Hood River Post Acute

1. Resident 10 was admitted to the facility in 2/2026 with diagnoses including hypertension (high blood pressure). A care plan dated 2/5/226 indicated Resident 10 was a full code, her/his advanced directive would be honored, and her/his advanced directive would be in the medical record at all times. A review of Resident 10GÇÖs medical record revealed no evidence of an advanced directive. On 3/10/26 at 1:13 PM, Staff 2 (DNS) stated Resident 14 did not have an advanced directive and education was initiated regarding the difference between an advanced directive and a POLST (Physician Order for Life Sustaining treatment). Staff 2 stated the expectation was for the RCM or the Social Service Director to ensure if a resident has an advanced directive, it was obtained and scanned into the resident's chart. -á 2. Resident 14 was admitted to the facility in 2/2026 with diagnoses including asthma. A 2/10/26 Baseline Care Plan Person-Centered Care Planning Evaluation revealed Resident 14GÇÖs advanced directive had been reviewed with Resident 14. A review of Resident 14GÇÖs medical record revealed no evidence of an advanced directive. On 3/10/26 at 1:13 PM, Staff 2 (DNS) stated Resident 14 did not have an advanced directive and education was initiated regarding the difference between an advanced directive and a POLST (Physician Order for Life Sustaining treatment). Staff 2 stated the expectation was for the RCM or the Social Service Director to ensure if a resident has an advanced directive, it was obtained and scanned into the resident's chart. -á

Resident #10 advance directive was reviewed, and any concerns were addressed at that time. #14 has discharged the facility. Audit completed with residents on advance directives, any concerns were addressed at that time. DON or designee to provide education to SS and Nurse managers on advance directive requirements. DON or designee will complete a random audit on new admission residents to verify advance directives reviewed and updated as indicated weekly x4 weeks, then monthly x 2 or until substantial compliance is met. The results of the audits will be brought to QAPI for review.

The facility's Resident Rights Policy from 8/2019 revealed: -Employees shall treat all residents with kindness, respect, and dignity. Federal and states laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to privacy and confidentiality. Resident 11 was admitted to the facility in 2/2026 with diagnoses including cerebral infarction (blood flow blockage of a section of the brain which often results in death of brain cells), tracheostomy (surgical airway opening to facilitate breathing), and locked-in state (full consciousness but an inability to move or speak). A 2/18/26 Admission MDS indicated Resident 11 to be in a comatose state with an inability to communicate. A 3/2/26 physician order included Resident 11GÇÖs tracheostomy to be suctioned every six hours and as needed to prevent airway blockage. On 3/10/26 at 8:31 AM Staff 10 (Respiratory Therapist) was observed performing suctioning for Resident 11GÇÖs tracheostomy with Resident 11GÇÖs door fully open. Resident 11 was visible from the main hallway of the facility. During the suctioning, Resident 11 was observed lifting both of her/his legs one foot off her/his bed and tremoring strongly for approximately three seconds multiple times. Residents were observed looking into Resident 11GÇÖs room from the hallway while the suctioning care was provided to Resident 11. On 3/11/26 at 1:00 PM Staff 10 was observed performing suctioning for Resident 11GÇÖs tracheostomy with Resident 11GÇÖs door fully open. Resident 11 was visible from the main hallway of the facility. During the suctioning, Resident 11GÇÖs legs were observed lifting one foot off her/his bed while tremoring strongly for approximately three seconds a total of six times. During the reactions to suctioning, three staff members and two residents passed by Resident 11GÇÖs room and looked into her/his room at Resident 11. On 3/11/26 at 1:17 PM Staff 10 stated Resident 11GÇÖs legs lifted off the bed and shook when the suctioning tube was required to go more than two inches deep. Staff 10 stated Resident 11 grimaced during the suctioning process. Staff 10 stated she had never been instructed to have Resident 11GÇÖs door closed when performing suctioning but understood maintaining privacy was important for all residents, but especially when a resident was unable to communicate or advocate for themselves. On 3/11/26 at 3:52 PM Witness 1 (Resident Representative) stated Resident 11 would not want her/his care to be provided visible to others and stated Resident 11GÇÖs door should be closed when suctioning care was provided. Witness 1 stated she/he was uncomfortable knowing suctioning care was provided to Resident 11 with the door wide open. -á On 3/11/26 at 4:06 PM Staff 9 (LPN/Resident Care Manager) stated when suctioning care was provided, having the door closed was important for Resident 11GÇÖs privacy. On 3/11/26 at 4:26 PM Staff 2 (DNS) confirmed Resident 11GÇÖs door should remain closed to maintain privacy when tracheostomy care was provided.

Resident #11 has been discharged to facility. Audit completed with residents with trach care for privacy concerns, any concerns were addressed at that time. DON or designee completed education completed with RT and LN’s on providing privacy with trach care and ensuring that the door is closed for residents privacy. DON or designee will complete a random audit on residents receiving trach care to ensure that the door or curtain is closed for privacy weekly x4 weeks, then monthly x 2 or until substantial compliance is met. The results of the audits will be brought to QAPI for review.

3. Resident 4 was admitted to the facility in 2007 with diagnoses including antisocial personality disorder (mental health condition) and dementia with behavioral disturbance. Resident 4's 8/1/25 Annual MDS indicated the resident received no Gradual Dose Reduction (GDR) was attempted and the physician did not document a GDR was clinically contraindicated. Resident 4's 2/2026 Physician Orders directed the facility staff to administer quetiapine fumarate (antipsychotic medication) 600 mg by mouth at bedtime. Resident 4's 2/2025 through 3/2026 MARs revealed the resident received quetiapine fumarate as ordered. Resident 4's health record did not include documented evidence a GDR was attempted or a documented rationale why a GDR was clinically contraindicated. On 3/12/2026 12:40 PM and 3/13/26 at 9:52 AM Staff 3 (RNCM) stated the resident was on a specialized unit and believed the residents on the Enhanced Care Unit (ECU) would not warrant a GDR due to their diagnoses. Staff 3 stated the residents on the ECU had their psychotropic medications and potential changes in condition reviewed monthly by the IDT (Intradisciplinary Team). Staff 3 was unable to provide the required GDR documentation for Resident 4. -á 4. Resident 71 was admitted to the facility in 2024 with diagnoses including bipolar disorder (mental health condition). Resident 71's 7/2/25 Annual MDS indicated the resident received an antipsychotic, no Gradual Dose Reduction (GDR) was attempted, and the physician did not document a GDR was clinically contraindicated. Resident 71's 2/2025 Physician Orders for medications included the following:-á - olanzapine (antipsychotic) give 10 mg by mouth in the evening. - Depakote sprinkles oral capsule delayed release (mood stabilizer) to give 1750 mg by mouth in the morning and 2000 mg by mouth at bedtime. Resident 71's 2/2025 through 3/2026 MARs revealed the resident received olanzapine and Depakote medications as ordered. Resident 71's health record did not include documented evidence a GDR was attempted or a documented rationale why a GDR was clinically contraindicated. On 3/12/2026 12:40 PM and 3/13/26 at 9:52 AM Staff 3 (RNCM) stated the resident was on a specialized unit and believed the residents on the Enhanced Care Unit (ECU) would not warrant a GDR due to their diagnoses. Staff 3 stated the residents on the ECU had their psychotropic medications and potential changes in condition reviewed monthly by the IDT (Intradisciplinary Team). Staff 3 was unable to provide the required GDR documentation for Resident 71.-á , 2. Resident 9 was admitted to the facility in 2020 with diagnoses including bipolar disorder (mental health condition). Resident 9's 2/2025 Physician Orders included the following: - olanzapine (antipsychotic) 5 mg by mouth in the morning and 10 mg by mouth in the evening. Resident 9's 1/26/26 Quarterly MDS indicated the resident received an antipsychotic, no Gradual Dose Reduction (GDR) was attempted, and the physician did not document a GDR was clinically contraindicated. Resident 9's 2/2025 MARs through 2/2026 MARs revealed the resident received olanzapine BID as ordered. Resident 9's health record did not include documented evidence a GDR for olanzapine was attempted between 2/2025 and 2/2026 or a documented rationale why a GDR was clinically contraindicated. On 3/12/2026 12:40 PM and 12:47 PM and on 3/13/26 at 9:52 AM Staff 3 (RNCM) stated the resident was on a specialized unit and believed the residents on the Enhanced Care Unit (ECU) would not warrant a GDR due to their diagnoses. Staff 3 stated the residents on the ECU had their psychotropic medications and potential changes in condition reviewed monthly by the IDT (Intradisciplinary Team). Staff 3 was unable to provide the required GDR documentation for Resident 9.-á , 1. Resident 8 was admitted to the facility in 6/2024 with diagnoses including paranoid schizophrenia (mental health condition) and anxiety disorder (mental health condition).-á Resident 8's 12/13/25 Quarterly MDS indicated the resident received antipsychotic and antianxiety medications with no Gradual Dose Reduction (GDR) attempted and no documentation existed from the physician indicating a GDR was clinically contraindicated.-á -áResident 8's 3/2026 Physician Orders included the following:-á -á - buspirone HCl Oral Tablet (antianxiety medication) 10 mg by mouth two times a day and 15 mg by mouth at bedtime for anxiety, active since 11/19/24. -á- perphenazine Oral Tablet 4 MG (antipsychotic medication) 4 mg by mouth two times a day, active since 6/4/24 Resident 8's 2/2026 and 3/2026 MARs revealed the resident received buspirone 10 mg twice per day, buspirone 15 mg at night, and perphenazine 4 mg twice per day as ordered.-á Resident 8's health record did not include documented evidence GDRs were attempted for buspirone or perphenazine, nor was there documented rationale for both medications why a GDR was clinically contraindicated.-á On 3/12/26 at 12:29 PM and 3/13/26 at 11:32 AM Staff 3 (RNCM) stated the resident was on a specialized unit and believed the residents on the Enhanced Care Unit (ECU) would not warrant a GDR due to their diagnoses. Staff 3 stated the residents on the ECU had their psychotropic medications and potential changes in condition reviewed monthly by the IDT (Intradisciplinary Team). -áStaff 3 was unable to provide the required GDR documentation for Resident 8.-á

Resident #8, 9, & 71 was reviewed for GDR with provider. Resident #4 discharged facility. Audit completed with residents receiving psychotropic medications to review GDR has been completed or reviewed with provider per regulation. RDCS provided education to DON on GDR requirements and documentation standards for psychotropic medication. DON or designee provided education to nurse managers and providers on GDR requirements and documentation standards. DON or designee will complete a random audit on residents with psychotropic medication to ensure GDR has been completed with documentation standards per regulation weekly x4 weeks, then monthly x2 or until substantial compliance is met. The results of the audits will be brought to QAPI for review.

Resident 82 was admitted to the facility in 9/2025 with diagnoses including seizures and anxiety. A physician order from 9/1/25 included 200 mg of lacosamide (antiseizure medication) to be administered twice a day for seizures. A physician order from 9/1/25 included 1 mg of clonazepam (antianxiety medication) to be administer twice a day for anxiety. Review of progress notes revealed Resident 82 transitioned home to an assisted living facility on 9/15/25. This note reports Resident 82 was provided his/her medications upon discharge. Review of Controlled Substance Log records from 9/2025 revealed Resident 82 had 33 tablets of lacosamide and 24 tablets of clonazepam which remained in the facility until they were disposed of on 11/9/25. Records showed the medications were not provided to Resident 82 upon discharge. On 3/10/26 at 2:31 PM Staff 9 (LPN/Resident Care Manager) stated residents discharge with their scheduled and PRN medications, but not general over the counter medications. Staff 9 stated antiseizure and antianxiety medications were types of medications a resident should be discharged home with. On 3/10/26 at 2:59 PM Staff 6 (RN) stated Resident 82 was to be provided her/his antiseizure and antianxiety medications upon discharge. On 3/10/26 at 3:04 PM Witness 2 (RN, External Facility Staff) reviewed Resident 82GÇÖs records regarding her/his transfer home. Witness 2 stated Resident 82 was not provided with the remaining doses of lacosamide and clonazepam upon discharge which required these medication to be reordered. Witness 2 stated Resident 82 experienced increased anxiety as result of not having her/his anxiety and seizure medications available. On 3/11/26 at 9:05 AM Resident 82 stated she/he was afraid after learning she/he did not arrive to the new facility with all of her/his medications but did not experience any seizures or anxiety attacks as a result of missed medications. On 3/11/26 at 10:36 AM Staff 2 (DNS) confirmed Resident 82 should have been provided the remaining doses lacosamide and clonazepam upon her/his discharge from the facility.

Resident #82  no longer at facility. Audit completed for discharge of residents from the past two weeks for any issues with medication, any concerns addressed at that time. DON or designee to provide education on nursing staff on ensuring that resident discharge with all appropriate medications or scripts for discharge. DON or designee will complete a random audit on residents with discharges to ensure that they were discharged with all appropriate medications or scripts weeklyx4, then monthly x2 or until substantial compliance is met. The results of the audits will be brought to QAPI for review.

Resident 83 was admitted to the facility in 3/2025 with diagnoses includine AlzhimerGÇÖs Disease and insomnia. A public complaint was made on 12/10/25 which alleged the facility failed to have intervention in place to mitigate Resident 83GÇÖs falls. A 4/3/25 facility investigation indicated on 3/21/25 Resident 83 was found on the floor in her/his room. The investigation did not include an analysis of the root cause of the fall, or whether care planned interventions were effective, or if any additional interventions were put in place. A 4/3/25 facility investigation indicated on 3/23/25 Resident 83 was observed self ambulating in the hall near the nurseGÇÖs station and Resident 83 was observed to fall. A 4/3/25 facility investigation indicated on 3/26/25 Resident 83 was found on the floor in her/his room. The investigation did not include an analysis of the root cause of the fall, or whether care planned interventions were effective, or if any additional interventions were put in place. A 4/3/25 facility investigation indicated on 3/27/25 Resident 83 was found on the floor in her/his room. The investigation did not include an analysis of the root cause of the fall, or whether care planned interventions were effective, or if any additional interventions were put in place. A 4/3/25 facility investigation indicated on 3/30/25 Resident 83 was observed falling in the hallway. The investigation did not include an analysis of the root cause of the fall, or whether care planned interventions were effective, or if any additional interventions were put in place. A 4/6/25 facility investigation indicated on 3/24/25 Resident 83 was observed to fall in her/his room. The investigation did not include an analysis of the root cause of the fall, or whether care planned interventions were effective, or if any additional interventions were put in place. A 4/14/25 facility investigation indicated on 4/8/25 Resident 83 was found on the floor in her/his room. The investigation did not include an analysis of the root cause of the fall, or whether care planned interventions were effective, or if any additional interventions were put in place. A 4/14/25 facility investigation indicated on 4/11/25 Resident 83 was found on the floor in her/his room. The investigation did not include an analysis of the root cause of the fall, or whether care planned interventions were effective, or if any additional interventions were put in place. A 5/1/25 facility investigation indicated on 4/27/25 Resident 83 was found on the floor in her/his room. The investigation did not include an analysis of the root cause or the fall, or whether care planned interventions were effective, or if any additional interventions were put in place. A 5/1/25 facility investigation indicated on 5/1/25 Resident 83 was found on the floor in her/his room. The investigation did not include an analysis of the root cause or the fall, or whether care planned interventions were effective, or if any additional interventions were put in place. A 5/19/25 facility investigation indicated on 5/16/25 Resident 83 was found on the floor in her/his room. The investigation did not include an analysis of the root cause or the fall, or whether care planned interventions were effective, or if any additional interventions were put in place. A 6/25/25 facility investigation indicated on 6/10/25 Resident 83 was observed standing up for her/his wheelchair and falling to the floor. The investigation did not include an analysis of the root cause or the fall, or whether care planned interventions were effective, or if any additional interventions were put in place. A 6/25/25 facility investigation indicated on 6/18/25 was found on the floor in her/his room. The investigation did not include an analysis of the root cause or the fall, or whether care planned interventions were effective, or if any additional interventions were put in place. A 7/11/25 facility investigation indicated on 7/2/25 Resident 83 was found on the floor of the hallway. The investigation did not include an analysis of the root cause or the fall, or whether care planned interventions were effective, or if any additional interventions were put in place. A 7/11/25 facility investigation indicated on 7/9/25 Resident 83 was found on the floor of her/his room. The investigation did not include an analysis of the root cause or the fall, or whether care planned interventions were effective, or if any additional interventions were put in place. A 9/19/25 facility investigation indicated on 8/30/25 Resident 83 was found on the floor in the hallway. The investigation did not include an analysis of the root cause or the fall, or whether care planned interventions were effective, or if any additional interventions were put in place. A 10/2/25 facility investigation indicated on 9/13/25 Resident 83 was found on the floor in her/his room. The investigation did not include an analysis of the root cause or the fall, or whether care planned interventions were effective, or if any additional interventions were put in place. A 11/3/25 facility investigation indicated on 10/5/25 Resident 83 was found on the floor in her/his room. The investigation did not include an analysis of the root cause or the fall, or whether care planned interventions were effective, or if any additional interventions were put in place. A 11/3/25 facility investigation indicated on 10/19/25 Resident 83 had a witnessed fall onto the floor. The investigation did not include an analysis of the root cause or the fall, or whether care planned interventions were effective, or if any additional interventions were put in place. A 12/7/25 facility investigation indicated on 11/9/25 Resident 83 was found on the floor in the hallway. The investigation did not include an analysis of the root cause or the fall, or whether care planned interventions were effective, or if any additional interventions were put in place. A 12/7/25 facility investigation indicated on 11/12/25 Resident 83 was found on the floor in the hallway. The investigation did not include an analysis of the root cause or the fall, or whether care planned interventions were effective, or if any additional interventions were put in place. A 1/4/26 facility investigation indicated on 12/6/25 Resident 83 was found on the floor in her/his room. The investigation did not include an analysis of the root cause or the fall, or whether care planned interventions were effective, or if any additional interventions were put in place. A 3/1/26 facility investigation indicated on 2/8/26 Resident 83 was found on floor in the hallway, The investigation did not include an analysis of the root cause or the fall, or whether care planned interventions were effective, or if any additional interventions were put in place. A review of Resident 83GÇÖs medical record revealed she/he passed away on 2/24/26. On 3/11/26 at 11:40 AM, Staff 2 (DNS) stated investigation were expected to be completed within five business days. Staff 2 stated the fall investigations for the falls on 3/21/25, 3/23/25, 3/24/25, 3/26/25, 6/10/25, 6/18/25, 7/2/25, 8/30/25, 9/13/25, 10/5/25, 10/19/25, 11/9/25, 11/12/25, 12/6/25, and 2/8/26 were completed late. Staff 2 stated the fall investigations were not through, were missing the root cause analysis for the falls, and were missing interventions put in place to help prevent further falls or help prevent injuries from falls.

Resident #83 no longer at facility. Audit completed to review residents with falls for the past 14 days reviewed for thorough investigation of any concerns addressed at that time. DON or designee educated LN’s on completing assessment and risk management including witness statements with all falls and education on following care plan. DON or designee will educate Nurse Managers on thorough investigations and timely investigations. DON or designee will review progress notes for any falls to make sure corresponding risk management is completed for thorough investigation weekly x4, then monthly x2 or until substantial compliance is met. The results of the audits will be brought to QAPI for review.

The facilityGÇÖs 9/1/24 policy and procedure related to indwelling catheters indicates care of residentsGÇÖ catheters includes monitoring for signs of complications. Resident 56 was admitted to the facility in 9/2025 with a diagnosis of acute and chronic respiratory failure with hypoxia (a potentially life-threatening condition where the lungs cannot adequately oxygenate the blood). Resident 56GÇÖs health record revealed she/he was her/his own representative and was cognitively intact. A review of Resident 56GÇÖs 9/24/25 Admission and 12/25/25 Quarterly MDS assessments revealed she/he had an indwelling suprapubic catheter. Resident 56's 10/1/25 Care Plan indicated the facility was to follow up with urology consults as ordered. A progress note written by Staff 5 (Attending Physician) on 11/20/25 at 8:31 AM revealed Resident 56 complained her/his suprapubic catheter leaked at the stoma which left her/his bed wet. The note indicated if Resident 56GÇÖs suprapubic catheter was leaking, staff were to refer to urology for an exchange or different size. A handwritten note from Staff 5 requested staff to refer Resident 56 to Urology to care for her/his leaking suprapubic catheter was uploaded to her/his health record on 11/20/25. A nursing progress note written by Staff 6 (RN) on 1/24/26 at 5:57 PM revealed a GÇ£large amount of urine leaking around suprapubic catheter.GÇ¥ -á On 3/9/26 at 11:29 AM Resident 56 stated, GÇ£I wish they could fix my catheter. It leaks and I end up being wet on my belly and it is uncomfortable.GÇ¥ Resident 56 pointed to a wet area low on her/his garment and stated, GÇ£I don't like to feel wet.GÇ¥ On 3/12/26 at 12:04 PM Staff 7 (CNA) stated she performed peri care around Resident 56GÇÖs suprapubic catheter stoma because it leaked. Staff 7 stated she used a warm wet washcloth to keep Resident 56 as clean and dry as possible whenever she provided incontinence care and whenever urine leaked from the stoma. Staff 7 stated Resident 56 let staff know when she/he leaked urine from her/his stoma. On 3/12/2026 at 3:20 PM Staff 4 (CNA) stated he was aware Resident 56GÇÖs suprapubic catheter leaked and she/he complained about her/his GÇ£belly feeling wet.GÇ¥ Staff 4 stated this was GÇ£pretty much the normGÇ¥ and CNAs perform peri care around the stoma, cleaned the area and regularly placed an absorbent pad below the stoma to help absorb the leaking urine.-á On 3/12/26 at 3:23 PM Staff 8 (LPN) stated the stoma for Resident 56GÇÖs suprapubic catheter was too big which caused it to leak urine. Staff 8 stated she observed Resident 56GÇÖs stoma regularly and CNAs had to provide peri care to the stoma to ensure the site was clean and dry because it leaked urine daily. Staff 8 stated she did not know if a urology referral and appointment were made. On 3/12/26 at 3:39 PM Staff 9 (LPN/RCM) stated she was aware Resident 56GÇÖs suprapubic catheter stoma leaked continuously and it was GÇ£bothersome.GÇ¥ Staff 9 stated she was aware of Staff 5GÇÖs order to refer Resident 56 to Urology but confirmed the referral was not made. Staff 9 stated she expected a referral to be made to urology when a suprapubic catheter stoma leaked.

Resident #5 Catheter referral was reviewed and processed. Audit completed on residents with catheters to ensure any referrals related to catheters were addressed; any concerns were addressed at that time. DON or designee to complete education on Nurse Managers on processing referrals for catheter related cares. DON or designee to complete audit for catheter referrals that are processed at a timely weeklyx4, then monthly x2 or until substantial compliance is met. The results of the audits will be brought to QAPI for review.

Resident 10 was admitted to the facility in 2/2026 with diagnoses including a Stage 3 Pressure Ulcer (a deep, full-thickness skin wound, often appearing as a crater, where the skin has broken down completely, exposing the fatty subcutaneous tissue) to her/his sacral region and left heel and moderate protein-calorie malnutrition. A 2/5/26 care plan indicated Resident 10 was at risk for nutritional imbalance due to a diagnosis of malnutrition. A review of Resident 10GÇÖs weights revealed the following: -2/11/26 200 lbs -2/17/26 190 lbs -3/5/26 179.8 lbs A review of the 2/4/26 Skin Issues Evaluations revealed Resident 10 had a Stage 3 Pressure Ulcer on her/his left ankle and sacrum at admission. A 2/12/26 Nutrition at Risk Evaluation revealed Resident 10 was started on a protein supplement twice a day due to wounds. A 2/13/26 physician order revealed Resident 10 had orders for a nutritional supplement twice a day. A review of a 2/23/26 Skin Issues Evaluations revealed Resident 10GÇÖs pressure ulcer on her/his sacrum worsened to a Stage 4 Pressure Ulcer (wounds that involve complete tissue loss with exposure of muscle, tendon, or bone). A 2/26/26 Nutrition at Risk Evaluation revealed Resident 10 was refusing her/his nutritional supplement and Resident 10 was consuming the protein supplement. A review of 2/2026 and 3/2026 MARs revealed Resident 10 refused the nutritional supplement which was started on 2/13/26. On 3/11/26 at 8:29 AM, Resident 10 was observed in bed with her/his breakfast tray in front of her/him, Resident 10 appeared to be sleeping and not eating. On 3/12/26 at 9:28 AM Resident 10 was observed sleeping in bed with her/his breakfast tray in from of her/him and food on her/his chest. A 3/12/26 review of Resident 10GÇÖs meal intake for the last 30 days from date of review, revealed Resident 10 ate 50% or less than of her/his meals or refused the meal 37 times. The documentation revealed Resident 10 was offered a health shake or ensure six times and refused 13 times. On 3/12/26 at 11:05 AM Staff 13 (RNCM) stated the expectation was if a resident consumes 50% or less of their meal, an alternate or meal replacement was offered. Staff 13 stated a protein supplement, and a nutritional supplement was started on 2/5/26, but Resident 10 has refused the nutritional supplement. Staff 13 confirmed Resident 10 had a significant weight loss and there were no interventions put in place since the weight loss occurred. OnGÇ»3/12/26 atGÇ»11:31GÇ»AM, StaffGÇ»2 (DNS) acknowledged ResidentGÇ»10 had experienced significant weight loss and no interventions had been implemented in response to the decline. StaffGÇ»2 stated discussions regarding hospice care had occurred with the family; however, the family was not yet ready for ResidentGÇ»10 to transition to hospice services.

Resident #10 was reviewed in NAR for weight loss, any recommendations were reviewed and updated. Audit completed for residents with significant weight changes to ensure that they are reviewed in NAR and any recommendations were reviewed and updated. DON or designee to provide education to nurse managers on reviewing residents in NAR for weight loss and getting interventions in place. DON or designee to complete a random audit on residents with weight loss to ensure that they have appropriate interventions in place and reviewed in NAR as indicated weeklyx4, then monthly x2 or until substantial compliance is met. The results of the audits will be brought to QAPI for review.

CDCGÇÖs 6/2021 Consideration for Use of Enhanced Barrier Precautions in Skilled Nursing Facilities instructed EBP were recommended for residents with indwelling medical devices, regardless of multidrug-resistant organism colonization status.-á Resident 55 was admitted to the facility in 2/2026 with diagnoses including gastrostomy status (a tube placed directly into the stomach through a small opening in the belly used for administering nutrition, fluids, and medications). Resident 55's 2/10/26 admission orders included an order for enhanced barrier precautions (EBP) (protective measures taken by nursing home staff for residents with specific germs or medical devices). On 3/9/26 and 3/10/26 between the hours of 8:37 AM and 3:38 PM no EBP signage or PPE was observed inside or outside Resident 55GÇÖs room. On 3/9/26 at 2:32 PM and 3/10/26 at 1:34 PM staff, including Staff 4 (CNA), were observed to complete cares with Resident 55 without wearing PPE beyond gloves. On 3/10/26 at 1:26 PM Staff 4 stated when providing care with residents with tube feeding, staff should wear a gown, mask, and gloves. Staff 4 stated a sign would be posted outside the residentGÇÖs door if they were on EBP.-á Staff 4 confirmed Resident 55 did not have EBP in place and PPE was not used beyond wearing gloves.-á On 3/10/26 at 1:56 PM Staff 2 (DNS) acknowledged Resident 55 did not have EBP in place, confirmed EBP signage was not posted, and confirmed EBP was indicated for Resident 55 due to the residentGÇÖs gastrostomy tube.-á-á

Resident #55 were reviewed to ensure EBP were placed as indicated any concerns addressed at that time. Review of residents on transmission-based precautions or enhanced barrier precautions was completed, any concerns addressed at that time. DON or designee reeducated staff on Enhanced Barrier Precautions including that the proper signage is in place. DON or designee will complete random audit to ensure that the appropriate transmission-based precautions or enhanced barrier precautions are in place weekly x4, then monthly x2 or until substantial compliance is met. The results of the audits will be brought to QAPI for review.

Based on interview and record review it was determined the facility failed to ensure a consent was obtained prior to administering antidepressant medications to residents for 1 of 5 sampled residents (#21) reviewed for unnecessary medications. This placed residents at risk for being uninformed about their medications. Findings include: Resident 21 was admitted to the facility in 8/2023 with diagnoses including fracture and dementia. Resident 21's 8/25/23 Physician Order indicated the resident was prescribed mirtazapine (antidepressant) for major depressive disorder. Resident 21's 8/2023 through 9/2024 MARs revealed the resident received mirtazapine daily. Review of Resident 21's health record revealed no documentation to indicate the resident was informed in advance of the risks and benefits of mirtazapine. On 9/25/24 at 10:57 AM Staff 2 (DNS) and Staff 3 (Regional Nurse Consultant) reviewed Resident 21's health record, acknowledged there was no documentation to indicate the resident was informed of the risks and benefits of mirtazapine and confirmed a consent was not obtained from Resident 21 or her/his representative prior to the resident starting the medication.

Resident #21 updated consent obtained for antidepressant medication. Audit run on all current residents on psychotropic medications to ensure consents are in place. No other deficiencies were identified. The admission checklist will be revised to emphasize the importance of obtaining consent for any psychotropic medication prior to administration. New orders for psychotropic drugs will be reviewed in MACC Monday  Friday to ensure consent has been obtained. Education will be provided for all LNs and RCMs to ensure compliance. Director of Nursing and/or Designee will be responsible for ongoing compliance. Random audits on 5 residents on psychotropic medications will be conducted weekly x2 and monthly x3. Director of Nursing and/or Designee will submit findings to QAPI meeting x 2 months.

Based on interview and record review it was determined the facility failed to ensure a safe system for a resident's self-administration of medication for 1 of 2 sampled residents (#6) reviewed for care planning. This placed residents at risk for adverse medication reactions. Findings include: Resident 6 admitted to the facility in 2022 with a diagnosis of multiple sclerosis. An 6/25/24 quarterly MDS revealed Resident 6 was cognitively intact. A 3/10/22 Self-Administration of Medication form revealed Resident 6 was assessed to be capable of self-administration of multiple medications. The form also indicated Resident was 6 was not to be left unattended while medication was being administered. A 4/1/24 Self-Administration of Medication form revealed Resident 6 was assessed to be capable of self-administration of Ventolin (respiratory medication) only. On 9/23/24 at 12:56 PM Staff 18 (RN) was observed to leave four unidentified medications at Resident 6's bedside and then left the room. When questioned Staff 18 stated she believed Resident 6 had a medication administration assessment completed that allowed Resident 6 to take her/his medications independently. Staff 18 confirmed she left medications with Resident 6 while she/he was unattended. On 9/24/24 at 2:27 PM staff 27 (CNA) stated in the evenings she observed medications left at Resident 6's bedside while she/he was unattended. On 9/25/24 at 2:31 PM Staff 2 (DNS) was made aware of the details of the medication self administration assessment as well as the observation of medications being left in resident 6's room while she/he was unattended. As of 9/27/24 at 9:57 AM no further information had been provided.

Resident #6 has been evaluated by the interdisciplinary team and has been determined clinically appropriate to self-administer her scheduled oral and inhaled medications after they are delivered to the resident in her room by an LN. Care plan updated to reflect changes. All residents who desire to self-administer medications will be reviewed by IDT to ensure they have the proper evaluations and care plans in place. Education will be provided to all LNs on the rights of medication administration, including the right to self-administer medications when clinically appropriate. They will be education on the proper evaluations and physicians order before medications can be self-administered. Residents identified and evaluated for self -administering medications will be audited x3 weekly then monthly x2 to ensure compliance and safety.

Based on observation, interview and record review it was determined the facility failed to ensure residents were allowed to retain personal possessions for 1 of 1 sampled resident (#9) reviewed for choices. This placed residents at risk for diminished quality of life. Findings include: Resident 9 was admitted to the facility in 7/2024 with diagnoses including Schizoaffective disorder (a mental health condition marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression and mania). Resident 9's 8/6/24 Admission MDS indicated the resident was cognitively intact and did not exhibit any mood symptoms or behaviors. The MDS also indicated it was very important to the resident to take care of her/his personal belongings. On 9/23/24 at 12:15 PM Resident 9 was observed in her/his wheelchair in the dining room. Resident 9 stated she/he wanted to speak with the State Surveyor but wanted Witness 1 (Family Member) to be present for the conversation via her/his cell phone. Resident 9 stated she/he would check out her/his cell phone from the office and then meet in her/his room. On 9/23/24 at 1:05 PM the State Surveyor spoke with Resident 9 in her/his room with Witness 1 available on the resident's cell phone. Resident 9 stated she/he was allowed to have her/his cell phone between the hours of 9:00 AM to 7:00 PM when she/he had to return it to the office. Resident 9 and Witness 1 stated the facility restricted Resident 9's access to her/his cell phone at night since admission. They were told Resident 9 needed to "learn to depend on [the facility]" and felt as if they "could not fight" the restriction. Resident 9 further stated she/he "did not like it and felt upset [she/he] could not call [her/his] mom when [she/he] wanted to." On 9/24/24 at 1:18 PM Staff 22 (CNA) and at 1:30 PM Staff 21 (CNA) stated they did not know why Resident 9 was not allowed to maintain her/his cell phone. On 9/24/24 at 2:33 PM Staff 23 (Enhanced Care Unit Program Supervisor) stated she "would not be surprised if [Resident 9] wanted it [her/his cell phone] all the time." Staff 23 further stated staff were concerned Resident 9's "roommate would take the phone so it was brought into the office to charge." No evidence was found in Resident 9's clinical record to indicate why the resident was not allowed to maintain her/his cell phone. On 9/24/24 at 3:47 PM Staff 1 (Administrator) acknowledged the findings of this investigation and stated she expected residents to be able to maintain their own cell phones unless a behavior care plan was in place to indicate otherwise.

The Guardian (Witness 1) was called on 9/24/24 to change cell phone use plan that was created on admission. A new plan for cell phone use/storage was agreed upon by Guardian, Administrator, CFL and Social Services on 9/24/24. No other residents in the Enhanced Care Unit have a cell phone. The administrator will educate staff of CFL and the Enhanced Care Unit on Residents Right to have access to personal property and the importance of documentation around behavior plans. The Administrator or Designee will audit new admits on the ECU for access to personal property x3 weeks and then monthly x2 months. IDT will review in QAPI to make sure all parties agree of plan and discuss other options around cell phone use on a locked mental health unit. Will continue to review in QAPI x2 months to ensure substantial compliance is met.

Based on interview and record review it was determined the facility failed to ensure residents had access to their personal funds on an ongoing basis for 2 of 2 sampled residents (#s 1 and 9). This placed residents at risk for lack of access to personal funds. Findings include: 1. Resident 1 was admitted to the facility in 10/2017 with diagnoses including borderline personality disorder (a mental disorder characterized by unstable moods, behavior and relationships). Resident 1's 7/18/24 Quarterly MDS indicated the resident was cognitively intact. On 9/24/24 at 9:22 AM Resident 1 stated she/he was only able to access her/his money during the day time. On 9/24/24 at 1:13 PM Staff 22 (CNA) stated if a resident wanted access to their money, she would direct the resident to wait for staff from the CFL (Center for Living, the community mental health program overseeing the facility's enhanced care unit). Staff 22 stated CFL staff were in the facility every day from approximately 9:00 AM to 7:00 PM. On 9/24/24 at 1:24 PM Staff 21 (CNA) stated she "did not deal with any money things" and the "CFL was responsible for dealing with that." Staff 21 stated she told residents who wanted their money, "you have to wait for CFL staff to get here." On 9/24/24 at 2:17 PM Staff 23 (Enhanced Care Unit Program Supervisor) stated "residents did not get their money if CFL staff were not available." On 9/25/24 at 8:44 AM Staff 25 (LPN) stated she did not know how to access resident money when CFL staff were not available. On 9/25/24 at 10:53 AM Staff 1 (Administrator) acknowledged the findings of this investigation. Staff 1 stated residents should have access to their money "all of the time." 2. Resident 9 was admitted to the facility in 7/2024 with diagnoses including Schizoaffective disorder (a mental health condition marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression and mania). Resident 9's 8/6/24 Admission MDS indicated the resident was cognitively intact. On 9/23/24 at 1:03 PM the State Surveyor spoke with Resident 9 in her/his room with Witness 1 (Family Member) available on the resident's cell phone. Resident 9 and Witness 1 stated the resident was not able to access her/his money after 7:00 PM on weekdays and past 4:00 PM on the weekends. On 9/24/24 at 1:13 PM Staff 22 (CNA) stated if a resident wanted access to their money, she would direct the resident to wait for staff from the CFL (Center for Living, the community mental health program overseeing the facility's enhanced care unit). Staff 22 stated CFL staff were in the facility every day from approximately 9:00 AM to 7:00 PM. On 9/24/24 at 1:24 PM Staff 21 (CNA) stated she "did not deal with any money things" and the "CFL was responsible for dealing with that." Staff 21 stated she told residents who wanted their money, "you have to wait for CFL staff to get here." On 9/24/24 at 2:17 PM Staff 23 (Enhanced Care Unit Program Supervisor) stated "residents did not get their money if CFL staff were not available." On 9/25/24 at 8:44 AM Staff 25 (LPN) stated she did not know how to access resident money when CFL staff were not available. On 9/25/24 at 10:53 AM Staff 1 (Administrator) acknowledged the findings of this investigation. Staff 1 stated residents should have access to their money "all of the time."

All residents have access to their funds in the facility. The administrator will educate staff in CFL and those that work on the locked mental health unit, that all residents have access to their funds and the use of Petty Cash at any time. The administrator will educate staff on after-hours access to personal funds and how that is provided for all residents in the facility whether they reside on the locked unit or not. The Administrator or Designee will speak to residents on the unit and audit new admits on the ECU x 2 months, to make sure they are aware of access to funds. IDT will review in QAPI to make sure all parties agree with the plan and discuss best communication practices on a locked mental health unit. Will continue to review in QAPI x2 months to ensure substantial compliance is met.

Based on observation and interview it was determined the facility failed to ensure contact information for pertinent State agencies and the required Long Term Care Ombudsman (LTCO) poster were accessible to residents for 1 of 2 units observed for required postings. This placed residents at risk for lack of information on how to file a complaint or how to report concerns. Findings include: On 9/23/24 at 11:00 AM the required postings to indicate how residents can contact the State Survey Agency, the State licensure office, adult protective services and LTCO were observed in a hallway outside of the facility's locked enhanced care unit (ECU). Neither posting was observed inside the ECU. On 9/25/24 at 3:30 PM Resident 1 stated she/he "had no idea" where to access the contact information for pertinent State agencies or the LTCO and she/he was interested to know this information. Resident 1 stated she/he was unable to leave the ECU without a staff escort. On 9/25/24 at 10:55 AM Staff 1 (Administrator) acknowledged the findings of this investigation and confirmed ECU residents could not access the required postings without staff assistance.

Additional Postings were ordered. Both locked Mental Health Units have a posting for Ombudsman and How to File a complaint on the walls for all residents to access and use as they need. The administrator will educate CFL and staff that work on the locked units about access to these services for the residents. We will discuss as a team how to best support and navigate the postings with residents who have severe mental illness. The administrator or Designee will audit locked units x2 months to make sure residents have access to these postings. IDT will review in QAPI to make sure all parties agree with the plan. Will continue to review in QAPI x2 months to ensure substantial compliance is met.

Based on observation and interview it was determined the facility failed to maintain a homelike environment and adequate hot water temperatures for 1 of 1 facility shower room reviewed for a homelike environment. This placed residents at risk for a cluttered and damaged shower environment as well as cold showers. Findings include: On 9/23/24 at 10:23 AM Resident 32 stated the water in main shower room was too cold. On 9/26/24 at 7:43 AM Resident 100 stated the water would go hot for a bit and then suddenly get cold. On 9/26/24 at 7:01 AM Staff 11 (CNA) stated she started the shower way ahead of time so the water could warm up. Staff 11 stated sometimes the water was too cold. On 9/26/24 at 7:56 AM staff 19 (maintenance director) tested the shower water temp after five or more minutes and it was 87 degrees F. Staff 19 indicated which hot water heater supplied the shower and the temperature gauge read 99 degrees F. On 9/27/24 at 7:26 AM Staff 1 (Administrator) tested the shower water temperature and it reached 94 degrees Fahrenheit. On 9/27/24 at 7:26 AM the main shower room was observed with sections of baseboard missing from the three partition walls on the left side of the shower room leaving exposed unfinished, uncleanable sheetrock. The partition wall furthest from the door had significant chunks and gouges near the base. The ceiling above the non-functioning side of the shower room appeared torn and potentially damaged by water. The vent above the non-functioning shower was observed to be dirty and the light bulb was exposed. The drain cover was also missing in the functional shower resulting in an approximately three inch hole in the floor and was a potential source of injury. 09/27/24 10:17 AM Staff 1 (Administrator) confirmed the damage and un-homelike state of the shower room as well as the hot water temperatures being out of the aceptable range.

Drain cover was replaced in shower room. Baseboard area is to be re-tiled with an additional secondary protection layer for metal lift legs to not chip it away. Curtains will be installed to place supplies and lifts behind and keep the shower room home-like. The temperature has been turned up to shower room. Ceiling/vent area on unused side of shower cleaned up and fixed. Administrator will education staff on home  like environment of shower room. Administrator or Designee will audit shower room for home-like atmosphere and cleanliness x3 weeks then monthly x 2 months. Administrator or Designee will audit shower temperature of shower room and other random 400 hall rooms x3 weeks then monthly x2 months. IDT will review in QAPI to make sure all parties agree with the plan. Will continue to review in QAPI x2 months to ensure substantial compliance is met.

Based on interview and record review it was determined the facility failed to ensure a PASARR Level II (Preadmission Screening for individuals with a mental disorder and/or individuals with intellectual disability) was completed for 2 of 2 sampled residents (#s 9 and 26) reviewed for PASARR. This placed residents at risk for not receiving specialized services. Findings include: The facility's 9/2024 PASARR Policy and Procedure directed the following: -If a Level II evaluation was indicated, the social worker would ensure a LMPH (licensed mental health professional) was scheduled to evaluate within a timely period. -If there was a significant change of condition that could affect a resident's diagnosed need for a PASARR Level II, staff should refer for a new PASARR Level II. -Follow up as needed per federal PASARR rules. 1. Resident 9 was admitted to the facility in 7/2024 with diagnoses including Schizoaffective disorder (a mental health condition marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression and mania) and cerebral palsy (a group of conditions that affect movement and posture and caused by damage that occurs to the developing brain, most often before birth). Resident 9's 7/31/24 PASARR Level I indicated the resident experienced indicators of both serious mental illness and a developmental disability. A review of Resident 9's Social Service Notes from 8/1/24 through 8/13/24 revealed a PASARR Level II was requested to address the resident's indicators of developmental disability but not her/his indicators of serious mental illness. On 9/25/24 at 9:39 AM Staff 4 (Social Services Director) stated PASARR Level IIs for serious mental illness were completed by the Center for Life (CFL), the organization who managed the facility's enhanced care unit, and she was not sure why the PASARR Level II for Resident 9 for her/his diagnosed serious mental illness had not been completed. On 9/25/24 at 10:56 AM Staff 1 (Administrator) acknowledged the findings of this investigation and provided no additional information. 2. Resident 26 was admitted to the facility in 1/2021 with diagnoses including anxiety and depression. Resident 26's 1/21/21 PASARR Level I indicated the resident did not have indicators of either serious mental illness or a developmental disability. A 6/21/23 PASARR Level II revealed Staff 4 (Social Services Director) requested a Level II evaluation for Resident 26 as the resident experienced a dramatic increase in paranoid delusions. A review of Resident 26's clinical record revealed the resident was hospitalized from 3/3/24 to 3/6/24. Resident 26 readmitted to the facility with a new PASARR Level I which indicated the resident had indicators of serious mental illness. No evidence was found in Resident 26's clinical record to indicate an additional PASARR Level II was requested to address the resident's new onset of serious mental illness indicators. On 9/26/24 at 3:47 PM Staff 4 (Social Services Director) stated Resident 26 was not physically aggressive in 6/2023 when the resident received her/his initial PASARR Level II. Staff 4 stated the resident had experienced a significant change of condition in 3/2024 on account of worsening behaviors and she should have requested an additional PASARR Level II following the resident's hospitalization but she did not. On 9/27/24 at 9:37 AM Staff 1 (Administrator) was informed of the findings and provided no additional information.

Resident 9s PASARR level II has been requested for SMI and DD, Social Service Director is following up on status every week and documenting in residents chart, until complete. Resident 26 PASARR level II has been requested. The Social Service Director will follow up weekly and document attempts in residents chart, until complete. CFL and new PASRR level II coordinator had an education on PASARR level IIs. Education on the process and how they should be carried out was provided. Administrator, DNS and Social Service Director met to educate each other and discuss in house process and documentation to support efforts made for completion. All PASARR level II requests in house are being followed up on and documented weekly. The Administrator or Designee will audit new admits weekly x3 then monthly x2 months for proper PASRRs and timely PASRR level II evaluations. IDT will review in QAPI to make sure all parties agree with the plan. Will continue to review in QAPI x2 months to ensure substantial compliance is met.

Based on observation, interview, and record review it was determined the facility failed to ensure care plans were revised to accurately to reflect the needs of residents for 2 of 4 sampled residents (#s 14 and 35) reviewed for weights and assistive devices. This placed residents at risk for unmet needs. Findings include: 1. Resident 14 was admitted to the facility in 6/2020 with diagnoses including dementia and parkinsonism (difficulty with movement). Resident 14's 7/2/24 Annual MDS revealed the resident was moderately cognitively impaired. A Care Plan dated 7/11/24 revealed Resident 14 used a mobility bar on the left side of the bed for inhanced bed mobility. Observations from 9/23/24 through 9/27/24 revealed Resident 14 did not have a mobility bar in place while the resident was in bed. On 9/26/24 at 9:51 AM Staff 11 (CNA) stated Resident 14 should have a bed mobility bar on her/his bed to help her/him with positioning while in bed. On 9/26/24 at 10:59 AM Staff 9 (LPN Resident Care Manager) stated Resident 14 had a mobility bed assist rail on her/his bed to assist with positioning and movement. On 9/27/24 at 9:10 AM Staff 2 (DNS) confirmed Resident 14's care plan had not been updated to reflect the resident no longer needed the mobility bar. 2. Resident 35 was admitted to the facility in 3/2023 with diagnoses including delusional disorders, depression and edema. Resident 35's Quarterly MDS revealed the resident was cognitively intact. A Care Plan dated 9/21/24 revealed Resident 35 used bilateral 1/4 inch rails on her/his bed due to a self-performance deficit. Observations from 9/23/24 through 9/27/24 revealed Resident 35 did not have bilateral 1/4 inch rails on her/his bed while the resident was in bed. On 9/24/24 at 3:01 PM Staff 24 (CNA) stated Resident 35 did not use any bed mobility devices. On 9/24/24 at 3:31 PM Staff 5 (RNCM) stated Resident 35 did not use bilateral bars and stated the care plan had not been updated. On 9/27/24 at 9:10 AM Staff 2 (DNS) confirmed Resident 35's care plan had not been updated to reflect the resident no longer needed the bilateral 1/4 inch rails while in bed. 3. Resident 35 was admitted to the facility in 3/2023 with diagnoses including delusional disorders, depression and edema. A Care Plan dated 9/21/24 revealed Resident 35 was to have her/his weight obtained daily due to diuretic therapy from edema. Resident 35's Quarterly MDS revealed the resident was cognitively intact. Review of Resident 35's clinical record revealed a 4/5/24 physician order for the resident to be weighed weekly. On 9/24/24 at 3:01 PM Staff 24 (CNA) stated Resident 35 was to be weighed everyday in the mornings. On 9/24/24 at 3:31 PM Staff 5 acknowledged Resident 35's care plan had not been revised to reflect Resident 35 was to be weighed weekly. On 9/24/24 at 3:52 PM Staff 2 (DNS) was informed of the findings. No additional information was provided.

Resident #14 re-assessed for mobility bars. Resident and IDT determined that mobility bars on both sides of the bed were appropriate to enhance bed positioning and movement. Mobility bars placed and care plan updated to reflect change. Resident #35 re-assessed for mobility bars. Resident and IDT determined that resident will not benefit from bilateral mobility bars. Care plan updated to reflect current status. Resident #35s MD orders and current weights reviewed with IDT, including provider. Assessment revealed appropriate weight frequency to be once weekly. Care plan and CNA tasks updated to reflect current orders. All residents will be audited to ensure that mobility bars are in place where appropriate and are reflected in the care plan. All residents will be audited to ensure that they are scheduled, and care planned to be weighed on appropriate schedules. Education will be provided to Resident Care Managers and LNs regarding the need for proper assessment and care planning regarding the use of mobility bars and weight schedules and keeping these records and tasks up to date. Director of Nursing or Designee will randomly audit 2 residents/week x3 weeks and monthly x 2 to ensure care plans and assessments for mobility bars and weight schedules are accurate.

Based on observation, interview and record review it was determined the facility failed to provide an on-going program to support individual activity interests and preferences for 1 of 2 sampled residents (#25) reviewed for activities. This placed residents at risk for lack of social interaction and isolation. Findings include: The facility's 3/2019 Activities Policy and Procedure indicated the following: -Each resident's physical, mental, spiritual, psychosocial and leisure choices as well as preferences for participation in activities will be assessed. This assessment will occur on admission, annually and with condition changes. -A monthly calendar shall be posted in designated areas of the facility. The scheduled activities will be planned at an appropriate frequency to provide diverse activity/recreational programs that address various cognitive and functional levels and meet the needs of the residents. Resident 25 was admitted to the facility in 1/2021 with a diagnoses including dementia and depression. Resident 25's 1/17/24 Annual MDS indicated the resident experienced short and long term memory loss, was severely impaired for decision making and her/his activity preferences were listening to music, doing things with groups of people, participating in favorite activities and spending time outdoors. The 3/28/24 Care Plan indicated the following: -Resident 25 was dependent on staff to meet emotional, intellectual, physical and social needs, dementia and physical limitations. -The resident's activity goal was to attend/participate in activities of choice 2-4 times weekly by next review date. -Ensure the activities the resident is attending are compatible with known interests and preferences. -Ensure the activities the resident is attending are compatible with individual needs and abilities. -Introduce the resident to residents with similar background, interests and encourage/facilitate interaction. -The resident needs one-to-one bedside/in-room visits and activities if unable to attend out of room events. A review of the facility's Activity Logs from 8/26/24 through 9/25/24 indicated Resident 25 received four one-to-one activities and did not participate in any group activities. Random observations of Resident 25 from 9/23/24 through 9/26/24 from 9:13 AM to 2:50 PM revealed the resident to be either in bed or in his/her wheelchair at the nurses station or in his/her room. No music was observed to play in the resident's room or at the nurses station. On 9/25/24 at 2:45 PM Staff 26 (CNA) stated Resident 25 was non-verbal, did not participate in activities and spent her/his day either sitting at the nurses station or sleeping in her/his room. On 9/26/24 at 9:28 AM Staff 11 (CNA) stated Resident 25 was non-verbal and was unable to make choices about activities or her/his rountine. Staff 11 stated the resident was "in her/his room a lot" and they were unaware of any activity interests outside of music. On 9/25/24 at 3:06 PM and 9/26/24 at 4:28 PM Staff 7 (Activities Director) indicated Resident 25 was non-verbal and unable to make activity choices. Staff 7 stated he did "not do much one-on-one activites with the resident" and was unable to articulate the resident's favorite activities outside of listening to music. Staff 7 stated he attempted a sensory mat with the resident at one point but had not attempted any additional sensory activities. On 9/27/24 at 10:04 AM Staff 1 (Administrator) acknowledged the findings of this investigation and did not provide any additional information.

Resident 25 has passed away since survey. The administrator will educate activity staff on care planning appropriate/resident focused activities, offering care planned activities and documenting all activities on logs. The Administrator or Designee will perform random audits on 2 residents care plans and activity logs x3 weeks, then monthly x2 months. IDT will review in QAPI to make sure all parties agree with the plan. Will continue to review in QAPI x2 months to ensure substantial compliance is met.

Based on interview and record review it was determined the facility failed to provide care in accordance with care planned interventions while transferring residents for 1 of 1 sampled resident (#31) reviewed for accidents. This failure resulted in avoidable skin tears to Resident 31's right arm. Findings include: Resident 31 was admitted to the facility in 9/2023 with diagnoses including stroke and kidney failure. Resident 31's Quarterly MDS dated 6/24/24 indicated the resident was moderately impaired in cognition. Resident 31's Care Plan dated 10/3/23 identified the resident was at risk for falls due to muscle weakness. Interventions on the care plan included: Two-person transfers with a hoyer lift, staff were to anticipate the resident's needs and to keep the call light and personal items within reach. A 12/6/23 Facility Reported Incident indicated Resident 31 was provided care by Staff 11 (CNA) and Staff 15 (CNA) during a transfer from bed to her/his wheelchair and sustained two skin tears to her/his right forearm. Staff 11 reported the injury happened while they assisted the resident with a transfer. Staff 18 (RN) assessed the resident and cleaned the skin tears which measured 1.5 cm each, and were horseshoe shaped. On 9/26/24 at 10:02 AM Staff 11 stated she recalled the incident on 12/5/23 when she was assisting Resident 31 with a transfer. Staff 11 stated she was not familiar with Resident 31 and the incident happened very quickly. Staff 11 acknowledged Resident 31 required two-person hoyer assistance with transfers and the care plan was not followed. On 9/26/24 at 5:16 PM Staff 2 (DNS) stated Resident 31 required two-person assistance with a hoyer for transfers at the time of the incident. Staff 2 stated the care plan was not followed by Staff 11 and Staff 15, a hoyer lift should have been used for the transfer. Staff 2 stated it was her expectation the care plans were always followed.

Resident #31 sustained two skin tears during a Facility Reported Incident on 12/6/23 while being transferred. The residents plan of care was not followed by the CNAs participating in the transfer, and Hoyer lift was not used as indicated. Immediate education regarding the expectation for the care plans to be followed at all times was provided to CNA staff on duty. All residents will have care plans reviewed for transfer status and CNA adherence to care plan. Any deficiencies will be immediately remedied with care plan updates, education, and discipline if necessary. Education provided to CNAs regarding the importance of confirming and following care plans during transfer. RCMs educated on importance of keeping transfer care plans up to date and monitoring for CNA adherence with transfers. Director of Nursing or Designee to randomly audit 3 resident transfers weekly x 3, then monthly x 2 to monitor for CNA compliance with transfer care plans. Data to be presented at QAPI x 2 months.

Based on observation, interview and record review it was determined the facility failed to ensure residents who were trauma survivors received trauma-informed care for 1 of 2 sampled residents (#1) reviewed for mood. This placed residents at risk for re-traumatization and decreased quality of life. Findings include: Resident 1 was admitted to the facility in 10/2017 with diagnoses including borderline personality disorder (a mental disorder characterized by unstable moods, behavior and relationships). The National Institute of Mental Health (NIMH) website section titled "Borderline Personality Disorder" indicated genetic, environmental and social factors may increase a person's risk of developing borderline personality disorder, and many people with borderline personality disorder report experiencing traumatic life events, such as abuse, abandonment or hardship during childhood. Resident 1's 7/18/24 Quarterly MDS indicated the resident was cognitively intact. On 9/24/24 at 9:17 AM Resident 1 was observed in her/his room in her/his wheelchair. Resident 1 stated she/he had a history of trauma as she/he "was abused as a child and teenage years." Resident 1 stated she/he was diagnosed with "multiple personality disorder about 10 years ago," and some of her/his personalities were "not nice" and "still hurt [her/him]." No evidence was found in Resident 1's clinical record to indicate the resident's past history of trauma and/or triggers which could cause re-traumatization were identified or assessed. On 9/25/24 at 9:50 AM and 10:16 AM Staff 4 (Social Services Director) stated she screened residents for trauma and developed care plans for those residents who indicated they experienced trauma, which included possible triggers for re-traumatization. Staff 4 stated she did not have any documentation to indicate Resident 1 was ever screened for trauma. On 9/25/24 at 11:02 AM Staff 1 (Administrator) acknowledged the findings of this investigation and did not provide any additional information.

Resident 1 had a trauma informed care interview completed, and care plan has been updated to reflect potential triggers in care provided. All residents audited to make sure trauma informed care interview has occurred and care planned appropriately. Administrator will educate Social Services, DNS, and RCMs on the importance of trauma informed care and documentation in the care record for care staff to follow. Administrator or Designee will audit all new admits x 3 weeks and monthly x2 months to make sure these interviews are occurring, and care planned appropriately. IDT will review in QAPI to make sure all parties agree with the plan. Will continue to review in QAPI x2 months to ensure substantial compliance is met.

Based on observation and interview it was determined the facility failed to ensure medications and biologicals were secured and accessible only to authorized personnel for 1 of 1 facility observed for secure medication and treatment carts. This placed residents at risk for misappropriation of medications and adverse medication consequences. Findings include: The facility Medication Storage Policy dated 1/2024 stated: "In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications (such as medication aides) are allowed access to medication carts. Medication rooms, cabinets and medication supplies should remain locked when not in use or attended by persons with authorized access." On 9/23/24 at 1:27 PM the treatment cart near the 300 hall was unlocked and unattended by staff. On 9/23/24 at 1:32 PM Staff 2 (DNS) confirmed the cart was left unlocked and unattended. On 9/26/24 at 1:19 PM the medication cart on the 500 hall was unlocked and unattended by staff. On 9/26/24 at 1:23 PM Staff 10 (LPN) confirmed the cart was left unlocked and unattended by staff. On 9/26/24 at 1:32 PM Staff 2 stated it was her expectation for the medication and treatment carts to remain locked when unattended.

Treatment cart near 300 hall was immediately locked upon discovery of deficiency. Medication cart on 500 hall was immediately locked upon discovery of deficiency. All medication and treatment carts throughout facility were checked and observed locked at time deficiencies were reported. No other deficiencies were noted. Education to be provided to all LNs on dangers of leaving carts unlocked, and the importance of safe medication handling at all times. Director of Nursing or Designee will round building at random times Monday  Friday x 3 weeks, then monthly x2 months to ensure compliance.

Based on observation, interview, and record review it was determined the facility failed to store foods at appropriate temperatures for 1 of 3 kitchen refrigerators reviewed for food safety. The facility's failure was determined to be an immediate jeopardy situation because raw meat stored outside of an acceptable temperature was planned to be used for an upcoming meal. Findings include: According to the U.S. Food and Drug Administration's Food Code 2022, (Chapter 3, Section 501.13), "food shall be thawed under refrigeration that maintains the food temperature at 41 degrees F or less." Chapter 3, Section 501.13 goes on to say, "improper thawing provides an opportunity for surviving bacteria to grow to harmful numbers and/or produce toxins." On 9/23/24 at 10:24 AM an initial inspection of the kitchen was performed. During this inspection an internal refrigerator thermometer read 45 degrees F. This refrigerator contained uncooked meat thawing, bacon, various salad dressings, cooked ham, cooked pulled pork, salami, pasteurized eggs, pasteurized cheeses and butter. On 9/25/24 at 11:20 AM the same refrigerator was inspected and the internal thermometer read 49 degrees F. This refrigerator contained the same items observed on 9/23/24 as well as uncooked beef being thawed. On 9/25/24 at 11:20 AM Staff 8 (Dietary Director) stated the fridge had problems staying cool for a few weeks. Staff 8 stated she thought this was either due to the location of the fridge or due to a problem with the door not fully closing and staying closed. Information was provided to Staff 8 regarding the temperature being at 49 degrees F and no action was taken by Staff 8. On 9/26/24 at 8:53 AM the Refrigerator Temperature Log for 9/2024 was reviewed and contained the following information: - 9/1: 50 F at 6:00 PM, - 9/2: 42 F at 6:00 PM, - 9/4: 43 F at 6:00 PM, - 9/5: 44 F at 6:00 PM, - 9/6: 46 F at 6:00 PM, - 9/7: 47 F at 6:00 PM, - 9/10: 42 F at 6:00 PM, - 9/15: 46 F at 6:00 PM, - 9/18: 43 F at 7:00 AM, - 9/18: 42 F at 6:00 PM, - 9/19: 42 F at 6:00 PM, - 9/22: 42 F at 9:00 AM, - 9/22: 42 F at 3:00 PM, - 9/23: 42 F at 7:00 AM, - 9/23: 43 F at 7:00 PM and - 9/24: 43 F at 2:00 PM. On 9/26/24 at 10:54 AM Staff 8 repeated she thought the problem was just the door not fully closing and checked to ensure the door was fully closed. Staff 8 repeated previous information about the refrigerator having had problems for a few weeks and added Staff 19 (Maintenance Director) was "maybe notified about it." Records of this notification were requested, but no records were provided. On 9/26/24 at 10:54 AM Staff 8 was requested to check the temperature of the uncooked beef which was observed to be 41.3 degrees F. No action was taken by Staff 8 after the temperature check. On 9/26/24 at 11:05 AM Staff 19 stated he had not been informed of the refrigerator temperatures being outside of the acceptable range until 9/26/24. On 9/26/24 at 1:20 PM Staff 8 was requested to check the temperature of the uncooked beef which was found to be at 42.9 degrees F with one thermometer. To ensure temperature accuracy, a second thermometer was used which read 42.6 degrees F. Staff 8 stated the uncooked beef had been in the fridge to thaw since 9/24/24. Staff 8 said she had planned on cooking the beef on 9/27/24 but then said, "I guess I'll do it tonight." On 9/26/24 at 2:44 PM the facility was notified of the Immediate Jeopardy (IJ) situation beginning 9/1/24 and an immediacy removal plan was requested. On 9/26/24 at 4:44 PM the facility submitted an acceptable immediacy removal plan which would abate the IJ situation. The immediacy removal plan included the following: - No foodborne illness had been identified. - All food was removed from the refrigerator and disposed. - The refrigerator was taken out of service. - New foods would be purchased to serve to residents. - All kitchen refrigerators would be checked for correct temperatures - The Administrator would educate the Dietary Manager and all dietary staff on 9/26/24 on the importance of refrigerator temperatures and action that should occur immediately with any food temperature concerns. Education would include storage, thawing, cooking and danger zone temperatures as well as when to dispose of any food that is in question. If dietary staff does not answer, they will be educated prior to their shift. - The Administrator would educate maintenance on the importance of placing a malfunctioning refrigerator out of service and action that should occur immediately with any food temperature concerns. - The Administrator of designee would audit refrigerator temperature logs daily for one week, then weekly for three weeks and then monthly for two months. - The findings would be brought to QAPI (Quality Assurance and Performance Improvement) for two months to ensure substantial compliance is met. - The Administrator would be responsible to ensure compliance. On 9/27/24 at 10:03 AM it was determined through observations, staff interviews and review of the facility documentation all aspects of the plan of correction were implemented and completed.

No foodborne illness has been identified  24-hour report run on all residents at 9AM on 9/26/24, no s/sx of any foodborne illness noted or reported. All food was immediately removed from the refrigerator not holding temperature, after Administrator was informed at 3:15 PM on 9/26/24. All food that was removed was disposed of in trash receptacles. Fridge was taken out of service immediately after Administrator was informed at 3:15PM on 9/26/24. New food will be purchased to serve to residents. All kitchen refrigerators will be checked for the correct temperature today 9/26/24, and logs will be reviewed today 9/26/24. Administrator will educate Dietary Manger and all dietary staff today 9/26/24 on importance of refrigerator temperatures and action that should occur immediately with any food temperature concerns. Education will include storage, thawing, cooking and danger zone temperatures as well as when to dispose of any food that is in question. If dietary staff does not answer, they will be educated prior to their next shift. Administrator will educate Maintenance on importance of placing a malfunctioning refrigerator out of service and action that should occur immediately with any food temperature concerns today 9/26/24. Administrator or Designee will audit refrigerator temperature logs daily x1 week, weekly x3 weeks and monthly x2 months. Random interview of dietary staff on proper procedure for refrigerator temps. 3 staff per week x2weeks and 3 staff monthly x2 months. IDT will review in QAPI to ensure all parties are aware and in agreement of plan. Will continue to review in QAPI x2 months to ensure substantial compliance is met. Administrator is responsible to ensure compliance.

Based on observation and interview it was determined the facility failed to ensure sanitary laundry services were provided for 2 of 6 halls reviewed for infection control. This placed residents at risk for cross contamination. Findings include: On 9/24/24 at 12:57 PM and at 1:10 PM Staff 20 (Laundry Services) was observed to deliver clean resident clothing throughout the 400 and 500 Halls and used a small uncovered laundry cart. The laundry cart was left unattended while Staff 20 delivered resident clothing from room to room. On 9/27/24 at 10:02 AM Staff 1 (Administrator) acknowledged that clean resident clothing should be covered while being delivered.

Laundry personnel changes have been made and all staff that work in Laundry have been educated on the importance of infection control and covering clean laundry in hallways. Administrator or Designee will perform random audits on laundry delivery x3 weeks and monthly x2months. IDT will review in QAPI to make sure all parties agree with the plan. Will continue to review in QAPI x2 months to ensure substantial compliance is met.

******************** 411-085-0310 Residents' Rights: Generally Refer to F552 and F557 ******************** 411-086-0260 Pharmaceutical Services Refer to F554 and F761 ******************** 411-085-0350 Residents' Rights: Personal Funds Refer to F567 ******************** 411-085-0030 Required Postings Refer to F575 ******************** 584 411-087-0100 Physical Environment: Generally Refer to F584 ******************** 411-086-0240 Social Services Refer to F645 and F699 ******************** 411-086-0060 Comprehensive Assessment and Care Plan Refer to F657 ******************** 411-086-0230 Activity Services Refer to F679 ******************** 411-086-0140 Nursing Services: Problem Resolution & Preventive Care Refer to F689 ******************** 411-086-0250 Dietary Services Refer to F812 ******************** 411-087-0230 Laundry Services Refer to F880 ********************

Based on observation, interview and record review it was determined the facility failed to protect the resident's right to be free from physical abuse by another resident for 1 of 3 sampled residents (#101) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 101 was admitted to the facility in 7/2020 with diagnoses including alcohol-induced dementia. Resident 101's 3/18/22 Quarterly MDS indicated the resident was cognitively intact. Resident 100 was admitted to the facility in 7/2021 with diagnoses including Lewy body dementia (a brain disorder that can lead to problems with thinking, movement, behavior and mood). Resident 100's 8/8/21 Behavior Care Plan revealed the following: -The resident experienced agitation and aggression. -Staff were to intervene as necessary to protect the rights and safety of others. Resident 100's 2/4/22 Quarterly MDS indicated the resident was severely cognitively impaired and was able to walk independently. A 4/2/22 FRI and Investigation revealed the following: -Staff 3 (Admission Director) heard yelling and cursing coming from Resident 100 and 101's shared room. -Staff 3 entered the room and observed Resident 101 on the ground. Resident 100 stood over Resident 101. -Resident 100 stated she/he hit Resident 101 in the face because the resident "stole [her/his] shorts and food." -Resident 101 stated Resident 100 slapped her/him in the face which caused her/him to fall to the ground. -Staff 5 (RN) entered the room and separated the residents. On 6/18/24 at 9:52 AM Staff 5 stated Resident 100 could be pleasant at times but angry and verbally aggressive at others. Staff 5 stated Resident 100 would "yell and cuss" at other residents. Staff 5 stated he was the nurse on duty when the altercation between Residents 100 and 101 occurred on 4/2/22. Staff 5 stated he recalled Resident 100 standing over Resident 101 with an angry look on her/his face and Resident 101 "appeared shocked." On 6/18/24 at 10:46 AM Resident 101 was observed in her/his room in bed. Resident 101 stated she/he felt safe at the facility. Resident 101 was unable to recall any details about the incident that occurred on 4/2/22 and did not remember Resident 100. On 6/18/24 at 10:50 AM Resident 100 was observed to sit in her/his wheelchair in the doorway of her/his room. Resident 100 was unable to recall any details about the incident. On 6/18/24 at 12:03 PM Staff 2 (Social Services Director) stated she spoke with Resident 100 on 4/2/22 following the altercation and Resident 100 confirmed she/he hit Resident 101 because she/he thought the resident was a classmate and was going through her/his belongings. Staff 2 stated Resident 101 was "shook up in the moment" following the altercation but had forgotten about the altercation not long after it occurred because the resident's "short term memory was so poor." On 6/18/24 at 12:45 PM Staff 3 stated she entered Resident 100 and 101's room on 4/2/22 because she heard yelling. Staff 3 stated when she arrived in the room, Resident 100 stood over Resident 101 who was on the ground. Staff 3 stated she helped remove Resident 100 from the room and stated Resident 101 "was very scared after the incident." On 6/18/24 at 3:02 PM Staff 1 (Administrator) confirmed Resident 100 hit Resident 101 on 4/2/22.

Residents 100 and 101 were separated and remain in different rooms, with no further incidents. Residents 100 and 101 do not remember the incident and do not have any long-term effects. The Director of Nursing or Designee reviewed cognitively impaired residents with behaviors in house to make sure all appropriate interventions are in place to match their physical abilities. The Director of Nursing or Designee will educate nursing staff on monitoring and addressing aggressive behaviors and implementing interventions that match one’s physical capabilities to prevent abuse. The Director of Nursing or Designee will audit new admits for cognitive impairment, behaviors and physical abilities for x3 weeks and then monthly x2 months. The Director of Nursing or Designee will report these audits at the facility monthly QAPI meeting for 60 days or until substantial compliance has been achieved or sustained as determined by the committee. The Director of Nursing is responsible to ensure compliance.

Based on interview and record review it was determined the facility failed to ensure adequate supervision and a safe environment for 1 of 3 sampled residents (#100) reviewed for elopement. This placed residents at risk for injury from accidents. Findings include: Resident 100 was admitted to the facility in 7/2021 with diagnoses including Lewy body dementia (a brain disorder that can lead to problems with thinking, movement, behavior and mood). Resident 100's 7/29/21 At Risk for Falls and ADL Care Plans revealed the following: -The resident was considered at high risk of falling. -The resident ambulated independently in the facility. -The resident used a front wheeled walker when ambulating on uneven surfaces. Resident 100's 3/17/22 Elopement Risk/Wanderer Care Plan revealed the following: -The resident was considered at risk to elope. -The resident wore a Wanderguard (a monitoring device that allows an alarm to be activated when a person attempts to leave a safe area). -The resident required frequent checks during routine rounds due to her/his dementia, independence with mobility and exit-seeking behaviors. -Staff were to distract the resident from wandering. Resident 100's 10/28/22 Social Service Quarterly Assessment revealed the resident would regularly exit-seek and got frustrated when staff did not open the doors and let her/him outside. Resident 100's 11/5/22 Quarterly MDS revealed the resident was severely cognitively impaired, exhibited wandering and experienced a fall with injury since her/his prior assessment. Resident 100's 11/15/22 Morse Fall Scale indicated the resident was at high risk of falling. Resident 100's 11/15/22 Elopement Risk Evaluation indicated the resident was at high risk to wander/elope. An 11/30/22 Incident Report and Summary revealed the following: -Resident 100 was near the front door to the facility when a UPS (United Parcel Service) driver entered the facility. -The UPS driver dropped off parcels and exited the facility. Resident 100 followed the driver outside of the facility. -An unidentified nurse called out to Resident 100, requesting she/he return to the facility. -Resident 100 stepped on a snow-covered sidewalk and fell on her/his left side. -Resident 100 was assisted into a wheelchair and quickly returned to the facility. -Resident 100 experienced pain in her/his left hip and left arm following the fall. On 6/18/24 at 9:52 AM Staff 5 (RN) stated Resident 100 "consistently hung out by the front door and repeatedly asked to go outside." Staff 5 stated Resident 100 had a Wanderguard on her/his ankle, and he would hear the alarm frequently going off because the resident was by the front or back door. On 6/18/22 at 3:22 PM Staff 1 (Administrator) stated Resident 100 had a Wanderguard due to "a lot of exit-seeking behaviors." Staff 1 stated Resident 100 was constantly at the doors, trying to get out of the facility. Staff 1 stated Resident 100 was "was nice and would make friends with people who would hold the door open for [her/him]." Staff 1 stated on 11/30/22 the weather conditions included snow and ice and acknowledged Resident 100 exited the facility behind a UPS driver and fell.

Signs are up for the entry/exit door to remind visitors to check with staff before allowing a resident to go outside and to make sure doors are always closed. Resident 100 was never out of the line of sight of staff. Resident 100 is no longer able to self-ambulate and is considered low risk for elopement. The Director of Nursing or Designee reviewed residents at risk for elopement in house to make sure appropriate interventions for supervision are in place. The Director of Nursing or Designee will educate facility staff on elopement risks, and supervision. The Director of Nursing or Designee will audit new admits for elopement risk, as well as newly identified elopement behaviors and the level of supervision needed due to physical abilities for x3 weeks and then monthly x2months. The Director of Nursing or Designee will report these audits at the facility monthly QAPI meeting for 60 days or until substantial compliance has been achieved or sustained as determined by the committee. The Director of Nursing is responsible to ensure compliance.

**************************** OAR 411-085-0310: Abuse Refer to F600. **************************** OAR 411-086-0140: Nursing Services: Problem Resolution and Prevention Care Refer to F689. ****************************

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 06/05/2023 and 06/11/2023, 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 07/04/2022 and 07/10/2022, 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 interview and record review it was determined the facility failed to ensure residents were free from significant medication errors for 4 of 4 (#s 3, 4, 6, and 7) sampled residents reviewed for medication errors. This placed residents at risk for adverse medication side effects. Findings include: 1. Resident 3 admitted to the facility in 2019 with diagnoses including diabetes. The 5/2021 physician order directed staff to administer Resident 3 Lantus Solution (long acting insulin) 100 UNIT/ML, inject 25 unit subcutaneously (under skin) in the evening and a Novolog Solution (short acting insulin) 100 UNIT/ML, inject as per sliding scale: if CBG 145 - 200 = 1 unit; CBG 201 - 250 = 2 units; CBG 251 - 300 = 3 units; CBG 301 - 350 = 4 units; CBG 351 - 400 = 5 units; 401+ = 6 units, CBG greater than 400 call physician, subcutaneously two times a day. A 5/1/21 progress note by Staff 4 (LPN), revealed Resident 3 was sent to the hospital emergency room to be monitored for an administration of a 25 unit dose of Novolog by Staff 4. Staff 8's (Nurse Practitioner) late entry 5/6/21 progress note revealed Resident 3 spent the night in the hospital due to hypoglycemia (low blood sugar) after receiving 25 units of Novolog instead of Lantus with her/his evening meal. At the hospital, was closely monitored until insulin wore off and returned to the facility. Resident 3 stated other than the inconvenienced, she/he felt completely normal and had no residual (remaining after) effect. Staff 8 assessed Resident 3 with no residual effects or outcome from the hospital admission for the insulin. In an interview on 12/14/21 at 8:31 PM, Staff 4 confirmed she administered insulin to Resident 3 on the evening of 5/1/21. On 12/15/21 at 4:00 PM, Staff 1 (Administrator) confirmed the medication error occurred for Resident 3 on 5/1/21. Staff 1 acknowledged Resident 3 had no adverse effects from this error. 2. Resident 4 admitted to the facility in 2014 with diagnoses including dementia and diabetes. A 6/28/21 physician order by Staff 8 (Nurse Practitioner) ordered Resident 4 Morphine (pain) 20 mg/mL concentrated liquid, and to take 1 mL by mouth, every hour as needed, for pain or air hunger (shortness of breath). Resident 4's 7/2021 MAR revealed a physician order for Morphine Sulfate Solution 20 MG/5 ML, give 0.5 ml by mouth as needed for pain or air hunger Resident 4's 7/4/21 at 8:46 PM MAR, indicated Staff 5 (LPN) administered Morphine Sulfate Solution 20 MG/5 ML, give 0.5 ml by mouth. Resident 4's 7/5/21 at 3:05 AM MAR indicated Staff 5 administered Morphine Sulfate Solution 20 MG/5 ML, give 0.5 ml by mouth. The 7/5/21 FRI revealed the morphine order was incorrectly entered into the MAR. The order faxed from the pharmacy was for morphine 20 mg/ml, give PO every two hours and the dose was entered for Morphine 20 mg/5 ml give 0.5 PO every two hours. The resident received 50 mg of Morphine instead of 10 mg of Morphine. On 12/14/21 at 8:01 PM, Staff 5 stated she administered Resident 4's morphine, according to the MAR, due to air hunger and pain. Staff 5 acknowledged these orders for morphine were clarified with Staff 8 after administration. Staff 5 stated she assessed Resident 4 after the first dose of Morphine and documented the Morphine as ineffective and administered another dose. She stated the resident continued to be monitored with no significant side effects assessed from the Morphine. On 12/15/21 at 4:00 PM, Staff 1 (Administrator) confirmed the medication error for Resident 4 on 7/4/21 and 7/5/21 occurred. 3. Resident 6 admitted to the facility in 11/2016 with diagnoses including vascular dementia and atrial fibrillation (irregular heartbeat). Resident 6's 11/2021 physician orders included orders for warfarin (anticoagulant medication) two mg every evening 11/1/21 through 11/7/21, recheck the INR (blood test to determine how fast the blood clots) on 11/7/21 night shift and fax the results to the PCP. An 11/8/21 progress note written by Staff 2 (DNS) indicated the following: "INR checked this morning . . . current dose is . . . 2 mg Monday through Sunday. Report to day [nurse], awaiting orders from [nurse practitioner]." An 11/8/21 FRI indicated Resident 6 did not receive a dose of warfarin on 11/9/21. Resident 6's 11/2021 MAR revealed no warfarin administration on Monday 11/8/21 and Tuesday 11/9/21, a total of two days without warfarin. An 11/10/21 progress note written by Staff 6 (RN) indicated there was no new warfarin order, Staff 2 and Staff 8 (Nurse Practitioner) were notified regarding the missed doses and new orders were requested. On 12/15/21 at 4:00 PM, Staff 2 confirmed the medication error for Resident 6's missed doses of her/his warfarin medication. 4. Resident 7 admitted to the facility in 1/2021 with diagnoses including cancer. Resident 7's 7/2021 physician orders included orders for diazepam (anxiety) two mg by mouth twice a day, Morphine Sulfate (pain) 45 mg by mouth twice a day and oxycodone HCL 10 mg by mouth every four hours as needed. The 7/4/21 Facility Root Cause Medication Error Report indicated Staff 5 (LPN) failed to sign the MAR and the narcotic book after administering diazepam two mg, Morphine Sulfate 45 mg and oxycodone 10 mg to Resident 7. An hour later, Staff 14 (LPN) administered diazepam two mg, Morphine Sulfate 45 mg and oxycodone 10 mg to Resident 7. The 7/5/21 late entry progress note, written by Staff 5 indicated Resident 7 received her/his medications twice. The progress note indicated Staff 5 administered the medications on 7/4/21 at 8:00 PM and Staff 14 administered the same medications on 7/4/21 at 9:00 PM. On 12/14/21 at 8:01 PM Staff 5 stated she and another nurse worked on the evening of 7/4/21. Staff 5 stated she administered Resident 7's medications and she was unsure why she did not sign the MAR and narcotic book. Staff 5 stated the medications should be documented in the MAR and narcotic book directly after administration. On 12/15/21 at 4:00 PM, Staff 1 (Administrator) confirmed the medication error for Resident 7 on 7/4/21 occurred.

Resident #3 orders for insulin and last 7 days of insulin medication administration were reviewed. Resident #4 no longer at facility Resident #6 is no longer on Warfarin. Resident #7 orders for pain medications and antianxiety medications and the last 7 days of these medication administrations were reviewed. The Director of Nursing or Designee identified residents that have orders for insulin, liquid morphine and/or warfarin and conducted a medication administration review on these residents for these medications. This review included review of the orders and a review of the last 7 days of medication administration, addressing any concerns identified. The Director of Nursing or Designee re-educated the Licensed Nurses on medication administration including 5 rights of medication administration, MAR documentation, Narcotic Book documentation, and Warfarin orders. The Director of Nursing or Designee re-educated the Nurse Leadership Team on reviewing new orders within the MACC clinical meeting and expectations in managing residents on Warfarin. The Director of Nursing or Designee will conduct 2 random med pass audits on residents with orders for insulin, liquid morphine and/or warfarin via observation and/or order review weekly x 3 weeks then monthly x 2 months. The Director of Nursing or Designee will report the results of these audits at the facility monthly Quality Assurance meeting for 60 days or until substantial compliance has been achieved as determined by the committee. The Director of Nursing is responsible to ensure compliance.

Based on interview and record review it was determined the facility failed to ensure resident health records were accurate for 3 of 4 (#s 3, 4, and 7) sampled residents reviewed for medications. This placed residents at risk for additional medication administrations, inaccurate and incomplete medical records. Findings include: 1. Resident 3 admitted to the facility in 2019 with diagnoses including diabetes. The 5/2021 physician order directed staff to administer Resident 3 Lantus Solution (long acting insulin) 100 UNIT/ML, inject 25 unit subcutaneously (under skin) in the evening and a Novolog Solution (short acting insulin) 100 UNIT/ML, inject as per sliding scale: if CBG 145 - 200 = 1 unit; CBG 201 - 250 = 2 units; CBG 251 - 300 = 3 units; CBG 301 - 350 = 4 units; CBG 351 - 400 = 5 units; 401+ = 6 units; CBG greater than 400 call physician, subcutaneously two times a day. A 5/1/21 progress note by Staff 4 (LPN), revealed Resident 3 was sent to the hospital emergency room to be monitored for an administration of a 25 unit dose of Novolog by Staff 4. Resident 3's 5/2021 MAR had no indication the Lantus or Novolog were administered. The MAR 5/1/21 section for Lantus and Novolog was blank. In an interview on 12/14/21 at 8:31 PM, Staff 4 confirmed she administered insulin to Resident 3 on the evening of 5/1/21 and she expected any medication administration to be documented in the MAR and coded to what occurred. On 12/15/21 at 4:00 PM, Staff 2 (DNS) confirmed the medication error occurred for Resident 3 on 5/1/21. Staff 2 stated she expected all nurses to document at the time of medication administration, even if an error occurred. 2. Resident 4 admitted to the facility in 2014 with diagnoses including dementia and diabetes. A 6/28/21 Staff 8 (Nurse Practitioner) physician order for Resident 4 to be given Morphine (pain) 20 mg/mL concentrated liquid, to take 1 mL by mouth, every hour as needed, for pain or air hunger (shortness of breath). A 7/2/21 order for Lorazepam (anxiety) 1 mg tablet, every six hours as needed for anxiety. There was no Lorazepam medication listed on Resident 4's 7/2021 MAR for opportunity to administer per physician order. Resident 4's 7/2021 MAR indicated Staff 5 (LPN) administered Morphine Sulfate Solution 20 MG/5 ML on 7/4/21 at 8:46 PM, by Staff 5 (LPN) and 7/5/21 at 3:05 AM, by Staff 5. No other entries for Morphine administration were documented. Resident 4's narcotic book documentation indicated she/he was administered Morphine on the following: - 7/4/21 at 10:46 PM, by Staff 5; - 7/4/21 at 11:00 PM, by Staff 5; - 7/5/21 at 2:45 AM by Staff 5; - 7/5/21 at 10:00 AM by Staff 9 (RN) and; - 7/5/21 at 9:40 AM by Staff 6 (RN). The 7/5/21 FRI revealed the Morphine order was incorrectly entered into the MAR. The order faxed from the pharmacy was for Morphine 20 mg/ml, give PO every two hours and the dose was entered for Morphine 20 mg/5 ml give 0.5 PO every two hours. On 12/14/21 at 8:01 PM, Staff 5 stated worked on the evening of 7/4/21. Staff 5 stated she administered Resident 4's medications and she was unsure why she would not sign the MAR and narcotic book. On 12/15/21 at 4:00 PM, Staff 1 (Administrator) and Staff 2 (DNS) confirmed they expected the all medications to be documented in the MAR immediately when administering medications. 3. Resident 7 admitted to the facility in 1/2021 with diagnoses including cancer. Resident 7's 7/2021 physician orders included orders for diazepam (anxiety) two mg by mouth twice a day, Morphine Sulfate (pain) 45 mg by mouth twice a day and oxycodone (pain) 10 mg by mouth every four hours as needed. The 7/4/21 Facility Root Cause Medication Error Report indicated Staff 5 (LPN) failed to sign the MAR and the narcotic book after administering diazepam two mg, Morphine Sulfate 45 mg and oxycodone 10 mg to Resident 7. An hour later, Staff 14 (LPN) administered diazepam two mg, Morphine Sulfate 45 mg and oxycodone 10 mg to Resident 7. The report indicated Staff 14 noticed Resident 7's medications were due and not documented as administered, so she administered Resident 7's medications. On 12/14/21 at 8:01 PM, Staff 5 stated she worked on the evening of 7/4/21. Staff 5 stated she administered Resident 7's medications and she was unsure why she did not sign the MAR and narcotic book. Staff 5 stated the medications should be documented in the MAR and narcotic book directly after administration. On 12/15/21 at 4:00 PM, Staff 1 (Administrator) and Staff 2 (DNS) confirmed they expected the medications to be documented in the MAR immediately when administering medications.

Resident #3 orders for insulin and last 7 days of insulin medication administration were reviewed. Resident #4 no longer at facility Resident #7 orders for pain medications and antianxiety medications and the last 7 days of these medication administrations were reviewed. The Director of Nursing or Designee re-educated the licensed nurses on the requirement to ensure resident health records were accurate, the education included: timely and complete medication administration on the MAR and Narcotic book. The Director of Nursing or Designee re-educated the Nurse Leadership Team on reviewing new orders within the MACC clinical meeting. The Director of Nursing or Designee will conduct 2 random med pass audits on residents for documentation compliance via observation and/or order review weekly x 3 weeks then monthly x 2 months. The Director of Nursing or Designee will report the results of these audits at the facility monthly Quality Assurance meeting for 60 days or until substantial compliance has been achieved as determined by the committee. The Director of Nursing is responsible to ensure compliance.

******************************************** OAR 411-086-0110 Pharmacy Services: Nursing Services: Resident Care Refer to F760 ******************************************** OAR 411-086-0300 Administration: Clinical Records Refer to F842 ********************************************