Avamere Rehabilitation of Eugene

Resident 3 was admitted to the facility in 2/2026 with diagnoses including respiratory failure and pneumonia. -á The facilityGÇÖs 3/5/26 investigation documented that staff found Resident 3 and suspected the resident was deceased during routine rounds. The nurse was notified, and the resident was confirmed as deceased. Resident 3 was not on hospice, had a Full Code status, and CPR was not initiated. Included in the investigation on 3/11/26, six days after the resident's death, that upon the nurse assessment Resident 3 did not have rigor mortis and the nurse did not initiate code blue or resuscitation interventions.-á -á A Nursing Facility Reported Incident Form, dated 3/13/26, indicated the incident from 3/5/26 was reported to the State Agency on 3/13/26. -á On 3/30/26 at 12:48 PM, Staff 26 (Regional Director of Quality Assurance) confirmed the facility did not report the incident to the State Agency within the required two-hour timeline.

FRI was submitted to Oregon DHS on 3/13/26 related to Resident #3’s death on 3/5/2026. Other current residents code status was reviewed to ensure correct wishes were accurate in PCC and there were no further reportable incidents. Issues identified were reviewed by Administrator and DNS for potential reporting. Management will be re-educated on neglect recognition and reporting.  Education will include how to identify what may be reportable and what actions to take when identified. Administrator or designee will interview 5 staff each week about how to identify and report potential neglect.  Audits will continue weekly x4 then monthly x3 to ensure reportable events are handled appropriately.  Results of audits will be shared with the QAPI committee.

Resident 8 was admitted to the facility in 3/2026 with diagnoses including chronic pain, absence of left leg below the knee, and after care following a surgical amputation. -á A 3/10/26 Admission MDS indicated Resident 8 was cognitively intact and required supervision or touching assistance with toileting, transfers, and bathing. No referrals were documented for medical equipment ordered, or home health referral submitted.-á -á A 3/11/26 Discharge Instructions documented Resident 8 was being discharged home and noted her/his current physical status required assistance and assistive devices. -á A 3/13/26 Nursing Note indicated at 12:23 AM, Resident 8 returned after an outing. The facility notified the police because her/his location was unknown. Resident 8 had been out with friends and was unaware of any concern. -á A 3/13/26 Social Services Note documented because Resident 8 was out past midnight, she/he was discharging from the facility. NOMNC was not issued due to leaving prior to scheduled discharge and leaving on own initiative. -á A 3/13/26 Discharge Summary note documented the discharge instructions were reviewed with Resident 8 and she/he refused to sign leaving the facility voluntarily. -á The facility's Voluntary Consent form included a handwritten statement that Resident 8 refused to sign.-á -á On 3/26/25 at 10:58 AM, Resident 8 stated he was ""kicked out"" of the facility for coming back late. Resident 8 stated she/he was currently sleeping on a friend's couch, and it was difficult to get around. -á On 3/30/26 at 10:36 AM, Staff 21 (Business Office Manager) stated Resident 8 did not have any financial notes for lack of payment and she did not have any information about why she/he discharged from the facility. -á On 3/30/26 at 12:06 PM, Staff 19 (Social Services Coordinator) stated Resident 8 stayed out late and the facility called the police. Resident 8 returned to the facility after midnight and because she/he was a Medicare resident, insurance would not cover her/him if out of the facility past midnight. Staff 19 stated Resident 8 was scheduled for discharge from the facility on 3/17/26. -á On 3/30/26 at 12:57 PM, Staff 27 (Regional Director of Operations) stated he thought it was a clerical error and confirmed the facility should have completed a normal discharge for Resident 8.

The facility failed to have a safe and orderly discharge for resident #8. Resident #8 is discharged and no further correction can be made. The administrator and director of nurses reviewed the discharge policy and deemed it appropriate. Residents (total 7) scheduled to discharge following survey exit on 3/30/2026 to 4/17/2026 were reviewed for appropriate discharge by administrator and social services coordinator. The facilities two social service coordinators, along with the administrator and director of nurses were re-educated on an "appropriate discharge" and the issuing of a Notice of Medicare Non-Coverage (NOMNC). The administrator or designee will audit 1 discharge per week and then monthly for 4 months.

Resident 28 was admitted to the facility in 9/2025 with diagnoses including type 2 diabetes mellitus. Resident 28's 12/10/25 Brief Interview for Mental Status revealed a BIMS of 15 (cognitively intact). On 1/12/26 at 1:40 PM, Resident 25 stated she/he had discussions with some of the nurses about her/his insulin because she/he wanted it administered before meals and it often was given after her/his dinner in the evenings.-á On 1/15/26 at 10:15 AM, Staff 10 (CNA) stated Resident 25 told her multiple times she/he wanted her/his insulin administered before meals. Staff 10 stated she reported the concern to nursing staff.-á On 1/16/26 at 12:53 PM, Staff 9 (LPN) stated a CNA told her Resident 25 was unhappy because she/he had not been administered her/his insulin before meals. Staff 9 stated she had not followed up with the physician about Resident 25's concern.-á On 1/16/26 at 1:10 PM, Staff 2 (DNS) stated when nurses became aware Resident 25 was requesting to have insulin administered before meals, they should have notified the physician to ensure Resident 25's insulin orders could be changed.-á -á -á -á

Timing of insulin administration for resident #25 has been updated per resident preference. Other current residents receiving insulin will be interviewed about administration preference and updates made as appropriate. Education provided to nurses about resident rights r/t medication administration including what steps to take if residents would like to make changes. DNS or designee will interview three residents weekly about insulin administration.  Audits will continue weekly x4 then monthly x3.  Results of audits will be shared with the QAPI committee.

1.Resident 6 was admitted to the facility in 12/2024 with diagnoses including end stage kidney disease and diabetes. A review of Resident 6GÇÖs medical record revealed an untitled form signed by Resident 6 on 3/29/25 which indicated Resident 6 wanted to initiate an advance directive. A record review revealed no evidence of an advance directive in Resident 6GÇÖs medical record. On 1/13/26 at 1:41 PM, Staff 3 (Regional Nurse Consultant) stated Resident 6 did not have an advance directive completed. On 1/20/26 at 12:00 PM, Staff 2 (DNS) stated staff were expected to follow up with residents regarding initiating and/or obtaining their advance directive. Resident 37 was admitted to facility in 12/2024 with diagnoses including diabetes and heart failure. A review of Resident 37GÇÖs medical record revealed an untitled form signed by Resident 37 on 12/24/24 which indicated Resident 37 had an advance directive and would provide it to the facility in 72 hours. A record review revealed no evidence of an advanced directive in Resident 37GÇÖs medical record. On 1/13/26 at 1:41 PM, Staff 3 (Regional Nurse Consultant) stated Resident 37 did not have an advance directive completed. On 1/20/26 at 12:00 PM, Staff 2 (DNS) stated staff were expected to follow up with residents regarding initiating and/or obtaining their advance directive. 2.Resident 37 was admitted to facility in 12/2024 with diagnoses including diabetes and heart failure. A review of Resident 37GÇÖs medical record revealed an untitled form signed by Resident 37 on 12/24/24 which indicated Resident 37 had an advance directive and would provide it to the facility in 72 hours. A record review revealed no evidence of an advanced directive in Resident 37GÇÖs medical record. On 1/13/26 at 1:41 PM, Staff 3 (Regional Nurse Consultant) stated Resident 37 did not have an advance directive completed. On 1/20/26 at 12:00 PM, Staff 2 (DNS) stated staff were expected to follow up with residents regarding initiating and/or obtaining their advance directive.

Residents 6 and 37 were interviewed about current Advanced Directives.  Resident 6 completed his Advanced Directive and it has been uploaded to his chart.  Resident 37’s daughter plans to bring the Advanced Directive in for her chart.  SSD will follow up with daughter periodically until document is received. Other current residents without an Advanced Directive on file were offered to complete an Advanced Directive or obtain them for their files. Education was provided to Social Services Directors about obtaining Advanced Directives when available and offering resources or assistance in completing one if the resident chooses to. Administrator or designee will audit 3 charts weekly for evidence of Advanced Directives being offered or on file.  Audits will continue weekly x4 then monthly x3.  Results of audits will be shared with the QAPI committee.

Resident 15 was admitted to the facility in 6/2025 with diagnoses including insomnia.-á Resident 15's 12/18/25 Brief Interview for Mental Status revealed a BIMS of 15 which indicated Resident 15 was cognitively intact. A review of the resident's clinical record indicated an order for 50 mg of trazodone had been entered in the Medical Administration Record (MAR) on 12/17/25. A review of the resident's clinical record indicated an order for 50 mg of trazodone had been entered in the Medical Administration Record (MAR) on 1/7/26 in addition to the existing order. On 1/13/26 at 10:30 AM, Resident 15 stated she/he thought she/he had received extra doses of trazodone and had not been able to do anything but sleep for two days. Resident 15 stated she/he was upset because she/he had been too sleepy to attend her/his physical therapy session and therapy was very important to her/him.-á On 1/14/26 at 2:14 PM, Witness 1 (Family Member) stated last week when she talked to Resident 15 she/he had been in tears and told Witness 1 she/he was so tired she/he couldn't function. Witness 1 called the facility and spoke to Staff 17 (CMA) who told her Resident 15's trazodone had been increased by 50 mg on 1/7/26 and 1/8/26. On 1/15/26 at 8:45 AM, Staff 17 stated when she saw there was a second order for 50 mg of trazodone in Resident 15's clinical record on 1/9/26 she checked with the resident and did not administer the medication. Staff 17 stated she noticed the extra dose had been administered on 1/7/26 and 1/8/26. Staff 17 stated she notified the nurse on duty of the duplicate order and again notified the nurse on duty the following day when she saw the order was unchanged in the system.-á On 1/15/25 at 1:30 PM, Staff 19 (LPN) stated she was unsure of the date but had looked at pending orders to teach Staff 18 (RN) how to enter orders. She stated she remembered there was a pending order for trazodone and she had Staff 18 enter the order in the clinical record. Staff 19 stated she was unaware there was an additional process to verify the orders before confirming them.-á On 1/16/2026 at 10:14 AM, Staff 18 stated Staff 19 had been training her on how to enter orders. Staff 18 stated she logged into the computer but had not realized she was actually creating an order and had not paid attention to the resident or medication information.-á On 1/16/26 at 8:17 AM, Staff 2 (DNS) stated the order was an error and should have been deleted, not confirmed. Staff 2 stated nurses should be verifying orders when they implemented them.-á

Resident #15 medications were reviewed and updated to accurately reflect current physician orders. Current residents with ED or hospitalization events in the last 2 weeks were reviewed for medication order accuracy and corrections made as appropriate. Education will be provided to nurses about process for new medication order entry and verification. DNS or designee will audit three charts weekly for accuracy of medication orders.  Audits will continue weekly x4 then monthly x3.  Results of audits will be shared with the QAPI committee.

-áResident 60 was admitted to the facility in 7/2024 with diagnoses including heart failure and kidney disease. The 3/4/25 Annual MDS indicated Resident 60 was cognitively intact. A care plan dated 12/24/25 indicated if Resident 60 accusatory comments about family, and/or staff not treating her/him well and denying her/his medications, staff must alert the nurse so they may assess for signs and symptoms of urinary tract infection since this had been the case in the past. On 1/12/26 at 2:13 PM Resident 60 indicated a CNA/CMA abused her/him. Resident 60 stated the staff member spoke meanly and was rough with her/him and she/he felt abused. Resident 60 stated the staff member treated her/him like a ""bad dog."" Resident 60 stated Staff 11 (LPN) was aware the staff member treated her/him badly but had not stopped the staff member. Resident 60 stated she/he was afraid of retaliation from the staff member and being discharged from the facility.-á On 1/12/26 at 2:16 PM Staff 11 stated the staff member she heard being rude to Resident 60 was Staff 26 (CNA/CMA). Staff 11 stated Staff 26's demeanor changed if she felt rushed or if she had a bad day. Staff 11 stated she heard Staff 26 be rude to other residents and other staff members observed this behavior as well, but she did not report the behavior to management. On 1/12/26 at 2:42 PM Staff 1 (Administrator) and Staff 2 (DNS) were notified Resident 60 stated she/he felt abused by Staff 26. Staff 1 indicated this was the first he had heard of Resident 60 feeling abused by Staff 26.-á On 1/12/26 at 2:52 PM Staff 1 and Staff 2 stated their expectation when a resident felt abused by a staff member was for staff to notify both of them immediately. Staff 2 stated staff must notify the provider and family and ensure the safety of all residents. -á

Resident #60 was interviewed by Administrator and DNS regarding staff concerns.  FRI was submitted to Oregon DHS on 1/12/26.  Nurse and CNA involved were suspended pending further investigation. Other current residents cared for by the nurse and CNA were interviewed for potential concerns.  Issues identified were reviewed by Administrator and DNS for potential reporting. Floor staff will be re-educated on abuse recognition and reporting.  Education will include how to identify what may be reportable and what actions to take when identified. Administrator or designee will interview 5 staff each week about how to identify and report potential abuse.  Audits will continue weekly x4 then monthly x3 to ensure reportable events are handled appropriately.  Results of audits will be shared with the QAPI committee.

Resident 14 was admitted to the facility in 11/2025 with diagnoses including rheumatoid arthritis, dementia, and unspecified deformity of the fingers. A 11/11/25 Admission MDS indicated Resident 14GÇÖs BIMS score was nine which indicated she/he had moderately impaired cognition. Resident 14 required setup and cleanup assistance for eating. A 11/6/25 Care Plan indicated Resident 14 required setup assistance for eating.-á Observations on 1/12/26 from 12:12 PM to 1:10 PM revealed Resident 14 arrived in the facility main dining room for lunch at 12:30 PM. Resident 14 received her/his meal at 12:42 PM. Resident 14 was seated in a wheelchair at a dining table, and the meal was not within her/his reach. Resident 14 was observed leaning forward in the chair two to three times, bringing her/his trunk closer to the dining table with effort, then sat back in the wheelchair. Staff in the dining room did not approach Resident 14 until 1:04 PM when assistance was provided in repositioning her/his feet on the wheelchair footrests. Staff removed Resident 14GÇÖs meal at 1:10 PM without asking if she/he was done eating. Staff assisted Resident 14 back to her/his room. During lunch service Resident 14 did not have any food or drink while in the dining room. Observations on 1/13/26 from 1:16 PM to 2:05 PM revealed Resident 14 was positioned in bed with the head of the bed elevated, and the overbed table was across her/his body from the left side of the bed.-á The lunch meal tray was on the overbed table. Resident 14 stated she/he had missed breakfast and was hungry. Resident 14GÇÖs right knee was in a bent position which limited the overbed table position towards Resident 14GÇÖs left side. Resident 14GÇÖs tray had one beverage with the lid removed, one beverage with the lid on, the lid was removed from the soup, and the meal included an open plate stewed beef and a baked potato. Resident 14GÇÖs baked potato was uncut, and the containers of butter and sour cream were unopened. Resident 14GÇÖs utensils were to the far-left side of the meal tray, and she/he reached them with difficulty after several tries with her/his right hand.-á Resident 14 attempted to use a fork to cut into the baked potato but only speared the potato on the fork.-á Resident 14 was then observed taking a bite of beef with some effort to reach and secure the food on her/his fork. When Staff 8 (CNA) removed the tray at 2:05 PM very little food was consumed, and all the unopened items remained unopened and uneaten.-á The uneaten baked potato was observed lying on the tray to the right of the plate.-á Resident 14 drank the entire opened beverage. In an interview on 1/13/26 at 2:05 PM, Staff 8 indicated Resident 14 could not cut her/his potatoes, apply butter to items on the tray, or open containers.-á On 1/14/26 at 2:20 PM Staff 9 (LPN) stated staff were expected to set up meals by placing the tray in front of the resident, cutting the meat, removing all lids, and making sure the resident had everything she/he needed within reach. On 1/20/26 at 11:38 AM, Staff 2 (DNS) stated staff were expected when setting up a meal to ensure food items were within reach, to remove the cover from the plate and open all containers and lids. Staff 2 stated staff were also encouraged to offer as a courtesy to cut foods if the resident wanted assistance.

Resident #14 was reviewed for assistance needed during mealtimes and appropriate interventions added to the care plan. Other current residents will be reviewed to ensure their care plans reflect assistance needed during mealtimes.  Adjustments will be made as appropriate. Education will be provided to nursing staff about importance of following the resident Kardex and ensuring proper set-up is provided per resident preference. DNS or designee will monitor 5 meals each week to ensure resident needs are met.  Audits will continue weekly x4 then monthly x3.  Results of audits will be shared with the QAPI committee.

Resident #11 was reapproached and nail care completed.  Education was provided to resident about importance of allowing cares from staff. Current residents were observed to ensure fingernails were trimmed and clean per resident preference. Education was provided to nursing staff about providing routine nail care per resident preference.  Education will include actions to take when residents refuse care. DNS or designee will observe 5 residents weekly to ensure nail care has been provided.  Audits will continue weekly x4 then monthly x3.  Results of audits will be shared with the QAPI committee.

2. Resident 42 was admitted to the facility in 5/2025 with diagnoses including stroke and weakness. A 5/23/25 care plan revealed Resident 42 required two-person assistance with transfers using FWW (Front Wheeled Walker). A 7/21/25, fall investigation revealed at approximately 10:00 AM Staff 15 (Former CNA) indicated she took Resident 42 to her/his room after a shower. Staff 15 grabbed Resident 42's FWW and assisted her/him to stand. Resident 42 felt her/his legs weaken, lost balance, and fell to the floor. Staff 15 did not review the care plan. -On 7/22/25 Staff 16 (Former LPN) was notified and indicated no injuries were found on the resident. -The investigation indicated during training, CNAs were taught to read the care plan for the residents' care needs. Staff 15 transferred Resident 42 without assistance when the care plan clearly stated she/he was a two-person transfer. -The Root Cause Analysis indicated the biggest contributing factor was Resident 42 was a two person assist with her/his FWW and Staff 15 did not check the care plan.-á On 1/14/26 4:24 PM Staff 15 stated she transferred Resident 42 to her/his wheelchair with the FWW, and the resident stood up and slid to the floor. Staff 15 stated she did not review the care plan which indicated Resident 42 was a two-person transfer with a FWW before she transferred her/him. On 1/14/26 4:25 PM Staff 16 stated Staff 15 notified her she gave resident 42 a shower and attempted to transfer her/him back to her/his wheelchair when the resident fell. Staff 16 stated Resident 42 was care planned as a two person assist with transfers and Staff 15 completed the transfer alone. On 1/15/26 at 3:02 PM Staff 1 (Administrator), Staff 2 (DNS), and Staff 3 (Regional Nurse Consultant) acknowledged Resident 42 was a two person transfer which was on her/his care plan. Staff 2 stated expectations were for staff to always look at the care plan before providing care for residents. Staff 3 stated the expectation was for an allegation of abuse or neglect to be reported to the State Survey Agency timely.-á , Resident 31 was admitted to the facility in 12/2025 with diagnoses including dementia. -á A 12/5/25 care plan indicated Resident 31 was at risk for falls and padded fall mats were to be placed at both sides of the bed when Resident 31 was in bed. On 1/13/26 at 9:27 AM, Resident 31 was observed in bed without a fall mat on the left side of her/his bed. On 1/14/26 at 9:01 AM, Resident 31 was observed in bed with the left side of the bed fall mat on the floor, but not next to Resident 31GÇÖs bed. On 1/14/26 at 2:43 PM, Resident 31 was observed in bed without a fall mat on the left side of her/his bed. On 1/14/26 at 2:45 PM, Staff 4 (CNA) stated Resident 31 was at risk for falls and was to have fall mats on the floor next to her/his bed while Resident 31 was in bed. Staff 4 confirmed Resident 31 did not have a fall mat on the left side of her/his bed and Staff 4 placed the fall mat on the left side of Resident 31GÇÖs bed. On 1/15/26 at 1:31 PM, Resident 31 was observed in bed, the fall mat for the left side of her/his bed was folded up and leaning against the foot of the bed. On 1/16/26 at 10:26 AM, Staff 5 (LPN Resident Care Manager) stated Resident 31 was at risk for falls and rolled out of bed when she/he first admitted. Staff 5 stated Resident 31 was care planned to have fall mats on the floor on both sides of the bed when she/he was in bed. Staff 5 stated staff were expected to follow the care plan. -á

Upon notification, staff returned fall mats to resident #31’s bedside per care plan.  Resident #42 was assessed and determined no injury occurred. Current residents were observed to ensure staff have followed the care plan r/t accident prevention. Education will be provided to nursing and therapy staff about ensuring interventions to prevent accidents are being followed per resident care plan. DNS or designee will observe 5 residents weekly to ensure interventions to prevent accidents are being followed per resident care plan.  Audits will continue weekly x4 then monthly x3.  Results of audits will be shared with the QAPI committee.

Resident 31 was admitted in 12/2025 with diagnoses including dysphagia (difficulty swallowing) and dementia. A review of Resident 31GÇÖs 12/14/25 hospital discharge summary indicated Resident 31 had orders for PT, OT, and ST. A review of Resident 31GÇÖs medical record revealed no evidence of PT, OT, or ST documentation since 12/14/25. On 1/12/26 at 12:21 PM, Resident 31 was observed up in a wheelchair that was tilted back, without a headrest, and without footrests. Resident 31GÇÖs head was observed to hang off the back of the wheelchair without support and Resident 31GÇÖs feet were not supported. On 1/16/26 at 10:26 AM Staff 5 (LPN Resident Care Manager) stated Resident 31 was re-admitted to the facility on an altered textured diet due to dysphagia, but stated Resident 31 was not re-admitted with orders for PT, OT, or ST. On 1/16/25 at 11:07 AM, Staff 6 (Speech Therapist) stated Resident 31 had dysphagia and should have been seen by ST. On 1/16/26 at 11:09 AM, Staff 7 (Therapy Manager) stated he was not notified of Resident 31GÇÖs order for PT, OT, and ST. On 1/16/26 at 11:24 AM, Staff 5 acknowledged Resident 31GÇÖs discharge summary indicated orders for PT, OT, and ST and stated Resident 31 should have been seen by therapy per orders at admission. On 1/20/26 at 12:00 PM, Staff 2 (DNS) stated therapy was expected to be provided per orders.

Resident 31 orders have been reviewed and updated to reflect current status within the facility. Current residents with therapy orders will be reviewed for accuracy and verified against current therapy caseload.  Any discrepancies will be resolved based on resident needs. Education provided to IDT and nurses about expectations when therapy services are ordered and how to communicate any changes or concerns. Administrator or designee will audit three charts weekly to ensure therapy services ordered are occurring.  Audits will continue weekly x4 then monthly x3.  Results of audits will be shared with the QAPI committee.

1. Resident 6 was admitted to the facility in 12/2024 with diagnoses including end stage kidney disease. On 1/13/26 at 10:28 AM, a review of Resident 6GÇÖs medical record revealed an untitled form signed by Resident 6 on 3/29/25 which indicated Resident 6 wanted to initiate an advance directive. On 1/13/26 at 3:00 PM, a review of Resident 6GÇÖs medical record revealed the untitled form signed by Resident 6 on 3/29/25 was no longer found in the electronic medical record. On 1/13/26 at 3:47 PM, Staff 4 (Regional Nurse Consultant) stated she deleted the untitled forms from Resident 6GÇÖs, Resident 37GÇÖs, and 19 additional active residentsGÇÖ medical records. Staff 4 stated she deleted the untitled forms because they were not official corporate forms. Staff 4 acknowledged medical records were expected to be retained and not deleted. 2. Resident 37 was admitted to the facility in 12/2024 with diagnoses including diabetes. On 1/13/26 at 11:01 AM, a review of Resident 37GÇÖs medical record revealed an untitled form signed by Resident 37 on 12/24/24 which indicated Resident 37 had an advance directive and would bring it into the facility within 72 hours. On 1/13/26 at 3:05 PM, a review of Resident 37GÇÖs medical record revealed the untitled form signed by Resident 31 on 12/24/24 was no longer found in the electronic medical record. On 1/13/26 at 3:47 PM, Staff 4 (Regional Nurse Consultant) stated she deleted the untitled forms from Resident 6GÇÖs, Resident 37GÇÖs, and 19 additional active residentsGÇÖ medical records. Staff 4 stated she deleted the untitled forms because they were not official corporate forms. Staff 4 acknowledged medical records were expected to be retained and not deleted.

Deleted documents for residents 6 and 37 were restored back into their charts.  Of the remaining 19 residents, 14 were able to be restored.  The remaining five resident’s documents were unrecoverable and were interviewed about their Advanced Directive preferences. Other current residents were reviewed and noted with documents intact. Education provided to RDQA, Administrator, DNS and Medical Records Director about expectations for record maintenance and destruction. Administrator or designee will interview the RDQA, DNS or Medical Records Director weekly about any record destruction that may have occurred.  Audits will continue weekly x4 then monthly x3.  Results of audits will be shared with the QAPI committee.

During the walk through of the facility laundry room on 1/15/26 at 12:11 PM, a hole in the wall was observed next to the wash machine. Behind the two wash machines and a clean linen cart was a large pool of standing water, the water appeared brown and dirty. Along the baseboard of the wall behind the two wash machines was a black substance which extended about an inch up the wall and an inch on the floor. Staff 13 (Housekeeping Director) stated the hole in the wall was present for some time but did not extend into the outside of the building. Staff 13 stated maintenance was notified of the standing water a few weeks ago, but it was not yet repaired. Staff 13 did not know what the black substance was. On 1/15/26 at 1:35 PM the standing water in the laundry room was observed, a cart of clean linen and laundry was near the water and a blanket from the cart was observed partially in the water. Staff 12 (Laundry Aide) confirmed the blanket touched the water and stated the blanket would be recleaned.-á On 1/15/25 at 3:15 PM Staff 1 (Administrator) walked through the laundry room; there was less standing water and some of the black substance appeared removed. Staff 1 confirmed the standing water and black substance on the wall and floor and acknowledged the laundry area needed to be repaired. Staff 1 asked Staff 12 if the water on the floor happened often, Staff 12 stated it occurred for the last three weeks when the wash machines were in use. Staff 12 stated the water and some of the black substance on the wall were just cleaned up.-á

Maintenance Director has sealed the hole in the laundry room wall with primed plywood.  Two small leaks were found in the plumbing behind the washing machines. Both leaks were sealed, and the floor was dried and mopped with a bleach solution to prevent any potential bacterial issues. Blanket having contact with water on the floor was cleaned. The Laundry room has been reorganized and separated into two sections. There is now a wash side, and a clean/dry side. Further issues in the laundry room are to be placed in the TELS system upon report to the maintenance director to create a work order." Laundry staff will be educated about infection control measures and bringing concerns to management if observed. Administrator or designee will inspect laundry area twice weekly to ensure infection control standards are met.  Audits will continue weekly x4 then monthly x3.  Results of audits will be shared with the QAPI committee.

1. Resident 3 was admitted to the facility in 6/2025 with diagnosis of hemiparesis (one-sided weakness) following a stroke.-á Resident 3GÇÖs record revealed the resident was offered but declined a PCV20 vaccine on 6/18/25.-á The Declination of Influenza or Pneumococcal Vaccination form signed by Resident 3 on 6/18/25 did not include education on the potential side effects of the pneumococcal vaccine. Resident 3GÇÖs record revealed the resident received an influenza vaccine 9/22/25. In an interview on 1/16/26 at 11:30 AM, Staff 25 (IP) confirmed no education was provided related to the possible adverse side effects of the influenza or pneumococcal vaccines. 2. Resident 10 was admitted to the facility in 6/2019 with diagnosis of severe morbid obesity. Resident 10GÇÖs immunization record revealed the resident received an influenza vaccine on 9/23/25. The immunization record indicated education on the potential side effects of the influenza vaccine did not occur. In an interview on 1/16/26 at 11:30 AM, Staff 25 (IP) confirmed no education was provided related to the possible adverse side effects of the influenza vaccine. 3. Resident 13 was admitted to the facility in 10/2025 with diagnosis of diabetes with hyperglycemia.-á Resident 13GÇÖs immunization record revealed the resident was offered a PCV20 and an influenza vaccine on 10/14/25 and chose to decline both. The Declination of Influenza or Pneumococcal Vaccination form signed by Resident 13 on 10/14/25 did not include education on the potential side effects of the pneumococcal and influenza vaccines. In an interview on 1/16/26 at 11:30 AM, Staff 25 (IP) confirmed no education was provided related to the possible adverse side effects of the influenza or pneumococcal vaccines. 4. Resident 14 was admitted to the facility in 11/2025 with diagnosis of rheumatoid arthritis. Resident 14GÇÖs record revealed the resident was offered a PCV20 and an influenza vaccine on 11/6/25 and chose to decline both. The Adult Vaccination Declination Form verbally reviewed with resident on 11/6/25 did not include education on the potential side effects of the pneumococcal and influenza vaccines. In an interview on 1/16/26 at 11:30 AM, Staff 25 (IP) confirmed no education was provided related to the possible adverse side effects of the influenza or pneumococcal vaccines. 5. Resident 30 was admitted in 5/2024 with diagnosis of Diabetes. Resident 30GÇÖs immunization record revealed the resident was offered a PCV20 vaccine and declined it on 11/5/25. The Adult Vaccination Declination Form reviewed verbally with Resident 30 on 11/5/25 did not include education on the potential side effects of the pneumococcal vaccine. -áResident 30GÇÖs immunization record revealed the resident received an influenza vaccine on 9/22/25.-á The immunization record indicated education on the potential side effects of the influenza vaccine did not occur. In an interview on 1/16/26 at 11:30 AM, Staff 25 (IP) confirmed no education was provided related to the possible adverse side effects of the influenza or pneumococcal vaccines.

Resident 3, 10, 13, 14 and 30 have received the FLU and Pneumococcal Vaccine Information Sheet (VIS) from the CDC for vaccine received at this facility. Other current residents receiving FLU and Pneumococcal vaccines in the last 30 days will be given the FLU and Pneumococcal VIS for any vaccines given at this facility. Education will be provided to nurses about providing the FLU and Pneumococcal VIS to residents who agree to receive a FLU and Pneumococcal vaccine, so they can be aware of the potential risks and benefits. DNS or designee will audit three charts weekly to ensure FLU and Pneumococcal vaccines administered have documentation of risk vs benefit education being provided.  Audits will continue weekly x4 then monthly x3.  Results of audits will be shared with the QAPI committee.

1. Resident 3 was admitted to the facility in 6/2025 with diagnosis of hemiparesis (one-sided weakness) following a stroke.-á Resident 3GÇÖs immunization record revealed she/he received a COVID-19 vaccine on 10/8/25. The Vaccine Consent Form signed by Resident 3 on 9/19/25 did not include education on the potential side effects of the COVID-19 vaccine. In an interview on 1/16/26 at 11:30 AM, Staff 25 (IP) confirmed no education was provided related to the possible adverse side effects of the COVID-19 vaccine. 2. Resident 10 was admitted to the facility in 6/2019 with diagnosis of severe morbid obesity. Resident 10GÇÖs immunization record revealed the resident was offered a COVID-19 vaccine on 9/19/25 and chose to decline. The Declination of COVID-19 Vaccination form did not include education on the potential side effects of the COVID-19 vaccine. In an interview on 1/16/26 at 11:30 AM, Staff 25 (IP) confirmed no education was provided related to the possible adverse side effects of the COVID-19 vaccine. 3. Resident 13 was admitted to the facility in 10/2025 with diagnosis of diabetes with hyperglycemia.-á Resident 13GÇÖs immunization record revealed the resident was offered a COVID-19 vaccine on 10/14/25 and chose to decline. The Declination of COVID-19 Vaccination Form did not include education on the potential side effects of the COVID-19 vaccine. In an interview on 1/16/26 at 11:30 AM, Staff 25 (IP) confirmed no education was provided related to the possible adverse side effects of the COVID-19 vaccine. 4. Resident 14 was admitted to the facility in 11/2025 with diagnosis of rheumatoid arthritis. Resident 14GÇÖs immunization record revealed the resident was offered a COVID-19 vaccine on 11/6/25 and chose to decline. The Adult Vaccination Declination Form verbally reviewed with resident on 11/6/25 did not include education on the potential side effects of the COVID-19 vaccine. 5. Resident 30 was admitted in 5/2024 with diagnosis of diabetes. Resident 30GÇÖs immunization record revealed the resident was offered a COVID-19 vaccine on 11/5/25 and chose to decline. The Adult Vaccination Declination Form verbally reviewed with resident on 11/5/25 did not include education on the potential side effects of the COVID-19 vaccine. In an interview on 1/16/26 at 11:30 AM, Staff 25 (IP) confirmed no education was provided related to the possible adverse side effects of the COVID-19 vaccine.

Resident 3, 10, 13, 14 and 30 have received the COVID Vaccine Information Sheet (VIS) from the CDC for vaccine received at this facility. Other current residents receiving COVID vaccines in the last 30 days will be given the COVID VIS for any vaccines given at this facility. Education will be provided to nurses about providing the COVID VIS to residents who agree to receive a COVID vaccine, so they can be aware of the potential risks and benefits. DNS or designee will audit three charts weekly to ensure COVID vaccines administered have documentation of risk vs benefit education being provided.  Audits will continue weekly x4 then monthly x3.  Results of audits will be shared with the QAPI committee.

Based on interview and record review it was determined the facility failed to ensure a resident received wound care according to physician orders for 1 of 3 sampled residents (#102) reviewed for wound care. This placed residents at risk for worsening wounds or infection. Findings include: Resident 102 was admitted to the facility in 3/2025, with diagnoses including an open fracture of the left lower leg with a deep incisional surgical site and diabetes. Resident 102's Hospital Discharge Instruction Orders dated 3/15/25 revealed staff were to make a follow-up appointment with the surgeon in two weeks and provide the following surgical wound care instructions: -Honeycomb dressing on for 7 days. Change if saturated more than 50%. Leave off after 7 days. Resident may shower. -Call MD for excessive drainage. -OK to remove staples two weeks after surgery if patient is still present in facility. -Apply ice to affected area as needed (typically 20 minutes every 2-3 hours) to control swelling and pain. -If splint or cast in place please keep clean and dry until first post visit. Resident 102's Admission Nursing Database dated 3/15/25 contained no information related to the resident's deep incisional surgical site of the left shin or for the care and treatment of the wound. The 3/2025 MAR and TAR for Resident 102 revealed no orders for wound care or monitoring of the wound from 3/15/25 to 3/31/25. Resident 102's Provider Progress Note dated 4/1/25 indicated the resident had missed her/his two week follow-up appointment with the surgeon and staff reported the resident's surgical wound had new slough (necrotic tissue), increased redness and some drainage. The provider determined the presence of cellulitis (bacterial infection of the skin and underlying tissue) and started the resident on an antibiotic. The 4/2025 updated MAR and TAR for Resident 102 revealed an order for wound care to the left shin daily and PRN every day shift. The TAR revealed no wound care was provided on 4/2/25 or 4/4/25. On 5/23/25 at 8:30 AM, Staff 4 (Wound Care/LPN) indicated Resident 102's surgical site should have been checked and monitored by nursing staff on admission. Staff 4 acknowledged the sutures had not been removed per the resident's physician's order. Staff 4 stated he saw the wound on 4/1/25 and reported his concerns regarding the resident's wound to the physician. On 5/23/25 at 9:00 AM, Staff 3 (RNCM) indicated the orders for wound care for the resident upon admission were not transcribed into the resident's medical record. Staff 3 acknowledged Resident 102's orders for her/his dressing was not implemented for the first seven days, there was no documentation for monitoring the resident's wound, the resident's follow-up appointment was missed and the resident's sutures were not removed.

The facility failed to ensure that resident 102 received wound care according to physician orders upon admission to the facility. Resident 102 had their wound care plan and orders reviewed for accuracy and completion. The facility determined that all residents who were admitted to the facility with wounds could be affected by this deficiency. A review of admissions for the last 2 weeks was completed to ensure accuracy and completion of physician wound care orders. If errors were found, they were corrected at that moment. The director of nursing and administrator reviewed the policy and procedures for wound care, following physician orders, and admission skin assessments and deemed them appropriate. All nurses were educated about these policies and procedures. The director of nursing or designee will audit new admissions for accurate admission skin assessments; physician follow up and wound care orders weekly for four weeks and then monthly for four months. All audits will be brought to the QAPI team for review.

Based on interview and record review it was determined the facility failed to provide an accurate and timely assessment of an open surgical wound within eight hours of admission for 1 of 1 sampled resident (#102) reviewed for wound care. This placed residents at risk of untimely treatment and worsening of the wound. Findings include: Resident 102 was admitted to the facility in 3/2025, with diagnoses including an open fracture of the left lower leg with a deep incisional surgical site and diabetes. Resident 102's Admission Nursing Database dated 3/15/25 contained no information or assessment of the resident's deep incisional surgical site of the left shin, nor any documentation of care and treatment of the wound. On 5/23/25 at 9:00 AM, Staff 3 (RNCM) acknowledged the Admission Nursing Database did not contain the required assessment of the resident's surgical site wound within the required eight hours of admission.

The facility failed to provide an accurate and timely assessment of an open surgical wound for Resident 102. Resident 102 had an accurate skin and wound assessment completed and uploaded into the chart. It was determined that all new admissions could be affected by this deficiency. All admissions for the last two weeks were assessed for accurate admission skin and wound assessments. If errors were found, they were corrected at that moment. The director of nursing and administrator reviewed the policy and procedures for wound care, following physician orders, and admission skin assessments and deemed them appropriate. All nurses were educated about these policies and procedures. The director of nursing or designee will audit new admissions for accurate admission skin assessments; physician follow up and wound care orders weekly for four weeks and then monthly for four months. All audits will be brought to the QAPI team for review.

**************************** OAR 411-086-0110 - Nursing Services: Resident Care Refer to F684 ****************************

Based on interview and record review it was determined the facility failed to ensure interventions to prevent a resident's elopement were in place for 1 of 3 sampled residents (#315) reviewed for accidents. This placed residents at risk for lack of a safe enviroment. Findings include: Resident 315 admitted to the facility in 5/2024 with diagnoses including Parkinson's disease (disease of the nervous system) and repeat falls. A 9/15/24 revised care plan indicated Resident 315 was an elopement risk with impaired safety awareness, she/he was not to leave the facility unattended and staff were to determine the reason for her/him wanting to leave the facility with pleasant diversions offered. A 9/16/24 Nursing Care Note indicated Resident 315 was observed exiting the facility out the back door (close to her/his room) by Staff 10 (CNA) and two staff followed the resident. Resident 315 came back into the building with assistance by Staff 3 (Resident Care Manager-LPN). Resident 315 acknowledged she/he attempted to leave the building (unattended) and 15-minute checks were implemented. A 9/16/24 Elopement Risk Evaluation indicated Resident 315 was cognitively impaired with poor decision-making skills, verbally expressed the desire to leave the building, had a history of wandering, but no history of elopement. A 9/27/24 revised care plan indicated Resident 315 was able to self-propel with the use of a manual wheelchair and may need one staff to assist for mobility if weak and fatigued. A 9/28/24 at 2:26 PM Alert Note indicated Resident 315 was observed in her/his wheelchair in the hall at 2:00 PM. At 2:03 PM a staff member observed the resident from a facility window at the top of the hill on the road next to the stop sign which was next to the facility. Resident 315 hid her/his wheelchair in the courtyard and went out a different back door (not close to his room). Resident was placed on 15 minute checks. A 9/28/24 at 10:01 PM Situation, Background, Assessment and Recommendation Progress Note indicated Resident 315 did not seek to leave the building for the last 30 days until 9/28/24. Resident 315 was interviewed and was able to described how and why she/he left the building. On 9/30/24 at 11:59 AM Staff 11 (CNA) stated he was aware Resident 315 was exit-seeking over the last seven days. On 9/30/24 at 12:28 PM Staff 3 stated there was no investigation completed related to the 9/16/24 elopement incident because Resident 315 did not leave the facility grounds. On 9/30/24 at 1:08 PM and 1:30 PM Staff 10 stated on 9/16/24 she observed Resident 315 on the outside of the back door with no other staff around. Staff 10 stated she assumed the resident knew the code for the back door based on her observation of the 9/16/24 incident because no other staff were in the vicinity. On 9/30/24 at 8:50 PM Staff 7 (LPN) stated she began an investigation when Resident 315 eloped from the building at 2:00 PM on 9/28/24. Staff 7 acknowledged Resident 315 was not asked how she/he exited the building until she/he exited the building the second time in the evening on 9/28/24. On 10/1/24 at 3:52 PM Staff 1 (Administrator in Training) stated an investigation for Resident 315's exit seeking behavior was not started as required for the 9/16/24 incident. Staff 1 stated because she was unaware of the 9/16/24 incident, she believed 15 minute checks were sufficient to keep Resident 315 safe on 9/28/24 at 2:00 PM when she was informed. Staff 1 acknowledged interventions related to her/his ability to leave the building unattended and elope was not discovered and implemented due to the lack of investigations after the first two incidents.

Situation: Resident 315 was discovered outside the facility around 2pm, code pink drill was initiated and Resident 315 returned to the facility. At this point in time Resident 315 was placed on 15-minute checks, elopement assessment was updated along with care plan, assessed for injuries, and physician and son were notified of the elopement. CNA went to go do a 15-minute check on Resident 315 and discovered that he was not in his room around 9pm. Code pink drill was initiated, and they were unable to locate Resident 315. Eugene Police department was notified of the clothes he was wearing and that he was seen within 5 minutes of the last check, inside the building by the nurse. Staff members were also dispatched into the community via car and foot to help try and locate Resident. Resident 315 returned to the facility approximately 15 minutes later. At this time, Resident 315 was placed on a one to one, Care plan updated, assessment for injuries completed, Physician and son max were notified. The facility failed to complete a risk management for an elopement attempt that Resident 315 had on 9/16/2024. Had the administrator and DON known about the elopement attempt at that time, we would have had different interventions in place, that could have prevented the elopements on 9/28/2024. For Resident 315: • Slums was completed on 9/30 showing a score of 17 • Labs were ordered on 9/30 • 9/28 SDS caseworker was contacted to help find placement • 9/28 Assistant Administrator educated Resident 315 on the importance of notifying staff when leaving the facility. The root cause of the elopement is that Resident 315 would like to return home. Unfortunately, Resident 315 no longer has a residence, the facility and SDS caseworker are working on a different discharge location for Resident 315 to help them attain their goals of discharging to the community. It is determined that all residents who are elopement risks could be affected by this deficiency. 9/28 and 10/4 all door codes to the facility were changed 10/4 Signs were hung that stated Make sure you are leaving with only your party at each exit door. Starting on 9/28 residents were reassessed for elopement and changes were made to care plan and Code pink binder as necessary Starting on 9/28 verbal education was given to staff on shift for elopement and wandering. Starting on 9/30 staff members were educated on elopement and wandering, and the importance of notification and risk management completion for an elopement attempt. They were instructed to make sure doors properly latch behind them, and not to share the door code with residents. To ensure ongoing compliance the facility will audit up to 5 residents for accurate elopement assessments weekly for four weeks, and then monthly for an additional 4 months. All audits will be brought to the QAPI team for review.

*********************************** OAR 411-086-0140 Nursing Services: Problem Resolution and Preventive Care Refer to F689 ***********************************

Based on interview and record review it was determined the facility failed to inform residents of the risks and benefits of psychotropic medication use for 1 of 5 sampled resident (#12) reviewed for medications. This placed residents at risk for being uniformed. Findings include: Resident 12 admitted to the facility in 2024 with diagnoses including anxiety disorder and depression. A review a 7/18/24 physician order revealed Resident 12 received Lexapro (antidepressant) daily. A review of the medical record revealed no risk and benefit information for Lexapro. On 8/5/24 at 10:26 AM Staff 2 (DNS) verified the risk and benefit information was not reviewed with Resident 12.

The facility failed to inform and give Resident 12 the right to make treatment decisions by not completing a consent for use of psychotropic medication for their Lexapro medication. An audit was done of R12’s psychotropic medications and consents were completed for all medications. It was determined that all residents that use psychotropic medications are at risk of being affected by this deficiency. An audit was completed of all psychotropic medications to ensure there were completed consents for them. The Director of Nursing Services and the administrator reviewed the policy for administering psychotropic medication and deemed the policy appropriate. All nurses and the social services director were educated on this policy. The director of nursing services or designee will audit all new start psychotropic medications weekly for four weeks, and then monthly times four months. All audits will be brought to the QAPI team to review.

Based on observation, interview, and record review it was determined the facility failed to assess a resident's ability to self-administer medications for 1 of 1 sampled resident (#11) reviewed for respiratory care. This placed residents at risk for improper medication administration. Findings include: Resident 11 was admitted to the facility in 8/2014 with diagnoses including COPD (lung disease). On 7/31/24 at 10:57 AM Resident 11 was sitting up in bed with two inhaler medications for COPD on the bedside table. Resident 11 explained these medications were used to help her/his breathing. No assessment was found in the medical record for self-administration of medications for Resident 11. On 7/31/24 at 11:23 AM Staff 26 (LPN) confirmed Resident 11 was not assessed to self-administer her/his medications and should have been assessed prior to self-administration of her/his medications.

The facility failed to remove inhaler medications from resident 11's bedside and did not have a resident self-administration of medication assessment completed for them. The inhaler medications were immediately removed from the beside. Resident 11 was assessed and deemed inappropriate to have medications left at bedside. It was determined that all residents could be affected by this deficiency. An audit was conducted in all resident rooms to ensure that medications were not at besides, unless there was a completed self-administration of medication assessment completed indicating that it was appropriate to do so. The director of nursing services and the administrator reviewed the self-administration of medication policy and deemed it appropriate. All nurses were educated on this policy. The director of nursing services or designee will audit 5 rooms to ensure medications are not being left at bedside weekly times four weeks, then monthly times four weeks. All audits will be brought to the QAPI team for review.

Based on interview and record review it was determined the facility failed to ensure residents were treated in a dignified manner for 1 of 3 sampled residents (#265) reviewed for dignity. This placed residents at risk for psychosocial harm. Findings include: Resident 265 was admitted to the facility in 12/2023 with diagnoses including depression. A 12/10/23 MDS indicated Resident 265 was cognitively intact. A review of a 2/9/24 Nursing Facility Reported Incident Form revealed Resident 265 had complained about a HIPPA violation committed by Staff 34 (former SSD). A review of a 2/12/24 witness statement from Staff 35 (Activities Director) revealed on 2/7/24 Staff 35 was driving the bus to the bank and heard Staff 34 talking with Resident 265 about the name Resident 265 preferred to go by and Staff 34 asked Resident 265 about her/his finances. When they returned to the facility, Staff 35 brought Resident 265 to her/his room and Resident 265 expressed to Staff 35 how the interaction with Staff 34 had upset her/him. A review of a 2/12/24 witness statement from Resident 265 stated on 2/7/24 Staff 3 asked her/him all kinds of probing questions about her/his preferred name her/his finances and Staff 34 stated Resident 265's house was in foreclosure. Resident 265 stated she/he told Staff 34 she was wrong and Staff 34 replied and said she had read Resident 265's chart and knew everything about her/him. Resident 265 stated she/he felt her/his HIPPA rights were violated. Resident 265 stated on 2/9/24 Staff 34 came into her/his room. Staff 34 asked how Resident 265 liked her/his new room, Resident 265's hands were shaking and she/he replied the room was ok. Staff 34 stated, "it could be worse, you could be homeless". A review of a 2/12/24 witness statement from Staff 34 revealed on 2/7/24 while on the bus she was talking to Resident 265 to try to make a connection with her/him. Staff 34 stated she asked about Resident 265's preferred name and asked about Resident 265's finances. Staff 34 stated there was another resident in the back of the bus but this resident was unable to hear the discussion. Staff 34 stated on 2/9/24 she checked in with Resident 265 and Staff 34 denied any issues from that visit. A review of a 2/12/24 investigation had indicated Staff 34 had violated Resident 265's HIPPA rights and had caused Resident 265 to have increased anxiety and distress. On 8/2/24 at 9:14 AM Staff 36 (CNA) stated Resident 265 had informed her of the incident on the bus on 2/7/24 with Staff 34. Staff 36 stated Resident 265 was a private person and was upset by the incident. On 8/2/24 at 10:00 AM Staff 35 stated she was driving Staff 34, Resident 265 and another resident to the bank. The other resident was sitting in the back of the bus and Resident 265 was sitting in the middle of the bus. Staff 35 stated she heard Staff 34 talking to Resident 265 about the name she/he preferred to go by and about Resident 265's house getting foreclosed on. Staff 35 stated she could hear Resident 265 getting upset but Staff 34 kept talking and did not appear to understand Resident 265 was getting upset. When they returned to the facility, Staff 35 took Resident 265 to her/his room. Resident 265 asked Staff 35 why Staff 34 would say those things in front of another resident and Resident 265 stated she felt like her/his privacy was violated. Staff 35 assisted Resident 265 with completing a grievance form. On 8/5/24 at 10:35 AM the investigation was reviewed with Staff 1 (Administrator in Training), no further information was provided.

The facility failed to respect Resident 265’s dignity by sharing their personal information in front of other residents. Resident 265 no longer lives in the facility. It was determined that all residents could be affected by this deficiency. Ambassador rounds were conducted on all current residents to ensure that there were no further concerns from other residents. The director of nursing services and administrator reviewed the policy for resident rights and deemed it appropriate. All staff were educated on this policy and the importance of keeping resident information private. The administrator or designee will audit 5 resident’s ambassador rounds for any concerns for respect or dignity weekly times four weeks, and then monthly times four months. All audits will be brought to the QAPI team for review.

Based on interview and record review it was determined the facility failed to provide rules and regulations governing resident conduct and responsibilities for 1 of 3 sampled residents (#214) reviewed for food. This placed residents at risk for being unformed about rules for resident conduct. Finding include: Resident 214 was admitted to the facility in 6/2024 with diagnoses including stroke and anxiety. A 1/2024 facility Resident Handbook indicated "compact refrigerators may be approved for patient use." A 7/16/24 Quarterly MDS indicated Resident 214 was cognitively intact. On 8/2/24 at 11:38 AM Resident 214 stated Staff 14 (Maintenance Director) at one time indicated small refrigerators were allowed in resident rooms and she/he was confused why a request for her/his own refrigerator was recently denied. Resident 214 stated she/he did not receive a copy of a Resident Handbook upon admission to the facility and had no knowledge related to any official rules related to compact refrigerators in resident rooms. On 8/2/24 at 3:49 PM Staff 1 (Administrator in Training) acknowledged at least since 3/2024 residents were not provided a copy of the Resident Handbook as expected.

The facility failed to notify resident 214 of their rights and rules of the facility upon admission. Resident 214 was given a resident handbook explaining these topics. It was determined that all residents could be affected by this deficiency. A resident handbook was provided to all residents in the facility, and a resident handbook will be provided upon admission to the facility. The administrator and the director of nursing services reviewed the resident handbook and determined that no changes needed to be made. The admissions coordinator and the director of social services were educated on the importance of providing residents with a resident handbook. The administrator or designee will audit 5 admissions to ensure that they receive a resident handbook weekly times four weeks, and then monthly times for months. All audits will be brought to the QAPI team for review.

Based on interview and record review it was determined the facility failed to obtain information related to advance directives and health care decisions for 2 of 3 sampled residents (#s 12 and 18) reviewed for advance directives. This placed residents at risk for not having their health care decisions honored. Findings include: 1. Resident 12 was admitted to the facility in 3/2024 with a diagnosis of a hip fracture. A 3/28/24 Admission 72-hour huddle note indicated Resident 12 had an advance directive and a copy was to be retained for the resident's electronic record. Resident 12's clinical record did not contain her/his advance directive. On 8/1/24 at 1:50 PM Staff 24 (Social Services Director) acknowledged Resident 12's electronic record did not contain an advance directive. , 2. Resident 18 was admitted to the facility in 5/2016 with diagnoses including congested heart failure (a disease in which the heart cannot pump enough blood). A 5/30/24 care conference indicated Resident 18 would like assistance formulating an Advanced Directive. A 7/30/24 review of Resident 18's medical record revealed no evidence of an Advanced Directive. On 7/31/24 at 10:43 AM Resident 18 stated she/he would like to complete an Advanced Directive. On 8/2/24 at 8:26 AM Staff 24 (Social Service Director) confirmed Resident 18 did not have an Advanced Directive on file.

The facility failed to ensure that an advanced directive was uploaded for resident 12 and resident 18 although the chart indicated that they had one. The social services director interviewed resident 12, who did not have an advanced directive but accepted information on completing it. Resident 18 was also interviewed and declined to have an advanced directive. It was determined that all residents could be affected by this deficiency. An audit was conducted on all residents, and those without advanced directives already in their chart were interviewed by the social services director and were provided with information on completing and advanced directives. The administrator and director of nursing services reviewed the policy and advanced directives and deemed it appropriate. All nurses and the social services director were educated on the importance of giving residents information about advanced directives. The administrator or designee will audit 5 new admissions’ charts for advanced directives weekly times four weeks, then monthly times four months. All audits will be brought to the QAPI team for review.

Based on interview and record review it was determined the facility failed to notify family for 2 of 4 sampled residents (#s 4 and 266) reviewed for notification. This placed resident representatives at risk for lack of being informed. Findings include: 1. Resident 4 was admitted to the facility in 1/2024 with a diagnosis of MS (multiple sclerosis: lack of electrical impulses from the brain to the body creating impaired body functions). Resident 4's undated Admission Record revealed Witness 6 (Family) was her/his first emergency contact. A 5/21/24 Progress Note revealed Resident 4 had a change in mentation, loose stools and, dark orange urine. The note indicated a RN sent the resident to the hospital for evaluation based on her/his history of decreased kidney function and diagnosis of MS. The note did not indicate Resident 4's emergency contact was notified. On 8/5/24 at 12:51 PM Witness 6 stated she was not notified of Resident 4's 5/2024 hospitalization. On 8/5/24 at 2:11 PM Staff 1 (Administrator) stated Resident 4's emergency contact was not notified of the resident's change of condition and hospitalization. , 2. Resident 266 was admitted to the facility in 7/2024 with diagnoses including dementia and history of UTIs. A 7/26/24 census for Resident 266 revealed she/he moved to a different room on 7/26/24. On 7/29/24 at 8:02 PM Witness 3 (Family) stated she was not informed prior to Resident 266's room move even when Witness 3 arrived for a family visit. Review of Resident 266's clinical record revealed no communication to family related to Resident 266's room move. On 8/2/24 at 3:53 PM Staff 9 (Admission Coordinator) stated she did not consider the impact of a room move on Resident 266 with her/his dementia. Staff 9 acknowledged the move occurred without family involvement and there was no written communication related to Resident 266's room move.

The facility failed to notify the responsible party resident 4 of an acute change that required resident to discharge to the hospital, and of resident 266 that they had moved rooms within the facility. The director of nursing services called the responsible parties of both residents and explained that the facility was initiating education so that this deficiency did not occur again. It was determined that all residents could be affected by this deficiency. The last 30 days of hospital discharges and facility room moves were audited for responsible party notification and were corrected as needed. The administrator and director of nursing services reviewed the policies regarding responsible party notification and deemed them appropriate. All nurses and interdisciplinary team were educated on the importance of notifying the responsible party of the resident with any changes to the resident. The director of nursing services or designee will audit 5 resident hospitalizations, or room moves for responsible party notifications weekly times four weeks, and then monthly times four months. All audits will be brought to the QAPI team for review.

Based on interview and record review it was determined the facility failed to maintain resident rights to privacy for 2 of 5 sampled residents (#s 263 and 265) reviewed for dignity and privacy. This placed residents at risk for psychosocial harm. Findings include: 1. Resident 263 was admitted to the facility in 6/2023 with diagnoses including dementia and malnutrition. A 1/16/24 Quarterly MDS indicated Resident 263 was cognitively impaired. A 2/9/24 Discharge Plan of Care indicated Resident 263 was discharged to a memory care facility. On 7/30/24 at 10:15 AM Witness 4 stated unwanted family members entered Resident 263's new memory care facility and she was unaware how they obtained the information regarding Resident 263's discharge location. A 7/31/24 Contacts list for Resident 263 indicated only Witness 4 (Family) and Witness 5 (Family) had access to Resident 263's medical information. On 7/31/24 at 4:18 PM Staff 1 (Administrator in Training) acknowledged she was aware Staff 27 (former Social Service Director) informed family members who were not on Resident 263's contact list about Resident 263's discharge location. , 2. Resident 265 was admitted to the facility in 12/2023 with diagnoses including depression. A 12/10/23 Admission MDS indicated Resident 265 was cognitively intact. A review of a 2/9/24 Nursing Facility Reported Incident Form revealed Resident 265 had complained about a HIPPA violation committed by Staff 34 (former SSD). A review of a 2/12/24 witness statement from Staff 35 (Activities Director) revealed on 2/7/24 Staff 35 was driving the bus to the bank and heard Staff 34 talking with Resident 265 about the name Resident 265 preferred to go by and Staff 34 asked Resident 265 about her/his finances. When they returned to the facility, Staff 35 brought Resident 265 to her/his room and Resident 265 expressed to Staff 35 how the interaction with Staff 34 had upset her/him. A review of a 2/12/24 witness statement from Resident 265 stated on 2/7/24 Staff 34 asked her/him all kinds of probing questions about her/his preferred name her/his finances and Staff 34 stated Resident 265's house was in foreclosure. Resident 265 stated she/he told Staff 34 she was wrong and Staff 34 replied and said she read Resident 265's chart and knew everything about her/him. Resident 265 stated she/he felt her/his HIPPA rights were violated. Resident 265 stated on 2/9/24 Staff 34 came into her/his room. Staff 34 asked how Resident 265 liked her/his new room, Resident 265's hands were shaking and she/he replied the room was ok. Staff 34 stated, "it could be worse, you could be homeless." A review of a 2/12/24 witness statement from Staff 34 stated on 2/7/24 while on the bus she was talking to Resident 265 to try to make a connection with her/him. Staff 34 stated she asked about Resident 265's preferred name and asked about Resident 265's finances. Staff 34 stated there was another resident in the back of the bus but this resident was unable to hear the discussion. Staff 34 stated on 2/9/24 she checked in with Resident 265 and Staff 34 denied any issues from that visit. A review of a 2/12/24 investigation had indicated Staff 34 violated Resident 265's HIPPA rights and caused Resident 265 to have increased anxiety and distress. On 8/2/24 at 9:14 AM Staff 36 (CNA) stated Resident 265 informed her of the incident on the bus on 2/7/24 with Staff 34. Staff 36 stated Resident 265 was a private person and was upset by the incident. On 8/2/24 at 10:00 AM Staff 35 stated she was driving Staff 34, Resident 265 and another resident to the bank. The other resident was sitting in the back of the bus and Resident 265 was sitting in the middle of the bus. Staff 35 stated she heard Staff 34 talking to Resident 265 about the name she/he preferred to go by and about Resident 265's house getting foreclosed on. Staff 35 stated she could hear Resident 265 getting upset but Staff 34 kept talking and did not appear to understand Resident 265 was getting upset. When they returned to the facility, Staff 35 took Resident 265 to her/his room. Resident 265 asked Staff 35 why Staff 34 would say those things in front of another resident and Resident 265 stated she felt like her/his privacy was violated. Staff 35 assisted Resident 265 complete a grievance form. On 8/5/24 at 10:35 AM the investigation was reviewed with Staff 1 (Administrator in Training), no further information was provided.

The facility failed to keep confidential and personal privacy of resident 263 and 265 information. Both residents no longer reside in the facility. It was determined that all residents could be affected by this deficiency. A house wide audit of Hierarchy forms and profiles were conducted to make sure that they matched the residents wishes of who could be informed with their information, and charts were updated as needed. The administrator and director of nursing services reviewed the policy for sharing resident information and deemed it appropriate. All staff were educated on the importance of keeping resident personal information private. The administrator or designee will audit 5 new admission charts for completed Hierarchy and profile forms for sharing information weekly times four weeks and then monthly times four months. All audits will be brought to the QAPI team for review.

Based on observation, interview, and record review it was determined the facility failed to provide a comfortable and homelike environment for 1 of 4 sampled residents (#48) reviewed for ADLS. This placed residents at risk for an unhomelike living environment. Findings include: Resident 48 admitted to the facility in 3/2024 with diagnoses including palliative care and schizophrenia (mental illness). Observations made from 7/29/24 through 8/1/24 on day and evening shifts revealed the following: -7/29/24 at 2:13 PM, fall mats with dried white and yellow debris, brown dirt and a blanket were on top of the fall mats. Washcloths in the resident's sink with a dark brown substance on them. -7/30/24 at 9:10 AM, fall mats still with dried white and yellow debris and what appeared to be pink ice cream or juice. -8/1/24 at 10:55 AM, large towels remained on the floor mat and dirty wash clothes in sink. Staff 19 (CNA) was observed going in and out of the resident's room without grabbing the dirty towels or washcloths. -8/1/24 at 11:02 AM, large towels with yellow and brown debris on the fall mats, and wash clothes in the sink with brown debris on them. -On 8/1/24 at 11:10 AM, Staff 29 (Regional Nurse Consultant) observed Resident 48's room and acknowledged the room was not a homelike environment.

The facility failed to provide a clean homelike environment for resident 48. Resident 48’s room was deep cleaned and all dirty linen and fall mats were removed. It was determined that all residents could be affected by this deficiency. Ambassador rounds were done on all rooms to ensure cleanliness and a homelike environment for each resident, and changes were made at the time of discovery. The administrator and director of nursing reviewed the standards for clean homelike environments and deemed them appropriate. All staff were educated on the importance of keeping a clean homelike environment in all resident rooms. The administrator or designee will audit 5 resident rooms for a clean homelike environment weekly times four weeks and then monthly times four months. All audits will be brought to the QAPI team for review.

Based on interview and record review it was determined the facility failed to ensure residents were free from neglect for 1 of 1 sampled resident (#264) reviewed for accidents. This place residents at risk for neglect. Findings include: Resident 264 admitted to the facility in 4/2024 with diagnoses including leg surgery and chronic pain. An 4/23/24 Admission MDS indicated Resident 264 was cognitively intact. A FRI (facility reported incident) indicated on 4/28/24 at 8:00 PM Resident 264 requested tea from Staff 28 (Former CNA). The tea was brought in a hydration mug with a straw, Resident 264 took a drink through the straw and the hot water burnt her/his tongue and roof of her/his mouth. The FRI indicated the administrator was notified on 4/29/24 at 11:00 AM A facility investigation, finalized on 4/29/24, concluded neglect was substantiated as Resident 264 was injured from the hot tea. On 7/31/24 at 11:25 AM Staff 19 (CNA) stated staff training involved not serving the resident really hot beverages, and to make sure the beverages are tempted before serving them to the residents. On 7/31/24 11:45 AM Resident 264 stated she/he was getting ready for bed and Staff 28 offered the resident some hot tea. Resident 264 stated Staff 28 returned with her/his hydration mug which had a large plastic straw, and took a large drink of the tea and burnt her/his mouth. Resident 264 stated Staff 28 filled the mug with extremely hot water and neglected to warn her/him that the tea was very hot. Resident 264 stated she/he was screaming from the pain, and burnt her/his throat and tongue. Resident 264 stated skin came off the roof or her/his mouth, and the pain lasted for approximately two days. On 7/31/24 at 12:14 PM Staff 8 (CNA) stated staff completed training related to hot beverages and to make sure they are not too hot for the residents. On 8/1/24 at 2:40 PM Staff 6 (LPN-Resident Care Manager) acknowledged the tea was hot enough to burn Resident 264's mouth and tongue and caused discomfort. Staff 6 stated staff completed training related to serving hot beverages to residents. Staff 6 acknowledged the staff member should have tempted the beverage before serving it to Resident 264.

The facility failed to keep resident 264 free from abuse and neglect by serving resident hot liquids that caused them to burn the inside of their mouth. Resident 264 no longer resides in the facility. It was determined that all residents could be affected by this deficiency. Ambassador rounds were conducted on all residents to ensure there were no other abuse or neglect allegations. The administrator and Director of nursing services reviewed the policy for abuse and neglect and deemed it appropriate. All staff were educated on this policy. The administrator or designee will audit 5 residents’ ambassador rounds for abuse and neglect allegations weekly times four weeks and then monthly times four months. All audits will be brought to the QAPI team for review.

Based on interview and record review it was determined the facility failed to report an allegation of neglect to the appropriate State Agency within two hours for 1 of 1 sampled resident (#264) reviewed for accidents. This placed residents at risk for abuse and neglect. Findings include: Resident 264 admitted to the facility in 4/2024 with diagnoses including leg surgery and chronic pain. An 4/23/24 Admission MDS indicated the Resident 264 was cognitively intact. A FRI (facility reported incident) indicated on 4/28/24 at 8:00 PM Resident 264 requested tea from Staff 28 (Former CNA). The tea was brought in a hydration mug with a straw, Resident 264 took a drink through the straw and the hot water burnt her/his tongue and roof of her/his mouth. The FRI indicated the administrator was notified on 4/29/24 at 11:00 AM A facility investigation, finalized on 4/29/24, concluded neglect was substantiated as Resident 264 was injured from the hot tea. On 8/1/24 at 2:40 PM Staff 6 (LPN-Resident Care Manager) acknowledged he was aware of the incident on 4/28/24 at 8:00 PM but did not send the FRI to the State Agency until 4/29/24 at 12:00 PM. Staff 6 acknowledged the facility did not report the neglect within the two hour timeframe.

The facility failed to report an abuse allegation for resident 264 within the two-hour time frame. Resident 264 no longer resides in the facility. It was determined that all residents could be affected by this deficiency. Facility Reported Incidents were reviewed for the last 30 days to determine if they were reported within the two-hour window. The administrator and Director of nursing were both educated on the importance of reporting alleged abuse allegations within the two-hour time frame. All staff were educated on the importance of reporting abuse allegations immediately to the administrator or director of nursing services. The administrator or designee will audit 5 residents’ ambassador rounds for abuse or neglect allegations weekly for four weeks and then monthly for four months. All audits will be brought to the QAPI team for review.

Based on observation, interview and record review it was determined the facility failed to implement a comprehensive care plan for 3 of 9 sampled residents (#s 2, 165, and 266) reviewed for medications, accidents, and hospice. This placed residents at risk for unmet care needs. Finding include: 1. Resident 2 was admitted to the facility in 2/2024 with diagnoses including diabetes and dementia. The 6/5/24 revised care plan indicated there was no initial care plan for Resident 2's diabetic goals and interventions. The 6/30/24 through 7/30/24 Order Review History Report indicated Resident 2 had multiple orders for diabetic care which started on 2/26/24 including nail care by nursing. The 7/2024 Diabetic Administration Record indicated Resident 2 received insulin each morning. On 8/1/24 at approximately 1:00 PM Staff 23 (LPN-Resident Care Manager) acknowledged Resident 2 lacked a diabetic care plan. 2. Resident 266 was admitted to the facility in 7/2024 with diagnoses including dementia and history of UTIs. A 7/16/24 Elopement Risk Evaluation identified Resident 266 as "high risk" for wandering. A 7/16/24 care plan had no goal or interventions related to Resident 266's high risk for wandering. On 7/29/24 at 12:41 PM and 3:05 PM Resident 266 was observed in the hall while wandering in her/his wheelchair and asked to get out of the building to find her/his car and family. On 8/1/24 at 12:46 PM Staff 6 (LPN-Resident Care Manager) acknowledged Resident 266's care plan was not complete related to her/his risk of elopement. , 3. Resident 165 was admitted to the facility in 7/2024 with diagnoses including hospice care. A review of Resident 165's clinical record revealed no comprehensive care plan was completed related to the resident's hospice care and or scheduled hospice visits. On 8/5/24 at 9:56 AM Staff 2 (DNS) acknowledged Resident 165's comprehensive care plan did not include any information regarding hospice care and services or scheduled hospice visits.

The facility failed to implement comprehensive care plans for three residents. Resident 2’s care plan was updated to reflect their diagnosis and care needed for his diabetes. Resident 266’s care plan was updated to reflect their high risk for wandering with appropriate interventions. Resident 165’s care plan was updated to reflect their end-of-life care and hospice involvement. It was determined that all residents could be affected by this deficiency. Care Plans for all residents were updated to reflect diabetes diagnosis and management; any wandering risk; and any hospice services as needed. The director of nursing services and administrator reviewed the policy for care plans and deemed it appropriate. All nurses and the interdisciplinary team were educated on this policy. The director of nursing or designee will review 5 resident care plans for accuracy weekly times four weeks, and then monthly for four months. All audits will be brought to the QAPI team for review.

Based on interview and record review it was determined the facility failed to update care plans for 4 of 11 sampled residents (#s 4, 15, 18, and 48) reviewed for UTIs, medications, ADLs, and accidents. This placed residents at risk for unmet care needs. Findings include: 1. Resident 4 was admitted to the facility in 1/2024 with a diagnosis of MS (multiple sclerosis: lack of electrical impulses from the brain to the body creating impaired body functions). Resident 4's care plan initiated on 5/7/24 revealed her/his urinary catheter was to be flushed (instilling a sterile solution into the catheter to ensure the tubing does not clog) three times per week. A 7/20/24 Progress Note revealed Resident 4's urology (specialized in urinary systems i.e. bladder, kidneys etc.) clinic sent physician orders to flush her/his urinary catheter (medical tubing inserted in the bladder to drain urine) one to two times each day. On 8/2/24 at 10:59 AM Staff 23 (LPN Resident Care Manager) stated when new orders were received for residents, the floor nurses were to update care plans. Staff 23 stated Resident 4's care plan was not updated to reflect a change in urinary catheter flushes. 2. Resident 15 was admitted to the facility in 11/2016 with a diagnosis of heart disease. A Care Plan revised on 5/16/24 revealed Resident 15 was at risk for falls and non-slip material was to be placed on her/his walker handles to prevent her/his hands from slipping. A 5/22/24 quarterly MDS indicated Resident 15 was cognitively intact. On 7/31/24 at 10:58 AM Resident 15's walker handles were observed without non-slip material. Resident 15 stated the non-slip material always came off and she/he did not use it because her/his hands did not slip. On 8/2/24 at 8:39 AM Staff 23 (LPN Resident Care Manager) stated she was not aware the resident no longer used the non-slip material on her/his walker and acknowledged the care plan was not updated. , 3. Resident 18 was admitted to the facility in 5/2016 with diagnoses including atrial fibrillation (an irregular heartbeat). A review of Resident 18's physician orders revealed a 7/11/22 order for apixaban, an anticoagulant medication (a blood thinner). A 7/31/24 review of Resident 18's care plan revealed no evidence of a care plan for anticoagulant medication. On 8/2/24 at 1:52 PM Staff 23 (LPN Resident Care Manager) Stated Resident 18 took an anticoagulant medication, apixaban, and confirmed Resident 18 was not care planned for anticoagulant medications. , 4. Resident 48 was admitted to the facility in 4/2024 with diagnoses including paranoid schizophrenia (mental disorder), chronic bed confinement, and hospice care. Resident 48's 3/14/24 care plan indicated the resident was moderate risk for falls related to a history of falls. The resident is bedbound with impaired mobility. Observations from 7/29/24 through 8/1/24 on day and evening shifts revealed Resident 48 had bilateral fall mats. On 7/31/23 at 11:06 AM Witness 9 (Caregiver) stated Resident 48 had fall mats "for a while related to falls." On 8/2/24 at 9:35 AM Staff 23 (LPN-Resident Care Manager) acknowledged Resident 48 had bilateral fall mats related to falls but the care plan was not revised for the fall mats.

The facility failed to maintain timely care planning revision for four residents within the facility. Resident 4’s care plan was updated to reflect current catheter care and needs. Resident 15 and 48’s care plans were updated to reflect current fall interventions. Resident 18’s care plan was updated to reflect current anticoagulant use and monitoring. It was determined that all residents could be affected by this deficiency. All resident care plans were audited to reflect current fall interventions, anticoagulant medications, and catheter care as needed. The director of nursing services and administrator reviewed the policy for care plans and deemed it appropriate. All nurses and the interdisciplinary team were educated on this policy. The director of nursing or designee will review 5 resident care plans for accuracy weekly times four weeks, and then monthly for four months. All audits will be brought to the QAPI team for review.

Based on observation, interview, and record review it was determined the facility failed to provide care and services to maintain good grooming and hygiene for 2 of 4 sampled residents (#s 48 and 164) reviewed for ADLs. This placed residents at risk for unmet needs. Findings include: 1. Resident 48 was admitted to the facility in 3/2024 with diagnoses including hospice services and chronic bed confinement. The 3/11/24 care plan indicated Resident 48 was totally dependent on staff for personal hygiene care and dressing. On 7/29/24 at 2:32 PM Resident 48 was observed to have greasy, uncombed hair, long jagged fingernails with brown debris underneath, food on her/his face and in her/his mouth, facial hair, and a shirt with dried dark brown debris. On 7/31/24 at 11:06 AM Witness 9 (Caregiver) stated Resident 48 did not receive the ADLS care she/he needed. Witness 9 stated Resident 48 needed staff to wash her/his hair, trim and clean her/his nails, shave her/him daily, lotion her/his dry feet, and put a clean shirt on the resident daily. Witness 9 stated she completed the ADL care while visiting but staff should provide the care. On 8/2/24 at 9:35 AM Staff 23 (LPN-Resident Care Manager) acknowledged Resident 48 should be cleaned up daily which included being shaved per her/his request. Staff 23 stated all ADLS should be completed by staff daily as the standard of care and not Witness 9. 2. Resident 164 was admitted to the facility in 7/2024 with diagnoses including hospice services and chronic dementia. The 7/12/24 care plan directed staff to provide constant/intermittent supervision with physical assist combing hair, brushing teeth, shaving, washing and drying face and hands. On 7/30/24 at 2:32 PM Resident 164 was observed with long fingernails with brown debris underneath. On 8/2/24 at 9:47 AM Staff 23 (LPN-Resident Care Manager) acknowledged Resident 164's nails were long with brown debris underneath and needed to be cleaned.

The facility failed to provide ADL care for 2 dependent residents in the facility. Residents 48 and 164 had ADL cares provided as the resident would allow, and their care plans were updated to reflect their current needs. It was determined that all dependent residents could be affected by this deficiency. Ambassador rounds were done on all residents to ensure that residents had the ADL care provided as they allowed. The director of nursing services and the administrator reviewed the ADL care standards and deemed them appropriate. All Nursing staff and the interdisciplinary team were educated on the importance of providing proper ADL care for all residents as they allowed. The director of nursing or designee will spot check 5 dependent residents for appropriate appearance weekly times four weeks, and then monthly times four months. All audits will be brought to the QAPI team for review.

Based on observation, interview, and record review it was determined the facility failed to follow-up with pain medication, perform neuro checks, follow physician orders and perform wound assessments for 5 of 10 sampled residents (#s 4, 15, 42, 163, and 165) reviewed for pain, accidents, UTI, and hospice. This placed residents at risk for unmet care needs. Findings include: 1. Resident 4 was admitted to the facility in 1/2024 with a diagnosis of MS ((multiple sclerosis: lack of electrical impulses from the brain to the body creating impaired body functions). A 7/2024 TAR revealed when Resident 4's urinary catheter (medical tubing inserted in the bladder to drain urine) was replaced, staff were to obtain a UA and culture (identified orginisms which caused a UTI). A 7/18/24 Progress Note revealed Resident 4 reported abdominal pain and there was no urine in the resident's catheter tubing or catheter urine collection bag. Staff replaced the existing catheter with a new sterile catheter and obtained a urine sample. A 7/18/24 Lab Results Report revealed the UA was not completed because the temperature of the sample was not correct and the urine was sent in the incorrect specimen collection tube. Resident 4's clinical record revealed no information to indicate a new sample was obtained. On 8/2/24 at 10:59 AM Staff 23 (LPN Resident Care Manager) stated if the sample was not able to be processed in the lab, staff should communicate with the physian and obtain orders if the UA was to be recollected. Staff 23 stated this was not done for Resident 4's 7/18/24 urine sample. 2. Resident 15 was admitted to the facility in 11/2016 with a diagnosis of heart disease. A 5/15/24 fall investigation revealed Resident 15 fell and hit her/his head. The fall was not observed by staff. A 5/15/24 Neurological Flow Sheet (a tool to identify a head injury) revealed staff were to obtain vital signs, check pupil size, assess if a resident could follow commands, and the assess the strength of her/his legs and arms. 12 of 22 opportunies a complete assessment was not performed. Eight of the incomplete assessments indicated Resident 4 refused the assessment or was sleeping. A 5/22/24 quarterly MDS revealed Resident 15 was cognitively intact. On 7/31/24 at 12:11 PM Resident 15 stated she/he did not refuse the neurological assessments and stated the assessments were important for the staff to monitor her/him after a fall when her/his head hit the floor hard. On 7/31/24 at 1:16 PM Staff 2 (DNS) stated the assessments should have been done to ensure the resident did not have a head injury. If the resident was asleep, staff should wake the resident and complete the assessment. 3. Resident 163 was admitted to the facility in 5/2024 with a diagnosis of cervical (neck) spine surgery. A 5/29/24 Admission Nursing Database assessment revealed Resident 163 had a neck incision and it was covered with a neck brace. There was no assessment of the incision. Resident 163's clinical record from 5/29/24 through 6/3/24 did not include any assessment of her/his incision. A 6/3/24 Discharge Skin Summary revealed the resident had a surgical incision that was covered. There was no assessment to describe the status of the incision. On 7/29/24 at 12:30 PM Witness 7 (Complainant) stated the dressing to the incision was not removed until 6/3/24 when Resident 163 was discharged from the facility and admitted to a new nursing facility. Witness 7 stated when the new facility staff removed the dressing the incision did not have signs of infection and was healing. On 8/1/24 at10:35 AM Staff 2 (DNS) stated she was not able to find an assessment of Resident 163's incision. , 4. Resident 42 was admitted to the facility in 7/2023 with diagnoses including spinal stenosis (a narrowing of the spinal canal in the lower part of the back). A review of a 12/7/23 neurology appointment form revealed orders for a MRI (magnetic resonance imaging test that uses magnets and radio waves to make detailed pictures of the inside of the body) of Resident 42's spine. A 2/15/24 Progress Note stated Resident 42 was unable to get an MRI completed due to a pacemaker with no information available on the type of pacemaker. The Progress Note stated the neurologist's office was to fax an order for a CT scan (computed tomography is a diagnostic test that uses a series of computerized views take from different angles to create internal pictures of the body). A review of Resident 42's medical record revealed no evidence of an order for a CT scan and no evidence it was completed. On 8/5/24 at 9:39 AM Staff 2 (DNS) stated Resident 42 was unable to get a MRI completed because there was no information about her/his pacemaker that was placed in China. Staff 2 stated the neurology office was notified in 2/2024 and was to send orders for a CT scan. Staff 2 confirmed there was no other documentation related to the CT scan and the it had not been completed. , 5. Resident 165 was admitted to the facility in 7/2024 with diagnoses including hospice. The 7/19/24 care plan for Resident 165 provide instructions for pain management including: assessment, monitoring for pain as well as prompt treatment with ordered pain medication. The goal was for Resident 165 to verbalize satisfaction with pain management by decreased reports of pain. The 7/23/24 Admission MDS indicated Resident 165 had pain related to lower left extremity infection. A progress note dated 7/21/24 at 5:20 PM indicated Resident 165 stated her/his pain was not well controlled with current medications. The on-call hospice nurse was to inform the hospice office on the morning of 7/22/24. A progress note dated 8/2/24 at 11:28 PM indicated hospice had an order for Resident 165 to receive morphine IR (immediate release). The note further indicated the resident was made aware due to her/him requesting the medication for a while. A progress note dated 8/2/24 at 1:31 PM indicated Resident 165 was not getting pain relief from the current regimen. Staff 17 (LPN) stated she told hospice again of the resident's concerns, but no new orders were provided. On 7/29/24 at 1:06 PM Resident 165 stated she/he had been asking hospice for morphine IR because the regimen she/he was on did not control her/his pain. On 7/30/24 at 1:44 PM Resident 165 was observed in her/his room and stated she/he was painful and her/his pain medications were not working. On 8/1/24 at 1:46 PM Resident 165 was observed in her/his room and stated she/he was in a lot of pain. Resident 165 stated she/he thought hospice was supposed to keep her/him comfortable but they were not. On 8/5/24 at 10:00 AM Staff 2 (DNS) stated she could not find physician notes indicating why the resident was not started on morphine IR when hospice was notified on 7/21/24.

The facility failed to uphold quality of care standards for four residents. Resident 4 did not have a UA followed up on timely; resident is currently being followed by outpatient urology clinic to help manage frequent UTIs. Resident 15 did not have completed neurological assessments after an unwitnessed fall; resident 15 was assessed for adverse neurological side effects from fall. Resident 42 did not have an order for CT followed up on time; CT scan was re-ordered to be completed. Resident 65’s pain level has been assessed by hospice and is continuing to make changes as their condition progresses. Resident 163 no longer resides in the facility. It was determined that all residents could be affected by this deficiency. An audit was completed for the last 30 days of falls, treatments and diagnostic orders, and any follow-up was done as needed. The director of nursing services and administrator reviewed the quality of care standards for patient and physician diagnostic follow-up and deemed them appropriate. All nurses were educated on the importance of follow-up with physician orders and resident diagnostics. The director of nursing services or designee will audit falls, treatment and diagnostic orders weekly for four weeks, and then monthly for four months. All audits will be brought to the QAPI team for review.

Based on interview, and record review it was determined the facility failed to investigate a new facility acquired pressure ulcer for 1 of 2 sampled residents (#20) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers. Findings include: Resident 20 was admitted to the facility in 2/2020 with diagnoses including hemiplegia (paralysis of one side of the body) of the left nondominant side. A 7/29/24 review of Resident 20's medical record revealed a 2/9/24 facility acquired stage 3 pressure ulcer (a full thickness tissue loss wound cause by pressure) to her/his sacrococcygel (tailbone). A review of a 7/29/24 Wound Evaluation revealed a stage 3 wound on Resident 20's sacrococcygel which measured 0.76 cm by 0.5 cm. On 8/1/24 at 12:28 PM Staff 37 (Regional Nurse Consultant) stated there was no investigation completed for Resident 20's 2/9/24 facility acquired pressure ulcer to her/his sacrococcygel. On 8/2/24 at 10:53 AM Resident 20 was observed to have an open stage 3 wound on her/his right upper buttock near the sacrococcygel area. Resident 20's wound and entire buttock area was surrounded by red moisture associated damaged skin.

The facility failed to investigate an in-house acquired pressure ulcer for resident 20. An investigation was completed on resident 20 and treatments are ongoing. It was determined that all residents could be affected by this deficiency. An audit was done for the last 30 days of in-house acquired pressure ulcers for completed investigations, those without investigations were completed at that time. The director of nursing services and the administrator reviewed the policy for pressure ulcers and deemed it appropriate. All nurses were educated on this policy. The director of nursing services or designee will audit 5 residents with wounds to ensure proper documentation and investigation is complete weekly times four weeks, and then monthly times four months. All audits will be brought to the QAPI team for review.

Based on observation, interview, and record review it was determined the facility failed to ensure windows on the first floor locked for 1 of 1 sampled resident (#163) reviewed for accidents. This placed residents at risk for an unsecured environment. Findings include: 1. Resident 163 was admitted to the facility in 5/2024 with a diagnosis of spinal (neck) surgery. A Census report from 5/29/24 through 6/3/24 revealed Resident 163 resided in Room 201 and 205. While in both rooms, Resident 163 was in a bed located by a window. On 7/29/24 at 12:30 PM Witness 7 (Complainant) stated Resident 163's windows were able to be opened even when the locking device was utilized. On 7/31/24 at 7:50 AM Staff 14 (Maintenance) verified the windows in both 201 and 205 had broken locking devices and were easily opened. Staff 14 stated he was not aware of the issue.

The facility failed to provide working windows that could have caused a hazard for resident 163. Resident 163 no longer resides in the facility. It was determined that all residents could be affected by this deficiency. All resident room windows were checked for the ability to latch close; windows were fixed as needed. The administrator and director of nursing services reviewed the policy for preventative maintenance and deemed it appropriate. All staff were educated in submitting maintenance tickets for broken equipment. The administrator or designee will spot check 5 resident windows for proper function weekly for four weeks, and then monthly for four months. All audits will be brought to the QAPI team for review.

Based on interview and record review it was determined the facility failed to provide adequate care for 2 of 3 sampled residents (#s 4 and 266) reviewed for UTIs. This placed residents at risk for UTIs. 1. Resident 4 was admitted to the facility in 1/2024 with a diagnosis of MS (multiple sclerosis: lack of electrical impulses from the brain to the body creating impaired body functions). A 1/26/24 admission MDS revealed Resident 4 had a urinary catheter (medical tubing inserted in the bladder to drain urine) and staff were to ensure the urine flowed to prevent UTIs. A 7/2024 TAR and associated Progress Notes revealed staff were to flush (instill sterile fluid to prevent the tubing from clogging) Resident 4's urinary catheter on Monday, Wednesday, and Fridays. From 7/1/24 through 7/19/24 staff had eight opportunities to flush the catheter. On five occasions the flush was not completed due to lack of sterile solution or "did not occur." On 8/5/24 at 12:51 PM Witness 6 (Family) stated Resident 4 was susceptible to UTIs and staff were to flush the catheter to ensure good urine flow. One Friday, staff did not flush the catheter and the staff reported it would get done on the next scheduled Monday. On 8/5/24 at 2:11 PM Staff 29 (Regional RN Consultant) stated there was a nationwide recall of sterile water. If a resident's catheter was not able to be flushed due to lack of supply, the physician was to be notified to determine if an alternate solution was to be used. A request was made to Staff 29 to provide documentation the flushes were completed as ordered. No additional information was provided. , 2. Resident 266 was admitted to the facility in 7/2024 with diagnoses including dementia and history of UTIs. A 6/19/24 hospital History and Physical indicated Resident 266 was seen at the emergency department and admitted to the hospital with increased confusion, dark urine and a fever. A 7/9/24 hospital Progress Note indicated Resident 266's repeat UTIs were most likely due to poor perineum (area around genitals) hygiene based on her/his unique anatomical features. A 7/16/24 care plan indicated Resident 266 required intermittent to constant supervision for personal hygiene including hands and perineum and had acute pain related to UTIs. A 7/22/24 Admission MDS indicated Resident 266 was frequently incontinent of bladder and never incontinent of bowel. On 8/1/24 at 12:06 PM Staff 11 (CNA) stated she understood general perineum care but did not recall any communication or training related to Resident 266's unique needs. On 8/1/24 at 12:46 PM Staff 6 (LPN-Resident Care Manager) stated Witness 3 (Family) revealed Resident 266 had distinct behaviors which increased with her/his UTIs and Witness 3 was informed by the hospital that lack of Resident 266's perineum care was likely the cause of her/his repeat UTIs. Staff 6 stated he did not review Resident 266's hospital notes and acknowledged Resident 266's care plan lacked personalized details related to her/his UTI symptoms. Staff 6 acknowledged he did not inform all CNAs verbally or update the resident's care plan regarding the need for improved perineum care for Resident 266.

The facility failed to provide proper catheter and incontinence care for residents R4 and R266 resulting in UTIs. It was determined that all residents could be affected by this deficiency. All CNAs were educated on proper incontinence and catheter care techniques and were required to show return demonstration. The director of nursing services and the administrator reviewed the catheter and incontinence care techniques and deemed them appropriate. All CNAs were educated on proper perineum care and accomplished return demonstration. The director of nursing services or designee will spot check 5 residents perineum care for proper technique weekly for four weeks, and then monthly for four months. All audits will be brought to the QAPI team for review.

Based on observation, interview, and record review it was determined the facility failed to ensure residents' respiratory equipment was maintained for 3 of 6 sampled residents (#s 11, 164 and 267) reviewed for respiratory, ADLs and dialysis. This placed residents at risk for respiratory issues. Findings include: 1. Resident 11 was admitted to the facility in 8/2014 with diagnoses including COPD (lung disease). The facility's revised Policy and Procedure dated 11/2011 indicated the following: - after a nebulizer (a compressor which turns liquid medications into a fine mist which is inhaled through a mouthpiece) treatment the nebulizer container should be removed, rinsed with fresh tap water, and dried on a clean paper towel or gauze sponge -reconnect to the administration set-up when air dried -Take care not to contaminate the internal nebulizer tubes -Wipe the mouthpiece with a damp paper towel or gauze sponge -Store the circuit in a plastic bag -Discard the administration set-up every seven days Observations from 7/29/24 through 8/5/24 on day and evening shifts revealed Resident 11 had nebulizer equipment including the mouthpiece in her/his recliner, laying on an emesis bag, urinal, and incontinent wipes. An incontinent pad, dirty shirt and dirty pillowcases were also on top of the equipment. A review of the resident's medical record revealed no documentation for the care and services of the nebulizer. On 8/2/24 at 9:21 AM Staff 23 (LPN-Resident Care Manager) confirmed Resident 11's nebulizer was not cleaned or stored in a sanitary manner and there was nothing in the resident's medical record for the care and services of the nebulizer. 2. Resident 164 was admitted to the facility in 7/2024 with diagnoses including pneumonia and hypoxia (oxygen deficiency). The facility's revised Policy and Procedure dated 11/2011 indicated the following: - after a nebulizer (a compressor which turns liquid medications into a fine mist which is inhaled through a mouthpiece) treatment the nebulizer container should be removed, rinsed with fresh tap water, and dried on a clean paper towel or gauze sponge -reconnect to the administration set-up when air dried -Take care not to contaminate the internal nebulizer tubes -Wipe the mouthpiece with a damp paper towel or gauze sponge -Store the circuit in a plastic bag -Discard the administration set-up every seven days Observations from 7/29/24 through 8/5/24 on day and evening shifts revealed Resident 164 had nebulizer equipment including the mouthpiece on her/his night stand with a bag of incontinent briefs, and bedding laying on top of the equipment. A review of the resident's medical record revealed no documentation for care and service of the nebulizer. On 8/2/24 at 9:47 AM Staff 23 (LPN-Resident Care Manager) confirmed Resident 164's nebulizer was not cleaned or stored in a sanitary manner and there was nothing in the resident's medical record regarding the care and services of the nebulizer equipment. , 3. Resident 267 admitted to the facility in 7/2024 with diagnoses including kidney failure and sleep apnea (interruption in breathing). A 7/24/24 Nursing Admission Assessment for respiratory indicated Resident 267 had a CPAP (Continuous Positive Airway Pressure) machine. Review of the clinical record for Resident 267 did not indicate any care plan interventions or treatments related to her/his CPAP machine. On 8/1/24 at 10:29 AM Resident 267 was observed in bed with a CPAP machine and exposed mask on her/his bedside table with a package of bowel movement wipes placed on top of the mask. Brown flecks were observed inside the tubing connected to the CPAP machine. On 8/1/24 at 11:04 AM Staff 11(CNA) confirmed Resident 267's CPAP mask was exposed during the day on her/his bedside table whenever she worked. On 8/1/24 at 11:06 AM Staff 6 (LPN-Resident Care Manager) acknowledged there was no follow-up to obtain orders or care plan for Resident 267's CPAP machine, the tubing was dirty, and the CPAP mask was improperly stored.

The facility failed to provide sanitary respiratory care to 3 residents. Residents 11 and 164 did not have clean and properly stored nebulizer equipment; this equipment was discarded and replaced with clean. Resident 267 did not have clean and properly stored mase and tubing for their CPAP machine; this equipment was properly cleaned, and then stored. It was determined that all residents who require equipment for respiratory care are at risk. An audit was done on all residents with nebulizers and CPAP machines to ensure that equipment was cleaned and stored properly. The director of nursing services and the administrator reviewed the policy for cleaning and storing oxygen equipment and deemed it appropriate. All nursing staff were educated on the importance of cleaning and storing oxygen equipment properly. The director of nursing or designee will audit 5 residents with oxygen equipment to ensure proper cleaning and storage weekly for four weeks, and then monthly for four weeks. All audits will be brought to the QAPI team for review.

Based on interview and record review it was determined the facility failed to evaluate and provide person centered interventions for 1 of 1 sampled resident (#51) reviewed for mood and behavior. This place residents at risk for re-traumatization. Finding include: Resident 51 was admitted to the facility in 5/2024 with diagnoses including PTSD (Post Traumatic Stress Disorder) and anxiety. A 5/25/24 care plan for trauma indicated Resident 51 had PTSD and to ask permission to approach the resident during activities such as personal care, delivering medication and combing/brushing of hair (which were not mentioned as triggers by Resident 51). An activity intervention included not to touch Resident 51 when she/he was sleeping. On 7/29/24 at 12:14 PM Resident 51 stated she/he had disturbing nightmares related to combat and staff were not aware of how to assist with her/his PTSD. Staff 51 stated she/he had requested counseling but there was no followup to the request. On 8/2/24 at 9:22 AM Staff 15 (CNA) confirmed Resident 51 had one to three disruptive nightmares weekly and believed other CNAs documented the nightmares. On 8/2/24 at 9:38 AM Staff 6 (LPN-Resident Care Manager) stated no nightmares were documented for Resident 51 so this issue was not addressed. On 8/2/24 at 10:08 AM Staff 24 (Social Services Director) stated no assessment form for PTSD was available or completed when Resident 51 was admitted so details about Resident 51's PTSD were unknown. Staff 24 stated he was unaware of Resident 51's request for counseling. On 8/2/24 at 10:18 AM Staff 2 (DNS) stated there was no formal training for PTSD when a new PTSD form was introduced six months prior. Staff 2 acknowledged the facility should have evaluated Resident 51 on admission for her/his PTSD, the care plan for trauma for the resident should be personalized and charting for Resident 51's nightmares needed to improve.

The facility failed to provide person centered trauma informed care for resident 51. Resident 51 no longer resides in the facility. It was determined that all residents could be affected by this deficiency. All residents had a trauma assessment completed, and care plans were updated accordingly. The administrator and director of nursing reviewed the policy for trauma informed care and deemed it appropriate. All staff were educated on the policy. The administrator or designee will audit 5 new admissions for trauma assessment and corresponding care plan weekly for four weeks, and then monthly for four months. All audits will be brought to the QAPI team for review.

Based on interview and record review it was determined the facility failed to complete nurse aide performance reviews every twelve months for 3 of 5 sampled CNAs (#s 3, 4, and 7) reviewed for staffing. Findings include: Review of 5/23/24 through 7/2024 training documents revealed the following: -Staff 3's last performance review was in 2022. -Staff 4's last performance review was in not in her record and her hire date was 7/18/22. -Staff 7's last performance review was in 2022. On 8/1/24 at 8:30 AM Staff 2 (DNS) verified Staff #s 3, 4, and 7 did not have their annual performance reviews.

The facility failed to provide annual performance reviews for three CNAs. These CNAs had performance reviews completed. No residents were cited in this deficiency, but all residents could be affected by it. An audit was done of all CNAs employed by the facility for a year or longer to ensure annual performance reviews were completed. The director of nursing services and administrator reviewed the standard performance reviews for CNAs and deemed it appropriate. The director of nursing services and Human resource representative were educated on the importance of proving timely annual performance reviews for CNA staff. The director of nursing services or designee will audit annual performance reviews for CNA staff monthly for the next 5 months. All audits will be brought to the QAPI team for review.

Based on interview and record review it was determined the facility failed to provide monitoring for anticoagulant medications for 1 of 5 sampled residents (#18) reviewed for medications. This placed residents at risk for unidentified medication adverse side effects. Findings include: Resident 18 was admitted to the facility in 5/2016 with diagnoses including atrial fibrillation (an irregular heartbeat). A review of Resident 18's physician orders revealed a 7/11/22 order for apixaban, an anticoagulant medication (a blood thinner). A 7/31/24 review of Resident 18's care plan revealed no evidence of a care plan for anticoagulant medication. An 8/2/24 review of Resident 18's medical record revealed no evidence of monitoring for adverse side effects from anticoagulant medications. On 8/2/24 at 1:52 PM Staff 23 (LPN Resident Care Manager) Stated Resident 18 took an anticoagulant medication, apixaban, and should have been monitored for adverse side effects such as bleeding and bruising. Staff 23 confirmed Resident 18 was not monitored for adverse side effects from anticoagulant medications.

The facility failed to ensure proper signs and symptom monitoring for resident 18’s anticoagulant medication. Resident 18’s care plan was updated to reflect the medication and signs and symptom monitoring for staff. All residents who are on an anticoagulant medication could be affected by this deficiency. An audit of all residents on anticoagulant medication was completed and care plans were updated as necessary. The director of nursing services and administrator reviewed the policy for anticoagulant medications and deemed it appropriate. All nurses were educated to the policy. The director of nursing or designee will audit 5 residents on anticoagulants for proper sign and symptom monitoring weekly for four weeks, and then monthly for four months. All audits will be brought to the QAPI team for review.

Based on interview and record review it was determined the facility failed to attempt a gradual dose reduction and montior for psychotropic medications for 2 of 5 sampled residents (#s 12 and 15) reviewed for medications. this placed residents at risk for adverse medication reactions. Findings include: 1. Resident 12 admitted to the facility in 3/2024 with diagnoses including anxiety disorder and depression. A review of 7/2024 MAR revealed Resident 12 was administered Lexapro (antidepressant), Trazodone (antidepressant), Xanax (antianxiety) and Buspirone (antianxiety). A review of the 7/2024 behavior monitors revealed interventions but did not list triggers for the resident's behaviors. On 8/1/24 at 10:46 AM Staff 15 (CNA) stated Resident 12 had triggers which made her/his anxiety worse. Staff 15 stated her/his triggers were when therapy comes into her/his room without some notification, if her/his call light was not answered timely, and if she/he feels lonely. Staff 15 stated there were more, but those were the main triggers. On 8/2/24 at 2:24 PM Staff 6 (LPN-Resident Care Manager) stated Resident 12 had triggers which made her/his anxiety and depression worse but they were not listed and staff were not aware of her/his triggers. Staff 6 acknowledged Resident 12 was not monitored appropriately for Lexapro, Trazodone, Xanax, and Buspirone. , 2. Resident 15 was admitted to the facility in 11/2016 with a diagnosis of heart disease. 8/8/23 through 10/31/23 Progress Notes revealed Resident 15 did not exhibit behaviors or change in mood. An undated medication report revealed on 10/21/23 Resident 15's Wellbutrin (antidepressant) was increased from 300 mg daily to 450 mg daily. A 12/21/23 Psychotropic Medication review revealed Resident 15 was pleasant to staff and no behaviors or moods were documented for the quarter. The form indicated Resident 15's last Wellbutrin GDR was 12/27/22. A 12/2023 MAR revealed Resident 15 was administered 450 mg daily. A 6/18/24 Psychotropic Medication review revealed Resident 15's last GDR was 12/6/23. On 8/2/24 at 8:39 AM Staff 23 (LPN Resident Care Manager)acknowledged the increase in her/his Wellbutrin in 10/2023. A request was made to Staff 23 to provide documentation to justify the increase to the dosage of Wellbutrin and the rationale for no GDR in 12/2023. No additional information was provided.

The facility failed to keep two residents free from unnecessary psychotropic medications. Resident 12’s care plan was updated to reflect triggers for anxiety. Resident 15’s medication was reviewed by the physician for a GDR attempt. All residents on psychotropic medications could be affected by this deficiency. An audit was conducted on all medications to ensure care plans included resident triggers, and that a schedule for GDRs was being followed by the facility. The director of nursing services and the administrator reviewed the policy for psychotropic medication and deemed it appropriate. All nurses and the interdisciplinary team were educated to the policy. The director of nursing services or designee will audit 5 residents on psychotropic medications for care plan and proper GDR management weekly for four weeks, and then monthly for four months. All audits will be brought to the QAPI team for review.

, , Based on interview and record review it was determined the facility failed to monitor residents who received psychotropic medications for 2 of 3 sampled residents (#s 12 and 310) reviewed for psychotropic medications. This placed residents at risk for adverse medication reactions. Findings include: 1. Resident 12 admitted to the facility in 5/2024 with diagnoses including depression and anxiety. A 7/18/24 physician order indicated Resident 12 was administered escitalopram (medication to treat anxiety) daily. An 8/26/24 revised care plan indicated Resident 12 experienced stress related to concerns with work, health, work schedule, eating too much late at night and her/his mental health disorder. The 9/2024 MAR indicated an 8/19/24 order for Resident 12 which permitted the resident to request Xanax (medication to treat anxiety) every four hours as needed for 60 days. Resident 12 was administered Xanax 23 times from 9/1/24 through 9/25/24 and the medication was labeled as "E" (effective) after each administration. The 9/2024 Behavior Monitor for Resident 12 indicated she/he had no behaviors from 9/1/24 through 9/25/24 and no specific triggers were identified for Resident 12. On 9/25/24 at 1:54 PM Staff 4 (Resident Care Manager-LPN) stated triggers for Resident 12 should be clearly identified for nursing and there was a lack of monitoring of her/his Xanax. On 9/25/24 at 3:40 PM Staff 8 (Corporate RN) confirmed there was a lack of monitoring for Resident 12's identified behaviors. 2. Resident 310 admitted to the facility in 8/2024 with diagnoses including depression and Parkinson's disease (a disorder of the nervous system). An 8/28/24 physician order indicated Resident 310 was to be administered duloxetine (antidepressant medication) each morning. An 8/29/24 care plan indicated side effects of antidepressant medications were to be monitored for Resident 310 which included confusion, insomnia, blurred vision, rash and dry mouth as examples. Review of Resident 310's clinical record revealed no monitoring for the side effects of her/his antidepressant medication. On 9/26/24 Staff 3 (Resident Care Manager-LPN) confirmed there was no monitoring in place for side effects related to Resident 310's antidepressant medication.

The facility failed to keep two residents free from unnecessary psychotropic medications. Resident 12 behavior monitoring order was updated to reflect the care plan with current behaviors and triggers. Resident 310 had side effect monitoring added to the treatment record to reflect what was in the current care plan. All residents on psychotropic medications could be affected by this deficiency. An audit was conducted on all medications to ensure care plans, consents, behavior monitoring, and side effect monitoring. The director of nursing services and the administrator reviewed the policy for psychotropic medication and deemed it appropriate. All nurses were educated to the policy. The director of nursing services or designee will audit up to 5 residents on psychotropic medications for accurate care plan, consents, Behavior monitoring orders, Side effect monitoring weekly for four weeks, and then monthly for four months. All audits will be brought to the QAPI team for review.

Based on observation and interview it was determined the facility failed to ensure a treatment cart was locked for 1 of 2 units (Shasta Unit). This placed residents at risk for injury. Findings include: On 7/30/24 at 2:23 PM to 2:43 PM a Shasta Unit treatment cart was observed to be unlocked. The cart was in an alcove and one wall of the alcove blocked the view of the cart from the nurse's station. Nursing staff and therapy staff walked by the cart at 2:28 PM, 2:33 PM, and 2:36 PM and did not lock the cart. On 7/30/24 at 2:43 PM Staff 31 (LPN) stated she just came on shift, was not aware the treatment cart was unlocked, and it should be locked.

The facility failed to properly store drugs and biologicals by having one treatment cart unlocked. No residents were cited in this deficiency, but all residents could be affected by it. An audit was done of all treatment and medication carts to ensure proper function of locking mechanisms. The director of nursing services and administrator reviewed the medication administration policy and deemed it appropriate. All nursing staff were educated to the policy. The director of nursing services or designee will do an audit to ensure all medication and treatment carts are locked weekly times four weeks, and then monthly times four months. All audits will be brought to the QAPI team for review.

Based on observation, interview and record review the facility failed to prepare therapeutic diets for 1 of 3 sampled residents (#267) reviewed for nutrition. This placed residents at risk for compromised nutrition. Finding include: The 7/31/24 posted lunch menu included: Smoke Sausage, Lyonnaise Potatoes and Steamed Cabbage. A Diet Spread Sheet for the 7/31/24 menu indicated residents with a limited salt, phosphate (dietary nutrient) or potassium (dietary nutrient) diet were to be served roasted pork in place of the sausage. 1. Resident 267 was admitted to the facility in 7/2024 with diagnoses including kidney failure and hip fracture. A 7/25/24 physician Order Details indicated Resident 267 was to receive a diet limited in salt, potassium and phosphate. On 8/1/24 at 10:29 AM Resident 267 stated on 7/31/24 the menu option provided for lunch included sausage (a food high in salt and phosphates) which was delivered. Resident 267 stated she/he ate the sausage because it was provided and trusted the facility to provide the correct diet. Resident 267 stated because she/he received dialysis treatments the therapeutic diet was very important. On 8/1/24 at 8:30 AM Staff 13 (Cook) stated he was never trained to provide alternative options for those on restricted diets according the spreadsheet and did not prepare the pork roast on 7/31/24 during lunch that was necessary to fulfill the requirements for therapeutic diets. On 8/5/24 at 9:53 AM Staff 21 (Dietary Manager) acknowledged since a new menu system began around 4/2024 no alternative menu items were purchased to accommodate those on therapeutic diets. Staff 21 stated theraputic diet should be followed. 2. On 7/31/24 at 12:00 PM Staff 13 (Cook) was observed to serve lunch for residents from the food he prepared. No pork roast was observed on the tray line. At approximately 1:10 PM a tray ticket for Room 206 was observed which indicated a limited salt, potassium and phosphate diet was to be served. The tray ticket included a typed option for chicken or pork roast. Sausage was served with the tray ticket to room 206. On 8/1/24 at 8:30 AM Staff 13 (Cook) stated he was never trained to provide alternative options for those on restricted diets according the spreadsheet and did not prepare the pork roast on 7/31/24 during lunch that was necessary to fulfill the requirements for therapeutic diets. On 8/5/24 at 9:53 AM Staff 21 (Dietary Manager) acknowledged since a new menu system began around 4/2024 no alternative menu items were purchased to accommodate those on therapeutic diets. Staff 21 stated theraputic diet should be followed.

The facility failed to provide resident 267 with their ordered therapeutic diet. It was determined that all residents that receive a therapeutic diet could be affected by this deficiency. All kitchen staff were immediately educated on therapeutic diets and were provided with a spreadsheet for each meal to show sufficient therapeutic substitutes. The Administrator and the director of nursing services reviewed the procedure for therapeutic diets and deemed it appropriate. All kitchen staff were educated on this procedure. The administrator of designee will audit tray line for proper therapeutic diets weekly times four weeks, and then monthly times four months. All audits will be brought to the QAPI team for review.

Based on observation, interview and record review the facility failed to provide food according to residents' meal preferences for 2 of 5 sampled residents (#s 1 and 214) reviewed for food. This placed residents at risk for lack of meal satisfaction. Finding include: The 4/23/24 Resident Council notes indicated residents had concerns about meal preferences that were not provided as requested including: -Residents who asked CNAs for an different menu selection after a meal was delivered often did not receive any replacement. -Residents' meal plates did not contain the foods which were selected by the residents. The 5/21/24 and 6/26/24 Resident Council notes indicated residents continued to have concerns about meal preferences that were not provided as requested and the dietary department was aware. 1. Resident 1 was admitted to the facility in 11/2016 with diagnoses including anemia and acute kidney failure. On 7/30/24 at 7:50 AM Resident 1 stated she/he often did not receive what she/he ordered for meals. On 7/31/24 11:10 AM Staff 21 (Dietary Manager) stated she was aware of issues with residents who did not receive food they ordered which should not occur. On 8/2/24 at 1:34 PM Resident 1's lunch meal tray was observed with only pasta and asparagus on the plate. The printed menu and tray ticket indicated Resident 1 selected the pasta, asparagus and potatoes. Resident 1 stated errors with her menu choices often occurred. Resident 1 also stated because of her/his own self-limiting special diet it was very important for her/him to receive the foods that were ordered. 2. Resident 214 was admitted to the facility in 2024 with diagnoses including stroke and anxiety. A 7/22/24 revised care plan indicated Resident 214 disliked mushy vegetables, beets, mushrooms, eggs, peas and carrots and requested small portions. 7/29/24 at 1:14 PM Resident 214 stated she/he does not want beets, peas and carrots but continued to receive them despite what was written on her/his ticket even during the current week. On 7/31/24 11:10 AM Staff 21 (Dietary Manager) stated she was aware of issues with residents who did not receive food they ordered which should not occur. 3. The 7/31/24 posted lunch menu included: Smoke Sausage, Lyonnaise Potatoes and Steamed Cabbage. On 7/31/24 11:10 AM Staff 21 (Dietary Manager) stated she was aware and acknowledged there were issues with their new menu system and tray ticket accuracy since the menu system was implemented around 4/2024. At approximately 1:07 PM a meal tray ticket for Room 201 was observed which indicated the resident requested potatoes and cabbage only. The meal tray also included sausage which was not requested by the resident. On 7/31/24 at 1:11 PM Staff 21 (Dietary Manager) stated the kitchen ran out of sausage during meal service, a resident in room 533 received no sausage despite her/his request for sausage and there was no sausage available for the sample meal tray. On 7/31/24 at approximately 1:36 PM a sample meal tray was received and did not include sausage on the sample tray.

The facility failed to provide food preferences for residents 214 and 1. Food preferences were updated for those residents and added to their tray cards. It was determined that all residents could be affected by this deficiency, and food preferences were updated for all residents. The administrator and the director of nursing services reviewed the procedure for resident meal choice and deemed it appropriate. All kitchen staff were educated on the resident meal choice procedure. The administrator of designee will audit tray line for correct resident choice weekly times four weeks, and then monthly times four months. All audits will be brought to the QAPI team for review.

Based on interview and record review it was determined the facility failed to ensure residents understood the meaning of an arbitration agreement (disputes are resolved with a neutral party and not in court) for 3 of 3 sampled residents (#s 9, 53, and 165) reviewed for arbitration. This placed residents at risk for being uninformed of their legal rights. Findings include: 1. Resident 9 was admitted to the facility in 5/2024 with a diagnosis of Parkinson's disease. A 5/14/24 admission MDS revealed Resident 9 was cognitively intact. A Patient and Facility Arbitration Agreement revealed Resident 9 signed the agreement on 5/9/24. On 7/31/24 at 12:15 PM Resident 9 stated she/he remembered signing a large number of papers at the time of her/his admission but did not recall anything about arbitration. On 7/31/24 at 12:25 PM Staff 9 (Admissions) stated she reviewed the arbitration agreement when she had a resident or resident representative sign the admission paperwork. Staff 9 stated she did not follow-up with residents after they signed the papers to ensure they understood what was signed. She was not sure if Resident 9 fully understood the agreement so she called Witness 2 (Family) and reviewed the arbitration document with her/him and Resident 9 signed the papers. On 7/31/24 at 4:23 PM Witness 2 stated did not know what an arbitration agreement was and only talked to the the facility about financial eligibility issues. 2. Resident 53 was admitted to the facility in 6/2024 with a diagnosis of heart disease. A Patient and Facility Arbitration Agreement revealed Resident 53 signed the agreement on 6/5/24. A 6/9/24 admission MDS revealed Resident 53 was cognitively intact. On 7/31/24 at 10:31 AM Resident 53 stated she/he "had no idea" what an arbitration agreement was. On 7/31/24 at 12:25 PM Staff 9 (Admissions) stated she reviewed the arbitration agreement with a resident when she had the resident or resident representative fill out the admission paperwork. If she felt a resident did not understand the agreement she called a resident's representative. Staff 9 stated she did not follow-up with residents after they signed the papers to ensure they understood the arbitration agreement. 3. Resident 165 was admitted to the facility in 7/2024 with a diagnosis of Parkinson's disease. A Patient and Facility Arbitration Agreement revealed Resident 165 signed the agreement on 7/19/24. A 7/23/24 admission MDS revealed Resident 156 was cognitively intact. On 7/31/24 at 8:05 AM Resident 165 stated she/he did not recall signing an arbitration agreement. Resident 165 stated an arbitration agreement was when another person spoke on your behalf. On 7/31/24 at 12:25 PM Staff 9 (Admissions) stated she reviewed the arbitration agreement with a resident when she had the resident or resident representative sign the admission paperwork. If she felt a resident did not understand the agreement she called a resident's representative. Staff 9 stated she did not follow-up with residents after they signed the papers to ensure they understood the arbitration agreement.

The facility failed to properly explain the arbitration agreements that 3 residents entered. The Social Services Director went and re-explained the arbitration agreement and asked if they would like to continue with the arbitration agreement or exit the agreement. It was determined that all residents who have entered an arbitration agreement with the facility could be affected by this deficiency. The Social Services Director went and re-explained the arbitration agreement and asked if they would like to continue with the arbitration agreement or exit the agreement. The administrator and director of nursing services reviewed the arbitration agreement and deemed it appropriate. The interdisciplinary team was educated on arbitration agreements and updated the procedure of educating those residents who have entered an arbitration agreement with their quarterly care conference. The administrator or designee will audit 5 new admissions for understanding of the arbitration agreement weekly times four weeks and then monthly times four months. All audits will be brought to the QAPI team for review.

Based on observation, interview, and record review it was determined the facility failed to follow appropriate infection control procedures, had delayed infection control implementation, inappropriate cohorting of residents for 1 of 1 facility. This deficient practice was determined to be an immediate jeopardy situation and the deficiency resulted in the spread of COVID 19. This placed residents at risk for continued spread of potential deadly infectious diseases. Findings include: According to the CDC website dated 6/2024 health care providers who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). According to the CDC website dated 3/2024 patients with suspected clostridium difficile should be placed in a singe-patient room, if a single-patient room is not available patients with confirmed clostridium difficile may room together. On 7/29/24 at 9:30 AM Staff 1 (Administrator in Training) informed surveyors upon entrance that the facility is in a COVID outbreak, 4 staff and 5 residents, there was no sign on the door to indicate a COVID outbreak. Staff 1 stated 4 staff and 5 residents tested positive on 7/29/24. On 7/29/24 at 10:57 AM the dispensers in the hall near rooms 507, 513, 517 and 520 had no sanitizer in them. On 7/29/24 at 12:01 PM Staff 4 (CNA) entered room 519, a COVID 19 precaution room, without eye protection. On 7/29/24 at 12:14 PM Staff 4 removed her dirty gown, gloves and mask, then proceeded to place a clean mask on. Staff 4 failed to perform hand hygiene after taking off the dirty mask and before putting on a clean mask. On 7/29/24 at 12:26 PM Staff 5 (LPN) was observed checking Resident 20's CBG. Resident 20 was on enteric (intestinal)contact precautions. Staff 5 exited the room with her dirty gloves still on and stated she was going to remove the dirty gloves after she sanitized the CBG monitor. Staff 5 sanitized the CBG monitor, removed the dirty gloves and used alcohol based sanitizer to clean her hands. When asked why Staff 5 did not wash hands with soap and water per the verbiage on the enteric precaution sign, Staff 5 stated she did not need to use soap and water because she did not change Resident 20. On 7/29/24 at 12:29 PM Witness 11 (Family) asked about staff wearing N95 masks. Witness 11 stated she was not notified the facility was in a COVID 19 outbreak and she would not have brought her son into the facility had she notified. On 7/29/24 at 12:46 PM Staff 26 (CNA) was observed delivering a lunch tray to Resident 20. Resident 20 was on enteric contact precautions. Staff 26 removed her dirty PPE and used alcohol based sanitizer upon exiting the room. When asked why Staff 26 did not wash her hands with soap and water, Staff 26 stated there was no need to wash with soap and water if not touching, "down below" and stated Resident 20 was on precautions for her/his catheter. On 7/29/26 at 12:46 PM Staff 4 was observed assisting Resident 43 with eating her/his lunch in a room with COVID 19 and enteric precautions. without wearing eye protection. Staff 4 stated she was informed she did not need to wear eye protection when providing care to Resident 43 since she/he had not tested positive for COVID 19, only her/his roommate had tested positive for COVID 19. On 7/26/24 at 1:08 PM Staff 34 (Infection Preventionist) stated staff entering a room on precautions for COVID 19, staff are expected to wear a gown, gloves, a mask and eye protection. Staff 34 stated when staff exit a room on COVID 19 precautions, staff are expected to remove their dirty PPE, including their mask, perform hand hygiene and then put a clean mask on. Staff 34 stated upon entering a room in enteric contact precaution room, staff are expected to wear a gown and gloves, and upon exiting the room staff are expected to remove the gown and gloves and wash their hands with soap and water. On 7/29/24 at 2:25 PM Staff 39 (housekeeping) stated she was aware there were multiple dispensers out of hand sanitizer in the COVID positive hall. Staff 39 stated she was unable to refill the dispensers because the facility had been out of hand sanitizer for a week. On 7/29/24 at 2:26 PM Staff 37 (CNA) was observed without eye protection while in a room on COVID 19 precautions. Staff 37 stated he does not wear eye protection and stated he usually wore his glasses with blinders on the side and acknowledged his glasses did not have blinders on them now. On 7/30/24 at 8:30 AM Staff 42 (CNA) was observed removing a dirty face shield, placing the dirty face shield in the clean PPE cart and without changing his face mask. On 7/30/24 at 12:57 PM Witness 10 (family) was observed in the facility without a face mask on. Witness 6 stated no one stopped her as she walked down the 500 hall and stated she was not informed of the COVID 19 outbreak in the facility. On 7/30/24 at 1:00 PM Staff 8 (CNA) was observed exiting room 107, a COVID 19 precaution. Staff 8 removed her dirty mask and placed on a clean mask without performing hand hygiene in between. Staff 34 was standing next to Staff 8 and had not intervened. Staff 8 acknowledged she should have performed hand hygiene before she obtained a clean mask and stated the clean cart of PPE was now contaminated, the clean PPE needed to be disposed of and the PPE cart needed to sanitized prior to being restocked. On 7/30/24 at 1:00 PM a cart was observed to have used COVID tests on the bottom shelf. Staff 34 acknowledged the used COVID 19 tests and stated he was going to throw them away when COVID testing was completed. On 7/30/24 at 1:28 PM Staff 40 (CNA) was observed exiting room 107, which was on COVID 19 precautions, wearing dirty PPE. Staff 40 went into the hall and put dirty dishes in a cart located in the hallway. Staff 40 stated he was trained to wear the same PPE worn in a COVID 19 precaution room when placing dirty dishes into the cart in the hallway. Staff 40 was observed going back to room 107, where he removed his dirty gown, gloves, and eye protection. Staff 40 was observed walking down the hall with his dirty mask on. Staff 40 stated he was looking for a new mask and then he located a new mask in the PPE cart outside room 107. On 7/30/24 at 2:07 PM Staff 34 stated the first staff and resident tested positive for COVID 19 on 7/25/24 and two more residents tested positive on 7/30/24. Staff 34 stated Resident 35 was placed on enteric precautions on 6/11/24 related to suspicion of clostridium difficile (a type of bacteria that can cause inflammation of the colon). Resident 30 was moved into Resident 35's room on 6/14/24, and Resident 35 tested positive for clostridium difficile on 6/17/24. Staff 34 stated Resident 30 should not have been moved in with Resident 35 due to the contagious risk of clostridium difficile. On 7/30/24 at 2:29 PM Staff 31 (Housekeeper) was observed exiting room 535, a COVID 19 precaution room. Staff 31 did not complete hand hygiene after she removed dirty surgical mask. Staff 31 was observed touching clean the laundry and entering into room 531 with the potentially contaminated laundry. On 7/30/24 at 6:31 PM Staff 43 (dietary aid) was observed washing dishes and walking through the kitchen with no face mask on. On 7/30/24 at 6:38 PM Staff 1, Staff 10 (Regional Nurse), Staff 2 (Administrator) and Staff 2 (DNS) were notified of the immediate jeopardy situation related to infection control. On 7/30/24 at 8:53 PM an acceptable immediate risk removal plan to address the serious risk to residents' health and welfare was received and implemented by the facility. The plan indicated the following facility actions: -The DNS and Administrators were educated on the COVID 19 Policy, Outbreak Checklist and COVID 19 Infection Control Manual. -The Infection Preventionist was placed on suspension due to the enormity of the deficiencies. -The new Infection Preventionist was educated on the COVID 19 Policy, Outbreak Checklist and COVID 19 Infection Control Manual and skills demonstrated. -New Infection Preventionist will be educated on the COVID 19 Policy, Outbreak Checklist and COVID 19 Infection Control Manual upon hire. -Starting on 7/30/24 all staff were educated on the COVID 19 Policy, Outbreak Checklist and COVID 19 Infection Control Manual for continued compliance of these policies, with emphasis on proper PPE usage and hand hygiene for each type of infection. -All staff will wear N95 masks while in resident care areas, and in COVID positive rooms will wear a N95 mask, gown, sanitized or disposable goggles and gloves when providing direct patent care and remove all these items before they leave COVID positive room and a new N95 mask will be placed. -DNS will put face shields on all the COVID 19 isolation carts to replace the need to use goggles exclusively. Staff were educated regarding the face shields usage and disposal. A few clean goggles were left in the isolation carts in case of need. -Starting 7/30/24 wide base resident testing will be completed every 2-3 days and as symptoms are present until the facility goes two weeks without any positive tests. -Starting 7/30/24 wide base staff testing will happen before staff members start their shift and as symptoms present until the facility goes two weeks without any positive test. -The SSD called the first emergency contact for each resident and informed them of the current COVID outbreak. -All new residents will be informed of the current COVID outbreak before admission the the facility. -A sign was place on all entrance doors to inform visitors about the COVID 19 outbreak and was placed next to the sign in sheet in the lobby. -Facility acquired hand sanitizer to fill all dispensers and extra to make sure it is accessible to staff for proper hand hygiene. The DNS and designees will conduct spot checks of proper hand hygiene, donning and doffing PPE, signage and equipment cleansing at least three times per shift per day for one week. Then once daily for one week. then once a week for 4 weeks. then once a month for four months. Any discrepancies will be brought to the QAPI team for further review. -The DNS or designee will review the 24-hour report and bowel care list Monday through Friday, Saturday and Sunday will be reviewed on Monday, for any symptoms of clostridium difficile, and to ensure policies had been followed correctly. Any discrepancies will be brought to the QAPI team for further review. On 7/31/24 at 9:28 AM Staff 25 (NA) stated she had just received training on infection control procedure and hand hygiene on 7/31/24 a few minutes before the interview. At 9:30 AM Staff 25 was observed exiting a room on COVID 19 precautions, Staff 25 failed to change her mask upon exit from the room. Staff 25 stated she was not trained on the need to change her mask after exiting a COVID 19 precaution room. Staff 25 was observed getting a clean mask, she held the clean mask in one hand while she removed her dirty mask with the other hand, she applied her clean mask with one hand while holding her dirty mask with the other hand, she balled up dirty mask in her hand, walked down the hall and threw away her dirty mask in a room that was not on precautions for COVID 19. Staff 25 had not performed hand hygiene until reminded to do so. On 7/31/24 at 9:51 AM Staff 11 (CNA) stated she tested herself for COVID 19 prior to working on 7/31/24. Staff 11 stated she was trained by Staff 6 (LPN Unit Manager/IP) to swab each nostril 3 times. On 7/31/24 at 9:53 AM Staff 32 (Housekeeper) stated she was tested for COVID 19 by Staff 33 (Housekeeping Manager) prior to start of work on 7/31/24. On 7/31/24 at 9:55 AM Staff 33 stated she was trained to perform COVID 19 tests by Staff 2 and to swab each nostril three times. A review of the COVID 19 testing instructions on 7/31/24 at 10:00 AM revealed each nostril needed to swabbed five times for 15 seconds. On 7/31/24 at 10:10 AM the COVID 19 testing instructions were reviewed with Staff 10 (Regional Nurse). Staff 10 acknowledged each nostril needed to be swabbed five times for 15 seconds and stated all staff and residents would be retested on 7/31/24. On 7/31/24 at 3:15 PM it was determined the immediacy was removed after verification of completion of the immediate jeopardy removal plan.

[F880] The facility failed to use proper infection control guidelines to keep residents safe from contracting COVID 19 and C Difficile. Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the deficient practices and prevent any additional residents from potential adverse outcomes: • Residents with an active COVID 19 infection were placed in isolation with Contact droplet barrier precautions, alert charting was started for infection monitoring, and vitals will be taken q-shift and as needed to help track active infection. • Starting on 7/30/2024 wide base resident testing is to be done every 2-3 days, and as symptoms present until the facility goes 2 weeks without any positive tests. • Starting on 7/30/2024 wide base staff testing will happen before staff members start their shift, and as symptoms present, until the facility goes 2 weeks without any positive tests. • Residents with an active C Difficile infection were placed on isolation with contact precautions, alert charting was started for infection monitoring, and physician was notified to have them placed on proper antibiotics for current infection. o Residents with C Difficile that have a roommate, the physician was contacted on the appropriateness of continued cohorting. Residents that were improperly cohorted were moved to a private room for continued monitoring. • If residents start showing symptoms of C Difficile the follow procedure will be followed: o Resident will be moved to a private room or cohorted with another patient that has C Difficile and placed on precautions o The physician will be notified to get treatment course o Residents will not be cohorted with C Difficile negative residents until active infection subsides Actions to Prevent Occurrences/Reoccurrences: • The following policies were reviewed by the Director Clinical Education o COVID Policy o Outbreak Checklist o COVID 19 Infection Control Manual o C Difficile Policy • The Director of Nursing Services and Administrators were educated on the above policies. • The infection preventionist was placed on suspension due to the enormity of the deficiencies. o New Infection Preventionist will be Art Bautista. Art was educated on the above policies and skills demonstration. New IP will also get education upon hire. • Starting on 7/30/2024 all staff were educated on the above policies for continued compliance of these policies. With emphasis on proper PPE usage and hand hygiene for each type of infection. • All staff will wear N95 masks while in resident care areas, and in COVID positive rooms will wear, N95 mask, new gown, sanitized or disposable goggles, and gloves when providing direct patient care, and removes all these items before they leave COVID positive rooms and put on new N95 mask. o DNS put face shields on all the Covid-19 isolation cards to replace the need to use goggles exclusively. Staff were educated re: their usage and disposal. A few goggles were left in isolation carts in case of need, they were all cleaned and disinfected appropriately. • Starting on 7/30/2024 wide base resident testing is to be done every 2-3 days, and as symptoms present until the facility goes 2 weeks without any positive tests. • Starting on 7/30/2024 wide base staff testing will happen before staff members start their shift, and as symptoms present, until the facility goes 2 weeks without any positive tests. • The Medical Director was notified on 7/30/2024 of the deficient practices. • The social services director called the first emergency contact for each resident and informed them of the current COVID outbreak. o All new residents will be informed of the current COVID outbreak before admission to the facility. • A Sign was placed on all entrance doors to inform visitors about the COVID 19 outbreak, and was placed next to sign in sheet in the lobby. • Facility acquired hand sanitizer to fill all dispenser and extra to make sure it is accessible to staff for proper hand hygiene. • The Director of nursing services and designees will be conducting spot checks of proper hand hygiene, donning and doffing PPE, Signage, and equipment cleansing at least 3 times per shift, per day for 1 week. Then once daily for 1 week. Then once a week for 4 weeks, then once a month for four months. Any discrepancies will be brought to the QAPI team for further review. • The Director of Nursing Services or designee will review the 24 hour report and bowel care list Monday through Friday and Saturday and Sunday will be reviewed on Monday for any symptoms of C Difficile, and to ensure policy had been followed correctly. Any discrepancies will be brought to the QAPI team for further review.

Based on interview and record review it was determined the facility failed to ensure antibiotics were indicated for 1 of 3 sampled residents (#4) reviewed for UTIs. This placed residents at risk for developing drug resistant organisms. Findings include: Resident 4 was admitted to the facility in 1/2024 with a diagnosis of MS (multiple sclerosis: lack of electrical impulses from the brain to the body creating impaired body functions). 3/2024 and 4/2024 MARs revealed Resident 4 was administered antibiotics for a "possible" UTI from 3/30/24 through 4/5/24. A 3/31/24 Lab Results form revealed Resident 4's UA did not require a culture. Resident 4's clinical record revealed there was no rationale for the continuation of antibiotics when there was no indication Resident 4 had a UTI. On 8/2/24 at 10:17 AM Staff 6 (LPN Resident Care Manager) verified there was no rationale documented in Resident 4's clinical record to indicate the benefit of the continuation of antibiotics outweighed the risks.

The facility failed to follow proper antibiotic stewardship for resident 4. This resident started being followed by Oregon Urology after the cited event. It was determined that all residents suspected of needing an antibiotic could be at risk because of this deficiency. All residents currently on antibiotics were reviewed for accuracy and necessity. The Director of nursing services and administrator reviewed the policy for antibiotic stewardship and deemed it appropriate. All nurses were educated on the policy. The director of nursing or designee will audit new start antibiotics for proper stewardship weekly for four weeks, and then monthly for four months. All audits will be brought to the QAPI team for review.

Based on interview and record review it was determined the facility failed to provide immunizations, consents and declinations for 3 of 5 sampled residents (#s 3, 20, and 22) reviewed for immunizations. This placed residents at risk for infections. Findings include: 1. Resident 3 was admitted to the facility in 12/2018 with diagnoses including congestive heart failure (a condition in which the heart cannot pump enough blood). An 8/5/44 review of Resident 3's immunizations revealed she/he received the COVID 19 vaccination on 12/23/20, 1/13/21 and 10/19/21, no evidence of COVID 19 boosters were administered after 10/19/21. An 8/5/24 review of Resident 3's medical record revealed no evidence of signed consents for the COVID 19 vaccinations received on 12/23/20, 1/13/21 and 10/19/21 and no evidence any COVID 19 booster vaccinations were offered, administered or declined after 10/19/21. On 8/5/24 at 10:35 AM Staff 1 (Administrator in Training) stated the vaccination offerings, consents and declinations were kept in a binder. Staff 1 was unable to locate Resident 3's consents for the COVID 19 vaccinations on 12/23/20, 1/13/21 and 10/19/21 and was unable to locate evidence Resident 3 was offered or declined any COVID vaccination boosters after 10/19/21. 2. Resident 20 was admitted to the facility in 3/2017 with diagnoses including chronic obstructive pulmonary disease (a lung disease causing restricted airflow and breathing problems). An 8/5/24 review of Resident 20's medical record revealed no evidence she/he was offered a pneumonia vaccination. On 8/5/24 at 10:35 AM Staff 1 (Administrator in Training) stated vaccination offerings, consents and declinations were kept in a binder. Staff 1 was unable to locate evidence Resident 20 was offered or refused a pneumonia vaccination. 3. Resident 22 was admitted to the facility in 12/2021 with diagnoses including chronic obstructive pulmonary disease (a lung disease causing restricted airflow and breathing problems). A 8/5/24 review of Resident 22's immunizations revealed she/he was administered a COVID 19 vaccination booster on 12/13/23. An 8/5/24 review of Resident 22's medical record revealed no evidence of a consent for the 12/13/23 administration of the COVID 19 vaccination booster. On 8/5/24 at 10:35 AM Staff 1 (Administrator in Training) stated vaccination offerings, consents and declinations were kept in a binder. Staff 1 was unable to locate Resident 22's consent for the COVID 19 vaccination booster.

The facility failed to offer and track vaccinations for three residents. Resident 3 was offered COVID booster. Resident 20 was offered the pneumonia vaccine. Resident 22 had their consents updated to reflect COVID boosters. It was determined that all residents could be affected by this deficiency. All residents had their ALERTISS documents pulled, and immunizations updated to reflect the current vaccination status. This list was then used to get updated consents for those vaccines that they are due for, and vaccine clinics have been scheduled. The Director of nursing services and administrator reviewed the policy for immunizations and deemed it appropriate. All nurses were educated on this policy. The director of nursing or designee will audit 5 new admissions for proper immunization documentation and consents weekly for four weeks, and then monthly for four months. All audits will be brought to the QAPI team for review.

Based on observation and interview it was determined the facility failed to ensure a call light was accessible for 2 of 3 sampled residents (#s 20 and 48) reviewed for hospice and pressure ulcers. This placed resident at risk for unmet needs. Findings include: 1. Resident 20 was admitted to the facility in 2/2020 with diagnoses including hemiplegia (paralysis of one side of the body) of the left nondominant side. On 7/31/24 at 11:12 AM Resident 20 was observed in bed, her/his call light hung off the left side of the bed between the mattress and side rail towards the floor. Resident 20 had softly yelled for help whenever a staff member walked past her/his room. On 7/31/24 between 11:12 AM and 11:26 AM multiple staff were observed to have walked past Resident 20's room without stopping or assisting Resident 20. On 7/31/24 at 11:26 AM Staff 33 (Housekeeping Manager) was observed cleaning Resident 20's door. Resident 20 asked for help to scratch her/his back and Staff 33 stated she could not assist but would get assistance. On 7/31/24 between 11:26 AM and 11:48 AM multiple staff were observed to have walked past Resident 20's room without stopping or assisting Resident 20. Resident 20 continued to yell out softly whenever a staff member walked past her/his door. On 7/31/24 at 11:48 the surveyor asked Staff 7 (CNA) if Resident 20's call light was in reach. Staff 7 stated it was not in reach, and then Staff 7 went into Resident 20's room to provide assistance. On 8/2/24 at 8:47 AM Resident 20 was observed in bed, her/his call light hung off the left side of the bed towards the floor between the mattress and side rail. On 8/2/24 at 9:39 AM Resident 20 was observed in bed, her/his call light continued to hang off the left side of the bed towards the floor between the mattress and side rail. On 8/2/24 at 9:46 AM Resident 20's call light was observed to still be hanging off the left side of the bed towards the floor between the mattress and side rail. Staff 4 (CNA) confirmed Resident 20's call light was not within reach and then fixed the call light so Resident 20 could reach it. On 8/2/24 at 10:25 AM Staff 23 (LPN Resident Care Manager) confirmed residents' call light were required to be within reach at all times. , 2. Resident 48 was admitted to the facility in 3/2024 with diagnoses including paranoid schizophrenia (mental disorder), chronic bed confinement, and hospice care. Resident 48's 3/14/24 care plan indicated the resident is moderate risk for falls related to a history of falls. The resident is bedbound with impaired mobility, and is non-verbal. Interventions were to keep call light within reach while in bed. Observations from 7/29/24 through 8/1/24 on day and evening shifts Resident 48's call light was in a dresser drawer and not within reach. On 7/31/24 at 11:36 AM Staff 28 (LPN) stated the resident was able to use her/his call light. Staff 28 verified the resident's call light was not within reach. On 8/1/24 at 11:26 AM Staff 17 (LPN) stated the resident was able to use her/his call light. Staff 17 verified the resident's call light was in the nightstand drawer and not within reach. On 8/2/24 at 9:35 AM Staff 23 (LPN-Resident Care Manager) stated Resident 48's call light should be within reach at all times and was not.

The facility failed to make sure that the call light was within reach for Residents 20 and 48. The maintenance director went into both rooms and added clips to the call light chords to help secure the call light to the bed. It was determined that all residents could be affected by this deficiency. Ambassador rounds were done for all residents and the residents were asked to show the staff members their call light and demonstrate using it. All call lights were left within reach. The director of nursing services and administrator reviewed the call light policy and deemed it appropriate. All staff were educated to the policy. The administrator or designee will audit 5 residents ambassador rounds for proper call light placement and return demonstration weekly for four weeks, and then monthly for four months. All audits will be brought to the QAPI team for review.

Based on interview and record review it was determined the facility failed to ensure CNAs received 12 hours of training for 3 of 5 sampled staff (#s 3, 4, and 7) reviewed for staffing. Findings include: Review of CNA training records revealed: -Staff 3 was hired in 7/2016 and did not have 12 hours of training for the last one year. -Staff 4 was hired in 7/2022 and did not have 12 hours of training for the last one year. -Staff 7 was hired in 9/2021 and did not have 12 hours of training for the last one year. On 8/1/24 at 8:30 AM Staff 2 (DNS) verified Staff 3, 4, and 7 did not have 12 hours of training in the last year.

The facility failed to provide 12 hours of annual training for all CNA staff members. No residents were cited in this deficiency, but all residents could be affected by this deficiency. All CNAs were provided an annual competency with return demonstration for all CNA ADL skills. The Director of nursing services and administrator reviewed the ADL competency and deemed it appropriate. All CNAs were given the ADL competency with return demonstration. The director of nursing or designee will audit monthly hourly education for completion by all CNAs monthly for six months. All audits will be brought to the QAPI team for review.

Based on interview and record review it was determined the facility failed to ensure minimum CNA staffing ratios for 14 of 53 days reviewed. This placed residents at risk for unmet care needs. Findings include: Review of 2/1/24 through 2/21/24 and 6/29/24 through 7/29/24 Direct Care Staff Daily Reports revealed the following dates did not meet the state minimum CNA requirements: -2/10/24 day and evening shift. -2/12/24 evening shift. -2/14/24 night shift. -2/15/24 night shift. -2/19/24 day shift. -6/29/24 day shift. -7/1/24 day shift. -7/5/24 night shift. -7/10/24 day shift. -7/12/24 night shift. -7/16/24 day shift. -7/22/24 evening shift. -7/27/24 day shift. -7/28/24 evening and night shift. On 7/30/24 at 11:00 AM Staff 1 (Administrator) verified the facility did not meet the state CNA minimum staff on the above listed dates .

The facility failed to maintain proper CNA ratios on multiple dates in 2024. No residents were cited in this deficiency, but all residents could be affected by this deficiency. The CNA schedule was pulled through September and the staffing coordinator is working with current employees and staffing agencies to fill open slots in our schedule. The director of nursing services and administrator reviewed the staffing ratios with the scheduler and updated the number of staff needed per shift according to those ratios. The director of nursing services or designee will audit the DHS staffing sheet for appropriate ratios daily to ensure continued compliance with CNA ratios. All DHS sheets will be brought to the QAPI team for review.

, Based on interview and record review it was determined the facility failed to ensure minimum CNA staffing requirements wre met for 9 of 99 shifts reviewed. This placed residents at risk for unmet care needs. Findings include: Review of 8/27/24 through 9/28/24 Direct Care Staff Daily Reports revealed the following shifts did not meet the state minimum CNA staffing requirements: -8/31/24 day and evening shift. -9/5/24 evening shift. -9/8/24 day and evening shift. -9/14/24 day and evening shift. -9/15/24 day and evening shift. On 10/1/24 Staff 9 (Scheduling Coordinator) stated she was not informed prior to a surge in resident census in order to adequately meet the minimum CNA staffing requirements. On 10/1/24 at 3:21 PM Staff 1 (Administrator in Training) was provided information related to the above shifts when the minimum CNA staffing requirements were not met. Staff 1 acknowledged the goal to meet minimum CNA staffing requirements was not met.

The facility failed to maintain proper CNA ratios on multiple dates in 2024. No residents were cited in this deficiency, but all residents could be affected by this deficiency. The CNA schedule was pulled through October and all shifts are filled according to the current census. A daily staffing meeting is being completed to mitigate any call-ins or vacations that need to be covered. The director of nursing services and administrator reviewed the staffing ratios with the scheduler and updated the number of staff needed per shift according to those ratios. We also educated all nurses in the building to check census verses CNAs at the beginning of each shift to ensure that there are adequate number of CNAs in the facility, and to call on call nurse to help fill any call-ins or no shows. The director of nursing services or designee will audit the DHS staffing sheet for appropriate ratios daily to ensure continued compliance with CNA ratios. All DHS sheets will be brought to the QAPI team for review.

Based on observation and interview it was determined the facility failed to have a full time administrator for 1 of 1 facility. This placed residents at risk for lack of administration. Findings include: On 8/5/24 at 1:20 PM a posted administrative license was observed for Staff 22 (Administrator). On 8/5/24 at 1:24 PM Staff 1 (Administrator in Training) and Staff 22 stated Staff 1 was not currently licensed in the State as an administrator and expected to complete the state-specific administrator training and testing requirements in 12/2024. Staff 22 stated she was not working onsite at the facility on a full-time basis.

The facility failed to staff a full-time licensed administrator in the facility from June 23rd onward, even though they had posted Administrator Megan Roemmich’s administrator license she was not in the building full-time. Megan Roemmich had her job duties re-arranged by Avamere, so that she could be in the facility full-time. Education was provided to the administrator and AIT about the requirements of having a full-time licensed administrator. All staff were re-educated on Megan Roemmich being the full-time licensed administrator and Victoria Malus being the Administrator in Training. Megan will make appropriate rounds with the staff, so that staff are aware that she is in the building and available for assistance when needed.

***************************************** OAR 411-085-0310 Resident Rights: Generally Refer to F552, F557, F572, F580 and F583 ***************************************** OAR 411-086-0260 Pharmaceutical Services Refer to F554 and F761 ***************************************** OAR 411-086-0040 Admission of Residents Refer to F578 ***************************************** OAR 411-087-0100 Physical Environment: Generally Refer to F584 ****************************************** OAR 411-085-0360 Abuse Refer to F600 and F609 ****************************************** OAR 411-86-0060 Comprehensive Assessment and Care Plan Refer to F656 and F657 ***************************************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F677, F684, and F695 ***************************************** OAR 411-086-0140 Nursing Services: Problem Resolution & Preventive Care Refer to F686, F689, F690, F757, F758, and F883 *************************************** OAR 411-086-0240 Social Services Refer to F699 **************************************** OAR 411-086-0310 Employee Orientation and In-Service Training Refer to F730 and F947 **************************************** OAR 411-086-0250 Dietary Services Refer to F803 and F806 **************************************** OAR 411-086-0110 Administrator Refer to F847 **************************************** OAR 411-086-0330 Infection Control and Universal Precautions Refer to F880 and F881 **************************************** OAR 411-087-0440 Electrical Systems: Alarm and Nurse Call Systems Refer to F919 ****************************************

***************************************** OAR 411-086-0140 Nursing Services: Problem Resolution & Preventive Care Refer to F758 ***************************************

Based on interview and record review it was determined the facility failed to honor the right to receive visitors of his or her choice for 1 of 3 sampled residents (#4) reviewed for visitation. This placed residents at risk for lack of visitation. Findings include: Resident 4 was admitted to the facility in 6/2023 with diagnoses including pressure ulcers. Review of a letter dated 10/10/23 revealed Witness 10 (Family Member) requested the facility not allow Witness 3 (Complainant) or Witness 7 (Friend) to visit the resident and to notify Witness 10 if anyone asked about the resident. Review of a MDS assessment dated 10/17/23 revealed the resident was cognitively intact. Review of a progress note dated 11/11/23 at 4:34 PM revealed the resident had visitors which included Witness 3. Staff had been instructed by the resident's responsible party Witness 3 was not allowed contact with the resident. The resident's visitors were asked to leave the facility, said good bye to the resident and left peacefully. Review of a progress note dated 11/11/23 at 4:38 PM revealed the nurse was notified by a staff person that Witness 3 was not allowed to visit the resident. Witness 10 informed the facility Witness 3 was not to visit the Resident. The note indicated staff were notified on the next shift to be aware of unauthorized visitors. Review of a progress note dated 11/15/23 at 11:18 AM revealed a phone call was received from Witness 3. Staff 2 (LPN) told Witness 3 that she/he was not allowed to speak with the resident. Witness 3 wanted Staff 2 to ask the resident if she/he wanted to speak to her/him. Staff 2 stated she would not ask the resident. Review of a progress note dated 11/15/23 at 11:35 AM revealed Staff 3 (RNCM) received a call from Witness 3 who inquired as to why she/he was unable to speak with her "grandma" and wanted clarification why she/he was unable to visit the resident. Witness 3 stated Witness 10 did not have the right to limit the resident's visitors. Witness 3 asked Staff 3 to speak to the resident and ask her/him if she/he wanted to see Witness 3. Staff 3 declined to do so. Resident was alert and oriented to self (cognitively intact) and Witness 3 was not on resident's contact list. Review of a progress note dated 11/15/23 at 1:02 PM revealed the resident received a call from Witness 7 (Friend). The note indicated Witness 7 was listed as someone that is not supposed to have contact with the resident. Staff 2 informed Witness 7 that she would speak to Witness 10 about allowing her/him talk to the resident. Staff 2 told Witness 7 that she/he was not able to speak to the resident. Review of a progress note dated 11/15/23 at 1:08 PM revealed Witness 7 called the facility and stated the resident asked her/him to call the resident back. Staff 2 informed Witness 7 she/he could not speak with the resident at this time. Witness 7 asked if the resident was being held hostage. Staff 2 stated that the resident was not, said goodbye and hung up. Review of a care plan dated 11/16/23 revealed the resident was care planned for psychosocial well-being and interventions included a list of people not allowed to visit the resident per the resident's request. The list included Witness 3 and Witness 7. Review of a physician order dated 11/17/23 revealed if any "callers who want to speak to resident MUST know the password: PELICAN. If they do not know this word, no calls may be transferred into her/his room". Review of the resident's profile in the electronic record revealed special instructions were listed which included people not allowed to visit the resident which included Witness 3 and Witness 7. Review of the November 2023, December 2023 and January 2024 Treatment Administration Records revealed "callers who want to speak to resident MUST know the password: PELICAN. If they do not know this word, no calls may be transferred into her room" and was initialed by staff each shift. In an interview on 1/24/24 at 9:51 AM Resident 4 indicated she/he wanted to speak to and visit with Witness 3 and had not spoken to Witness 3 in some time. In an interview on 1/26/24 at 8:55 AM Resident 4 said Witness 3 was a longtime friend of the family. In an interview on 1/26/24 at 9:01 AM Witness 3 said the facility would not allow her/him to visit the resident because she/he was not on the approved list of people allowed to talk to the resident. Witness 3 said she/he had never caused any problems at the facility and just wanted to see the resident. In an interview on 1/26/24 at 9:40 AM Staff 2 said on 11/15/23 she spoke with Witness 3 and Witness 7. Both were listed as people the resident was not allowed to visit with. Staff 2 acknowledged she did not ask the resident if she/he wanted to visit with Witness 3 and 7. In an interview on 1/29/24 at 8:47 AM Staff 1 (DNS) acknowledged staff did not allow the resident a choice of who she/he could visit with. In an interview on 2/1/24 at 8:58 AM Staff 3 spoke with Witness 3 on 11/15/23 and told her/him they were not allowed to speak to the resident. Staff 3 acknowledged she did not ask the resident if she/he wanted or preferred.

F563 Right to Receive/Deny Visitors 1. How the nursing home will correct the deficiency as it relates to the resident: Resident 4 is no longer at the facility. 2. How the nursing home will act to protect residents in similar situations: Current Residents were reviewed for any visitor restrictions. No other findings noted. Residents were educated on their Resident Rights, Right to Receive/Deny Visitors; CFR(s): 483.10(f)(4)(ii)-(v) by February 27, 2024. 3. Measures the nursing home will take or the systems it will alter to ensure that the problems does not recur: DNS/Designee educated Staff on Resident Right to Receive/Deny Visitors; CFR(s): 483.10(f)(4)(ii)-(v) by February 27, 2024. 4. How the nursing home plans to monitor its performance to make sure that solutions are sustained. DNS/Designee will randomly audit patients weekly for 4 weeks to validate that facility is providing resident has a right to receive visitors. Findings will be reported to QAPI Committee monthly for 3 months. Date of completion by February 27, 2024

******************************** OAR 411-085-0340 Residents' Rights: Visitor Access Refer to F563 ********************************

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 08/14/2023 and 08/20/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on interview and record review it was determined the facility failed to provide care and services to ensure the resident's right to be free from abuse was honored for 1 of 1 sampled resident (#13) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 13 admitted to the facility in 2019 with diagnoses including depression and anxiety. A facility Incident Report dated 2/4/23 indicated Resident 13 reported Staff 17 (CNA) "treated her/him badly" and attempted to change the resident's brief without permission. The resident indicated Staff 17 and Staff 16 came into the room. Staff 17 forcefully pulled her/his covers back and put her hands on the resident to undo her/his brief. Resident 13 told the CNA to stop and tried to push the CNA away. The resident reported Staff 17 said she/he stunk and would not listen when the resident told her to stop. The resident screamed at Staff 17. The nurse came in and pulled the CNA off the resident and had the CNA leave the room. The facility Incident Report dated 2/4/23 also included the following: -On 2/8/23 Witness 19 (Roommate) reported she heard Resident 13 yell "Ouch" or "No" or something similar. Witness 19 heard Resident 13 start screaming, "Get your hands off me!" and Resident 13 started crying and screaming like she/he was in a panic. It sounded like Resident 13 was being attacked. The nurse ran in so it must have been loud because the door was closed. Witness 19 did not want Staff 17 to ever come back because she did not how to treat people. -On 2/8/23 Staff 18 (LPN) reported she saw the two CNAs go into the resident's room. Five minutes later she heard Resident 13 screaming, "leave me alone, leave me alone!" The resident sounded distressed. The resident said Staff 17 had grabbed her/his hands and tried to force her/him into changing her/his brief. The resident told Staff 18 the CNA was" rude and aggressive". Staff 17 was argumentative with Staff 18 but finally left the room. -On 2/9/23 witness accounts corroborated the resident's grievance. The event was substantiated as abuse and Staff 17 was terminated. On 8/9/23 at 3:32 PM Resident 13 stated she/he remembered the incident very well and was still very angry about what happened. The CNA grabbed her/his brief and tried to pull it off very aggressively. The resident tried to push Staff 17 off of her/him but the CNA would not listen. The resident said she/he screamed and swore at Staff 17 because she/he felt she/he was being attacked. Resident 13 said Staff 17 was physically abusive to her/him when trying to pull off the brief and was holding her/his hands down. The resident said her/his roommate heard the whole thing and was very upset, too. During the interview with Resident 13 on 8/9/23 at 3:32 PM the resident was observed to get quite distressed when explaining what happened. The resident became agitated and was upset by the incident. On 8/10/23 at 10:34 AM Staff 16 (CNA) indicated she was in the room with Staff 17 when the incident occurred. She said Staff 17 tried to force the resident to be changed and would not take no for an answer. She held the resident down and ripped the sheets off the bed, then tried to rip the brief off the resident. The resident was screaming at her. Staff 17 was screaming and swearing at the resident too. Staff 16 said she was telling Staff 17 to stop but she would not stop. Staff 17 said the resident stunk and had to be changed right then and just kept trying to force the resident. Staff 17 was pushing the resident's hands aside but the resident did not want to be changed. Staff 16 said Staff 17 had an attitude from the time they first went into the room, but the resident had the right to say no. Staff 16 also said she felt Staff 17 should not work with residents. She had never heard a CNA speak to or treat a resident that way. On 8/10/23 at 2:00 PM Staff 1 (Administrator) acknowledged abuse had occurred. Although the facility had determined abuse had occurred related to intimidation of the resident, she understood there was also physical abuse related to Staff 17 putting her hands on the resident, verbal abuse related to swearing, intimidating and screaming at the resident and psychosocial harm related to the resident's emotional distress from the incident.

Resident #13 and all residents are at at risk for abuse if caregivers do not respect residents rights or do not have a clear understanding of what constitutes abuse. All nursing staff will be re-educated on residents rights and what constitutes abuse. New staff will be educated on resident's rights and abuse during their new hire orientation. All resident care managers will be re-educated on the types of abuse. All resident grievances will be reviewed daily at stand-up and a summary of findings presented during the monthly QAPI committee. This will be an ongoing practice.

Based on interview and record review it was determined the facility failed to ensure sufficient nursing staffing on a 24-hour basis for 1 of 1 building reviewed for staffing. This placed residents at risk for unmet care needs. Findings include: Review of Direct Care Staff Daily Reports from 3/1/23 through 3/31/23, 4/1/23 through 4/30/23 and 7/1/23 through 7/31/23 revealed the facility was understaffed for CNAs 29 of 31 days in 3/2023, 15 of 30 days in 4/2023 and 9 of 30 days in 7/2023 or 53 of the 91 days reviewed. Resident Council Notes were reviewed from 3/2023, 4/2023 and 7/2023 and included the following: *3/22/23: CNAs would come in and write on the white boards (daily care staff) and residents would not see the CNAs again during the shift. -Trash cans in resident bathrooms were hardly ever checked and CNAs were to empty them on every shift. -Agency CNAs never brought snack carts around, even some of the long term CNAs did not bring it around. The snacks were important to diabetic residents especially at bedtime. -CNAs were not asking residents regular daily questions related to input (food and fluids) and output (urine and bowel) so residents had no idea what was being charted about them. -Urinals were not being rinsed out which caused odors. *4/22/23: -Call lights were becoming an issue again. There were response times up to 49 minutes. It would be helpful if staff would at least pop in to see what was needed. -Staff did not take a minute, before leaving the room, to ensure residents had all they needed. -Many staff were seen outside of rooms chatting instead of answering call lights. *7/25/23: Continued issue of nursing staff not offering to change the resident's bed sheets on at least one of their shower days. -Beds not being made daily continued to be an issue. -Call light wait times had increased again. CNAs were seen walking past call lights if they were not assigned to the rooms. When CNAs went to lunch the resident's call-light remained on until the CNA returned (CNA lunch times were 30 minutes). -Shower rooms were not being cleaned after each use. -CNAs were not documenting how much residents were eating. -Ice water was not being refilled throughout the day. A Grievance form dated 7/25/23 included an interview with Resident 21 which indicated the resident turned on her/his call light around 9:10 AM. The resident had a staff member check if the call light was working, and it was. The call light was finally answered about 10:05 AM by the CNA. Resident 21 wrote, "This happened frequently and they always said the same thing, "I was at lunch" or they were not my assigned CNA." The following interviews were conducted with residents: On 8/2/23 at 2:00 PM Resident 19 indicated she/he waited over 30 minutes for a response to the call light and had to sit in a wet brief which was very uncomfortable. Resident 19 indicated she/he called her/his spouse to come in and help. On 8/2/23 at 2:17 PM Resident 22 said call lights were a problem. They could take anywhere from 20 minutes to over an hour. The resident said she/he had a really bad heart and was afraid no one would answer the call light to help. Resident 22 also indicated she/he had a 46 minute wait time for a call light recently. Some CNAs would walk past call lights often and not answer them. Resident 22 said she/he "drew the line" at 10 minutes response time to call lights. If response was over that time, it was too long. On 8/9/23 at 5:47 PM Resident 20 stated the facility had a major staffing issue which got worse after COVID. From the beginning of the year it was bad. Agency staff would chart they completed her/his personal nursing treatments when they had not. They sometimes did not even come into the room. The resident would ask staff on the next shift to verify this. When the facility only had one nurse on the long term care unit, the residents did not get all their nursing treatments done. One nurse could not do it all with 40 to 50 residents. The residents regularly had call light response times of 40 minutes to 1 and 1/2 hours including while they were sitting in their own bowel movement or sitting in urine from a leaky catheter. There was one emergency on night shift for a fall which needed the one nurse and all the aides to help, so there was no one to give the resident her/his medications. There have been a lot of unwitnessed falls because there was not enough staff to oversee the residents with behavior issues. Resident 20 stated she/he needed her/his cares done because they are "what keeps me alive." The following interviews were conducted with Staff: On 8/3/23 at 11:14 AM Staff 21 (LPN) said staffing was an issue at the facility, the same as everywhere else. They did try to get floor staff but were not always successful. The Maintenance Director, the Activities Director and the Social Services Assistant were all CNAs and they got called to work the floor as CNAs often. Weekends were an on-going issue, for all shifts. The main shortage on the weekends was for nurses, both LPN and RNs. Staff 21 stated the staffing problem had gotten worse in the past year. On 8/3/23 at 1:17 PM Staff 20 (CNA) said the facility was short of staff especially lately. If someone called out for a shift, they could not find anyone to fill the shift. The facility was short of CNAs and LPNs. The day shift was usually fine, but not always, the evening and night shift were bad and the facility was always short on weekends. Staff were often working 10 to 12 hour days and always needed to rush to get tasks completed. There were many residents with behavior issues which took up a lot of time and the acuity rate in the building was high. When they were short of staff on evenings or weekends it was hard to take lunches and they could not do showers. They could not move the showers to the next day because day shift would have too many showers and could not get them done either. A recent night shift had only 3 CNAs for the whole building and the facility had 60 residents. That was 20 residents for each CNA which was a lot. Sometimes a nurse had from 40 to 50 residents by themselves on the long-term-care hall. When they were short of nurses there were residents who missed treatments. Resident 20 had extensive care needs with wound care on the back, skin creams and flushing of her/his nephrostomy tube (artificial opening created between the kidney and the skin which allows for the urinary diversion directly from the upper part of the urinary system) which could not get done. On 8/3/23 at 2:15 PM Staff 13 (CNA) stated night shift and evening shift had the most trouble with staffing. They had lost one big staffing agency which did not help the situation. It was hard sometimes to complete all their tasks assigned because of how many residents they would end up with. It depended on the acuity and the acuity in the facility was frequently high. People were just not showing up for shifts and it was really hard to find coverage if someone did not show up. On 8/3/23 at 2:30 PM Staff 12 (LPN) stated evening shifts, night shifts and weekends had the most difficulty with staffing. The facility also needed more LPNs. On weekends, if a nurse needed to help with wound care it limited what they could get done on the shift. If there was a fall or a new admit they did not have time to touch the TAR which included nail care, creams and other minor nursing tasks. Falls were a big problem because there were so many of them. On evenings, for the last couple weeks, the facility only had four CNAs and there should be 5. Staff 12 said quite often they were working short of staff. The facility did have a new CNA class but the CNAs hired were only for day shift and that was not the shifts which had the most trouble with understaffing. Staff 12 stated residents were not always getting prompt responses from staff. On 8/4/23 at 2:22 PM Staff 3 (RNCM) said staffing shortages for evenings, nights and weekends (Friday, Saturday and Sunday) were the worst. The evening shift was short one person currently. She came to work a few weeks ago and there was only one nurse for the whole building. On weekends they need more LPNs and CNAs. Staff 3 also said the agency staff frequently did not show up and did not call in. On 8/9/23 at 2:43 PM Staff 20 (CNA) stated on evening shift they did not have enough CNAs. When they did not have enough CNAs, they could not do showers and it had been that way since the beginning of the year. If you missed showers, you could not put it on the next day because day shift did not have time to do it either. On night shift if you were short CNAs, it threw the whole schedule off. The night CNAs would have to start rounds early to get them done on time, so they would have to start them at 3:00 AM and the next shift came in at 6:00 AM. So some residents would go over the 2 hour toileting times and they would have briefs that were soaked. On 8/10/23 at 9:43 AM Staff 19 (CNA) indicated when the facility was understaffed only some nurses would pitch in and help. Some days they had 20 residents each. Staff 19 said she knew in 4/2023 Resident 21 waited an hour to get put to bed. When only 3 CNAs worked evenings the residents would not get their showers. The facility was not able to get replacement staff for call outs or no shows. The staffing agencies did not always have someone to send out or agency staff did not always show up. Some people did not want to work, some staff were burnt out and many did not want to pick up extra shifts. On weekends, staff was very bare. The facility recently had a day with five new resident admissions and Staff 19 said that would be a struggle even with adequate staff. On 8/2/23 at 11:15 PM Staff 2 (DNS) acknowledged the facility staffing shortages during 2023.

All residents are at risk for unmet care needs if minimum staffing standards are not maintained. The Administrator or designee will actively recruit staff through the Avamere website, Indeed, and OHCA posting and continue to utilize agency staffing as available. The Administrator and staffing coordinator or designees will meet 5 times a week to analyze & review weekly staffing needs for a minimum of 4 weeks, until significant compliance is met. An analysis of the findings will be reviewed during the monthly QAPI committee.

Based on interview and record review it was determined the facility failed to ensure minimum CNA staffing ratios were maintained for 29 of 31 days in 3/2023,15 of 30 days in 4/2023 and 9 of 30 days in 7/2023 reviewed for minimum CNA staffing. This placed residents at risk for delayed care and unmet needs. Findings include: Review of Direct Care Staff Daily Reports from 3/1/23 through 3/31/23, 4/1/23 through 4/30/23 and 7/1/23 through 7/31/23 revealed the facility was understaffed for CNAs 29 of 31 days in 3/2023, 15 of 30 days in 4/2023 and 9 of 30 days in 7/2023 or 53 of the 91 days reviewed. On 8/2/23 at 11:15 PM Staff 2 (DNS) acknowledged the CNA staffing shortages during 2023.

All residents are at risk for unmet care needs if minimum staffing standards are not maintained. The Administrator or designee will actively recruit staff through the Avamere website, Indeed, and OHCA posting. The Director of Nursing or Designee will re-educate nursing staff on appropriate call light response time. Call light response times will be audited on all shifts weekly for 4 weeks. Results of the audit will be reported to the Administrator and the findings will be reviewed during the monthly QAPI committee. The Administrator or Designee will educate Nursing Staff on the Attendance Policy and appropriate call-in time frame, to allow facility time to get staffing coverage. The Administrator and staffing coordinator or designees will meet 5 times a week to analyze & review weekly staffing needs for a minimum of 4 weeks, until significant compliance is met. An analysis of the findings will be reviewed during the monthly QAPI committee.

*********************************** OAR 411-085-0360 Abuse Refer to F600 *********************************** OAR 411-086-0100 Nursing Services: Staffing Plan Refer to F725 **********************************

Based on interview and record review it was determined the facility failed to update the care plan regarding a pressure ulcer for 1 of 3 residents (#10) reviewed for pressure ulcers. This placed residents at risk for lack of proper wound care. Findings include: Resident 10 was admitted to the facility in 6/2021 with diagnoses including quadriplegia. Review of an incident report dated 7/11/21 revealed during care staff discovered an open area of the skin on the resident's coccyx and right buttock. Staff immediately started treatment and the resident's physician was notified. Review of a Skin/Wound note dated 8/3/21 revealed the resident had a change of condition and was sent to a local hospital for evaluation. Review of a care plan revised on 8/4/21 revealed no focus, goals or interventions regarding the resident's coccyx and buttock wounds. The care plan only referred to the resident's post surgical incision care. In an interview on 7/14/22 at 10:30 AM Staff 1 (DNS) acknowledged Resident 10's care plan was not updated to reflect the resident's current wound status and care.

Avamere Rehabilitation of Eugene provides the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Resident #10 is no longer in the facility. All residents with wounds are at risk for lack of wound care if the care plan is not updated. Care plans for all residents identified in Wound Rounds will be audited for accuracy and revised as needed. Resident Care Managers have been reeducated on the Care Planning process and revising Care Plan when changes occur, including new wounds and wound care at wound clinic. The DNS or designee will perform random audits weekly for 4 weeks of the care plans for residents with wound care to ensure accuracy of the care plan. The results of the audits will be shared with the administrator and reviewed during the monthly QAPI committee.

Based on interview and record review it was determined the facility failed to follow physician orders for restorative assistance (RA) for 1 of 2 residents (#8) reviewed for restorative assistance. This placed residents at risk for a decline in activities of daily living. Findings include: Resident 8 was admitted to the facility in 9/2020 with diagnoses including congestive heart failure. Review of a physician order dated 12/27/19 revealed the resident was to receive upper body exercise to help with weight loss three times a week at a minimum (12 days). The order was discontinued on 4/30/22. Review of a Documentation Survey Report (ADLs) for 11/2021 revealed the resident was offered or received active range of motion seven times. Review of a Documentation Survey Report (ADLs) for 12/2021 revealed the resident was offered or received active range of motion five times. Review of a Documentation Survey Report (ADLs) for 1/2022 revealed the resident was offered or received active range of motion seven times. Review of a Documentation Survey Report (ADLs) for 2/2022 revealed the resident was offered or received active range of motion six times. Review of a Documentation Survey Report (ADLs) for 3/2022 revealed the resident was offered or received active range of motion five times. Review of a Documentation Survey Report (ADLs) for 4/2022 revealed the resident was offered or received active range of motion five times. In an interview on 7/1/22 at 11:27 AM Resident 8 said the facility did not provide RA as ordered by her/his physician. Resident 8 said she/he would like to exercise five times a week. In an interview on 7/7/22 at 10:19 AM Staff 3 (RA/CNA) said he provided RA for Resident 8 for about a year, two days a week. Staff 3 was not aware there was a physician order for RA three days a week. In an interview on 7/7/22 at 10:40 AM Staff 4 (RNCM) acknowledged the physician order for exercise three days a week was not followed by the facility.

Avamere Rehabilitation of Eugene makes certain that residents receive treatment and care in accordance with professional standards of practice, ensuring the physicians orders are followed. Resident #8 is currently receiving RA treatments five times a week. All physician orders of current residents will be audited for restorative assistance (RA) orders to ensure that current orders are being followed. Nursing staff will be re-educated on the triple check process for transcribing orders not directly entered by the provider. The DNS or designee will perform a random audit of the RA care plans for 4 weeks for accuracy. The results of the audits will be shared with the administrator and reviewed during the monthly QAPI committee.

Based on interview and record review it was determined the facility failed to follow the care plan for ADLs for 1 of 3 residents (#12) reviewed for falls. This placed residents at risk for accidents. Findings include: Resident 12 was admitted to the facility in 4/2021 with diagnoses including a brain injury. Review of an ADL care plan for toileting updated 6/1/21 revealed the resident required two person assistance with toileting (incontinent care). The care plan also indicated the resident required two person assistance with bed baths updated 2/4/22. Review of a nursing care note dated 6/25/22 at 12:55 PM revealed Staff 5 (RN) was approached by Staff 6 (CNA) who needed assistance with Resident 12 who was on the floor in the resident's room. The resident was lying next to the bed with blood coming from the resident's head. 911 was called and the resident was transported to a local hospital for evaluation. Review of a hospital note dated 6/25/22 revealed the resident had a one cm superficial cut on the side of the resident's head. Review of an incident report and investigation dated 6/30/22 revealed Staff 6 had just completed a bed bath for the resident when Staff 6 noticed the resident had an incontinence episode. Staff 6 turned the resident on her/his side and the resident had a spastic episode which made the resident fall out of bed on to the floor. The report indicated the resident hit her/his head on the nightstand before landing on the floor. The investigation indicated Staff 6 did not have another staff person in the resident's room for assistance with bathing. In an interview on 7/7/22 at 9:45 AM Resident 12 indicated on 6/25/22 she/he fell out of bed during a bed bath and was sent to a local hospital. Resident 12 said Staff 6 completed the bed bath alone and should of had another CNA in the room for assistance. Resident 12 said she/he was care planned for two-person assistance with bed baths. In an interview on 7/14/22 at 8:54 AM Staff 6 said on 6/25/22 he was giving Resident 12 a bed bath and the resident had a incontinent episode. Staff 6 said he rolled the resident on the resident's side, the resident had a body spasm and went over the edge of the bed on to the floor. Staff 6 acknowledged he performed the bed bath alone and was not aware the resident was care planned for two-person assistance with bed baths. In an interview on 7/22/22 at 2:00 PM Staff 1 (DNS) acknowledged the resident's care plan was not followed regarding bed baths and toileting.

Avamere Rehab of Eugene ensures that each resident receives adequate supervision and assistance to prevent accidents. Nursing Staff have been re-educated on following the care plan for two person assist for bathing for Resident # 12. The care plans of all residents have been reviewed to ensure that the care plan meets their current level of need. The Director of Nursing or Designee will perform a random audit of residents for four weeks to ensure the care plan is being followed. Results of the audits will be provided to the administrator and reviewed at the monthly QAPI committee.

************************************ OAR 411-086-0140 Nursing Services: Problem Resolution & Preventative Care Refer to F689 ************************************ OAR 411-086-0110 Nursing Services: Resident Care Refer to F684 ************************************ OAR 411 -86-0060 Comprehensive Assessment and Care plan Refer to F657 ************************************