Porthaven Post Acute

An undated facility Resident Council Policy indicated the following: -A Resident Council Response Form will be utilized to track issues and their resolution.-á The facility department related to any issues will be responsible for addressing the item(s) of concern. -á -The Quality Assurance and Performance Improvement (QAPI) Committee will review information and feedback from the Resident Council as part of their quality review.-á -á -Issues documented on council response forms may be referred to the QAPI Committee, if applicable (i.e., the issue is of serious nature or if there is a pattern, etc.). -á A review of the 1/2025 through 11/2025 grievance book revealed that there were no grievances submitted by the Resident Council.-á A review of the Resident Council Minutes from 8/2025 through 11/2025 revealed multiple concerns including but not limited to call light wait times, lack of adequate CNAs on the floor, language barrier and dietary concerns brought up from the resident council which included old and new business. No evidence was found concerns or grievances were addressed. During the 12/3/25 2:30 PM interview with the Resident Council members, seven of the twelve residents in attendance (#s11, 15, 21, 30, 44, 52, and 82) stated concerns and suggestions brought up during Resident Council were not followed up or addressed by the facility beyond talking to the department head. On 12/4/25 at 8:47 AM, Staff 14 (Activity Director) stated, she spoke at Resident Council regarding old business to see if the residentsGÇÖ view had changed or there were changes with the concerns. Staff 14 stated she brought the resident councilGÇÖs concerns and suggestions to the administrator who would go to each department head to speak to them to come up with a plan.-á-á On 12/5/25 at 1:57 PM Staff 1 (Administrator) stated concerns from Resident Council were separated, and Staff 15 (Social Services Director) managed grievances. Staff 14 was responsible for documenting concerns, notifying relevant departments, following up on outcomes, and reporting back to the Resident Council. Staff 1 acknowledged the need for a more effective process to address concerns and emphasized the importance of timely communication and updates to the Resident Council and completion of timely grievances. -á On 12/5/25 1:57 PM Staff 15 stated grievances from Resident Council were on a separate form, and she did not receive any grievances from Staff 14 or Resident Council. She stated Staff 14 followed up on Resident Council grievances and was a separate process.-á-áShe stated Staff 14 followed up on the Resident Council grievances with a separate process that did not go through the social services department.-á-á

The facility immediately implemented a standardized Resident Council Response & Tracking Process to ensure all concerns and grievances raised by the Resident Council are documented, addressed, and formally responded to in writing. This has been done by implementing a resident council response form/grievance form which allows each concern raised for prompt response and assigned to a responsible department head with a due date. Resident 11, 21, 30, 44, 52, and 82 notified of the new resident council response form and process for follow up with resident council concerns/grievances (Resident 15 not found on sample list provided). Residents who participate in resident council have been provided with a copy of the new resident council response form. Education has been provided to resident council/Activities Director on the newly implemented resident council response form and process of addressing concerns. Administrator/designee will monitor. Administrator/Designee will review resident council grievances for appropriate follow up monthly until compliance is achieved.  Results of audit will be reviewed in QAPI.

The facilityGÇÖs policy titled Cleaning and Disinfection Environment Surfaces, adopted on 8/1/24 indicated the following: Policy: Environmental surfaces are cleaned and disinfected according to CDC recommendations for disinfection of healthcare facilities and the OSHA Bloodborne Pathogens Standard.-á-áA one-step process and an EPA-registered hospital disinfectant designed for housekeeping purposes is used in resident care areas where: a. uncertainty exists about the nature of the soil on the surfaces (e.g., blood or body fluid contamination versus routine dust or dirt) or b. uncertainty exists about the presence of multi-drug-resistant organisms on such surfaces. Resident 11 admitted to the facility on 6/4/25 for atherosclerosis of the left lower leg with ulceration and right above knee amputation.-á The MDS dated 9/15/25 revealed Resident 11's BIMS score was 15, which indicated she/he was cognitively intact. The resident was independent with toilet hygiene and toilet transfers. In an interview with Resident 11 on 12/2/25 9:18 AM she/he stated the communal toilet/shower rooms smelled and often had feces on the toilet seats. Resident 11 stated she/he used multiple communal toilet and shower rooms for toileting and showering. Random observations of communal toilet/shower rooms from 12/2/25 through 12/5/25 revealed the following: *12/2/25 at 10:58 AM a CNA placed a shower chair in the communal shower room across from room 127 and room 129. Brown material was on the inside edge of the toilet. and a strong urine odor. A crumpled-up paper towel was under the shower chair with bits of paper just outside the shower mat. Multiple staff were in and out of the communal shower without cleaning the area. *12/2/25 at 11:10 AM the communal shower across from room 134 had a reclining shower chair with an approximately one-inch smear of brown material on the seat and crevasses where the commode basin would fit. *12/3/25 at 9:16 AM through 9:36 AM the communal shower across from room 134 had the same reclining shower chair and the brown material was still on the seat and crevasses. The reclining chair was moved by Staff 18 (CNA) but she did not clean the chair after usage with another resident and the brown material remained. *12/3/25 at 9:46 AM Staff 18 pushed a resident out of the communal shower room across from room 134 in a shower chair. The shower room door was left open and unclean, with saturated towels, washcloths and brown material on the shower room floor and matted hair on the grab bar. A sign was posted in the shower area which indicated after each shower provided to residents not to leave towels or clothes, empty trash cans, and keep shower room clean and ready for other residents to use. At 9:54 AM Staff 18 returned to the communal shower, sprayed the area with the shower nozzle but did not disinfect the area. *12/3/25 at 10:11 AM Staff 18 walked a resident down to the communal shower across from room 134 and closed the door. At 10:40 AM Staff 18 left the shower room and left the door open. The shower had an odor of bowel movement and brown material was on the shower floor. At 10:43 AM Staff 7 (CNA) entered the shower room sprayed the soiled area with water and did not disinfectant the communal shower. At 12:04 PM the shower chair had dried brown material on the seat, and the shower area was unclean. *12/3/25 at 11:00 AM Staff 7 returned to the toilet/shower room across from room 134 to finish cleaning. Staff 7 left the communal shower area, and the brown smear remained on the toilet seat and crumpled paper was on the floor. *12/3/25 at 12:04 PM the bath/shower room across from room 134 had the same brown smear on the toilet seat and crumpled paper on the floor. The shower chair still had dried brown material on the seat. *12/4/25 at 12:31 PM and at 3:40 PM the toilet/shower room across from room 154 was unclean. The toilet seat and bowl had brown smears and a shower chair with brown smears was in front of the sink. The door of the room was left open. *12/4/25 at 5:48 PM on and on 12/5/25 at 7:04 AM the toilet in the communal shower room across from room 154 had the same brown smears on the toilet seat. -á -á On 12/3/25 at 10:46 AM, Staff 7 stated after completing a shower, staff either dressed the resident in the shower room or assisted them back to their room in a shower chair before returning to clean up. Staff 7 stated a disinfectant spray bottle was located in the utility room was available for cleaning the shower chair, but she did not use the disinfectant. She stated the facility had not provided specific guidance for cleaning the floor and mats, so she typically used the shower sprayer and, sometimes added shampoo or soap. Staff 7 confirmed when bowel incontinence occurred, she used a washcloth with soap to wipe surfaces and sprayed feces down the drain. Staff 7 stated staff were expected to disinfect the shower with a chemical spray before the next use, she acknowledged she had not done so. She stated if the bath/shower room was not clean, staff were instructed to close the door to prevent resident use before cleaning. On 12/4/25 at 12:46 PM Staff 23 (Housekeeper) stated there was a problem with CNAs not cleaning the bathroom, between when housekeepers deep cleaned.-á-áShe stated after CNAs completed showers, they would often only pick up the residentsGÇÖ items and leave everything else.-á-áShe reported these concerns to management, but nothing happened.-á-áShe stated it was a safety concern when residents use dirty bathrooms.-á-áStaff 23 stated GÇ£we are supposed to clean it in the momentGÇ¥ and housekeeping cleaned the bath/shower rooms at least daily but sometimes multiple times in a day when CNAs asked.-á-áShe stated the door was supposed to remain closed when unclean and if open, the bathroom was available for resident use.-á In an interview on 12/4/25 at 1:04 PM Staff 16 (Housekeeping Manager) confirmed the communal toilet/shower rooms were cleaned by housekeeping at least daily, more if needed.-á-áShe stated CNAs should check the bathroom after independent residents used the bathroom and were expected to clean and sanitize after each resident.-á Staff 16-ástated communal toilet/shower room doors were to stay closed until the room was cleaned but at times residents utilize the communal toilet/shower room before being cleaned and sanitized appropriately.-á-áStaff 16 stated if housekeeping staff came to her with complaints, she reported concerns to the nurses.-á On 12/4/25 at 4:01 PM Staff 19 (CNA) stated when asked about the cleaning process after showers, GÇ£I am not a housekeeper, I am a CNA.-á-áWhat I bring to the shower room, I bring out and put the shower chairs back in a safe place.GÇ¥-á-áStaff 19 stated she would put the yellow sign out to let others know the room was not available and housekeeping had the chemicals to clean the shower rooms.-á-áStaff 19 stated she sprayed the shower chairs with water but sometimes used the soap in the room.-áShe stated if the toilet was dirty before she brought a resident into the shower room, she would put on gloves and clean it with hot water, paper towels or a washcloth.-á-áShe stated housekeeping cleaned the communal toilets once per day or she called them to clean the toilet if they looked unclean. On 12/5/25 at 7:12 AM Staff 2 (DNS) confirmed the communal toilet/shower room across from room 154 was unclean with feces on the communal toilet and she acknowledged the communal toilet/shower rooms should not have been left uncleaned. Staff 2 stated CNAs were expected to clean the toilet and shower chairs when they were unclean.-á-áShe stated staff had access to a disinfectant spray, which they were supposed to use.-á-áStaff 2 stated housekeeping rounded and were to clean areas considered high-risk surfaces and clean the communal bath/shower rooms.

The toilet/shower rooms were immediately cleaned and disinfected. Soiled shower chairs and equipment were removed from service, cleaned, and disinfected according to facility policy and CDC guidelines. All other shower rooms, toilets, and shower chairs were reviewed, cleaned, and disinfected as needed. CNA education completed on  post-shower cleaning and disinfection responsibilities. Housekeeping Manager/DNS/designee will conduct random audits weekly x4 and monthly x2 or until compliance is achieved, of communal bathrooms and shower equipment for cleanliness. Findings are reviewed weekly through QAPI.

The facility's 6/2018 Activity Programs Policy indicated activities offered were based on the comprehensive resident-centered assessment and the preferences of each resident and-ádocumented in the resident's medical record.-á Resident 42 was admitted to the facility in 10/2025 with diagnoses including dementia. Resident 42's 10/29/25 Admission MDS revealed the resident was mildly cognitively impaired and listening to preferred music was a very important activity to the resident. The Activities CAA indicated an activity care plan would be created and updated as needed.-á Resident 42's Activity Task Records from 11/9/25 to 12/8/25 revealed the resident did not participate in any music-themed activities.-á A review of Resident 42's clinical record revealed no activity care plan was developed for the resident.-á Random observations of Resident 42 from 12/2/25 through 12/5/25 between 8:44 AM to 2:55 PM revealed the resident was in her/his room in bed. No music was observed to play in the resident's room.-á On 12/3/25 at 11:12 AM, Resident 42 stated she/he preferred to spend her/his time in her/his room. Resident 42 stated she/he loved to listen to music, especially Christmas music, and had not been able to do so since her/his admission to the facility.-á On 12/8/25 at 7:11 AM, Staff 11 (CNA) stated she did not know Resident 42's activity interests, including if the resident liked music. Staff 11 stated she looked in the care plan to learn about a resident's activity interests.-á On 12/8/25 at 7:21 AM and 12:25 PM, Staff 12 (CNA) stated Resident 42 spent all of her/his time in her/his room, and the resident did not have any activity interests. Staff 12 further stated she had never heard music on in the resident's room.-á On 12/8/25 at 8:01 AM and 12:13 PM, Staff 13 (CNA) stated she did not know Resident 42's activity interests, but she would look in the resident's care plan to find the information.-á On 12/8/25 at 8:16 AM and 1:00 PM, Staff 7 (CNA) stated she did not know Resident 42's activity interests, and she had never heard music play in the resident's room. Staff 7 stated she was not sure if activity interests were listed in resident care plans. On 12/8/25 at 11:47 AM, Staff 14 (Activity Director) stated she completed activity interest interviews with residents shortly after their admission to the facility and added this information to resident activity care plans. Staff 14 stated music was a ""big"" activity for Resident 42, but she did not know which type(s) of music the resident preferred. Staff 14 stated Resident 42 should have an activity care plan in place, which included her/his musical preferences, but acknowledged the resident did not have anything listed on the care plan.-á

An individualized activity care plan was immediately developed for Resident #42 based on documented preferences, including music. All residents were reviewed to ensure they have a resident centered activity program and deficiencies were corrected Activity Director will be educated by the administrator on the need for individual care plans Activities director/administrator will randomly audit new admissions weekly x4 and monthly x2 for compliance. Audits will be reviewed in QAPI.

Resident 14 was admitted to the facility in 10/2025 with diagnoses including an open wound on her/his right foot and morbid obesity. Resident 14's 10/12/25 admission MDS revealed she/he had moderate cognitive impairment and was dependent for bed mobility, transfers and toileting hygiene. Signed physician orders dated 10/14/25 revealed Resident 14 was to receive 0.5ML of Tirzepatide injected subcutaneously every seven days for diabetes mellitus and weight management. A review of Resident 14's medication administration records revealed she/he did not receive an injection of Tirzepatide as ordered on the following days: -11/19/25 -11/26/25 -12/3/25 A progress note created on 11/19/25 revealed Resident 14 was given her/his final weekly dose and a new order was placed for her/his next dose. On 12/3/25 at 9:57 AM Resident 14 stated, she/he started receiving the Tirzepatide as ordered on 10/14/25 and received weekly doses until 11/13/25. Resident 14 stated the medication was important to her/him because it would help her/him lose weight so she/he could participate in therapy and improve her/his strength and overall health. Resident 14 stated she/he did not know why the facility ran out of the Tirzepatide and thought it might be related to the cost of the medication. On 12/4/25 at 9:34 AM Staff 4 (LPN) stated she was aware Resident 14 missed doses of Tirzepatide and the refill was awaiting approval. Staff 4 stated the delay may have been because ""the pharmacy ran out or because it was a high-cost medication."" On 12/4/25 at 9:48 AM Staff 6 (LPN-Resident Care Manager) stated she was aware Resident 14 missed three doses of Tirzepatide. Staff 6 stated the pharmacy was looking for an alternative because it was a high-cost medication. Staff 6 stated she expected Resident 14 to receive all of her/his medications as ordered by the physician. On 12/4/25 at 10:23 AM Staff 2 (DNS) stated the facility had a contingency plan to call the pharmacy and have medications ""statted"" to the facility if they ran out of a resident's medications. Staff 2 also stated she expected staff to call the physician for an alternate medication in the interim, but this plan was not followed. Staff 2 stated she was aware Resident 14 missed doses of Tirzepatide and she expected residents to receive medications as ordered by their physicians.-á

Provider notified of missed medication.  Resident 14’s medication was ordered and administered to the resident. No adverse reactions from missed medication. Other residents on glp medications were reviewed to ensure they have been receiving their medication.  No other deficiencies were identified Nurses and medication aides were educated on what to do when a medication is not available.  DNS and Administrator educated on pharmacy processes for high-cost medications to ensure timely approval for these medications. Random audits of missed medication reports will be conducted weekly x4 and monthly x2 or until compliance is achieved.  Audit results will be reviewed in QAPI.

The facility's 7/2017 Resident Mobility and ROM Policy indicated the following: -Residents with limited ROM received treatment and services to increase and/or prevent a further decrease in ROM. -As part of the comprehensive assessment, the nurse identified conditions that placed the resident at risk for complications related to ROM and mobility, including contractures.-á -The care plan would be developed based on the comprehensive assessment and revised as needed.-á -The care plan would include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and ROM.-á -Interventions included therapies, the provision of necessary equipment, and/or exercises and would be based on professional standards of practice and be consistent with state laws and practice acts.-á -The care plan would include the type, frequency and duration of interventions, as well as measurable goals and objectives.-á Resident 42 was admitted to the facility in 10/2025 with diagnoses including dementia and hemiplegia (paralysis on one side of the body). Resident 42's 10/29/25 Admission MDS revealed the resident was mildly cognitively impaired and experienced upper and lower extremity impairment on one side of the body.-á An 11/11/25 Progress Note revealed Resident 42 experienced significant mobility and ADL impairment and persistent right-sided hemiplegia following a stroke. No evidence was found in Resident 42's clinical record to indicate a care plan was developed to address the resident's right-sided weakness.-á Random observations of Resident 42 on 12/2/25 and 12/3/25 from 8:44 AM to 2:55 PM revealed the resident to be in her/his room in bed. The resident's four fingers on her/his right hand pressed into the palm of her/his hand and the resident's right thumb pushed tightly into her/his right index finger. -á On 12/3/25 at 11:12 AM, Resident 42 attempted to open the fingers on her/his right hand with her left hand and was only able to slightly raise the index and middle fingers on her/his right hand. The resident stated the facility had ""done nothing"" for her/his hand contracture, and she/he was interested in using a rolled washcloth or a therapy carrot (an orthotic device that positions the fingers away from the palm to protect the skin from excessive moisture, pressure and the risk of nail puncture).-á On 12/4/25 at 12:51 PM, Resident 42 was observed in her/his room in bed. A small piece of rolled gauze was observed in the resident's right hand between her/his fingers and palm. The resident stated she/he was happy to have something placed in her/his hand.-á On 12/8/25 at 7:16 AM, Staff 24 (CNA) stated she did not know anything about Resident 42's hand contracture or related interventions.-á On 12/8/25 at 7:21 AM, Staff 12 (CNA) stated Resident 42 did not use her/his right hand, and it ""stayed curled up."" Staff 12 stated she placed rolled gauze in the resident's right hand because she noticed her/his fingers ""were curled."" Staff 12 stated the resident did not have any care plan interventions related to her/his hand contracture, and she often did not see anything placed in the resident's right hand. On 12/8/25 at 7:25 AM, Staff 25 (Director of Rehabilitation and OT) stated a splint had been ordered to be used for Resident 42's right hand contracture, and staff were to place a hand roll in the resident's contracted hand until the splint arrived at the facility. Staff 25 stated he informed one unidentified CNA of this intervention but did not inform other staff or ensure a care plan was created. On 12/8/25 at 7:47 AM, Staff 26 (LPN) stated she was the nurse assigned to work with Resident 42. Staff 26 stated she was unfamiliar with Resident 42 and her/his right-hand contracture. Staff 26 state she would look in the resident's care plan to find information about her/his contracture.-á On 12/8/25 at 1:41 PM, Staff 27 (Regional RN) stated she expected a care plan to be created and implemented for residents who utilized orthotic devices.-á

A comprehensive mobility and ROM care plan was developed for Resident #42, including hand positioning devices and therapy interventions. Other residents at risk of worsening contractures were reviewed to ensure appropriate treatment and services are in place.  All deficiencies will be corrected. Therapy director educated on completing assessment and developing a care plan for treatment of residents with contractures.  Nurses educated on notifying therapy if residents have contractures or are at risk for decreased ROM. Random audits of residents with contractures will be conducted to ensure treatment and services are in place weekly x 4, monthly x2, or until compliance is achieved.  Results of these audits will be discussed in QAPI

The facility's 9/2024 Smoking Policy indicated the following: -Residents who do not meet the established criteria to smoke independently are aided/supervised during smoking activities.-á -Residents are not allowed to borrow cigarettes or other smoking materials from other residents.-á -All smoking materials are locked up, including smoking materials for residents who are assessed to be a supervised smoker.-á Resident 73 was admitted to the facility in 11/2025 with diagnoses including intracerebral hemorrhage (brain bleed).-á Resident 73's 11/26/25 Admission MDS revealed the resident was mildly cognitively impaired and did not use tobacco.-á Resident 73's 12/1/25 Smoking Assessment revealed the resident was cognitively impaired, smoked cigarettes, could not light her/his own smoking device and required supervision when she/he smoked.-á Resident 73's 12/1/25 Smoking Care Plan directed the following: -The resident required supervision to smoke. -The resident was to wear a smoking apron when she/he smoked. -The resident's smoking paraphernalia was to be stored per facility procedure. On 12/1/25 at 1:51 PM, Resident 73 was observed in her/his room in bed and held an unlit cigarette in her/his left hand. The resident stated ""a friend"" at the facility provided her/him with cigarettes. On 12/4/25 at 6:13 AM, Staff 28 (CNA) stated Resident 73 smoked independently at night. Staff 28 stated she did not know where the resident's smoking material was supposed to be stored.-á On 12/4/25 at 12:39 PM, Resident 73 was observed in her/his room in bed. The resident stated she/he did not wear an apron when she/he smoked, and staff did not supervise or ""help"" her/him when she/he smoked but wished they did.-á On 12/5/25 at 6:14 AM, Staff 29 (CNA) stated she did not know if Resident 73 required supervision when she/he smoked. Staff 29 stated the resident usually went out to smoke with another resident at the facility.-á On 12/5/26 at 6:20 AM, Staff 30 (CNA) stated Resident 73 smoked ""whenever"" at night, she/he smoked independently and did not wear a smoke apron.-á On 12/5/25 at 6:32 AM, Staff 31 (RN) stated she knew Resident 73 smoked but did not know if staff supervised her/him when she/he smoked. On 12/5/25 at 7:00 AM, Staff 32 (CNA) stated Resident 73 smoked independently, and the resident kept her/his smoking materials in the drawer of her/his nightstand, in her/his jacket or in the pouch on her/his wheelchair.-á On 12/5/25 at 11:00 AM, Staff 37 (LPN-Resident Care Manager) stated Resident 73 required supervised when she/he smoked and her/his smoking material was to be locked up. On 12/5/25 at 11:01 AM, Staff 2 (DNS) stated she expected Resident 73's care plan to be followed with regards to smoking and her/his smoking material.-á

Resident #73 is no longer at the facility. The DNS and clinical designee will audit the other residents that need supervision while smoking and ensure that the smoking policy/procedure is being followed, and their care plans are up to date. Staff have been educated on following the smoking care plan for supervised smokers and ensure that smoking materials are kept in a secure location. Random smokers will be audited to ensure their care plan is followed and that smoking materials are kept secure weekly x4 and monthly x2 or until compliance is achieved. The results of the audits will be reviewed in QAPI.

The Center for Disease Control 11/24/25 Food Safety guidelines include the following information: Bacteria can multiply rapidly if food is left at room temperature or in the GÇ£Danger ZoneGÇ¥ between 40 degrees F and 140 degrees F. Never leave perishable food (meat, dairy, and cut fruit) out for more than two hours. Resident 5 was admitted to the facility in 8/2024 with diagnoses including anxiety disorder and PTSD (Post Traumatic Stress Disorder). A Care Plan updated 8/25/25 included interventions for room cleaning including asking resident if room could be cleaned and ensuring safe/sanitation in the room. Review of records revealed no specific information of education provided to Resident 5 on risks of having meals kept in her/his room for extended periods or alternate techniques attempted to ensure Resident 5GÇÖs safety with food while accommodating for Resident 5GÇÖs food preferences. On 12/1/25 at 11:34 AM four food trays were observed in Resident 5GÇÖs room. Three of those trays had full or partially full glasses of milk. Opened yogurt containers were observed on multiple food trays. On 12/4/25 at 1:50 PM Resident 5 stated she/he requested food trays to be left in her/his room. Resident 5 stated she/he often consumed the food and drinks, including her/his milk and yogurt, several hours after meals were delivered. Resident 5 stated she/he occasionally consumer the milk and yogurt overnight. On 12/5/25 at 9:24 AM Staff 36 (CNA) stated Resident 5 often saved food in her/his room overnight. On 12/5/25 at 12:03 PM Staff 16 (Dietary Manager) stated Resident 5 requested food to be left in her/his room often. When asked if Staff 16 provided education to Resident 5 regarding consuming dairy products left out longer than two hours, Staff 16 was unable to provide any records.-á On 12/8/25 at 12:42 PM Staff 5 (LPN-Resident Care Manager) confirmed Resident 5 preferences regarding food were being honored with leaving her/his meal tray in her/his room for extended periods, but food safety practices were not followed, and no detailed education was provided to Resident 5 regarding the risk of consuming dairy products exposed to room temperature longer than two hours. On 12/8/25 at 12:58 PM Staff 5 entered Resident 5GÇÖs room and three food trays were observed in her/his room. One tray contained a dish with meat and a glass of milk. A meal ticket was observed on the tray which indicated the meal was from dinner on 12/7/25.

Resident #5 allowed removal of food. However, Resident continues to not allow staff to remove old trays from her room. Education on risks vs benefits of allowing food tray removal has been conducted and care plans have been updated. Other rooms were reviewed to ensure that old food trays have been removed in a timely manner. No other issues were identified. Staff have been educated to remove trays in a timely manner and to notify RCM/DNS if any residents prefer to keep trays or food in their room.  RCM’s have been educated to complete a risk versus benefits with resident when food is kept in room for too long. Random resident rooms will be audited by Admin/designee weekly x4 and monthly x2, or until compliance is achieved.  Results of audit will be reviewed in QAPI.

Resident 5 was readmitted to the facility in 2/2025, for congestive heart failure and delusional disorders. On 8/4/25 at 2:40 PM and 8/5/2025 at 4:01 PM, Witness 1 (Primary Physician) stated Resident 5 was discharged unsafely to the residentGÇÖs family home, which had no running water, rats, and no heat in the winter. Witness 1 further stated the facility had never included them in any discharge planning nor had the facility informed them that Resident 5 was discharged.-á On 8/6/2025 at 4:20 PM, Witness 2 (former Social Services Director) stated Resident 5 was really discouraged from returning to his/her family home due to unsafe situations, including a rat infestation, no running water, and no electricity. Resident 5GÇÖs clinical records indicated an IDT meeting was held on 11/17/2024, which stated it was unsafe to discharge Resident 5. -á Resident 5GÇÖs Social History Review dated 5/9/2025 indicated Resident 5 wanted to discharge back to her/his family home, which was an unsafe discharge. Resident 5GÇÖs Discharge Summary, signed on 5/20/2025, indicated the resident was discharged on 5/21/2025 at 11:00 AM to their home/community. There was no documented evidence that the facilityGÇÖs interdisciplinary team met to ensure Resident 5 was safely discharged on 5/21/2025. On 8/7/2025 at 1:01 PM, Staff 2 (Administrator), Staff 5 (Director of Nursing), and Staff 6 (Regional RN Consultant) were informed of Resident 5GÇÖs unsafe discharge and no additional information was provided.

Resident 5 is currently in another skilled facility and is doing well there. Upcoming discharges were reviewed to ensure a safe discharge is in place and the resident’s primary physician is aware of the discharge. IDT educated on discharge process including ensuring a safe discharge location is in place before discharge and that the primary care physician is notified. Administrator/Designee will audit discharges weekly x4, monthly x2, or until compliance is achieved. The results of these audits will be discussed in QAPI for any further monitoring needs.

Based on interview and record review it was determined the facility failed to protect the resident's right to be free from physical abuse for 1 of 1 resident (#2) reviewed for physical abuse. This resulted in physical injury and prolonged pain which required increased pharmaceutical interventions. Findings include: Resident 2 was admitted to the facility in 4/2023 with diagnoses including multiple spinal fractures and mild cognitive impairment. The 1/9/25 Quarterly MDS, revealed Resident 2 had severe cognitive impairment and was independent with mobility. Resident 1 was admitted to the facility in 11/2023 with diagnoses including restlessness and agitation. A 8/13/24 Quarterly MDS, revealed Resident 1 had severe cognitive impairment and was independent with mobility. An email communication record from 11/30/23 from Staff 19 (Prior Interim DNS) reported Resident 1 was a very violent person with behaviors and provided contact information for Resident 1's probation officer. A review of Resident 1's clinical record including her/his care plan revealed no information regarding her/his violent behavior. A 3/27/25 Progress Note revealed Resident 2 stopped when walking by Resident 1 in the hallway. Resident 1 was observed pushing Resident 2 to the ground and punching Resident 2. Resident 2 reported pain and numbness in her/his right side after the incident. A 3/27/25 Emergency Department Encounter Note reported Resident 2 was determined to have a lumbar spinal fracture, rib pain and difficulty breathing as a result of the incident. A review of Resident 2's pain records (pain scale, which rates pain from 1 to 10, to describe how pain affects daily activity. Mild Pain [1-3], moderate pain [4-6] and severe pain [7-10]) from 3/28/25 through 4/9/25 revealed the following: - 3/28/25 8 out of 10 pain, - 3/30/25 8 out of 10 pain, - 3/31/25 5 out of 10 pain, - 4/1/25 8 out of 10 pain, - 4/2/25 8 out of 10 pain, - 4/3/25 9 out of 10 pain, - 4/4/25 8 out of 10 pain, - 4/5/25 10 out of 10 pain, - 4/6/25 5 out of 10 pain and - 4/9/25 9 out of 10 pain. Review of the 3/2025 and 4/2025 MARs revealed the following medications were provided to Resident 2 to address increased and prolonged pain: - Acetaminophen at 650 mg was received one to two times a day from 3/28/25 through 4/3/25 with a pain level recorded at moderate to severe pain levels recorded upon administration. - Ibuprofen at 600 mg three times a day was received from 3/28/25 through 4/2/25. - Oxycodone at 5 mg was received two to four times a day from 3/31/25 through 4/5/25 with moderate to severe pain levels recorded upon administration. - Fentanyl Patch at 12 mcg was applied on 4/7/25. - Morphine sulfate at .5 ml was provided three times a day on 4/5/25 and 4/6/25. - Morphine sulfate at .25 ml was provided twice on 4/9/25. A 4/3/25 Facility Investigation Summary reported on 3/27/25 at 3:45 PM Resident 1 called Resident 2 a "bitch" when walking past her/him. Resident 2 asked Resident 1, "What did you say?" Resident 1 responded by saying, "Fuck you, motherfucker" and then pushed Resident 2 causing her/him to lose her/his balance, hit the wall behind her/him and fall to the ground. Staff were required to immediately intervene and separate the two residents. A 4/5/25 Progress Note written by Staff 20 (Licensed Vocational Nurse) revealed Resident 2 was experiencing increased confusion and agitation, was refusing to eat, was refusing to take medications and refusing all care. Attempts to contact Resident 1 were unsuccessful and Resident 2 passed away. On 4/15/25 at 10:57 AM Staff 17 (CNA) stated Resident 2 was mostly independent prior to the incident but was bedridden and often screamed out in pain when ADL care and repositioning assistance was provided. On 4/15/25 at 11:22 AM Staff 16 (CNA) stated Resident 2 was thriving before the incident. Staff 16 stated Resident 2 did not like to be touched after the incident due to increased pain. Staff 16 stated Resident 2 regularly walked around the facility prior to the incident but did not continue due to increased and prolonged pain for weeks after the incident. On 4/15/25 at 11:44 AM Staff 12 (Social Service Director) and Staff 13 (Social Services Assistant) stated they collected information regarding the incident. Staff 12 reported Resident 2 was walking by Resident 1 when Resident 1 made an unknown verbal remark towards Resident 2. Resident 2 was hard of hearing and asked for the statement to be repeated, upon which Resident 1 pushed Resident 2 against the wall. This caused Resident 2 to fall to the floor. Resident 1 was observed to be punching Resident 2 which required staff intervention. Staff 12 reported the police were called and Resident 1 was arrested immediately after the incident. Staff 12 and Staff 13 reported Resident 2 experienced increased pain and remained in bed all day. On 4/15/25 at 1:14 PM Staff 11 (RN) stated she witnessed the incident. Staff 11 stated she heard yelling down the hall and observed Resident 1 push Resident 2 down with both hands resulting in a fall to the ground over her/his walker. Staff 11 stated she was required to rush over to separate Resident 1 and Resident 2. Staff 11 stated Resident 2 was on the ground and yelled "get me up! get me up," while complaining of pain to her/his ribs. Staff 11 stated Resident 2 appeared in shock immediately following the incident. Staff 11 stated she considered what she observed as assault. During an interview on 4/15/25 at 1:54 PM with Staff 10 (LPN-Resident Care Manager) and Staff 7 (LPN-Resident Care Manager), Staff 7 stated Resident 2 was medically stable prior to the incident. Staff 7 and Staff 10 stated Resident 2 changed from being up and walking around to not getting out of bed after the incident. Staff 10 stated Resident 2 had increased pain and decreased ability to hold a conversation after the incident. Staff 10 confirmed the incident was abuse. On 4/15/25 at 2:47 PM Staff 1 (Administrator) acknowledged Resident 2 was physically abused by Resident 1 on 3/27/25.

Resident 1 no longer resides at the facility Resident 2 is currently discharged from the facility Other residents were interviewed to ensure no other incidents have taken place and that they feel safe in the facility. All staff educated on abuse policy Administrator/designee will do random interviews with residents and staff to monitor for abuse weekly x4, monthly x2 or until compliance is achieved. Results of these audits will be discussed in QAPI for review.

************************** OAR 411-085-0360: Abuse Refer to F600 **************************

Based on interview and record review it was determined the facility failed to accurately document wound assessments and dressing change refusals for 1 of 3 sampled residents (# 3) reviewed for accuracy of medical records. This placed residents at risk for inaccurate medical records and risk for injury and/or decreased ability for recovery. Findings include: Resident 3 was admitted to the facility in 1/2025 with diagnoses including acute and subacute infective endocarditis (infection). An undated facility policy pertaining to documentation indicated the following: - all nursing staff must document resident assessments. - Documentation should be timely, complete and entered in the appropriate PCC module. - Refusals of care are to be documented in the progress notes including interventions used, resident response, and any notifications made. Resident 3 had the following weekly wound assessments documented in her/his medical record: 1/20/25, 1/24/25, 1/30/25, 2/6/25, 2/13/25, 2/20/25, 2/27/25, 3/6/25, 3/7/25, 3/20/25, and 4/7/25. There was no documented assessments found between 3/20/25 and 4/7/25. Weekly wound assessments dated 1/20/25, 1/24/25, 1/30/25, 2/6/25, 2/13/25, 2/20/25, 2/27/25, 3/7/25, and 4/7/25 were found to be incomplete. The assessments were missing all or part of the following: - wound measurements; - wound description; - percentage of slough vs granulation vs epithelial; - type of wound. On 4/9/25 at 7:28 AM, Staff 5 (LPN/Care Manager) stated Resident 3 had refused the last three wound assessments from an outside wound agency. This information was not documented in Resident 3's medical record. On 4/9/25 at 8:03 AM, Staff 3 (RN) stated the nurses were instructed to fill in the assessment form after they had completed their wound assessment. Staff 3 confirmed weekly wound assessments were not fully completed. On 4/9/25 at 8:26 AM, Staff 3 (RN) and Staff 4 (RN) confirmed the weekly wound assessments were incomplete and not all refusals of care were documented appropriately.

Resident # 3 is discharged from the facility. Other residents with wounds will be reviewed for the deficient practice and any found will be corrected. Licensed nurses will be educated to document all refusals of wound care and any missed treatments. RCM’s will be educated to fill in wound assessments each week completely and to document any missed or refusals appropriately. Random audits on residents requiring wound assessments will be completed to ensure compliance weekly x4, monthly x2 or until compliance is achieved. The results of these audits will be discussed in QAPI for further need of interventions.

Based on observation, interview and record review it was determined the facility failed to follow infection control standards for 1 of 3 residents (# 2) sampled reviewed for infection control. This placed residents at risk for exposure and contraction of infectious diseases. Findings include: Resident 2 was admitted to the facility in 3/2025 with diagnoses including open wound to left foot. A 3/20/25 Admission MDS revealed Resident 2 was cognitively intact. On 4/8/25 at 10:00 AM, during an observation of a chronic wound dressing change, an unidentified female placed an enhanced barrier precaution sign on the door to Resident 2's room. Staff 6 (RN) and Staff 5 (LPN/Care Manager) were observed to then put appropriate PPE on and continue Resident 2's dressing change. There was no documentation found in Resident 2's clinical record indicating she/he had been placed on enhanced barrier precautions for a chronic wound. On 4/8/25 at 10:56 AM, Staff 6 confirmed he had not worn appropriate PPE (gown) when he provided care to Resident 2. On 4/8/25 at 10:59 AM, Resident 2 stated she/he had been in the facility since mid-March. Resident 2 stated today (4/8/25) was the first day she/he had seen staff wear PPE gowns when they provided care for her/his chronic wound. On 4/8/25 at 3:05 PM, Staff 5 (LPN/Care Manager) stated normal procedure was to implement enhanced barrier precautions for a chronic wound, catheter, central line, feeding tube, etc. upon admission. Staff 5 confirmed there should have been an enhanced barrier precautions sign posted and appropriate PPE worn.

Resident 2 was discharged from the facility All residents were reviewed for the need for enhanced barrier precautions and those deficiencies will be corrected. Infection preventionist was educated on enhanced barrier precaution practices and protocols. Staff were educated on enhanced barrier precautions including who should be on them and when and what PPE is required. Random audits on residents will be completed weekly to ensure enhanced barrier precautions are in place if needed weekly x4, monthly x2 or until compliance is achieved. The results of these audits will be discussed in QAPI for further need of interventions. Random audits on staff providing care to residents requiring EBP will be conducted to ensure proper PPE is worn if needed weekly x4, monthly x2 or until compliance is achieved. The results of these audits will be discussed in QAPI for further need of interventions.

************************************* 411-086-0300 - Clinical Records F842 ************************************* 411-086-0330 - Infection Control and Universal Precautions F880 *************************************

Based on observation, interview and record review it was determined the facility failed to protect the resident's right to be free from sexual abuse by another resident for 1 of 1 sampled residents (#11) reviewed for sexual abuse. This placed residents at risk for psychological harm. Findings include: The facility's Abuse policy, revised 1/2023, stated the facility and staff would protect residents from all types of abuse. The facility's Resident Sexual Consent policy dated 9/2022, stated a resident's consent to engage in sexual activity is not valid if a resident lacks the capacity to consent. Any forced sexual activity with a resident is considered sexual abuse. Resident 10 admitted to the facility 7/2024, with diagnoses including Alzheimer's disease. Resident 10's 8/2024 MDS indicated she/he was cognitively intact. Resident 10 was discharged home on 8/28/24. Resident 11 admitted to the facility 5/2024, with diagnoses including Factor X chromosome (a genetic disorder causing developmental and intellectual disability). Resident 11's Quarterly Minimum Data Set (MDS) indicated the resident had severe cognitive impairment. Review of Resident 10 and Resident 11's clinical record found no evidence a Sexual Consent Form was completed. A Facility Reported Incident (FRI) dated 8/20/24 at 6:30 PM, revealed Resident 10 was observed to be rubbing Resident 11's genitalia in an annexed TV area. Both residents were immediately separated and were assessed for injuries by Staff 5 (LPN) and Staff 6 (RN). No injuries were noted. Observations made on 8/29/24 at 11:05 AM, revealed Resident 10 was discharged. Resident 11 attended meals in the dining room and self-propelled via wheelchair through-out the community. On 8/29/24 at 11:05 AM, Resident 11 was observed in the hallway and self-propelled her/himself via wheelchair to the dining room for bingo. Resident 11 stated she/he was not afraid of any other resident at the facility. On 8/29/24 at 11:20 AM, Resident 12, Resident 13 and Resident 14 all stated they had not been inappropriately touched while residing in the facility. On 8/30/24 at 1:03 PM, Staff 6 stated she was notified by Staff 8 (CNA) a resident was being touched inappropriately by another resident in the TV room. Staff 6 stated the residents were immediately separated, management and providers were notified and both residents were brought back to their individual rooms and placed on alert monitoring. Resident 10 was placed on a 1:1 supervision and Resident 11 had a STOP sign placed on their room door. On 8/30/24 at 1:28 PM, Staff 8 stated on 8/20/24 around 6:10 PM, she witnessed Resident 10's hand on Resident 11's genitals and Resident 10 was rubbing aggressively. Staff 8 stated Resident 10 saw her and stopped. Staff 8 separated the two residents and notified Staff 6 immediately. On 8/30/24 at 4:45 PM, Staff 1 (Administrator) acknowledged Resident 11 had been sexually abused and will continue to monitor the resident for any psychological impact.

1.Resident 10 was discharged from the facility. Resident 11 was placed on alert charting to monitor for psychosocial distress and had no evidence of any distress. Res 11 had no further incidents regarding abuse 2.Residents interviewed to see if there were any other concerns of sexual abuse, residents not able to be interviewed had a skin check completed 3.Staff education completed on abuse policy, including prevention and reporting. 4.Random residents and staff will be interviewed weekly x 4 and monthly x2. Any negative findings will be brought to the QAPI committee for review and recommendations as determined by the committee or until substantial compliance has been achieved. The Administrator is reasonable for compliance.

************************** OAR 411-085-0360 - Abuse Refer to F600 ***************************

Based on interview and record review it was determined the facility failed to involve residents/representatives in the care planning process for 2 of 2 sampled residents (#s 4 and 41) reviewed for care planning and dementia. This placed residents at risk for unmet needs. Findings include: 1. Resident 4 was admitted to the facility in 5/2009 with diagnoses including dementia. A review of Resident 4's medical record revealed the last care conference completed for Resident 4 was on 2/5/24. On 8/15/24 at 10:12 AM Staff 11 (SSD) stated Resident 4 had not had a care conference completed since 2/5/24. On 8/15/24 at 12:54 AM Staff 6 (LPN Resident Care Manager) and Staff 4 (LPN Resident Care Manager) stated care plan revisions and reviews are reviewed with the resident and/or representatives on a quarterly basis during the care conference. Staff 6 stated Resident 4 was overdue for a care conference. 2. Resident 41 was admitted to the facility in 1/2023 with diagnoses including acute respiratory failure. A 6/15/24 Quarterly MDS revealed Resident 41 had moderate cognitive decline. A review of Resident 41's medical record revealed the last care conference completed for Resident 41 was on 1/24/24. On 8/14/24 at 11:22 AM Staff 4 (LPN Resident Care Manager) stated Resident 41 had a care conference completed in June 2024, she was unsure of the date, she was unsure if the resident's representative was invited and she was unable to provide documentation of the care conference being completed in June 2024. On 8/14/24 at 11:48 AM Staff 11 (SSD) stated the last care conference documented for Resident 41 was in 1/2024. Staff 11 stated she was getting caught up and back on track with care conferences. On 8/15/24 at 12:54 PM Staff 4 and Staff 6 (LPN Resident Care Manager) stated care plan revisions and reviews are reviewed with the resident and/or representatives on a quarterly basis during the care conference.

1.The Interdisciplinary Team (IDT) held care plan meetings for Resident #4 on 08/23/2024 and Resident #41 on 9/5/24. For Resident #4, the resident’s representative attended the care plan meeting. For Resident #41, the resident and the sister of the resident attended. 2.Social Services Designee (SSD) audited care plans for the last 3 months and corrected any deficiencies 3.IDT members educated on the importance of inviting residents/representatives into the Care Plan meetings. 4.SSD and/or designee will monitor that the resident and/or their representative are invited into the Care Plan meeting weekly x 4, and then monthly x 2. Any negative findings will be brought to the QAPI committee for review and recommendations as determined by the committee or until substantial compliance has been achieved. The Administrator is reasonable for compliance.

Based on observation and interview it was determined the facility failed to maintain a homelike environment for 3 of 4 halls reviewed for environment. This placed residents at risk for living in an unkempt environment. Findings include: Observations of the facility's general environment and residents' rooms from 8/12/24 through 8/16/24 identified the following issues: -A light cover on the annex hall near room 109 was cracked with missing chunks of the lighting cover. -One hall light was out on the annex hall near room 107. -Two lights were out in the dining room. -Dirty vent covers in rooms 155, 157, 158, the center hall outside the employee room and outside the RCM office near the west hall. -The east hall near the O2 storage closet had a torn/jagged baseboard to the left of the closet door. -The east hall near the emergency exit had broken pieces of plastic on both wall corners approximately 3 inches in length that were sharp/jagged. -A lower corner wall near the west hall and RCM office was separated with approximately 3 inches of separation with sharp/jagged edges. -A lower corner wall near the center hall and resident bathroom had approximately 6 inches of missing/broken plastic with sharp/jagged edges. -The entrance to the clean laundry area had a wall corner with broken sharp/jagged edges in three different areas on the wall protector. -The entrance to the facility where the directory sign was had a corner with approximately 3-4 inches of missing plastic protector with sharp/jagged edges. -The west hall outside the nurses station had a wall corner with approximately 3-4 inches of missing plastic protector with sharp/jagged edges. On 8/16/24 at 10:24 AM Staff 1 (Administrator) and Staff 18 (Maintenance Director) acknowledged the identified concerns.

•Maintenance Director ordered replacement parts and replaced/repaired/cleaned: 1. Light cover on the Annex Hall near Room 109 2. One hall light was out on the Annex Hall near Room 107 3. Two lights were out in the dining room 4. Dirty vent covers in Rooms 155, 157, 158, the Center Hall outside the e employee room and outside the RCM office near the West Hall 5. The baseboard on the East Hall near the 02 storage closest 6. East hall near the emergency exit had broken pieces of plastic on both wall corners 7. Lower corner wall near the West Hall and RCM office 8. Lower corner wall near the Center Hall and resident bathroom 9. Entrance to the clean laundry area had a wall corner with sharp/jagged edges 10. Entrance to the facility where the director sign was had a corner with missing plastic protector 11. West Hall outside the nursing station had a wall corner with missing plastic protector • Administrator and Maintenance Director went around the facility to see if there were any additional items that need to be replaced/cleaned/repaired. Three additional items were identified and replaced with new plastic corner protectors. • Administrator educated the Maintenance Director on the importance of making frequent facility rounds to ensure a safe and homelike environment for the residents and to correct any issues found asap. • The administrator and/or designee will do maintenance rounds with the Maintenance Director weekly x4, and then monthly x 2. Any negative findings will be brought to the QAPI committee for review and recommendations as determined by the committee or until substantial compliance has been achieved. The Administrator is reasonable for compliance.

Based on interview and record review it was determined the facility failed to follow up on grievances for 1 of 1 resident (#309) reviewed for personal property. This placed residents at risk for unmet needs. Findings include: Resident 309 was admitted to the facility in 6/2020 with diagnoses including depression. On 7/8/24 a public complaint was received with allegations of missing personal property. On 8/12/24 at 5:25 PM Witness 1 (Complainant) stated Resident 309 was discharged from the facility in 4/2024 and was missing some personal belongings. Witness 1 stated she informed the facility via phone of the missing items but had not received a reply from the facility. On 8/13/24 at 9:41 AM Staff 4 (SSD) stated she never received a complaint or grievance related to missing personal items from Resident 309 or her/his representatives. An 8/14/24 review of the facility grievance binder revealed no evidence of a grievance from Resident 309 or her/his representatives. On 8/14/24 at 11:20 AM Staff 4 (LPN Resident Care Manager) stated she was Resident 309's care manager but had not received any grievances or complaints from Resident 309 or her/his representatives related to missing personal items. On 8/15/24 at 10:42 AM Staff 12 (Receptionist) stated she received a call from Witness 1 after Resident 309 discharged. Staff 12 stated Witness 1 reported not all of Resident 309's personal items had transferred with her/him upon discharge. Staff 12 stated she could not remember if she reported this to management. On 8/15/24 at 11:29 AM Staff 1 (Administrator) stated he had not received a report of Resident 309 missing any personal items. On 8/16/24 at 8:15 AM Staff 11 stated she was the facility grievance officer. Staff 11 stated she expected staff to report all written and verbal grievances to her or the administrator. On 8/16/24 at 8:25 AM Staff 1 stated verbal grievances are expected to be treated and followed up on just like written grievances.

1.The receptionist called the family of Resident #309 to follow up with the missing items. 2.Social Services Designee (SSD) interviewed residents to see if anyone had any outstanding grievances and followed up on any issues 3.Staff Development Coordinator (SDC) educated staff on the facility's Grievance Policy and Procedure. 4.SSD provided a 1:1 education to the receptionist on the importance of reporting grievances to the facility grievance officer. 5.SSD and/or designee will monitor grievances by interviewing 5 residents weekly x 4, and then monthly x 2. Any negative findings will be brought to the QAPI committee for review and recommendations as determined by the committee or until substantial compliance has been achieved. The Administrator is reasonable for compliance.

Based on interview and record review it was determined the facility failed to ensure the Office of the State Long Term Care Ombudsman was notified of resident hospitalizations for 1 of 1 sampled resident (# 56) reviewed for hospitalization. This placed residents at risk for lack of advocacy by the Ombudsman's office. Findings include: Resident 56 was admitted to the facility in 5/2024 with diagnoses including urinary tract infection and bacteremia (bacteria in blood). Resident 56's 5/23/24 Discharge MDS indicated the resident was discharged to an acute care hospital. A review of Resident 56's health record revealed no documentation to indicate the state/local Ombudsman was notified Resident 56 was discharged to a hospital. On 8/15/24 at 12:51 PM Staff 1 (Administrator) stated the facility did not notify the Ombudsman of discharged residents.

1.Medical Records Director (MRD) sent a notice of discharge to the State Long Term Care Ombudsman Office for Resident #56. 2.MRD audited the last 30 days of resident discharges. MRD reported as needed to the ombudsman 3.Administrator provided a 1:1 education to MRD on the importance of sending notices of discharge to the State Long Term Care Ombudsman Office. 4.Transfers will be discussed daily in stand up to ensure med recs has them on the list to send. Med Recs will send this list to the ombudsman 2 times a month 5.Administrator/Designee will audit transfers to ensure they were sent to the ombudsman monthly x4 and until compliance is achieved. Any negative findings will be brought to the QAPI committee for review and recommendations as determined by the committee or until substantial compliance has been achieved. The Administrator is reasonable for compliance.

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 2 of 3 residents (#s 4 and 56 ) reviewed for hospitalization. This placed residents at risk for lack of knowledge regarding their choices and potential financial responsibilities. Findings include: 1. Resident 4 was admitted to the facility in 5/2009 with diagnoses including epilepsy and dementia. A 1/31/24 Progress Note revealed Resident 4 experienced a change in condition which required increased medical attention and she/he was transferred to a hospital. A review of Resident 4's health record revealed no documentation to indicate a copy of the facility's bed hold policy was provided to Resident 4 when she/he experienced a change in condition and was transferred to a hospital. On 8/15/24 at 1:24 PM Staff 1 (Administrator) confirmed a bed hold policy was not provided to Resident 4 when she/he experienced a change in condition and was required to be transferred to a hospital. On 8/16/24 at 8:52 AM Staff 3 (Interim DNS) confirmed a bed hold policy was not provided to Resident 4 when she/he was transferred to a hospital. 2. Resident 56 was admitted to the facility in 5/2024 with diagnoses including urinary tract infection and bacteremia (bacteria in blood). A 5/23/24 Progress Note revealed Resident 56 experienced a change in condition which required increased medical attention and she/he was transferred to a hospital. A review of Resident 56's health record revealed no documentation to indicate a copy of the facility's bed hold policy was provided to Resident 56 when she/he experienced a change in condition and was transferred to a hospital. On 8/15/24 at 1:24 PM Staff 1 (Administrator) confirmed a bed hold policy was not provided to Resident 56 when she/he experienced a change in condition and was required to be transferred to a hospital. On 8/16/24 at 8:52 AM Staff 3 (Interim DNS) confirmed a bed hold policy was not provided to Resident 56 when she/he was transferred to a hospital.

1.Staff Development Coordinator (SDC) called Resident #4’s representative to explain and offer a bed hold policy. Resident #56 was discharged from the facility already. 2.Medical Records Director (MRD) audited residents that are currently at the hospital to ensure they were explained and offered a bed hold. Any deficiencies found were corrected. 3.SDC educated staff on the facility’s bed hold policy. 4.Administrator provided 1:1 education to Social Services Director (SSD) on the facility’s bed hold policy. 5.Discharges will be reviewed daily in MACC meeting to ensure bed hold policy was offered 6.SSD and/or designee will monitor resident discharges to the acute hospital and ensure they were offered a bed hold for weekly x4, and then monthly x 2. Any negative findings will be brought to the QAPI committee for review and recommendations as determined by the committee or until substantial compliance has been achieved. The Administrator is reasonable for compliance.

Based on observation, interview and record review it was determined the facility failed to accurately assess residents for oxygen therapy and wounds for 2 of 6 sampled residents (#s 22 and 37) reviewed for respiratory care and skin conditions. This placed residents at risk for inaccurate assessments and unmet care needs. Findings include: 1. Resident 22 was admitted to the facility in 1/2023 with diagnoses including heart attack and chronic obstructive pulmonary disease (a group of lung diseases that make it difficult to breathe). Resident 22's 12/17/24 through 6/11/24 Physician Order indicated the resident was to receive supplemental oxygen therapy at 2 LPM (liters per minute) per NC (nasal cannula-a non-invasive medical device that provides supplemental oxygen to resident's through their noses) for signs of cyanosis (bluish or purple discoloration of the skin, lips and nail beds caused by lack of oxygen), symptoms of dyspnea (difficulty breathing) or shortness of breath. Resident 22's 6/11/24 through 7/30/24 Physician Order indicated the resident was to receive supplemental oxygen therapy at 3 LPM to 5 LPM as needed per NC. Resident 22's 7/30/24 Physician Order indicated the resident was to receive supplemental oxygen therapy at 2 LPM to 4 LPM continuously per NC. Resident 22's 6/12/24, 7/3/24 and 8/6/24 Significant Change MDSs indicated Resident 22 did not require supplemental oxygen therapy. Multiple observations from 8/12/24 through 8/16/24 between the hours of 8:00 AM and 3:30 PM revealed Resident 22 received supplemental oxygen therapy. On 8/15/24 at 11:35 AM Staff 4 (RNCM) confirmed Resident 22 received supplemental oxygen therapy and the resident's MDSs should have reflected the resident's need for oxygen. , 2. Resident 37 was readmitted to the facility in 2/2024 with diagnoses including diabetes, peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) and an acquired absence of right toes. Resident 37's 5/10/24 and 5/17/24 Podiatry Outpatient Notes indicated the resident had a diabetic foot ulcer. Resident 37's 7/14/24 Quarterly MDS indicated the resident had a surgical wound and she/he did not have a diabetic foot ulcer. On 8/16/24 at 11:46 AM Staff 2 (DNS) and Staff 3 (Interim DNS) acknowledged the findings of this investigation and Staff 3 confirmed Resident 37's MDS was inaccurate.

1.MDS Coordinator reviewed MDSs for Resident 22 and Resident 37. MDS Coordinator reviewed significant change MDSs for 6/12/24, 7/3/24, and 8/26/24 and corrected it. MDS Coordinator reviewed Resident 37’s quarterly MDS and corrected it. 2.Director of Nursing Services (DNS) audited the past 30 days of MDS to ensure it is correct and accurate and any issues were corrected 3.DNS provided 1:1 education to MDS Coordinator on the importance of Accuracy of Assessments. 4.DNS and/or designee will monitor the accuracy of MDS assessments on a weekly basis x 4, and then monthly x 2. Any negative findings will be brought to the QAPI committee for review and recommendations as determined by the committee or until substantial compliance has been achieved. The Administrator is reasonable for compliance.

Based on observation, interview and record review it was determined the facility failed to ensure care plans were revised to accurately reflect the needs of residents for 2 of 7 sampled residents (#s 22 and 28) reviewed for respiratory care and unnecessary medications. This placed residents at risk for unmet needs. Findings include: 1. Resident 22 was admitted to the facility in 1/2023 with diagnoses including heart attack and chronic obstructive pulmonary disease (a group of lung diseases that make it difficult to breathe). Resident 22's 7/30/24 Physician Order indicated the resident was to receive supplemental oxygen therapy at 2 to 4 LPM (liters per minute) continuously per NC (nasal cannula-a non-invasive medical device that provides supplemental oxygen through the nose). Resident 22's 5/14/24 (most current) Care Plan indicated the resident was to receive oxygen per NC at 2 LPM as needed to maintain oxygen saturation levels (a measurement of how well the lungs are working) between 88% and 92%. Observations from 8/12/24 through 8/16/24 between the hours of 8:00 AM to 3:30 PM revealed Resident 22 received oxygen therapy at 3 LPM, continuously. On 8/14/24 at 2:49 PM Staff 21 (RN) stated Resident 22 received continuous oxygen per NC. On 8/15/24 at 12:48 PM Staff 3 (Interim DNS) reviewed Resident 22's oxygen orders and current care plan. Staff 3 stated Resident 22's care plan did not reflect the resident's current supplemental oxygen orders and she expected the resident's care plan and oxygen orders to "match." , 2. Resident 28 was admitted to the facility in 8/2023 with diagnoses including heart failure. Resident 28's 5/31/24 Nutrition At Risk Care Plan indicated the resident was to be weighed weekly. Resident 28's 8/2024 Physician Orders directed the resident to be weighed daily. On 8/15/24 at 9:39 AM Staff 29 (CNA) stated she was unsure if Resident 28 was to be weighed weekly or daily but stated she found this information in the resident's care plan. On 8/15/24 at 12:14 PM Staff 3 (Interim DNS) reviewed Resident 28's Physician Orders, stated she/he was to be weighed daily and confirmed the care plan needed to be revised.

1.Director of Nursing Services (DNS) and Resident Care Managers (RCMs) reviewed and updated Resident #22 and Resident #2’s care plans. 2.DNS and RCMs reviewed care plans for all residents to ensure it is updated to reflect the most up to date physician orders. 3.DNS educated RCMs on Care Plan Timing and Revision. 4.New orders will be reviewed during clinical meetings and care plans will be updated at that time. 5.DNS and/or designee will monitor 5 resident’s care plans weekly x 4, and then monthly x 2. Any negative findings will be brought to the QAPI committee for review and recommendations as determined by the committee or until substantial compliance has been achieved. The Administrator is reasonable for compliance.

Based on observation, interview and record review it was determined the facility failed to provided nail care services to 1 of 1 resident (# 24) reviewed for ADL care. This placed residents at risk of unmet care needs. Findings include: Resident 24 was admitted to the facility in 2/2020 with diagnoses including a stroke resulting in hemiplegia (partial or complete loss of function of one side of the body). Physician orders from 7/11/22 stated a licensed nurse was to check fingernails and toe nails once a week and trim as needed. A 6/5/24 Care Plan included Resident 24 requiring extensive assistance with ADL tasks including hygiene and grooming. Review of LN Care Records from 6/2024 through 8/2024 revealed nail care was marked as not needed on the following dates: - 6/3/24, - 6/24/24, - 7/1/24, - 7/8/24, - 7/15/24, - 7/22/24, - 7/29/24, - 8/5/24 and - 8/12/24. Review of LN Care Records from 6/2024 revealed Resident 24 refused nail trimming on the following dates: - 6/10/24 and - 6/17/24. On 8/13/24 at 12:35 PM Resident 24 stated her/his nails were too long, nail care had not been offered to her/him recently and she/he would not have refused nail care if it was offered. Resident 24's nails were observed to be extended a quarter of an inch and had dirt under each of the nails on both hands. On 8/13/24 at 1:06 PM Staff 4 (RNCM) confirmed Resident 24's nails were dirty and had not been trimmed for an extended period.

1.Resident 24’s nails was trimmed and cut. 2.Director of Nursing Service (DNS) and Resident Care Manager (RCM) checked all residents’ nails and ensured all nails were trimmed and cut as desired by the resident. 3.Staff Development Coordinator (SDC) educated nursing staff on the importance of providing nail care to residents. 4.DNS and/or designee will monitor 5 residents weekly x 4, and then monthly x2. Any negative findings will be brought to the QAPI committee for review and recommendations as determined by the committee or until substantial compliance has been achieved. The Administrator is reasonable for compliance.

Based on observation, interview and record review it was determined the facility failed to start antibiotic treatment timely or follow physician orders for 2 of 9 sampled residents (#s 4 and 28) reviewed for skin condition and unnecessary medications. This placed residents at risk for unmet needs. Finding include: 1. Resident 28 was admitted to the facility in 8/2023 with diagnoses including heart failure, diabetes with a foot ulcer and cellulitis (a bacterial skin infection) of the left lower limb. a. Resident 28's 5/20/24 Quarterly MDS revealed the resident was cognitively intact, had a total of two venous ulcers (leg ulcers caused by problems with blood flow in a person's leg veins) and arterial ulcers (a painful, deep sore or wound in the skin of the lower leg or foot) and received the application of nonsurgical dressings and ointments/medications other than to her/his feet. A 6/26/24 Progress Note indicated Resident 28 was observed to have "three large greenish patches" on her/his right lower extremity with a slight odor. The progress note also indicated the resident's on-call provider was notified, a wound culture was ordered and the provider requested the wound nurse obtain the wound culture during her visit on 6/27/24. A 6/27/24 Encounter Note completed by Staff 30 (NP) stated the wound nurse obtained a culture of Resident 28's leg and indicated the wound "might be infected" and the resident's pain was "a little worse than normal." A 6/27/24 United Wound Healing Note completed by Staff 31 (Wound Nurse) indicated Resident 28's leg wounds had "heavy serous (clear fluid that leaks out of wounds) to green drainage with odor." The note indicated a wound culture was obtained by Staff 31 and Staff 31 would notify the facility of the results of the culture which was typically in three to five days. A 7/1/24 Wound Culture Report indicated Resident 28's wound culture was positive for multiple bacteria. Resident 28's 7/2024 MAR revealed the resident received vancomycin (a strong antibiotic used to treat infections caused by bacteria) intravenously (by means of a vein) from 7/18/24 through 7/28/24 and levofloxacin (an oral antibiotic) from 7/18/24 through 7/27/24. No evidence was found in Resident 28's clinical record to indicate Staff 30 was informed of the resident's wound culture results prior to 7/18/24. On 8/13/24 at 3:55 PM Staff 21 (RN) stated she recalled the wound culture was completed on 6/27/24 and would have expected to have seen the results by 7/4/24. Staff 21 stated Staff 30 was not notified of the results of the wound culture until 7/18/24 and that was why the resident "started on antibiotics late." On 8/14/24 at 11:12 AM Staff 15 (RN) stated a resident's provider typically received results of a wound culture within three days and was unsure why there was a delay in Staff 30 receiving Resident 28's wound culture results. On 8/14/24 at 2:54 PM Resident 28 was observed to sit in her/his room in her/his wheelchair. Both of the resident's lower extremities were covered in bandages. Resident 28 was unable to recall the state of her/his wounds or pain caused by the wounds from the prior month. Resident 28 stated her/his wounds had "been bad for so long and they had progressively gotten worse" and the "pain was the same." On 8/14/24 at 3:18 PM Staff 6 (Infection Preventionist) and Staff 2 (DNS) acknowledged the findings of this investigation. Staff 6 confirmed Resident 28's provider was not notified of the wound culture results until 7/18/24, and as a result, did not receive timely treatment for her/his wound infections. b. Resident 28's 8/2024 Physician Orders directed the resident to be weighed daily and for her/his physician to be notified if the resident gained two pounds in two days or five or more pounds in a week. Resident 28's 7/2024 and 8/2024 LN Task Records revealed the following: -On 7/9/24, the resident weighed 240.5 lbs (pounds). -On 7/11/24, the resident weighed 243.5 lbs (a gain of 3.5 lbs). -On 7/26/24, the resident weighed 236.5 lbs. -On 7/28/24, the resident weighed 240 lbs (a gain of 3.5 lbs). -On 8/1/24, the resident weighed 235 lbs. -On 8/3/24, the resident weighed 240 lbs (a gain of 5 lbs). No evidence was found in Resident 28's clinical record to indicate her/his physician was notified of her/his weight gains. On 8/15/24 Staff 3 (Interim DNS) stated Resident 28's provider should have been notified of her/his weight gains on 7/11/24, 7/28/24 and 8/3/24 and was not. , 2. Resident 4 was admitted to the facility in 5/2009 with diagnoses including depression. A review of Resident 4's 4/10/23 hospital readmission orders revealed orders for sertraline (a medication used to treat depression). A review of Resident 4's 4/2023 MAR revealed no evidence sertraline was added to her/his MAR as ordered on her/his 4/10/23 hospital readmission orders. A 4/4/24 Rogue Psychiatric Consultant Progress Note revealed Resident 4 continued to have physical and verbal behaviors with care activities and these behaviors had increased in 6/2023 and persisted since. A recommendation were made for Resident 4 to restart previous medication that was stopped in 4/2023. A 4/11/24 Provider Progress Note revealed Resident 4 was having increased behaviors and stated Resident 4 stopped taking sertraline about a year ago. A review of Resident 4's medical record revealed sertraline was restarted on 5/6/24. On 8/15/24 at 1:07 PM Staff 3 (Interim DNS) stated Resident 4's sertraline was ordered and not transcribed on her/his 4/10/23 readmission to the facility. Staff 3 confirmed this was a medication error.

1.Resident 28 culture was reported to provider and antibiotics were prescribed for his wound and has no other signs and symptoms of infection. 2.Resident 28’s weights were reviewed, and provider was notified of weight gain per order 3.Resident 4 had her Sertraline restarted on 5/6/24. Provider was notified of the medication error 4.All resident’s with wounds were reviewed for s/s of infection or other needs of treatment. No other issues were noted 5.All resident’s with daily weights were reviewed, and their providers were updated of any concerns 6.All resident’s that were readmitted from in the last 30 days were reviewed to ensure all orders were carried out per hospital discharge paperwork. No other issues were found 7.Licensed nurses were educated on provider notification of lab results and daily weights outside of parameters, and to review hospital discharge paperwork and input all medication orders. 8.RCM’s were educated to review labs, weights, and readmissions during the daily clinical meeting to ensure labs are followed up on, weights were reported to the provider per order, and that readmitted resident’s medication list is up to date. 9.DNS/Designee will monitor the daily clinical meeting to ensure these tasks are completed. Random audits of weights, labs and readmissions will be conducted weekly for 4 weeks, monthly for 2 months or until compliance is achieved.

Based on interview and record review it was determined the facility failed to ensure necessary interventions were in place and followed to reduce the risk of falls and to thoroughly investigate the cause of a fall for 2 of 5 sampled residents (#s 37 and 360) reviewed for skin conditions and falls. This placed residents at risk for falls. Findings include: 1. Resident 37 was admitted to the facility in 7/2023 with diagnoses including diabetes, acquired absence of left foot, acquired absence of right toes and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). Resident 37's 7/9/23 Morse Fall Scale indicated the resident was at high risk to fall. Resident 37's 3/7/24 At Risk For Falls Care Plan revealed the following: -The resident experienced impaired physical mobility as a result of the surgical amputation of her/his left foot. -The resident had a history of falls. -The resident's call light/personal items were to be within reach. -The resident was to wear nonskid footwear when transferring. -Staff were to remind the resident to use the call light for assistance. -The resident was at low risk to fall. Resident 37's 3/7/24 ADL Care Plan revealed the resident was non-ambulatory and "no weight bearing left." Resident 37's 4/13/24 Quarterly MDS indicated the resident was cognitively intact, experienced lower extremity impairment on one side and used a wheelchair. A 5/13/24 Incident Report revealed the following: -Resident 37 experienced an unwitnessed fall in her/his room. -The resident stated she/he attempted to walk as she/he wanted to go back home and she/he had stairs in her/his home. -The resident had no restrictions related to her/his ability to bear weight. -Conclusion: The resident adhered to her/his physician orders when this event occurred. No evidence was found in Resident 37's health record to indicate the resident's care plan was followed prior to the fall or a thorough investigation was completed after the fall. No detailed information about the resident's fall was obtained, including where in the room the resident was found at the time of the fall, whether or not her/his call light was activated, the last time she/he interacted with staff, whether or not the resident wore nonskid footwear or whether or not the resident's personal items were in reach. On 8/16/24 at 11:30 AM Staff 2 (DNS) and Staff 3 (Interim DNS) acknowledged the findings of this investigation. Staff 3 stated a thorough fall investigation included an evaluation of the events that lead up to the fall, resident and witness statements, a review of the resident's care plan and an interview with the staff person who provided care to the resident prior to the fall. Staff 3 confirmed the investigation of Resident 37's fall on 5/13/24 was not thorough and stated it was unclear if the resident's care plan was followed. Staff 3 further stated the resident's At Risk For Falls Care Plan and the conclusion of the investigation were inaccurate. , 2. Resident 360 was admitted to the facility in 7/2024 with diagnoses including urinary tract infection and acute kidney failure. An Investigation Report dated 8/9/24 indicated on 8/3/24 at about 10:00 PM, Resident 360 was found on the floor by a CNA during rounds and Resident 360 had been sleeping prior to event and had a urinal at bedside. Resident 360 was disoriented and forgot she/he had a urinal when she/he woke up. The resident stated at the time she/he was getting up to go to the bathroom. When questioned later by a facility RCM (Resident Care Manager), Resident 360 did not remember what happened. The investigation did not include witness statements. On 8/15/24 at 3:36 PM Staff 4 (RNCM) stated the only witness to Resident 360's fall was Staff 28 (CNA). Staff 4 stated she tried calling Staff 28 for a follow up, but Staff 28 did not respond. On 8/15/24 at 4:44 PM staff 28 stated she was driving and needed to call back for an interview. She did not call back. On 8/16/24 at 9:34 AM Staff 4 acknowledged that she did not interview Staff 28. Staff 4 was informed this investigation did not include a witness statements, and Staff 4 agreed. On 8/16/24 at 11:26 AM Staff 3 (Interim DNS) stated the RNCM was expected to obtain resident and witness statements, and the investigation should show the "whole picture." Staff 2 (DNS) acknowledged abuse or neglect could not be ruled out because the investigation was not thorough.

1.Resident 37’s recent falls were re-reviewed, and the plan of care was updated as needed 2.Resident 360’s recent falls were re- reviewed, and the plan of care was updated as needed 3.Residents that have fallen in the last 14 days were re-reviewed and their plans of care were updated. 4.RCMs were educated on completing investigations thoroughly and updating the plan of care as needed. Falls will be reviewed daily in clinical meeting until the investigation is complete and the care plan is updated. 5.Administrator/Designee will audit falls to ensure a thorough investigation was completed and the plan of care was updated weekly x4, monthly x2 or until compliance is achieved.

Based on interview and record review it was determined the facility failed to follow physician orders and provide correct humidity administration for 1 of 1 sampled resident (#17) reviewed for respiratory care. This placed residents at risk for improper humidity administration. Findings include: A Respiratory Treatment Policy and Procedure dated 6/22/22 stated: "It is the policy of this center that residents receive respiratory treatments and monitoring per their physician orders, standards of practice and care plan." Resident 17 admitted to the facility in 3/2024 with diagnoses including respiratory failure which included a tracheostomy required to breathe and malnutrition. A 3/13/24 physician order for Resident 17 revealed the resident used humidity mist via her/his tracheostomy with a flow rate of eight liters per minute at all times. The 6/13/24 Quarterly MDS indicated Resident 17 was severely cognitively impaired. On 8/15/24 at 8:50 AM Staff 19 (LPN) observed Resident 17's humidity mist and confirmed it was set at four liters per minute. On 8/15/24 at 10:57 AM Staff 3 (Interim DNS) confirmed Resident 17's humidity mist was to be set a eight liters at all times.

1.Licensed nurse set the flow rate of the humidity mist to the prescribed order 2.Director of Nursing Services (DNS) and Resident Care Managers (RCMs) audited residents who has orders for humidity via trach mist. Any deficiencies found were corrected. 3.Staff Development Coordinator (SDC) educated licensed nurses on ensuring the settings on the humidity mist follows the physician order. 4.DNS and/or designee will monitor residents with trach to have accurate humidity mist settings for weekly x 4, and then monthly x 2. Any negative findings will be brought to the QAPI committee for review and recommendations as determined by the committee or until substantial compliance has been achieved. The Administrator is reasonable for compliance.

Based on interview and record review it was determined the facility failed to employ a Physical Therapist to provide therapy services to 1 of 1 resident (# 209) reviewed for therapy services. This placed residents at risk of a decline in function and/or a delayed recovery. Findings include: Resident 209 admitted to the facility on 8/6/24 with diagnoses including multiple left toe fractures. Hospital orders from 8/6/24 included instructions for Resident 209 to receive a PT evaluation and services. Review of therapy records on from 8/6/24 to 8/13/24 revealed Resident 209 had not been evaluated by PT and therefore had not received PT services to assist with her/his transfer safety and mobility. On 8/14/24 at 2:50 PM Staff 20 (Rehabilitation Director) stated the facility had not been able to have a consistent physical therapist who performed evaluations or provided therapy services. Staff 20 stated the frequency and duration of therapy services had to be reduced for all residents due to insufficient therapy staff. Staff 20 stated ideally residents who required therapy would have received one discipline of therapy five times a week and another disciple based on their areas of deficiencies. Staff 20 confirmed Resident 209 had not received physical therapy services from 8/6/24 through 8/13/24.

1.Physical Therapist finished and completed physical therapy evaluation on 08/14/2024. 2.Director of Rehabilitation (DOR) audited admissions in the last 30 days with orders for physical therapy, occupational therapy, and/or speech therapy has had their evaluations completed timely. Any deficiencies found were corrected. 3.On 08/29,2024, the Regional Director of Rehabilitation provided 1:1 education to DOR on the importance of scheduling timely therapy evaluations. 4.New admits will be reviewed in MACC and if therapy orders are noted, RCM will ensure the rehab manager is aware 5.Administrator and/or designee will monitor admissions that comes in with therapy orders and meet with DOR to ensure therapy evaluations are schedule timely for weekly x 4 and then monthly x 2. Any negative findings will be brought to the QAPI committee for review and recommendations as determined by the committee or until substantial compliance has been achieved. The Administrator is reasonable for compliance.

Based on interview and record review it was determined the facility failed to have a plan in place to coordinate care and document hospice services for 1 of 1 sampled resident (#359) reviewed for hospice. This placed residents at risk for lack of coordination of care. Findings include: Resident 359 admitted to the facility in 7/2024 with diagnoses including failure to thrive and acute kidney failure. Resident's 359's health record indicated the resident was admitted to hospice services on 8/6/24. There was no further documentation including contact information, physican's orders for hospice services, hospice care plan or hospice notes. On 8/13/24 at 2:01 PM Staff 11 (Social Services Director) stated resident 359 began hospice services on 8/6/24 and Staff 11 did not know when they came in to care for the resident. On 8/14/24 at 10:00 AM Staff 23 (CNA) stated she thought the resident received hospice services, but had not seen any hospice providers and had no communication with any hospice staff. On 8/15/24 at 10:17 AM Staff 5 (RNCM) acknowledged there was no hospice documentation in Resident 359's health record.

1.Resident Care Manager (RCM) requested documentation from the hospice for Resident #359 to be put in their medical record. 2.Director of Nursing Services (DNS) and RCMs reviewed residents that are on hospice level of care and any deficiencies were corrected 3.DNS educated RCMs on the importance of receiving hospice documentation such as contact information, physician's orders for hospice services, hospice care plan, and/or hospice notes. 4.DNS and/or designee will request a calendar of scheduled hospice visits for each hospice resident in the facility and the documentation will be followed up in clinical meeting 5.DNS and/or designee will follow up with hospice for their documentations weekly x 4 and then monthly x 2. Any negative findings will be brought to the QAPI committee for review and recommendations as determined by the committee or until substantial compliance has been achieved. The Administrator is reasonable for compliance.

Based on observation, interview, and record review it was determined the facility failed to follow infection control standards for 2 of 4 halls (East and Annex Halls), 1 of 1 dining room, and 2 of 4 sampled residents (#s 28 and 37) reviewed for dining and skin conditions. This placed residents at risk for exposure and contraction of infectious diseases. Findings include: 1. The Centers for Disease Control and Prevention website, section titled "Infection Prevention during Blood Glucose Monitoring and Insulin Administration" specified there was an increased risk for exposure to bloodborne viruses through contaminated equipment, such as glucometers, when shared. Using a [glucometer] for more than one person without cleaning and disinfecting it in between uses contributed to transmission of HBV (Hepatitis B virus). [Glucometers] should be cleaned and disinfected after every use. The facility's 4/2019 Disinfection of Point-of-Care Devices/Instrument Policy & Procedure specified all point-of-care devices, including glucometers, will be cleaned and disinfected according to manufacturer recommendation using EPA (Environmental Protection Agency) approved disinfectants. Resident 37 was admitted to the facility in 7/2023 with diagnoses including type II diabetes. Resident 28 was admitted to the facility in 8/2023 with diagnoses including type II diabetes. On 8/14/24 at 12:29 PM Staff 32 (Agency RN) was observed in Resident 28 and 37's shared room. Staff 32 used a glucometer and obtained Resident 28's blood sugar. Staff 32 returned to the medication cart in the hallway, placed the glucometer on the top surface of the cart and disinfected the glucometer with an alcohol prep pad. At 12:35 PM Staff 32 returned to the room with the used glucometer and stated she was going to obtain Resident 37's blood sugar. The State Surveyor requested to speak with Staff 32 prior to obtaining Resident 37's blood sugar. Staff 32 stated she used alcohol wipes to disinfect shared glucometers because "the purple top wipes caused a lot of errors" and she had seen other nurses use them at the facility. On 8/14/24 at 12:40 PM Staff 6 (Infection Preventionist) stated she was unsure if alcohol wipes were effective against blood borne pathogens. On 8/14/24 at 1:05 PM Staff 6 provided the glucometer's manufacturer instructions which indicated the glucometer was to be disinfected between patient uses by wiping it with a CaviWipe towelette (durable towelettes that offer quick, easy-to-use, time-saving convenience and kill organisms in only three minutes) or EPA-registered disinfecting wipe in between tests and be cleaned prior to disinfecting. Review of Resident 28 and Resident 37's health record revealed no diagnoses including viral bloodborne pathogens. On 8/14/24 at 2:33 PM Staff 2 (DNS) stated glucometers were to be disinfected according to manufacturer instructions and alcohol wipes were not to be used to disinfect glucometers as they did not kill blood borne pathogens. 2. The facility's 7/2024 Transmission Based Precautions Policy & Procedure specified the following related to Enhanced Barrier Precautions (EBP): -Residents with wounds required EBP. -Personnel was to wear gloves and a gown when dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, therapy and device care/use for a resident on EBP. -EBP applies when a wound is open and/or draining. Resident 28 was admitted to the facility in 8/2023 with diagnoses including heart failure, diabetes with a foot ulcer, cellulitis (a bacterial skin infection) of the left lower limb and acquired absence of the right foot. Resident 28's 5/20/24 Quarterly MDS revealed the resident was cognitively intact, had a total of two venous ulcers (leg ulcers caused by problems with blood flow in a person's leg veins) and arterial ulcers (a painful, deep sore or wound in the skin of the lower leg or foot) and received the application of nonsurgical dressings and ointments/medications other than to her/his feet. On 8/12/24 at 10:20 AM Staff 24 was observed to push Resident 28 in her/his wheelchair from the facility's shower room, down the hall and into the resident's shared room. The resident's legs were not covered and revealed large open wounds with chunks of missing skin and yellowish puss on both legs. A sign outside of Resident 28's room indicated she/he was on EBP. After Staff 24 assisted the resident to her/his side of the room, Staff 24 placed a towel under the resident's left foot and right stump, removed the resident's breakfast tray and exited the room. Staff 24 did not wear gloves or a gown when she pushed the resident in her/his wheelchair or when she placed a towel under her/his foot/stump. Staff 24 was not observed to perform hand hygiene after she pushed the resident in her/his wheelchair and prior to retrieving the towel that was placed under her/his bare foot/stump. At 10:23 AM Resident 28 was observed with her/his bare foot/stump off of the towel and directly on the floor. At this time, the resident's right leg was observed with blood running down. On 8/12/24 at 10:32 AM Staff 24 stated staff were supposed to wear gloves, a mask and a gown whenever they worked with residents who were on EBP. Staff 24 stated Resident 28 was on EBP and she did not wear the appropriate PPE when she transported the resident from the shower room or when providing her/him with a towel. Staff 24 further stated she liked to put a towel under the resident's foot/stump because they "leaked water." Observations of Resident 28 on 8/12/24 from 10:23 AM to 10:59 AM revealed Resident 28's foot/stump to rest uncovered on the floor of her/his room. A pool of clear fluid was observed on the ground where the resident's foot/stump had previously rested. At 10:43 AM Staff 15 (RN) entered the resident's room, asked the resident if the towel was underneath her/his foot/stump, said "oh," pointed to the towel on the ground and left the room. On 8/12/24 at 10:59 AM Staff 15 re-entered the resident's room to provide treatments to both of the resident's legs. Prior to completing the treatments, Staff 15 was observed to step in the pool of clear fluid on the floor of the resident's room. At 11:47 AM Staff 15 stated she expected staff to wear gloves when they assisted Resident 28 when her/his wounds were uncovered. Staff 15 stated she thought the resident's foot and stump should be on a towel when uncovered "because they wept a lot and I don't know what else to do." On 8/13/24 at 12:45 PM Resident 28 was observed to sit in her/his wheelchair in her/his room. The resident's leg wounds were covered and she/he wore non-skid socks over the bandages on her/his feet. No towel was observed underneath the resident's foot/stump and a wet towel was observed in a clump next to the foot of the resident's bed. Resident 28 stated her/his foot and stump were always leaking but she/he could not tell or feel it when they did. On 8/14/24 at 9:40 AM Staff 10 (CNA) stated she had frequently seen a trail of liquid coming from Resident 28's feet on the floor throughout the facility. Staff 10 stated she had not been instructed on what to do when she noticed the trail of liquid on the floor from the resident's feet but thought housekeeping regularly mopped the floors. Staff 10 further stated she regularly changed the resident's socks and towel as they were often soaked all the way through with liquid from her/his feet. On 8/14/24 at 10:21 AM Staff 29 (CNA) stated she had noticed "a couple of times in the hallway" liquid trails coming from Resident 28's feet. Staff 29 stated she noticed some staff just put a towel down when they noticed the trail but she would clean it up with a towel and then take the dirty towel to the laundry. On 8/14/24 at 11:53 AM Resident 28 was observed to wheel her/himself down the hall, around a corner and into a shared resident bathroom. A trail of clear liquid was observed on the ground that followed the resident from her/his room to the bathroom. An unidentified staff person assisted the resident into the bathroom, closed the door behind the resident and stepped into the liquid left on the floor. From 11:53 AM to 12:15 PM five different staff and two different residents were observed to step in the liquid Resident 28 left behind on the floor. On 8/14/24 at 2:54 PM Resident 28 stated her/his room was cleaned and mopped only once in the morning each day. On 8/15/24 at 9:38 AM Staff 29 was observed to leave the resident shower room with a black garbage bag filled with used towels. Staff 29 did not wear gloves or a gown. At 9:39 AM Staff 29 stated she just gave Resident 28 a shower during which she wore gloves and a mask but not a gown. Staff 29 stated the garbage bag was filled with dirty towels from Resident 28's shower. On 8/15/24 at 11:50 AM Staff 6 (Infection Preventionist) and Staff 17 (RN Consultant) acknowledged the findings of this investigation. Staff 17 stated she expected staff to wear a gown and gloves when with Resident 28 any time her/his wounds were not covered and when assisting her/him with a shower. Staff 17 stated she expected Resident 28's wounds to be covered when out of her/his room and staff "should clean the floor as soon as possible" if the liquid coming from Resident 28's foot/stump could not be contained. Staff 17 further stated she expected staff to "keep on top of changing the resident's dressings and socks." , 3. The facility's Hand Hygiene Policy, last revised 12/15/21, indicated hand hygiene was the primary means of preventing the transmission of infection. On 8/12/24 between the hours of 12:11 PM and 12:30 PM, during the lunch meal in the main dining room and residents' lunch tray pass on the Annex Hall, the following observations were made: -12:18 PM Staff 26 (CNA) was observed in the main dining area wearing a surgical mask which was below her nose. Staff 26 adjusted her surgical mask and then assisted a resident to prepare and set-up their lunch tray. No hand hygiene was performed. Staff 26 was, again, observed with her surgical mask below her nose, adjusted her mask and then assisted another resident to prepare and set-up their tray, touching the resident's silverware and tray items. No hand hygiene was completed after adjusting her mask or between assisting residents. -12:25 PM Staff 27 (CNA) was observed passing beverages on Annex Hall. Staff 27 entered room 110, adjusted the resident's bedside table and moved objects on the table prior to placing the beverage down. Staff 27 was observed repeating this process for residents' in rooms 113, 114, 116 and 119. Staff 27 did not complete hand hygiene after exiting or before entering any of the residents' rooms. On 8/12/24 at 12:22 PM Staff 26 stated she was not supposed to touch her surgical mask but if she did, she was supposed to complete hand hygiene. Staff 26 confirmed she did not complete hand hygiene after touching her mask or between residents. On 8/12/24 at 12:31 PM Staff 27 stated he was supposed to complete hand hygiene after touching "something" belonging to a resident. Staff 27 stated he tried to do as much hand hygiene as possible but did not always consistently perform hand hyiene. On 8/16/24 at 8:35 AM and 10:01 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 3 (Interim DNS) stated staff were expected to complete hand hygiene each time they went in and out of a resident's room. Staff 1 and Staff 2 stated they also expected hand hygiene to be completed after touching something dirty and before touching something clean. , 4. On 8/13/24 at 12:56 PM Staff 13 (CNA) was observed in the east hall picking up dirty food trays. Staff 13 picked up room 147's dirty tray, placed it in the cart and went into room 151, no hand hygiene was completed. Staff 13 exited room 151 and went into room 152, no hand hygiene was completed. Staff 13 exited room 152 with a dirty food tray, placed it in the cart and with into room 144, no hand hygiene was completed. Staff 13 was observed in room 144 attempting to assist the resident with eating, the resident refused the meal, staff 13 exited room 144 with the dirty food tray and placed it in the cart, no hand hygiene was completed. Staff 13 stated she was not taught to clean her hands between picking up dirty food trays. On 8/16/24 at 8:35 AM Staff 3 (Interim DON) stated staff are expected to perform hand hygeine each time they go in and out of rooms.

1.The glucometer was immediately disinfected per manufacturer's instructions 2.Resident 28 had medication and treatment adjustments to address the leaking wounds. They are no longer weeping outside of the dressing. Resident remains on EB precautions. Resident's wounds are covered when leaving the room and staff will wear appropriate PPE when caring for Resident 28 3.Staff 26, 27, and 13 were immediately educated on when to perform hand hygiene 4.All resident’s with wounds were reviewed to ensure their wounds are appropriately dressed without leaking and are covered when they leave their room. They are on EB precautions and staff wear appropriate PPE when caring for them 5.Licensed nurses were educated on how and when to clean glucometer devices 6.Licensed nurses and CNAs were educated that wounds should be covered before residents come out of their room and report to the provider or their nurse if there are any issues with the dressing leaking. Staff educated on when to wear PPE when caring for residents on EB precautions. Staff educated on when and how to complete hand hygiene. 7.DNS/Designee will complete random audits on hand hygiene, the cleaning of glucometers, and residents on EB precautions weekly x4, monthly x 2 or until compliance is achieved.

Based on interview and record review it was determined the facility failed to obtain reference checks for 3 of 5 newly hired facility staff members (#s 8, 9 and 10) reviewed for background checks. This placed residents at risk for abuse. Findings include: On 8/13/24 at 9:53 AM Staff 22 (Human Resources) stated she completed reference checks for employment candidates. A review of the facility's new hires in the previous four months revealed the following: -Staff 8 (CNA) was hired on 5/20/24; -Staff 9 (CNA) was hired on 6/11/24 and -Staff 10 (NA) was hired on 4/25/24. There was no evidence reference checks were completed for Staff 8, Staff 9 and Staff 10. On 8/13/24 at 9:53 AM Staff 22 confirmed she was unable to locate any reference checks for Staff 8, Staff 9 and Staff 10.

1.Facility’s Human Resource and Payroll Coordinator (HRPC) completed reference checks for Staff 8, Staff 9, and Staff 10. 2.HR audited the last 10 new hires to see if reference checks were done. 10 of the new hires’ references checks were not done. It has now been completed. 3.Administrator educated the hiring manager on the importance of having reference checks done for prospective employees 4.Administrator and/or designee will ensure reference checks are done for all prospective employees prior to employment for weekly x 4 and then monthly x 2. Any negative findings will be brought to the QAPI committee for review and recommendations as determined by the committee or until substantial compliance has been achieved. The Administrator is reasonable for compliance.

Based on observation and interview it was determined the facility failed to ensure a nurse call light system with an audible signal at the nurse station and visible signal in the corridor outside the residents' rooms for 1 of 1 facility reviewed for call light response times. This placed residents at risk for lack of timely assistance and unmet needs. Findings include: Random observations from 8/12/24 through 8/16/24 between the hours of 8:00 AM and 3:30 PM revealed: - The nurses' stations where the call light system monitors were located did not consistently have staff present and no audible sound was heard when call lights were activated. - The call light monitors located in the hallways did not have audible sound. - When a resident utilized their call light, the light outside the resident's room did not illuminate. On 8/14/24 at 8:02 AM Room 110's call light was activated but the light outside the resident's room did not illuminate and no audible sound was heard on the call light monitors in the hallways or at the nurses' stations. On 8/14/24 at 8:04 AM and 8:54 AM Staff 10 (CNA) and Staff 23 (CNA) stated resident rooms did not have an audio or visual signal to indicate an activated resident call light. Staff 10 and Staff 23 stated in order to see if residents' call lights were activated, they had to locate a call light monitor in one of the hallways or at a nurse's station because they did not carry call light notification devices on their persons. On 8/16/24 at 10:01 PM Staff 1 (Administrator) confirmed the facility had a wireless nurse call light system (a call system that was not audible at the nurses' stations and did not illuminate outside residents' rooms) and the facility did not renew their previous wireless nurse call light system waiver that expired in 10/2022.

1.All residents in the facility are affected by the deficient practice. 2.Administrator will submit a “Nursing Facility Wavier Request to Oregon Administrative Rule.” Residents in the facility have the potential to be affected by the deficient practice. 3.Regional Support Nurse (RSN) provided 1:1 education to Administrator about the importance of renewing waivers prior it to being expired. 4.Waivers will be audited yearly and renewed as needed.

******************** 411-085-0310 Residents' Rights: Generally Refer to F553 and F585 ******************** 411-087-0100 Physical Environment: Generally Refer to F584 ******************** 411-085-0360 Abuse Refer to F610 ******************** 411-088-0080 Notice Requirements Refer to F623 ******************** 411-088-0050 Right to Return from Hospital Refer to F625 ******************** 411-086-0300 Clinical Records Refer to F641 ******************** 411-086-0060 Comprehensive Assessment and Care Plan Refer to F657 ******************** 411-086-0110 Nursing Services: Resident Care Refer to F677, F684 and F695 ******************** 411-086-0140 Nursing Services: Problem Resolution & Preventive Care Refer to F689 ******************** 411-086-0110 Administrator Refer to F840 ******************** 411-086-0010 Administrator Refer to F849 ******************** 411-086-0330 Infection Control and Universal Precautions Refer to F880 ********************

Based on observation and interview it was determined the facility failed to have adequate staff available to meet resident care needs in a timely manner for 1 of 1 facility reviewed for staffing and call light response times. This placed residents at risk for delayed and unmet needs and lengthy call light response times. Findings include: On 5/9/24 the facility had a census of 63 residents. On 5/13/24, Staff 2 (DNS) provided a list of residents who: -Required two-person mechanical lift transfers: 12 -Required one or two-person extensive or total assistance for bathing: 58 -Required one or two-person extensive or total assistance for toileting: 22 -Required one or two-person extensive or total assistance for dressing: 39 -Required suctioning due to a tracheostomy (an opening into the trachea from the outside due to obstructed breathing): 2 -Required tube feedings: 4 -Had behavioral healthcare needs: 8 Observations from 5/9/24 through 5/13/24 from the hours of 8:15 AM to 1:30 PM revealed the following concerns: -5/9/24 at 8:36 AM the call light in room 106 was activated. The call light was responded to at 9:23 AM for a total wait time of 47 minutes. -5/9/24 at 10:41 AM the call light in room 137 was activated. The call light was responded to at 11:10 AM for a total wait time of 29 minutes. -5/9/24 at 11:33 AM the call light in room 106 was activated. The call light was responded to at 1:15 PM for a total wait time of one hour and 42 minutes. During that time, the resident's spouse was observed, several times, to leave room 106 in an attempt to find assistance. On several occasions, multiple staff were observed walking past room 106 without responding to the activated call light. -5/9/24 at 12:38 PM the call light in room 153 was activated. The call light was responded to at 1:16 PM for a total wait time of 38 minutes. -5/9/24 at 12:43 PM the call light in room 148 was activated. The call light was responded to at 1:16 PM for a total wait time of 33 minutes. -5/9/24 at 1:14 PM the call light in room 126 was activated. The call light was responded to at 2:25 PM for a total wait time of one hour and 41 minutes. -5/10/24: at 8:15 AM the call light in room 137 was activated. The call light was responded to at 8:59 AM for a total wait time of 44 minutes. -5/13/24 at 8:52 AM the call light in the east front hall bathroom was activated. The call light was responded to at 9:17 for a total wait time of 25 minutes. On 5/9/24 at 10:13 AM Witness 1 (Complainant) reported Resident 4 arrived at the facility from the hospital around noon on 2/17/24. Witness 1 stated Resident 4 was taken to her/his assigned room but nobody checked on her/him so Resident 4 activated her/his call light and, still no one came. Witness 1 stated Resident 4 then called a neighbor who came and picked the resident up from the facility and took her/him home. Witness 1 stated Resident 4 left because of the lack of available and timely help. On 5/9/24 at 12:40 PM Witness 2 (Family) reported the call light in room 106 was activated since 11:33 AM because Resident 9 wanted to get back into bed after therapy. Witness 2 stated Resident 9 required two-person assistance, using a mechanical lift, to get back into bed so the resident had to wait until the CNAs finished "feeding" other residents. Resident 9 stated she/he was tired but "OK". At 1:14 PM, Witness 2 was observed notifying Staff 11 (RN) that Resident 9 had been sitting up "too long" and needed to be assisted back to bed. On 5/9/24 at 2:02 PM Staff 12 (CNA) stated the facility was "always short staffed." Staff 12 stated she was assigned several high acuity residents, including two residents who took over one hour to "feed" and another resident who would "get up and fall" if not watched closely. Staff 12 stated she ran "all over the place" and it was difficult to get all of the residents' care done in a timely manner. On 5/9/24 at 3:05 PM Staff 14 (CNA) stated as far back as 9/2023, the facility was short staffed. She stated during 1/2024 and 2/2024, she was assigned as many as 12 residents. Staff 12 stated there was an "ongoing" issue with CNAs being assigned several residents who required "a lot of care and a lot of time." Staff 14 stated when the facility was short staffed, CNAs were unable to provide the "social interaction that enriches" the lives of residents and resident interactions became "task-centered" instead of "person-centered." In addition, Staff 14 stated when staffing was not adequate, showers were missed and resident falls increased. Staff 14 stated she never took a break and often had to stay late to complete resident care and get her charting done. On 5/10/24 at 9:20 AM Staff 15 (CNA) reported over the past year and up until 2/2024, staffing was "horrid." Staff 15 stated the facility was "always" short staffed and CNAs were "overloaded." Staff 15 stated she was assigned up to 10 residents, at times, which resulted in a "lack of care" for the residents. Staff 15 stated when the facility was inadequately staffed, residents had to wait longer to get changed, showers were missed and call light response times were long. On 5/10/24 at 10:22 AM and 5/13/24 at 9:50 AM Resident 9 stated it could take an hour to an hour and a half to be assisted. Resident 9 reported around mealtime there was no CNA assistance available because there were two residents that required total assistance for eating and they each took up to an hour each to eat. Resident 9 stated over the weekend, she/he did not receive a shower because there was not adequate staff to assist her/him. Resident 9 stated, because of her/his medical condition, she/he was scared when staff were not available to answer the call light timely when she/he was alone in her/his room. On 5/13/24 at 10:18 AM Staff 24 (Staffing Coordinator) stated she determined CNA staffing based on the mandatory minimum CNA staffing ratios. Staff 24 stated she did not know the acuity needs of the residents, including the newly admitted residents, unless a CNA or nurse notified her but there was a lack of communication regarding resident acuity. Staff 24 stated the facility was aware of long call light response times but was unsure as to why long call light response times persisted and were an ongoing problem. Staff 24 stated staff were expected to respond to call lights within 15 minutes. On 5/13/24 at 11:52 AM staffing concerns, including long call light response times, were reviewed with Staff 1 (Administrator). Staff 1 stated the facility typically staffed according to the mandatory minimum CNA staffing ratios and he expected call lights to be responded to "promptly" but within 15 minutes, maximum.

How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Residents in Room 106, 137, and 148 were interviewed regarding the call lights. Resident in 106 was noted with concerns and resident was informed of the facility’s plan of correction. Resident was satisfied. Residents in Room 153 and 126 were already discharged from the facility. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: Residents who reside in the facility are at potential risk for this deficient practice. All residents were interviewed, and concerns were addressed by informing them of the facility’s plan of correction. iAlert (call light system) phones will be given to licensed nurses on the medication cart and clinical management staff to monitor call lights and assist if needed. Measures the nursing home will take or the systems it will alter to ensure that the problem does not recur: Staff Development Coordinator (SDC) and/or designee re-educated staff on expectations of answering and resetting call lights. Staff is to notify management of any issues or concerns regarding call lights. SDC and/or designee will re-educate staff on effective communication with teammates to ensure resident care is provided in a timely manner. Staff is to notify management of any issues or concerns regarding completing resident care timely. How the nursing home plans to monitor its performance to make sure that solutions are sustained: To ensure ongoing compliance, the Director of Nursing Services or designee will conduct resident interviews weekly x4, then monthly x 2 regarding call light response and will continue until compliance is achieved. Results of interviews will be brought to the QAPI committee for review and recommendations as determined by the committee or until substantial compliance has been achieved. The Administrator is reasonable for compliance.

************************* OAR 411-086-0100 Nursing Services: Staffing Refer to F725. *************************

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 04/01/2024 and 04/07/2024, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 02/05/2024 and 02/11/2024, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on interview and record review it was determined the facility failed to implement policies and procedures for the prevention of sexual abuse for 2 of 2 sampled residents (#s 1 and 2) reviewed for abuse. This failure, determined to be an immediate jeopardy situation, placed residents at risk for sexual abuse when staff witnessed repeated nonconsensual sexual activity without putting interventions in place. Findings include: A 1/2023 facility abuse policy indicated the following. - A thorough investigation is completed through a systematic collection and review of evidence/information that describes and explains an event or series of events. It seeks to determine if abuse occurred, and how to prevent further occurrences. - Sexual abuse is defined as sexual contact where the resident has no ability to consent. - Residents with sexual behaviors are assessed to determine their ability to give informed consent related to sexual acts. - Staff with knowledge of inappropriate sexual comments or contact between residents are to report immediately to the facility administration. Resident 1 was admitted in 12/2022 with diagnoses including schizoaffective disorder, bipolar disorder and cognitive impairment. Resident 1's 1/12/24 Quarterly MDS indicated moderate cognitive impairment. Resident 2 was admitted in 4/2023 with a diagnosis of cognitive impairment. Resident 2's 1/19/24 Quarterly MDS indicated moderate cognitive impairment. A Facility Reported Incident (FRI) was submitted on 1/29/24 which indicated Resident 1 was observed fellating Resident 2 on 1/27/24. Staff 3 (CNA) separated the two residents and informed management. A Review of Resident 1 and 2's clinical records from 1/1/24 through 1/27/24 revealed the following regarding their sexual interactions: - No progress notes. - No physician orders. - No monitoring tasks for CNAs. - No care plan revisions for Resident 1. - No sexual behavior care plan for Resident 2. - No notification of Resident 2's public guardian. - No notification of either physician. - No facility sexual consent assessment. - An untitled document dated 1/15/24, written by Witness 1 (Licensed Clinical Social Worker, LCSW), which indicated a sexual incident between Resident 1 and Resident 2 occurred "a few days prior." The document indicated Resident 1 did not have the cognitive capacity to understand the consequences of engaging in a sexual relationship. Witness 1 recommended moving either resident's room to a different room to monitor Resident 1's safety as Resident 1 was at risk for sexual abuse. On 1/30/24 at 10:45 AM Staff 1 (Administrator) and Staff 2 (DNS) stated on 1/29/24 the facility put interventions in place to prevent sex abuse. The facility initiated one on one supervision of Resident 1. The ombudsman, police, providers, and responsible parties were notified. Resident 1 was moved to the other side of the facility. Staff 2 requested a psychological review of both residents. In-services were initiated for all staff related to identification and reporting of abuse. On 1/30/24 at 11:48 AM Staff 3 (CNA) confirmed she observed Resident 1 and Resident 2 engaging in a sex act in the doorway of Resident 2's room on 1/27/24. Staff 3 stated she reported the incident to Staff 4 (LPN). Staff 3 stated the incident was reported to Staff 5 (HR/Payroll) the manager of the day on 1/27/24. Staff 3 indicated she was told by management that because both residents were cognitively impaired there was no problem with the behavior. Staff 3 confirmed she only reported the incident because it occurred within eyesight of other residents. On 1/30/24 at 1:23 PM Staff 5 stated, on 1/27/24 when she was manager of the day, Staff 4 came to her and said "I don't know what to do, [Resident 1] and [Resident 2] were doing something." Staff 5 stated she told Staff 4, "If the residents were doing something to make sure neither of them were doing anything they didn't want to. If one doesn't want to then separate them." When asked to clarify what was meant by "doing something", Staff 5 indicated she was not sure what occurred. Staff 5 stated she did not know Resident 1 and Resident 2 were involved in an actual sex act and told Staff 4 she should have been notified sooner. Staff 5 stated she never followed up with Staff 4 regarding this incident. Staff 5 stated she would have had to ask what the proper procedure was. On 2/1/24 at 4:00 PM Witness 1 stated her understanding at the time of the 1/15/24 evaluation was that a sex act occurred. Witness 1 stated she shared her recommendations with facility administration and asked repeatedly from 1/15/24 through 1/29/24 if the residents were moved for Resident 1's safety. On 2/1/24 at 10:51 AM Staff 7 (CNA) indicated she observed Residents1 and Resident 2 engage in a sexual activity during a bible study activity during the week of 1/22/24. Staff 7 stated she saw Resident 1 holding Resident 2's exposed genitalia. Staff 7 stated management was made aware of the incident and as a result staff were told to "try" to keep the residents apart. Staff 7 stated keeping the residents separated was "very difficult" because Resident 1 and Resident 2's rooms were right across from each other. Staff 7 stated she was aware of sexual activity between Residents 1 and 2 since approximately 1/11/24. On 2/1/24 at 11:38 AM Staff 8 (CNA) indicated she was made aware of Resident 1 and Resident 2's sexual activities by fellow staff but received no instruction from management on how to keep the residents safe. Staff 8 stated the attempts to keep Residents 1 and 2 separate were constant the last week and a half. Staff 8 stated staff did not have an updated plan of care regarding the residents' sexual activity, and as a result did not know to keep Residents 1 and 2 separated. On 2/1/24 at 12:07 PM Staff 9 (LPN) stated it was difficult to pinpoint when Resident 1 and Resident 2's sexual activities started because the facility staff did not react when they became aware of the incidents. Staff 9 stated she expected an investigation of the residents' relationship would have occurred, and interventions put in place. Staff 9 estimated the residents' sexual activities started on approximately 1/1/24. During interviews on 1/30/24 at 12:40 PM, 2/1/24 at 12:43 PM, and 2/2/24 at 9:38 AM Staff 6 (Social Services Director) stated 1/27/24 was the first time "anything was reported to me." Staff 6 stated "until something is written down and documented I do not respond." Staff 6 confirmed she heard talk of Resident 1 and 2 having a sexual relationship prior to 1/27/24 but did not investigate it. Staff 6 stated she was aware of the evaluation completed and was aware of the recommendation to separate Residents 1 and 2 for their safety. Staff 6 confirmed Resident 2 was moved on 1/29/24, 14 days after it was recommended the residents be separated for Resident 1's safety, and two days after the 1/27/29 incident. Staff 6 confirmed the residents' sexual interactions should have been documented from the beginning. Staff 6 confirmed no action was taken regarding the 1/27/29 sexual incident between Residents 1 and 2 until 1/29/24. On 2/1/24 at 1:20 PM Staff 10 (RN) stated staff were not trained properly in what to do when they observed a sex act between two residents. Staff 10 confirmed there was no documentation that Residents 1 and 2 were monitored for sexual behavior. On 1/30/24 at 10:24 AM time Staff 2 acknowledged Witness 1's recommendations for Resident 1's safety were not followed. Staff 2 indicated in response to the sexual activity between Residents 1 and 2 the facility should have put immediate safety interventions in place, requested a psychiatric consult for both residents, notified all needed parties, and updated care plans. Staff 2 indicated staff who were aware of the sexual activities should have separated the residents and informed management, and management should have initiated an investigation when the first incident occurred. Staff 2 confirmed these activities were not initiated until 1/29/24, two days after the date of the most recent incident. On 2/2/24 at 2:39 PM the facility was notified of the Immediate jeopardy (IJ) situation, determined to begin as of 1/15/24, and an immediacy removal plan was requested. On 12/2/24 at 4:20 PM the facility submitted an acceptable immediacy removal plan. The immediacy removal plan included the following: Residents 1 and 2 still reside in the facility. Resident 1 was assessed for s/sx of psychological distress and has been placed on 1:1 staff supervision. Resident 2 was assessed for s/sx of psychological distress. Completed on 1/31/24. Residents 1 and 2's care plans have been updated to reflect the current plan of care, including sexual consent capacity assessments. Resident 2 has been educated on safe sex practices and sexual consent facility policy. Completed on 1/30/24. Residents who reside in the facility are at potential risk for this deficient practice. Resident and staff interviews to be completed to determine if there have been any other sexual relationships identified. Completed 2/2/24 by 4:00pm. 1. The alleged perpetrator was interviewed regarding the behavior and placed on 1:1 supervision. Completed on 1/29/24. Resident placed on alert monitoring for any continued behaviors. Completed 1/29/24. Complete sexual consent capacity assessment 1 and 2. Completed on 1/31/24. 2. Alleged victim interviewed regarding the incident and assessed for any emotional distress due to the interaction.Completed 1/29/24. Resident placed on alert monitoring for any distress related to the incident. Completed on 1/29/24. Complete a sexual consent capacity assessment for resident 1 and 2. Completed on 1/31/24. 3. Providers of the involved residents notified. Completed 1/29/24. 4. Families/POA of the involved residents notified. Completed on 1/30/24. 5. Local police notified. Completed 1/29/24. 6. Ombudsman notified. Completed on 1/29/24. 7. Pharmacy consultant notified to complete medication review on alleged perpetrator. Completed on 1/31/24. 8. Interview able residents questioned regarding their interactions with other residents to help identify any other potential residents the female resident may have performed sexual acts on. Completed 1/30/24. If other residents are identified, the center will complete steps 2 through 7 for them. Completed 1/30/24. 9. Non-interview able residents had their skin assessments completed to identify any potential impairments to their groin area indicating sexual contact. Completed on 1/31/24. If other residents are identified, center will complete steps 2 through 7 for them. Completed on 1/31/24. 10. Staff interviews initiated to help identify any other instances where the resident may have been engaged in sexual activity with another resident. Completed on 2/1/24. For any additional instances identified, the center will follow steps 2 through 7. Completed on 2/1/24. 11. Current actively working Staff have been re-educated on center abuse and neglect policy on 2/2/24 by 5:00pm. All Staff have been notified that they need to be reeducated prior to the start of shift. Resident council held to review resident rights with those in attendance, completed on 2/1/24. 12. Resident care plan reviewed and updated on 1/31/24. 13. An ad hoc QAPI meeting held with the medical director and members of the IDT to review incident and active plan to prevent abuse in the center. Feedback from the medical director solicited for any recommended additions to the current interventions. Completed on 1/30/24. - Administrator and/or designee-initiated re-education with staff on what to do if they see residents engaging in sexual acts with other residents, who to alert, and how to protect the residents from non-consensual sex. Education was initiated on the facility's abuse and neglect policy, and sexual consent policy. Completed on 2/2/24. - Record reviews on Resident 1 and Resident 2 were completed to look for any other incidents to investigate. Completed on 2/1/24. - QAPI meeting and medical director in agreement with IDT. Social Services involved in assessment process along with medical director. Completed on 1/31/24. - To ensure ongoing compliance, DNS or designee will conduct chart review, resident and staff interviews around sexual activities weekly x 4, then monthly x 2, 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. - The Administrator is responsible for compliance. - Dates when the corrective action will be completed: 2/2/24. The immediacy was determined to be removed on 2/2/24 at the close of business based on onsite verification of implementation of the IJ removal plan.

How will the nursing home correct the deficiency as it relates to residents:¿¿¿ Residents 1 and 2 still reside in the facility. Resident 1 was assessed for s/sx of psychological distress and has been placed on 1:1 staff supervision. Resident 2 was assessed for s/sx of psychological distress. Dates when the corrective action will be completed: 1/31/2024¿ ¿ Resident 1 and 2 care plans have been updated to reflect the current plan of care, including sexual consent capacity assessment. Resident 2 has been educated on safe sex practices and sexual consent facility policy. Dates when the corrective action will be completed: 1/30/2024 ¿ How the nursing home will act to protect residents in similar situations:¿¿ ¿ Residents who reside in the facility are at potential risk for this deficient practice. Resident and staff interviews to be completed to determine if there have been any other sexual relationships identified. Dates when the corrective action will be completed: 2/2/2024¿¿ The alleged perpetrator was interviewed regarding the behavior and placed on 1:1 supervision. Resident placed on alert monitoring for any continued behaviors. Complete sexual consent capacity assessment 1 and 2. Alleged victim interviewed regarding the incident and assessed for any emotional distress due to the interaction. Resident placed on alert monitoring for any distress related to the incident. Complete a sexual consent capacity assessment for resident 1 and 2. Providers of the involved residents notified. Families/POA of the involved residents notified. Local police notified. Ombudsman notified. Pharmacy consultant notified to complete medication review on alleged perpetrator. Interview able residents questioned regarding their interactions with other residents to help identify any other potential residents the female resident may have performed sexual acts on. If other residents are identified, the center will complete steps 2 through 7 for them. Non-interviewable residents had their skin assessments completed to identify any potential impairments to their groin area indicating sexual contact. If other residents are identified, center will complete steps 2 through 7 for them. Staff interviews initiated to help identify any other instances where the resident may have been engaged in sexual activity with another resident. For any additional instances identified, the center will follow steps 2 through 7. Current actively working Staff have been re-educated on center abuse and neglect policy on 2/2/2024 by 5:00pm. All Staff have been notified that they need to be reeducated prior to the start of shift. Resident council held to review resident rights with those in attendance. Resident care plan reviewed and updated.¿ An ad hoc QAPI meeting held with the medical director and members of the IDT to review incident and active plan to prevent abuse in the center. Feedback from the medical director solicited for any recommended additions to the current interventions. Dates when the corrective action will be completed: 02/02/2024 Measures the nursing home will take or the systems it will alter to ensure that the problem does not recur:¿¿ ¿ Administrator and/or designee-initiated re-education with staff on what to do if they see residents engaging in sexual acts with other residents, who to alert, and how to protect the residents from non-consensual sex. Education was initiated on the facility’s abuse and neglect policy, and sexual consent policy. Dates when the corrective action will be completed: 02/02/2024. ¿ ¿ ¿Record reviews on Resident 1 and Resident 2 were completed to look for any other incidents to investigate. Dates when the corrective action will be completed: 02/01/2024.¿ ¿ QAPI meeting and medical director in agreement with IDT. Social Services involved in assessment process along with medical director. Dates when the corrective action will be completed: 01/31/2024.¿ ¿ How the nursing home plans to monitor its performance to make sure that solutions are sustained:¿¿ ¿ To ensure ongoing compliance, DNS or designee will conduct chart review, resident and staff interviews around sexual activities weekly x 4, then monthly x 2, 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.¿¿ ¿ The Administrator is reasonable for compliance.¿ ¿ Dates when the corrective action will be completed: 02/02/2024

************************** OAR 411-085-0360 Abuse Refer to F600 **************************

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 01/22/2024 and 01/28/2024, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 01/01/2024 and 01/07/2024, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on interview and record review it was determined the facility failed to ensure residents were free from abuse for 1 of 3 sampled residents (#1) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 1 was admitted to the facility in 12/2019 with diagnoses including stroke and dementia. Resident 2 was admitted to the facility in 3/2023 with diagnoses including anxiety and depression. A facility incident report dated 4/30/23 indicated at approximately 9:45 AM Resident 1 (who was on one-to-one staff supervision due to behavioral issues.) and Resident 2 started arguing with each other during a smoking break. Resident 2 told Resident 1 to "shut up" and used a racial slur. On 12/21/23 at 1:09 PM Staff 3 (CNA) stated on 4/30/23 she was assigned to monitor Resident 1 related to her/his behavior issues. Staff 3 stated while out in the smoking area Resident 1 was talking a lot and Resident 2 told Resident 1 to "shut the [profanity] up." The argument escalated with the residents verbally and physically threatening each other and Resident 1 told Resident 2 "shut up [racial slur]. Staff 3 stated she stepped in between the residents and called for help. Once the residents were separated Staff 3 stated she continued to monitor Resident 1 who was "not really upset" about the altercation. On 12/27/23 at 10:01 AM Staff 1 (Administrator) confirmed the event occurred as described in the 4/30/23 incident report.

F600 Residents 1 and 2 have both been discharged from the facility. Resident 2 was assessed for s/sx of psychological distress, and none were found. Resident 1s care plan updated to reflect redirecting resident when agitated to mitigate recurrence. Residents who reside in the facility are at potential risk for this deficient practice. Random resident and staff interviews were completed to determine if there are any resident-to-resident conflicts that need to be reported, investigated and interventions to be put into place. A baseline audit has been completed and all residents with behaviors have been placed on the behavior list. Staff reeducation by the Administrator or designee will be completed regarding resident-to-resident altercations and strategies to prevent an altercation when possible. To ensure ongoing compliance, DNS or designee will conduct 3 random resident and staff interviews around resident-to-resident altercations weekly x 4, then monthly x 2, 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. The Administrator is reasonable for compliance. Dates when the corrective action will be completed: 02/14/2024

Based on interview and record review it was determined the facility failed to timely report allegations of abuse for 2 of 3 sampled residents (#s 6 and 7) reviewed for abuse reporting. This placed residents at risk for abuse. Findings include: 1. Resident 6 was admitted to the facility in 6/2020 with diagnoses including seizures and anxiety. A facility incident report dated 7/21/23 indicated on 7/21/23 an unnamed CNA reported Resident 6 was found wet, with a garbage bag underneath her/him during morning cares on 7/19/23. A Nursing Facility Reported Incident Form dated 7/21/23 indicated the incident was reported to the Sate Agency on 7/21/23. On 12/28/23 at 9:45 AM Staff 1 (Administrator) confirmed the incident was not reported to the State Agency in a timely manner. 2. Resident 7 was admitted to the facility in 10/2022 with diagnoses including obesity and anxiety. A facility incident report dated 7/26/23 indicated on 7/24/23 an unnamed CNA reported another unnamed CNA threw a gown at Resident 7. A Nursing Facility Reported Incident Form dated 7/26/23 indicated the incident was reported to the Sate Agency on 7/26/23. On 12/28/23 at 9:45 AM Staff 1 (Administrator) confirmed the incident was not reported to the State Agency in a timely manner.

F609 Residents 6 and 7 continue to reside in the facility. Residents 6 and 7 were educated on the error. RSN re-educated Administrator and DNS of expectations. Residents who reside in the facility are at potential risk for this deficient practice. The facility will report timely to the state agency any incidents of abuse or neglect. RSN or designee will complete reeducation to Administrator, DNS and staff regarding reporting of potential abuse and neglect. To ensure ongoing compliance, the Administrator or designee will audit Risk Managements and Grievances weekly x 4, then monthly x 2, 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. The Administrator is reasonable for compliance. Dates when the corrective action will be completed: 02/14/2024

Based on interview and record review it was determined the facility failed to report an allegation of abuse to the state agency within the required timeframe for 1 of 1 sampled resident (#10) reviewed for reporting allegations. This placed residents at risk for abuse. Findings include: The facility reported an allegation of abuse between Staff 12 (Agency CNA) and Resident 10 which occurred on 2/16/24. The FRI form was received by the state agency on 2/19/24 at 5:19 PM. On 8/11/23 at 12:37 PM Staff 1 (Administrator) confirmed the incident was not reported to the state agency in the required time frame within two hours of an allegation of abuse.

F-609 - Reporting Residents 10 continue to reside in the facility. Residents who reside in the facility are at potential risk for this deficient practice. The facility will report timely to the state agency on any incidents of abuse or neglect. RSN or designee will complete reeducation to Administrator, DNS, and staff regarding reporting of potential abuse and neglect. To ensure ongoing compliance, the Administrator or designee will audit Risk Managements and Grievances for incidents of abuse or neglect weekly x 4, then monthly x 2, 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. The Administrator is responsible for compliance. Dates when the corrective action will be completed: 03/22/2024

Based on interview and record review it was determined the facility failed to ensure a safe discharge for 1 of 3 sampled residents (#13) reviewed for discharge. This placed residents at risk for accidents and lack of ADL care. Findings include: Resident 13 was admitted to the facility in 10/2023 with diagnoses including neck surgery and foot fracture. Resident 13's SNF Utilization Review Skilled dated 11/7/23 indicated the resident had upper body weakness, needed assistance with eating and the resident's upper body (strength and mobility) did not improve. The resident needed maximum assistance with dressing, toileting and bathing. The discharge plan indicated the resident still needed to work on upper body strength. Resident 13's Discharge Summary/Plan of Care dated 12/4/23 indicated the resident was discharging to her/his private residence and home health services would be arranged. Resident 13's Progress Notes dated 12/4/23 indicated the resident was discharged to her/his home with home health services set up. On 12/27/23 at 3:00 PM Witness 5 (Complainant) stated Resident 13 was discharge home but still could not move her/his arms well enough to feed her/himself or get out of bed. The facility said she/he would get help at home. On 12/28/23 at 9:08 AM Witness 6 (Home Health Services Triage RN) stated there was no record of Resident 13 in their system. On 12/28/23 at 11:30 AM and 11:59 PM Staff 5 (Social Services Director) acknowledged Resident 13 should have received home health services when she/he discharged from the facility. Staff 5 stated she had no answer for why home health services were not arranged for the resident upon discharge.

F660 Residents 13 is no longer in the facility Residents who are discharging home alone will be ordered home health or have documentation as to why it was not ordered. A baseline audit has been completed of all residents in the last 30 days that discharged to ensure home health has been ordered as appropriate. Staff reeducation by the Administrator or designee will be completed regarding discharge planning and expectations surrounding home health care To ensure ongoing compliance, Social Services or designee will audit discharges for home health weekly x 4, then monthly x 2, 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. The Administrator is reasonable for compliance. Dates when the corrective action will be completed: 02/14/2024

Based on interview and record review it was determined the facility failed to ensure a safe discharge for 1 of 3 sampled residents (#14) reviewed for discharge. This placed residents at risk for accidents and lack of ADL care. Findings include: Resident 14 was admitted to the facility in 1/2024 with diagnoses including acquired absence of the right leg below the knee. Resident 14's 2/1/24 Admission MDS indicated the resident was cognitively intact, had surgical wounds that required wound care, received IV (intravenous) medications and required partial-to-moderate assistance from staff with bathing. Resident 14's 2/2024 Physician Orders indicated the resident was to be straight catheterized (a procedure used to drain the bladder and collect urine) every eight hours due to urinary retention. Resident 14's 2/19/24 ADL Self Care Performance Deficit Care Plan revealed the resident required limited assistance from one person with bathing, dressing and toileting and required extensive assistance from one person with transferring. A 2/19/24 Encounter Note written by Staff 4 (NP) revealed Resident 14 was going to discharge and the facility's social worker was to set up home health services. Resident 14's 2/19/24 PT Discharge Summary recommendations included a home exercise program, home health services and outpatient services. Resident 14's 2/20/24 At Risk for Falls Care Plan revealed the resident rolled out of bed on 2/16/24 and experienced an unwitnessed fall on 2/20/24. The Care Plan revealed the following interventions: -Remind the resident to use her/his call light for assistance. -Maintenance staff was to place a transfer bar on the side of the bed the resident self-transferred from. -Resident to go home with home health. A 2/20/24 Progress Note written by Staff 5 (Social Services Coordinator) indicated Resident 14 was going to discharge from the facility on 2/20/24 and she/he declined home health and outpatient services. A review of Resident 14's 2/23/24 SNF Discharge Summary revealed the following sections were blank: -Summary of Resident Status. -Medications and Treatments Post-Discharge. -Nursing Recap of Stay. Review of Resident 14's clinical record revealed the facility failed to do the following upon the resident's discharge from the facility: -Notify the resident's physician when the resident declined home health services. -Provide education to the resident regarding catheter care or fall prevention strategies. -Provide the resident with necessary treatment or fall prevention supplies. -Complete any other measure to ensure a safe discharge for the resident. An attempt was made to contact Resident 14 on 2/28/24 but the resident's phone was not set up to receive phone calls. On 2/28/24 at 2:07 PM Witness 1 (Family Member) stated he spoke with Resident 14 on 2/27/24 who indicated the facility was supposed to "send [her/him] over help since [she/he] needed help because [she/he] had one leg cut off" but the resident had not received any help. On 2/28/24 at 3:16 PM Staff 6 (RCM-LPN) stated Resident 14 was not completely independent when she/he discharged from the facility but she/he wanted to go home. Staff 6 stated floor nurses typically provided education to residents on medications, treatments and other care needs up until the resident discharged from the facility. Staff 6 stated she did not see any record that indicated Resident 14 received any education or training regarding the care of her/his catheter or fall prevention strategies. Staff 6 stated she was unaware if the resident was sent home with any catheter supplies. Staff 6 stated she thought the resident discharged with home health services in place. On 2/28/24 at 4:22 PM Staff 1 (Administrator), Staff 2 (Interim DNS) and Staff 3 (Regional Nurse Consultant) acknowledged the findings of this investigation. Staff 3 stated residents and/or family members should be trained on catheter care needs and other safety issues prior to a resident's discharge. Staff 3 stated Resident 14's medical provider should have been notified she/he declined home health services prior to the resident's discharge and Adult Protective Services should have been notified as well.

F660  DC Planning Residents 14 is no longer in the facility. Residents who are discharging home are at potential risk for this deficient practice. A baseline audit has been completed of all residents who have discharged in the last 7 days to ensure proper education, treatment services, and supplies have been provided to allow for a safe and successful discharge. Social Services and Resident Care Manager staff will be reeducation by the Administrator or designee will be completed regarding discharge planning and expectations for a successful discharge. To ensure ongoing compliance, Administrator or designee will audit ongoing discharge assessments to ensure all elements are completed for a successful discharge weekly x 4, then monthly x 2, 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. The Administrator is responsible for compliance. Dates when the corrective action will be completed: 03/22/2024

Based on interview and record review it was determined the facility failed to ensure a resident was provided ADL care for 1 of 3 sampled residents (#4) reviewed for ADLs. This placed residents at risk for poor hygiene and pressure ulcers. Findings include: Resident 4 was admitted to the facility in 5/2023 with diagnoses including diabetes and anxiety. An undated facility Event Summary indicated overnight between 6/23/23 and 6/24/23 Resident 4 reported she/he was left in her/his wheelchair all night. Staff 4 (CNA) who was assigned to Resident 4 during the night shift stated she was not aware the resident was in her/his wheelchair all night. Staff 4 was terminated for neglect of Resident 4. On 12/27/23 at 10:34 AM Staff 1 (Administrator) confirmed the incident occurred according to the Event Summary.

F677 Residents 4 is no longer in the facility. Residents who reside in the facility are at potential risk for this deficient practice. Resident and staff interviews to be completed to determine if there are any other incidents that need to be investigated and interventions to be put into place. A baseline audit has been completed and all residents requiring assistance with laying down at HS. Staff reeducation by the Administrator or designee will be completed regarding expectations with ADLs and completion of tasks. Re-offering and notifying the nurse of unusual events. To ensure ongoing compliance, DNS or designee will conduct 5 random resident and staff interviews around HS ADL assistance and completion weekly x 4, then monthly x 2, 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. The Administrator is reasonable for compliance. Dates when the corrective action will be completed: 02/14/2024

Based on interview and record review it was determined the facility failed to ensure a resident was provided supervision and positioning assistance with eating and follow a resident's care plan related to bed mobility and bathing for 2 of 3 sampled residents (#s 5 and 11) reviewed for accidents. This resulted in Resident 5 aspirating while eating without supervision and positioning assistance. Findings include: 1. Resident 5 was admitted to the facility in 2023 with diagnoses including difficulty swallowing following a stroke and respiratory failure. Resident 5's Care Plan initiated on 7/11/23 indicated the resident required one-on-one staff supervision while eating. A Progress Note dated 7/23/23 indicated Resident 5's breakfast tray was left at the resident's bedside without the head of the bed elevated. The resident ate breakfast without staff assistance, began coughing and displayed signs and symptoms of aspiration (when food enters the lungs or airway by accident). The nurse assisted the resident with deep breathing and appeared to clear the obstruction. The resident's lung sounds were diminished with wheezing. A facility incident investigation dated 7/23/23 indicated a morning meal tray was left at the resident's bedside and the resident started eating without the head of the bed raised. The resident was coughing significantly and had signs and symptoms of aspiration. The report indicated "Neglect not substantiated." A chest x-ray dated 7/23/23 indicated Resident 5 had "basal infiltrate" (substance denser than air in an area of the lungs which should normally be clear) and "small left-sided pleaural effusion" (fluid between the two linings of the lung cavity) "possibly due to aspiration." Resident 5's 7/24/23 Cognitive Loss / Dementia, Nutritional Status and ADL Functional / Rehabilitation Potential CAAs indicated the resident had some impaired cognition related to a recent stroke. The resident had impaired swallowing and required altered food texture including thickened fluids due to a recent stroke. The resident required extensive assistance with most ADLs. On 12/21/23 at 10:25 AM Staff 8 (CNA) stated on the morning of 7/23/23 she was assigned to answer call lights while other staff were passing meal trays to residents in their rooms. She stated she told the staff passing trays Resident 5 needed staff assistance with eating. Staff 8 did not know who left the tray at Resident 5's bedside unsupervised. On 12/21/23 at 1:22 PM Staff 9 (CNA) stated she may have left the tray at Resident 5's bedside and she did not know the resident required supervision with eating. Staff 9 stated the resident's care plan indicated she/he only needed to have the tray set up for her/him. On 12/21/23 at 12:06 PM Staff 10 (Regional Director of Operations) and Staff 1 (Administrator) confirmed Resident 5's care plan was not followed and their internal investigation should have substantiated neglect. 2. Resident 11 was admitted to the facility in 2023 with diagnoses including right knee fracture and obesity. a. Resident 11's Care Plan initiated on 7/3/23 indicated the resident required the extensive assistance of two people with bathing, bed mobility and toileting. The resident required a mechanical lift and the extensive assistance of two people with transfers. A facility incident report dated 8/9/23 indicated Resident 11 fell in the shower while being assisted by Staff 6 (CNA). The resident's care plan was not followed because the resident was non-weight bearing on the right leg and used a mechanical lift for transfers. On 1/4/24 at 9:10 AM Staff 6 stated Resident 11 started to sit on the shower chair but missed the edge and slid to the floor. Staff 6 acknowledged he was the only staff assisting the resident with the shower at the time of the fall and stated he was not aware the resident was non-weight bearing. On 1/4/24 at 9:58 AM Staff 1 (Administrator) confirmed Resident 11's care plan was not followed which resulted in a fall. b. Resident 11's Care Plan initiated on 7/3/23 indicated the resident required the extensive assistance of two people with bathing, bed mobility and toileting. The resident required a mechanical lift and the extensive assistance of two people with transfers. A facility incident report dated 8/17/23 indicated Resident 11 fell out of her/his bed when Staff 7 (CNA) rolled the resident over too far while providing incontinence care. On 1/3/24 at 9:11 AM Staff 7 stated Resident 11 rolled over too far and her/his momentum took her/him off the bed. Staff 7 did not recall another staff assisting her and most staff provided care with just one staff because the resident was able to help. On 1/4/24 at 9:58 AM Staff 1 (Administrator) confirmed Resident 11's care plan was not followed which resulted in a fall.

F689 Resident 5 and 11 no longer reside in the facility. Residents who require assistance with eating are on an assisted with eating list. Trays are held until the resident is ready to be assisted with eating. Staff will be reeducated on safe dining practices and swallow precautions. DNS or designee will audit mealtimes randomly to spot check practices during meals and ensure safety for residents requiring assistance weekly x 4, then monthly x 2, 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. Dates when the corrective action will be completed: 02/14/2024

Based on observation, interview and record review it was determined the facility failed to ensure residents were provided supervision and aspiration precautions at mealtimes and follow resident care plans related to bed mobility and toileting for 2 of 3 sampled residents (#s 8 and 11) reviewed for accidents. This placed residents at risk for aspiration and accidents. Findings include: 1. Resident 11 admitted to the facility in 10/2020 with diagnoses including dysphagia (difficulty swallowing). Resident 11's 1/8/24 Nutrition Care Plan indicated the resident required the assistance of one person to eat. On 2/28/24 at 12:22 PM Staff 9 (CNA) was observed to deliver a meal tray to Resident 11 while she/he was in her/his bed, with no other people in the room. Staff 9 placed the meal tray on the over bed table in front of the resident and exited the room. On 2/28/24 at 12:24 PM Staff 13 (CNA) was observed to enter Resident 11's room and ask her/him if she/he wanted beverages for the meal. While Resident 11 was in her/his bed and was eating, Staff 13 exited the room. No staff were present to assist Resident 11 eat her/his meal. At 12: 25 PM Staff 13 stated she obtained information of how to care for residents from the care plan. On 2/28/24 at 4:22 PM Staff 1 (Administrator), Staff 2 (Interim DNS) and Staff 3 (Regional Nurse Consultant) acknowledged the findings of this investigation. Staff 3 confirmed Resident 11 required assistance from one person to eat. Staff 3 stated Resident 11 should not be left alone to eat and expected staff to follow the resident's care plan. , 2. Resident 11 was admitted to the facility in 7/2022 with diagnoses including left-sided hemiplegia (paralysis of the muscles of the lower face, arm and leg on one side of the body). Resident 11's 1/8/24 ADL Self Care Performance Deficit Care Plan indicated the resident required extensive assistance from two people with toileting and bed mobility. Resident 11's 1/15/24 Quarterly MDS indicated the resident was severely cognitively impaired, dependent on assistance from staff with toileting hygiene and required substantial/maximal assistance from staff when rolling left and right. On 2/28/24 at 11:45 AM Staff 9 (CNA) was observed to walk into Resident 11's room and close the door behind her. At 12:00 PM Staff 9 exited the room and stated she independently provided incontinence care for Resident 11 and repositioned her/him so she/he was comfortable. Staff 9 stated the resident required assistance from one person with her/his toileting and repositioning needs and she found this information in the resident's Kardex (a tool that gives a brief overview of each resident's care needs). On 2/28/24 at 2:37 PM Staff 10 (CNA) and at 2:45 PM Staff 11 (CNA) stated Resident 11 required assistance from one person with incontinence care and they found this information in the resident's Kardex. On 2/28/24 at 4:22 PM Staff 1 (Administrator), Staff 2 (Interim DNS) and Staff 3 (Regional Nurse Consultant) acknowledged the findings of this investigation. Staff 3 confirmed Resident 11 required assistance from two staff with incontinence care and bed mobility and expected staff to follow the resident's care plan. 3. Resident 8 was admitted to the facility in 12/2023 with diagnoses including dysphagia (swallowing difficulties). Resident 8's 12/28/23 Admission MDS revealed the resident was moderately cognitively impaired, required supervision or touching assistance when eating, experienced loss of liquids/solids from her/his mouth when eating or drinking, coughed or choked during meals or when swallowing medications and received a mechanically altered diet. Resident 8's 12/28/23 SNF Nutrition at Risk indicated the resident required close supervision with meals. Resident 8's 1/4/24 Swallowing Problem Care Plan revealed the following: -Supervision was to be provided when eating. -The resident was to alternate small bites and sips when eating. -A teaspoon was to be used for eating. -The resident was not to use straws. -The resident required staff instruction to eat slowly and to chew each bite thoroughly. On 2/28/24 at 12:20 PM Resident 8 was observed to eat in the dining room. One staff was observed in the dining room with their back to resident. No staff were present at Resident 8's table. On 2/28/24 at 12:23 PM Staff 7 (CNA) sat down across from Resident 8 at her/his table in the dining room and provided assistance to another resident. From 12:23 PM to 12:49 PM Resident 8 was observed to take large bites of her/his meal without any instruction or cueing provided to take smaller bites or to take a drink in between bites. Resident 8 was observed to cough loudly throughout the meal, use a straw for her/his liquids and use a regular spoon to eat. On 2/28/24 at 2:55 PM Staff 8 (CNA) stated Resident 8 required supervision at mealtimes but stated "lots of times people set her/him up and leave, but [she/he] was a high aspiration risk." On 2/28/24 at 4:22 PM Staff 1 (Administrator), Staff 2 (Interim DNS) and Staff 3 (Regional Nurse Consultant) acknowledged the findings of this investigation. Staff 3 stated she expected staff to sit down and assist Resident 8 during meals and follow her/his care plan.

F689 - Free of Accident Hazards/Supervision/Devices Residents 8 and 11 still reside in the facility. Residents #8 and 11 had their Care plan updated to reflect their current abilities based on chart review, interviews of residents, staff, and therapy. Residents who reside in the facility are at potential risk for this deficient practice. Residents who require assistance with eating had their care plans and Kardex reviewed and updated. DNS or designee to review or update the care plan and Kardex weekly and PRN with new admits and changes. Residents found with on-going non-compliance offered risk versus benefit and ST re-evaluation to see if swallow had improved. Trays are held until the resident is ready to be assisted with eating. Residents ADL care plans have been updated to reflect current level of performance for toileting and bed mobility. Staff will be reeducated in safe dining practices, swallow precautions, and ADL performance needs around toileting and bed mobility. DNS or designee will audit mealtimes randomly to spot check practices during meals and ensure safety for residents requiring assistance weekly x 4, then monthly x 2, and will continue until compliance is achieved. DNS or designee will audit toileting and bed mobility by either staff observation or interviews to ensure resident care plan is followed for safety for residents requiring assistance weekly x 4, then monthly x 2, 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. Dates when the corrective action will be completed: 03/22/2024

******************** 411-085-0360 Abuse Refer to F-600 and F-609 ******************** 411-086-0060 Comprehensive Assessment and Care Plan Refer to F-660 ******************** 411-086-0100 Nursing Services: Resident Care Refer to F-677 ******************** 411-086-0140 Nursing Services: Problem Resolution & Preventive Care Refer to F-689 ********************

******************** 411-085-0360 Abuse Refer to F-609 ******************** 411-086-0060 Comprehensive Assessment and Care Plan Refer to F-660 ******************** 411-086-0140 Nursing Services: Problem Resolution & Preventive Care Refer to F-689 ******************** 411-085-0220 Quality Assurance Refer to F-867

Based on interview and record review it was determined the facility's quality assessment and performance improvement committee (QAPI) failed to systematically identify and correct deficiencies in the areas of reporting abuse, safe discharge and accident prevention. This placed residents at risk of abuse, accidents and injuries. Findings include: The facility's 1/4/2024 complaint survey identified the following: 1. The facility failed to report allegations of abuse timely. This deficient practice was also identified on the 2/2024 revisit survey. During an interview on 2/28/24 at 4:22 PM and 2/29/24 at 11:16 AM Staff 1 (Administrator), Staff 2 (Interim DNS) and Staff 3 (Regional RN) acknowledged the QAPI system the facility had in place was not effective. Staff 3 shared audits she completed which did not systematically address the identified residents and areas the QAPI committee was to address in the facility's plan of correction. Additional information provided by the facility on 2/29/24 and 3/1/24 failed to demonstrate a root cause analysis, systems to identify, report, track, investigate, analyzed, use data and information collected related to the identified citations on the 1/4/24 2567 Form. Refer to F609. 2. The facility failed to ensure safe resident discharges from the facility. This deficient practice was also identified on the 2/2024 revisit survey. During an interview on 2/28/24 at 4:22 PM and 2/29/24 at 11:16 AM Staff 1 (Administrator), Staff 2 (Interim DNS) and Staff 3 (Regional RN) acknowledged the QAPI system the facility had in place was not effective. Staff 3 shared audits she completed which did not systematically address the identified residents and areas the QAPI committee was to address in the facility's plan of correction. Additional information provided by the facility on 2/29/24 and 3/1/24 failed to demonstrate a root cause analysis, systems to identify, report, track, investigate, analyzed, use data and information collected related to the identified citations on the 1/4/24 2567 Form. Refer to F660. 3. The facility failed to provide ensure care plans were followed to prevent accidents. This deficient practice was also identified on the 2/2024 revisit survey. During an interview on 2/28/24 at 4:22 PM and 2/29/24 at 11:16 AM Staff 1 (Administrator), Staff 2 (Interim DNS) and Staff 3 (Regional RN) acknowledged the QAPI system the facility had in place was not effective. Staff 3 shared audits she completed which did not systematically address the identified residents and areas the QAPI committee was to address in the facility's plan of correction. Additional information provided by the facility on 2/29/24 and 3/1/24 failed to demonstrate a root cause analysis, systems to identify, report, track, investigate, analyzed, use data and information collected related to the identified citations on the 1/4/24 2567 Form. Refer to F689.

F867  QAPI Facility QAPI committee has initiated the plan of correction on the identified concerns. The alleged deficient practice places all residents at risk of being affected. Facility administrator was re-educated on QAPI by regional support staff. Facility QAPI committee will follow up on QAPI plans to ensure compliance. Facility IDT will review areas of concerns that will be taken through the QAPI committee for corrective action. Facility regional support will review QAPI minutes with the IDT monthly for 3 months to ensure areas of concerns are addressed. The results of this audit and any corrective action taken will be reported to the monthly QAPI committee for 3 months, or ongoing until substantial compliance has been achieved. Administrator is responsible for compliance. Dates when the corrective action will be completed: 03/22/2024

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 12/11/2023 and 12/17/2023, 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 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 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 09/11/2023 and 09/17/2023, 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 prevent elopement for 1 of 2 sampled residents (#100) reviewed for elopement. This placed residents at risk for lack of supervision and elopement. Findings include: Resident 100 admitted the facility 3/31/23 with diagnoses including stroke and kidney failure. Resident 100's care plan dated 4/12/23 indicated she/he had significant impaired cognitive functioning and was at risk for elopement and wandering. There were no interventions in place on the care plan. On 6/25/23 the facility submitted a report to the state agency indicating Resident 100 left the facility on that date at approximately 12:15 PM. She/he walked out to the smoking area and was observed to walk away from the facility by another resident. Nursing notes dated 6/25/23 at 2:09 PM revealed the facility implemented a search in the faciity and surrounding neighborhood but were unable to locate Resident 100. She/he was found several blocks away by a passerby after the resident fell on the sidewalk. The facility was contacted and the resident was sent to the emergency department. She/he had bruising and scabs on her/his face but sustained no serious injuries. Resident 100 was observed during the survey period to have one on one supervision by staff and did not recall the incident. On 7/31/23 at 2:00 PM Staff 1 (Administrator) and Staff 2 (DNS) were advised of the investigative findings and provided no additional information.

Resident #100 returned from the ER on 6/25/23 without any major injuries. She is under 1:1 supervision and the center is actively working on a safe discharge in a secure facility. Center completed an audit of residents at risk for elopement. Residents at risk have implementations in place to ensure safety. Re-education was completed:¿¿¿ For center staff (includes LNs, CNAs, Housekeeping, Laundry, Dietary) by the administrator/designee on how to identify residents at risk for elopement, where the resident information is kept who are at risk for elopement, to alert if they see a resident exiting the center without supervision. For residents, by the administrator, during resident council on safety and to alert center staff if they witness a resident being unsafe or leaving the center unsafely. DNS or designee will check on 2 residents a week for 4 weeks and 1 resident a month for 2 months to validate elopement prevention interventions are in place and effective. The results of the audit and any corrective action taken will be reported by the monthly QAPI committee.

Based on interview and record review, it was determined the facility failed to provide appropriate catheter care for 1 of 2 sampled residents (#101) reviewed for catheter care. This placed residents at risk for medical complications. Findings include: The facility's "In-Dwelling Urinary Catheter" Policy and Procedure, revised 2/2019 stated catheter care included bag and tubing changes, prevention of drag on the catheter tubing, routine catheter care and monitoring for signs of complications. Resident 101 was admitted to the facility on 4/19/23 with diagnoses including quadriplegia (paralysis of all four limbs) and respiratory failure. Resident 101's care plan and initial nursing assessment dated 4/19/23 indicated Resident 101 had an indwelling Foley catheter due to a neurogenic bladder (lack of bladder control due to a brain, spinal cord or nerve injury). Interventions were to ensure adequate catheter care, monitor and document signs and symptoms of pain and discomfort and/or UTI symptoms and ensure the tubing was free of kinks. A late entry nursing note written by Staff 8 (Former LPN) dated 5/10/23 at 3:41 PM revealed Resident 101 complained of pain in her/his lower abdomen and requested that staff flush her/his catheter. This procedure was completed by Staff 8 with no relief noted. The catheter was replaced and the resident reported immediate relief. An alert note written by Staff 8 dated 5/10/23 at 6:54 PM revealed Resident 101 reported feeling pressure in the abdominal area again and her/his urine was observed to be bloody. The on call physician was contacted, orders for another catheter flush were received, and the resident's blood thinner medication was placed on hold. The catheter was flushed again and the resident had no further complaints of pressure or pain at that time. A late entry provider noted dated 5/11/23 revealed Resident 101 was seen by the facility's physician due to the reports of hematuria (bloody urine) the previous day. Resident 101 stated the catheter change was "rough" and the physician recommended staff observe and review precautions related to the resident's medical conditions. The resident's catheter was observed by the physician to be clearing with a few small clots observed in the tubing and her/his vital signs were stable. A nursing note dated 5/11/23 at 8:37 PM revealed the resident was complaining of pain, was shivering and had a temperature of 101.1. The on call provider was contacted and the resident was sent to the emergency department (ED) at approximately 10:30 PM. ED notes dated 5/11/23 and 5/12/23 revealed Resident 101 was diagnosed with sepsis from urinary source and from other infectious sources and revealed the foley balloon was inflated in the resident's urethra rather than the bladder. On 7/19/23 at 9:20 AM, Witness 2 (Complainant) stated she/he was told by hospital staff Resident 101's catheter was placed incorrectly and "blew out" her/his urethra. She/he also reported the resident was heavily bleeding as a result of the misplaced catheter. On 7/27/23 at 11:00 AM, Witness 1 (ED physician) confirmed the catheter was inflated in Resident 101's urethra and should have been inflated in the bladder. Witness 1 confirmed the resident experienced blood loss but noted the blood loss was also attributed to the resident's blood thinner prescription and hemorrhagic cystitis (an inflammatory condition of the bladder resulting in bleeding not caused by the catheter change). Witness 1 stated the catheter was removed in the ED and a referral to urology was made. On 7/27/23 at 2:18 PM, Staff 1 (Administrator) and Staff 2 (DNS) confirmed Staff 8 changed Resident 101's catheter on 5/10/23 and the resident was sent to the ED on 5/11/23.

Resident #101 discharged from the center on 5/11/23. The center completed an audit of all other residents with tracheostomies to ensure appropriate care and interventions are in place. Re-education was completed by DNS and SDC:The facility LNs completed competencies on tracheostomy care. LNs on immediately notifying MD of all clinical concerns. DNS or designee will check on 1 resident a week for 4 weeks and 1 resident a month for 2 months to observe tracheostomy care to ensure competency and compliance. The results of the audit and any corrective action taken will be reported by the monthly QAPI committee.

Based on interview and record review it was determined the facility failed to provide respiratory care and services for 1 of 1 sampled resident (#101) reviewed for tracheostomy care (a surgical opening made in the windpipe to provide an airway to the lungs). This placed residents at risk for adverse respiratory effects. Findings include: The facility's "Tracheostomy Tube Insertion" policy and procedure, reviewed 4/2022 listed procedures nurses were to complete for tracheostomy cares as ordered by the attending physician. Resident 101 was admitted to the facility on 4/19/23 with diagnoses including quadriplegia (paralysis of all four limbs) and respiratory failure. Orders on the 5/2023 TAR were to "change disposable inner cannula (a thin tube inserted into the windpipe) every day and PRN every day shift and to change trache twill ties or trache tube holder on bath days and PRN." The TAR reflected Staff 8 (Former LPN) changed the cannula on 5/10/23 and 5/11/23 and the twill ties on 5/11/23. On 5/11/23 at approximately 10:30 PM, Resident 101 was sent to the emergency department (ED) with complaints of abdominal pain and fever. A review of Resident 101's clinical record revealed no indication the resident had no respiratory issues on 5/11/23 prior to going to the hospital. Hospital notes from 5/11/23 revealed CT scans of the resident's chest and airway were completed and the tracheostomy tube was noted to be located in the soft tissue of Resident 101's throat rather than in the airway. Resident 101 did not have breathing issues while at the ED and was breathing room air on her/his own. On 7/27/23 at 11:00 AM, Witness 1 (ED Physician) stated he ordered the CT scans of the resident's chest due to wanting to rule out pneumonia because Resident 101 was diagnosed with sepsis. The trach tube was observed to be in the wrong position. Witness 1 stated this finding was incidental, Resident 101 was breathing on her/his own on room air and had no respiratory issues when she/he admitted to the ED. On 7/27/23 at 2:18 PM Staff 1 (Administrator) and Staff 2 (DNS) confirmed Staff 8 changed the resident's tracheostomy cannula on 5/11/23 and provided no additional information.

Resident #101 discharged from center on 05/11/2023. An audit of residents with urinary catheters was completed by RSN and DNS to validate catheter placement by evaluating drainage. Re-education was completed by DNS: LNs educated on catheter competency and insertion techniques. LNs on securing catheter tubing by using catheter stabilization devices. DNS or designee will check on 1 resident a week for 4 weeks and 1 resident a month for 2 months to observe catheter care to ensure competency and compliance. The results of the audit and any corrective action taken will be reported by the monthly QAPI committee

****************************************** OAR 411-086-0350: Nursing Services: Problem Resolution and Preventive Care Refer to F689 ****************************************** OAR 411-086-0140: Nursing Services: Problem Resolution and Preventive Care Refer to F690 ****************************************** OAR 411-085-0110: Nursing Services: Resident Care Refer to F695 *****************************************

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 06/19/2023 and 06/25/2023, 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 written information to residents concerning the right to formulate an advance directive for 3 of 3 sampled residents (#s 1, 44 and 99) reviewed for advance directives. This placed residents at risk for not having their health care decisions honored. Findings include: Records reviewed for Residents 1, 44 and 99 revealed no documentation of an advance directive or documentation to indicate the residents were informed of or provided written information concerning their right to formulate an advance directive. On 5/3/23 at 10:02 AM Staff 19 (Regional Director of Operations) stated advance directives were typically sent with the resident from the hospital and placed in their medical record. Staff 19 stated it was his expectation staff asked for advance directives prior to admission and offered one within the first 72 hours of admission. On 5/3/23 at 11:32 AM Staff 1 (Administrator) stated she had not educated social services on going over advance directives prior to admission or offering one within the first 72 hours. Staff 1 stated it was her expectation a physical copy was provided upon admission and residents were offered an opportunity to formulate and advance directive.

Advanced directives were discussed at length with residents #1, 44, and 99. Audit of all residents in the facility completed to identify which residents did not have an advanced directive. Residents that did not have an advanced directive were identified, and social services discussed advanced directives at length. Social services director educated on discussing advanced directives during initial care conferences, quarterly care conferences, and as needed, and to document in care conference note. Admin will audit 4 residents a month for 3 months. The results of the audit and any corrective action taken will be reported to the monthly QAPI committee for 3 months.

Based on interview and record review it was determined the facility failed to provide a Notice of Medicare Non-coverage for 2 of 3 sampled residents (#s 102 and 103) reviewed for beneficiary notification. This placed residents at risk for unknown financial liabilities. Findings include: 1. Resident 102 was admitted to the facility on 1/11/23 with diagnoses including influenza and heart attack. Resident 102's Clinical Census (reviewed on 5/5/23) indicated the resident's last covered day of Medicare Part A services (skilled services including therapy) was 1/21/23. On 5/4/23 at 9:26 AM Staff 1 (Administrator) was asked to provide documentation demonstrating Resident 102 was provided a Notice of Medicare Non-Coverage (NOMNC) which notified the resident of skilled services ending and their rights of appeal. On 5/4/23 at 11:20 Staff 19 (Regional Director of Operations) stated Resident 102 was not provided with a NOMNC prior to discharge, but a notice should have been provided. 2. Resident 103 was admitted to the facility on 3/31/23 with diagnoses including seizures. Resident 103's Clinical Census (reviewed on 5/5/23) indicated the resident's last covered day of Medicare Part A services (skilled services including therapy) was 4/17/23. On 5/4/23 at 9:26 AM Staff 1 (Administrator) was asked to provide documentation demonstrating Resident 103 was provided a Notice of Medicare Non-Coverage (NOMNC) which notified the resident of skilled services ending and their rights of appeal. On 5/4/23 at 11:20 Staff 19 (Regional Director of Operations) stated Resident 102 was not provided with a NOMNC prior to discharge, but a notice should have been provided.

Resident #102 was discharged from the center on 01/21/23. Resident #103 was discharged from the center on 04/17/23. A completed audit of residents being discharged in the last 30 days was completed to identify any missed NOMNCs. No missing NOMNCs were identified. Social Services director was educated on the NOMNC policy. Administrator will audit 2 residents a month for one month, and one resident a month for two months to ensure NOMNC was given if appropriate. The results of the audit and any corrective action taken will be reported to the monthly QAPI committee for 3 months.

Based on 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 resident (#248) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 21 was admitted to the facility in 2019 with diagnoses including dementia with behavior disturbance. Resident 21's 3/16/22 Care Plan included monitoring for behaviors including verbal and physical aggression. Resident 248 was admitted to the facility in 1/2023 with diagnoses including anxiety disorder. Resident 248's 2/2023 cognitive assessment concluded normal cognitive function. Review of a 3/6/23 Facility Incident Report indicated Resident 21 was attempting to get hot chocolate from the kitchen and was asked to wait. Resident 21 observed Resident 248 laughing with staff members and assumed Resident 248 was laughing at her/him. Resident 21 approached and verbally threatened to strike Resident 248. Staff 13 (CNA) intervened and removed Resident 248 from the altercation. A Progress Note dated 3/7/23 at 8:35 AM stated, "Resident [248] less interactive with staff and residents while out of room this shift than baseline. Speech was lower, gaze directed downward and unrelaxed posture present." A Progress Note dated 3/7/23 at 7:38 PM reported Resident 248 stated, "I don't have to put up with it. I am allowed to be safe here too" regarding the incident between her/himself and Resident 21. On 5/4/23 at 10:17 AM Resident 248 stated she/he did not feel safe and had to watch where Resident 21 was after the incident. Resident 248 stated she/he "didn't know if [Resident 21] was going to go off at any time." On 5/4/23 at 10:40 AM Staff 13 stated she recalled Resident 21 threatened to "beat us up with a cane" during the incident on 3/6/23. Staff 13 stated Resident 248 became upset and required redirection to avoid a physical altercation. On 5/4/23 at 11:04 AM Staff 1 (Administrator) and Staff 2 (Interim DNS) confirmed verbal abuse occurred during the incident described above.

Incident reported as a FRI on 3/5/23. Resident #248 discharged from the center on 03/27/23. Alleged perpetrator is on 1:1 and discharge is being planned. Review of all incidents from the last 60 days completed to ensure there is not an abuse incident that the center is not aware of. All center staff educated on abuse and neglect policy, and resident safety. Administrator will review one resident a week for four weeks, and one resident a month for two months to ensure no abuse incidents occurred. The results of the audit and any corrective action taken will be reported to the monthly QAPI committee for 3 months.

Based on interview and record review is was determined the facility failed to ensure a resident's care plan reflected the needs of the resident for 1 of 2 sampled residents (#99) reviewed for ADLs. This placed residents at risk for pain and injury. Findings include: Resident 99 was admitted to the facility in 2023 with diagnoses including paralysis and Ehlers-Danlos syndrome (a disorder which can cause overly flexible joints which can cause pain and dislocations). A review of Resident 99's Care Plan initiated on 4/19/23 revealed no instructions for staff to handle the resident carefully to prevent joint pain or dislocation. On 5/2/23 at 9:29 AM Resident 99 stated during care staff caused a subluxation (partial dislocation) of her/his left shoulder which caused severe pain. A 4/25/23 incident investigation indicated while Resident 99 was being turned in bed, the resident's arm dropped and caused pain to the resident's left shoulder. The investigation concluded the resident's disease process caused the resident's bones to "pop in and out." No new care plan interventions were recommended. On 5/3/23 at 1:50 PM Staff 2 (Interim DNS) verified Resident 99's care plan did not include instructions for staff to handle the resident carefully to prevent joint pain or dislocation. Staff 2 also verified the care plan was not updated after the 4/25/23 incident.

Resident #99 care plan was updated to reflect his diagnosis on 05/05/23. A review of ADL care plan was completed for all residents to validate accuracy. Resident care managers educated on care planning resident diagnoses. Resident care plans will reflect their ADL status. Director of Nursing will review 1 resident a week for 4 weeks, and 1 resident a month for 2 months. The results of the audit and any corrective action taken will be reported to the monthly QAPI committee for 3 months.

Based on observation, interview and record review it was determined the facility failed to provide bed baths for 2 of 2 sampled residents (#s 6 and 99) reviewed for ADLs. This placed residents at risk for lack of hygiene. Findings include: 1. Resident 99 was admitted to the facility in 2023 with diagnoses including paralysis. On 5/2/23 at 9:31 AM Resident 99 stated she/he had not received a bed bath since she/he was admitted to the facility on 4/19/23 because the facility had to order hypoallergenic soap. Resident 99's bathing record from 4/20/23 through 5/1/23 indicated the resident received bed baths on 4/24/23, 4/27/23 and 4/29/23. On 5/3/23 at 11:36 AM Staff 13 (CNA) confirmed Resident 99 was not receiving bed baths because the facility did not have the special soap for Resident 99 and were just wiping the resident down with water. On 5/3/23 at 12:19 PM Staff 1 (Administrator) stated she ordered the special soap for Resident 99 and it was delivered the last week of 4/2023. The soap was called Vanicream. On 5/3/23 at 12:27 PM the bottle of Vanicream was found in Resident 99's room. The bottle indicated it was a shampoo, not body wash. On 5/3/23 at 12:36 PM Staff 1 stated the Vanicream was what she was told to order. , 2. Resident 6 was admitted to the facility in 2022 with diagnoses including a knee fracture and obesity. Resident 6's 3/10/23 Quarterly MDS indicated the resident had intact cognition and was totally dependent with one person physical assistance for bathing. Resident 6's 4/8/23 through 4/29/23 bathing task logs indicated the following information: -4/8: resident refused; -4/12: activity did not occur; -4/15: resident refused; -4/22: not applicable; -4/26: bed bath provided; -4/29: activity did not occur. A review of Resident 6's Progress Notes from 4/1/23 through 4/30/23 revealed no documentation indicating Resident 6 was provided with additional bathing opportunities if bathing was refused or not provided. On 5/1/23 at 3:38 PM Resident 6 stated she/he preferred bed baths and did not receive them on a regular basis. Resident 6 stated she/he never refused bed baths. On 5/3/23 at 8:45 AM Staff 6 (CNA) stated Resident 6 never refused bed baths. On 5/3/23 at 12:07 PM Staff 3 (LPN/Care Manager) stated Resident 6's bathing schedule in the electronic health record did not match the CNA's bathing assignments which resulted in Resident 6's bed baths being missed. Staff 3 confirmed Resident 6 received only one bed bath in 4/2023.

Resident #6 was offered a shower on 5/6/23, and he accepted. Resident skin was assessed and no skin issues were noted related to lack of bathing. Resident #99 was provided with body wash of his choice and a bath was provided on 5/8/2023. Resident skin was assessed and no issues noted related to lack of using body soap. Resident shower records for the last 30 days were reviewed to identify anyone who has not received routine showers/baths. Residents were then provided with a shower/bath, per their preference. CNAs were re-educated by the DNS to offer bath/shower per care plan. If resident refuses, CNAs to alert the licensed nurse. Licensed nurses were re-educated by the DNS to follow up with residents if they are refusing a shower/bath. Missed showers/baths will be reviewed in the clinical review and followed up as needed. DNS will review 2 residents a week for 4 weeks, and 1 resident a month for 2 months to ensure baths are being provided per care plan. The results of this audit and any corrective action will be reported to the monthly QAPI committee for 3 months.

Based on interview and record review it was determined the facility failed to ensure physician orders were followed for 2 of 6 sampled residents (#s 23 and 43) reviewed for unnecessary medications and amputation healing. This placed residents at risk for adverse medication consequences and inadequate amputation healing. Findings include: 1. Resident 23 was admitted to the facility in 2/2020 with diagnoses including heart failure, high blood pressure and arteriosclerotic heart disease (thickening and hardening of the heart arteries). A 10/31/22 physician order indicated Resident 23 was prescribed clonidine transdermal patch for hypertensive heart disease with heart failure (heart damage due to chronic high blood pressure), to be applied every Monday and the old patch removed. A review of Resident 23's 4/2023 MAR indicated the clonidine patch was not applied and the old patch was not removed on Monday, 4/10/23. A review of Resident 23's 4/2023 Progress Notes revealed no documentation regarding the resident's missed clonidine patch and no evidence Resident 23's medical provider was informed of the missed medication. On 5/3/23 at 10:07 AM and 11:21 AM Staff 4 (RNCM) confirmed Resident 23 did not receive the clonidine patch on 4/10/23 as prescribed which resulted in the resident not receiving the medication for an entire week. Staff 4 stated she spoke with the nurse on duty 4/10/23 and the nurse reported she did not administer Resident 23's clonidine patch, did not document the missed medication in Resident 23's healthcare record and did not notify the medical provider regarding the missed medication. , 2. Resident 43 was admitted to the facility in 2/2023 with diagnoses including a left leg above the knee amputation. A 3/17/23 physician's order indicated Resident 43 was to wear two shrinker stockings at all times to prepare for a prosthetic fitting. On 5/3/23 at 10:58 AM Resident 43 was observed not wearing shrinker stockings. Resident 43 stated she/he did not plan on using the shrinker stockings anymore. On 5/3/23 at 12:24 PM Staff 17 (RN) was observed assisting Resident 43. Staff 17 provided no instructions or education to Resident 43 regarding wearing shrinker stockings. Resident 43 was observed not wearing shrinker stockings when Staff 17 exited Resident 43's room. On 5/3/23 at 1:26 PM Staff 23 (RNCM) stated Resident 43 was to wear shrinker stockings at all times. If Resident 43 refused to wear the shrinker stockings education was to be provided regarding why the stockings were required. Staff 23 approached Staff 17 and confirmed no education was provided to Resident 43 regarding wearing shrinker stockings. On 5/3/23 at 1:57 PM Staff 2 (Interim DNS) confirmed Resident 43 should have been checked to determined if she/he was wearing the shrinker stockings and should have been provided education on the risk of not wearing the shrinker stockings when she/he refused.

Medication error occurred for resident #23 missed clonidine patch. The resident did not have any adverse effects, and her blood pressures were reviewed without needing any additional follow-up. Provider was notified of resident #43 refusing his shrinker. A review of residents with clonidine patches was done to identify any other missed doses. No issues were identified. A review of residents with orders for shrinkers was completed to ensure plan of care was being followed. No issues were identified. LNs were re-educated by the DNS on the follow up process if a medication is not accessible. LNs were re-educated on documenting accurately on resident record by the DNS. LNs were re-educated on provider notification requirement if a resident is refusing treatment per their plan of care by the DNS. DNS to review 2 residents a week for 4 weeks and 1 resident a month for 2 months to ensure orders are being followed. The results of the audit and any corrective action taken will be reported to the monthly QAPI committee for 3 months.

Based on observation, interview and record review it was determined the facility failed to provide necessary services for pressure ulcer care for 1 of 1 sampled resident (#7) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers. Findings include: Resident 7 was admitted to the facility in 2019 and was diagnosed with a Stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle) on her/his coccyx (tailbone) in 1/2022. Resident 7's 1/2023 Care Plan included instructions for pressure ulcer healing for her/his coccyx including repositioning Resident 7 at least every two hours. On 5/1/23 at 2:52 PM Resident 7 said, "[she/he] would be lying if [she/he] said I was repositioned every two hours." On 5/2/23 at 10:21 AM Resident 7 stated she/he had not been repositioned since she/he had received breakfast around 8:00 AM that morning. Observations of Resident 7 were made on 5/3/23 from 10:15 AM through 12:27 PM. No positioning change assistance was provided during the observation period. At 12:27 PM, Resident 7 stated she/he had not been repositioned since she/he received breakfast that day. On 5/3/23 at 12:37 PM Staff 27 (CNA) stated she was assigned Resident 7 on 5/3/23. Staff 27 stated she did not know if Resident 7 required repositioning for pressure ulcer care. Staff 27 stated Resident 7 had not been repositioned since the start of her shift that morning. On 5/3/23 at 12:43 PM Staff 26 (RNCM) confirmed Resident 7 was to be repositioned at least every two hours to reduce the risk of worsening pressure ulcers.

Resident #7 wound was reassessed and there were no changes to the wound. The resident was offered repositioning for comfort. Pressure injuries in the center were re-assessed and none were identified as having worsened or with signs of infection. CNAs were re-educated by DNS on repositioning dependent residents while they are in their beds or their wheelchairs. DNS will review 1 resident a week for 4 weeks, and then 1 resident a month for 2 months to ensure they are being repositioned to prevent pressure. The results of the audit and any corrective action taken will be reported to the monthly QAPI committee for 3 months.

Based on observation, interview and record review it was determined the facility failed to provide foot care for 1 of 2 sampled residents (#6) reviewed for ADLs. This placed residents at risk for increased foot problems. Findings include: Resident 6 was admitted to the facility in 12/2022 with diagnoses including a knee fracture and obesity. Resident 6's 3/10/23 Quarterly MDS indicated the resident had intact cognition and required extensive assistance with one person physical assistance for personal hygiene. On 5/1/23 at 3:38 PM and 5/3/23 at 8:58 AM Resident 6 was observed with long, yellow and very thick toenails on both feet. Resident 6 stated her/his toenails were starting to get long before she/he was admitted to the facility and the toenails grew a lot since her/his admission. Resident 6 stated she/he asked a nurse to trim her/his toenails a long time ago but they said they did not have the right type of clippers. Resident 6 stated nothing had been done about her/his long toenails. A review of Resident 6's health record did not include evidence the resident received toenail care. On 5/3/23 at 9:10 AM Staff 7 (RN) stated he frequently provided skin care to Resident 6's legs and feet but did not focus on the resident's toenails so he did not notice that Resident 6's toenails were long. Staff 7 confirmed Resident 6 had long, yellow, and very thick toenails on both feet which needed to be cut. Staff 7 stated he would attempt to cut the resident's toenails and if unable he would refer her/him to a podiatrist. On 5/3/23 at 12:07 PM Staff 3 (LPN/Care Manager) reported Staff 7 was unable to cut Resident 6's toenails and acknowledged the resident required the services of a podiatrist.

Podiatry consult was initiated for resident #6 for toenail care. Resident toenails were evaluated and podiatry consults were placed for residents who need it. CNAs were re-educated by the DNS on providing nail care to residents per their plan of care. LNs were re-educated on by the DNS to provide nail care to diabetic patients per plan of care. DNS to audit 1 resident a week for 4 weeks and 1 resident a month for 2 months to ensure nail care is provided. The results of the audit and any corrective action taken will be reported to the monthly QAPI committee for 3 months.

Based on observation, interview and record review it was determined the facility failed to provide brace/splint devices to prevent further decrease in range of motion for 2 of 2 sampled residents (#s 14 and 27) reviewed for ROM. This placed residents at risk for worsening contractures. Findings include: 1. Resident 14 was admitted to the facility in 2018 with diagnoses including stroke and left sided flaccid hemiplegia (severe or complete loss of motor function on one side of the body). Resident 14's 1/26/23 Annual MDS indicated the resident had upper and lower extremity impairment on one side and there were 0 days with brace/splint assistance. Resident 14's current Care Plan instructed staff to apply the resident's brace twice daily for four hours and remove for four hours in between. Resident 14's 4/1/23 through 4/30/23 Brace Donning log indicated the following: -Staff documented Resident 14 wore her/his brace for 3-15 minutes on 11 days. -Staff documented Resident 14 refused her/his brace on 13 days. -Staff documented "not applicable" on 15 days. Observations on 5/1/23 at 11:45 AM, 5/2/23 at 1:43 PM and 4:52 PM, 5/3/23 at 10:38 AM, 5/4/23 at 2:27 PM and 5/5/23 at 8:28 AM revealed Resident 14 not wearing a brace/splint on her/his left arm as ordered. On 5/1/23 at 11:45 AM Resident 14 stated her/his left arm was paralyzed and was "dead". Resident 14 stated she/he was supposed to wear a brace on her/his left arm, daily. The resident stated she/he was unable to put the brace on herself/himself and nobody "puts it on". Resident 14 reported she/he did not wear the brace because it went missing "a long time ago". On 5/2/23 at 2:32 PM Staff 10 (CNA) stated the restorative aid or therapy applied residents' braces. On 5/3/23 at 8:26 AM Staff 12 (CNA) stated Resident 14 did not have a brace. On 5/3/23 at 12:23 PM Staff 4 (RNCM) reported she did not recall Resident 14 wearing a brace for a long time. On 5/3/23 at 3:19 PM Resident 14 was observed telling Staff 3 (LPN/Care Manager) that her/his brace had been missing for a long time. Staff 3 asked Resident 14 if she/he would wear the brace if it was available and Resident 14 replied, "yes". Resident 14 reported she/he never refused to wear the brace. On 5/4/23 at 2:30 PM Staff 4 reported speaking with several CNAs and confirmed Resident 14's brace was not being put on and staff were incorrectly documenting on the Brace Donning log. 2. Resident 27 was admitted to the facility in 2020 with diagnoses including stroke and right sided hemiplegia/hemiparesis (Loss of strength on one side of the body.) Resident 27's 3/12/23 Quarterly MDS indicated the resident had upper and lower extremity impairment on one side and there were 0 days with brace/splint assistance. Resident 27's current Right Upper Extremity Contracture Care Plan instructed staff to apply brace/splint for right wrist/hand at bedtime for at least two hours. Resident 27's 4/2023 Documentation Survey Report for the resident's brace/splint indicated 26 out of 30 days were marked as "NA" (not applicable). On 5/1/23 at 9:44 AM Resident 27 stated she/he was supposed to wear a brace on her/his right hand but the brace no longer fit. Resident 27 was observed with her/his right middle, ring and little finger contracted and was unable to extend these three fingers. Resident 27 showed Surveyor her/his brace and attempted to place it on her/his right wrist/hand but the brace no longer fit properly. On 5/3/23 at 8:08 AM and 8:23 AM Staff 11 (CNA) and Staff 12 (NA) stated Resident 27 did not have a brace for her/his right hand. On 5/3/23 at 12:27 PM Resident 27 told Staff 4 (RNCM) that staff were not putting on her/his brace or completing exercises on her/his right hand as ordered. Resident 27 took her/his brace from her/his bedside dresser drawer. Staff 4 attempted to put the brace on Resident 27's right wrist/hand but the brace no longer fit. Staff 4 stated Resident 27's contractures had worsened. On 5/4/23 at 2:30 PM Staff 4 stated she expected staff to put on Resident 27's brace and if the brace no longer fit, staff should let the nurse know so an alert could be made and the Care Manager notified. Staff 4 stated a new OT evaluation would be needed to address Resident 27's worsened contractures.

Resident #27 had an OT referral placed on 5/3/23 to be re-evaluated for contracture management. His current plan of care was updated. Resident #14 splint was located and placed in a secure location accessible to staff. Resident agreed to leaving it there to ensure that it can be placed on her. Residents with contractures were re-evaluated and any resident identified as needing further follow up were referred to OT for treatment. CNAs were re-educated by the DNS on placing resident splints per their plan of care. CNAs were re-educated by the DNS on alerting the LN if a splint is not located for treatment. DNS to check 1 resident per week for 4 weeks and 1 resident a month for 2 months to ensure splints are being placed per plan of care. The results of the audit and any corrective action will be reported to the monthly QAPI committee for 3 months.

1.

Based on observation and interview it was determined the facility failed to ensure residents' environment was free from hazards for 1 of 1 facilities randomly observed. This placed residents at risk for injury and blood borne infection. Findings include: a. A random observation on 5/1/23 at 11:14 AM revealed several unused syringes on top of a medication cart by room 111. The syringes were unsecured and unmonitored by staff. On 5/1/23 at 11:18 AM Staff 1 (Administrator) verified the syringes were unsecured. b. A random observation on 5/2/23 at 9:21 AM revealed a large sharps container on a cart by room 108. The sharps container did not have a lid on the top and numerous used sharps and syringes were in the container. The container was not being monitored by staff. On 5/2/23 at 10:29 AM Staff 20 (former Administrator) verified the sharps container did not have a lid and had used sharps including syringes. , 2. 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 1 of 3 residents (#14) reviewed for smoking. This placed residents at risk for burns and smoking related accidents. The facility's Smoking Policy and Procedure for Independent and Supervised, last revised 3/2020, indicated the following: -Smoking policy is communicated to the resident prior to or upon admission to the center. -Residents who are safe to smoke independently and safely manage their smoking materials are allowed to do so in a manner that is safe according to the assessment. -Residents who do not adhere to the smoking policies are 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. Resident 14 was admitted to the facility in 2018 with diagnoses including a stroke. a. Resident 14's 1/26/23 and 4/27/23 Smoking Safety Evaluations revealed the resident was independent for smoking when using a smoking apron. The 4/27/23 Smoking Safety Evaluation revealed Resident 14 refused to wear a smoking apron and the resident rolled her/his own cigarettes which "may make them looser than normal and cause the fire to fall onto her/his clothing." Resident 14's revised 2/8/23 Smoking Care Plan indicated the resident was able to smoke, unsupervised, when wearing a smoking apron. On 5/1/23 at 11:49 AM Resident 14 stated she/he was instructed to wear a smoking apron while smoking but she/he never wore it. On 5/1/23 at 12:29 Resident 14 was observed in the outside smoking area with no smoking apron on. On 5/3/23 at 8:30 AM Staff 5 (Regional Nurse) confirmed Resident 14 had been assessed on 4/27/23 and care planned as being safe to independently smoke as long as she/he wore a smoking apron. She further stated Resident 14 refused to wear a smoking apron so on 5/1/23 she reassessed her and determined Resident 14 no longer required a smoking apron in order to smoke unsupervised. b. On 5/1/23 at 12:36 PM a tray of loose smoking tobacco heaped in a large pile, large bag of smoking tobacco (approximately 5 lbs.) and numerous cigarette papers attached to filters were observed in Resident 14's room. The smoking materials were easily visible from the hallway. Random observations from 5/1/23 between the hours of 8:00 AM and 2:00 PM revealed Resident 14 was frequently out of her/his room, leaving her/his smoking materials unattended and visible from the hallway. On 5/1/23 at 1:24 PM Staff 1 (Administrator) provided a list of five residents who were cognitively impaired and independently walked throughout the facility. On 5/4/23 at 3:15 PM Staff 2 (Interim DNS) and Staff 5 acknowledged Resident 14's smoking materials were not properly stored and stated they were working with the residents and staff to ensure smoking materials were safely stored.

LN whose personal insulin needles were in her supply bag on the cart was re-educated on securing syringes, and supplies were removed from resident reach. Sharps container without a lid was removed and replaced with another with a lid. Smoking materials for resident #14 were secured in a night stand in her room. Resident agreed to secure her smoking materials. Center rounds were completed to ensure all sharps containers were properly secured. Nurses carts were checked to ensure no personal supplies of sharps were accessible to residents. Center rounds were completed to ensure smoking materials are secured. Social services director re-educated residents ho smoke about keeping their smoking items secured/on-person and not accessible to other residents. LNs and CNAs were re-educated by the DNS on securing smoking items if any are seen without resident supervision or presence in its vicinity. LNs and CNAs were educate on not leaving personal sharps in places accessible to residents. LNs were re-educated by the DNS in ensuring all sharps containers have lids and to replace them as needed. Administrator will complete 2 rounds per week for 4 weeks and 1 round a month for 2 months to validate smoking materials are secure. DNS will complete 2 center rounds a week for 4 weeks, and 1 round per month for 2 months to ensure no sharps are left unsecured. The results of the audits and any corrective action taken will be reported to the monthly QAPI committee for 3 months.

Based on observation, interview and record review it was determined the facility failed to conduct post dialysis assessments of resident's condition for 1 of 1 sampled resident (#31) reviewed for dialysis. This placed residents at risk for potential unmet care needs upon return from dialysis. Findings include: Resident 31 was re-admitted to the facility in 12/2022 with diagnosis including end stage renal disease and diabetes with other diabetic kidney complications. Resident 31's Care Plan identified she/he needed dialysis due to end stage renal disease, which was scheduled every Monday, Wednesday and Friday. Interventions included to monitor and report any problems with the resident's access site to the physician or dialysis nurse. The facility's Dialysis Transfer Form included a Post Dialysis Nursing Assessment to be completed by the facility upon the residents return from dialysis. The Post Dialysis Nursing Assessment included the following sections: Lung sounds, access site, bruit, thrill, signs/symptoms of post dialysis complications, temperature, pulse, rate, BP and did the resident eat her/his lunch/snacks. Review of the residents Dialysis Transfer Forms from 4/1/23 through 5/3/23, found the following dates where the Post Dialysis Nursing Evaluation was not completed: -4/3/23 -4/5/23 -4/7/23 -4/10/23 -4/14/23 -4/17/23 -4/21/23 -4/24/23 -4/29/23 -5/1/23 There was no documentation in the resident's Progress Notes from 4/1/23 to 5/3/23 of a post dialysis evaluation. In an interview on 5/3/23 at 8:30 AM Staff 17 (RN) stated Resident 31 had a dialysis book which went with the resident to her/his dialysis appointments and upon return staff were to complete the second part of the form (Post Dialysis Nursing Assessment). Staff 17 stated their process was to complete the post dialysis evaluation and stated she understood not completing the post evaluation form could be seen as the evaluation not being done. On 5/3/23 at 11:36 AM Resident 31 was observed in her/his room sitting in her/his wheelchair. Resident 31 stated she/he was on dialysis and showed this surveyor her/his fistula site located on the upper left arm, which was covered with a clean dressing. On 5/3/23 at 12:26 PM Resident 31 was observed to have removed her/his pressure dressing on her/his fistuala site and there was a small amount of fresh blood at the site. On 5/3/23 at 12:22 PM Resident 31 stated she/he had to wait often for staff to assess her/him after dialysis appointments. In an interview on 5/3/23 at 12:33 PM Staff 17 (RN) Staff 17 acknowledged she did not complete the resident's vital signs until one hour after Resident 31 had returned to the facility. Staff 17 also acknowledged Resident 31's pressure dressing had been removed too soon and the dialysis access site was noted to have bled. In an interview on 5/3/23 at 1:36 PM Staff 4 (RNCM) stated her expectation was the Post Dialysis Nursing Assessments were completed to show staff conducted the residents post dialysis evaluation. Staff 4 stated she was not aware the forms were not being completed and acknowledged the missing assessments. In an interview on 5/4/23 at 9:07 AM Staff 18 (LPN) stated the facility did not have a process to alert her when Resident 31 returned to the facility from her/his dialysis appointments. Staff 18 stated she did not complete the Post Dialysis Nursing Assessment forms. In an interview on 5/4/23 at 2:42 PM Staff 2 (DNS) stated she expected staff to check vital signs within 30 minutes to ensure the resident's dressing was clean, dry and intact, assess the resident upon return to the facility and document on the Post Dialysis Nursing Assessment form.

Resident #31 was assessed on 05/03/23 and was not in any distress related to his dialysis treatment. Residents who are on dialysis were assessed for any changes in condition. None were identified. LNs were re-educated by the DNS on completing post-dialysis assessment on residents to ensure that there is not an acute change in condition or bleeding from their fistulas. DNS will check 1 resident a week for 4 weeks, and 1 resident a month for 2 months to validate post-dialysis assessments are being completed. The results of the audit and any corrective action taken will be reported to the monthly QAPI committee for 3 months.

Based on observation, interview and record review it was determined the facility failed to ensure sufficient staffing to meet resident care needs in a timely manner for 4 of 6 residents (#s 6, 14, 18 and 25) reviewed for staffing concerns. This placed residents at risk for delayed and unmet care needs. Findings include: 1. Resident 6 was admitted to the facility in 2022 with diagnoses including a knee fracture and obesity. Resident 6's 3/10/23 Quarterly MDS revealed the resident was cognitively intact. Resident 6's 12/1/22 Self Care Performance ADL Care Plan indicated the resident required extensive assistance with one to two person assistance for bed mobility, dressing, toileting, transfers and personal hygiene. Resident 6's 4/18/23 through 5/2/23 iAlert (call light tracking records) indicated the following delayed response times: Call light times between 20 minutes and 30 minutes: 17 Call light times between 31 minutes and 45 minutes: 7 Call light times between 46 minutes and one hour: 8 Call light times over one hour: 3 Resident 6's call light times were delayed 26% of the time. On 5/1/23 at 3:44 PM Resident 6 stated the facility was always understaffed and sometimes took 30 minutes to three hours to answer her/his call light. Resident 6 reported she/he "gets stuck" waiting to have her/his briefs changed. Resident 6 stated she/he had to call the facility's front desk several times to ask them to answer her/his light. On 5/4/23 at 10:47 AM Staff 8 (Staffing Coordinator) stated the expected call light response time was no longer than 15 minutes. 2. Resident 14 was admitted to the facility in 2018 with diagnoses including a stroke. Resident 14's 1/26/23 Annual MDS revealed the resident was cognitively intact. Resident 14's 5/10/19 Self Care Performance ADL Care Plan indicated the resident required extensive assistance with one person assistance for bed mobility, dressing, toileting, transfers and personal hygiene. Resident 14's 4/18/23 through 5/2/23 iAlert (call light tracking records) indicated the following delayed response times: Call light times between 20 minutes and 30 minutes: 2 Call light times between 31 minutes and 45 minutes: 5 Call light times over one hour: 3 Resident 14's call light times were delayed 45% of the time. On 5/1/23 at 11:40 AM Resident 14 stated it sometimes took over one hour for staff to answer her/his call light. Resident 14 reported recently at bedtime, she/he was groggy after taking sleeping medication and fell from the wheelchair because she/he waited so long for staff to respond to her/his call light. On 5/4/23 at 10:47 AM Staff 8 (Staffing Coordinator) stated the expected call light response time was no longer than 15 minutes. 3. Resident 25 was admitted to the facility in 2020 with diagnoses including paraplegia (inability to move the lower body secondary to spinal injury.) Resident 25's 4/4/23 Quarterly MDS revealed the resident was cognitively intact. Resident 25's 9/25/20 Self Care Performance ADL Care Plan indicated the resident required extensive assistance to total dependence with one to two person assistance for bed mobility, dressing, toileting, transfers and personal hygiene. Resident 25's 4/18/23 through 5/2/23 iAlert (call light tracking records) indicated the following delayed response times: Call light times between 20 minutes and 30 minutes: 7 Call light times between 31 minutes and 45 minutes: 3 Call light times over one hour: 2 Call light times over two hours: 1 Call light times over 3 hours: 1 Resident 25's call light times were delayed 23% of the time. On 5/1/23 at 2:03 PM Resident 25 reported her/his call light was on since 11:19 AM and she/he was "sick" of the staff taking so long to respond to her/his call light. Resident 25 stated she/he had not seen a CNA the entire day. Surveyor observed the call light monitor located at the main nursing station and, with Staff 15 (Medical Records), confirmed Resident 25's call light was activated at 11:19 AM and indicated "not taken" status. On 5/4/23 at 10:47 AM Staff 8 (Staffing Coordinator) stated the expected call light response time was no longer than 15 minutes. , 4. Resident 18 was admitted to the facility in 2023 with diagnosis including congestive heart failure and chronic respiratory failure. Resident 18's 3/10/23 Annual MDS revealed the resident was cognitively intact. Resident 18's 3/22/23 Self Care Performance ADL Plan indicated the resident required extensive assistance for bed mobility and toileting. Resident 18's 4/18/23 through 5/2/23 iAlert (call light tracking records) indicated the following delayed response times: Call light times between 20 minutes and 30 minutes: 10 Call light times between 31 minutes and 45 minutes: 4 Call light times between 46 minutes and one hour: 3 Resident 18's call light times were delayed 12% of the time. On 5/1/23 at 3:00 PM Resident 18 stated she/he used her/his call light and had to wait up to an hour for staff to assist her/him with ADL care. On 5/4/23 at 10:47 AM Staff 8 (Staffing Coordinator) stated the expected call light response time was no longer than 15 minutes.

Resident #6, 14, 18, and 25 were assessed for any needs. Maintenance reviewed their call lights to validate proper functioning. Center administrator completed interviews on a sample of resident to identify call light response issues, and validate that resident needs are being met. Concerns identified were addressed accordingly. CNAs were re-educated by the DNS in answering call lights in a timely manner. LNs were re-educated by the DNS in assisting CNAs respond to resident needs if they are unable to take care of a need right away. Administrator will check 2 residents per week for 4 weeks and 1 resident per month for 2 months to validate call light response time is adequate. The results of the audit and any corrective action taken will be reported to the monthly QAPI committee for 3 months.

Based on interview and record review it was determined the facility failed to ensure resident records were accurate for 2 of 3 sampled residents (#s 43 and 99) reviewed for bathing and skin conditions. This placed residents at risk for poor hygiene and improper amputation healing. Findings include: 1. Resident 99 was admitted to the facility in 2023 with diagnoses including paralysis. On 5/2/23 at 9:31 AM Resident 99 stated she/he had not received a bed bath since she/he was admitted to the facility on 4/19/23 because the facility had to order hypoallergenic soap. Resident 99's bathing record from 4/20/23 through 5/1/23 indicated the resident received bed baths on 4/24/23, 4/27/23 and 4/29/23. On 5/3/23 at 11:36 AM Staff 13 (CNA) confirmed Resident 99 was not receiving bed baths because they did not have the special soap for Resident 99 and were just wiping the resident down with water. Refer to F677 example 1. , 2. Resident 43 was admitted to the facility in 2023 with diagnoses including a left leg above the knee amputation. A 3/17/23 physician's order indicated Resident 43 was to wear two shrinker stockings at all times to prepare for a prosthetic fitting. Resident 43's 5/2023 TAR included orders to wear two shrinker stockings on her/his left leg at all times. On 5/3/23 at 10:58 AM Resident 43 was observed not wearing shrinker stockings on her/his left leg. Resident 43 stated she/he stopped wearing the stockings on 5/2/23 and did not plan on using the shrinker stockings anymore. On 5/3/23 at 12:24 PM Staff 17 (RN) was observed assisting Resident 43. Resident 43 was observed not wearing shrinker stockings on her/his left leg when Staff 17 exited Resident 43's room. Review of Resident 43's TAR on 5/3/23 at 1:20 PM revealed Staff 17 recorded Resident 43 was wearing two shrinker stockings on her/his left leg. On 5/3/23 1:26 PM Staff 23 (RNCM) stated Resident 43 was to wear two shrinker stockings on his left leg at all times. Staff 23 was asked to review Resident 43's 5/2023 TAR and stated it indicated Resident 43 was recorded to be wearing two shrinker stockings. Staff 23 approached Resident 43 and asked if she/he was wearing two shrinker stockings. Resident 43 stated she/he was not and had not worn the shrinker stockings since 5/2/23. On 5/3/23 at 1:57 PM Staff 2 (Interim DNS) confirmed Resident 43 should not have been documented as wearing shrinker stockings if she/he was not wearing them. Refer to F684 example 2.

Resident #43 erroneous documentation regarding his shrinker were struck out and accurately documented by the LN providing care on 5/5/23. Resident #99 was given his body wash of choice and provided a bath on 5/8/23. Residents with shrinkers were reviewed to validate that shrinkers are being placed as ordered. Supply of soap was checked to ensure baths and showers are given with body wash/soap. CNAs were re-educated by the DNS on using soap for baths/showers. If a resident requests a specific body soap to alert nurse managers. LNs were re-educated by the DNS on ensuring accuracy of documentation. If a resident refuses, the LN is to document accordingly. DNS will check 2 residents a week for 4 weeks and 1 resident a month for 2 months to validate accuracy of care being provided. The results of the audit and any corrective action taken will be reported to the monthly QAPI committee for 3 months.

Based on observation and interview it was determined the facility failed to maintain respiratory care equipment in a sanitary manner and perform wound care in a sterile manner for 2 of 2 sampled residents (#s 29 and 99) reviewed for respiratory care. This placed residents at risk for infection. Findings include: 1. Resident 99 was admitted to the facility in 2023 with diagnoses including paralysis. A physician order dated 4/20/23 indicated staff were to change Resident 99's disposable inner cannula (The smaller inner tube which inserted into the larger outer tube of a tracheostomy (an independent airway created by a surgical incision in the neck into the windpipe)) every day. Resident 99's 5/2023 TAR included replacement of the inner cannula and tracheostomy care every day and PRN. On 5/3/23 at 9:42 AM Staff 17 (RN) was observed as she performed tracheostomy care for Resident 99. Resident 99 had a vertical tracheotomy (the incision which created the tracheostomy) which extended slightly below the outer cannula and a bandage was in place over the incision. Staff 17 obtained a new bandage which was too large and found scissors in a drawer of the resident's room to cut the bandage in half. The Surveyor stopped Staff 17 from cutting the bandage because she had not sanitized the scissors. Staff 17 asked the Surveyor if it was appropriate to clean the scissors with soap and water. The Surveyor indicated alcohol should be used. Staff 17 cleaned the scissors with alcohol and cut the bandage in half. Staff 17 opened a sterile tracheostomy care kit, donned sterile gloves and opened the container of cleaning solution. Staff 17 used her sterile gloves to remove the resident's dirty dressing. While wearing the same gloves, Staff 17 took gauze from the kit, wetted it with the cleaning solution to clean around the resident's tracheotomy and wiped across the incision (The standard of practice for wound or incision cleaning is to wipe away from the wound or incision to prevent debris or contaminants from getting into the wound or incision). Staff 17 put the new bandage over the tracheotomy incision while wearing the same gloves. Staff 17 then removed the resident's inner cannula and replaced it with a new one again while wearing the same gloves. On 5/3/23 at 10:21 AM Resident 99's tracheostomy care provided by Staff 17 was discussed with Staff 22 (Resource RN). Staff 22 confirmed removal of the dirty bandage and cleaning was a clean procedure which should have been completed first. Staff 22 stated when cleaning the wound or tracheostomy the procedure was to wipe away from the wound. Tracheostomy care was a sterile procedure which should have been completed after the cleaning and bandage was replaced. On 5/3/23 at 11:02 AM the concerns with tracheostomy care technique were discussed with Staff 17 who did not provide any additional information. 2. Resident 39 was admitted to the facility in 2023 with diagnoses including cancer of the tongue and tracheostomy (an independent airway created by a surgical incision in the neck into the windpipe). On 5/1/23 at 9:48 AM Resident 29's Yankauer (tool used to suction secretions from the mouth and throat) was observed lying in a drawer of the resident's bedside table. The Yankauer was uncovered and in direct contact with the drawer. On 5/1/23 at 9:48 AM Staff 21 (RN) verified the Yankauer should have been covered.

Resident #29 yankauer was discarded and a new yankauer was placed securely and not exposed. Resident #99 wound was evaluated and no signs or symptoms of infection were noted. Resident #99 wound care was completed again using proper technique following infection control guidance. Residents who need suctioning had their supplies audited to ensure they are secure Residents who had wound care provided by the same LN were re-done. The wounds were assessed for any signs or symptoms of infection. None were identified. LNs were provided a wound care competency to ensure infection control is practiced. LNs were re-educated by the DNS in securing respiratory equipment properly so they are not exposed to the bare environment. DNS to check 2 residents per week for 4 weeks, and 1 resident per month for 2 months to ensure respiratory equipment is secure. DNS to check 1 resident per week for 4 weeks, and 1 resident per month for 2 months to ensure proper wound care technique is followed. The results of the audit and any corrective action taken will be reported to the monthly QAPI committee for 3 months.

Based on observation, interview and record review it was determined the facility failed to ensure residents' call lights were functional for 1 of 1 sampled resident (#27) reviewed for call light functioning concerns. This placed residents at risk for delayed assistance. Findings include: Resident 27 was admitted to the facility in 2020 with diagnoses including a stroke. On 5/1/23 at 3:00 PM, 5/2/23 at 8:30 AM and 9:29 AM and 5/3/23 at 8:19 AM Resident 27 turned on her/his call light which was observed to not be activated on the call light monitors located in the hallways and at the nursing station. On 5/1/23 at 3:00 PM Resident 27 stated her/his call light did not work and had not been working for a while. On 5/3/23 at 8:20 AM Resident 27 turned on her/his call light and Staff 11 (CNA) confirmed the resident's call light did not activate. Staff 11 pulled the call light cord from the device and re-inserted it and the call light still did not activate. On 5/3/23 at 10:40 AM Staff 16 (Maintenance Director) confirmed Resident 27's call light was not working. Staff 16 stated he completed monthly facility rounds to check call light functioning. Staff 16 was asked to provide documentation which indicated when the last monthly call light round occurred. No documentation was received.

Resident #27 call light was fixed by maintenance on 5/3/23. All rooms were checked for call light functioning and no other rooms were identified with non-functioning call lights. LNs and CNAs were re-educated by DNS on notifying the maintenance director or the administrator if a call light is not functioning. Maintenance director was re-educated by the administrator on checking call light functioning more frequently to ensure they are working properly. Administrator will complete center rounds 2 times per week for 4 weeks, and 1 time per month for 2 months to ensure call lights are functioning as intended. The results of the audit and any corrective action taken will be reported to the QAPI committee for 3 months.

*********************** 411-086-0040 Admission of Residents (Advanced Directive) Refer to F578 *********************** 411-085-0320 Residents' Rights: Charges and Rates Refer to F582 *********************** 411-085-0360 Abuse Refer to F600 *********************** 411-086-0060 Comprehensive Assessment and Care Plan Refer to F656 *********************** 411-086-0110 Nursing Services: Resident Care Refer to F677, F684, F687 and F698 *********************** 411-086-0150 Nursing Services: Restorative Care Refer to F688 *********************** 411-086-0350 Smoking Refer to F689 *********************** 411-086-0140 Nursing Services: Problem Resolution and Preventive Care Refer to F686 and F689 *********************** 411-086-0100 Nursing Services: Staffing Refer to F725 *********************** 411-086-0300 Clinical Records Refer to F842 *********************** 411-086-0330 Infection Control and Universal Precautions Refer to F880 *********************** 411-087-0440 Electrical Systems: Alarm and Nurse Call Systems Refer to F919 ***********************

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 04/25/2022 and 05/01/2022, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on observation, interview and record review it was determined the facility failed to ensure oxygen concentrators were maintained appropriately for 3 of 5 sampled residents (#s 24, 28 and 37) reviewed for respiratory care and hospitalizations. This placed residents at risk for breathing unclean air. Findings include: 1. Resident 24 was admitted to the facility in 2016 with diagnoses including chronic pain and respiratory failure with hypercapnia (excessive carbon dioxide in the bloodstream due to inadequate respiration). a. On 3/17/22 at 10:53 AM Resident 24 was observed lying in bed and she/he received O2 (oxygen) via a nasal cannula. Resident 24 stated the staff previously did not change the nasal cannula or O2 tubing regularly, but they started to change them recently. On 3/18/22 at 10:50 AM the O2 concentrator (a machine that filters and concentrates O2 from ambient air to provide 90 to 95 percent pure O2) filter was observed and found covered with a layer of dust. Resident 24's 10/17/20 Care Plan did not include information related to her/his use of O2. The 2/2022 TAR indicated the nasal cannula and tubing was changed weekly every Sunday. The TAR did not include information regarding cleaning the concentrator filter. The 3/2022 TAR indicated an entry dated 3/21/22 to clean the concentrator and the concentrator filter every day shift on Mondays. On 3/22/22 at 9:47 AM Staff 8 (CNA) stated Resident 24's O2 was kept on continuously, staff helped with monitoring the O2 and any problems were reported to the nurses. On 3/22/22 at 10:52 AM the filter of Resident 24's O2 concentrator was observed to have a covering of dust and did not appear to have been cleaned recently. On 3/22/22 at 12:29 PM Staff 7 (RN) stated the cannula and tubing was changed weekly by the nurses. Staff 7 indicated there was another staff member who took care of all the O2 tubing and changed filters but they no longer worked at the facility. During an interview on 3/22/22 at 2:32 PM Staff 4 (LPN Resident Care Manager) acknowledged the O2 therapy and related care was not included on Resident 24's Care Plan as a focus area. Staff 4 stated it was documented on the 3/2022 TAR that the concentrator filter was cleaned and she did not know why it was not done. b. A 2/17/20 Physician Order indicated the resident was to receive O2 continuous at 1 L (liter) per minute via nasal cannula. Staff were to monitor the resident's O2 sats every shift. Staff were instructed they could increase the O2 by 0.5 L if the O2 sat was less than 90 to a maximum O2 of 2 L per minute. Resident 24's 1/1/22 through 2/21/22 TARs revealed on 107 occasions staff documented administration of 2.5 L of O2 to the resident for O2 sats that were greater 90. On 3/23/22 at 11:36 AM Staff 5 (RNCM) acknowledged the physician orders were not followed for the amount of O2 administered. 2. Resident 28 was admitted to the facility in 12/2019 with diagnoses including chronic obstructive lung disease and sleep apnea. On 3/17/22 at 2:52 PM Resident 28 was observed in bed and appeared drowsy. The resident's O2 was not on due to the nasal cannula and tubing being lodged between the side of the bed and the left side rail device. The resident verbalized she/he was aware the O2 tubing and cannula was "stuck" down the side of the bed. The resident's O2 concentrator (a machine that filters and concentrates O2 from ambient air to provide 90 to 95 percent pure O2) filter was observed and found to be covered with a layer of dust. On 3/18/22 at 11:25 AM Resident 28's O2 concentrator filter was observed to be covered with dust. On 3/22/22 at 1:35 PM Staff 1 (Administrator) and the surveyor discussed the lack of a clean O2 concentrator filter for Resident 28. Staff 1 indicated the filters should be part of a routine cleaning schedule and if it was on the TAR the nurses would be responsible. On 3/22/22 at 2:32 PM Staff 4 (LPN Resident Care Manager) provided copies of task sheets for the past 30 days and there was no documented evidence Resident 28's concentrator filter was cleaned. , 3. Resident 37 admitted to the facility in 2/2021 with diagnoses including dementia and chronic obstructive lung disease. The resident received supplemental oxygen from an oxygen concentrator (a cabinet that houses an air compressor and filters to provide long term oxygen via tubing). According to the World Health Organization (WHO), an oxygen concentrator draws in room air and passes it through a series of filters that remove dust, bacteria, and other particulates. A 3/9/22 order instructed staff to clean the resident's oxygen concentrator filter every Sunday. On 3/22/22 at 10:56 AM Resident 37's oxygen concentrator was observed and it did not have a filter in place. On 3/22/22 at 11:08 AM Staff 7 (RN) confirmed there was not a filter on the concentrator. On 3/22/22 at 3:28 PM Staff 4 (LPN Resident Care Manager) stated the concentrator needed a filter.

“This Plan of Correction is prepared and submitted as required by law. By submitting this Plan of Correction, Porthaven Healthcare Center does not admit that the deficiency listed on this form exists, nor does the Center admit to any statements, findings, facts, or conclusions that form the basis for the alleged deficiency. The Center reserves the right to challenge in legal and/or regulatory or administrative proceedings the deficiency, statements, facts, and conclusions that form the basis for the deficiency.” F695 Residents cited were 37, 38, 24. All cited residents had oxygen concentrators and their filters cleaned. The Director of Nursing or Designee performed an audit of all current residents using oxygen concentrators to confirm all were clean and that nursing tasks are in place to clean the oxygen concentrators including their filters appropriately. The Director of Nursing or Designee re-educated Licensed nurses on facility policy and appropriate cleaning practices for the oxygen concentrators. The Director of Nursing or Designee will perform routine visual auditing for appropriate cleaning of the oxygen concentrators of all residents routinely using oxygen concentrators weekly x4 weeks then monthly until sustained improvement is achieved. The Director of Nursing or Designee will report the results of these audits at the facility monthly Quality Assurance meeting until sustained improvement is achieved and a lesser frequency is deemed appropriate by the committee. The Administrator is responsible for ensuring compliance.

****************************** 411-085-0110 Nursing Services: Resident Care Refer to F695

Based on interview and record review it was determined the facility failed to ensure residents were free from abuse for 3 of 4 sampled residents (#s 22, 23 and 26) reviewed for abuse. This placed residents at risk for lessened quality of life and risk of abuse. Findings include: 1. Resident 22 was admitted to the facility in 11/2019 with diagnoses including diabetes and kidney failure. The 11/22/19 Admission MDS revealed Resident 22 had no problem with long-term or short-term memory. Resident 23 admitted to the facility in 7/2018 with diagnoses including obesity and hypertension. Resident 23's Annual 10/22/19 MDS revealed a BIMS score of 15 (cognitively intact). On 11/19/19 the State Agency received a FRI which alleged Witness 45 (Former CNA) abused Residents 22 and 23. The FRI report revealed on 11/19/19 Resident 22 reported that Witness 45 came into her/his side of the room and told her/him the TV was too loud. Resident 22 reported Witness 45 took the remote control from her/his hand and turned down the TV volume without asking her/him. Resident 22 reported Witness 45 returned to care for Resident 23 in the room. Resident 23 reported to staff overhearing the same incident as Resident 22 reported. Staff 2 (DNS) interviewed both residents about the incident and Resident 22 reported feeling fearful and was shaken about the incident. Resident 22 reported this incident to her/his son (Witness 46) who came to visit her/him shortly after the incident. Witness 46 was at Resident 22's bedside when he heard Witness 45 come into the room to yell and speak inappropriately at Resident 23. When Staff 2 met with Resident 23, she/he reported Witness 45 stormed into her/his room, yelled and cursed at her/him about the incident. Once Witness 45 left the room, Resident 23 reported she/he felt fearful. The facility investigation indicated Witness 45 refused to speak with Staff 2 or Witness 38 (Former Administrator) about the incident. Witness 45 sent an email on 11/19/19 at 4:49 PM to Witness 38 which stated, "Resident said the tv was to loud and wanted it turn down so I went over and asked other to turn it down. Resident did not know where the remote was I found it on her/his bed and she/he turn down tv. Then resident stated to me to get out and not come back." No other statement or interview from Witness 45 was provided. In an interview on 10/27/21 at 12:06 PM, Witness 46 stated he recalled Witness 45 came into the room, as he sat by Resident 22's bed and overheard Witness 45 yell at and threaten Resident 23 that her/his lies were going to get Witness 45 in trouble. Witness 46 recalled Resident 22 was visibly upset by shaking, tearful and stated she/he was fearful. Phone calls were made to Witness 45 on 10/27/21 at 1:59 PM and 10/28/21 at 11:21 AM. Detailed voice messages were left for Witness 45 to return call for information about the 2019 incident by 10/29/21 at 11:00 AM. No return call was received from Witness 45 as of 11/1/21 at 6:48 PM. On 10/28/21 at 3:26 PM, Staff 2 confirmed the 11/19/19 incident of verbal abuse by Witness 45 to Resident 22 and Resident 23. Staff 2 acknowledged Witness 45 was suspended after the incident and employment was terminated. 2. Resident 25 admitted to the facility on 3/2021 with diagnoses including anxiety and depression. Resident 25's 4/21/21 care plan for behaviors included a history of yelling and verbal outbursts towards others. The 9/22/21 Quarterly MDS assessed Resident 25's BIMS score at 11 (moderate cognition). Resident 26 admitted to the facility in 9/2021 with diagnosis including knee pain and arthritis. Resident 26's 10/1/21 Admission MDS indicated a BIMS score of 15 (cognitively intact). On 9/29/21 FRI was received by the State Agency which alleged Resident 25 verbally abused Resident 26. The FRI report revealed Resident 25 yelled at her/his roommate, Resident 26, when Resident 26 was talking on the phone. Resident 25 yelled at Resident 26 to "speak English" and Resident 26 was fearful of Resident 25. Residents were separated and moved to another room. A 9/29/21 Progress note revealed Resident 25 was verbally loud, angry with her/his roommate and staff. Resident 25 yelled at her/his roommate, attempted to get out of bed, thrashed at the curtains and shouted at her/his roommate, "speak English, get [her/him] out of here, I will shoot you with a gun . . ." On 10/28/21 Staff 3 (SSD) acknowledged the incident and stated the monitoring after the incident did not indicate psychosocial distress for Resident 26. Resident 26 felt safe in another room and separated from Resident 25. In an interview on 10/28/21 at 3:26 PM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged the verbal abuse from Resident 25 to Resident 26.

F600 Free from abuse and neglect Resident 22 expired prior to the citation. Resident 23 was monitored and showed no further emotional distress. Resident 26 was monitored and showed no memory of the incident. All facility staff have completed annual abuse training to date. The Administrator or Designee will complete interviews of all interview-able facility residents for any instances of abuse. The Administrator or Designee will complete audits for facility grievances for potential abuse investigations weekly x4 and then monthly until sustained improvement is achieved. The Administrator or Designee will be responsible for scheduled annual Abuse training of facility staff. The Administrator or Designee will report the results of these audits at the facility monthly Quality Assurance meeting until sustained improvement is achieved and a lesser frequency is deemed appropriate by the committee. The Administrator is responsible for ensuring compliance.

Based on interview and record review, the facility failed to develop and implement an effective discharge planning process to ensure post-discharge care and safety needs were met for 1 of 5 sampled residents (#1) reviewed for discharge. This placed residents at risk for unsafe discharges. Findings include: Resident 1 admitted to the facility in 4/2019 with diagnoses including muscular dystrophy (progressive weakening and wasting of the muscle), cognitive communication deficit, muscle weakness, and essential hemorrhagic (blood from ruptured blood vessel) Thrombocythemia-Thrombocytosis (abnormal blood clotting or bleeding and body produces too many platelets). Resident 1's current In Room Care plan, last updated 6/3/19 directed staff to provide two-person extensive assistance while the resident transferred, toileted for both bowel and bladder, and to bathe. Resident 1's current care plan initiated on 6/6/21 for a fall on 6/5/19. The care plan indicated the fall was due to Resident 1 not following therapy recommendations to use the sideboard and not to self-transfer. The 7/19/19 Quarterly MDS revealed staff assessed Resident 1 as independent to make decisions as she/he refused to participate in the BIMS assessment. Resident 1's bed mobility, transfer, dressing, and toilet use were coded as two-person extensive assist. Personal hygiene was coded as one-person extensive assist. Resident 1 used a wheelchair for mobility. The 8/5/19 at 1:52 PM progress note by Witness 38 (Former Administrator) revealed Resident 1 expressed she/he wanted to leave facility. Witness 38 informed Resident 1 the list of extended stay properties Resident 1 provided were not wheelchair accessible. Staff 3's (SSD) 8/6/19 at 10:29 AM progress note disclosed Resident 1 decided to direct her/his own discharge and wanted to go to a budget extended stay motel. Staff 3's 8/6/19 at 10:37 AM discharge note revealed Resident 1 was to leave today and she ordered Home Health RN, PT/OT, Bathe Aide and Masters of Social Work. The facility would provide the wheelchair and arrange transportation to take Resident 1 to the extended stay motel. The 8/6/19 at 3:00 PM progress note by Witness 38 revealed Resident 1 discharged to a budget motel (extended stay) to be closer to a friend and she/he would not disclose name or contact information. Witness 38 provided Resident 1 with a $100.00 gift card to assist with food and also provided non-perishable food items with the resident. Staff 3's 8/6/19 at 3:29 PM progress note revealed Resident 1 discharged from the facility to the extended stay motel. The facility provided Resident 1 with a wheelchair, slide board for transfers, paid for a two week stay at the motel, $100.00 gift card for food and food items. Resident 1 was sent with medications and contacts for community resources. The 8/6/19 Discharge Summary/Plan of Care form by Staff 3 disclosed Resident 1's discharge was labeled unscheduled. A 8/13/19 progress note by Staff 3 revealed Resident 1's case manager called to report the home health agency had not visited Resident 1 at the motel. Staff 3 informed the case manager Resident 1 was scheduled for a primary care provider (PCP) appointment on 8/14/19 which was written on her/his discharge paperwork. Note it was eight days after Resident 1's discharge from facility before her/his appointment. A 8/15/19 progress note revealed Staff 3 received a call from home health which reported Resident 1 did not attend her/his PCP appointment and Home Health would not follow Resident 1. Staff 3 notified the resident's case manager who then told Staff 3 Resident 1's phone was not working. During an interview on 10/14/21 at 9:41 AM and 11/1/21 at 1:34 PM, Witness 14 (complainant) stated Resident 1 was discharged from the facility on 6/6/19 to an extended stay motel room which was not safe for the resident due to the level of care the resident required. Witness 14 reported the motel room was not wheelchair accessible with a lip to the entry door which prevented the resident from leaving the motel room. The bathroom did not allow a wheelchair to enter to access the toilet or bathing. The bed was too high to allow a slide board from wheelchair to the bed. Resident 1 was found in her/his motel room covered in feces and urine which penetrated the wheelchair as the resident was not able to transfer from her/his wheelchair. The motel staff had assisted the resident on several occassions when they found the resident in the same condition. Witness 14 confirmed Resident 1 wanted to leave the facility. On 10/28/21 at 1:37 PM, Staff 3 acknowledged the unscheduled discharge for Resident 1 to an extended stay motel. Staff 3 confirmed Witness 38 was the Administrator at the time of Resident 1's discharge from the facility. Staff 3 reported Witness 38 lead the discharge Resident 1 and paid for the motel room and provided a gift card for food. Staff 3 acknowledged she had not called APS to report concerns at time of discharge, after home health reported they would not serve the resident, or when Resident 1 did not have a working phone. On 10/28/21 at 3:26 PM, Staff 2 (DNS) acknowledged the discharge of Resident 1 to an extended stay motel. Staff 2 was unaware how Resident 1 would get assistance for ADLs. Staff 2 stated she would need to ask Witness 38 about the knowledge of the non-accessible wheelchair motel room.

F660 Discharge Planning Process Resident #1 expressed desire to leave the facility and was discharged from the facility in 2019. Audit residents discharged in the last 30 days to assure appropriate discharge planning by the facility. Inservice provided to the IDT team regarding the discharge planning process including patient discharge needs and goals and effective transition back to post-discharge care. IDT to review anticipated DCs to assure needs of patient will be met in post-discharge setting Administrator or Designee will report the results of these audits at the facility monthly Quality Assurance meeting until sustained improvement is achieved and a lesser frequency is deemed appropriate by the committee. The Administrator is responsible for ensuring compliance.

Based on observation, interview and record review it was determined the facility failed to provide care and services to maintain good grooming and hygiene for 1 of 4 sampled residents (#2) reviewed for ADLs. This placed residents at risk for unmet needs. Findings include: Resident 2 was admitted to the facility in 3/2019 with diagnoses including a broken back. A 3/28/19 Admission MDS revealed Resident 2 required one-person physical assist with bathing. Point of Care History report with a start date of 3/21/19 revealed the following showers from 3/21/19 through 4/11/19: -3/26/19 total dependence for bathing by Staff 31 (CNA) -3/29/19 total dependence for bathing by Staff 31 -4/2/19 assist with part of bathing by Staff 32 (RN) who was a CNA at the time of the incident in 2019. -4/5/19 assist with part of bathing by Staff 31 -4/9/19 assist with part of bathing by Staff 33 (CNA) On 10/18/21 at 10:46 AM Witness 13 (Family Member) stated Resident 2 did not obtain showers two times a week. On 10/28/21 at 8:39 AM Staff 31 (Former CNA) stated in 3/2019 and 4/2019 the facility was short staffed and there were instances when she documented completing a shower for a resident when she had not actually done so. Staff 31 stated showers were time consuming and there was not always enough time to complete them. On 11/1/21 at 10:03 AM Staff 1 (Administrator) and Staff 2 (DNS) stated they expected staff to document a shower was not completed and to notify the next shift a shower for the resident needed to be completed.

F677 ADL Care Provided for Dependent Residents Resident #2 discharged from the facility in 2019 Education will be provided to staff on appropriate documentation of care and services provided Audit will be completed through resident interview and observation for compliance of ADL charting to ADL tasks performed Administrator or Designee will report the results of these audits at the facility monthly Quality Assurance meeting until sustained improvement is achieved and a lesser frequency is deemed appropriate by the committee. The Administrator is responsible for ensuring compliance.

Based on interview and record review it was determined the facility failed to implement pressure ulcer treatments for 1 of 3 sampled residents (#5) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers. Findings include: Resident 5 was admitted to the facility on 11/14/19 with diagnoses including difficulty walking and muscle weakness. An 11/21/19 Pressure Skin CAA indicated Resident 5 admitted with a Stage 2 pressure ulcer to the sacrum and deep tissue injury to the bilateral buttocks. An 11/26/19 Skin Grid form revealed on 11/26/19 Resident 5 had the following skin issues: -Deep tissue pressure ulcer to the sacrum which was present on admission. The wound was 0.4 cm in length and 0.6 cm in width wound bed was purple. -Stage 2 to the left buttock which was one cm in length and 2.5 cm in width wound bed was red and was present on admission. -Deep tissue pressure ulcer to the right buttock which was 0.3 in length and 0.5 in width with purple wound bed which was present on admission. Wound orders were put in. A 11/2019 TAR instructed staff to cleanse pressure wounds to the sacrum, right buttock and left buttock and to apply foam dressing. every other day with a start date of 11/28/19. No documentation was found in clinical records physician orders or treatment were in place for Resident 5's pressure ulcers from 11/14/19 through 11/27/19. On 11/1/21 at 10:08 AM Staff 2 (DNS) stated she would review the information. No additional information was provided .

F686 Treatment/ Services to Prevent/Heal Pressure Ulcer Resident 9 Discharged from facility prior to the citation. The Director of Nursing or Designee will ensure facility LNs and RCMs receive education on wound care management of pressure ulcers and verification of current wound care competency. The Director of Nursing or Designee will perform an initial 30day audit of new admits and skin impairment incident reports to ensure appropriate treatment is in place. The Director of Nursing or Designee will perform routine auditing of all residents with pressure ulcers to ensure appropriate treatment is in place weekly x4 weeks then monthly until sustained improvement is achieved. The Director of Nursing or Designee will report the results of these audits at the facility monthly Quality Assurance meeting until sustained improvement is achieved and a lesser frequency is deemed appropriate by the committee. The Administrator is responsible for ensuring compliance.

Based on interview and record review it was determined the facility failed to provide timely toileting assistance for 1 of 9 sampled residents (#10) reviewed for incontinent care. This placed residents at risk for not maintaining continence. Findings include: Resident 10 was admitted to the facility in 5/2020 with diagnoses including COPD and anxiety. A 5/21/20 care plan indicated Resident 10 had occasional bowel incontinence due to soiling herself/himself when upset with direct care staff. Interventions included Resident 10 being able to toilet herself/himself independently. A review of the iAlert Page Reports (call light time reports) from 5/21/20 through 6/10/20 revealed the following for call light wait times or resets (a call light reset by a CNA or other staff member) over 20 minutes for Resident 10: -5/21/20: 2:44 PM 44 minutes. -5/22/21: 9:42 AM 33 minutes, 10:42 AM 52 minutes and 2:20 PM 35 minutes. -5/23/20: 11:29 AM 31 minutes, 4:22 PM one hour, 7:23 PM 29 minutes and 11:33 PM 22 minutes. -5/24/20: 7:59 AM one hour, 44 minutes, 12:26 PM one hour, 32 minutes, 4:35 PM 52 minutes, reset for 22 minutes with a total time of one hour 13 minutes and 6:18 PM 33 minutes. -5/25/20: 3:10 PM one hour, 6:33 PM 47 minutes, 10:25 PM 59 minute and 11:38 PM 23 minutes. -5/26/20: 10:06 AM 31 minutes and 11:49 PM 24 minutes. -5/27/20: 10:20 PM 24 minutes. -5/28/20: 4:42 PM 26 minutes. -5/29/20: 5:35 PM 33 minutes. -5/30/20: 8:29 AM 11 minutes, a reset for 27 minutes with a total time of 39 minutes, 11:25 AM 29 minutes, 5:28 PM 23 minutes with a reset 49 seconds the completed task was in two hours 51 minutes with a total time of 3 hours and 15 minutes, 8:44 PM 37 minutes. -5/31/20: 8:18 AM 58 minutes, 11:23 AM 42 minutes, a reset of 12 minutes with a total time of 54 minutes, 2:52 PM 34 minutes. -6/1/20: 4:34 PM 36 minutes, 6:07 PM 25 minutes, a reset of one hour 21 minutes with a total time of one hour 47 minutes. -6/2/20: 2:36 AM 42 minutes, 2:50 PM 41 minutes, a reset for 18 minutes total 59 minutes, 4:23 PM 26 minutes, 6:16 PM 30 minutes, 8:41 PM 48 minutes, reset 22 minutes with a total time one hour and 11 minutes. -6/3/20: 11:34 AM 56 minutes, 12:57 PM 29 minutes, 4:27 PM 29 minutes. -6/5/20: 6:27 AM 40 minutes, 7:22 PM 29 minutes, reset 9 minutes total 38 minutes, 8:17 PM 52 minutes, reset of 20 minutes, the task was completed in 58 minutes, with a total time of two hours and nine minutes, and 10:27 PM 22 minutes with a reset time of 16 minutes with the total time of 38 minutes. -6/6/20: 10:01 PM 21 minutes. -6/7/20: 5:59 PM 35 minutes with a reset of 18 minutes with the total time of 53 minutes. -6/9/20: 11:07 AM 50 minutes with a reset of 14 minutes with the total time of one hour four minutes and 1:32 PM 26 minutes. -6/10/20: 5:29 AM 31 minutes. A 5/2020 Documentation Survey Report revealed the following for Resident 10's bowel elimination: -5/21/20 no bowel movement -5/22/20 no bowel movement -5/23/20 no bowel movement -5/24/20 evening shift, continent -5/25/20 day, continent -5/26/20 no bowel movement -5/27/20 no bowel movement -5/28/20 day, continent -5/29/20 no bowel movement -5/30/20 day, incontinent -5/31/20 incontinent all three shifts A 5/28/20 Admission MDS revealed Resident 10 was cognitively intact and required extensive two person physical assistance with toileting. Resident 10 was not steady moving off and on the toilet and was only able to stabilize with staff assistance and was always continent of bowel. A 6/2020 Documentation Survey Report revealed the following for Resident 10's bowel elimination from 6/1/20 through 6/10/20: -6/1/20 day and night shift incontinent -6/2/20 evening incontinent -6/3/20 incontinent all three shifts -6/4/20 incontinent day and night shift continent eve -6/5/20 incontinent all three shifts -6/6/20 incontinent day and eve -6/7/20 incontinent evening -6/8/20 no bowel movement -6/9/20 no bowel movement -6/10/20 incontinent day and evening On 10/19/21 at 10:35 Resident 10 stated one instance in 5/2020 she/he was left on the toilet for three and a half hours. Resident 10 stated she/he kept pushing her/his call light and no one came. Resident 10 stated her/his legs no longer had feeling in them and it took four to five people to transfer her/him back to bed. Resident 10 stated she/he no longer went to the bathroom again until she/he had the strength to use the toilet on her/his own because she/he was afraid it would occur again. On 10/26/21 at 12:08 PM Witness 34 (Former CNA) stated in 5/2020 and 6/2020 he would be responsible for 7 to 10 residents and sometimes more than 10 on day shift. If another CNA did not come into work the residents that CNA was responsible for would be distributed between the remaining CNAs working. Staff 14 stated if he was providing a shower other CNAs were supposed to answer his call lights, and if they could not answer his call lights there would be a longer call light wait times for residents. On 10/29/21 at 1:03 PM Witness 32 (Former CNA) stated the facility was short staffed in 6/2020 and she could not complete all of her required daily tasks. Residents complained of long call light times and had incontinent episodes due to waiting. On 11/1/21 at 10:16 AM Staff 1 (Administrator) and Staff 2 (DNS) stated the expectation of the staff was for the CNA's hall partner to answer the call lights if the resident's CNA was busy. All staff are to answer call lights and call light wait times should be monitored.

F690 Bowel Bladder Incontinence, Catheter, UTI Resident 10 Discharged from facility prior to citation. The Director of Nursing or Designee will ensure facility LNs and CNAs are on re-educated on appropriate call light response times and expectations on incontinent care. The Director of Nursing or Designee will perform routine auditing of call light response times for out of standard wait times and interview residents on care needs met weekly x4 and then monthly until sustained improvement is achieved. The Director of Nursing or Designee will report the results of these audits at the facility monthly Quality Assurance meeting until sustained improvement is achieved and a lesser frequency is deemed appropriate by the committee. The Administrator is responsible for ensuring compliance.

Based on interview and record review it was determined the facility failed to ensure a resident received appropriate care and services related to a feeding tube for 1 of 4 sampled resident (#9) reviewed for feeding tubes. This placed residents at risk for complications related to use of a feeding tube. Findings include: The facility's policy and procedure for g-tube (Gastrostomy feeding tube: a tube inserted directly into the stomach to give direct access for supplemental feeding, hydration or medications): If cans (food) are opened and not used in their entirety, the can should be timed, dated, covered and kept in the refrigerator when not in use. Nursing staff should remove the can at least one hour prior to use to warm to room temperature. This is done to prevent abdominal cramping. Resident 9 was admitted to the facility in 3/2020 with diagnoses including chronic respiratory failure, diabetes and stroke. A 3/18/20 MDS indicated Resident 9 had a feeding tube. A 3/2020 MAR indicated Staff 30 (RN) administered the following medications via Resident 9's g-tube on day shift from 3/15/20 through 3/18/20: Lansoprazole (decrease the amount of acid in the stomach), Polyethylene (treat constipation), Phenytoin (prevent and control seizures), Senna (laxative), Carvedilol, Hydralazine and Clonidine (all three treat high blood pressure). A 3/18/20 Grievance Concern Problem Identification and Follow-up indicated there was a concern about interactions with Staff 30 and Witness 3 (Family Member) and medication administration with Resident 9. Staff 30 administered Resident 9's medications via g-tube with ice water, she/he was fidgeting and obviously uncomfortable but Staff 30 did not stop. Room temperature bottled water was available in the room for the nurses to administer medications. Witness 3 attempted to inform Staff 30 but she was not cooperative. Administrative review indicated Staff 30 would no longer provide care to Resident 9 by request of Witness 3. On 10/15/21 at 8:21 AM Witness 3 stated Staff 30 administered Resident 9's medications via g-tube and Resident 9 was squirming in bed. Staff 30 administered the medications with ice cold water which caused Resident 9 to squirm. Staff 30 told Witness 3 that was how she administered the medication for all residents. On 10/28/21 at 10:27 AM Staff 30 stated when administering medications to residents with a g-tube she would use the water on her medication cart. At times the water on the cart will have ice in it depending on the weather. If the resident preferred warm water they will tell her and she will use warm water. On 11/1/21 at 10:12 AM Staff 1 (Administrator) and Staff 2 (DNS) stated the standard of practice for administering medications to resident with g-tubes was to have the water at room temperature.

F693 Tube Feeding Management/Restore Eating Skills Resident 9 Discharged from facility prior to citation. The Director of Nursing completed corrective action to the listed LN at time of the grievance. The Director of Nursing or Designee will ensure facility LNs are re-educated on appropriate administration of enteral Tube Feeding medications and verification of competency on appropriate administration of enteral tube feeding medications. The Director of Nursing or Designee will perform auditing of tube feeding medication administration competency for all LN to ensure it is current. A routine audit of at least 4 LNs administration of medication by tube feeding weekly x4 weeks and then monthly until sustained improvement. The Director of Nursing or Designee will report the results of these audits at the facility monthly Quality Assurance meeting until sustained improvement is achieved and a lesser frequency is deemed appropriate by the committee. The Administrator is responsible for ensuring compliance.

Based on observation, interview and record review it was determined the facility failed to provide respiratory care and services in accordance with residents' physician orders and care plans for 1 of 3 sampled residents (#27) reviewed for respiratory services. This placed residents at risk for unmet respiratory needs. Findings include: Resident 27 admitted to the facility on 7/2021 with diagnosis including obstructive sleep apnea and chronic respiratory failure. A 7/8/21 care plan indicated Resident 27 had altered respiratory status, difficulty breathing due to sleep apnea and chronic respiratory failure with interventions which included a Bipap (bilevel Positive airway pressure a mode of respiratory ventilation used for treatment of sleep apnea) with full face mask, administer medications as ordered and monitor for effectiveness and side effects. A 9/21/21 Alert Note indicated Resident 27's Bipap mask was torn on the inner lower side of the mask. Staff 34 (RN) was able to make the mask work for short term but the seal was not as good on the lower edge. The 10/7/21 signed physician orders instructed staff to apply Bipap at bedtime with full face mask at bedtime related to chronic respiratory failure with hypoxia and obstructive sleep apnea with a start date of 8/12/21. A 10/2021 TAR instructed staff to administer Bipap at bedtime with full face mask for chronic respiratory failure with hypoxia and sleep apnea with a start date of 8/12/21. The TAR indicated the following for Bipap: -10/1/21 no documentation Bipap was applied. -10/9/21 no documentation Bipap was applied. -10/12/21 referred reader to administration notes. -10/13/21 no documentation Bipap was applied. -10/18/21 referred the reader to administration notes. -10/20/21 referred the reader to administration notes. A 10/12/21 Administration Note indicated Resident 27 was not ready for application of the Bipap. Staff would alert the night shift. No documentation was found in clinical records showing night shift applied Resident 27's Bipap. On 10/14/21 at 9:21 AM Resident 27's Bipap mask was observed in place on her/his face. Air could be heard leaking out of the lower part of the mask. Resident 27 pointed to an area on the bottom of the mask to show where a tear was located in the mask. Resident 27 stated the mask had a rip in the bottom about a month ago and the facility ordered a new one but it had not arrived. Resident 27 stated staff did not put on her/his Bipap the night of 10/13/21. On 10/15/21 at 4:04 PM Staff 1 (Administrator) stated per nursing staff the Bipap was working well and had a good seal, but the facility did have the provider replace the mask on 10/15/21. A 10/18/21 Administration Note indicated Resident 27 was not ready for application of the Bipap. Staff would alert night shift. No documentation was found in clinical records night shift applied Resident 27's Bipap. A 10/20/21 Administration Note indicated Resident 27 was not ready for application of the Bipap. Staff would alert night shift. No documentation was found in clinical records night shift applied Resident 27's Bipap. On 11/1/21 at 10:19 AM Staff 1 (Administrator) and Staff 2 (DNS) stated if contracted vendor did not have the needed equipment the facility would attempt to order from a different vendor, and the nurse also reported a proper seal of the Bipap mask.

F695 Respiratory/Tracheostomy Care and Suctioning Resident 27 had BiPap mask replaced on 10/15/21 and has had no further equipment issues. The Director of Nursing or Designee completed corrective action to the assigned LN and RCM on appropriate response and follow-through to broken resident respiratory DME. The Director of Nursing or Designee will ensure facility LNs and RCMs are re-educated on appropriate response and follow-through of broken resident respiratory DME. The Director of Nursing or Designee to complete an Audit for the past 30days of all residents using BiPap/Cpap respiratory equipment for functionality and updated servicing. The Director of Nursing or Designee to complete an Audit weekly res using respiratory equipment for functionality and f/u for servicing weekly x4 weeks and then monthly until sustained improvement. The Director of Nursing or Designee will report the results of these audits at the facility monthly Quality Assurance meeting until sustained improvement is achieved and a lesser frequency is deemed appropriate by the committee. The Administrator is responsible for ensuring compliance.

Based on interview and record review it was determined the facility failed to ensure call lights were answered timely for 6 of 16 sampled residents (#s 5, 6, 9, 10, 21 and 27) reviewed for call light times and timely incontinent care. This placed residents at risk for unmet needs. Findings include: 1. Resident 5 was admitted to the facility in 11/2019 with diagnoses including difficulty walking and muscle weakness. A 11/29/19 Admission MDS revealed Resident 5 was always incontinent of bowel and bladder and required two-person assistance with toileting. A 12/2/19 care plan indicated to be sure Resident 5's call light was in reach and encourage the resident to use for assistance as needed. Resident 5 needed prompt response to all requests for assistance. A review of the iAlert Page Report from 1/1/20 through 1/7/20 Resident 5 pushed her/his call light 54 times. Four of the instances revealed the following for call light answer times over 20 minutes: -1/2/20: 7:42 PM 32 minutes, reset 19 minutes, 11:27 PM 36 minutes, reset 5 minutes. -1/4/20: 23 minutes -1/7/20: 39 minutes On 10/14/21 at 12:34 PM Witness 2 (Family Member) stated Resident 5 would push her/his call light and it would take 35 to 40 minutes for staff to come into the room. On 10/26/21 at 11:5 AM Witness 30 (Former CNA) stated the facility was short staffed in 1/2020. Witness 30 stated he did not always have time to complete required tasks each day and would provide basic care to the residents. On 10/28/21 at 9:47 AM Witness 33 (Former CNA) stated in 1/2020 he did not complete all required tasks each day because the facility was short staffed. Witness 33 stated most call lights were answered as the staff were not supposed to have the call light wait time go over half an hour. On 11/1/21 at 10:09 AM Staff 1 (Administrator) and Staff 2 (DNS) stated they expected staff to answer call lights within 10 minutes. The hall partner should assist the CNA and if call light wait times go over 30 minutes the nurse should intervene. 2. Resident 6 was admitted to the facility in 12/2018 with diagnoses including anxiety. A 10/2/19 Quarterly MDS revealed Resident 6 required extensive assistance with toilet use with two-person physical assist. On 12/26/19 a public complaint was received indicating on 12/22/19 Resident 6 called a community counseling phone line with concerns she/he sat in a soiled undergarment for two hours. During the call the resident called out for assistance seven instances with no response from staff. Resident 6 also reported her/his window was open and she/he was cold, and no one would help her/him. A review of the iAlert Page Report from 12/16/19 through 12/22/19 revealed on 12/22/19 Resident 6 pushed her/his call light 21 times. Four of times revealed the following for call light answer times over 20 minutes: -9:16 AM call light was answered after 25 minutes. -11:05 AM call light was answered after 30 minutes. -1:26 PM call light was answered after 47 minutes. -10:16 PM call light was answered after 21 minutes. A 12/2019 Documentation Survey Report revealed on 12/22/19 Resident 6 had three bowel movements as follows: -Day shift: incontinent, large, loose/diarrhea -Evening shift extra-large, loose/diarrhea -Night shift incontinent medium, loose diarrhea. A 12/22/19 at 3:47 PM Administration Note revealed Resident 6 had diarrhea. A 12/22/19 at 10:11 PM Alert Note revealed Resident 6 had a large amount of diarrhea two times. On 10/26/21 at 10:29 AM Staff 8 (CNA) stated in 12/2019 and 1/2020 the facility was short staffed and some residents pushed their call lights frequently. Staff 8 stated if he gave a resident a shower call light wait times could be long. On 11/1/21 at 10:09 AM Staff 1 (Administrator) and Staff 2 (DNS) stated they expected staff to answer call lights within 10 minutes. The hall partner should assist the CNA and if call light wait times go over 30 minutes the nurse should intervene. 3. Resident 9 was admitted to the facility in 3/2020 with diagnoses including chronic respiratory failure, diabetes and stroke. A 3/12/20 care plan indicated Resident 9 was unable to use her/his call light and to provide frequent safety checks. A 3/13/20 Nurses Note indicated Witness 3 (Family Member) stated she could help with Resident 9. Staff encouraged Resident 9 to ask for assistance if it was needed. A review of the iAlert Page Report (call light time report) from 3/11/20 through 3/23/20 revealed Resident 9's call light was pushed 44 times 11 of the times revealed the following for call light answer times over 20 minutes: -3/14/20 5:55 PM 41 minutes -3/16/20 1:54 PM 22 minutes -3/19/20 4:55 AM 20 minutes, 8:50 AM 25 minutes and 12:57 PM 37 minutes. -3/20/20 11:41 AM 40 minutes, and 6:15 PM one hour and 12 minutes. -3/21/20 4:59 AM 34 minutes, 5:45 AM 27 minutes. -3/22/20 7:18 PM 24 minutes -3/23/20 9:01 AM 27 minutes On 10/15/21 at 8:21 AM Witness 3 (Family Member) stated she used the call light to obtain assistance for Resident 9 in 3/2020 and staff did not respond timely which occurred during all shifts. After waiting for 25 minutes or more Witness 3 would provide Resident 9's care. On 10/26/21 at 10:38 AM Staff 8 (CNA) stated since around 3/2020 it was "crazy". Staff 8 stated most of the time the facility was short staffed and there was not enough time to complete all the required assignments each day. Staff 8 stated when the residents are alert and oriented you must follow their schedule and they push their call lights frequently. At times if he was giving a shower and it was busy the call light times could be long. Staff 8 stated he gave priority to the residents who were incontinent. If the residents were not alert and oriented the CNAs could have their own daily schedule. On 11/1/21 at 10:09 AM Staff 1 (Administrator) and Staff 2 (DNS) stated they expected staff to answer call lights within 10 minutes. The hall partner should assist the CNA and if call light wait times go over 30 minutes the nurse should intervene. 4. Resident 10 was admitted to the facility in 5/2020 with diagnoses including COPD and anxiety. A review of the iAlert Page Reports (call light time reports) from 5/21/20 through 6/30/20 revealed the following for call light wait times or resets (a call light reset by a CNA or other staff member) over 20 minutes for Resident 10: -5/21/20: 2:44 PM 44 minutes. -5/22/21: 9:42 AM 33 minutes, 10:42 AM 52 minutes and 2:20 PM 35 minutes. -5/23/20: 11:29 AM 31 minutes, 4:22 PM one hour, 7:23 PM 29 minutes and 11:33 PM 22 minutes. -5/24/20: 7:59 AM one hour, 44 minutes, 12:26 PM one hour, 32 minutes, 4:35 PM 52 minutes, reset for 22 minutes with a total time of one hour 13 minutes and 6:18 PM 33 minutes. -5/25/20: 3:10 PM one hour, 6:33 PM 47 minutes, 10:25 PM 59 minute and 11:38 PM 23 minutes. -5/26/20: 10:06 AM 31 minutes and 11:49 PM 24 minutes. -5/27/20: 10:20 PM 24 minutes. -5/28/20: 4:42 PM 26 minutes. -5/29/20: 5:35 PM 33 minutes. -5/30/20: 8:29 AM 11 minutes, a reset for 27 minutes with a total time of 39 minutes, 11:25 AM 29 minutes, 5:28 PM 23 minutes with a reset 49 seconds the completed task was in two hours 51 minutes with a total time of 3 hours and 15 minutes, 8:44 PM 37 minutes. -5/31/20: 8:18 AM 58 minutes, 11:23 AM 42 minutes, a reset of 12 minutes with a total time of 54 minutes, 2:52 PM 34 minutes. -6/1/20: 4:34 PM 36 minutes, 6:07 PM 25 minutes, a reset of one hour 21 minutes with a total time of one hour 47 minutes. -6/2/20: 2:36 AM 42 minutes, 2:50 PM 41 minutes, a reset for 18 minutes total 59 minutes, 4:23 PM 26 minutes, 6:16 PM 30 minutes, 8:41 PM 48 minutes, reset 22 minutes with a total time one hour and 11 minutes. -6/3/20: 11:34 AM 56 minutes, 12:57 PM 29 minutes, 4:27 PM 29 minutes. -6/5/20: 6:27 AM 40 minutes, 7:22 PM 29 minutes, reset 9 minutes total 38 minutes, 8:17 PM 52 minutes, reset of 20 minutes, the task was completed in 58 minutes, with a total time of two hours and nine minutes, and 10:27 PM 22 minutes with a reset time of 16 minutes with the total time of 38 minutes. -6/6/20: 10:01 PM 21 minutes. -6/7/20: 5:59 PM 35 minutes with a reset of 18 minutes with the total time of 53 minutes. -6/9/20: 11:07 AM 50 minutes with a reset of 14 minutes with the total time of one hour four minutes and 1:32 PM 26 minutes. -6/10/20: 5:29 AM 31 minutes. -6/12/20: 3:12 PM four minutes with a reset time of 42 minutes the task was completed in 13 seconds with a total time of 46 minutes, 7:15 PM 26 minutes with a reset of 19 minutes the task was completed in two seconds with total time of 45 minutes. -6/13/20: 3:02 PM 31 minutes and 10:23 PM 22 minutes. -6/14/20: 4:38 PM 26 minutes. -6/15/20: 8:28 AM 22 minutes and 2:29 PM 49 minutes. -6/16/20: 8:47 AM one hour seven minutes with a reset time of 29 minutes and the task was completed in two hours 21 minutes with a total time of three hours and 58 minutes, 12:45 PM 22 minutes with a reset time of 12 minutes with a total time of 35 minutes and 11:57 PM 22 minutes. -6/17/20: 2:26 PM 31 minutes. -6/18/20: 10:59 AM 36 minutes with a reset time of 39 minutes with a total time of one hour 15 minutes. -6/19/20: 3:33 PM 30 minutes and 10:50 PM 48 minutes reset time of 9 minutes with a total time of 57 minutes. -6/20/20: 12:22 AM one hour, 1:28 PM 22 minutes, 3:11 PM 25 minutes, 7:56 PM 29 minutes and 8:45 PM 41 minutes. -6/23/20: 10:49 AM 47 minutes, 11:41 AM 26 minutes with a reset time of 19 minutes and total time of 46 minutes and 11:16 PM 39 minutes. -6/24/20: 11:19 AM 24 minutes and 1:52 PM 26 minutes with a reset time of 29 minutes and a total time of 55 minutes. -6/25/20: 3:01 PM 36 minutes with a reset time for 14 minutes with a total time of 50 minutes. -6/26/20: 2:16 PM 30 minutes and 2:47 PM 31 minutes. -6/27/20: 7:23 PM 59 minutes. -6/28/20: 2:49 PM one hour. -6/29/20: 8:59 AM 57 minutes, 3:27 PM 40 minutes and 5:51 PM 21 minutes. -6/30/20: 5:44 PM 21 minutes, 8:31 PM 21 minutes and 10:33 PM 25 minutes. On 10/19/21 at 10:35 Resident 10 stated her/his call light times were over 20 minutes frequently. Resident 10 reported one instance in 5/2020 she/he was left on the toilet for three and a half hours. Resident 10 stated she/he kept pushing her/his call light and no one came. On 10/26/21 at 12:08 PM Witness 34 (Former CNA) stated in 5/2020 and 6/2020 he would be responsible for 7 to 10 residents and sometimes more than 10 on day shift. If another CNA did not come into work the residents that CNA was responsible for would be distributed between the remaining CNAs working. Staff 14 stated if he was providing a shower other CNAs were supposed to answer his call lights, and if they could not answer his call lights there would be longer call light wait times for residents. On 10/29/21 at 1:03 PM Witness 32 (Former CNA) stated the facility was short staffed in 6/2020 and at times she did not complete all her required daily tasks which occurred daily. Residents complained of long call light times and had incontinent episodes due to waiting for staff assistance. On 10/29/21 at 4:05 PM Staff 11 (CNA) stated in 5/2020 and 6/2020 if call light wait times were long, she would go in and inform the resident they had one person ahead of them and she would leave her phone to let them know she would be returning to assist them. Staff 11 stated some residents have incontinent episodes if the facility was short staffed and you cannot get to the resident in time. On 11/1/21 at 10:09 AM Staff 1 (Administrator) and Staff 2 (DNS) stated they expected staff to answer call lights within 10 minutes. The hall partner should assist the CNA and if call light wait times go over 30 minutes the nurse should intervene. 5. Resident 21 admitted to the facility on 2/2021 with diagnosis including dementia and anxiety disorder. A 2/3/21 care plan indicated Resident 21 was a fall risk due to weakness and poor visual function with interventions including remind Resident 21 to use call light for assistance, keep call light within reach and Resident 21 needed prompt response to all requests for assistance. A review of the iAlert Page Report (call light time report) from 6/1/21 through 6/16/21 revealed Resident 21 pushed her/his call light 137 times five of the times revealed the following for call light answer times or resets over 20 minutes: -6/1/21: 10:27 PM 24 minutes. -6/4/21: 2:24 PM 2:32 minutes, reset 23 minutes. -6/7/21: 1:38 AM 32 seconds, reset 24 minutes. -6/12/21: 12:36 PM 23 minutes. -6/16/21: 6:29 AM 24 minutes. On 10/26/21 at 10:17 AM Staff 7 (CNA) stated staff attempt to answer Resident 21's call light as quickly as possible more than other residents because she/he writes two to three page letters and complains. When a resident complains of a long call light time Staff 7 will tell them he will come back to assist them. On 11/1/21 at 10:09 AM Staff 1 (Administrator) and Staff 2 (DNS) stated they expected staff to answer call lights within 10 minutes. The hall partner should assist the CNA and if call light wait times go over 30 minutes the nurse should intervene. 6. Resident 27 admitted to the facility on 7/2021 with diagnosis including obstructive sleep apnea and chronic respiratory failure. A 7/8/21 care plan indicated Resident 27 had altered respiratory status, difficulty breathing due to sleep apnea and chronic respiratory failure. Resident 27 was at risk for falls with interventions including call light within reach and remind to use call light for assistance. A review of the iAlert Page Report (call light response logs) from 10/1/21 through 10/13/21 revealed the following: -Resident 27's call light was triggered 117 times 15 of the times revealed call light answer times or resets over 20 minutes: -10/1/21: 11:36 AM 38 minutes, 12:30 PM 44 minutes, 4:48 PM 24 minutes, 10:22 PM 43 minutes. -10/2/21: 8:19 AM 47 minutes, 1:09 PM 36 minutes. -10/3/21: 2:27 PM 23 minutes. -10/8/21: 2:44 PM 23 minutes. -10/9/21: 5:56 PM 29 minutes. -10/10/21: 8:44 PM 19 minutes then reset with addition 34 minutes. -10/11/21: 2:25 PM 55 minutes, 5:14 PM 7 minutes then reset with additional 48 minutes, 8:39 PM 1 minute then reset with additional 59 minutes, 10:12 PM 29 minutes. -10/12/21: 8:56 AM 29 minutes. On 10/14/21 at 9:21 AM Resident 27 stated call light wait times sometimes take over an hour. At times staff will come tell her/him there are other people needing assistance before her/him and then they never come back to assist. On 10/29/21 at 4:05 PM Staff 11 (CNA) stated some residents complain of long call light wait times. Staff 11 stated on days the facility was short staffed some residents had incontinent episodes due to waiting for their call light to be answered. On 11/1/21 at 10:09 AM Staff 1 (Administrator) and Staff 2 (DNS) stated they expected staff to answer call lights within 10 minutes. The hall partner should assist the CNA and if call light wait times go over 30 minutes the nurse should intervene.

F725 Resident 5, 6, 9, 10, were discharged from the facility. Residents 21 and 27 remain in the facility. Care needs will be assured though 2x/week routine resident interviews until substantial improvement is obtained. Inservice provided to staff on expectations surrounding call light response times Partner with community and internal partners to provide NA training courses, and recruit new staff members Call light response times monitored with staff follow up for long call light response times weekdays x 3 weeks or until substantial compliance is achieved Administrator or Designee will report the results of these audits at the facility monthly Quality Assurance meeting until sustained improvement is achieved and a lesser frequency is deemed appropriate by the committee. The Administrator is responsible for ensuring compliance.

**************************************** OAR 411-085-0360 Abuse Refer to F600 *************************************** OAR 411-086-0160 Nursing Services: Discharge Summary Refer to F660 **************************************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F677, F693 and F695 ***************************************** OAR 411-086-0140 Nursing Services: Problem Resolution & Preventive Care Refer to F686 and F690 *************************************** OAR 411-086-0100 Nursing Services: Staffing Refer to F725 ***************************************

Based on interview and record review it was determined the facility failed to ensure state minimum bariatric CNA staffing ratios were maintained for 18 of 34 days reviewed for staffing. This placed residents at risk for delayed treatment and unmet care needs. Findings include: NF (Nursing Facility)-21-047 Provider Alert, dated 9/1/21, reiterated the need for facilities to staff one additional CNA per shift above the minimum licensing staffing standard for every five bariatric residents approved to receive the bariatric rate. On 9/27/21, the facility had three residents approved for the bariatric rate. A review of the Direct Care Staff Daily Reports from 9/1/21 through 9/26/21 revealed the following days when state minimum bariatric CNA staffing ratios were not met: 9/3/21-night shift staffed 3 CNAs and 4 were required. 9/4/21-day shift staffed 6.5 CNAs and 7 were required. 9/6/21-night shift staffed 3 CNAs and 4 were required. 9/7/21-night shift staffed 3 CNAs and 4 were required. 9/8/21-night shift staffed 3 CNAs and 4 were required. 9/9/21-night shift staffed 3 CNAs and 4 were required. 9/11/21-day shift staffed 5.5 CNAs and 7 were required. 9/12/21-day shift staffed 6.5 CNAs and 7 were required. 9/14/21-day shift staffed 6.5 CNAs and 7 were required. 9/18/21-day shift staffed 6.5 CNAs and 8 were required. 9/19/21-day shift staffed 6.5 CNAs and 8 were required. 9/20/21-day shift staffed 6.5 CNAs and 8 were required. 9/21/21-day shift staffed 5 CNAs and 8 were required. 9/22/21-day shift staffed 7.5 CNAs and 8 were required. 9/23/21-night shift staffed 3 CNAs and 4 were required. 9/24/21-night shift staffed 3 CNAs and 4 were required. 9/25/21-day shift staffed 6.5 CNAs and 8 were required and night shift staffed 3 CNAs and 4 were required. 9/26/21-day shift staffed 7.5 CNAs and 8 were required and night shift staffed 3 CNAs and 4 were required. On 9/28/21 at 8:45 AM Staff 1 (Administrator) acknowledged the failure to meet state minimum bariatric CNA staffing ratios.

M183 1. Staff were scheduled to support Bariatric program requirements; staffing was short due to various reasons and center was unable to mitigate shortage additionally center did not bill for bariatric rate for days where staffing was short. 2. Review of bariatric program requirements, residents were removed from Bariatric program via Medicaid Case Worker. 3. Facility will review program staffing requirements for compliance prior to adding a resident to the bariatric program. 4. Administrator or Designee did training with DNS and Staffer on program requirements. 5. Administrator or Designee will review weekly x 3 weeks then monthly x 2 months for bariatric program compliance ~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. 6. The Administrator is responsible to ensure compliance