achieved. Audits will be brought through QAPI for review

Based on interview and record review it was determined the facility failed to ensure physician orders were followed for 3 of 5 sampled residents (#s 8, 34 and 66) reviewed for unnecessary medications. This placed residents at risk for adverse medication consequences. Findings include: 1. Resident 34 was admitted to the facility in 3/2023 with diagnoses including major depression and diabetes. a. A 10/28/24 Physician Order indicated Resident 34 was prescribed clonidine (an anti-anxiety medication) one tablet every six hours as needed. Hold if systolic blood pressure (SBP-the maximum pressure in your blood vessels when your heart contracts and pumps blood) was less than 110. Resident 34's 10/2024 MAR indicated the resident received clonidine one time on 10/29/24, three times on 10/30/24 and one time on 10/31/24. A review of Resident 34's health record revealed no evidence the resident's blood pressure was assessed prior to administering clonidine. On 11/7/24 at 8:33 AM Staff 12 (LPN) reviewed Resident 34's MAR and stated the resident's SBP was not assessed prior to administering Resident 34's clonidine because the MAR was not set-up in a way staff would know to check the resident's blood pressure and hold the medication if the resident's SBP was less than 110. On 11/7/24 at 11:57 AM Staff 4 (LPN-Care Manager) confirmed there was no evidence staff assessed Resident 34's SBP prior to administering the resident's clonidine. b. An 8/1/24 Physician Order indicated Resident 34 was prescribed metoprolol succinate ER (to treat high blood pressure) to be given in the morning. Hold if systolic blood pressure (SBP-the maximum pressure in your blood vessels when your heart contracts and pumps blood) was less than 110 and/or heart rate (HR) was less than 55. Resident 34's 10/2024 MAR indicated the resident received metoprolol succinate ER on all days. A review of Resident 34's health record revealed no evidence the resident's blood pressure and heart rate were assessed prior to administering metoprolol succinate ER. On 11/7/24 at 8:33 AM Staff 12 (LPN) reviewed Resident 34's MAR and stated the resident's SBP and HR were not assessed prior to administering Resident 34's metoprolol because the MAR was not set-up in a way staff would know to check the resident's blood pressure and HR and hold the medication if SBP was less than 110 and HR was less than 55. On 11/7/24 at 11:57 AM Staff 4 (LPN-Care Manager) confirmed there was no evidence staff assessed Resident 34's SBP and HR prior to administering the resident's metoprolol. 2. Resident 66 was admitted to the facility in 10/2024 with diagnoses including major depressive disorder. a. A 10/8/24 Physician Order indicated Resident 66 was prescribed Clindamycin Phosphate External topical medication (a topical antibiotic) to be applied to affected area every morning and at bedtime. Resident 66's 10/2024 MAR indicated the resident's Clindamycin topical antibiotic was not applied according to physician orders on the following days: -10/9 AM; -10/17 PM. On 11/7/24 at 8:24 AM Staff 12 (LPN) stated on 10/9/24 she did not apply Resident 34's Clindamycin topical antibiotic because she was unable to locate the medication in the cart. On 11/7/24 at 11:21 AM Staff 4 (LPN-Care Manager) confirmed Resident 34's Clindamycin topical antibiotic was not provided on 10/9/24 and 10/17/24 and there was no documentation in the resident's health record as to why the medication was missed. b. A 10/8/24 Physician Order indicated Resident 66 was prescribed Diprolene External Ointment (for relief of redness, swelling, heat, inflammation and itching caused by skin problems) to be applied to affected areas in the morning and at bedtime. Resident 66's 10/2024 MAR indicated the resident's Diprolene was not applied according to physician orders on the following days: -10/9 AM; -10/11 AM. On 11/7/24 at 8:24 AM Staff 12 (LPN) stated on 10/9/24 she did not apply Resident 34's Diprolene External Ointment because she was unable to locate the medication in the cart. On 11/7/24 at 11:21 AM Staff 4 (LPN-Care Manager) confirmed Resident 66's Diprolene External Ointment was not provided on 10/9/24 and 10/11/24 and there was no documentation in the resident's health record as to why the medication was missed. c. A 10/11/24 Physician Order indicated Resident 66 was prescribed Protonix (treats gastric reflux and damage to the esophagus) one time a day. Resident 66's 10/2024 MAR indicated the resident's Protonix was not given according to physician orders on the following days: -10/12; -10/22; -10/25 and -10/26. On 11/7/24 at 8:24 AM Staff 12 (LPN) stated she did not know why Resident 66's Protonix was not administered. On 11/7/24 at 11:21 AM Staff 4 (LPN-Care Manager) confirmed Resident 66's Protonix was not administered on 10/12/24, 10/22/24, 10/25/24 and 10/26/24 and there was no documentation in the resident's health record as to why the medication was missed. Staff 4 stated Protonix was stored in the facility's Cubex (automated medication dispensing system) so the medication was available and should not have been missed. , 3. Resident 8 was admitted 8/2024 with diagnoses that included high blood pressure and sleep apnea. An 8/22/24 Physician Order indicated Resident 8 was prescribed Prozasin (a medication used for high blood pressure and treatment of nightmares) with instructions to hold the medication if the systolic blood pressure (SBP) was less that 110. Review of Resident 8's 10/2024 MAR revealed the resident's Prozasin was given outside of the physician's parameters on the following days: -10/11/24 SPB 103 -10/24/24 SBP 94 -10/30/24 SBP 104 -10/31/24 SBP 56 On 11/7/24 at 2:48 PM Staff 3 (RNCM) confirmed medication documentation indicated the medication was administered on the dates the systolic blood pressure was below 110. On 11/8/24 at 8:33 AM Staff 16 (CMA) confirmed medication documentation indicated the medication was administered on the dates the systolic blood pressure was below 110. On 11/8/24 at 11:03 AM Staff 2 (Interim DNS) notified of findings and no additional information was provided.

Resident 34’s provider was notified of the blood pressure not being taken before the meds were administered. The orders were updated to include checking the blood pressure before administration. Resident 66’s provider was notified of the missed administration of 3 medications. The RCM verified the medications were available and on the medication cart. Resident 8’s provider was notified of the medication administration error. The resident was assessed with no adverse findings. Other resident records were reviewed to look for missed medications, medications given outside of hold orders, and blood pressure medications that have hold orders that do not have indicate to take a blood pressure reading. All deficiencies were corrected. Licensed nurses were educated to ensure physician orders were followed as written, orders contain a blood pressure reading for medications with hold orders, and what to do if a medication is not available. DNS/Designee will complete random chart audits to ensure medications were administered as ordered and that orders with hold parameters have the indication for nurses to take necessary vital sign weekly x 4 and monthly x2 or until compliance is achieved. Audits will be brought through QAPI for review

Based on observation, interview, and record review it was determined the facility failed to assist in vision care needs for 1 of 1 sampled resident (#34) reviewed for vision. This placed residents at risk for impaired vision. Findings include: Resident 34 was admitted to the facility in 3/2023 with diagnoses including major depression and diabetes. A 12/27/23 Request for Medical Eye Care, resident authorization form, indicated Resident 34 consented to have a vision examination on 12/27/23. The 9/14/24 Quarterly MDS indicated Resident 34 had intact cognitive functioning and the resident wore glasses. A review of Resident 34's heath record revealed no evidence a vision examination was scheduled or completed. Observations from 11/5/24 through 11/7/24 between the hours of 10:14 AM and 9:01 PM revealed Resident 34 was not wearing glasses. On 11/5/24 at 9:23 AM, Resident 34 stated she/he was supposed to get glasses last year around Christmastime but nothing happened. Resident 34 stated she/he asked for an appointment several times but was yet to be scheduled for a vision examination. On 11/7/24 at 8:43 AM, Staff 2 (DNS) confirmed there was no evidence in Resident 34's health record that a vision examination was completed. Staff 2 stated the resident authorized to have a vision examination completed last December but the examination was never scheduled. On 11/7/24 at 8:47 AM, Staff 14 (Social Services Director) confirmed Resident 34 should have been scheduled for a vision examination but her/his examination "fell through the cracks" and was not completed.

Resident 34 was seem by the eye doctor and glasses are on order. All residents were reviewed for the need to see the eye doctor. They were all seen in the facility. Licensed nurses were educated to notify Social Services if a resident needs vision care. Social services were educated on ensuring necessary eye care is carried out for residents that need it. Social Services/Designee will do random resident interviews to ensure their vision care is satisfactory weekly x 4 and monthly x 2 or until compliance is achieved. Audits will be brought through QAPI for review

Based on interview and record review it was determined the facility failed to ensure residents who were trauma survivors received trauma-informed care for 1 of 1 sampled resident (# 39) reviewed for mood. This placed residents at risk for re-traumatization and decreased quality of life. Findings include: The facility's 8/2024 Trauma-Informed Care Policy and Procedure revealed the following: -Realize the prevalence of trauma: Through education and training of care staff, -Recognize how trauma affects individuals: Through education and identification of triggers, -Responding/putting knowledge into practice: Through development of resident-centered care planning, and -Resisting re-traumatization: Through avoiding identified triggers and making empathetic, reasonable modifications to the care approach and environment. Resident 39 was admitted to the facility in 7/2022 with diagnoses including Post-traumatic stress disorder (PTSD) and major depressive disorder. Resident 39's 7/25/22 Social Services Assessment revealed the resident was not assessed for her/his diagnosis of PTSD. Resident 39's 10/9/24 Quarterly MDS revealed the resident was able to make her/himself understood and understood others without difficulty. No evidence was found in Resident 39's clinical record to indicate an assessment of the resident's trauma was completed or a care plan was developed to address the resident's potential trauma triggers. On 11/5/24 at 3:14 PM Staff 14 (Social Services Director) stated resident trauma screenings were to be completed at the time of admission for all residents, especially those residents with a diagnosis of PTSD. On 11/5/24 at 3:42 PM Staff 4 (LPN Care Manager) acknowledged the findings of this investigation and stated Resident 39 should have had trauma informed screening completed.

Res 39 was assessed for the need for trauma informed care and her care plan was updated accordingly All resident charts were reviewed to ensure they have been assessed for the need for trauma informed care. Any deficiencies were corrected. Social services were educated on the need to assess all residents for the need for trauma informed care and to develop a care plan to assist with preventing re-traumatization Social services/Designee will audit random resident charts to ensure they were assessed for the need for trauma informed care weekly x4 and monthly x2 or until compliance is achieved. Audits will be brought through QAPI for review

Based on interview and record review it was determined the facility failed to ensure CNAs received annual performance reviews for 5 of 5 randomly selected CNA staff (#s 6, 7, 8, 9 and 10) reviewed for sufficient and competent staffing. This placed residents at risk for lack of care by competent staff. Findings include: A review of personnel records on 11/6/24 at 12:01 PM with Staff 23 (Human Resources/Payroll) indicated the following employees had not received their annual performance evaluations: -Staff 6 (CNA), hire date 9/17/15: no annual performance review was completed. -Staff 7 (CNA), hire date 9/16/14: no annual performance review was completed. -Staff 8 (CNA), hire date 9/15/17: no annual performance review was completed. -Staff 9 (CNA), hire date 8/1/08: no annual performance review was completed. -Staff 10 (CNA), hire date 6/24/14: no annual performance review was completed. On 11/6/24 at 12:01 PM Staff 23 confirmed annual performance reviews for Staff 6, Staff 7, Staff 8, Staff 9 and Staff 10 were not completed.

Employee’s 6,7,8,9 and 10 all received annual performance reviews Employee files were audited to ensure they had an annual performance review. All deficiencies were corrected DNS educated on ensuring all CNA’s receive an annual performance review HR/Designee will audit 5 files of CNAs to ensure employees receive an annual performance review weekly x 4 and monthly x2 or until compliance is achieved. Audits will be brought through QAPI for review

Based on observation and interviews it was determined the facility failed to ensure medications and biologicals were maintained within secured (locked) locations, accessible only to designated staff for 3 of 6 medication and treatment carts reviewed for safe medication storage. This placed residents at risk for unsafe access to medications and diversion of medication. Findings include: The facility's 1/2023 Storage of Medication Policy stated: "In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications (such as medication aides) are allowed access to medication carts. Medication rooms, cabinets and medications supplies should remain locked when not in use or attended by persons with authorized access." 1. On 11/6/24 at 1:38 PM a treatment cart was observed to be unlocked on Hall 1. The nurse was not in view of the cart. On 11/6/24 at 1:47 PM Staff 12 (LPN) confirmed the cart was unlocked. , 2. On 11/7/24 at 9:53 AM a medication cart was observed to be unlocked and unattended on Hall 3. On 11/7/24 at 9:57 AM Staff 32 (LPN) confirmed the cart containing perscription medications and inhalers was left unlocked and unattended. , 3. On 11/5/24 at 8:07 AM the treatment cart in Hall 1 was observed to be unlocked and unattended. Staff 19 (LPN) returned to cart within one minute. He explained the contents of the cart included wound treatment supplies, equipment for checking blood sugar levels, and residents' insulin (an injectable medication). He also confirm the treatment cart had been left unlocked and unattended. On 11/8/24 at 11:03 AM Staff 2 (Interim DNS) was notified of the findings. No additional information was provided. 4. On 11/6/24 at 8:55 PM the treatment cart and the Hall 1 medication cart were observed near the south entrance. The treatment cart was unlocked and the computer on the medication cart open to a resident's medical record. Both were unattended. At 9:00 PM Staff 17 (RN) confirmed the cart had been unlocked and the computer had been unsecured. On 11/8/24 at 11:03 AM Staff 2 (Interim DNS) was notified of the findings. No additional information was provided.

Treatment cart on hall 1 was locked and secured. Computer on hall 1 treatment cart was secured. Medication cart on hall 3 was locked and secured. All other carts and computers were checked to ensure they were locked and secured while unattended Licensed nurses were educated to ensure that computers, med carts, and treatment carts should be locked and secured while unattended DNS/Designee will randomly monitor computers, med carts, and treatment carts to ensure they are locked and secured while unattended weekly x 4 monthly x2 or until compliance is achieved. Audits will be brought through QAPI for review

Based on observation, interview and record review it was determined the facility failed to ensure the ice machine and ice machine scoop were cleaned adequately to maintain sanitary conditions in 1 of 1 kitchen reviewed for sanitary kitchen services. This placed residents at risk of foodborne illness. Findings include: 1. On 11/4/24 at 9:34 AM the ice machine adjacent to the kitchen was observed to have a pink/black substance on a plastic shield inside the machine. Condensation was observed dripping over the substance onto the ice. On 11/4/24 at 9:39 AM Staff 18 (Maintenance Director) stated the ice machine was cleaned every month. Staff 18 acknowledged the presence of the pink/black substance and confirmed the ice machine should be free of any debris or contaminants. On 11/4/24 at 9:58 AM Staff 1 (Administrator) acknowledged the existence of pink/black substance inside the ice machine and stated the ice machine needed to be cleaned. 2. On 11/4/24 at 9:34 AM the ice machine scoop located on the wall next to the ice machine was observed to be stored in a clear plastic container with a black substance and clear slime on the bottom of the container. On 11/4/24 at 9:49 AM Staff 18 (Maintenance Director) stated the ice machine scoop container needed to be cleaned and acknowledged the presence of a black substance and clear slime. On 11/4/24 at 9:58 AM Staff 1 (Administrator) acknowledged the existence of black substance and clear slime on the bottom of the ice scoop container and stated the container needed to be cleaned.

The ice machine adjacent to the kitchen was immediately placed out of service. The ice machine was replaced. The scoop and clear plastic container were cleaned and disinfected. There are no other ice machines in the building Education provided to dietary manager and maintenance director to ensure ice machines, ice scoop, and ice scoop container are on a cleaning schedule. Staff educated to notify maintenance or dietary if any concerns with cleanliness or malfunction of ice machine, scoop, or container the scoop is held in. Maintenance Director/designee will review ice machine, scoop, and container the scoop is held in for cleanliness 2x weekly for 2 weeks, weekly for 2 weeks, and monthly x2 or until compliance is achieved. Audits will be brought through QAPI for review.

Based on interview and record review it was determined the facility failed to ensure CNA staff received 12 hours of in-service training annually for 5 of 5 randomly selected staff members (#s 6, 7, 8, 9, and 10) reviewed for evidence of in-service training. This placed residents at risk for lack of quality care. Findings include: On 11/6/24 at 1:19 PM Staff 23 (Human Resources/Payroll) provided a list of annual training hours for CNA staff which revealed the following: -Staff 6 (CNA): 0 annual training hours; -Staff 7 (CNA): 8 annual training hours; -Staff 8 (CNA): 11 annual training hours; -Staff 9 (CNA): 0 annual training hours and -Staff 10 (CNA) 8 annual training hours. On 11/6/24 at 1:19 PM Staff 23 confirmed Staff 6, Staff 7, Staff 8, Staff 9 and Staff 10 did not complete the required 12 hours of annual in-service training. On 11/8/24 at 11:09 AM Staff 1 (Administrator) acknowledged CNA staff were required to have 12 hours of annual in-service training.

Staff 6, 7, 8, 9, 10 were scheduled their required in-services and notified to complete them Other staff were reviewed to ensure their 12 hours of in-services have been completed. Necessary trainings were scheduled and staff notified to complete them. CNAs educated on training site, how and when to complete trainings, and to notify DNS if they have any issues. DNS educated on required trainings and tracking to ensure that staff get them completed. DNS/Designee will audit random staff files to ensure required trainings are completed weekly x4 and monthly x2 or until compliance is achieved. Audits will be brought through QAPI for review.

******************** OAR 411-085-0310: Residents' Rights: Generally Refer to F552 ******************** OAR 411-087-0100: Physical Environment: Generally Refer to F584 ******************** OAR 411-085-0360: Abuse Refer to F600 and F609 ******************** OAR 411-088-0080: Notice Requirements Refer to F623 ******************** OAR 411-088-0050: Right to Return from Hospital Refer to F625 ******************** OAR 411-086-0110: Nursing Services: Resident Care Refer to F684 and F685 ******************** OAR 411-086-0240: Social Services Refer to F699 ******************** OAR 411-086-0310: Employee Orientation and In-Service Training Refer to F730 and F947 ******************** OAR 411-086-0260: Pharmaceutical Services Refer to F761 ******************** OAR 411-086-0250: Dietary Services Refer to F812 ********************

Based on observation, interview and record review it was determined the facility failed to ensure residents were appropriately supervised while smoking for 1 of 3 sampled residents (#106) reviewed for smoking safety. This placed residents at risk for injury from fire hazards. Findings include: The facility's Smoking Policy, revised 10/2023 stated residents who wished to smoke were evaluated for their ability to smoke safely. Residents who did not meet the safety criteria established by the facility to smoke independently were aided or supervised by facility staff during smoking activities. Resident 106 admitted to the facility in 2016, with diagnoses including diabetes mellitus and stroke. Resident 106's MDS Quarterly dated 7/11/24 revealed a BIMS score of 11, indicating the resident had moderate cognitive impairment. Resident 106's Smoking Safety Evaluation dated 8/14/24 revealed Resident 106 did not have adequate cognitive skills or memory recall, did not recognize designated smoking areas and could not identify proper smoking receptacles. The IDT decision stated "observations [of resident] having lighting materials in room, attempting to light cigarette, staff intervened. Conversation with [the resident], commented [she/he] didn't know that [she/he] couldn't smoke in [her/his] room. Due to above findings, [the resident] has been reassessed/changed to supervised smoker." On 10/2/24 at 2:57 PM, Resident 106 was observed in the courtyard smoking area and was smoking a lit cigarette. No designated staff were observed to be in the courtyard supervising the resident. Immediately after the observation was made, Staff 4 (LPN) , who was inside the building close to the smoking area, confirmed Resident 106 was seated in the smoking area. On 10/8/24 at 1:30 PM, Staff 1 (Administrator) and Staff 2 (DNS) were advised of the findings of the investigation and provided no additional information.

F 689 Free from Accident Hazards/Supervision/Devices (483.25) 1. Resident ID# 106 will have care plan reviewed and updated accordingly. Also, the DNS will reevaluate this resident and other dependent smokers for their ability or lack thereof to smoke. 2. Dependent resident smokers in the facility are at risk for this deficient practice. These residents will be educated on the facilitys smoking policy and procedure. Education will be extended to all residents in the facility who smoke. Discussion on the facilitys smoking policy and procedure will continue in the next resident council meeting. No other resident affected based on interviews 3. All staff, especially nurses and CNAs will be reeducated on the facilitys smoking policy starting 10/21/24.Administrator or Designee will include education on the facilitys smoking policy in the next monthly all staff meeting. New hires will also be educated on the smoking policy and procedures upon hire. All residents who smoke will be provided with storage for smoking materials and these will be kept in the smoking area and or front nurses station under the care of staff. 4. Administrator/designee will conduct an audit in the rooms of all residents who smoke to make sure that no cigarette or smoking material(s) is kept in residents room. This will occur weekly for 3 weeks, and then monthly for the next 2 months, and will continue until compliance is achieved. Results of room audits will be discussed weekly in the morning clinical meeting and monthly in the monthly QAPI meetings for review and recommendations as determined by the committee or until substantial compliance has been achieved.

********************************* OAR 411-086-0350: Smoking Refer to F689 *********************************

Based on interview and record review it was determined the facility failed to ensure residents were free from misappropriation of property for 1 of 2 sampled residents (# 106) reviewed for misappropriation. This placed residents at risk for loss of property. Findings include: Resident 106 was admitted to the facility in 2022 with diagnoses including chronic kidney disease and heart failure. Resident 106's MDS Quarterly dated 5/7/24 revealed she/he was cognitively intact with a BIMS score of 15. The facility submitted a report to the state agency on 5/30/23 which stated Resident 106 had loaned Staff 4 (Former CNA) money and the facility started an investigation which included suspending Staff 4. On 5/30/24 at 12:48 PM, Resident 106 confirmed she/he loaned Staff 4 money on several occasions prior to May 2023 and Staff 4 had paid back the money. Resident 106 stated in May 2023 she/he loaned Staff 4 $700.00 for new tires and was not paid back. Staff 4 was unable to be interviewed due to no longer working at the facility. On 6/6/24 at 11:00 AM, Staff 1 (Administrator) and Staff 2 (DNS) were informed of the findings of misappropriation of Resident 106's property and provided no additional information.

F 602 Free from Misappropriation/Exploitation (483.12) 1. Resident ID# 106’ will have her care plan reviewed and updated accordingly. Also, the Administrator would review the facility’s investigation Reporting and Protection Policy by 6/12/2024. 2. Residents that reside in the facility are at risk for this deficient practice. Reeducation was provided to residents about gift giving and offering money to employees is prohibited, was provided to residents at Resident Council. No other resident affected based on interviews 3. All staff will be reeducated on Abuse investigation reporting and protection policy with emphasis on misappropriation starting on 6/12/2024. DON/Designee will continue yearly education for staff on abuse, misappropriation policy. All new hires will receive education on Abuse, misappropriation policy upon hire. 4. Administrator/designee will conduct an audit of all risk mgmt. grievances or reports of abuse, misappropriation to determine if proper procedures, timely investigation, documentation and reporting are followed to ensure that no resident reports of abuse, misappropriation are missed, and policy and procedures are followed for residents' protection. This will occur weekly for 3 weeks, and then monthly for the next 2 months, and will continue until compliance is achieved. Results of audits will be brought to the QAPI committee for review and recommendations as determined by the committee or until substantial compliance has been achieved.

************************************** OAR 411-085-0360: Abuse Refer to F602

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 11/06/2023 and 11/12/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on observation and interview it was determined the facility failed to maintain a safe, clean and homelike environment on 4 of 4 resident halls and 1 of 1 resident outside courtyard patio reviewed for environment. This placed residents at risk for tripping and living in an unkept and unhomelike environment. Findings include: Observations of the facility's outside resident courtyard patio and resident rooms from 7/25/23 through 7/28/23 found the following issues: -Numerous deep cracks, lifted and uneven cement surfaces and areas of missing cement were observed on the resident courtyard patio which posed a tripping hazard. Multiple residents were observed utilizing the outside courtyard patio on a frequent basis. -Room 103 had a hole in the wall, chipped paint on the walls, the flooring in front of the window was cracked and non-skid strips in front of the toilet were lifted and peeling which were a tripping hazard. Urine was observed on the far wall to the left of the toilet, a wash cloth with a yellow and brown substance was draped over the garbage container in the bathroom and soiled gloves were on the bathroom floor. -Rooms 108, 127, 130, 137, 138 and 139 had multiple scrapes on the walls ranging from small to large scrapes and areas on the walls that required patching and painting. -Room 109 had an area of missing tile on the floor, a ceiling stain, a fist sized hole in the wall, scraped walls and areas on the walls which required painting. -Room 112's window was stained and dirty. -Room 125 had large scrapes on the wall by the window and the resident reported there were ants frequently on the window pane near her/his bed and belongings. -Room 143 had holes in the ceiling and the ceiling was stained. On 7/28/23 at 9:05 AM Staff 4 (Maintenance Director) stated he completed monthly inspections of the walls and ceilings in residents' rooms. During a walk-through of the facility and the resident outside courtyard, Staff 4 acknowledged the needed repairs in the identified resident rooms. Staff 4 reported prior to his hiring the facility hired a painter but they left before the painting was finished. Staff 4 confirmed the resident outside courtyard patio had multiple areas that were a tripping hazard. Staff 4 stated he previously spoke to a contractor regarding repairing the patio but the cost was too much so he wanted other contractors to provide bids. Staff 4 acknowledged multiple residents used the courtyard on a daily basis and nothing was currently in place to warn residents of the various areas identified as tripping hazards. 7/28/23 at 9:36 AM Staff 6 (Director of Operations) acknowledged the resident courtyard patio had multiple areas that required repair and were tripping hazards for the residents.

Resident courtyard patio was repaired or scheduled for repair. Room 103 had walls repaired and painted where needed, floor repaired, and bathroom cleaned. Rooms 108, 127, 130, 137, 138 and 139 had walls repaired and painted where needed. Room 112 window was cleaned. Room 125 had wall repaired and painted where needed and ant problem addressed. Room 143 had ceiling repaired and painted where needed. Other resident rooms will be reviewed to ensure that walls are in good repair and painted where needed, that floors are in good repair where needed and bathrooms cleaned. Maintenance will be re-educated to complete room checks to ensure walls and ceilings are in good repair. Housekeeping will be re-educated on ensuring bathrooms are kept clean. Random audits of resident rooms/bathrooms by the Administrator/Designee to ensure walls and ceilings are in good repair and bathrooms are kept clean will be conducted weekly X2 and monthly X2 and will continue until compliance is achieved. The outcomes will be reported at QAPI for review and recommendations as determined by the committee or until substantial compliance has been achieved.

Based on interview and record review it was determined the facility failed to develop and implement care plans for 1 of 2 sampled residents (#18) reviewed for hospitalization. This placed residents at risk for unmet needs. Findings include: Resident 18 admitted to the facility in 2022 with diagnoses including schizoaffective disorder (a mood disorder) and anxiety disorder. The 6/12/23 Quarterly MDS indicated Resident 18 was cognitively intact and was not exhibiting behaviors at that time. A closed care plan from a prior admission to the facility dated 5/11/22 indicated Resident 18 had a history of expressing suicidal ideations in an attempt to be admitted to the hospital. The closed care plan also included extensive resident centered interventions for identified behaviors. Resident 18's current care plan reviewed on 7/30/23 did not include a history of expressing suicidal ideations identified on the 5/11/22 closed care plan, specific behaviors, nor interventions to manage these behaviors. Resident 18's Kardex (bedside care plan for providing direct resident care) reviewed on 7/30/23 indicated Resident 18 was a good historian of her/his behaviors. No information about what the behaviors were or how to respond appropriately to them was included. On 7/31/23 at 9:34 AM Staff 7 (RNCM), Staff 9 (LPN), Staff 10 (RNCM) confirmed Resident 18 had significant behaviors in the past and was managed well on the current medication regimen. Staff 7, Staff 9, and Staff 10 all confirmed Resident 18's behaviors and interventions should be on the current care plan and accessible to all staff providing care.

Resident #18’s current plan of care was updated with specific behaviors and interventions to manage the behaviors. Other residents with behaviors will be reviewed to ensure an appropriate care plan is in place to monitor behaviors and with interventions to respond to the behaviors. Licensed nurses and IDT will be educated to put a care plan in place for residents who have behaviors that includes specific behavior and interventions to respond to the behavior. Random audits by the DNS or Designee of residents with behaviors will be conducted weekly x2 and monthly x2 and will continue until compliance is achieved. The results of the audits will be reported at QAPI for review and recommendations as determined by the committee or until substantial compliance has been achieved.

Based on interview and record review it was determined the facility failed to follow physician orders for 1 of 5 sampled residents (#4) reviewed for unnecessary medications. This placed residents at risk for adverse medication consequences. Findings include: Resident 4 was admitted to the facility in 2018 with diagnoses including diabetes and chronic kidney disease requiring dialysis. 1. A 6/13/23 and revised 7/10/23 physician order indicated Resident 4 was prescribed lispro insulin (a rapid acting insulin that lowers blood glucose) before meals. A review of Resident 4's 7/1/23 through 7/26/23 DAR (diabetic administration record) indicated the resident's lispro insulin was not administered according to physician orders on the following days: -7/4 lunch dose missed; -7/6 lunch dose missed; -7/8 lunch dose missed; -7/11 lunch dose missed; -7/15 lunch dose missed; -7/18 lunch dose missed; -7/20 lunch dose missed; -7/22 lunch dose missed; -7/23 lunch dose missed. On 7/27/23 at 11:07 AM Staff 7 (RNCM) reviewed Resident 4's lispro insulin DAR and stated the resident's lispro insulin should have been administered on the dates identified. 2. A 5/19/23 physician order indicated Resident 4 was prescribed gabapentin (to treat nerve pain) every morning and bedtime and to hold all doses of gabapentin on skipped dialysis days. A review of Resident 4's 7/1/23 through 7/27/23 MAR indicated the resident was not administered gabapentin according to physician orders on the following days: -7/1 morning dose missed; -7/2 morning dose missed; -7/3 morning dose missed; -7/5 morning dose missed; -7/7 morning dose missed; -7/10 morning dose missed; -7/12 morning dose missed; -7/16 morning dose missed; -7/17 morning dose missed; -7/19 morning dose missed; -7/24 morning dose missed. A review of Resident 4's health care record indicated the only day the resident skipped dialysis was on 7/25/23. On 7/27/23 at 11:07 AM Staff 7 (RNCM) reviewed Resident 4's gabapentin MAR and stated the resident's gabapentin should have been administered on the dates identified. 3. A 5/18/23 physician order indicated Resident 4 was prescribed lactulose (to reduce ammonia in the blood) three times a day every Tuesday, Thursday and Saturday. A review of Resident 4's 7/1/23 through 7/26/23 MAR indicated the resident's lactulose was not administered according to physician orders on the following days: -7/4 mid-day dose missed; -7/8 mid-day dose missed; -7/11 mid-day dose missed; -7/15 mid-day dose missed; -7/18 mid-day dose missed; -7/22 mid-day dose missed; On 7/27/23 at 11:07 AM Staff 7 (RNCM) reviewed Resident 4's lactulose MAR and stated the resident's lactulose should have been administered on the dates identified. 4. A 5/17/23 physician order indicated Resident 4 was prescribed lanthanum carbonate (to treat excessive phosphate in the blood) three times a day with meals. A review of Resident 4's 7/1/23 through 7/26/23 MAR indicated the resident's lanthanum carbonate was not administered according to physician orders on the following days: -7/4 mid-day dose missed; -7/6 mid-day dose missed; -7/8 mid-day dose missed; -7/11 mid-day dose missed; -7/15 mid-day dose missed; -7/18 mid-day dose missed; -7/22 mid-day dose missed; -7/23 mid-day dose missed; On 7/27/23 at 11:07 AM Staff 7 (RNCM) reviewed Resident 4's lanthanum carbonate MAR and stated the resident's lanthanum carbonate should have been administered on the dates identified. 5. A 5/17/23 physician order indicated Resident 4 was prescribed sevelamer carbonate (used to lower blood phosphate levels when on dialysis) three times a day with meals. A review of Resident 4's 7/1/23 through 7/26/23 MAR indicated the resident's sevelamer carbonate was not administered according to physician orders on the following days: -7/4 lunch dose missed; -7/6 lunch dose missed; -7/8 lunch dose missed; -7/11 lunch dose missed; -7/13 lunch dose missed; -7/15 lunch dose missed; -7/18 lunch dose missed; -7/20 lunch dose missed; -7/22 lunch dose missed. On 7/27/23 at 11:07 AM Staff 7 (RNCM) reviewed Resident 4's sevelamer MAR and stated the resident's sevelamer should have been administered on the dates identified. 6. A 5/16/23 physician order indicated Resident 4 was prescribed Tums (to reduce heartburn) three times a day. A review of Resident 4's 7/1/23 through 7/26/23 MAR indicated the resident's Tums was not administered according to physician orders on the following days: -7/4 mid-day dose missed; -7/6 mid-day dose missed; -7/8 mid-day dose missed; -7/11 mid-day dose missed; -7/15 mid-day dose missed; -7/18 mid-day dose missed; -7/20 mid-day dose missed; -7/22 mid-day dose missed. On 7/27/23 at 11:07 AM Staff 7 (RNCM) reviewed Resident 4's Tums MAR and stated the resident's Tums should have been administered on the dates identified. 7. A 7/21/23 to 7/25/23 physician order indicated Resident 4 was prescribed metoprolol (to treat high blood pressure) two times a day. A review of Resident 4's 7/1/23 through 7/25/23 MAR indicated the resident's metoprolol was not administered according to physician orders on the following days: -7/22 morning and evening dose missed. On 7/27/23 at 11:07 AM Staff 7 (RNCM) reviewed Resident 4's metoprolol MAR and stated the resident's metoprolol should have been administered on the dates identified.

Resident #4’s orders were reviewed with the MD and resident to ensure times of medications were scheduled around dialysis. Other residents that leave the facility for dialysis will be reviewed for medication times and updated as indicated. Licensed nurses will be educated on dialysis policy and procedure and MD notification when medications are missed or need to be rescheduled. Random audits by the DNS/Designee of residents for medication times around dialysis days and times will be conducted weekly x2 and monthly x2 and will continue until compliance is achieved. The outcomes will be reported at QAPI for review and recommendations as determined by the committee or until substantial compliance has been achieved.

Based on interview and record review it was determined the facility failed to accurately assess and provide or offer pressure ulcer wound care for 1 of 2 sampled residents (#117) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers or delayed healing. Findings include: Resident 117 was readmitted to the facility in 2022 with diagnoses including malnutrition. On 12/13/22 at 10:47 AM Witness 1 (Complainant) stated Resident 117 reported the facility should have done more to prevent the resident's pressure ulcers from worsening. Resident 117's Progress Notes from 8/1/22 through 12/12/22 revealed extensive documentation of the resident's refusals of care including pressure ulcer treatment and pressure off-loading. The notes also included frequent education provided to the resident regarding the risks of refusing treatments and off-loading. Resident 117's 9/2022 TAR revealed the resident had wound treatments ordered for pressure ulcers to the left and right buttocks three times per week. The TAR indicated wound care was completed three times out of thirteen opportunities for the right buttock and four out of thirteen opportunities for the left buttock. For both wounds the TAR documented "Other/See Progress Notes" three times, "Drug Refused" once, "OOF [out of facility] without Meds" twice, no documentation four times for the right buttock and no documentation three times for the left buttock. Resident 117's 9/2022 Progress Notes and TAR revealed a lack of documentation to indicate either why wound care was not provided, if the treatments were rescheduled or if the resident was reapproached at a later time. Resident 117's 9/2022 "SNF Skin - Wound" assessments revealed inaccurate labeling, description and wound bed characterization of the left buttock wound and inaccurate labeling, staging and wound bed characterization of the right buttock wound. On 7/28/23 at 11:11 AM Staff 1 (Administrator), Staff 3 (RN Consultant) and Staff 6 (Regional Director of Operations) agreed in 9/2022 wound care was not provided as ordered, wound assessments were not accurate and documentation was lacking regarding rescheduling wound care or reapproaching the resident.

Resident 117 discharged from the facility. Other residents with pressure ulcers were reviewed to ensure that appropriate treatments were in place and appropriate documentation was completed. Licensed nurses will be educated to complete wound treatments as ordered, reapproach the resident at a later time if they refuse a treatment, and ensure appropriate documentation and notifications when a resident continues to refuse. Licensed nurses will be educated on appropriate wound assessments and documentation. Random audits by the DNS/Designee of residents with pressure wounds will be conducted weekly x2 and monthly x2 and will continue until compliance is achieved. The results of audits will be reported at QAPI for review and recommendations as determined by the committee or until substantial compliance has been achieved.

Based on observation, interview and record review it was determined the facility failed to ensure smoking care plan interventions were followed and smoking materials were stored in a safe manner for 3 of 3 residents (#s 11, 14 and 33) reviewed for smoking. This placed residents at risk for burns and smoking related accidents. Findings include: The facility's Smoking Policy and Procedure for Independent smokers, last revised 3/2020, indicated the following: -The smoking policy was communicated to the resident prior to or upon admission to the center. -Residents who were safe to smoke independently and safely manage their smoking materials were allowed to do so in a manner that was safe according to the assessment. -Residents who did not adhere to smoking policies were subject to additional interventions and safety measures, including but not limited to, revocation of their ability to smoke while a resident at the center and discharge from the center. 1. Resident 11 was admitted to the facility in 2022 with diagnoses including COPD (a lung disease causing breathing problems) and chronic kidney disease. Resident 11's 5/3/23 Smoking Safety Evaluation indicated the resident was able to smoke independently and knew how to properly store smoking materials. On 7/26/23 at 9:49 AM and 7/27/23 at 12:43 PM Resident 11 was observed with unsecured smoking materials in her/his room. On 7/27/23 at 9:15 AM Staff 8 (Activities Director) stated residents determined to be able to smoke independently were provided outside lockboxes to store their smoking materials. Staff 8 stated smoking materials were to be secured at all times. Staff 8 and surveyor observed Resident 11's lockbox and determined the lockbox was empty though Resident 11 was asleep in her/his room. On 7/27/23 at 12:43 PM Resident 11 stated she/he had an outside lockbox but she/he did not take the time to use it and kept her/his smoking materials unsecured in her/his room. On 7/27/23 at 1:44 PM Staff 1 (Administrator) stated Resident 11 had unsecured smoking materials in her/his room and all smoking materials needed to be secured. 2. Resident 14 was admitted to the facility in 2016 with diagnoses including multiple sclerosis (a progressive disease of the brain and spinal cord). Resident 14's 6/30/23 Smoking Safety Evaluation indicated the resident was able to smoke independently and knew how to properly store smoking materials. . On 7/25/23 at 2:11 PM and 7/27/23 at 9:25 AM Resident 14 was observed with unsecured smoking materials in her/his room. On 7/25/23 at 2:11 PM Resident 14 stated she/he kept her/his smoking materials in a bag on the back of her/his wheelchair. Smoking materials were also observed in jars lined up on Resident 14's bed. On 7/27/23 at 9:15 AM Staff 8 (Activities Director) stated residents determined to be able to smoke independently were provided outside lockboxes to store their smoking materials. Staff 8 stated smoking materials were to be secured at all times. Staff 8 and surveyor observed Resident 14's lockbox and determined the lockbox was empty and Resident 14 was in bed. On 7/27/23 at 9:38 AM Staff 1 (Administrator) confirmed Resident 14 had unsecured smoking materials in her/his room and all smoking materials needed to be secured. , 3. Resident 33 was admitted to the facility in 2021 with diagnoses including vascular dementia with behavioral disturbance and general weakness. A 7/19/23 provider progress note revealed Resident 33 was at risk for injury when handling cigarettes as she/he often forgot she/he was holding a cigarette and had been known to burn her/his clothes. One-on-one supervision was required when the resident was smoking. A list of residents who smoked was provided by facility on 7/25/23 and indicated Resident 33 required supervision while smoking. The Kardex (bed side care plan used for direct resident care) reviewed on 7/27/23 included Resident 33 required a smoking apron while smoking and supervision at all times. Resident 33's Smoking Safety Evaluation completed on 7/26/23 determined the resident always required a smoking vest and supervision while smoking. On 7/27/23 at 10:33 AM Resident 33 was observed through the south east courtyard door window with a lit cigarette in her/his hand and was not wearing a smoking apron with other residents, including Resident 6. No burn marks were observed on Resident 33 clothes. There were no staff observed within line of sight of the resident who was smoking without an apron. Resident 6 went back inside facility and reported Resident 33 dropped ash on her/his fleece pajama pants and did not have staff assistance. Resident 6 reported Staff 15 (CNA) was on her phone and not paying attention to Resident 33. On 7/28/23 at 1:22 PM Staff 9 (LPN) confirmed staff were expected to be physically present with residents for supervision needs not just "eyes-on" supervision. Staff 9 confirmed the protocol for residents who refused a smoking apron was to notify a nurse or manager for support. On 7/28/23 at 2:28 PM Staff 15 (CNA) confirmed she was the staff member outside in the smoking area on 7/28/23 with Resident 33. Staff 15 reported Resident 33 became upset when offered a smoking apron and refused to wear it. Staff 15 confirmed she proceeded to light a cigarette for Resident 33 anyway and did not notify a nurse or manager as instructed. On 7/31/23 at 9:51 AM Staff 6 (Director of Operations) who was present during the incident on 7/27/23 at 10:36 AM confirmed Resident 33 was not wearing a smoking apron while smoking. He also confirmed all smoking-related instructions were found readily on the Kardex.

Resident 11 and Resident 14’s smoking materials were secured in a lock box. Both were re-educated that smoking materials must be kept in a secured lock box. Resident 33 will not be given a lit cigarette if she refuses to wear a smoking apron. Staff supervising her will keep her in the line of site while she smokes. Residents who smoke will be reviewed to ensure their smoking materials are locked up and they are following recommended safety interventions. Residents who smoke will be re-educated on the smoking policy and safety protocols. Staff who supervise residents while smoking will be educated on safety protocols and how to respond if a resident refuses. Staff will also be educated to actively supervise residents who need assistance, at all times, while they are out smoking. Random audits by the Administrator/Designee will be conducted to ensure smoking materials are locked up and proper safety interventions are being followed weekly x2 and monthly x2 and will continue until compliance is achieved. The outcomes will be reported at QAPI for review and recommendations as determined by the committee or until substantial compliance has been achieved.

Based on interview and record review it was determined the facility failed to ensure gradual dose reductions (GDRs) were attempted for residents on psychotropic medications for 1 of 5 sampled residents (#18) reviewed for unnecessary medications. This placed residents at risk for adverse medication consequences. Findings include: Resident 18 admitted to the facility in 2022 with diagnoses including schizoaffective disorder (mood disorder) and anxiety disorder. The 6/12/23 Quarterly MDS indicated Resident 18 was cognitively intact. Resident 18's current active physician orders indicated the following: - Zyprexa (antipsychotic) 20mg by mouth at bedtime. Order last updated 10/17/22 - Invega (antipsychotic) 3mg extended release one time a day. Order last updated 10/17/22 - Sertraline (antidepressant) 150mg one time a day. Order last updated 9/3/2022 A review of Resident 18's clinical record from 9/2022 through 7/2023 revealed no documentation to support or rationalize gradual dose reductions not being attempted. On 7/31/23 at 10:08 AM Staff 7 (RNCM), Staff 9 (LPN), Staff 10 (RNCM) confirmed the facility did not pursue obtaining GDR due to Resident 18's stability on the current medications. Staff 7, Staff 9, and Staff 10 believed Resident 18's physicians had provided adequate rationale for declination of a GDR but were unable to produce the documentation of physician rationale for not attempting GDRs.

Residents 18’s physician does not wish to pursue a GDR of the psychotropic medications and will document adequate rationale for the declination. Other residents on psychotropic medications will be reviewed to ensure a GDR has been attempted or the appropriate adequate rationale is documented by the physician. IDT will be educated on the psychotropic medications policy including GDR recommendations and appropriate documentation needed for adequate rationale by the physician for declinations of a GDR. Random residents on psychotropic medications will be reviewed by the DNS/Designee for the need of a GDR or appropriate documentation of declination by a physician weekly x2 and monthly x2 and will continue until compliance is achieved. The outcomes will be reported at QAPI for review and recommendations as determined by the committee or until substantial compliance has been achieved.

Based on observation and interview it was determined the facility failed to follow appropriate hand hygiene while preparing and serving food for 1 of 1 kitchen reviewed. This placed residents at risk for cross contamination and foodborne illness. Findings include: On 7/27/23 at 11:39 AM during the kitchen inspection, Staff 14 (Dietary Aid) was observed touching a kitchen door and handle. The door was white in color with numerous dark brown markings on front and back. Afterwards Staff 14 resumed preparing trays. Staff 14 did not change his gloves and perform hand hygiene. On 7/28/23 between 11:31 AM and 12:08 PM Staff 14 was observed with gloved hands touching a white kitchen door with numerous dark brown markings on front and back, cart handles, refrigerator handles, his clothing, facemask and silverware during lunch food service without changing his gloves and performing hand hygiene. On 7/28/23 between 11:31 AM and 11:50 AM Staff 13 (Cook) and Staff 14 were wearing facemasks pulled down below their noses. Staff 13 and Staff 14 touched their facemasks to adjust them with their gloved hands and did not change their gloves and perform hand hygiene. On 7/28/23 between 11:31 AM and 12:50 PM Staff 13 was wearing gloves and touched a microwave door handle, steam table scoops, her facemask and silverware while plating food from the steam table without changing her gloves and performing hand hygiene. On 7/28/23 at 11:49 AM Staff 16 (Dietary Manager) confirmed it was her expectation all kitchen staff should perform routine hand-hygiene whenever they left the food prep area or touched potentially contaminated surfaces.

Staff 13 and 14 were educated on hand hygiene. Kitchen staff will be monitored to ensure that proper hand hygiene is being performed. Kitchen staff will be re-educated on hand hygiene. Random audits will be conducted on kitchen staff hand hygiene weekly X2 and monthly X2 and will continue until compliance is achieved. The outcomes will be reported at QAPI for review and recommendations as determined by the committee or until substantial compliance has been achieved.

Based on interview and record review it was determined the facility failed to meet the minimum required CNA staffing ratio on 11 of 53 days reviewed for staffing. This placed residents at risk for unmet care needs. Findings include: A review of the Direct Care Staff Daily Reports from 6/1/23 through 7/24/23 revealed the following days when the state minimum required CNA staffing ratios were not met for one or more shifts: 6/2/23 census 74. day shift - 10 CNA's on duty (11 required) 6/4/23 census 71. day shift - 7 CNA's on duty (11 required) 6/9/23 census 71. day shift - 10 CNA's on duty (11 required) 6/12/23 census 69. day shift - 8 CNA's on duty (10 required) 6/18/23 census 72. day shift - 10 CNA's on duty (11 required) 6/19/23 census 73. day shift- 10 CNA's on duty (11 required) 6/23/23 census 72. day shift 10 CNA's on duty (11 required) 7/3/23 census 68. day shift - 9 CNA's on duty (10 required) 7/7/23 census 71. day shift - 9 CNA's on duty (11 required) 7/10/23 census 70. day shift - 8 CNA's on duty (10 required) 7/18/23 census 69. day shift - 9 CNA's on duty (10 required) On 7/28/23 at 1:54 PM Staff 5 (Staffing Coordinator) and Staff 1 (Administrator) acknowledged not all staff show up as scheduled and that sometimes they cannot fill the shift.

No Residents were identified as being affected. The Administrator and Staffing Coordinator reviewed last week of staffing for compliance, identifying and addressing trends and/or concerns. The Administrator or Designee reeducated staffing coordinator on CNA Staffing ratios, including NA to CNA ratio not exceeding 25%. Facility will utilize our emergency staffing plan when there is a possibility of falling under the mandated staffing ratio. The Administrator or Designee will audit staffing for OR CNA Staffing ratio compliance weekly x 2 weeks, then monthly x2 months to ensure compliance. The outcomes will be reported at QAPI for review and recommendations as determined by the committee or until substantial compliance has been achieved.

************* 411-087-0100 Physical Environment: Generally Refer to F584 ************* 411-086-0060 Comprehensive Assessment and Care Plan Refer to F656 ************* 411-086-0110 Nursing Services: Resident Care Refer to F684 ************* 411-086-0140 Nursing Services: Problem Resolution and Preventive Care Refer to F686 and F758 ************* 411-086-0350 Smoking Refer to F689 ************* 411-086-0250 Dietary Services Refer to F812 *************

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

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 06/05/2023 and 06/11/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on interview and record review it was determined the facility failed to provide colostomy care for 1 of 1 resident (#301) reviewed for colostomy care. This placed residents at risk of unmet care needs. Findings include: Resident 301 was admitted to the facility in 9/2022 with diagnoses including hemiplegia (loss of function of one half of the body) and cognitive impairment. Hospital discharge orders from 9/28/22 indicated Resident 301 had colostomy bag used for digestive drainage. The Documentation Survey Report v2 from 10/2022 included instructions for Resident 301's colostomy bag to be emptied every shift. Review of this report revealed Resident 301's colostomy bag was not emptied from 10/1/22 until 10/7/22. Review of additional facility records from 10/2022 revealed no indication Resident 301's colostomy bag was maintained until 10/7/22. On 6/1/23 at 10:30 AM Staff 3 (RCM-LPN) stated Resident 301 arrived to the facility with a colostomy bag which was to be emptied at least every shift. Staff 3 confirmed Resident 301's records indicated Resident 301 did not receive appropriate colostomy bag care.

F 691- Colostomy, urostomy, or Ileostomy care What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice Resident 301 has orders in place to ensure colostomy bag is emptied every shift. " How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. All residents with a colostomy, were audited to ensure orders were in place to empty the bag " What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur; and, Nurses will be educated to ensure that orders are put in place upon admission or at the time a colostomy bag is placed. New residents with a colostomy, will be reviewed in MACC meeting to ensure proper care orders are in place. " How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur, i.e., what program will be put into place to monitor the continued effectiveness of the systemic change. Residents with a colostomy, will be audited for compliance weekly x4 and monthly x2 or until compliance is achieved. " Dates when corrective action will be completed. 6/27/23

Based on interview and record review it was determined the facility failed to follow infection control isolation practices for 1 of 3 residents (#301) reviewed for infection control practices. This placed residents at risk for exposure to COVID-19 infection. Findings include: Resident 302 was readmitted to the facility in 8/2022 with diagnoses of end stage renal disease (kidney failure). Resident 301 was admitted to the facility in 9/2022 with diagnoses including hemiplegia (paralysis of half of the body). Resident 302's SNF Resident Infection Report from 11/21/22 revealed Resident 302 was determined to have tested positive for COVID-19 with the onset date documented as 11/20/22. Review of the facility's Daily Census Logs from 11/20/22 and 11/21/22 revealed Resident 301 and Resident 302 were in a shared room. These logs also revealed Room 108 was unoccupied and available to be used on 11/20/22 and 11/21/22. Review of Resident 301's record revealed no room change occurred in 11/2022 when Resident 302 was determined to be positive for COVID-19. On 6/1/23 at 10:07 AM Staff 4 (Infection Preventionist) stated the facility's COVID-19 infection control policy included the following: when a resident showed signs or symptoms or tested positive for COVID-19 in a shared room, one resident was to be moved to single room if available to decrease the risk a resident contracting COVID-19. On 6/1/23 at 10:30 AM Staff 3 (RCM-LPN) confirmed Resident 301 should have been moved to Room 108 to reduce risk of exposure to COVID-19.

F 880- Infection Prevention and Control What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice The resident is not currently exposed to any other resident with Covid 19 " How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. All residents reviewed, no residents have Covid 19 currently. " What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur; and, Infection preventionist, IDT team and licensed nurses will be educated to move room mates of covid positive residents when a room is available. " How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur, i.e., what program will be put into place to monitor the continued effectiveness of the systemic change. New Covid positive residents will be reviewed to ensure room mates were moved timely when able weekly x4 and monthly x2 until compliance is achieved. " Dates when corrective action will be completed. 6/27/23

************************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F-691 ************************** OAR 411-086-0330 Infection Control and Universal Precautions Refern to F-880 **************************

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 05/22/2023 and 05/28/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 04/24/2023 and 04/30/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on interview and record review it was determined the facility failed to perform a safe discharge for 1 of 3 sampled residents (#401) reviewed for unsafe discharges. This placed residents at risk for unmet needs upon discharge. Findings include: Resident 401 was admitted to the facility in 5/2022 with diagnoses including morbid obesity. Resident 401's BIMS assessment from 11/2022 indicated normal cognitive function. Resident 401's medication orders from 11/28/22 instructed 7.5 mg of oxycodone to be provided every six hours as needed for pain. Review of medication administration records from 12/1/2022 through 12/17/2022 indicated Resident 401 experienced moderate to severe pain and requested oxycodone to decrease pain levels for 12 of 17 days reviewed. Resident 401's discharge orders from 12/17/22 indicated Resident 401 was to discharge from the facility with current medications, including oxycodone. A progress note from 12/17/2022 indicated Resident 401 was discharged from the facility. Review of Resident 401's Narcotic Book record from 12/2022 revealed Resident 401 had 15 remaining 5 mg tablets of oxycodone upon discharge. On 1/3/23 at 10:48 AM Resident 401 stated she/he discharged from the facility on 12/17/22 without her/his remaining oxycodone medication to assist with pain management. Resident 401 stated she/he experienced pain in her/his back at six of ten continuously with increases to nine out of ten after she/he transitioned home. On 1/4/23 at 10:26 AM and 11:47 AM Staff 3 (Resident Care Manager) confirmed Resident 401 was discharged from the facility without her/his oxycodone medication.

F660 Discharge Planning Process What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident #401 discharged from the facility on 12/17/22. Resident #401 returned to the facility on 12/29/22 • How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. Residents who are discharging will be reviewed during the MACC process. RCM’s will follow up with the nurses to ensure prescribed medications are sent home with the resident. • What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur; and, All licensed nurses will be in-serviced on discharge process and sending medications home with resident. • How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur, i.e., what program will be put into place to monitor the continued effectiveness of the systemic change. To ensure on-going compliance the DNS/designee will complete audits to validate this process. These audits will be weekly x 3 weeks, monthly x 2 months with results reported to the Quality Assurance Committee overseen by the Administrator. If a threshold of 95% is not achieved, an action plan will be developed to ensure compliance.

*************** OAR 411-086-0060 Comprehensive Assessment and Care Plan Refer to F660 ***************

Based on interview and record review it was determined the facility failed to ensure a safe discharge for 1 of 3 sampled residents (#22) reviewed for discharge. This placed residents at risk for an unsafe discharge. Findings include: Resident 22 was admitted to the facility in 1/2022 with diagnoses including stroke, chronic pain syndrome, diabetes and depression. Resident 22's 5/17/22 Discharge MDS indicated no score for her/his BIMS as she/he was rarely or never understood with moderate memory impairment. Staff 5 (SSD) wrote a progress note on 2/3/22 which revealed Witness 2 (Resident's friend) called and discussed Resident 22's discharge plan. Resident 22's 3/21/22 Physical Therapy Treatment Encounter Note(s) by Staff 4 (Physical Therapy Assistant) indicated she provided caregiver training to a potential caregiver for bed mobility activities to increase functional skills, to roll, scoot, bridge (arch back) to facilitate bed mobility and transfer from bed to wheelchair. She instructed the potential care giver if the resident fell to use a gait belt with two people or call the fire department. No additional documentation was found to indicate additional care giver training. A 5/16/22 progress note indicated Resident 22 would need wound care due to a pressure ulcer on her/his coccyx. A 5/17/22 progress note by Staff 3 (RN) revealed he had Resident 22 sign all the necessary paperwork to discharge. He gave the resident medications, a glucometer and supplies to check her/his blood sugar. The resident left the facility in a wheelchair. The 5/17/22 progress note by Staff 3 did not indicate any wound care supplies were provided for Resident 22 at discharge. On 5/17/22 Resident 22 discharged to Witness 1's (Resident's Friend) home. Record review from 4/13/22 to 5/17/22 revealed no caregiver training for Witness 1. On 9/13/22 at 2:26 PM Witness 1 stated she met with a person one time briefly to talk about Resident 22's discharge to her home. Witness 1 was not told about a pressure ulcer prior to discharge, was not taught how to care for the resident, and she was shocked by the level of care Resident 22 required. Witness 1 stated she never provided wound care while the resident stayed at her home. On 9/15/22 at 1:15 PM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged they expected caregiver training be completed prior to discharge and documented in the resident's medical record. Staff 2 confirmed Resident 22 readmitted to the facility about a week later and the coccyx pressure ulcer did not worsen.

Menlo POC F660 1) Resident 22 returned to Facility with wound improvements and no harm from discharge process. 2) Discharge process was reviewed and updated to ensure all aspects of safe discharge process are met. 3) Social Service Department has been inservice by PCI Social Worker on Discharge Process and Safe Discharge documentation and to order all supplies. RCMS have been inserviced by DNS on proper discharge process and to provide oversight to floor nurses on all discharges, to educate caregivers and provide oversight to ensure all proper medications and supplies are sent home DNS has inserviced all LN on ensuring proper discharge and all education and supplies are sent. 4) All discharges will be audited by DNS or designee during MACC process for the next month, and random audits will be conducted on discharges for three months afterward until substantial compliance is attained. Findings reported to QAPI for oversight and compliance. Administrator and DNS will be responsible for monitoring of this POC.

*************** OAR 411-086-0060 Comprehensive Assessment and Care Plan Refer to F660 ***************

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 03/07/2022 and 03/13/2022, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on interview and record review it was determined the facility failed to ensure residents were free from physical abuse for 1 of 7 sampled residents (#28) reviewed for abuse. This failure resulted in Resident 28 sustaining a broken jaw, which required surgery and necessitated a diet texture modification, after the resident was struck by another resident. Findings include: Resident 28 admitted to the facility in 3/2021 with diagnoses including malnutrition. Resident 28's 4/1/21 care plan indicated the resident required extensive assistance with ambulation, bathing, bed mobility, dressing, grooming, toileting, and transferring. Resident 28's 7/8/21 Quarterly MDS indicated the resident was 65 years old, 67 inches tall and weighed 140 pounds. Resident 18 admitted to the facility in 5/2021 with diagnoses including respiratory failure. Resident 18's 8/15/21 Quarterly MDS indicated the resident was 42 years old, 70 inches tall and weighed 225 pounds. Resident 18's care plan, updated 9/5/21, indicated the resident was independent with ambulation, bathing, bed mobility, dressing, grooming, toileting and transferring. Facility investigative documents for an incident on 10/7/21 indicated Residents 18 and 28 were in a verbal altercation with Staff 41 (CNA) present in the room. Staff 41 left to get help and then nursing staff heard Resident 18 yell out for assistance because Resident 28 was "not doing well." Staff 26 (LPN) found Resident 28 slumped back in her/his wheelchair, bleeding and unresponsive. Resident 28 told staff she/he struck Resident 18. Resident 28 was sent to the Emergency Department and was diagnosed with a broken mandible (jaw). Police responded to the facility and arrested Resident 18. The facility determined Resident 18 physically abused Resident 28. A 10/7/21 hospital note indicated Resident 28 was "punched in the jaw" and diagnosed with a left mandible fracture, dislocation and intracranial bleed. The note indicated Resident 28 was referred for necessary surgical repair and was ordered to have a puree diet for six weeks. No evidence was found in Resident 28's medical record to indicate the resident experienced sustained emotional distress. Attempts to contact Resident 18 on 2/14/22 and 2/15/22 were unsuccessful. On 2/15/22 at 9:42 AM Staff 31 (Social Services) stated Resident 28's baseline behaviors did not change after the incident. On 2/15/22 at 9:53 AM Staff 41 stated the two residents were arguing about taking a shower when she left the room to get a blanket for one of the residents. Within seconds of leaving the room she heard the nurse call for help. Staff 41 saw Resident 18 standing outside the room and saw Resident 28 bleeding, confused and looking "very bad." Staff 41 stated Resident 18 admitted to striking Resident 28. On 2/15/22 at 10:18 AM Staff 26 stated Resident 18 told him Resident 28 needed help. Staff 26 found Resident 28 tilted back in a wheelchair, unresponsive, bleeding, not breathing and with her/his legs up in the air. Staff 26 put the resident's wheelchair back on the ground and the resident began breathing again. Staff 26 stated Resident 18 admitted to striking Resident 28. Staff 26 said Resident 18 "hit a disabled, elderly [resident] in a wheelchair who weighed half [her/his] weight." During interviews with Staff 3 (DNS) and Staff 40 (Regional Director of Operations) from 2/15/22 through 2/17/22 the staff stated the facility investigated the incident and concluded Resident 18 physically abused Resident 28. Facility nursing staff and administrative staff were inserviced regarding abuse policies and procedures after the incident, and no additional instances of abuse were identified since the 10/7/21 incident. This incident was determined to be past noncompliance based on corrective measures put in place by the facility after the incident. As a result of the incident on 10/7/21 the facility instituted the following: - A complete investigation related to the 10/7/21 incident. - In-service trainings from 10/11/21 through 11/1/21 for nursing staff related to abuse definitions, as well as abuse incident policies and procedures. - In-service trainings from 10/11/21 through 11/1/21 for administrative staff related to abuse incident reporting, investigations and documentation. No evidence was found to indicate additional abuse incidents occurred after 10/7/21. The facility was determined to be back in compliance with this regulation as of 11/1/21.

Based on interview and record review the facility failed to follow wound care orders for 1 of 3 sampled residents (#2) reviewed for wound care. This placed residents at risk for worsening wounds and infection. Findings include: Resident 2 was admitted to the facility in 11/2019 with diagnoses including a right above knee amputation. On 4/14/21 the resident was seen by a wound care specialist and new wound care orders for the resident's non-healing left lower leg wound were provided. The resident was to be evaluated by a vascular surgeon due to a non-healing arterial ulcer. At a 4/21/21 wound care specialist appointment a wound care order indicated a continued recommendation for Resident 2 to see a vascular surgeon. The April 2021 physician orders, care plan, progress notes and TAR had no documentation to indicate an appointment with the vascular surgeon was made. On 2/10/22 at 10:30 AM Staff 29 (LPN, former LPN Resident Care Manager) confirmed no appointment was made for Resident 2 to see the vascular specialist. Staff 29 stated the facility should have ensured a vascular appointment was scheduled prior to the resident's discharge on 5/6/21.

F684 1. Resident #2 has discharged from this facility. 2. United Wound Healing reports for residents being seen by their clinician will be reviewed to ensure that any recommendations noted have been initiated. 3. RCMs will be educated on review and implementation of UWH recommendations each week following completion of wound rounds. 4. DON or designee will audit UWH reports to validate that new orders/recommendations have been initiated weekly for four weeks and then every other week until compliance met. Results of audits will be reviewed at monthly QAPI and issues addressed as needed. 5. DON is responsible for overall compliance. 6. Date of compliance: April 1 2022

The findings of the complaint health revisit survey conducted on 04/18/22 are documented in this report. The facility was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.

Based on interview and record review it was determined the facility failed to ensure the resident environment was free from accident hazards and failed to ensure residents received appropriate supervision and assistance to prevent accidents for 3 of 7 sampled residents (#s 9, 17 and 25) reviewed for accidents. This placed residents at risk for injury and elopement. Findings include: 1. Resident 17 was admitted to the facility in 7/2021 with diagnoses including stroke, aftercare for a cranioplasty (a surgery repair of the skull) and paralysis of one side of the body. Resident 17's Admission MDS dated 7/23/21 indicated the resident required extensive assistance with transferring and had unknown cognitive loss and the inability to speak. Resident 17's care plan at the time of the incident (9/13/21) indicated the resident was independent for ambulation but required two people and a lift for transferring. The care plan instructed staff to monitor adaptive devices for safe use. Progress notes dated 9/13/21 indicated Staff 29 (LPN) was called into Resident 17's room on 9/13/21. Staff 29 found the resident's transfer pole came loose from the ceiling and struck the resident on the right side of her/his face/temple. The resident was assessed and there were no signs/symptoms to warrant being sent to the hospital until a few hours later when the resident had episodes of vomiting. The resident was then sent to the emergency department. Hospital notes dated 9/13/21 reported Resident 17 was struck on the right side of her/his head when a transfer pole dislodged and fell on the resident. The notes reported no significant change in vital signs, cognition, level of consciousness and no neurological deficits. Imaging results indicated no injury and no complications. The facility's incident investigation dated 9/13/21 revealed Resident 17's transfer pole came loose from the ceiling and fell on the resident. The incident was unwitnessed. The investigation concluded the accident was due to equipment failure. On 2/3/22 at 11:56 AM Staff 12 (Maintenance) stated the transfer pole in Resident 17's room was not tightened enough to the ceiling, came loose and fell onto the resident. He stated prior to the accident no one had reported the pole was loose and there was no documentation regarding monitoring of the pole. On 2/15/22 at 12:43 PM Staff 2 (Interim Administrator) confirmed the transfer pole failed and there was no documentation of any inspections prior to the pole failing. , 2. Resident 9 admitted to the facility in 6/2021 with diagnoses including left leg amputation and presence of an artificial hip joint on the right side. The resident's 6/8/21 care plan indicated two staff were to assist Resident 9 with transfers from bed using a portable total body lift. A progress note dated 6/8/21 indicated Resident 9 was sent to the emergency department after the resident's hip became displaced during a staff-assisted transfer from her/his bed to a commode. The resident returned to the facility on the same day with new orders for hip precautions. A facility incident report dated 6/8/21 indicated Staff 24 (CNA), Staff 27 (CNA), and Staff 28 (RN) transferred the Resident 9 from bed with a sit-to-stand lift (portable lift intended for residents with some mobility but who need help to rise from a sitting position), which was contrary to Resident 9's care plan. During the transfer the resident heard a pop and reported her/his hip was displaced. During interviews on 2/3/22 with Staff 24, Staff 27 and Staff 28 the staff indicated they were aware that Resident 9 was care planned for a total body lift, but a sit-to-stand lift was used on 6/8/21 at the resident's request. On 2/4/22 at 12:25 PM Staff 3 (DNS) stated Resident 9 was noncompliant with precautions related to her/his hip and the resident's hip became displaced frequently. Staff 3 acknowledged Resident 9's hip became displaced when staff used the wrong lift to transfer the resident. 3. Resident 25 admitted on 9/24/21 with diagnoses including encephalopathy (a disease affecting brain function). The facility's policy for Elopement/Wandering, revised 3/2020, included the following: "Elopement occurs when a resident leaves the premises... without authorization and/or necessary supervision to do so. "13. In the case of actual missing person or elopement, the following procedures are followed: c. ...Document the factual account of occurrence in the progress notes and initiate the Elopement Log of Events. f. Coordinate emergency team for vehicle and foot wearch. l. Have staff member knock on every door... within a 2-3 block radius. s. Call to notify state reporting agency. "14. Upon return to the center, the licensed nurse completes the following: a. The licensed nurse completes a head to toe physical exam and documents results in the medical record. c. Document the factual account of the occurrence in progress notes. d. Complete new Elopement Risk Evaluation. e. Complete Incident Report f. Complete Elopement Log of Events." A 10/2/21 at 3:18 AM progress note written by Staff 28 (RN) indicated Resident 25 was identifed as missing at approximately 8:00 PM. Staff searched the area and contacted law enforcement to report the resident was missing. Law enforcement called and notified the facility that the resident was at a local hospital and would return to the facility. A 10/2/21 at 6:08 AM progress note written by Staff 28 indicated Resident 25 returned to the facility at 5:58 AM from the hospital with no new orders. No factual account of occurrence, Incident Report, Elopement Log, state reporting agency notification, updated Elopement Risk Evaluation, or evidence of physical exam was found in the resident's clinical records or the facility records. On 2/18/22 at 11:04 AM Staff 28 stated he was unable to recall the events related to Resident 25's elopement on 10/2/21. Staff 28 stated he did not remember any facility staff interviewing him regarding what occurred. On 2/18/22 at 11:35 AM Staff 10 (LPN Resident Care Manager) stated the facility did not complete an updated Elopement Risk Evaluation after the 10/2/21 elopement. Staff 10 acknowledged there was no evidence to indicate the facility's policies related to elopement were followed.

F689 1. Residents #9 and #25 have discharged from this facility. Resident # 17 transfer pole was replaced and stability verified by Maintenance Director. 2. Maintenance Director will conduct rounds to verify that all transfer poles are safely installed and stable. Resident care plans and Kardex will be reviewed to verify that method of transfer is correct for resident current status. Stock of Hoyer slings will be audited and additional slings obtained as needed including slings for use when toileting. Resident records will be reviewed for Elopement Risk Evaluations and completed if needed. Residents who are found to be at risk for elopement will have care plan review and Elopement Book checked for resident information. Care plans and Elopement Book will be updated as needed. 3. Maintenance Director will complete scheduled rounds to check equipment for safety issues and make repairs as needed. Staff will be retrained on reporting equipment problems to Maintenance Director for repair. CNAs will be retrained on following resident care plan, and appropriate steps to take when resident does not want to follow care plan, including reporting to LN for care concerns and RCMs for re-evaluation and care plan update. Staff will be retrained on location of Elopement Book, use of Elopement Log of Events in case of actual elopement, completion of Risk Management (Incident) report including physical exam of resident, FRI reporting of elopement, and reporting of residents showing risk for elopement to DON/RCMs for assessment and care planning. 4. Administrator will audit documentation of scheduled equipment rounds and completion of maintenance requests weekly for one month, then twice weekly until compliance met. DON, RCMs or designee will complete observations of resident care to verify that transfers are completed per resident care plan twice weekly for four weeks, then once a week until compliance met. Staff will be re-educated during rounds as needed. Newly admitted resident records will be reviewed by RCMs to verify that Elopement Risk Assessment is complete and that those identified as at risk for elopement have appropriate follow-up. Audit of any actual elopement events will be completed to verify that all steps of policy are followed. Results of audits will be brought to QAPI meeting monthly and issues addressed as needed. 5. Administrator and DON are responsible for overall compliance. 6. Date of Compliance: April 1 2022

, The findings of the complaint health revisit survey conducted on 04/18/22 are documented in this report. The facility was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.

Based on interview and record review it was determined the facility failed to administer pain medications for 1 of 4 sampled residents (#23) reviewed for pain. This placed residents at risk for unrelieved pain. Findings include: Resident 23 admitted to the facility on 9/2021 with diagnoses including amputation and chronic pain syndrome. A physician order dated 9/29/21 indicated Resident 23 was to receive 5 mg of Oxycodone three times a day for pain and 100 mg of Pregabalin (nerve pain medication) three times a day for pain related to diabetic neuropathy. Resident 23's 11/2021 MAR indicated the resident did not receive Oxycodone on 11/6/21 due to the medication being unavailable. A 11/29/21 Grievance Communication Form revealed Resident 23 identified a concern about running out of medication on 11/6/21. The facility stated Oxycodone (narcotic pain medication) was unavailable for one day, and a new prescription was received on 11/7/21. Resident 23's 12/2021 MAR indicated the resident did not receive Pregabalin on 12/27/21 due to the medication being unavailable. In an interview on 2/3/22 at 11:00 AM Staff 3 (DNS) and Staff 13 (RNCM) confirmed Resident 23 did not receive Oxycodone and Pregabalin due to the medication not being reordered timely. In an interview on 2/4/22 at 3:00 PM Staff 26 (LPN) stated the facility had issues with medications running out due to staff not reordering the medications timely.

F697 1. Resident #23 has discharged from this facility. 2. Resident records will be reviewed to identify concerns related to pain medication supply and any issues addressed. 3. LNs will be retrained on timely reordering of medications and reporting of difficulties getting medications to DON/RCMs for follow-up. 4. Medication doses not given will be reviewed by DON/RCMs during the morning clinical meeting via the PCC dashboard to identify any concerns related to lack of supply. Supply concerns will be addressed with LN staff and Pharmacy as appropriate. This will be an ongoing process. 5. DON is responsible for overall compliance. 6. Compliance Date: April 1 2022

The findings of the complaint health revisit survey conducted on 04/18/22 are documented in this report. The facility was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.

Based on interview and record review it was determined the facility failed to provide diagnostic services to meet resident needs for 1 of 2 sampled residents (#15) reviewed for diagnostic services. This failure placed residents at risk for undiagnosed needs. Findings include: Resident 15 admitted to the facility in 8/2021 with diagnoses including cancer. A 8/26/21 diet order indicated Resident 15 was to receive a low carbohydrate dinner on 8/26/21, no breakfast on 8/27/21, and was to be NPO (no food or drink by mouth except for medication) after 6:00 AM on 8/27/21 in order to prepare for a medical procedure. The 8/2021 MAR indicated Resident 15 was to be NPO after 6:00 AM on 8/27/21 to prepare the resident for a PET scan (imaging test). The MAR indicated the resident received 237 ml of a liquid supplement at 8:00 AM on 8/27/21. Resident 15's meal record for 8/27/21 indicated the resident ate 26-50% of her/his breakfast on 8/27/21. Hospital records dated 8/27/21 indicate Resident 15 was unable to receive the PET scan because the resident ate food that morning. During interviews with Staff 1 (Administrator), Staff 10 (LPN Resident Care Manager), and Staff 35 (Regional Support Nurse) from 2/8/22 through 2/10/22 the staff acknowledged the records indicated Resident 15 was not to receive food or drink on 8/27/21, but received both food and drink and was not able to complete the imaging tests.

F776 1. Resident #15 has discharged from this facility. 2. Resident records will be reviewed to verify that diagnostic tests ordered by Provider have been completed, results reported to Provider and notification and follow-up orders documented. 3. LNs will be retrained on entering diagnostic test orders including any necessary preparation needed and scheduling of tests, notification of Provider when results are received, and documentation of notification and follow-up in resident progress notes. 4. Resident records will be audited by DONs/RCMs or designee to verify that diagnostic testing ordered was completed and results reported to Provider when received. Audits will be completed weekly for four weeks and every two weeks until compliance met. Results of audits will be brought to QAPI meeting monthly and issues addressed as needed. 5. DON is responsible for overall compliance. 6. Compliance Date: April 1 2022

The findings of the complaint health revisit survey conducted on 04/18/22 are documented in this report. The facility was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.

Based on interview and record review it was determined the facility failed to notify the ordering physician of the results of an ordered x-ray for 1 of 7 sampled residents (#4) reviewed for accidents. This placed residents at risk for delayed treatment and unidentified injuries. Findings include: Resident 4 was admitted to the facility in 8/2014 with diagnoses including congestive heart failure and chronic pain. A 10/23/20 at 2:45 PM a radiology report indicated the physician ordered an x-ray of Resident 4's left leg due to complaints of knee pain after a fall. The report revealed acute fractures of the distal femur and proximal fibula. A 10/27/20 late entry progress note by Staff 29 (LPN/former LPN Resident Care Manager) documented the physician was notified of the x-ray results on 10/26/20 and the physician ordered the resident to be transferred to the hospital. On 2/18/22 at 2:07 PM Staff 29 stated the x-ray results were delivered via fax on 10/23/20 but not reviewed by any nursing staff or reported to the physician until 10/26/20.

F777 1. Resident #4 has discharged from this facility. 2. Resident records will be reviewed to verify that diagnostic tests ordered by Provider have been completed, results reported to Provider and notification and follow-up orders documented. 3. LNs will be retrained on entering diagnostic test orders including any necessary preparation needed and scheduling of tests, notification of Provider when results are received, and documentation of notification and follow-up in resident progress notes. 4. Resident records will be audited by DONs/RCMs or designee to verify that diagnostic testing ordered was completed and results reported to Provider when received. Audits will be completed weekly for four weeks and every two weeks until compliance met. Results of audits will be brought to QAPI meeting monthly and issues addressed as needed. 5. DON is responsible for overall compliance. 6. Compliance Date: April 1 2022

The findings of the complaint health revisit survey conducted on 04/18/22 are documented in this report. The facility was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.

Based on interview and record review it was determined the facility failed to ensure resident medical records were complete for 2 of 7 sampled residents (#s 15 and 19) reviewed for diagnostic services and change of condition. This placed residents at risk for unidentified care needs. Findings include: 1. Resident 19 admitted to the facility in 9/2021 with diagnoses including hypertension. Resident 19's blood pressure record indicated a reading of 193/87 (hypertensive crisis) on 10/9/21 at 8:12 PM and 8:13 PM. A progress note dated 10/10/21 at 2:34 AM indicated Resident 19 returned to the facility from the hospital via emergency medical transport at 2:25 AM after the resident's blood pressure stabilized from 210/98 to 150/72. No information related to an assessment of the resident's condition or what caused the resident to be sent to the hospital was found in the resident's medical record. On 2/10/22 at 12:39 PM Staff 10 (LPN Resident Care Manager) acknowledged there was no information in Resident 19's medical record regarding the resident's need for emergent medical attention on 10/10/21. 2. Resident 15 admitted to the facility in 8/2021 with diagnoses including cancer. A 8/26/21 diet order indicated Resident 15 was to receive a low carbohydrate dinner on 8/26/21, no breakfast on 8/27/21, and was to be NPO (no food or drink by mouth except for medication) after 6:00 AM on 8/27/21 in order to prepare for a medical procedure. The 8/2021 MAR indicated Resident 15 was to be NPO after 6:00 AM on 8/27/21 to prepare the resident for a PET scan (imaging test). No physician's order was found in the resident's medical record regarding the PET scan or the NPO order. On 2/10/22 at 12:35 PM Staff 10 (LPN Resident Care Manager) stated she did not know where the order for the PET scan and NPO came from as there was a lack of documentation.

F842 1. Residents #19 and #15 have discharged from this facility. 2. Resident records will be reviewed to verify that those sent to the ED have a progress note documenting the change in condition and transfer to the hospital. Resident records will be reviewed to verify that diagnostic tests ordered by Provider have been completed, results reported to Provider and notification and follow-up orders documented. 3. LNs will be retrained on identifying changes in condition, and documentation of response to COD including assessment, Provider notification and ED transfers. LNs will be retrained on entering diagnostic test orders including any necessary preparation needed and scheduling of tests, notification of Provider when results are received, and documentation of notification and follow-up in resident progress notes. 4. Resident records will be audited by DONs/RCMs or designee to verify that diagnostic testing ordered was completed and results reported to Provider when received. Audits will be completed weekly for four weeks and every two weeks until compliance met. Results of audits will be brought to QAPI meeting monthly and issues addressed as needed. 5. DON is responsible for overall compliance. 6. Compliance Date: April 1 2022

The findings of the complaint health revisit survey conducted on 04/18/22 are documented in this report. The facility was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.

****************************** OAR 411-085-0360 Abuse Refer to F600 ****************************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F684 and F697 ****************************** OAR 411-086-0140 Nursing Services: Problem Resolution & Preventive Care Refer to F689 ****************************** OAR 411-086-0010 Administrator Refer to F776 ****************************** OAR 411-086-0200 Nursing Services: Notification Refer to F777 ****************************** OAR 411-086-0300 Clinical Records Refer to F842 ******************************

The findings of the complaint revisit health survey conducted on 04/18/22 are documented in this report. The facility was found to be in substantial compliance with OAR 411 - 85 through 89.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 11/22/2021 and 11/28/2021, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on interview and record review it was determined the facility failed to thoroughly and accurately complete the Direct Care Staff Daily Report (DCSDR) for 35 of 35 days reviewed for staffing. This placed all residents and the public at risk for lack of accurate staffing information. The Direct Care Staff Daily Reports for 8/24/21 through 9/27/21 revealed the facility failed to provide correct CNA counts and hours worked on all days reviewed and failed to provide the correct census on the following days: 8/29/21, 8/30/21, 8/31/21, 9/2/21, 9/3/21, 9/5/21, 9/6/21, 9/7/21, 9/8/21, 9/11/21, 9/13/21, 9/14/21, 9/15/21, 9/16/21, 9/17/21, 9/18/21, 9/19/21, 9/20/21, 9/21/21, 9/22/21, 9/23/21, 9/24/21 and 9/25/21. In an interview on 9/28/21/21 at 4:20 PM PM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged the failure to provide correct CNA counts, CNA hours and census.

M180 Nursing Services: Daily Staff Public Posting Corrective Action(s) for residents identified to have been affected. No resident identified to be potentially affected. Identified of residents with the potential to be affected. No resident identified to be affected. Measured to prevent recurrence: Staffing coordinator will ensure daily staff public posting is accurate with the C.N.A count and census. Monitor for Corrective Action: The Administrator or designee will audit daily for 4 weeks and weekly for 4 weeks to monitor accurate public posting. Issues will be reviewed during the monthly QAPI meeting and a Performance Improvement Plan will be developed as necessary.

Based on interview and record review it was determined the facility failed to ensure state minimum CNA staffing ratios were maintained for 8 of 35 days and the use of Personal Care Assistance (PCAs) and Nursing Assistants (NAs) did not exceed more than 25% of the CNA staffing ratios on 17 of 35 days reviewed for staffing. This placed residents at risk for delayed treatment and unmet care needs. Findings include: Per Oregon Administrative Rule (OAR) 411-086-0100 (temporary rule), the facility was required to have one CNA for every 8.5 residents during day shift, one CNA for every 12 residents during evening shift, and one CNA for every 18 residents during night shift. Facilities were allowed to utilize PCAs, NAs, OTs and PTs in meeting no more than 25% of the CNA staffing ratio. From 8/24/21 through 9/27/21, the facility utilized PCAs and NAs. A review of the Direct Care Staff Daily Reports (DCSDRs) from 8/24/21 through 9/27/21 revealed the following days when state minimum CNA staffing ratios were not met. 8/25/21-night shift. 8/28/21-evening shift. 8/29/21-night shift. 9/4/21-day shift. 9/6/21-day shift. 9/12/21-day shift. 9/18/21-evening shift. 9/21/21-night shift. A review of the DCSDRs from 8/24/21 through 9/27/21 revealed the following days when the facility's use of PCAs and NAs exceeded the 25% maximum ratio. 8/24/21-evening shift (40%). 8/28/21-day (33%) and evening shifts (40%). 8/29/21-day (44%) and evening shifts (33%). 8/30/21-day shift (33%). 9/1/21-evening shift (33%). 9/2/21-evening shift (33%). 9/4/21-evening shift (50%). 9/5/21-day shift (33%). 9/9/21-evening shift (50%). 9/10/21-evening shift (33%). 9/11/21-evening shift (33%). 9/12/21-evening shift (33%). 9/13/21-evening shift (33%). 9/17/21- evening shift (33%). 9/18/21-evening shift (60%). 9/24/21-evening shift (33%). 9/25/21-evening shift (33%). On 9/29/21 at 4:20 PM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged the failure to meet state minimum CNA staffing ratios and confirmed the facility exceeded the 25% maximum ratio of PCA and NA utilization.

M183 Minimum CNA Staffing Corrective Action(s) for residents identified to have been affected. No Residents Cited. Identified of residents with the potential to be affected The Administrator or Designee re-educated the Staffing Coordinator, Leadership Team and Charge nurses on the requirement that uncertified nursing aids cannot be more than 25% of the total aids on duty. Measured to prevent recurrence: The Administrator or Designee will audit staffing within morning stand up for uncertified nursing aids being no more than 25% of total aids compliance daily x 2 weeks then weekly x 3 weeks. Monitor for Corrective Action: The Administrator or Designee will report the results of these audits at the facility monthly Quality Assurance meeting for 60 days or until substantial compliance has been achieved or sustained as determined by the committee.