Columbia Basin Care Facility

The facilityGÇÖs 1/1/26 Abuse and Neglect Protections and Responsibilities Policy directed the Executive Director (Administrator) or designee to immediately report all allegations of suspected abuse through a FRI.-á During the 1/26/26 at 9:26 AM entrance conference meeting, Staff 1 (Administrator) notified the surveyor the facility had an incident over the weekend and were going to submit a FRI to the SA (state agency). On 1/26/26 at 12:14 PM Staff 2 (DNS) notified the surveyor Resident 24 was involved in an allegation of abuse on 1/24/26 and the facility would complete a FRI when the investigation was complete. On 1/29/26 at 7:16 PM the SA received a FRI and investigation about the 1/24/26 allegation of abuse for Resident 24. -á On 1/30/26 at 11:16 AM Staff 14 (LPN) stated she/he called Staff 2 the morning of 1/24/26 to report the Police were at the facility for an allegation of abuse for Resident 24. -á -á On 1/30/26 at 12:00 PM Staff 1 stated he was aware of the allegation of abuse with Resident 24 on 1/26/26. He stated he expected the facility to investigate the allegation and report to the SA in 24 hours. After further discussion Staff 1 stated he was aware of the two-hour required reporting time to the SA and confirmed the FRI was not reported to the SA within the required two-hours.

How the nursing home will correct the deficiency as it relates to the resident: The facility reviewed the incident related to the delayed Facility Reported Incident (FRI). The Administrator ensured the incident was reported in accordance with state requirements. The involved resident was assessed, and no adverse outcomes were identified. How the nursing home will act to protect residents in similar situations: The facility reviewed all FRIs submitted within the past 30 days to ensure timely reporting in accordance with state and federal regulations. Any identified concerns were addressed promptly. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur: The Administrator or designee will educate department heads and licensed staff on required timelines for FRI reporting and documentation per facility policy and state regulation. How the nursing home plans to monitor its performance to make sure that solutions are sustained: The Administrator or designee will audit all FRIs Daily for four weeks, then weekly for two months, to ensure incidents are reported timely and accurately. Results will be reviewed through the QAPI program 02/10/26

The facility's 1/1/26 Activities of Daily Living Policy indicated a resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene. The facility will maintain individual objectives of the care plan and periodic review and evaluation.-á Resident 24 was admitted to the facility in 6/2024 with diagnoses including dementia. Resident 24's 10/16/25 Care Plan revealed the following: -Staff were to set the resident up for daily hand and face washing and combing of hair and assist as needed.-á -The resident required assistance from one staff person with bathing.-á Resident 24's 1/2/26 Quarterly MDS revealed the resident was cognitively intact and required partial-to-moderate assistance from staff with personal hygiene.-á On 1/26/26 at 9:46 AM, Staff 30 (CNA) was observed in Resident 24's room preparing to assist the resident with a shower.-á On 1/26/26 at 12:50 PM, Resident 24 was observed in her/his room in her/his wheelchair. Gray and white facial hair, approximately an eighth-to-a-quarter of an inch long, was observed on the right and left sides of the resident's chin.-á On 1/28/26 at 11:53 AM, Resident 24 was observed in the facility's independent dining room, and gray and white facial hair, approximately an eighth-to-a-quarter of an inch long, was observed on the right and left sides of the resident's chin. Resident 24 stated the facial hair ""really bothers me and I want it gone."" Resident 24 stated no one offered to assist her/him to trim the facial hair in ""about a week,"" and it was irritating to have facial hair. Resident 24 further stated she/he had not been asked regarding facial hair preferences, and she/he would never refuse to have it trimmed when offered.-á-á On 1/28/26 at 1:10 PM, Staff 20 (CNA) stated resident preferences for facial hair trimming were listed in their care plan. Staff 20 stated he did not regularly work with Resident 24 but stated her/his family requested the resident's facial hair to be removed.-á On 1/28/26 at 1:20 PM, Staff 18 (CNA) stated staff were expected to assist residents with removing facial hair on shower days and as needed. Staff 18 stated Resident 24 had a personal shaver, and she/he preferred staff to remove her/his facial hair. Staff 18 stated the resident never requested to be shaved but was always cooperative when offered.-á On 1/28/26 at 12:41 PM, Staff 27 (CNA) stated she assisted Resident 24 with facial hair trimming on shower days and the resident did not refuse.-á On 1/28/26 at 3:45 PM, Staff 30 (CNA) stated he provided assistance to residents with facial hair trimming on their scheduled shower days. Staff 30 stated he assisted Resident 24 with a shower on 1/26/26 but did not offer to assist the resident to trim her/his facial hair at this time. Staff 30 further stated Resident 24 was cooperative with facial hair trimming. On 1/28/26 at 4:17 PM, Staff 4 (RNCM) stated resident facial hair grooming should be offered to residents on a daily basis and specific resident preferences for facial hair trimming were located in the resident's care plan. Staff 4 observed Resident 24's facial hair and confirmed the resident was in need of facial hair trimming.-á

How the nursing home will correct the deficiency as it relates to the resident: The identified resident’s ADL care needs were reviewed, and personal hygiene care, including facial hair removal, was provided in accordance with the resident’s care plan. How the nursing home will act to protect residents in similar situations: Audits of dependent residents were conducted to ensure ADL care, including grooming and hygiene, is provided per care plans. Identified concerns were addressed promptly. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur: The Director of Nursing or designee will educate direct care staff on providing complete ADL care, including grooming needs, per resident care plans. Shower sheet update to specify attention to both male and female shaving needs on shower days . All staff that is not present will be educated on their return to duty How the nursing home plans to monitor its performance to make sure that solutions are sustained: The Director of Nursing Services or designee will conduct random audits weekly for four weeks , then monthly for two months, to ensure residents receive ADL care per their care plans. Reviewing a minimum of 5 residents. Results will be reviewed at QAPI. 02/10/26

Resident 3 was admitted to the facility in 2/2023 with a diagnosis including chronic atrial fibrillation (irregular heart rhythm), diabetes and hyperlipidemia. Physician orders dated 11/2/25 indicated Resident 3 was prescribed the following medications: -Insulin aspart (fast-acting insulin)100 units/ml pen to be given before meals. -Insulin glargine Solostar (long-lasting insulin) 60 units every 12 hours. -Potassium citrate (helps prevent kidney stones) 2 tablets by mouth two times a day. -Senna Plus (bowel medication) two times a day. -Venlafaxine HCl (antidepressant) one time a day. -Gemfibrozil (treats high cholesterol) one time a day. -Metoprolol Succinate (treats high blood pressure) one time a day. -MiraLAX (bowel medication) one time a day. -Atorvastatin (treats high cholesterol) one time a day. -Digoxin (treats heart failure and abnormal heart rhythms) one time a day. -Vitamin D one time a day. -oxycodone (pain medication) three times a day. -Losartan potassium (treats high blood pressure) one time a day.-á -á A review of Resident 3GÇÖs 12/2025 through 1/2026 MARs and DARs (diabetic administration record) revealed the following medications were not administered on the following days: *Insulin Aspart on 12/12/25 and 1/27/26 lunch missed both days. *Insulin Glargine Solostar on 1/27/26 AM dose was missed. *Potassium Citrate on 12/14/25, 12/15/25, 12/26/25 (twice), 12/29/25, 1/13/26, 1/16/26, 1/18/26, 1/20/26, 1/21/26, 1/23/26, and 1/27/26. *Senna Plus on 12/14/25, 12/15/25, 12/26/25 (twice), and 12/29/25. *Venlafaxine on 12/26/25, 1/13/26, 1/16/26, 1/18/26, 1/20/26, 1/21/26, 1/23/26, and 1/27/26. *Gemfibrozil on 1/26/25, 1/13/26, 1/16/26, 1/18/26, 1/20/26, 1/21/26, 1/23/26, and 1/27/26. *Metoprolol Succinate on 12/26/25, 1/13/26, 1/16/26, 1/18/26, 1/20/26, 1/21/26, 1/23/26, and 1/27/26. *MiraLAX on 12/26/25 1/13/26, 1/16/26, 1/18/26, 1/20/26, 1/21/26, 1/23/26, and 1/27/26. *Atorvastatin on 12/14/25, 12/15/25, 12/26/25, and 12/29/26. *Digoxin on 12/14/25, 12/15/25, 12/26/25, and 12/29/25. *Vitamin D on 1/13/26, 1/16/26, 1/18/26, 1/20/26, 1/21/26, 1/23/26, and 1/27/26. *Senna plus on 1/13/26, 1/16/26, 1/18/26, 1/20/26, 1/21/26, 1/23/26, and 1/27/26. *Oxycodone on 1/13/26, 1/16/26, 1/18/26, 1/20/26, 1/21/26, 1/23/26, and 1/27/26. *Losartan potassium on 1/13/26, 1/16/26, 1/18/26, 1/20/26, 1/21/26, 1/23/26, and 1/27/26. On 1/30/26 at 11:03 AM Staff 15 (LPN) reviewed Resident 3GÇÖs 12/2025 and 1/2026 MAR and DAR and stated he did not administer the residentGÇÖs medications as ordered. -áStaff 15 stated he had not administered the medications because Resident 3 was sleeping. Staff 15 stated he did not notify the physician until the week of 1/26/26 regarding the missed medications for Resident 3. On 1/30/26 at 12:13 PM Staff 3 (RNCM) and 12:34 PM Staff 2 (DNS) were interviewed. Both stated the physician should have been notified after each missed medication, and each missed medication should have been documented as to why the medication was not administered in the health record. Staff 2 stated staff were expected to implement and follow physician's orders. Staff 2 acknowledged Resident 3GÇÖs medications were not administered per physician orders, and the physician was not notified timely.-á

How the nursing home will correct the deficiency as it relates to the resident: The resident’s medication administration record was reviewed, and the physician was notified. Medication orders were clarified and administered per provider directive. The resident was assessed and monitored with no adverse outcomes noted. How the nursing home will act to protect residents in similar situations: Audits of Medication Administration Records (MARs) for the past 3 days were conducted to ensure medications are administered per physician orders. Any discrepancies were corrected promptly. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur: The Director of Nursing or designee will educate licensed nurses (LN) on following physician orders and documenting medication administration accurately. All Licensed staff that is not present will be educated on their return to duty, How the nursing home plans to monitor its performance to make sure that solutions are sustained: Random MAR audits will be conducted weekly for four weeks, then monthly for two months. Findings will be reviewed through the QAPI process. 2/10/2026

The facility's 1/1/26 Accidents and Supervision Policy indicated the resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents, including monitoring for effectiveness and modifying interventions when necessary.-á Resident 24 was admitted to the facility in 6/2024 with diagnoses including oral dysphagia (difficulty chewing, manipulating and controlling food or liquid within the mouth using the tongue, lips and jaw) and oropharyngeal dysphagia (difficulty moving food from the mouth to the throat, often causing coughing, choking or food sticking in the throat).-á Resident 24's 7/3/24 SLP Evaluation and Plan of Treatment indicated the resident was not to use straws.-á Resident 24's 9/3/25 SLP Evaluation and Plan of Treatment completed by Staff 26 (SLP) revealed the resident experienced moderately severe oropharyngeal dysphagia (significant difficulty moving food/liquid from the mouth to the throat and is marked by an ineffectual cough reflex, frequent choking and a high risk of aspiration pneumonia). The Evaluation did not make mention about the resident's use of straws.-á Resident 24's 10/20/25 Care Plan revealed the following: -The resident was able to feed her/himself with supervision as she/he was at risk to choke.-á -Staff were to encourage the resident to be upright for all meals related to dysphagia.-á -The resident was to take small single bites/sips and alternate liquids and solids.-á -Reduce distractions.-á -No straws.-á Resident 24's 1/2/26 Quarterly MDS revealed the resident was cognitively intact and on a mechanically altered diet.-á Resident 24's current Physician Orders revealed the resident was not to use straws.-á On 1/26/26 at 1:00 PM, Resident 24 stated she/he was on a pureed diet because she/he had difficulty swallowing. The resident did not indicate any restrictions regarding the use of straws.-á On 1/27/26 at 8:28 AM, Resident 24 was observed to drink with a straw from a paper cup in the facility's assisted dining room. The resident was observed to cough after she/he took a drink.-á On 1/28/26 at 11:45 AM, Resident 24 was observed to eat lunch in the facility's independent dining room with her/his family present. A paper cup that contained milk and a straw was observed on her/his meal tray. The resident was not observed taking a drink of milk with the straw.-á On 1/28/26 at 12:41 PM, Staff 27 (CNA) stated Resident 24 used straws ""all of the time"" as they helped the resident to swallow. Staff 27 stated the resident needed to be cued to slow down at mealtimes and ""some days [she/he] had more choking than others."" On 1/28/26 at 12:48 PM, Resident 24 was observed in her/his wheelchair in her/his room. The resident's overbed table was within reach. A water bottle contained a large bore straw (a drinking tube with a wide internal diameter that reduces the suction effort required to drink) sat on top of the overbed table.-á On 1/28/26 at 1:20 PM, Staff 18 (CNA) stated Resident 24 was allowed to use straws, but she/he tended to eat and drink too fast and required reminders to slow down. Staff 18 stated Resident 24 had not ""had a choking episode, just coughing."" On 1/28/26 at 4:08 PM, Staff 28 (RD) stated Resident 24 should not use straws with a physician's order in place that directed no straws.-á On 1/29/26 at 8:12 AM, Staff 14 (LPN) stated the resident required cues to take smaller bites and smaller sips at mealtimes. Staff 14 reviewed the resident's care plan and stated she/he was not to use straws.-á On 1/29/26 at 8:19 AM, Staff 29 (Dietary Manager) stated the dietary program he utilized in the kitchen indicated Resident 24 was not to use straws.-á On 1/29/26 at 8:23 AM Staff 21 (Director of Rehabilitation) stated Resident 24's SLP evaluation on 9/3/2025 was completed by Staff 26 after a choking episode, which was a result of the resident's family providing the resident with a regular textured cookie. Staff 21 stated ""the choking incident was not really liquids"" and the intervention related to the resident not using straws had been in place since her/his admission to the facility. Staff 21 further stated Staff 26 was on vacation and unavailable for an interview.-á On 1/29/26 at 9:55 AM, Staff 4 (RNCM) and Staff 2 (DNS) were present for an interview. Staff 4 stated Resident 24's care plan for no straws reflected the resident's physician orders, and she would not alter the resident's care plan unless directed to do so by the SLP. Staff 4 further stated she had not been instructed by Staff 26 to remove the no straws intervention from the resident's care plan. Staff 2 stated either the resident ""can have straws and the care plan was wrong or [she/he] can't."" Staff 2 stated the physician's orders and the resident's care plan needed to align with actual practice.-á

How the nursing home will correct the deficiency as it relates to the resident: The resident’s care plan was reviewed, and dietary staff were re-educated on the resident’s no-straw restriction. The resident is now receiving care per the care plan. How the nursing home will act to protect residents in similar situations: 100 % Audit of residents with swallowing precautions, related to straw restrictions was conducted to ensure care plans are followed. Any concerns were addressed immediately. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur: The Director of Nursing or designee will educate nursing and dietary staff on following care plan interventions related to swallowing precautions related to straw restriction. Staff not present will be educated on their return to duty. How the nursing home plans to monitor its performance to make sure that solutions are sustained: Audits will be completed weekly for four weeks, then monthly for two months, to ensure care plans are followed. Results will be reviewed during QAPI and adjusted as needed. 02/10/26

The facility's 1/1/26 Ostomy (an artificial opening in an organ of the body, created during an operation) Care Policy instructed the following:-á -Ostomy care will be provided by licensed nurses under the orders of the attending physician. -The resident's goals and preferences for care and treatment of the ostomy will be used to formulate a plan of care for the ostomy.-á -The frequency of pouch changes and the products required for changing ostomy devices will be noted on the resident's person-centered care plan.-á -Direct care staff members will observe and respond to any signs of resident's discomfort about the ostomy or its care. -The surrounding skin of the ostomy will be monitored for excoriation (the act of scratching, rubbing or scraping the skin, often leading to raw, irritated lesions, sores, or wounds), abrasion (a superficial wound caused by the skin rubbing or scraping against a rough surface) and breakdown. Changes in the pouching system or frequency of pouch changes will be made, as appropriate.-á -The comprehensive care plan will reflect any special products or pouching techniques needed to prevent or manage any skin breakdown surrounding the ostomy.-á -For ongoing pouching problems or other problems associated with the ostomy, appropriate referrals will be made.-á Resident 13 was admitted to the facility in 1/2026 with diagnoses including the presence of an ileostomy. Resident 13's 1/6/26 Hospital Notes revealed the resident underwent a conversion of a gastric sleeve to a Single Anastomosis Duodeno-Ileal Bypass with Sleeve Gastrectomy (SADI-S, a revisional two-part surgery that modifies a previous sleeve gastrectomy to increase weight loss and improve metabolic issues) in 12/2025, which contributed to the resident receiving an ileostomy.-á-á Resident 13's 1/9/26 Hospital Discharge Orders and Instructions revealed the following: -Witness 1 (Bariatric Surgeon) was the resident's admitting and attending provider during her/his hospitalization.-á -The provider was to be contacted with any abnormal redness or other symptoms of concern.-á -Information on how to contact the provider included contact information for the resident's Bariatric Surgery Team.-á -An appointment was to be scheduled with the resident's primary care provider in one-to-two weeks for management of the resident's chronic conditions and home medication management.-á Resident 13's 1/9/26 Nursing Admission Screening completed by Staff 8 (RN) did not indicate the resident experienced any skin issues. The Screening directed the reader to the Skin Observation Assessment.-á No Skin Observation Assessment was completed on 1/9/26. Resident 13's 1/10/26 Physician Orders directed the following: -The ostomy pouch was to be removed with adhesive remover. -The resident's skin was to be cleansed with warm water and dried thoroughly.-á -Stoma powder was to be applied onto red skin irritation. -The powder was to be dabbed with Cavilon skin prep (a liquid film-forming skin protectant that dries quickly to form a breathable, transparent, waterproof coating on the skin).-á -A barrier ring was to be placed around the stoma in a double layer with the inner edge of the ring caulked with paste.-á -A medium fistula pouch (a specialized, adhesive and usually drainable appliance designed to cover an abnormal opening between an internal organ and the skin) was to be applied with a hole cut to offset the pouch away from the midline incision.-á -The ostomy pouch was to be changed as needed for leakage.-á -The resident was to receive a head-to-toe skin observation weekly. All existing and new skin issues were to be documented and a summary provided. A review of Resident 13's TAR from 1/10/26 through 1/25/26 revealed the resident required her/his ostomy to be changed at least one time per shift on 14 different shifts, and the changes on five of the shifts were noted to be ineffective.-á A 1/11/26 Skin Observation Tool completed by Staff 10 (RN) revealed Resident 13 had an abdominal surgical site in the healing stage. The Tool revealed the resident's surgical site was under her/his navel, and she/he also had a feeding tube and ostomy. No additional details about the resident's skin were documented.-á A 1/12/26 Telemedicine Visit completed by Staff 17 (NP) revealed Resident 13 experienced ""a lot of pain,"" and as a result, new pain medication orders were provided. Staff 17 indicated the resident's skin that was visible was warm, dry and free of rashes. The Visit indicated any skin-related concerns could be found in the nursing assessment.-á Resident 13's 1/15/26 Admission MDS revealed the resident was cognitively intact, had an ostomy and surgical wound, experienced occasional pain and participated in physical therapy. The Functional Abilities CAA revealed the resident required assistance managing her/his ostomy bag.-á Resident 13's 1/15/26 Wound Management Care Plan revealed the following: -The resident had a new ileostomy. -Staff were to monitor the ileostomy and abdominal surgical opening for redness, increased temperature, induration (hardening and thickening of skin tissue) and drainage. Concerns were to be reported to the resident's primary care physician.-á -The provider was to be notified if no signs of improvement on current wound regimen. -Provide wound care per treatment order.-á A 1/17/26 Progress Note revealed Resident 13 was transferred to the emergency department per her/his request due to increased abdominal pain located near her/his ileostomy site. The ileostomy site and abdominal skin was noted to be free of redness with an ostomy bag in place and functioning at the time of her/his transfer.-á A 1/17/26 Emergency Department Note indicated Resident 13's ostomy was functioning and without signs and symptoms of an infection.-á A 1/18/26 Skin Observation Tool completed by Staff 14 (LPN) revealed Resident 13 had a rash on her/his right, front iliac crest (located just below the waistline). No additional details about the rash were provided.-á A 1/18/26 Progress Note written by Staff 11 (RN) indicated Resident 13 had a rash around her/his colostomy bag, and the bag was changed twice during the shift due to leakage.-á A 1/20/26 Progress Note revealed Resident 13's ostomy bag was leaking and repaired with tape.-á Resident 13's 1/2026 TAR revealed a weekly head-to-toe skin observation was completed by Staff 7 (LPN) on 1/21/26. A plus (+) sign was documented on the TAR, but no summary or note was found related to the resident's skin on 1/21/26.-á A review of Resident 13's Physical Therapy Notes revealed the resident was either not appropriate or unable to participate in therapy due to issues with her/his ostomy bag, including the bag not sealing and the bag needing to be removed due to skin irritation, on 1/21/26, 1/22/26 and 1/23/26. On 1/24/26 the resident's participation was limited as she/he refused to change position, ambulate or toilet on account of the issues with her/his ostomy bag. A 1/22/26 and 1/23/26 Progress Note revealed Resident 13's ostomy bag was off at this time due to excoriation and awaiting supplies.-á A 1/23/26 Telemedicine Visit completed by Staff 23 (Medical Director) indicated Resident 13 had burning on her/his skin around the ileostomy bag related to leaking stool, and she/he had a red rash to the right abdomen around the ileostomy bag near the tape and at the skin folds. Staff 23 ordered Silvadene cream (a prescription topical antibiotic cream used to prevent and treat wound infections in second-and-third-degree burns) to be applied around the ileostomy bag three times a day for five days.-á-á A 1/24/26 Progress Note revealed Resident 13's ostomy bag was changed twice during the shift related to leakage.-á A 1/25/26 Progress Note revealed Resident 13's ostomy bag was repaired at different instances ""due to leakage because there was no more bags left."" A 1/25/26 Skin Observation Tool completed by Staff 14 documented a rash to Resident 13's front, right iliac crest that was being treated with Silvadene. No additional details about the rash were provided.-á On 1/26/26 at 10:28 AM, Resident 13 was observed in her/his room reclined in an armchair with an incontinence brief covering her/his abdomen. Resident 13 stated the facility ran out of ostomy bags because staff ""can't get the bags to stick."" Resident 13 stated the ostomy bags did not stay on long because her/his stoma was surgically put in a difficult place. Resident 13 stated the facility ran out of ostomy supplies twice since her/his admission, and a result, she/he went days using an incontinent brief or pad to cover the site and to absorb the leakage. Resident 13 stated the briefs and pads did not fully absorb the leaking stool which resulted in the ""thicker stool just sitting on top of the skin."" Resident 13 began to cry and stated her/his skin was so excoriated and it burned.-á On 1/26/26 at 11:50 AM, Resident 13 stated Staff 7 just put on a new ostomy bag, but it was already leaking. Resident 13 stated she/he was ""pouring shit everywhere."" Resident 13 stated she/he reported the leakage to Staff 12 (LPN) and was told she/he would have to wait until after lunch to have the bag replaced. Brownish-green stool was observed to leak out of the right and left sides of the resident's ileostomy at this time. The skin surrounding the resident's ileostomy was observed to be bright red extending approximately five-to-six inches around the entirety of the ostomy along with a scattered red rash. In tears, Resident 13 stated it was ""an awful feeling, especially as it [stool] goes over that burnt skin.""-á On 1/26/26 at 12:04 PM, Staff 7 yelled from the hallway into Resident 13's room that she ""had 800 things to do and then would be back to fix the ostomy.""-á A 1/26/26 Progress Note written at 1:55 PM indicated Witness 1 was contacted regarding the concerns with Resident 13's ileostomy. The Note further indicated a picture of the resident's abdomen was provided to Witness 1, which resulted in Witness 1 directing the resident to return to the hospital.-á On 1/26/26 at 4:50 PM, Resident 13 stated she/he was being readmitted to the hospital on 1/27/26. Resident 13 stated she/he experienced slight redness around her/his ostomy during her/his initial hospitalization, but the site had become bright red and burned since her admission to the facility. Resident 13 stated it ""hurts to move"" on account of the ""burning pain that is constant."" Resident 13 stated she/he stopped participating in physical therapy because her/his bag constantly leaked. Resident 13 stated with tears in her/his eyes that she/he was embarrassed by the constant stool leaking, and she/he felt gross and like a burden. Resident 13 stated ""it sucked"" that the facility ran out of ostomy bags and ""they should have ordered more if they knew they weren't sticking instead of two little boxes."" Resident 13 further stated she/he was so exhausted because every time she/he tried to sleep, the ostomy leaked, and she/he had to stay awake to hold it.-á On 1/27/26 at 8:30 AM, Resident 13 was observed in her/his room reclined in an armchair. The floor surrounding the right side of the resident's armchair was covered in stool-stained washcloths. Resident 13 covered her/his ileostomy with a washcloth that was soaked in stool. The resident removed the washcloth and brownish-green stool quickly and continuously leaked from the ostomy bag. The skin around the ileostomy appeared raw and bright red. Resident 13 stated her/his ileostomy bag was changed around 6:45 AM and started leaking almost instantly afterwards. Resident 13 stated she reported the leakage to two different CNAs who stated they informed the nurse, but no nurse had responded. At 8:34 AM, Staff 12 was at the resident's door and stated she was ""right in the middle of breakfast and would be there when done."" At 8:35 AM Staff 12 returned to the resident's room to change the resident's leaking ostomy bag. Staff 12 removed the tape and ostomy bag and described the skin underneath to be bright red, irritated and excoriated. Staff 12 stated she was going to replace the resident's ostomy bag with a smaller bag than what was ordered because the larger bags ""lay on the skin and cause more skin problems."" Staff 12 further stated the resident had an order for Silvadine but she did not use it because she ""did not know where they want me to put it because it will just make the adhesive not stick.""-á On 1/27/26 at 9:04 AM, Staff 12 stated the resident's ileostomy bag required frequent changes since the resident's admission to the facility, and the hospital ordered ""bigger bags that did not work at all because the skin around the wound was weeping."" Staff 12 stated they had been changing the resident's ileostomy bag at least three times daily instead of three times weekly which was the standard. Staff 12 stated the facility was out of the resident's ordered ostomy bags on 1/26/26, so she had the resident use an incontinence brief to ""keep it contained"" because she did not think of putting a smaller bag on at the time.-á On 1/27/26 at 10:17 AM, Witness 3 (Family Member) stated Resident 13's skin progressively worsened over her/his stay at the facility, the resident went for days ""with just a diaper covering [her/him] trying to air out the skin,"" and the resident was miserable at the facility. Witness 3 further stated stool constantly poured out of the resident's ileostomy bag at the facility, and she did not understand why Witness 1 was not contacted sooner.-á On 1/28/26 at 6:17 AM, Staff 18 (CNA) stated Resident 13 had been leaking liquid stool for at least a week. Staff 18 stated she did not notice redness around the ostomy site following the resident's admission to the facility nor did the resident complain about burning. Staff 18 stated she observed the resident's skin with the ileostomy bag removed ""about a week ago and it was red and raw."" Staff 18 stated they used an incontinence brief to try and contain the leakage. On 1/28/26 at 6:32 PM, Staff 8 stated Resident 13 leaked liquid stool from her/his ileostomy ""on-and-off"" since her/his admission to the facility which caused increased redness and excoriation of the skin around the resident's ileostomy. Staff 8 stated the resident's ostomy site was between her/his skin folds, so whenever the resident would bend, the bag would leak and need to be changed. Staff 8 stated the facility ran out of ostomy bags for two days last week, so she was ""just trying to keep the area clean because the bags we had in the facility did not fit."" Staff 8 stated she never applied Silvadine to the resident's skin because ""the order did not pop up for me"" but did not think the ointment would help because it would prevent the ostomy bags from adhering to the resident's skin. Staff 8 stated she did not notify the resident's provider of the stool leakage or difficulty with the ostomy bags because she was ""under the impression management was dealing with this."" On 1/28/26 at 7:36 AM, Staff 11 stated Resident 13 required her/his ostomy bag to be changed two-to-three times per shift. Staff 11 stated she typically completed an assessment and notified the provider when a new skin issue was noted but stated she did not notify Resident 13's provider when she initially observed the resident's rash on 1/18/26. Staff 11 further stated she did not apply Silvadine when she changed the resident's ileostomy on 1/25/26, and stated she ""just cleaned the site and put the barrier cream"" instead.-á On 1/28/26 at 8:39 AM, Staff 14 stated the facility ran out of Resident 13's ostomy supplies ""rather quickly"" because of the location of the ostomy. Staff 14 stated the resident's ostomy leaked ""from the beginning, every day, sometimes as soon as you changed it."" Staff 14 stated he used the bags provided by the hospital as well as the ones from the facility and neither worked, ""nothing would stick."" Staff 14 stated the redness around the resident's ostomy ""was growing,"" the resident was tearful and she/he complained about her/his skin burning and being painful. Staff 14 stated he was the treatment nurse on 1/18/26, so he notified the charge nurse about the resident's rash on 1/18/26. Staff 14 stated he expected the charge nurse to notify the resident's provider of the new skin issue.-á On 1/28/26 at 10:17 AM, Staff 19 (CNA) stated she observed Resident 13's skin to be ""very red and irritated the last few days"" the resident was at the facility. Staff 19 stated the resident went through five or six bags in one shift because the bags would not stick to the skin. Staff 19 stated the resident had been out of ostomy bags for the last ""couple of days"" she/he was at the facility, and the solution was to cover her/his abdomen with a brief and change the brief out about every 30 minutes. Staff 19 said the resident never complained about the brief ""but you could tell it made [her/him] feel bad.""-á On 1/28/26 at 1:25 PM, Staff 20 (CNA) stated Resident 13's ostomy leaked greenish-brown stool ""all of the time."" Staff 20 stated the resident's skin became ""more red and irritated"" over time, and she/he was upset and embarrassed by the leaking stool. Staff 20 stated the resident was ""very distraught and angry at times"" and was in a lot of pain. Staff 20 further stated the resident wanted to be sent back to the hospital but was never sent.-á On 1/28/26 at 1:37 PM, Staff 17 stated she completed a virtual visit with Resident 13 on 1/12/26, and the focus of that visit was on pain management. Staff 17 stated she was informed the ostomy site was in a ""tricky place"" and that the bag would come off ""here and there."" Staff 17 stated she was not aware the resident went for periods of time without an ostomy bag in place or that staff did not consistently utilize the Silvadine cream. Staff 17 stated she advised the facility to make Witness 1 aware of the difficulties around the bag coming off, and her primary role in the care of Resident 13 was pain management. Staff 17 further stated she deferred the care of Resident 13's ileostomy to Witness 1 because ""it was so complicated"" and it was standard to have the surgeon involved and ""cut out the middleman.""-á On 1/29/26 at 9:14 AM, Witness 2 (Nurse Care Coordinator for Bariatric Surgery) stated the first time the hospital received contact from the facility regarding Resident 13 was on 1/26/26. Witness 2 stated the facility sent her team a picture of the resident's abdomen ""which was very concerning"" and that it ""definitely looked like there was something going on for a while."" Witness 2 stated she did not understand why the facility did not report the resident's irritated skin and leaking ostomy sooner.-á On 1/29/26 at 10:04 AM, Witness 1 stated Resident 13 received ""such unfortunate care at the facility"" and was upset she was not notified sooner about the difficulties the facility experienced with her/his pouching situation. Witness 1 stated the resident experienced ""damaged, raw and painful skin"" and a burn from all of the contents of the ileostomy being exposed to her/his skin which extended out six inches on all sides as a result of the care provided at the facility. Witness 1 stated the first time her office was contacted regarding Resident 13 was on 1/26/26, and she could not believe that ""we are here and available and happy to talk and no one even tried."" Witness 1 stated the resident's discharge paperwork contained all the contact information on how to get a hold of us. Witness 1 further stated from what she saw in the picture the facility sent on 1/26/26, it looked like the resident's skin concerns had been going on for ""maybe a week.""-á On 1/29/26 at 11:01 AM, Staff 7 stated she observed Resident 13 to have some excoriation around her/his ostomy site a ""couple of days"" after she/he admitted to the facility which extend out approximately four-to-six centimeters. Staff 7 stated the resident would go through five-to-eight ostomy bags on her shift because of the challenging placement of the resident's ostomy. Staff 7 stated she recalled two different occasions the facility ran out of the resident's ostomy bags, so they used an incontinence brief to absorb the leakage. Staff 7 stated the leaking ostomy made it difficult for the resident to sleep and made the resident feel ""disgusting."" Staff 7 stated she did not notify the resident's provider about the frequent leakage of the resident's ostomy bag or of the difficulty keeping the bag on as she was a treatment nurse and charge nurses were responsible for notifying providers. Staff 7 stated she completed the resident's head-to-toe skin assessment on 1/21/26, and the plus sign she documented indicated the resident had a new or worsening skin issue. Staff 7 stated she did not report this observation to anyone as ""everybody had seen it"" and Staff 2 (DNS) and Staff 4 (RNCM) were aware. Staff 7 stated the resident's skin excoriation ""was huge"" on 1/23/26 but she was not involved in the resident's telehealth visit with Staff 7. Staff 7 further stated when she observed the resident's skin on 1/23/26 there were ""pustular blisters around the stoma (a surgically made hole in the abdomen that allows body waste to be removed from the body directly through the end of the bowel into a collection bag) and could tell the excoriation was going to a deeper level of the skin."" On 1/29/26 at 12:11 PM, Staff 14 (RN) stated he observed Resident 13's abdomen skin about ""a week or 10 days ago"" and it was ""quite red."" Staff 14 stated he did not contact the resident's provider regarding her/his excoriated skin because Staff 4 was aware, he was a charge nurse and treatment nurses were responsible to communicate this information to the provider.-á On 1/29/26 at 1:16 PM, Staff 21 (Director of Rehab) stated Resident 13 refused physical therapy on 1/21/26, 1/22/26 and 1/23/26 due to issues with her/his ostomy bag. Staff 21 stated the resident's participation on 1/24/26 was limited to exercises in bed.-á On 1/29/26 at 1:30 PM, Staff 22 (Central Supply) stated Resident 13 required a different type of ostomy bag compared to the ones the facility kept on hand. Staff 22 stated the resident ran out of ostomy bags on two different occasions because she was not notified about the need to order until they were ""low or until it's too late.""-á On 1/29/26 at 3:24 PM, Staff 2 and Staff 4 were present for an interview. Staff 4 stated Resident 13 admitted to the facility with a high output of brown-green stool, and staff tried ""lots of things"" to get the resident's ostomy bag to adhere to her/his skin but ""nothing would work."" Staff 4 stated she was not aware of the resident's recent therapy refusals or of the resident not sleeping at night because of the ostomy leakage. Staff 4 stated charge nurses should have notified the resident's doctor of these concerns. Staff 2 stated she observed the skin around Resident 13's ostomy on 1/22/26 and it was red, raw and irritated. Staff 2 stated the resident used four-to-five ostomy bags a day because of the difficulty they experienced to get the bag to seal on account of the location of the ostomy. Staff 2 stated she was not aware the resident went for periods of time without an ostomy bag in place and the provider should have been notified. Staff 2 stated she was not aware the resident utilized an incontinent brief to absorb ostomy leakage and that ""should never be a solution."" Staff 2 stated she was not aware the resident was unable to sleep at night because of the leakage or that nurses did not consistently utilize the Silvadene cream. Staff 2 further stated Witness 1 was not contacted because the facility relied on Staff 17 and Staff 23 for guidance.-á On 1/30/26 at 7:32 AM, Staff 23 stated she completed a video call with Resident 13 on 1/23/26 for a routine visit. Staff 23 stated the redness around the ostomy bag caught her attention, and she thought the resident could be allergic to the tape, and as a result, ordered Silvadine cream for the resident. Staff 23 stated the resident's ostomy was covered with a bag during the telehealth visit, so her view of the abdomen was limited. Staff 23 stated she was not informed of the excoriation or redness underneath the bag, and staff never sent her a picture of the resident's abdomen. Staff 23 stated she was unaware the resident was going periods of time without a bag in place and was never informed the Silvadine was not being used. Staff 23 further stated Staff 17 managed the resident's day-to-day needs but Witness 1 should have been managing the resident's ostomy because it was a surgical situation.-á -á

How the nursing home will correct the deficiency as it relates to the resident: The resident’s ostomy care was assessed, and the physician/surgeon was notified. Appropriate interventions were implemented per provider directive. The resident does not currently reside in the nursing home. How the nursing home will act to protect residents in similar situations: 100 % Audit of residents with ostomies were conducted to ensure care is provided per standards of practice and provider orders. Identified concerns were addressed promptly. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur: The Director of Nursing or designee will educate licensed nursing staff on proper ostomy treatment and timely provider notification when concerns are identified. Staff that is not present will be educated at their return to duty. How the nursing home plans to monitor its performance to make sure that solutions are sustained: The Director of Nursing Services or designee will conduct weekly audits for four weeks then monthly for two months, regarding provider notifications and following treatment orders.. Results will be reviewed during QAPI and as needed. 02/10/26

The facility's 1/1/26 Care and Treatment of Feeding Tubes Policy directed feeding tubes to be utilized according to physician orders, which typically included the kind of feeding and its caloric value, volume, duration, mechanism of administration and frequency of flush.-á Resident 13 was admitted to the facility in 1/2026 with diagnoses including other artificial openings of gastrointestinal tract status (the status of having an artificial opening [stoma] in the digestive tract that requires monitoring).-á Resident 13's 1/15/26 Admission MDS revealed the resident was cognitively intact and used a feeding tube.-á Resident 13's 1/22/26 Physician Orders indicated the following: -The resident was to receive 65 ml of Jevity (a brand of fiber-fortified, therapeutic medical nutrition formula designed primarily for tube feeding) via her/his J-Tube (Jejunostomy tube, a soft feeding tube inserted through the abdominal skin directly into the mid-section of the small intestine to deliver nutrition and fluids) for 18 hours per day from 6:00 PM through 12:00 PM.-á -The nutrition formula container, syringe and administration set was to be labeled with the resident's name, date, time and nurse's initials and changed daily on night shift.-á -The syringe used for the tube feeding was to be changed daily on day shift.-á -The feeding tube was to be flushed with 200 cc (cubic centimeter) of water every eight hours and with 60 cc before and after medication administration.-á On 1/26/26 at 11:58 AM, Resident 13 was observed reclined in an armchair in her/his room. An undated and unlabeled plastic cylinder filled with 250 ml of water sat on the counter next to the resident's sink in her/his room. An undated and unlabeled plastic syringe rested inside the cylinder. Resident 13 stated staff regularly reported to her/him that facility was out of the syringes she/he needed for her/his tube feed flushes and medication administration. Resident 13 stated ""I can't tell you how long that one has been used"" in reference to the syringe in the cylinder on the counter next to her/his sink. On 1/26/26 at 4:50 PM, an undated and unlabeled plastic cylinder filled with 250 ml of water sat on the counter next to the resident's sink in her/his room. An undated and unlabeled plastic syringe rested inside the cylinder.-á On 1/27/2026 at 8:30 AM, Resident 13 was observed reclined in an armchair in her/his room. An unlabeled and undated nutrition bag was hung on a feeding pole and the resident's tube feed was running. An undated and unlabeled plastic cylinder filled with 100 ml of water sat on the counter next to the resident's sink in her/his room. An undated and unlabeled plastic syringe rested inside the cylinder.-á On 1/27/26 at 9:50 AM, Staff 7 (LPN) was observed to stop and unhook the resident's tube feed as the resident was leaving the facility. Staff 7 was observed to insert 60 ml of water from the unlabeled and undated cylinder with the unlabeled and undated syringe into the resident's feeding port. Staff 7 stated the syringe she used to complete the flush of the resident's port was the same syringe the resident ""was sent with from the hospital."" Staff 7 stated it was standard practice to use a new syringe every 24 hours, but the facility did not have the specific syringes Resident 13 required for her/his tube feed. Staff 7 stated the plastic cylinders should be labeled and dated and changed out every day and was unsure when the cylinder in the resident's room was last changed. Staff 7 stated the resident's current nutrition bag was not dated or labeled, and she did not usually pay attention to the bag, she ""just unhooked and threw it away"" on her shift.-á On 1/28/26 at 7:36 AM, Staff 11 (RN) stated syringes used for Resident 13's tube feeds were to be discarded after each use and nutrition bags were to be dated and labeled.-á On 1/28/26 at 8:39 AM, Staff 14 (LPN) stated he always labeled and dated Resident 13's nutritional bags when he started the resident's tube feed. Staff 14 stated he changed the syringe ""every few days"" because he was unsure of when it was last changed since it was not dated.-á On 1/28/26 at 1:37 PM, Staff 17 (NP) stated she expected staff to follow whatever orders were in place with regards to resident tube feeds.-á On 1/29/26 at 3:24 PM, Staff 4 (RNCM) stated she expected nutritional bags to be labeled and dated when they were hung. Staff 4 further stated she expected syringes used to flush feeding ports and to administer medications to be labeled, dated and discarded every 24 hours.

How the nursing home will correct the deficiency as it relates to the resident: 100% audit of residents with tube feeding orders were reviewed and implemented per physician directive. The resident was assessed and monitored with no adverse outcomes noted. How the nursing home will act to protect residents in similar situations: Audits of residents receiving tube feedings were conducted to ensure physician orders are followed accurately. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur: The Director of Nursing or designee will educate licensed nurses on following tube feeding orders and documenting care appropriately., regarding labeling of syringes, cylinders and tubing per protocol. Staff not present will be educated at their return to duty. How the nursing home plans to monitor its performance to make sure that solutions are sustained: Random audits will be conducted weekly for four weeks, then monthly for two months, checking that all tubing, cylinders and syringes are labeled as ordered; with results reviewed through QAPI. 02/10/26

The facility's 1/1/26 Binding Arbitration Agreements Policy indicated the facility shall do the following when explaining the arbitration agreement: -Explicitly inform the resident or his or her representative of his or her right not to sign the agreement as a condition of admission to, or as a requirement to continue to receive care at this facility. -Explain to the resident and his or her representative in a form and manner that he or she understands, including in a language the resident and his or her representative understands.-á -Ensure the resident or his or her representative acknowledges that he or she understands the agreement.-á The facility's undated Arbitration Agreement included the following: -You acknowledge that you have the option of not signing this Agreement and not being bound by the arbitration provisions contained herein. The execution of this Arbitration Agreement is voluntary and is not a condition of residency to the facility and not a requirement to continue to receive care at the facility.-á -You understand that you have the right to seek legal counsel concerning this arbitration agreement, the execution of this arbitration agreement is not a pre-condition to residency of the resident to the facility and this arbitration agreement may be withdrawn by written notice to the facility from the resident within 30 days of signature. -The parties understand and agree that by entering into this Arbitration Agreement they are agreeing to submit any dispute to an arbitrator instead of decided by a judge and a jury. If you sign this agreement, you will not have the right to have your case decided by a judge and a jury.-á -By signing, you acknowledge that you have been afforded an opportunity to read the arbitration agreement, had it explained to you in a language/form/manner that you understand, had an opportunity to ask questions about this agreement and that you understand and accept the terms as described herein.-á On 2/2/26 at 9:55 AM, Staff 25 (Social Services Director) stated she was responsible for reviewing and explaining the facility's Arbitration Agreement with residents and/or their representatives. Staff 25 stated when she reviewed the form with residents and/or their representatives, she explained a signature on the form indicated their acknowledgement the form had been reviewed, not that they were entering into an arbitration agreement. Staff 25 further stated she had not ""paid close attention"" to the form and did not discuss with residents and/or their representatives they had 30 days to withdraw this agreement.-á Resident 1 was admitted to the facility in 11/2025 with diagnoses including diabetes.-á Resident 1's 11/18/25 Admission MDS revealed the resident was cognitively intact.-á Resident 1's health record included the facility's Arbitration Agreement, dated 11/18/25 and signed by the resident.-á On 2/2/26 at 10:36 AM, Resident 1 stated she/he signed the facility's Arbitration Agreement because it was explained to her/him that her/his signature indicated arbitration was available. Resident 1 stated she/he was not sure if she/he would have signed the form if she/he understood she/he was agreeing to arbitration.-á Resident 2 was admitted to the facility in 12/2025 with diagnoses including chronic obstructive pulmonary disease.-á Resident 2's 12/11/25 Admission MDS revealed the resident was cognitively intact.-á Resident 2's health record included the facility's Arbitration Agreement, dated 12/10/25 and signed by the resident.-á On 2/2/26 at 10:42 AM, Resident 2 stated she/he recalled signing the facility's Arbitration Agreement but was not informed she/he had 30 days to rescind the agreement.-á Resident 45 was admitted to the facility in 12/2025 with diagnoses including femur fracture.-á Resident 45's 12/16/25 Admission MDS revealed the resident was cognitively intact.-á Resident 45's health record included the facility's Arbitration Agreement, dated 12/19/25 and electronically signed by the resident.-á On 2/2/26 at 10:50 AM, Resident 45 stated she/he recalled signing the facility's Arbitration Agreement but was not informed she/he had 30 days to rescind the agreement.-á On 2/2/26 at 10:56 AM, Staff 1 (Administrator) was notified Staff 25 did not fully understand and did not comprehensively explain the Arbitration Agreement to residents. Staff 1 was notified Residents 1, 2 and 45 did not fully understand the Arbitration Agreement, and the residents did not recall it being explained to them in detail. Staff 1 stated he expected the residents, ""and especially the families,"" to receive a verbal explanation on their right to rescind the agreement within 30 days of signing but also stated a resident's signature on the Arbitration Agreement meant ""I have seen it and read it.""-á-á

How the nursing home will correct the deficiency as it relates to the resident: The facility reviewed admission agreements and ensured residents and/or responsible parties were properly informed of arbitration agreements and opt-out rights. How the nursing home will act to protect residents in similar situations: Audits of admission packets were completed to ensure required disclosures and timelines are communicated. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur: The Administrator or designee will educate admissions team on arbitration notification requirements and documentation standards. How the nursing home plans to monitor its performance to make sure that solutions are sustained: All New admissions will be interviewed within 7 days to validate understanding of the binding arbitration agreement. for four weeks, then 2 admissions randomly monthly for two months. Findings will be reviewed during QAPI. 02/10/26

The facility's 10/2011 Obtaining a Fingerstick Glucose Level Policy indicated, ""Clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice."" A 9/2024 Arkray Technical Brief Manufacturer Manual indicated, ""Disinfect common use glucometers with the use of approved disinfectant wipes."" The glucometer was to be wiped with the disinfecting wipe and left wet for two minutes to ensure disinfection.-á Resident 1 was admitted to the facility on 11/14/25 with diagnoses including Hepatitis C (a viral and potentially deadly infection that affects the liver). 12/2025 and 1/2026 MARs indicated Resident 1 received blood glucose monitoring before meals and at bedtime.-á On 1/27/26 from 11:03 AM through 11:33 AM, Staff 7 (LPN) used a single shared Arkray glucometer to check the CBGs for residents on the West hall and North hall. Between each resident, Staff 7 wiped the glucometer with an alcohol prep pad that was saturated with 70% isopropyl alcohol, which was not an acceptable disinfecting wipe based on manufacturer recommendations. On 1/27/26 at 11:26 AM, Staff 7 stated she was the primary nurse responsible for checking CBGs for the entire facility that day. Staff 7 stated she used alcohol wipes to disinfect the glucometers after each use. Staff 7 stated she was instructed to clean the glucometer with the alcohol wipe. Staff 7 stated no residents had their own glucometer for CBG checks.-á On 1/27/26 at 11:58 AM, Staff 15 (LPN) stated blood glucose monitors were shared between residents and he used approved disinfecting wipes to disinfect the glucometer after resident use.-á On 1/27/26 at 12:58 PM Resident 1 stated Staff 7 checked her/his blood sugar daily.-á On 1/27/26 at 1:49 PM, Staff 2 (DNS) stated she was unaware staff used alcohol pads to disinfect the blood glucose monitors. Staff 2 expected staff to use approved disinfecting wipes to sanitize the glucometer after each resident use. Staff 2 acknowledged using alcohol pads to disinfect glucometers was not sufficient.-á A facility census provided by Staff 2, dated 1/27/26, indicated there were 18 residents who received daily CBG checks, including Resident 1.-á On 1/27/26 at 3:57 PM, the facility administrative staff, including Staff 1 (Administrator), and Staff 2 were notified that the deficient practice related to the failure to properly disinfect the common use glucometer constituted an Immediate Jeopardy (IJ) situation and were provided a copy of the IJ Template.-á On 1/27/26 at 6:17 PM an acceptable plan to remove the IJ situation was submitted by the facility. The plan indicated the facility would implement the following actions: -All glucometers were removed from use and disinfected. Facility-approved EPA registered disinfectant wipes approved for blood glucose monitoring equipment were implemented immediately. -All licensed nurses working were immediately re-educated and competency-validated on proper glucometer cleaning, disinfection, and standard precautions on 1/27/26. All other licensed nurses would be educated and observed prior to their next scheduled shift.-á -Supplies of approved disinfectant wipes were stocked on all medication carts and treatment areas to ensure immediate access.-á -Competency-based training on CBG monitoring and infection prevention was implemented for all licensed nurses, medication aides and new hires during orientation.-á -Visual reminders and laminated instruction cards outlining proper glucometer cleaning steps were placed on medication carts.-á -The DNS or designee and the Infection Preventionist will conduct direct observational audits of CBG monitoring practices five times a week for two weeks, once a week for two months and quarterly thereafter.-á -Audit results will be reported to the QAPI Committee and reviewed at monthly Governing Body meetings. From 1/27/26 through 1/28/26 the IJ removal plan was verified as implemented by the survey team. No additional concerns related to the IJ situation were noted.

n 1/27/26 at 6:17 PM an acceptable plan to remove the IJ situation was submitted by the facility. The plan indicated the facility would implement the following actions: - All glucometers were removed from use and disinfected. Facility-approved EPA registered disinfectant wipes approved for blood glucose monitoring equipment were implemented immediately. - - All licensed nurses working were immediately eeducated and competency-validated on proper glucometer cleaning, disinfection, and standard precautions on 1/27/26. All other licensed nurses would be educated and observed prior to their next scheduled shift. - Supplies of approved disinfectant wipes were stocked on all medication carts and treatment areas to ensure immediate access. - Competency-based training on CBG monitoring and infection prevention was implemented for all licensed nurses, medication aides and new hires during orientation. - Visual reminders and laminated instruction cards outlining proper glucometer cleaning steps were placed on medication carts. - The DNS or designee and the Infection Preventionist will conduct direct observational audits of CBG monitoring practices five times a week for two weeks, once a week for two months and quarterly thereafter. - Audit results will be reported to the QAPI Committee And adjusted as needed. 02/02/26

Based on observation and interview it was determined the facility failed to ensure resident care equipment was in good repair for 1 of 4 sampled residents (#3) reviewed for environment. This placed residents at risk for uncomfortable and unsanitary care equipment. Findings include: Resident 3 was admitted to the facility in 2017 with diagnoses including multiple sclerosis (a degenerative disease). Resident 3's 7/19/24 Quarterly MDS indicated the resident was cognitively intact and used a wheelchair. Observations from 8/26/24 through 8/29/24 between the hours of 7:00 AM and 5:30 PM revealed Resident 3 to sit in her/his wheelchair. The wheelchair's left armrest vinyl covering was torn open approximately five inches with protruding sharp, rough edges. The wheelchair's right armrest vinyl covering was torn and cracked with protruding sharp, rough edges. Resident 3 stated she/he used the wheelchair everyday and the armrests were ugly and rough on her/his skin. On 8/29/24 at 11:05 AM Staff 6 (CNA) stated if resident care equipment was in disrepair, it was reported to maintenance. Staff 6 stated she cared for Resident 3 for several days and had not noticed or reported any issues with the resident's wheelchair. On 8/29/24 at 11:13 AM Staff 21 (RNCM) stated staff were assigned to complete wheelchair inspections every evening. Staff 21 observed Resident 3's wheelchair armrests and confirmed they were torn and in disrepair.

Resident 3’s wheelchair was replaced on 8/29/24. Infection Control and/or designee will audit all residents in a wheelchair to ensure the wheelchairs are in good repair no later than October 19, 2024. Wheelchairs identified as being torn, having vinyl cracked, and otherwise in disrepair will be noted and communicated with Environmental Services so a replacement chair can be put in place. Nursing staff will be in-serviced no later than October 19, 2024, on the importance of identifying wheelchairs that are not in good repair and how to communicate via TELS that a chair needs to be looked over by Environmental Services and/or Designee. Staff will also be educated on where back-up chairs are kept if a wheelchair requires immediate attention. Infection Control and/or designee will be responsible for reviewing wheelchairs monthly to ensure they are in good repair; the results of the audit will be given to Environmental Services and the Director of Nursing. Environmental Services Director and/or Designee will be responsible for communicating with QAPI no less often than quarterly for the next 6 months on chairs that have been put into TELS for review/repair.

Based on interviews and record review, it was determined the facility failed to protect the resident's right to be free from physical abuse by a resident for 1 of 3 sampled residents (#16) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 16 was admitted to the facility in 1/2024 with diagnoses including stroke. Resident 16's admission MDS dated 2/29/24 revealed a BIMS score of 3, which indicated severe cognitive impairment. Resident 13 was admitted to the facility in 11/2023 with diagnoses including stroke and depression. Resident 13's Incident Note revealed on 7/6/24 Resident 16 was sitting near the nurses station not talking and Resident 13 yelled "do not touch my chair or I am fucking going to let you have it." Resident 13 and 16 were separated and Resident 13 continued to yell out and cuss at residents and staff. Resident 13 was placed into her/his room. A 7/8/24 facility investigation report revealed Resident 13 and Resident 16 were near each other in the hallway near the nurses station. Resident 13 thought two men were holding her/his wheelchair. There was only one resident close to Resident 13 and she/he was not holding her/his chair. Resident 13 yelled "let go of my chair." Resident 13 then hit Resident 16 in the face with an open hand leaving a small open area on her/his face. Resident 13 was confused at the time related to her/his current disease processes and history of behaviors. Resident 16 was in proximity and potentially caused the situation to occur. The residents were separated. Resident 13's quarterly MDS dated 7/26/24 revealed a BIMS of 10 which indicated moderate cognitive impact. On 8/28/24 at 6:32 AM Resident 13 stated on 7/6/24 she/he was trying to go to lunch or dinner and two residents grabbed her/his wheelchair on both sides. Resident 13 told them to let go or she/he was going to hit her/him. The residents did not let go so Resident 13 hit one of the residents. On 8/28/24 at 8:26 AM Staff 5 (Medication Aide) stated on 7/6/24 she had the medication cart by the medication room, and she heard Resident 13 being extremely loud and was "punching the crap out of" Resident 16. Staff 5 stated it was like "boom, boom, boom" Staff 5 stated Resident 16 was very gentle and was not the type of person to come up on someone. Staff 5 stated Resident 13 was having a "bad day." The nurse told her Resident 13 had attempted to punch her. Staff 5 stated a few times a month Resident 13 gets angry for no reason. On 8/28/24 at 8:13 AM Staff 4 (LPN) stated on 7/6/24 she was at the nurses station. Resident 16 was speaking to another resident and Resident 13 was behind Resident 16. Resident 13 hit Resident 16 on the temple area and she separated them and took Resident 13 to her/his room. Resident 13 had attempted to hit Staff 4 and "verbally abused" staff and attempted to hit staff. Resident 13 told her she/he punched Resident 16 because she/he would not "shut up." On 8/29/24 at 10:54 AM Resident 16 stated she/he felt safe in the facility. Resident 16 stated Resident 13 made her/him uncomfortable to be around but she/he no longer felt uncomfortable around Resident 13. On 8/30/24 at 8:50 AM Staff 1 (Administrator) and Staff 2 (Interim DNS) were notified of the investigative findings

Residents 13 and 16 were both separated at the time of the event on 7/6/2024. Care plans were updated, and residents have remained separated as appropriate from each other. This was a resident-to-resident event. No other residents have been identified as being affected by the situation that occurred on 7/6/2024. We are unable to predict a resident-to-resident negative interaction but can identify residents who have the potential for behaviors. Social Services and/or designee will audit care plans for residents who have a known history of behaviors with others and ensure the care plan is current with interventions on how to re-direct and/or deescalated. This audit will occur no later than October 19, 2024, and continue monthly for 3 months. The IDT meets Monday-Friday for stand-up and will communicate any incidents that involved resident-to-residents at the meeting. Staff will be in-serviced no later than October 19, 2024, on how to deescalate resident behavior and signs of agitation amongst residents and how to re-direct. Social Services and/or designee, will be responsible for reporting resident behavior and/or a change in resident aggression to the IDT team as appropriate for follow-up and intervention management. Any FRI reports submitted during the month will be reviewed no less often than quarterly with QAPI.

Based on interview and record review it was determined the facility failed to document and conduct a significant change MDS assessment for 1 of 5 sampled residents (#13) reviewed for medications. This placed residents at risk for unassessed care needs. Findings include: Resident 13 was admitted to the facility in 11/2023 with diagnoses including stroke and depression. Review of the 11/9/24 admission MDS for Resident 13 revealed the following: -BIMS of 14 which indicated the resident was cognitively intact. -Substantial to maximal assistance with toileting hygiene, bathing self, sit to lying, lying to sitting, chair to bed transfer, toilet transfer, and shower transfer. -Partial to moderate assistance rolling left and right -Occasionally incontinent of bowel and bladder. -No physical restraints or alarms. Review of a 2/15/24 Alert Note indicated Resident 13 had a seizure lasting approximately three to four minutes. A new physician's order for topiramate (anticonvulsant) was prescribed. Review of a 2/15/24 New Prescription report indicated Resident 13 was prescribed topiramate for epilepsy. Review of a 7/9/24 care plan revealed Resident 13 had a resident-to-resident altercation where Resident 13 and made physical contact with Resident 16. Review of the 7/26/24 quarterly MDS for Resident 13 revealed the following: -BIMS of 10 which indicated moderate cognitive impairment. -Dependent for toileting hygiene, bathing self, sit to lying, lying to sitting, chair to bed transfer, toilet transfer, and shower transfer. -Substantial to maximal assistance rolling left and right. -Always incontinent of bowel and bladder. -WanderGuard (to alert staff when residents wander). No significant change assessment was found in Resident 13's clinical record. On 8/28/24 at 7:31 AM Resident 13 stated she/he had "good days and bad days" with her/his cognition and she/he did not know why. On 8/28/24 at 8:13 AM Staff 4 (LPN) stated Resident 13 will randomly cuss the "f bomb." Staff 4 stated she/he has behaviors after a family member visits the facility which was about every three weeks. Resident 13 verbally abuses staff and tries to hit them. Resident 13 will masturbate during showers then apologize after. Staff 4 stated Resident 13 hit Resident 16 in the head in 7/2024. On 8/30/24 at 8:44 AM Staff 1 (Administrator) and Staff 2 (Interim DNS) confirmed Resident 13 should have a significant change MDS completed.

Resident 13 will be evaluated for a significant change MDS and one will be opened and reviewed no later than October 19, 2024, as deemed necessary by the MDS coordinator. MDS Coordinator and/or Designee will audit resident charts to identify if there have been any significant changes in the last 30-days resulting in the need to initiate a significant change MDS that have not been identified. Based on the results of the audit, the MDS coordinator will follow up. MDS coordinator and Nursing Staff on the IDT will be in-serviced no later than October 19, 2024, on the importance of identifying significant changes in residents and when to open a significant change MDS. MDS coordinator and/or designee will be responsible for communicating with QAPI any significant change MDSs that are conducted for the next 6 months.

Based on interview and record review it was determined the facility failed to ensure PASARR I (Pre-Admission Screening/Resident Review) screening was completed prior to admission for 1 of 1 sampled resident (#25) reviewed for PASARR. This placed residents at risk for inappropriate placement in a nursing facility and lack of needed services. Findings include: Resident 25 admitted to the facility in 7/2024 with diagnoses including multiple sclerosis (a chronic disease of the central nervous system that interrupts the flow of information within the brain and between the brain and body) and major depressive disorder (a mental health disorder characterized by persistently depressed mood causing significant impairment in daily life). A review of Resident 25's 7/23/24 admission MDS revealed she/he was cognitively intact and required substantial assistance/was dependent on staff for the completion of her/his ADLs. No evidence was found in Resident 25's health record to indicate the facility completed a PASARR I prior to her/his admission to the facility. On 8/28/24 at 9:17 AM Staff 3 (Social Services Director) stated every resident admitted to the facility needed a PASARR I because it justified their placement in a nursing facility. She stated she expected to have a PASARR I for every resident in the building either on the date of admission or by the following business day. Staff 3 confirmed Resident 25 was in the facility for more than a month and her/his PASARR I was not added to her/his electronic health record.

Resident 25’s PASARR was uploaded into the chart on 08/28/2024. Social Services Director and/or Designee will audit all admits within the last 30-days to ensure that a PASARR is on file. The admissions team will be in-serviced no later than October 19, 2024, on the importance of ensuring a PASARR is in place at the time of admission to the facility. Medical Records and/or designee will be responsible for bringing to the attention of IDT if a PASARR is missing at the time of admission. To identify this, Medical Records and/or Designee will audit the admit paperwork within 24-hour of admission and/or on Monday following a weekend admit ensuring all documentation including a PASARR is in the resident’s chart. If something is identified as missing, Medical Records and/or designee will work to obtain the required documentation. The audit results for admission paperwork will be reviewed with QAPI no less often than quarterly for the next 6 months.

Based on interview and record review it was determined facility staff failed to follow professional standards of practice for a diagnosis for 1 of 5 (#13) sampled residents reviewed for medications. Findings include: Resident 13 was admitted to the facility in 11/2023 with diagnoses including stroke and depression. A 11/9/23 Admission MDS indicated Resident 13 was cognitively intact and did not have a diagnosis of seizure disorder or epilepsy. A review of Resident 13's current comprehensive care plan revealed no documentation of seizure disorder or epilepsy. Review of Resident 13's Alert Notes revealed the following: -2/14/24 on alert for new medication olanzapine (antipsychotic). -2/15/24 had a seizure at 10:50 AM lasting approximately three to four minutes. A new physician order for topiramate (anticonvulsant) was prescribed. -2/16/24 had a seizure on dayshift. New orders to increase topiramate. -2/18/24 sent to the emergency department because of confusion, and slurred speech. A review a 2/15/24 New Prescription report indicated Resident 13 was prescribed topiramate for epilepsy. A 2/21/24 Hospitalist Discharge Summary revealed Resident 13 was admitted for sepsis due to UTI. A 7/26/24 quarterly MDS indicated Resident 13 did not have a diagnosis of seizure disorder or epilepsy. An 8/2024 MAR instructed staff to administer topiramate in the morning for convulsions with a start date of 2/16/24. No documentation was found in Resident 13's clinical record to indicate she/he had a history of epilepsy. On 8/28/24 at 6:32 AM Resident 13 stated when she/he was not administered gabapentin in a timely manner she/he would get muscle cramps from "head to toe" and they would appear as convulsions when the cramps became intense. On 8/28/24 at 11:59 AM Staff 9 (Pharmacist Consultant) stated the possibility was low for Resident 13 to have a seizure as a side effect for olanzapine. Staff 9 stated Resident 13 had COVID-19 in 1/2024 and sepsis in 2/2024 which also could have caused the seizure. Staff 9 stated "there was a lot going on" around that time for Resident 13. On 8/30/24 at 8:44 AM Staff 1 (Administrator) and Staff 2 (Interim DNS) stated Staff 29 (Nurse Practitioner) should consult with the physician about the diagnosis of epilepsy.

Resident 13’s diagnosis and medications will be reviewed no later than October 19, 2024. The facility will work with Resident 13’s PCP to schedule an appointment for the diagnosis of seizure/ epilepsy to be reviewed as it relates to the mediation topiramate. An audit will be conducted by Medical Records and/or Designee no later than October 19, 2024, to audit all residents on topiramate to ensure that they have a diagnosis associated with the medication. The results of the audit will be discussed with the nurse management team. The nurse management team will be in-serviced no later than October 19, 2024, on the importance of checking that mediations have a diagnosis to go with them. Medical Records and/or designee will pull a report on any new medications weekly and review to ensure an appropriate medical diagnosis is associated with the medication. The audit will be discussed with Nursing management for any additional follow-up on a weekly basis. Medications identified as not having a diagnosis will be tracked and reported no less often than Quarterly at QAPI.

Based on observation, interview, and record review it was determined the facility failed to ensure dependent residents received required assistance with ADLs for 1 of 2 sampled residents (#13) reviewed for ADLs. This placed residents at risk for unmet needs. Findings include: Resident 13 was admitted to the facility in 11/2023 with diagnoses including a stroke and chronic pain. A 11/21/23 care plan indicated Resident 13 had a self-care deficit which required substantial assistance with ADL tasks including grooming. Review of the Documentation Survey Report on 8/26/24 revealed no documentation Resident 13 received personal hygiene on day shift or evening shift. On 8/26/24 at 10:55 AM, 8/27/24 at 12:44 PM and 8/28/24 at 9:16 AM Resident 13 was observed with a brown stain going from the left side of her/his mouth down to the bottom of her/his chin approximately one-half inch wide. On 8/28/24 at 9:19 AM Staff 8 (RCM Assistant) confirmed Resident 13's brown stain on her/his chin. On 8/30/24 at 8:42 AM Staff 1 (Administrator) and Staff 2 (Interim DNS) stated the expectation of staff were to clean Resident 13's face.

Resident 13’s brown stain on his face was cleaned on 8/28/2024. Resident Care Managers (RCM’s) of the 1st and 2nd floor unit will be assigned to conduct an audit of all residents with a self-care deficit who require substantial assistance with ADL’s related to grooming are receiving the care and services necessary to maintain good nutrition, grooming, and personal/oral hygiene no later than October 19, 2024. Nursing staff will be in-serviced no later than October 19, 2024, on ensuring services are being conducted to maintain good nutrition, grooming, personal and oral hygiene for residents residing in the facility. Nursing staff will also be in-serviced on the importance of documenting care and services provided to avoid gaps in charting. The RCM’s of the unit will be required to audit 2 residents at random per month identified as needing substantial assistance with ADL’s related to grooming, nutrition and hygiene. The goal of the audit will be to ensure that necessary care and services are being provided. This audit will be assigned for the next 6 months. During this timeframe, medical records will pull out a weekly report identifying any documentation that might be missing. The results of the audit will be discussed with QAPI no less often than quarterly for the next 6 months.

Based on observation, interview, and record review it was determined the facility failed to ensure implementation of care plan interventions for 1 of 1 sampled resident (#23) reviewed for falls. This placed residents at risk for injury. Findings include: Resident 23 was admitted to the facility in 5/2019 with diagnoses including fracture of left lower leg, dementia, and high blood pressure. Resident 23's 7/24/24 quarterly MDS revealed the resident had a history of a fall. A review of progress notes revealed the resident reported an unwitnessed fall on 4/27/24. No injuries were noted. Review of Resident 23's Care Plan initiated 3/27/24 identified the resident was at risk for falls. Intervention revisions on 4/30/24 included a fall mat at the side of the bed. This intervention was also on the in room care plan. Observations on 8/26/24, 8/27/24, and 8/28/24 between 6:23 AM and 12:42 PM revealed a fall mat was not placed at the side of the bed. On 8/27/24 and 8/28/24 at 12:57 PM, 3:48 PM, and 9:24 AM Staff 19 (CNA), Staff 22 (NA), and Staff 23 (CNA) stated Resident 23 had an in room care plan checked daily. They did not know there was supposed to be a fall mat at bedside. On 8/28/24 at 9:43 AM Staff 12 (RNCM) confirmed the intervention for a fall mat at bedside was on the Care Plan and the in room care plan. She confirmed the fall mat was not placed at bedside.

Resident 23’s care plan and bedside care plan were updated on 09/05/2024, to remove the fall mat at bedside from the care plan. An audit will be conducted by Infection Control and/or designee no later than October 19, 2024, to identify residents with a fall mat beside their bed to confirm that it is listed on the care plan and vs. verse that if a fall mat is on the care plan, that it is at the bedside. Nursing staff will be educated no later than October 19, 2024, on reviewing care plans and closet care plans to identify the care and services that are required for residents residing at the facility. A list of residents with fall mats on their care plan will be drafted and reviewed quarterly and/or as needed to ensure that it is still appropriate. For the next 6 months, Infection Control and/or Designee will be assigned to conduct monthly audits of resident rooms with fall mats to make sure the care plan matches. The results of the audit will be taken to QAPI no less often than quarterly.

Based on observation, interview and record review it was determined the facility failed to obtain a physician order and provide PICC (peripherally inserted central catheter) dressing care for 1 of 1 sampled resident (#146) reviewed for intravenous (IV) medications. This placed residents at risk for central catheter-related infections. Findings include: The 2011 CDC (Centers for Disease Control) guidelines on how to handle and maintain central lines specified to perform routine dressing changes every two to seven days and the CDC's Checklist for Prevention of Central Line Associated Blood Stream Infections specified to change semipermeable dressings at least every seven days. The facility's 3/2022 Peripheral and Midline IV Dressing Changes Policy and Procedure specified the following: - Maintain sterile dressing (transparent semi-permeable membrane [TSM] dressing for all peripheral catheter sites. - Change the dressing at least every seven days for TSM dressing. Resident 146 was admitted to the facility on 8/14/24 with diagnoses including lung abscess with pneumonia. Resident 146's 8/2024 admission MDS indicated the resident was cognitively intact. Resident 146's 8/14/24 Admission Orders included the following: - Central Venous Access Care (PICC), per facility protocol. Review of Resident 146's 8/14/24 through 8/26/24 health record revealed no physician order or resident-specific protocol for PICC dressing care. There was no documentation which indicated Resident 146's PICC dressing care was provided during the 12 day period from 8/14/24 to 8/26/24. On 8/26/24 at 1:15 PM Resident 146's left upper arm was observed with a PICC and TCM dressing. The PICC dressing was dated 8/26/24. Resident 146 stated the dressing was changed "today" and had not been changed since she/he was admitted to the facility on 8/14/24. On 8/27/24 at 1:11 PM Staff 24 (RN) stated she changed Resident 146's PICC dressing on 8/26/24 after she noticed it had not been changed since the resident's admission on 8/14/24. Staff 24 acknowledged she did not document the PICC dressing care was completed and confirmed there was no physician order or protocol in Resident 146's health record. On 8/27/24 at 1:16 PM Staff 21 (RNCM) stated the PICC dressing care facility protocol and PICC care standard of practice included to ensure PICC dressings were changed every 7 days and as needed. Staff 21 stated Resident 146's PICC dressing care was not provided until 8/26/24, 12 days after the resident's admission.

Resident 146 is no longer residing in the facility. An audit will be conducted no later than October 19, 2024, to identify any residents with a PICC to ensure that they have a physician’s order in place and nursing staff are documenting dressing changes. Licensed Nursing staff, Medical Records, and Nurse Managers will be in-serviced no later than October 19, 2024, on the requirements for dressing care for PICC’s and the requirements for documenting care/services and ensuring the physicians order is in place. RCM’s and/or designee will audit all residents with PICC lines weekly to ensure that they have orders to handle and maintain central lines including routine dressing changes every 2 to 7 days. This will be monitored weekly x4, then semimonthly for 1 month, then monthly for one month, and brought to QAPI for review for 3 months.

Based on interview and record review it was determined the facility failed to ensure a resident's total program of care was reviewed and documented for 3 of 5 sampled residents (#s 4, 21 and 23) reviewed for medications. This placed residents at risk for unassessed medical needs and adverse side effects of medication. Findings include: 1. Resident 4 was admitted to the facility in 2020 with diagnoses including neuralgia (nerve pain). Resident 4's 3/2024, 5/2024 and 7/2024 provider visits, conducted and documented by Staff 29 (Gerontology Nurse Practitioner) were reviewed. The provider visit documentation lacked sufficient evidence to indicate the provider evaluated Resident 4's condition and reviewed the resident's total program of care. On 8/29/24 at 3:57 PM staff 29 stated she visited the residents at the scheduled times and as needed and was not sure where the documentation ended up in the residents' electronic health record. Staff 29 did not provide additional information in regard to her reviews, evaluations and documentation of Resident 4's total program of care. On 8/30/24 at 10:02 AM Staff 1 (Administrator) and Staff 2 (DNS) reviewed Staff 29's provider notes. Staff 2 stated the notes "could be better" and stated Staff 29's notes were not comprehensive. , 2. Resident 21 was admitted to the facility in 2/2023 with diagnoses including chronic pain and dementia. Resident 21's provider visit notes from 4/2024, 6/2024 and 8/2024 by Staff 29 (Gerontology Nurse Practitioner) were reviewed. The provider visit documentation lacked sufficient evidence to indicate the provider evaluated Resident 21's condition or reviewed the resident's total program of care. On 8/29/24 at 3:57 PM Staff 29 stated she visited the residents at the scheduled times and as needed and was not sure where the documentation ended up in the residents' electronic health record. Staff 29 did not provide additional information in regard to her reviews, evaluations and documentation of Resident 21's total program of care. On 8/30/24 at 10:02 AM Staff 1 (Administrator) and Staff 2 (DNS) reviewed Staff 29's provider notes. Staff 2 stated the notes "could be better" and stated Staff 29's notes were not comprehensive. , 3. Resident 23 was admitted to the facility in 5/2019 with diagnoses including dementia, hypertension, and high blood pressure. Resident 23's provider visit notes from 6/21/24, 7/12/24 and 8/16/24 by Staff 29 (Gerontology Nurse Practitioner) were reviewed. The provider visit documentation lacked sufficient evidence to indicate the provider evaluated Resident 23's condition or reviewed the resident's total program of care. On 8/29/24 at 3:57 PM Staff 29 stated she visited the residents at the scheduled times and as needed and was not sure where the documentation ended up in the residents' electronic health record. Staff 29 did not provide additional information in regard to her reviews, evaluations and documentation of Resident 23's total program of care. On 8/30/24 at 10:02 AM Staff 1 (Administrator) and Staff 2 (DNS) reviewed Staff 29's provider notes. Staff 2 stated the notes "could be better" and stated Staff 29's notes were not comprehensive.

Residents 4, 21, and 23 will have a comprehensive review by their PCP no later than October 19, 2024, to ensure that documentation can indicate a sufficient review of the resident’s total program of care. Medical Records and/or designee will audit residents for the last 30-days to see if the documentation provided by the provider meets a comprehensive review of medication and residents total program of care. Residents identified as missing documentation will be sent to the provider no later than October 19, 2024, for additional documentation/review. No later than October 19, 2024, a notice will be communicated with providers on the importance of ensuring sufficient evidence to indicate the provider evaluated the resident’s condition and reviewed the resident’s total program of care including medication and medical needs. Medical records will review 1 chart per week x 4 weeks, then 1 chart every 2 weeks for one month, then monthly for 1 month to ensure comprehensive review by PCP. This will be brought to QAPI for 3 months then reevaluated to ensure compliance.

Based on interview and record review it was determined the facility failed to ensure residents were seen by a physician for 1 of 5 sampled residents (#13) reviewed for medications. This placed residents at risk for unmet medical needs. Findings include: Resident 13 was admitted to the facility in 11/2023 with diagnoses including a stroke and chronic pain. A review of Resident 13's clinical record indicated there were no physician visits documented since his/her admission. On 8/28/24 at 12:45 PM Staff 1 (Administrator) and Staff 3 (Social Services Supervisor) confirmed there was no physician visit for Resident 13 since admission.

Resident 13 will be seen by an MD no later than October 19, 2024. The facility will conduct an audit of medicare residents admitted in the last 30-days to identify any residents who are missing an MD visit and get those scheduled on/or before October 19, 2024. The facility will send a notice to the providers no later than October 19, 2024, outlining the OAR requirements for physician visits in a nursing home. Medical Records and/or designee will be responsible for communicating will the providers residents who are required to be seen by an MD. The list sent to providers will be reviewed with the IDT team to help ensure compliance with the requirement. If a resident has not been seen by the date outlined, the facility will communicate no later than 10 days past the date of the required visit that they are required to be seen. The facility will work with providers on how they would like to receive this communication. Medical Records and/or Designee will report to QAPI no less often than quarterly the list of residents requiring Medicare MD visits. Medical records will audit 1 chart per week for 4 weeks, then 1 chart 2x per month x1 month, then monthly for one month to ensure that the resident has been seen by a physician as required. This will be brought to QAPI for months.

Based on interview and record review it was determined the facility failed to the ensure the Direct Care Staff Daily Report (DCSDR) postings were accurate for 16 of 27 days reviewed for staffing. This placed residents and visitors at risk for inaccurate staffing information. Findings include: Review of the 8/1/24 through 8/27/24 DCSDR indicated the following days when the number of hours CNAs and/or NAs worked were inaccurate on the daily postings: 8/1, 8/2, 8/3, 8/4, 8/5, 8/6, 8/9, 8/10, 8/11, 8/14, 8/19, 8/20, 8/23, 8/25, 8/26, and 8/27. On 8/29/24 at 8:24 AM Staff 17 (Staffing Coordinator) stated she did not fully understand how to complete the DCSDR and did not update the report to reflect changes that occurred in the schedules. On 8/29/24 at 10:10 AM Staff 1 (Administrator) stated she expected the DCSDR to be accurate.

The daily staffing record was corrected for 8/1, 8/2, 8/3; 8/4, 8/5, 8/6, 8/9, 8/10, 8/11, 8/14, 8/19, 8/20, 8/23, 8/25, 8/26, and 8/27. The daily staffing records will be reviewed no later than October 19, 2024 for the last 30-days to ensure that the records are accurate and reflect any staffing changes that occurred during the shift. Staffing Coordinator and Licenses Nurses, will be in-serviced on the importance of updating the daily staffing report to accurately reflect the hours worked by C.N.A’s and NA’s. This in-service will occur no later than October 19, 2024. The Staffing Coordinator and/or designee will be responsible for reviewing the daily staffing report to ensure that it matches the daily schedule. Weekly, the daily staffing reports will be reviewed by the Director of Nursing and/or designee to ensure they match the staffing schedule for the next 3 months. Any discrepancies in the audit of the reports will be discussed with QAPI no less often than quarterly.

Based on observation, interview, and record review it was determined the facility failed to ensure the provision of prescribed medications for 1 of 8 sampled residents (#147) reviewed for medications. This placed residents at risk for not receiving prescribed medications. Findings include: Resident 147 was admitted to the facility on 8/22/24 with diagnoses including pelvis fracture. Resident 147's 8/22/24 Physician Orders included the following: - Preservision AREDs 2 oral capsule by mouth in the morning; - Psyllium oral capsule 0.52 grams, 2 capsules in the evening; - Tolterodine Tartrate ER capsule 4 mg in the morning. Resident 147's 8/2024 MAR revealed Preservision AREDs 2 oral capsule, psyllium oral capsule and the tolterodine tartrate were marked "9" on 8/22/24, 8/23/24, 8/24/24, 8/25/24 and 8/26/24. On 8/27/24 at 9:44 AM Staff 7 (CMA) stated the "9" documented on the MAR meant the medication was not available. Staff 7 stated the pharmacy should be notified and the facility should get the medications as soon as possible. Staff 7 stated she had not contacted the pharmacy to notify the medications were not available for five days since the resident admitted and was unsure if the physician was notified. On 8/27/24 at 10:00 AM Staff 12 (RNCM) stated medications should be available when a resident admits to the facility. Staff 12 stated if a medication was unavailable, staff needed to check the cubex (supply of back up medications) and if the medication was not in the cubex, the pharmacy was called to deliver the medications right away. Staff 12 reviewed Resident 147's MAR and stated she was unaware the medications were not available. Staff 12 stated she expected staff to call the pharmacy and notify the physician within one day of recognizing a medication was not available.

Resident 147’s all ordered medications were received by 8/28/2024. An audit report will be pulled no later than October 19,2024, to identify any other medications being documented as “undeliverable” for follow-up. Licensed Nursing Staff and Medication Aide’s will be in-serviced no later than October 19, 2024, on how to handle medications identified as unavailable when scheduled and facility policy on communicating with pharmacy and PCP. Medical records and/or designee will pull missing med pass report daily M-F and this will be distributed to nurse management team and reviewed for follow-up during clinical meeting x3 months to ensure meds are deliverable. This will be brought to QAPI for 3 months.

Based on interview and record review it was determined the facility failed to follow up on pharmacy recommendations for 1 of 5 sampled residents (#13) reviewed for medications. This placed residents at risk for adverse medication reactions. Findings include: Resident 13 was admitted to the facility in 11/2023 with diagnoses including insomnia. Resident 13's 6/7/24 Pharmacist's Report to Nursing revealed the following recommendation: -Resident 13 was ordered trazodone (to treat depression) at bedtime for insomnia and to administer one extra tablet if not asleep within one hour. Recommendations were to discontinue the current trazodone order and re-enter the order with scheduled and PRN portions separated so the administration could be charted on each portion. Resident 13's 6/2024 MAR revealed trazodone continued as previously ordered and the pharmacist's recommendations were not implemented. Resident 13's 7/8/24 Pharmacist's Report to Nursing revealed the following recommendation: -Resident 13 was ordered trazodone (to treat depression) at bedtime for insomnia and to administer one extra tablet if not asleep within one hour. Recommendations were to discontinue the current trazodone order and re-enter the order with scheduled and PRN portions separated. A handwritten note on the report revealed "done 7/15/24." Resident 13's 7/2024 MAR revealed trazodone continued as previously ordered. On 7/16/24 the same order for trazodone was added to the PRN section of the MAR. The Consultant Pharmacist's recommendations were not fully implemented. On 8/30/24 at 8:53 AM Staff 1 (Administrator) and Staff 2 (Interim DNS) stated they would like pharmacy recommendations implemented within a week.

On 11/15/2023 Resident 13’s care plan was updated to include IDT & pharmacist will meet and discuss GDR of psychotropic medication quarterly & PRN. Resident 13 is no longer on trazodone. This order has since been clarified in the orders and now show it as DC’d. The facility will review the pharmacist recommendations for the last 30 days and ensure compliance is achieved with recommendations no later than October 19, 2024. The Nurse Management Team will be in-serviced no later than October 19, 2024, on following up with the pharmacist report in a timely manner and ensuring suggestions/recommendations are implemented prior to the next routine visit. The DNS and/or designee will be responsible for reviewing the pharmacy recommendations monthly and auditing to ensure suggestions have been implemented between visits. The results of the pharmacist monthly report will be taken to QAPI no less often than quarterly.

Based on interview and record review it was determined the facility failed to adequately monitor psychotropic medications for 1 of 5 sampled residents (#13) reviewed for medications. This placed residents at risk for lack of effective medication management. Findings include: Resident 13 was admitted to the facility in 11/2023 with diagnoses including insomnia, depression and pain. A 5/12/24 revised care plan indicated Resident 13 received psychotropic drugs which included fluoxetine for depression, trazodone for insomnia and olanzapine for depression. Interventions included to monitor and document the side effects and effectiveness of the medications every shift. No documentation was found in Resident 13's clinical record to indicate her/his medications' side effects and medication effectiveness were documented every shift. A review of Resident 19's signed Physician Order Summary Report dated 8/1/24 revealed the following medications: -Trazodone (for depression) 50 mg at bedtime for insomnia. -Olanzapine (an antipsychotic to treat severe agitation) 2.5 mg two times a day for depression. -Fluoxetine (antidepressant) 20 mg in the morning for depression. On 8/28/24 at 8:13 AM Staff 4 (LPN) stated when the facility switched systems to track clinical records resident side effect monitoring was no longer added to their records. Staff 4 stated she notified management of the needed monitoring, but it was not added. On 8/28/24 at 12:45 PM Staff 1 (Administrator) and Staff 3 (Social Services Supervisor) confirmed there was no monitoring for antipsychotic and antidepressant medications.

Resident 13’s medications were reviewed and resident was placed on monitoring for medication effectiveness and side effects on September 27, 2024. We are adding monitoring for side effects of these medications along with effectiveness of the medication to our EMR system to be documented and monitored every shift to be completed no later than Oct 19, 2024. This documentation will be located in the MAR. All residents on this classification of medication will have these orders input into this system no later than October 19, 2024. Monitoring: To monitor this, RCM or designee will audit 1 resident per week that is taking psychotropic medications to ensure proper documentation is occurring every shift to include effectiveness of each psychotropic medication along with any side effects associated. RCM and/or designee will report the results of their audit no less often that quarterly to QAPI.

Based on observation, interview, and record review it was determined the facility failed to store and handle food in a manner to minimize cross contamination in 1 of 1 kitchen and 1 of 2 snack refrigerators reviewed for sanitary conditions. This placed residents at risk for foodborne illness. Findings include: 1. On 8/26/24 at 10:16 AM during the initial tour of the facility's kitchen, the following was observed in the walk in refrigerator and dry storage area: -Raw meat stored in the walk in refrigerator on a wire rack shelf directly above eggs and cartons of liquid whole eggs; and -Plastic handled scoops stored in the brown sugar, powdered sugar, white sugar and dry pasta storage bins. The scoops' handles touched the food in the bins. On 8/26/24 at 10:24 AM Staff 30 (Food Service Director) stated the meat in the refrigerator should be stored on the bottom shelf to avoid it dripping on the food below it and the scoops should be stored in their holsters to avoid cross contamination. Staff 30 stated, "somebody just got lazy." 2. On 8/28/24 at 11:39 AM while plating foods for lunch service, Staff 31 (Dietary Cook) opened the oven door to remove a cooked chicken breast and placed it on a plate. He then picked up a dinner roll with the same gloved hand he used to open the oven door and placed it on a resident's lunch plate and did not change gloves. On 8/28/24 at 11:40 AM Staff 31 stated he did not change his gloves after touching the oven door handle and that created an opportunity for cross contamination. He stated, "That was my mistake. I could have used tongs to plate the dinner roll." On 08/28/24 12:05 PM Staff 30 (Food Service Director) stated he expected staff to change gloves after touching potentially contaminated equipment and before touching food being served. 3. Review of the US FDA 2022 Food Code revealed: -food prepared and held cold must be clearly marked with date prepared or by day which the food shall be consumed or discarded with a maximum of seven days if held at 41 degrees F. On 8/27/24 at 10:20 AM two plastic mugs with sip lids were observed in the snack refrigerator within the 2nd floor Kitchenette / Nurse station. The mugs were not labeled and they contained a brown thickened liquid. On 8/27/24 at 10:24 AM Staff 21 (RNCM) stated the drinks needed to be labeled and she removed them from the refrigerator. On 8/27/24 at 10:35 AM Staff 30 (Food Service Director) stated he did not know who placed the mugs in the refrigerator. He stated, "Everything brought up from the kitchen to any of the snack fridges should be labeled and dated to make sure we know when it was added and when it should be removed. Also if it is for a specific resident, staff need to know that."

On 8/26/2024 when the raw meat was identified on the wire rack above the eggs and the plastic handled scoops were found in the bins, they were removed and stored properly by kitchen staff. On 8/27/2024, the two undated plastic cups with lids were removed from the kitchenette. On 8/29/2024, dietary staff were in-serviced on how to properly store, prepare, distribute and serve food in accordance with professional standards for food service safety and the Oregon Food Code. Dietary staff were also in-serviced with the proper storage of utensils placed in storage bins and how to use and clean them. Signage was placed for display as a reference guide for proper storage methods on 8/30/2024. All dietary Staff were retrained on how to prepare, distribute and serve food in accordance with professional standards for food service safety. In accordance with the Oregon Food Code on 8/29/2024 on proper use of gloves, utensils, and tools when handling ready to eat foods. All dietary Staff were retrained on how to prepare, distribute and serve food in accordance with professional standards for food service safety. In accordance with the Oregon Food Code on 8/29/2024 on proper techniques of label and dating food items placed in the kitchenette refrigerators. Signage was posted on the kitchenette fridges on proper labeling techniques. Nursing staff will be-in serviced no later than October 19, 2024, on what can/cannot be placed in the kitchenette fridges/freezers and the protocol for labeling and dating items. Infection Control and/or Designee will be responsible for conducting weekly audits for the next 2 months to ensure that items in the kitchenets are labeled and dated. Any food items found not in compliance will be destroyed. The results of the audit will be discussed with QAPI no less often than quarterly for 6 months. The Dietary Supervisor and/or designee will be responsible for spot checking 1x/week for the next 2 months the walk-in freezer to ensure proper storage of food and spot checking serve out for one meal to ensure proper handling of food is occurring. Results of the audit will be discussed with QAPI no less often than quarterly.

Based on observation, interview, and record review it was determined the facility failed to implement appropriate Enhanced Barrier Precautions (EBP) and failed to ensure appropriate use of PPE for 3 of 3 sampled residents (#s 3, 146, and 296) reviewed for infection control. This placed residents at risk for the spread of infection. Findings include: 1. The CDC's 4/3/24 website, section titled, Transmission Based Precautions, specified Contact Precautions are the second tier of basic infection control and are to be used in addition to Standard Precautions for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission. Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. Resident 146 was admitted to the facility in 8/2024 with diagnoses including abscess of the lung with pneumonia. Observations on 8/26/24 and 8/27/24 between the hours of 7:45 AM and 3:50 PM revealed Contact Precautions signage was posted on the wall adjacent to Resident 146's door. A trash receptacle, labeled "PPE DISPOSAL" was located outside Resident 146's room. Multiple staff were observed at various times to enter Resident 146's room and provide care. Staff did not don PPE prior to entering the room. On 8/26/24 at 12:46 PM Staff 26 (NA) stated she was unsure what PPE she needed to don prior to entering Resident 146's room. On 8/27/24 at 8:28 AM Resident 146 stated since her/his admisison to the facility, staff did not consistently don PPE while providing care. On 8/29/24 at 11:42 AM Staff 21 (RNCM) stated there was confusion regarding the Contact Precautions placed on Resident 146. On 8/29/24 at 1:39 PM Staff 1 (Administrator) and Staff 2 (DNS) were notified of the findings of this investigation. Staff 2 acknowledged Contact Precautions indicated staff should don PPE prior to entering the resident's room. , 2. Resident 43 was admitted to the facility in 7/2024 with diagnoses including an infected right leg wound. A 7/30/24 Physician Order stated wound care which included wound cleaning and redressing for Resident 43's infected right leg wound. A 8/9/24 cognitive assessment determined Resident 43 to have normal cognitive function. On 8/26/24 from 11:00 AM through 3:00 PM staff were observed entering rooms throughout the facility determined to require enhanced barrier precautions without wearing gloves and/or gowns. Staff were observed leaving these same rooms after providing brief changes with plastic bags which included soiled briefs and other fluid exposed materials. On 8/26/24 at 2:55 PM Staff 32 (LPN) stated she provided Resident 43's dressing change that day. Staff 32 stated she wore gloves and a mask, but did not wear a gown. Staff 32 stated she had never been instructed to wear a gown when providing wound care. On 8/26/24 at 2:59 PM Resident 43 stated staff who provided hands on care had worn gloves when providing care, but had never worn a gown. On 8/29/24 at 9:08 AM Staff 33 (CNA) stated containers with PPE have been located outside of resident rooms with EBP, including Resident 43, but PPE had not previously been worn when providing contact care with these residents. On 8/29/24 at 9:34 AM Staff 34 (Infection Preventionist) stated she was not aware gowns were required to be worn when providing hands on care to residents on EBP. Staff 34 confirmed enhanced barrier precautions were required for residents with open wounds or any tubes used for fluid drainage, including Resident 43. 3. On 08/26/24 at 11:17 AM the following observations were made of rooms requiring enhanced barrier precautions: - A container labeled as PPE disposal was located outside of rooms 110 and 124. Used PPE was observed inside both of these containers. - No PPE disposal container was observed outside or inside room 109. On 8/26/24 at 3:07 PM Staff 1 (Administrator) and Staff 2 (DNS) were shown the current infection control practices regarding disposal of used PPE in rooms with enhanced barrier precautions and confirmed the incorrect practices were being performed. , 4. Resident 296 was admitted to the facility in 8/2024 with diagnoses including a leg fracture requiring a leg immobilizer and history of a stroke. Resident 296's 8/20/2024 Admission MDS revealed the resident used an indwelling catheter. An observation on 8/26/24 at 10:49 AM revealed Resident 296 had a catheter drainage bag on the side of the bed. The resident confirmed she/he used an indwelling catheter. There were no Enhanced Barrier Precautions in place. On 8/29/24 at 1:59 PM Staff 21 (RNCM) confirmed resident 296 should have been on Enhanced Barrier Precautions due to his/her indwelling catheter.

Resident 146 has been discharged from the facility. Resident 3 and 296 have been reviewed and had enhanced barrier precautions implemented during the time of survey. No later than October 19, 2024, residents identified as have enhanced barrier precautions will have their care plans evaluated to ensure care plans match what is occurring. PPE, trash receptacles and carts have been appropriately placed per guidance. Infection Control and/or designee will audit all residents on enhanced barrier precautions monthly to ensure PPE, and equipment is appropriately used and in place. Staff were in-serviced on 8/27/2024 regarding enhanced barrier precautions. We will in-service staff again on enhanced barrier precautions and the appropriate PPE no later than October 19, 2024. Infection Control and/or Designee will be responsible for auditing 1x/week staff entering/providing care/ exiting the resident room to ensure appropriate procedures are followed. This audit will occur no later than October 19, 2024, and continue weekly for 2 months and then audited monthly for 6-months. The results of the audit will be taken to QAPI no less often than quarterly for review and feedback for compliance.

**************************************** OAR 411-087-0100 Physical Environment Refer to F584 **************************************** OAR 411-085-0360 Abuse Refer to F600 **************************************** OAR 411-086-0060 Comprehensive Assessment and Care Plan Refer to F637 **************************************** OAR 411-070-0043 Pre-Admission Screening and Resident Review (PASRR) Refer to F645 **************************************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F658, F677 and F694 ***************************************** OAR 411-086-0140 Nursing Services: Problem Resolution & Preventive Care Refer to F689 and F758 *************************************** OAR 411-086-0200 Physician Services Refer to F711 and F712 **************************************** OAR 411-085-0030 Required Postings Refer to F732 *************************************** OAR 411-086-0260 Pharmacy Services: Pharmaceutical Services Refer to F755 and F756 *************************************** OAR 411-086-0250 Dietary Services Refer to F812 *************************************** OAR 411-86-330 Infection Control and Universal Precautions Refer to F880 ****************************************

Based on interview and record review the facility failed ensure 1 of 5 residents (R) (R4) reviewed for pneumococcal immunizations included documentation showing the resident or the resident's representative was provided education regarding the risks and benefits of vaccination prior to its administration. This failed practice increased the risks of resident's not being aware of and identifying side effects or complications associated with the vaccination. Findings include: Record review showed R4 was admitted on 3/17/2018, was over 79 years old and had diagnosis including dementia and multiple sclerosis (chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord, symptoms may include numbness, impairment of speech and of muscular coordination, blurred vision, and severe fatigue). Review of Preventive Health Care tab of electronic health record showed the facility administered Pneumococcal 20-valent Conjugate Vaccine (Prevnar 20) to R4 on 1/31/23. The box showing "education provided to resident/family/POA (power of attorney)" was not checked "yes" or "no". During concurrent record review and interview on 6/27/23 at 2:38 PM Infection Preventionist (IP) reviewed above Prevnar 20 documentation and stated that she administered pneumococcal immunization. IP further stated that she went over CDC (Centers for Disease Control and Prevention) Vaccine Information Statement (VIS) with resident but forgot to document that she provided resident education on the risks and benefits. IP stated that she should have documented education provided to resident, but she didn't. Review of R4's progress notes showed documentation on 1/31/23 that resident was given Prevnar 20 immunization. Review of records from time period of 1/23/23 to 26/23 did not show any documented evidence that resident/representative received education on risks and benefits of Prevnar 20. During an interview on 6/27/23 at 2:57 PM Director of Nursing (DON) stated that it is her expectation and the facility process for staff to complete the Preventive Health care immunization form including documentation that residents and their family member or representative are informed of risks and benefits prior to vaccination. DON further stated that she educated IP about this step in the process as it is the same process for all immunizations; including covid, influenza and pneumococcal. Facility policy Influenza & Pneumococcal Disease Prevention Policy and Procedure, revised March 21, 2022, documented "before offering the immunization, ... ...each resident or the resident's legal representative receives education regarding the benefits and potential side effects of the immunization ....The resident's medical record includes ....documentation that the resident or the resident's legal representative was provided education regarding the benefits and potential side effects of the ...pneumococcal immunizations."

Resident R4’s medical record will be updated to include the risk/benefit’s of the Pneumococcal vaccine. Medical Records and/or designee will conduct on audit of in-house pneumococcal vaccine administrations for the last year to ensure the risk/benefit information was given. This audit will be completed no later than July 21, 2023. The DNS will in-service RN/LPN staff on educating residents/representatives on risk/benefits when administering vaccines and the importance of documenting this communication in the medical record. This in service will occur no later than July 21, 2023. We will continue with our current policy on providing vaccination information statements (VIS) to resident/representatives and obtaining consent from the appropriate party prior to administration of the Pneumococcal vaccine. IP and/or designee will be responsible for updating the QAPI team on Pneumococcal vaccines no less often than quarterly until we know the system is functioning.

Based on observation, interview and record review it was determined the facility failed to protect the resident's right to be free from physical abuse by a resident for 2 of 5 sampled residents (#s 159 and 23) reviewed for 4 allegations of resident-to-resident abuse. This placed residents at risk for abuse. Findings include: 1. Resident 157 was admitted to the facility in 8/2021 with diagnoses including dementia with behaviors and mixed receptive-expressive language disorder. Resident 157's 8/9/22 Annual MDS indicated she/he was not able to answer cognitive questions to assess a BIMS score. Staff assessed Resident 157 with short term memory problems and impaired decision-making skills. Resident 159 was admitted to the facility in 1/2016 with diagnoses including chronic heart failure. Resident 159's 4/1/22 Annual MDS indicated a BIMS score of 13 (cognitively intact). A FRI was submitted to the State Agency on 6/20/22 which revealed the following: On 6/20/22 Resident 159 used her/his foot to push Resident 157 away from her/his feet so her/his feet did not get run over by Resident 157's wheelchair. Resident 157 then struck Resident 159 in the face. Resident 159 put her/his arm up and Resident 157 hit her/his arm. Resident 159 reported she/he was pinched by Resident 157 on her/his top right hand. Resident 159 obtained a bruise on the top of her/his right hand. Staff relocated the residents, assessed for injury and completed an investigation. On 5/5/23 at 10:10 AM Staff 1 (Administrator) confirmed the incident and findings of abuse from the facility investigation. Staff 1 expected residents to be free from abuse. No additional information was provided. , 2. Resident 161 was admitted to the facility in 4/2023 with diagnoses including fracture of the femur. Resident 161's 4/28/23 Admission MDS revealed the resident was cognitively intact. Resident 23 was admitted to the facility in 12/2020 with diagnoses including dementia with behaviors. Resident 23's 2/23/23 Quarterly MDS revealed the resident experienced moderate cognitive impairement. Resident 51 was admitted to the facility in 3/2023 with diagnoses including dementia with agitation. Resident 51's Admission MDS revealed the resident experienced severe cognitive impairment. A review of Resident 51's Progress Notes from 3/17/23 through 4/28/23 revealed the following: -The resident was confused and wandered all over the unit and into other resident rooms. -The resident experienced agitation and was physically aggressive towards staff. -The resident yelled at other residents. -The resident was difficult to redirect and required the administration of PRN antipsychotic medications (medications used to help reduce psychotic symptoms like hallucinations, delusions and disordered thinking) by mouth and intramuscularly to deescalate her/his behaviors. A 4/29/23 Event Report completed by Staff 5 (RN) revealed the following: -Resident 51 was found in Resident 161's room at 10:05 AM by Staff 6 (Agency CNA). -Staff 6 observed Resident 51 squeezing Resident 161's left wrist and banging Resident 161's hand on the bedside table. -Staff 6 removed Resident 51 from Resident 161's room. -Staff 5 assessed Resident 161 and determined no injuries from this incident occurred. -Resident 51 was not receptive to redirection and required constant monitoring by staff. A 4/29/23 Event Report completed by Staff 5 (RN) revealed the following: -Resident 51 was found in Resident 23's room at 11:09 AM with both hands wrapped around Resident 23's right forearm. Resident 51 dug her/his nails into Resident 23's skin and twisted the skin. -Staff 5 was alerted to this incident as Resident 23 yelled. -Staff 5 removed Resident 51's hands from Resident 23's forearm and escorted her/him out of the room. -Resident 23 had four fingernail markings on her/his forearm. An attempt to interview Resident 51 occurred on 5/1/23 at 1:31 PM but the resident was unable to participate due to cognitive impairment. Random observations of Resident 51 conducted from 5/1/23 through 5/5/23 between 5:10 AM to 2:24 PM revealed the resident in her/his wheelchair. The resident wandered the hallways, wandered into other resident rooms and engaged in activities at the nurse's station. On 5/3/23 at 9:51 AM Resident 161 stated Resident 51 entered her/his room on 4/29/23, grabbed her/his right hand and squeezed it really hard. Resident 161 stated it hurt but she/he did not sustain an injury from the incident. Resident 161 stated she/he told Resident 51 to stop but she/he did not, and it took approximately five minutes before a staff member intervened. Resident 161 stated a stop sign was placed on her/his doorway after the incident and she/he had not experienced any issues with Resident 51 since this time. Resident 161 stated she/he felt safe in the facility and was not worried about a repeat occurrence. On 5/3/23 at 1:18 PM Resident 23 stated Resident 51 entered her/his room on 4/29/23. Resident 23 stated she/he told the resident to leave but she/he refused. Resident 23 stated Resident 51 grabbed her/his right arm and that the incident "scared [her/him] more than anything." Resident 23 stated a nurse intervened after she/he screamed and removed Resident 51 from her/his room. Resident 23 stated she/he sustained a small bruise from the incident on her/his forearm. Resident 23 stated she/he did not think Resident 51 would attempt to re-enter her/his room but also "you never know." On 5/4/23 at 9:45 AM Staff 5 (RN) stated she checked on Resident 161 on 4/29/23 after she heard the resident yell, which was out of character for this resident. Staff 5 stated Resident 51 held Resident 161's left arm with both hands and banged it on the bedside table. Staff 5 stated she removed Resident 51's hands from Resident 161, removed Resident 51 from the room, assessed Resident 161 for injuries and noted there were none. Staff 5 stated this incident occurred around 9:30 AM, and prior to the incident, Resident 51 had been going into other resident rooms throughout the morning and had been difficult to redirect. Staff 5 stated she brought Resident 51 to the nurse's station where she could observe the resident following the incident with Resident 161. Staff 5 indicated Resident 51 was both agitated and restless following the incident with Resident 161. Staff 5 stated she left Resident 51 alone at the nurse's station at around 11:00 AM as she had to check resident blood sugars, and it was shortly thereafter when Resident 23 yelled "get him off of me." Staff 5 stated she entered Resident 23's room and saw Resident 51 digging the nails of both hands into the resident's right arm. Staff 5 stated Resident 23 was very scared and she removed Resident 51 from the room. Staff 5 stated Resident 23 sustained a 1cmx1.5cm bruise to her/his right forearm from the incident. Staff 5 stated Resident 51 required one-to-one supervision on this shift but they did not have enough staff to provide it. On 5/4/23 at 3:29 PM Staff 1 (Administrator) and Staff 2 (DNS) were informed abuse was substantiated and provided no additional information related to either incident.

Residents 157 and 159 are no longer at the facility. Resident 161 was moved to another floor on 05/25/23. Resident 151,23 and 51’s care plans were reviewed and updated as needed on 05/01/2023. Care Plans of residents identified as having cognitive impairment will be reviewed no later than June 27, 2023, to ensure proper interventions are in place to prevent abuse and neglect. All Staff will be in-serviced on identifying residents with behaviors who have the potential to pose a risk to others. In-servicing will also include ways to prevent/ de-escalate residents with behaviors and knowing when to intervene. This in-service will occur no later than June 27, 2023. Residents identified as having behaviors will be reviewed monthly and/or as needed at psychotropic. A summary of individuals reviewed at psychotropic will be reviewed at QAPI no less often than quarterly.

Based on interview and record review it was determined the facility failed to complete a comprehensive assessment for 1 of 3 sampled residents (#51) reviewed for accidents. This placed residents at risk for unmet needs. Findings include: Resident 51 was admitted to the facility in 3/2023 with diagnoses including dementia with agitation. A review of Resident 51's 3/13/23 Admission MDS ADLs Functional Status/Rehabilitation Potential, Urinary Incontinence and Indwelling Catheter and Nutritional Status CAAs identified the following problem areas: - Bed Mobility self-performance; - Transfer self-performance; - Walk in Room self-performance; - Walk in Corridor self-performance; - Locomotion On-Unit self-performance; - Dressing self-performance; - Eating self-performance; - Toilet Use self-performance; - Grooming/Personal Hygiene self-performance; - Bathing self-performance; - Urinary continence; - Weight was too low or too high and - Therapeutic Diet was indicated. The 3/13/23 Functional Status/Rehabilitation Potential, Urinary Incontinence and Indwelling Catheter and Nutritional Status CAAs referred to the Initial/Annual Nursing Assessment Summary dated 3/29/23 for a comprehensive assessment of each care area. A review of Resident 51's 3/29/23 Initial/Annual Nursing Assessment Summary revealed the assessment was blank. On 5/4/23 at 12:08 PM Staff 3 (RNCM) confirmed both Resident 51's 3/13/23 CAAs and 3/29/23 Initial/Annual Nursing Assessment Summary were not completed and should have been within 14 days following Resident 51's admission. On 5/4/23 at 3:29 PM Staff 1 (Administrator) and Staff 2 (DNS) were informed of the findings and confirmed the CAAs should have been completed within 14 days after Resident 51 was admitted to the facility.

Resident 51’s CAA and initial/annual assessment summary were completed on 05/16/2023. The Medical Records Director will conduct an audit of all CAA’s and initial/annual assessments to ensure that they are completed within the approved timeframe. This audit will occur no later than June 27, 2023. Residents identified as having incomplete CAA’s and/or initial/annual assessments will be brought to the attention of the IDT team and updated no later than June 27, 2023. Education will be provided by the DNS’s and/or Designee to the RCMs on the correct timeframe for completing CAA’s and initial/annual assessments. Medical Records will continue to conduct weekly audits to ensure assessments are completed within the approved timeframe. The audits conducted by medical records will be reviewed with QAPI no less often than quarterly until compliance is achieved.

Based on interview and record review it was determined the facility failed to accurately code behaviors in resident MDS assessments for 1 of 3 sampled residents (#51) reviewed for accidents. This placed residents at risk for inaccurate assessments and unmet care needs. Findings include: Resident 51 was admitted to the facility in 3/2023 with diagnoses including dementia with agitation. A review of Resident 51's Progress Notes revealed the following: -On 3/10/23 the resident was found downstairs on the first floor looking for her/his room. A CNA brought her/him back to the second floor. -On 3/11/23 the resident was found downstairs by the doors leading to the outside of the facility. A Wander Guard (a bracelet worn by residents at-risk for wandering that sends an alert when residents get close to a monitored door) was placed on Resident 51's left ankle. A review of Resident 51's 3/13/23 Admission MDS revealed the resident did not exhibit the behavior of wandering. On 5/3/23 at 1:42 PM Staff 4 (RNCM) stated Resident 51 had exhibited wandering since her/his admission to the facility. On 5/4/23 at 9:45 AM Staff 5 (RN) stated the Wander Guard was put on Resident 51 shortly after her/his admission because she/he pushed on the doors at the end of the second floor hallways . Staff 5 further stated Resident 51 had successfully gotten on the elevator and went downstairs independently, which was unsafe for this resident. On 5/4/23 at 11:45 AM Staff 3 (RNCM) stated Resident 51 was very impulsive and wandered the hallways. Staff 3 reviewed the resident's Admission MDS and stated wandering should have been coded.

Resident 51 has been identified as a wonder risk and was assessed and care planned for this behavior on 5/3/2023. Resident 51’s admission MDS will be corrected no later than June 1, 2023. The DNS and/or Designee will audit residents who are at risk for wondering to ensure assessments are completed and documented in the resident care plan. This audit will occur no later than June 27, 2023. The DNS will provide an in-service to SSD and RCMs on the importance of correctly entering behaviors into the MDS. All Staff will be in-serviced on the signs of wondering and facility policy. Both in-services will occur no later than June 27, 2023. Residents will continue to be assessed upon admission and quarterly for behaviors including risk of wondering. Residents identified as wondering will be reviewed at QAPI no less often than quarterly.

Based on observation, interview and record review it was determined the facility failed to develop a care plan for the use of a table tray for 1 of 2 sampled residents (#1) reviewed for physical restraints. This placed residents at risk for unmet needs. Findings include: Resident 1 was admitted to the facility in 1999 with diagnoses including quadriplegia (paralyzed). Resident 1's 3/22/23 Restraint/Adaptive Assessment indicated Resident 1 used a lap tray on her his wheelchair. Observations were made of Resident 1 with a lap tray on her/his wheelchair on 5/1/22 at 2:30 PM, 5/2/23 at 1:39 PM and 5/4/23 at 11:41 AM. On 5/4/23 at 1:09 PM Staff 17 (CNA) stated she referred to the resident's in-room care plan to determine the resident's care needs. Record review of Resident 1's 5/4/23 in room care plan did not indicate she/he used a lap tray. On 5/5/23 at 9:25 AM Staff 4 (RNCM) confirmed the lap tray was not included on the in-room care plan which directed staff when and how to use the lap tray. Staff 4 stated she expected items such as a lap tray to be on the in-room care plan so staff would know how to care for the resident.

Resident 1’s care plan was updated on 05/08/2023 to include the use of a lap table tray. DNS and/or designee will provide an in-service to SSD, RCM’s and nurses on the importance of care plans and keeping them updated. In-service will be provided to All Nursing staff on the importance of consulting the care plan when providing care and services to residents. In-servicing will occur no later than June 27, 2023. SSD and/or Designee will conduct an audit of all residents using a tray or other adaptive equipment device to ensure it is on the care plan. This audit will occur no later than June 27, 2023. A random audit on residents with assisted devices will be conducted quarterly for the next year to ensure proper care planning of adaptive equipment. Results of the audit will be discussed with QAPI.

Based on interview and record review, it was determined the facility failed to revise care plans in the areas of safety and fall prevention for 1 of 4 sampled residents (#51) reviewed for accidents. This placed residents at risk for repeated falls. Findings include: Resident 51 was admitted to the facility in 3/2023 with diagnoses including dementia with agitation. Resident 51's Admission MDS indicated the resident was severely cognitively impaired, experienced a fall in the last month prior to admission, experienced a fall in the last two to six months prior to admission and experienced a fracture from a fall in the last six months prior to admission. Event Reports for Resident 51 revealed she/he experienced a fall on 3/21/23, 3/22/23, 3/24/23, 3/27/23, 4/15/23, 4/18/23, 4/21/23 and 4/29/23. The 3/21/23 Fall Investigation Report completed by Staff 2 (DNS) indicated the following care plan interventions remained appropriate and were followed: -Keep the bedroom door open as the resident allowed. -The resident was to wear non-skid socks or be barefoot when in bed and wear non-skid socks or shoes when out of bed. -Frequent checks. The 3/24/23 Fall Investigation Report completed by Staff 2 (DNS) indicated the following care plan interventions remained appropriate and were followed: -Keep the bedroom door open as the resident allowed. -The resident was to wear non-skid socks or be barefoot when in bed and wear non-skid socks or shoes when out of bed. -Frequent checks when the resident was in her/his room. -Call light to be within the resident's reach. -Signage in room (above television and on bathroom door) to remind the resident to ask for assistance prior to transferring. On 5/2/23 at 1:11 PM Resident 51 was observed sitting alone in her/his room in her/his wheelchair without shoes or socks on attempting to stand. Resident 51 was observed to use the overbed table to push up on, resulting in her/him raising up out of the wheelchair a few inches for a short time and then fell backwards into her/his wheelchair. The surveyor turned on the resident's call light at 1:11 PM as the resident continued to attempt to unsafely stand. At 1:18 PM Staff 18 (Nurse Practitioner) entered the room followed by Staff 21 (CMA) at 1:20 PM. On 5/2/23 at 2:05 PM Resident 51's in-room care plan was observed in the closet. Checkmarks were placed by non-skid socks, floor mat (with a date of 4/27/23) and Wander Guard (a bracelet worn by residents at-risk of wandering that sends an alertwhen residents get close to a monitored door) in the section entitled Safety Measures. An undated hand-written note was added to the care plan that stated the resident was at risk for injury related to wandering into resident rooms and she/he was to be redirected to her/his room. A note dated 5/1/23 instructed staff to keep Resident 51 separated from residents in rooms 202 and 216A. There was no mention of the care plan interventions listed in the 3/21/23 and 3/24/23 Fall Investigation Reports on Resident 51's posted in-room care plan. On 5/3/23 at 10:05 AM Staff 21 (CMA) stated she gained information about how to care for residents from their in-room care plans located inside the closet in each resident room. On 5/3/23 at 3:12 PM Staff 22 (CNA) stated he used the in-room care plan to obtain interventions related to falls and behaviors for the residents. Staff 22 reviewed Resident 51's in-room care plan and stated it was not a thorough care plan. On 5/4/23 at 3:29 PM Staff 1 (Administrator) and Staff 2 (DNS) were informed of the findings. Staff 2 stated nursing staff received information on care plan interventions for residents from staff daily huddles and from the resident in-room care plans. Staff 2 reviewed a copy of Resident 51's posted in-room care plan and confirmed the additional fall prevention interventions were not added to the in-room care plan.

Resident 51’s care plan was updated on 05/10/2023. Residents identified as having a fall in the last 30-days will be reviewed by the DNS and/or designee to ensure the care plan is updated with safety intervention. This review will occur no later than June 27, 2023. DNS will conduct an in-service with the RCM’s to ensure care plan interventions are updated with the investigation of an incident and accidents. In-service will occur no later than June 27, 2023. Weekly meetings have been scheduled with the RCM’s/DNS/Admin to review I/A’s and confirm interventions have been added to the care plans. A summary of all I/A’s will be reviewed with QAPI no less often than quarterly.

Based on interview and record review it was determined the facility failed to ensure the services provided met professional standards of practice related to prescribing antipsychotic medication for 1 of 5 sampled residents (#10) reviewed for unnecessary medications. This placed residents at risk for unnecessary antipsychotic medications and adverse medication side effects. Findings include: OAR 851-055-0010 Scope and Standards of Practice for All Licensed Advanced Practice Registered Nurses (APRN) indicated the following: - The APRN independently provides healthcare services within the scope of practice for which the APRN is educationally prepared and clinically trained with competency maintained in accordance with any other applicable rules, regulations, and prevailing standards. All standards and scope of practice found in OAR 851-045 related to the practice of Registered Nursing are applicable to APRNs. OAR 851-045-0060 Scope of Practice Standards for Registered Nurses indicated the following: - Standards related to the Registered Nurse's responsibility for nursing practice implementation. Applying nursing knowledge, critical thinking and clinical judgment effectively in the synthesis of biological, psychological, social, sexual, economic, cultural and spiritual aspects of the client's condition or needs, the Registered Nurse shall: - Conduct and document initial and ongoing comprehensive and focused nursing assessments of the health status of clients by collecting objective and subjective data from observations, examinations, interviews, and written records in an accurate and timely manner as appropriate to the client's health care needs and context of care; - Validate data by utilizing available resources, including interactions with the client and health team members; - Establish and document nursing diagnostic statements and/or reasoned conclusions which serve as the basis for the plan or program of care. Resident 10 was admitted to the facility in 12/2022 with diagnoses including dementia and leg fracture. Resident 10's 3/14/23 Quarterly MDS and 3/27/23 Significant Change MDS indicated she/he had severe cognitive impairment, did not have hallucinations or delusions and no physical, verbal or other behaviors. The MDS assessments indicated the resident received an antipsychotic medication on a routine basis and did not have an active psychiatric or mood disorder. Review of Resident 10's 12/2022, 1/2023, 2/2023 and up to 3/11/23 health records revealed no documented evidence the resident experienced hallucinations, delusions, behaviors, distress or agitation. A 3/8/23 Provider Care Visit Note, written by Staff 8 (APRN) revealed no documentation which indicated the resident experienced hallucinations, delusions, behaviors, distress or agitation. A 3/11/23 facsimile to the facility from Staff 8 revealed a new order for Seroquel (antipsychotic medication) 12.5 mg by mouth every 12 hours. The fax did not include a diagnosis or a clinical indication for use of the Seroquel. Review of Resident 10's 3/2023, 4/2023 and 5/2023 MARs revealed the resident received Seroquel 12.5 mg every 12 hours, every day beginning 3/11/23. On 5/5/23 at 8:44 AM Staff 4 (RNCM) stated she could not recall why Staff 8 prescribed the Seroquel to Resident 10. Staff 4 reviewed Resident 10's health record and was unable to find documentation she/he experienced behaviors, agitation or distress and was unable to find a clinical rationale for the Seroquel. Staff 4 acknowledged Seroquel was an antipsychotic and agreed the medication required an appropriate diagnosis and clinical rationale before prescribing. On 5/8/23 at 12:35 PM Staff 8 stated she was Resident 10's provider, visited the resident in the facility twice between 12/2022 and 5/2023 and confirmed she prescribed the Seroquel on 3/11/23. When asked about the process related to prescribing antipsychotics, Staff 8 responded she generally preferred not to but if a resident was actively hallucinating, then she would prescribe the medication for 14 days. Staff 8 stated Witness 5 (family) kept her "apprised" of Resident 10 and stated Witness 5 reported Resident 10 was confused. When asked if she spoke with the facility's staff who directly cared for the resident or if she reviewed Resident 10's health record for evidence of hallucinations, delusions, confusion, behaviors, agitation or distress prior to prescribing the Seroquel, Staff 8 responded Witness 5 told her the resident was confused and Witness 5 "knew the resident better than anyone." On 5/8/23 at 1:07 PM Staff 1 (Administrator) was informed Resident 10 received an antipsychotic every 12 hours twice daily since 3/11/23 without evidence of documented clinical rationale in her/his health record. Staff 1 stated prior to a provider prescribing an antipsychotic to a resident, she expected documented evidence an antipsychotic was necessary and clinically appropriate. Staff 1 stated documented evidence included an assessment for the use of the antipsychotic, behaviors tracked and monitored, care planned interventions, evidence of non-pharmacological interventions and evidence other factors, such as infection, were ruled out.

Resident 10 is no longer at the facility. The DNS’s and/or designee will provide education to the providers on prescribing psychotropics and the documentation and assessments that are required prior to prescribing. The DNS and/or Designee will also in-service SSD and RCM’s on the importance of confirming a diagnosis when a psychotropic mediation is prescribed by a provider. In-Services will occur no later than June 27, 2023. SSD will conduct an audit for the last 30-days to ensure any new psychotropic mediations have a diagnosis attached and documentation for use. On going, we will continue to review psychotropics quarterly with the MDS assessment and take the findings to the psychotropic review committee. SSD will provide an update on the audit to QAPI no less often than quarterly.

Based on observation, interview and record review it was determined the facility failed to assess the root cause, notify the physician, obtain a treatment order, update the care plan, routinely monitor and implement a plan of care for a facility acquired pressure ulcer for 1 of 1 sampled resident (#10) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers. Findings include: Resident 10 was admitted to the facility in 12/2022 with diagnoses including dementia and leg fracture. Resident 10's 3/14/23 Quarterly MDS and 3/27/23 Significant Change MDS indicated the resident had an unhealed Stage II (open wound) pressure ulcer and required pressure ulcer care. A 3/5/23 Wound Management Detail Report, completed by Staff 24 (former LPN), indicated the resident had an area of necrotic (dead) tissue which measured 3 cm in length and 3.5 cm in width on her/his left heel. The Report did not include a root cause analysis to determine how or when the wound developed, whether the provider was notified, if wound treatment was provided or needed or if the care plan was updated. A 3/8/23 Provider Care Visit Note revealed the following: - "[Patient] is noted to have developed a new pressure ulcer of [her/his] heel." The note did not indicate whether the provider assessed the wound or if treatment for wound care was ordered and initiated. A 3/10/23 Wound Management Detail Report, completed by Staff 10, indicated the following: - "scab on heel measuring 2 x 2.7 cm. Scab intact with no [signs and symptoms] of infection. No [complaint of] pain. Cleaned area and using foam boots to keep pressure off heels." The Report did not include whether the provider was notified, if the treatment was approved by the provider or if the care plan was updated. A 3/17/23 Wound Management Detail Report, completed by Staff 10, indicated the following: - "wound on heel stable, area of eschar (dead tissue) with no [signs and symptoms] of infection. No drainage or redness. Using "podus boot" to keep pressure [off] heels. 1.5 cm in length and 2 cm in width." The Report did not indicate whether the provider was notified, if the treatment was approved by the provider or if the care plan was updated to include the use of the boots. A 3/24/23 Wound Management Detail Report, completed by Staff 25 (former LPN), indicated the following: - necrotic tissue, 1.5 cm in length and 2 cm in width. The Report did not include whether the provider was notified, if the treatment was approved by the provider or if the care plan was updated to include the necrotic tissue. A 4/7/23 Wound Management Detail Report, completed by Staff 10, indicated the following: - "wound is stable. Resident using "posey boots" to offload pressure." 1 cm in length and 1.5 cm in width. The Report did not indicate the provider was notified or if the care plan was updated. A 4/14/23 Wound Management Detail Report, completed by Staff 10, indicated the following: - "wound on heel stable. Cleaned area measured at 1 cm x 1.5 cm. No complaints from the resident. Added moisturizer to legs and feet. Resident continues to wear 'podus boots.'" The Report did not include whether the provider was notified, if the treatment was approved by the provider or if the care plan was updated to include the use of the boots. Review of Resident 10's health record revealed no Wound Management Detail Report and no other type of comprehensive assessment of the heel wound was completed after 4/14/23. Resident 10's Care Plan, last reviewed 3/30/23, indicated the resident had a Stage II pressure ulcer on her/his coccyx (tail bone area). The interventions included the following: - Braden scale (risk for pressure ulcer assessment) upon admission, quarterly, annually and PRN; - See nutrition plan of care; - See urinary care plan; - 1/2 side rails to head of bed to enhance independence with bed mobility; - PT/OT/ST per current order; - See ADL care plan. The Care Plan lacked resident-centered interventions related to wound care and prevention and did not include information regarding a heel wound/pressure ulcer. Resident 10's undated in-room care plan did not contain any information related to the Stage II pressure ulcer on the coccyx, wounds or pressure ulcers on her/his heels and did not include the use of the foam boots. Observations of Resident 10 from 5/1/23 through 5/8/23 between the hours of 5:00 AM and 4:15 PM revealed the resident in her/his room and in bed with foam boots donned on both feet. When asked if she/he had wounds, Resident 10 replied she/he did not know. On 5/2/23 at 2:04 PM Staff 10 (LPN) stated she believed Resident 10 had a pressure ulcer on one of her/his heels. Staff 10 stated she was unsure how or when the wound started and believed the wound was "stable." Staff 10 stated she used the care plan in Resident 10's closet to find information related to the resident's care needs. On 5/2/23 at 2:20 PM Staff 11 (CNA) stated she thought Resident 10 might have a wound on her/his heels and one on her/his "bottom" and stated the resident was supposed to wear foam boots on both feet. Staff 11 stated she referred to the care plan in Resident 10's closet to find information related to the resident's care needs. On 5/3/23 at 10:22 AM and 12:54 PM Staff 9 (LPN) and Staff 13 (CNA) stated Resident 10 did not have pressure ulcers or wounds. On 5/3/23 1:14 PM Staff 4 (RNCM) stated when a new wound or pressure ulcer was identified, the process included a comprehensive assessment of the wound, the resident was placed on alert charting, the provider was notified, a treatment plan obtained, the care plan updated, and the wound was assessed and measured weekly. When asked if Resident 10 had pressure ulcers or wounds, Staff 4 stated she believed Resident 10 had a pressure ulcer on her/his heel. Staff 4 reviewed Resident 10's health record and acknowledged Resident 10 had a heel wound identified on 3/5/23. Staff 4 acknowledged there were no wound assessments and measurements completed after 4/14/23 and no documentation to indicate if the wound was worsened or healed. She confirmed there was no treatment plan implemented, the care plan was not updated to reflect Resident 10's wounds and the care plan lacked wound specific interventions. On 5/3/23 at 1:29 PM Staff 2 (DNS) stated Resident 10 had a pressure ulcer on her/his left heel which was identified on 3/5/23. Staff 2 stated when Resident 10's heel wound was identified on 3/5/23, the nurse failed to stage the pressure ulcer appropriately, notify the provider and obtain a treatment order, write a progress note about the wound, create a skin event, update the care plan and notify the family.

Resident 10 is no longer at the facility. An audit will be conducted no later than June 27, 2023, for anyone identified as having a pressure injury. Individuals identified as having a pressure injury will have their care plan reviewed to make sure interventions are in place. The DNS will provide an in-service to nursing staff on conducting root cause analysis to determine how or when wounds develop, notifying provider, and updating the care plan. Newly identified pressure injuries will be discussed during the facility’s weekly incident and accident meeting to ensure appropriate documentation and notification is completed along with any updates to the care plan. The results of the weekly I/A meetings will be reviewed with QAPI no less often than quarterly.

Based on observation, interview and record review it was determined the facility failed to ensure residents did not experience an injury during a transfer for 2 of 4 sampled residents (#s 14 and 160) reviewed for accidents. This failure resulted in major injury and hospitalization. Findings include: 1. Resident 14 was admitted to the facility in 4/2015 with diagnoses including Alzheimer's disease. Resident 14's 4/11/17 Care Plan indicated the resident required a mechanical lift transfer with two staff. Resident 14's 11/23/20 Quarterly MDS indicated the resident was severely cognitively impaired, her/his arms were impaired and she/he was totally dependent on two people for transfers. A 12/21/20 Progress Note written by Staff 26 (Former Staff RN) revealed at 6:25 AM, Resident 14 fell from the mechanical lift sling while being transferred from her/his bed to the wheelchair. Resident 14 fell backwards and head first to the ground. Staff 26 assessed Resident 14 and noted the back of the resident's head had a 8 cm x 7 cm hematoma (mass of blood and bruising), a 4 cm x 0.8 cm laceration (open area) and was bleeding from the back of her/his head. Staff 26 applied pressure and observed the resident wince and frown in pain. Staff 26 cleansed Resident 14's head laceration, applied steri-strips and the wound continued to bleed and swell. Staff 26 received a physician order to send the resident to the emergency room for treatment and Resident 14 was sent out. A 12/21/20 Event Report, written by Staff 26, indicated Staff 14 (CNA) and Staff 27 (Former CNA) attempted to transfer Resident 14 from her/his bed to the wheelchair. During the transfer with the mechanical lift, the left sling loop detached from the lift hook, which caused the resident to fall head first to the floor. It was determined Staff 14 and Staff 27 followed the resident's care plan and the lift was used appropriately. The 12/21/20 Emergency Department Notes indicated the resident sustained a contusion (injury resulting in tissue damage and bleeding) and a 2.5 cm scalp laceration to the back of her/his head which required sutures. On 5/2/23 at 10:36 AM Witness 1 (Complainant) stated he was concerned about Resident 14 being "dropped" from the mechanical lift in 2020 and was concerned it was not the only time this type of event occurred. On 5/2/23 at 12:54 PM Staff 12 and Staff 14 were observed to appropriately transfer Resident 14 from her/his wheelchair to the bed with the mechanical lift. After Staff 12 and Staff 14 completed Resident 14's transfer, Staff 14 was asked if Resident 14 had a fall from the mechanical lift. Staff 14 stated "awhile ago," she and another CNA attempted to transfer Resident 14 using a mechanical lift when the sling hook "just slid out of the hook" causing the resident to fall to the floor. Staff 14 stated the resident's head hit the floor, it was awful and there was blood everywhere. She stated the fall incident occurred a long time ago and she could not recall the name of the other CNA or nurse who helped. Staff 14 stated the incident was the "weirdest thing" and had not happened again since 2020. Staff 14 stated mechanical lift transfers required two staff at all times. Review of Resident 14's health record and event history revealed no other incidents when the resident fell from the mechanical lift. On 5/4/23 at 12:20 PM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged Resident 14 fell from the mechanical lift, sustained a contusion and scalp laceration, was sent to the emergency department due to continued bleeding and swelling and required sutures. No additional information was provided. , 2. Resident 160 was admitted to the facility in 9/2021 with diagnoses including malignant neoplasm (cancer) of the long bones lower in the left limb. Resident 160's 9/11/21 Admission MDS indicated a BIMS score of 15 (cognitively intact) and she/he required a two-person extensive assist with transfers. Resident 160's 9/2021 Care Plan directed staff to provide her/him with a two person assist for transfers. A 9/11/21 Progress Note by Staff 3 (RNCM) indicated a CNA notified her Resident 160 experienced increased hip pain after a transfer from her/his wheelchair to the bed. During the assessment Resident 160 reported "12/10" pain level (1/10 scale with 10 the highest pain) and stated, "hip just doesn't feel right." When Staff 3 asked what happened, Resident 160 stated she/he stood from the wheelchair and when she/he sat down to the low positioned bed, it caused the hip to go out. Resident 160 was sent to the emergency room. A 9/11/21 Progress Note revealed Resident 160's family stated she/he needed another surgery due to her/his hip dislocation. A 9/13/21 Progress Note indicated Resident 160 was treated for a dislocated hip per hospital communication with the facility. An undated root cause analysis by Staff 29 (Former Administrator) concluded Resident 160's in-room care plan instructed staff to use two people when transferring her/him. One CNA completed the transfer on 9/11/21 when the hip was dislocated. The CNA told Staff 29 Resident 160 was insistent to get back to bed. The CNA did not follow the care plan and one person assist was used to transfer Resident 160 into her/his bed. During an interview on 5/4/23 at 12:26 PM Witness 7 (Complainant) stated Resident 160 told her that on 9/11/21 two staff came into the room but one left. The one staff who stayed attempted to get her/him into bed on her own and did not use a gait belt and the bed was in a low position. Resident 160 told her she/he was dropped during the transfer which caused the hip to dislocate. Resident 160 was sent to the hospital after the incident and required surgery due a severely dislocated hip and fracture. She observed Resident 160 in extreme pain before and after the surgery. On 5/4/23 at 1:28 PM Staff 2 (DNS) acknowledged Resident 160's progress notes and the incident. Staff 2 stated she expected the care plan to be followed by staff when care was provided. On 5/5/23 at 10:10 AM Staff 1 (Administrator) acknowledged the incident and the root cause analysis from the former administrator. Staff 1 expected staff to follow the care plan. No additional information was provided. , Based on observation, interview and record review it was determined the facility failed to ensure adequate supervision to prevent resident-to-resident altercations for 1 of 4 sampled residents (#51) reviewed for accidents. This placed residents at risk for resident-to-resident altercations, injury and abuse. Findings include: Resident 51 was admitted to the facility in 3/2023 with diagnoses including dementia with agitation. A review of Resident 51's Progress Notes from 3/17/23 through 4/28/23 revealed the following: -The resident was confused and wandered all over the unit and into other resident rooms. -The resident experienced agitation and was physically aggressive towards staff. -The resident yelled at other residents. -The resident was difficult to redirect and required the administration of an antipsychotic medication by mouth and intramuscularly to deescalate her/his behaviors. Two incidents occurred on 4/29/23 in which Resident 51 was involved. First, Resident 51 squeezed Resident 161's left wrist and hit her/his hand on a bedside table. Second, Resident 51 dug her/his nails into Resident 23's skin and twisted the skin. On 5/1/23 at 1:53 PM Resident 51 was observed in Resident 23's room without staff present. Resident 23 and her/his roommate yelled at Resident 51 to leave and Resident 23's roommate attempted to push Resident 51's wheelchair back out of the room. Staff 7 (RN) intervened and removed Resident 51 from the room. The 5/2/23 Occurrence Investigation Final Summary Reports for the incidents that occurred on 4/29/23 between Resident 51 and Resident 161 and Resident 51 and Resident 23 indicated both of the altercations were isolated events. The Report indicated staff were to keep Resident 51 separated from Resident 23 and Resident 161. On 5/4/23 at 10:30 AM Staff 19 (Human Resources Director) stated staffing levels were determined by the facility census and resident acuity. Staff 19 stated she was a part of the daily management team meeting during which resident needs were discussed. On 5/4/23 at 11:02 AM Staff 6 (Agency CNA) stated Resident 51 was confused, aggravated and wandering on 4/29/23. Staff 6 stated she was instructed by the nurse to "keep an eye on Resident 51" as best as she could but stated that was impossible as she was responsible for the care of nine residents on 4/29/23, including Resident 51. Staff 6 stated the facility was not adequately staffed to provide sufficient supervision of Resident 51. On 5/5/23 at 9:28 AM Staff 5 (RN) stated two CNAs were assigned to the second floor on 4/29/23 at the time of the two resident-to-resident altercations that involved Resident 51. Staff 5 stated Staff 6 (Agency CNA) was responsible for the care of nine residents at the time, including Resident 51. Staff 5 stated the daily CNA staffing sheets were pre-assigned. Staff 5 stated she requested additional CNA support prior to 4/29/23 on the second floor but did not receive it as the census was low. Staff 5 stated she requested additional CNA support after the altercations but did not recall having more than two CNAs assigned to the second floor. Staff 5 stated she did not feel staff were able to adequately supervise Resident 51. Staff 5 further stated Resident 51 received an injection of Haldol (antipsychotic medication prescribed for agitation) in the early morning of 5/5/23 as she/he was agitated and physically aggressive. On 5/5/23 at 10:14 AM Staff 19 (Human Resources Director) and Staff 20 (CNA/Staffing) stated they worked closely together with regards to the facility's staffing needs and were responsible for filling out the staffing sheets for both floors of the facility. Staff 19 stated they made CNA assignments according to the census and resident behaviors. Staff 20 stated she assigned staff to provide Resident 51 with one-to-one supervision when increased behaviors were reported and staff were available. Staff 20 stated she was not aware of any recent behaviors of Resident 51 or of any resident-to-resident altercations involving Resident 51. Staff 20 stated she thought Resident 51 "had been doing way better" and if she had been made aware of her/his behaviors, she would have assigned the "float CNA" to the second floor instead of the first floor where the float was consistently assigned. Staff 20 stated she was not aware Resident 51 received any PRN medication during the nightshift as a result of behaviors. On 5/5/23 at 10:01 AM Staff 15 (CNA/CMA) stated he was currently responsible for the care of nine residents on his shift, including Resident 51. Staff 15 stated he did not feel he was able to provide sufficient supervision of Resident 51, and when he entered other resident rooms to assist with care, he "hoped and prayed everything went well" with regards to Resident 51. Staff 15 stated he found Resident 51 in other resident rooms on a daily basis and was only sometimes able to find another staff to supervise Resident 51 when he went into other resident rooms or on break. On 5/5/23 Staff 1 (Administrator) stated Staff 19 participated in the daily morning meetings during which staffing and residents were discussed. Staff 1 stated providing additional staff to supervise Resident 51 was dependent upon her/his behaviors. Staff 1 stated she was surprised Staff 19 was not aware of Resident 51's behaviors on account of her participation in the daily meetings and did not have any additional information to provide.

Resident 14 remains in the facility with no further falls out of the Hoyer lift. Resident 160 is no longer in the facility. Resident 51’s medication and care plan have been reviewed and his/her behaviors have decreased with wandering and agitation. The following will occur no later than June 27, 2023: Nursing staff will be in-serviced on proper transferring protocol including mechanical lifts. All Staff will be in-serviced on identifying residents with behaviors who have the potential to pose a risk to others. In-servicing will also include ways to prevent/ de-escalate residents with behaviors and knowing when to intervene. SSD and RCM’s will be in-serviced on facilities wandering policy. No later than June 27, 2023, all slings and Hoyer lifts will be audited by RA and/or designee to ensure that they are in proper working condition. No later than June 27, 2023, all residents with a wander guard will be reviewed to make sure orders are up to date. The facility has a policy and procedure in place to check Hoyer slings prior to circulation and throughout the year. This system appears to be working as there have been no other falls from a Hoyer lift reported. Incidents and accidents are reviewed weekly and in the event of an injury related to transfers, including mechanical lifts, it will be reviewed with QAPI no less often than quarterly. Residents identified as having a resident-to-resident altercation will be reviewed within 5 days and taken to IDT team for review and reported to QAPI no less often than quarterly.

Based on interview and record review it was determined the facility failed to identify and comprehensively assess weight loss and ensure weights were monitored for 2 of 3 sampled residents (#s 42 and 51) reviewed for nutrition. This placed residents at risk for unidentified weight changes. Findings include: The facility's Weight Assessment and Intervention Policy and Procedure, revised 3/2022, instructed the following: -Residents were weighed upon admission and at established intervals; -Weights were recorded in each individual's medical record and on the unit weight record; -Any weight change of five percent or more since last weight assessment was retaken the next day for confirmation. 1. Resident 51 was admitted to the facility in 3/2023 with diagnoses including dementia with agitation and lung cancer. Resident 51's Admission MDS indicated she/he was severely cognitively impaired. Resident 51's 3/15/23 Initial Nutritional Assessment completed by Staff 16 (RD) revealed the resident's oral intake was very good at each meal and she/he met her/his nutritional needs. The Assessment also identified the resident as being a low nutritional risk. A review of Resident 51's weights since admission revealed the following: -3/7/23: 234 pounds; -3/8/23: 235.4 pounds; -3/9/23: 233.4 pounds; -3/16/23: 233.6 pounds; -3/23/23: weight not taken; -3/30/23: weight not taken and -4/18/23: 216.7 pounds (a 7.23% loss from 3/16/23 which is considered severe). No evidence was found in the resident's record to indicate the severe weight loss was identified or any action was taken. On 5/3/23 at 11:02 AM Staff 17 (CNA) stated when weights were entered into the resident's electronic health record, the system automatically identified and flagged if a resident had lost or gained three pounds. Staff 17 stated CNAs were responsible for notifying the nurse of these weight changes. On 5/3/23 at 11:50 AM Staff 16 (RD) stated she completed nutritional assessments for residents at the time of admission and with any weight loss. Staff 16 stated she was not aware of Resident 51's weight loss until 5/3/23. On 5/3/23 at 11:55 AM Staff 2 (DNS) confirmed the facility did not identify or take action regarding Resident 51's severe weight loss in a timely manner. On 5/4/23 at 12:13 PM Staff 3 (RNCM) stated Resident 51's provider was not made aware of the resident's severe weight loss until 5/4/23. , 2. Resident 42 was admitted to the facility in 12/2022 with diagnoses including renal failure. Resident 42's 4/19/23 Quarterly MDS indicated a BIMS score of 15 (cognitively intact). A review of Resident 42's weights since admission revealed the following: - 12/5/22 at 152.4 pounds - 12/15/22 at 161 pounds - 1/20/23 at 157.2 pounds - 1/24/23 at 150.2 pounds - 1/31/23 at 151.2 pounds - 2/7/23 at 116.2 pounds - 2/10/23 at 158.6 pounds - 3/7/23 at 157.8 pounds - 3/10/23 at 154.8 pounds No evidence was found in the resident's record to indicate the severe weight loss or gain was identified or any action was taken. On 5/3/23 at 11:55 AM Staff 17 (CNA) stated that when weights were entered into the resident's electronic health record, the system automatically identified and flagged if a resident had lost or gained three pounds. Staff 17 stated CNAs were responsible for notifying the nurse of these weight changes. On 5/3/23 at 11:55 AM Staff 2 (DNS) confirmed the CNAs were flagged by the computer with abnormal weight entries and she expected the CNAs to report to the charge nurse who would then put the resident on a list to be reweighed the following day. On 5/4/23 at 12:13 PM Staff 3 (RNCM) confirmed Resident 42 had weights identified as out of range. She stated Resident 42 should have been reweighed the day after out of range weights were obtained to confirm the weight gains and losses were accurate.

RD will review Resident 51 and 42’s weight no later than June 27, 2023, to ensure appropriate interventions are in place to avoid unnecessary weight gain/loss. Medical Records and/or designee will run an audit no later than June 27, 2023, of all resident weights to ensure that there are no other residents identified as needing a re-weight and/or RD intervention. Nursing staff will be in-serviced no later than June 27, 2023, on the facilities policy and procedures for gathering weights. For the next 3 months Medical Records and/or designee will pull a weight report weekly for the RCM’s/DNS to ensure weights are logged and tracked appropriately. The results of the audit will be discussed with QAPI no less often than quarterly.

Based on observation, interview and record review it was determined the facility failed to ensure residents were assessed appropriately before administration of an anti-psychotic medication for 1 of 5 sampled residents (# 10) reviewed for unnecessary medications. This placed residents at risk for unnecessary medication adverse side effects. Findings include: The facility's 7/2022 Psychotropic Medication Use Policy & Procedure specified the following: - Residents who have not used psychotropic medications are not prescribed or given these medications unless the medication is determined to be necessary to treat a specific condition that is diagnosed and documented in the medical record; - Consideration of the use of any psychotropic medication is based on comprehensive review of the resident. This includes evaluation of the resident's signs and symptoms in order to identify underlying causes; - Non-pharmacological approaches are used to minimize the need for medications; - When determining whether to initiate, modify or discontinue medication therapy, the [interdisciplinary team] conducts an evaluation of the resident to clarify other causes for symptoms have been ruled out and signs and symptoms are clinically significant enough to warrant medication therapy. Resident 10 was admitted to the facility in 12/2022 with diagnoses including dementia and leg fracture. Resident 10's 3/14/23 Quarterly MDS and 3/27/23 Significant Change MDS indicated she/he had severe cognitive impairment, did not have hallucinations or delusions and no physical, verbal or other behaviors. The MDS indicated the resident received an antipsychotic medication on a routine basis and did not have an active psychiatric or mood disorder. A 3/8/23 Provider Care Visit Note, written by Staff 8 (ARNP: Advanced Registered Nurse Practitioner) revealed no documentation the resident experienced hallucinations, delusions, behaviors, distress or agitation. Review of Resident 10's 12/2022, 1/2023, 2/2023 and up to 3/11/23 health records revealed no documentation the resident experienced hallucinations, delusions, behaviors, distress or agitation. A 3/11/23 facsimile (fax) to the facility from Staff 8 revealed a new order for Seroquel (an antipsychotic medication) 12.5 mg by mouth every 12 hours. The fax did not include a diagnosis or indication for the use for the Seroquel. Review of Resident 10's 3/2023, 4/2023 and 5/2023 MARs revealed the resident received Seroquel 12.5 mg every 12 hours, every day beginning 3/11/23. Observations of Resident 10 from 5/1/23 through 5/8/23 between the hours of 5:00 AM and 4:15 PM revealed the resident in her/his room and in bed. Resident 10 asked if it was day or night, was not agitated and she/he engaged in simple conversation when she/he was awake. On 5/2/23 at 2:20 PM and 5/5/23 at 8:38 AM Staff 11 (CNA) and Staff 12 (CNA) stated the resident was "sweet," confused at times and talked to the wall and people who weren't in the room sometimes. Staff 11 and Staff 12 stated the resident was not agitated, upset or distressed during times of her/his occasional confusion. On 5/5/23 at 8:44 AM Staff 4 (RNCM) stated Resident 10 was confused at times, tried to stand up once, was mostly "peaceful and quiet," and did not have unusual behaviors, agitation or distress. Staff 4 stated she could not recall why the Seroquel was prescribed. Staff 4 reviewed Resident 10's health record and was unable to find documentation she/he experienced behaviors, agitation or distress and was unable to find a clinical rationale for the Seroquel. Staff 4 acknowledged Seroquel was an antipsychotic and agreed the medication required an appropriate diagnosis and adequate evidence in the resident's health record that behaviors, agitation and distress occurred, documentation of non-pharmacological interventions attempted to alleviate the resident's condition and what other underlying causes for the behaviors were ruled out. On 5/8/23 at 12:35 PM Staff 8 stated she was Resident 10's provider. Staff 8 confirmed she prescribed the Seroquel on 3/11/23 after Resident 10's daughter told her the resident was confused. On 5/8/23 at 11:48 AM and 1:07 PM Staff 1 (Administrator) was informed Resident 10 received an antipsychotic medication every 12 hours twice daily since 3/11/23 without evidence of clinical rationale documented in her/his health record. Staff 1 stated prior to a provider prescribing an antipsychotic to a resident, she expected the resident's health record to include documentation of an assessment, behaviors tracked and monitored, care planned interventions, evidence non-pharmacological interventions were attempted and evidence other factors, such as infections, were ruled out.

Resident 10 is no longer at the facility. The DNS’s and/or designee will provide education to the providers on prescribing psychotropics and the documentation and assessments that are required prior to prescribing. The DNS and/or Designee will also in-service SSD and RCM’s on the importance of confirming a diagnosis when a psychotropic mediation is prescribed by a provider. In-Services will occur no later than June 27, 2023. SSD will conduct an audit for the last 30-days to ensure any new psychotropic mediations have a diagnosis attached and documentation for use. On going, we will continue to review psychotropics quarterly with the MDS assessment and take the findings to the psychotropic committee. SSD will provide an update on the audit to QAPI no less often than quarterly.

Based on observation, interview and record review it was determined the facility failed to provide routine dental services for 1 of 1 sampled resident (#6) reviewed for dental needs. This placed residents at risk of unmet dental needs. Findings include: Resident 6 was admitted to the facility in 6/2020 with diagnoses including stroke. A review of Resident 6's 4/17/23 Annual MDS revealed she/he was cognitively intact. On 5/2/23 at 9:45 AM Resident 6 was observed to have several missing upper front teeth. Many of her/his remaining native teeth appeared decayed, broken and grey. Resident 6 stated she/he was independent when completing oral care and had a history of multiple extractions. A review of Resident 6's progress notes revealed she/he was assessed by a dentist on 11/29/21. The dentist recommended extracting the resident's remaining teeth and fitting her/him for dentures. Resident 6 declined this treatment due to her/his preference for implants. The dentist recommended the resident return for further treatment. No additional notes were found in Resident 6's electronic health record to indicate she/he was assessed by a dentist after 11/29/21 or that the facility attempted to arrange additional appointments. On 5/2/23 at 2:26 PM Staff 3 (RNCM) confirmed Resident 6 did not have a follow-up appointment with a dentist after 11/29/21. She stated it was "a long time ago" and "we should be checking in with [her/him] more regularly about it."

Resident 6 has a dental appointment scheduled for November 16, 2023. This was the earliest appointment available; resident 6 is on a waiting list for an earlier appointment is possible. Medical Records and/or Designee will audit resident records for the last year to identify if any other residents are missing dental follow-up appointments. Medical Records and/or designee will pull a weekly report for appointments to ensure outside provider visit are received and uploaded to the resident’s medical record. Medical Records will be responsible for communicating with the IDT any follow-up appointments that need scheduled. In the event appointments are identified as having missing follow-up documentation, Medical Records and/or designee will follow up with the provider for additional information. The results of the weekly report will be reviewed with IDT and taken to QAPI no less often than quarterly.

Based on interview and record review it was determined the facility failed to ensure state minimum CNA staffing ratios were maintained for 68 of 152 sampled days reviewed for staffing. This placed residents at risk for delayed treatment and unmet care needs. Findings include: A review of the facility Direct Care Staff Reports from 7/1/22 through 9/30/22 and 4/1/23 through 4/30/23 revealed the facility had insufficient CNA staff for one or more shifts on the following dates: -7/1/2022: noc (night) shift -7/2/2022: day shift; noc shift -7/3/2022: day shift; evening shift -7/5/2022: evening shift; noc shift -7/6/2022: evening shift; noc shift -7/7/2022: day shift; noc shift -7/8/2022: day shift; noc shift -7/9/2022: day shift; evening shift; noc shift -7/10/2022: noc shift -7/11/2022: day shift; evening shift; noc shift -7/12/2022: day shift; evening shift; noc shift -7/13/2022: day shift; noc shift -7/17/2022: day shift; noc shift -7/18/2022: day shift; noc shift -7/21/2022: noc shift -7/24/2022:day shift; noc shift -7/26/2022: day shift -7/27/2022: day shift -7/29/2022: noc shift -7/30/2022: day shift; evening shift; noc shift -7/31/2022: day shift -8/3/2022: evening shift -8/7/2022: day shift -8/9/2022: evening shift -8/11/2022: day shift; evening shift -8/12/2022: evening shift -8/14/2022: evening shift -8/15/2022: evening shift -8/16/2022: noc shift -8/17/2022: noc shift -8/21/2022: day shift; evening shift -8/22-2022: day shift; evening shift; noc shift -8/23/2022: noc shift -8/26/2022: day shift; evening shift; noc shift -8/27/2022: noc shift -8/28/2022: day shift; evening shift -8/30/2022: day shift; evening shift -9/2/2022: day shift; evening shift; noc shift -9/3/2022: day shift; evening shift; noc shift -9/4/2022: day shift; noc shift -9/5/2022: day shift; evening shift; noc shift -9/6/2022: day shift; evening shift; noc shift -9/7/2022: day shift -9/8/2022: day shift -9/9/2022: day shift -9/10/2022: day shift; noc shift -9/11/2022: evening shift; noc shift -9/14/2022: day shift -9/16/2022: day shift; noc shift -9/17/2022: day shift; noc shift -9/18/2022: day shift -9/19/2022: evening shift; noc shift -9/20/2022: day shift; noc shift -9/21/2022: evening shift -9/23/2022: day shift; evening shift; noc shift -9/24/2022: day shift; evening shift; noc shift -9/25/2022: day shift; evening shift; noc shift -9/26/2022: day shift; evening shift; noc shift -9/27/2022: evening shift; noc shift -9/28/2022: evening shift; noc shift -9/30/2022: day shift; noc shift -4/1/2023: day shift -4/3/2023: day shift -4/5/2023: day shift -4/6/2023: day shift -4/7/2023: day shift -4/15/2023: day shift -4/17/2023: day shift On 5/4/23 at 4:09 PM Staff 2 (DNS) acknowledged the CNA to resident ratios "have been low" in comparison to expected standards.

HR, DNS, and the Administrator are all working together to ensure ODHS minimum staffing ratios are met. Open shifts are being sent to all staff employed by the facility and staffing agencies. All avenues for filling shifts are being explored and utilized. The facility currently has a NA program running and we plan to start another class in July 2023. We are trying to retain all the students we send through the course. Ads for current C.N.A openings are posted and routinely updated/reviewed on our facility website, indeed, Facebook, and other marketing websites. Routine wage studies are being conducted and rates were just updated April 1, 2023. HR, DNS, and Administrator are meeting weekly to discuss the staffing needs in the facility and to ensure all avenues for filling open positions are exhausted. We have identified two staff members who rotate a staffing cell phone on the weekends. A reminder will be sent no later than June 27, 2023, to all staff employed at Columbia Basin on the importance of showing up when scheduled and if needing to call-out the appropriate timelines for doing so per the employee handbook. HR and/or designee will continue to be responsible for reviewing staffing needs at QAPI no less often than quarterly.

*************************** OAR 411-085-0310 Residents' Rights: Generally Refer to F600 *************************** OAR 411-086-0060 - Comprehensive Assessment and Care Plan Refer to F636, F656 and F657 *************************** OAR 411-086-0300 Clinical Records Refer to F641 *************************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F658 *************************** OAR 411-086-0140 - Nursing Services: Problem Resolution and Preventive Care Refer to F686, F689, F692 and F758 *************************** OAR 411-086-0210 Dental Services Refer to F791 ***************************

Based on interview and record review it was determined the facility failed to ensure bathing was provided for 4 of 4 sampled residents (#s 1, 5, 14, and 18) reviewed for sufficient staffing. This placed residents at risk for poor hygiene. Findings include: 1. Resident 1 admitted to the facility on 2/2020 with diagnoses including hypertension. Record review of the Point of Care History bathing records from 10/2022 revealed Resident 1 was not offered or provided bathing from 10/15/22 to 10/26/22, 11 days. On 11/3/22 at 1:01 PM Staff 8 (CNA) stated CNAs did not have time to shower or bathe residents due to the lack of staff. On 11/4/22 at 10:28 AM Staff 2 (DNS) stated it was standard practice to offer residents a shower two times a week and as needed or requested. Staff 2 acknowledged many residents did not get bathed as care planned due to lack of staff. 2. Resident 5 admitted to the facility on 8/2022 with diagnoses including a fracture to lower leg. Record review of the untitled form identified showers missed with one column of showers not completed in greater than seven days and another column of refusals. Resident 5 was listed on 11/2/22 with 26 days since last shower. No refusals were documented. On 11/3/22 at 1:01 PM Staff 8 (CNA) stated CNAs did not have time to shower or bathe residents due to the lack of staff. On 11/4/22 at 10:28 AM Staff 2 (DNS) stated it was standard practice to offer residents a shower two times a week and as needed or requested. Staff 2 acknowledged many residents did not get bathed as care planned due to lack of staff. 3. Resident 14 admitted to the facility on 1/2016 with diagnoses including stroke. Record review of the untitled form identified showers missed with one column of showers not done in greater than seven days and another column of refusals. Resident 14 was listed on 11/1/22 with 14 days since last shower. No refusals were documented. On 11/3/22 at 1:01 PM Staff 8 (CNA) stated CNAs did not have time to shower or bathe residents due to the lack of staff. On 11/4/22 at 10:28 AM Staff 2 (DNS) stated it was standard practice to offer residents a shower two times a week and as needed or requested. Staff 2 acknowledged many residents did not get bathed as care planned due to lack of staff. 4. Resident 18 admitted to the facility in 10/2017 with diagnoses including dementia. Record review of the untitled form identified showers missed with one column of showers not done in greater than seven days and another column of refusals. Resident 18 was listed on 11/2/22 with 17 days since last shower. No refusals were documented. On 11/3/22 at 1:01 PM Staff 8 (CNA) stated CNAs did not have time to shower or bathe residents due to the lack of staff. On 11/4/22 at 10:28 AM Staff 2 (DNS) stated it was standard practice to offer residents a shower two times a week and as needed or requested. Staff 2 acknowledged many residents did not get bathed as care planned due to lack of staff.

Resident 1 discharged from the facility on 10/27/2022. RCM(s) will speak with Resident 5, 14 and 18 to offer a shower/bath and confirm shower/bathing preferences no later than December 2, 2022. An audit for showers will be pulled no later than December 24, 2022 for all residents to identify any missed documentation and/or refusals. Based off the audit, showers will be offered to residents who have been identified as having no documentation and/or recent refusals. C.N. A’s will be in-serviced no later than December 24, 2022, on the importance of grooming and personal hygiene services. The in-service will also include the importance of documenting showers and/or refusals. Medical Records and/or designee will continue to be responsible for pulling a weekly shower audit report and giving it to the DNS and RCMs for review/follow-up to ensure compliance is achieved. The results of the weekly audit will be discussed at QAPI.

Based on interview and record review it was determined the facility failed to ensure state minimum staffing ratios were maintained for 57 of 77 days (124 of 231 shifts) reviewed for staffing. This placed residents at risk for delayed treatment and unmet care needs. Findings include: A review of the Direct Care Staff Daily Reports from 7/1/22 through 8/15/22 revealed the following days and shifts when state minimum staffing ratios were not met: 7/1/22 - night shift. 7/2/22 - day, evening, and night shifts. 7/3/22 - day, evening, and night shifts. 7/5/22 - day, evening, and night shifts. 7/6/22 - day, evening, and night shifts. 7/7/22 - day shift. 7/8/22 - day and night shifts. 7/9/22 - day, evening, and night shifts. 7/10/22 - night shift. 7/11/22 - day, evening, and night shifts. 7/12/22 - day, evening, and night shifts. 7/13/22 - day and night shifts. 7/17/22 - day, evening, and night shifts. 7/18/22 - day, evening, and night shifts. 7/17/22 - day, evening, and night shifts. 7/24/22 - day, evening, and night shifts. 7/26/22 - day, evening, and night shifts. 7/27/22 - day, and night shifts. 7/29/22 - night shift. 7/30/22 - day, evening, and night shifts. 7/31/22 - day, evening, and night shifts. 8/3/22 - evening and night shifts. 8/4/22 - night shift. 8/7/22 - day and night shifts. 8/9/22 - evening shift. 8/11/22 - day shift. 8/12/22 - day and night shifts. 8/14/22 - day, evening, and night shifts. 8/15/22 - day shift. A review of the Direct Care Staff Daily Reports from 10/1/22 through 10/31/22 revealed the following days and shifts when state minimum staffing ratios were not met. 10/1/22 - day and night shifts. 10/2/22 - day shift. 10/3/22 - day, evening, and night shifts. 10/5/22 - day, and evening shifts. 10/6/22 - day shift. 10/9/22 - day and evening shifts. 10/10/22 - day and evening shifts. 10/11/22 - day and evening shifts. 10/12/22 - day and evening shifts. 10/13/22 - day, evening, and night shifts. 10/14/22 - day, evening, and night shifts. 10/15/22 - day, evening, and night shifts. 10/16/22 - day shift. 10/17/22 - day and evening shifts. 10/18/22 - day, evening, and night shifts. 10/19/22 - day, evening, and night shifts. 10/20/22 - day, and evening shifts. 10/21/22 - evening shift. 10/22/22 - day, evening, and night shifts. 10/23/22 - day, evening, and night shifts. 10/24/22 - evening shift. 10/25/22 - evening shift. 10/26/22 - day, evening, and night shifts. 10/27/22 - day, evening, and night shifts. 10/28/22 - day shift. 10/29/22 - day shift. 10/30/22 - day shift. 10/31/22 - day and evening shifts. On 11/4/22 at 10:28 AM Staff 2 (DNS) and Staff 3 (Human Resource Manager) acknowledged the failure to meet state minimum staffing ratios.

Human Resources Director, Director of Nursing, and Administrator are all working together to ensure ODHS Minimum Staffing Ratios are met. Open shifts are being sent to all nursing staff and agency for review. All avenues for filling open shifts are being explored and utilized. Efforts include but are not limited to, offering bonuses, competitive wage, staff appreciation, recognition of hard work at All Staff meetings, etc. The facility just graduated an NA class and has another class going at this time. The facility plans to retain the students as NA’s until they are licensed as C.N.A’s. The facility plans to hold another NA class in January 2023. Ads for open C.N.A positions continue to be posted on the facility website, indeed, Facebook, and other marketing websites. Human Resources Director, Director of Nursing, and Administrator and/or designee will meet Monday-Friday to discuss staffing needs. This meeting will be held in the morning to identify any open shifts for the day/upcoming days that require attention. If new needs are identified in the meeting, certified nursing staff and agency will be notified of the open positions. Nursing staff will be in-serviced no later than December 24, 2022, on the importance of showing up when scheduled and if needing to call-out the appropriate timeline for doing so per employee handbook. The Human Resource Director and/or designee will continue to track call-ins and report findings to DNS and/or designee for follow up. The Human Resource Director and/or designee will provide an update on staffing and open shifts to the QAPI team no less often than quarterly.

***************************** OAR 411-086-0100 Quality of Life; Nursing Services: Resident Care Refer to F677 *****************************

Based on interview and record review it was determined the facility failed to obtain copies of Advance Directives in resident records for 3 of 4 sampled residents (#s 21, 47 and 50) reviewed for Advance Directives. This placed residents at risk for not having their health care decisions honored. Findings include: a. Resident 21 had multiple facility admissions and was last admitted to the facility 9/2021. The Admission Advance Directive form indicated the resident had an Advance Directive. No copy of an Advance Directive was located in the resident's record. On 3/24/22 at 9:02 AM Resident 21 stated she/he did not recall giving the facility a copy of the Advance Directive although the resident did state she/he recalled completing one. b. Resident 47 was admitted to the facility in 2014 with advanced dementia. A facility Advanced Directive Acknowledgement form indicated Resident 47 executed an advanced directive. No copy of an Advance Directive was located in the resident's record. , c. Resident 50 was admitted to the facility in 7/2012 with diagnoses including dementia without behavioral disturbance and major depressive disorder. Resident 50's 2/21/22 Annual MDS indicated the resident was severely cognitively impaired. The 4/16/18 facility Advance Directive Acknowledgement form indicated Resident 50 executed an Advance Directive. There was no copy of Resident 50's Advance Directive found in the resident's clinical record. On 3/24/22 at 12:57 PM, Staff 8 (Social Services) confirmed the facility did not have a copy of Resident 21, 47 or 50's Advance Directive. On 3/25/22 at 12:02 PM, Staff 1 (Administrator) and Staff 2 (DNS) were notified of the findings of the investigation. No other information was provided.

1. On March 25, 2022, Residents 21, 47, and 50 were sent a letter requesting copies of their executed Advanced Directive be brought into the facility. 2. The Social Services Director conducted an audit on 03/25/2022 for in-house residents to identify who else might be affected by F578. Individuals identified as acknowledging they had an Advanced Directive but not providing a copy to the facility were sent a notice requesting documents be provided. The notice stated, “Columbia Basin Care is required to have documentation in each patient’s medical record indicating whether the patient has an advance directive or not. If an advanced directive has been established, please ensure that the facility is provided with a copy of this document. Providing a copy of this document is at your discretion but out goal is to honor the Residents wishes in the event they are not able to voice them.” 3. On March 25, 2022, the facilities care conference notice was updated to include a box reminding residents/POA’s to provide a copy of their Advance Directive. This notice will be reviewed with residents/families during quarterly conferences if documentation has not been obtained. For residents admitting to the facility, Columbia Basin Care has them acknowledge if they have an advance directive executed or not upon admission. For individuals who do not provide a copy of the advance directive at the time of completing paperwork, the Social Services Director and/or designee will send out a reminder via mail, email, and/or phone call requesting documentation be provided. Efforts to try and obtain a copy of one’s Advance Directive will be documented in the patient’s medical record. For individuals who do not provide a copy of the executed document, the facility will send out quarterly reminders requesting documentation. 4. The Social Services Director and/or designee will keep a list of residents who have acknowledged they have an advance directive but have not provided a copy of the document. This list will be evaluated at least quarterly and residents on the list will be provided a notice to bring in documentation during quarterly care conferences. The Social Services Director and/or designee will be responsible for providing updates to QAPI no less often than quarterly on the status of the list. 5. The facility will ensure contact has been made no later than May 14, 2022, with residents and/or representatives who have not provided a copy of their executed Advance Directive. Efforts to try and obtain documentation will be documented in the resident’s medical record.

Based on observation, interview and record review it was determined the facility failed to assess a resident's ability to independently complete oral care for 1 of 1 sampled resident (#17) reviewed for oral care. This placed residents at risk for unmet needs. Findings include: Resident 17 was admitted in 11/2005. Diagnoses included neuromuscular disorder, pain in right shoulder, and gastrostomy (a feeding tube inserted through the abdominal wall). An Annual MDS dated 12/20/21 identified the resident required extensive assistance of one person for personal hygiene which included brushing teeth. There was no CAA completed by nursing staff for the assessment area of ADLs. On 3/22/22 at 11:15 AM Resident 17 was observed to have missing top teeth, debris coating lower teeth, and thick, white particles in her/his mouth that were visible when speaking. The resident confirmed not taking any food or fluids by mouth and later confirmed she/he was not able to brush her/his own teeth. On 3/25/22 at approximately 3:00 PM Staff 4 (Assistant Resident Care Manager-LPN) was asked how she monitored or assessed Resident 17 for oral health. She stated she had not noticed the status of the resident's mouth and confirmed she had not directly observed the resident's mouth or asked the resident or direct care givers about oral care. Refer to F677

1- On 3/28/22 Resident 17’s care plan was updated to have assistance with oral care. A dental appointment is scheduled for 5/24/22. A sonic brush will be ordered no later than 04/18/22 to keep Resident 17 independent with brushing his teeth. 2- No later than 5/14/22 DNS and/or RCM will conduct an audit on all residents that have natural teeth or dentures to make sure oral care needs are care planned appropriately. No later than 5/14/22 Medical Records and/or Designee will audit dental appointments for the last 6 months to identify who needs an upcoming appointment. 3- CNAs will be in-serviced no later than 5/14/22 on oral care data collection and reporting. LPN, RN, RCM will be in-serviced on oral care assessment and care planning no later than 5/14/22. RCM (staff4) did a CAA process training on 3/10/22 and MDS training on 2/9-2/11/22. RCM (staff3) did MDS training on 2/9-2/11/22. The DNS will audit new admits comprehensive dental assessments. RCMs will continue to assess oral care needs with their quarterly interviews and document any changes in the Quarterly Nursing Summary. 4- Review of the audit will be taken to QAPI for review and suggestions no less often than quarterly for up to one year.

Based on interview and record review it was determined the facility failed to update the resident's care plan related to skin integrity for 1 of 2 sampled residents (#10) reviewed for pressure ulcers. This placed residents at risk of unmet needs. Findings include: Resident 10 was admitted to the facility in 2017. The resident had diagnoses including peripheral neuropathy (chronic nerve pain), edema, depression, and weakness. The Comprehensive Care Plan dated 2/17/21, under "Pressure Ulcer" identified Resident 10 at risk for skin damage related to advancing age, incontinence, medication use, needing "staff assistance with some ADLs and independence of ambulation." On 3/11/22 a urinary catheter was ordered and implemented due to urinary retention. The resident remained incontinent of bowel only. Between 3/16/22 and 3/24/22 the resident developed pressure-related skin injuries to her/his bilateral heels, coccyx and left lower extremity. On 3/23/22 Staff 20 (LPN) determined the resident should not be wearing shoes until the areas on the resident's heels were resolved. The Comprehensive Care Plan was updated on 3/17/22 and 3/23/22 related to the identification of a "possible deep tissue injury" to coccyx and bilateral heels. Resident 10's In Room Care Plan intended for direct care staff, included a directive dated 2/28/17 to "make sure to float heels and change position due to current pressure concerns." It did not specify location of the current wounds or the directive not to wear shoes. The In Room Care Plan was not updated to include the use of the catheter. On 3/25/22 at 3:32 PM findings related to the care plans were discussed with Staff 2 (DNS) and Staff 4 (Assistant Resident Care Manager-LPN). Staff 4 expressed understanding of concerns about not having details on the In Room Care Plan. Refer to F686

1- Pressure injuries added to BSCP on 03/28/22 for Resident 10. 2- DNS and/or RCM will conduct an audit no later than 5/14/22 on all residents with pressure injuries and make sure BSCP has current pressure injuries listed. 3- Nurses will be in-serviced on pressure injury care planning at the nurse meeting on 04/12/22. Once a pressure injury is identified it will be care planned with interventions. RCMs will audit BSCP once an Event is created. DNS and/or designee will audit all new admits with pressure injuries to ensure documentation is in place. 4- Review of the audit will be taken to QAPI for review and suggestions no less often than quarterly for up to one year.

Based on observation, interview and record review it was determined the facility failed to ensure a resident received adequate oral care for 1 of 1 sampled resident (#17) reviewed for oral care. This placed residents at increased risk of infection. Findings include: Resident 17 was admitted in 2005 with diagnoses including a neuromuscular disorder, history of antibiotic resistant infections, and pneumonia. The resident was NPO (nothing by mouth) and received nutrition through a gastrostomy tube (tube inserted into the stomach through the abdomen). According to the most recent annual MDS dated 12/20/21 the resident was cognitively intact and required extensive assistance of one person for personal hygiene. There were no identified dental concerns. The 12/20/21 CAA worksheet referenced the "Initial/Annual Nursing Assessment Summary dated 1/7/22. The 1/7/22 Annual Nursing Assessment Summary was blank. The resident's Comprehensive Care Plan for ADLs was last updated 9/15/21 and indicated Resident 17 required extensive assistance for most of her/his ADLs due to generalized weakness and impaired mobility. According to the care plan the resident could brush her/his own teeth but may need help setting up as she/he had an electric toothbrush. On 3/22/22 at 11:15 AM Resident 17 was observed to have missing top teeth, debris coating lower teeth, and thick white particles in her/his mouth that were visible when speaking. The resident confirmed not taking any food or fluids by mouth. On 3/23/22 at 12:26 PM Staff 23 (CNA) stated she had not ever seen the resident brush her/his teeth and did not do it for the resident. On 3/24/22 at 6:54 AM Resident 17 was asked if she/he had an electric toothbrush. The resident stated, "yes, but I don't use it. My hands don't work." The resident gestured to show she/he could not bring hands high enough. The resident further explained she/he doesn't eat, therefore is not putting anything in her/his mouth. A thick white substance was again observed on the resident's lower teeth. On 3/24/22 at 9:21 AM Staff 24 (CNA) stated she was familiar with Resident 17 and stated the resident did her/his own oral care. On 3/25/22 at approximately 3:00 PM Staff 4 (Assistant Resident Care Manager-LPN) was asked how she monitored or assessed Resident 17 for oral health. She stated Resident 17 had last been to the dentist for a cleaning in 2019. She stated she had not noticed the status of the resident's mouth and did not know she/he was not cleaning her/his teeth.

1- Care plan was updated for Resident 17 to have assistance with oral care on 3/28/22. A dental appointment is scheduled for 5/24/22. A sonic brush is going to be ordered no later than 04/18/22 to keep Resident 17 independent with brushing his teeth. 2- DNS and/or RCM will conduct an audit no later than 5/14/22 for all residents who triggered dependent for ADL care on their last MDS to ensure oral care is care planned appropriately. Care plan will be reviewed by RCM to make sure needs with oral care are on BSCP and Comprehensive care plan. 3- CNAs will be in-serviced no later than 05/14/22 on reporting decline in ADL function to a licensed nurse. LPN, RN, RCM will be in-serviced on ADL assessment and care planning a decline or change in ADL function no later than 05/14/22. The DNS will audit new admits comprehensive ADL assessments. RCMs will continue to assess ADL function with their quarterly MDS and document any changes in the Quarterly Nursing Summary. 4- Review of the audit will be taken to QAPI for review and suggestions no less often than quarterly for up to one year.

Based on observation, interview and record review it was determined the facility failed to consistently implement the plan of care related to repositioning, inform direct care staff of new areas of skin breakdown and comprehensively assess and periodically evaluate pressure ulcers for 2 of 2 sampled residents (#s 10 and 25) reviewed for pressure ulcers. This placed the residents at increased risk for complications associated with pressure ulcers. Findings include: 1. Resident 10 was admitted to the facility in 2017. The resident had diagnoses including history of bowel obstruction, chronic atrial fibrillation with use of anticoagulant, peripheral neuropathy (chronic nerve pain), edema, depression, skin cancer, osteoporosis and weakness. An annual MDS dated 12/16/21 identified moderate cognitive impairment, incontinence of bowel and bladder and constant moderate pain. According to the MDS, Resident 10 required extensive assistance from one staff person for bed mobility and transfer and was not ambulatory. The resident was not identified to have weight loss or pressure ulcers but was identified at risk for pressure ulcers. The Pressure Ulcer CAA referenced the Annual Nursing Assessment dated 12/31/21. This document was blank. There was no comprehensive assessment in the record of the resident's risk factors, co-morbid conditions, medications, refusal of care, cognitive impairment, exposure of skin to urinary and fecal incontinence, or potential nutrition deficits. The Comprehensive Care Plan dated 2/17/21, under "Pressure Ulcer" identified Resident 10 was at risk for skin damage related to advancing age, incontinence, medication use, needing "staff assistance with some ADLs and independence of ambulation." On 3/11/22 a urinary catheter was ordered and implemented due to urinary retention. The resident remained incontinent of bowel only. A Skin Integrity Event dated 3/16/22 identified the resident had several reddish/purple non-blanchable spots located on her/his coccyx. This area measured 5 cm by 6 cm with the skin intact. "Airbed initiated and treatment to rinse with NS, apply skin prep and hydrocolloid dressing." A second Skin Integrity Event dated 3/22/22 described suspected deep tissue injury on the resident's bilateral heels. The left heel was 3.5 cm x 1.5 cm deep red purple. The right heel measured 5 cm x 2.5 cm and was described as a serosanguinous (blood mixed with clear fluid) filled blister. Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration of intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. The care plan was updated on 3/17/22 and 3/23/22 related to the identification of a "possible deep tissue injury" to the resident's coccyx and bilateral heels. Interventions included an air bed, nutrition consult as needed, update wound management document weekly, and notify physician for signs or symptoms of infection or if the wound deteriorates. Resident 10's In Room Care Plan intended for direct care staff included a directive to, "make sure to float heels and change position due to current pressure concerns." It did not specify location of the wounds or specifically mention the wound on the resident's coccyx. On 3/23/22 at 8:41 AM an RN surveyor observed wound care to the resident's bilateral heels with Staff 10 (LPN). The right heel had an intact blister filled with dark reddish-purple fluid. The left heel had a smaller dark reddish-purple area. The surrounding skin was normal in appearance. Staff 10 stated she wanted Staff 20 (LPN Wound Care Nurse) to look at the resident's heels. Staff 20 looked at the resident's wounds and determined current treatment was appropriate but added protective foam dressings and stated the resident should not be wearing regular socks and shoes until the wounds resolved. On 3/24/22 at 7:09 AM Resident 10 was observed seated in a wheelchair near the nurses' station with shoes over the dressings on her/his feet. A catheter leg bag was affixed to the resident's ankle with a strap. Staff 10 (LPN) was observed to remove the resident's shoes and replace with non-skid socks. The resident's In Room Care Plan did not include the directive to avoid wearing shoes. Observations on 3/24/22 between 7:00 am and 1:30 PM indicated Resident 10 remained up in a wheelchair throughout the morning until after Resident 10 finished lunch. On 3/24/22 at 1:31 PM, with the resident's permission, an RN surveyor observed the resident transferred to bed by Staff 22 (CNA) via a mechanical lift. The resident's incontinence garment was changed due to soiling from bowel incontinence. An intact dressing was observed over the resident's coccyx area. In an interview on 3/24/22 at 1:42 PM Staff 22 confirmed Resident 10 was up in her/his wheelchair all morning until after lunch. Staff 22 stated she offered to help the resident to lay down before lunch but the resident refused. On 3/24/22 at 1:49 PM, an RN surveyor with permission from Resident 10, observed Staff 10 (LPN) provide wound care to the resident's coccyx. The resident's urinary catheter leg bag was observed to be wrapped under the resident's left lower leg above the ankle. When Staff 10 undid the strap she found two additional areas of skin injury under the strap. The wounds appeared dark reddish-purple with intact skin. The coccyx dressing was then removed. The resident's coccyx area was slightly reddened and there was a shallow open area with a pink wound bed and a small amount of straw colored drainage on the dressing. Staff 10 stated the wound did not look, "as good as it did yesterday." On 3/25/22 at 10:05 AM Staff 16 (CNA) stated Resident 10 was to be repositioned every two hours. It had been four days since she last worked with Resident 10. She stated she knew the resident had skin breakdown on the heels and on the left lower extremity from the catheter leg bag, which was no longer in use. She did not know the resident had a wound on her/his coccyx. On 3/25/22 at 2:36 PM Staff 21 (CNA) confirmed she was assigned to Resident 10 for the evening shift. She stated the resident had been up in her/his wheelchair since before lunch and was still up as she/he wanted to eat a snack. She was not aware the resident had any areas of skin breakdown and would find out by looking at the care plan or from a report from the last shift. She indicated the resident had been up in her/his wheelchair for approximately 2-1/2 hours. On 3/25/22 at 3:32 PM observations of extended time up in wheelchair, staff interviews, missing CAAs and the care plan were discussed with Staff 2 (DNS) and Staff 4 (Assistant Resident Care Manager-LPN). Staff 4 stated Resident 10 had a recent overall decline. They were aware of problems with assessments and care plans and confirmed the resident should be repositioned every two hours. They stated they may be conducting a significant change assessment for Resident 10. , 2. Resident 25 was admitted to the facility in 1/2022 with diagnoses including left hip fracture, pain and dementia. From 3/21/22 to 3/24/22 between the hours of 8:30 AM to 4:30 PM, observations were made of Resident 25. During these observations the resident's heels were observed to be floated and placed in Podus Boots (foot boot to prevent and heal ulcers of the heel and toe and safeguard against foot drop) when in bed and both heels were placed in soft boots when out of bed and up in her/his wheelchair. The 1/6/22 Admit nursing note indicated Resident 25 had blanching redness on her/his coccyx area with an open area on the left buttock that was "dime sized." The 1/7/22 Baseline Care plan indicated Resident 25 had a Stage 2 pressure ulcer on the left buttock and was at high risk of skin breakdown. Progress Notes indicated the following: On 1/9/22, Resident 25 was noted having a dressing on her/his coccyx that was removed and having a possible pressure sore under it with the skin still being intact. Treatment orders were made to start skin paste bid/PRN to the resident's coccyx. On 1/15/22, Resident 25's bilateral heels were noted to have possible unstageable pressure areas. The left center heel had a 3 cm x 4 cm fluid filled [blister] with apparent serous (thin clear or light yellow) fluid. The left lateral heel had a 1 cm x 2 cm [blister] with apparent serosanguinous (a mixture of serous fluid and blood) fluid. The right center heel had a 2 cm x 3 cm with apparent serous filled blister. A nursing order was entered to monitor bid and to notify the primary care physician if the wounds worsened. Care plan interventions of floating the resident's heels while in bed and apply cushioned heel protectors when up in her/his wheelchair were implemented. The 1/18/22 Nursing Assessment indicated Resident 25 was admitted to the facility with a Stage 2 pressure ulcer with treatment in place. The location of the Stage 2 pressure was not documented. The assessment also noted the resident had Unstageable pressure ulcers to her/his bilateral heels and treatment orders were received. The 1/31/22 Pressure Ulcer Care Plan indicated Resident 25 was at risk for pressure injury due to decreased mobility. She/he was noted to have a Stage 2 pressure ulcer on coccyx/Unstageable pressure ulcer bilateral heels and spend the majority of her/his time in bed/wheelchair. For the Stage 2 pressure ulcer on Resident 25's coccyx that was identified by the facility during the resident's admission, there was no documentation of any wound assessments or evaluations (including size, fluid if present, pain, description of the wound, and evidence of healing) or monitoring in the resident's clinical record. The status and condition of the pressure ulcer on the resident's coccyx was unknown due to the lack of documentation. For the unstageable pressure ulcers to Resident 25's bilateral heels that were identified by the facility on 1/15/22, there was no follow up documentation (with the exception of a 2/2/22 Wound Management sheet) of any wound assessments or evaluations (including size, fluid if present, pain, description of the wound, and evidence of healing) after the initial assessment in the resident's clinical record. The status and condition of the pressure ulcers on the resident's bilateral heels were unknown due to the lack of documentation. The facility did not have a system in place to ensure the protocols for daily monitoring and for periodic documentation of measurements, terminology, frequency of assessment, and documentation were implemented. In an interview on 3/21/22 at 2:35 PM, Staff 5 (RN) was not aware of any pressure ulcers on Resident 25's coccyx, but stated the resident had pressure ulcers on her/his heels. Staff 5 was not able to provide any information on the status of the resident's pressure ulcers. In an interview on 3/24/22 at 9:27 AM, Staff 3 (RNCM) verified Resident 25 had pressure ulcers on her/his coccyx and bilateral heels. She stated the resident was admitted with a pressure ulcer on her/his coccyx which to her knowledge was now healed. Staff 3 was unable to locate any assessment, evaluation or monitoring of the coccyx pressure ulcer in the resident's record. Staff 3 stated she had recently observed the resident's heel pressure ulcers, but did not document her observation. When asked about documenting skin checks and pressure ulcer observations, Staff 3 stated the nurses should be doing weekly skin checks and documenting them. She acknowledged there was no documentation of any assessment or evaluation of the resident's coccyx pressure ulcer and limited documentation of the heel pressure ulcers in the resident's record. On 3/24/22 at 9:55 AM, wound observations were made by Staff 3 (RNCM) and an RN Surveyor with permission from the resident. A skin assessment of Resident 25 was completed which included an assessment of the resident's heels and coccyx/buttock area. The Stage 2 pressure ulcer on the resident's coccyx had resolved. The unstageable pressure ulcers on the resident's bilateral heels were measured and noted to show improvement toward healing. In an interview on 3/24/22 at 12:01 PM, Staff 2 (DNS) was notified of the lack of documentation for the pressure ulcers on Resident 25's coccyx and heels. Staff 2 acknowledged Resident 25's weekly skin sheets and wound observations were not documented in the resident's record.

1- On 03/28/22 Resident 10’s care plan was updated to include all pressure injuries. Care plan updated for Resident 25 on 03/31/22 to include all pressure injuries with interventions to prevent skin breakdown. On 3/28/22 orders reviewed for Resident 10 and 25 to make sure wound management is completed weekly by a licensed nurse which includes tracking measurements and progress of pressure injury. Current wound orders in place for both residents. 2- The DNS and/or RCMS will conduct an audit no later than 5/14/22 on anyone identified as having a pressure injury to make sure order for treatment are in place and weekly monitoring is being done. RCM and/or designee will review each new Pressure injury event created to make sure order and weekly wound management tracking gets initiated. 3- Skin sheet PIP was initiated on 02/15/22. In-service completed with Charge Nurses and RCM on 2/24/22 related to skin sheet initiation and completion. By 05/14/22 DNS will establish a weekly routine for auditing pressure injuries. 4- Review of the audit will be taken to QAPI for review and suggestions no less often than quarterly for up to one year.

Based on observation, interview and record review it was determined the facility failed to provide restorative services as recommended by a physical therapist for 1 of 2 sampled residents (#44) reviewed for mobility. This placed residents at risk for a decline in functional ability. Findings include: Resident 44 was admitted in 11/2021 with diagnoses including sepsis, depression, multiple sclerosis, and partial paralysis of one side. An Admission MDS dated 11/29/21 indicated Resident 44 required extensive assistance from two persons for bed mobility and transfer, and extensive assistance from one person for dressing and hygiene. The Quarterly MDS dated 2/22/22 indicated the resident required extensive assist from one person for bed mobility, dressing and hygiene and extensive assistance from two persons for transfer. Review of Physical Therapy notes indicated Resident 44 received five days of skilled therapy and was discharged to a Restorative Aide (RA) program on 12/2/21. The resident's Comprehensive Care plan was updated on 1/22/22 to include a problem statement related to ADL Functional/ Rehabilitation Potential. The problem was defined as "physical limitations that prevent [her/him] from completing ... ADLs without assistance." Interventions included PT/OT as ordered and desired, and an RA program as ordered; review progress monthly and as needed. On 3/21/22 at 2:48 PM the resident demonstrated her/his right shoulder limited ROM. Resident 44 stated she/he was supposed to get RA for 15 minutes, three times a week which the resident stated was not enough. Resident 44 stated most of the time RA staff was not present. The resident reported she/he was evaluated by PT while being still ill from a urinary tract infection and believed she/he could do more now that she/he had recovered. On 3/23/22 at 9:56 AM Staff 25 (CMA/CNA/RA) stated she worked as an RA three days a week, Monday, Wednesday and Friday. She stated she was pulled from RA duties to work as a CNA, CMA or transportation assistant when needed. Review of the RA documentation for Resident 44 from 12/13/21 to 3/23/22 indicated the resident received 18 out of 48 ordered sessions during that time frame. A 2/28/22 Restorative Meeting progress note documented the resident was, "using omni cycle to lower extremities [three times] per week and doing well. Will continue with program." There was no mention of frequency of actual sessions, the resident's satisfaction with the program or alternative therapy the resident might consider when RA was unavailable. There was no documentation found to indicate Resident 44 experienced a decline in functional abilities. On 3/25/22 at 3:11 PM Staff 4 (Assistant Resident Care Manager-LPN) stated there was a period of time in 2/2022 when the resident was not able to go upstairs to receive RA services as ordered due to a positive COVID-19 case in the facility and also during 2/2022 the RA staff was pulled from RA duties due to COVID-related staffing shortages. She confirmed the resident did not receive RA services as ordered or planned.

1- Resident 44 received outpatient PT orders to eval and tx at Water’s Edge on 4/9/22. On 4/1/22 the facility added RA on Tuesday and Thursdays allowing for RA services up to 5 days per week. 2- RCM’s and/or designee will conduct an audit no later than 5/14/22 of all residents currently on an RA program to confirm services are being offered as ordered. DNS/SSD/RCM and/or designee will randomly pick 2 residents no later than 5/14/22 on RA services to conduct a survey to ensure the program is meeting their expectations. This survey will be conducted for 3 consecutive months. 3- On 03/28/2022 RA provided with a calendar to track progress and participation of each resident starting 04/01/22. This will provide more accurate communication between RA and RCM when reviewing the program monthly. RCM will continue to meet monthly with RA to assess the RA program and resident participation. 4- Review of the audit will be taken to QAPI for review and suggestions no less often than quarterly for up to one year.

Based on observation, interview and record review it was determined the facility failed to ensure staff performed adequate hand hygiene and use of personal protection equipment (PPE) for 2 of 2 floors reviewed for infection control. This placed residents at risk for spread of COVID-19 infection. Findings include: The Centers for Disease Control (CDC) "Coronavirus Disease 2019 (COVID-19), last revised 6/19/20, directed nursing facilities to implement Universal Source Control which referred to facemasks to cover a person's mouth and nose to prevent spread of respiratory secretions when talking, sneezing or coughing. Because of the potential for asymptomatic and pre-symptomatic transmission, source control measures are recommended for all staff in the healthcare facility, even if they do not have symptoms of COVID-19. Healthcare providers should wear a facemask at all times while they are in the healthcare facility, including breakrooms or other spaces where they might encounter co-workers. Staff should be aware of the importance of performing hand hygiene immediately before and after any contact with their facemasks. The Centers for Disease Control (CDC), "Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings - Recommendations of the Healthcare Infection Control Practices Advisory Committee(HICPAC) requires the use of Standard Precautions to care for all patients in all settings including maintaining effective areas in hand hygiene and risk assessment with the use of appropriate personal protective equipment (e.g. gloves, gowns, face masks based on activities being performed to prevent the transmission of infections to healthcare personnel or patients as indicated in core practice guidance. Section 5A - Subsection 2: Requires the use of alcohol-based hand rub or wash with soap and water for the following clinical indications: immediately before touching a patient, before performing an aseptic task, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patients immediate environment, after contact with blood, body fluids or contaminated surfaces, immediately after glove removal. According to the CDC signage posted on the door for a resident on quarantine precautions, PPE should be donned in the following order gown, mask, face shield and gloves. On 3/24/22 at 9:04 AM Staff 9 (RN) entered a resident's room who was recently admitted and placed on quarantine precautions. At 9:07 AM, Staff 9 donned gloves, gown, face shield, tied back of gown, walked down the hall to the medication cart, opened the med cart, returned to the room and brought in all equipment with the same gloves on. At 9:10 AM, Staff 9 adjusted her face shield and N-95 mask with her gloves on, asked a surveyor to hand her some ice packs that were located on the isolation cart and took the ice packs. Staff 9 did not change her gloves or complete hand hygiene at any time during the observed sequence. On 3/24/22 at 11:50 AM Staff 11 (CNA) and Staff 18 (CNA) were observed at the first floor Nurses' Station talking with other care staff with their masks down below their chins, exposing their mouth and nose with their eye protection off. On 3/24/22 at 12:16 PM Staff 15 (Environmental Services Director) was observed conversing in the Social Services Directors Office with Staff 8 (Social Services Director) with his mask off, less than six-feet apart from Staff 8. On 3/24/22 at 12:19 PM Staff 18 (CNA) passed trays to residents during lunch time with her mask below her nose. At 12:32 PM, Staff 18 transferred residents to and from the dining room with her mask below her nose. On 3/24/22 at 12:21 PM Staff 8 and Staff 15 were interviewed regarding the facility's mask wearing and PPE policy and procedures. Staff 8 stated when under an Executive Order, staff were required to wear masks and face shields at all times. Staff 8 stated when the facility was not under an Executive Order, masks were still required, but when staff were in private offices they were allowed to have their mask off when they are alone and not with another staff member. Staff 15 indicated he was new to the facility and was not aware of the requirement. On 3/24/22 at 12:35 PM Staff 3 (Resident Care Manager) was observed to don gloves and self-administer a COVID-19 test. After the test was self-administered, Staff 3 placed the test swab in the vial, used the pen on the table, filled out documentation while wearing the same gloves she had used to self-administer the COVID-19 test and was observed placing the pen back on the table and doffed her gloves. Staff 3 was not observed to change gloves, perform hand hygiene, or sanitize the pen during the observation. On 3/24/22 at 12:55 PM Staff 7 (CNA) was observed in the second floor dining room rubbing her eyes while she assisted a resident. Staff 7 did not perform hand hygiene procedures after she rubbed her eyes and continued to assist the resident with meal service. On 3/25/22 at approximately 5:30 PM, the findings were shared with Staff 1 (Administrator) and Staff 2 (DNS). No other information was provided.

1. RN’s and LPN’s will be in-serviced on proper PPE usage during the nurses meeting on 04/12/2022. C.N.A staff will be in-serviced on proper ways to wear a mask during the weekly huddle on 04/13/2022. All staff will be in-serviced on PPE usage during the April All Staff meeting. On 4/12/2022 signage with the proper ways to wear a mask will be posted near both nurse’s stations for staff to view as a visual reminder. On 04/12/2022 the Environmental Services Director was in-serviced on the guidelines for social distancing and mask usage during an outbreak and the proper usage of a mask for day-to-day operations. At the April All Staff meeting, all staff will be in-serviced on the proper steps of self-administering a COVID-19 as it relates to PPE usage and sanitizing of the area before/after test administration. 2. All Staff will be in-serviced on the following topics no later than 05/14/2022: i. Sparkling Surfaces ii. Clean Hands iii. Closely Monitor Residents iv. Keep COVID-19 Out 3. Audits will be conducted by the Social Distancing officer, DNS, Administrator, and/or designee to ensure staff are complying with appropriately wearing mask, social distancing, and performing hand hygiene as needed. 4. Results of the audit will be taken to QAPI for review and suggestions no less often than quarterly for up to one year.

Based on interview and record review it was determined the facility failed to ensure state minimum CNA staffing ratios were maintained for 35 of 49 days reviewed for staffing. This placed residents at risk for delayed treatment and unmet care needs. Findings include:: A review of the Direct Care Staff Daily Reports from 2/1/22 through 3/21/22 revealed the following days when state minimum CNA staffing ratios were not met. -2/1/22- evening shift was short 0.7 CNA; -2/2/22-evening shift was short 1.5 CNAs; -2/3/22-evenings and night shifts were short one CNA; -2/4/22-day shift was short one CNA; -2/5/22-day shift was short one CNA and evening shift was short 1.75 CNAs; -2/6/22-day shift was short one CNA and night shift was short 0.5 CNAs; -2/7/22-day shift was short one CNA and night shift was short 0.7 CNAs; -2/8/22-day shift was short 1.43 CNAs and night shift was short two CNAs; -2/9/22-evening shift was short one CNA and night shift was short 0.75 CNAs; -2/10/22-evening shift was short 2.75 CNAs and night shift was short one CNA; -2/11/22-evening shift was short four CNAs and night shift was short one CNA; -2/12/22-day and evening shifts were short one CNA; -2/13/22-day shift was short one CNA and night shift was short 0.75 CNAs; -2/14/22-days shift was short 1.31 CNAs, evening shift was short two CNAs and night shift was short 0.75 CNAs; -2/17/22-night shift was short 1.5 CNAs; -2/18/22-day shift was short one CNA; -2/19/22-day shift was short 1.5 CNAs; -2/20/22-day shift was short one CNA; -2/21/22-evening shift was short 1.4 CNAs; -2/22/22-day shift was short one CNA; -2/23/22-night shift was short two CNAs; -2/24/22-night shift was short 0.65 CNAs; -2/25/22-day shift was short one CNA and evening shift was short 0.5 CNAs; -2/26/22-day and night shift was short one CNA and evening shift was short 0.3 CNAs; -2/27/22-day shift was short one CNA; -2/28/22-evening shift was short 0.53 CNAs and night shift was short 1.5 CNAs; -3/1/22-day shift was short two CNAs and evening and night shift was short one CNA; -3/2/22-evening shift was short one CNA and night shift was short 0.5 CNAs; -3/3/22-day shift was short one CNA, evening shift was short 2.15 CNAs and night shift was short 1.5 CNAs; -3/4/22-day shift was short 1.5 CNAs and evening shift was short 1.55 CNAs; -3/5/22-day shift was short one CNA and evening shift was short 1.44 CNAs; -3/7/22-evening shift was short 1.62 CNAs and night shift was short one CNA; -3/16/22-day shift was short one CNA; -3/18/22-evening shift was short 1.5 CNAs and night shift 0.84 CNAs; -3/21/22-evening shift was short 1.5 CNAs. On 3/24/22 at 10:03 AM, Staff 26 (HR Director/Staffing) acknowledged the facility's failure to meet minimum CNA staffing ratios. On 3/25/22 at 12:02 PM, Staff 1 (Administrator) and Staff 2 (DNS) confirmed the CNA staffing shortages for the period of time reviewed.

1. Human Resource Director, Director of Nursing, and Administrator all are working together to ensure the facility meets Oregon DHS Minimum Staffing Ratios. Open shifts are being sent to agency and facility staff to try and fill. The facility has also sent in request to OHA for staffing assistance. The request for continued assistance has not been approved at this time. All efforts are being made to obtain coverage and efforts are being documented for tracking purposes. The facility is currently hiring for NA students to start a class at the end of April/ start of May 2022. The facility has also been utilizing PCA’s to assist with open shifts. The facility is also identified 90-day retention efforts to try and incentivize staff to go on a 4on-2off rotation and switch days to help on evening and noc shift where shortages are likely to occur. 2. Human Resource Director, Director of Nursing, Administrator and/or designee will meet Monday-Friday to discuss staffing needs after our morning meeting to identify any open shifts for the day and ensure staff and agency are aware of the shifts to try and obtain coverage. 3. RN’s and LPN’s will be educated no later than 05/14/22 on assisting with filling shifts due to call-ins that occur after normal business hours and/or on the weekend. 4. The Human Resource Director and/or designee will audit call-ins monthly to ensure there is not a pattern amongst staff that needs to be addressed. Results of the audit will be discussed with the Administrator and DNS at our staffing meetings. 5. The Human Resource Director and/or designee will provide an update on staffing and open shifts to the QAPI team no less often than quarterly.

*************************** OAR 411-086-0040 - Advanced Directives Refer to F578 *************************** OAR 411-086-0060 - Comprehensive Assessment and Care Plan Refer to F636 and F657 *************************** OAR 411-086-0110 - Nursing Services: Resident Care Refer to F677 *************************** OAR 411-086-0140 - Nursing Services: Problem Resolution and Preventive Care Refer to F686 *************************** OAR 411-086-0150 - Nursing Services: Restorative Care Refer to F688 *************************** OAR 411-086-0330 - Infection Control and Universal Precautions Refer to F880 ***************************

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Based on observation, interview and record review it was determined the facility failed to ensure proper use of personal protective equipment (PPE) (Staff #5, #13), failed to clean and disinfect resident-care equipment (#5) prior to use on another resident and failed to use an EPA registered disinfectant (#5) to clean and disinfect resident-care equipment to prevent the spread of COVID-19. This put the residents at risk of contracting COVID-19. Findings include: a. The facility's 2/11/19 Cleaning/Disinfecting Equipment Shared Among Residents policy stated the vital machines shared among residents are to be cleaned with Micro-Kill One Germicidal Alcohol Wipes after each resident use. On 8/5/21 at 2:20 PM Staff 5 (CNA) was observed going into room 205 with resident-care equipment to obtain vital signs. On 8/5/21 at 2:23 PM Staff 5 entered room 207 with the same resident-care equipment to obtain vital signs without cleaning and disinfecting the equipment between residents. In an interview on 8/5/21 at 2:25 PM Staff 5 acknowledged she hand sanitized after each resident but did not clean or disinfect the resident-care equipment after use on one resident before using the equipment on another resident to obtain vital signs. Staff 5 stated she cleaned the equipment after she obtained all the residents' vital signs. On 8/5/21 at 2:41 PM Staff 5 was observed cleaning and disinfecting equipment used for resident care without gloves, using the ProCure hand sanitizing wipes at the nurses' station. The ProCure hand sanitizing wipes were not found on the EPA-N list for disinfectants against COVID-19. In an interview on 8/5/21 at 2:56 PM Staff 19 (RCM) stated the ProCure hand sanitizing wipes found at the nurses' station were used for resident hand hygiene and to disinfect the counter at the nurses' station. She stated staff should be using the Micro-Kill One germicidal alcohol wipes (EPA 9480-4) to clean and disinfect resident-care equipment. In a phone interview on 8/16/21 at 4:14 PM Staff 2 (DNS) stated she expected the staff to use EPA registered disinfectants to clean and disinfect resident-care equipment. b. The facility's March 2020 Infectious Diseases Policy and Procedure stated the correct use of PPE is critical to preventing staff exposure to an infectious disease. The sequence of donning (putting on) PPE is recommended: Gown, mask, face shield/goggles, gloves. CDC guidance, demonstrated on pictograph posters throughout the facility, recommended: Gown, mask, face shield/goggles, gloves. On 8/11/21 at 12:00 PM Staff 13 (RN) was observed to don (putting on) PPE outside a resident's room who was on Transmission Based Precautions (TBP). Staff 13 performed hand hygiene, removed her face shield, pulled a white gown over her head and over her mask, replaced her face shield and entered the room. At 8/11/21 at 12:05 PM Staff 13 doffed (sequence of taking off ) PPE in the resident's room behind closed doors. In an interview with Staff 13, she acknowledged she had removed her face shield then pulled the white isolation gown on over her head while her mask remained in place. Staff 13 recognized she self-contaminated leaving a potentially dirty mask on and pulling the gown over her head. She agreed that she was not instructed to do it that way and the donning sequence she performed was incorrect. In a phone interview on 8/16/21 at 4:14 PM Staff 2 (DNS) stated she expected the staff to don/doff PPE per facility policy and CDC guidance.

1) Staff member #5 will be in-serviced no later than October 1, 2021 on the appropriate disinfectant to use when wiping down the vitals machine before use on another resident. In-servicing shall be completed by the DNS, Infection Control Nurse or Designee on all current staff members to assure that each staff member understands what products to use with IFC rationale and to include CBC policy and procedures. Pictures of the EPA-N approved products that are used in the facility will be laminated and located at each nurses station, laundry, housekeeping and dietary. Will be completed no later than October 1, 2021. 2)Staff member #13 will be in-serviced no later than October 1, 2021 on the appropriate way to don and doff PPE. In-servicing shall be completed by the DNS, Infection Control Nurse or Designee on all current staff members to assure that each staff member understands the sequencing of donning (putting on) and doffing (removing) PPE safely. Will continue to perform random monthly audits on staff donning/doffing PPE. During in-servicing all staff will receive a copy of CDC How to Safely Donn/Doff PPE. Will be completed not later than October 1, 2021. 3) The DNS or Designee shall monitor the auditing process for proper disinfectant use and PPE compliance monthly. A PIP shall be developed on the deficient practices and presented to the QAPI teams October meeting. The DNS shall report the progress of the PIP to the QAPI team monthly X3 and quarterly thereafter.

**************************** OAR 411-086-0330 Infection Control and Universal Precautions Refer to F-880 ****************************

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 07/26/2021 and 08/01/2021, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.