The Creston Health and Rehabilitation

1. Resident 5 admitted to the facility on 5/24/26 with diagnoses including an opened wound to his/her left foot and decreased white blood cell count. Resident 5's Progress Notes documented: -On 6/5/26 at 5:59 AM, Resident 5 complained of pain and burning upon urination. -On 6/8/26, a urinalysis was collected from Resident 5. -On 6/10/25, Resident 5 continued to complain of pain and burning with urination, had an active UTI and results of a culture and sensitivity were pending. On 6/15/26 at 12:15 PM, Resident 5 stated she/he first notified the facility of their UTI symptoms about two weeks prior. Resident 5 explained the facility completed a UA about one week prior which was positive and thought she/he would have an antibiotic prescribed but had not yet received one. Resident 5 also complained of ongoing pain with urination. On 6/17/26 at 10:22 AM, Resident 5 stated she/he received the first dose of antibiotics the previous night. She/he explained the results of her culture and sensitivity were sent to an assisted living and not the nursing facility, which caused their treatment to be delayed. On 6/17/26 at 12:01 PM, Staff 1 (Administrator) provided the results of Resident 5's culture and sensitivity test dated 6/12/26 at 2:02 PM because the results were not available in Resident 5's electronic health record. The results included a handwritten note by Staff 13 (RN) indicating an antibiotic was prescribed by the on-call provider on 6/16/26. On 6/17/26 at 3:37 PM, Staff 9 (Nurse Practitioner) stated normally a provider was alerted by phone by the facility for a positive UA and culture and sensitivity test and results are viewable in the electronic health record. Staff 9 stated the UA results and culture and sensitivity were not available in the electronic health record at time of interview, but Staff 13 had called the on-call provider on 6/16/26. On 6/17/26 at 3:49 PM and 6/18/26 at 8:40 AM, attempts to contact Staff 13 were unsuccessful. On 6/18/26 at 9:38 AM, Staff 11 (LPN) stated the lab results are typically posted in residents' electronic health record by the lab for viewing, and stated the lab typically calls the facility for critical labs or culture and sensitivity reports. She stated if she was expecting a result that was not available in the electronic health record, she would call the lab for clarification. On 6/18/26 at 9:43 AM, Staff 12 (RN/Assistant DNS) stated Resident 5's culture and sensitivity results should have been available for viewing in the electronic health record on 6/12/26 but were sent to Resident 5's assisted living facility. Staff 12 stated on 6/16/26 she called Resident 5's assisted living and found the results. She stated Staff 13 then called the on-call provider and got the order for the appropriate antibiotic.-á On 6/18/26 at 10:01 AM, Staff 2 (DNS) stated normally results are uploaded to residents' electronic health record by the lab when available and the lab also calls to notify staff of the culture and sensitivity results. Staff 2 explained he would have expected the nurses to call the lab for results if they were not available in the electronic health record and to notify the provider of issues so a determination could be made on whether the resident should be sent to the ER for evaluation, which was not done. 2. Resident 6 admitted to the facility in 2024 with diagnoses including chronic multifocal osteomyelitis of right ankle and foot, Type II diabetes with diabetic polyneuropathy and pressure injuries on both lower extremities. Resident 6 discharged from the facility in 3/2026. Resident 6's Physician Orders documented a 2/11/26 order for doxycycline (an antibiotic medication) 100 mg tablet BID for 10 days for a skin and soft tissue infection. Resident 6's 2/2026 MAR documented the medication was started on 2/17/26 (6 days after the orders). On 6/17/26 at 2:13 PM, Staff 7 (LPN) stated the facility received orders from Resident 6's provider through a fax number accessible only to certain staff, which caused the orders to be received late. On 6/18/26 at 9:43 AM, Staff 12 (RN/Assistant DNS) stated Resident 6's provider faxed orders to a fax number that was only accessible to admission staff, likely resulting in orders to be received late. On 6/18/26 at 10:01 AM, Staff 12 (DNS) stated normally Resident 6's providers faxed orders and called to ensure the order was received. Staff 12 explained that on 2/17/26 Staff 13 (RN) found an order for Resident 6 and brought it to him as Staff 12 was the charge nurse that day. Staff 12 called the provider to verify the order and the provider stated to start the order and give as directed because Resident 6 had an abscess. Staff 12 stated he should have documented this in a progress note, but could not find the documentation.-á

1.  Resident #5 is no longer residing in the facility. Resident #6 remains residing in the facility. A retrospective review of the medical records for Resident #6 was completed. The attending providers were notified of the delays in treatment, and the records were reviewed to determine whether any adverse outcomes resulted from the delayed implementation of physician orders and antibiotic therapy. 2.  DNS or designee, reviewed residents with pending laboratory cultures or sensitivities, recent antibiotic orders, and physician orders received by fax or electronic transmission within the previous 30 days to identify any delays in receipt, provider notification, order implementation, or medication initiation. Any concerns identified during the review were investigated, providers were notified as appropriate, and corrective action was taken. 3. Licensed nursing staff were educated on: Timely receipt, transcription, verification, and implementation of physician orders. Monitoring and follow-up of pending laboratory results, including culture and sensitivity reports. Timely provider notification of positive laboratory findings or missing results. Documentation requirements for provider notification and follow-up actions. Escalation procedures when laboratory results or physician orders are not received as expected. The facility reviewed laboratory result routing and physician office fax and electronic communication processes to ensure results and orders are directed to the appropriate location. A tracking process was implemented for pending laboratory results and physician orders to assist nursing staff in monitoring follow-up until completion. 4. DNS, or designee, will audit five residents each week for four weeks who have new physician orders and/or pending laboratory results to verify timely receipt of orders, provider notification, implementation of physician orders, medication initiation, and appropriate documentation. Audits will continue monthly for two additional months. Any concerns identified during the audits will be addressed promptly through education, counseling, or additional process improvement. 5. DNS, or designee, is responsible for ensuring ongoing compliance. Audit findings and trends will be reviewed by the QAPI, and additional corrective actions will be implemented as needed until substantial compliance is achieved.

-á 5. Resident 48 was admitted to the facility in 10/2023 with diagnoses including Parkinson's disease (a progressive movement disorder of the nervous system). Resident 48's 9/10/25 Care Plan revealed the following interventions: -Staff were to ensure the resident's call light was within reach. -Staff were to remind the resident during encounters to use the call light to request assistance. -The resident required prompt response to all requests for assistance.-á Resident 48's 1/25/26 Quarterly MDS revealed the resident experienced short-and-long term memory loss, was severely impaired for decision-making, experienced upper and lower body impairment on both sides and was dependent on assistance from staff for all ADL care. On 2/23/26 at 10:50 AM, Resident 48 was observed in her/his room in bed. A pressure-activated call light (used by people with limited dexterity or motor skills) was observed wrapped around the top portion of the left upper bed rail across from the resident's left shoulder. The resident was unable to answer any questions about her/his call light at this time.-á On 2/24/26 at 11:42 AM, Resident 48 stated she/he would use her/his call light if it was within reach.-á On 2/24/26 at 11:42 AM, 2/25/26 at 8:58 AM and 2/26/26 at 5:47 AM, Resident 48 was observed in her/his room in bed. A pressure-activated call light was observed wrapped around the top portion of the left upper bed rail across from the resident's left shoulder. Resident 48 reached across her/his body with her/his right arm, attempted to activate the call light but was unable to reach it.-á On 2/26/26 at 10:30 AM, Staff 14 (RN) stated Resident 48 used her/his right arm to activate her/his pressure-activated call light as the resident's left side was ""more limited."" Staff 14 stated Resident 48 would not be able to reach her/his call light if it was placed near her/his left shoulder.-á On 2/26/26 at 1:28 PM, Staff 15 (CNA) stated Resident 48 did not use her/his left arm ""for anything"" and the resident used her/his call light on the days when she/he was more alert. At 1:42 PM, Staff 15 observed the resident in bed with her/his call light wrapped around the left bed rail and stated the resident would ""probably not"" be able to access the call light.-á On 2/27/26 at 10:23 AM, Staff 6 (CNA) stated Resident 48 did ""better with [her/his] right side,"" she/he used her/his call light and the call light needed to be positioned by her/his hand.-á On 2/27/26 at 10:32 AM, Staff 1 (Administrator), Staff 2 (DNS) and Staff 24 (MDS Coordinator-RN) were present for an interview. Staff 24 stated Resident 48 had ""very low strength on one side"" and the call light should be placed in her/his lap to be accessible.-á , The facilityGÇÖs undated Accommodation of Needs Policy indicated: -The facility will treat each resident with respect and dignity and will evaluate and make reasonable accommodations for the individual needs and preferences of a resident, expect when the health and safety of the individual or other residents would be endangered. -The facility will make reasonable accommodations to individualize the residentGÇÖs physical environment including their personal bathroom, bedroom, and common living areas within the facility. -Facility staff shall make efforts to reasonably accommodate the needs and preferences of the resident as they make use of their physical environment. -Based on individual needs and preferences, the facility will assist the resident in maintaining and/or achieving independent functioning, dignity, and well-being to the extent possible. 1. Resident 40 was admitted to the facility in 7/2021 with diagnoses including chronic joint disease of the knees and morbid obesity. The 5/25/25 Annual MDS indicated the resident had no cognitive impairment and was dependent for mobility and transfers. A maintenance request dated 1/24/26 completed by Staff 13 (CNA) stated Resident 40 GÇ£wanted the bed she/he had upstairs because this one is too small.GÇ¥ On 2/23/26 at 3:28 PM, Resident 40 stated she/he moved rooms and was told their bed would be moved to the new room. The bed was not moved and she/he was now in a smaller bed. Resident 40 stated she/he preferred the previous bed, because the smaller bed made her/his mobility difficult. On 2/26/25 at 10:05 AM Staff 14 (CNA) stated Resident 40 was in a larger bed prior to moving rooms. Staff 14 stated Resident 40 requested a larger bed and stated maintenance was notified. On 2/26/26 at 12:04 PM, Staff 7 (Director of Facility Services) stated he would expect maintenance requests be completed within 24 hours and was unaware of Resident 40GÇÖs request dated 1/24/26. He confirmed it was not completed. On 2/26/26 at 2:59 PM, Staff 1 (Administrator) stated Resident 40GÇÖs previous bed was returned to the rental company. He stated he would expect Resident 40GÇÖs maintenance request for the larger bed to be completed within 24 hours. 2. Resident 21 was admitted to the facility in 8/2024 with diagnoses including diabetes and left leg abrasion. Resident 21GÇÖs 6/8/25 Annual MDS indicated the resident had no cognitive impairment and was dependent on staff for mobility, ambulation and transfers. On 2/24/26 at 9:22 AM, Resident 21 was observed in bed and attempted to turn on the overbed light, the resident reached from a lying position in bed, to turn on the overbed light using a butter knife. Resident 21 was unable to reach the light switch with her/his hands and used the butter knife to reach the light. Resident 21 was successful in turning on the light with the butter knife. On 2/24/26 at 9:22 AM, Resident 21 stated there was a GÇ£toggle like switchGÇ¥ to turn the overbed light on, but she/he was unable to reach the switch. Resident 21 stated she/he needed to use the butter knife or had to call staff assistance when she/he needed the light turned on and off. On 2/26/26 at 10:05 AM, Staff 14 (CNA), stated most residents had no way of turning the overbed light on and off without calling for assistance. She stated Resident 21 frequently called for assistance to turn the overbed light on and off. On 2/26/26 at 12:04 PM, Staff 1 (Administrator) and Staff 7 (Director of Facility Services) stated residents with beds equipped with the toggle-like switch had to activate their call light to receive help. Staff 1 stated if residents were physically capable to operate the overbed light, they should have been provided with the means to do so. , 3. Resident 49 was admitted to the facility in 10/2025 with diagnoses including a right hip fracture. -á -á Resident 49's 1/18/26 Quarterly MDS indicated the resident had no cognitive impairment and was dependent for mobility, transfers and ambulation.-á -á Observations from 2/24/26 through 2/26/26 between the hours of 8:00 AM and 4:30 PM revealed Resident 49 had no ability to turn on her/his overbed light unless she/he called staff for assistance.-á -á On 2/24/26 at 1:08 PM, Resident 49 stated there was a ""little button over there"" that turned on the overbed light, but she/he was unable to reach the light switch and had to call for staff assistance when she/he needed the light turned on and off.-á -á On 2/25/26 at 8:42 AM, Staff 4 (CNA) stated some residents were unable to turn their overbed lights on and off because the newer beds no longer had overbed light controls. Staff 4 stated if a resident did not have a pull cord (such as Resident 49) the resident had to get out of bed or call staff to turn their overbed light on and off.-á -á On 2/25/26 at 12:29 PM, Staff 6 (CNA) stated Resident 49's bed did not have a pull cord to turn on her/his overbed light, so the resident had to call for staff assistance when she/he wanted the overbed light on or off.-á -á On 2/26/26 at 12:03 PM, Staff 1 (Administrator) and Staff 7 (Director of Facility Services) stated some residents had pull cords and were able to turn their overbed light on and off but those who did not had to activate their call light to get help. Staff 1 stated if residents were able to physically turn on the overbed light, they should have a way to do so.-á -á 4. Resident 53 was admitted to the facility in 1/2026 with diagnoses including multiple fractures of the spine, multiple fractures of the pelvis, fractures of the right lower leg, multiple fractures of the ribs and a fractured neck.-á -á Resident 53's 1/18/26 Admission MDS indicated the resident had no cognitive impairment, was dependent for bed mobility and was unable to transfer or ambulate.-á -á Observations from 2/24/26 through 2/26/26 between the hours of 8:00 AM and 4:30 PM revealed Resident 53 had no ability to turn on her/his overbed light unless she/he called staff for assistance.-á -á On 2/23/26 at 9:48 AM and 2/25/26 at 9:20 AM, Resident 53 stated she/he had no way of turning on the overbed light. Resident 53 stated she/he was unable to walk and had no bed controls, so she/he had to call staff for assistance to turn the overbed light on and off.-á -á On 2/25/26 at 8:42 AM, Staff 4 (CNA) stated some residents were unable to turn their overbed lights on and off because the newer beds no longer had overbed light controls. Staff 4 stated if a resident did not have a pull cord (such as Resident 53) the resident had to get out of bed or call staff to turn their overbed light on and off.-á -á On 2/25/26 at 12:29 PM, Staff 6 (CNA) stated Resident 53's bed did not have a pull cord to turn on her/his overbed light, so the resident had to call for staff assistance when she/he wanted the overbed light on or off.-á -á On 2/26/26 at 12:03 PM, Staff 1 (Administrator) and Staff 7 (Director of Facility Services) stated some residents had pull cords and were able to turn their overbed light on and off but those who did not had to activate their call light to get help. Staff 1 stated if residents were able to physically turn on the overbed light, they should have a way to do so.-á , The facilityGÇÖs undated Accommodation of Needs Policy indicated: -The facility will treat each resident with respect and dignity and will evaluate and make reasonable accommodations for the individual needs and preferences of a resident, expect when the health and safety of the individual or other residents would be endangered. -The facility will make reasonable accommodations to individualize the residentGÇÖs physical environment including their personal bathroom, bedroom, and common living areas within the facility. -Facility staff shall make efforts to reasonably accommodate the needs and preferences of the resident as they make use of their physical environment. -Based on individual needs and preferences, the facility will assist the resident in maintaining and/or achieving independent functioning, dignity, and well-being to the extent possible. 1. Resident 40 was admitted to the facility in 7/2021 with diagnoses including chronic joint disease of the knees and morbid obesity. The 5/25/25 Annual MDS indicated the resident had no cognitive impairment and was dependent for mobility and transfers. A maintenance request dated 1/24/26 completed by Staff 13 (CNA) stated Resident 40 GÇ£wanted the bed she/he had upstairs because this one is too small.GÇ¥ On 2/23/26 at 3:28 PM, Resident 40 stated she/he moved rooms and was told their bed would be moved to the new room. The bed was not moved and she/he was now in a smaller bed. Resident 40 stated she/he preferred the previous bed, because the smaller bed made her/his mobility difficult. On 2/26/25 at 10:05 AM Staff 14 (CNA) stated Resident 40 was in a larger bed prior to moving rooms. Staff 14 stated Resident 40 requested a larger bed and stated maintenance was notified. On 2/26/26 at 12:04 PM, Staff 7 (Director of Facility Services) stated he would expect maintenance requests be completed within 24 hours and was unaware of Resident 40GÇÖs request dated 1/24/26. He confirmed it was not completed. On 2/26/26 at 2:59 PM, Staff 1 (Administrator) stated Resident 40GÇÖs previous bed was returned to the rental company. He stated he would expect Resident 40GÇÖs maintenance request for the larger bed to be completed within 24 hours. -á 2. Resident 21 was admitted to the facility in 8/2024 with diagnoses including diabetes and left leg abrasion. Resident 21GÇÖs 6/8/25 Annual MDS indicated the resident had no cognitive impairment and was dependent on staff for mobility, ambulation and transfers. On 2/24/26 at 9:22 AM, Resident 21 was observed in bed and attempted to turn on the overbed light, the resident reached from a lying position in bed, to turn on the overbed light using a butter knife. Resident 21 was unable to reach the light switch with her/his hands and used the butter knife to reach the light. Resident 21 was successful in turning on the light with the butter knife. On 2/24/26 at 9:22 AM, Resident 21 stated there was a GÇ£toggle like switchGÇ¥ to turn the overbed light on, but she/he was unable to reach the switch. Resident 21 stated she/he needed to use the butter knife or had to call staff assistance when she/he needed the light turned on and off. On 2/26/26 at 10:05 AM, Staff 14 (CNA), stated most residents had no way of turning the overbed light on and off without calling for assistance. She stated Resident 21 frequently called for assistance to turn the overbed light on and off. On 2/26/26 at 12:04 PM, Staff 1 (Administrator) and Staff 7 (Director of Facility Services) stated residents with beds equipped with the toggle-like switch had to activate their call light to receive help. Staff 1 stated if residents were physically capable to operate the overbed light, they should have been provided with the means to do so. -á 3. Resident 49 was admitted to the facility in 10/2025 with diagnoses including a right hip fracture. -á -á Resident 49's 1/18/26 Quarterly MDS indicated the resident had no cognitive impairment and was dependent for mobility, transfers and ambulation.-á -á Observations from 2/24/26 through 2/26/26 between the hours of 8:00 AM and 4:30 PM revealed Resident 49 had no ability to turn on her/his overbed light unless she/he called staff for assistance.-á -á On 2/24/26 at 1:08 PM, Resident 49 stated there was a ""little button over there"" that turned on the overbed light, but she/he was unable to reach the light switch and had to call for staff assistance when she/he needed the light turned on and off.-á -á On 2/25/26 at 8:42 AM, Staff 4 (CNA) stated some residents were unable to turn their overbed lights on and off because the newer beds no longer had overbed light controls. Staff 4 stated if a resident did not have a pull cord (such as Resident 49) the resident had to get out of bed or call staff to turn their overbed light on and off.-á -á On 2/25/26 at 12:29 PM, Staff 6 (CNA) stated Resident 49's bed did not have a pull cord to turn on her/his overbed light, so the resident had to call for staff assistance when she/he wanted the overbed light on or off.-á -á On 2/26/26 at 12:03 PM, Staff 1 (Administrator) and Staff 7 (Director of Facility Services) stated some residents had pull cords and were able to turn their overbed light on and off but those who did not had to activate their call light to get help. Staff 1 stated if residents were able to physically turn on the overbed light, they should have a way to do so.-á -á 4. Resident 53 was admitted to the facility in 1/2026 with diagnoses including multiple fractures of the spine, multiple fractures of the pelvis, fractures of the right lower leg, multiple fractures of the ribs and a fractured neck.-á -á Resident 53's 1/18/26 Admission MDS indicated the resident had no cognitive impairment, was dependent for bed mobility and was unable to transfer or ambulate.-á -á Observations from 2/24/26 through 2/26/26 between the hours of 8:00 AM and 4:30 PM revealed Resident 53 had no ability to turn on her/his overbed light unless she/he called staff for assistance.-á -á On 2/23/26 at 9:48 AM and 2/25/26 at 9:20 AM, Resident 53 stated she/he had no way of turning on the overbed light. Resident 53 stated she/he was unable to walk and had no bed controls, so she/he had to call staff for assistance to turn the overbed light on and off.-á -á On 2/25/26 at 8:42 AM, Staff 4 (CNA) stated some residents were unable to turn their overbed lights on and off because the newer beds no longer had overbed light controls. Staff 4 stated if a resident did not have a pull cord (such as Resident 53) the resident had to get out of bed or call staff to turn their overbed light on and off.-á -á On 2/25/26 at 12:29 PM, Staff 6 (CNA) stated Resident 53's bed did not have a pull cord to turn on her/his overbed light, so the resident had to call for staff assistance when she/he wanted the overbed light on or off.-á -á On 2/26/26 at 12:03 PM, Staff 1 (Administrator) and Staff 7 (Director of Facility Services) stated some residents had pull cords and were able to turn their overbed light on and off but those who did not had to activate their call light to get help. Staff 1 stated if residents were able to physically turn on the overbed light, they should have a way to do so.-á -á 5. Resident 48 was admitted to the facility in 10/2023 with diagnoses including Parkinson's disease (a progressive movement disorder of the nervous system). Resident 48's 9/10/25 Care Plan revealed the following interventions: -Staff were to ensure the resident's call light was within reach. -Staff were to remind the resident during encounters to use the call light to request assistance. -The resident required prompt response to all requests for assistance.-á Resident 48's 1/25/26 Quarterly MDS revealed the resident experienced short-and-long term memory loss, was severely impaired for decision-making, experienced upper and lower body impairment on both sides and was dependent on assistance from staff for all ADL care. On 2/23/26 at 10:50 AM, Resident 48 was observed in her/his room in bed. A pressure-activated call light (used by people with limited dexterity or motor skills) was observed wrapped around the top portion of the left upper bed rail across from the resident's left shoulder. The resident was unable to answer any questions about her/his call light at this time.-á On 2/24/26 at 11:42 AM, Resident 48 stated she/he would use her/his call light if it was within reach.-á On 2/24/26 at 11:42 AM, 2/25/26 at 8:58 AM and 2/26/26 at 5:47 AM, Resident 48 was observed in her/his room in bed. A pressure-activated call light was observed wrapped around the top portion of the left upper bed rail across from the resident's left shoulder. Resident 48 reached across her/his body with her/his right arm, attempted to activate the call light but was unable to reach it.-á On 2/26/26 at 10:30 AM, Staff 14 (RN) stated Resident 48 used her/his right arm to activate her/his pressure-activated call light as the resident's left side was ""more limited."" Staff 14 stated Resident 48 would not be able to reach her/his call light if it was placed near her/his left shoulder.-á On 2/26/26 at 1:28 PM, Staff 15 (CNA) stated Resident 48 did not use her/his left arm ""for anything"" and the resident used her/his call light on the days when she/he was more alert. At 1:42 PM, Staff 15 observed the resident in bed with her/his call light wrapped around the left bed rail and stated the resident would ""probably not"" be able to access the call light.-á On 2/27/26 at 10:23 AM, Staff 6 (CNA) stated Resident 48 did ""better with [her/his] right side,"" she/he used her/his call light and the call light needed to be positioned by her/his hand.-á On 2/27/26 at 10:32 AM, Staff 1 (Administrator), Staff 2 (DNS) and Staff 24 (MDS Coordinator-RN) were present for an interview. Staff 24 stated Resident 48 had ""very low strength on one side"" and the call light should be placed in her/his lap to be accessible.-á

Plan of Correction (POC) Disclaimer Statement: Submission of this Plan of Correction does not constitute an admission of the facts alleged or agreement with the survey findings. Corrective Actions Residents 40 was not happy with the bed and had the mattress switched out. Resident 40 said she was happy with the change on 3/12/2026. Residents 21, 49, 53 had a pull cords ordered each of the overbed light to turn on and off as of 3/19/2026. Resident 48 had the call light within reach of functioning hand on 2/27/2026, then Care Plan for Resident 48 was updated on 3/19/2026. Identification of Other Individuals Each resident currently in the facility was assessed to determine whether any adaptations were needed to promote resident independence with using call lights and turning on/off overhead lights was completed on 03/20/2026. Any necessary changes were implemented or parts are ordered to install. Systemic Changes and Education Director of Nursing Services or Designee will educate clinical staff by 03/31/2026 on treating each resident with respect and dignity by ensuring reasonable accommodations are in place to promote the individual needs and preferences and promote resident independence with the use of call lights and overhead lights. Monitoring The Director of Nursing or Designee will audit residents requiring adaptations to call lights and/or overhead lights to ensure that such adaptations are in place and effective to enable resident independence with the use of the call light and/or turning on/off the overhead light. Any necessary changes will be implemented at the time of observance. Audits will be completed weekly x4 weeks, every other week for 4 weeks, then monthly x1 month or until substantial compliance is determined by the QAPI Committee. Effective Date of Compliance 03/31/2026

Resident 60 was admitted to the facility on 1/12/26 with Medicare A benefits. A 2/2/26 NOMNC (Notice of Medicare Non-Coverage) indicated Resident 60's Medicare Part A benefits ended on 2/4/26. Review of Resident 60's health record indicated the resident remained in the facility and was financially responsible for her/his care from 2/5/26 to 2/26/26. There was no documentation indicating the SNF ABN notification was provided to Resident 60 or their representative to inform them of the resident's daily out-of-pocket costs.-á On 2/24/26 at 2:27 PM Staff 9 (Social Services Director) acknowledged Resident 60 was not issued a SNF ABN. Staff 9 stated her expectation was residents or their representatives were informed of the resident's daily out-of-pocket costs via a SNF ABN notification form. On 2/27/2026 at 12:30 PM Staff 1 (Administrator) acknowledged Resident 60 was not issued a SNF ABN. Staff 1 stated he expected all residents to be issued a SNF ABN if they stayed in the facility.-á

F582 - Medicaid/Medicare Coverage/Liability Notice Corrective Actions Resident 60 has since passed away after hospice admission. Identification of Other Individuals A review Social Services Coordinator was completed for issued ABN’s and NOMNC of residents who discharged or had a payer changes on 03/13/2026. Three residents were identified within these categories and each one had an ABN and/or NONMC issued timely. Systemic Changes and Education Social Services Coordinator or Designee will review policy and procedure/systems and processes then update or remind staff of policy. Social Services Coordinator or Designee will then educate clinical leaders and BOM on when to issue ABN’s and NOMNC when residents discharge or have payer changes. Education will be completed by 03/20/2026. Monitoring The Social Services Coordinator or Designee will audit NOMNC and ABNs for residents who discharge or have a payer change once a week for x4 weeks, every other week for 4 weeks, then monthly x1 month or until substantial compliance is determined by the QAPI Committee. Effective Date of Compliance 03/31/2026

1. Resident 15 was admitted to the facility in 10/2025 with a diagnosis of a right leg fracture. Resident 15's health record revealed she/he was discharged from the facility on 10/19/25. No evidence was found in Resident 15's health record to indicate the facility transmitted her/his 5-day or Discharge MDS assessments. On 2/26/26 at 4:13 PM Staff 8 (Medical Records) acknowledged Resident 15's missing Medicare 5-day and Discharge MDS assessments and stated she failed to verify their transmittal status after submitting them. On 2/27/26 at 1:47 PM Staff 1 (Administrator) stated MDS assessments were important because they provided information for the development of resident-centered care plans. Staff 1 stated he expected MDS assessments to be completed correctly and submitted in a timely manner. 2. Resident 78 was admitted to the facility in 8/2025 with a diagnosis of a right foot fracture. Resident 78's health record revealed she/he was discharged from the facility on 10/2/25. No evidence was found in Resident 78's health record to indicate the facility transmitted her/his MDS discharge assessment. On 2/26/26 at 4:13 PM Staff 8 (Medical Records) acknowledged Resident 78's missing MDS Discharge assessment and stated she failed to verify its transmittal status after submitting it. On 2/27/26 at 1:47 PM Staff 1 (Administrator) stated MDS assessments were important because they provided information for the development of resident-centered care plans. Staff 1 stated he expected MDS assessments to be completed correctly and submitted in a timely manner. 3. Resident 79 was admitted to the facility in 3/2025 with a diagnosis of a left arm fracture. Resident 79's health record revealed she/he was discharged from the facility on 5/1/25. No evidence was found in Resident 79's health record to indicate the facility transmitted her/his MDS discharge assessment. On 2/26/26 at 4:13 PM Staff 8 (Medical Records) acknowledged Resident 79's missing MDS discharge assessment and stated she failed to verify its transmittal status after submitting it.-á On 2/27/26 at 1:47 PM Staff 1 (Administrator) stated MDS assessments were important because they provided information for the development of resident-centered care plans. Staff 1 stated he expected MDS assessments to be completed correctly and submitted in a timely manner. 4. Resident 80 was admitted to the facility in 6/2024 with a diagnosis of a periprosthetic fracture (a break in the bone occurring adjacent to an orthopedic implant) of the left hip joint. Resident 80's health record revealed she/he was discharged from the facility on 7/18/24. No evidence was found in Resident 80's health record to indicate the facility completed and transmitted her/his Entry tracking assessment or her/his Medicare 5-day assessment. On 2/26/26 at 4:13 PM Staff 8 (Medical Records) acknowledged Resident 80's missing MDS Entry and Medicare 5-day assessments and stated she failed to verify their transmittal status after submitting them. On 2/27/26 at 1:47 PM Staff 1 (Administrator) stated MDS assessments were important because they provided information for the development of resident-centered care plans. Staff 1 stated he expected MDS assessments to be completed correctly and submitted in a timely manner. 5. Resident 82 was admitted to the facility in 4/2025 with a diagnosis of other idiopathic peripheral autonomic neuropathy (acquired disorders with unknown causes that disrupt involuntary bodily functions, such as blood pressure, digestion and sweating). Resident 82's health record revealed she/he was discharged from the facility on 10/2/25. No evidence was found in Resident 82's health record to indicate the facility completed and transmitted her/his discharge assessment. On 2/26/26 at 4:13 PM Staff 8 (Medical Records) acknowledged Resident 80's missing Discharge assessment and stated she failed to verify its transmittal status after submitting it. On 2/27/26 at 1:47 PM Staff 1 (Administrator) stated MDS assessments were important because they provided information for the development of resident-centered care plans. Staff 1 stated he expected MDS assessments to be completed correctly and submitted in a timely manner. 6. Resident 83 was admitted to the facility in 4/2025 with diagnoses including stroke and dementia. Resident 83's health record revealed she/he was discharged from the facility on 5/1/25. No evidence was found in Resident 83's health record to indicate the facility transmitted her/his discharge assessment. On 2/26/26 at 4:13 PM Staff 8 (Medical Records) acknowledged Resident 83's missing Discharge assessment and stated she failed to verify its transmittal status after submitting it. On 2/27/26 at 1:47 PM Staff 1 (Administrator) stated MDS assessments were important because they provided information for the development of resident-centered care plans. Staff 1 stated he expected MDS assessments to be completed correctly and submitted in a timely manner. 7. Resident 84 was admitted to the facility in 3/2025 with a diagnosis of severe protein-calorie malnutrition. Resident 84's health record revealed she/he died in the facility on 5/9/25. No evidence was found in Resident 84's health record to indicate the facility completed and transmitted her/his Death in Facility discharge assessment. On 2/26/26 at 4:13 PM Staff 8 (Medical Records) acknowledged Resident 84's missing Death in Facility discharge assessment and stated she failed to verify its transmittal status after submitting it. On 2/27/26 at 1:47 PM Staff 1 (Administrator) stated MDS assessments were important because they provided information for the development of resident-centered care plans. Staff 1 stated he expected MDS assessments to be completed correctly and submitted in a timely manner.

Corrective Actions The MDSs for Residents 15, 78, 79, 80, 82, 83, and 84 were reviewed for errors. Any necessary corrections were made and resubmitted on 03/18/2026. Identification of Other Individuals All MDS submitted in the last 30 days were reviewed for errors on 03/19/2026. One error was identified, corrected and resubmitted on 03/19/2026. Systemic Changes and Education Medical Records or Designee will run an MDS 3.0 Missing OBRA Assessment Report each week to identify any rejected MDS’. MDS Nurse will make any necessary corrections and resubmit the MDS by the next working day. The Administrator or Designee will educate the MDS Nurse and clinical leaders on the importance of accurate and timely MDS submission by 03/31/2026. Monitoring Medical Records or Designee will audit rejected MDSs weekly for X3 months or until substantial compliance is determined by the QAPI Committee. Effective Date of Compliance 03/31/2026

The facility's 9/2024 Activities of Daily Living Policy revealed the following: -A resident who is unable to carry out, or dependent with, activities of daily living will receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene.-á -The facility will maintain individual objectives of the care plan and periodic review and evaluation.-á Resident 48 was admitted to the facility in 10/2023 with diagnoses including Parkinson's disease (a progressive movement disorder of the nervous system). Resident 48's 9/10/25 ADL Care Plan revealed the resident required assistance from one person with dressing. Resident 48's 1/25/26 Quarterly MDS revealed the resident experienced short-and-long term memory loss, was severely impaired for decision-making, dependent on assistance from staff for all ADL care and did not exhibit the behavior of rejecting care. A review of Resident 48's Upper and Lower Body Dressing Task Logs from 2/3/26 to 2/25/26 revealed the resident did not refuse to get dressed.-á On 2/23/26 at 12:27 PM, Resident 48 was observed in her/his room in bed wearing a hospital gown. Resident 48 stated wearing a hospital gown was not her/his preference, and she/he liked to get dressed. Resident 48 further stated no staff offered to assist her/him to get dressed on 2/23/26.-á On 2/23/26 at 3:19 PM, Witness 3 (Family Member) stated Resident 48 got dressed every morning prior to her/his admission to the facility. Witness 3 stated the last few times he visited Resident 48 at the facility; the resident was dressed in a hospital gown.-á On 2/24/26 at 3:17 PM, Resident 48 was observed in her/his room in bed wearing a hospital gown. Resident 48 stated she/he wanted to get dressed in regular clothes, but no staff had offered to assist her/him to do so.-á On 2/25/26 at 1:42 PM, Resident 48 was observed in her/his room in bed wearing a hospital gown.-á On 2/26/26 at 5:13 AM, Staff 23 (CNA) stated she was unaware of Resident 48's clothing preferences, but stated all residents were expected to get dressed in the morning unless the resident refused.-á On 2/26/26 at 5:56 AM, Staff 33 (CNA) stated Resident 48 was cooperative with care and did ""not refuse anything.""-á On 2/26/26 at 10:30 AM, Staff 14 (RN) stated she had not seen Resident 48 dressed in something other than a hospital gown in the last month. Staff 14 further stated she thought Resident 48 preferred to wear nightgowns during the day and she had never received reports from CNA staff of the resident refusing to get dressed or change clothes.-á On 2/26/26 at 1:28 PM, Staff 15 (CNA) stated she encouraged all residents to get up and get dressed before breakfast. Staff 15 stated Resident 48 was dependent on staff assistance to get dressed and the resident did not refuse.-á On 2/27/26 at 10:32 AM, Staff 1 (Administrator), Staff 2 (DNS) and Staff 24 (MDS Coordinator-RN) were present for an interview. Staff 2 stated she expected all residents to get dressed in the morning unless their care plan specified otherwise. Staff 24 further stated Resident 48's care plan did not specify a preference to wear hospital gowns or that she/he was resistive to care.-á

Corrective Actions Resident 48 was assisted with changing his/her clothes and assisted up in a wheelchair on 2/26/2026. Identification of Other Individuals The ADL needs of all current residents was completed on 03/17/2026 to validate individual needs with ADLs has been identified and accurately documented on the care plan. Any resident’s identified variances were update. Systemic Changes and Education The Director of Nursing Services or Designee will educate Assistant Director of Nurses, MDS Nurse, and other clinical leaders on the importance of timely and accurate identification of ADL needs and updating the residents’ care plan to reflect those needs. Clinical staff will be educated on using and following the ADL interventions outlined on each residents’ care plan to  provide assistance according to the residents’ individual needs. Education will be completed by 3/31/2026. Monitoring Director of Nursing Services or Designee will audit new admission or readmission, quarterly or annual personal centered care plans for ADL accuracy and accurate implementation by staff once a week for x4 weeks, every other week for 4 weeks, then monthly x1 month or until substantial compliance is determined by the QAPI Committee. Effective Date of Compliance 03/31/2026

The facility's Activities Policy revealed residents would be encouraged to participate in scheduled activities, and special considerations would be made for developing meaningful activities for residents with dementia and/or special needs.-á Resident 48 was admitted to the facility in 10/2023 with diagnoses including Parkinson's disease (a progressive movement disorder of the nervous system). Resident 48's 9/10/25 Activity Care Plan revealed the following: -The resident's preferred activities included visiting with family and friends, watching the Hallmark Channel and the morning and evening news on television, listening to rock and roll, classical, '70s and '80s music and playing bingo.-á -The resident would inform staff if she/he wanted to participate in activities. -The resident was able to self-direct her/his activity program.-á Resident 48's 11/2/25 Annual MDS revealed the resident was severely cognitively impaired, dependent on assistance from staff for all ADL care and her/his activities of importance included listening to music and doing her/his favorite activities.-á Resident 48's 2/17/26 Activity Assessment revealed the resident participated in independent activities of choice and a one-to-one program, rarely initiated conversations and was dependent on others for wheelchair transportation.-á A review of Activity Progress Note Documentation from 11/1/25 through 2/23/26 revealed Resident 48 received a one-to-one visit on 11/21/25 and 2/2/26.-á No evidence was found in Resident 48's clinical record to indicate she/he participated in out-of-room activities, including socializing with others or playing bingo.-á On 2/23/26 at 10:50 AM, Resident 48 was observed in her/his room in bed. No music played and the television that the resident shared with her/his roommate was off. Resident 48 was unable to answer any questions about her/his activity preferences at this time.-á On 2/23/26 at 3:19 PM, Witness 3 (Family Member) stated Resident 48 did not enjoy watching television, but she/he liked to listen to music, especially soothing music, being around others and visiting with friends. Witness 3 stated the resident experienced a decline in functioning, and as a result, needed help to make decisions.-á On 2/24/2026 at 8:48 AM, Resident 48 was observed awake in her/his room in bed. The resident's shared television was off. Resident 48 stated she/he wanted to get out of bed to attend activities and to go outside but staff did not help her/him to do so. Resident 48 further stated she/he enjoyed listening to music, especially '80s music, but she/he rarely had the opportunity to listen to this genre of music.-á On 2/24/26 at 11:42 AM, Resident 48 was observed awake in her/his room in bed. '70s music played on the resident's shared television. Resident 48 stated she/he was ""usually bored"" and she/he was interested in getting out of bed, but no staff had offered her/him the opportunity to do so. After this interaction, Resident 48 thanked the state surveyor for the visit.-á On 2/24/26 at 3:17 PM, Resident 48 was observed in room in bed. The resident's shared television played '70s music. Resident 48 stated she/he received a hand massage today, she/he enjoyed it and ""it had been a while"" since she/he last received one. Resident 48 asked the state surveyor to turn off the music as she/he was unable to do so independently.-á Random observations of Resident 48 on 2/25/26 from 8:58 AM to 2:38 PM revealed the resident to be awake in her/his room in bed. The shared television was off and no music played.-á -áOn 2/26/26 at 10:06 AM, Resident 48 was observed in her/his room and sat in her/his wheelchair. Rock music played loudly from the resident's shared television. Resident 48 stated she/he did not like the music.-á On 2/26/26 at 5:13 AM, Staff 23 (CNA) stated Resident 48 was not able to use the television remote independently, and she/he usually watched whatever program her/his roommate selected on their shared television.-á On 2/26/26 at 5:40 AM, Staff 32 (Agency LPN) stated he was unaware of Resident 48's activity preferences but would look in the resident's care plan to find this information. Staff 32 further stated he had seen the resident out of her/his room ""once or twice."" On 2/26/26 at 5:56 AM, Staff 33 (CNA) stated Resident 48 was usually in bed and she had not seen the resident out of her/his room for any activities. Staff 33 stated the resident was cooperative with care and did ""not refuse anything."" On 2/26/26 at 10:30 AM, Staff 14 (RN), stated Resident 48 got up in her/his wheelchair ""today for the first time in a long time."" Staff 14 stated the resident ""did not really do much,"" the resident's cognition varied, she/he was not able to express her/his wants or needs or self-initiate any activities. Staff 14 stated the resident's roommate picked which programs played on their shared television, the resident enjoyed being around others when alert, and she was unaware of any reports of the resident refusing care, including getting out of bed.-á On 2/26/26 at 1:28 PM, Staff 15 (CNA) stated Resident 48's ""alertness was on-and-off."" Staff 15 stated she was unsure if the resident liked music but thought the resident liked to have the television on, not to watch, but ""as background."" Staff 15 stated she did not know if the resident enjoyed being around others and she was unaware of any activity participation for the resident.-á On 2/27/26 at 10:23 AM, Staff 6 (CNA) stated Resident 48 alternated between days when she/he would sleep a lot and other days when she/he would be ""very alert and laughing."" Staff 6 stated the resident was cooperative with care on the days she/he was alert but staff ""did not typically get [the resident] out of bed.""-á On 2/27/26 at 10:32 AM, Staff 1 (Administrator), Staff 2 (DNS) and Staff 24 (MDS Coordinator-RN) were present for an interview. Staff 24 stated Resident 48 needed to be offered the opportunity to get out of bed as the resident did not request to do so, and they had never been made aware the resident refused to get out of bed. Staff 24 further stated the resident was ""such a social butterfly"" and she/he enjoyed ""being around people and around the building."" Staff 1 stated the resident was ""very much a people person."" On 2/27/26 at 11:44 AM, Staff 1 and Staff 26 (Activity Director) were present for an interview. Staff 26 stated residents who were able to self-initiate activities were residents who were ""very cognitive, outspoken"" and could ""self-advocate."" Staff 26 stated residents identified to receive one-to-one visits were those residents who could not self-initiate activities and/or did not attend group activities. Staff 26 stated her goal was to visit with residents who were identified as needing one-to-one visits ""a few times a week, and worse case, one time a week."" Staff 26 stated one-to-one visits were documented in the resident's progress notes when they occurred. Staff 26 stated Resident 48 was to receive one-to-one visits and she thought she visited with the resident ""maybe two-to-three times a month."" Staff 26 stated Resident 48 enjoyed watching crime shows on television but did not know how often she/he was able to do so as she was unsure if her/his roommate enjoyed these types of shows. Staff 26 stated the resident enjoyed '70s and '80s music but her/his roommate ""was not excited about it,"" so she provided Resident 48 with a personal radio on 2/27/26. Staff 26 stated Resident 48's cognition was ""not super,"" and her/his care plan was in need of revision. Staff 26 stated Resident 48 used to get up to play bingo and come out of her/his room, but she had not seen the resident do either in a while. Staff 26 stated she did not think the resident refused to get out of bed and the last time she invited the resident to an activity was around Christmas.-á

Corrective Actions Resident 48 was interviewed to identify his/her activities of interest on 03/13/2026. It was determined he/she would benefit from one-on-one activities to watch television, listen to music or be invited to bingo or other group activities. Resident 48’s tasks were updated to reflect these activity interests. Identification of Other Individuals All current residents who don’t participate in group activities were interviewed by 03/19/2026 to identify activities of interest. The resident tasks for each current resident was reviewed to validate that the care plan for each resident reflected the identified activities of interest. Any variances were remedied. Systemic Changes and Education The Administrator or Designee will educate Activity Directors and staff on the importance of interviewing residents to identify and provide activities of interest to each resident and updating each residents’ care plan to reflect these preferences. Education will be completed by 3/31/2026. Monitoring Activities Director or Designee will audit 10 random resident Activity care plans to validate accuracy and implementation weekly for x4 weeks, every other week for 4 weeks, then monthly x1 month or until substantial compliance is determined by the QAPI Committee. Effective Date of Compliance 03/31/2026

The facility's 4/9/25 Hearing Services Policy revealed the following: -The facility was to ensure all residents had access to hearing services and received adaptive equipment as indicated.-á -The social worker/designee was responsible for assisting residents in locating and utilizing any available resources for the provision of hearing services.-á -Once the need for hearing services was identified, the social worker/designee was to assist the resident to make appointments and arrange for transportation.-á Resident 1 was readmitted to the facility in 1/2025 with diagnoses including congestive heart failure.-á A 2/19/25 Audiogram (a graph that plots hearing thresholds to determine the type, degree and configuration of an individual's hearing loss) recommended Resident 1 receive a hearing aid consultation and her/his hearing to be retested in three months.-á Resident 1's 5/6/25 Care Plan revealed the following: -The resident was hard of hearing and did not wear hearing aids. -Conversations with the resident were best in a low volume environment.-á -Staff were to use a loud and clear voice.-á -The resident would ask the speaker to repeat as needed.-á -The resident preferred to keep the volume of her/his television loud as she/he was hard of hearing.-á A 7/23/25 and 10/16/25 Care Conference Meeting Note revealed Resident 1 expressed she/he could not hear out of her/his left ear and she/he wanted hearing aids.-á Resident 1's 1/11/26 Annual MDS revealed the resident was moderately cognitively impaired but was able to communicate with others without difficulty.-á A 1/8/26 Care Conference Meeting Note revealed Resident 1's left ear was ""fading"" and she/he needed hearing aids.-á No evidence was found in Resident 1's clinical record to indicate her/his hearing was retested or she/he received a hearing aid consultation.-á On 2/23/26 at 10:04 AM, Resident 1 was observed in her/his room in bed. The resident's television was on and could be heard from the hallway even with the door to her/his room closed. Resident 1 turned off the television and stated she/he could partially hear out of her/his right ear but could not hear at all out of her/his left ear. Resident 1 further stated she/he saw an audiologist ""about a year ago"" who recommended hearing aids but nothing was done with this recommendation.-á On 2/25/26 at 1:47 PM, Staff 31 (CNA) stated Resident 1's hearing was ""partial"" and that was why the resident's television volume was always up so high.-á On 2/26/26 at 5:10 AM, Staff 23 (CNA) stated Resident 1 could not hear on one side, so staff had to yell in order for her/him to hear. Staff 23 stated the volume of the resident's television was ""always over 100,"" and staff would ask the resident to reduce the television's volume during interactions in order for the resident to hear better.-á On 2/26/26 at 5:35 AM, Staff 32 (Agency LPN) stated Resident 1 was ""very hard of hearing,"" so much so, that the resident's television could be heard in the kitchen down the hall. Staff 32 stated he frequently repeated his communications to the resident because she/he could not hear.-á On 2/26/26 at 8:26 AM, Staff 14 (RN) stated Resident 1 ""always"" had complaints about her/his hearing.-á On 2/26/26 at 11:06 AM, Staff 9 (Social Services Director) stated hearing appointments were scheduled for residents ""as soon as possible"" after a hearing need was identified. Staff 9 stated she was unaware Resident 1 had an audiogram in 2/2025 and did not know the resident was interested in receiving hearing aids until 1/2026. Staff 9 stated the resident was on a list to be seen by a hearing provider but confirmed the resident had not received any follow up hearing appointments since her/his audiogram in 2/2025.-á On 2/26/26 at 11:49 AM, Staff 2 (DNS) stated hearing aid referrals should be followed up on ""as soon as possible,"" and Resident 1's hearing should have been retested in 5/2025.-á

Corrective Actions Resident 1 had an audiologist appointment attempt to schedule with her on 03/14/2026, resident refused. A second attempt to schedule an appointment was made on 03/19/2026. Identification of Other Individuals All current residents were assessed to determine whether their hearing and vision needs are met on 03/17/2026. Two residents were identified needing appointments, and referrals were faxed for appointments to be scheduled. Systemic Changes and Education Social Services Coordinator or Designee will educate clinical staff on reporting hearing or vision impairments so appropriate appointments can be scheduled. Education will be completed by 3/31/2026. Monitoring Social Services or Designee will inquire about hearing/vision needs during quarterly care plan meetings and schedule appointments as needed. Effective Date of Compliance 03/31/2026

2. Resident 48 was admitted to the facility in 10/2023 with diagnoses including repeated falls.-á Resident 48's 9/10/25 Fall Risk Care Plan revealed the following interventions: -An orange leaf was to be placed on the resident's name plate outside her/his room to alert staff the resident was at high risk to fall.-á -The bed was to be kept in the lowest position with the exception of providing care.-á -Fall mats were to be placed on both sides of the bed at all times with the exception of providing care.-á -A sign was to be used to remind the resident to use her/his call light and to wear non-skid socks.-á Resident 48's 1/21/26 Fall Risk Assessment revealed the resident was at moderate risk to fall.-á Resident 48's 1/25/26 Quarterly MDS revealed the resident experienced short-and-long term memory loss, was severely impaired for decision-making and dependent on assistance from staff for all ADL care.-á Random observations of Resident 48 from 2/23/26 to 2/26/26 between 5:47 AM and 3:17 PM revealed the resident to be in her/his room in bed. No orange leaf was observed on the resident's name plate outside of her/his room, no fall mats were in place on either side of the resident's bed and no sign was observed in the resident's room to remind her/him to use her/his call light and to wear non-skid socks. The door to the resident's room was either completely shut or slightly cracked open. The privacy curtain that separated Resident 48 from her/his roommate was always pulled as far as it could extend, so the resident was not visible from the hall even when the door was cracked open.-á On 2/26/26 at 5:13 AM, Staff 23 (CNA) stated Resident 48 was at risk to fall, so the resident's bed was to be in a low position with fall mats placed on both sides once care was complete. On 2/26/26 at 5:40 AM, Staff 32 (Agency LPN) stated Resident 48 was alert but experienced moments of confusion. Staff 32 stated he did not know if the resident was considered at risk to fall.-á On 2/26/26 at 5:56 AM, Staff 33 (CNA) stated Resident 48 was at risk to fall, and a ""sticker"" should be placed outside of the door to the resident's room to indicate she/he was at risk to fall. Staff 33 stated the resident was supposed to have fall mats in place at all times outside of care, the resident's door was to be open at all times and staff were to ""peak in"" every time they walked by the resident's room.-á On 2/26/26 at 10:30 AM, Staff 14 (RN) stated Resident 48's cognition varied, and at times, the resident would kick her/his legs out of bed as she/he believed she/he could get up and walk. Staff 14 stated the resident kicked her/his legs out of bed on 2/26/26 and told the CNAs she/he was going to walk out of the room. Staff 14 stated she had not seen fall mats used for Resident 48 since 6/2025, but she thought the resident was still at risk to fall. Staff 14 reviewed Resident 48's care plan and stated the resident should have an orange leaf placed outside of her/his room to indicate she/he was at risk to fall and confirmed the resident did not have an orange leaf in place. Staff 14 further stated residents who had an orange leaf placed outside of their room should have their door open at all times outside of providing care, and even with Resident 48's door open, the resident was unable to be visualized by staff as the privacy curtain was always fully extended between Resident 48 and her/his roommate. On 2/26/26 at 1:28 PM, Staff 15 (CNA) stated she found fall prevention interventions in resident care plans. Staff 15 stated an orange leaf outside of a resident's door indicated the resident was at risk to fall, and staff were to perform frequent checks on these residents. Staff 15 stated Resident 48 was to have fall mats on both sides of her/his bed in place, her/his door was to be propped open and the resident required frequent safety checks.-á On 2/27/26 at 10:32 AM, Staff 1 (Administrator), Staff 2 (DNS) and Staff 24 (MDS Coordinator-RN) were present for an interview. Staff 24 stated an orange leaf outside of a resident room indicated the resident was at risk to fall, and as a result, the door to the resident's room was to be open outside of care, the resident's bed was to be at a low level and staff were to complete frequent safety rounds on the resident. Staff 1, Staff 2 and Staff 24 stated Resident 48 was at risk to fall and confirmed her/his care plan was accurate. Staff 24 stated Resident 48 should have an orange leaf placed outside of the door to her/his room, fall mats should be in place on both sides of the bed outside of care and a sign should be available in the resident's room reminding her/him to use her/his call light. Staff 24 further stated the privacy curtain in Resident 48's room was always pulled, so staff would not be able to visualize the resident during safety rounds without going all the way into the resident's room.-á , The facility's undated Fall Prevention Program Policy revealed the following: -Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. -Interventions will be monitored for effectiveness, and the plan of care will be revised and needed.-á -When any resident experiences a fall, the facility will assess the resident, complete a post-fall assessment, complete an incident report, notify the physician and family, review the resident's care plan and update as indicated, document all assessments and actions and obtain witness statements in the case of injury.-á 1. Resident 74 was admitted to the facility in 10/2024 with diagnoses including left collarbone fracture with routine healing and unspecified fall. Resident 74GÇÖs 10/16/24 care plan indicated the resident was a moderate fall risk requiring two-staff participation to use toilet and two-staff participation for transfers.-á Resident 74GÇÖs 10/22/24 Admission MDS indicated the resident was cognitively intact and dependent on staff for toilet transfers.-á Review of Resident 74GÇÖs medical record following the 11/14/24 fall and hospital transfer indicated the resident did not return to the facility. The facilityGÇÖs 11/26/24 Discharge Summary for Resident 74 indicated the resident had a left ankle fracture as her/his final diagnosis. The 11/14/24 10:41 AM Fall Incident Report for Resident 74 indicated Staff 18 (Former Staff CNA) assisted the resident in transferring from the wheelchair to the toilet without assistance from another staff member. Staff 18 reported they attempted to transfer the resident to the toilet; however, the residentGÇÖs legs gave out and she/he was unable to stand. Staff 18 held the resident from behind and lowered her/him fully onto the floor and turned on the bathroom call light for help. At the time of the incident Resident 74 reported to Staff 18 her/his leg hurt. Staff 19 (Former Staff LPN) responded to Staff 18GÇÖs call for assistance, assessed Resident 74, and found no injuries at the time of the incident. -áAt approximately 1:00 PM Staff 27 (Nurse Practitioner) assessed Resident 74 at the facility and notified Staff 19 the residentGÇÖs left ankle was swollen and bruised.-á The 11/14/24 1:53 PM Nurse Progress Note indicated Staff 27 instructed Staff 19 to send Resident 74 to the Emergency Department. The resident left via medical transportation and Staff 20 (Former DNS) and Witness 2 (Family Member) were notified. Multiple attempts were made to reach Witness 1 (Complainant) for interview but were unsuccessful. On 2/24/26 at 5:16 PM Witness 2 (Family Member) stated Resident 74 was sent to the facility for care and rehabilitation following a fall at home. Witness 2 stated Resident 74 fell in the bathroom at the facility while being transferred to the toilet. Witness 2 stated Resident 74 was unable to bear her/his own weight at the time of the fall and indicated the resident was a two-person transfer. Witness 2 stated Resident 74 was transferred to the hospital following the fall and was found to have fractured her/his left ankle. Witness 2 stated Resident 74 told them the CNA who assisted with her/his toilet transfer had her/him stand without providing support and collapsed because no one was holding onto her/him. Witness 2 expressed they were frustrated Resident 74 had a fall at the facility.-á Multiple attempts were made to reach Staff 18 for interview but were unsuccessful. -á On 2/25/26 at 6:08 PM Staff 19 stated they did not remember Resident 74 or the fall and did not recall writing the incident report. No further information was provided by Staff 19. On 2/26/26 at 11:57 AM Staff 20 stated they investigated Resident 74GÇÖs fall and determined Staff 18 improperly transferred the resident to the toilet, resulting in a fall during which the resident sustained an ankle fracture. The fracture was concluded to be strongly correlated to the fall. Staff 20 stated Resident 74GÇÖs care plan indicated the resident required a two-person transfer assist for toileting. Staff 20 stated Staff 18 acknowledged they did not review Resident 74GÇÖs care plan, they were not aware the resident was a two-person transfer and performed a one-person transfer with the resident at the time of the incident. Staff 20 stated Staff 18 was placed on administrative leave following the incident.-á On 2/26/26 at 4:28 PM Staff 21 (Former Staffing Coordinator) stated they were witness to Staff 18GÇÖs interview. Staff 21 stated the investigation revealed Resident 74 was improperly transferred for toileting by Staff 18 resulting in a fall and the resident sustained an ankle injury. Staff 21 stated Staff 18 admitted they did not review Resident 74GÇÖs care plan, they did not know the resident was a two-person transfer for toileting, and they performed a one-person transfer with the resident at the time of the incident.-á On 2/27/26 at 9:28 AM Staff 2 (DNS) and Staff 16 (Infection Preventionist) stated they expected CNAs to review and follow residentsGÇÖ care plans. Staff 2 and Staff 16 reviewed Resident 74GÇÖs care plan and Fall Incident Report and acknowledged the care plan was not followed at the time of the fall. , 3. Resident 2 was admitted to the facility in 5/2024 with diagnoses including diabetes and history of falling. The 1/7/26 Significant Change MDS indicated Resident 2 was unable to complete the BIMS interview and was dependent on staff for mobility, transfers and was unable to ambulate. The 1/7/26 Fall Risk Assessment indicated Resident 2 was a moderate fall risk. The 5/30/24 Fall Care Plan indicated Resident 2 had a goal to be free from avoidable falls. A revision to the Fall Care Plan on 1/7/26 directed staff to ensure Resident 2GÇÖs bed was kept in the lowest position outside of cares. Observations on 2/24/26 at 11:45 AM and again at 2:34 PM revealed Resident 2 was lying in bed and the bed was not in the lowest position. Resident 2GÇÖs bed was between knee and waist height (approximately 2-3 feet). On 2/25/26 at 1:24 PM and 2/26/26 at 5:51 AM, Resident 2 was observed lying flat in bed asleep and the bed was not in the lowest position. Resident 2GÇÖs bed was at waist level (approximately 3 feet).-á On 2/25/26 at 1:19 PM, Staff 22 (CNA) stated Resident 2 was not a fall risk. Staff 22 was unaware of any fall precautions for Resident 2. On 2/26/26 at 9:48 AM Staff 25 (LPN) stated Resident 2 was not a fall risk. Staff 22 was unaware of any fall precautions for Resident 2. On 2/27/26 at 10:31 AM, Staff 24 (MDS coordinator-RN), Staff 2 (DNS), and Staff 1 (Administrator) confirmed Resident 2GÇÖs was a moderate fall risk and her/his care plan included intervention for her/his bed to be in the lowest position outside of cares. Staff 2 and Staff 1 both confirmed they would expect Resident 2GÇÖs care plan to be followed and her/his bed to be in the lowest position. Staff 1 confirmed the lowest position would be at approximately 18 inches. , The facility's undated Fall Prevention Program Policy revealed the following: -Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. -Interventions will be monitored for effectiveness, and the plan of care will be revised and needed.-á -When any resident experiences a fall, the facility will assess the resident, complete a post-fall assessment, complete an incident report, notify the physician and family, review the resident's care plan and update as indicated, document all assessments and actions and obtain witness statements in the case of injury.-á 1. Resident 74 was admitted to the facility in 10/2024 with diagnoses including left collarbone fracture with routine healing and unspecified fall. Resident 74GÇÖs 10/16/24 care plan indicated the resident was a moderate fall risk requiring two-staff participation to use toilet and two-staff participation for transfers.-á Resident 74GÇÖs 10/22/24 Admission MDS indicated the resident was cognitively intact and dependent on staff for toilet transfers.-á Review of Resident 74GÇÖs medical record following the 11/14/24 fall and hospital transfer indicated the resident did not return to the facility. The facilityGÇÖs 11/26/24 Discharge Summary for Resident 74 indicated the resident had a left ankle fracture as her/his final diagnosis. The 11/14/24 10:41 AM Fall Incident Report for Resident 74 indicated Staff 18 (Former Staff CNA) assisted the resident in transferring from the wheelchair to the toilet without assistance from another staff member. Staff 18 reported they attempted to transfer the resident to the toilet; however, the residentGÇÖs legs gave out and she/he was unable to stand. Staff 18 held the resident from behind and lowered her/him fully onto the floor and turned on the bathroom call light for help. At the time of the incident Resident 74 reported to Staff 18 her/his leg hurt. Staff 19 (Former Staff LPN) responded to Staff 18GÇÖs call for assistance, assessed Resident 74, and found no injuries at the time of the incident. -áAt approximately 1:00 PM Staff 27 (Nurse Practitioner) assessed Resident 74 at the facility and notified Staff 19 the residentGÇÖs left ankle was swollen and bruised.-á The 11/14/24 1:53 PM Nurse Progress Note indicated Staff 27 instructed Staff 19 to send Resident 74 to the Emergency Department. The resident left via medical transportation and Staff 20 (Former DNS) and Witness 2 (Family Member) were notified. Multiple attempts were made to reach Witness 1 (Complainant) for interview but were unsuccessful. On 2/24/26 at 5:16 PM Witness 2 (Family Member) stated Resident 74 was sent to the facility for care and rehabilitation following a fall at home. Witness 2 stated Resident 74 fell in the bathroom at the facility while being transferred to the toilet. Witness 2 stated Resident 74 was unable to bear her/his own weight at the time of the fall and indicated the resident was a two-person transfer. Witness 2 stated Resident 74 was transferred to the hospital following the fall and was found to have fractured her/his left ankle. Witness 2 stated Resident 74 told them the CNA who assisted with her/his toilet transfer had her/him stand without providing support and collapsed because no one was holding onto her/him. Witness 2 expressed they were frustrated Resident 74 had a fall at the facility.-á Multiple attempts were made to reach Staff 18 for interview but were unsuccessful. -á On 2/25/26 at 6:08 PM Staff 19 stated they did not remember Resident 74 or the fall and did not recall writing the incident report. No further information was provided by Staff 19. On 2/26/26 at 11:57 AM Staff 20 stated they investigated Resident 74GÇÖs fall and determined Staff 18 improperly transferred the resident to the toilet, resulting in a fall during which the resident sustained an ankle fracture. The fracture was concluded to be strongly correlated to the fall. Staff 20 stated Resident 74GÇÖs care plan indicated the resident required a two-person transfer assist for toileting. Staff 20 stated Staff 18 acknowledged they did not review Resident 74GÇÖs care plan, they were not aware the resident was a two-person transfer and performed a one-person transfer with the resident at the time of the incident. Staff 20 stated Staff 18 was placed on administrative leave following the incident.-á On 2/26/26 at 4:28 PM Staff 21 (Former Staffing Coordinator) stated they were witness to Staff 18GÇÖs interview. Staff 21 stated the investigation revealed Resident 74 was improperly transferred for toileting by Staff 18 resulting in a fall and the resident sustained an ankle injury. Staff 21 stated Staff 18 admitted they did not review Resident 74GÇÖs care plan, they did not know the resident was a two-person transfer for toileting, and they performed a one-person transfer with the resident at the time of the incident.-á On 2/27/26 at 9:28 AM Staff 2 (DNS) and Staff 16 (Infection Preventionist) stated they expected CNAs to review and follow residentsGÇÖ care plans. Staff 2 and Staff 16 reviewed Resident 74GÇÖs care plan and Fall Incident Report and acknowledged the care plan was not followed at the time of the fall. -á 2. Resident 48 was admitted to the facility in 10/2023 with diagnoses including repeated falls.-á Resident 48's 9/10/25 Fall Risk Care Plan revealed the following interventions: -An orange leaf was to be placed on the resident's name plate outside her/his room to alert staff the resident was at high risk to fall.-á -The bed was to be kept in the lowest position with the exception of providing care.-á -Fall mats were to be placed on both sides of the bed at all times with the exception of providing care.-á -A sign was to be used to remind the resident to use her/his call light and to wear non-skid socks.-á Resident 48's 1/21/26 Fall Risk Assessment revealed the resident was at moderate risk to fall.-á Resident 48's 1/25/26 Quarterly MDS revealed the resident experienced short-and-long term memory loss, was severely impaired for decision-making and dependent on assistance from staff for all ADL care.-á Random observations of Resident 48 from 2/23/26 to 2/26/26 between 5:47 AM and 3:17 PM revealed the resident to be in her/his room in bed. No orange leaf was observed on the resident's name plate outside of her/his room, no fall mats were in place on either side of the resident's bed and no sign was observed in the resident's room to remind her/him to use her/his call light and to wear non-skid socks. The door to the resident's room was either completely shut or slightly cracked open. The privacy curtain that separated Resident 48 from her/his roommate was always pulled as far as it could extend, so the resident was not visible from the hall even when the door was cracked open.-á On 2/26/26 at 5:13 AM, Staff 23 (CNA) stated Resident 48 was at risk to fall, so the resident's bed was to be in a low position with fall mats placed on both sides once care was complete. On 2/26/26 at 5:40 AM, Staff 32 (Agency LPN) stated Resident 48 was alert but experienced moments of confusion. Staff 32 stated he did not know if the resident was considered at risk to fall.-á On 2/26/26 at 5:56 AM, Staff 33 (CNA) stated Resident 48 was at risk to fall, and a ""sticker"" should be placed outside of the door to the resident's room to indicate she/he was at risk to fall. Staff 33 stated the resident was supposed to have fall mats in place at all times outside of care, the resident's door was to be open at all times and staff were to ""peak in"" every time they walked by the resident's room.-á On 2/26/26 at 10:30 AM, Staff 14 (RN) stated Resident 48's cognition varied, and at times, the resident would kick her/his legs out of bed as she/he believed she/he could get up and walk. Staff 14 stated the resident kicked her/his legs out of bed on 2/26/26 and told the CNAs she/he was going to walk out of the room. Staff 14 stated she had not seen fall mats used for Resident 48 since 6/2025, but she thought the resident was still at risk to fall. Staff 14 reviewed Resident 48's care plan and stated the resident should have an orange leaf placed outside of her/his room to indicate she/he was at risk to fall and confirmed the resident did not have an orange leaf in place. Staff 14 further stated residents who had an orange leaf placed outside of their room should have their door open at all times outside of providing care, and even with Resident 48's door open, the resident was unable to be visualized by staff as the privacy curtain was always fully extended between Resident 48 and her/his roommate. On 2/26/26 at 1:28 PM, Staff 15 (CNA) stated she found fall prevention interventions in resident care plans. Staff 15 stated an orange leaf outside of a resident's door indicated the resident was at risk to fall, and staff were to perform frequent checks on these residents. Staff 15 stated Resident 48 was to have fall mats on both sides of her/his bed in place, her/his door was to be propped open and the resident required frequent safety checks.-á On 2/27/26 at 10:32 AM, Staff 1 (Administrator), Staff 2 (DNS) and Staff 24 (MDS Coordinator-RN) were present for an interview. Staff 24 stated an orange leaf outside of a resident room indicated the resident was at risk to fall, and as a result, the door to the resident's room was to be open outside of care, the resident's bed was to be at a low level and staff were to complete frequent safety rounds on the resident. Staff 1, Staff 2 and Staff 24 stated Resident 48 was at risk to fall and confirmed her/his care plan was accurate. Staff 24 stated Resident 48 should have an orange leaf placed outside of the door to her/his room, fall mats should be in place on both sides of the bed outside of care and a sign should be available in the resident's room reminding her/him to use her/his call light. Staff 24 further stated the privacy curtain in Resident 48's room was always pulled, so staff would not be able to visualize the resident during safety rounds without going all the way into the resident's room.-á -á 3. Resident 2 was admitted to the facility in 5/2024 with diagnoses including diabetes and history of falling. The 1/7/26 Significant Change MDS indicated Resident 2 was unable to complete the BIMS interview and was dependent on staff for mobility, transfers and was unable to ambulate. The 1/7/26 Fall Risk Assessment indicated Resident 2 was a moderate fall risk. The 5/30/24 Fall Care Plan indicated Resident 2 had a goal to be free from avoidable falls. A revision to the Fall Care Plan on 1/7/26 directed staff to ensure Resident 2GÇÖs bed was kept in the lowest position outside of cares. Observations on 2/24/26 at 11:45 AM and again at 2:34 PM revealed Resident 2 was lying in bed and the bed was not in the lowest position. Resident 2GÇÖs bed was between knee and waist height (approximately 2-3 feet). On 2/25/26 at 1:24 PM and 2/26/26 at 5:51 AM, Resident 2 was observed lying flat in bed asleep and the bed was not in the lowest position. Resident 2GÇÖs bed was at waist level (approximately 3 feet).-á On 2/25/26 at 1:19 PM, Staff 22 (CNA) stated Resident 2 was not a fall risk. Staff 22 was unaware of any fall precautions for Resident 2. On 2/26/26 at 9:48 AM Staff 25 (LPN) stated Resident 2 was not a fall risk. Staff 22 was unaware of any fall precautions for Resident 2. On 2/27/26 at 10:31 AM, Staff 24 (MDS coordinator-RN), Staff 2 (DNS), and Staff 1 (Administrator) confirmed Resident 2GÇÖs was a moderate fall risk and her/his care plan included intervention for her/his bed to be in the lowest position outside of cares. Staff 2 and Staff 1 both confirmed they would expect Resident 2GÇÖs care plan to be followed and her/his bed to be in the lowest position. Staff 1 confirmed the lowest position would be at approximately 18 inches.

Corrective Actions Resident 74 discharged from the facility on 11/14/2024. Resident 48 has been reevaluated and found that she is not a fall risk due to inability to roll over or get out of bed. Care plan updated on 3/17/2026. Resident 2’s care plan has been reviewed and resident is able to have bed at residents preferred height. Identification of Other Individuals The care plans for all current residents were reviewed on 03/19/2026 to validate that each care plan includes the level of assistance required for transfers. Any necessary changes were updated on the care plans. Systemic Changes and Education Director of Nursing or Designee will educate clinical staff about ensuring the transfer status on each resident’s care plan is current and updated so ensure safe transfers of residents according to their individual needs. Education will be completed by 3/31/2026. Monitoring Director of Nursing or Designee will review the care plans for 10 random residents to validate the transfer status has been updated and remains appropriate to the reviewed residents’ individual needs twice weekly for x4 weeks, weekly x4 weeks, then every other week x1 month or until substantial compliance is determined by the QAPI Committee. The Director of Nursing or Designee will observe the transfer to 10 random residents to validate that staff are transferring the resident as stated on the residents’ care plan twice weekly for x4 weeks, weekly x4 weeks, then every other week x1 month or until substantial compliance is determined by the QAPI Committee. Effective Date of Compliance 03/31/2026

A review of personnel records on 2/26/26 indicated the following employees had not received their annual performance evaluations: -Staff 5 (CNA), hired date was 6/1989 and a performance review was not completed. -Staff 10 (CNA), hired date was 12/2024 and a performance review was not completed. -Staff 11 (CNA), hired date was 5/2024 and a performance review was not completed. -Staff 12 (CNA), hired date was 12/2022 and a performance review was not completed. -Staff 13 (CNA), hired date was 7/2002 and a performance review was not completed. On 2/26/26 at 2:59 PM Staff 29 (HR Assistant) stated she was unable to locate the most recent annual performance reviews for Staff 5, Staff 10, Staff 11, Staff 12, and Staff 13 and was unsure if they were completed for Staff 5, Staff 10, Staff 11, Staff 12, and Staff 13.-á On 2/27/2026 at 12:30 PM Staff 1 (Administrator) expected the annual performances to completed and confirmed annual performance reviews were not completed for Staff 5, Staff 10, Staff 11, Staff 12, and Staff 13.-á

Corrective Actions The CNA staff reviews for CNA 5, 10, 11, 12, and 13 were completed by 03/13/2026. Identification of Other Individuals Human Resource Director completed a review of the staffing records for all current CNA staff on 03/06/2026 to identify CNAs who have been employed by Friendship Health Center for 12 months or longer. Those staff found without an annual review were completed by 03/13/2026. Systemic Changes and Education Human Resource Director or Designee will educate clinical leadership of the importance of completing timely performance reviews one month prior to the annual hire date for CNA’s. Education was completed by 3/6/2026. Human Resources Director or Designee will also notify clinical leadership of timely performance reviews one month prior to the annual hire date for CNA’s. Monitoring Human Resource Director or Designee will provide a list of CNAs to the Director of Nurses or Designee two months prior to the CNAs annual hire date. The Director of Nurses or Designee will complete the CNA annual review the month prior to the annual hire date. The Human Resource Director or Designee will complete a monthly audit to validate CNA annual reviews are begin completed prior to the annual hire date. The Human Resource Director or Designee will complete random audits of CNA staff files to validate annual reviews are being completed prior to the annual hire date monthly x3 months or until sufficient compliance has been determined by the QAPI Committee. Effective Date of Compliance 03/31/2026

A review of the Direct Care Staff Daily Reports (DCSDR) from 1/23/26 through 2/23/26 revealed 11 of 30 days when portions of the form were left blank or were inaccurate. The incomplete or inaccurate information included daily census and the number of working staff. The dates included: -1/28/26-á -2/4/26-á -2/5/26-á -2/6/26-á -2/9/26-á -2/10/26-á -2/11/26-á -2/14/26-á -2/18/26-á -2/19/26-á -2/20/26-á On 2/27/26 at 9:11 AM Staff 15 (Staffing Coordinator) stated the lead CNAs were trained to fill in the DCSDRs and a nurse reviewed and signed the report before it was posted for each shift. Staff 15 acknowledged the DCSDRs were incomplete and inaccurate for the identified dates.-á On 2/27/2026 at 12:30 PM Staff 1 (Administrator) expected the posted DCSDRs were accurate for each shift.-á

Corrective Actions Lead CNA’s and Staffing Coordinator were educated on 3/17/2026 about the need to complete accurate posting for each shift of each day. Identification of Other Individuals Not applicable. Systemic Changes and Education Director of Nursing Services or Designee have provided a task reminder to Lead CNA’s to post nurse staffing information each shift each day on 3/17/2026. Administrator reviewed with key clinical leaders on the importance of nurse staff information postings each day for each shift on 3/6/2026. Additional key staff will have training by 3/31/2026. Monitoring Director of Nursing Services or Designee will complete nurse staff information posting audit 1 X week for 4 weeks, every other week for 2 weeks and once a month for one month or until substantial compliance is determined by the QAPI Committee. Effective Date of Compliance 03/31/2026

-á 2. On 2/23/26 at 9:25 AM, Staff 34 (RN) was observed to leave the medication cart in the D Hall unlocked and unattended where multiple staff were present. At 9:29 AM, Staff 34 returned to the cart and stated it should be locked at all times when not in use. Staff 34 revealed the contents of the cart to include all medications for residents in rooms 180 through 188, insulin pens, bowel care medications, prescription inhalers, eye drops, over-the-counter pain medications and supplements.-á On 2/26/26 at 6:00 AM, Staff 32 (Agency LPN) stated the medication cart should always be locked when not in use. On 2/26/26 at 10:32 AM, Staff 2 (DNS) stated she expected medication carts to be locked any time they were unattended.-á -á , The facilityGÇÖs 4/2025 Medication Storage Policy revealed the following: -All drugs and biologicals were to be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medications rooms) under proper temperature controls.-á -Refrigerated products were to be maintained at temperatures between 36 degrees F and 46 degrees F. -Unused medications that were outdated were to be destroyed. 1. The 2013 insulin lispro (HumaLOG) Kwikpen manufacturer instructions for storage and handling indicated unopened insulin pens should be stored in the refrigerator between 36 degrees F and 46 degrees F, and once opened, the pens should be discarded after 28 days. The 2018 insulin Humulin 70/30 Kwikpen manufacturer instructions for storage and handling indicated unopened insulin pens should be stored in the refrigerator between 36 degrees F and 46 degrees F, and once opened, pens should be discarded after 10 days. On 2/24/26 at 2:01 PM the 100 floor B wing medication cart was observed to have an unopened insulin lispro (HumaLOG) Kwikpen in a drawer.-á On 2/24/26 at 2:01 PM Staff 30 (LPN) confirmed the unopened insulin pen was in the medication cart and stated it should be refrigerated until it was opened.-á On 2/25/26 at 9:06 AM the 200 floor D wing medication cart was observed to have an open humulin 70/30 (NovoLOG) Kwikpen without an open date and one bottle of MaxTussin congestion expectorant with an expiration date of 11/2025 in its drawers. On 2/26/26 at 9:06 AM Staff 17 (RN) confirmed the open and undated insulin pen and expired expectorant. Staff 17 stated, once opened, insulin is generally good for 28 days but varied depending on the type of insulin and insulin pens should be labeled with an open date; additionally, Staff 17 stated the expired medication should have been removed and discarded. On 2/26/26 at 10:32 AM Staff 2 (DNS) confirmed unopened insulin was to be refrigerated and should not be stored in the medication carts. Additionally, Staff 2 stated once insulin is opened, it should be dated with an open date, as insulin was generally good for only 28 days after opening, but varied depending on the type of insulin. Staff 2 further stated expired medications should not be stored in the medication carts and should be promptly removed and destroyed.-á

Corrective Actions Expired medications were removed from medication carts by 2/27/2026. Insulin pens not opened and not dated were removed from the carts by 2/27/2026. Agency Nurse was educated on importance of locking medication carts when not at arms length of medication cart by 3/17/2026. Identification of Other Individuals On 3/18/2026 the ADNS and the IP Nurse reviewed each of the medication carts for any expired or improperly stored medications, as well as carts are locked. None were found at that time. Systemic Changes and Education During routine rounding, the IP Nurse or Designee shall include checks of medication carts to validate expired meds have been removed and returned to pharmacy or destroyed and medication carts are locked. IP Nurse or designee to provide education to licensed nurses and CMA’s about medication carts to be free from expired medications or previous residents meds and medication carts are locked. The education will be completed by 03/31/2026. Monitoring IP Nurse or designee to perform audits to confirm medication carts are free from expired medications or previous residents. Audits will be conducted once a week for 4 weeks, every other week for 4 weeks and once per month for 1 month. Results will be shared with QAPI until substantial compliance is achieved. Effective Date of Compliance 03/31/2026

Findings: Resident 1 Review of the medical record indicated that R1 was admitted on 10/7/25 with diagnosis including fracture of unspecified part of neck of right femur, unspecified severe protein-calorie malnutrition, and adult failure to thrive and need assistance with personal care. Review of R1GÇÖs progress notes dated 10/08/25 indicated that R1 GÇ£was concerned about returning home.GÇ¥ Review of Care Conference notes dated 10/14/25 indicated that R1 lives in RV (recreational vehicle) park (a designated area where RV owners can park and stay) with her dog. R1 was GÇ£concerned about cookingGÇ¥ because R1 GÇ£canGÇÖt see.GÇ¥ The notes also indicated that R1's friend was ""helping clean her trailer and has taken care of the bug infestation.GÇ¥ Review of progress notes dated 10/15/25 indicated R1 GÇ£lives independently but in unsafe situations may need placement; a close neighbor is her next of kin, who is now moving away.GÇ¥ Review of Social Services progress notes dated 10/17/25 indicated that Social Services staff called Multnomah County APS (Adult Protective Services) regarding R1GÇÖs unsafe discharge due to GÇ£cockroach infested trailer, lack of running water, no electricity.GÇ¥ According to the notes, APS suggested resident to GÇ£looks into assistive livingGÇ¥ and GÇ£have resident call ADRC ( Aging and Disability Resource Connection ) for assistance with fumigation.GÇ¥ Review of Discharge Evaluation notes dated 10/17/25 indicated that R1 GÇ£is missing her dog very much and would like to be home.GÇ¥ Review of Nurses notes dated 10/19/25 indicated GÇ£Resident [R1] was discharged today as planned. She went home using her walker and was pick up in front of the hospital by her friendGǪGÇ¥ Review of Discharge Instruction Tool indicated that R1 was discharged on 10/19/25 at 6AM with in home care included Physical Therapy, Occupational Therapy, Wound Care, Social Work referral and APS referral. Discharge instructions were provided to R1. Review of R1GÇÖs care plan did not include an individualized discharge plan. In an interview on 01/06/26 at 11:31 AM, the Social Services Coordinator (SSC) 2 stated that she started working with the facility last November 2025. R1GÇÖs care plan was reviewed and SSC2 confirmed that there was no discharge care plan developed for R1. SSC2 stated, GÇ£Care planning is developed right after admission because you never know what will happen and we want to be prepared to discharge resident safely according to their goals.GÇ¥ In an interview on 01/06/26 at 11:38 AM, the Administrator stated that R1 is GÇ£not safe to go home. We told her she cannot, but she said she wants to go home because she has a dog.GÇ¥ The Administrator added that the facility GÇ£found out about the bed bugs when someone brought clothing with bed bugsGÇ¥ and it prompt SSC1 to report the R1GÇÖs housing situation to APS. In an interview and concurrent record review on 01/06/26 at 11:51 AM, the Director of Nursing Services (DNS) stated, GÇ£(R1) wanted to return home to see her dog. She has poor vision. She could not really see. We encouraged her to go to ALF [Assisted Living Facility] but sheGÇÖs persistent to go home.""-áReview of R1GÇÖs medical record and confirmed with DNS and SSC2, revealed no documentation that the facility contacted or followed up with APS and/or ADRC to verify resolution of the reported cockroach and bed bug infestation and lack of utilities in R1GÇÖs RV before discharge on 10/19/25 to ensure a safe transition. Additionally, no documentation of risk discussion, refusal-of-care process, or confirmation of environmental safety. Resident 2 R2 medical record review showed that the resident was admitted on 10/15/25 and was discharged home with home health services on 10/27/25. Review of R2GÇÖs care plan with the DNS on 01/06/26 at 2:16 PM revealed R2GÇÖs care plan did not include a discharge plan that address the residentGÇÖs stated discharge goals or identify follow-up care, medications, or services required after discharge. The DNS confirmed a comprehensive discharge plan was not developed prior to R2GÇÖs discharge. Resident 3 R3 medical record review showed that the resident was admitted on 10/16/25 and was discharged to assisted living on 10/27/25. Review of R3GÇÖs care plan with the DNS on 01/06/26 at 2:25 PM revealed R3GÇÖs care plan did not include a discharge plan that addresses the residentGÇÖs stated discharge goals or identify follow-up care, medications, or services required after discharge. The DNS confirmed a comprehensive discharge plan was not developed prior to R3GÇÖs discharge. Review of the facility policy titled Discharge Planning Process dated 04/08/25 indicated, GÇ£Discharge planning is a process that generally begins on admission and involves identifying each residentGÇÖs discharge goals and needs, developing and implementing interventions to address them, and continuously evaluating them throughout the residentGÇÖs stay to ensure a successful discharge.GÇ¥ Procedures included the following but not limited to: GÇ£1. The facility will support each resident in the exercise of his or her right to participate in his or her care and treatment, including planning for discharge. 2. The facility will determine the resident's expected goals and outcomes regarding discharge upon admission, routinely in accordance with the MDS assessment cycle, and as needed. a.Initial information and discharge goals will be included in the resident's baseline care plan. b. Subsequent assessment of information and discharge goals will be included in the resident's comprehensive plan of care. 3. If discharge to community is determined to not be feasible, the facility will document in the clinical record who made the determination and why. 4. In cases where the resident wishes to be discharged to a setting that does not appear to meet his or her post-discharge needs, or appears unsafe, the interdisciplinary team will treat this situation similarly to refusal of care: a. Discuss with the resident, {and/or his or her representative, if applicable) and document the implications and/or risks of being discharged to a location that is not equipped to meet his/her needs and attempt to ascertain why the resident is choosing that location. b. Offer other, more suitable options of locations that are equipped to meet the needs of the residents. Document any discussions related to the options presented. c. Document refusals of other options that could meet the residentsGÇÖ needs. d. At time of discharge, follow policies regarding discharges Against Medical Advice, and refer to Adult Protective Services, as necessaryGǪ 7. The ongoing process of developing the discharge plan will include a regular re-evaluation of the resident to identify changes that require modification of the discharge plan, and updating of the discharge plan, as needed, to reflect the modificationsGǪ9. The facility will update a resident's comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entitiesGǪGÇ¥ Review of facility policy titled, GÇ£Comprehensive Care PlansGÇ¥ dated 09/13/24 indicated, GÇ£3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the residentsGÇÖ highest practicable physical, mental, and psychosocial well-being. b. Any services that would otherwise be furnished, are not provided due to the resident's exercise of his or her right to refuse treatment. c. Any specialized services or specialized rehabilitation services the nursing facility will provide as a result of PASARR recommendations. d. The residentsGÇÖ goals for admission, desired outcomes, and preferences for future discharge. e. Discharge plans, as appropriateGǪGÇ¥

Plan of Correction (POC) Disclaimer Statement: The plans of correction below reflect required responses to the alleged deficiencies cited by surveyors from Center for Medicare and Medicaid Services (CMS). Any alleged deficient practices cited are the sole perspective of the CMS surveyors and do not reflect the culmination of overall daily practices and care at Friendship Health Center. CMS surveyor's statements and alleged deficiencies do not reflect the opinion, viewpoint, or assessment of Friendship Health Center. Plans of corrections submitted by Friendship Health Center are not an admission of guilt nor confirmation to the allegations of deficient practice cited by CMS surveyors. Friendship Health Center welcomes inquiries and is available to discuss alleged deficiencies cited to provide additional context and insight consistent with Friendship Health Center 's assessment and perspective of alleged deficiencies. Corrective Actions Resident R1 was reviewed for discharge plan. The resident voiced concerns about returning home and was noted in the progress note, but not in the care plan. Despite encouraging resident to stay at facility until clinically safe, resident chose to return home. APS was contacted by facility for resident safety. Home health was arranged but refused by resident. Follow up phone call was not made to resident after discharge. Resident R2 and R3 did not have discharge goal noted in the care plan. Both were discharged home with home health and/or DME. Neither has a follow up phone call after discharge. Identification of Other Individuals A review of residents in facility and discharge goals were added to care plans beginning the week of 1/6/2026. Recent resident who discharged from the facility were contacted by phone or left messages to ensure safety of the residents. Systemic Changes and Education New residents and readmissions will have discharge goals included in care plan as appropriate (long-term residents will state the plan to remain at FHC). Documentation will be completed for a) discharge orders, b) home health and durable medical equipment orders, and c) follow up call/message for discharged residents. Discharge Policy and Procedure will be updated to reflect systemic changes. Director of Nursing Services or Designee will ensure baseline care plans have discharge goals. MDS or Designee will ensure comprehensive care plans include discharge goals. Social Services Coordinator or Designee will document a) discharge orders, b) home health and durable medical equipment orders, and c) follow up call/message for discharged residents. Monitoring The Social Services Coordinator or Designee will audit 1) discharge goals in care plans, 2) documentation confirming orders were received by outside entities, and 3) follow up call/message provided to each discharged resident weekly for x4 weeks, every other week for 4 weeks, then monthly x1 month or until substantial compliance is determined by the QAPI Committee. Effective Date of Compliance 02/28/2026

Based on observation, interview and record review, it was determined the facility failed to assess and conduct weekly wound evaluations for pressure ulcer care for 1 of 3 sampled residents (#3) reviewed for pressure ulcers. This placed residents at an increased risk for delayed healing and inadequate treatment. Findings include: Resident 2 was admitted to the facility in 7/2024, with diagnoses including atherosclerosis of the arteries (build up of plaque in the arteries, narrowing them and reducing blood flow), diabetes, hypertension, chronic heart failure and atrial fibrillation. On 2/27/25 at 9:25 AM, 12:38 PM, and on 2/28/25 at 8:25 AM, Resident 2 was observed sitting in her/his electric wheelchair in her/his room or through the facility. Resident 2 was pleasant, alert and oriented with clear speech. On 2/28/25 at 10:32 AM, RN surveyor observed Resident 2's pressure ulcer located on her/his right buttock, ischial area (lower part of the pelvis) to be closed, smaller than the size of a penny, reddened area. Resident 2's 1/26/25 Weekly Skin Evaluation identified the resident had a right buttock pressure ulcer, 0.25 x 0.25 x 0.0 cm, with no drainage. The stage of the wound was not identified. Resident 2's 1/29/25 Progress Note indicated the resident has open excoriation to the right ischium which has declined and the wound was open., with defined wound edges and measuring 0.4 x 0.5 x 0.0 cm. The wound bed is 100% slough, no serous drainage (a clear, thin, watery fluid that is released from a wound) noted. The open wound appears pressure related and suspected to be an unstageable pressure injury. There was no documented evidence weekly skin evaluations were conducted until 2/16/25, 17 days after 1/29/25. Subsequent weekly skin evaluations on 2/5/25 and 2/12/25 were not conducted. Resident 2's Weekly Skin Evaluations found the following: -2/16/25: Right gluteal fold, pressure. Right buttock pressure injury, clean with wound cleanser, skin prep surrounding skin, cover with a foam dressing every day until resolved. -2/23/25: Wound to right buttock. Moisture associated skin damage (MASD) to right and left quadrant. Dressing to right buttock dry and intact. The Weekly Skin assessments for 2/16/25 and 2/23/25 did not identify the stage of the pressure ulcer, include measurements, or provide a description of the wound. On 2/27/25 at 1:54 PM, Staff 2 (RN/Wound Nurse) stated Resident 2 has a Stage 3 on her/his buttocks due to the resident not wanting to get out of her/his electric wheelchair. Staff stated we encourage the resident to get off her/his buttocks, but the resident prefers to be up in her/his wheelchair. On 2/28/25 at 8:31 AM, Staff 4 (CNA) stated Resident 2 was independent with her/his ADLs and was always in her/his electric wheelchair. In an interview on 2/28/25 at 11:06 AM, Staff 1 (DNS), stated she would expect weekly skin assessments to be conducted and to have a wound staged, measured and description provided on the skin evaluations. Staff stated she had ordered a wheelchair cushion for the resident, but she/he removes the cushion and places it in her/his manual wheelchair.

This plan of correction is prepared and submitted as required by law. By submitting this Plan of Correction, Friendship Health Center does not admit the citations listed on the CMS 2567 exists, nor denies. The facility reserves the right to challenge in legal and/or regulatory or Corrective Actions Resident 2 had notes of pressure injury that resolved on 12/4/2024. Nurse continued to document about the wound after it resolved. Nurse making notes was educated to document skin assessments until wound resolved, then accurately document weekly per regulations. Identification of Others A review of other residents with high potential for potential skin breakdown was completed by DNS on 03/13/2025. Five additional residents at-risk for wounds were identified for potential wound care needs. Each care plan is up to date and being followed. Notes are accurate and complete. Systemic Changes and Education DNS or designee to educate nursing staff beginning 03/19/2025 how to properly document wound assessment each week per regulations. DNS or designee will complete training by 03/31/2025. Monitoring DNS or designee to audit charts for wound care patients to ensure proper documentation of wound assessments are completed. Audits will be once a week for one for 4 weeks, then twice a month for 1 month and once a month for 1 month. Results will be shared with QAPI until substantial compliance is achieved. Date of Compliance 03/31/2025

************************ OAR 411-086-0140 - Nursing Services: Problem Resolution and Preventive Care Refer to F686 ************************

Based on observation, interview and record review it was determined the facility failed to ensure dignified language was used to address residents and their equipment for 1 of 1 facility and 1 of 2 sampled residents (#14) reviewed for dignity. This placed residents at risk for a decreased quality of life. Findings include: The Alzheimer's Association's Greater Missouri Chapter's 7/2017 "Person Centered Care in Nursing Homes and Assisted Living" revealed language is important in the change to person centered care. Language can either support change efforts or undermine them. Concepts of personalization and relationship-building cannot take root when a resident requiring assistance at mealtime is referred to as a "feeder" or when the act of walking is referred to as "ambulation." Purposeful lives unfold in communities, not in "facilities." The widely used language of long-term care continues to reflect an institutional orientation. Part of a change effort must be thoughtful consideration of the words and expressions used to describe the care provided and the way people and spaces are referred to in long term care communities. 1. On 10/7/24 at 11:54 AM three metal meal tray carts on the facility's second floor and on 10/15/24 at 10:47 AM one metal meal tray cart on the facility's first floor were observed with a sign posted on each above an open container that read: "For bibs/cloth protectors and green wipes only." On 10/15/24 at 9:13 AM Staff 1 (Administrator) acknowledged the findings and did not provide any additional information. 2. Resident 14 was admitted to the facility in 12/2020 with diagnoses including Parkinson's disease (a chronic brain disorder that causes movement problems, mental health issues and other health concerns). A 9/16/24 Progress Note revealed Resident 14 was identified as a "1:1 feeder." On 10/7/24 at 1:04 PM an unidentified CNA entered Resident 14's room with the resident's meal tray and stated the resident "was a feeder." On 10/14/24 at 10:48 AM Staff 26 (CNA) stated the facility used the term "feeder" to describe residents who needed supervision at mealtimes and Resident 14 was considered a feeder. On 10/15/24 9:13 AM Staff 1 (Administrator) acknowledged the findings and did not provide any additional information.

This plan of correction is prepared and submitted as required by law. By submitting this Plan of Correction, Friendship Health Center does not admit the citations listed on the CMS 2567 exists, nor denies. The facility reserves the right to challenge in legal and/or regulatory or administrative proceedings the deficiency, statements, facts and conclusions that form the alleged citations. Corrective Actions Signs noting “Bibs” were removed on 10/14/2024. Staff caring for Resident #14 on 10/14/24 received 1:1 education from DNS regarding the importance of using dignified language with residents and in reference to items used to care for residents. Identification of Other Individuals An inspection of all resident care area was completed on 10/15/2024 to validate that no other signs containing undignified words or phrases was in use. No other signage was identified. Systemic Changes and Education Clinical, laundry, kitchen, and environmental staff will be educated by 11/30/24 on the importance of using dignified language with residents and in reference to items to care for residents. Monitoring DNS or designee will complete random rounds on varying days and shifts to validate that staff are using dignified language with residents 2x/week x2 weeks, weekly x4 weeks, then every other week x4 weeks or until substantial compliance is determined by the QAPI Committee. Effective Date of Compliance 11/30/2024

Based on interview and record review it was determined the facility failed to obtain consents for the use of psychotropic medications for 2 of 6 sampled residents (#s 1 and 77) reviewed for medications. This placed residents at risk for the loss of the right to decline the use of psychotropic medications. Findings include: 1. Resident 1 was admitted to the facility in 5/2024 with a diagnosis of severe malnutrition. An 8/26/24 quarterly MDS revealed Resident 1 was cognitively intact. A 10/2024 MAR revealed Resident 1 was administered the following psychotropic medications: -Sertraline (antidepressant) with a start date of 5/24/24. -Trazodone (antidepressant also used to assist with sleep) with a start date of 5/24/24. Resident 1's clinical record did not include consents for the use of the psychotropic medications. On 10/10/24 at 12:38 PM Staff 2 (DNS) stated social services was to obtain consents for psychotropic medications. Staff 2 acknowledged consents were not completed for Resident 1's psychotropic medications. , 2. Resident 77 was admitted to the facility in 3/2024 with diagnoses including anemia and major depressive disorder. Resident 77's 3/22/24 Physician Order indicated the resident was prescribed Celexa (antidepressant) for depression. Resident 77's 3/2024 MAR revealed the resident received Celexa daily starting on 3/22/24. Review of Resident 77's health record revealed no documentation to indicate the resident was informed in advance of the risks and benefits of Celexa. On 10/10/24 at 1:30 PM Staff 2 (DNS) reviewed Resident 77's health record, acknowledged there was no documentation the resident was informed of the risks and benefits of Celexa and confirmed a consent was not obtained prior to the resident starting the medication.

Corrective Actions Resident #1 and Resident #77 signed an informed consent to receive psychotropic medications on 11/01/24. Identification of Other Individuals An audit of residents receiving psychotropic medications was completed by the DNS on 10/31/24. Any areas of concerns were remedied at that time. Systemic Changes and Education A review of new psychotropic medication orders shall be completed during morning meeting. When new orders for psychotropic medications are received, the DNS or designee shall validate that an informed consent has been signed by the resident/representative. Licensed nurses will be educated by 11/30/24 regarding the importance of obtaining an informed consent from the resident/representative prior to administering psychotropic medications. The DNS or designee will audit new psychotropic medication orders to validate that the resident/representative signed an informed consent 2x/week x4 weeks, weekly x4 weeks, then every other week for 4 weeks or until substantial compliance is determined by the QAPI Committee. Effective Date of Compliance 11/30/2024

Based on observation, interview, and record review it was determined the facility failed to honor a resident's preference for room layout for 1 of 2 sampled residents (#16) reviewed for choices. This placed residents at risk for depression. Findings include: 1. Resident 16 was admitted to the facility in 2/2020 with a diagnosis of diabetes. A 2/29/24 annual MDS revealed Resident 16 was cognitively intact, had weakness, and was in the facility for long term care. On 10/10/24 at 9:08 AM and 10/10/24 at 11:55 AM Resident 16 was observed in her/his room, a transfer pole was positioned on the left side of her/his bed, and Resident 16's spouse was observed in the bed to the right of the transfer pole. Resident 16 stated she/he was in a significant relationship with her/his spouse for 36 years. Resident 16 stated she/he wished the two beds were closer together to allow her/him to hold hands with her/his spouse. Resident 16 also stated she/he had PTSD (post traumatic stress disorder) and her/his spouse was able to calm her/him when she/he woke with vivid dreams. Resident 16 stated she/he requested a bed change and nothing was done. On 10/10/24 at 9:15 AM Staff 9 (Social Services Coordinator) stated in the past she heard Resident 16 wanted her/his bed closer to her/his spouse's bed. Staff 9 stated she was not aware if it was assessed. Staff 9 stated Staff 2 (DNS) would need to approve the move, involve therapy, and other departments to ensure it was safe. On 10/10/24 at 10:39 AM Staff 2 stated she was not aware of Resident 16's desire to be closer to her/his spouse. Staff 2 stated it could be done but an assessment would need to be done to ensure it was safe.

F 561 SELF DETERMINATION Corrective Actions Resident #16 met with the DNS, Social Worker, and Therapy Director on 10/17/24 and stated they preferred the current layout of the room. Identification of Other Individuals Interviews were completed with all other residents sharing a room by the DNS on 10/31/24. All residents interviewed voiced satisfaction with current room layout. Systemic Changes and Education A Room Layout Request Form has been implemented for residents to submit to the IDT to request a change with the furniture layout, remove/add furniture, or have other items added/removed. Forms are kept at the Nurses Station, Reception Desk, Social Service Office, and in the Activities Room. Staff may assist resident in completing and submitting the form. Completed forms shall be reviewed during morning meeting. Room Layout Request Forms shall be reviewed during the morning meeting. An IDT Member Designee and Maintenance shall review the requests with the resident and accommodations made as permitted by the room size and resident care needs. Residents that share a room will be asked at the quarterly care plan meeting if the current room layout meets their needs and preferences. Any preferences and requests related to furniture placement will be evaluated and accommodated as possible within the room size limitations and resident care needs. Nursing staff, Social Services, Activities, and Maintenance will be educated by 11/30/24 regarding informing a member of the IDT or maintenance of resident preferences or requests related to furniture placement within the resident’s room. The Room Layout Request Form will be introduced at the November Resident Council. Monitoring Room Layout Request Forms shall be audited by the NHA or Designee to validate that resident preferences have been addressed in a satisfactory manner with the resident weekly x4 weeks, then every other week x8 weeks or until substantial compliance is determined by the QAPI Committee. Effective Date of Compliance 11/30/24

Based on interview and record review it was determined the facility failed to ensure residents had an advance directive for 2 of 4 sampled residents (#s 1 and 16) reviewed for advance directives. This placed residents at risk for end-of-life choices not being honored. Findings include: 1. Resident 1 was admitted to the facility in 5/2024 with a diagnosis of severe malnutrition. An 8/26/24 quarterly MDS revealed Resident 1 was cognitively intact. An 8/29/24 Care Conference Meeting form revealed Resident 1 did not have an advance directive. The form did not indicate if staff provided Resident 1 information related to an advance directive or if the resident wanted to fill out an advance directive. On 10/10/24 at 11:38 AM Resident 1 stated she/he used to have an advance directive but did not know where it was and did not recall if the facility talked to her/him about an advance directive. Resident 1 also stated she/he definitely would not want tube feedings. On 10/10/24 at 9:11 AM Staff 9 (Social Services Coordinator) stated advance directive information was reviewed during care conferences and if a resident was provided information it was to be documented in the resident's record. Staff 9 stated there was no indication information was provided to Resident 1. 2. Resident 16 was admitted to the facility in 2/2020 with a diagnosis of diabetes. An 8/11/24 quarterly MDS revealed Resident 16 was cognitively intact. An 8/8/24 Care Conference Meeting form revealed Resident 16 did not have an advance directive. On 10/10/24 at 9:11 AM Staff 9 (Social Services Coordinator) stated advance directive information was reviewed with residents during care conferences. If a resident was offered advance directive information it was documented in the clinical record. Staff 9 stated there was no indication an advance directive was offered.

Corrective Actions Resident 1 was provided Oregon Advance Directive packet as part of the admission/readmission agreement on 10/09/2024. Resident 11 was provided the Advance Directive Disclosure to determine her wishes about care on 11/04/2024. Identification of Other Individuals Residents receive Oregon Advance Directive packet upon admission/readmission. Residents/Representatives will acknowledge Advance Directive status and wishes with the Advance Directive Disclosure by 11/30/2024. Systemic Changes and Education Admissions Director or designee will provide Oregon Advance Directives to each admission/readmission to Resident/Representative at time of admission. The Advance Directive Disclosure will allow 1) Resident/Representative to verify they have an Advance Directive to provide Medical Records for staff to follow, 2) Resident/Representative would like assistance to complete Advance Directive with Social Services, or 3) Resident/Representative do not have an Advance Directive and do not want one. Per the Advance Directive Policy, Social Service or designee will review resident/representative desire to change status of Advance Directive upon significant change of condition and/or quarterly care conferences. Monitoring Medical Records or designee will audit for Advance Directive Disclosure acknowledgement upon admission/readmission, significant change, or quarterly care conferences once a week for 4 weeks, twice a month for one month, and then one time a month until resolved. Audit results will be shared with QAPI until substantial compliance is achieved. Effective Date of Compliance 11/30/24

Based on interview and record review it was determined the facility failed to ensure a resident's emergency contact was notified of a resident's hospitalization for 1 of 2 sampled residents (#16) reviewed for hospitalization. This placed residents' representatives at risk for not being informed of a resident's change in medical condition. Finding include: Resident 16 was admitted to the facility in 2/2020 with a diagnosis of diabetes. Resident 13 was admitted to the facility 2/2020 with a diagnosis of dementia. An undated Admission Record revealed Resident 13 was Resident 16's first emergency contact and Witness 1 (Acquaintance) was Resident 16's second emergency contact. An 8/4/24 quarterly MDS revealed Resident 13 was cognitively impaired. An 8/11/24 quarterly MDS revealed Resident 16 was cognitively intact. Progress Notes revealed on 6/24/24 Resident 16 vomited, was pale, clammy, and did her/his mental status was not at baseline. Resident 16 was transported to the local hospital for evaluation and treatment. There was no note to indicate Resident 16's first or second emergency contact was notified. On 10/7/24 at 10:25 AM Resident 16 stated Resident 13 was her/his first emergency contact and had dementia. Resident 16 sated no one was called when she/he was hospitalized in 6/2024. On 10/10/24 at 8:05 AM Staff 28 (LPN) stated Resident 16's spouse had dementia. Staff notified Resident 13 when Resident 16 was hospitalized but Resident 13 only understood Resident 16 was not in the room but did not know why. On 10/10/24 at 12:51 PM Staff 2 (DNS) stated there was no indication in Resident 16's clinical record her/his emergency contacts were notified of her/his hospitalization.

Corrective Actions Resident #16s second emergency contact was notified of Resident 16s transfer to Emergency Department on 10/26/24. Identification of Other Individuals A review of other residents transferred in the last 30 days was completed on 10/31/24. No other concerns were identified. Systemic Changes and Education During morning meeting, the DNS or Designee shall review the progress notes of any residents that transferred since the previous morning meeting to validate that the residents emergency contact was notified. Emergency contact information shall be reviewed with each resident during their quarterly care conference to validate that contact information is current and that the individuals named as the emergency contact are still cognitively able to serve as the emergency contacts. A discharge checklist has been created that outlines the required steps for a discharge from the facility to the ED to remind the nurse to notify the emergency contact. Nursing staff will be educated by 11/30/24 on the use of the Discharge Checklist and regarding the importance of notifying a residents emergency contact upon discharge to the ED and documenting who was notified and the date and time that individual was notified in the progress notes. If the nurse is not able to reach the first emergency contact, or the first emergency contact does not have the cognitive ability to comprehend the transfer, the second emergency contact will be notified. Monitoring The DNS or Designee shall review the progress notes of any resident that discharged to the ED to validate that the residents emergency contact was notified regarding the discharge to the ED 2x/week x4 weeks, weekly x4 weeks, then every other week x4 weeks or until substantial compliance is determined by the QAPI Committee. Effective Date of Compliance 11/30/24

Based on interview and record review it was determined the facility failed to ensure NOMNC (Notice of Medicare Non-Coverage) notifications were provided to 2 of 3 sampled residents (#s 75 and 290) and failed to provide SNF ABN (Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage) notifications to 2 of 3 sampled residents (#s 49 and 75) reviewed for Beneficiary Notification. This placed residents and their representatives at risk for lack of knowledge regarding their right to appeal and unknown financial liabilities. Findings include: 1. Resident 75 was admitted to the facility on 4/19/24 with Medicare Part A benefits. Resident 75's SNF Beneficiary Protection Notification Review provided by the facility indicated the resident's last covered day for Medicare Part A services was 5/27/24 and Resident 75 remained in the facility. According to the SNF Beneficiary Protection Notification form, the resident did not receive the required NOMNC notification to notify the resident or their representative when their Medicare Part A coverage ended and provided them the opportunity to appeal, and was not provided with a SNF ABN notification to inform them or their representative of potential out-of-pocket expenses. On 10/14/24 at 1:15 PM and 2:54 PM Staff 9 (Social Services Coordinator) stated the facility did not issue SNF ABN notifications to residents when they were discharged from Medicare Part A services and remained in the facility and confirmed Resident 75 did not receive the required SNF ABN notifications. Staff 9 also confirmed Resident 75 did not receive the required NOMNC notification to notify the resident or their representative when their Medicare Part A coverage ended. On 10/15/24 at 9:01 AM Staff 1 (Interim Administrator) acknowledged the facility was not consistently issuing NOMNC and SNF ABN notifications to residents and their representatives as required. 2. Resident 290 was admitted to the facility on 6/19/24 with Medicare Part A benefits. Resident 290's SNF Beneficiary Protection Notification Review provided by the facility indicated the resident's last covered day for Medicare Part A services was 7/11/24 and Resident 290 discharged home. According to the SNF Beneficiary Protection Notification form, the resident did not receive the required NOMNC notification to notify the resident or their representative when their Medicare Part A coverage ended and provided them the opportunity to appeal. On 10/14/24 at 1:15 PM and 2:54 PM Staff 9 (Social Services Coordinator) stated Resident 290 did not receive the required NOMNC notification to notify the resident or their representative when their Medicare Part A coverage ended. On 10/15/24 at 9:01 AM Staff 1 (Interim Administrator) acknowledged the facility was not consistently issuing NOMNC and SNF ABN notifications to residents and their representatives as required. 3. Resident 49 was admitted to the facility on 5/30/24 with Medicare Part A benefits. Resident 49's SNF Beneficiary Protection Notification Review provided by the facility indicated the resident's last covered day for Medicare Part A services was 8/15/24 and Resident 49 remained in the facility. According to the SNF Beneficiary Notification form, the resident was not provided with a SNF ABN notification to inform them or their representative of potential out-of-pocket expenses. On 10/14/24 at 1:15 PM and 2:54 PM Staff 9 (Social Services Coordinator) stated the facility did not issue SNF ABN notifications to residents when they were discharged from Medicare Part A services and remained in the facility and confirmed Resident 49 did not receive the required SNF ABN notification. On 10/15/24 at 9:01 AM Staff 1 (Interim Administrator) acknowledged the facility was not consistently issuing NOMNC and SNF ABN notifications to residents and their representatives as required.

Corrective Actions Resident #75 had a payer change on 05/27/2024. Resident #290 discharged on 07/12/2024. Resident #49 had a payer change on 08/16/2024 and a NOMNC was documented at that time. Identification of Other Individuals A 30-day look back was completed on 11/08/24 by the Medical Records Designee or other designee to validate residents received a NOMNC or ABN as required. No other residents were identified. Systemic Changes and Education Billing Manager will work with Admissions to share potential charges and patient liability to residents/representative upon admission or adding Medicare Part B. IDT will review patient at morning meetings and share when patients will be discharged from services. A NOMNC or ABN will be issued timely to allow patient time to appeal but will notify of possible patient liability out of pocket to continue receiving services. Facility will not charge while decisions are pending. NOMNC and ABNs will be uploaded into patient chart by Medical Records or designee. Medical records or designee will audit discharged patient services weekly to ensure NOMNC and ABNs are completed. IDT team will address any variances. Social Services workers, billers, and medical records staff will be educated regarding when a NOMNC or ABN is to be provided to the resident by 11/30/24. Monitoring Medical Records Designee or other designee will audit the medical records of residents required to receive a NOMNC or ABN to validate that the NOMNC or ABN were issued as required weekly x4 weeks, every other week for 4 weeks, then monthly x1 month or until substantial compliance is determined by the QAPI Committee. Effective Date of Compliance 11/30/2024

Based on observation, interview and record review it was determined the facility failed to provide a homelike environment for 1 of 1 resident (#340) reviewed for hospice and in 1 of 1 facility reviewed for environment. This placed residents at risk for a lack of autonomy and living in an unkempt environment. Findings include: The facility's revised 7/3/23 Safe and Homelike Environment Policy directed staff in accordance with residents' rights, the facility would provide a safe, clean, comfortable and homelike environment. The facility would create and maintain, to the extent possible, a homelike environment that de-emphasizes the institutional character of the setting. 1. Resident 340 was admitted to the facility in 8/2024 with diagnoses including dementia. On 10/7/24 at 12:01 PM Resident 340 was observed in her/his room with no personalized items or decorations in the room. On 10/10/24 at 1:47 PM Resident 340 stated she/he would like "something good to look at" in her/his room. On 10/14/24 at 9:50 AM Staff 7 (Activities Coordinator) stated it was up to the residents' family to bring in items to personalize a residents' room. On 10/14/24 at 11:16 AM Staff 9 (Social Services Coordinator) stated she provided social services for Resident 340's room. Staff 9 stated if the long-term residents wanted to decorate the residents' room, they could have their family bring personal items into the facility and she would check with administration first to see if it was okay. To her knowledge, Resident 304's family had not been contacted and the facility had not provided personalized decorations for her/him to look at in her/his room. On 10/15/24 at 9:13 AM Staff 1 (Interim Administrator) acknowledged he expected resident rooms' to be personalized. , Observations of the facility's general environment and residents' rooms from 10/7/24 through 10/15/24 identified the following issues: -Hall C had 2 missing handrail end caps on each side of the hall exposing sharp/jagged edges. -The west hall outside the kitchen entrance had a missing handrail end cap. -The handrails across from therapy room had an approximate 2 inch open gap exposing metal. -The sitting area on the 1st floor surrounding the nurses station had four couches made from synthetic material that were torn and tattered. -The library on the 2nd floor had a couch and chair made from synthetic material that were torn and tattered. -Large sections of missing brown paint on the door frames for rooms 135, 144, 156, 169, 183, 184, 260, and the housekeeping closet (1st floor) door across from room 169. -Room 134's door had an approximate 4 inch piece of wood missing on the lower section exposing sharp/jagged edges. -Dirty light fixtures outside Room 188 and outside the 1st floor elevator on the west hall. -Room 283 had large sections of missing paint on the door. -The lower sections of the corner walls outside Rooms 237, 243, 253, 256, 283 had an approximate 4 inch gouge with missing paint and exposed drywall. On 10/15/24 at 8:20 AM Staff 1 (Administrator) and Staff 10 (Director of Facility Services) acknowledged the identified rooms and maintenance concerns needed to be repaired.

Corrective Actions Activities Director visited with wife of Resident 340 about adding pictures or other items to make the room look more homelike on 10/14/2024. Resident 340’s wife shared that she could copy off pictures to bring into resident’s room. Identification of Other Individuals On 10/23/2024 Activities Director reviewed all other resident’s décor for any others that can use personalized items. No others were identified. Systemic Changes and Education Activities Director will educate activities and social services departments about identifying personal belongings for resident rooms to be a homelike environment by 11/30/2024. Monitoring Activities director will complete an audit once a week for 4 weeks, and twice a month for two months. Results will be shared with QAPI until substantial compliance is achieved. Effective Date of Compliance 11/30/2024

Based on interview and record review it was determined the facility failed to ensure a system was in place to resolve resident grievances promptly for 1 of 1 resident (#57) reviewed for abuse. This placed residents at risk for unresolved grievances. Findings include: Resident 57 was admitted to the facility in 5/2022 with diagnoses including osteoarthritis (degenerative joint disease) and lower back pain. On 10/7/24 at 4:22 PM Resident 57 expressed she/he had concerns with her/his caregiver "the other day." Resident 57 stated she/he told Staff 19 (RN) and Staff 38 (LPN) about her/his concerns and requested a grievance form be completed. On 10/9/24 at 8:23 AM Staff 1 (Interim Administrator) was unaware of Resident 57's concerns about the caregiver and at 9:51 AM Staff 1 confirmed a grievance form was not created for Resident 57's expressed concerns. On 10/9/24 at 11:03 AM Staff 19 confirmed Resident 57 spoke to her about her/his concerns regarding the caregiver on 10/7/24 and she told Staff 17 (Social Services Director) to complete a grievance form. On 10/14/24 at 5:43 AM Staff 38 confirmed Resident 57 told her about the caregiver concerns and she provided Staff 19 with the information. On 10/15/24 at 9:13 AM Staff 1 acknowledged he expected grievance forms to be completed promptly for resident concerns.

Corrective Actions On 10/07/2024 Resident 57 reported claims of abuse to Staff that occurred on 10/05/2024. Administrator was notified on 10/09/2024 and initiated an FRI. A grievance form was completed on 10/09/2024 but administrator was not aware grievance was opened. Identification of Other Individuals Social Services Director completed an audit on 11/01/2024 to review any FRI initiated for the past month to ensure a grievance was opened if necessary. No other concerns were identified. Systemic Changes and Education Social Services Director or designee to provide education via in-service for all floor staff and leadership team on grievance process. Guide and memos on abuse reporting for grievances posted for all staff to be completed by 11/30/2024. Monitoring Social Services Director or designee to audit FRI and grievances each week for 4 weeks and twice a month for 2 months. Results will be shared with QAPI until substantial compliance is achieved. Effective Date of Compliance 11/30/2024

Based on interview and record review it was determined the facility failed to ensure a bed hold policy was provided to a resident when transferred to the hospital for 2 of 2 sampled residents (#s 16 and 33) reviewed for hospitalization. This placed residents at risk for lack of knowledge related to the right to return to the facility. Findings include: 1. Resident 16 was admitted to the facility in 2/2020 with a diagnosis of diabetes. Progress Notes revealed Resident 16 was discharged to the hospital on 6/24/24. Resident 16's clinical record did not indicate Resident 16 was provided a facility bed hold policy. An 8/11/24 quarterly MDS revealed Resident 16 was cognitively intact. On 10/7/24 at 10:25 AM Resident 16 stated she/he did not recall staff providing her/him a bed hold policy when she/he went to the hospital. On 10/10/24 at 12:51 PM Staff 2 (DNS) stated upon admission to the facility residents were provided a bed hold policy. Staff 2 stated usually the admission director provided a bed hold policy upon discharge, but currently there was no admission director. No additional information was provided. , 2. Resident 33 was admitted to the facility in 12/2021 with diagnoses including chronic respiratory failure with hypoxia (a condition in which the body does not have enough oxygen in the blood). A review of Resident 33's health record revealed she/he was transferred to the hospital on 6/1/24, 6/14/24, 7/11/24, 9/8/24 and 10/2/24. No evidence was found in Resident 33's health record to indicate a written notice of the facility's bed hold policy was provided to Resident 33 when she/he was transferred to the hospital on 6/1/24, 6/14/24, 7/11/24, 9/8/24 and 10/2/24. On 10/11/24 at 9:32 AM Staff 3 (Medical Records) stated the facility did not provide residents with a written bed hold policy prior to transferring them to the hospital. On 10/15/24 at 10:27 AM Staff 1 (Interim Administrator) acknowleged residents were not provided with written bed hold policies upon transfer to the hospital.

Corrective Actions Resident 33 discharged to hospital but will receive the bed hold policy upon readmission. Resident 16 will receive the revised Bed Hold Policy by 11/08/2024. Identification of Other Individuals All other residents will receive the revised Bed Hold Policy by 11/08/2024. Systemic Changes and Education Administrator or designee will ensure the admission packets will share the Bed Hold Policy for all resident upon admission. Admissions director or designee to provide education for nurses to provide Bed Hold Prior to Transfer for resident when they transfer out of facility. Monitoring Administrator or designee will conduct audits of Bed Hold Policy upon admission and Bed Hold Prior to Transfer each week for 4 weeks, twice a month for a month and 1 time a month. Results will be shared with QAPI until substantial compliance is achieved. Effective Date of Compliance 11/30/2024

, Based on observation, interview and record review it was determined the facility failed to accurately assess residents for communication, dental, and transfers for 3 of 9 sampled residents (#s 1, 14 and 20) reviewed for communication, dental, and rehabilitation. This placed residents at risk for inaccurate assessments and unmet care needs. Findings include: 1. Centers for Medicare & Medicaid Services 10/2024 Resident Assessment Instrument (RAI) Version 3.0 Manual directed the following: -A resident who was able to express requests and ideas clearly should be assessed as "understood." -A resident who experienced difficulty communicating some words or finishing thoughts but was able to be understood if prompted or given time, experienced delayed responses or required some prompting to make self understood should be assessed "usually understood." -A resident who was able to clearly comprehend the speaker's message and demonstrated comprehension by words or actions/behaviors should be assessed as "understands." -A resident who missed some part or intent of the speaker's message but comprehended most of it or who may have periodic difficulties integrating information but generally demonstrated comprehension by responding in words or actions should be assessed as "usually understands." Resident 14 was admitted to the facility in 12/2020 with diagnoses including Parkinson's disease (a chronic brain disorder that causes movement problems, mental health issues and other health concerns). Resident 14's 9/8/24 Quarterly MDS revealed the resident was cognitively intact, had unclear speech, was able to make her/himself understood without difficulty and was able to understand others without difficulty. On 10/7/24 at 12:56 PM Resident 14 was observed in her/his room in bed. Resident 14 spoke slowly and softly, experienced delayed responses and required time to express her/himself. Resident 14 frequently repeated her/himself in order to be understood and she/he stated "staff needed to be patient with [her/him]." The State Surveyor repeated questions on a number of occasions during the interview in order to improve the resident's understanding. On 10/14/24 at 10:23 AM Staff 25 (CNA) stated Resident 14 was "very soft spoken" and when she interacted with the resident, she always turned the television off and listened closely. Staff 25 stated the resident "needed a second" to understand and communicate her/his responses. On 10/14/24 at 10:48 AM Staff 26 (CNA) stated Resident 14's communication was "sometimes really good and sometimes [the resident] was really out of it." Staff 26 stated she often asked Resident 14 to repeat her/his message or question, and if she still had trouble understanding, she would get another staff person to help with understanding. On 10/14/24 at 11:21 AM Staff 17 (Social Services Director) stated Resident 14 "varied in [her/his] communication abilities" as she/he went "through different moods and alertness levels." Staff 17 stated she frequently repeated statements to Resident 14, asked the resident if she/he understood her question or message and gave the resident time to answer questions. On 10/14/24 at 1:10 PM Staff 2 (Interim DNS) acknowledged Resident 14's MDS was inaccurately assessed and stated Resident 14's difficulties with communication were not of recent onset. 2. Resident 20 was admitted to the facility in 9/2022 with diagnoses including a history of falls. Resident 20's 9/1/24 Annual MDS indicated the resident required partial-to-moderate assistance from staff with transfers. Resident 20's 9/11/24 ADL Performance Deficit Care Plan revealed the resident required assistance from two staff and the use of a hoyer lift (a mobile device that helps caregivers safely transfer patients with limited mobility from one place to another) for all transfers. On 10/10/24 at 10:36 AM Staff 23 (Agency CNA) and at 10:46 AM Staff 24 (CNA) stated Resident 20 required a hoyer lift for all transfers. On 10/10/24 at 4:37 PM Staff 2 (Interim DNS) acknowledged Resident 20's 9/1/24 Annual MDS was inaccurately assessed as the resident required assistance from two staff and the use of a hoyer lift for all transfers. 3. Resident 1 was admitted to the facility in 5/2024 with a diagnosis of severe malnutrition. On 10/7/24 at 10:46 AM Resident 1 was observed to have no teeth. A 6/7/24 significant change MDS indicated Resident 1 did not have dental issues including not having teeth. On 10/10/24 at 5:01 PM Staff 2 (DNS) acknowledged Resident 1's dental status was not accurately assessed.

Corrective Actions Resident 14 was coded by Social Services Director as understood on the most recent MDS. During the look back period the resident communication abilities were clear but may fluctuate due to comorbidities. Social Services provided a white board to assist when resident struggles to communicate clearly and care plan updated on 11/07/2024. A correction MDS was completed on 10/10/24 for Resident #20 to reflect the need for a two-person lift for transfers. Identification of Others A review of current residents with an ARD date of 10/20/24 or 10/27/24 was completed on 11/05/24 to validate that the information entered reflected the residents’ status accurately. No other variances were identified. Systemic Changes and Education The MDS nurses and Social Services staff will be educated by 11/30/24 regarding the RAI manual and the importance of accurate assessments in each section of the MDS. Monitoring The DNS or Designee shall complete random audits of at least three MDSs to validate that the information entered accurately reflects the residents’ status weekly for 4 weeks, every other week x4 weeks, and monthly for 1 month or until substantial compliance is determined by the QAPI Committee. Date of Compliance 11/30/24

Based on observation, interview, and record review it was determined the facility failed to ensure care plans were revised to accurately reflect the needs of residents for 4 of 13 sampled residents (#s 5, 7, 35, and 73) reviewed for accidents, pressure ulcers, position and mobility. This placed residents at risk for unmet needs. Findings include: 1. Resident 5 was admitted to the facility in 4/2024 with a diagnosis of paralysis. A 7/17/24 Pressure Injury investigation revealed a new DTI (Deep tissue injury: damage to the soft tissue beneath the skin caused by pressure or shear. Often appears as a dark purple or maroon area) to the inner knee. The cause of the injury was determined to be from her/his bedside table putting pressure on the knee. Resident 5's care plan was not updated to direct staff to monitor pressure on Resident 5's leg from the bedside table. On 10/11/24 at 9:11 AM Staff 2 (DNS) stated Resident 5 did not have sensation in her/his legs. When the wound nurse performed wound care to the resident's sacral region she found the inner knee DTI. The wound nurse identified the bedside table was pressing on the area. Staff 2 acknowledged the care plan was not updated to ensure pressure was not applied to the resident's legs. , 2. Resident 73 was admitted to the facility in 9/2023 with diagnoses including a fractured hip. a. Resident 73's 9/21/23 Care Plan indicated the resident was incontinent of bowel and bladder. Resident 73's 9/15/24 Annual MDS indicated the resident was always continent of bowel and bladder. On 10/10/24 at 12:04 PM and 12:54 PM Staff 24 (CNA) and Staff 26 (CNA) reported Resident 73 was independent with most care and was continent of bowel and bladder. On 10/11/24 at 10:55 AM Staff 2 (Interim DNS) reviewed Resident 73's current care plan and reported the resident was not incontinent, and the resident's current care plan did not accurately reflect her/his continence status. She stated she expected residents' care plans to accurately reflect current interventions. b. A 7/9/24 Facility Incident report indicated Resident 73 left the facility around 1:00 PM on 7/8/24 and did not return until 7:00 AM on 7/9/24. New interventions were identified which included ensuring the resident took her/his cell phone and water bottle with her/him when leaving the facility. Also, Staff 17 (Social Service Director) would provide Resident 73 with a fanny pack to carry her/his cell phone and wallet, and facility key personnel names and phone contact information would be placed in the fanny pack. Resident 73 was to take her/his fanny pack when she/he left the facility. Resident 73's 9/5/24 Care Plan indicated the following: -The resident was to sign out and tell staff when she/he was leaving the facility. -The resident would take her/his cell phone when going out. Resident 73's 9/15/24 Annual MDS indicated the resident was able to make her/his own decisions and direct her/his own care. On 10/10/24 at 9:51 AM Resident 73 was able to locate her/his fanny pack in her/his room and stated she/he was supposed to take the fanny pack when leaving the facility. On 10/10/24 at 1:55 PM Staff 2 (Interim DNS) reviewed Resident 73's care plan and confirmed the resident's care plan did not accurately reflect her/his current care plan interventions related to leaving the facility. She stated she expected residents' care plans to accurately reflect current interventions. 3. Resident 35 was admitted to the facility in 1/2018 with diagnoses including a stroke and difficulty swallowing. Resident 35's 3/19/22 Care Plan indicated the following: -No straws allowed (due to difficulty swallowing). Resident 35's 5/14/24 SLP Discharge Summary did not indicate the resident was unsafe using straws. Resident 35's 9/8/24 Quarterly MDS indicated the resident had no choking or coughing during the assessment period. Multiple observations from 10/7/24 through 10/14/24 between the hours of 8:00 AM and 4:30 PM revealed Resident 35 used straws to drink liquids. On 10/7/24 at 1:24 PM Staff 25 (CNA) stated the resident used straws when drinking. On 10/14/24 at 10:42 AM Staff 2 (Interim DNS) stated she reviewed Resident 35's care plan interventions and the resident's care plan was inaccurate regarding the resident's safety using straws. She stated she expected residents' care plans to accurately reflect current interventions. , Resident 7 was admitted to the facility in 11/2019 with diagnoses including multiple sclerosis and depression. Resident 7's health record revealed she/he had contractures to the left shoulder, hips, and knees upon admission. A 3/17/24 annual MDS revealed Resident 7 had impaired mobility of her/his upper and lower extremities. A 9/23/24 Care Plan revealed Resident 7 had an RA program related to maintaining baseline ROM to her/his bilateral upper extemities as long as possible. Random observations of Resident 7 from 10/7/24 through 10/11/24 from 11:31 AM to 4:16 PM revealed Resident 7 in bed with her/his left arm contracted. The resident had difficulty turning her/his neck to see who was in the room. On 10/11/24 at 1:56 PM Staff 2 (Interim DNS) stated the RA program for Resident 7 was discontinued on 10/18/23 when she/he was admitted to the hospital. Staff 2 acknowledged the care plan had not been revised.

Corrective Actions The care plan for Resident #5 was updated on 10/11/24 to include care and monitoring for DTI to the inner knee and to ensure the bedside table is not resting in her body. The most recent MDS for Resident #73 completed on [DATE] and indicates that the resident is continent of bowel and bladder. The resident’s care plan was updated on 10/10/24 to include interventions reflective of the resident’s current toileting needs. A SLP report for Resident #35 was reviewed on 10/14/24 which noted that there were not concerns with the use of straws. The resident’s care plan was updated to show that the resident may use straws. The RA program for Resident #7 was reinstated on 10/11/24 and the resident’s care plan was updated to include the receipt of A RA program. Identification of Others A review of other residents with quarterly of annual assessments with an ARD date of 10/20/24 was completed on 11/05/24 to validate that their care plans reflected the findings of the MDS assessments. No other variances were identified. Systemic Changes and Education The MDS nurses will be educated by 11/30/24 regarding the importance of coordinating MDSs with the resident’s care plan Monitoring The DNS or Designee will complete random audits of at least three MDSs to validate that the information entered accurately reflects the resident’s status and is coordinated with the resident’s care plan weekly x4 weeks, every other week x4 weeks, then monthly X1 month or until substantial compliance is determined by the QAPI Committee. Date of Compliance 11/30/24

Based on observation, interview and record review it was determined the facility failed to provide appropriate treatment and services in the area of communication for 1 of 4 sampled residents (#53) reviewed for communication. This placed residents at risk for diminished quality of life and potential decline in their ability to carry out activities of daily living. Findings include: Resident 53 was admitted to the facility in 7/2021 with diagnoses including dementia. Resident 53's 9/22/24 Quarterly MDS revealed the resident was severely cognitively impaired and her/his ability to hear was highly impaired. Resident 53's 10/1/24 Communication Problem Care Plan revealed the following: -Use a dry erase board as needed to facilitate communication and understanding. -Use alternative communication tools as needed, such as a communication book/board, writing pad, gestures, signs and pictures. -9/15/21: The resident was not a candidate for hearing aids per family report. On 10/7/24 at 12:37 PM Resident 53 was observed in her/his room in bed. Resident 53 stated she/he was "a little bit deaf and wore hearing aides but [she/he] did not know where they were." The State Surveyor needed to repeat questions to the resident, even when speaking at an elevated volume, in order to improve understanding. At this time, no accessible communication tools, including a communication board or dry erase board, were observed in the resident's room. Random observations of Resident 53 conducted from 10/7/24 through 10/14/24 from 5:09 AM to 3:54 PM revealed the resident to be in her/his room either in bed or in her/his wheelchair. No accessible communication tools were observed in the resident's room. On 10/11/24 at 10:15 AM Staff 25 (CNA) stated communicating with Resident 53 "was very hard," interactions were often "a guessing game" and it was difficult to determine what the resident was trying to say. Staff 25 stated she had never utilized any communication tools or devices to improve interactions with the resident, including a communication board, dry erase board or a hearing amplification device. On 10/14/24 at 11:15 AM Staff 17 (Social Services Director) stated Resident 53 was "very hard of hearing" and she used a white board when she interacted with the resident to improve communication. Staff 17 stated she did not know if Resident 53 had a communication board or white board available in her/his room for other staff to use during their interactions and she was unaware if the resident would benefit from alternative amplification devices or if they had been tried. On 10/14/24 at 12:44 PM Staff 2 (Interim DNS) acknowledged the findings of this investigation and stated she was unsure which communication interventions had been trialed with Resident 53 to improve communication and did not know if current care plan interventions were accurate.

Corrective Actions The care plan for Resident #53 was updated on 11/01/24 to include the use of a communication board or white board when communicating with the resident. Identification of Other Individuals The care plans of other residents with hearing impairment were reviewed on 11/01/24. No other concerns were identified. Systemic Changes and Education The DNS or Designee shall review the communication needs with residents during quarterly care conferences. Updates to the care plan will be made as appropriate. Licensed nurses and Social Services will be educated by 11/30/24 regarding facilitating the communication needs of residents with hearing impairments. Monitoring The DNS or Designee will meet with residents with hearing impairments to validate that they are receiving communication interventions according to the care plan weekly x4 weeks, then every other week for 8 weeks or until substantial compliance is determined by the QAPI Committee. Effective Date of Compliance 11/30/24

Based on observation, interview and record review it was determined the facility failed to provide the necessary care and services to maintain personal hygiene for 1 of 5 sampled residents (#51) reviewed for ADLs. This placed residents at risk for poor personal hygiene. Findings include: Resident 51 was admitted to the facility in 6/2024 with a dignoses including dementia. Resident 51's 9/15/24 Quarterly MDS indicated her/his cognition was moderately impaired and she/he required assistance or supervision with personal hygiene. Resident 51 was observed from 10/7/24 at 1:30 PM to 10/11/24 at 12:08 PM with a significant amount of chin hairs. On 10/9/24 at 8:37 AM Resident 51 stated she/he did not want chin hairs and needed help to shave them. The 10/11/24 Kardex (bedside care plan) directed staff to shave Resident 51 as necessary. On 10/11/24 at 9:57 AM Staff 43 (CNA) stated she obtained information to care for Resident 51 from the Kardex. On 10/11/24 at 11:30 AM Staff 28 (LPN) confirmed Resident 51 had long chin hairs and staff should assist the resident. Resident 51 told Staff 28 "I want my beard shaved off." On 10/11/24 at 12:08 PM Staff 2 (Interim DNS) stated she expected Resident 51 to be shaven on the scheduled days of Monday and Friday.

Corrective Actions Resident #51 was shaved on 10/11/24. An ADL task was created to shave Resident #51 twice a week moving forward. Identification of Other Individuals A visual check of other residents requiring assistance with shaving was completed on 10/31/24. No other residents were identified. Systemic Changes and Education ADL tasks will be created in the electronic medical record (EMR) to alert nursing assistants of residents requiring assistance with shaving. Any resident refusals will be documented and reported to the charge nurse. Licensed nurses and nursing assistants will be educated by 11/30/24 of the ADL tasks to be created in EMR, the importance of assisting residents with ADL tasks, and documenting and reporting refusals of care. Monitoring The DNS or Designee will review the ADL documentation for residents requiring assistance with shaving to validate that the shaving tasks are being completed weekly x1 month, then every other week x8 weeks or until substantial compliance is determined by the QAPI Committee. Effective Date of Compliance 11/30/24

Based on observation, interview and record review, it was determined the facility failed to provide an ongoing program to support individual activity interests and preferences for 4 of 4 sampled residents (#s 38, 51, 53 and 340) reviewed for activities. This placed residents at risk for isolation, lack of social interaction and engagement. Findings include: The facility's 2023 Activities Policy indicated the facility was to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan and preferences. Facility-sponsored group, individual and independent activities were designed to meet the interests of each resident, as well as support their physical, mental and psychosocial well-being. Special considerations would be made for developing meaningful activities for residents with dementia and/or special needs. 1. Resident 51 was admitted to the facility in 6/2024 with diagnoses including dementia. Resident 51's 7/1/24 Activity Care Plan revealed the following: -The resident was able to communicate verbally and able to make her/his needs known. -The resident was able and preferred to direct her/his own activities of choice. -The resident preferred to visit with family on the phone in her/his room. -The resident preferred the following activities: to read books and magazines; to listen country and Christian music; to read books and magazines; to watch television football, basketball games, news channel 8 and the Hallmark channel. Resident 51's 7/3/24 Admission MDS revealed the resident was severely cognitively impaired. The MDS revealed it was somewhat important for Resident 51 to have books, newspapers and magazines to read, listen to music, to be around pets/animals, to keep up with the news, to do things with groups of people, go outside and participate in religious activities. It was very important for her/him to do her/his favorite activities. The facility's 10/2024 Activity Calendar revealed the following scheduled activities: -10/7/24 8:00 AM Daily Chronicle (passed a daily information sheet to resident rooms) 11:00 AM Mail time and One-on-Ones (delivered mail and talked to residents in their rooms) 3:00 PM Bingo -10/8/24 8:00 AM Daily Chronicle 11:00 AM Mail time and One-on-Ones 3:00 PM Bible study (five residents in attendance) -10/9/24 8:00 AM Daily Chronicle 11:00 It's Mail time and Vicki from Holy Family 2:30 PM One-on-Ones with Joy 3:00 PM Wii Bowling -10/10/24 8:00 AM Daily Chronicle 11:00 AM Mail time 2:00 April Trivia and popcorn (one resident in attendance) -10/11/24 8:00 AM Daily Chronicle 11:00 AM It's Mail time 3:00 PM Bingo A review of Resident 51's Activity participation documentation in progress notes from 6/27/24 through 10/14/24 revealed the resident had the following activity involvement: -9/17/24 Staff 7 (Activity Director) talked to the resident about her/his family; -9/19/24 attended a music session prior to lunch; -10/3/24 was provided a magazine and talked about the Hallmark channel; -10/10/24 was invited to a cards group and resident declined. On 10/8/24 at 9:38 AM Resident 51 stated she/he "gets bored" and has "nothing to do." Random observations of Resident 53 from 10/8/24 through 10/11/24 from 8:37 AM to 3:52 PM revealed the resident to be in her/his room either in bed or in her/his wheelchair. The resident's television was turned on with a low volume to a cartoon channel, the blinds were sometimes closed, no books or magazines were available, and no music played. The resident was observed to go to lunch in the dining room two times. The 10/11/24 Kardex (bedside care plan) directed staff to report to the nurse of any changes in unusual activity attendance patterns or refusals to attend activities. On 10/14/24 at 9:16 AM Staff 7 (Activity Director) stated residents with a dementia diagnosis received one-to-one visits. Staff 7 stated Resident 51 was unable to self-initiate activities and for her one-to-one visits with the resident she primarily provided a magazine, talked to the resident about her/his family and talked about the Hallmark channel. Staff 7 stated she had "gone in there a couple of times to visit and invite" her/him to an activity. Staff 7 also confirmed all activity department resident participation was documented in the progress notes. On 10/15/24 at 9:13 AM Staff 1 (Administrator) acknowledged the findings of this investigation and did not provide any additional information. 2. Resident 340 was admitted to the facility in 8/2024 with diagnoses including dementia. Resident 340's 8/16/24 Admission MDS revealed the resident was severely cognitively impaired. The MDS also revealed Resident 340 considered it was very important to do her/his favorite activities, to have books, newspapers and magazines to read, to listen to music, to be around animals, to keep up with the news and to go outside. It was not very important to do things with groups of people. Resident 340's 10/11/24 Kardex (bedside care plan) revealed the following: -The resident was able to communicate physically but not verbally. -The resident was able to direct her/his own activities. -The resident could communicate very well verbally but could actively listen and tried to engage in conversation with peers. -The resident's preferred activities were the following: watch television baseball, football, other sports and the news. On 10/7/24 at 12:01 PM Resident 340 was observed to lie in her/his bed with no television, no music and said loudly "if you give me an idea" to a CNA. No sensory stimulation was provided in the room. On 10/10/24 at 10:44 AM Resident 340 was observed in bed with her/his television set on a Spanish speaking cartoon. Resident 304 stated she/he does not speak or understand Spanish and never watched cartoons in the past. The resident then attempted to use a television remote unsuccessfully. She/he talked about going to work and she/he wanted "something to do" and later pointed out her/his window to the beautiful weather. Random observations of Resident 340 from 10/7/24 through 10/10/24 from 8:34 AM to 3:54 PM revealed the resident to be in her/his room in bed. The television was often set to a cartoon channel and no reading materials or music were available. The weather was observed to be warm and not raining. On 10/14/24 at 9:16 AM Staff 7 (Activity Director) stated residents with a dementia diagnosis received one-to-one visits. Staff 7 stated she was unfamiliar with Resident 340 and thought maybe the Activity Assistant staff visited her/him once after her/his admission. Staff 7 confirmed all the activity department resident participation was documented in the progress notes. A review of Resident 340's Progress Note Activity documentation from 8/8/24 through 10/11/24 revealed the resident had no activity department involvement or visits. On 10/15/24 at 9:13 AM Staff 1 (Administrator) acknowledged the findings of this investigation and did not provide any additional information. , 3. Resident 38 was admitted to the facility in 7/2021 with diagnoses including dementia. Resident 38's 6/30/24 Annual MDS revealed the resident was cognitively intact and The resident's preferred activities were the following: to read books, magazines and newspapers to, listen to music, spend time around animals, do things with groups of people, go outside and participate in her/his favorite activities and religious practices. Resident 38's 9/26/24 Activity Care Plan revealed the following: -The resident spent most of her/his time in bed and occasionally participated in facility group activities. -Ask the resident if she/he wanted to participate in bingo. -The resident needed assistance/escort to activity functions. -The resident's preferred activities included visits with her/his family, television, music, group activities such as music and bingo, religious visits and to get her/his nails done. The facility's Activity Calendar revealed the following scheduled activities: -10/7/24 8:00 AM Daily Chronicle 11:00 AM Mail time and One-on-Ones 3:00 PM Bingo -10/8/24 8:00 AM Daily Chronicle 11:00 AM Mail time and One-on-Ones 3:00 PM Bible study -10/9/24 8:00 AM Daily Chronicle 11:00 It's Mail time and Vicki from Holy Family 2:30 PM One-on-Ones with Joy 3:00 PM Wii Bowling -10/10/24 8:00 AM Daily Chronicle 11:00 AM Mail time 2:00 April Trivia and popcorn -10/11/24 8:00 AM Daily Chronicle 11:00 AM It's Mail time 3:00 PM Bingo A review of Resident 38's Activity Task Log and activity documentation from 9/15/24 through 10/11/24 revealed the resident did not participate in any out-of-room or group activities and no documentation was found to indicate she/he was invited to participate. Random observations of Resident 38 conducted between 10/7/24 to 10/11/24 from 5:07 AM through 3:57 PM revealed the resident to be in her/his room in bed with the blinds closed and the television off. On 10/7/24 at 10:59 AM Resident 38 stated she/he did not participate in activities at the facility because she/he "did not get invited." Resident 38 stated she/he "went to bingo once, and it was fun, but [she/he] did not get invited back." Resident 38 stated she/he would like the opportunity to participate in musical activities as well as other games but thought she/he was not invited as it was "a big deal with me because I need the Hoyer [a mechanical device designed to lift and transfer residents from one place to another] and a chair." Resident 38 further stated she/he enjoyed reading large print newspapers, magazines and books "when [she/he] could get them." On 10/8/24 at 11:56 AM Resident 38 stated she/he did not go to bingo yesterday because no one invited her/him. On 10/9/24 at 1:42 PM Resident 38 stated she/he wanted to participate in the 3:00 PM scheduled activity of Wii Bowling as it "sounded fun." On 10/10/24 at 8:51 AM Resident 38 stated she/he did not participate in Wii Bowling yesterday because no one invited her/him. On 10/11/24 at 10:09 AM Staff 44 (Agency CNA) stated she had never seen Resident 38 "do anything" and was not aware of any of the resident's activity interests. On 10/11/24 at 10:23 AM Staff 25 (CNA) stated Resident 38 spent her/his day in bed and she had never seen the resident engaged in an activity. Staff 25 stated she knew the resident liked cats but was unsure of any additional activity interests. On 10/11/24 at 3:15 PM Staff 26 (CNA) stated Resident 38 spent her/his days in bed, never really watched television and did not go outside. On 10/14/24 at 9:16 AM Staff 7 (Activity Director) stated Resident 38 was "hard to get to engage." Staff 7 stated she stopped inviting the resident to group activities because of the resident's repeated refusals. Staff 7 stated the resident's activity care plan did not include all of her/his activity interests and she had not attempted additional person-centered ideas to get Resident 38 engaged in activities. On 10/15/24 at 9:13 AM Staff 1 (Administrator) was informed of the findings and no additional information was provided. 4. Resident 53 was admitted to the facility in 7/2021 with diagnoses including dementia. Resident 53's 6/30/24 Annual MDS revealed the resident was severely cognitively impaired and her/his ability to hear was highly impaired. The MDS also revealed the following activities were important to Resident 53: to read books, newspapers and magazines, listen to music, be around animals, keep up with the news, do things with groups of people, go outside, do her/his favorite activities and participate in religious practices. Resident 53's 10/1/24 Activity Care Plan revealed the following: -The resident preferred independent and in-room activities. -The resident was able to direct her/his own activities of choice. -The resident preferred to visit with family on the phone in her/his room, read romance books or magazines and watch the news. -The resident would come out of her/his room to stroll the hallway and visit with staff. The facility's Activity Calendar revealed the following scheduled activities: -10/7/24 8:00 AM Daily Chronicle 11:00 AM Mail time and One-on-Ones 3:00 PM Bingo -10/8/24 8:00 AM Daily Chronicle 11:00 AM Mail time and One-on-Ones 3:00 PM Bible study -10/9/24 8:00 AM Daily Chronicle 11:00 It's Mail time and Vicki from Holy Family 2:30 PM One-on-Ones with Joy 3:00 PM Wii Bowling -10/10/24 8:00 AM Daily Chronicle 11:00 AM Mail time 2:00 April Trivia and popcorn -10/11/24 8:00 AM Daily Chronicle 11:00 AM It's Mail time 3:00 PM Bingo A review of Resident 53's Activity Task Log and activity documentation from 9/15/24 through 10/13/24 revealed the resident had a conversation with a visitor or received a one-to-one on six occasions but did not participate in a group activity, go outside or participate in a religious practice or animal visit. No evidence was found in the resident's clinical record to indicate the resident was invited to any of her/his preferred or favorite activities. Random observations of Resident 53 from 10/7/24 through 10/14/24 from 5:07 AM to 3:54 PM revealed the resident to be in her/his room either in bed or in her/his wheelchair. The resident's television was turned on with a low volume, the blinds were closed, no reading material was available and the lights were either off or low. On 10/8/24 at 3:54 PM Resident 53 was unable to answer questions about her/his activity interests and stated "I still can't get you" in response to the State surveyor's questions. On 10/11/24 at 10:15 AM Staff 25 (CNA) stated she had never seen Resident 53 participate in an activity and she was unaware of the resident's activity interests. Staff 25 stated Resident 53 usually spent all day in bed. Staff 25 further stated activity staff told her if she was supposed to get a resident ready so they could attend an activity and she had never been asked to assist Resident 53 to get ready for an activity. On 10/14/24 at 9:!6 AM Staff 7 (Activity Director) stated residents with a dementia diagnosis received one-to-one visits. Staff 7 stated Resident 53 was unable to self-initiate activities, the resident was "not real talkative" and her one-to-one visits with the resident primarily consisted of "trying to talk." Staff 7 stated she previously offered the resident a painting activity on one occasion but had not attempted any additional sensory activities with the resident. Staff 7 stated the last time she offered the resident any reading material was last month, the resident had not been invited to a group activity in over a week and all of the resident's activity interests were not included in her/his care plan. On 10/15/24 at 9:13 AM Staff 1 (Administrator) acknowledged the findings of this investigation and did not provide any additional information.

Corrective Actions The Activities care plan for Resident #38 was reviewed on 11/05/24 was updated to include attending bingo twice as week, attending communion each week in her room, keep blinds drawn, and watching TV in her room according to her stated activity preferences. The Activities care plan for Resident #51 was updated on 10/10/24 to include inviting resident to play cards with other residents and other resident activities according to the resident’s stated activity preferences. The Activities care plan for Resident #53 was reviewed on 11/05/24 and was updated to reflect current abilities and interests of resident for one on one and visits with staff. The Activities care plan for Resident #340 was updated to include 1:1 visits from the resident’s wife and watching TV programs together with his wife. An Activities care conference was held on 10/14/24 with the resident’s wife to identify other resident activity presences and his care plan was updated accordingly at that time. Identification of Others A review of residents who have not been attending activities for the past 30 days was completed on 11/07/24. Residents who have not attended activities were interviewed to and their activities preferences were identified and their care plans were updated accordingly. Systemic Changes and Education Prior to scheduled activities, Activity staff will round with residents to invite and encourage residents to attend the activity. If mobility assistance is needed for resident to attend the activity, Activity staff will communicate with the nursing assistants and licensed nurses so that appropriate assistance can be provided to attend the activity. An ADL task will be entered for residents preferring to complete independent activities to provide direction to nursing assistance as to what activities to assist the resident with. The Activities Director or Designee will complete a weekly review of the activity participation of the resident to identify any decrease in participation. The activity plan of care and associated tasks will be updated as appropriate. Activities staff, licensed nurses, and nursing assistants will be educated by 11/30/2024 regarding the importance of assisting residents to attend activities or participate in independent activities per care plan. Monitoring Activities Director or Designee will audit resident activity participation to identify any decreases in participation weekly x4 weeks, every other week x4 weeks, then monthly x2 months or until substantial compliance is determined by the QAPI committee. Effective Date of Compliance 11/30/2024

Based on observation, interview, and record review it was determined the facility failed to ensure residents' change of condition was assessed for 2 of 6 sampled residents (#s 38 and 89) reviewed for hospitalization and unnecessary medications. This failure, determined to be an immediate jeopardy situation, resulted in the delayed assessment of Resident 89 when she/he was experiencing a significant change in condition, resulting in delayed treatment. Resident 89 later died at the hospital. This placed all residents at risk for delayed assessments and treatments and constituted substandard quality of care. Findings include: Per National Library of Medicine online resource: Bleeding in the upper stomach and intestinal region carries a high morbidity (sudden onset of a health condition) and mortality (death) which can be lowered by timely evaluation and treatment. Signs of this condition include vomit which looked like coffee grounds. 1. Resident 89 was admitted to the facility on 8/2/24 with a diagnosis of lung cancer with metastasis (cancer spreads to other body systems). Resident 89's 7/30/24 physician orders revealed Resident 89 was a full code (life sustaining treatment provided if there were no respirations or heart beat). Vital signs from 8/2/24 to 8/8/24 revealed Resident 89's vital signs were last obtained on 8/7/24 at 2:22 PM. Resident 89's pulse was 81 (normal healthy adult range 60-100) and respirations were 18 breaths per minute (normal healthy adult range 12-18) and blood pressure was not obtained. Progress Notes revealed the following: -8/2/24 Resident 89 was admitted to the facility for therapy. Resident 89 was alert to person, place, time, and situation and was able to make her/his needs known. Resident 89 was continent of bowel and bladder and was able to eat independently. -8/4/24 Resident 89 was able to make her/his needs known. -8/5/24 Resident 89 was assessed by her/his physician and was assessed to be a full code. Resident 89 reported she/he wanted to get stronger and go home. Resident 89 was assessed to have a normal thought process, was in no distress, and interacted during the exam. Resident 89's abdomen was soft and nontender. Resident 89 was also assessed to have normal range of motion to her/his arms, had weakness to the left ankle, and her/his skin was normal in appearance and temperature. Resident 89 was a candidate for hospice but "prefers to be a full code." -8/6/24 and 8/7/24 Resident 89 participated with therapy without issue and was alert with some forgetfulness. -8/8/24 note written at 3:40 AM by Staff 30 (LPN) indicated Resident 89 vomited once, Zofran (treats nausea) was administered, and Resident 89 did not have continued vomiting. Resident 89 was placed on alert charting. There was no documentation of vital signs, characteristics of the vomit, or if the resident's physician was notified. -8/8/24 note written at 10:09 AM revealed at 6:50 AM Resident 89 was observed by a nurse to be in bed sleeping. At 7:20 AM a CNA summoned the nurse urgently and Resident 89 was found without a pulse or respirations. Staff initiated CPR (cardiopulmonary resuscitation: chest compressions and manual ventilations), emergency services were notified, and at 8:00 AM Resident 89 was transported to the local hospital. -8/8/24 note written at 12:13 PM and 12:20 PM by Staff 2 (DNS) revealed she called Staff 34 (CNA) who worked the night shift on 8/8/24 and Staff 34 stated Resident 89 reported nausea and vomited once. The vomit "looked like coffee grounds." The note indicated Staff 34 reported to Staff 30 (LPN) Resident 89 vomited but "nothing else." Staff 34 reported Resident 89 was "a little pale", not acting her/himself, and "maybe a little lethargic." Staff 34 stated on 8/8/24 at 5:15 AM she checked on the resident and Resident 89 was pale and sleeping. The note indicated Staff 34 was educated to inform the nurse of the color and consistency of fluids even if the nurse did not ask. Staff 30, who worked 8/8/24, reported the CNA informed her Resident 89 vomited at about 1:30 AM. Staff 30 stated she assessed the resident, the resident was able to talk, was able to report nausea, had "good color" and no other signs or symptoms. On 10/08/24 at 12:41 PM Staff 34 stated prior to 8/7/24 Resident 89 was usually very talkative and engaged when she provided care. On 8/7/24 at approximately 11:00 PM Resident 89 was clammy, tired, and did not talk much. Staff 34 stated she requested Staff 30 check on Resident 89. Staff 34 stated she was not sure if Staff 30 checked on Resident 89 because Staff 34 was busy caring for other residents. Staff 34 stated at approximately 1:00 AM, when she next checked on Resident 89, she found the resident with vomit coming out of her/his mouth and on her/his gown, the resident was incontinent of a large bowel movement, and she/he did not respond very much. Staff 34 stated she notified Staff 30. Staff 34 also stated she told Staff 30 Resident 89 had coffee ground vomit. Staff 34 indicated she was in the room with Resident 89 for about 10 minutes providing care after she notified the nurse and the nurse did not come into the room. Staff 34 stated she was not sure when Staff 30 checked on the resident. Staff 34 stated she did not obtain vital signs and the next time she saw Resident 89 was at about 5:15 AM and she/he was breathing but was still pale and clammy. On 10/8/24 at 1:21 PM Staff 33 (Nurse Practitioner) stated if a resident was a full code, no matter their medical condition, staff needed to treat a resident's change of condition. If a resident had coffee ground vomit and a medical provider was not on site to assess the resident, staff were to send the resident out to the hospital because staff were limited in the interventions they would be able to provide at the facility. On 10/8/24 at 2:00 PM Staff 35 (Physician) stated if a resident had coffee ground vomit and was stable the facility could monitor the resident in the facility. Monitoring would include vital signs. Staff 35 stated if a resident had a change in mental status, was pale and clammy, in addition to the coffee ground vomit, the resident would not be stable, the physician should be notified for guidance, and the resident should be sent to the hospital for evaluation. On 10/8/24 at 3:55 PM Staff 30 stated she did not recall Resident 89, but stated if a resident had coffee ground vomit the resident should be sent to the hospital because it could indicate internal bleeding. Staff 30 also stated if a resident's physician was called to obtain orders a note should be made in the progress notes regarding the resident's condition which required communication with the physician. On 10/8/24 at 12:01 PM and 3:58 PM Staff 2 (DNS) stated when she walked into the building on 8/8/24 staff were already performing CPR on Resident 89. Staff 2 stated she spoke to staff who worked the night shift and the day shift nurse who found Resident 89 without pulse or respirations. The day nurse stated Staff 30 reported the resident had nausea, vomiting, and nothing else. Staff 30 stated the resident was nauseated, she gave Zofran and it helped. Staff 2 stated Staff 30 reported she did not evaluate or see the vomit. Staff 2 indicated she called Staff 34, asked about the vomit, and she stated "you won't believe it, but it looked just like coffee grounds." Staff 2 stated she educated the Staff 34 to always describe to the nurse what the vomit looked like. Staff 2 also educated Staff 30 to always do more of an assessment and ask what the vomit looked like. Staff 2 acknowledged on 8/8/24 at approximately 1:00 AM Resident 89 was administered Zofran and the resident was found without a pulse or respirations at about 7:00 AM. Staff 2 verified there were no vital signs obtained on 8/8/24 and there was no assessment of the resident and resident's vomit. Staff 2 stated Staff 30 reported she did an assessment but did not document it. Staff 2 confirmed on 8/8/24 at approximately 11:40 AM Resident 89 died at the hospital. On 10/9/24 at 10:18 AM Staff 2 (Administrator) was notified of the immediate jeopardy (IJ) situation and was provided the IJ template related to the facility failure to assess, monitor, and document a resident's significant change of condition. As a result of the deficient practice, treatment was delayed for Resident 89. On 10/9/24 at 3:27 PM, an acceptable facility IJ removal plan was submitted by the facility. The plan indicated the facility would implement the following: -On 10/9/24 a review of other residents' change of condition, over the past week that may be affected, was completed by the DNS and designated staff. Other residents identified with a change of condition were to have assessments completed by the end of the day and residents' primary care physicians would be notified as appropriate. -Education for the Nurse and CNA was completed by the assistant DNS after the incident on 8/8/24. Further education would be completed on 10/9/24 with every employee (clinical, administrative, social service, activities, housekeeping, dietary and maintenance) to communicate changes in condition. Employees not on shift would be trained prior to starting shift with review of policy and procedure , then signing off on understanding and implementation. Once notified of a change of condition, the nurse would document, complete an assessment that day, and notify the primary care physician as appropriate. - Performance Improvement Project for change of condition would be initiated by the DNS or designee to audit 1.) Resident change of condition and 2.) Nurse assessments were completed the day of reported change of condition. The audits would be conducted weekly for one month, then twice a month for two months, and randomly thereafter. Results would be shared with Quality Assurance and Performance Improvement committee until substantial compliance was achieved. Additional documentation was later provided to show additional staff were educated about reporting changes of condition by staff 2 during huddles on 8/8/24, 8/9/24, 8/13/24 and 8/15/24, thereby removing the immediate jepordy on 8/15/24. , 2. Resident 38 was admitted to the facility in 7/2021 with diagnoses including hypertension (a condition where the pressure of blood in the blood vessels is consistently too high), coronary artery disease (heart disease) and peripheral vascular disease (a circulatory condition that occurs when blood vessels outside of the brain and heart narrow, spasm or become blocked). Resident 28's 6/30/24 Annual MDS revealed the resident was cognitively intact and received a diuretic (a medication used to treat fluid retention [edema] and swelling caused by congestive heart failure, liver disease, kidney disease and other medical conditions). The Dehydration/Fluid Maintenance CAA indicated the resident had adequate fluid intake and did not appear dehydrated. In response to the question in the CAA which asked whether or not dehydration/fluid maintenance would be addressed in the resident's care plan, "not assessed" was checked. A review of Resident 38's weights revealed the following: -On 8/9/24 the resident weighed 154.5 pounds. -On 9/11/24 the resident weighed 163.4 pounds. This represented an 8.9 pound weight gain from her/his weight on 8/9/24. -On 10/8/24 the resident weighed 171.5 pounds. This represented an 8.1 pound weight gain from her/his weight on 9/11/24 and a 17 pound weight gain from her/his weight on 8/9/24. Resident 38's 9/10/24 Physician Progress Note indicated the resident experienced brawny edema (a type of edema that does not indent when pressure is applied, unlike pitting edema, when a swollen part of your body has a dimple [or pit] after you press it for a few seconds) of her/his lower legs. A 10/9/24 Physician's Order directed Resident 38 to receive furosemide (a diuretic) one time daily for edema. No evidence was found in Resident 38's clinical record to indicate the resident's weight gains had been reported to the resident's physician or the underlying cause of the weight gain had been assessed, any systems were in place to monitor changes in the resident's edema or the potential for fluid overload (indicative of too much water in a person's body which can raise blood pressure and force the heart to work harder) had been assessed. On 10/11/24 at 12:24 PM Staff 2 (DNS) stated Resident 38's edema was not being monitored and should be and she did not know if Resident 38's physician had been notified of the resident's weight gains. On 10/11/24 at 12:52 PM Resident 38 was observed in her/his room in bed. Staff 40 (RN) removed the resident's socks in order to assess her/his legs and feet. An indent in each of the resident's legs was observed once the socks were removed. When Staff 40 pushed on the resident's ankles, she/he yelled out and stated Staff 40 was hurting her/him. Staff 40 stated the resident's ankles were a "plus 1" for edema (a barely visible dent that immediately rebounded after pressure was applied) but the top of her/his feet were a "plus 2" (a slight pit that went away within 15 seconds). Staff 40 stated the resident did not have scheduled monitoring for her/his edema, the top of her/his foot was "not normally like that," the change in swelling was not reported to her and the physician had not been notified of this change. On 10/11/24 at 2:03 PM Staff 41 (Agency RN) stated she was the charge nurse for day shift and was responsible for Resident 38's care. Staff 41 stated she did not receive any reports of Resident 38's edema. On 10/11/24 at 3:05 PM Staff 2 acknowledged the findings and provided no additional information.

Corrective Actions Education for the Nurse and CNA was completed by the ADNS immediately after the incident on 8/8/2024. Licensed nurses and nursing assistants were educated regarding the importance of recognizing changes of condition then communicating all details to the nurse assigned to the resident. The licensed nurses were educated regarding the importance of documenting all information shared by the nursing assistances or other nurses, contacting the primary care physician, and any new orders received, and updating the resident care plan as appropriate. Education sessions were completed on 08/09/24, 08/13/24, and 08/15/24. On 10/09/2024, DNS spoke with charge nurses and reviewed alert charting for all current residents change of condition that may be affected from 10/07/2024 to 10/09/2024. On 10/11/24 Resident 38 had an order placed to monitor BLE for increased edema every shift and the nurse notified PCP related to weight gain and increased edema. Identification of Other Individuals The alert charting for all current residents was reviewed on 10/09/24 to identify any change of condition. Residents identified as experiencing a change of condition were assessed and the primary care provider was notified. Any new orders received were carried out. Systemic Changes and Education Upon receiving information regarding a resident change of condition, the licensed nurse will complete a timely assessment and notify the primary care physician. The licensed nurse will document what was communicated to the nurse from staff, assessment findings, notification to the primary care provider (as applicable), any new orders received, and notification to the resident representative as appropriate. The DNS or Designee will review the 24-hour report during morning meeting to identify in potential resident changes of condition to validate that the appropriate orders, interventions, and documentation is present. Any variances will be addressed at the time of identification and the residents status will be reviewed at the afternoon Stand Down meeting. Clinical, administrative, social services, activities, housekeeping, dietary and maintenance were educated on the importance of communicating changes of condition to the licensed nurses. This education was completed on 10/09/24. Any staff not on shift received the education via COVR text with Change of Condition attachment on 10/09/24. Unscheduled staff will respond Yes to DNS or designee for reading the training. All new agency and new employees will have the Change of Condition training as part of orientation process. Once notified of a change of condition, the Nurse will document, complete an assessment timely, and notification of PCP, as appropriate. Monitoring The DNS or Designee will review the 24-hour report to identify any potential resident changes of condition and validate that the appropriate orders, interventions, and documentation is present 5x/week x2 weeks, 3x/week x2 weeks, weekly x4 weeks, then every other week x4 weeks or until substantial compliance is determined by the QAPI Committee. Effective Date of Compliance 11/30/24

Based on observation, interview, and record review it was determined the facility failed to ensure a resident was provided restorative services and a resident with limited range of motion received appropriate treatment and services to prevent further decreases in range of motion for 4 of 10 sampled residents (#s 5, 7, 16 and 50) reviewed for ADLs and mobility. This placed residents at risk for decrease in range of motion and worsening contractures. Findings include: 1. Resident 5 was admitted to the facility in 4/2024 with a diagnosis of paralysis. A 6/5/24 Therapy RA Referral form revealed staff were to assist Resident 5 with exercises three times a week. Exercises included weights for upper body strength and edge of bed exercises. A 7/28/24 quarterly MDS revealed Resident 5 was cognitively intact. On 10/10/24 at 11:49 AM Resident 5 stated she/he was no longer getting therapy and was weaker. On 10/10/24 at 8:11 AM Staff 36 (RA) stated Resident 5 was just restarted on therapy on 10/8/24. Staff 36 stated initially Resident 5 was not able to sit at the edge of the bed because she/he had a pressure ulcer to the coccyx region but was able to do arm exercises in bed. On 10/10/24 at 1:14 PM Staff 2 (DNS) stated initially Resident's RA program was designed to have her/him sit at the bedside and do arm weights. Staff 2 stated due to the pressure ulcer, Resident 5 did not want to sit at the bedside. Staff 2 stated she was not sure the reason the resident was not reassessed to implement in-bed exercises. 2. Resident 16 was admitted to the facility in 2/2020 with a diagnosis of diabetes. A 9/9/24 through 10/8/24 RA Program documentation revealed Resident 16 was to be seen two to three times a week for arm exercises. The form revealed resident 16 refused once and was "not available" on 16 occasions. Two times it was documented as "Not Applicable." On 10/7/24 at 10:22 AM Resident 16 stated staff did not assist with exercises and she/he felt weaker. On 10/10/24 at 8:13 AM Staff 36 (RA) stated if she marked not available it meant the resident was not assisted up by the CNA staff and therefore she was not able to assist the resident to go to to the therapy gym. Staff 36 stated she could assist Resident 16 in a wheelchair but she had other RA appointments and would not be able to see all the other residents. Staff 36 also stated Resident 16 did not refuse to exercise. On 10/10/24 at 10:32 AM Staff 21 (Director of Therapy) stated Resident 16 was in the RA program for quite a while and RA should always try to assist the resident to be up at a specific time to do her/his exercise. , 3. Resident 50 was admitted to the facility in 11/2021 with diagnoses including hemiplegia (a total or partial paralysis of one side of the body that results from disease of or injury to the motor centers of the brain) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs and facial muscles). Resident 50's 7/14/24 Annual MDS indicated the resident was severely cognitively impaired, experienced upper extremity impairment on one side and an active or passive range of motion program was not provided to the resident in the prior seven days. Resident 50's 7/19/23 through 8/15/23 OT Evaluation and Plan of Treatment indicated the resident exhibited contractures in all right upper extremity joints and pain with ROM. Resident 50's 8/4/24 Care Plan revealed the following: -The resident had an RA program in place to prevent right upper extremity contractures, pain and compromised skin integrity. -Monitor the resident's progress towards an RA program goal of three times daily. -Review the resident's RA program as needed. Resident 50's 8/15/24 OT Discharge Summary directed the resident to receive a restorative program which included gentle passive range of motion to the resident's right shoulder, elbow, wrist and digits with the goal of prevention of further contracture and pain in her/his right upper extremity. No evidence was found in Resident 50's clinical record to indicate the resident's upper extremity impairment was comprehensively assessed, ongoing monitoring of her/his upper extremity impairment was provided or the resident's RA program was re-evaluated for appropriateness. On 10/8/24 at 11:50 AM Resident 50 was observed in her/his room in bed. The resident's right arm was bent at the elbow and her/his right hand rested on the top of her/his chest. The resident's right thumb was tucked into the palm of her/his hand and the right pointer and little finger rested on top of the middle and ring finger. The fingers on Resident 50's left hand were observed to be in a loose fist. Resident 50 stated she/he was unable to move or straighten her/his fingers or thumb on her/his right hand and her/his right hand "hurt a little bit." The resident was able to somewhat straighten her/his fingers on her/his left hand with verbal prompting but was unable to straighten them completely. On 10/10/24 at 9:06 AM Staff 20 (CNA/RA) stated she was the facility's RA and she completed restorative exercises with Resident 50 one to two times weekly. Staff 20 further stated she had seen Resident 50's contractures "slowly get worse." On 10/10/24 at 9:50 AM Staff 21 (Director of Therapy) stated Resident 50 received a therapy evaluation in 2023 for contracture management and she would expect the resident to be referred back to therapy if she/he experienced new or worsening contractures. At 2:01 PM the State Surveyor and Staff 21 observed Resident 50 in her/his room in bed. Staff 21 stated she thought "the right hand seemed more contracted," the left hand had "maybe mild contractures," she was unaware of her/his new and worsening contractures and she "would have expected to see a referral" to therapy to address the resident's contractures. On 10/10/24 at 3:57 PM Staff 2 (Interim DNS) stated she expected the nurses and the RA to report new or worsening contractures to the DNS. Staff 2 further stated Resident 50's contractures had not been assessed, there was no on-going monitoring of the resident's contractures, she could not tell if the resident's contractures had worsened and nothing was being done to prevent contractures from developing in the resident's left hand. , 4. Resident 7 was admitted to the facility in 11/2019 with diagnoses including multiple sclerosis and depression. A 3/17/24 annual MDS revealed Resident 7 had impaired mobility of the upper and lower extremities. Resident 7's 9/23/24 Care Plan included the following: -The resident had an RA program related to maintaining baseline ROM to bilateral upper extremity as long as possible. -The resident had contractures to left shoulder, hips, and knees upon admission. -The goal of the RA program was to maintain baseline ROM to bilateral upper extremity. -Evaluate for therapy as appropriate. -RCC/RCM would review RA program as needed. A restorative note dated 7/18/23 revealed a new order was received for a restorative program for bilateral upper extremity ROM and the care plan was updated. Random observations of Resident 7 from 10/7/24 through 10/11/24 from 11:31 AM to 4:16 PM revealed Resident 7 in bed with her/his left arm contracted. Staff 20 indicated Resident 7 refused RA when she last worked with the resident. On 10/11/24 at 9:39 AM Staff 20 (CNA/RA) stated she had not worked with Resident 7 for about a year. Staff 20 indicated Resident 7 refused RA when she last worked with the resident. Staff 20 stated the resident's contractures had worsened over the years since she/he was admitted. On 10/11/24 at 1:56 PM Staff 2 (Interim DNS) stated the RA program for Resident 7 was discontinued on 10/18/23 when resident was admitted to the hospital. Staff 2 confirmed the program should have restarted when Resident 7 returned to the facility but was not.

Corrective Actions Resident 5’s RA program revised so resident may perform exercise in bed on 10/24/2024. Resident 7’s RA program was reinitiated on 10/11/2024. DNS educated RA staff about Resident 16’s program to document all attempts, what was done or refused on 10/10/2024. Resident 50 has RA program revised for contracture management performed 1-2 times per day on 10/15/2024 by adding a CNA task to assist with contracture management. Identification of Others DNS reviewed other residents receiving RA programs was completed on 11/03/2024. No other concerns were identified. Systemic Changes and Education During morning meetings, clinical leaders will review orders for recent admits/readmits to ensure RA program orders have been entered correctly. A weekly audit will be conducted by DNS or designee to ensure all orders complete and accurate. During monthly RA meetings, RA IDT will review all active RA programs to ensure all are accurate. Appropriateness of RA programs in regard to other medical needs will be assessed at this meeting as well and at least two other alternatives will be attempted before DC program completely. All active RA programs will be kept in a binder going forward and will be checked when a resident is readmitting to ensure RA program reinitiates after hospitalization. DNS or designee from RA IDT will educate clinical staff on RA program processes and systems. New assessment will be created for residents with contractures to monitor for worsening and if indicated, a referral will be placed to therapy to evaluate; and education to nurses will be provided. Training and the new assessment will be implemented by 11/30/2024. Monitoring DNS or designee will Audit once a week for one for 1 month, then twice a month for 2 months, then monthly for 2 months. Results will be shared with QAPI until substantial compliance is achieved. Date of Compliance 11/30/2024

Based on interview and record review it was determined the facility failed to ensure residents were free from accident hazards for 3 of 6 sampled residents (#s 6, 50 and 60) reviewed for accidents. This placed residents at risk for falls and adverse medication consequences. Findings include: 1. Resident 6 was admitted to the facility 12/2022 with a diagnosis of diabetes. A care plan revised on 6/8/24 revealed Resident 6 was to be transferred by two staff. A 9/29/24 quarterly MDS revealed Resident 6 was cognitively intact. On 9/18/24 Witness 2 (Complainant) reported facility staff was observed to transfer Resident 6 with one staff and not two. It was reported Resident 16 was fearful during the transfer but did not fall. On 10/8/24 at 10:42 AM Witness 2 stated on 9/18/24 Witness 3 (Community Nurse) was entering Resident 6's room and a CNA who was already in the room was transferring Resident 6 with a mechanical device and no additional staff were in the room. On 10/8/24 at 8:11 PM Staff 31 (CNA) stated she recalled a day when she transferred Resident 6, the resident's legs became weak and Resident 6 almost fell. Staff 31 stated another person walked into the room and Staff 31 requested assistance. Staff 31 did not recall if Resident 6 was a one person or a two person transfer at that time. Staff 2 acknowledged on 9/18/24 Resident 6 required two staff for transfers. , 2. Resident 60 was admitted to the facility in 8/2023 with diagnoses including acute respiratory failure with hypoxia (a condition in which the body does not have enough oxygen in the blood). Resident 60's 8/4/24 Annual MDS indicated the resident was cognitively intact. Observations from 10/7/24 through 10/10/24 between the hours of 8:00 AM and 4:30 PM, Triad Hydrophilic Wound Dressing (a sterile, zinc-oxide based wound dressing) and a bottle of 10% iodine (a topical antiseptic agent used for treatment and prevention of infection in wounds) sat out in the open, on the counter-top, next to the sink in Resident 60's room. On 10/7/24 at 12:39 PM Resident 60 stated the Triad Hydrophilic Wound Dressing and iodine was always on the counter-top for staff to use when they treated wounds on her/his legs and toes. On 10/10/24 at 1:35 PM Staff 14 (LPN) confirmed Trial Hydrophilic Wound Dressing and iodine was on the counter, unsecured and out in the open in Resident 60's room. Staff 14 stated wound care medications should be out of sight, secured in a closed drawer or cabinet so they were not easily grabbed. On 10/14/24 at 12:34 PM Staff 2 (Interim DNS) acknowledged medications left out in the open, unsecured in residents' rooms would be an accident hazard. , 3. Resident 50 was admitted to the facility in 11/2021 with diagnoses including dementia. Resident 50's 7/13/24 Fall Risk Assessment indicated the resident was considered at moderate risk to fall. Resident 50's 7/14/24 Annual MDS revealed the resident was severely cognitively impaired and experienced two falls without injury since her/his prior assessment. Resident 50's 8/4/24 At Risk For Falls Care Plan revealed the resident's bed was to be in a low position and fall mats were to be placed on both sides of the bed when the resident was in bed. On 10/7/24 at 2:18 PM and on 10/8/24 at 11:50 AM Resident 50 was observed in her/his room in bed. On both occasions, the resident's bed was at knee height and no fall mat was placed on the right side of the resident's bed. On 10/9/24 at 8:19 AM Resident 50 was observed in her/his room in bed. The resident's legs hung off of the right side of the bed, her/his left foot was caught in the sheet and the resident yelled "help me get out of bed." On 10/9/24 at 9:21 AM Staff 16 (Agency CNA) stated Resident 50 was considered at risk to fall and she/he needed fall mats "sometimes in the evening." On 10/10/24 at 12:35 PM Staff 15 (LPN) stated Resident 50 had "occasional falls" as she/he would "put her/his legs out of bed and then slide." Staff 15 stated the resident's bed was to be in a low position and a fall mat placed on each side of the bed when occupied. At this time, Staff 15 observed the resident in bed, stated her/his bed "should be lower than this" and lowered the bed to the floor. On 10/10/24 at 3:57 PM Staff 2 (Interim DNS) stated she expected Resident 50's bed to be in a low position with a fall mat on each side of the bed when the resident was in bed.

Corrective Actions Resident 50’s bed was set at correct height and fall mats were put into the correct position beside the bed on 10/10/2024. Resident 60 had wound care supplies put away in resident closet on 10/14/2024. Resident 6’s CNA was educated on 2 person versus 1 person transfer per care plan on 10/09/2024. Resident 50, 60, and 6 care plans have been reviewed and updated as needed. Identification of Others A review of other residents with high potential for accident or hazard was completed by DNS on 11/04/2024. No other concerns were identified. Systemic Changes and Education DNS began education on 10/29/24 to clinical staff on following the care plan completely to avoid accidents and hazards. DNS or designee will provide clinical staff with hands on training to identify potential accidents and prevent them to be completed by 11/30/2024. Monitoring DNS or designee to audit rooms by spot checking in various areas throughout the facility to ensure they are free from potential hazards or accidents. Audit will be once a week for one for 4 weeks, then twice a month for 2 months. Results will be shared with QAPI until substantial compliance is achieved. Date of Compliance 11/30/2024

Based on observation, interview and record review it was determined the facility failed to provide treatment and services to correct ongoing signs of depressive behavior for 1 of 1 sampled resident (#20) reviewed for behaviors. This placed residents at risk for not maintaining their highest practicable physical, mental and psychosocial well-being. Findings include: Resident 20 was admitted to the facility in 9/2022 with diagnoses including depression and adjustment disorder (a group of symptoms, such as stress, anxiety, feeling sad or hopeless, and physical symptoms that can occur after you go through a stressful life event). A review of Resident 20's Patient Health Questionnaire-9 (PHQ-9, a nine-item diagnostic tool used to assess for the presence and severity of depressive symptoms and a possible depressive disorder in adult patients in primary care settings) from 3/2024 through 9/2024 revealed the following: -On 3/10/24 the resident scored a 3, indicating she/he felt little interest or pleasure in doing things nearly every day. This score indicated minimal depression. -On 6/9/24 the resident scored a 6, indicating she/he felt little interest or pleasure in doing things nearly every day and felt down, depressed or hopeless nearly every day. This score indicated mild depression. -On 9/1/24 the resident scored an 8, indicating she/he felt little interest or pleasure in doing things nearly every day, felt down, depressed or hopeless nearly every day, had trouble falling or staying asleep or sleeping too much on several days and felt tired or had little energy on several days. This score indicated mild depression. Resident 20's 9/1/24 Annual MDS indicated the resident was moderately cognitively impaired. The CAAs indicated the resident's psychosocial well-being would be addressed in her/his care plan with a goal of improvement in well-being. Resident 20's 9/11/24 Depression Care Plan revealed the following: -The resident's depressed behaviors included feelings of loneliness, negative self-talk and withdrawn behavior. -Monitor, record and report to the resident's physician prn any risk for harm to self. -Monitor, record, report to the resident's physician prn any risk for harming others. -Routine and prn pharmacy review per protocol. -Specific Interventions: encourage the resident to attend group activities as able and assist with calling family. The problems and interventions listed in Resident 20's 9/11/24 Depression Care Plan reflected the same problems and interventions listed in the resident's 6/19/24 Depression Care Plan. No evidence was found in Resident 20's clinical record to indicate any new or additional interventions to address or monitor the resident's deteriorating mood state and/or new mood symptoms were added or trialed. On 10/7/24 at 12:23 PM and 10/10/24 at 1:43 PM Resident 20 was observed in her/his room in bed. Resident 20 stated the staff did "not give a shit" about her/him, she/he "pretty much just stayed in bed and waited for friends to come and visit," she/he "spent all her/his time laying down" and she/he "would do exercises and games, all of those things, but [she/he] was not invited." Resident 20 further stated she/he wanted to talk to the social worker about her/his mood but thought "they had written me off." On 10/9/24 at 9:21 AM Staff 16 (Agency CNA) stated Resident 20 did nothing but watch television in her/his room in bed. On 10/11/24 at 10:21 AM Staff 25 (CNA) stated Resident 20 was "negative and not happy to be here." Staff 25 further stated she had not seen the resident out of bed for months and she/he spent all of her/his time in bed watching television. On 10/14/24 at 11:40 AM Staff 17 (Social Services Director) stated she used to report changes in resident PHQ-9 scores and/or new mood symptoms to the former resident care manager, but at present, the facility "probably did not have a good system." Staff 17 stated she could not recall if she reported the resident's new mood symptoms and/or worsening mood to the facility's current resident care manager and she "did not know" if any new interventions or monitoring of the resident's mood was put in place following her/his 9/1/24 PHQ-9 evaluation and MDS Assessment. On 10/14/24 at 12:44 PM Staff 2 (Interim DNS) stated she was also the facility's resident care manager. Staff 2 stated she was made not aware of Resident 20's worsening scores on the PHQ-9 or new mood symptoms and she should have been.

Corrective Actions The care plan for Resident #20 was reviewed and updated on 11/05/24 to include offering counseling for mental health services due to increased symptoms of depression. Resident expressed desire to participate in 1:1 activities or social services each week. Identification of Others A review of current residents at risk for psychosocial decline was completed on 11/07/2024. [X number of residents were identified and care plans were updated… OR No other residents were identified.] Systemic Changes and Education During morning meeting, the Social Services Director or Designee shall review the 24-hour report progress notes to identify any documented psychosocial changes that could potentially impact a resident’s well-being. Changes to an identified residents’ plan of care shall be updated with new interventions implemented as appropriate. The social services staff and licensed nurses will be educated by 11/30/2024 on identifying psychosocial changes that could potentially impact a resident’s well-being and the importance of notifying the Social Services Director so appropriate interventions can be implemented. Monitoring Social Services Director or designee will review the 24-hour progress notes to identify any psychosocial changes that could potentially impact a resident’s well-being weekly x4 weeks, every other week x4 weeks, then monthly x1 month or until substantial compliance is determined by the QAPI Committee. Date of Compliance 11/30/2024

Based on observation, interview, and record review it was determined the facility failed to obtain and provide routine medication for 2 of 5 sampled residents (#s 33 and 49) reviewed for unnecessary medications. This placed residents at risk for not receiving prescribed medications. Findings include: 1. Resident 33 was admitted to the facility in 12/2021 with diagnoses including chronic respiratory failure with hypoxia (a condition in which the body does not have enough oxygen in the blood). a. Resident 33's 9/17/24 Physician Order indicated the resident was prescribed Vitamin B12, one time a day due to a vitamin deficiency. Resident 33's 9/2024 MAR indicated Vitamin B12 was not available on 9/18/24, 9/19/24, 9/20/24, 9/21/24, 9/22/24 and 9/23/24 which resulted in the resident not receiving the medication. On 10/10/24 at 12:50 PM Staff 19 (RN) reviewed Resident 33's MAR and stated when medications were not available, the charge nurse should be notified. Staff 19 stated Resident 33 went "too many days" without her/his Vitamin B12 and "that's a problem." Staff 19 stated she was unaware Resident 33's Vitamin B12 was not available. On 10/11/24 at 8:55 AM Staff 18 (CMA) reviewed Resident 33's 9/2024 and confirmed the resident's Vitamin B12 was not available on 9/18/24, 9/19/24, 9/20/24, 9/21/24, 9/22/24 and 9/23/24. Staff 18 was unable to recall why Resident 33's Vitamin B12 was unavailable but stated medications should be ordered approximately one week in advance, and if not available, then the charge nurse should be notified so the pharmacy could be contacted. Staff 18 was unsure if he notified the charge nurse that Resident 33's Vitamin B12 was not available. On 10/11/24 at 2:49 PM Staff 2 (Interim DNS) confirmed Resident 33's Vitamin B12 was not available. She stated she expected nursing staff to contact the pharmacy to determine why the medication was unavailable and then call the provider to get direction regarding the missed doses. Staff 2 acknowledged neither the pharmacy nor the provider was contacted. b. Resident 33's 9/17/24 Physician Order indicated the resident was prescribed folic acid (works closely with Vitamin B12 to help make red blood cells and help iron work properly in the body), one time a day. Resident 33's 9/2024 MAR indicated folic acid was not available on 9/19/24, 9/20/24, 9/21/24 and 9/22/24 which resulted in the resident not receiving the medication. On 10/10/24 at 12:50 PM Staff 19 (RN) reviewed Resident 33's MAR and stated when medications were not available, the charge nurse should be notified. Staff 19 stated Resident 33 went "too many days" without her/his folic acid and "that's a problem." Staff 19 stated she was unaware Resident 33's folic acid was not available. On 10/11/24 at 8:55 AM Staff 18 (CMA) reviewed Resident 33's 9/2024 MAR and confirmed the resident's folic acid was not available on 9/19/24, 9/20/24, 9/21/24 and 9/22/24. Staff 18 was unable to recall why Resident 33's folic acid was unavailable but stated medications should be ordered approximately one week in advance, and if not available, then the charge nurse should be notified so the pharmacy could be contacted. Staff 18 was unsure if he notified the charge nurse Resident 33's folic acid was not available. On 10/11/24 at 2:49 PM Staff 2 (Interim DNS) confirmed Resident 33's folic acid was not available. She stated she expected nursing staff to contact the pharmacy to determine why the medication was unavailable and then call the provider to get direction regarding the missed doses. Staff 2 acknowledged neither the pharmacy nor the provider were contacted. c. Resident 33's 9/17/24 Physician Order indicated the resident was prescribed Invokana (a medication to lower blood sugar levels), one time a day for diabetes. Resident 33's 9/2024 MAR indicated Invokana was not available on 9/18/24 and 9/19/24 which resulted in the resident not receiving the medication. On 10/10/24 at 12:50 PM Staff 19 (RN) reviewed Resident 33's MAR and stated when medications were not available, the charge nurse should be notified. Staff 19 stated Resident 33 went "too many days" without her/his Invokana and "that's a problem." Staff 19 stated she was unaware Resident 33's Invokana was not available. On 10/11/24 at 8:55 AM Staff 18 (CMA) reviewed Resident 33's 9/2024 MAR and confirmed the resident's Invokana was not available on 9/18/24 and 9/19/24. Staff 18 was unable to recall why Resident 33's Invokana was unavailable but stated medications should be ordered approximately one week in advance, and if not available, then the charge nurse should be notified so the pharmacy could be contacted. Staff 18 was unsure if he notified the charge nurse Resident 33's Invokana was not available. On 10/11/24 at 2:49 PM Staff 2 (Interim DNS) confirmed Resident 33's Invokana was not available. She stated she expected nursing staff to contact the pharmacy to determine why the medication was unavailable and then call the provider to get direction regarding the missed doses. Staff 2 acknowledged neither the pharmacy nor the provider were contacted. , 2. Resident 49 was admitted to the facility in 5/2024 with diagnoses including hyperlipidemia (high cholesterol) and kidney failure. A 5/31/24 BIMS indicated Resident 49 had normal cognitive function. a. A 5/30/24 Physician Order indicated Resident 49 was to receive 20 mg of pravastatin at bedtime for cholesterol. Review of a 10/2024 MAR revealed Resident 49 did not receive pravastatin on the following dates: - 10/1/24, - 10/3/24, - 10/4/24, - 10/5/24, - 10/7/24, - 10/8/24, - 10/9/24, - 10/10/24, - 10/11/24, - 10/12/24 and - 10/13/24 On 10/14/24 at 11:16 AM Staff 13 (LPN) was unable to locate Resident 49's pravastatin in the medication cart. Staff 13 stated he would communicate with the physician about renewing orders when a medication was found to be out of stock. On 10/14/24 at 11:51 AM Staff 2 (Interim DNS) stated she had not been informed Resident 49's pravastatin was not available to be administered until 10/14/24. Staff 2 confirmed Resident 49 had not received pravastatin on the dates listed and no action had been taken to obtain the medication. b. A 5/30/24 Physician Order indicated Resident 49 was to receive five mg of oxycodone every three hours as needed. Review of a 10/2024 MAR revealed Resident 49 did not receive oxycodone on 10/12/24 and 10/13/24. On 10/14/24 at 10:57 AM Resident 49 stated she/he had experienced moderate pain on 10/12/24 and 10/13/24, she/he requested oxycodone to assist with pain reduction, and was told the medication was not available. On 10/14/24 at 11:16 AM Staff 13 (LPN) attempted to locate Resident 49's oxycodone and stated it was not located in the medication cart. Staff 13 did locate a sticky note with information that appeared to be related to Resident 49's oxycodone but stated it was unclear and he was unable to determine if Resident 49 had any extra prescribed doses of oxycodone available. On 10/14/24 at 11:51 AM Staff 2 (Interim DNS) confirmed Resident 49 did not receive her/his oxycodone medication when requested on 10/12/24 and 10/13/24, as it was not available.

Corrective Actions The Vitamin B 12, folic acid, Invokana for Resident #33 was obtained on 10/12/2024. DNS follow up with pharmacy on 10/14/2024 about order for Resident #49s pravastatin and oxycodone. Pharmacy indicated patient ordered meds through home pharmacy. Identification of Other Individuals A review was completed of the medication supply for all current residents on 11/05/2024 to validate that all medications were on hand. Any variances were validated. Systemic Changes and Education The NOC nurse assigned to each medication cart shall complete a review of the medication cart to validate that all medications are on hand for each resident assigned to that medication cart. Any medications found to be at a 7-day supply will be reordered from the pharmacy. All licensed nurses and CMAs assigned to medication carts will monitor the medication supply on hand and when a medication is down to a 7-day supply, the nurse will validate that a refill has been requested and will request a refill if it has not. The licensed nurses and CMAs are to notify the DNS if any concerns arise with the refill process. During morning meeting, the DNS or Designee will review the MAR administration codes to identify any Not Administrated medications and validate with the nurse that the medication is on hand, or a refill has been requested. Licensed nurses will receive education by 11/30/24 regarding the importance of requesting a refill when a medication supply is down to 7-days on hand. Monitoring The DNS will review the MAR administration codes to identify any Not Administrated medications and validate with the nurse that the medication is on hand, or a refill has been requested 2x/week x4 weeks, then weekly x4 weeks, then every other week for 4 weeks or until substantial compliance is determined by the QAPI Committee. Effective Date of Compliance 11/30/24

Based on interview and record review it was determined the facility failed to ensure a resident was monitored for side effects of antidepressants for 1 of 5 sampled residents (#1) reviewed for unnecessary medications. This placed residents at risk for an adverse medication regimen. Findings include: Resident 1 was admitted to the facility in 5/2024 with a diagnosis of severe malnutrition. Resident 1's 10/2024 MAR revealed Resident 1 was administered trazodone (antidepressant which can also help with sleep) daily with a start date of 5/24/24 and sertraline (antidepressant) daily with a start date of 5/24/24. A care plan initiated 5/31/24 revealed Resident 1 was administered antidepressants and potential side effects included drowsiness, suicidal thoughts, confusion, and increased falls. Review of Resident 1's clinical record did not indicate staff monitored her/him for psychotropic medication side effects. On 10/10/24 at 12:38 PM Staff 2 (DNS) stated staff were to document psychotropic medication side effect monitoring on the MARs. Staff 2 acknowledged staff did not monitor Resident 1 for possible side effects.

Corrective Actions Orders for to monitor for side effects of antidepressant medication was entered on 10/10/2024 for Resident #1. Identification of Other Individuals An audit of the orders for residents receiving psychotropic medications was completed on 11/04/24 to validate that side effect monitoring orders are in place. No other concerns were identified. Systemic Changes and Education During morning meeting, the DNS or Designee will review new orders for psychotropic medications to validate that side effect monitoring orders have been entered. Licensed nurses and unit secretaries will be educated by 11/30/24 regarding the importance of including side effect monitoring orders for all psychotropic medications. Monitoring The DNS or Designee will review new orders for psychotropic medications to validate that side effect monitoring orders have been entered weekly x4 weeks, every other week for 4 weeks, then monthly x1 month or until substantial compliance is determined by the QAPI Committee. Effective Date of Compliance 11/30/24

Based on observation, interview and record review it was it was determined the facility failed to ensure a medication error rate of less than 5%. The facility administration error rate was 19.23% with 5 errors in 26 opportunities. This placed residents at risk for an ineffective medication regimen. Findings include: Resident 343 was admitted to the facility in10/2024 with a diagnosis of heart disease. Epocrates Online (web based pharmacy resource) revealed levothyroxine (hormone replacement)should be taken 15 to 60 minutes before breakfast with a full glass of water at the same time daily. It also indicated the following drug to drug interactions: -levothyroxine and metformin (treats diabetes): deceases antidiabetic agent. -levothyroxine and metoprolol (treats high blood pressure) may decrease antihypertensive. -levothyroxine and sucubitril (treats heart failure and high blood pressure) may decrease antihypertensive. -levothyroxine and omeprazole (treats acid reflux) may decrease thyroid hormone levels. A current Order Summary Report revealed Resident 343 was to be administered levothyroxine 30 minutes before meals. On 10/9/24 at 8:49 AM Resident 343 was observed with her/his meal tray being removed from her/his room. Resident 343 stated she was done eating. Resident 343's hot cereal bowl was observed to be empty. Staff 32 (Agency LPN) was observed to administer the following medications to Resident 343: -levothyroxine -sucubitril -metformin -omeprazole Staff 32 stated she asked other staff if it was okay to administer levothyroxine with other medications and after meals and staff told her it did not matter. On 10/9/24 at 5:09 PM Staff 2 (DNS) acknowledged Resident 343's physician's order was to administer levothyroxine without food and levothyroxine had drug to drug interactions with multiple medications.

Corrective Actions Resident #343 was assessed on 10/09/2024 for adverse reactions related to medications received on 10/09/24. No adverse effects were identified. Identification of Other Individuals An audit of the MAR with a lookback period of 1 week was completed on 11/06/2024 to validate that medications were administered according to the times indicated on the MAR. Residents identified for receiving medications outside of ordered time were reported to PCP and placed on monitoring for any adverse effects. Systemic Changes and Education Licensed nurses and CMAs will be educated by 11/30/24 on the importance of administering medications according to the specific times indicated on the MAR to prevent medication errors and potential adverse effects to the residents. Monitoring The DNS or Designee will observe the medication pass of 3 varied licensed nurses/CMAs on varying dates and shifts to validate that medications are being administered according to the specific times indicated on the MAR 3x/week x4 weeks, 2x/week x4 weeks, then weekly x4 weeks or until substantial compliance is determined by the QAPI Committee. Effective Date of Compliance 11/30/24

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 5 of 6 halls (1B, 1C, 1D, 2C and 2D) observed for secure medication and treatment carts. This placed residents at risk for misappropriation of medications and adverse medication consequences. Findings include: 1. On 10/8/24 the following occurred: -8:02 AM a treatment cart on 1D was observed to be unlocked, a CNA walked by the cart but did not lock the cart. -8:07 AM Staff 15 (LPN) locked the cart. Staff 15 stated she was not responsible for the the treatment cart which was unlocked and it was the night shift cart. Staff 15 stated the cart contained medicated creams and should be locked. 2. On 10/10/24 at 5:40 PM a medication cart located on the 1B hall was observed to be unlocked with no staff within sight of the cart. Staff 17 (Social Services Director) indicated the cart was to be locked and she informed a nurse who was in a resident's room. , 3. On 10/8/24 at 3:53 PM a treatment cart was observed to be unlocked on 2C. The nurse was not in view of the cart. On 10/8/24 at 4:09 PM Staff 6 (LPN) confirmed the cart was unlocked. 4. On 10/10/24 at 8:22 AM a medication cart was observed to be unlocked on 2C. The nurse was not in view of the cart. On 10/10/24 at 8:26 AM Staff 14 (LPN) confirmed the cart was unlocked. 5. On 10/14/24 at 9:41 AM a medication cart was observed to be unlocked on 2C. The nurse was not in view of the cart. On 10/14/24 at 9:46 AM Staff 8 (CMA) confirmed the cart was unlocked. 6. On 10/14/24 at 9:59 AM a medication cart was observed to be unlocked on 1C. The nurse was not in view of the cart. On 10/14/24 at 10:05 AM Staff 13 (LPN) confirmed the cart was unlocked. 7. On 10/15/24 at 8:06 AM a treatment cart was observed to be unlocked on 1D. The nurse was not in view of the cart. On 10/15/24 at 8:13 AM Staff 2 (DNS) confirmed the cart was unlocked. On 10/15/24 at 8:13 AM Staff 2 stated it was her expectation for the medication and treatment carts to remain locked when unattended.

Corrective Actions DNS or designee provided 1:1 education for licensed nurses and CMA’s about always ensuring med carts/treatment carts are locked when they are not physically standing in arms length of the cart. This education took place from 10/10/2024 to 10/15/2024. Identification of Other Individuals A review by DNS and IP nurse of med carts/treatment carts was completed on 10/15/2024 found no medication/treatment carts unlocked nor missing medications for the previous week. Systemic Changes and Education During routine rounding, the DNS or Designee shall include checks of medication carts to validate that the carts are being locked when not in use or within arms-length of the nurse. IP Nurse or designee to provide education to licensed nurses and CMA’s about med carts/treatment carts to be locked any time personnel step outside of arms reach of the cart. The education will be completed by 11/30/2024. Monitoring IP Nurse or designee to perform audits to confirm carts are being locked and nurses and CMA’s are aware of this expectation. Audits will be conducted 2 times per week for 4 weeks, 1 time per week for 8 weeks. Results will be shared with QAPI until substantial compliance is achieved. Effective Date of Compliance 11/30/24

Based on observation, interview, and record review it was determined the facility failed to ensure a follow-up dental exam was scheduled for 1 of 4 sampled residents (#16) reviewed for dental. This placed residents at risk for delayed treatment. Findings include: Resident 16 was admitted to the facility in 2/2020 with a diagnosis of diabetes. A 7/23/24 Progress Note indicated all of Resident 16's teeth were extracted. An 8/11/24 quarterly MDS revealed Resident 16 was cognitively intact. An 10/2024 Upcoming Appointment Requests list revealed Resident 16 was not on the list to be seen by a dentist. On 10/7/24 Resident 16 stated her/his teeth were pulled a few months prior, there were no follow-up appointments made and she/he wanted dentures. On 10/11/24 at 9:53 AM and 10/11/24 at 10:20 AM Staff 17 (Social Services Director) stated a dentist came to the facility two to three times a year. Staff 17 stated after teeth were pulled a resident's gums healing time varied from resident to resident and a resident needed to to be examined to determine if denture fitting was appropriate. Staff 17 stated Resident 16 was not on the current list to be seen and she would call to see when Resident 16 required an exam. On 10/16/24 at 11:22 AM Witness 4 (Dentist) stated he pulled Resident 16's teeth and on average, after teeth were pulled, gums healed in approximately eight weeks and the denture process could start.

Corrective Actions Resident #16 received a dental appointment on 10/14/2024 and final denture impressions were made on 10/23/24. Resident #16’s dentures are in the process of being made and are expected to be delivered within the next 30 days. Identification of Other Individuals The Social Service Director reviewed the dental needs for all current all residents. 4 additional residents were in need of dental appointments, which were completed on 10/14/24 and 10/23/24. Systemic Changes and Education The Social Services Director or Designee will ask about dental needs during each resident’s quarterly care plan meeting. Dental appointments will be scheduled accordingly. During morning meeting, the Social Services Director or Designee will review the progress notes for current residents any evidence of dental needs (mouth pain, chewing difficulties, chipped teeth, etc.) and schedule dental appointments accordingly. Social Services Director or Designee will educate licensed nurses, nursing assistants, and social services staff by 11/30/2024 on identifying dental needs and communicating any findings back to the Social Services Director so that dental appointments can be scheduled accordingly. Monitoring The Social Services Director or Designee will review the progress notes for current residents for any evidence of dental needs so that dental appointments can be scheduled accordingly weekly x4 weeks, every other week x8 weeks or until substantial compliance is determined by the QAPI committee. Date of Compliance 11/30/2024

Based on observation, interview and record review it was determined the facility failed to ensure foods were labeled and stored to ensure proper food storage practices were followed in 1 of 1 kitchen reviewed. This placed residents at risk for foodborne illness. Findings include: Review of the US FDA 2022 Food Code revealed: -food prepared and held cold must be clearly marked with date prepared or by day which the food shall be consumed or discarded. During the initial tour of the kitchen on 10/7/24 at 9:40 AM Staff 39 (Dietary Manager) verified and threw away the following undated and unlabeled items: "Reach-in" refrigerator: -A gyro sandwich wrapped in foil; -Prune juice poured into multiple glasses; -Three green salads. Walk-in refrigerator: -An opened container of chicken stock base; -Olives stored in a plastic container; -Cut tomatoes in a plastic container partially covered with plastic wrap; -Shredded carts stored in a plastic container. On 10/7/24 at 9:54 AM Staff 39 stated he expected all items in the refrigerators to be labeled, dated and covered, especially the opened items. On 10/7/24 at 10:00 AM Staff 1 (Interim Administrator) acknowledged he expected all food in the refrigerator to be dated.

Corrective Actions The identified label was removed from the refrigerator on 10/07/24. Identification of Other Individuals An audit of the expiration dates of all food items in the kitchen and food storage areas was completed on 10/07/24. No other expired food items were identified. Systemic Changes and Education The Director of Dietary Services or Designee will complete weekly audits of the expiration dates of all food items in the kitchen and food storage areas. Any food set to expire will be discarded. Dietary staff will be educated by 11/30/24 of proper food storage techniques, including completing regular expiration date checks. Monitoring The Director of Dietary Services or Designee will complete weekly audits of the expiration dates of all food items in the kitchen and food storage areas weekly x4 weeks, every other week x4 weeks, then monthly x 1 month or until substantial compliance is determined by the QAPI Committee. Effective Date of Compliance 11/30/24

Based on observation, interview and record review it was determined the facility failed to ensure residents received timely specialized rehabilitative services (PT and OT services) for 1 of 1 sampled resident (#20) reviewed for rehabilitation and restorative. This failure resulted in Resident 20 displaying a depressed mood, verbalizing feelings of frustration and a decline in physical functioning. Findings include: The facility's 1/2023 Therapy Evaluation Policy indicated the following: -The Rehabilitation Department was to be notified when a physician order was written for therapy evaluation and treatment. -The licensed therapist was to perform a chart review and initiate the evaluation. -The initial evaluation was to be completed within two to three days from the time the referral was written. Resident 20 was admitted to the facility in 9/2022 with diagnoses including a history of falls. A review of Resident 20's clinical record revealed she/he was hospitalized from 10/23/23 to 10/27/23 related to sepsis (a life-threatening condition that occurs when the body's immune system overreacts to an infection, causing inflammation, blood clots and leaky blood vessels) secondary to a urinary tract infection. Resident 20's 10/26/23 PT Treatment Note completed during the resident's hospital stay indicated the resident was able to complete a stand-pivot transfer to a chair, bedside commode or wheelchair with a gait belt, front-wheeled walker and contact guard assist (a type of assistance where a caregiver places one or two hands on a patient to help with balance but does not provide any other help with a task). The note further indicated the resident required standby assistance from a caregiver for bed mobility. Resident 20's 10/27/23 ICF Admission Orders directed nursing staff to continue with the functional mobility and ADL levels established in the hospital as allowed per weightbearing status until the resident was seen by PT. Resident 20's 10/27/23 Physician Orders indicated PT and OT was to assess and treat the resident. Resident 20's 10/27/23 Readmission Form indicated the resident required limited assistance from staff with transfers. No evidence was found in Resident 20's clinical record to indicate she/he was assessed and treated by PT or OT since she/he readmitted to the facility from the hospital on 10/27/23. Resident 20's 9/1/24 Modification of Annual MDS Assessment indicated the resident was moderately cognitively impaired, dependent on staff assistance for transfers and experienced mild depression. The CAAs further indicated the resident required extensive assistance with bed mobility as she/he experienced deconditioning (a decline in physical and mental function that occurs due to a lack of physical activity or extended bed rest), pain and weakness. Resident 20's 9/11/24 ADL Performance Deficit Care Plan revealed the following: -The resident required assistance from two staff and the use of a Hoyer lift (a mobile device that helps caregivers safely transfer patients with limited mobility from one place to another) for all transfers. -The resident was unable to use a bedside commode or toilet. On 10/7/24 at 12:01 PM Resident 20 was observed in her/his room, in bed. Resident 20 stated she/he did not receive any therapy, "no one does any exercises with me" and she/he "pretty much just stayed in bed and waited for friends to come and visit." Resident 20 stated no one at the facility "gave a shit" and she/he thought all the staff "had written [her/him] off." On 10/10/24 at 1:43 PM Resident 20 stated she/he felt as if she/he "had physically declined and was weaker all over." Resident 20 stated she/he did not sit up very well anymore because she/he spent all her/his time laying down, she/he wanted to be able to stand again and she/he did "not like feeling weaker and dependent." On 10/10/24 at 10:00 AM Staff 20 (CNA/RA) stated she was not responsible for assisting the resident with any restorative exercises and the resident did not currently receive any therapy services. On 10/10/24 at 10:36 AM Staff 23 (Agency CNA) stated Resident 20 required a Hoyer lift for transfers and the resident no longer used the toilet or bedside commode but had incontinent care provided in bed instead. Staff 23 stated the resident was a more active participant in her/his ADLs a few months ago but "right now she had to do everything for [the resident's] lower body." On 10/10/24 at 10:46 AM Staff 24 (CNA) stated she had not seen Resident 20 get out of bed since 2/2024. Staff 24 further stated in 2/2024 the resident required the assistance of one to two staff with transfers but now she/he used a Hoyer lift. On 10/10/24 at 2:12 PM Staff 21 (Director of Therapy) stated she was not aware of Resident 20's order for PT and OT from 10/27/2023 and the last time the resident received therapy services was in 5/2023. On 10/10/24 at 4:37 PM Staff 2 (Interim DNS) acknowledged the findings and confirmed the resident should have received therapy services following her/his hospitalization in 10/2023 but did not.

Corrective Actions Resident #20 was reviewed for PT/OT services on 10/17/2024. PT/OT services are not indicated at this time. A Restorative Assistance (RA) program was initiated for Resident #20 on 10/24/2024. Identification of Other Individuals A review of residents that returned from the hospital in the last 30 days was completed on 11/04/24. No residents in need of RA services were identified. Systemic Changes and Education Residents returning from the hospital that do not have orders for PT/OT services will be assessed for restorative needs and an RA program will be initiated as indicated. A new RA assessment will be implemented by 11/30/24. Unit secretaries will be educated regarding entering readmission orders, including therapy orders. Licensed nurses will be educated regarding entering, confirming, and completing readmission orders, including therapy orders. Monitoring The DNS or Designee will audit the therapy orders for readmitting residents to validate confirmation and completion of the orders weekly for x4 weeks, every other week for 4 weeks, then monthly x1 month or until substantial compliance is determined by the QAPI Committee. Effective Date of Compliance 11/30/24

Based on observation, interview and record review it was determined the facility failed to ensure residents received timely specialized rehabilitative services (PT and OT services) for 1 of 3 sampled residents (#20) reviewed for rehabilitative services. This placed residents at risk for declined mobility and lack of quality of life. Findings include: The facility's 1/2023 Therapy Evaluation Policy indicated the following: -The Rehabilitation Department was to be notified when a physician order was written for therapy evaluation and treatment. -The licensed therapist was to perform a chart review and initiate the evaluation. -The initial evaluation was to be completed within two to three days from the time the referral was written. Resident 20 was readmitted to the facility in 10/2023 with diagnoses including a history of falls. A 10/17/24 Physician Order directed Resident 20 to receive PT and OT evaluations and treatment. Resident 20's 11/24/24 Quarterly MDS Assessment revealed the resident was moderately cognitively impaired and did not receive any PT or OT services. Resident 20's 11/25/24 Authorization for Medical Care Form revealed the resident's insurance provider authorized the resident to receive "evaluation and occupational therapy." On 12/11/24 at 10:33 AM and 2:02 PM Resident 20 was observed in her/his room in bed. Resident 20 stated she/he was "not doing any therapy" and if she/he was offered an opportunity to participate in PT and/or OT she/he would participate because the resident wanted "to be able to walk again." On 12/11/24 at 10:42 AM Staff 3 (Director of Rehab) stated after Resident 20 received a physician order for PT and OT on 10/17/24, she faxed the resident's insurance provider on 10/17/24, 11/6/24 and 11/14/24 the information required for insurance to authorize PT and OT but the facility was still waiting for the insurance provider to authorize therapy services for the resident. Staff 3 stated she thought she left a voicemail last week with an unidentified person who worked for the resident's insurance provider "to see where they were in the process, if something was pending or what the hold up was" but she did not receive a return phone call. Staff 3 stated she sent an email on 12/8/24 to an unidentified staff person who worked at the facility and who had access to EPIC (one of the largest providers of health information technology, used primarily by large U.S. hospitals and health systems to access, organize, store and share electronic medical records) to see if she could find any information but the staff person had not emailed her back. Staff 3 stated she sent an email to a care coordinator at the resident's insurance provider this morning to check the status of the resident's therapy authorization. No evidence was found in Resident 20's clinical record to indicate any additional efforts outside of an unreturned voicemail that was left "last week" for an unidentified person who worked for the resident's insurance provider, an unreturned email that was sent on 12/8/24 to an unidentified staff person at the facility or an email sent on 12/11/24 to a care coordinator at the resident's insurance company, including the notification of the resident's primary care physician or the facility's medical director, were to ensure the resident received timely therapy services. On 12/11/24 at 11:01 AM Staff 2 (DNS) stated when there was a delay in an authorization from an insurance provider for therapy, "we call and bother them to approve." Staff 2 stated she would consider having Resident 20 seen by her/his primary care physician associated with the resident's insurance provider to help with the authorization process but she had not yet scheduled an appointment. On 12/11/24 at 11:28 AM and 12:11 PM Staff 3 stated she followed up with the unidentified staff person at the facility since last interacting with the state surveyor, and this staff person found an authorization for the resident to receive an OT evaluation and treatment in the EPIC system dated 11/25/24. Staff 3 further stated "a lot of the time, this was handled by the RNCM, they would follow up" with resident insurance providers when there was a delay in authorizations for therapy services. On 12/11/24 at 12:32 PM Staff 2 (DNS) stated she found out on 12/11/24 Resident 20 received authorization for OT evaluation and services on 11/25/24 and did not know "why it sat" in the EPIC system "with no notification for a week and a half." On 12/11/24 at 2:28 PM Staff 1 (Administrator) and Staff 2 were present for an interview. Staff 1 acknowledged the findings and stated the facility needed to increase their efforts to "weekly, but if not getting it, increase our urgency" to daily in the case of making contact with Resident 20's insurance company for a therapy authorization. Staff 1 stated the facility's medical director should be involved if the facility did not receive timely therapy authorizations.

Corrective Actions Resident #20 was reviewed for PT/OT services on 10/17/2024 and authorization request sent to insurance. A Restorative Assistance (RA) program was initiated for Resident #20 on 10/24/2024. Insurance authorized OT on 11/23/2024 and PT on 12/12/2024. OT began on 12/12/2024 and PT began on 12/13. Identification of Other Individuals A review of residents returned from the hospital in the last 30 days and residents identified for therapy services was completed on 12/12/24. Two Residents were identified. Authorization of services requested by insurance and have started therapy services. Systemic Changes and Education New residents, readmissions, and residents identified in-house for therapy (PT, OT, SLP), restorative program, and/or reauthorizations will be included in a weekly Verification of Funding (VOF) status email with IDT (DNS, Director of Rehab, Billing, Administrator, Admissions). Residents returning from the hospital that do not have orders for PT/OT/SLP services will be assessed for restorative needs and an RA program will be initiated as indicated. Weekly Utilization Review (UR) meetings may discuss therapy needs/progress. Daily standup can also address therapy needs between weekly VOF status email. Residents identified for therapy services will be included on a weekly (VOF) status email to include IDT (DNS, Director of Rehab, Billing, Administrator, Admissions). If residents have not received authorization/started services for 2 weeks, insurance will be contacted 2x week for 2 weeks. After week 4, the medical director and/or PCP will be notified to conduct peer review request with insurance. Monitoring The Director of Therapy or Designee will audit the therapy orders, reauthorization, and restorative program residents weekly for x4 weeks, every other week for 4 weeks, then monthly x1 month or until substantial compliance is determined by the QAPI Committee. Effective Date of Compliance 12/13/24

Based on interview and record review it was determined the facility failed to ensure residents were fully informed and understood the binding arbitration agreement for 1 of 1 facility reviewed for binding arbitration agreements. This placed residents at risk of being uninformed regarding their legal rights. Findings include: On 10/14/24 at 1:01 PM Staff 1 (Administrator) stated the facility offered a Mediation and Arbitration Clause to residents upon admission. Staff 1 stated he and Staff 5 (Bookkeeper) were responsible for the process of explaining the agreement to residents upon admission. On 10/14/24 at 1:06 PM Staff 5 stated she was responsible to provide residents with information related the facility's Mediation and Arbitration Clause. Staff 5 stated the information was part of the admission handbook, she did not explain the arbitration process to residents nor did she obtain signatures with dates. On 10/14/24 at 1:06 PM Staff 1 acknowledged the facility did not have a clear process for providing information regarding binding arbitration agreements to residents.

All residents are provided the “Mediation and Arbitration Clause” upon admission/readmission. Administrator or designee will provide revised Arbitration Agreement Policy to all residents/representatives and explained to them in language they can understand by 11/30/2024. Inter Disciplinary Team (IDT) reviewed policy and procedure for Arbitration Agreement. Administrator or designee to provide education on visiting with each resident upon admission about the Arbitration Agreement Policy and let them know the resident has the right to rescind within 30 days of signing an Arbitration Agreement. Administrator or designee to audit one time a week for 4 weeks and 2 times a month for 2 months using the “Admission Documents Review Acknowledgement.” Results will be shared with QAPI until substantial compliance is achieved.

Based on observation, interview, and record review it was determined the facility failed to ensure community use CBG monitors were cleaned with an approved disinfectant for 3 of 6 sampled units (2, 2D and 1B) observed during medication administration and random observations, failed to implement EBP (enhanced barrier precautions: gloves and gowns worn during high contact for wounds and indwelling devices) timely for 1 of 2 sampled residents (#5) reviewed for pressure ulcers, failed to transport linens in a sanitary manner, and failed to ensure a legionella water management plan for 1 of 1 facility. This placed residents at risk for cross contamination. Findings include: 1. On 10/8/24 at 8:34 AM Staff 15 (LPN) was observed to clean a community use CBG with an alcohol swab. Staff 15 was stopped prior to entering a resident's room to perform a CBG check. Staff 15 stated she used alcohol swabs to clean CBG machines and at times used bleach wipes. On 10/8/24 at 9:05 AM Staff 37 (LPN) sated she cleaned the community use CBG on the 1B hall with alcohol wipes. All residents with CBG orders were reviewed and were found to not have any bloodborne pathogen diagnoses. On 10/8/24 2:35 PM Staff 2 (DNS) acknowledged alcohol wipes were not effective against blood borne pathogens. 2. Resident 5 was admitted to the facility in 4/2024 with a diagnosis of a chronic pressure ulcer. Resident 5's TARs revealed wound care was provided from 4/24/24, date of admission, to the current date. Progress Notes by Staff 29 (IP) revealed the following: -4/25/24 Resident 5 was identified to have a urostomy tube (surgical tube to drain urine from the bladder), an advanced bone infection from a chronic pressure ulcer, and had a history of a drug resistant organism. The note also indicated Resident 5 "does not require any Transmission Based Precautions (EBP) at this time." Resident 5's care plan was not updated with EBP until 8/2024. On 10/11/24 at 9:34 AM Staff 29 stated when a resident was admitted to the facility she looked at the admission paperwork to identify if a resident had a clinical need for EBP, including chronic wounds, a care plan was implemented, signage placed on the resident's door and the PPE was placed by the resident's room. Staff 29 acknowledged Resident 5 was admitted to the facility in 4/2024 and EBP was not implemented until 8/2024. , 3. On 10/10/24 at 12:16 PM Staff 22 (Laundry Services) was observed to deliver clean resident clothing throughout wings B and C on the 2nd floor. A small sheet was draped over a portion of the cart but did not cover all of the clean clothing as staff went from room to room. On 10/10/24 at 12:16 PM Staff 22 indicated she always delivered clean laundry in this manner. On 10/11/24 at 2:10 PM Staff 1 (Administrator) acknowledged the findings of this investigation and did not provide any additional information. 4. On 10/10/24 at 8:45 AM Staff 10 (Campus Director of Facility Services) was asked about the facility's water management program related to potential areas of Legionella growth. Staff 10 stated she was not aware of a program. Staff 10 stated she had not monitored for areas of potential Legionella growth since taking the position in March 2024. On 10/10/24 at 4:19 PM Staff 1 (Administrator) confirmed the facility had not developed and implemented a water management program. No further information was provided.

Enhanced Barrier Precautions Corrective Actions Resident #5 was evaluated for potential adverse effects, and none were identified. Staff caring for Resident #5 were educated on or before 08/01/2024 about importance of following enhanced barrier precautions (EBP) while providing ADL care. Staff donned appropriate PPE moving forward since that time. Identification of Other Individuals An observation audit was completed on 10/11/2024 to identify any other potential incidents of staff providing ADL care without EBP. Any areas of concern were remedied at the time of the observation. Systemic Changes and Education Nursing staff will be educated by 11/30/2024 regarding the importance of following EBP and donning appropriate PPE while providing ADL and clinical care to resident requiring EBP. Monitoring DON or designee will complete random walking rounds on varying shifts and units to observe for appropriate use of PPE with residents requiring EBP 3x/week x4weeks, weekly x4 weeks., then every other week for 4 weeks or until substantial compliance is determined by the QAPI Committee. Effective Date of Compliance 11/30/2024 Capillary Blood Glucose Corrective Actions The identified capillary blood glucose (CBG) machine was cleaned with bleach disinfectant on 10/08/2024. Nurse 15 received 1:1 education on 10/08/2024 of the importance of using bleach disinfectant wipes after each use to prevent the spread of blood borne pathogens. Identification of Other Individuals Review of CBG residents was completed on 10/08/2024 for any adverse effects. None were identified. The CBG machines on each medication cart were cleaned with bleach disinfectant wipes on 10/08/2024 after each use moving forward. Systemic Changes and Education Each medication cart has bleach disinfectant wipes available to clean CBG machines since 10/08/2024. Central Supply will include bleach disinfectant wipes in the weekly stocking of nursing supplies. Nursing staff will be educated by 11/30/2024 regarding the importance of wiping CBG machines with bleach disinfectant wipes after each use in order to prevent the spread of blood borne pathogens. Monitoring DON or designee will complete random walking rounds on varying shifts and units to validate that CBG machines are being wiped after each use 3x/week x4weeks, weekly x4 weeks, then every other week x4 weeks or until substantial compliance is determined by the QAPI Committee. Effective Date of Compliance 11/30/2024 Laundry Covered During Transport Corrective Actions Laundry staff working on 10/10/2024 received 1:1 education on the importance of covering all laundry prior to transporting and delivering clean laundry throughout the building. Identification of Other Individuals A check of all laundry carts was completed on 10/10/2024 to validate that each cart had a cover that covered the entire laundry cart from top to bottom. A cover was applied over clothing for delivery on 10/10/2024. Systemic Changes and Education A cover is now applied over all clothing being delivered to resident rooms. If the cover is found to be partial or removed during transport of clothing, all clothing potentially compromised will be rewashed before delivery. Environmental Services Manager or designee will audit resident clothing delivery each week. Audits will be kept in the maintenance binder. Laundry staff will be educated by 11/30/2024 regarding the importance of covering laundry prior to transporting and delivering the clean laundry throughout the building. Monitoring Administrator or designee will complete random walking rounds on varying dates and shifts to validate that laundry is being covered prior to transporting and delivering the clean laundry throughout the building 2x/week x4weeks, weekly x4 weeks, then every other week x4 weeks or until substantial compliance is determined by the QAPI Committee. Effective Date of Compliance 11/30/2024 Legionella Corrective Actions The Water Management Plan was reviewed on 10/30/2024 and the facility is scheduled for Legionella testing on 11/15/2024. Identification of Other Individuals A review of current residents and vital signs was completed on 11/01/2024 to assess for signs of symptoms of Legionella (high fever, cough, diarrhea and new or worsening confusion). No residents were identified with symptoms. Systemic Changes and Education Director of Facilities Services or designee will complete monthly Legionella testing. Legionella testing logs will be available in the maintenance binder. Members of the Water Management Team received education on the Legionella testing process and schedule on 11/07/2024. Regular Legionella testing began on 11/15/2024. Monitoring Legionella testing will be completed monthly for 3 months, starting 11/15/2024. Administrator or designee will review of monthly Maintenance Logs to validate that required testing and monitoring is being completed timely, including Legionella testing according to the Water Management policy. Results will be reviewed by the monthly QAPI meeting until substantial compliance is achieved. Effective Date of Compliance 11/30/2024

****************************** OAR 411-085-0310 Residents' Right: Generally Refer to F550, F552, F561, F585 ****************************** OAR 411-086-0260 Pharmaceutical Services Refer to F755, F761 ****************************** OAR 411-086-0040 Admission of Residents: Advanced Directive Refer to F578 ****************************** OAR 411-086-0130 Nursing Services: Notification Refer to F580 ****************************** OAR 411-085-0320 Resident's Rights: Charges and Rates Refer to F582 ****************************** OAR 411-086-0140 Nursing Services: Problem Resolution and Preventive Care Refer to F584, F689, F758 ****************************** OAR 411-088-0050 Right to Return from Hospital Refer to F625 ****************************** OAR 411-086-0060 Comprehensive Assessment and Care Plan Refer to F657 ****************************** OAR 411-086-0300 Clinical Records Refer to F641 ****************************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F676, F677, F684, F759 ****************************** OAR 411-086-0230 Activities Refer to F679 ****************************** OAR 411-086-0150 Nursing Services: Restorative Care Refer to F688 ****************************** OAR 411-086-0240 Social Services Refer to F742 ****************************** OAR 411-086-0210 Dental Services Refer to F791 ****************************** OAR 411-086-0250 Dietary Services Refer to F812 ****************************** OAR 411-086-0220 Rehabilitative Services Refer to F825 ****************************** OAR 411-086-0110 Administrator Refer to F847 ****************************** OAR 411-086-0330 Infection Control and Universal Precautions Refer to F880 ****************************** OAR 411-087-0230 Laundry Services Refer to F880 ******************************

****************************** OAR 411-086-0220 Rehabilitative Services Refer to F825 ******************************

Based on interview and record review, the facility failed to complete a discharge summary with required information for wound care and possible wound infection for 1 of 1 sampled resident (# 17) reviewed for unsafe discharge. The facility's failure to provide instructions for the care of the wound and the possible wound infection in the discharge summary information caused the resident's wound to worsen at home resulting in re-admission to a hospital. Findings include: Resident 17 was admitted to the facility in 5/2024 with diagnoses including hip fracture with surgical repair, heart failure, and a history of falling. Resident 17's care plan dated 5/14/24 indicated the resident required frequent skin inspections. Staff were to observe for redness, open areas, scratches, cuts, bruises, and report changes. Resident 17 was also at risk for developing pressure injuries and new skin issues related to her/his right hip fracture from a ground level fall. A hospital Discharge Summary dated 5/14/24 directed the following: follow up with orthopedic surgeon for post operative care, X-ray and staple removal on 5/27/24 and complete INRs (blood test) per facility protocol while on Warfarin. Resident 17 was subsequently discharged from the nursing facility on 6/3/24. At that time, the surgical staples had not been removed, there was no evidence a timely follow-up appointment with the orthopedic surgeon, and an INR scheduled for 6/3/24 was not completed. Resident 17's Weekly Skin Evaluation dated 5/28/24 at 9:38 AM listed the resident's wounds and skin issues as including the following: -Superior incision to the right hip with 9 staples intact. Scant serosanguinous (fluid with small amount of blood) drainage noted. -Inferior incision to the right hip with slough (dead tissue within a wound) and 14 staples intact. Scant serosanguinous (fluid with blood) drainage noted. -Anterior incision to the right thigh with 2 staples intact. 1 staple had fallen out. -More posterior incisions to the right thigh, one with 3 staples intact and another with 2 staples intact. Mild redness noted to staples of all incisions, no abnormal warmth, periwound with moderate bruising and swelling. The resident complained of pain related to the incisions. -Right hip with moderate bruising and swelling. -Scattered scabbing and bruising. -MASD (moisture associated skin damage) to the rectum. -New: mild rash to both axilla (armpits). -Right shin, calf and foot with increased redness and warmth -3+ pitting edema to both flanks, hips, and thighs. -Monitor redness and warmth to the right lower extremities (alert charting) On 5/28/24 at 9:53 AM Staff 25 (LPN) wrote a note to the provider: Resident 17's right shin, calf and foot had increased redness, warmth, and pain. The resident was also noted with new 3+ pitting edema (swelling) to bilateral flanks, hips & thighs. Please assess. On 5/29/24 at 10:01 PM an Alert Note indicated the resident remained on alert to monitor redness and warmth to right lower extremities. On assessment, redness was noted to the right lower extremity, right upper quadrant, and the right lower quadrant. On 5/29/24 at 2:58 PM Staff 27's (Provider) progress note indicated the right lower extremity was no longer warm but still with redness. Please contact surgeons' office and alert them of the change. Did the patient have a follow-up appointment with the surgeon? On 5/29/24 at 2:59 PM Staff 27's (Provider) additional progress note included: The resident's right leg seems somewhat improved today but right lower incision with slough. Continue to monitor closely and alert providers if warmth returns or further concerns. Would like to defer to surgeons' office if able but please call if not able to get a return call within 24 hrs or there is worsening of condition. Discharge Condition: Guarded. Resident 17 will need close follow up. Discharge Instructions: The facility was to provide instructions upon discharge. Home Health needs: Nursing, Physical Therapy, Occupational Therapy Follow up Appointments: Follow up with PCP and specialists upon discharge. Erythema noted to the RLE. Continue to monitor. Continued slough in the lower incision to the right lateral thigh. The resident will need to follow up with surgeon. A review of the facility's 5/31/24 Discharge Instructions Tool revealed the discharge tool was not complete and failed to include the following required information: -No facility physician, Primary Care Physician (PCP), or pharmacy information was included and no contact information was provided. -The In-Home Care section listed "To Be Determined". A Home Health Agency was not identified, home health needs were not listed, and no appointments were set up for the resident. Per a medical provider progress note the resident required: Nursing, Physical Therapy, and Occupational Therapy Home Health upon discharge. -No medication education was provided to the resident or representative. -Prevention and Disease Management education was not provided. -COVID testing and Vaccination information was not provided. -A Brief Medical History and Review of Reason for Admission was not included. - Current treatments, Therapies, and Education provided: there was only one note present which directed to "follow up with hospital ACC (Anticoagulation Clinic) as an INR was due that day". No provider was identified for the follow up INR which was due that day. The resident discharged after 3:30 PM but the INR due "that day" was not completed by staff. -No infection information was included in the Discharge Tool. On 5/28/24 Staff 25 (LPN)identified lower extremity redness, warmth, and pain. The concern for those symptoms would be a possible infection in the wound. There was no follow-up by staff related to the possible infection and no wound care information or instructions were provided to the resident or family at discharge. The Discharge Tool revealed no information related to the following: mobility level, transfer status, scheduled appointments or tests, or barriers to discharge. A 6/3/24 at 3:27 PM progress note indicated the resident discharged home at 3:30 PM via medical transport. A facility Discharge Summary dated 6/3/24 signed by the physician on 6/15/24 (12 days later) contained a final diagnosis and a summary of the treatment provided but was not given to the resident at the time of discharge. A 6/5/24 hospital Emergency Department discharge to hospital Neurotrauma ICU Admission report included the following information: -The resident's family brought the resident into the hospital because she/he had become more lethargic over the last 24 hours and they were concerned about infection in her/his hip. The resident had discharged to home two days prior on 6/3/24 from a skilled nursing facility. -Resident 17 was admitted with a post-operative wound infection and persistent encephalopathy (brain disease which alters brain function or structure). The resident had a progressive and notable decline in mental and functional status over the last few months. -Recent right neck fracture with surgical intervention. Recovered at a skilled nursing facility but did not have follow-up with Orthopedic surgeon. Staples remained in place and per report should have been removed 10 days postoperative. Surgical sites with erythema (redness), exudates (oozing fluid or pus), induration (hardening of soft tissue). Orthopedic surgery consults for evaluation of surgical sites, with follow-up surgical swab completed and now growing Gram-positive bacteria and Gram-negative bacteria. The resident was started on an antibiotic and further antibiotics would be determined pending speciation (formation of new species of bacteria) -SKIN: The resident's skin was pale, warm, dry, with multiple areas of wounds over the chest wall, abdomen, buttock, bilateral arms, and fingertips. The right hip surgical wounds were reviewed and staples remained in place. Upper linear wound with significant drainage. The lower vertical lateral wound had sutures still in place with exudates and some wound dehiscence (wound reopened) and erythema. -Wound History: break in the right femoral neck. Surgical site infection with wound dehiscence. A 6/10/2024 hospital Intraoperative Wound note indicated a right hip irrigation and debridement was performed by the surgeon. On 7/3/24 at 12:30 PM Witness 10 (Family member) stated when the resident discharged home her/his mentation was very different from her/his baseline and her/his physical condition had deteriorated. Witness 10 said the resident was home less than 48 hours when they had to send her/him to the hospital. The resident broke her/his hip on 5/6/24 and the staples should have been removed within 2-3 weeks but they were never taken out and both large incisions were swollen and weeping. The lower incision staples were zigzagged and there were pitted holes along the suture line. When the resident went back to the hospital on 6/5/24, she/he had surgery again to open the wound and flush out an infection. The facility staff did not provide any oral or written communication for wound care or follow up for the possible infection to the resident or family. No plan of care was provided when the resident discharged and Witness 10 said she was completely unprepared for how to care for the resident. On 7/25/24 at 2:23 PM Staff 3 (RNCM) acknowledged the Discharge Tool for Resident 17 was not completed thoroughly. A copy of the completed Tool was supposed to go home with the resident. Staff should be using the Tool which was in place. The resident did not receive all the information required for discharge. On 7/29/24 at 12:38 PM Staff 25 (LPN) stated Resident 17's surgical wounds were draining since admission. There was no follow-up provided with the surgeon while the resident was at the facility. Staff 25 said staff called the surgeon for an urgent appointment but for after the resident discharged. The incision staples were not removed. Staff 25 stated staff must have missed the staple removal order on the admit orders. The admit orders also indicated a surgical follow-up appointment was needed in 3 weeks. Staff 25 said no appointment was mentioned, or the need to make an appointment, in the Discharge Tool. Staff 25 also stated when she looked at the Discharge Tool there were no instructions for the resident's wound care or possible infection and "wound care information should have been in the discharge paperwork." On 7/30/24 at 1:08 PM Staff 2 (DNS) acknowledged the Discharge Summary Tool was not complete, thorough or contain the required information for the resident's discharge which should have included wound care instructions and follow-up for the possible wound infection.

Resident #17 discharged with no record of follow-up appointment nor wound care instructions for care at home in discharge paperwork. Patient returned to hospital and did not return to facility. A review of other residents’ discharge plans that may be affected was completed by DNS on 8/20/2024. No other concerns were identified. IDT team (DNS, ADNS, Administrator, Social Service, RCM, IP Nurse) reviewed the discharge tools and process, then updated the discharge tools and process to include additional information for staff to provide residents or responsible party upon discharge. IDT team working with PCC to modify form appropriate to facility use. Education for Nurses and Social Workers was provided to complete the updated discharge process. Training completed by DNS, ADNS or designee 8/20/2024. PIP implemented for discharge summary audit to be conducted by DNS, ADNS or designee to ensure discharge tools and process are being followed. Audit will be conducted weekly for 1 month, then twice a month for 2 months and randomly thereafter. Results will be shared with QAPI until substantial compliance is achieved.

Based on interview and record review it was determined the facility failed to follow physician orders and provide correct oxygen administration for 1 of 3 sampled residents (#12) reviewed for physician orders. This placed residents at risk for improper oxygen administration. Findings include: Resident 12 admitted to the facility in 8/2020 with diagnoses including diabetes and kidney disease. 1. The 3/26/24 Hospital After Visit Summary revealed an order to increase Resident 12's oxygen via nasal cannula to 3/lpm (liters per minute). The March 2024 TARS revealed the following dates and shifts when oxygen was administered incorrectly: -3/26/24 night shift - 2/lpm -3/30/24 day, evening and night shift - 4/lpm -3/31/24 day and evening - 4/lpm On 7/23/24 at 12:15 PM Staff 15 (LPN Resident Care Manager) verified Resident 12's oxygen administration orders were not followed on 3/26/24, 3/30/24 and 3/31/24. 2. "The RN Educator" website instructed a (regular) oxygen face mask was used for oxygen flow rates from 6 - 12/lpm. A minimum of 6/lpm of oxygen flow was needed to prevent re-breathing of exhaled carbon dioxide. The 3/26/24 Hospital After Visit Summary revealed an order to increase Resident 12's oxygen via nasal cannula to 3/lpm. The 3/26/24 Progress Note revealed Resident 12 complained of difficulty breathing, her/his O2 sat was 88% - 92% (normal range is 95% - 100%), and the resident's oxygen was increased to 3/lpm via face mask. The 4/10/24 Progress Notes revealed the following: -2:44 PM: The previous shift placed Resident 12 on oxygen at 3/lpm via face mask. -2:44 PM: The oxygen flow rate was increased to 4/lpm via face mask. -3:37 PM: Resident 12 requested to use a nasal cannula, her/his current O2 sat was 85% on 4/lpm which was above her/his current O2 order, and the resident would not wear the face mask because she/he was unable to breathe. -3:56 PM: Resident 12 refused to wear the face mask and her/his O2 sat was 85% on 4/lpm via nasal cannula. The resident requested and was transferred to the hospital. On 7/24/24 at 11:40 AM Staff 19 (RN) verified she incorrectly placed an oxygen face mask on Resident 12 on 3/26/24. On 7/23/24 at 12:15 PM Staff 15 (LPN Resident Care Manager) verified Resident 12 was placed on an oxygen face mask incorrectly on 3/26/24 and 4/20/24.

A review of other residents’ with oxygen orders was completed by RCC or designee for second level on 08/20/2024. Other residents affected by this deficiency were identified and addressed with updated orders. Education for Nurses for oxygen administration was completed by DNS, ADNS or designee 08/20/2024. DNS, ADNS or designee will audit oxygen administration for patients weekly for 1 month, then twice a month for 2 months and then randomly thereafter. Results will be shared with QAPI until substantial compliance is achieved.

Based on interview and record review it was determined the facility failed to ensure licensed nursing staff possessed the competencies and skill sets necessary related to oxygen administration for 1 of 3 sampled residents (#12) reviewed for physician orders. This placed all residents at risk for unsafe oxygen administration. Findings include: "The RN Educator" website instructed a (regular) oxygen face mask was used for oxygen flow rates from 6 - 12/lpm (liters per minute). A minimum of 6/lpm of oxygen flow was needed to prevent the rebreathing of exhaled carbon dioxide. Resident 12 admitted to the facility in 8/2020 with diagnoses of diabetes and kidney disease. Resident 12's 3/26/24 Progress Note revealed she/he complained of difficulty breathing, her/his O2 sat was 88% - 92% (normal range is 95% - 100%), and the resident's oxygen was increased to 3/lpm via face mask. The 4/10/24 Progress Notes revealed the following: -2:44 PM: The previous shift placed Resident 12 on oxygen at 3/lpm via face mask. -2:44 PM: The oxygen flow rate was increased to 4/lpm via face mask. -3:37 PM: Resident 12 requested to use a nasal cannula, her/his current O2 sat was 85% on 4/lpm which was above her/his current oxygen order, and the resident would not wear the face mask because she/he was unable to breathe. -3:56 PM: Resident 12 refused to wear the face mask and O2 sat was 85% on 4/lpm via nasal cannula. The resident requested and was transferred to the hospital. On 7/24/24 at 11:40 AM Staff 19 (RN) verified she incorrectly placed an oxygen face mask on Resident 12 on 3/26/24. Staff 19 stated she now realized a minimum of 6/lpm was necessary when the face mask was utilized and she did not know what happened to a resident when less than 6/lpm was used. On 7/23/24 at 12:15 PM Staff 15 (LPN Resident Care Manager) verified Resident 12 was placed on an oxygen face mask incorrectly on 3/26/24 and 4/20/24. Staff 15 stated she did not know what the minimum oxygen requirement was to utilize a face mask, did not know what would happen to a resident when less than 6/lpm was used and had never received oxygen administration training from the facility. On 7/30/24 at 10:05 AM Staff 5 (LPN, Staff Development) acknowledged the facility nursing staff required more training on oxygen administration use. Refer to F695

Resident #12 was placed on an oxygen mask incorrectly. A review of other residents’ with oxygen orders was completed by RCC or designee for second level on 08/20/2024. Other residents affected by this deficiency were identified and addressed with updated orders. Education for Nurses for oxygen administration was completed by DNS, ADNS or designee 08/20/2024. DNS, ADNS or designee will audit oxygen administration for patients weekly for 1 month, then twice a month for 2 months and then randomly thereafter. Results will be shared with QAPI until substantial compliance is achieved.

Based on observation, interview and record review it was determined the facility failed to ensure wheelchairs were clean and sanitary for 1 of 3 sampled residents (#13) reviewed for equipment. This placed residents at risk for unclean wheelchairs. Findings include: Resident 13 admitted to the facility in 11/2019 with diagnoses including multiple sclerosis (disease which deteriorates the brain and spinal cord) and paraplegia (lower body paralysis). On 7/22/24 at 10:59 AM Resident 13's wheelchair was observed to have crumbs on the bottom cushion and small (approximately 1 inch by 1 inch) brown smudge marks to the bottom cushion and the inside of the left armrest. On 7/24/24 at 10:46 AM Resident 13's wheelchair was observed to have crumbs and a small brown smudge (approximately 1 inch by 1 inch) on the bottom cushion. On 7/26/24 at 12:30 PM Resident 13's wheelchair was observed to be dirty with crumbs on the bottom cushion. [The wheelchair did not appear to be cleaned as documented in the July 2024 TARS.] Resident 13's July 2024 TARS revealed her/his wheelchair was to be cleaned monthly and as needed. The task was documented as completed on 7/26/24. The 4/30/24 Resident Council Notes revealed the residents felt their wheelchairs were either getting dirty or already "very dirty" and requested the wheelchairs be on a cleaning schedule. The 6/25/24 Resident Council Notes revealed the residents asked to have their wheelchairs cleaned and to start a cleaning schedule. On 7/24/24 at 10:46 Staff 28 (Agency CNA) verified Resident 13's wheelchair had crumbs over the bottom cushion and a small brown smudge mark to the bottom cushion. On 7/24/24 at 10:50 AM Resident 13 stated the facility does not keep her/his wheelchair clean and it was currently dirty. On 7/26/24 at 12:30 PM Staff 29 (LPN) and Staff 15 (LPN Resident Care Manager) verified the wheelchair was dirty. Staff 29 verified she documented the wheelchair was cleaned although she had not cleaned it.

Resident #13 wheelchair appeared dirty and was cleaned immediately by LPN. A review of wheelchair cleaning log and resident wheelchair cleanliness were completed by Director of Facilities on 08/17/2024. No other concerns were identified. IDT team (DNS, ADNS, IP Nurse, Director of Facilities) reviewed wheelchair cleaning log and identified staff responsible to ensure wheelchairs are cleaned regularly. Education for Nurses, CNA’s, housekeeping, and maintenance staff concerning wheelchair cleaning schedule or more frequently by staff as needed by Director of Facilities or designee. Wheelchair cleaning audit will be conducted by Director of Facilities or designee to ensure Wheelchair cleaning log is complete and observe wheelchair cleanliness. Audit will be conducted weekly for 1 month, then twice a month for 2 months, then randomly. Results will be shared with QAPI until substantial compliance is achieved.

************************* OAR 411-85-0360 - Abuse Refer to F610 ************************* OAR 411-086-0160 - Nursing Services: Discharge Summary Refer to F661 ************************* OAR 411-086-0110 - Nursing Services: Resident Care Refer to F695 ************************* OAR 411-086-0100 - Nursing Services: Staffing Refer to F726 ************************* OAR 411-087-0100 - Physical Environment Generally Refer to F921 ************************************

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 01/22/2024 and 01/28/2024, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on observation, interview and record review it was determined the facility failed to ensure residents were free from neglect. The facility failed to ensure residents received basic care for 4 of 4 sampled residents (#s 200, 300, 500, and 700) reviewed for ADL's. This neglect was due to the failure of the facility to provide adequate staffing which resulted in long call light times, lack of timely incontinence care and showers not completed on scheduled days. This failure placed all residents at risk for neglect of care. Findings include: According the the Centers for Medicare and Medicaid Services (CMS), Sec. 483.5, "Neglect" means "the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress." 1. ADL AND INCONTINENCE CARE a. Resident 200 admitted to the facility on 7/21/23 with diagnoses including hip fracture and Parkinson's Disease. Resident 200's Admission MDS dated 7/27/23 revealed no cognitive impairment with a BIMS score of 13. The MDS functional status section revealed the resident required extensive assistance with most ADL's, including assistance with showers. On 9/8/23 at 9:43 AM Witness 1 (Complainant) stated Resident 200 did not receive showers for several days after she/he was admitted due to the facility's staffing issues. Resident 200's bathing/shower logs were reviewed and no showers were documented from 7/21/23 through 8/3/23. On 9/18/23 at 3:30 PM, Staff 3 (RNCM) confirmed the facility had staffing issues and the bathing/shower logs reflected no showers were given to Resident 200. Refer to F677, example a. b. Resident 500 admitted to the facility in 4/2023 with diagnoses including hypertension and stroke. On 5/10/23 the facility reported to the State Agency Staff 9 (Agency CNA) failed to change Resident 500 during the overnight shift. Resident 500 told Staff 9 she/he needed to be changed, was soaked with urine, the bed sheets were urine soaked and she/he had rolled to the edge of the bed to avoid lying in the soaked bed sheets. Staff 9 did not change Resident 500's brief and instead rolled her/him back into the middle of the bed onto the soaked bed sheets and left the room. Staff 2 (DNS) initiated an investigation and interviewed Resident 500 and her/his roommate. Resident 500 confirmed the incident had occurred but denied feeling unsafe. The facility concluded Resident 500 had not received incontinence care by Staff 9. On 9/8/23 at 10:38 AM, Resident 500 stated she/he remembered the incident, confirmed the facility frequently had long call light wait times and staff told her/him they had a lot of other residents to care for. On 9/18/23 at 4:00 PM, Staff 1 (Administrator) and Staff 2 (DNS) were notified of the investigative findings and provided no additional information. Refer to F677, example b. c. Resident 700 admitted to the facility 3/2023 with diagnoses including pneumonia and sepsis (a system wide infection that can be life threatening). On 9/8/23 at 1:00 PM Resident 700 stated there were long call light times and some CNAs ignored her/his call light. She/he stated there were a couple of occasions a bowel movement dried on her/his skin before the call light was answered. Resident 700 stated she/he had talked to management about staffing but so far nothing was done about it. On 9/18/23 at 1:04 PM Resident 700 stated she/he waited over 40 minutes after pressing the call light the past weekend. On 9/18/23 at 4:00 PM, Staff 1 (Administrator) and Staff 2 (DNS) were notified of the investigative findings. Staff 1 and Staff 2 said the expected call light response time was five minutes. Staff 2 stated the facility's staffing were to state ratios and not based on resident acuity. Refer to F677, example c. d. Resident 300 admitted to the facility in 4/2022 with diagnoses including kidney disease and heart failure. On 9/8/23 at 10:49 AM, Resident 300 stated there were long call light times that could be up to 30 minutes during day shift and up to an hour and a half on NOC (overnight) shift. Resident 300 reported she/he was so frustrated about the staffing situation that she/he filed a grievance but nothing was done about it. On 9/18/23 at 4:00 PM, Staff 1 (Administrator) and Staff 2 (DNS) were notified of the investigative findings. Staff 1 and Staff 2 said the expected call light response time was five minutes. Staff 2 stated the facility's staffing were to state ratios and not based on resident acuity. Refer to F677, example d. 2. RESIDENT COUNCIL In an interview on 9/18/23 at 11:55 AM, the facility's Resident Council President reported the following concerns: -Facility management are re-assigning long term care staff from upstairs to downstairs where the short term rehabilitation residents are despite the long term residents requesting the same staff remain on the second floor to ensure continuity of care; -Agency staff are assigned to the long term care unit and do not know the residents routines and preferences, which caused distress to the residents; -Agency staff are ignoring call lights and residents are not getting basic cares completed timely; -Regular full time CNAs on the long term care unit are over extended and cannot complete their tasks; -Multiple long term care residents have filed grievances related to staffing in the past month and management did nothing about it. 3. STAFF INTERVIEWS On 9/8/23 at 11:05 AM, Staff 10 (CNA) stated for the past month, the facility was short staffed, the facility terminated almost all agency contracts and retained only one staffing agency. Staff 10 stated at times, agency staff did not show up for assigned shifts. On 9/12/23 at 2:40 PM, Staff 11 (CNA) stated the staffing levels and lack of communication with management were bad at the facility and several regular staff had resigned which resulted in more staffing shortages. Staff 11 reported on the long term care floor the bariatric residents were under-reported to the state agency and in reality there were almost a dozen residents who required two person or more assistance for almost all ADLs. Staff 11 stated there were multiple residents that did not get timely incontinence care, were left in soiled briefs for long periods of time and residents were not getting showers on their assigned shower days because there weren't enough staff to complete the tasks. Staff 11 stated "this is their home and management is ignoring the issue." On 9/12/23 at 1:39 PM, Staff 8 (LPN) stated in 8/2023 the facility was short staffed and agency staff was frequently used. Staff 8 stated some agency staff "were there just to get a paycheck" and more full time staff were needed. On 9/12/23 at 3:12 PM, Staff 14 (LPN) stated there were staffing shortages for both nurses and CNAs. Staff 14 stated the facility took CMAs off the schedule and told nurses to pass medications and complete treatments in addition to their nursing duties. Staff 14 stated "there isn't enough nursing staff to complete everything and this will go on my license if there's a problem or something goes wrong. This is unsafe." Staff 14 reported there were shifts when she/he covered two resident units and nurses usually were assigned one unit. On 9/13/23 at 1:12 PM, Staff 15 (LPN) stated there were multiple days in the past couple of months when the facility was short staffed. Staff 15 stated residents were not getting showers, the second floor of the facility had a high acuity level that was not reflected in staff assignments and more than half the residents on the second floor required two person transfers. Staff 15 reported CMA's were no longer on the work schedule and nurses were expected to pass medications and administer treatments such as insulin which resulted in medication administered late and treatments such as blood sugar checks not completed before residents ate meals. On 9/13/23 at 3:20 PM, Staff 12 (CNA) stated the facility's staffing levels were too low and residents were not getting incontinence care completed timely, residents were not getting restorative therapy because the assigned RA was covering CNA duties, and residents complained their call lights were not answered timely. Staff 12 stated CMA's were cut from the schedules and this impacted the nurses as well. On 9/18/23 at 11:26 AM, Witness 4 (Confidential Staff Member) stated the facility had several bariatric residents that were not counted toward state bariatric ratio but still required two or more staff to complete care. Witness 4 stated staff who had worked at the facility for years had left, management was aware of the issue yet did nothing about it. Witness 4 reported residents complained every day about the staffing issue and several grievances were filed by residents. On 9/18/23 at 1:46 PM Staff 3 (Assistant DNS) stated the full time staffing scheduler passed away in August and she and a newly hired staffing coordinator worked on staff scheduling. She stated the facility staffed nurse aides to state ratios although the facility had a high acuity rate that included residents with high care needs and several bariatric residents. These high care needs on certain units required more nurse aides than state ratios recommended and recently the decision was made to remove "float" CNAs from the schedule. The facility's corporate management made the decision to reduce the number of nurse aides to state ratios which negatively impacted resident care as a result of the reduced staffing levels. 4. STAFFING DOCUMENTATION The facility's bariatric resident count was provided for 9/8/23 and indicated there were two bariatric residents on the first floor and six bariatric residents on the second floor. The Direct Care Staff Daily Report (DCSDR) for that date did not reflect correct CNA to bariatric resident staffing ratios were used. A review of the facility DCSDR's from 8/1/23 through 8/31/23 revealed the facility had insufficient CNA staff based on state minimum staffing ratios for one or more shifts on the following randomized dates chosen: 8/1/23, 8/6/23, 8/13/23, 8/26/23 and 8/31/23 using the bariatric resident ratio. Several DCSDR's were missing for 8/2023. 5. GRIEVANCES Resident grievances for 8/2023 were reviewed. There were a total of nine grievances filed by nine residents related to inaqeduate staffing. 6. CALL LIGHT OBSERVATIONS Call light observations were made on 9/8/23 across two shifts. The first floor rehabilitation unit had several call lights on longer than 15 minutes during those observations. On 9/18/23 at 4:00 PM, Staff 1 (Administrator) and Staff 2 (DNS) were notified of the investigative findings. Staff 1 and Staff 2 said the expected call light response time was five minutes. Staff 2 stated the facility's staffing were to state ratios and not based on resident acuity.

Resident #200, #300, #500, and #700s concerns were addressed by facility administration. No other concerns were identified. An audit of other residents was completed via grievance and POC charting review. No other concerns were identified. Education was provided: Abuse and Neglect was completed by DNS via all-staff meeting. CNA re-education on resident ADL care was completed by DNS/SDC/RCM. DNS or Designee to audit POC Charting to ensure care completion 3 times a week for 4 weeks, then 3 times a month for 2 months. The results of this audit and any corrective action taken will be presented to the QAPI committee for 3 months.

Based on interview and record review it was determined the facility failed to ensure residents were free from misappropriation of personal property for 2 of 2 sampled residents (#s 400 and 800) reviewed for misappropriation of property. This placed residents at risk for theft. Findlings include: 1. Resident 800 was admitted to the facility on 4/26/23 with diagnoses including amputation of the left leg below the knee and anxiety disorder. Resident 800's Quarterly MDS dated 7/30/23 revealed she/he was cognitively intact with a BIMS score of 15. On 8/28/23 the facility reported to the State Agency Resident 800 reported her/his credit/debit card had been stolen 7/2023. The resident initially thought the card was accidentally thrown away but subsequently learned charges were made to the card that she/he had not authorized. The facility initiated an investigation and made a referral to law enforcement. On 9/8/23 at 4:06 PM, Resident 800 confirmed the card was taken from her/his room in July 2023 when she/he left the room to attend physical therapy. Resident 800 stated she/he now used the provided lockbox to store valuables when she/he left the room. On 9/18/23 at 4:00 PM, Staff 1 (Administrator) and Staff 2 (DNS) confirmed Resident 800's debit/credit card was taken from her/his room. 2. Resident 400 was admitted to the facility in 2017 with diagnoses including chronic respiratory failure and major depressive disorder. Resident 400's Quarterly MDS dated 7/23/23 revealed she/he was cognitively intact with a BIMS score of 15. On 8/11/23 the facility reported to the State Agency Resident 400 reported her/his credit card was missing and the card was used to make charges that she/he had not authorized. The facility initiated an investigation and made a referral to law enforcement. Resident 400 was not interviewed due to hospitalization. On 9/18/23 at 4:00 PM, Staff 1 (Administrator) and Staff 2 (DNS) confirmed Resident 400's debit/credit card was taken from her/his room.

Resident #800 and #400s complaints were reported to the state, investigated by the facility, and reported to law enforcement. The suspected perpetrators were placed on a do not return list and are not allowed to work in the facility. An audit of resident rooms was conducted to ensure availability and function of lock boxes to secure resident belongings. Education was provided on abuse and neglect via all-staff meeting and in-service. DNS or Designee to audit 4 resident rooms per week for 4 weeks, and 2 resident rooms per month for 2 months to ensure that lock boxes are available, functioning and that use is being encouraged. The results of the audit and any disciplinary action taken will be reported to the QAPI committee for 3 months.

Based on interview and record review it was determined the facility failed to ensure Staff 9 (Agency CNA) met professional standards of care for 1 of 3 sampled residents (#500) reviewed for incidents. This placed residents at risk for unmet care needs. Findings include: OAR 851-063-0090 Conduct Unbecoming a Nursing Assistant: A CNA, regardless of job location, responsibilities, of use of the title "CNA," whose behavior fails to conform to the legal standard and accepted standards of the nursing assistant profession, or who may adversely affect the health, safety of welfare of the public, may be found guilty of conduct unbecoming a nursing assistant. Such conduct includes but is not limited to: (1) Conduct, regardless of setting, related to general fitness to perform nursing assistant authorized duties: (a) Demonstrated incidents of violent, abusive, neglectful or reckless behavior; (2) Conduct related to acheiving and maintaining clinical competency: (a) Failing to conform to the essential standards of acceptable and prevailing nursing assistant performance of duties. Actual injury need not be established. Resident 500 admitted to the facility in 4/2023 with diagnoses including hypertension and stroke. Resident 500's 7/9/23 MDS Quarterly revealed she/he had moderate cognitive impairment with a BIMS score of 12. Resident 500's functional status included requiring extensive assistance with most ADLs, including toileting. Resident 500 was frequently incontinent of bowel and bladder. On 5/10/23 the facility reported to the State Agency Staff 9 worked the previous NOC (overnight) shift. At approximately 8:00 AM, the day shift CNA advised Staff 8 (LPN) that Resident 500 was very upset because she/he was not been changed by Staff 9 during the NOC shift. Staff 8 immediately reported the incident to Staff 3 (RNCM), who spoke to the resident. The resident stated Staff 9 came to her/his room after she/he activated the call light. Resident 500 told Staff 9 she/he needed to be changed, was soaked with urine, the bed sheets were urine soaked and she/he had rolled to the edge of the bed to avoid lying in the soaked bed sheets. Staff 9 did not change Resident 500's brief and instead rolled her/him back into the middle of the bed onto the soaked bed sheets and left the room. Staff 2 (DNS) initiated an investigation and interviewed Resident 500 and her/his roommate. Resident 500 confirmed the incident had occurred but denied feeling unsafe. Resident 500's roommate told Staff 2 "the CNA didn't come in to help her/him. She/he was wet and pushed her/his call light a few times, each time she (Staff 9) came in, turned off the call light, pushed her/him to the center of the bed and walked out. She/he needs help, you know. I even pushed the call light for her/him a few times." The facility concluded Resident 500 had not received incontinent care by Staff 9, completed a skin assessment and unsuccesfully attempted to get a statement from Staff 9. The facility's plan of action was to ensure Staff 9 did not return to the facility and the resident was placed on alert charting. On 9/8/23 at 10:38 AM, Resident 500 stated she/he remembered the incident but did not recall the name of the CNA and stated "it was a long time ago." On 9/12/23 at 1:45 PM, Staff 8 confirmed she was told about the incident and immediately reported it to Staff 3. On 9/12/23 at 2:00 PM, Staff 9 stated she did not recall the incident but remembered the facility called her to discuss a complaint. She stated she called the facility back but didn't reach anyone and never heard anything else. Staff 9 stated she now worked for a different staffing agency, worked at the facility several times since 5/2023 and provided care to Resident 500 since the reported incident. A review of the facility's staffing schedule revealed Staff 9 worked at the facility during 8/2023. On 9/18/23 at 4:00 PM, Staff 1 (Administrator) and Staff 2 were notified of the investigative findings and provided no additional information.

The center completed a skin assessment on Resident #500 to ensure no harm occurred. The resident was then monitored for signs and symptoms of distress. No further concerns were noted. The center placed the agency staff member on the Do Not Return list through all contracted agencies to ensure the staff member will not be able to return through any agency to the facility. An audit of residents who received care from Agency Staff 9 was completed to ensure care was received and there were no other concerns by other residents. Education was completed: Abuse and neglect training delivered via all-staff meeting and in-service. Staff Development Coordinator to re-educate CNAs on care competencies. Staffing coordinator was re-educated on the Do Not Return list and ensuring compliance with it. DNS or Designee to audit the CNA schedule 1 time per week for 4 weeks, and 2 times a month for 2 months to ensure that do not return staff are not being utilized in the facility. The results of the audit and any disciplinary action taken will be reported to the QAPI committee for 3 months.

Based on interview and record review it was determined the facility failed to provide ADL care to 4 of 4 sampled residents (#s 200, 300, 500 and 700) reviewed for ADLs. This placed residents at risk for unmet needs. Findings include: a. Resident 200 admitted to the facility on 7/21/23 with diagnoses including hip fracture and Parkinson's Disease. Resident 200's Admission MDS dated 7/27/23 revealed no cognitive impairment with a BIMS score of 13. The MDS functional status section revealed the resident required extensive assistance with most ADLs, including assistance with showers. On 9/8/23 at 9:43 AM Witness 1 (Complainant) stated Resident 200 did not receive showers for several days after she/he was admitted due to the facility's staffing issues. Resident 200's bathing/shower logs were reviewed and no showers were documented from 7/21/23 through 8/3/23. On 9/18/23 at 3:30 PM, Staff 3 (RNCM) confirmed the facility had staffing issues and the bathing/shower logs reflected no showers were given to Resident 200. b. Resident 500 admitted to the facility in 4/2023 with diagnoses including hypertension and stroke. Resident 500's 7/9/23 MDS Quarterly revealed she/he had moderate cognitive impairment with a BIMS score of 12. The MDS functional status section revealed the resident required extensive assistance with most ADLs, including toileting. Resident 500 was frequently incontinent of bowel and bladder. On 5/10/23 the facility reported to the State Agency Staff 9 worked the previous NOC (overnight) shift. At approximately 8:00 AM, the day shift CNA advised Staff 8 (LPN) that Resident 500 was very upset because she/he was not changed by Staff 9 during the NOC shift. Staff 8 immediately reported the incident to Staff 3 (RNCM), who spoke to the resident. The resident stated Staff 9 came to her/his room after she/he activated the call light. Resident 500 told Staff 9 she/he needed to be changed and was soaked with urine, the bed sheets were urine soaked and she/he had rolled to the edge of the bed to avoid lying in the soaked bed sheets. Staff 9 did not change Resident 500's brief and instead rolled her/him back into the middle of the bed onto the soaked bed sheets and left the room. Staff 2 (DNS) initiated an investigation and interviewed Resident 500 and her/his roommate. Resident 500 confirmed the incident occurred but denied feeling unsafe. The facility concluded Resident 500 had not received incontinent care by Staff 9. On 9/8/23 at 10:38 AM, Resident 500 stated she/he remembered the incident but did not recall the name of the CNA and stated "it was a long time ago." On 9/18/23 at 4:00 PM, Staff 1 (Administrator) and Staff 2 (DNS) were notified of the investigative findings and provided no additional information. c. Resident 700 admitted to the facility 3/2023 with diagnoses including pneumonia and sepsis (a system wide infection that can be life threatening). Resident 700's Admission MDS dated 7/25/23 revealed no cognitive impairment with a BIMS score of 15. The MDS functional status section revealed the resident required extensive assistance with most ADLs, including bed mobility, transfers and dressing. On 9/8/23 at 1:00 PM Resident 700 stated there were long call light times and some CNAs ignored her/his call light. She/he stated there were a couple of occasions a bowel movement dried on her/his skin before the call light was answered. Resident 700 stated she/he talked to management about staffing but so far nothing was done about it. On 9/18/23 at 4:00 PM, Staff 1 (Administrator) and Staff 2 (DNS) were notified of the investigative findings and provided no additional information. d. Resident 300 admitted to the facility in 4/2022 with diagnoses including kidney disease and heart failure. Resident 300's Quarterly MDS dated 7/2/23 revealed moderate cognitive impairment with a BIMS score of 10. The MDS functional status section revealed she/he required 1-2 person assistance with toileting. On 9/8/23 at 10:49 AM, Resident 300 stated there were long call light times that could be up to 30 minutes during day shift and up to an hour and a half on NOC (overnight) shift. Resident 300 noted "I watch the clock when I press the button. On NOC shift it takes a long, long time." Resident 300 reported she/he was so frustrated about the staffing situation that she/he filed a grievance but nothing was done about it. On 9/18/23 at 4:00 PM, Staff 1 (Administrator) and Staff 2 (DNS) were notified of the investigative findings and provided no additional information.

Resident #200 was discharged from the center on 8/31/23. Resident #500s concerns regarding call light wait times were addressed by facility leadership. Resident # 700s concern regarding call light times was addressed by facility leadership. Resident #300s concerns regarding call light times were addressed by facility leadership. DNS conducted ADL Care analysis of Unit 200 and Unit 500 to establish ADLS need of those units focusing on Hoyer Transfers, Assisted Dinners and Total Incontinent Residents, the 3 elements of Heavy ADLS Care areas. Random call Audit on Unit 200 and Unit 500 on all shifts to determine Call Light Response Time. The result of ADLS Analysis and Call Light Response Time was used to adjust baseline staffing needs. The center created an additional 2 shower aide positions to assist with ADL cares. DNS or designee to conduct ADL need analysis and Random Call Light Audit for 2 weeks, then once a month for 2 months or until substantial compliance is achieved. DNS to put a performance improvement plan in place for ADLS Care Analysis and Random Call Light Audit a report will be discuss at QAPI to assist with Staff assignments.

Based on interview and record review it was determined the facility failed to follow physician's orders for 1 of 3 sampled residents (#200) reviewed for physician orders. This placed residents at risk for lack of medical care. Findings include: 1. Resident 200 admitted to the facility 7/2023 with diagnoses including hip fracture and Parkinson's Disease. Resident 200's Admission MDS dated 7/27/23 revealed no cognitive impairment with a BIMS score of 13. On 9/8/23 at 9:43 AM Witness 1 (Complainant) stated a few weeks into her/his stay, Resident 200 told him she/he had neck and spinal pain and wanted x-rays. Witness 1 stated he contacted the facility and requested the x-rays be completed. However, the facility did not provide the x-rays and Resident 200 used an outside provider to get the x-rays completed. Resident 200 was not interviewed due to discharge. Clincial records reviewed indicated a secure conversation note written by Staff 3 (RNCM) on 8/7/23 at 3:58 PM to the facility's provider which requested an order for x-rays and was approved. No x-ray results were found in the resident's chart. On 9/18/23 at 3:17 PM, Staff 3 confirmed no x-rays were completed by the facility.

Resident #200 discharged from the center on 8/31/23. After a record review, all other care concerns had been addressed during the residents stay. A record review of other residents was completed to ensure medical interventions and requests were completed as ordered by the provider. No other concerns were identified. Education was provided to nursing staff: Procedure for LNs on reporting new orders to the residents care manager to ensure completion and follow-up. Resident care managers re-educated on documenting order changes, completing necessary tasks, and reporting to the DNS when completed or if intervention is needed. DNS or designee to audit 3 resident charts per week for 4 weeks, and 2 resident charts per month for 2 months to ensure provider orders are being followed as ordered in a timely manner. The results of the audit and any disciplinary action taken will be reported to the QAPI Committee for 3 months.

Based on observation, interview and record review it was determined the facility failed to ensure sufficient staffing to meet resident care needs for 1 of 1 facility reviewed for sufficient and competent staffing. This placed residents at risk for delayed and unmet care needs. Findings include: 1 a. Resident 200 admitted to the facility on 7/21/23 with diagnoses including hip fracture and Parkinson's Disease. Resident 200's Admission MDS dated 7/27/23 revealed no cognitive impairment with a BIMS score of 13. The MDS functional status section revealed the resident required extensive assistance with most ADLs, including assistance with showers. On 9/8/23 at 9:43 AM Witness 1 (Complainant) stated Resident 200 did not receive showers for several days after she/he was admitted due to the facility's staffing issues. Resident 200's bathing/shower logs were reviewed and no showers were documented from 7/21/23 through 8/3/23. On 9/18/23 at 3:30 PM, Staff 3 (RNCM) confirmed the facility had staffing issues and the bathing/shower logs reflected no showers were given to Resident 200. b. Resident 500 admitted to the facility in 4/2023 with diagnoses including hypertension and stroke. Resident 500's 7/9/23 MDS Quarterly revealed she/he had moderate cognitive impairment with a BIMS score of 12. The MDS functional status section revealed the resident required extensive assistance with most ADLs, including toileting. Resident 500 was frequently incontinent of bowel and bladder. On 9/8/23 at 10:38 AM, Resident 500 confirmed the facility frequently had long call light wait times and staff told her/him they had a lot of other residents to care for. On 9/18/23 at 4:00 PM, Staff 1 (Administrator) and Staff 2 (DNS) were notified of the investigative findings. Staff 1 and Staff 2 said the expected call light response time was five minutes. Staff 2 stated the facility's staffing were to state ratios and not based on resident acuity. c. Resident 700 admitted to the facility 3/2023 with diagnoses including pneumonia and sepsis (a system wide infection that can be life threatening). Resident 700's Admission MDS dated 7/25/23 revealed no cognitive impairment with a BIMS score of 15. The MDS functional status section revealed the resident required extensive assistance with most ADLs, including bed mobility, transfers and dressing. On 9/8/23 at 1:00 PM Resident 700 stated there were long call light times and some CNA's ignored her/his call light. She/he stated there were a couple of occasions a bowel movement dried on her/his skin before the call light was answered. Resident 700 stated staff told her/him several times they were short staffed and there were times no CNA was assigned to Resident 700's wing. She/he stated during those times, the CNA would not be able to see the call lights activated on her/his wing, was unaware of call lights activated and only could see them if the staff walked back to the unit. Resident 700 stated she/he had talked to management about staffing but so far nothing was done about it. On 9/18/23 at 1:04 PM Resident 700 stated she/he waited over 40 minutes after pressing the call light the past weekend. On 9/18/23 at 4:00 PM, Staff 1 (Administrator) and Staff 2 (DNS) were notified of the investigative findings. Staff 1 and Staff 2 said the expected call light response time was five minutes. Staff 2 stated the facility's staffing were to state ratios and not based on resident acuity. d. Resident 300 admitted to the facility in 4/2022 with diagnoses including kidney disease and heart failure. Resident 300's Quarterly MDS dated 7/2/23 revealed moderate cognitive impairment with a BIMS score of 10. The MDS functional status section revealed she/he required 1-2 person assistance with toileting. On 9/8/23 at 10:49 AM, Resident 300 stated there were long call light times that could be up to 30 minutes during day shift and up to an hour and a half on NOC (overnight) shift. Resident 300 noted "I watch the clock when I press the button. On NOC shift it takes a long, long time." Resident 300 stated there were frequently agency staff assigned to their wing, the new agency staff did not know the long term care residents and it was frustrating to have to "train" them how to provide care to her/him and other residents. Resident 300 reported she/he was so frustrated about the staffing situation that she/he filed a grievance but nothing had been done about it. 2. During an interview on 9/18/23 at 11:55 AM, the facility's Resident Council President stated the following concerns: -Facility management are re-assigning long term care staff from upstairs to downstairs where the short term rehabilitation residents are despite the long term residents requesting the same staff remain on the second floor to ensure continuity of care; -Agency staff are assigned to the long term care unit and do not know the resident's routines and preferences, which caused distress to the residents; -Agency staff are ignoring call lights and residents are not getting basic cares completed timely; -Regular full time CNA's on the long term care unit are over extended and cannot complete their tasks; -Multiple long term care residents have filed grievances related to staffing in the past month and management has done nothing about it. 3. Interviews with staff revealed the following concerns: On 9/8/23 at 11:05 AM, Staff 10 (CNA) stated for the past month, the facility was short staffed, the facility terminated almost all agency contracts and retained only one staffing agency. Staff 10 stated at times, agency staff did not show up for assigned shifts. On 9/12/23 at 2:40 PM, Staff 11 (CNA) stated the staffing levels and lack of communication with management were bad at the facility and several regular staff had resigned which resulted in more staffing shortages. Staff 11 reported on the long term care floor the bariatric residents were under-reported to the state agency and in reality there were almost a dozen residents who required two person or more assistance for almost all ADLs. Staff 11 stated there were multiple residents that did not get timely incontinence care, were left in soiled briefs for long periods of time and residents were not getting showers on their assigned shower days because there weren't enough staff to complete the tasks. Staff 11 stated "this is their home and management is ignoring the issue." On 9/12/23 at 1:39 PM, Staff 8 (LPN) stated in 8/2023 the facility was short staffed and agency staff was frequently used. Staff 8 stated some agency staff "were there just to get a paycheck" and more full time staff were needed. On 9/12/23 at 3:12 PM, Staff 14 (LPN) stated there were staffing shortages for both nurses and CNAs. Staff 14 stated the facility took CMAs off the schedule and told nurses to pass medications and complete treatments in addition to their nursing duties. Staff 14 stated "there isn't enough nursing staff to complete everything and this will go on my license if there's a problem or something goes wrong. This is unsafe." Staff 14 reported there were shifts when she/he covered two resident units and nurses usually were assigned one unit. On 9/13/23 at 1:12 PM, Staff 15 (LPN) stated there were multiple days in the past couple of months when the facility was short staffed. Staff 15 stated residents were not getting showers, the second floor of the facility had a high acuity level that was not reflected in staff assignments and more than half the residents on the second floor required two person transfers. Staff 15 reported CMAs were no longer on the work schedule and nurses were expected to pass medications and administer treatments such as insulin which resulted in medication administered late and treatments such as blood sugar checks not completed before residents ate meals. On 9/13/23 at 3:20 PM, Staff 12 (CNA) stated the facility's staffing levels were too low and residents were not getting incontinence care completed timely, residents were not getting restorative therapy because the assigned RA was covering CNA duties, and residents complained their call lights were not answered timely. Staff 12 stated CMAs were cut from the schedules and this impacted the nurses as well. On 9/18/23 at 11:26 AM, Witness 4 (Confidential Staff Member) stated the facility had several bariatric residents that were not counted toward state bariatric ratio but still required two or more staff to complete care. Witness 4 stated staff who had worked at the facility for years had left, management was aware of the issue yet did nothing about it. Witness 4 reported residents complained every day about the staffing issue and several grievances were filed by residents. On 9/18/23 at 1:46 PM Staff 3 (Assistant DNS) stated the full time staffing scheduler passed away in August and she and a newly hired staffing coordinator worked on staff scheduling. She stated the facility staffed nurse aides to state ratios although the facility had a high acuity rate that included residents with high care needs and several bariatric residents. These high care needs on certain units required more nurse aides than state ratios recommended and recently the decision was made to remove "float" CNAs from the schedule. The facility's corporate management made the decision to reduce the number of nurse aides to state ratios which negatively impacted resident care as a result of the reduced staffing levels. 4. The facility's bariatric resident count was provided for 9/8/23 and indicated there were two bariatric residents on the first floor and six bariatric residents on the second floor. The Direct Care Staff Daily Report (DCSDR) for that date did not reflect correct CNA to bariatric resident staffing ratios were used. A review of the facility DCSDR's from 8/1/23 through 8/31/23 revealed the facility had insufficient CNA staff based on state minimum staffing ratios for one or more shifts on the following randomized dates chosen: 8/1/23, 8/6/23, 8/13/23, 8/26/23 and 8/31/23 using the bariatric resident ratio. Several DCSDR's were missing for 8/2023. 5. Resident grievances for 8/2023 were reviewed. There were a total of nine grievances filed by nine residents related to inaqeduate staffing. 6. Call light observations were made on 9/8/23 across two shifts. The first floor rehabilitation unit had several call lights on longer than 15 minutes during those observations. On 9/18/23 at 4:00 PM, Staff 1 (Administrator) and Staff 2 (DNS) were notified of the investigative findings. Staff 1 and Staff 2 said the expected call light response time was five minutes. Staff 2 stated the facility's staffing were to state ratios and not based on resident acuity.

Resident #200 was discharged from the center on 8/31/23. Resident #500s concerns regarding call light wait times were addressed by facility leadership. Resident # 700s concern regarding call light times was addressed by facility leadership. Resident #300s concerns regarding call light times were addressed by facility leadership. Call light audits were completed by Administrator and DNS to identify issues causing long call light wait times. The facility added 2 new positions on the floor to ensure ADL cares are being completed timely. Education was completed: Center staff re-educated on abuse and neglect. Scheduling coordinator was educated on staffing to acuity as well as maintaining compliance with state mandated ratios. DNS or Designee to audit call lights 2 times a week for 4 weeks, and 2 times a month for 2 months to ensure timely responses are occurring. The results of the audit and any corrective action taken will be reported to the QAPI committee for 3 months.

Based on interview and record review the facility failed to implement a Quality Assessment and Performance Improvement (QAPI) program which identified quality deficiencies, developed and implemented action plans to correct identified quality of care deficiencies. The facility failed to initiate a QA review related to staffing despite multiple concerns relayed to management by staff and residents and failed to respond to complaints and grievances filed by residents related to staffing shortages for 8/2023. This placed all residents at risk of not receiving the care and services for optimal resident outcomes. Findings include: The facility's QAPI policy and procedure, created in 2017 and reviewed 3/2022, stated the facility's QAPI plan would "ensure a systematic, comprehensive, data-driven approach to care in order to prevent adverse events, reduce risk to residents and caregivers, promote safety and quality of care, and support each individual's choices and self identified quality of life. The QAPI plan is ongoing and comprehensive, dealing with the full range of services and departments, addresses all systems of care and management practices, includes clinical care, regulatory practice, quality of life and resident autonomy and choice." Observations on 9/8/23 revealed long call light times. Residents interviewed on 9/8/23 through 9/18/23 revealed they routinely did not receive incontinence care for over an hour, call light times were as long as one and a half hours, showers were not given on scheduled days, staffing levels declined and the facility's quality of care was lessened as a result of the reduced staffing levels. Staff interviews conducted from 9/8/23 through 9/18/23 revealed they were not able to respond timely to call lights, could not provide personal care timely, medication administration and nursing treatments were delayed due to CMAs being cut from the schedule and the facility was staffing based on state ratios rather than resident acuity. Staff reported feeling frustrated, reported high staff turnover and acknowledged they were not able to provide the level of care the residents needed. Several staff stated multiple residents required two or more persons for transfers, re-positioning and personal cares which resulted in other residents waiting for extended periods of time to receive personal care. Staff stated they conveyed concerns to administration about staffing levels but nothing was done. On 9/18/23 at 1:46 PM Staff 3 (Assistant DNS) stated the facility staffed nurse aides to state ratios although the facility had a high acuity rate that included residents with high care needs and several bariatric residents. These high care needs on certain units required more nurse aides than state ratios recommended and recently the decision was made to remove "float" CNAs from the schedule. She confirmed the facility's corporate management made the decision to reduce the number of nurse aides to state ratios which negatively impacted resident care as a result of the reduced staffing levels. On 9/18/23 at 4:00 PM, Staff 1 (Administrator) stated there was no QAPI program in place that addressed the current staffing concerns. Refer to F600 and F725.

The center held an ad-hoc QAPI to review, analyze and address staffing related concerns and grievances by staff and residents. The QAPI committee created and implemented a performance improvement plan to address the aforementioned staffing concerns. The center added 2 new positions to the day and evening shift to ensure that staffing needs are met, and quality of care is being provided. Education was completed: Staffing coordinator educated on additional positions created, as well as staffing to acuity. Nursing educated on call-light response times and assisting other sections when possible. Management educated on assisting on the floor where it is appropriate. Administrator or designee to audit the CNA to resident ratio 1 time per week for 4 weeks, then 2 times per month for 2 months to ensure that both mandated staffing requirements are met as well as acuity based staffing per performance improvement plan. The results of this audit and any disciplinary action will be reported to the QAPI committee for 3 months.

Based on interview and record review it was determined the facility failed to ensure one additional CNA was staffed above the licensing staffing standard for every five individuals receiving the bariatric (an individual with a physician diagnosis of obesity with a body mass index greater than 40 and requires additional assistance) reimbursement rate for 1 of 6 units. The placed bariatric residents at risk for delayed treatment and unmet care needs. Findings include: The facility's bariatric resident count was provided for 9/8/23 and indicated there were two bariatric residents on the first floor and six bariatric residents on the second floor. The Direct Care Staff Daily Report (DCSDR) for that date did not reflect correct CNA to bariatric resident staffing ratios were used. Review of the 8/2023 Direct Care Staff Daily Reports revealed the following dates when state CNA bariatric staffing ratios were not met: 8/1/23-all shifts, 8/6/23-all shifts, 8/13/23-all shifts, 8/26/23-all shifts, and 8/31/23-all shifts. On 9/18/23 at 11:26 AM, Witness 4 (Confidential staff member) stated the facility had several bariatric residents that were not counted toward state bariatric ratio but still required two or more staff to complete care. Witness 4 confirmed the CNA staffing levels did not include bariatric residents. On 9/18/23 at 1:46 PM Staff 3 (Assistant DNS) stated the facility staffed nurse aides to state ratios although the facility had a high acuity rate that included several bariatric residents. These high care needs on certain units required more nurse aides than state ratios recommended and recently the decision was made to remove "float" CNA's from the schedule. Staff 3 confirmed the CNA staffing levels did not include bariatric residents. On 9/18/23 at 4:00 PM, Staff 1 (Administrator) and Staff 2 (DNS) were notified of the investigative findings and provided no additional information.

No residents were identified as being affected The Administrator and Staffing Coordinator reviewed last month of staffing for compliance, identifying and addressing trends and/or concerns. Education was provided to the staffing coordinator on bariatric staffing regulations. The staffing coordinator was also provided with a backup plan to counter unplanned staffing shortages. The Administrator or Designee will audit staffing for bariatric staffing ratio compliance weekly for 2 weeks, then monthly for 2 months to ensure compliance. The outcome and any disciplinary action taken as a result of the audit will be reported at QAPI for 3 months.

*********************************** OAR 411-085-0360: Abuse Refer to F600 & F602 ***************************************** OAR 411-086-0110: Nursing Services: Resident Care Refer to F684, F658 & F677 **************************************** OAR 411-086-0140: Nursing Services: Problem Resolution & Preventive Care Refer to F689 **************************************** OAR 411-086-0100: Nursing Services: Staffing Refer to F725 **************************************** OAR 411-085-0220: Quality Assurance Refer to F865 ****************************************

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 08/28/2023 and 09/03/2023, 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 08/14/2023 and 08/20/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on 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 07/31/2023 and 08/06/2023, 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 07/10/2023 and 07/16/2023, 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 observation, interview and record review it was determined the facility failed to ensure residents were assessed for self-administration of medications and a physician order was in place for 1 of 6 sampled residents (#6) observed for medication administration. This placed residents at risk for adverse medication-related consequences. Findings include: Resident 6 was admitted to the facility in 11/2021 with diagnoses including chronic obstructive pulmonary disease (lung disease). Resident 6's 6/1/23 physician orders included the following: - fluticasone propionate suspension 50 mcg, two sprays in each nostril two times a day, to be administered by CMA/Licensed Nurse to ensure adherence. Resident 6's 6/2023 MAR indicated the following: - fluticasone propionate suspension 50 mcg, two sprays in each nostril two times a day, to be administered by CMA/Licensed Nurse to ensure adherence. Resident 6's health record revealed no physician order and no medication self-administration assessment which indicated the resident was able to safely store and self-administer medications. On 6/28/23 at 7:31 AM Staff 21 (CMA) administered Resident 6's morning medications and did not administer the fluticasone propionate nasal spray. On 6/30/23 at 9:37 AM Staff 21 reviewed Resident 6's physician orders and confirmed the fluticasone propionate nasal spray order directed the medication to be administered by the CMA or Licensed Nurse to ensure adherence. Staff 21 stated Resident 6 kept the fluticasone propionate nasal spray in her/his room and she/he self-administered the medication. Staff 21 stated he did not observe Resident 6 self-administer or ensure adherence for the nasal spray. On 6/30/23 at 10:35 AM Staff 2 (DNS) stated a medication self-administration assessment was completed to evaluate if a resident was competent to safely self-administer and store medications. Staff 2 stated once a resident was approved, the facility obtained a physician order for self-administration. Staff 2 reviewed Resident 6's health record and confirmed there was no self-administration assessment or physician order in place.

Resident #6 was reassessed for self administration. The physician order is in place and care plan is reflecting the change. Education was provided by RCC on safe storage of her medication in her locked drawer. IDT conducted a review of other residents in the same situation. One more resident was identified with self care administration; assessment, order and care plan are in place for that other resident. RCC will conduct weekly audit x 4 and monthly audits to assure compliance. RCC will bring those audits to QAPI meetings until sufficient practice is achieved. DNS or designee are now conducting nursing huddles 3 times a week to address nursing issues including self administration, assessements, care plans.

Based on observation, interview and record review it was determined the facility failed to ensure a call light was readily accessible for 1 of 1 resident (#1) reviewed for accommodation of needs. This placed the resident at risk for delayed staff assistance. Findings include: Resident 1 was admitted to the facility in 2022 with diagnoses including dementia, history of traumatic brain injury, generalized weakness. According to the Admission MDS assessment dated 8/14/22 and the most recent Quarterly MDS assessment dated 5/14/23 Resident 1 required extensive assistance for bed mobility. The resident's care plan updated on 5/20/23 under Falls section included the following intervention: "Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed." Observations on 6/27/23 at 9:46 AM revealed Resident 1 in bed with the head of bed near 40 degrees. Resident 1 was observed to have difficulty reaching items on her/his tray table. Resident 1 asked the surveyor for assistance, and was prompted to use her/his call light. The call light was positioned on the right-side bed rail. The resident was observed to reach across her/his body with the left hand from the semi-reclined position. Resident 1 stated, "I can't reach it." On 6/29/23 at 8:49 AM Staff 26 (CNA) stated Resident 1 needed assistance to reposition in bed but she believed the resident was able to reach her/his call light. On 6/30/23 at 11:15 AM Staff 22 (LPN Resident Care Coordinator) indicated her expectation was the call light should be within reach at all times and the resident may need one clipped to her/his chest.

Resident #1 call light is now clipped to his chest at all time. RCC conducted staff education on having a call light within resident #1 's reach and to report any malfunction. Resident was encouraged to use his call light and to report if unable to use it. Care plan was update to reflect this change. Education was provided to staff on keeping resident #1's items on a tray within reach. Care plan has been reviewed in that effect. RCC reminded staff that This resident requires extensive assistance with bed mobility, and will need 2 persons for repositioning. When needed, staff will reposition resident at appropriate HOB level. Care plan has been reviewed. Other Residents needing extensive assistance with bed mobility and Residents with diagnosis of dementia, generalized weakness, TBI, CVA ,decreased bed mobility... were identified throughout the facility by IDT. RCCs are educating staff through huddles 3 times a week, in-services on making sure call lights and items on residents' tray are within reach. Daily rounds by DNS or designee are done in resident #1's room and other residents' rooms to assure compliance. Audit results will be brought to daily clinical meeting and in QAPI by DNS or designee until this deficient practice is remedied.

Based on observation and interview it was determined the facility failed to maintain comfortable sound levels for 1 of 1 facility observed for environment. This placed residents at risk for an uncomfortable environment. Findings include: Resident 51 was admitted to the facility in 2020 with diagnoses including major depression and borderline personality disorder. On 6/13/22 at 10:05 AM Resident 328 (Former resident) reported in the two months prior to 6/13/22, Resident 51 yelled and screamed throughout the day and night. Resident 328 stated Resident 51's constant yelling caused her/him migraine headaches and disrupted family visits. Resident 328 stated she/he spoke to several staff members who acknowledged her/his concerns and informed her/him there was not much they could do. Multiple observations from 6/26/23 through 6/30/23 between the hours of 8:00 AM and 4:00 PM revealed Resident 51 intermittently yelled at different times of the day. Resident 51's voice was audible throughout the first floor, on the second floor and outside of the facility. On 6/27/23 at 2:08 PM Staff 24 (CNA) stated Resident 51 chronically yelled. Staff 24 stated staff did many things to try to console Resident 51 but she/he kept yelling. Staff 24 stated Resident 51 was eventually moved to another floor but she/he continued to yell. On 6/27/23 at 2:49 PM Resident 46 stated in the past few weeks, she/he discussed Resident 51's yelling with most of the nurses but nothing improved. Resident 46 stated she/he made a "deal with the nurses" to keep her/his door closed but stated "I don't know why we have to put up with it." On 6/27/23 at 3:03 PM Staff 5 (RN) stated Resident 51 yelled a lot which made it very hard for the residents. Staff 5 stated staff closed Resident 328's door but the yelling got to the point that Resident 328 could not "take it anymore." She stated Resident 51 would not allow staff to close her/his door. Staff 5 stated Resident 51 was finally moved to a different floor. On 6/28/23 at 8:39 AM Staff 25 (CNA) stated Resident 51 yelled constantly. Staff 25 stated when Resident 51 was on the second floor most of the residents were not happy about the yelling. Staff 25 reported some residents were ready to leave the facility because Resident 51 was so loud. Staff 25 stated she could hear Resident 51's yelling sometimes from the parking lot when she arrived to work. Staff 25 reported both staff and residents were frustrated with Resident 51's constant yelling. Staff 5 stated Resident 51 was moved to another floor but the resident still yelled. On 6/29/23 at 12:11 PM Staff 2 (DNS) stated he was aware Resident 51 yelled and this was a problem for the residents and their families. Staff 2 acknowledged Resident 51's yelling affected other residents and impacted the environment.

IDT met with Resident # 51 and offered mental health services through Cascadia Mental Health including counselling and medication review. Other residents that are exposent to noise were identified and offered mitigation measures such as closing the door, use of headphones, offered various activities of choice. Nursing staff monitors Resident's behavior every Shift and documents. Nursing Staff will notify MD for increased Resident's behaviors. Facility offered and is working with Resident for placement in suitable environment in the community like group homes. Meanwhile resident is in a private room in this facility and her needs are anticipated by all staff. DNS or designee will conduct frequent rounds to monitor noise level DNS/RCMs will audit 24/72 hours Chart notes Monday to Fri for increased behaviors. DNS/RCM will bring Resident behavior documentation to QAPI to monitor progress.

Based on interview and record review it was determined the facility failed to ensure MDS assessments were coded accurately for 3 of 7 sampled residents (#s 2, 18 and 35) reviewed for food and unnecessary medications. This placed residents at risk for inaccurate assessments. Findings include: 1. Resident 2 was admitted to the facility in 2021 with diagnoses including heart failure. Resident 2's 4/2/23 Quarterly MDS indicated no therapeutic diet or altered food texture. Resident 2's 6/2023 physician orders included the following: - Diabetic 2GM sodium diet, mechanical soft texture. On 6/29/23 at 10:52 AM Staff 22 (LPN Resident Care Coordinator) stated Resident 2 had a therapeutic diet with altered food texture and confirmed the 4/2/23 Quarterly MDS was not coded accurately. 2. Resident 35 was admitted to the facility in 2017 with diagnoses including anxiety disorder. Resident 35's 4/23/23 Significant Change MDS indicated the resident did not receive antipsychotic medication. Resident 35's 4/2023 physician orders included the following: - quetiapine fumarate (antipsychotic medication) 400 mg for depression/anxiety. Resident 35's 4/2023 MAR revealed the resident received quetiapine fumarate daily. On 6/29/23 at 11:45 AM Staff 22 (LPN Resident Care Coordinator) reviewed Resident 35's 4/2023 Significant Change MDS and physician orders. Staff 22 confirmed Resident 35 received an antipsychotic medication daily and the MDS was not coded accurately. , 3. Resident 18 was admitted to the facility in 2022 with diagnoses including major depressive disorder. Review of the 5/2023 MAR indicated daily use of aripiprazole 2mg, an antipsychotic medication. The Significant Change MDS dated 5/25/23, under medications, did not identify daily use of the antipsychotic medication. On 6/29/23 at 11:14 AM Staff 22 (LPN Resident Care Coordinator) confirmed Resident 18 was prescribed aripiprazole daily and this was a coding error on the 5/25/23 MDS.

RCM has reviewed corrected and updated the MDS coding error on Resident # 2, 18, and 35. Other Resident that could be affected by this situation were assessed. No other Resident were identified to be affected by MDS coding error. Medical record Director or designer will assign MDS and put out the MDS schedule weekly on Mondays. During morning Stand Up meetings Monday to Friday Medical records Director will go over MDSes that are due or will mature within the next 3 days. RCM/ADNS will review MDS for correct coding before submissions. RCMs/RCC are encouraged to take MDS coding class per Relias learning. HR will assign and audit training completion on MDS coding DNS/designee will draw a PIP and bring PIP results to QAPI, until substantial compliance is achie

Based on observation, interview and record review it was determined the facility failed to implement the care plan related to positioning in bed for meals for 1 of 4 sampled residents (#1) reviewed for ADLs. This placed residents at risk for loss of independence, safety and comfort with eating. Findings include: Resident 1 was admitted to facility in 8/2022 with diagnoses of GERD (gastroesophageal reflux disease), dementia and weakness. The resident's Comprehensive Care Plan dated 8/14/2023 included a problem statement related to the resident's diagnosis of GERD. Interventions included to keep the head of Resident 1's bed upright during and for an hour after meals. Resident 1 was to have her/his food cut up into bite-size pieces and was to receive assistance with meals as needed. According to the Admission MDS assessment dated 8/14/22 and the most recent Quarterly MDS dated 5/14/23 Resident 1 required extensive assistance of one staff person for bed mobility and set-up assistance for eating. On 6/26/23 at 10:39 AM Resident 1 was observed eating breakfast. The resident's head of bed (HOB) was at approximately 40 degrees elevation. Resident 1 had a small fruit bowl spilled on her/his clothing protector. No staff assistance was observed. The resident's food was not cut into bite-size pieces. Observations on 6/27/23 at 9:46 AM revealed Resident 1 in bed with the HOB near 40 degrees. Resident 1 was observed to have difficulty reaching items on her/his tray table during breakfast and was observed eating oatmeal with spilled oatmeal on her/his clothing protector. On 6/29/23 at 8:49 AM Staff 26 (CNA) stated Resident 1 needed assistance to reposition in bed and lately required the assistance of two staff at times. On 6/30/23 at 11:15 AM Staff 22 (LPN Resident Care Coordinator) indicated her expectation was the resident should be positioned upright in bed and the resident's HOB should be elevated higher than 40 degrees.

Resident #1 was immediately assessed by nursing staff and care plan and kardex were updated to 1:1 assist with all meals. Other resident affected by such condition were identified by IDT and care plans and Kardex were updated. Resident #1's food will be cut by staff assisting him with meals. Nursing huddles started and will be conducted 3 time a week on the unit to remind staff on residents needing 1:1 assistance with meals. RCM will conduct rounds during meals x 1 week, and weekly x 4 weeks until substantial compliance is achieved. RCM will bring those results to QAPI.

Based on interview and record review it was determined the facility failed to provide ADL care to dependent residents for 2 of 4 sampled residents (#s 8 and 19) reviewed for ADL care. This placed residents at risk for unmet hygiene needs. Findings include: Resident 19 was admitted to the facility in 2020 with diagnoses including diabetes. Resident 19's 11/9/22 ADL Care Plan indicated Resident 19 required assistance of one staff for showering twice weekly and as necessary. Staff were to follow the facility's protocol for shower refusals and Resident 19 preferred showers during scheduled shower days. Resident 19's 5/21/23 Quarterly MDS indicated the resident was cognitively intact and bathing did not occur. Resident 19's 5/1/23 through 6/26/23 bathing task logs indicated the resident received a bed bath or shower on the following days: -6/2, 6/7, 6/12, 6/14, 6/21 and 6/26. A review of Resident 19's Progress Notes from 5/1/23 through 6/26/23 revealed no documentation Resident 20 was provided with additional bathing opportunities when bathing was not provided. On 6/26/23 at 10:56 AM Resident 19 stated she/he was supposed to receive showers twice a week but she/he did not receive them consistently. On 6/28/23 at 2:06 PM Staff 23 (CNA) stated Resident 19 was supposed to be showered twice a week. Staff 23 stated when a resident refused showers she informed the charge nurse and documented "refusal" on the bathing task logs. On 6/28/23 at 3:02 PM Staff 3 (RNCM) reviewed Resident 19's bathing task logs and stated Resident 19 "definitely" did not receive showers twice weekly. On 6/28/23 at 12:21 PM Staff 2 (DNS) stated he expected Resident 19 to receive showers twice weekly as scheduled. , 2. Resident 8 was admitted to the facility in 2019 with diagnoses including multiple sclerosis and depression. An 11/12/19 Care Plan included Resident 8 required assistance with personal hygiene and grooming tasks. Resident 8's 6/2023 Personal Hygiene Care Records revealed she/he required assistance with personal hygiene tasks, including shaving. On 6/26/23 at 11:21 AM Resident 8 was observed to have extensive chin hair. Resident 8 stated she/he did not receive assistance with facial hair grooming as often as needed. On 6/28/23 at 3:07 PM Staff 33 (CNA) was observed assisting Resident 8 with bathing. On 6/28/23 at 3:09 PM Staff 32 (CNA) stated residents received assistance with shaving, usually on shower days. On 6/28/23 at 3:22 PM Staff 33 (CNA) stated she was finished assisting Resident 8 with her/his shower. Staff 33 stated she did not assist Resident 8 with facial shaving. Staff 33 stated she should have asked Resident 8 if she/he wanted to be assisted with shaving. On 6/29/23 at 12:28 PM Staff 22 (LPN Resident Care Coordinator) confirmed shaving assistance should have been provided to Resident 8 as her/his facial hair grows in quickly.

IDT reviewed shower schedule/documentation and discussed with resident #8 on shower preferences. IDT offered additional shower preferences to resident #8. Other residents affected by this deficiency were identified and addressed. RCM are reviewing and auditing shower logs Monday to Friday at clinical meeting and ensures there is proper documentation for shower/ refusals. RCM ensures additional showers are offered once a refusal is noted. RCM are conducting nursing huddles 3 times a week on ADLs including shower/ refusal protocol. DNS will have in place a PIP on showers and bring results to QAPI.

Based on observation, interview and record review it was determined the facility failed to provide support for a resident's choice of independent activities for 1 of 2 sampled residents (#34) reviewed for activities. This placed residents at risk for unmet psychosocial needs and isolation. Findings include: Resident 34 was admitted to the facility in 2023 with diagnoses including severe morbid obesity and Ehlers-Danlos syndrome (A disorder which affects connective tissue, primarily the skin, joints and blood vessel walls.) On 6/26/23 at 1:58 PM Resident 34 stated she/he was unable to get out of bed due to her/his medical conditions. The resident stated the only activity she had available was the TV and she/he was "bored out of (her/his) mind." The resident stated the activities staff did not check on her/him to see if she/he needed or wanted anything else to do. No other independent activities such as books or puzzles were observed in the resident's room. Resident 34's 4/28/23 Activity Evaluation indicated the resident had a past or current interest in various activities including games, crafts, arts, music, reading, audio books, writing, computers, TV, talking, social events and news. Resident 34's activity participation log from 5/29/23 through 6/27/23 revealed no resident refusals of activities. Resident 34's current Care Plan as of 6/28/23 indicated the resident preferred to direct her/his own care and activities of her/his choice. The resident's preferred activities were talking on the phone, visits, music, TV programs and using her/his computer. On 6/29/23 at 10:37 AM and 11:10 AM Staff 7 (Activities Director) stated Resident 34's main interests were using her/his computer and TV. The resident was not interested in group activities and declined offers of puzzles and books. The resident liked music and was shown how to access music channels on the TV. Staff 7 stated she did not make regular scheduled rounds on residents to offer independent activities. Staff 7 stated she has not had an assistant for over a year and it was difficult for her to see all the residents. Staff 7 provided an update that she went to check on Resident 34 and discovered the resident did not have a computer in her/his room because it was a desktop model (not portable such as a laptop or tablet). On 6/29/23 at 12:42 PM Staff 1 (Administrator) confirmed there was only one activities staff for the entire facility. When Staff 1 was asked if having only one activities staff was enough for all 82 residents she shook her head.

Activity director met with resident #34 about her activities of interest. Books of choice from the unit library were provided to resident #34. Note books and drawing books were provided to resident #34. Activity director or designee will have an activity session every other day with resident #34 for independent activity of choice. Other residents affected by the same deficiency were identified by IDT and were care planned for independent activities. Activity director or designee will be visiting with those residents every other day for independent activities in their rooms as appropriate. Activity director hall request assistance from other staff members when the need for activity increases. DNS or designee will audit independent activity log for identified residents weekly x 3 weeks and monthly until substantial compliance is achieved. DNS/RCM will initiate a PIP and bring results to QAPI for review.

Based on interview and record review it was determined the facility failed to consistently perform pressure ulcer assessments and wound care for 1 of 4 sampled residents (# 56) reviewed for pressure ulcer care. This placed residents at risk for worsening pressure ulcers. Findings include: Resident 56 was admitted to the facility in 2021 with diagnoses including paraplegia. A 9/14/21 Weekly Skin Evaluation determined Resident 56 acquired an unstageable left ischeal tuberosity (boney prominence at lower inner buttocks) pressure ulcer. The orders of care for this pressure ulcer continued until 6/2023 and included full skin assessments to be completed weekly. On 11/18/21 United Wound Healing began providing weekly sacral wound care and full skin assessments for Resident 56. Review of Resident 56's care records from 2/2023 through 4/2023 revealed United Wound Healing care was provided on 2/2/23 and then not again until 4/20/23. Review of Resident 56's Weekly Skin Evaluations from 2/2023 through 3/2023 performed by facility nursing staff indicated the assessments were performed only on the following dates: - 2/21/23 - 3/17/23 - 3/24/23 - 3/31/23 A review of United Wound Healing documentation indicated the wound improved between 2/2023 through 4/2023. On 6/28/23 at 10:19 AM Staff 31 (LPN) stated United Wound Healing was responsible for performing full wound assessments weekly for Resident 56's sacral pressure ulcer. Staff 31 stated a pressure ulcer assessment included the size and stage of the pressure ulcer. On 6/28/23 at 11:02 AM and 1:23 PM Staff 22 (LPN Resident Care Coordinator) confirmed Resident 58 did not receive wound care and assessments from United Wound Healing as scheduled during 2/2023, 3/2023 and 4/2023 due to a scheduling conflict. Staff 22 stated nursing staff should have continued to perform full wound care and assessments on Resident 56 during 2/2023, 3/2023 and 4/2023 to monitor Resident 56's sacral pressure ulcer.

Wound nurse assessed and eveluated reisdent #56 pressure injury. The wound is stable and healing well with reduced measurements; No signs of infection noted. Resident # 56 continues on United healing case load. No Other resident was identified to be affected by this deficiency. The DNS has restructured the wound program and all units have a dedicated wound care nurse . This wound care nurse keeps wound assessment and measurements up to date weekly. DNS or designee will communicate with the wound care nurses if a resident was missed on weekly wound rounds by United Wound Healing Provider. in such a case, the wound nurse will then complete the missing assessment andd documentation. DNS or designee will review and audit weekly wound care summary notes for completion. DNS or designee will have a PIP on wound care and will bring results to QAPI.

Based on observation, interview and record review it was determined the facility failed to follow physician orders for oxygen therapy for 1 of 1 sampled resident (#25) reviewed for oxygen. This placed residents at risk for unnecessary oxygen therapy. Findings include: Resident 25 was admitted to the facility in 2023 with diagnoses including sleep apnea. Resident 25's 6/2023 physician orders included oxygen therapy at two liters per minute as needed for shortness of breath. Resident 25's 6/2023 MAR revealed no oxygen administration was documented from 6/1/2023 through 6/28/23. On 6/26/23 at 10:24 AM and on 6/28/23 at 9:03 AM Resident 25 was observed with oxygen administration being provided via nasal cannula at two liters per minute. A review of Resident 25's 6/2023 Progress Notes revealed no evidence the resident complained of shortness of breath on 6/26/23 and 6/28/23. On 6/28/23 at 8:54 AM Staff 4 (CNA) stated Resident 25 was always on oxygen therapy when she/he was in bed. On 6/28/23 at 9:03 AM Staff 5 (RN) stated she had not assessed Resident 25 for shortness of breath and acknowledged the resident was currently receiving oxygen therapy at two liters per minute. Staff 5 verified the resident's oxygen therapy order was PRN for shortness of breath. Staff 5 stated the resident was already on oxygen when she started her shift. On 6/28/23 at 12:12 PM Staff 3 (RNCM) verified Resident 25's oxygen therapy order was PRN for shortness of breath and staff should document a rationale for the use of oxygen therapy. Staff 3 confirmed Resident 25's 6/2023 MAR revealed no staff initials to indicate oxygen therapy was provided.

Resident was assessed for respiratory status and was stable on room air. Resident PRN o2 orders are reviewed and updated with parameters to administer supplemental oxygen. No other resident was affected by this deficiency. DNS and clinical team review all new PRN oxygen orders Monday- Friday to ensure all parameters are completed. DNS or designee will audit resident's oxygen level weekly on the chart 5 days a week x 2 and weekly until substantial compliance is achieved. Results will be brought to QAPI.

Based on interview and record review it was determined the facility failed to ensure physician visits occurred as required for 1 of 5 sampled residents (#40) reviewed for unnecessary medications. This placed residents at risk for unassessed needs. Findings include: Resident 40 was admitted to the facility in 2021 with diagnoses including vascular disease. Review of Resident 40's health record revealed no documentation the resident was seen by her/his physician at least every 60 days. On 6/28/23 at 1:30 PM Staff 22 (LPN Resident Care Coordinator) stated Resident 40's physician did not see the resident "very often." Staff 22 reviewed Resident 40's health record and was unable to locate physician notes or documentation to indicate the physician visited the resident as required. On 6/30/23 at 10:52 AM Staff 2 (DNS) was notified of the findings of this investigation and stated the physician was required to see the resident once every 60 days.

Medical records sent a request for Physician Chart notes from Resident #40's Physician. Chart notes were obtained and Scanned in Residents Chart. Resident's Physician reminded of required visit for compliance. Other Resident affected by this deficiency were promptly identified and added to the POC. Medical records will have a calendar and will send reminders to physicians for upcoming visits. - Medical Records will keep track ,obtain documentation and scan in residents' chart. - The Medical director will be consulted for advice if a physician is unable to visit a resident. - Medical records will run chart audits on physician visits according to schedule. DNS or designee will audit physician visit weekly x 4 and then monthly until deficient practice is remedied.DNS/Designee will bring to QAPI.

Based on observation, interview and record review it was determined the facility failed to ensure a medication pass error rate of less than 5%. There were three errors in 28 opportunities resulting in a 10.71% error rate. This placed residents at risk for reduced medication efficacy and adverse medication side effects. Findings include: Resident 6 was admitted to the facility in 11/2021 with diagnoses including chronic obstructive pulmonary disease (lung disease). Resident 6's 6/2023 physician orders included the following: - cholecalciferol tablet, 50 mcg, give two tablets one time a day; - fluticasone propionate suspension 50 mcg, two sprays in each nostril two times a day, to be administered by CMA/Licensed Nurse to ensure adherence; - polyethylene glycol 3350 powder, give 17 gm one time a day. On 6/28/23 from 7:31 to 8:00 AM Staff 21 (CMA) was observed for Resident 6's morning medication administration. During the observation, Staff 21 did not dispense and administer the cholecalciferol tablets, fluticasone propionate nasal spray or the polyethylene glycol 3350 powder. On 6/30/23 at 9:37 AM Staff 21 reviewed Resident 6's 6/28/23 MAR and verified he did not administer the cholecalciferol tablets or the polyethylene glycol 3350 powder during the observed morning medication administration. Staff 21 stated Resident 6 kept the fluticasone propionate nasal spray in her/his room to self-administer and he did not ensure the resident received the nasal spray. Staff 21 confirmed the physician order for the fluticasone propionate nasal spray included direction to be administered by CMA/Licensed Nurse to ensure adherence. On 6/30/23 at 10:35 AM Staff 2 (DNS) was notified of Staff 21's failure to administer Resident 6's cholecalciferol and polyethylene glycol 3350 powder medications as ordered and acknowledged the omissions would be considered medication errors. Staff 2 was notified Staff 21 did not administer or ensure Resident 6 received the fluticasone propionate nasal spray as ordered and acknowledged it was considered a medication error.

RCM reviewed Resident #6's medication orders with CMA. Resident #6's order for self administration was also reviewed for the Fluticasone nasal spray. RCM met with resident #6 on medication administration time preference. RCM updated resident's preference and notified CMA and Nursing Staff. No other resident was identified to be affected by this deficiency. RCM completed resident #6 medication self administration assessment. RCM updated Resident order for self administration Resident #6 has a locked drawer for her medication storage in her room. RCM will make random visit to Resident's room for compliance. DNS or designee will do random medication pass audits weekly x 3 and monthly until substantial compliance is achieved. DNS will PIP in place and will bring results to QAPI.

Based on observation, interview and record review it was determined the facility failed to ensure resident records were accurate for 2 of 10 sampled residents (#s 6 and 56) reviewed for medication administration and pressure ulcer care. This placed residents at risk for inaccurate health records and worsening pressure ulcers. Findings include: 1. Resident 6 was admitted to the facility in 2021 with diagnoses including chronic obstructive pulmonary disease (lung disease). Resident 6's 6/2023 physician orders included the following: - cholecalciferol tablet, 50 mcg, give two tablets one time a day; - fluticasone propionate suspension 50 mcg, two sprays in each nostril two times a day, to be administered by CMA/Licensed Nurse to ensure adherence; - polyethylene glycol 3350 powder, give 17 gm one time a day. On 6/28/23 from 7:31 to 8:00 AM Staff 21 (CMA) was observed for Resident 6's morning medication administration. During the observation, Staff 21 did not dispense and administer the cholecalciferol tablet, fluticasone propionate nasal spray or the polyethylene glycol 3350 powder. Resident 6's 6/28/23 MAR revealed Staff 21 documented he administered the following at 8:08 AM: - cholecalciferol tablet, 50 mcg, two tablets; - fluticasone propionate suspension 50 mcg, two sprays in each nostril; - polyethylene glycol 3350 powder, give 17 gm. On 6/30/23 at 9:37 AM Staff 21 reviewed Resident 6's 6/28/23 MAR and verified his initials and the 8:08 AM administration times. Staff 21 verified he did not administer the cholecalciferol tablets, the fluticasone propionate nasal spray or the polyethylene glycol 3350 powder during the observed morning administration. Staff 21 stated Resident 6 kept the fluticasone propionate nasal spray in her/his room and stated he did not know what time or observe whether the resident received the fluticasone propionate nasal spray. Staff 21 stated he dispensed and administered the cholecalciferol tablets and polyethylene glycol 3350 powder "later after breakfast" and confirmed the 8:08 AM administration times documented did not accurately reflect the actual administration times of each medication. On 6/30/23 at 10:35 AM Staff 2 (DNS) was notified of the inaccurate documentation of medication administration times. Staff 2 stated he expected the documentation on the MAR to accurately reflect the time of administration. , 2. Resident 56 was admitted to the facility in 2021 with diagnoses including paraplegia. A 9/14/21 Weekly Skin Evaluation determined Resident 56 acquired an unstageable left ischeal tuberosity (boney prominence at lower inner buttocks) pressure ulcer. The orders of care for this pressure ulcer continued until 6/2023 and included full skin assessments to be completed weekly. Review of Resident 56's wound care records for her/his left ischeal tuberosity ulcer from 3/2023 through 4/2023 revealed the following: - 3/17/23 - No assessment on stage or size of the pressure ulcer documented; - 3/24/23 - No assessment on stage or size of the pressure ulcer documented; - 4/7/23 - No assessment on stage or size of the pressure ulcer documented; - 4/14/23 - No assessment on stage or size of the pressure ulcer documented; - 4/21/23 - No assessment on stage or size of the pressure ulcer documented. On 6/28/23 at 11:02 AM and 1:23 PM Staff 22 (LPN Resident Care Coordinator) stated a full wound assessment included staging and measuring and should be performed and documented weekly to determine a need for modified care for residents with pressure ulcers. Staff confirmed Resident 56's pressure ulcer assessments documented during 3/2023 and 4/2023 were incomplete as the wound was not measured or staged.

1- RCM reviewed Resident #6's medication orders with CMA. Resident #6's order for self administration was also reviewed for the Fluticasone nasal spray. RCM met with resident #6 on medication administration time preference. RCM updated resident's preference and notified CMA and Nursing Staff. No other resident was identified to be affected by this deficiency. RCM completed resident #6 medication self administration assessment. RCM updated Resident order for self administration Resident #6 has a locked drawer for her medication storage in her room. RCM will make random visit to Resident's room for compliance. DNS or designee will do random medication pass audits weekly x 3 and monthly until substantial compliance is achieved. DNS will PIP in place and will bring results to QAPI. 2- Wound nurse assessed and eveluated reisdent #56 pressure injury. The wound is stable and healing well with reduced measurements; No signs of infection noted. Resident # 56 continues on United healing case load. No Other resident was identified to be affected by this deficiency. The DNS has restructured the wound program and all units have a dedicated wound care nurse . This wound care nurse keeps wound assessment and measurements up to date weekly. DNS or designee will communicate with the wound care nurses if a resident was missed on weekly wound rounds by United Wound Healing Provider. in such a case, the wound nurse will then complete the missing assessment andd documentation. DNS or designee will review and audit weekly wound care summary notes for completion. DNS or designee will have a PIP on wound care and will bring results to QAPI.

Based on interview and record review it was determined the facility failed to provide active supervision of staff working on a preliminary status basis for 9 of 12 staff (#s 1, 9, 12, 15, 16, 17, 18, 19 and 20) reviewed for background checks. This placed residents at risk for abuse. Findings include: On 6/28/23 at 11:36 AM and 6/29/23 at 11:43 AM Staff 14 (Human Resource Director) provided a current list of staff on preliminary status. Staff 14 reported the identified staff were considered on preliminary status while the facility waited for clearance of their background checks. Staff 14 confirmed the facility did not have a policy regarding active supervision or a system in place to provide active supervision to employees whose background checks were pending. On 6/29/23 at 12:25 PM Staff 2 (DNS) stated the facility did not have a system in place to provide active supervision of staff working prior to clearance of their background check.

HR has reviewed all current employees file to identify staff that meet criteria of active supervision. HR updated policies to include active supervision for employees that met the criteria. No other employees was identified to be affected by this deficiency. HR has Red tags placed Employee Badges to identify employees that are on active supervision status. HR educated Facility Staff on Active supervision HR will update new hires status accoording to background check results to ensure compliance. HR will audit employees files monthly for compliance until substantial compliances achieved. HR will bring all those results to QAPI.

**************************** OAR 411-086-0260 - Pharmaceutical Services Refer to F554 **************************** OAR 411-086-0360 - Resident Furnishings, Equipment Refer to F558 **************************** OAR 411-085-0310 - Residents' Rights: Generally Refer to F584 **************************** OAR 411-086-0300 - Clinical Records Refer to F641 and F842 **************************** OAR 411-086-0060 - Comprehensive Assessment and Care Plan Refer to F656 **************************** OAR 411-086-0110 - Nursing Services: Resident Care Refer to F677, F695 and F759 **************************** OAR 411-086-0230 - Activity Services Refer to F679 **************************** OAR 411-086-0140 - Nursing Services: Problem Resolution and Preventive Care Refer to F686 **************************** OAR 411-086-0200 - Physician Services Refer to F712 ****************************

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 interviews and record review it was determined the facility failed to ensure residents were free from misappropriation of financial resources for 1 of 7 sampled residents (#100) reviewed for abuse. This placed residents at risk for financial abuse. Findings include: The facility's 3/2017 Abuse, Incident and Injury Reporting policy indicated all residents living at the facility will be free from abuse, neglect, exploitation, mistreatment or misappropriation of property. Resident 100 admitted to the facility in 10/2022 with diagnoses including mild cognitive impairment. The facility abuse investigation #6004, dated 12/7/22, indicated the following: - On 12/6/22, Resident 100 was alerted by Witness 1 (Family) of unauthorized charges on her/his debit card. Resident 100 notified the floor nurse who assisted Resident 100 to search for the debit card which could not be located. Witness 1 filed a police report. -On 12/7/22, Resident 100 reported to Staff 8 that Witness 1 discovered unauthorized transactions on her/his debit card. Resident 100 looked in her/his purse for the debit card and both the debit card and $50.00 in cash were missing. -On 12/8/22 the facility determined abuse and a crime occurred. The facility was unable to identify a specific perpetrator but concluded Resident 100's debit card was used and cash was taken from her/his purse while Resident 100 resided at the facility. -On 12/10/22 Resident 100 was reimbursed $50. A 12/12/22 Grievance/Compliment/Concern Form was completed by Staff 8 which indicated on 12/7/22 Resident 100 informed Staff 8 she/he was "robbed" and was missing $50.00 cash and a debit card. The facility was unable to locate the items and Resident 100 was reimbursed $50.00. On 2/14/23 at 8:50 AM an attempt was made to contact Witness 1. No return call was received. On 2/14/23 at 9:00 AM Staff 8 stated on 12/7/22 she met with Resident 100 to complete discharge paperwork when Resident 100 told her she/he had been "robbed". Staff 8 stated Resident 100 reported Witness 1 called her/him the previous evening because there were unauthorized charges on her/his debit card. At that time, Resident 100 determined her/his debit card and $50.00 cash were missing. Staff 8 stated Resident 100 did not leave the facility thus the resident's debit card and cash were stolen while she/he resided at the facility. Staff 8 stated Resident 100 was reimbursed $50.00 cash and Witness 1 filed fraud charges with the bank to have the debit card charges removed. Staff 8 stated she received no further information from the police, Witness 1 or Resident 100 since the resident discharged. On 2/14/23 at 9:14 AM, 9:39 AM and 10:55 AM attempts were made to contact Resident 100. No return call was received. On 2/14/23 at 11:38 AM Staff 2 (DNS) confirmed Resident 100's debit card and cash were stolen while the resident resided in the facility. Staff 2 stated this was abuse and a crime and they were unable to identify the specific perpetrator.

This Plan of Correction is prepared and submitted as required by law. By submitting this Plan of Correction, the facility does not admit that the deficiencies listed in this exist, nor denies. The Center will admit statements, findings, facts, or conclusions that form the basis for the alleged deficiency. The Center reserves the right to challenge in legal and/or regulatory or administrative proceedings the deficiency, statements, facts, and conclusions that form the basis for the deficiency. The facility does and will continue to assure all residents are free from abuse, neglect and misappropriation and exploitation of resident property. In regard to resident #100, when we were notified of the event, an investigation was started, police were notified and report was made, multiple staff members from all shifts were interviewed. Facility notified regulatory authorities via FRI form. Resident received reimbursement of $50.00 cash. There was no other negative outcome from this incident. Resident has since discharged from the facility. DNS, Administrator, Social Services Director and Maintenance Director reviewed and revised Resident Personal Belongings Policy and Missing Property Policy. All departments will be in serviced on the revised policy for Personal Belongings as well as the Abuse and Neglect Policy. Medical Records Director or designee will randomly audit current resident charts for Inventory Sheet completion monthly for 3 months. QAPI Committee will review audits and determine depending on trends, the timing of on-going audits. Administrator/DNS or designee are responsible for overall compliance. Compliance date, April 4, 2023.

OAR 411-085-0360: Abuse

Refer to F602 *****************************

Based on interview and record review it was determined the facility failed to investigate an allegation of abuse for 1 of 2 sampled residents (#30) reviewed for allegations of abuse. This placed residents at risk for further abuse and psychosocial harm. Findings include: Resident 30 was admitted to the facility on 11/24/19 with diagnoses including stroke (cerebral infarction) and bowel and bladder incontinence. Resident 30's MDS dated 11/28/21 revealed a BIMS score of 14 which indicated the resident had no cognitive impairment. Resident 30's 11/28/21 ADL care area assessments revealed she/he required extensive one person assistance for transfers to bed, for toileting and dressing and she/he was frequently incontinent of bowel and bladder. Resident 30's care plan dated 2/2022 indicated Resident 30 had a behavior problem related to a history of confabulating stories and making accusations toward staff. There was no documentation in 2021 or the first quarter of 2022 to indicate these behaviors occurred. On 4/26/22 at 10:24 AM and on 4/29/22 at 12:29 PM, Resident 30 stated on approximately 4/5/22 Staff 17 (CNA) helped Resident 30 transfer onto the toilet, then left. Resident 30 stated she/he finished using the toilet and when Staff 17 returned, Resident 30 commented about the amount of time it took for Staff 17 to answer the call light. Staff 17 told Resident 30 to not speak to him that way or he would leave Resident 30 on the toilet. Resident 30 stated she/he spoke to Staff 9 (Staffing Coordinator) because "she did the hiring and firing" and told Staff 9 she/he did not want Staff 17 to care for her/him any longer. Staff 9 agreed not to have Staff 17 provide care for Resident 30 any longer and told the resident Staff 17's behavior was unacceptable. Resident 30 stated she/he informed Staff 10 (CMA/CNA) about the incident the following morning. On 5/3/22 at 8:14 AM Staff 10 was interviewed and recalled Resident 30 told him about the incident involving Resident 30 and Staff 17. Staff 10 stated there were "words exchanged back and forth". Resident 30 was upset the next day about what happened. On 5/3/22 at 9:49 AM Staff 9 confirmed she talked to Resident 30 about Staff 17 no longer providing care to her/him and about the incident. Staff 9 recalled Resident 30 telling her Staff 17 said he would leave Resident 30 on the toilet if the resident talked to him that way. Staff 9 acknowledged she should have reported the incident to management and confirmed if a resident made an allegation against a staff member, it was the expectation of the facility that staff reported the allegations. On 5/3/22 at 10:04 AM, Staff 1 (Administrator) was informed of the findings of this investigation. She stated there was no investigation initiated and Staff 1 was not aware of the incident. She confirmed it was an expectation of the facility to investigate a reported allegation by a resident against a staff member.

DNS completed full Incident Investigation for resident # 30 and ruled out abuse and neglect. 5/3/22 DNS Completed FRI and sent it in. 5/3/22 Care plan for resident #30 was reviewed by DNS and revised. 5/3/22 DNS placed staff #17 on administrative leave pending investigation. 5/3/22 DNS immediately re-educated staff #9, 10, 17 and other staff not numbered here on definition of abuse and reporting requirements. 5/3/22 All residents are at risk for being impacted by this deficient practice in which the staff failed to identify investigate and report potential alleged abuse. DNS or designee will complete all staff in-service on Abuse and Abuse reporting requirements. 6/23/22 DNS and PIP team will complete PIP to review with QAPI. 6/23/22 RCC/RCM or designee will audit 2 charts daily to monitor for possible episodes of suspected or true abuse weekly. 6/23/22 RCM/RCC or designee will bring results of audits to QAPI X 3 months then quarterly. 6/23/22 DNS or Designee will update and review Abuse & Reporting PIP to QAPI X 3 months or 100% compliance is reached. 6/23/22

Based on observation, interview and record review the facility failed to revise and review the plan of care after a completed assessment for 1 of 5 sampled residents (#29) reviewed for ADL care. This placed residents at risk for unmet care needs. Findings include: Resident 29 admitted to the facility in 2/2020 with diagnoses including diabetes and depression. The 2/20/22 Annual MDS revealed Resident 29 required one person to physically assist her/him for bathing and personal hygiene. The 3/17/22 updated care plan revealed Resident 29 was independent for personal hygiene and no reference was found related to bathing needs. Review of Resident 29's clinical record revealed no review of her/his care plan occurred with Resident 28 since 8/2021. On 4/25/22 at 5:19 PM Resident 29 stated she/he needed more assistance with personal hygiene and bed baths as a result of her/his decrease in strength and energy. Resident 29 stated sometimes she/he was too weak to complete her/his own bed bath and it was months since she/he last had a discussion or reviewed her/his plan of care especially related to ADL needs. On 4/27/22 at 2:45 PM Staff 6 (CNA) stated according to her/his care plan Resident 29 was independent after set-up for her/his bed bath and personal hygiene and if she/he required more assistance the resident could request it. On 4/27/22 at 2:54 PM Staff 7 (LPN/CNA) stated he was aware Resident 29 no longer could wash her/his hair without assistance. Staff 7 noticed a decline in her/his ADL abilities over the last month and communicated the change to Staff 8 (LPN). On 4/27/22 at 3:22 PM Staff 5 (RNCM) stated she was not notified of issues with Resident 29's bathing and personal hygiene needs. On 4/27/22 at 3:34 PM Staff 2 (DNS) acknowledged the process to systematically review and involve the resident with care plans did not occur with Resident 29 since 8/2021. On 4/28/22 at 4:04 AM Staff 8 stated she was not aware Resident 29 was care planned for independent personal hygiene and confirmed Resident 29 at her/his baseline was not able to complete her/his bed bath at night. On 4/28/22 at 11:48 AM Staff 2 (DNS) stated Resident 29's bathing needs should be separately noted in the care plan and the care plan should be updated to meet the assessed needs and preferences of the resident.

Resident #29s care plan and tasks were updated to current level of ability by RCM. 4/27/22 All residents are at risk for being impacted by this deficient practice. DNS or designee will hold an in-service for all staff functioning as RCC/RCMs, on updating care plans and tasks to ensure they meet the residents current ability. 6/23/22 RCC/RCM will audit all residents care plans and tasks to assure they meet residents current ability. 6/23/22 RCC/RCM will audit each residents care plan and tasks quarterly and PRN with the MDS process to ensure they meet the residents current ability 6/23/22 RCC/RCM or designee will perform chart audits monthly (10% of the resident population) to assure care plan and tasks meet the residents current ability. 6/23/22 RCC/RCM or designee will bring the results of the monthly chart audits to QAPI X 3 months or until 100% compliance is reached. 6/23/22

Based on observation, interview and record review it was determined the facility failed to ensure the facility maintained a medication error rate of less than 5%. There were 6 errors in 27 opportunities resulting in a 22% medication error rate. This placed residents at risk for adverse side effects from medications. Findings include: On 4/27/22 at 7:05 AM Staff 19 (LPN) prepared the following medications for Resident 12: *amlodipine (blood pressure medication) *vitamin D (supplement) *glipizide (diabetic medication) *Pradaxa (thrombin inhibitor medication) *Culturelle (probiotic supplement) *carvedilol (blood pressure medication) On 4/27/22 at 7:10 AM Staff 19 (LPN) entered Resident 12's room and gave Resident 12 the medicine cup which contained her/his medications. Staff 19 exited the room without monitoring to ensure Resident 12 took the medications. Staff 19 was stopped by the surveyor after she exited the resident room and was asked if Resident 12 had an order to self-administer her/his own medication. Staff 19 stated Resident 12 did not and immediately returned to Resident 12's room. Resident 12 had self-administered her/his medications. Staff 19 then stated she made an error and should not have allowed Resident 12 to self-administer the medication. On 5/2/22 at 12:40 PM Staff 2 (DNS) acknowledged when Staff 19 left Resident 12's medications with the resident to self-administer was a medication error. ,

Resident #12 will be assessed for ability to self-medicate or ability to leave medications at the bedside. 6/23/22 Staff #19 was counselled about leaving medications at the bedside by DNS. 4/27/22 Staff development or designee will do a 10% of resident population random audit medication review to rule out medication error. 6/23/22 DNS will complete an all-Nursing Staff training on medication administration to include leaving medications at the bed side. 6/23/22 Staff Development Coordinator or designee will do 1 medication pass observation/audit per month. 6/23/22 Staff Development Coordinator or designee will bring the results of the medication pass observations/audit to QAPI X 3 months or until 100% compliance is reached. 6/23/22

Based on observation and interview it was determined the facility failed to properly store and label food for 1 of 1 kitchen reviewed for food storage. This placed residents at risk for foodborne illness. Findings include: On 5/2/22 at 6:20 PM the kitchen walk-in refrigerator was inspected: -Two large clear plastic containers with green lids were observed on the shelf; one contained canned peaches and the other contained sliced beets. Neither container was dated or labeled. -Two small white bowls were observed on the shelf: one bowl contained half of a tomato and the other contained a sliced onion with plastic wrap covering the bowls. Neither of the bowls was dated or labeled. -A stainless steel container was observed on the shelf that contained several cooked sausages with plastic wrap covering the container. The container was not dated or labeled. -A small black plastic bowl was observed to contain an opened block of butter with plastic wrap covering the top of the bowl. Neither the bowl nor the plastic wrap was dated or labeled. On 5/2/22 at 6:29 PM, Staff 11 (Dietary Services) and Staff 12 (Dietary Services) were shown the containers of unlabeled food and confirmed food opened and placed in containers should be labeled and dated. On 5/3/22 at 8:40 AM Staff 4 (Dietary Services Manager) confirmed it was an expectation of the facility that all food placed in containers be labeled and dated.

Dietary Manager will counsel staff # 11 & 12 for proper food labeling and storage. 6/23/22 Undated items were disposed of 5/2/2022. All residents are at risk for being impacted by this deficient practice. Dietary Manger or designee will perform a full Dietary Staff in-service on food, sanitation and storage rules. 6/23/22 Dietary Manager or designee will complete food/sanitation audit weekly X 4 weeks, then monthly thereafter. 6/23/22 Dietary Manager or designee will do random audits weekly and the results will be brought to QAPI monthly. 6/23/22

Based on interview and record review the facility failed to annually update the facility assessment to include current staffing needs and resources related to COVID-19. This place residents a risk for unmet needs. Findings include: Review of the 6/2018 Facility Assessment revealed the assessment was not updated, as necessary, or at least annually. The assessment was not comprehensive and did not include any changes in staffing since 2019 or reference to facility resources related to COVID-19 requirements. On 5/3/22 at 12:21 PM Staff 13 (Chief Executive Officer) acknowledged the available facility assessment was last updated in 2018 and was not current.

All residents are at risk for being impacted by this deficient practice. The Facility Assessment will be reviewed and updated by said date and at a minimum of yearly thereafter. 6/23/22 Administrator or designee will bring Facility Assessment to QAPI for final sign off. 6/23/22 DNS or designee will audit quarterly for accuracy and update as needed. 6/23/22 DNS or designee will bring the results of the audit to QAPI X 3 months or until 100% compliance is reached.

Based on observation, interview and record review it was determined the facility failed to follow infection control procedures for a resident on isolation precautions for 1 of 10 sampled residents (#1) reviewed for medication administration. This placed residents at risk for facility acquired infection. Findings include: On 4/27/22 at 7:20 AM Staff 20 (LPN) entered Resident 1's room to administer medication and wore only a N95 mask and face shield. Staff 20 did not don a gown and gloves. Infection control signage on Resident 1's door indicated all staff and visitors were required to don full PPE (personal protection equipment) with a N95 mask prior to entering the room. On 4/27/22 at 7:24 AM Staff 20 verified the infection control signage on Resident 1's door instructed staff to don full PPE. Staff 20 further stated she did not don full PPE prior to entering Resident 1's room and administering the medication. ,

IP Nurse reviewed resident #1s precautions and removed her from pink precautions and updated care plan. 4/29/22 IP Nurse/DNS or designee will in-service staff #20 on Infection Prevention to include PPE and donning and doffing it. 6/23/22 All residents are at risk for being impacted by this deficient practice. IP Nurse or designee will review all residents on precautions for continued need 6/23/22 IP Nurse or designee will conduct an All Staff Inservice on PPE and Infection Control to include precautions. 6/23/22 IP Nurse or designee will conduct 2 random PPE audits weekly on staff. 6/23/22 Results from the audits will be brought to QAPI X 3 months.

Based on interview and record review it was determined the facility failed to ensure eight hours of RN coverage between day and evening shifts for 9 of 35 days reviewed for staffing. This placed residents at risk for lack of comprehensive assessments. Findings include: The Direct Care Staff Daily Reports from 3/25/22 through 4/28/22 revealed the facility did not have a RN charge nurse on duty for eight consecutive hours between day and evening shifts for the following dates: 3/25/22 3/30/22 3/31/22 4/1/22 4/9/22 4/13/22 4/16/22 4/27/22 4/28/22 On 5/1/22 at 8:15 PM Staff 18 (LPN) stated there were weekends when RN coverage was not available and was aware requests for wound assessments were not completed timely. On 5/2/22 at 3:43 PM Staff 9 (Staffing Director) stated the facility relied on agency staff for RN coverage and RNs were difficult to find. On 5/3/22 at 12:14 PM Staff 1 (Administrator) acknowledged the requirement for eight hours of RN staffing between day and evening shifts was not met.

All residents and staff are at risk for this deficient practice. Administration team has reviewed the current RN job posting and refreshed it as well as increased the sign on bonus. 5/11/22 Administration team will analyze the current RN wages to ensure that they meet industry standard and make any needed adjustments. 6/23/22 Staffing Coordinator or designee will continue to attempt to contract with agencies to ensure that at least one RN is scheduled 8 hours between the hours of day and evening shift for the days that the facility RN is not available. 6/23/22 Staffing Coordinator or designee will exhaust all avenues to replace an RN that calls in with another RN. 6/23/22 Staffing Coordinator or designee will report to administration team daily if not able to fill an RN shift for further trouble shooting. 6/23/22 Staffing Coordinator or designee will audit and report out RN shifts not able to be covered to the Administrator or designee weekly. 6/23/22 Administrator or designee will report results of the audit to QAPI monthly for three months and then quarterly. 6/23/22

OAR 411-085-0360: Abuse

Refer to F610 ****************** OAR 411-086-0060: Comprehensive Assessments and Care Plan Refer to F657 ****************** OAR 411-086-0110: Nursing Services: Resident Care Refer to F759 ****************** OAR 411-086-0250: Dietary Services Refer to F812 ****************** OAR 411-085-0010: Administrator Refer to F838 ****************** OAR 411-086-0330: Infection Control and Universal Precautions Refer to F880 ******************