Reedwood Post Acute

Based on observation, interview, and record review it was determined the facility failed to maintain comfortable temperature levels, and a safe and home like environment for 1 of 1 facility reviewed for comfortable temperatures and homelike environment. This placed residents at risk for an uncomfortable and unhomelike environment. Findings include: 1. On 12/26/23, 1/17/24 and 1/18/24 public concerns were reported to the State Agency which alleged residents had to endure cold temperatures due to heating issues in the facility and many residents had to wear coats, hats and gloves to stay warm. The report indicated the facility had some heat in the hallways so residents gathered in common areas with coats and hats on but individual resident rooms were "ice boxes" due to the heating system not working properly since 11/2023. The report alledged the facility's temperatures were "cruel and inhumane treatment." Multiple observations from 3/4/24 through 3/6/24 between the hours of 8:00 AM and 4:00 PM revealed the following: -Many residents in their rooms and hallways wore extra clothing, coats, shawls and hats; -Many residents in their rooms were covered with two or more blankets; -Cold drafts were felt in some areas of the hallways, common areas and in some residents' rooms; -Some residents opened their room windows to cool off their rooms. On 3/4/24 at 9:46 AM and 3/5/24 at 12:38 PM and 1:06 PM Resident 38 stated in the past, her/his room was "really" cold but on 3/5/24, her/his room was "about 105 degrees" and she/he was sweating so she/he opened the window. Resident 38 stated the room was so hot she/he "wanted to sleep in the hallway." Resident 38 stated sometimes her/his room was too hot so she/he had to open her/his window or the door to do "anything I can" to regulate her/his room temperature. On 3/4/24 at 10:47 AM Resident 247 stated she/he was a resident in the facility in 11/2023 through the end of 12/2023. Resident 247 stated during her/his stay, there were periods when the facility had no heat, her/his room was always "freezing" and during the night her/his room was below 61 F. Resident 247 reported Staff 8 (Maintenance Director) covered the inside of her/his room window with plastic but the room remained cold so Staff 8 placed plastic on the outside of her/his room window. Resident 247 reported she/he continued to be cold so she/he was moved to a different room which was "colder and more confining." Resident 247 reported she/he was provided with an electric blanket which then "confined" her/him to her/his room in order to stay warm and also caused her/him to be too hot, sweat and then "freeze." Resident 247 stated the temperatures in the facility fluctuated between cold and hot depending on the location in the building. Resident 247 stated there were many residents that "congregated" at the end of the hallway where a wall heating/cooling device was mounted and blew warm air and many residents wore coats, hats and gloves to stay warm. Resident 247 reported she/he "didn't have real healing until I discharged" because of the "frigid" temperatures she/he had to endure for one month before being discharged home. Resident 247 stated at the time of her/his discharge, the heating system was not yet fixed. On 3/6/24 at 8:10 AM Resident 197 was observed in bed, covered with three blankets. Resident 197 stated her/his room was "drafty." A cold draft was evident when standing near Resident 197's bed and in the middle of the room. Resident 197 reported she/he was "freezing" and she/he usually needed extra blankets to stay warm. Resident 32 shared the room with Resident 197 and reported she/he was also "freezing" and required extra blankets. Staff 13 (CNA) reported the two residents were "always" cold and Resident 32 frequently verbalized she/he was "freezing." On 3/6/24 at 9:15 AM Resident 98 was observed dressed with a coat, hat and shawl while in the dining room and then sitting in the area surrounding the nurses station. With the assistance of Witness 3 (Interpreter), Resident 98 stated she/he was "always" cold. On 3/6/24 at 9:17 AM Resident 7 was observed in the dining room and then sitting in the area by the fishtank near the nurses station, wearing two shirts, a wool vest and a crocheted shawl. With the assistance of Witness 3 (Interpreter), Resident 7 stated her/his room was cold which made her/him "shake." Resident 7 stated her/his room was especially cold "all night long" which made it hard to sleep. On 3/6/24 at 1:50 PM Resident 10 stated she/he got cold at night and used an electric blanket to warm up. Resident 10 stated when she/he got cold, her/his bones "ache and hurt." On 3/5/24 Staff 8 provided temperature logs from 12/1/23 through 3/1/24. The temperature logs were completed weekly and seven resident rooms were audited for temperature levels, each week. Temperature readings ranged from a low of 67 F to a high of 90 F. On 3/5/24 at 1:06 PM and 3/6/24 at 8:06 AM Staff 8 assessed temperatures of various areas of the facility including common areas such as the dining room, hallways, around the nurses station and multiple residents' rooms. Temperature readings ranged from a low of 66 F to a high of 87 F. On 3/5/24 at 12:26 PM Staff 8 reported in 10/2023, he noted the pilot light for the heater was not working correctly so he contacted a service company. On 10/24/23, the service company partially completed the necessary repairs but additional repairs were still needed. Staff 8 stated, to date, the additional repairs had not been completed. Staff 8 reported there were other parts of the heating system that broke and were serviced in 1/2024 and 2/2024. Staff 8 stated Resident 247 complained about cold temperatures and a draft in her/his room so he covered the room window with plastic and Resident 247 was provided an electric blanket. Staff 8 stated Resident 247 was moved to another room. Staff 8 reported some of the residents' rooms were colder and some were warmer because there was no way to regulate temperatures in the residents' rooms because the heating system was so old. Staff 8 stated he attempted to keep temperatures between 68 F and 75 F. On 3/7/24 at 10:24 AM and 11:57 AM Staff 1 (Administrator) stated temperature issues in the facility related to the heating system were identified in 11/2023. Staff 1 stated he created a PIP (Performance Improvement Plan (a means of measuring a process or procedure then modifying the process or procedure to increase effectiveness)) to address temperature concerns. Staff 1 stated the PIP was ongoing but they had not been completing daily resident audits to ensure residents were warm and the facility was meeting the residents' comfort needs, as outlined in the PIP. Staff 1 stated the facility bought hats, extra blankets, a blanket warmer, moved residents to different rooms and encouraged residents to wear extra clothing, sit in warmer areas of the facility or leave their room doors open for warmth. For rooms that were too hot, the facility provided fans and encouraged the residents to open their room windows to cool their rooms down. Staff 1 stated the heating system was "kind of but not really" fixed and they continued to wait on parts. Staff 1 reported he was "surprised" at the number of residents that complained about the temperatures but they had not "formally" checked in with the residents for "awhile." Staff 1 stated his goal was to maintain temperatures at a comfortable level for the residents. , 2. Observations of the facility's general environment from 3/4/24 through 3/7/24 identified the following issues: -End cap on the lower wall guard next to the fish tank was broken with sharp and jagged edges. -End cap on the lower wall guard outside the storage room on the south hall was broken with sharp and jagged edges. -End cap on the lower wall guard to the right of the nurses station was broken with sharp and jagged edges. -End cap on the lower wall in the entryway was broken and cracked. On 3/7/24 at 10:15 AM Staff 1 (Administrator) and Staff 8 (Maintenance Director) acknowledged the identified concerns needed to be repaired. , 3. On 3/4/24 at 10:19 AM two large patches of dry wall mud (used for repairing cracks and holes in existing drywall and plaster surfaces) were observed on the wall behind Resident 20's bed. Multiple gouges were observed on the resident's wooden baseboard along the wall to the right of the resident's bed which revealed jagged sections in the baseboard. With the assistance of Witness 1 (Interpreter), Resident 20 stated the condition of her/his walls and baseboard had been this way for quite some time, their condition bothered her/him and she/he wanted them repaired. On 3/7/24 at 10:16 AM Staff 1 (Administrator), Staff 8 (Maintenance Director) and Staff 19 (Administrator-in-Training) were present for an interview and facility walk-through. Staff 8 stated staff were expected to add any maintenance concerns to the facility's electronic maintenance system so he could follow up and complete the repairs. Staff 8 stated he was also in resident rooms at least weekly or monthly looking for issues. Staff 1 stated when the facility had resident beds available, he tried to "do bed management and move residents around" so rooms could be painted and repaired. Staff 1 stated Resident 20's room "had not been empty in a long time" and was in need of repair. On 3/7/24 at 10:29 AM Staff 1, Staff 8 and Staff 19 observed Resident 20's room. Staff 8 stated he was not aware the resident's baseboards were in need of repair and that he mudded the wall above Resident 20's bed approximately two-to-three months ago but had not been able to return to sand and paint the wall. 4. On 3/4/24 at 10:56 AM light spills were observed on the wall as well as scratches and gouges to the wooden baseboard behind Resident 9's bed. On 3/7/24 at 10:16 AM Staff 1 (Administrator), Staff 8 (Maintenance Director) and Staff 19 (Administrator-in-Training) were present for an interview and facility walk-through. Staff 8 stated staff were expected to add any maintenance concerns to the facility's electronic maintenance system so he could follow up and complete the repairs. Staff 8 stated he was also in resident rooms at least weekly or monthly looking for issues including wall damage. On 3/7/24 at 10:29 AM Staff 1, Staff 8 and Staff 19 observed Resident 9's room. Staff 8 stated he was not aware the resident's baseboards were in need of repair. Staff 8 further stated he was not aware of the condition of Resident 9's wall and acknowledged it needed to be cleaned. 5. On 3/4/24 at 12:37 PM large scrapes were observed on the wall next to Resident 14's recliner. On 3/7/24 at 10:16 AM Staff 1 (Administrator), Staff 8 (Maintenance Director) and Staff 19 (Administrator-in-Training) were present for an interview and facility walk-through. Staff 8 stated staff were expected to add any maintenance concerns to the facility's electronic maintenance system so he could follow up and complete the repairs. Staff 8 stated he was also in resident rooms at least weekly or monthly looking for issues including wall damage. On 3/7/24 at 10:29 AM Staff 1, Staff 8 and Staff 19 observed Resident 14's room. Staff 8 stated he was not aware the resident's wall was damaged and acknowledged it was in need of repair.

F584: Homelike Environment (heat and room repair) 1. Boiler/Heating system was fixed by the vendor on 3/11/2024. The scratched walls in Rm 16 and Rm 9 were fixed and painted on 3/22/24. Thermometers were installed in all rooms to correctly measure ambient temperature on 3/8/24. Current damaged bumpers were taped to prevent injury and remedied to surveyor's satisfaction prior to ending the survey. The new bumpers were in the process of being ordered as of 3/1/2024. The new bumpers will be installed once they arrive. 2. Residents rooms were assessed as well as common areas for other safety/maintenance concerns and any concerns identified, were addressed. 3. Staff were re-educated in how to report environmental concerns via the facility maintenance reporting system 4. Repairs and environmental concerns are monitored through the reporting software, grievance process, and resident council meetings. Audits will be completed by Administrator or designee weekly for one month, then monthly for two months to ensure that rooms look presentable and are comfortable for the resident. 5. Results of the audits will be brough to the facilitys monthly QAPI meeting until a lesser frequency is deemed appropriate.

Based on interview and record review it was determined the facility failed to protect the resident's right to be free from physical abuse for 1 of 2 sampled residents (#'s 12 and 97) reviewed for resident-to-resident abuse. This placed residents at risk for abuse. Findings include: Resident 12 was admitted to the facility in 8/2019 with diagnoses including dementia with behaviors. Resident 12's 12/31/23 Quarterly MDS indicated a BIMS score of two (severe cognitive impairment) and no behaviors demonstrated. Resident 97 was admitted to the facility in 5/2023 with diagnoses including dementia with mild agitation. Resident 97's 10/23/23 Significant Change of Condition MDS indicated a BIMS score of two (severe cognitive impairment) and yelling behaviors. On 9/30/23 the facility submitted a FRI which indicated Resident 12 hit Resident 97. On 3/5/24 at 11:00 AM Staff 15 (CNA) stated she went to get Resident 12 a sweater and overheard Resident 97 yelling, which was a normal behavior. When she returned, Resident 12 had self-propelled herself/himself over to Resident 97, near the nursing station. Staff 15 witnessed Resident 12 hit Resident 97 on the arm and she separated and redirected the residents. On 3/7/24 at 11:22 AM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged the 9/30/23 incident between Resident 12 and Resident 97.

F600: Free from Abuse and Neglect/ 1. Resident #97 expired on 1/1/2024. Resident #12 remains in the facility and has no lasting effects and cannot recollect the event. 2. Residents were reviewed via incident reporting process for the potential for resident to resident altercations and those at risk were care planned accordingly. 3. Staff will be re-educated on abuse and neglect specifically surrounding resident to resident altercations and prevention. The facility will continue education with new hire and annual abuse and neglect training for staff. 4. Resident altercations, events and behaviors are monitored through the center event reporting process. Event reports and grievances will continue to be reviewed with the facility stand-up meeting for any suggestion of abuse or neglect. A weekly audit for one month then monthly for two months will be completed by the Administrator/designee to confirm appropriate interventions are in place to prevent altercations. 5. Results of audits will be brought to the facilitys monthly QAPI meeting until a lesser frequency is deemed appropriate.

Based on interview and record review the facility failed to provide the required written notice of a bed hold policy before or upon transfer to the hospital for 1 of 3 residents (#8) reviewed for hospitalization. This placed residents at risk to be uninformed of their rights. Findings include: A facility bed hold policy last reviewed 3/2019 indicated "the resident and/or resident representative will be informed of this policy in writing upon admission, transfer or leave of absence. If unable to provide at the time of transfer or leave of absence, the policy will be provided within 24 hours." Resident 8 re-admitted to the facility in 1/2024 with a diagnosis of paraplegia (loss of control of motor function). A 1/6/24 progress note indicated Resident 8 was discharged to the hospital for a medical condition. A 1/8/24 progress note indicated Resident 8 was re-admitted to the facility. Record review completed on 3/5/24 revealed Resident 8 and her/his family were not provided with a written bed hold policy or a bed hold agreement when Resident 8 discharged to the hospital on 1/6/24 or within 24 hours. Further record review also revealed Resident 8 and her/his family did not receive the facility's bed hold policy and did not sign a bed hold agreement upon admission. On 3/6/24 at 11:15 AM Staff 6 (Social Services Director) confirmed she did not provide a written bed hold agreement or discuss holding Resident 8's bed with her/his family when Resident 8 discharged to the hospital. Staff 6 confirmed there was no record a bed hold policy or agreement was provided to Resident 8 or her/his family upon admission.

F625: Bed Hold Notice 1. Resident #8 family was provided a bed hold policy. 2. A review of transfers for the last 30 days was completed and issues identified were resolved. 3. Licensed nursing and Social Services will be re-educated on the bed hold policy. 4. Bed holds will be reviewed during the facility stand up meeting to ensure timeliness for any resident who transfers out of the facility. 5. Results of the audits will be brought to the facilitys monthly QAPI meeting until a lesser frequency is deemed appropriate.

Based on observation, interview and record review it was determined the facility failed to accurately assess 3 of 7 sampled residents (#s 6, 20 and 297) reviewed for unnecessary medications and accidents. This placed residents at risk for unassessed needs. Findings include: 1. Resident 6 admitted to the facility in 2015 with diagnoses including mood disorder. A 6/5/21 physician order indicated Resident 6 received Seroquel (antipsychotic) BID for bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). Resident 6's 12/2023 MAR revealed she/he was administered Seroquel from 12/1/23 through 12/31/23. The 12/31/23 Annual MDS indicated the resident did not receive Seroquel during the MDS look back period from 12/24/23 through 12/31/23. On 3/5/24 at 3:14 PM Staff 2 (DNS) acknowledged Resident 6's MDS was inaccurate. , 2. Resident 297 was admitted to the facility in 12/2018 with diagnoses including diabetes and osteoporosis (disease that causes bones to become weak). On 11/26/23 a Fall Investigation revealed the resident had an unwitnessed fall in her/his room which resulted in the resident having a fractured nose. The 12/17/23 Annual MDS indicated Resident 297 had two or more non-injury falls since admission. On 3/6/24 at 10:20 AM Staff 4 (RNCM) stated she was responsible for completing Resident 297's Annual MDS related to falls. Staff 4 confirmed Resident 297 had a fall with injury and the 12/17/23 Annual MDS was inaccurate. On 3/7/24 at 9:45 AM Staff 2 (DNS) acknowledged Resident 297's MDS was inaccurate for falls. , 3. Resident 20 was admitted to the facility in 7/2019 with diagnoses including left-sided hemiplegia (paralysis of one side of the body) and hemiparesis (one-sided muscle weakness). Resident 20's Left Arm and Leg Pain Care Plan, initiated 7/18/19, indicated the resident had a left hand contracture. Resident 20's 7/9/23 Annual MDS indicated the resident had upper extremity impairment on one side, needed or wanted an interpreter to communicate with health care staff and the resident's preferred language was Chinese. Resident 20's 10/8/23 and 1/7/24 Quarterly MDS Assessments indicated the resident did not have an upper extremity impairment. On 3/4/24 at 10:19 AM and 3/5/24 at 11:17 AM Resident 20 was observed in her/his room in bed. Resident 20's left elbow was tightly bent in towards her/his chest and her/his left hand rested on the top of her/his chest. The fingers of the resident's left hand were tucked into the palm of her/his hand. With assistance from Witness 1 (Interpreter), the resident demonstrated she/he could not fully straighten her/his left arm or fingers on her/his left hand. On 3/6/24 at 11:35 AM Staff 4 (RNCM) stated Resident 20 had an upper extremity impairment and the 10/8/23 and 1/7/24 Quarterly MDS Assessments were inaccurate. On 3/6/24 at 1:08 PM Staff 2 (DNS) was informed of the findings and stated Resident 20's upper extremity impairment was inaccurately assessed on her/his 10/8/23 and 1/7/24 Quarterly MDS Assessments.

F641: MDS Coding 1. Residents #20, #297, #6 MDS coding was corrected. 2. Current MDS for Residents were reviewed for accurate coding changes required were corrected. 3. Resident Care Managers were re-educated on MDS coding. 4. Weekly audits for three MDS for one month, then monthly for two months will be completed by DNS/Designee to ensure accuracy. 5. Results of the audits will be brought to the facilitys monthly QAPI meeting until a lesser frequency is deemed appropriate.

Based on observation, interview and record review it was determined the facility failed to ensure dependent residents received required assistance with ADLs for 1 of 2 sampled residents (#14) reviewed for ADLs. This placed residents at risk for unmet ADL needs and loss of dignity. Findings include: Resident 14 was admitted to the facility in 3/2020 with diagnoses including dementia. Observations from 3/4/24 through 3/6/24 between the hours of 8:00 AM and 4:00 PM revealed Resident 14 had numerous hairs, up to approximately 1.5 inches long, on the lower portion of her/his chin. Resident 14's 12/24/23 Quarterly MDS indicated the resident had moderate cognitive impairment and required the substantial to maximal assistance of one staff for personal hygiene care which included shaving. Resident 14's 3/2024 Care Plan revealed the resident required the assistance of one staff with hair, make-up and shaving. On 3/4/24 at 12:26 PM Resident 14 stated she/he did not like hair on her/his chin and wanted the hair removed. On 3/5/24 at 2:34 PM Staff 14 (CNA) stated she was frequently assigned Resident 14 and never shaved the resident's chin hair. On 3/5/24 at 2:43 PM Staff 20 (CNA) reported she did not shave Resident 14's chin hair because she did not know how. Staff 20 stated she did not ask Resident 14 if she/he wanted her/his chin hair removed because "I would not point that out." On 3/6/24 at 10:16 AM Staff 3 (RNCM) confirmed Resident 14 had long chin hairs present. Resident 14 told Staff 3 she/he wanted her/his chin hair removed. On 3/7/24 at 8:24 AM Staff 2 (DNS) stated she expected staff to shave Resident 14's chin hairs if the resident wanted them removed.

F677: ADL 1. Resident #14 facial hair was removed. 2. An audit of residents was completed and those with facial hair were assisted with removal per preference. Careplan interventions were updated as needed. 3. Staff will be re-educated on resident preferences regarding facial hair. Those with facial hair care plans were updated with tasks to ensure the residents are being offered assistance with facial hair removal. 4. DNS/Designee will review three residents weekly for one month, then monthly for two months to validate that resident's facial hair is being removed per their preference. 5. Results of the audits will be brought to the facilitys monthly QAPI meeting until a lesser frequency is deemed appropriate.

Based on observation, interview and record review it was determined the facility failed to provide an ongoing person-centered activities program for 1 of 3 sampled residents (#9) reviewed for activities. This placed residents at risk of a decline in psychosocial well-being and diminished quality of life. Findings include: Resident 9 was readmitted to the facility in 9/2023 with diagnoses including dementia. Resident 9's 12/12/23 Activity Assessment indicated the resident's favorite activities included exercise groups, socials and performers. Resident 9's 12/30/23 Annual MDS revealed the resident was severely cognitively impaired. The MDS Staff Assessment of Daily and Activity Preferences indicated the following activities were important to Resident 9: -Listening to music; -Doing things with groups of people; -Participating in favorite activities; and -Participating in religious activities or practices. Resident 9's 2/22/23 Care Plan revealed the following related to the resident's activity goals and interventions: -The resident was to receive one-to-one visits from staff two-to-three times per week for sensory stimulation. -The resident previously spoke Chinese, was non verbal at this time and was hard of hearing. Staff must write in Chinese to communicate. -The resident enjoyed watching television and reading Chinese newspapers and books. -Ensure adaptive equipment was provided, including paper and pen. -Invite the resident to scheduled activities. -The resident needed assistance/escort to activity functions. -The resident was to be up in her/his wheelchair daily and offered daily activities. Resident 9's 2/6/24 through 3/5/24 Activity Daily #1 and #2 Task Records revealed the resident participated in an independent activity on a daily basis, participated in music/singing on 2/17/24 and 2/22/24, participated in a special event on 2/23/24 and refused an activity on 3/5/24. Resident 9's 2/7/24 through 3/5/24 Activity Task Record revealed the resident received regular one-to-one visits which consisted of socializing/conversing. The facility's 3/2024 Activity Calendar revealed the following scheduled activities: -3/4/24: 9:45 AM Exercise 10:30 AM Playdough 3:30 PM Bingo 6:15 PM News -3/5/24: 9:45 AM Exercise 10:00 AM Youtube Videos 3:30 PM Crafts 6:15 PM Dice No evidence was found in Resident 9's clinical record to indicate the resident participated in her/his identified favorite and preferred activities of exercise and religious activities/practices from 2/6/24 through 3/5/24 or that the resident refused activities outside of the single instance on 3/5/24. Resident 9's clinical record identified socials and doing things with groups of people as important to the resident. Resident 9's clinical record indicated she/he participated in a group activity on three occasions from 2/6/24 through 3/5/24. Observations of Resident 9 conducted on 3/4/24 and 3/5/24 between 8:38 AM to 3:43 PM revealed the resident to be in her/his room either in bed or in her/his wheelchair with the television on. No paper, pens or Chinese newspapers or books were observed in the resident's room. On 3/5/24 at 9:57 AM Resident 9 was observed in her/his wheelchair in her/his room. The resident opened her/his eyes in response to the surveyor greeting. The facility's exercise group occurred at this time in the dining room. On 3/6/24 at 9:20 AM Staff 16 (CNA) stated Resident 9 enjoyed being "involved and social." Staff 16 stated the resident enjoyed being out of her/his room and "being around people or sitting by the window near the front entrance." Staff 16 stated the resident did not actively participate in activities, including exercise, but she/he still liked to watch. Staff 16 stated Resident 9 did not read newspapers or books and she communicated with her/him by talking, not by writing. On 3/6/24 at 9:27 AM Staff 17 (CNA) stated it had "been a little while since [Resident 9] had been at a group activity" and she noticed a decline in the resident's out-of-room activity participation when the resident received a feeding tube. Staff 17 stated she had never seen the resident read either newspapers or books, use writing and reading to communicate or have music on in her/his room. On 3/6/24 at 12:31 PM Staff 18 (Life Enrichment Assistant) stated Resident 9 enjoyed card games, music, socials and group activities. Staff 18 stated "it had been a long time since they wrote on paper" to communicate with the resident and she/he no longer read the newspaper or books. Staff 18 stated the resident did not go to exercise group often and it "had been a while" since she/he last attended the facility's church service. Staff 18 stated she completed one-to-one visits with Resident 9 one-to-two times per week which consisted of her asking the resident how she/he was doing, if she/he felt better or if she/he needed help. Staff 18 stated she would sometimes bring music to these visits but had never attempted additional sensory activities with Resident 9 during these visits outside of talking and music, on occasion. Staff 18 further stated she recorded the resident as participating in an independent activity any time she saw the resident in her/his room with her/his eyes opened and the television on. On 3/6/24 at 2:41 PM Staff 1 (Administrator) and Staff 19 (Administrator-in-Training) acknowledged the findings of this investigation. Staff 1 stated he expected Resident 9 to receive different types of sensory activities outside of those that were verbal and Resident 9's care plan was in need of revision.

F679: Activities for dependent residents 1. Resident #9 care plan was updated to reflect current interests. Resident is being offered documented activity programs and participation documented accordingly. 2. An audit was completed for those residents who are dependent on staff to provide activities, issues identified were resolved. 3. Activities director and activities assistants educated on developing and providing appropriate activity programs to support residents individualized interests. Education provided in regard to documentation of accurate care plans and making changes to individual activity programs as interests and needs change. 4. To ensure ongoing compliance the administrator/designee will review activity programs and observe individualized activity interests are being provided for five residents weekly for two weeks and then monthly for two months. 5. Results will be brought to QAPI monthly for 3 months for review and recommendations. 6. The Administrator/Designee is responsible for compliance.

******************** 411-086-0140 Nursing Services: Problem Resolution and Preventive Care Refer to F-584 ******************** 411-087-0100 Physical Environment: Generally Refer to F-584 ******************** 411-087-0450 Heating & Ventilation System Refer to F-584 ******************** 411-085-0360 Abuse Refer to F-600 ******************** 411-088-0050 Right to Return from Hospital Refer to F-625 ******************** 411-086-0300 Clinical Records Refer to F-641 ******************** 411-086-0110 Nursing Services: Resident Care Refer to F-677 ******************** 411-086-0230 Activity Services Refer to F-679 ********************

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 02/13/2023 and 02/19/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 12/05/2022 and 12/11/2022, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on observation, interview and record review it was determined the facility failed to update a care plan to reflect changes in care needs for 2 of 3 sampled residents (#s 24 and 40) reviewed for ADLs. This placed residents at risk for unmet needs. Findings include: 1. Resident 24 was admitted to the facility in 2019 and readmitted in 2021 with diagnoses including history of stroke with left sided weakness and hypoxia (low levels of oxygen in the body). Resident 24's 10/6/19 care plan included interventions to apply a left foot boot while in bed and apply a left arm sling. An intervention was added to apply a left palm protector on 6/6/2020, and re-initiated in 7/7/2021 when the resident was readmitted from the hospital. On 11/30/22 between 12:40 PM and 3:16 PM, 12/1/22 between 8:57 AM and 3:23 PM, and 12/2/22 between 8:49 AM and 10:30 AM, Resident 24 was observed in bed without the left palm protector, left arm sling, and left foot boot. On 11/30/22 at 1:22 PM Staff 14 (CNA) stated she did not recall Resident 24 using a palm protector, left arm sling, and left foot boot. On 12/1/22 at 9:21 AM Staff 15 (CNA) stated Resident 24 did not have a palm protector, arm sling or boot. Staff 15 checked the Kardex (a brief care plan for staff providing direct care) and stated she did not place a palm protector in the resident's hand and had not seen one in the resident's room Staff 15 was unable to locate the devices in the resident's room. On 12/2/22 at 10:32 AM Staff 5 (LPN) stated the resident's care plan was updated quarterly at care conferences with the resident, family, and interdisciplinary team. Staff 5 stated each item on the care plan was reviewed at care conferences. Staff 5 stated the left palm protector, arm sling and boot were trialed during the resident's initial 2019 admission but were discontinued and were not removed from the care plan. 2. Resident 40 was admitted to the facility in 8/2022 with diagnoses including colitis (inflammation in the colon). Resident 40's 7/29/22 physician's diet order indicated the resident was ordered pureed texture. Resident 40's Diet Order and Communication changed to minced and moist texture on 11/22/22. Review of Resident 40's care plan on 11/30/22 provided no information of resident's current diet texture. On 11/29/22 at 1:17 PM Witness 1 (Family) expressed concern about Resident 40's weight and stated the family requested a diet upgrade from puree texture to minced and moist diet texture in early 11/2022 to improve the resident's nutritional intake. On 12/1/22 at 9:27 AM and 12/1/22 at 2:38 PM Staff 13 (CNA) and Staff 14 (CNA) stated the resident's diet texture was pureed. On 12/1/22 at 3:20 PM Staff 17 (LPN) stated the resident's diet was minced and moist, then Staff 17 looked in the resident's health record and stated it was puree. On 12/2/22 at 1:54 PM Staff 5 (LPN) confirmed the care plan and health record was not updated.

"This Plan of Correction is prepared and submitted as required by law. By submitting this plan of correction, Prestige Care of Reedwood does not admit that the deficiency listed on this form exist, nor does the Center admit to any statements, findings, facts, or conclusions that form the basis for the alleged deficiency. The Center reserves the right to challenge in legal and/or regulatory or administrative proceedings the deficiency, statements, facts and conclusions that form the basis for the deficiency." Resident #24 care plan was updated to reflect current care needs. Resident #40 care plan was updated to reflect current care needs. Residents with care needs are at risk related to this citation. Residents with care plans to include durable medical devices and those with diet orders will be reviewed for accuracy. Education provided to RCMs to ensure care plans are updated upon admission, at minimum quarterly, and for any pertinent changes to the plan of care throughout the quarter including ADL needs. To ensure ongoing compliance the DNS/Designee will complete care plan audits to validate Residents care plans are being updated timely, including medical devices, diet orders and ADL needs. These care plan audits will be completed for five Residents weekly for two weeks then five Residents monthly for two months. Results will be brought to monthly QAPI for three months for review and recommendations. The DNS/Designee is responsible for compliance.

Based on observation, interview and record review it was determined the facility failed to provide an ongoing activities program designed to meet the individual interests and needs of residents for 1 of 4 sampled residents (#29) reviewed for activities. This placed residents at risk for diminished physical, emotional and psychosocial well-being. Findings include: Resident 29 was admitted to the facility in 2021 with diagnoses including Alzheimer's disease and dementia without behavioral, mood or psychotic disturbance. The 1/18/21 Activities Initial Interview revealed Resident 29 used to go to church, read the Bible, watched some TV and wished to participate in activities. The activity participation section revealed it was unknown if the resident wanted to participate in group activities, go on outings, wanted one-to-one visits or liked independent activities. It was indicated Resident 29's activities needed to be modified to accommodate for the resident's cognitive and communication deficits and communication needed to be kept to simple yes/no questions. The 1/16/22 Annual MDS revealed Resident 29 had severe cognitive deficits and her/his preferred activities included snacks between meals, staying up past 8:00 PM, reading books/newspapers/magazines, doing things in groups of people, spending time outdoors and participating in religious activities or practices. The 7/11/22 Activity Assessment-Annual and Quarterly indicated Resident 29 attended some group activities and participated at times, the resident enjoyed reading and activity related focuses remained appropriate as per current care plan. The 10/11/22 Activity Assessment-Annual and Quarterly indicated due to a cognitive decline, Resident 29 showed little interest in doing things and spent most of her/his time sleeping. Resident 29 enjoyed holding a stuffed animal/cat. The resident interacted some during one-to-one visits and the resident used to like to read but primarily slept now. The plan indicated activity related focuses remained appropriate per the current care plan and the interventions were partially effective in attaining goals. The 10/11/22 Social Service Quarterly Assessment indicated Resident 29 had no significant change in cognition, the resident was directable by staff and staff could typically entertain the resident by providing her/him with reading materials. Resident 29's current care plan indicated the following: -Dependent for activities; -Ensure activities the resident is attending are compatible with physical and mental capabilities, compatible with known interests and preferences, adapted as needed (such as large print, holders if resident lacks hand strength, task segmentation), compatible with individual needs and abilities and age appropriate; -Provide the resident with materials for individual activities as desired. The resident likes the following independent activities: books, although the resident does not read, having books around her/him is comfort for her/him; -Play classic jazz music from Frank Sinatra for the resident. The resident's favorite song is Blue Sky by Frank Sinatra; -Likes to read her/his Bible. Please offer it to her/him and -Offer activity apron, coloring and snacks. Resident 29's Daily Activity logs from 11/3/22 through 12/2/22 indicated the following: 11/3: exercise group; 11/9: exercise group; 11/16: exercise group; 11/22: movies; 11/29: exercise group and music and 12/2: exercise group. Resident 29's Independent Daily Activity logs from 11/3/22 through 12/2/22 indicated the resident participated in independent activities on 28 out of 30 days. Resident 29's One-to-One Activity log from 11/3/22 through 12/2/22 indicated the resident had no one-to-one visits prior to 12/2/22. Observations of Resident 29's activities included the following: -11/30/22 at 12:28 PM Resident 29 was sitting at the nursing station staring ahead. The resident did not have a stuffed animal/cat, books around her/him, her/his Bible or coloring materials. No residents or staff were interacting with Resident 29. -11/30/22 at 12:50 PM, 2:27 PM and 3:35 PM Resident 29 was in bed with her/his TV on and the volume was inaudible. Resident 29 did not have music playing, a stuffed animal/cat or books around her/him. There was no Bible available. -12/1/22 at 8:38 AM and 8:57 AM Resident 29 was dressed and sitting at the nursing station with her/his eyes intermittently closed and other times looking around. At one point, Resident 29 was holding her/his head in her/his hands, slouched forward. The resident did not have a stuffed animal/cat, books around her/him, her/his Bible or coloring materials. No residents or staff were interacting with Resident 29. -12/1/22 at 9:07 AM Resident 29 was taken to the Vietnamese church group by a staff member. On the way to the activity, Resident 29 asked the staff member if she/he could go outside and the staff member responded "no" and placed the resident in the Vietnamese church activity. At 9:26 AM the resident remained in the Vietnamese church activity with the activity being conducted in Vietnamese (Resident 29 spoke English). Resident 29 was slouched over. -12/1/22 at 10:44 AM Resident 29 was observed in a fingernail grooming activity group leaning on her/his right hand with her/his eyes closed, positioned in the group. The staff member was painting a different resident's nails while speaking Chinese. -12/1/22 at 3:55 PM Resident 29 was sitting in the hallway at the nursing station. The resident did not have a stuffed animal/cat, books around her/him, her/his Bible or coloring materials. No residents or staff were interacting with Resident 29. -12/2/22 at 8:30 AM and 9:25 AM Resident 29 was dressed and sitting at the nursing station. Resident 29 was alert and talking to herself/himself. Resident 29 did not have a stuffed animal/cat, books around her/him, her/his Bible or coloring materials. No residents or staff were interacting with the resident. -12/2/22 10:34 AM Resident 29 was in a badminton group. Staff 4 (Activities Director) batted a balloon at Resident 29 and the resident made no attempt to respond to the balloon coming directly towards her/him. -12/2/22 at 2:08 PM Resident 29 was in bed with her/his TV on and the volume was inaudible. Resident 29 did not have music playing, a stuffed animal/cat or books around her/him. No Bible was available. On 12/1/22 at 9:34 AM Staff 12 (CNA) reported Resident 29 liked to drink tea, liked the facility's interactive toy cat, coloring, someone sitting next to her/him and talking, enjoyed music, singing and getting her/his nails done. Staff 12 stated Resident 29 was unable to complete independent activities and required assistance for everything. She stated Resident 29 used to enjoy reading, especially the Bible but the resident could no longer read. Staff 12 stated Resident 29 went to exercise groups but usually did not participate. On 12/1/22 at 11:08 AM Staff 13 (CNA) reported Resident 29 enjoyed reading especially large printed materials such as signs around the facility. Staff 13 stated Resident 29 liked to interact with the facility's interactive toy cat. Staff 13 stated Resident 29 was not able to complete independent activities and rarely participated when in the exercise group. Staff 13 stated she did not observe Resident 29 interacting with the TV. On 12/2/22 at 8:50 AM Staff 4 (Activities Director) stated with dementia residents she made activities more simple like relaxing touch and massage, music and sensory activities such as putting fragrant lotion on resident's hands. Staff 4 stated music was powerful with the dementia population and she offered music in the resident's rooms and in groups. Staff 4 stated Resident 29 enjoyed music, eating, one-on-ones and the facility's interactive toy cat. Staff 4 stated Resident 29 used to read but Resident 29's reading skills had declined over the past month. She stated Resident 29 was dependent for activities and unable to complete independent activities. Staff 4 reviewed Resident 29's activity logs and confirmed the majority of the activities documented were independent activities (which the resident was incapable of performing) and no one-to-one activities were completed in the past 30 days. Staff 4 stated she was unsure if music played in the resident's room and Resident 29 used to have books in her/his room but was not sure what happened to them. Staff 4 reported Resident 29 did not watch the TV when it was on in her/his room. Staff 4 stated it was not appropriate to have Resident 29 in the Vietnamese church group and she was unsure why the resident was brought to that activity.

Resident #29 activity interests updated to reflect current interests. Resident is being offered documented activity program and participation documented accordingly. Residents who are dependent on staff to provide activities, are at risk related to this citation. Review complete to identify Residents at risk for having individualized activity interests unmet, and programs implemented accordingly. Activities department educated on developing and providing appropriate activity programs to support Residents individualized interests. Education provided in regard to documentation of participation and making changes to individual activity programs as interests change. To ensure ongoing compliance the Administrator/Designee will review activity programs and observe individualized activity interests are being provided for five residents weekly for two weeks and then monthly for two months. Results will be brought to QAPI monthly for three months for review and recommendations. The Administrator/Designee is responsible for compliance.

Based on interview and record review it was determined the facility failed to provide timely laboratory services for 1 of 5 sampled residents (#24) reviewed for unnecessary medications. This placed resident at risk for delayed treatment. Findings include: Resident 24 was admitted to the facility in 2019 with diagnoses including convulsions. The Note to Attending Physician/Prescriber dated 2/25/22 identified the need for a "Depakote (an anti-convulsant) level at the next convenient blood draw day per CMS regulatory compliance." On 2/28/22 Staff 22 (Nurse Practitioner) checked "Agree" and wrote "will check valproic acid (Depakote) at next blood draw." A review of Resident 24's health record revealed the resident had blood draws for basic metabolic panels on 9/17/22 and 10/14/22. The resident's valproic acid level blood draw was not completed until 11/9/22, which was over eight months after the pharmacy recommendation was made. On 12/2/22 at 10:28 AM Staff 5 (LPN) stated to minimize discomfort, when a non-urgent lab was ordered, it was added to the next scheduled routine blood draw. Staff 5 acknowledged the resident had routine labs drawn in 9/2022 and 10/2022. Staff 5 confirmed Resident 24's valproic acid level lab was not drawn until 11/2022. On 12/05/22 at 10:02 AM Staff 2 (DNS) confirmed facility's policy of combining non-urgent lab draws with the next routine blood draw. Provided no additional information.

Resident #24 ordered labs were obtained and completed. Residents requiring lab services are at risk related to this citation. Residents with lab orders are reviewed during MACC meeting to ensure lab orders are processed timely. Current labs ordered were audited and ensured they were completed timely. Education provided to nurses and RCMs regarding timely processing of lab orders. Scheduled lab orders will be placed at the time the order is received. To ensure ongoing compliance the DNS/Designee will perform audits of lab orders to ensure entry of order and notification to outside lab completed timely. Audits will be completed on new orders for two weeks then monthly for two months. The outcomes will be brought to QAPI monthly for three months of review and recommendations. DNS/Designee is responsible for compliance.

Based on observation, interview and record review it was determined the facility failed to prepare and handle food in a sanitary manner in 1 of 1 kitchen reviewed for food service. This placed residents at risk for foodborne illness. Findings include: On 12/1/22 at 11:14 AM Staff 18 (Dietary Aide) walked out of the kitchen and into the hallway while wearing gloves. Staff 18 unlocked a food storage door, retrieved a beverage cart, and returned to the kitchen without performing hand hygiene or changing her gloves. Staff 18 proceeded to the back of the kitchen to the sink/dishwasher area and wiped down the countertops then walked towards the front of the kitchen and began handling clean coffee cups to prepare drinks for lunch. On 12/1/22 from 11:44 AM through 12:18 PM, the following observations of the resident lunch tray service were made: - Staff 19 (Cook) used her gloved hand and grabbed noodles from one bowl to add to another bowl then added beef soup to both bowls after having touched various other surfaces and utensils with the same gloves. -After completing hand hygiene, Staff 19 (Cook) dried her hands with paper towels and placed her used paper towels on the stove top next to the clean plates and scoops. -Staff 20 (Dietary Aide) and Staff 21 (Cook) placed their fingers in the inner surface of bowls prior to placing them on the food tray after touching other potentially unclean surfaces. On 12/5/22 at 10:20 AM Staff 3 (Dietary Manager) confirmed he was made aware of the concerns and was already planning staff training.

No Residents found to have been affected by mishandling of food or the lack of changing gloves while outside of the kitchen. Residents eating food from the kitchen have potential of being affected by the outcome of this citation. No residents had any signs of gastric distress or infection within the 72 hours after 12/1/2022. Kitchen staff educated on proper preparation and handling of food and equipment in a sanitary manner. Education surrounding hand hygiene and proper use of gloves completed. To ensure ongoing compliance the Administrator/designee will perform food preparation and food handling observations weekly for four weeks then monthly for two months. Results will be brought to QAPI monthly for three months for review and recommendations. The Administrator/designee is responsible for compliance.

Based on observation, interview and record review it was determined the facility failed to develop and follow practices to sanitarily transport, store and handle laundry for 1 of 1 laundry cart and 1 of 1 laundry room reviewed for infection control. This placed residents at risk for receiving contaminated laundry and infection. Findings include. 1. On 11/29/22 12:06 PM Staff 7 (Laundry) was observed delivering clean resident laundry using a small uncovered metal cart. On 11/30/22 and 12/1/22 between 8:45 AM and 9:03 AM Staff 7 was observed delivering clean resident laundry using a plastic cart with shelving. The cart had a cover; however, one side remained open and uncovered for the duration of laundry delivery. Staff 7 was observed to leave the laundry cart parked in a resident hallway with the uncovered side of the cart open to the hallway. On 12/1/22 at 10:31 AM Staff 7 stated she never used the small metal cart without a cover to deliver resident laundry. She stated she was unaware she needed to use the covers on the clean laundry cart during the transportation and delivery of clean laundry. On 12/2/22 at 12:25 PM Staff 1 (Administrator) was informed of these findings. He did not express any concerns about resident laundry being delivered uncovered and provided no additional information. 2. On 12/1/22 at 10:31 AM observations of the facility's laundry room revealed a small metal cart used to move laundered linen from the washing machine to the dryer placed in the soiled utility room of the laundry area directly next to the sink used to rinse overly soiled linen. On 12/1/22 at 10:31 AM Staff 7 (Laundry) was asked about the use and location of the small metal cart. At this time, Staff 7 moved the small metal cart from the soiled utility room of the laundry area and positioned it next to the washing machines in the clean portion of the laundry area and loaded it with freshly washed laundry from the washing machine without cleaning the cart. She stated the cart should never be left in the soiled portion of the laundry area but nursing staff had access to the laundry room and moved items around. On 12/2/22 at 12:25 PM Staff 1 (Administrator) was informed of these findings. He stated he was unaware of any issues related to laundry and no additional information was provided. 3. The facility's 12/2021 Soiled Laundry and Bedding Policy and Procedure specified the following procedure when handling and transporting laundry: *Place contaminated laundry in a bag or container at the location where it is used and do not sort or rinse at the location of use. *Place and transport contaminated laundry in bags or containers in accordance with established policies governing the handling and disposal of contaminated items. *Anyone who handles soiled laundry wears protective gloves and other appropriate protective equipment (e.g., gowns if soiling of clothing is likely). *Environmental services and nursing staff will place and transport contaminated laundry that is wet enough to potentially leak or soak through the bag or container in double bags or leak-proof bags or containers. CNA interviews regarding the process for handling overly soiled resident laundry revealed the following: *On 12/1/22 at 11:26 AM Staff 9 (CNA) stated she wiped resident bowel movements off of resident clothing using incontinence wipes in the resident room. She stated she placed the wiped off clothing in a plastic bag and placed the plastic bag containing the contaminated linen in the bin in the soiled utility room. She stated she never used the sink in the soiled utility room to rinse overly soiled resident clothing. *On 12/1/22 at 11:42 AM Staff 8 (CNA) stated she cleaned overly soiled laundry in the sink in the soiled utility room wearing only gloves and a mask. *On 12/1/22 at 3:49 PM Staff 10 (CNA) stated he rinsed bowel movements out of resident clothing in the soiled utility room and then put the rinsed clothing in the resident's mesh laundry bag located on a hook inside of each resident's closet. He stated he placed these laundry bags in the bin in the soiled area of the facility's laundry room at the end of his shift. He stated he never wore any personal protective equipment when rinsing overly soiled linen outside of gloves and a mask. *On 12/2/22 at 4:04 PM Staff 11 (CNA) stated she washed resident laundry containing bowel movements in the resident's personal sink. Once rinsed, she stated she placed the laundry in the resident's mesh laundry bag located on the hook inside of each resident's closet and placed the laundry bag into the bin in the soiled utility room. On 12/2/22 at 12:25 PM Staff 1 (Administrator) was informed of these findings. He stated he was unaware of any issues related to laundry and no additional information was provided.

No Residents found to have been affected Residents using the facility laundry to process personal clothing or facility linen have potential of being affected by the outcome of this citation. Laundry staff educated on proper delivery of clean linens. Laundry and nursing staff educated to keep clean equipment out of contaminated areas such as soiled utility rooms or disinfect prior to use. Staff handling soiled linen were educated on proper handling and transporting of soiled laundry. Infection control education provided surrounding the risk factors associated with mishandling of linens. To ensure ongoing compliance the Administrator/Designee will perform audits weekly for four weeks then monthly audits for two months. These audits will include interviews with staff as well as observation of soiled linen as well as clean linen. Soiled utility rooms checked for clean equipment. Results will be brought to QAPI monthly for three months for review and recommendations. Administrator/Designee is responsible for compliance.

******************** 411-086-0060 Comprehensive Assessment and Care Plan Refer to F-657 ******************** 411-086-0230 Activity Services Refer to F-679 ******************** 411-086-0010 Administrator Refer to F-772 ******************** 411-086-0250 Dietary Services Refer to F-812 ******************** 411-086-0330 Infection Control and Universal Precautions Refer to F-880 ********************

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 07/25/2022 and 07/31/2022, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 05/23/2022 and 05/29/2022, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on observation, interview and record review it was determined the facility failed to store food, prepare food, and follow sanitizing protocol in accordance with professional standards for food service safety for 1 of 1 facility kitchen reviewed for food services. This placed residents at risk for foodborne illness. Findings include: 1. During a tour of the kitchen with Staff 2 (Dietary Manager) on 12/6/21 at 9:18 AM the following items were observed in the refrigerator and dry storage area: - A plate of cooked food, undated. - A container of salted black beans, undated. - Browning sauce, opened in 2018, expired in 2019. - Red wine vinegar, opened in 2018, expired in 2019. - Yellow food coloring, opened in 2019. Staff 2 indicated the identified items were old and discarded the items. 2. During a tour of the kitchen on 12/9/21 at 10:51 AM frozen raw chicken was observed in the kitchen sink with water running over it. Two uncovered containers of chemical sanitizer with rags were observed in the same sink adjacent to the raw chicken. On 12/9/21 at 11:36 AM Staff 2 acknowledged chemical sanitizer was not to be stored in the same sink with food as it presented a risk for cross contamination. 3. During a tour of the kitchen on 12/9/21 at 10:51 AM a 12/2021 chlorine sanitizer concentration log for the dishwasher was observed posted next to the dishwasher. The log indicated measurements of "90/140" parts per million were recorded three times per day. The container of test strips indicated increments of 50 from 0 to 200. The form indicated parts per million was to be between 50 and 100, and to inform the dietary manager if it was outside that range. On 12/9/21 at 10:51 AM Staff 2 was asked what the documentation of "90/140" represented and he said he did not know. Staff 2 was asked to test the sanitizer concentration and he determined the concentration was between 100 and 200. Staff 2 acknowledged there was no way to obtain a measurement of "90/140" from the test strips and staff did not monitor the sanitizer concentration appropriately.

This Plan of Correction is prepared and submitted as required by law. By submitting this plan of correction, Prestige Care of Reedwood does not admit that the deficiency listed on this form exist, nor does the Center admit to any statements, findings, facts, or conclusions that form the basis for the alleged deficiency. The Center reserves the right to challenge in legal and/or regulatory or administrative proceedings the deficiency, statements, facts, and conclusions that form the basis for the deficiency. All items in the refrigerator and dry storage that were not labeled, dated, or expired were discarded. Current dishwasher chlorine levels are within range. All residents and staff have the potential of being affected. Dietary staff have been re-educated on how to properly label and date items in the refrigerators and dry storage area. They have been instructed to throw away expired items. Dietary staff have been re-educated that sanitizer is not to be stored in the same sink as food as it presents a risk for cross contamination. Dietary staff have been re-educated on how to properly check and document the chlorine sanitation levels for the dishwasher. Dietary Manager, Administrator, or designee will perform audits of refrigerator and dry items once a week for 4 weeks, and then once a month for three months to ensure items are safely stored and disposed of if expired. Dietary Manager, Administrator, or designee will perform audit of the sink once a week for 4 weeks, and then once a month for three months to ensure cross contamination does not occur. Dietary Manager, Administrator, or designee will perform audit of the dishwasher sanitation log once a week for 4 weeks, and then once a month for three months to ensure dietary staff understand how to check the sanitizer concentration level. Results from the audits will be reviewed monthly at our QA meeting and a process improvement plan will be developed if necessary.

, Based on observation and interview, the facility failed to store food in accordance with professional standards for food service safety for one of one facility kitchens. This placed residents at risk for foodborne illness. Findings include: During a tour of the kitchen on 2/4/22 at 10:25 AM, the following item was observed: In the walk in refrigerator, a clear plastic container of cooked rice was placed on the top shelf and covered with plastic wrap. There was no label on the container indicating the date the food was prepared. On 2/4/22 at 10:40 AM, Staff 2 (Cook) confirmed that food stored in the refrigerator should be labeled and dated. On 2/4/2 at 10:45 AM, Staff 1 (Administrator) was advised of these findings and had no further information.

No POC Required

******************************** 411-086-0250 Dietary Services Refer to F812 ********************************

******************************* 411-086-0250 Dietary Services Refer to F 812 *******************************

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 11/29/2021 and 12/05/2021, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on observation, interview and record review, the facility failed to provide care and services to ensure residents were free from physical abuse for 2 of 3 sampled residents (#s 4 and 5). This placed residents at risk for abuse by another resident. Findings include: The facility abuse policy, "Abuse screening, training, identification, investigation, reporting and protection-Oregon" revised 2/2019, revealed it was the facility's policy to identify types of abuse, investigate and report allegations of abuse and protect residents from abuse. 1.Resident 3 admitted to the facility in 5/2017 with diagnoses including unspecified dementia without behavioral disturbance, diabetes and hypertension. Resident 3's Annual MDS dated 11/15/20 revealed a BIMS score of 5, indicating severe cognitive impairment. Resident 5 admitted to the facility in 1/2020 with diagnoses including Parkinson's Disease, Multi System Degeneration of the Autonomic Nervous System and depressive/anxiety disorders. Resident 5's Annual MDS dated 12/2020 had no BIMS score as the resident was unable to answer questions and was rarely/never understood. A Nursing Facility Reported Incident Form was submitted to the State Agency on 9/19/20 and reported the following: On 9/19/20, Resident 3 was in the hallway outside her/his room and saw Resident 5 approach Resident 3's doorway. Resident 3 became upset, walked to Resident 5 and struck her/him in the face. Resident 3 advised Staff 11 (Charge Nurse) she/he did not want Resident 5 blocking the door which was why she/he struck Resident 5. A 9/19/20 SNF Root Cause - Resident to Resident form revealed Resident 3 was in her/his wheelchair in the hallway. Staff 5 (CMA) saw Resident 3 approach Resident 5 with her/his fist raised and ran toward the residents to intervene but was unable to reach the residents in time. Resident 5 was unable to move her/his wheelchair out of Resident 3's way due to the progression of her/his disease. Resident 5 was interviewed via translator and indicated pain to her/his left cheek, which was red where she/he was struck. Resident 3 initiated the contact and contributing factors were disease, behavioral changes which included physically abusive behaviors. Resident 3's care plan revised in 11/2019 revealed she/he was monitored after attempting to touch her/his spouse while in the spouse's room. Resident 3's spouse was uncomfortable with the attempted contact and inteventions were put in place. Resident 3's behavior monitor was revised on 4/7/20 due to behaviors which included attempting to touch other residents, verbal and physical aggression toward staff and others. Resident 5's care plan revised 9/23/20 revealed she/he had mobility issues related to Parkinson's Disease, was at risk for injury related to anticoagulant therapy and had a psychosocial well being problem related to being hit by Resident 3. The care plan noted Resident 5 was upset as a result of the incident on 9/19/20. Progress notes reviewed from 9/1/20 through 9/30/20 revealed on 9/3/20, Resident 3's behavior monitor was updated due to a display of threatening behaviors. On 9/19/20, Resident 5 was struck by Resident 3. Resident 5 pointed to her/his left cheek to indicate where she/he was struck and reported pain. Staff 11 spoke to Resident 3, telling her/him it was inappropriate to hit other residents but she/he continued yelling it was necessary because Resident 5 had blocked her/his doorway. Resident 5's progress notes revealed there was no psychosocial harm as a result of the incident. On 8/2/21 at 11:28 AM, Staff 4 (RCM) stated Resident 5 was placed in front of Resident 3's room where she/he was struck. Staff 5 saw Resident 3 approaching Resident 5 in a threatening manner but could not get to the resident in time. Staff 4 acknowleged there was a behavior monitoring note added to the care plan on 9/3/20 due to Resident 3's threatening behavior. On 8/2/21 at 3:20 PM, Staff 5 (CMA) stated he observed Resident 3 hit Resident 5 in the face on 9/19/20. Staff 5 attempted to intervene, ran to the residents but was unable to intervene on time. On 8/6/21 at 11:28 AM, Staff 11 stated she was the unit charge nurse on 9/19/20. Staff 11 revealed Resident 3 had dementia and often had angry outbursts. Resident 5 was non verbal but "mumbled" and this possibly irritated Resident 3, who hit Resident 5 in the face. Staff 11 recalled being told by staff in 2019 Resident 3 had a history of aggressive behaviors. On 8/9/21 at 12:42 PM, Staff 2 (DNS) stated Resident 3 was care planned for the loss of her/his spouse in 9/2020. Staff 2 stated the resident only had minor behaviors up to that point and was not aggressive toward residents or staff. On 8/10/21 at 2:00 PM, Staff 2 confirmed it was an expectation of the facility for residents to be free from abuse. On 8/10/21 at 2:00 PM, Staff 1 (Administrator) confirmed it was an expectation of the facility for residents to be free from abuse. 2. Resident 3 admitted to the facility in 5/2017 with diagnoses including unspecified dementia without behavioral disturbance, diabetes and hypertension. Resident 3's Annual MDS dated 11/15/20 revealed a BIMS score of 5, indicating severe cognitive impairment. Resident 4 was admitted to the facility on 2/2016 with diagnoses including stroke, hemiplegia, hemiparesis and quadriplegia. Resident 4's Annual MDS dated 5/16/21 had no BIMS score as the resident was unable to answer questions and was rarely/never understood. A Nursing Facility Reported Incident Form was submitted to the State Agency on 9/8/20 and reported the following: On 9/5/20, Resident 4 was yelling in her/his native language while lying in bed. Resident 3 became upset by the yelling, walked to Resident 4's bed and struck her/him on the arm. Staff 6 was in the room, witnessed the abuse and separated the residents. Resident 4 was moved to a new room. A 9/5/20 SNF Root Cause - Resident to Resident form revealed Resident 3 told staff she/he hit Resident 4 because she/he was noisy. Resident 3 initiated the contact. The contributing factors were disease, behavioral changes which included physically abusive behaviors and a history of aggression. Resident 3's care plan revised in 11/2019 revealed she/he was monitored after attempting to touch her/his spouse while in the spouse's room. Resident 3's spouse was uncomfortable with the attempted contact and inteventions were put in place. Resident 3's behavior monitor was revised on 4/7/20 due to behaviors which included attempting to touch other residents, verbal and physical aggression toward staff and others. Resident 4's 7/25/20 care plan revealed she/he was on a behavior monitor which included physically striking others, screaming and using offensive language in her/his native language, which Resident 3 understood. Progress notes reviewed from 4/2019 through 12/2020 revealed Resident 3 pushed another resident on 4/6/19, causing the other resident to fall forward and bump her/his head on the door. This resulted in the other resident sustaining an injury to her/his head. A 9/3/20 progress note revealed the resident's behavior monitor was updated due to a display of threatening behavior. A 9/5/20 progress note revealed Staff 6 (CNA) witnessed Resident 3 walk to Resident 4's bed and strike her/him on the arm due to Resident 4 being noisy. On 8/4/21 at 11:28 AM, Staff 4 (RCM) stated Resident 3 was not physically abusive and never tried to hit anyone prior to the 9/5/20 resident to resident altercation. Staff 4 acknowledged there was a behavior monitoring note added to the care plan on 9/3/20 due to the resident's threatening behavior. On 8/4/21 at 11:28 AM, Staff 2 (DNS) stated Resident 3 hit Resident 4 in their room due to Resident 4 cursing. Staff 2 stated all interventions were in place when the altercation occurred. On 8/4/21 at 11:53 AM, Staff 9 (CNA) stated Resident 3 had a history of angry behaviors, went into other residents' rooms and tried to touch members of the opposite gender sexually. Staff 9 revealed Resident 3 was physically aggressive toward staff prior to 9/5/20. On 8/4/21 at 12:20 PM, Staff 8 (CNA) stated Resident 3 had a history of hitting and kicking at staff who attempted to assist her/him with cares. Staff 8 reported she witnessed the resident grab other residents' chest area without their consent and said this occurred more than once prior to 9/5/20. On 8/4/21 at 4:25 PM, Staff 6 (CNA) stated she could not recall the incident. On 8/6/21 at 1:18 PM, Staff 10 (CNA) stated she was struck by Resident 3 in 2019 when attempting to change her/his incontinence brief. On 8/10/21 at 2:00 PM, Staff 2 confirmed it was an expectation of the facility for residents to be free from abuse. On 8/10/21 at 2:00 PM, Staff 1 (Administrator) confirmed it was an expectation of the facility for residents to be free from abuse.

This Plan of Correction is prepared and submitted as required by law. By submitting this plan of correction, Prestige Care and Rehabilitation of Reedwood does not admit that the deficiency listed on this form exist, nor does the Center admit to any statements, findings, facts, or conclusions that form the basis for the alleged deficiency. Resident #3 expired 12/13/2020, Resident #5 expired 3/1/2021, Resident #4 was found to have no lasting effects and cannot recollect the event. All Residents have the potential of being affected. Resident to resident events and center grievances for the last 30 days reviewed for appropriate interventions and follow up. Center staff will be re-educated on abuse and neglect reporting and response. The center will continue with new hire and annual abuse and neglect training with staff. The centers team will monitor Residents for indications of emotional distress or change in behavior following a traumatic loss. Baseline trauma screens will continue to be completed following admission for new residents. Following traumatic loss, Social Services Director will re-evaluate the trauma screen assessment to potentially modify support needs and team will initiate additional interventions as appropriate to address new onset or escalation of behaviors. Resident altercations, events and behaviors are monitored through the center event reporting process. Event reports and grievances will continue to be reviewed with the center stand-up meeting for any suggestion of abuse or neglect. A weekly audit will be completed by the DNS/designee to confirm appropriate intervention and timely and appropriate reporting as indicated in accordance with state reporting requirements. Results of audits will be brought to the center's monthly QAPI meeting until a lesser frequency is deemed appropriate.

Based on interview and record review it was determined the facility failed to ensure allegations of abuse or neglect were reported to the state agency within mandated timelines for 1 of 3 sampled residents (#4) reviewed for abuse. This placed residents at increased risk for abuse. Findings include: Resident 4 was admitted to the facility in 2/2016 with diagnoses including stroke, hemiplegia, hemiparesis and quadriplegia. The facility abuse policy, "Abuse screening, training, identification, investigation, reporting and protection-Oregon" revised 2/2019, revealed it was the facility's policy to identify types of abuse, investigate and report allegations of abuse and protect residents from abuse. Facility staff mandated to immediately report the abuse were identified as the Facility Administrator, Director of Nursing or Charge Nurse. A Nursing Facility Reported Incident Form was submitted to the State Agency on 9/8/20 at 4:37 PM and reported the following: On 9/5/20, Resident 4 was yelling in her/his native language while lying in bed. Resident 3 became upset by the yelling, walked to Resident 4's bed and struck her/him on the arm. Staff 6 was in the room, witnessed the abuse and separated the residents. On 8/11/21 at 2:00 PM, Staff 2 (DNS) was unable to recall why the abuse was not reported within the mandated timelines. On 8/11/21 at 2:00 PM, Staff 1 (Administrator) was unable to recall why the abuse was not reported within the mandated timelines.

Resident #3 has expired and Resident #4 remains in facility with no lasting effects and unable to recollect the event. Center's staff will be re-educated on abuse and neglect reporting and response. The center will continue with new hire and annual abuse and neglect training with staff. Resident altercations and events are monitored through the center event reporting process. Event reports and grievances will continue to be reviewed with the centers stand-up meeting for any suggestion of abuse or neglect. A weekly audit will be completed by the Administrator/designee to confirm completion of timely and appropriate reporting as indicated in accordance with state reporting requirements and center intervention. Results of audits will be brought to the center's monthly QAPI meeting until a lesser frequency is deemed appropriate.

************************************* OAR 411-085-0360 Abuse Refer to F600 and F609 *************************************