Regency Care of Rogue Valley

The 8/2024 Facilities Bed Hold Policy and Agreement Form indicated a resident who was temporarily absent from the facility because of a Break in Services (defined under Oregon law as a hospitalization or leave of absence) may apply for a bed hold to ensure her/his bed was preserved for her/his anticipated return. The policy indicated at the time of discharge to the hospital; the discharging nurse would give the residents and representatives a copy of the Bed Hold Policy and Agreement. 1.Resident 51 was admitted to the facility on 1/12/26 with diagnoses including muscle weakness and stroke. On 1/18/26, Resident 51 left for a physician appointment. After the appointment, Resident 51 went home with Witness 1 (Family Member).-á On 1/18/26 at 10:37 PM, Staff 5 (RN) spoke with Witness 1 on the phone. Witness 1 indicated Resident 51 fell asleep and would not return to the facility that night but would return the following day. On 3/24/26 at 1:33 PM, Witness 1 stated Resident 51 returned to the facility the following day, but when she/he arrived, the facility had discharged the resident. Witness 1 stated there was no notification the resident would be discharged and the resident was not offered a bed hold.-á On 3/25/26 at 12:17 PM, Staff 3 (Social Services) stated she oversaw discharges but if a resident went home for an overnight visit, the RCM or DNS oversaw the leave. Staff 3 stated when a resident went out overnight her/his bed was held and they were not charged. On 3/25/26 at 12:53 PM, Staff 6 (RNCM) stated Resident 51 returned to the facility after 24 hours and management decided she/he would be discharged. Staff 6 stated the overnight visit was a therapeutic leave and Resident 51GÇÖs bed should have been held for his/her return. Staff 6 acknowledged staff did not call the spouse in the morning to discuss what time the resident would return, no documentation was sent to the resident or spouse regarding discharge or bed hold, and Resident 51 should not have been discharged. On 3/25/26 at 1:54 PM, Staff 3 stated Resident 51 went to her/his appointment and did not return by midnight and the IDT considered her/him leaving the facility AMA (against medical advice). Staff 3 stated Resident 51 and Witness 1 should have been called regarding return to the facility and they were not. Staff 3 acknowledged no discharge documentation or bed hold information was sent to Resident 51 or Witness 1. On 3/26/26 at 10:28 AM, Staff 1 (Administrator) acknowledged Resident 51 did not receive documentation regarding a discharge, was not offered a bed hold, and was not assessed for a safe discharge. Staff 1 stated Resident 51GÇÖs discharge was unplanned and unsafe. 2. Resident 49 was admitted to the facility in 12/2025 with diagnoses including respiratory failure and kidney disease. A progress note dated 1/4/26 indicated Resident 49 had oxygen saturation of 52% on room air, secretions in her/his lungs which could not be cleared with suctioning (removal of airway secretions), and respirations were labored. Staff 3 (LPN) provided oxygen, contacted the family who agreed to send the resident to the hospital, and called emergency transport. On 3/25/26 at 12:15 PM, Witness 3 (POA) stated when Resident 49 was sent to the hospital she/he was not offered a bed hold for her/his return. On 3/25/26 at 12:17 PM, Staff 3 (Social Services) stated she oversaw discharges and provided bed holds for residents or their POAs. Staff 3 stated she did not provide a bed hold for Resident 49 or her/his POA. On 3/26/26 at 10:46 AM, Staff 1 (Administrator) acknowledged residents or their POAs needed to be offered a bed hold when they were discharged to the hospital or on leave of absence from the facility.

Corrective Action: Resident 49 and 51 no longer reside in the facility. Identification of Others at Risk: All residents discharged to the hospital or on leave of absence within the last 30 days were audited to ensure a Bed Hold was offered and documented.  Corrections were implemented as needed. Systemic Changes: Transfer, Discharge, and Bed Hold Policy and Procedures were reviewed to ensure compliance with F628.  Corrections implemented as needed. Facility implemented 24-hour follow up protocol for residents who don't return as expected. Admin and/or Designee will provide re-education to IDT regarding therapeutic leave vs. AMA vs, discharge and facility Bed Hold Policy. DNS and/or Designee will provide re-education to licensed nurses regarding bed hold requirements, discharge and transfer procedures, and required documentation and communication standards. Monitoring: Facility will conduct audit as follows: Weekly for four weeks Monthly for two months Results of audit will be reviewed for any identified trends and brought to QAPI for three months to identify any system revisions needed, and/or further educational needs. Individual Responsible for Monitoring: Admin and/or Designee

Based on interview and record review it was determined the facility failed to notify a resident prior to change of administration of medication for 1 of 1 sampled resident (#139) reviewed for informed consent. This placed residents at risk for lack of informed consent. Findings include: Resident 139 admitted to the facility in 2024 with diagnoses including depression. A 3/26/24 Admission MDS indicated Resident 139 was cognitively intact. Admission orders signed 3/28/24 revealed Citalopram (an anti-depressant) 60mg at bedtime and Imipramine (an anti-depressant) 50mg at bedtime for depression. An 4/9/24 provider order specified Citalopram 20mg at bedtime and Imipramine 25mg at bedtime for depression. An 4/18/24 provider note indicated the provider spoke with Resident 139 and she/he had no unaddressed concerns. A review of Resident 139's chart revealed no documentation to indicate Resident 139 was notified of the changes to her/his medications. On 11/18/24 at 2:49 PM Resident 139 stated she/he was taking Citalopram 60mg and Imipramine 50mg at bedtime as a successful depression treatment for years. She/He stated the facility reduced her/his medications without her/his knowledge or consent. On 11/20/24 at 12:10 PM Staff 23 (Social Services Director/Admissions) verified no other information was present in Resident 139's chart regarding notification of medication changes.

Corrective Action: Resident: 139 is no longer in facility Identification of Others: Other facility residents on psychotropic medications were audited to ensure medication consents are on file. Corrections were implemented as needed. Systemic Changes: a) Policies and procedures were reviewed to ensure compliance with F552. Correction implements as needed. b) DNS and/or Designee will provide re-education to LNs regarding residents’ rights to be informed and make decisions about their treatment. Monitoring: DNS and/or Designee will audit new psychotropic orders daily (M-F) to ensure medication consents are on file. The audit will be daily (M-F) for one month. Then monthly for two months. Results of audit will be reviewed for any identified trends and brought to QAPI for three months to identify any needed system revisions, trends, and/or further educational needs. Individual Responsible for Monitoring: DNS and/or Designee

Based on observation, interview, and record review it was determined the facility failed to provide a meaningful activity program for 1 of 1 sampled resident (#3) reviewed for activities. This placed residents at risk for lack of social engagement. Findings include: Resident 3 admitted to the facility in 8/2023 with a diagnosis of paralysis. A 7/23/24 annual MDS revealed Resident 3 was cognitively impaired, preferred to stay in bed, and required assistance with ADLs. When interviewed, Resident 3 indicated choosing activities was very important. Activities important to Resident 3 included interaction with pets and reading. A care plan initiated on 8/23/23 and revised on 10/7/24 indicated Resident 3 was at risk for little activity involvement related to physical mobility, decreased ROM, impaired motor skills, and deficits in judgement. Activities to offer included to invite Resident 3 to group activities, provide 1:1 visits, and to provide reading material. An 10/23/24 Activities Quarterly Participation Review form indicated Resident 3 preferred to self-direct her/his own activities, did not want to participate in group activities, and 1:1 visits were acceptable. The form indicated there was only one 1:1 activity provided during the previous quarter. Resident 3's favorite activities included reading the bible, looking out her/his window, napping, and visits with family and her/his roommate. An Activity Participation log from 10/22/24 through 11/16/24 indicated Resident 3 participated in independent activities. The activity identified was "snack offered." No 1:1 visits were provided, no "reading", and no other visits occurred. On 11/18/24 at 12:30 PM Resident 3 stated there was not much to do for activities. Resident 3 was not able to articulate what she/he wanted to do. On 11/19/24 at 2:45 PM Staff 8 (CNA) stated Resident 3 did not like television, but enjoyed talking and joking. Staff 8 stated staff offered Resident 3 group activities, but she did not like group activities. Observations revealed: -On 11/18/24 at 12:30 PM Resident 3 was in bed, awake, window blinds closed, and there was no television or music playing in the background. -On 11/19/24 at 10:18 AM Resident 3 was observed in bed with her/his eyes shut, there was no music or television playing in the background. -On 11/20/24 at 8:51 AM Resident 3 was observed in bed with her/his eyes shut and her/his window blinds closed. -On 11/20/24 at 9:22 AM Resident 3 was in bed, awake, and her/his blinds were shut. On 11/20/24 at 8:27 AM Staff 3 (Activity Supervisor) stated both she and her/his assistant provided 1:1 visits with residents. If a visit was provided it was documented in the resident's clinical record. Staff 3 stated the facility had a volunteer with a dog visit the facility, but it was very infrequent. Staff 3 acknowledged Resident 3 liked pets and there were some facility staff who had pets in the facility which Resident 3 may enjoy. Staff 3 stated Resident 3 slept a lot but was awake for meals and showers. Staff 3 indicated 1:1 visits could be scheduled during the times Resident 3 was awake. Staff 3 stated she was not sure if Resident 3 was able to read and stated the facility had an audible book player, but did not offer it to Resident 3. Staff 3 acknowledged the resident only had "snacks" as documented activities and family did not come in very often. On 11/20/24 at 9:21 AM Staff 7 (CMA) stated Resident 3's blinds were often shut, but Resident 3, on occasion, asked staff to open her/his blinds.

Corrective Action: Resident 3 was reassessed by Activities Director to identify their specific interests and needs. Resident 3’s preferences have been incorporated into their activities care plan. Identification of Others: Other facility residents in-like situations will be reassessed by the Activities Director to ensure their specific interests and needs are incorporated in their care plan. Corrections were implemented as needed. Systemic Changes: a) Facility implemented an enhanced 1:1 activity program to supplement group activities. The 1:1 enhanced activity program will include activities such as sensory stimulation, reminiscing, and reading/storytelling b) Executive Director and/or Designee will re-educate staff in resident-center activity planning and documentation. Monitoring: Monthly and at IDT Care Conferences, satisfaction surveys and activity audits will be conducted to ensure compliance with F679. Results will be reviewed for any identifiable trends and brought to QAPI for three months to identify any needed revisions, trends, and/or further educational needs. Individual Responsible for Monitoring: Executive Director and/or Designee

Based on interview and record review it was determined the facility failed to properly assess a pressure ulcer and revise treatments for 1 of 1 sampled resident (#5) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers. Findings include: Resident 5 admitted to the facility in 3/2017 with diagnoses including dementia and failure to thrive. An 4/11/24 Annual Pressure Ulcer CAA indicated Resident 5 was at risk for pressure ulcers, was unable to make position changes independently, and had recurrent MASD (Moisture Associated Skin Damage). A 7/4/24 Unavoidable Pressure Injury Evaluation indicated Resident 5 had MASD which resulted in a pressure injury due to fragile skin and impaired skin integrity despite pressure injury interventions. An 10/2/24 Quarterly MDS indicated Resident 5 had a facility acquired Stage 3 (full thickness tissue loss) pressure ulcer. An 10/12/24 physician order indicated Resident 5 was to receive wound care to her/his coccyx (tailbone) every evening which included to cover the wound bed with calcium alginate (dressing to treat wounds with moderate to heavy drainage), apply marathon (wound protective layer) to the peri-wound (tissue surrounding the wound) and cover the wound with a foam dressing. An 10/29/24 Wound Evaluation revealed Resident 5's Stage 3 coccyx wound was improving, the peri-wound area was denuded (surface area removed), the wound exudate (fluid) was moderate and measured 0.51 cm x 0.76 cm and was 0.1 cm in depth. The progress notes indicated the wound was healing and current treatment continued. A 11/4/24 Wound Evaluation revealed Resident 5's wound was deteriorating, the exudate was light and bloody, and the wound measured 1.71 cm x 3.89 cm and it was 0.1 cm in depth. Progress notes indicated the current treatment continued. A 11/15/24 Wound Evaluation revealed Resident 5's wound continued to deteriorate, the exudate was light and bloody, and the wound measured 7.67 cm x 14.69 cm and it was 0.1 cm in depth. Progress notes indicated the wound size greatly increased due to the adhesive from the dressing which irritated the skin, but the pressure injury was nearly resolved. No new notes related to wound treatment were found. On 11/19/24 at 5:14 PM Staff 14 (LPN) stated she completed Resident 5's wound treatment weekly, the wound was improving but the surrounding area around the wound appeared to worsen. Staff 14 stated Staff 4 (RN-Patient Care Coordinator) assessed Resident 5's wound weekly and determined what treatments were necessary. On 11/20/24 at 1:46 PM Staff 15 (LPN) stated a few weeks earlier she observed two to three new red spots near Resident 5's coccyx wound that remained closed but "wanted to open" (indication of a Stage 1 pressure ulcer when the skin is intact and appears red). Staff 15 stated Resident 5's entire coccyx wound area appeared worse compared to prior observations and Staff 4 was aware. On 11/20/24 at 3:28 PM Staff 4 stated she believed Resident 5's coccyx wound was healing and wanted to focus on the coccyx wound before the surrounding skin issue was addressed. Staff 4 stated she did not consider an alternative to the residents' current wound treatment despite the changes observed to the surrounding skin. At 11/20/24 at approximately 3:30 PM Staff 2 (DNS) reviewed the wound documentation and acknowledged Resident 5's wound should be assessed as two separate wounds with a new treatment regimen considered at the time the surrounding skin area of the initial wound deteriorated.

Corrective Action: Facility immediately reassessed resident 5’s wound(s) and a new assessment was opened for the identified second wound. Both of Resident 5’s wounds are being monitored weekly until resolved. Identification of Others: All residents with wounds were assessed to ensure compliance with F686. Corrections were implemented as needed. Systemic Changes: a) DNS and/or Designee will re-educate staff regarding pressure ulcer policy and procedure. b) DNS will audit current wounds to ensure accuracy of assessment and treatment(s) are appropriate. c) Implementation of a Skin-at-Risk meeting. The meeting will be weekly for two months and then monthly thereafter. Monitoring: Audit findings will be brought to QAPI for three months to identify any needed revisions, trends, and/or further educational needs. Individual Responsible for Monitoring: DNS and/or Designee

Based on interview and record review it was determined the facility failed to ensure a resident was provided an RA program for 1 of 1 sampled resident (#3) reviewed for mobility. This placed residents at risk for increased weakness. Findings include: Resident 3 admitted to the facility in 8/2023 with a diagnosis of paralysis. A 7/23/24 annual MDS indicated Resident 3 had impaired cognition, was bed bound, required a mechanical lift for transfers, and assistance with ADLs. An 8/3/24 PT Discharge Summary revealed Resident 3 was provided therapy services to assist her/him with increased independence with bed mobility, sitting balance while in a wheelchair, and improve ROM to her/his legs. The benefit of therapy was to prevent contractures and muscle wasting. Discharge recommendation included a RA program. The RA program was for ROM for feet mobility and leg rotation. The RA program was also to assist in maintaining the resident's ability to sit at the side of the bed, transfer to the wheelchair, and participate in bed mobility. A care plan revised on 10/30/24 revealed Resident 3 had a walking deficit and impaired bed mobility due to decreased ROM, decreased cognition, impaired balance, and weakness. Interventions indicated therapy was to be provided as needed, but she/he had poor therapy participation. The care plan indicated Resident 3 did not walk and she/he was dependent on one staff to assist with turning and sitting up in bed. The care plan did not include a RA program. Review of Resident 3's clinical record did not include documentation to indicate a RA program was implemented. On 11/19/24 at 4:09 PM Staff 22 (Therapy Director) verified Resident 3 participated in therapy from 6/25/24 to 8/3/24 for leg ROM. Staff 22 verified a RA program was established. If RA was determined to be appropriate the RA staff would be trained in the program and then the program would be implemented. Staff 22 stated she did not see a RA program in the RA book. On 11/19/24 at 4:42 PM Staff 5 (RA) stated he worked in the facility for many years and never worked with Resident 3. On 11/19/24 at 4:55 PM Staff 4 (RN Patient Care Coordinator) stated if therapy recommended a RA program, they set up the exercises and provided a copy of the referral to her. She then ensured the resident was provided restorative services. After a period of time if the resident did not participate the RA program would be re-reevaluated and determined if it should continue or discontinue. Staff 4 stated Resident 3 historically refused therapy. Staff 4 stated she was never provided a RA referral to implement for Resident 3.

Corrective Action: Resident 3 was immediately reassessed for therapy and RA program. Corrections were implemented as needed. Identification of Others: Other residents who are on therapy services or have recently completed therapy services in the last 30 days were audited for RA program recommendations and implementations. Corrections were made as needed. Systemic Changes: a) Implementation of new Therapy Discharge Recommendation form to include RA recommendations will be provided to RN Patient Care Coordinators. b) DNS and/or Designee will provide education to therapy staff and RN Patient Care Coordinators regarding new Therapy Discharge Recommendation form. Monitoring: DNS and/or Designee will be responsible for auditing residents discharging off Part B therapy services and implementations of therapy form. Audit finding will be brought to QAPI for three months to identify any needed revisions, trends, and/or further educational needs. Individual Responsible for Monitoring: DNS and/or Designee

Based on observation, interview and record review it was determined the facility failed to maintain water temperatures for 2 of 6 sampled residents (#s 27 and 88) reviewed for environment and accidents. This placed residents at risk for burns. Findings include: 1. Resident 27 admitted to the facility 10/2024 with a diagnosis of a wedge compression fracture. An 10/2024 admission MDS revealed Resident 27 was cognitively intact. Resident 27 resided in Birch Hall. On 11/19/24 at 10:54 AM Resident 27 stated on one occassion she/he used the sink to wet her/his hair. On 11/19/24 at 10:56 AM Staff 6 (Maintenance Director) used a digital thermometer to test the hot water temperature at the tap of the sink in Resident 27's room. The thermometer indicated the hot water temperature was 125 degrees F. Staff 6 acknowledged the temperature of the hot water in Resident 27's room needed to be "dialed down." , 2. Resident 88 admitted to the facility 11/2024 with a diagnosis of hip surgery. A 11/14/24 admission MDS revealed Resident 88 was cognitively intact. Resident 88 resided in Cedar Hall. On 11/18/24 at 2:59 PM te hot water at the tap of the sink in Resident 88's bathroom was hot to touch when checked by the surveyor. On 11/19/24 at 9:30 AM Resident 88 stated the water was "very hot" if she/he was not careful, but she was able to adjust the temperature. On 11/19/24 at 9:51 AM Staff 6 (Maintenance Director) measured the temperature of the hot water in Resident 88's bathroom and it was observed to be 126 degrees F. Staff 6 stated the hot water heater was in a room adjacent to Resident 88's bathroom. On 11/19/24 at 2:21 PM Staff 6 stated he performed weekly water temperature checks in random resident rooms. Staff 6 indicated his goal was to keep the water temperature between 113 and 118 degrees F. Staff 6 stated no one reported concernsregarding excess water temparature in resident rooms.

Corrective Action: Water temperatures for the hot water heaters supplying water to residents 27 and 88 rooms were immediately adjusted to a lower level. Identification of Others: All facility hot water heaters temperatures supplying hot water to resident rooms were audited to ensure they are in compliance with F689. Corrections implemented as needed. Systemic Changes: a) Executive Director and/or Designee will provide re-education to all staff on safe water temperatures. b) Maintenance Director and/or Designee will spot audit water temperatures on the facility’s four wings weekly for one month, then monthly for two months to ensure ongoing compliance with F689. Monitoring: Audit findings will be brought QAPI for three months to identify any needed revisions, trends, and/or further educational needs. Individual Responsible for Monitoring: Executive Director and/or Designee

Based on interview and record review it was determined the facility failed to ensure respiratory treatments were implemented timely and diagnostic results were available in the medical record timely for 1 of 1 sampled resident (#1) reviewed for respiratory care. This placed residents at risk for respiratory complications. Findings include: Resident 1 admitted to the facility in 8/2021 with a diagnosis of a stroke. Progress Notes revealed: -10/8/24 Resident 1 was assessed by her/his NP for shortness of breath and orders were placed for a PRN nebulizer (machine which turns liquid medicine into a mist that can be inhaled to treat lung conditions). The note was not signed by the NP as completed until 10/26/24. -10/10/24 Resident 1 had shortness of breath, wheezing, and the physician was faxed to obtain an order for a nebulizer. -10/11/24 Resident 1 had chest pain with deep breaths, an order for a chest x-ray was obtained, and staff were waiting for results. -10/17/24 staff called radiology for x-rays obtained on 10/11/24. -10/21/24 staff confirmed radiology was completed on 10/11/24. Resident 1's 10/2024 MAR revealed her/his nebulizer was started on 10/10/24 and not started on 10/8/24 when prescribed by the NP. Resident 1's record indicated the x-ray ordered on 10/11/24 was faxed to the facility on 10/28/24. On 11/19/24 at 2:00 PM Staff 4 (RN Patient Care Coordinator) stated when a medical provider assessed residents they communicated their findings with facility staff, or wrote orders. Staff 4 stated if an x-ray was ordered and obtained, the results were usually in the chart within one week. If the results were not in the record staff called for the results. Staff 4 acknowledged the x-ray was not faxed to the facility until 10/28/24. Staff 4 was not sure the reason why the nebulizer was not started on the day the NP assessed Resident 1.

Corrective Action: X-Ray results for Resident 1 were reviewed by RN Resident Care Coordinator and corrections implemented as needed. Identification of Others: All chest x-rays in the last 30 days will be reviewed to ensure proper follow up was carry out. Correction implemented a needed. Systemic Changes: a) DNS and/or Designee will provide re-education to nursing staff regarding timely implementation of respiratory treatments. b) Review/audit of new order listing report at the daily (M-F) clinical meeting. Audit will be done daily for one month, weekly for a month and then monthly for one month to ensure ongoing compliance with F695. Monitoring: Audit findings will be brought QAPI for three months to identify any needed revisions, trends, and/or further educational needs. Individual Responsible for Monitoring: DNS and/or Designee

Based on interview and record review it was determined the facility failed to monitor a resident's thyroid hormone level for 1 of 5 sampled residents (#1) reviewed for medications. This placed residents at risk for a non-therapeutic medication regimen. Findings include: Resident 1 admitted to the facility in 8/2021 with a diagnosis of obesity. A 9/20/24 Order Summary Report revealed Resident 1 was administered Synthroid (hormone to increase thyroid levels). The start date was 10/9/21. Resident 1's clinical record revealed her/his last TSH (thyroid stimulating hormone; monitors thyroid function) test was obtained on 11/20/22 and the results were within therapeutic range. No additional TSH test results were in the clinical record. On 11/19/24 at 2:00 PM Staff 10 (LPN IP) stated TSH levels were usually checked annually. A request was made to Staff 10 to provide documentation a TSH level was obtained yearly after 2022 or a rationale was in the resident's record indicating it was not required. No additional information was provided. On 11/19/24 at 5:00 PM in interview with Staff 4 (RN Patient Care Coordinator) and Staff 2 (DNS), Staff 2 stated stated the pharmacy reported the TSH was usually checked annually.

Corrective Action: TSH was obtained for Resident1. Corrections implemented as needed. Identification of Others: All residents on Thyroid medication, in the last year, will be audited to ensure annual TSH labs have been obtained. Systemic Changes: a) DNS and/or Designee will provide re-education nursing staff regarding unnecessary medication. b) Pharmacist to incorporate TSH lab draws into pharmacy recommendations and provide recommendations to the facility on an on-going basis. Monitoring: DNS and/or Designee will audit Thyroid levels. Audit findings will be brought QAPI for three months to identify any needed revisions, trends, and/or further educational needs. Individual Responsible for Monitoring: DNS and/or Designee

Based on observation, interview and record review it was determined the facility failed to ensure concerns regarding proper food temperatures were addressed for Resident Council and 2 of 5 sampled residents (#s 9 and 25) reviewed for food. This placed residents at risk for food that was not palatable. Findings include: A 9/9/24 computer dashboard communication revealed CNAs were provided a reminder to not reheat anything for a resident in a microwave oven because resident safety and staff licenses were at risk. Staff were given the following direction: "Coffee-offer to get them a new cup. Food-ask the kitchen to reheat the food." 1. On 11/20/24 at 11:00 AM nine residents attended a Resident Council meeting. A majority of the residents in attendance agreed staff were not allowed to warm or address cold food concerns when a resident stated she/he was concerned about cold food. On 11/20/24 at 8:04 AM Staff 11 (Dietary Manager) stated the kitchen had one additional meal available if a resident requested warmer food during a meal service. Staff 11 stated food handled by a resident could not be reheated in the kitchen due to cross-contamination. Staff 1 (Administrator) stated she was not aware of reports related to residents' cold food and acknowledged staff education was necessary to address residents' cold food concerns. 2. Resident 9 admitted to the facility in 2020 with diagnoses including chronic pain and dementia. A 9/19/24 Annual MDS indicated Resident 9 had mild cognitive impairment. On 11/20/24 at 12:06 PM Resident 9 was observed in her/his room eating lunch with frozen strawberries on her/his plate. Resident 9 stated she/he was waiting for the strawberries to thaw before she ate them and indicated staff did not know how to address issues with cold food. Resident 9 stated she/he was mobile and routinely went to the kitchen to directly address concerns regarding cold food. On 11/20/24 at 8:04 AM Staff 11 (Dietary Manager) stated the kitchen had one additional meal available if a resident requested warmer food during a meal service. Staff 11 stated food handled by a resident could not be reheated in the kitchen due to cross-contamination. Staff 1 (Administrator) acknowledged staff education was necessary to address residents' cold food concerns. 3. Resident 25 admitted to the facility in 6/2023 with diagnoses including stroke and malnutrition. The 8/9/23 Orders Details for Resident 25's diet indicated she/he received regular nutritionally enhanced meals. A 5/31/24 revised care plan indicated Resident 25 had poor intake and to encourage and offer alternatives with respect to her/his preferences. On 11/18/24 at 12:10 PM Resident 25 stated she/he ate meals slowly and staff did not reheat her/his meals or beverages to accommodate her/his needs. Resident 25 stated she/he would eat more if her/his food was warmed including fruit. On 11/19/24 at 12:48 PM Staff 17 (CNA) stated staff were not allowed to reheat residents' food once a meal was touched by a resident. Staff 17 stated Resident 25 complained about cold food about 25 percent of the time, but nothing could be done to address Resident 25's concerns. On 11/19/24 at 3:39 PM Staff 18 (CNA) stated staff were not allowed to reheat residents' food, but the kitchen was to provide new servings of the meal if a resident requested warmer food. On 11/20/24 at 8:04 AM Staff 11 (Dietary Manager) stated the kitchen had one additional meal available if a resident requested warmer food during a meal service. Staff 11 stated food touched by a resident could not be reheated in the kitchen due to cross-contamination. Staff 1 (Administrator) acknowledged staff education was necessary to address residents' cold food concerns.

Corrective Action: Residents 9 and 25 were reassessed by Dietary Manager for food preferences and facility process for re-heating food. Residents preferences have been incorporated into their comprehensive care plans. Identification of Others: All facility residents are at risk for similar food related temperature concerns. All residents will be interviewed for any food-related concerns. Systemic Changes: a) Reviewed policies and procedures on outside food and proper reheating to ensure compliance with F804. Corrections implemented as needed. b) Executive Director and/or Designee to provide re-education to staff regarding re-heating of food. c) Executive Director and/or Designee to provide re-education to dietary staff on proper food preparation, plating, and temperature maintenance to ensure palatability and visual appeal. d) Initiate a monthly food counsel meeting with residents and the Dietary Manager and/or Designee where dining services can be discussed. Monitoring: Conduct weekly audits of food temperatures and resident satisfaction for one month, every other week for one month and then one month for a month. Results will be reviewed for any identifiable trends and brought to QAPI for three months to identify any needed revisions, trends, and/or further educational needs. Individual Responsible for Monitoring: Executive Director and/or Designee

****************************** OAR 411-085-0310 Residents' Rights: Generally Refer to F552 ****************************** OAR 411-086-0230 Activity Services Refer to F679 ****************************** OAR 411-086-0140 Nursing Services: Problem Resolution & Preventive Care Refer to F686, F689 and F757 ****************************** OAR 411-086-0150 Restorative Care Refer to F688 ****************************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F695 ****************************** OAR 411-086-0250 Dietary Services Refer to F804 ******************************

Based on interview and record review it was determined the facility failed to provide appropriate care and treatment, and failed to follow physician orders for 1 of 1 sampled resident (#1) reviewed for injury of unknown origin. This placed residents at risk for injuries and lack of physician oversight. Findings include: Resident 1 was admitted to the facility in 1/2021 with multiple fractures of ribs. a. A 12/15/21 revised care plan revealed Resident 1 had moderate to severe calcific tendinitis (calcium deposits form in the tendon) to her/his hands. Interventions for Resident 1 were described as areas of pain to the left shoulder, left knee pain and right wrist/hand. A 1/10/22 Incident Note indicated Resident 1 was noted to have blisters on her/his abdominal area. Resident 1 was unable to describe how they occurred. Resident 1 was placed on alert charting. A 1/10/22 at 11:38 AM New Skin Issue investigation indicated Resident 1 was found to have intact blisters on her/his lower abdominal area during cares. Resident 1 was unaware of the blistering. The injury location was indicated as the front right and left iliac crest (the three most significant bones that make up the hip bone). The blisters were around the umbilical area from three o'clock to seven o'clock. There was a total of three blisters around her/his belly button with the larger blister measuring five cm by six cm. There was some pale and blanchable redness around the large blister. A hot water bottle was not found in Resident 1's room and was ruled out as a contributing factor during the investigation. After the investigation was completed, it was determined the hot water bottle was not used for more than 12 hours. The last use was on the prior evening shift and was placed on Resident 1's hand with a pillowcase over the water bottle to prevent direct contact with her/his skin. Resident 1 indicated the hot water bottle was used on her/his hand and the way she/he sat up in her/his chair if the water bottle rolled out of place or got dropped it would land on her/his upper abdomen and not where the blisters were located. The hot water bottle was removed from her/his room to prevent potential future skin issues and Resident 1 was aware of the removal. An undated handwritten statement by Staff 12 (CNA) indicated she bought "hot packs" for Resident 1 earlier in 12/2021 and was informed the hot packs were allowed because they did not require to be microwaved. The hot packs were "bladder" bags which were filled with warm tap water. On 1/9/22 before Resident 1 presented with blisters, when staff put her/him into bed, Resident 1 liked a large pillow under each arm and rested her/his hands on those pillows. Resident 1's hot packs were placed on the top of the pillows and did not meet her/his skin on her/his abdomen. The hot packs were only for her/his hands because she/he had pain. Staff placed them into a pillowcase or placed a towel over them so there was no direct contact to her/his skin. No documentation was found in clinical records that Resident 1 was care planned or had a physician order for treatment or intervention using hot packs, hot water bottles or warm rags to be placed on her/his hands. A 3/15/22 Wound Clinic Progress Notes indicated Resident 1 presented with an open wound to the abdomen caused by a hot water bottle. The burn wound was debrided, the history came from the family and Resident 1's medical records. The age of the wounds was 10 weeks and they measured 9.5 cm by 8.5 cm by 0.1 cm, with a total wound area of 80.75 cm2. There was subcutaneous (beneath all layers of skin) eschar (dead tissue which is cast off from the surface of the skin, particularly after a burn injury but also can be seen in gangrene, ulcer, fungal infections, and bite wounds), granulation (new connective tissue which forms on the surface of a wound during healing process) was 10 percent, slough (necrotic tissue which needs to be removed) was 30 percent, unstable eschar was 50 percent, stable eschar was 10 percent, and serosanguineous (both blood and liquid part of the blood which is yellowish in color) drainage was present. The pain level was noted at five out of 10 since the last visit. Resident 1 was diagnosed with a burn of the abdomen with an unspecified burn degree. A 9/19/22 Significant Change MDS indicated Resident 1 had a BIMS of 9 indicating moderate cognitive impairment. On 12/8/22 at 7:59 AM Witness 1 (Complainant) stated the physicians who saw Resident 1's blisters indicated it was caused from burning to the skin. Witness 1 stated she was first told by the facility it was from a medication reaction, but never heard what medication. She was then informed it was from Resident 1's incontinent brief which caused the blisters on her/his abdomen. Witness 1 stated she believed the CNAs were trying to help Resident 1 with her/his cold hands when placing the hot water bottle. On 12/8/22 at 10:10 AM Resident 9 stated she/he was Resident 1's roommate in 1/2022 and she/he saw staff using a hot water bottle on Resident 1 once or twice and heard a conversation that they could no longer use the hot water bottle for Resident 1 anymore. On 12/13/22 at 10:30 AM Witness 7 (Wound Clinic Family Nurse Practitioner) stated she did not believe the wounds on Resident 1's abdomen were caused by an incontinent brief. Witness 7 stated her assessment was the wounds were burns caused by the hot water bottle as the wounds were in the shape of a hot water bottle. On 12/14/22 at 12:38 PM Staff 2 (DNS) stated she knew the hospital and the wound clinic described Resident 1's abdominal wounds as burns and that is what the family believed. Staff 2 stated she believed that was why the hospital and wound clinic documented the wounds as burns. Staff 2 stated Staff 3 (RNRCM) ruled out the wounds as burns and the investigation found the blisters were caused from Resident 1's incontinent briefs which developed eschar as they evolved. On 12/16/22 at 9:51 AM Staff 31 (RN) stated she observed the hot water pack in Resident 1's room and she removed it from the room. On 12/16/22 at 10:59 AM Staff 10 (CNA) stated she used warm rags which she put in a pillowcase for Resident 1 but she did not use a hot water packs. Staff 10 stated someone gave Resident 1 a "water bag thing" but she never saw any one use it. Staff 10 stated she saw the wounds on Resident 1's abdomen and they were above her/his belly button. Staff 1 stated Resident 1's brief went below her/his belly button for comfort. Staff 10 stated there were two to three wounds in one area and one was bigger and they were not all the same size. Staff 10 stated since working as a CNA for 19 years she never saw a brief cause wounds like Resident 1 had on her/his abdomen. Staff 19 stated she did not see burns on a resident in her 19 years working as a CNA. On 12/20/22 at 12:23 PM Staff 12 (CNA) stated she was the staff member who purchased the hot packs for Christmas in 12/2021 for Resident 1's hands. Staff 12 described the hot pack as an old-fashioned pack which was "balloon shaped", was made of rubberized material, and it was pleated from the base to the top which had the lid in which to put in either cold or warm water. Staff 12 stated she spoke to the RCM before purchasing the hot packs to make sure it was okay to use. Staff 12 stated she used warm tap water in the pack and either placed them into a pillowcase or placed a towel on top of the pack before placing on Resident 1's hands. On 12/21/22 at 9:33 AM Staff 38 (Nurse Practitioner) stated she believed the abdominal blisters could have been caused by the brief from the plastic fold and from the brief being too small on Resident 1. Staff 38 stated it was also possible the blisters could have been caused from a burn. On 12/22/22 at 10:01 AM Staff 1 (Administrator) and Staff 2 (DNS) confirmed Resident 1 did not have physician orders and was not care planned for the use of a hot water packs. b. A 1/10/22 Incident Note indicated Resident 1 had blisters to her/his abdominal area. Resident 1 was unable to describe how they occurred. Resident 1 was placed on alert charting. A revised 2/1/22 care plan indicated Resident 1 required one staff for incontinent care, she/he may use two staff for comfort, and she/he was totally incontinent of bowel. Resident 1 used bariatric size disposable incontinent briefs. A 1/10/22 at 11:38 AM New Skin Issue investigation indicated Resident 1 was found to have intact blisters on her/his lower abdominal area during cares. Resident 1 was unaware of the blistering. Notes written on 1/11/22 indicated staff noted multiple fluid fill blisters on Resident 1's abdomen. The blisters were around the belly button area from three o'clock to seven o'clock. There was a total of three blisters around her/his belly button and the larger blister measured five cm by six cm. There was some pale and blanchable redness around the large blister. Staff indicated they used a different size incontinent brief as the bariatric brief normally used for Resident 1 was on back-order and was out of stock at the facility. The staff used a brief which was one size smaller on Resident 1. Staff stated the brief was "a bit snugged" on her/him and might have caused compression and friction creating the blisters on her/his lower abdomen and belly button area. An undated handwritten statement by Staff 12 (CNA) indicated she was assisting Resident 1 into bed and her/his brief was not the right size because they were not available. Staff 12 noticed a small open area on her/his left side where the brief was fastened and mentioned the briefs were too small. Staff 12 proceeded to fasten the brief as loose as possible so it was not cutting into her/his skin. A 1/14/22 "Physician/ARNP/PA Note" indicated Staff 38 (Nurse Practitioner) indicated Resident 1 was evaluated for a large fluid filled blister to lower abdomen. Staff 38 wrote "CAN believe blister came with using different adult briefs causing reaction", and recommended to allow the blister fluid to reabsorb into Resident 1's body. On 12/8/22 at 7:59 AM Witness 1 (Complainant) stated she was first told by the facility the blistering was from a reaction to medication, but never heard what medication, and she was then informed it was from Resident 1's brief which caused the blisters on her/his abdomen. On 12/14/22 at 12:38 PM Staff 2 (DNS) stated Staff 3 (RNRCM) ruled out the abdominal wounds as burns and the investigation found the blisters were caused from Resident 1's incontinent briefs which developed eschar as they evolved. On 12/20/22 at 12:23 PM Staff 12 (CNA) stated she had to use smaller size briefs for a while as the facility was out of stock for Resident 1's size. Staff 12 stated the brief fit under Resident 1's abdominal fold and Staff 12 usually placed a pillowcase in Resident 1's abdominal fold for comfort. Staff 12 stated the brief was not touching the area of the abdominal wounds and she did not know how the wounds occurred. Staff 12 stated it was "super random". On 12/21/22 at 9:33 AM Staff 38 (Nurse Practitioner) stated she believed the blisters could have been caused by the brief from the plastic fold and from the brief being too small on Resident 1. On 12/22/22 at 10:01 AM Staff 1 (Administrator) and Staff 2 (DNS) stated when the facility became aware Resident 1's brief size was out of stock and on back-order the facility placed an order with a different company. Staff 2 stated if a smaller size brief had to be used on a resident it was suggested not to attach the tabs. c. A 1/20/21 Admission Profile revealed Resident 1 had ace wraps on both lower legs and usually wore stockings at home which would be on during the day and off during the night. Resident 1 used the ace wraps 24 hours a day seven days a week since she/he went to the hospital. Lotion was applied to Resident 1's legs and the wraps were put back into place. A review of Resident 1's clinical medical records revealed no physician order for the leg wraps to be applied on 1/20/21. On 12/22/22 at 10:23 AM Staff 1 (Administrator) and Staff 2 (DNS) stated it was expected of staff to reach out to a physician for an order if Resident 1 insisted on having the leg wraps be put on.

1) Individual Resident: a. Resident 1 no longer resides in the facility. 2) Residents in Similar Situations: a. Other facility residents were audited by Central Supply for correct brief sizing. Corrections were implemented as needed. b. Other facility residents were audited by DNS for use of leg wraps, correlating physician orders, and care plan interventions. Corrections were implemented as needed. 3) 1) Individual Resident: a. Resident 1 no longer resides in the facility. 2) Residents in Similar Situations: a. Other facility residents were audited by Central Supply for correct brief sizing. Corrections were implemented as needed. b. Other facility residents were audited by DNS for use of leg wraps, correlating physician orders, and care plan interventions. Corrections were implemented as needed. 3) Re-Education: a. Admin and/or Designee will provide re-education to staff regarding best practices on use of heating devices. b. Staff Developer and/or Designee will provide re-education to LNs regarding policy/procedure for heating pads, and use of legs wraps. 4) On-Going Monitoring: a. DNS and/or designee will audit new admissions weekly for 1 month and then monthly for 2 months to ensure the none-use of heating devices and ace bandaged wraps to lower extremities have correlating physician orders and care plan interventions. Results of audit will be reviewed for any identified trends and brought to QAPI for 3 months to identify any needed system revisions, trends, and/or further educational needs. 5) Individual to Ensure Compliance a. DNS will ensure compliance a. Admin and/or Designee will provide re-education to staff regarding best practices on use of heating devices. b. Staff Developer and/or Designee will provide re-education to LNs regarding policy/procedure for heating pads, and use of legs wraps. 4) On-Going Monitoring: a. DNS and/or designee will audit new admissions weekly for 1 month and then monthly for 2 months to ensure the none-use of heating devices and ace bandaged wraps to lower extremities have correlating physician orders and care plan interventions. Results of audit will be reviewed for any identified trends and brought to QAPI for 3 months to identify any needed system revisions, trends, and/or further educational needs. 5) Individual to Ensure Compliance a. DNS will ensure compliance

Based on interview and record review it was determined the facility failed to ensure resident records were complete and accurate for 2 of 6 sampled residents (#s 1 and 11) reviewed for pressure ulcers and change of condition. This placed residents at risk for inaccurate clinical records. Findings include: 1. Resident 1 was admitted to the facility in 1/2021 with diagnoses including diabetes. A 2/24/22 Weekly Non-Pressure Skin Condition Assessment revealed Resident 1 had what started as superficial wounds on the gluteal cleft and bilateral buttocks area. The wound bed was red and the Periwound was macerated. The measurement of the wound was 2 cm length by 1 cm width, and a depth of 0.28 cm, with a small amount of serous exudate (clear, thin and watery discharge). Wound bed granulation tissue was present which was pale pink to beefy red in color, and the surrounding skin was bright red and blanchable. The progress of the wound was noted as improved but fragile, and the treatment of calcium alginate on the open and moist wounds would continue. A 3/2/22 Hospital Wound Care Progress Note revealed Resident 1 had a Stage 2 sacrum pressure ulcer which was present on admission. A 3/7/22 Admission Profile for readmission revealed Resident 1 had non-pressure skin conditions which were present on admission. The profile indicated Resident 1 did not have a pressure ulcer, venous stasis, arterial or diabetic ulcers. Resident 1 had an open area to the sacrum and right buttock with no measurements of the wounds. No other information was provided about the sacrum or right buttock wounds. A 3/7/22 Skin Condition assessment sheet with body diagrams indicated an open area to Resident 1's sacrum area and right buttock. A 3/15/22 Wound Clinic Progress Notes revealed Resident 1 had a diagnosis of a Stage 2 pressure ulcer to the sacral region. The wound measured 2 cm in length by 0.5 cm in width with a depth of 0.1 cm, and an area of 1 cm2. A 3/18/22 Weekly Non-Pressure Skin Assessment revealed Resident 1 had superficial wounds to the gluteal cleft with a length of 2 cm by width of 1 cm and a depth of .28 cm. No documentation was found in clinical records for a pressure ulcer assessment of Resident 1's sacrum Stage 2 pressure ulcer. On 12/22/22 at 10:05 AM Staff 1 (Administrator) and Staff 2 (DNS) stated when Resident 1 first developed the wound on her/his buttocks it was determined to be moisture associated skin damage. When Resident 1 discharged to the hospital the wound presented as a pressure ulcer and the hospital did not see the wound in its initial stages. The hospital provided their determination to the wound clinic and the facility did not agree with the staging of the wound and felt it was a moisture associated wound. 2. Resident 11 was admitted to the facility in 11/2022 with diagnoses including hip dislocation. A 12/2022 TAR instructed staff to administer Thera Worx Relief (topical solution to relieve muscle spasms) topically every four hours PRN for spasms. It was documented Resident 11 was administered Thera Worx on 12/3/22 and 12/7/22 at 9:24 AM. On 12/7/22 at 11:53 AM Resident 11 was screaming and requesting the "blue thing" to be removed from between her/his legs as it was causing her/him pain. On 12/8/22 at 9:29 AM Staff 8 (LPN) stated she administered the Thera Worx to Resident three instances on 12/7/22 and she forgot to document the second two administrations on the TAR. Staff 8 stated the blue wedge was in between Resident 11's legs so her/his hip would not become dislocated. On 12/9/22 at 9:37 AM Resident 11 stated the muscle spasms she/he was having the last few days caused her/him to scream out in pain as she/he could not move to relieve the pain. On 12/22/22 at 10:45 AM Staff 1 (Administrator) and Staff 2 (DNS) stated each time a PRN medication was used it should be documented on the TAR.

1) Individual Resident: a. Residents 1 and 11 no longer reside in the facility. 2) Residents in Similar Situation: a. Facility audit was completed for like residents with ulcers to ensure wounds are staged per standardized pressure injury characteristics. Any discrepancies will be reviewed with the physician for clarification. b. Facility audit was completed for like residents with topical pain medication use to ensure TAR entries matched order administration. 3) Re-Education: a. DNS and/or Designee will provide re-education to nurse managers regarding identifying pressure ulcers vs non-pressure ulcers related wounds. b. Staff Developer and/or Designee 4) On-Going Monitoring: a. Medical Records and/or Designee will audit new orders for topical pain medications weekly for 1 month and then monthly for 2 months to ensure appropriate documentation of topical pain medications. Results of audit will be reviewed for any identified trends and brought to QAPI for 3 months to identify any needed system revisions, trends, and/or further educational needs. 5) Individual to Ensure Compliance: a. DNS and/or Designee will ensure compliance

**************************************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F684 **************************************** OAR 311-086-0300 Clinical Records Refer to F842 ***************************************

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 11/21/2022 and 11/27/2022, 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 11/07/2022 and 11/13/2022, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 09/20/2021 and 09/26/2021, 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 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 08/09/2021 and 08/15/2021, 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.