Avamere Rehabilitation of King City

Based on interview and record review it was determined the facility failed to respond timely to a change of condition for 1 of 3 sampled residents (#4) reviewed for change of condition. This placed residents at risk for a decline in overall functioning. Findings include: The facility's 3/2018 Acute Condition Changes-Clinical Protocol policy documented the nurse shall assess and document/report the following baseline information: vital signs, neurological status, current pain level, level of consciousness, and onset, duration and severity of condition.-á Resident 4 was re-admitted to the facility in 12/2025 with diagnoses including multiple sclerosis and opioid use.-á Resident 4's Quarterly MDS dated 1/2026 documented a BIMS score of 15 indicating the resident was cognitively intact. Resident 4's assessment also indicated she/he had chronic pain. The 11/25/25 Blood Pressure Summary Report documented Resident 4's blood pressure was 86/53 at 5:00 AM by Staff 6 (LPN).-á Resident 4's 11/25/25 Progress Note at 6:50 AM, indicated Staff 6 charted Resident 4's blood pressure as 70/50. Staff 6 called provider and 911. No additional information was documented.-á On 2/18/26 at 2:32 PM, Staff 6 (LPN) stated she had cared for Resident 4 during the night shift on 11/24/25 through 11/25/25. Staff 6 stated the morning of 11/25/25 staff was unable to wake Resident 4. Staff 6 stated Resident 4's blood pressure was abnormal and low. Staff 6 called the provider then called 911.-á A Fire and Rescue Public Incident Report documented that a call from the facility was received on 11/25/25 at 6:46 AM stating Resident 4 was found with altered mental status. Paramedics arrived at the facility at 6:50 AM. Staff 6 (LPN) reported to the paramedics that Resident 4 was found altered at 5:00 AM. Paramedics administered Narcan (an antidote for opioids), and Resident 4's vital signs improved. Resident 4 was transported to the hospital.-á On 2/20/26 at 10:19 AM, Staff 14 (CNA) stated she had cared for Resident 4 during the night shift on 11/24/25 through 11/25/25. Staff 14 stated Resident 4 appeared to be sleeping through-out the night. Staff 14 stated when she took Resident 4's blood pressure at 5:00 AM it was very low. Staff 14 alerted Staff 6 (LPN) and Resident 4's blood pressure was rechecked and continued to be low. Staff 14 stated Staff 6 assisted her in providing incontinence care to Resident 4. Staff 14 stated it was odd Resident 4 did not wake up during care because the resident usually woke up when staff laid the resident flat. Staff 14 stated Resident 4 sometimes would stay awake for three days and then slept hard. Staff 14 stated Resident 4 did not respond to them. Staff 14 stated Staff 6 called the provider and 911. The 12/2/25 Hospital Discharge Summary revealed Resident 4 was admitted to the hospital for septic shock due to UTI, acute kidney injury, acute metabolic encephalopathy and acute hypoxic/hypercapnic respiratory failure. On 2/20/26 at 2:46 PM, Staff 1 (Administrator) acknowledged there was a delay by staff in responding to Resident 4's change of condition and Resident 4's progress notes did not include the baseline information regarding her/his change of condition.-á -á -á -á -á -á -á

This: Resident is currently stable. Like: Residents who experience a change in condition may experience a delay in care if staff do not immediately alert the provider or 911 as appropriate or have progress notes, including baseline information regarding the change in condition, in their chart. Education: Nurses were re-educated regarding procedure for residents experiencing change in condition and appropriate chart notes. Audit: Audit residents experiencing change of condition for timely provider/911 notification and adequate chart notes weekly for 2 weeks then monthly for 2 months with results brought to QAPI for review and recommendations.

Based on observation, interview and record review it was determined the facility failed to acquire the correct route for an emergency (Narcan) medication for 1 of 3 sampled residents (#4) reviewed for pharmaceutical services. This placed residents at risk for not receiving the correct route for their emergency medication. Findings include: -á Resident 4 was re-admitted to the facility in 12/2025 with diagnoses including multiple sclerosis, diabetes and opioid use. -á Resident 4GÇÖs 11/2025 Physician Orders included an order for naloxone HCL (Narcan-an antidote medication for opioids) nasal liquid 4mg/0.1ML to be administered in both nostrils as needed for decreased responsiveness. -á On 2/19/26 at 12:34 PM, observations of the facility's emergency kit found Narcan as an intravenous route rather than the nasal route as prescribed for Resident 4. -á On 2/20/26 at 2:46 PM, Staff 1 (Administrator) acknowledged the facility did not have the correct Narcan route administration (nasal) for Resident 4.-á -á

This: Facility has Narcan on hand that matches this residents order for the medication: Naloxone HCL NASAL liquid. Like: Residents who have orders for Narcan are at risk that the facility doesn't have the medication that matches their prescribed route.  Facility standing orders now reflect Nasal Narcan for residents with narcotic medications. Education: Nurses have been educated that our standing orders are for Nasal Narcan and have been educated where that is in the facility. Audit: Residents who have narcotic medication orders also have Nasal Narcan orders weekly for 2 week then monthly for 2 months with results brought to QAPI for review and recommendations.

Resident 74 readmitted to the facility in 2024 with diagnoses including depression and anxiety. A 9/11/24 Facility Reported Incident indicated on 9/9/24 an incident between Resident 74 and Staff 9 (Former Medical Records) occurred outside in the garden area of the facility. Staff 8 (Housekeeping Manager) heard Staff 9 call Resident 74 a GÇ£Goddamn fucking liar.GÇ¥ The incident was witnessed by several residents and Staff 11 (Activities Director). The facility incident report indicated on 9/9/24 Resident 74 was outside in the garden. Resident 74 and Staff 9 were heard arguing about a plant that was allegedly uprooted and thrown in the garbage by the resident. Resident 74 denied the allegation and indicated another resident asked her/him to uproot the plant and move it to a different area for it to grow. The facility concluded staff 9 did not treat Resident 74 with dignity and respect. Facility interviews indicated the following: - -á-á-á-á-á-á-á-á-á Resident 74 indicated she/he was being blamed and was called a lair by Staff 9. Resident 74 indicated she/he started the yelling because she/he was upset for being blamed for something she/he didnGÇÖt do. - -á-á-á-á-á-á-á-á-á Staff 11 indicated she saw Staff 9 and Resident 74 yelling at each other over the plant. Staff 11 indicated Resident 74 insisted she/he did not throw the plant away and Staff 9 called the resident a GÇ£liar."" -á Staff 11 indicated heated words were exchanged between Staff 8 and Resident 74. - -á-á-á-á-á-á-á-á-á Staff 8 indicated she heard yelling in the garden area and heard Staff 9 call Resident 74 a GÇ£goddamn fucking liarGÇ¥ and went to de-escalate the situation. -á - -á-á-á-á-á-á-á-á-á Staff 9 denied calling Resident 74 a liar and indicated another resident called her/him a liar. Staff 9 indicated Resident 74 started yelling at her. Staff 9 indicated her voice may have been raised. On 12/2/25 at 10:23 AM Staff 11 stated the incident between Staff 9 and Resident 74 occurred in the garden area. Staff 11 stated she heard the resident and Staff 9 getting into an argument about plants being pulled and thrown away. Staff 11 stated she heard Staff 9 call Resident 74 a liar. Staff 11 stated it was inappropriate for Staff 9 to call the resident a liar and the incident was uncomfortable for everyone. Staff 11 stated she could not recall if profanities were used by Staff 9. On 12/2/25 at 10:25 AM Staff 8 stated the incident occurred outside in the garden. Staff 8 stated she heard Staff 9 say either GÇ£shut the fuck upGÇ¥ or shut the hell upGÇ¥ to Resident 74. Staff 8 stated Staff 9 and Resident 74 were yelling at each other, and she went outside and told them both to calm down. On 12/4/25 at 9:01 AM Staff 9 stated another resident told her Resident 74 pulled out plants. Staff 9 stated she told Resident 74 that no one called her/him a liar. Staff 9 denied raising her voice and stated she used her GÇ£motherGÇ¥ tone with Resident 74 and only repeated back what Resident 74 had said, GÇ£fucking liar."" On 12/1/25 at 9:59 AM Staff 1 (Administrator) acknowledged the lack of dignity and respect occurred between Staff 9 and Resident 74 on 9/9/24. On 9/17/24 the facility provided information to indicate an action plan to prevent future occurrences was completed; audits, education and an in-service was completed related to treating resident with respect and dignity. The deficient practice was determined to be past non-compliance, corrected on 9/17/24. -á

Resident 60 admitted to the facility in 7/2025 with a diagnosis of Atherosclerosis (hardening of arteries) of left leg with rest pain. Resident 60GÇÖs 7/15/25 Quarterly MDS indicated the resident was cognitively intact. Resident 60GÇÖs 11/10/25 Physician Order indicated Resident 60GÇÖs morphine was to be changed from TID to BID. Resident 60GÇÖs health record revealed no evidence the decrease in morphine was discussed with the resident. A Progress Note dated 11/15/25 completed by Staff 20 (RN) indicated Resident 60 expressed frustration regarding recent medication changes and those changes were made without her/his consent. On 12/1/25 at 12:54 PM Resident 60 reported her/his morphine pain medication was recently reduced and reported she/he was not included in the decision. On 12/3/25 at 4:04 PM Staff 3 (LPN Resident Care Manager) reviewed Resident 60GÇÖs health record and acknowledged that the resident was not included and informed in the decision to change the residentGÇÖs pain medication. On 12/4/25 at 3:27 PM Staff 2 (DNS) was notified of the findings of this investigation. Staff 2 stated when a residentGÇÖs pain medication was changed, the resident was to be included and informed.

This – Discussion has been completed with this resident regarding plan for reduction of pain medications while managing pain. Like – Residents who are having their pain medication reduced are at risk for not being included or informed of medication change. Education – Nurses – Resident needs to be notified of changes to medications PRIOR to adjustment.  MD – Discussion with resident regarding plan for medication changes needs to be noted prior to changes. Audit – Residents who are having their pain medication reduced have note in chart re discussion/plan. Audits Weekly x2 then Monthly x2 with results brought to QAPI for review and recommendations. Responsible – DON or designee will be responsible for ongoing compliance.

Resident 16 was admitted to the facility in 1/2024 with diagnoses including type 2 diabetes mellitus.-á Resident 16GÇÖs 8/5/25 physician order indicated the use of bilateral bed mobility bars. Resident 16GÇÖs Care Plan, revised on 9/3/25, revealed bilateral mobility bars were to be used to increase resident participation with bed mobility. Resident 16GÇÖs 11/2025 Annual MDS revealed Resident 16 was cognitively intact and required one-person assistance with mobility. Multiple observations from 12/1/25 through 12/4/25 between the hours of 11:01 AM to 3:33 PM revealed there was one mobility bar on the right side of Resident 16GÇÖs bed. On 12/1/25 at 11:01 AM and 12/3/25 at 1:29 PM Resident 16 stated she/he was told she/he would have two mobility bars placed on her/his bed, but was only provided with one mobility bar. Resident 16 stated mobility bars would help her/him reposition herself/himself in bed. On 12/3/25 1:43 PM Staff 12 (CNA) stated Resident 16 used the mobility bar on her/his bed to assist with transfers and had only seen one mobility bar. On 12/4/25 at 10:32 AM Staff 24 (CNA) stated Resident 16 needed help adjusting herself/himself in bed when she/he was weak. Staff 24 stated the resident was care planned for one mobility bar according to Resident 16GÇÖs Kardex (a system used by CNA staff to communicate important information). On 12/4/25 at 11:12 AM Staff 3 (LPN Resident Care Manager) confirmed Resident 16 was supposed to have two mobility bars on her/his bed. On 12/5/25 at 9:54 AM Staff 1 (Administrator) stated her expectation was Resident 16GÇÖs care plan and physician orders for two mobility bars would be followed. Staff 1 confirmed Resident 16 only had one mobility bar on her/his bed.

This – Resident was evaluated for need for bilateral mobility bars, confirmed need for bilateral, second bar was added. Like – Residents who have orders for bilateral mobility bars are at risk for having one missed. Education – Nursing – Residents who have orders for mobility bars need to have them care planned and accurately added to the Kardex. Audit – Residents who have mobility bar orders  - Order, Kardex match, in place - Audits Weekly x2 then Monthly x2 with results brought to QAPI for review and recommendations. Responsible – DON or designee is responsible for ongoing compliance.

Resident 2 was admitted to the facility in 4/2025 with diagnoses including dementia. -á The resident's care plan for cognitive impairment, updated on 8/9/25, indicated behavioral disturbance and anxiety. Behavioral interventions included: assessing needs, creating a safe environment, offering activities, and reassuring the resident.-á -á The 10/9/25 Quarterly MDS identified Resident 2 was assessed to have no behaviors. -á ResidentGÇÖs 2GÇÖs 11/2025 MAR revealed an order for PRN lorazepam (anti-anxiety) every four hours as needed for agitation, anxiety, restlessness, or nausea. The MAR indicated the PRN lorazepam was administered 20 times. -á No evidence or documentation was found in Resident 2GÇÖs health record which demonstrated the use of nonpharmacological interventions prior to the administration of lorazepam, or a rationale for the use of lorazepam. -á From 12/2/25 through 12/5/25 between the hours of 8:42 AM and 3:15 PM the resident was observed to be in her/his room either in a wheelchair sleeping or awake and without behaviors. -á On 12/4/25 at 1:20 PM Staff 13 (CNA) reported Resident 2 occasionally had behaviors such as screaming or hitting at people but was easily redirected by watching television and drinking hot cocoa. -á -á On 12/4/25 at 1:39 PM Staff 32 (CNA) was able to identify strategies of giving hot cocoa and offering care choices as appropriate options for managing Resident 2GÇÖs behaviors. Staff 32 said resident could be aggressive at times but was typically good natured. -á On 12/5/25 at 9:59 AM Staff 33 (CNA) identified Resident 2GÇÖs behaviors occurred about twice per week when the resident wanted attention or hot cocoa. Staff 33 said the resident was redirected by putting on movies, braiding hair, or providing hot cocoa. -á On 12/5/25 9:49 AM Staff 19 (LPN) stated Resident 2GÇÖs behaviors related to the use of lorazepam included yelling out if something was in her/his way, repeatedly asking for ice cream, and putting herself/himself on the floor. Staff 19 said the resident was redirected with music and watching DVDs.-á -á On 12/5/25 10:09 AM Staff 3 (LPN Resident Care Manager) said the expectation was for nurses to document each time behaviors occurred and resulted in the administration of PRN lorazepam. Staff 3 acknowledged the need for staff to utilize nonpharmacological interventions prior to administering PRN lorazepam.

This – Resident has been adjusted for specific use of PRN psych meds and also added non-pharmacological interventions. Like – Residents who have PRN psych meds are at risk for improper usage/withholding due to subjective parameters or lack of non-pharm interventions. Education – Nursing – Parameters for PRN medication, specific behaviours, need to be written into orders and that non-pharm interventions need to be utalised and documented as failed prior to dose.  Additionally, notes to resident behaviour must also be included. Audit – Residents who have PRN psych med orders – Objective? Audits completed weekly x2 weeks then monthly x2 months with results brought to QAPI for review and recommendations. Responsible – DON or designee responsible for ongoing compliance.

2. Resident 20 admitted to the facility in 10/2025 with diagnoses including malignant neoplasm (cancerous tumor) of the brain. -á Resident 20GÇÖs 10/16/25 admission Activity Profile, completed by Staff 11 (Activity Director) identified the resident was in the facility for Hospice/End of life care. Resident 20 enjoyed listening to music, family visits and reminiscing. -á Resident 20GÇÖs 10/17/25 Admission MDS assessed music was very important and it was somewhat to participate in religious services and/or practices and participate in her/his favorite activities. She/he was identified to have hospice services with a life expectancy of less than six months. -á On 12/3/25 at 8:24 AM and 10:50 AM Resident 20 was observed to lie in her/his dark room, no television or music playing, with eyes open and she/he was unresponsive to verbal stimuli. At 12:32 PM her/his family was visiting and Witness 9 (Family) stated the television was broken, and she/he had no music opportunities in the room. -á On 12/3/25 at 2:23 PM Staff 29 (CNA) stated they obtained the information to provide care including activities from the care plan. Resident 20 listened to music on her/his television and they took her/him to the activity room sometimes to listen to music. Staff 29 stated the Activity Director did not invite residents unless CNAs took the residents down to the activity room. -á On 12/4/25 at 12:08 PM Resident 20 was observed in her/his bed with family visiting. The family brought in a music device to listen to while they were visiting as the television still was not working and the facility did not provide any alternative way to listen to music. -á A care plan dated 12/4/25 revealed Resident 20 was dependent on staff for participation in activities. Activities such as music, one on one visits, television and group activities were to be offered per the resident's choice and as tolerated. -á On 12/4/25 Resident 20GÇÖs past 30 days of activity participation revealed no one on one visit were documented as offered and it was documented she/he attended three group activities. -á On 12/4/25 at 12:33 PM Staff 11 stated she was unaware Resident 20 received hospice services and confirmed she completed the Activity Profile which indicated hospice services were received upon admission. Staff 11 confirmed the lack of activity participation documentation for Resident 20 and acknowledged the group activity documented for 12/2/25 was an in-room pet visit by a volunteer. She was unable to express meaningful one on one visits with Resident 20 or engaging group activities. Staff 11 stated she was unaware Resident 20GÇÖs television was broken as she did not see the resident this past week because she was too busy with everything to get to all residents. -á On 12/4/25 at 1:24 PM Witness 9 stated they were aware Resident 20 would sit in front of the television in the dining room while music played but no engagement or interactions occurred. -á On 12/5/25 at 10:42 AM Staff 1 (Administrator) stated she expected Resident 20 to be offered, as tolerated, resident centered, meaningful and engaging activities, especially since she/he was on hospice. Staff 1 expected all activities to be provided and documented. -á 3. Resident 5 admitted to the facility in 2020 with diagnoses including major depression. -á Resident 5GÇÖs most recent Activity Profile assessment dated 5/7/20, identified her/his leisure interests as fishing, camping, outdoors, car shows, outdoor shows, radio with music from the past, reading horror and documentaries, card games, bingo game, mechanics, art, drawing, painting and bible studies. -á Resident 5GÇÖs 8/26/25 Significant Change MDS assessed her/him to be cognitively intact with little interest or pleasure in doing things and feeling down. The Activity Preferences section identified the only activity preferences were to do her/his favorite activities and to go outside. -á On 12/3/25 at 8:27 AM, 10:20 AM, 12:40 PM, 2:43 PM and 12/4/25 at 10:11 AM Resident 5 was observed to lie in her/his bed, with a hat over her/his eyes in a dark, quiet room and not engaged in any diversional leisure activities.-á -á On 12/4/25 at 12:16 PM Staff 32 (CNA) stated Resident 5 did not participate in activities and she never saw the Activities Director interact with the resident. -á On 12/4/25 at 12:22 PM Resident 5 stated she/he asked for reading glasses several months ago and did not receive them. His room was observed not to have any reading books of horror or documentaries, and she/he stated she/he would read if the glasses and books were available. Resident 5 stated she/he could make her/his own leisure decisions but wanted access to more leisure items of interest to occupy her/his time as she/he was bored often. Resident 5 stated she/he did not get asked to attend groups, except for this week and even if she/he wanted to attend groups this week the November 2025 acalendar was still up in her/his room so she/he did not know the daily activities. -á Resident 5GÇÖs 12/4/25 Care Plan directed staff to offer one on one activities, provide supplies to facilitate independent activities such as birdseed, squirrel food, gardening supplies and to sit outside. -á The 12/4/25 Activity Task for participation for the last 30 days revealed Resident 5 participated in no self-directed activities, no one on one activities and refused two groups activities. -á On 12/4/25 at 12:33 PM Staff 11 confirmed the lack of activity participation documentation. Staff 11 could not express Resident 5GÇÖs offered opportunities of an ongoing resident centered activities program which incorporated the residentGÇÖs interests, hobbies and cultural preferences which was integral to maintaining and/or improving the residentGÇÖs physical, mental, and psychosocial well-being and independence. -á On 12/5/25 at 10:42 AM Staff 1 (Administrator) stated she expected Resident 5 to be offered and provided supplies for resident centered, meaningful and engaging activities.-á , The facilityGÇÖs 11/2025 Activities Policy revealed the activities program was provided to support the well-being of residents and to encourage both independence and community interaction. The facility provided an activities program that addressed the intellectual, social, spiritual, creative, and physical needs, capabilities, and interests of each resident. 1. Resident 4 was admitted to the facility in 2021 with diagnoses including major depressive disorder and dementia. Resident 4GÇÖs Activities Care Plan, revised on 7/11/25, indicated the following: -Resident 4 liked music, pet therapy, one-on-one conversations, reminiscing, stuffed animals, gardening, flowers, and birds. -Resident 4 was to have one-on-one bedside visits and activities to include music, animal visits, bird watching discussions, manicures, hand massages, and assistance looking through magazines. -Resident 4 was Christian, and the Activities Department was to provide gospel music. Resident 4GÇÖs 10/15/25 Significant Change MDS revealed the resident had severe cognitive impairment. Her/his activity preferences indicated it was somewhat or very important to do her/his favorite activities, be around animals, and participate in religious services and practices. Resident 4's 11/4/25 through 12/4/25 Group Activity Task Log and One-On-One Activity Task Log contained no data regarding activity participation for one-on-one visits and one refusal on 12/1/25 for group participation. A review of Resident 4GÇÖs electronic health record contained no evidence the resident participated in any activities. A review of the facility's activities calendar revealed five different activities each day between 8:30 AM and 6:00 PM From 12/1/25 through 12/4/25 Resident 4 was observed awake in her/his room with the blinds closed and not engaged in any activities on 9 occasions. On 12/4/25 at 10:19 AM Staff 24 (CNA) stated Resident 4 did not get out of bed, and she/he got confused when out of her/his room. Staff 4 stated she has not seen any activities occurring in Resident 4GÇÖs room, and she was not aware of any one-on-one activities being done. Staff 24 stated Resident 4 would benefit from one-on-one activities. On 12/4/25 at 11:24 AM Staff 25 (CNA) stated Resident 4 spent her/his day in bed and would benefit from one-on-one activity visits. On 12/4/25 at 12:34 PM Staff 11 (Activities Director) stated she was the only person in the activities department, and was responsible for completing all care conferences, Activity MDS Assessments, Activities Admission Profiles, shopping for residents, delivering mail, engaging residents in group and one-on-one person-centered activities, as well as assisting with many resident requests. She stated there was no one to provide activities on the weekends or when she was not in the facility. Staff 11 was unable to provide dates or times of any specific activities completed with Resident 4 and confirmed no activities documentation was completed. Staff 11 stated she did not have enough time to meet all residentsGÇÖ activity needs. On 12/5/25 at 8:41 AM Resident 4 stated she/he liked to look out of her/his window, listen to music, bird watch, and visit with pets. On 12/5/25 at 9:54 AM Staff 1 (Administrator) stated her expectations were that all residents received activities according to their person-centered care plan. Staff 1 stated she was actively recruiting for an additional activities assistant position.

This – Residents have their care plan updated to include 1:1 and independent activities, 1 on 1 interactions have been noted. Any broken devices have been repaired to working status or device to listen to music provided. Like – Residents who primarily remain in their room and/or decline to attend activities are at risk for not having their social needs met. Education – Activities – Residents are to be invited to daily activities, regardless of part participations and independent activities of their choosing  as well as 1:1 interactions will be provided on a regular basis.  Residents are to have current monthly calendar posted in their rooms.  Interactions will be noted appropriately in the chart. Audit – Activities charting for residents who require 1:1 or in room activities; Audits Weekly x2 then Monthly x2 with results brought to QAPI for review and recommendations. Responsible – Administrator or designee is responsible for ongoing compliance.

Resident 60 admitted to the facility in 7/2025 with a diagnosis of Atherosclerosis (hardening of arteries) of left leg with rest pain. Resident 60GÇÖs 7/15/25 Quarterly MDS indicated the resident was cognitively intact, had almost constant pain and received scheduled and PRN pain medication. Resident 60GÇÖs 10/17/25 Pain Care Plan included to attempt non-medication interventions prior to administration of pain medication, provide pain medications per the physicianGÇÖs orders, provide diversional activities, and to report complaints of pain to the nurse. The 10/17/25 Pain Evaluation specified Resident 60 received scheduled and PRN pain medication. The pain was reported as neuropathic, aching and burning in her/his lower back and left lower extremity. The pain was almost constant and was rated 7 out of 10 on the pain scale. Resident 60GÇÖs 11/10/25 Physician Order indicated Resident 60GÇÖs morphine changed from TID to BID. Progress Notes dated 11/11/25-12/4/25 noted Resident 60GÇÖs complaints of increased pain. Resident 60 expressed concerns to staff that the pain was not adequately controlled and requested to speak with a provider. There was no documentation in Resident 60GÇÖs health record to indicate the provider followed up regarding the ongoing pain complaints. On 12/1/25 at 12:54 PM Resident 60 reported her/his morphine pain medication was recently reduced and stated since the reduction she/he experienced increased phantom pain, restless leg symptoms, and difficulty sleeping. Resident 60 stated she/he reported increased pain to staff and asked to talk to the provider. Resident 60 stated the provider did not speak with her/him. Resident 60 was observed sitting up in bed and periodically rubbed her/his left leg. On 12/3/25 at 2:58 PM Staff 29 (CNA) reported Resident 60 complained of pain while using the bed pan or turning in bed. On 12/3/25 at 4:04 PM Staff 3 (LPN Resident Care Manager) reviewed Resident 60GÇÖs health record and acknowledged Resident 60 complained of increased pain from 11/11/25 through 12/3/25. Staff 3 stated the provider was notified of the increased pain on 11/11/25. Staff 3 acknowledged there was no follow up after that date. Staff 3 stated she expected the increased pain to be addressed within a few days of the provider notification. -á -á -á

This – Resident felt pain was not managed well due to decrease in medication and refusal to use non-pharmacological interventions.  Review of medications and plan of care between resident and provider to explore pain management medication options, including use of non-pharmacological interventions, has been completed to resident satisfaction. Like – Residents going thru medication tapering may experience increased pain Education – Nurses – Communication with doctor regarding pain including follow up, charting to pain management when in taper. Audit – Pain management for residents in a taper weekly x2 weeks then monthly x2 months with results brought to QAPI for review and recommendations. Responsible – DON or designee is responsible for ongoing compliance.

The facilityGÇÖs 8/2025 Behavioral Health Services Policy revealed residents who exhibited signs of emotional/psychological distress received services and support to address their individual needs and goals for care. Resident 47 was admitted to the facility in 10/2025 with diagnoses including major depressive disorder.-áResident 47GÇÖs 10/11/25 hospital History and Physical Exam revealed Resident 47 had a diagnosis of suicidal ideations. Resident 47GÇÖs 10/17/25 Social History Evaluation revealed Resident 47 stated she/he had a history of suicidal ideations. Resident 47GÇÖs Care Plan dated 10/17/25 did not have interventions for suicidal ideations. On 12/1/25 at 9:51 AM Resident 4 stated she/he tried to commit suicide in the past and had suicidal thoughts occasionally since admission to the facility. Resident 4 stated, GÇ£I have told them I am ready to go.GÇ¥ On 12/4/25 at 10:03 AM Staff 24 (CNA) stated she was unaware of Resident 47GÇÖs suicidal ideations. -á On 12/4/25 at 11:36 AM Staff 25 (CNA) stated Resident 47GÇÖs mood and behaviors fluctuated and included dysregulation of mood, yelling, rude and sexual comments, and demanding behaviors. Staff 25 was unaware of Resident 47's suicidal ideations. On 12/4/25 at 1:37 PM Staff 10 (Social Services Director) stated she did not know Resident 47 had suicidal ideations. Staff 10 stated she reviewed the Social History Evaluation for Resident 47 but did not review it closely enough to notice the suicidal ideations mentioned in the evaluation. Staff 10 stated she would have referred Resident 47 to the facilityGÇÖs mental health provider right away, talked to family and Resident 47 about her/his suicidal ideations right away, and would have added care plan interventions immediately, if she knew about Resident 47GÇÖs suicidal ideations. Staff 10 stated she did not speak with Resident 47 beyond one meeting regarding behaviors in therapy. On 12/4/25 at 1:51 PM Staff 28 (Social Services Coordinator) stated Staff 10 reviewed the Social History Evaluation before it was finalized. Staff 28 stated she noted suicidal ideations on Resident 47GÇÖs 10/17/25 Social History Evaluation, but no follow-up occurred. She stated she did not speak to Resident 47 except for discharge planning. On 12/5/25 at 9:54 AM Staff 1 (Administrator) stated she expected residents with a diagnosis or statements of suicidal ideation to be immediately and comprehensively assessed the resident and determined what services were needed.-á

This – Resident expressed depression and SI on mental health screening.  Resident  was seen been seen by Behavioural support services on 12/11/25 Like – Residents who verbalise or express mental health complications are at risk for not having needs met if referral is not made. Education – Social Services – Residents who indicate issues on PHQ9 need to be referred for BSS for screening on their next visit and put on alert for Psycho-social distress. Audit – Residents who have PHQ9 – Referral needed – Made – Seen; weekly x2 weeks then monthly x2 months with results brought to QAPI for review and recommendations Responsible – Administrator or designee is responsible for ongoing compliance

On 10/13/25 a FRI was received that indicated on 10/11/25 at 10:00 PM it was discovered that Resident 2 was missing methadone (narcotic medication). -áThe facility investigation indicated on 10/12/25 two staff members counted narcotic medication at the end of their shift and found Resident 2 had 18 tablets of missing methadone. A staff member indicated she may have thrown away the medication. The facility was unable to locate the missing medication The 300 hall Controlled Substance Book number 29, page 108 revealed methadone had 18 tablets remaining on 10/11/25. There was no indication of the disposition of the remaining medication. On 12/4/25 at 8:24 AM Staff 12 (CMA) stated she worked a double shift on 10/11/25 and may have accidentally thrown the medication away. Staff 12 stated there were no discrepancies when counting with the oncoming CMA, Staff 23 (CMA) and they did not compare the narcotic pages to the narcotic cards. On 12/4/25 at 2:27 PM Staff 23 (CMA) stated she counted narcotics with Staff 12 on 10/11/25 and did not find a discrepancy because the narcotic pages were not compared with the narcotic cards. On 12/4/25 at 8:53 AM Staff 2 (DNS) acknowledged Resident 2 had 18 doses of methadone that were unaccounted for and Staff 12 and Staff 23 failed to reconcile narcotic medication. On 12/5/25 the facility provided information to indicate an action plan to prevent future occurrences was completed; audits, education and an in-service was completed related to controlled medication storage, controlled medication administration and abuse. The deficient practice was determined to be past non-compliance, corrected on 11/19/25.

A review of the Direct Care Staff Daily Reports from 2/1/25 through 2/27/25 revealed the facility had insufficient CNA staff for one or more shifts on the following dates: -2/1/25 -2/2/25 -2/6/25 -2/9/25 -2/10/25 -2/23/25 On 12/4/25 at 11:33 AM Staff 1 (Administrator) acknowledged the facility did not meet minimum CNA staffing requirements for the identified dates.

This Facility failed to ensure proper staffing 1 month of 1 st quarter 2025.  NHA, DON, and HR no longer at this facility.  M-F Staffing meeting put into place to review staffing and address needs. Like – Residents are at risk for not having their needs met of staffing isn’t sufficient. Education – Staffing, HR, DON, NHA – M-F meeting necessary to review staffing needs and ensure adequate coverage and needs being met. Audit – Review daily staffing report for gaps and ensure coverage and needs met. ; weekly x2 weeks then monthly x2 months with results brought to QAPI for review and recommendations Responsible – NHA or designee is responsible for ongoing compliance.

Based on interview and record review it was determined the facility failed to ensure there were sufficient nursing staff available to provide the necessary care and services to meet residents' needs in 1 of 1 facility reviewed for staffing. This placed residents at risk for unmet care needs. Findings include: The facility's 10/2019 Staffing Policy indicated the facility provided an on-going review of resident acuity and ensured adequate staffing to meet scheduled and unscheduled needs of the residents. 1. A review of the Resident Council notes revealed the following: -The 9/2024 Resident Council notes revealed resident concerns about call light wait times. -The 10/2024 Resident Council notes revealed residents call lights were deactivated without providing care. -The 12/2024 Resident Council notes revealed residents stated the 300 Hall required heavy care. The residents felt more staff was needed and the residents stated they had to wait a long time for food trays to be removed. The facility's 9/2024 through 12/2024 Direct Care Staff Daily reports revealed the facility was understaffed for CNAs for 39 of 116 days reviewed for the state minimum staffing requirements. On 1/7/25 the facility had a census of 60 residents. On 1/7/25, Staff 1 (Administrator) provided a list of residents who: -Required two-person mechanical lift transfers:16; -Were dependent for ADLs: 13; -Were considered high fall risks: 21 and -Were at risk for elopement: 3 On 1/9/25 at 2:45 PM Staff 20 (Scheduling Coordinator) confirmed, from 9/7/24 through 12/31/24, CNA staffing was short on many shifts. On 1/10/25 at 1:32 PM Staff 1 (Administrator) acknowledged the facility struggled to maintain adequate staffing levels and made efforts to meet the state minimum CNA requirements. 2. On 10/22/24 a public complaint was received by the State Agency which alleged the facility was short staffed CNAs resulting in long call light response times and basic care not being met. On 10/25/24 three public complaints were received by the State Agency which alleged the facility was short staffed CNAs on 9/28/24, 10/6/24 and 10/7/24 resulting in decreased quality of care, requests not met timely, safety of residents at risk for a fall, and long call light response times. It was reported that residents were anxious, agitated, and worried they would not receive the care they needed. On 12/26/24 a public complaint was received by the State Agency which alleged the facility was short staffed CNAs on 12/24/24 and 12/26/24 resulting in residents not receiving showers and long call light response times. On 12/30/24 a public complaint was received by the State Agency which alleged the facility was short staffed CNAs resulting in residents not receiving showers, lack of timely incontinence care and long call light response times of over an hour. On 1/7/25 at 11:26 AM and 11:35 AM Staff 23 (CNA) and Staff 3 (CNA) stated the evening shift often ran short staffed CNAs. Staff 23 stated several residents required two person assistance and some residents were at risk for elopement. Staff 3 stated residents' scheduled showers often were not completed when the facility ran short staffed. On 1/7/25 at 1:34 PM, 3:19 PM and 3:36 PM Staff 10 (CNA), Staff 17 (CNA) and Staff 16 (CNA) stated when the facility ran short staffed CNAs on the evening and night shifts they were directed to provide residents with basic care, which resulted in increased behaviors from residents. On 1/8/25 at 2:32 PM Staff 24 (RN) stated the night shift on weekends ran short staffed of CNAs and there were several residents who are up all night. On 1/8/25 at 2:43 PM Staff 25 (CNA) stated evenings and weekends tended to have longer call light wait times due to the short staffed CNAs. On 1/8/25 at 3:02 PM and at 3:08 PM Staff 26 (CNA) and Staff 14 (CNA) stated due to short staffed CNAs the staff did not receive their scheduled breaks and lunches. Staff 14 stated it was very tough to complete tasks like showers. On 1/9/25 at 10:12 AM Staff 21 (CMA) stated on 12/24/24 the evening shift was short staffed CNAs; only three CNAs arrived for work. Staff 21 stated ADL tasks were not offered and documentation in resident medical records was not completed. On 1/9/25 at 2:45 PM Staff 20 (Scheduling Coordinator) stated she staffed CNAs based on the census and by the CNA mandatory minimum staffing ratios. Staff 20 confirmed, from 9/7/24 through 12/31/24, CNA staffing was short on many shifts. On 1/10/25 at 1:32 PM Staff 1 (Administrator) acknowledged the facility struggled to maintain adequate staffing levels and made efforts to meet the state minimum CNA requirements. Staff 1 stated he was unaware of residents not receiving scheduled showers due to short staffing. 3. Resident 6 was admitted to the facility in 2019 with diagnoses including fibromyalgia and diabetes. The 10/26/24 Quarterly MDS indicated Resident 6 was cognitively intact and required substantial assistance with showering. On 12/30/24 a public complaint was received by the State Agency which alleged the facility was short staffed CNAs on 12/24/24 and 12/26/24 resulting in residents not receiving showers. A review of the 12/2024 shower log revealed the resident "was not available" and did not receive a shower on 12/26/24, and the last shower received was on 12/22/24. A review of the 12/26/24 progress notes revealed Resident 6 was offered a shower by the CNA and refused. On 1/8/25 at 2:31 PM Witness 2 (Complainant) stated the facility was often understaffed, especially on evening shift. Witness 2 stated Resident 6 did not receive a scheduled shower on 12/26/24 due to short staffed CNAs. On 1/9/25 at 11:40 AM Staff 19 (CNA) stated they worked the evening shift on 12/26/24 and the facility was short staffed three CNAs. Staff 19 stated Resident 6's scheduled shower was not completed due to low staffing and the resident required two-person assistance. Staff 19 stated Resident 6 never refused a shower on 12/26/24. On 1/9/25 at 1:04 PM Resident 6 stated she/he did not receive a shower on 12/26/24 as the facility was short staffed CNAs so the shower was skipped. The resident stated that was a common occurrence. On 1/9/25 at 11:52 AM Staff 2 (Regional RN) confirmed Resident 6 did not receive a shower on 12/26/24. On 1/10/25 at 12:40 PM Staff 22 (RN) stated they worked the evening shift on 12/26/24 and recalled the facility was short staffed CNAs that shift. Staff 22 stated Resident 6 required two-person assistance with showering and that was difficult to complete when they are short staffed. On 1/10/25 at 1:33 PM Staff 1 (Administrator) stated he was unaware of residents not receiving scheduled showers due to short staffing. , 4. Resident 15 was admitted to the facility in 6/24/24 with diagnoses including urinary tract infection and diabetes. The 12/29/24 Quarterly MDS indicated Resident 15 was cognitively intact and required substantial assistance with showering. On 1/9/25 at 1:08 PM Resident 15 stated her/his shower days were on Tuesdays and Fridays and was unsure if she/he missed any showers. Resident 15's December 2024 shower log revealed the resident received a shower on 12/13/24, refused a shower on 12/17/24, and received showers on 12/20/24 and on 12/27/24. Resident 15 went seven days between showers for two weeks. On 1/10/25 at 11:32 AM Staff 16 (CNA) stated Resident 15 did not receive a shower due to staffing shortage. Staff 16 stated Resident 15 was scheduled for a shower on 12/24/24, however, due to staffing shortage, no scheduled showers were completed on that day. On 1/10/25 at 12:16 PM Staff 2 (Regional RN) stated it was her expectation that all showers were completed as scheduled. If a shower was refused or missed, it would be completed at the next shift or next day. Staff 2 confirmed Resident 15 received three showers in two weeks. , 5. Resident 10 admitted to the facility 2014 with a diagnosis of a stroke. Resident 10's 9/30/24 Annual MDS revealed a BIMS score of 15 (cognitively intact). A review of the updated 12/24/24 Facility Shower Schedule indicated showers were given to Resident 10 on Tuesdays and Fridays. A review of the Documentation Survey Report from 12/2024 revealed a shower were not provided to Resident 10 on 12/24/24. On 1/9/25 at 12:22 PM Staff 16 (CNA) stated they worked the evening shift on 12/24/24 with two other CNAs. Staff 16 stated with three CNAs during the evening and a census of 58 it was impossible to complete ADL tasks for the residents. Staff 16 stated during the evening shift on 12/24/24 showers were not provided to any residents. On 1/9/25 at 12:34 PM Staff 18 (CNA) stated during the evening shift on 12/24/24 showers were not provided to residents due to being understaffed. On 1/10/25 at 12:09 PM Staff 2 (Regional RN) acknowledged a shower was not provided to Resident 10 on 12/24/24. Staff 2 confirmed the expectation for the facility was to offer residents showers as scheduled and if the facility was short staffed the resident must be offered a shower the next day.

1. All residents in the facility are potentially affected. 2. The staffing coordinator and administrator or designee will audit staffing schedules 2 weeks in advance to determine staffing challenges and to ensure staffing needs are met. 3. Staffing Coordinator will be educated in regulations. Facility staff will be educated on regulations associated with calling off shifts and the impact on staffing ratios. Facility and staff will be educated of the expectation of meeting call light waiting times and ensuring all residents are showered as appropriate to their schedule. 4. The administrator /designee will audit staffing schedules with the staffing coordinator on Monday through Friday daily in stand-up to ensure staffing needs are met. HR/Benefits Coordinator will review productivity of recruitment with # of leads, interviews, new hires and all orientation activities associate to new hires Monday through Friday in stand-up for three weeks, then monthly for two months to ensure staff are adhering to the expected call light waiting times, shower schedules are being met and hiring of new staff to support staffing ratios. Discrepancies will be corrected immediately and brought to QAPI for Further evaluation. 5. Administrator or designee is responsible for ensuring correction.

Based on interview and record review it was determined the facility failed to ensure state minimum CNA staffing ratios were maintained for 39 of 116 sampled days reviewed for sufficient staffing. This placed residents at risk for delayed treatment and unmet care needs. Findings include: A review of the facility's Direct Care Staff Daily Reports from 9/7/24 through 12/31/24 revealed the facility did not meet mandatory minimum CNA ratios for one or more shifts on the following dates: -9/7/24: evening shift. -9/12/24: night shift. -9/17/24: day shift. -9/21/24: night shift. -9/24/24: evening shift. -9/28/24: night shift. -10/5/24: night shift. -10/6/24: day and night shift. -10/9/24: day shift. -10/10/24: evening shift. -10/13/24: day shift. -10/14/24: day shift. -10/19/24: day and night shift. -10/20/24: day and night shift. -10/23/24: day and evening shift. -10/26/24: night shift. -10/27/24: day and evening shift. -10/29/24: day and evening shift. -11/5/24: evening shift. -11/8/24: night shift. -11/11/24: day and evening shift. -11/17/24: day and evening shift. -11/18/24: evening shift. -11/21/24: evening shift. -11/23/24: evening shift. -11/24/24: evening and night shift. -11/25/24: day shift. -11/30/24: day shift. -12/1/24: evening shift. -12/18/24: evening shift. -12/19/24: evening shift. -12/21/24: night shift. -12/22/24: day shift. -12/24/24: day, evening, and night shift. -12/26/24: evening shift. -12/28/24: night shift. -12/29/24: day and evening shift. -12/30/24: day shift. -12/31/24: day and evening shift. On 1/9/25 at 2:45 PM Staff 20 (Scheduling Coordinator) stated she staffed CNAs based on the census and by the state's CNA mandatory minimum staffing ratios. Staff 20 reviewed the 9/7/24 through 12/31/24 Direct Care Staff Daily Reports and confirmed the facility did not meet CNA staffing ratios on the dates identified. On 1/10/25 at 1:32 PM Staff 1 (Administrator) acknowledged the facility struggled to maintain adequate staffing levels and indicated the facility made efforts to meet the minimum state minimum CNA requirements.

1. All residents in the facility are potentially affected. 2. The staffing coordinator and administrator or designee will audit staffing schedules 2 weeks in advance to determine staffing challenges and to ensure staffing needs are met. 3. Staffing Coordinator will be educated in regulations. Facility staff will be educated on regulations associated with calling off shifts and the impact to staffing ratios. Facility and staff will be educated of the expectation of meeting call light waiting times and provide two interventions in meeting the expected time frame. 4. The administrator /designee will audit staffing schedules with the staffing coordinator on Monday through Friday daily in stand-up to ensure staffing needs are met. HR/Benefits Coordinator will review productivity of recruitment with # of leads, interviews, new hires and all orientation activities associate to new hires Monday through Friday in stand-up for three weeks, then monthly for two months to ensure staff are adhering to the expected call light waiting times and hiring of new staff to support staffing ratios. Discrepancies will be corrected immediately and brought to QAPI for Further evaluation. 5. Administrator/designee is responsible for ensuring correction.

************************** OAR 411-086-0100: Nursing Services: Staffing Refer to F725 **************************

Based on observation, interview and record review it was determined the facility failed to accurately assess a resident's cognition for 1 of 1 sampled resident (#47) reviewed for communication. This placed residents at risk for unassessed needs. Findings include: Resident 47 was admitted to the facility in 11/2023 with diagnoses including dementia. Resident 47's 11/27/23 Admission MDS, 2/27/24 Quarterly MDS and 5/29/24 Quarterly MDS Assessments indicated the resident's preferred language was Vietnamese, and the resident needed or wanted an interpreter to communicate with a doctor or health care staff, was usually able to understand others and was usually able to make her/himself understood. Resident 47's 11/27/23 Admission MDS, 2/27/24 Quarterly MDS and 5/29/24 Quarterly MDS Assessments indicated a BIMS interview was not attempted with the resident as the resident was rarely/never understood. No evidence was found in Resident 47's clinical record to indicate an interpreter was utilized to help assess the resident's cognition during the 11/27/23 Admission MDS, 2/27/24 Quarterly MDS or 5/29/24 Quarterly MDS Assessments . On 7/17/24 at 11:31 AM Resident 47 was observed in her/his room in her/his wheelchair. With the assistance of a Vietnamese translator, Resident 47 stated she/he felt as if no one at the facility understood her/him. On 7/17/24 at 12:24 PM Staff 25 (Social Services Director) stated when she evaluated Resident 47's cognition, she completed a staff assessment instead of using a translator with the resident. On 7/17/23 at 12:36 PM Staff 23 stated he was unaware of Resident 47's preference for an interpreter when communicating with health care staff. Staff 23 confirmed he completed all MDS interviews with the resident in English and without an interpreter. On 7/17/24 at 4:40 PM Staff 2 (DNS) acknowledged the findings and stated she expected staff to utilize a translator during all interactions with Resident 47, especially when completing interviews required for the MDS.

1. How will the nursing home correct the deficiency as it relates to the resident? Resident #47 will be re-evaluated using an interpreter service and revise the MDS with the new MDS assessment data. 2. How the nursing home will act to protect residents and staff in similar situations. The DNS/designee will audit residents in the facility for communication language deficit and identify interpreter needs. Discrepancies found will be immediately corrected 3. Measures the nursing home will take or systems it will alter to ensure that the problem does not occur. Facility Staff will be educated on Interpreter Services, how to arrange these services, identify devices used for interpreter services, and the importance of communicating with interpreter services in the medical field. 4. How the nursing home plans to monitor performance to make sure that solutions are sustained? The DNS/designee and Admission Coordinator will audit new admissions for interpreter needs prior to admission Monday through Friday. Discrepancies found will be immediately corrected and brought to QAPI for further evaluation. 5. Name and Title of the person responsible to ensure correction. DNS/Designee

Based on interview and record review it was determined the facility failed to ensure a Level I PASARR (Preadmission Screening for Individuals with a Mental Disorder and Individuals with Intellectual Disability) was completed for 1 of 1 sampled resident (#45) reviewed for PASARR. This placed residents at risk for inappropriate placement in a nursing facility and a lack of needed services. Findings include: Resident 45 was admitted to the facility in 6/2023 with diagnoses including stroke and schizophrenia (a mental disorder). A review of the resident's electronic health record revealed no evidence Resident 45 had a screening Level I PASARR completed prior to admission. On 7/17/24 at 11:13 AM Staff 11 (Medical Records) and Staff 1 (Administrator) confirmed they were unable to locate a screening Level 1 PASARR for Resident 45.

1. How will the nursing home correct the deficiency as it relates to the resident? Resident #45’s PASARR Level 1 will be re-initiated. 2. How the nursing home will act to protect residents and staff in similar situations. Social Services/designee will audit residents in the facility for PASARR Level 1s, ensuring accuracy. If the PASARR Level 1 is inaccurate a new PASARR will be initiated and reviewed for PASARR Level 2 evaluation. Discrepancies found will be immediately corrected. 3. Measures the nursing home will take or systems it will alter to ensure that the problem does not occur. Social Services Director and Assistant, Admissions Coordinator, and DNS will be educated on the PASARR Process. 4. How the nursing home plans to monitor performance to make sure that solutions are sustained? The Social Services Director/designee will audit new admissions for PASARR Level 1s and accuracy Monday through Friday x3 weeks, then weekly x3 weeks, then monthly x2 months. Discrepancies identified will be immediately corrected and brought to QAPI for further evaluation. 5. Name and Title of the person responsible to ensure correction. Social Services Director/designee

Based on observation, interview and record review it was determined the facility failed to implement care plan interventions in the area of dining and nutrition for 1 of 2 sampled residents (#10) reviewed for nutrition. This placed residents at risk for unmet nutritional needs. Findings include: Resident 10 was admitted to the facility in 12/2016 with diagnoses including dysphagia (difficulty swallowing). Resident 10's 5/2/24 Annual MDS revealed the resident experienced short-and-long-term memory loss, was moderately impaired for decision making, required supervision or touching assistance with eating and was edentulous (without teeth). Resident 10's 5/16/24 Nutrition at Risk Care Plan indicated staff were to ensure the resident was in an upright position of 75 to 90 degrees during meals as the resident was considered at risk to aspirate. On 7/15/24 at 11:53 AM Resident 10 was observed to eat in bed. The resident's head-of-bed was elevated to approximately 45 degrees. On 7/17/24 at 8:07 PM Staff 10 (CNA) and at 8:27 PM Staff 19 (CNA) stated they were unsure of any positioning interventions or requirements at mealtimes for Resident 10. On 7/18/24 at 11:57 AM Resident 10 was observed to eat in bed. The resident's head-of-bed was elevated to approximately 45 degrees. Resident 10 was observed to hold her/his plate in her/his lap and food spilled from the resident's utensil as she/he attempted to eat. At 12:16 PM Staff 2 (DNS) and Staff 21 (Resident Care Coordinator) observed Resident 10 in bed with her/his meal tray. Staff 21 stated Resident 10 was supposed to be in an upright position at mealtimes. Staff 2 stated the resident's head-of-bed was between 30 to 40 degrees which was not considered an upright position.

How will the nursing home correct the deficiency as it relates to the resident? Resident 10 will be educated on the importance of sitting upright, 75 to 90 degrees when eating to decrease aspiration and provided with a risk vs. benefits indicating pros and cons of sitting up 75-90 degrees for meals. 2. How the nursing home will act to protect residents and staff in similar situations. DNS/designee will audit residents at risk for aspiration to ensure that care plans/Kardex’s indicate resident positioning during meals. Discrepancies identified will be corrected immediately. 3. Measures the nursing home will take or systems it will alter to ensure that the problem does not occur: Facility staff will be educated on resident positioning during meals for residents identified as having aspiration precautions and complications associated with aspiration. 4. How the nursing home plans to monitor performance to make sure that solutions are sustained? The DNS/designee will audit residents on aspiration precautions for proper positioning during meals Monday through Friday x 2 weeks then weekly x 2 weeks then monthly x 2 months. Discrepancies found will be immediately corrected and brought to QAPI for further evaluation. 5. Name and Title of the person responsible to ensure correction: DNS/Designee

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 2 of 7 sampled residents (#s 45 and 48) reviewed for ADLs and falls. This placed residents at risk for unmet needs. Findings include: 1. Resident 45 was admitted to the facility in 6/2023 with diagnoses including stroke and schizophrenia (a mental disorder). Resident 45's 6/14/24 Annual MDS indicated the resident required supervision or touch assistance for eating. Resident 45's current Care Plan indicated Resident 45 required one person assistance for eating. Observations from 7/15/24 through 7/18/24 between the hours of 8:00 AM to 4:30 PM revealed Resident 45 ate her/his meals without assistance. On 7/17/24 at 7:43 AM, 7:48 AM and 8:05 AM Staff 9 (CNA), Staff 10 (CNA) and Staff 16 (CNA) reported Resident 45 ate her/his meals without assistance. Staff 9 stated staff set-up Resident 45's tray and then the resident was independent with eating. On 7/19/24 at 8:43 AM Staff 3 (LPN-Care Manager) stated Resident 45 was independent with eating and no longer required one person assistance. Staff 3 stated she expected the care plan to accurately reflect the resident's current level of functioning. 2. Resident 48 was admitted to the facility in 6/2024 with diagnoses including osteomyelitis (inflammation or swelling in the bone caused by an infection) and muscle weakness. A 6/24/24 Fall Investigation indicated Resident 48 required bilateral mobility bars on her/his bed to aid in bed mobility and provide tactile reminders as to where the edge of the bed was in order to prevent Resident 48 from rolling out of bed. A 6/25/24 Physician Order indicated Resident 48 required bilateral mobility bars for bed mobility. A 6/25/24 Safety Device Assessment and Consent indicated Resident 48 consented to have bilateral mobility bars on her/his bed. Resident 48's 6/17/24 Bed Mobility Care Plan indicated Resident 48 assisted staff with turning herself/himself in bed. Resident 48's Fall Care Plan indicated the resident required one person assistance with transfers. There were no care plan interventions reflective of Resident 48's use of bilateral mobility bars to aid in bed mobility or provide reminders as to where the edge of the bed was in order to prevent the resident from rolling out of bed. Observations from 7/15/24 through 7/17/24 between the hours of 8:35 AM to 8:27 PM revealed Resident 45 had mobility bars on her/his bed. On 7/18/24 at 11:09 AM Staff 2 (DNS) confirmed Resident 48's care plan was not revised to reflect the resident's use of bilateral mobility bars and she expected the care plan to accurately reflect the resident's current bed mobility and fall prevention interventions.

How will the nursing home correct the deficiency as it relates to the resident? Resident 45 care plan will be reviewed and updated with current level of supervision for dining. Resident 48 Care plan revised to reflect the use of bilateral mobility bars. 2. How the nursing home will act to protect residents and staff in similar situations. The DNS/Designee will audit care plans and orders of residents in the facility that use mobility bars and for supervision needs with dining. Discrepancies found will be immediately corrected. 3. Measures the nursing home will take or systems it will alter to ensure that the problem does not occur. Facility staff will be educated in the process of placing mobility bars for residents to include orders, Safety device information and consent, TELs updated, and care plan updated with proper interventions. 4. How the nursing home plans to monitor performance to make sure that solutions are sustained? The DNS/designee will audit newly admitted residents who have orders for mobility bars and level of supervision for dining Monday through Friday x3 weeks, then weekly x3 weeks then monthly x2 months. Discrepancies identified will be immediately corrected and brought to QAPI for further evaluation. 5. Name and Title of the person responsible to ensure correction: DNS/Designee

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 1 sampled resident (#47) 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 47 was admitted to the facility in 11/2023 with diagnoses including dementia. Resident 47's 11/27/23 Admission MDS, 2/27/24 Quarterly MDS and 5/29/24 Quarterly MDS Assessments indicated the resident's preferred language was Vietnamese, and the resident needed or wanted an interpreter to communicate with a doctor or health care staff, was usually able to understand others and was usually able to make her/himself understood. Resident 47's 4/11/24 Communication Care Plan indicated the following: -Arrange translator for Vietnamese as necessary to communicate with the resident. -Use the iPad (a small touchscreen computer) at the nurse's station to log in and indicate the language needed. Resident 47's 6/4/24 Comprehensive Plan of Care Review indicated the resident was able to understand very simple instructions and responded at times. On 7/15/24 at 1:09 PM Staff 26 (CNA) stated the facility did not have a translation service available to use with Resident 47. Staff 26 further stated staff asked Resident 47 yes or no questions and the resident usually said yes to everything. On 7/15/24 at 1:13 PM Witness 6 (Family Member) stated Resident 47's native language was Vietnamese and the resident spoke and understood limited English. Witness 6 stated the resident was able to communicate only her/his basic needs in English. On 7/17/24 at 10:19 AM Staff 14 (CNA) stated she thought Resident 47's native language was Taiwanese and did not know if the facility had a translation service available to use when interacting with the resident. Staff 14 stated Resident 47 said "yes to everything" and there were "things [she/he] did not understand." Staff 14 stated she was unaware of the resident's interests and preferences, and "since [she/he] got here, it is just room to dining room for meals and back to [her/his] room." On 7/17/24 at 10:45 AM Staff 20 (CNA) stated she never utilized a translation service when interacting with Resident 47. Staff 20 stated Resident 47 was only able to say excuse me, yes, no and "usually said nothing." On 7/17/24 at 11:00 AM Staff 27 (CNA) stated she had trouble communicating with Resident 47 because she did not speak Cantonese. On 7/17/24 at 11:31 AM with the assistance of a Vietnamese translator, Resident 47 stated she/he felt as if no one at the facility understood her/him. Resident 47 further stated no one at the facility had ever asked her/him about her/his likes, interests or preferences. On 7/17/24 at 12:24 PM Staff 25 (Social Services Director) stated she did regular "check-ins" with Resident 47 in English. Staff 25 stated Resident 47 did not respond appropriately at times or respond at all due to her/his dementia and confirmed her interactions with the resident were exclusively in English. On 7/17/24 at 4:40 PM Staff 2 (DNS) stated she expected staff to utilize the translation service on the iPad "all the time" when interacting with Resident 47 and acknowledged the resident's communication care plan was unclear.

How will the nursing home correct the deficiency as it relates to the resident? Resident 47 MDS will be re-evaluated using an interpreter service and care plan revised. 2. How the nursing home will act to protect residents and staff in similar situations. The Admissions Coordinator will audit for the need of interpreter services upon acceptance of new residents and coordinate with Social Services for translator services. Discrepancies found will be immediately corrected. 3. Measures the nursing home will take or systems it will alter to ensure that the problem does not occur: Facility staff will be educated on the use of interpreter services available for the residents utilizing an iPad or telephone. 4. How the nursing home plans to monitor performance to make sure that solutions are sustained? The DNS/designee, Admissions Director and Social Services will audit the need for interpreter services Monday through Friday. Discrepancies found will be immediately corrected and brought to QAPI for further evaluation. 5. Name and Title of the person responsible to ensure correction: Admissions Coordinator, Social Services, DNS/ Designee

Based on observation, interview and record review it was determined the facility failed to ensure dependent residents received required assistance with ADLs for 2 of 5 sampled residents (#s 19 and 28) reviewed for ADLs. This placed residents at risk for unmet ADL needs and loss of dignity. Findings include: Resident 19 was admitted to the facility in 1/2017 with diagnoses including respiratory failure with hypoxia (when the respiratory system can not provide adequate oxygen to the body) and major depressive disorder. Observations from 7/15/24 through 7/17/24 between the hours of 8:12 AM and 2:39 PM revealed Resident 19 had numerous hairs, approximately 1/2 inch long, on her/his upper lip and lower portion of her/his chin. Resident 19's 5/16/24 Quarterly MDS indicated the resident had severe cognitive impairment and required substantial to maximal assistance from staff for personal hygiene care which included shaving. On 7/16/24 At 2:39 PM Resident 19 indicated she/he did not like hair on her/his upper lip and chin and she/he wanted the hair removed. On 7/17/24 at 8:13 AM Staff 14 (CNA) stated she had never been instructed to remove Resident 19's facial hair and she did not shave the resident's upper lip or chin hair. On 7/17/24 at 12:36 PM Staff 13 (LPN) confirmed Resident 9 had facial hair on her/his upper lip and lower portion of the chin. Staff 13 stated CNA staff would shave a resident's facial hair if the resident agreed. Resident 19 indicated to Staff 13 that she/he wanted her/his facial hair removed. On 7/18/24 at 8:57 AM Staff 2 (DNS) stated she expected staff to offer Resident 19 the opportunity to have her/his face shaved and to shave the resident if she/he agreed. , 2. Resident 28 was admitted to the facility in 2/2019 with diagnoses including obesity and polyneuropathy (damage to nerves in extremities resulting in weakness, numbness and/or pain). A 5/8/24 cognitive assessment indicated Resident 28 had normal cognitive function. A 5/10/24 Care Plan indicated Resident 28 required assistance from two staff members with bed baths. Review of bathing records from 3/2024 through 7/2024 indicated Resident 28 was to receive bed baths twice a week. During this period, Resident 28 was documented to have refused bed baths on the following dates: - 3/7/24, - 3/11/24, - 4/4/24, - 4/7/24, - 4/28/24, - 5/12/24, - 5/26/24, - 6/16/24 and - 6/23/24. On 7/18/24 at 10:27 AM Staff 12 (CNA) stated multiple residents especially those who required assistance from two member did not receive showers or bed baths during 3/2024 and 4/2024 due to staffing shortages. On 7/19/24 at 9:51 AM Resident 28 stated she/he had refused only two bed baths since she/he was admitted. Resident stated she/he had been told by CNAs a bed bath could not be provided during 3/2024 and 4/2024 because only one staff member was available. On 7/19/24 at 12:18 PM Staff 2 (DNS) confirmed missed showers/bed baths were determined to a problem, potentially due to CNA staffing levels, but was unable to determine if this issued had been resolved. Refer to F725 and M183.

How will the nursing home correct the deficiency as it relates to the resident? Resident 19’s Care plan has been updated to reflect the wishes of the resident to have her facial hair shaved. Resident 28’s care plan will be updated to ensure that resident preferences are being implemented on the care plan. 2. How the nursing home will act to protect residents and staff in similar situations. DNS/designee will audit Resident grooming and bathing records for the last 14 days to ensure ADL cares have been completed. Discrepancies found will be corrected immediately. 3. Measures the nursing home will take or systems it will alter to ensure that the problem does not occur: Nursing staff will be educated on ADL care principles, individualized resident needs, dignity and respect. 4. How the nursing home plans to monitor performance to make sure that solutions are sustained? DNS/Designee will audit 5 random residents for grooming and bathing weekly x 3 weeks, then monthly x 2 months. Discrepancies will be corrected immediately and brought to QAPI for further evaluation. 5. Name and Title of the person responsible to ensure correction: DNS/Designee

Based on observation, interview and record review it was determined the facility failed to provide an ongoing person-centered activity program for 3 of 3 sampled dependent residents (#s 9, 24 and 47) reviewed for activities. This placed residents at risk of a decline in psychosocial well-being and diminished quality of life. Findings include: The facility's 2/2005 Activities Policy revealed the facility was to encourage each resident to maintain normal leisure activity. The facility would provide an activities program that addressed the intellectual, social, spiritual, creative and physical needs, capabilities and interests of each resident. The activity program would promote each resident's self-respect by providing activities that supported self-expression and choice. 1. Resident 9 was admitted to the facility in 5/2021 with diagnoses including major depressive disorder and dementia. Resident 9's 6/11/21 and revised 11/16/21 Activities Care Plan indicated the following: -Resident 9 liked music, pet therapy, visiting with the chaplain, gardening, flowers and birds. -Resident 9 was to have one-on-one bedside visits and activities to include music, animal visits, bird watching discussions, manicures, hand massages and assistance looking through magazines. -Resident 9 was Christian and the Activities Department was to provide gospel music and set-up Chaplain visits as needed. Resident 9's 6/24/24 Significant Change MDS revealed the resident had severe cognitive impairments. Her/his activity preferences indicated it was somewhat or very important to have books, newspapers and magazines to read, do favorite activities, participate in religious services and practices and be around animals. Resident 9's 6/16/24 through 7/16/24 Group Activity Task Log and One-On-One Activity Task Log contained no data regarding activity participation. A review of Resident 9's electronic health record contained no evidence the resident participated in any activities. The facility's 7/2024 Activity Calendar revealed the following scheduled activities: Monday, 7/15/24: -8:30 AM Morning Room Rounds -11:00 AM Large Group: Exercises -1:00 PM Birdhouse Building & Painting -3:00 PM Afternoon Rounds & Mail -6:00 PM Independent Activities (CNA led) Tuesday, 7/16/24: -8:30 AM Morning Room Rounds -11:30 AM Resident Shopping -1:00 PM Gardening Club -3:00 PM Afternoon Rounds & Mail -6:00 PM Featured Movie (CNA led) Wednesday, 7/17/24: -8:30 AM Morning Room Rounds -11:00 AM Large Group: Exercises -1:00 PM Resident Council -3:00 PM Afternoon Rounds & Mail -6:00 PM Independent Activities (CNA led) Observations from 7/15/24 through 7/18/24 between the hours of 8:00 AM and 7:30 PM revealed Resident 9 was in her/his room, typically with the blinds closed and the lights low, and was not engaged in any activities. No magazines, books or newspapers were observed; no music was playing and no one-on-one activities took place. On 7/16/24 at 2:30 PM Resident 9 stated she/he liked to play bingo and "the balls." Resident 9 stated she/he loved to read "anything I can get my hands on." On 7/17/24 at 7:40 AM Staff 9 (CNA) stated Resident 9 rarely got up out of bed. She stated she had not seen any activities occurring in Resident 9's room and she was not aware of any one-on-one activities being done in residents' rooms, just group activities being conducted in the dining room. On 7/17/24 at 8:16 AM Staff 14 (CNA) stated she had never seen Resident 9 engaged in any one-on-one activities in the resident's room. On 7/18/24 at 8:33 AM Staff 6 (Activities Director) stated she was the only person in the activities department and she was responsible for completing all of the care conferences, Activity MDS Assessments, Activity Admission Profiles, shopping for the residents, delivering mail, engaging residents in group and one-on-one person-centered activities; as well as assisting with many resident requests. She stated there was no one to provide activities on the weekends. Staff 6 was unable to provide dates or times of any specific activities completed with Resident 9 and confirmed no activities documentation was completed. On 7/19/24 at 9:40 AM Staff 1 (Administrator) stated his expectation was all residents received activities according to their person-centered care plan and he needed to "work on" getting additional help in the activities department. 2. Resident 24 was admitted to the facility in 10/2023 with diagnoses including dementia. Resident 24's 10/30/23 Activity Profile indicated the resident spoke Farsi/Arabic and required a translator. Resident 24's 11/8/23 and revised 11/16/23 Activities Care Plan indicated the following: -Resident 24 liked visits from her/his spouse, eating ice cream and other comfort foods, watching television and reading. -Resident 24 was to have twice weekly social visits for special updates on activities and assistance with self-directed activities. Resident 24's 4/30/24 Significant Change MDS revealed the resident had short and long term memory deficits. Her/his activity preferences indicated it was somewhat or very important to listen to music, be around animals, go outside to get fresh air when the weather was good, do things with groups of people, do favorite activities and participate in religious services or practices. Resident 24's 6/16/24 through 7/16/24 Group Activity Task Log and One-On-One Activity Task Log contained no data regarding activity participation. A review of Resident 24's electronic health record revealed no evidence the resident participated in any activities. The facility's 7/2024 Activity Calendar revealed the following scheduled activities: Monday, 7/15/24: -8:30 AM Morning Room Rounds -11:00 AM Large Group: Exercises -1:00 PM Birdhouse Building & Painting -3:00 PM Afternoon Rounds & Mail -6:00 PM Independent Activities (CNA led) Tuesday, 7/16/24: -8:30 AM Morning Room Rounds -11:30 AM Resident Shopping -1:00 PM Gardening Club -3:00 PM Afternoon Rounds & Mail -6:00 PM Featured Movie (CNA led) Wednesday, 7/17/24: -8:30 AM Morning Room Rounds -11:00 AM Large Group: Exercises -1:00 PM Resident Council -3:00 PM Afternoon Rounds & Mail -6:00 PM Independent Activities (CNA led) Observations from 7/15/24 through 7/18/24 between the hours of 8:00 AM and 8:00 PM revealed the resident was in her/his room with no music, books or materials to complete self-directed activities. Resident 24 was typically awake in bed with her/his television on without sound and closed captioning (text that reflects an audio track that can be read while watching visual content) on in English. On one occasion in the evening, Resident 24 was observed up in her/his wheelchair in a lobby area, placed in front of a television being broadcast in English, with four other residents. No one-on-one activities were observed during any observations. On 7/17/24 at 9:53 AM Staff 4 (CNA) stated she tried to get an I-Pad for Resident 24 to watch television on because her/his room television did not have Arabic channels but she was not successful getting an I-Pad. Staff 4 stated she had not seen any one-on-one activities occurring with Resident 24 and the resident "just sits" in her/his room unless her/his spouse comes to visit. On 7/18/24 at 8:33 AM Staff 6 (Activities Director) stated she was the only person in the activities department and she was responsible for completing all of the care conferences, Activity MDS Assessments, Activity Admission Profiles, shopping for the residents, delivering mail, engaging residents in group and one-on-one person-centered activities; as well as assisting with many resident requests. She stated there was no one to provide activities on the weekends. Staff 6 was unable to provide dates or times of any specific activities completed with Resident 24 and confirmed no activities documentation was completed. On 7/19/24 at 9:40 AM Staff 1 (Administrator) stated his expectation was all residents received activities according to their person-centered care plan and he needed to "work on" getting additional help in the activities department. , 3. Resident 47 was admitted to the facility in 11/2023 with diagnoses including dementia. Resident 47's 11/23/23 Activity Profile indicated the resident spoke Vietnamese and was unable to communicate or answer questions in English. Resident 47's 11/27/23 Admission MDS indicated the resident experienced short-and-long-term memory loss and identified the following as activity preferences for the resident: -Reading books, newspapers or magazines; -Listening to music; -Being around animals such as pets; -Keeping up with the news; -Doing things with groups of people; -Participating in favorite activities; and -Spending time outdoors. Resident 47's 2/27/24 Social Determinants of Health Form indicated the resident spoke Vietnamese, she/he needed or wanted an interpreter to communicate with a doctor or health care staff and she/he "sometimes" felt lonely or isolated from those around her/him. Resident 47's 3/17/24 Activity Care Plan revealed the following: -The resident's activity goal was to attend/participate in activities of choice two-to-three times per week. -The resident was dependent upon staff for activities. -The resident's activity interests included passively participating in large group activities, watching television, one-to-one conversation and chair exercises. -One-to-one in-room activities were needed if the resident was unable to attend out of room events. -The resident required an escort to activity functions. A review of Resident 47's 6/17/24 through 7/15/24 activity participation records revealed no evidence the resident participated in a group, one-to-one or self-directed activity during this timeframe. The facility's 7/2024 Activity Calendar revealed the following scheduled activities: Monday, 7/15/24: -8:30 AM Morning Room Rounds -11:00 AM Large Group: Exercises -1:00 PM Birdhouse Building & Painting -3:00 PM Afternoon Rounds & Mail -6:00 PM Independent Activities (CNA led) Tuesday, 7/16/24: -8:30 AM Morning Room Rounds -11:30 AM Resident Shopping -1:00 PM Gardening Club -3:00 PM Afternoon Rounds & Mail -6:00 PM Featured Movie (CNA led) Wednesday, 7/17/24: -8:30 AM Morning Room Rounds -11:00 AM Large Group: Exercises -1:00 PM Resident Council -3:00 PM Afternoon Rounds & Mail -6:00 PM Independent Activities (CNA led) Observations of Resident 47 conducted from 7/15/24 to 7/17/24 between 9:41 AM through 4:28 PM revealed the resident to be in bed in her/his room or in her/his wheelchair in her/his room or in the dining room. The resident's eyes were observed to be closed during each observation. When the resident was observed in her/his room, no television or music played and no books, magazines or newspapers were observed. Resident 47's roommate's television could be heard from the hallway and the content was in English. When the resident was observed in the dining room, the television was on and content played in English. On 7/15/24 at 1:04 PM, 7/17/24 at 9:41 AM and 7/17/24 at 11:31 AM the resident verbally responded to the surveyor's greeting with her/his eyes closed. On 7/15/24 at 1:13 PM Witness 6 (Family Member) stated Resident 47's native language was Vietnamese and the resident spoke and understood limited English. Witness 6 stated the resident was able to communicate only her/his basic needs in English. On 7/17/24 at 10:19 AM Staff 14 (CNA) stated she was unaware of any activity interests for Resident 47. Staff 14 stated since the resident came to the facility, "it was just room to dining room for meals and back to [her/his] room to lay down." Staff 14 further stated the resident never participated in group activities, went outside, had the television or music on in her/his room or had books, newspapers or magazines available to read. On 7/17/24 at 10:45 AM Staff 20 (CNA) stated Resident 47 spent all of her/his time either sleeping or eating. Staff 20 stated the resident did not participate in group activities or go outside. Staff 20 further stated she had never seen the resident with books, newspapers or magazines. On 7/17/24 at 11:00 AM Staff 27 (CNA) stated she thought Resident 47 enjoyed listening to music and watching television but it was difficult for her/him to do either in her/his room because the resident's roommate's television was "really loud." Staff 27 stated Resident 47 did not open her/his eyes often. On 7/17/24 at 11:17 AM a group of residents was observed in the facility's dining room and participated in an exercise activity with a ball and parachute. Resident 47 was observed at this time in her/his room in bed with the lights and television off. On 7/17/24 at 11:31 AM Resident 47 was observed in her/his room and sat in her/his wheelchair with her/his eyes closed. The State Surveyor, with the assistance of a Vietnamese translator attempted an interview at this time. As soon as the resident heard the translator speak in Vietnamese, the resident pulled opened her/his eyelids with her/his hand and verbally engaged in the interview. Resident 47 stated "I don't do anything here." Resident 47 stated she/he would "love to" participate in group activities and go outside when the weather was nice but no one offered these activities. Resident 47 further stated she/he enjoyed reading, songs, exercise and pets but no one at the facility had ever asked her/him about her/his likes and preferences. On 7/17/24 at 4:09 PM Staff 6 (Activity Director) stated she did not attempt the Preferences for Customary Routine and Activities interview required at the time of Resident 47's 11/27/23 Admission MDS Assessment with the resident because she was informed the resident did not speak English, so she interviewed Witness 6 instead. Staff 6 stated she typically added the resident activity preferences and interests she learned from this interview to the resident's care plan and stated Resident 47's activity care plan needed to be updated. Staff 6 stated she completed one-to-one visits with Resident 47 during mealtimes when she would primarily ask the resident in English about her/his meal. Staff 6 stated she did not use a translator during her interactions with Resident 47. Staff 6 stated she documented resident activity participation in each resident's clinical record which included any refusals and if the resident was sleeping. Staff 6 acknowledged Resident 47 did not have any activities, refusals or instances of sleeping documented from 6/17/24 to 7/15/24 and stated she "sometimes did not get to charting at the end of the day." Staff 6 stated CNAs were responsible to turn on Resident 47's television when she/he was in her/his room and the resident watched television with English programming when in the dining room. Staff 6 further stated she did not invite Resident 47 to the group exercise activity this morning because the resident's eyes were closed and she did not like to bother residents if they were sleeping. On 7/17/24 at 4:40 PM Staff 2 (DNS) stated she expected resident activity participation to be documented daily and staff to utilize a translation service when interacting with Resident 47. Staff 2 further stated she expected books, newspapers and magazines to be provided to Resident 47, television and music to be available to Resident 47 and one-to-one visits to be offered to Resident 47 daily, all in Vietnamese.

1.How will the nursing home correct the deficiency as it relates to the resident? Resident # 24 is no longer in facility. Resident # 9 Care plan will be reviewed and updated with the resident's current likes and dislikes. Resident #47 Care plan will be reviewed and updated with current activities he enjoys. 2.How the nursing home will act to protect residents and staff in similar situations. Activities Director/designee will audit residents for communication, cognition, and mobility difference and implement activities appropriate in order to meet individual needs. 3. Measures the nursing home will take or systems it will alter to ensure that the problem does not occur: Facility staff will be educated on how to engage residents in activities that have communication, cognition and mobility differences. 4.How the nursing home plans to monitor performance to make sure that solutions are sustained? Activities Director/designee will audit new admits Monday through Friday to ensure activities meet resident needs and care plan is in place that identify resident needs. 5.Name and Title of the person responsible to ensure correction: Activities Director/Designee

Based on interview and record review it was determined the facility failed to ensure physician orders were followed for 1 of 5 sampled residents (#24) reviewed for unnecessary medications. This placed residents at risk for adverse medication consequences. Findings include: Resident 24 was admitted to the facility in 10/2023 with diagnoses including dementia A 12/7/23 Physician Order indicated Resident 24 was prescribed a lidocaine 4% pain patch to be applied to the resident's lower back, one patch once daily. The lidocaine 4% pain patch was to be on for 12 hours and off for 12 hours. A review of Resident 24's 7/1/24 through 7/31/24 MAR indicated the resident's lidocaine 4% pain patch was not administered according to the physician orders on the following days: -7/6/24, 7/8/24, 7/9/24 and 7/10/24. On 7/18/24 at 12:17 PM Staff 7 (CMA) stated there were no lidocaine 4% pain patches available in the facility on 7/10/24, so she was unable to provide Resident 24 with her/his lidocaine pain patch. On 7/18/24 at 12:27 PM Staff 8 (Maintenance Director) stated he was responsible for ordering Resident 24's lidocaine 4 % pain patches and the pain patches were not ordered timely because ordering supplies was a new task for him and he was unsure how the ordering system worked. On 7/19/24 at 10:23 AM Staff 1 (Administrator) stated Staff 8 took over the responsibility of ordering supplies on 7/1/24 so he was not familiar enough with the supply ordering process but "that should never happen."

How will the nursing home correct the deficiency as it relates to the resident? Resident #24 is no longer in the facility. 2. How the nursing home will act to protect residents and staff in similar situations. DNS/Designee will audit Central Supply using a PAR list to ensure adequate supplies are available. Discrepancies found will be corrected immediately. 3. Measures the nursing home will take or systems it will alter to ensure that the problem does not occur: Nursing staff will be educated on a sufficient number of supplies available, keeping par levels and when to order timely. 4. How the nursing home plans to monitor performance to make sure that solutions are sustained? DNS/Designee will audit OTC supply room using a PAR list and start order process as needed 2x weekly for 3 weeks, then weekly for 3 weeks, then monthly x2 months. Discrepancies will be corrected immediately and brought to QAPI to further evaluation. 5. Name and Title of the person responsible to ensure correction: Maintenance/DNS/Designee

Based on observation, interview and record review it was determined the facility failed to ensure residents with limited range of motion and/or mobility received restorative services and equipment to prevent a further decrease in range of motion for 2 of 4 sampled residents (#s 10 and 25) reviewed for position/mobility and rehab/restorative. This placed residents at risk for worsening contractures and physical decline. Findings include: 1. Resident 10 was admitted to the facility in 12/2016 with diagnoses including hemiplegia (complete paralysis on one side of the body) and hemiparesis (partial weakness on one side of the body) following a stroke. Resident 10's 5/2/24 Annual MDS revealed the resident experienced short-and-long-term memory loss, upper and lower extremity impairment on one side of her/his body and did not utilize splint or brace assistance. Resident 10's 7/2024 Physician Orders directed the resident to wear a right hand splint as tolerated. Observations conducted from 7/15/24 to 7/18/24 between 7:42 AM through 8:19 PM revealed Resident 10 to be in her/his wheelchair or bed. The resident's right hand was in a fist and the resident did not wear a splint. On 7/16/24 at 3:12 PM Resident 10 was able to partially open the four fingers on her/his right hand with visual prompting but was unable to answer any questions regarding her/his hand, a splint or pain. On 7/17/24 at 8:07 PM Staff 10 (CNA), on 7/17/24 at 8:27 PM Staff 19 (CNA) and on 7/18/24 at 12:02 PM Staff 20 (CNA) stated they had never seen Resident 10 wear a brace and did not know she/he had one. No evidence was found in Resident 10's clinical record to indicate the resident's upper extremity impairment was comprehensively assessed, ongoing monitoring of her/his upper extremity impairment was being provided, a care plan was developed to address the resident's upper extremity impairment or the right hand splint was available and offered to the resident. On 7/18/24 at 12:39 PM Staff 2 (DNS) and Staff 21 (Resident Care Coordinator) acknowledged the findings of this investigation. Staff 2 stated assessments and on-going monitoring of Resident 10's right hand contracture were not completed and she was unsure if the resident's hand splint was even appropriate. , 2. Resident 25 admitted to the facility in 10/2022 with diagnoses including history of falls, and stroke with hemiplegia and hemiparesis (paralysis and weakness of one side of the body). The quarterly MDS, dated 5/30/24, showed a BIMS score of 15 which indicated she/he was cognitively intact, and required minimal assistance from one staff for eating and oral/personal hygiene, maximal assistance from one to two staff for ADLs/cares, and she/he was dependent on one to two staff for wheelchair mobility and transfers. The resident's care plan, updated 4/6/23, revealed that she/he was at moderate risk for falls and needed a restorative care program to prevent decline in level of function. Interventions were updated on 6/6/24 to include a detailed ROM plan with monthly reviews. On 7/15/24 at 1:11PM Resident 25 demonstrated her/his ability to move arms effectively, and inability to move their legs effectively. Resident 25 stated they were supposed to receive restorative therapy three times a week, she/he received restorative therapy once a week on average, and during care conference on 6/13/24 a restorative therapy plan was discussed with her/him and their responsible party. Review of 5/2/24 restorative therapy program referral for Resident 25 noted ROM and balance exercises, with interventions for upper and lower body, to be conducted in sessions three to five times per week. A care conference note on 6/13/24 indicated Resident 25 was encouraged to work with restorative therapy daily for four weeks prior to a resident requested physical therapy evaluation. Review of RA documentation for Resident 25 from 6/15/24 to 7/16/24 indicated nine therapy sessions and one resident refusal out of 13 to 22 ordered sessions. There was no documentation to indicate Resident 25 experienced a decline in functional abilities. On 7/17/24 at 8:55 AM Staff 15 (CNA/RA) stated RA staff had a restorative therapy plan for Resident 25 averaging three days per week, and Resident 25 had shown increased willingness to do work and participate. She stated RA staff had been pulled to the floor to work as CNA staff frequently this summer. On 7/17/24 at 2:13 PM Staff 23 (MDS Coordinator) stated he implemented and monitored restorative therapy, and three sessions per week was a standard schedule. He stated if restorative therapy staff were pulled to the floor as CNA staff, the restorative therapy team attempted make up sessions with residents. He stated some missed days could not be made up, and he prioritized sessions for residents with multiple missed sessions. On 7/19/24 at 1:42 PM findings were discussed with Staff 2 (DNS), and no additional information was provided.

1.How will the nursing home correct the deficiency as it relates to the resident? Resident 10 will be re-evaluated for use of hand splint by Physical Therapy and care plan updated to reflect current needs. Resident 25 will be re-evaluated by Physical Therapy for decrease in ROM/mobility in hands and provide recommendations if warranted. 2. How the nursing home will act to protect residents and staff in similar situations. MDS/RA Coordinator will audit residents who are on Restorative Aid Programs and ensure treatment plans reflect the current needs of the resident. Discrepancies found will be immediately corrected. 3. Measures the nursing home will take or systems it will alter to ensure that the problem does not occur: The MDS coordinator/designee will educate nursing staff that RAs will not be pulled to the floor for staffing needs. 4. How the nursing home plans to monitor performance to make sure that solutions are sustained? MDS/RA Coordinator/designee will audit residents currently on a RA program ensuring programs are completed weekly x3 weeks, then bi-monthly x1 month, then monthly x 2 months. Discrepancies found will be immediately corrected and brough to QAPI for further evaluation. 5. Name and Title of the person responsible to ensure correction: MDS/RA Coordinator/Designee

Based on interview and record review it was determined the facility failed to ensure there were sufficient nursing staff available to provide the necessary care and services to meet residents' needs in 1 of 1 facility reviewed for staffing. This placed residents at risk for unmet care needs. Findings include: On 7/25/24 the facility had a census of 62 residents. On 7/18/24, Staff 1 (Administrator) provided a list of residents who: -Required two-person mechanical lift transfers: 23; -Required one or two-person extensive or total assistance for bathing: 47; -Required one or two-person extensive or total assistance for toileting: 47; -Required one or two-person extensive or total assistance for dressing: 49; -Required two person assistance at all times for all care: 11; -Had behavioral healthcare needs which required monitoring: 28; -Were at risk for elopement: 5 and -Were considered high fall risks: 14 1. On 2/1/24 a public complaint was received by the State Agency which alleged the facility was short staffed CNAs on all shifts resulting in residents not being toileted timely, long call light response times and basic care not being met. The complaint indicated the facility had been short staffed for months. On 2/12/24 a public complaint was received by the State Agency which alleged the facility was short staffed CNAs on all shifts but evening shift was impacted the most, staff were unable to provide showers and, in general, resident care was diminished. On 4/8/24 a public complaint was received by the State Agency which alleged the facility was short staffed CNAs which resulted in residents not receiving showers and staff not being able to properly monitor residents who required supervision when eating. On 5/20/24 a public complaint was received by the State Agency which alleged the facility was short staffed CNAs, especially on night shift which resulted in residents not getting needed care. On 6/17/24 two public complaints were received by the State Agency which alleged the facility was short staffed CNAs for the past several months resulting in staff not being able to properly monitor and supervise residents during meals and some residents were unable to be showered. On 7/15/24 at 11:16 AM Resident 35 stated she/he sometimes waited over 30 minutes, pretty much daily, for someone to answer her/his call light. Resident 35 stated long call light times occurred across all shifts. On 7/15/24 at 1:15 PM Resident 22 stated call light response times could take up to one hour. Resident 22 stated the facility was short-handed, especially on the weekends. Resident 22 stated, "I filled my diaper a couple of times because they didn't get here in time." On 7/15/24 at 1:24 PM Resident 36 stated the facility needed more staff. Resident 36 stated she/he required two persons using a mechanical lift to transfer her/him and sometimes she/he was told there were not enough staff to transfer her/him to the chair. On 7/16/24 at 8:34 AM Witness 4 (Complainant) reported since 2/2024 there was "constant" low CNA staffing. Witness 4 stated the facility was often three to four CNA staff short. Witness 4 stated staffing was "bad" which resulted in increased falls, residents missing showers and residents having to remain up in their chairs longer than they should. On 7/16/24 at 8:21 AM Witness 3 (Complainant) reported CNA staffing was "bad", especially on weekends, since approximately 2/2024. Witness 3 stated the facility was three or four CNA staff short on many shifts in 2/2024 and 3/2024 and now CNA staffing was often one to two CNAs short on many shifts. Witness 3 stated when CNA staffing was low, call light response times were longer and CNA staff did not have time to provide showers to residents. On 7/16/24 at 1:28 PM Witness 1 (Complainant) stated the facility did not staff CNAs to meet the mandatory CNA minimum staffing ratio requirements. Witness 1 stated CNAs were frequently working one to two CNAs short, especially on the weekends. Witness 1 stated low staffing occurred "off and on for months." Witness 1 stated low CNA staffing impacted staff's ability to monitor residents which resulted in increased falls. Witness 1 stated the facility continued to admit new residents even though they were unable to meet CNA staffing ratios, which had the potential to result in injuries to the resident and/or staff. On 7/16/24 at 2:58 PM Witness 2 (Complainant) stated low CNA staffing was ongoing since 1/2024, especially on the weekends. Witness 2 stated staff were unable to provide showers to residents or properly supervise residents who were identified to be at high risk for aspiration (inhaling food or liquids into the lung). Witness 2 stated she was concerned residents might choke. Witness 2 stated the facility had many residents who required two person assistance with transfers but many times transfers were completed with only one person due to a lack of available staff. Witness 2 reported the facility continued to accept new admits even when they knew they were unable to adequately staff CNAs. On 7/17/24 at 4:51 PM Witness 5 (Complainant) stated staffing was "horrible" and many CNA staff quit. Witness 5 stated when CNA staffing was low, staff could not provide showers, staff were unable to complete two person mechanical lift transfers and staff were unable to toilet residents in a timely manner which resulted in a lack of dignity for the residents. Witness 5 stated CNA staffing was a "dumpster fire" since 1/2024. Witness 5 reported many staff did not get their breaks. Witness 5 stated the facility did not "have the right staffing" for the level of acuity of the residents. On 7/17/24 at 7:52 AM, 8:08 AM and 8:16 AM Staff 16 (CNA), Staff 10 (CNA) and Staff 14 (CNA) reported the facility was consistently short staffed one to two CNAs, especially on the weekends. Staff 16 and Staff 14 reported CNA staff often did not get their breaks or lunches. Staff 16 and Staff 14 stated residents who required two person mechanical lift transfers often had to wait a long time, showers got bumped and staff were unable to provide supervision to residents who ate in their rooms. Staff 10 reported the facility had difficulty retaining CNA staff. On 7/18/24 at 9:14 AM Staff 18 (Staffing Coordinator) stated she staffed CNAs based on the census and by the CNA mandatory minimum staffing ratios. Staff 18 stated she "heard" there were staffing concerns. Staff 8 confirmed, from 2/2024 through 7/14/24, CNA staffing was short on many shifts. On 7/19/24 at 9:14 AM Staff 1 (Administrator) stated he was aware the facility had staffing issues and struggled to maintain adequate staffing levels. 2. Resident 22 was admitted to the facility in 1/2024 with diagnoses including a fractured hip. A 6/23/24 5-Day MDS indicated Resident 22 had no cognitive impairment and assistance levels ranged from moderate to maximal assistance from staff for multiple ADLs. Review of Resident 22's 6/1/24 through 7/17/24 Call Light Tracking Sheet revealed the following call light response times: -6/1/24 at 9:37 PM: call light response time 38 minutes; -6/4/24 at 5:54 AM: call light response time 32 minutes; -6/6/24 at 3:00 AM: call light response time 24 minutes; -6/6/24 at 5:27 PM: call light response time 23 minutes; -6/6/24 at 3:54 PM: call light response time 16 minutes; -6/8/24 at 9:58 AM: call light response time 20 minutes; -6/9/24 at 3:37 AM: call light response time 20 minutes; -6/9/24 at 9:09 PM: call light response time 18 minutes; -6/10/24 at 5:38 AM: call light response time 40 minutes; -6/10/24 at 2:33 PM: call light response time 37 minutes; -6/12/24 at 12:23 AM: call light response time 17 minutes; -6/12/24 at 5:37 AM: call light response time 18 minutes; -6/12/24 at 11:50 AM: call light response time 17 minutes; -6/19/24 at 1:24 PM: call light response time 23 minutes; -6/19/24 at 8:18 PM: call light response time 40 minutes; -6/20/24 at 6:22 AM: call light response time 27 minutes; -6/20/24 at 2:23 PM: call light response time 16 minutes; -6/23/24 at 8:03 PM: call light response time one hour; -6/23/24 at 9:19 PM: call light response time 21 minutes; -6/24/24 at 3:58 PM: call light response time 18 minutes; -6/24/24 at 9:38 PM: call light response time 19 minutes; -6/27/24 at 5:03 AM: call light response time 22 minutes; -6/27/24 at 9:44 AM: call light response time 16 minutes; -6/29/24 at 10:40 AM: call light response time 24 minutes; -7/2/24 at 2:38 PM: call light response time 20 minutes; -7/3/24 at 7:17 AM: call light response time 21 minutes; -7/6/24 at 8:14 AM: call light response time 29 minutes; -7/9/24 at 10:30 AM: call light response time 19 minutes; -7/10/24 at 3:51 PM: call light response time 17 minutes; -7/11/24 at 8:21 AM: call light response time 24 minutes; -7/15/24 at 7:44 AM: call light response time 16 minutes and -7/15/24 at 9:56 AM: call light response time 20 minutes. On 7/15/24 at 1:15 PM Resident 22 stated call light response times could take up to one hour. Resident 22 stated the facility was short-handed, especially on the weekends. Resident 22 stated, "I filled my diaper a couple of times because they didn't get here in time." On 7/19/24 at 9:14 AM and 12:45 PM Staff 1 (Administrator) stated he was aware the facility had staffing issues and struggled to maintain adequate staffing levels. Staff 1 stated he would like to see call light response times no longer than 15 minutes and anything longer than 15 minutes would be "an issue." 3. Resident 25 was admitted to the facility in 10/2022 with diagnoses including a stroke with hemiplegia and hemiparesis (paralysis and weakness of one side of the body). Resident 25's 10/31/22 Fall Prevention Care Plan instructed staff to remind the resident to wait for staff assistance when she/he was up in her/his chair and to ensure the call light was within Resident 25's reach. A 5/30/24 Quarterly MDS indicated Resident 25 had no cognitive impairment and assistance levels ranged from maximal to dependent assistance from staff for multiple ADLs. Review of Resident 25's 6/1/24 through 7/17/24 Call Light Tracking Sheet revealed the following call light response times: -6/2/24 at 11:46 AM: call light response time 16 minutes; -6/3/24 at 5:00 PM: call light response time 40 minutes; -6/5/24 at 4:20 AM: call light response time 43 minutes; -6/6/24 at 2:47 AM: call light response time 24 minutes; -6/9/24 at 1:22 PM: call light response time 22 minutes; -6/13/24 at 2:04 PM: call light response time 21 minutes; -6/15/24 at 2:40 AM: call light response time 23 minutes; -6/16/24 at 1:28 PM: call light response time 16 minutes; -6/17/24 at 10:39 PM: call lighte response time 29 minutes; -6/18/24 12:06 AM: call light response time 17 minutes; -6/18/24 at 1:50 AM: call light response time 17 minutes; -6/18/24 at 9:41 PM: call light response time 16 minutes; -6/25/24 at 7:42 AM: call light response time 25 minutes; -6/25/24 at 11:21 AM: call light response time 29 minutes; -6/26/24 at 5:28 PM: call light response time 32 minutes; -6/30/24 at 12:04 PM: call light response time 22 minutes; -7/1/24 at 7:13 AM: call light response time 17 minutes; -7/2/24 at 6:02 AM: call light response time 36 minutes; -7/2/24 at 2:54 PM: call light response time 18 minutes; -7/4/24 at 11:33 AM: call light response time 21 minutes; -7/4/24 at 6:39 PM: call light response time 17 minutes; -7/6/24 at 10:52 AM: call light response time 16 minutes; -7/6/24 at 6:00 PM: call light response time 24 minutes; -7/7/24 at 6:54 PM: call light response time 49 minutes; -7/10/24 at 11:18 AM: call light response time 36 minutes; -7/11/24 at 9:25 AM: call light response time 26 minutes; -7/11/24 at 6:48 PM: call light response time 18 minutes; -7/12/24 at 10:55 AM: call light response time 17 minutes; -7/12/24 at 4:47 PM: call light response time 22 minutes; -7/16/24 at 4:53 AM: call light response time 16 minutes and -7/16/24 at 6:32 PM: call light response time 20 minutes. On 7/15/24 at 1:11 PM Resident 25 stated her/his call light response times were up to 30 to 40 minutes, at times. On 7/19/24 at 9:14 AM and 12:45 PM Staff 1 (Administrator) stated he was aware the facility had staffing issues and struggled to maintain adequate staffing levels. Staff 1 stated he would like to see call light response times no longer than 15 minutes and anything longer than 15 minutes would be "an issue."

1.How will the nursing home correct the deficiency as it relates to the resident? Residents in the facility are all potentially affected. 2.How the nursing home will act to protect residents and staff in similar situations. The Staffing Coordinator will audit staffing schedules for two weeks in advance to determine staffing challenges and to ensure staffing needs are met. Discrepancies found will be immediately corrected. 3.Measures the nursing home will take or systems it will alter to ensure that the problem does not occur. Facility Staff will be educated on the expectation of meeting call light waiting times and provided 2 interventions in meeting the expected time frame. 4.How the nursing home plans to monitor performance to make sure that solutions are sustained? The Administrator/designee will audit staffing schedules with the Staffing Coordinator on Mondays weekly to ensure staffing needs are met and will audit the call light report Monday through Friday in stand-up x3 weeks, then weekly x3 weeks, then monthly time 2 months to ensure staff are adhering to the expected call light waiting time. Discrepancies found will be corrected immediately and brought to QAPI for further evaluation. 5. Name and Title of the person responsible to ensure correction. Administrator/Designee

Based on observation, interview and record review it was determined the facility failed to ensure the appropriate diet texture was followed for 1 of 2 sampled residents (#10) reviewed for nutrition. This placed residents at risk for choking. Findings include: Resident 10 was admitted to the facility in 12/2016 with diagnoses including dysphagia (difficulty swallowing). The facility's 9/2019 Food Size & Testing Methods Form defined a regular, easy to chew diet as the following: -No restrictions to food piece size. -Normal, everyday foods of soft and tender texture. -Foods must break apart easily and pass the fork pressure test. Resident 10's 5/2/24 Annual MDS revealed the resident experienced short-and-long-term memory loss, was moderately impaired for decision making, required supervision or touch assistance with eating and was edentulous (without teeth). Resident 10's 7/2024 Physician Orders directed the resident to receive a regular, easy to chew diet. On 7/15/24 at 11:53 AM Resident 10 was observed to eat in bed. The resident's meal tray sat on top of an overbed table and the meal ticket on the tray stated beef fajitas. Resident 10 was observed to attempt a bite of the beef fajitas and was unable to bite through the tortilla with her/his gums. The contents of the fajita spilled out of the tortilla and landed on the resident's chest. The resident picked up the beef pieces which ranged from one-to-two inches in length and put them in her/his mouth. Resident 10 was unable to answer any questions about her/his diet. On 7/17/24 at 8:27 PM Staff 19 (CNA) stated Resident 10 was not considered at risk to aspirate and thought the resident received a regular diet. On 7/18/24 at 12:16 PM Staff 2 (DNS) and Staff 21 (Resident Care Coordinator) along with the State Surveyor observed Resident 10 in bed with her/his meal tray on an overbed table in front of the resident. Staff 2 attempted to cut the meat on the resident's plate with a fork and could not. Staff 2 confirmed the meat Resident 10 was served was not easy to chew and should have been. Staff 2 and Staff 21 were informed of the beef fajitas served to Resident 10 on 7/15/24, and Staff 2 stated beef fajitas and tortillas were not considered easy to chew foods.

1.How will the nursing home correct the deficiency as it relates to the resident? Residents in the facility are all potentially affected. 2.How the nursing home will act to protect residents and staff in similar situations. Dietary Manager/Designee will audit dietary textures to ensure residents are provided the correct texture. 3. Measures the nursing home will take or systems it will alter to ensure that the problem does not occur: Facility Staff will be educated on the importance of delivering the correct texture of food to residents and how to read the diet slip on the tray. 4.How the nursing home plans to monitor performance to make sure that solutions are sustained? Dietary Manager/designee will monitor meal textures of residents Monday through Friday x3 weeks, then weekly x3weeks, then monthly x2 months to ensure proper texture is provided to each resident. Discrepancies found will be corrected immediately and brought to QAPI for further evaluation. 5.Name and Title of the person responsible to ensure correction: Dietary Manager/designee

Based on observation, interview and record review it was determined the facility failed to ensure beverages were labeled and stored in a manner to minimize spoilage and bulk food items were stored in a manner to minimize cross contamination in 1 of 1 kitchen reviewed for sanitary conditions. This placed residents at risk of foodborne illness. Findings include: On 7/15/24 at 9:49 AM during the initial tour of the kitchen dry storage area, a plastic scoop was observed to be partially buried in the bulk sugar. Staff 24 acknowledged the scoop was not stored appropriately and stated it should be in the provided holster above the sugar rather than in the supply of sugar, to minimize the risk of cross contamination. On 7/15/24 at 9:57 AM the following items were observed to be stored in the snack refrigerator in the facility's 100 hallway: -A previously-opened liter container of nectar-thick lemon water dated "6/23" -A previously-opened liter container of nectar-thick lemon water dated "6/4" -A previously-opened liter container of nectar-thick orange juice labeled "Use by 6/26" Staff 24 acknowledged the manner in which these items were labeled was unclear as they did not indicate if the dates referred to when they were opened or when they should be discarded. He stated these items should be discarded as it was unsafe to store and use juice beyond seven days after it was opened. Staff 24 stated he was not clear about who was supposed to monitor and discard outdated items in the snack refrigerator. On 7/19/24 at 1:12 PM Staff 1 acknowledged the deficiencies observed in the kitchen's dry storage area and in the snack refrigerator. He stated he expected the facility staff to label items when they were opened and when they should be discarded in order to reduce the risk of spoilage. He stated he also expected staff to store dry goods in a manner to avoid cross contamination.

1. How will the nursing home correct the deficiency as it relates to the resident? Resident in the facility have the potential of being affected. 2. How the nursing home will act to protect residents and staff in similar situations. The Administrator/designee will audit resident snack refrigerator for dates and expiration of food items. Discrepancies found will be immediately corrected. The Administrator/designee will audit bulk food bins to ensure gloves and scoops are used and properly stored to ensure no cross contamination/spoilage. Discrepancies found will be immediately corrected. 3. Measures the nursing home will take or systems it will alter to ensure that the problem does not occur. Facility kitchen staff will be educated on the importance of professional standards for food safety service especially related to labeling correct dates, discarding past due dated items, and minimizing the risk of cross contamination and spoilage. Gloves will also be used when handling any bulk food items. 4. How the nursing home plans to monitor performance to make sure that solutions are sustained? The Administrator/Designee will audit refrigerators for dates, labeling, and expired food items Monday through Friday x3 weeks, then weekly x3 weeks, then monthly x2 months, and will audit the bulk food storage containers 3 times weekly for 3 weeks, then weekly x3 weeks, then monthly x 2 months to ensure scoops are stored appropriately and gloves are within reach of the bulk container for use. Any discrepancies found will be immediately corrected and brought to QAPI for further evaluation. 5. Name and Title of the person responsible to ensure correction. Administrator/Designee

Based on interview and record review it was determined the facility failed to ensure State minimum CNA staffing ratios were maintained for 66 of 166 sampled days reviewed for sufficient staffing. This placed residents at risk for delayed treatment and unmet care needs. Findings include: A review of the facility Direct Care Staff Daily Reports from 2/1/24 through 7/15/24 revealed the facility did not meet mandatory minimum CNA ratios for one or more shifts on the following dates: February 2024: -2/1, 2/5, 2/10, 2/11, 2/12, 2/14, 2/16, 2/17, 2/18, 2/19, 2/24 and 2/25. March 2024: -3/18, 3/19, 3/23, 3/25, 3/26, 3/27 and 3/31. April 2024: -4/1, 4/4, 4/5, 4/6, 4/7, 4/11, 4/13, 4/14, 4/15, 4/20, 4/21 and 4/28. May 2024: -5/2, 5/4, 5/5, 5/6, 5/8, 5/9, 5/12, 5/16, 5/17, 5/18, 5/19, 5/25 and 5/28. June 2024: -6/1, 6/5, 6/6, 6/7, 6/8, 6/16, 6/17, 6/20, 6/21, 6/22 and 6/23. July 2024: -7/2, 7/3, 7/4, 7/5, 7/6, 7/7, 7/8, 7/9, 7/11, 7/13 and 7/14. On 7/18/24 at 9:14 AM Staff 18 (Staffing Coordinator) stated she staffed CNAs based on the census and by the CNA mandatory minimum staffing ratios. Staff 18 stated she "heard" there were staffing concerns. Staff 8 reviewed the 2/1/24 through 7/15/24 Direct Care Staff Daily Reports and confirmed the facility did not meet CNA staffing ratios on the dates identified. On 7/19/24 at 9:14 AM Staff 1 (Administrator) stated he was aware the facility had staffing issues and struggled to maintain adequate staffing levels.

1.How will the nursing home correct the deficiency as it relates to the resident? Residents in the facility are all potentially affected. 2.How the nursing home will act to protect residents and staff in similar situations. The Staffing Coordinator will audit staffing schedules for two weeks in advance to determine staffing challenges and to ensure staffing needs are met. Discrepancies found will be immediately corrected. 3.Measures the nursing home will take or systems it will alter to ensure that the problem does not occur. Facility Staff will be educated on the expectation of meeting call light waiting times and provided 2 interventions in meeting the expected time frame. 4.How the nursing home plans to monitor performance to make sure that solutions are sustained? The Administrator/designee will audit staffing schedules with the Staffing Coordinator on Mondays weekly to ensure staffing needs are met and will audit the call light report Monday through Friday in stand-up x3 weeks, then weekly x3 weeks, then monthly time 2 months to ensure staff are adhering to the expected call light waiting time. Discrepancies found will be corrected immediately and brought to QAPI for further evaluation. 5.Name and Title of the person responsible to ensure correction. Administrator/Designee

************************** OAR 411-086-0300: Clinical Records Refer to F641 ************************** OAR 411-070-0043: Pre-Admission Screening and Resident Review (PASRR) Refer to F645 ************************** OAR 411-086-0060: Comprehensive Assessment and Care Plan Refer to F656 and F657 ************************** OAR 411-086-0110: Nursing Services: Resident Care Refer to F676, F677 and F684 ************************** OAR 411-086-0230: Activity Services Refer to F679 ************************** OAR 411-086-0150: Nursing Services: Restorative Care Refer to F688 ************************** OAR 411-086-0100: Nursing Services: Staffing Refer to F725 ************************** OAR 411-086-0250: Dietary Services Refer to F805 and F812 **************************

Based on interview and record review it was determined the facility failed to provide written information to residents concerning the right to formulate an advance directive for 5 of 5 sampled residents (#s 2, 7, 20, 23 and 50) reviewed for advance directives. Findings include: Records reviewed for Residents 2, 7, 20, 23 and 50 revealed no documentation of an advance directive or documentation to indicate the residents were informed of or provided written information concerning their right to formulate an advance directive. On 4/5/23 at 2:39 PM Staff 6 (Social Services Coordinator) stated she asked about a POLST (Physician Orders for Life Sustaining Treatment) upon admission but not advance directives. Staff 6 stated the facility had no process for discussing advance directives upon admission and was unable to provide documentation to verify residents were notified of their right to formulate an advance directive or to ensure a copy was obtained if a resident had an advance directive.

Res. #2,7,20,23 & 50: facility continues to work with pt., POA or insurance to obtain copy of advanced directive if already completed. If they do not have an advanced directive, Social Service working with pt. or POA to complete if pt. wants one. An entire in-house audit has been completed to ensure residents who want an advance directive have the opportunity to get one in place. Social services and administrative team were educated by the administrator on completion of advance directive and federal regulations that the resident has the right to form an advance directive. Advance directives are discussed with the resident on admission, 72-hour huddle and again at care conferences. Admin. Or designee will complete an audit of 5 patients charts to see if advanced directive is in chart, or if one not completed, if patient would like to complete one and process has been initiated. These audits will be weekly for four weeks and then at two-week intervals for another 2 months. Results of these audits will be brought to monthly QAPI and Quarterly quality meetings for review until substantial compliance has been met for 2 consecutive quarters.

Based on observation and interview it was determined the facility failed to ensure a resident's bathroom was clean and free of persistent odor for 1 of 4 sampled residents (#31) reviewed for environment. This placed residents at risk for lack of a clean, homelike environment. Findings include: On 4/5/23 at 11:10 AM there was a strong odor of urine in Resident 31's bathroom. A pile of crumpled paper towels and a large puddle of liquid were observed on the floor near the toilet. On 4/5/23 at 11:19 AM Staff 23 (Housekeeper) was asked about the process for cleaning resident rooms. Staff 23 stated it was divided between shifts and every room including bathrooms and showers was cleaned daily. When asked about Resident 31's room Staff 23 indicated the resident frequently urinated on the floor and her/his room was a priority for cleaning. Resident rooms were not cleaned during meal times and he had not cleaned the resident room yet that day. He stated when he cleaned the resident's room he mopped the floor around the bed working his way to the bathroom. He stated the resident often tracked urine from the bathroom around her/his room. Staff 23 indicated housekeeping cleaned Resident 31's room once a day. On 4/5/23 at 12:25 PM the resident's bathroom was noted to be recently cleaned, however the urine odor remained. Observations from 4/5/23 and 4/7/23 at various times of the day revealed a persistent odor of urine in the resident's bathroom. On 4/6/23 at 7:26 AM Staff 1 (Administrator) stated the facility was aware of an issue with urine in Resident 31's room. Housekeeping made regular rounds and the CNAs cleaned in between. On 4/6/23 at 9:02 AM Staff 20 (CNA) stated she regularly worked both day and evening shift. Resident 31 was independent with toileting but sometimes urinated on the floor in her/his room and bathroom. She stated CNAs only used towels and bath blankets to soak up the urine.

Res. #31’s care plan was updated with new interventions to encourage patient to urinate in the toilet. Resident room received deep clean. House keeping staff cleaning twice per day. Nursing staff clean rooms if needed in-between housekeeping cleans. Administrator/DNS have inserviced staff on expectation of clean any areas noted with urine smells. Administrator or designee to do 3 random room audits per day of different rooms five times per week, for four weeks. Then three random audits per day for three days per week. Results of these audits will be brought to monthly QAPI and Quarterly quality meetings for review until substantial compliance has been met.

Based on interview and record review it was determined the facility failed to ensure a resident representative was able to file a grievance in a timely manner for 1 of 1 sampled resident reviewed for grievances (#31). This placed residents at risk for unresolved concerns. Findings include: Resident 31 was admitted to the facility in 2020 with diagnoses including bipolar disorder and vascular dementia. On 4/4/23 at 1:32 PM Witness 4 (Family) stated the facility sent a grievance form by email but she was not able to open the attachment. She wanted to follow up on concerns about a missing cell phone. According to a social services progress note dated 1/5/23 by Staff 6 (Social Service Coordinator) Witness 4 reported the missing cell phone and stated she wasn't able to video chat with the resident. The note indicated the facility would "check on the lost items." A Social Services progress note by a different staff member dated 1/9/23 stated Witness 4 was told "we have to file a grievance to get the phone replaced." A 4/6/2023 at 11:32 AM Social Services Note indicated a copy of a blank grievance was sent to Witness 4 to fill out for the missing cell phone on 1/9/23. The blank form was sent via encrypted email. At 2:54 PM on 4/6/23 an email was received from Witness 4 stating she was unable to open the form. On 4/6/23 at 2:25 PM Staff 6 (Social Services Coordinator) confirmed the resident's family member reported the missing cell phone on 1/5/23 and according to social service notes the facility was to check on it but there was no follow up found. She emailed Witness 4 about this but Witness 4 could not open the encrypted email. She indicated she would send another form by postal mail. On 4/10/23 at 11:24 AM Staff 3 (Regional Nurse Consultant) stated the staff person hearing the grievance could fill out the form. She confirmed it was not necessary that the resident representative fill out the form herself and indicated the three month delay was avoidable.

Res. #31 was interviewed by Administrator. He was found to have all his personal belongings. This was verified by the resident, POA and informed social services. Also, informed and educated POA and resident about grievances. Administrator educated all department managers on grievances, process, and procedures and who can fill out the grievance. Five Abaqis interviews of the residents will be completed weekly by the Administrator or designee. If any concerns are found they will be put onto grievances, investigated and followed up on by Administrator or designee. All grievances will be recorded, and logs kept of grievances. Results of these audits will be brought to monthly QAPI and Quarterly quality meetings for review until substantial compliance has been met.

Based on observation, interview and record review it was determined the facility failed to implement or develop a comprehensive care plan for 1 of 5 sampled residents (# 16) reviewed for medications. This placed residents at risk for unmet needs. Findings include: Resident 16 was admitted to the facility in 2022 with diagnoses including stroke and thrombophilia (blood clots too easily). Resident 16's 10/17/22 CAAs indicated the resident had a history of recurrent strokes secondary to thrombophilia. Resident 16 had INR (blood test to determine dosing for anticoagulant medication) testing ordered and was followed by hematology (treatment of blood disorders) as an outpatient. Resident 16's 4/2023 physician's orders included warfarin (anticoagulant medication) once daily for thrombophilia. Resident 16's 4/2023 care plan did not include safety interventions and monitoring for bruising or bleeding related to anticoagulant use. On 4/10/23 at 9:46 AM Staff 16 (CNA) stated he would have to ask the nurse or medication aide if a resident took an anticoagulant. Staff 16 reported he did not see monitoring for side effects of an anticoagulant on Resident 16's Kardex (patient care summary). On 4/10/23 at 10:33 Staff 5 (Resident Care Coordinator/LPN) confirmed Resident 16 received an anticoagulant medication (warfarin) which placed the resident at greater risk for bruising and bleeding. Staff 5 verified the resident's care plan did not include monitoring for bruising or bleeding related to anticoagulant use.

Res. #16’s careplan has been updated to reflect anticoagulation use and side effects. All residents on Anticoagulation therapy have updated Care plans to reflect side effects of anticoagulation use. Side effects have also been added to care plans. DNS or Designee will audit 3 residents on anticoagulation therapy per week to ensure care plans reflect usage and side effects. DNS or designee will educate RCM, LN on proper protocol for care planning for Anticoagulation therapy. Results of audits will be brought to monthly QAPI meeting and Quarterly QA meeting until substantial compliance has been met.

Based on observation, interview and record review it was determined the facility failed to revise care plans in the areas of nutrition and ADLs for 1 of 1 sampled resident (#309) reviewed for nutrition. This placed residents at risk for unmet needs. Findings include: Resident 309 was admitted to the facility in 3/2023 with diagnoses including stroke and hemiplegia (paralysis of one side of the body). Resident 309's 3/15/23 Physician Orders revealed the resident received a pureed texture diet and was able to feed herself/himself with guidance and supervision for safety. Resident 309's 3/16/23 Care Plan revealed the following interventions: -Close supervision and some physical help with eating; -Alternate between solids and liquids; -Encourage the resident to remain in an upright position for at least 30 minutes after meals; -Ensure the resident completed swallowing without pocketing foods; and -Instruct the resident to chew slowly and not to talk while chewing or swallowing. Resident 309's 3/20/23 Admission MDS revealed the resident was cognitively intact and required set-up assistance with supervision when eating. On 4/4/23 at 9:33 AM Resident 309 stated she/he ate independently and did not require any assistance from staff. On 4/5/23 at 1:03 PM Staff 17 (RN) stated Resident 309 required set-up assistance at meal times but was otherwise independent with eating. Observations of Resident 309 on 4/7/23 from 7:47 AM to 8:02 AM revealed the resident to be sitting up on the side of her/his bed eating breakfast. No staff were present in the resident's room. The resident could be visualized from the hallway but no staff members in the hallway during this time period were observed to look into the resident's room until 8:02 AM when a staff member entered the room to answer the resident's roommate's call light. No coughing or other evidence of Resident 309 not being able to clear her/his airway was observed. On 4/7/23 at 8:08 AM Staff 8 (CNA) stated Resident 309 was at risk to aspirate when eating so staff were responsible for watching the resident at meal times. She stated staff did not have to be in the room but had to be close by in order to see the resident when she/he was eating. On 4/7/23 at 12:49 PM Staff 5 (LPN/Resident Care Coordinator) stated according to the care plan, staff were supposed to have continuous eyesight of Resident 309 when she/he was eating. Staff 5 confirmed the observations from 4/7/23 of the resident during breakfast were not consistent with the interventions outlined in the resident's care plan. The resident's care plan did not match his current level of function.

Res. # 309’s care plan has been reviewed and updated to reflect his current status. DNS or designee will audit All residents on Aspiration precautions weekly to ensure their care plan reflects current status and staff following all aspiration interventions. DNS or Designee will educate LN, CNA, CMA on aspiration policy and following the care plan. Results of audits will be brought to monthly QAPI meeting and Quarterly QA until substantial compliance has been met for 2 consecutive quarters.

Based on observation, interview and record review it was determined the facility failed to ensure residents with limited range of motion received equipment to prevent further decrease in range of motion for 1 of 3 sampled residents (#32) reviewed for position and mobility. This placed residents at risk for worsening contractures. Findings include: Resident 32 was admitted to the facility in 8/2019 with diagnoses including Alzheimer's disease. Resident 32's 3/9/23 Quarterly MDS revealed the resident was severely cognitively impaired, required extensive assistance from staff with dressing, personal hygiene and eating and had upper extremity impairment on one side. Resident 32's 3/7/23 Care Plan indicated the resident was to have bilateral inflatable cone shaped splints (called carrots) placed in both hands. The Care Plan indicated the carrot splints were okay to be removed when the resident participated with eating and dressing. Observations of the resident from 4/3/23 to 4/7/23 between 8:35 AM to 4:20 PM revealed the resident's right thumb was tucked in under the remaining four fingers curling into the resident's right palm and the left thumb tucked completely under the resident's index finger with the remaining four fingers curling into the resident's left palm. Resident 32 was not observed to have bilateral carrot splints placed in her/his hands at any point during these observations. On 4/5/23 at 2:53 PM Staff 20 (CNA) stated staff used to put little blue cones or a rolled wash cloth in each of Resident 32's hands but staff were no longer doing this. On 4/5/23 at 4:16 PM Staff 21 (LPN) stated Resident 32 was supposed to have hand rolls in at all times because her/his hands were making a fist. On 4/7/23 at 12:46 PM Staff 5 (LPN/Resident Care Coordinator) confirmed Resident 32 was supposed to have carrot splints in her/his hands at all times.

Resident # 32 audited- now has carrots in place as outlined in the care plan. All residents in the house with orders for equipment for ROM will have audit done weekly by DNS or designee. DNS or Designee to educate LN, CNA for applying devices as per care plan. All Staff meeting 4/24/2023 addressed Restorative Program “What Is Restorative Program & Why Is It Important To Our Building?” Discussed knee braces, hand wrist braces, carrots or cones for hands to help keep hands open and from developing contractures or further contractures. Results of audits will be brought to monthly QAPI meeting and Quarterly QA until substantial compliance has been met.

Based on interview and record review it was determined the facility failed to ensure an RN was available for at least eight consecutive hours for 16 of 40 days reviewed for RN coverage. This placed residents at risk for delayed nursing assessments. Findings include: A review of the DCSDR (Direct Care Staff Daily Reports) revealed the following: In 7/2022 12 days were reviewed and revealed eight days without RN coverage on 7/20/22, 7/21/22, 7/25/22, 7/26/22, 7/27/22, 7/29/22, 7/30/22 and 7/31/22. In 8/2022 12 days were reviewed and revealed seven days without out RN coverage on 8/7/22, 8/12/22, 8/13/22, 8/14/22, 8/19/22, 8/20/22 and 8/21/22. In 10/2022 16 days were reviewed and revealed one day without RN coverage on 10/27/22. On 4/7/23 at 2:16 PM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged the lack of RN coverage for 7/2022, 8/2022 and 10/2022. Staff 1 stated they were working to ensure the facility had appropriate RN coverage.

Currently Avamere Rehabilitation King City has four full time RN’s. the schedule reflects RN coverage as outlined in 483.35 (b)(2). The Administrator to educate Staffing Director on regulations. Administrator /DNS will audit nurses schedule five days per week to ensure RN coverage eight hours per day 7 days per week. Results of these audits will be brought to monthly QAPI and Quarterly quality meetings for review until substantial compliance has been met.

Based on interview and record review it was determined the facility failed to withhold a blood pressure medication according to physician ordered parameters for 1 of 5 sampled residents (#49) reviewed for medications. This placed residents at risk for low blood pressure. Findings include: Resident 49 was admitted to the facility in 10/2022 with diagnoses including paroxysmal atrial fibrillation (an irregular heart rate that commonly causes poor blood flow). Resident 49's 3/11/23 Physician Orders included metoprolol tartrate (treats high blood pressure, chest pain and heart failure) twice daily and to hold the medication if the resident's systolic (the upper number in a blood pressure reading) blood pressure was less than 100 or if the resident's heart rate was less than 70. Resident 49's 3/2023 and 4/2023 MARs revealed the metoprolol tartrate was administered on 3/12/23, 3/14/23, 3/18/23, 3/20/23, 3/21/23, 3/23/23, 3/26/23, 3/27/23, 3/29/23, 3/31/23, 4/1/23 and 4/4/23 when the resident's heart rate was less than 70. On 4/7/23 at 10:15 AM Staff 22 (CMA) reviewed Resident 49's 3/2023 and 4/2023 MARs and confirmed the metoprolol tartrate should have been held on the identified dates as the resident's pulse was outside of parameters. On 4/7/23 at 1:09 PM Staff 5 (LPN/Resident Care Coordinator) verified Resident 49 was administered metoprolol tartrate on 3/12/23, 3/14/23, 3/18/23, 3/20/23, 3/21/23, 3/23/23, 3/26/23, 3/27/23, 3/29/23, 3/31/23, 4/1/23 and 4/4/23 when the resident's heart rate was less than 70.

Resident #49, care plan reviewed and revised. Complete house audit done to ensure All Med Orders are being followed and medications held when appropriate. Risk management completed when appropriate. DNS to inservice LN and CMA’s on protocol of passing medications and following physician orders. DNS of Designee to ensure LN and CMA are following MD orders regarding parameters. Audit to include no less than 5 resident med pass per week to ensure all orders are being followed including holding medications if appropriate. Results of audits will be brought to monthly QAPI meeting and Quarterly QA until substantial compliance has been met.

Based on observation, interview and record review it was determined the facility failed to ensure a medication error rate of less than five percent for 1 of 6 sampled residents (#309) reviewed for medication administration. There were five errors in 29 opportunities resulting in a 17.24% error rate. This placed residents at risk for adverse medication consequences. Findings include: Resident 309 was admitted to the facility in 2023 with diagnoses including stroke. Resident 309's 3/15/23 physician's orders included: - crush medications in a teaspoon of puree (a smooth blended food) - aspirin chewable - multivitamin with minerals - atorvastatin (cholesterol lowering medication) - levetiracetam (used to treat seizures) - tamsulosin (urinary retention medication) Resident 309's March and April 2023 MARs and TARs did not include the physician's order for the resident's medications to be crushed. Resident 309's 3/16/23 Care Plan included an aspiration precaution intervention to crush medications in applesauce or pudding. On 4/6/23 at 9:25 AM Staff 22 (CMA) was observed to administer Resident 309's aspirin, multivitamin, atorvastatin, levetiracetam and tamsulosin medications whole with a drink. Staff 22 stated the resident had an order to crush her/his medications but the resident preferred them given whole. In an interview on 4/10/23 at 10:45 AM with Staff 5 (Resident Care Coordinator/LPN) and Staff 3 (Regional Nurse Consultant) Staff 5 stated Resident 390 was to receive her/his medications crushed with puree, applesauce or pudding. Staff 5 reported she was not aware the resident was taking her/his medications whole. Staff 5 reported she would expect the CMA administering medications to notify the nurse of the resident's preference to take the medications whole for follow-up with the doctor and speech therapy.

Resident #309, Care plan now has orders to reflect how resident takes his medications. All residents in house with special orders for med pass have been reviewed for accuracy. DNS or Designee to educate RCM, LN, CMA on proper protocol for documentation and following through for med pass. The Order will be in EMAR under Special Instructions. DNS or designee will audit 5 residents med pass per week. Results of audits will be brought to monthly QAPI meeting and Quarterly QA until substantial compliance has been met.

Based on observation and interview it was determined the facility failed to store food in a sanitary manner for 1 of 1 facility kitchen reviewed for sanitary food storage. This placed residents at risk for food-borne illness and contaminated food. Findings include: On 4/3/23 at 9:15 AM during the initial tour of the facility's walk-in refrigerator and dry storage room the following were observed: Walk-in refrigerator: -An open and undated bag of sliced cheese; -An open and undated container of chocolate pudding covered with plastic wrap; -An open and undated bottle of teriyaki sauce; and -An open and undated bottle of sesame dressing. Dry storage room: -An open and undated package of turkey powder gravy mix; -An open and undated package of chicken powder gravy mix; -An open and undated package of brown powder gravy mix; -An open and undated bag of spaghetti; and -Two open and undated bags of cereal. On 4/3/23 at 9:18 AM Staff 24 (Cook) confirmed the above items were not appropriately dated and stated it was policy for food items to be dated immediately after initial use. On 4/4/23 at 1:20 PM Staff 25 (Dietary Manager) stated food items were to be dated as soon as they were opened.

Registered Dietician or designee will educate kitchen staff on storage of food in a sanitary manner. RD or designee will complete walk thru audits of the refrigerator and dry storage area no less often then twice per week. Results of these audits will be brought to monthly QAPI and Quarterly QA until substantial compliance has been met.

Based on interview and record review it was determined the facility failed to ensure reference checks were completed for 5 of 5 sampled staff (#s 9, 10, 11, 12 and 13) reviewed for reference checks. This placed residents at risk for care from unqualified staff. Findings include: Reference checks were requested on 4/4/23 for Staff 9 (Admissions Director), Staff 10 (Activities Director), Staff 11 (LPN), Staff 12 (CNA) and Staff 13 (RCM). On 4/4/23 at 2:30 PM Staff 14 (Human Resource/Staffing Coordinator) stated he had not completed reference checks on new hires. On 4/6/23 at 9:10 AM Staff 1 (Administrator) confirmed there were no reference checks completed for Staff 9, Staff 10, Staff 11, Staff 12 and Staff 13.

To ensure all reference checks are verified and documented, an audit was completed of all current employees. All employees without written documentation from reference checks will be requested to submit new reference checks to be documented and placed into employee files. Education by the Administrator with the Staffing director on OAR 411-085-0200 (2) (a-c). Audits will be conducted among all current employees and newly hired employees by the Administrator or designee twice per week over the next four weeks to ensure documented reference checks are completed. Then weekly for the next two months. Results of these audits will be brought to monthly QAPI and Quarterly quality meetings for review until substantial compliance has been met.

Based on interview and record review it was determined the facility failed to maintain appropriate RN coverage for at least eight consecutive hours between the start of day shift and the end of evening shift for 22 of 77 days reviewed for staffing. This placed residents at risk for unmet assessments and care needs. Findings include: A review of the DCSDR (Direct Care Staff Daily Reports) revealed the following: In 7/2022 12 days were reviewed and revealed nine days without appropriate RN coverage on 7/20/22, 7/21/22, 7/23/22, 7/25/22, 7/26/22, 7/27/22, 7/29/22, 7/30/22 and 7/31/22. In 8/2022 12 days were reviewed and revealed eight days without appropriate RN coverage on 8/7/22, 8/12/22, 8/13/22, 8/14/22, 8/19/22, 8/20/22, 8/21/22 and 8/28/22. In 10/2022 16 days were reviewed and revealed two days without appropriate RN coverage on 10/18/22 and 10/27/22. In 12/2022 16 days were reviewed and revealed one day without appropriate RN coverage on 12/4/22. From 3/13/23 through 4/2/23 21 days were reviewed and revealed two days without appropriate RN coverage on 3/19/23 and 4/2/23. On 4/7/23 at 2:16 PM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged the lack of RN coverage for 7/2022, 8/2022, 10/2022, 12/2022 and 3/13/23 through 4/2/23. Staff 1 stated they were working to ensure the facility had appropriate RN coverage.

Currently Avamere Rehabilitation King City has four full time RN’s. the schedule reflects RN coverage as outlined in 483.35 (b)(2). The Administrator to educate Staffing Director on regulations. Administrator /DNS will audit nurses schedule five days per week to ensure RN coverage eight hours per day. Results of these audits will be brought to monthly QAPI and Quarterly quality meetings for review until substantial compliance has been met.

Based on interview and record review it was determined the facility failed to meet the required CNA staffing ratio 18 for 89 days reviewed for staffing. This placed residents at risk for unmet care needs. Findings include: A review of the DCSDR (Direct Care Staff Daily Reports) revealed the following days when the state minimum CNA staffing ratios were not met for one or more shifts: -7/23/22: Day and evening shift. -7/24/22: Day and evening shift. -7/25/22: Evening shift. -7/26/22: Evening shift. -7/28/22: Evening shift. -7/31/22: Day shift. -10/16/22: Evening shift. -10/22/22: Evening shift. -10/23/22: Day and evening shift. -10/28/22: Evening shift. -10/30/22: Day shift. -11/12/22: Evening shift. -12/3/33: Evening shift. -12/4/22: Day shift. -12/5/22: Evening shift. -12/10/22: Evening shift. -3/18/23: Day shift. -3/26/23: Day shift. On 4/7/23 at 2:16 PM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged the lack of CNA coverage and acknowledged the facility did not meet the minimum CNA ratios. Staff 1 stated they were working to ensure the facility had appropriate CNA coverage.

Ongoing recruitment and certification will continue for qualified nursing aids, who meet all requirements to hire. The facility has initiated agency staffing, to assist in meeting minimum staffing ratios. Administrator and Staffing Coordinator/HR has a recruitment and retention plan and committee and will continue to evaluate and update as appropriate. The administrator/designee will complete an audit of the DHS staffing form 4 times a week for 3 months or until substantial compliance has been achieved to ensure the C.N.A staffing ratios meet the OAR minimum staffing requirements for C.N.As. Findings will be reviewed in the monthly QAPI meeting and quarterly thereafter with action plans.

OAR-411-086-0040: Admission of Residents

Refer to F578 ***** OAR-411-085-0100: Physical Environment: Generally Refer to F584 ***** OAR-411-087-0310: Residents' Rights: Generally Refer to F585 ***** OAR 411-085-0060: Comprehensive Assessment and Care Plan Refer to F656 and F657 ***** OAR-411-086-0110: Nursing Services: Resident Care Refer to F759 ***** OAR-411-086-0150 Nursing Services: Restorative Care Refer to F688 ***** OAR-411-086-0100: Nursing Services: Staffing Refer to F727 ***** OAR-411-086-0140: Nursing Services: Problem Resolution and Preventive Care Refer to F757 ***** OAR-411-086-0250: Dietary Services Refer to F812 *****

Based on interview and record review, it was determined the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 1 of 2 sampled residents (#100). This placed Resident 100 at risk for further abuse and placed other residents at increased risk for abuse. Findings include: Resident 100 was admitted to the facility in 2/2022 with diagnoses including hypertensive chronic kidney disease (a condition caused by damage to the blood flow of the kidneys). Resident 100's 2/6/23 MDS identified resident with a BIMS score of 5 (severe cognitive impairment). A 3/19/23 Facility Document indicated around 12:30 PM, Staff 3 (CNA) discovered Staff 4 (Restorative Aide) in Resident 100's room with the residents pants pulled down to her/his ankles. Staff 4 indicated he was about to perform range of motion (ROM) exercises for the resident. Staff 3 asked why Resident 100's pants were down; Staff 4 became defensive and left the room. Staff 3 (CNA) reported the matter to Staff 5 (Resident Care Manager). A review of facility records from 3/19/23 to 3/22/23 revealed no FR report was filed with the State Agency. On 3/22/23 at 11:40 AM, Staff 1 (Administrator) confirmed that Resident 100 was discovered to have her/his pants down in the residents room. Administrator stated that no investigation was conducted to rule out abuse and no FRI was submitted on the basis that no abuse had occurred as no marks were discovered on Resident 100's upon completion of RCM's assessment.

Res. #100 has been assessed from head to toe. No redness, swelling, bruising or open areas found. All residents could be at risk if policy and state guidelines are not followed. All interviewable residents, have been interviewed. Any issues that could be of concern, were reported per guidelines. All department managers have received in service from RNC regarding recognizing, investigating and reporting any signs or symptoms of abuse or neglect as well as reporting guideline per company and state policy. Admin. Or designee will continue to interview 5 residents per week using the abaqis resident interview tool. Any areas of concern will be immediately investigated with a Risk management or grievance. A FRI. will be completed and thorough investigation will be done for any abuse or neglect suspected. These audits will continue weekly for 2 months and then every 2 weeks. Results of these audits will be brought to monthly QAPI until substantial compliance has been met for 3 consecutive months.

Based on observation, interview and record review it was determined the facility failed to thoroughly investigate and rule out incidents of potential sexual abuse without adequate evidence for 1 of 2 sampled residents (#100) reviewed for abuse. This deficient practice was determined to be an immediate jeopardy situation and placed Resident 100 at risk of sexual abuse. Findings include: Resident 100 was admitted to the facility in 2/2022 with diagnoses including hypertensive chronic kidney disease (a condition caused by damage to the blood flow of the kidneys). Resident 100's 2/6/23 MDS identified resident with a BIMS score of 5 (severe cognitive impairment). Resident 101 was admitted to the facility in 2/2019 with diagnoses including cellulitis of the left lower limb (a condition caused by painful, swollen, and inflamed legs). Resident 101's 1/25/23 MDS identified resident with a BIMS score of 15 (cognitively intact) A 3/19/23 Facility Document indicated around 12:30 PM, Staff 3 (CNA) discovered Staff 4 (RA) in Room 411-B with Resident 100. Resident 100's pants were observed to be down to her/his ankles. Staff 4 indicated he was about to perform (ROM) exercises for the resident. Staff 3 asked why Resident 100's pants were down; Staff 4 became defensive and left the room. Staff 3 (CNA) reported the matter to Staff 5 (Resident Care Manager). On 3/19/23 at 1:40 PM, Staff 5 (Resident Care Manager) documented that Resident 100 was discovered with her/his pants below their ankles, Staff 5 instructed Staff 3 and Staff 4 to return to work. Staff 5 indicated the incident was a "he said, she said situation" and did not believe the sitatuation warrented an investigation. Staff 5 stated she did not determine how Resident 100's pants were removed. A review of facility records revealed no investigation report was created to determine cause of incident, no FRI was reported to the State Agency, Resident 101 was not monitored for safety, and Staff 4 was not reassigned or removed from the facility. On 3/22/23 at 10:19 AM, Resident 101 stated she/he felt unsafe with Staff 4 (RA) performing cares on her/him due to inappropriate verbal conversations and touching of her/his arms. Resident 101 stated she/he reported this to the facility but Resident 101 indicated she/he still felt scared due to Staff 4's continuance to access her/his room even though Staff 4 was reassigned to a different hall. On 3/22/23 at 11:25 AM, Staff 6 (CNA) indicated he performed care and a brief change with Resident 100 exactly 30 minutes prior to the date of the 3/22/23 incident. Staff 6 stated he witnessed an argument occur between the Staff 3 and Staff 4. Staff 6 was asked by Staff 3 to enter the room and discovered Resident 100's pants were below the resident's ankles with Staff 4 present in the room. Staff 6 stated that the incident was reported to Staff 1 (Administrator) and Staff 2 (DNS), but Staff 4 was not removed from the floor. On 3/22/23 at 11:40 AM, Staff 1 (Administrator) confirmed Resident 100 was discovered to have her/his pants down in the resident's room. The Administrator stated no investigation was conducted to rule out abuse and no FRI was submitted on the basis that no abuse had occurred as no marks were discovered on Resident 100 upon completion of Resident Care Manager's assessment. Staff 1 stated that Staff 4 (RA) was not placed on suspension and was still on the schedule. Staff 1 stated that no additional investigation was necessary, and the resident was not placed on behavior monitoring as they believed no abuse had occurred. On 3/22/23 at 11:40 AM, Staff 1 (Administrator) confirmed Staff 4 was not placed on suspension and is currently still on the schedule working the floor. On 3/22/23 at 4:41 PM Staff 4 confirmed he was in Resident 100's room with the resident's pants down but denied the allegation. On 3/22/23 at 2:34 PM the facility was notified of the Immediate Jeopardy (IJ) situation and an immediacy removal plan was requested. On 3/22/23 at 4:29 PM the facility submitted an acceptable immediacy removal plan. The immediacy removal plan included the following: [Res 100] is still a resident of this facility. Assessment will be completed of resident for any signs or symptoms of any type of physical assault. This will be documented in the resident's HER. Resident will be placed on alert for the next 72 hours to monitor for any adverse potential effects. Admin/DNS or designee will complete thorough investigation into reported incident. [Staff 4] involved in the potential incident has been removed from the schedule and has been informed that he is not allowed on the facility premises until otherwise notified by Admin. All current interviewable residents will be interviewed by Department managers in regard to care and concerns they may have. Any issues brought forth will be immediately investigated and reported (FRI) if appropriate. This will be completed within the next 24 hours. Department manages will be in-serviced by Regional Nurse Consultant in regards to company and state policy regarding how to complete an investigation. This will be completed within the next 24 hours. Admin/DNS or designee will complete 5 random resident interviews weekly utilizing the abaqis resident interviews. Any issues or concerns will be investigated and reported as appropriately outlined in the policy. These audits will continue weekly for 2 months and then every 2 weeks. Results of these audits will be brought to monthly QAPI until substantial compliance has been met for 3 consecutive months On 3/23/23 at 2:00 PM observations, record reviews and interviews were completed which verified the immediacy removal plan was fully implemented on 3/23/23.

Res. #100 reported incident has been thoroughly investigated. C.N.A./RA was suspended and has not been back to the building. Res.# 100 was placed on alert charting for 72 hours to monitor for any signs or symptoms of abuse. None was found. All residents could be at risk if company and state policy is not followed regarding investigations. All residents that could be interviewed, have been interviewed utilizing the abaqis resident interview. And reported neglect or abuse by the resident, has been reported and thoroughly investigated. Admin. Or designee will continue to interview 5 residents per week using the abaqis resident interview tool. Any areas of concern will be immediately investigated with a Risk management or grievance. A FRI. will be completed and thorough investigation will be done for any abuse or neglect suspected. These audits will continue weekly for 2 months and then every 2 weeks. Results of these audits will be brought to monthly QAPI until substantial compliance has been met for 3 consecutive months. Admin. Or designee will audit all grievances and risk managements to ensure thoroughness of investigation is completed. These audits will be done 5 days per week for 4 weeks and then 3 days per week. These audits will continue until substantial compliance has been met.

************************************** OAR 411-085-0360 Abuse Refer to F609 ************************************** OAR 411-085-0360 Abuse Refer to F610 **************************************

Based on interview and record review it was determined the facility failed to notify a resident's representative timely for 2 of 6 sampled residents (#s 2 and 3) reviewed for change of condition and falls. This placed resident responsible parties at risk for not being informed. Findings include: 1. Resident 3 admitted to the facility in 2022 with diagnoses including a traumatic subdural hemorrhage (brain bleed). Review of Resident 3's medical record indicated the resident's spouse as her/his first emergency contact. A 4/28/22 Fall Investigation indicated Resident 3 suffered a fall on 4/27/22 at 8:50 PM due to self transferring without assistance. A witness statement from Staff 11 (former LPN) indicated she did not notify Resident 3's spouse of the fall until later in the early morning of 4/28/22 due to not having "much information to provide to the [spouse] initially." On 9/26/22 at 12:52 PM Staff 11 verified she did not notify Resident 3's spouse of the fall until the following day on 4/28/22 at 6:00 AM. , 2. Resident 2 admitted to the facility in 2020 with diagnoses including dementia. A 6/6/22 Progress Note revealed Resident 2 was transferred to the hospital for a change of condition including right sided shakiness and the inability to walk or self transfer. A 6/7/22 Progress Note indicated Resident 2 was admitted to the hospital and the hospital nurse would notify Resident 2's family. The note further stated the facility would also contact Resident 2's family. Review of the medical record revealed no evidence Resident 2's emergency contact was notified on 6/6/22 of Resident 2's change of condition and transfer to the hospital. On 9/26/22 at 10:29 AM Staff 9 (LPN Resident Care Manager) verified Resident 2's emergency contact was not contacted on 6/6/22.

1. Resident number 3 is no longer a patient at our facility. 2. All residents with falls have potential to be affected by staff not following the policy to contact family or POA in a timely manner. 3. Licensed nurses will be in serviced by DNS or designee regarding policy to notify family or POA in a timely manner after a fall. 4. DNS or designee will audit all risk management’s 3 times per week to ensure proper timely notification of emergency contacts completed. 5. Audits will be completed three times per week for four weeks, then monthly. 6. Audits will be brought to QAPI until substantial compliance received. 1. Resident number 2 was sent to the hospital 06/06/2022, readmitted 06/10/2022 back to the facility. 2. Any residents transferred to the hospital are at risk of emergency contacts not being notified timely if policy not followed. 3. Licensed nurses will be in serviced by DNS or designee regarding policy to notify family or POA in a timely manner after a transfer to the hospital. 4. DNS or designee will audit all risk managements and hospital transfers 3 times per week to ensure proper notification of emergency contacts are completed. 5. Audits will be completed three times per week for four weeks, then monthly. 6. Audits will be brought to QAPI until substantial compliance received.

************************************** OAR 411-086-0130 Nursing Services: Notification Refer to F580 **************************************

Based on interview and record review it was determined the facility failed to follow dietician recommendations timely for 1 of 1 sampled resident (#38) reviewed for nutrition. This placed residents at risk for weight loss. Findings include: Resident 38 admitted to the facility in 2019 with diagnoses including heart disease and dementia. A 2/11/22 nutritional progress note revealed Resident 38 had a 7.1% weight loss over the past 36 days and the dietician recommendations included: to obtain weekly weights for NAR (nutrition at risk), to obtain an order for 60 ml of the house nutritional supplement twice daily between meals and to document the amount of the house nutritional supplement consumed. Review of Resident 38's clinical record revealed the facility followed up on the dietician's recommendations 2/16/22, five days after the recommended were received. On 2/16/22 at 1:06 PM Staff 6 (RN) stated often the dietician made recommendations directly to the nurse. When recommendations were received directly from the dietician, the nurse usually processed them by the end of the shift and notified (Staff 9) LPN Resident Care Manager. On 2/17/22 at 11:05 AM Staff 7 (LPN) stated recommendations from the dietician went to Staff 9 who processed the orders and passed the information onto the nursing staff. On 2/16/22 at 3:13 PM Staff 8 (Dietician) stated nutritional recommendations were written in a progress note and an email was sent to Staff 9, DNS, Dietary Manager and the Administrator. Staff 8 confirmed she sent the email with Resident 38's recommendations on 2/11/22. Staff 8 stated recommendations were generally processed and orders were obtained within a couple of days. On 2/18/22 at 9:29 AM Staff 9 stated when the dietician recommendations were received via email at the end of the day they were typically processed the next day. Staff 9 confirmed the dietician's recommendations for Resident 38 were not followed up on timely.

•Resident 38 still in facility and Dietician rec completed •All residents in house that have Dietician recommendations have been completed. •All residents at risk for delay RD recommendations •nurse managers will be in-serviced on RD recommendation policy of 72 hour/follow up. Inservice will be completed by DNS or designee. •DNS or designee will audit 5 residents per week to ensure RD recommendations have been completed timely. This audit will occur for 3 months and then monthly until substantial compliance has been achieved. Results will be brought to QAPI.

Based on observation, interview and record review it was determined the facility failed to use a hairnet and complete hand hygiene while serving food during a random kitchen observation and a tray line observation for 1 of 1 kitchen reviewed. This placed residents at risk for food borne illness. Findings include: 1. The 5/2018 facility Food Safety and Sanitation Policy indicated hair restraints were required in the kitchen and should cover all hair on the head. On 2/18/22 at 9:49 AM Staff 13 (Cook) was observed in the kitchen without a hair net. Staff 13 stated she sometimes wore a hair net and on this day had her hair pulled back and planned on using a hairnet later in the day. On 2/18/22 at 10:01 AM Staff 14 (Dietary Manager) stated staff were expected to wear hairnets at all times in the kitchen. 2. The 5/2018 facility Food Safety and Sanitation Policy indicated "all staff will wash their hands just before they start to work in the kitchen and when they used their hands in an unsanitary way such as smoking, sneezing, using the restroom, handling poisonous compounds, dirty dishes, touching face, hair other people, etc." On 2/18/22 at 11:24 AM during a tray line observation while wearing gloves Staff 13 (Cook) used a spatula to scoop up a piece of fish and held the fish on the spatula with her hand. Staff 13 then used a spatula to scoop up some french fries onto the plate and adjusted the fries on the plate with her gloved hand. She then opened a warming oven door to access some vegetables. Staff 13 was about to continue to dish more food onto the plate but this surveyor stopped her and pointed out her hand touched the warming oven door handle. Staff 13 recognized and acknowledged she should have changed her gloves before continuing to serve food. On 2/18/22 at 11:51 AM Staff 14 (Dietary Manager) acknowledged Staff 13 should have changed gloves after she touched the warming oven door handle.

•All residents at risk of food bourn illness •All dietary staff in-serviced by RD or designee on proper food safety and sanitation policies, including food handling and hairnets. •RD or designee will audit kitchen staff 2 times per week to ensure hair nets are in place and proper hand sanitation and food handling is being followed. This audit will continue for 3 months and then monthly until substantial compliance has been achieved. Results of these audits will be brought to QAPI.

Based on observation, interview and record review it was determined the facility failed to ensure an unvaccinated, newly admitted resident was placed on Transmission-Based Precautions (TBP) for COVID-19 for 1 of 1 sampled resident (# 200) and failed to ensure appropriate Personal Protective Equipment (PPE) was used while conducting resident COVID-19 testing for 2 of 2 staff (#s 9 and 17) reviewed for infection control. This placed the residents at risk for contracting and/or spreading COVID-19. Findings include: 1. The CDC's Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes updated 2/2/22, recommended the use of Transmission-Based Precautions (quarantine) for residents who are newly admitted to the facility if they are not up to date with all recommended COVID-19 vaccine doses. Resident 200 admitted to the facility in 2/2022 with diagnoses including pneumonia. The resident's 2/2022 Admission MDS indicated she/he was cognitively intact. Resident 200's immunization record revealed the resident was not vaccinated for COVID-19. On 2/11/22 at 2:08 PM Resident 200 was observed to have her/his door open with no signage on the door to indicate she/he was on TBP and there was no PPE cart located outside of the resident's room. On 2/14/22 at 10:13 AM Staff 2 (Interim DNS) confirmed Resident 200 was a newly admitted, unvaccinated resident and should have been placed on TBP. 2. The CDC's Interim Guidelines for Collecting and Handling of Clinical Specimens for COVID-19 Testing, updated 10/25/21, recommended facility staff who collected specimens of residents maintain proper infection control and use recommended PPE, which included an N95 mask or higher-level respirator, eye protection, gloves, and a gown. The Avamere SNF Division: 2/14/22 COVID-19 Testing Program Guidelines stated: "During specimen collection, facilities must maintain proper infection control and use recommended PPE, which includes the tester to wear an N95, eye protection, gloves, and a gown, when collecting specimens". On 2/15/22 at 9:20 AM Staff 9 (LPN Resident Care Manager) and Staff 17 (Interim LPN Resident Care Manager) were observed to enter resident rooms 309, 403 and room 406 and tested the residents for COVID-19 using a nasal swab. Both staff members were observed to wear N95's, face shields and gloves. Neither of the staff members wore a gown. On 2/17/22 at 1:06 PM Staff 2 (Interim DNS) stated she conducted COVID-19 testing on residents and did not wear a gown to test the residents. Staff 2 stated the facility's policy was to wear a gown for testing and staff should have worn a gown.

•DNS or designee will complete training: Keep COVID-19 Out! https://youtu.be/7srwrF9MGdw Lessons - https://youtu.be/YYTATw9yav4 and inservice nursing staff on proper PPE usage as well as risk factors for following infection control guidelines. •Res. 200 was sent to Covid recovery unit and has since returned to facility. •Complete house audit was done by DNS to ensure appropriate precautions are in place with proper signage and PPE outside room. •All new residents admitted unvaccinated are at risk. •DNS or designee will complete audits on new admissions 5 days per week to ensure all new admissions that are unvaccinated, have appropriate precautions including signage and PPE in place. This audit will be completed for 3 months and then monthly until substantial compliance has been achieved. Results of these audits will be brought to QAPI. •Nurses will be in-serviced by DNS or designee regarding policy of gowning while completing covid testing of staff and residents. •DNS or designee will audit the nurse completing covid testing weekly to ensure policy being followed as outlined in Avamere policy as well as CDC policy. This audit will be completed for 3 months and then monthly until substantial compliance has been achieved. Results of this audit will be brought to QAPI.

Based on interview and record review it was determined the facility failed to designate a qualified and trained Infection Preventionist for 1 of 1 facility reviewed for Infection Prevention and Control. This placed residents at increased risk for contracting an infection. Findings include: The CDC's Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, updated 2/2/22, stated a strong infection prevention and control (IPC) program is critical to protect both residents and healthcare personnel. An IPC program should be assigned to one or more individuals with training in infection prevention and control to provide on-site management of the IPC program. On 2/17/22 at 1:06 PM Staff 2 (Interim DNS) stated the facility did not have an Infection Preventionist. She stated she did not take the Infection Preventionist training course and was not certified. On 2/22/22 at 10:30 AM Staff 1 (Administrator) stated the facility did not have an Infection Preventionist (IP) and did not have anyone certified in that role. Staff 1 stated his expectation was to have a certified IP.

"Facility currently has a part time IP. This IP is currently in the process of becoming certified. We estimate completing by 4/1/22 "Facility will have assistance from other Avameres IP until King Citys IP has become certified. "RNC or designee will complete inservice for Admin. And DNS regarding regulations of IP requirements

411-086-0140 Nursing Services: Problem Resolution and Prevention Refer to F-692 ******************************************** 411-086-0250 Dietary Services Refer to F-812 *************************************************** 411-086-0330 Infection Control and Universal Precautions Refer to F-880 **************************************************** 411-085-0220 Infection Control: Licensee, Employees, Consultants Refer to F-882

Based on observation, interview, and record review, it was determined the facility failed to respond in a timely manner to a resident's request for assistance with toileting for 1 of 3 sampled residents (#15) reviewed for dignity. This placed residents at risk for psychosocial harm. Findings include: Resident 15 admitted to the facility in 8/2021 with diagnoses including a traumatic brain injury and a history of falls. The 8/20/21 Bowel and Bladder Evaluation indicated Resident 15 "always" voided appropriately without incontinence and was "never" incontinent of stool. The assessment indicated the resident was alert and oriented and was "always" aware of the need to toilet. The 8/24/21 Admission MDS indicated Resident 15 was occasionally incontinent of bladder and frequently incontinent of bowel. The resident had a BIMs of 8, indicating moderately impaired cognition. The 8/24/21 Urinary Incontinence CAA indicated Resident 15 was occasionally incontinent of bladder and needed assistance with toileting due to diagnoses. The resident was frequently incontinent of bowel since admission but had some toileting awareness. Resident 15 was at risk for skin breakdown due to incontinence and was on Lasix (diuretic) which could exacerbate toileting function with urgency and frequency. The 9/22/21 care plan indicated Resident 15 required one-person staff assistance for toileting and had mixed bladder incontinence. Interventions included: the resident's brief size and "incontinent program total incontinence." The Bladder Task Sheets were reviewed from 8/25/21 through 9/23/21 (30 days). Resident 15 was noted as continent of bladder on 13 shifts and was both continent and incontinent of bladder on 15 shifts. On 9/23/21 at 8:21 AM Resident 15's call light was observed on. Resident 15 stated to the surveyor she/he needed to "poop". The surveyor could smell a strong odor of urine coming from Resident 15. At 8:23 AM Staff 20 (CNA) was observed to turn off the call light and go into another resident room. On 9/23/21 at 8:24 AM Resident 15 stated staff did not assist her/him to the toilet and turned off the call light. Resident 15 stated she/he was able to use the toilet, but it could take staff up to 20 minutes to assist, so the resident had "accidents" due to staffing shortages. Resident 15 stated staff would often turn off her/his call light without assisting her/him. The resident stated she/he could not walk but knew when she/he had to have bowel movement or urinate, and staff let the resident soil her/himself and would "just clean me up." At 8:59 AM Resident 15 stated she/he had urinated in her/his brief while waiting and the sensation to have a bowel movement "went away." Resident 15 stated she/he felt "frustrated" when she/he was not assisted and was left in a soiled brief. On 9/23/21 at 9:23 AM staff had still not assisted Resident 15 with toileting. The surveyor observed Staff 20 and Staff 21 (CNA) gowning for a different resident room and stopped them. Staff 20 and Staff 21 stated Resident 15 was incontinent per their knowledge. Staff 20 acknowledged she turned off the call light due to not wanting a "long call light time" and stated Resident 15 had wanted "to poop." Staff 20 stated she was unable to assist Resident 15 with toileting due to staffing as she and Staff 21 were the only CNAs for the hall and were working their way down the hall changing residents. On 9/23/21 at 9:30 AM Resident 15 had a scheduled meeting with family and administrative staff with the door closed. Resident 15 was still not changed. At 9:55 AM Resident 15 was assisted with incontinence care. On 10/4/21 at 10:45 AM Staff 26 (LPN Resident Care Manager) stated Resident 15 was incontinent, but when the resident was admitted she/he had mixed incontinence. The resident requested to use the toilet, but rarely voided, but Staff 26 stated she wanted staff to keep offering to toilet the resident. Staff 26 acknowledged the long wait time for Resident 15 to be toileted and expected staff not to turn off the call light before providing care. Refer to F677 and F725.

"Resident 15, no longer a resident at facility. "All residents that require assistance with toileting are at risk "DNS or designee will in-service-CNA and CMA, Licensed Nurses, IDT on facility standards for call light response of 15 to 20 minutes. Educate staff on dignity related to response of call lights and necessary care. "Administrator/DNS or designee will audit call light responses and audit by interview, 5 residents to ensure needs are met and dignity respected. no less than 5 random shifts weekly x 4 weeks. Then 1 x week for 4 weeks. Then Monthly x 2 month or until substantial compliance met. Results will be brought to QA for 3 months.

Based on observation, interview and record review it was determined the facility failed to ensure a resident's environment accommodated the individual needs and preferences for 1 of 3 sampled residents (#14) reviewed for pressure ulcers. This placed residents at risk for contractures and skin breakdown. Findings include: Resident 14 was readmitted to the facility in 6/2021 with diagnoses including hemiplegia (paralysis to one side of the body). The 8/1/21 BIMS indicated Resident 14 was cognitively intact. On 9/30/21 at 9:46 AM Resident 14 was observed lying in bed with her/his head near the top of the mattress and her/his knees bent and feet were close to the footboard. On 9/30/21 at 9:46 AM Resident 14 stated her/his bed was too short and that she/he could not stretch all the way out in bed. On 9/30/21 at 11:29 AM Staff 9 (CNA) acknowledged the bed was too short for the resident. Staff 9 stated she believed the resident had been using the bed for about six months and she requested a longer bed for the resident from the resident care managers on a few occasions. On 9/30/21 at 11:44 AM Staff 29 (Regional RN) observed Resident 14 in bed and acknowledged her/his bed was too short and the resident could not stretch her/his legs out all of the way.

"Resident 14, has received appropriately sized bed "All residents are at risk for improper reasonable accommodations "DNS or Designee will in-service Nursing and IDT on observation and notification of residents individual needs and preferences regarding their bed sizing "DNS or Designee will audit all residents while physically in bed and upon admission. Quarterly during care conference and PRN per resident grievance. Audit and Grievance log will be brought to QA for next 3 month or until substantial compliance met.

Based on observation, interview and record review it was determined the facility failed to ensure residents were free from neglect. The facility failed to identify, monitor and assess residents at risk for aspiration. The facility failed to ensure there was adequate staffing in place to meet acuity levels, which lead to the inability to provide bathing assistance for an entire hall, inability to provide toileting assistance in a timely manner, and the inability to monitor residents identified at risk for falls (resulting in hospitalization and reoccurring falls). The facility failed to ensure medications were passed without errors and to ensure there was a program in place for systemic medication error identification, analysis and action. The cumulative effect of these failures in providing care and services contributed to an environment of neglect for 10 of 34 residents (#s 1, 5, 15, 16, 17, 22, 25, 31, 32, and 33) reviewed. Findings include: According to the Centers for Medicare & Medicaid Services (CMS), §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." ASPIRATION RISK Resident 1 Resident 1's 6/24/21 Physician Order indicated Resident 1 was on aspiration precautions with close supervision, no water pitcher or thin liquids at bedside, and small bites, small sips, and "slow rate." On 9/20/21 the following was observed during continuous observations: *12:27 PM Resident 1 was observed to have fluids at her/his bedside within reach. The Survey Team asked Staff 3 (Speech Pathologist) about Resident 1's aspiration status. Staff 3 removed the liquids in front of Resident 1 and confirmed there was both juice and water at bedside. *Resident 1 was observed to have a pink sign above the bed which indicated the resident was on aspiration precautions and required close supervision with meals and to encourage small bites, small sips, and slow rate. *12:42 PM Staff 4 (CNA) was observed exiting Resident 1's room and closed the door. Staff 4 stated Resident 1 had food in her/his room, she had just set the resident up, and the resident was eating independently. *12:43 PM Surveyors and Staff 4 entered Resident 1's room and observed the resident eating a pureed meal independently. Staff 4 stated Resident 1 was supposed to be supervised while eating. *12:52 PM Surveyor knocked on Resident 1's closed door, looked in the room and observed Resident 1 continuing to feed her/himself with no staff present. Two cups of fluid were also observed within reach of the resident. *12:58 PM Staff 5 (LPN Resident Care Manager) stated Resident 1 required "intermittent supervision" and the facility was in the process of changing the resident's care plan. Staff 5 removed the two drink cups from Resident 1's bedside. On 9/20/21 at 1:47 PM Staff 2 (DNS) was asked for the assessment or order for intermittent supervision and stated she was unable to find an assessment or order which indicated Resident 1 required intermittent supervision. On 9/20/21 at 2:48 PM Staff 1 (Administrator) and Staff 2 (DNS) confirmed the most recent signed physician orders were correct and indicated Resident 1 required close supervision with meals and no liquids at bedside. Staff 2 confirmed Resident 1 had not been assessed by the speech pathologist since 4/2020. Staff 1 and Staff 2 confirmed intermittent supervision was inaccurate. Refer to F689. STAFFING Resident 17 Resident 17's 3/8/21 Admission Fall Assessment indicated Resident 17 was at high risk for falls due to incontinence, medication use, and experienced multiple falls prior to admission. The Resident's 3/9/21 Baseline Fall Care Plan indicated Resident 17 was "(high, moderate, low)" risk for falls related to: the resident had an actual fall with "no injury, minor injury, serious injury." Interventions included: monitor for decline or improvement in mobility, wear non-skid socks, and ensure the call light was within reach at all times. The resident required two staff-person assistance with transfers. The resident sustained falls in the facility on 3/15/21, the morning of 3/29/21, and the evening of 3/29/21. The 3/29/21 Fall Investigation indicated Resident 17 had an unwitnessed fall and was found on the floor lying on her/his back in the assisted dining room at approximately 8:15 PM with no staff present. The resident reported she/he tried to transfer from the locked wheelchair to a dining room chair. Resident 17 reported her/his baseline low back pain worsened significantly after the fall with 6/10 pain noted. The resident had fallen earlier that morning and received neurological checks. Staff 57 (CNA) stated Resident 17 was restless and attempting to get out bed, so he "wheeled" the resident to the assisted dining room to sit with two other residents. Staff 56 (CNA) stated she last visualized the resident in the dining room at 8:00 PM while walking by and the resident was not attempting to transfer. Resident 17 was sent to the hospital and was diagnosed with a lumbar fracture. Hospital records indicated Resident 17 was hospitalized from 3/29/21 through 4/6/21 and sustained closed compression fractures of the L2 and L3 vertebra and noted baseline low back pain was worse after the fall on 3/29/21. On 10/1/21 at 2:20 PM Staff 34 (CNA) stated Resident 17 was at times impulsive with transfers. Staff 34 stated there were concerns related to monitoring residents due to staffing shortages and staff attempted to monitor residents, but a lot of times staff were so busy they were unable to check on residents. On 10/4/21 at 2:59 PM Staff 57 (CNA) stated he could not recall specifics regarding Resident 17's fall but stated staff were not able to monitor residents who were at risk for falls. Refer to F689 and F725 FALLS Resident 5 Resident 5's Fall Care Plan was initiated and last updated on 6/2/21. The resident was noted as a high risk for falls due to a history of multiple falls. A fall investigation indicated on 8/17/21 at approximately 5:30 AM, Resident 5 was found on the floor mat next to the bed facing the foot of the bed. Resident 5 was observed to be "frail, quiet, and bloody." The resident sustained an upper lip and forehead laceration with "copious amounts" of blood noted. Resident 5 was non-verbal; pain was assessed at 3/10. The resident was last observed at 3:00 AM and then not observed again until 5:30 AM. The investigation summary indicated falls continued to be "difficult to prevent" and the facility would continue to care plan against major injury. On 8/17/21 Hospital Records indicated Resident 5 required sutures to repair her/his head laceration. The 8/19/21 Fall Assessment indicated Resident 5 was a high fall risk and had multiple falls (more than two) in the past six months at the facility. On 9/23/21 at 1:40 PM Staff 54 (CNA) stated Resident 5 sustained a fall with injury due to staff being "really busy" and him not being able to check on the resident until after 5:00 AM due to staffing shortages. Staff 54 stated Resident 5 sometimes slept through the night but sometimes was impulsive and moved around "a lot" in bed and staff had to watch her/him closely. On 10/6/21 at 10:13 AM Staff 5 (LPN Resident Care Manager) acknowledged the resident was last visualized two and a half hours prior to being found on the floor and the expectation for high fall risks was frequent checks, which she stated was every fifteen minutes. Refer to F689 and F725 Resident 25 Resident 25's 9/19/21 Annual MDS Fall CAA revealed Resident 25 was at risk for falls related to impaired gait and balance, a history of falls and the use of anti-depressant medication. The CAA indicated Resident 25 had difficulty with ambulation and periods of increased confusion. The 9/19/21 Annual Dementia CAA revealed Resident 25 needed reminders and cueing for some ADL's and general supervision for safety due to impaired functional mobility and being a fall risk. It further indicated Resident 25 had impaired safety awareness and was not always cognizant of her/his mobility limitations. The 9/30/20 Fall Care Plan revealed Resident 25 was at risk for falls related to decreased mobility, activity intolerance and poor safety awareness secondary to Parkinson's Disease and associated cognitive impairment and deconditioning. Interventions included frequent checks for safety. The facility fall incident report revealed Resident 25 sustained five falls in a 27 day look-back period between 9/7/21 through 10/4/21. The 9/7/21 Fall Investigation indicated Resident 25 was found on the floor in her/his room. Resident 25 indicated she/he slid out of bed when she/he attempted to transfer to the wheelchair. The 9/9/21 Fall Investigation indicated Resident 25 was found lying on the floor in her/his room next to the bed with one arm wrapped around the assistive transfer pole. Resident 25 was disoriented and confused. Resident 25 had attempted to transfer into the wheelchair, slipped on the floor and hit her/his head. Resident 25 was last checked on one and a half hours prior to the incident. Resident 25 was transferred to the hospital that same day. The 9/28/21 2:28 AM Fall Investigation indicated Resident 25 was found on the floor of her/his room yelling for help. Resident 25 indicated she/he attempted to stand-up to urinate, slipped and fell to the floor. The investigation indicated the resident was last seen 40 minutes prior to the fall. The 9/28/21 8:50 AM Fall Investigation indicated Resident 25 was found on the floor next to the bed and transfer pole. Resident 25 indicated she/he slid off the bed when she/he attempted to get up to use the urinal. The investigation indicated Resident 25 was last seen approximately one hour before the fall. A 10/4/21 Progress Note indicated Resident 25 was found on the floor by her/his bed. Resident 25 indicated she/he slid out of bed onto the floor when she/he reached for the urinal. [The Fall Investigation was not yet completed as of 10/4/21.] On 9/29/21 at 1:55 PM Staff 56 (CNA) indicated Resident 25 needed to be monitored more frequently due to being a fall risk. Staff 56 indicated she/he and other staff informed the administrative staff on multiple occasions of the concern and reported the resident should not be left unassisted due to her/his multiple falls but the administrative staff had not updated her/his plan of care. On 10/1/21 at 9:58 AM Staff 12 (CNA) stated Resident 25's room was at the end of the hall, there was not enough staff to monitor Resident 25, she/he was very impulsive and a fall risk. Staff 12 stated she had repeatedly informed management of this concern until she was "blue in the face" however Resident 25's plan of care did not change. On 10/1/21 at 1:21 PM Staff 26 (LPN Resident Care Manager) stated Resident 25 was constantly falling and she was running out of ideas how to update her/his plan of care. Staff 26 acknowledged no fall interventions were updated in 9/2021 after any of the falls. Staff 26 stated frequent checks were every two hours and further stated this was "not ideal." Staff 26 verified Resident 25 required more supervision but the facility could not accommodate this need due to current staffing levels. Refer F725. ADL Assistance Resident 15 a. Resident 15's 8/20/21 Bowel and Bladder Evaluation indicated Resident 15 "always" voided appropriately without incontinence and was "never" incontinent of stool. The assessment indicated the resident was alert and oriented and was "always" aware of the need to toilet. The 8/24/21 Admission MDS indicated Resident 15 was occasionally incontinent of bladder and frequently incontinent of bowel. The resident had a BIMs of 8, indicating moderately impaired cognition. The 8/24/21 Urinary Incontinence CAA indicated Resident 15 was occasionally incontinent of bladder and needed assistance with toileting due to diagnoses. The resident was frequently incontinent of bowel since admission due to physiological and functional reasons but had some toileting awareness. The 9/22/21 Care Plan indicated Resident 15 required one-person staff assistance for toileting and had mixed bladder incontinence. Interventions included: the resident's brief size and "incontinent program: total incontinence." On 9/23/21 at 8:21 AM Resident 15's call light was observed on. Resident 15 stated she/he needed to "poop." At 8:23 AM Staff 20 (CNA) was observed to turn off the call light and go into another resident room. On 9/23/21 at 8:24 AM Resident 15 stated staff did not assist her/him to the toilet and turned off the call light. The surveyor could smell a strong odor of urine coming from Resident 15's brief. Resident 15 stated she/he was able to use the toilet, but it could take staff up to 20 minutes to assist so the resident had "accidents" due to staffing shortages. Resident 15 stated staff would often turn off her/his call light without assisting her/him. The resident stated she/he knew when she/he had to have bowel movement or urinate, and staff let the resident soil her/himself and would "just clean me up". At 8:59 AM Resident 15 stated she/he had urinated in her/his brief while waiting and the sensation to have a bowel movement had "went away." Resident 15 stated she/he felt "frustrated" when she/he was left in a soiled brief. On 9/23/21 at 9:23 AM staff had still not assisted Resident 15 with toileting. Staff 20 and Staff 21 (CNA) stated Resident 15 was incontinent per their knowledge. Staff 20 acknowledged she turned off the call light due to not wanting a "long call light time" and stated Resident 15 had wanted "to poop." Staff 20 stated she was unable to assist Resident 15 with toileting due to staffing as she and Staff 21 were the only CNAs for the hall and were working their way down the hall changing residents. Refer to F550 and F725. b. Resident 15's 8/24/21 Admission MDS indicated Resident 15 was moderately cognitively impaired and the resident required staff physical assistance with bathing. Resident 15's current care plan indicated the resident was totally dependent on staff for bathing. On 9/21/21 at 5:52 PM and 6:23 PM Staff 21 (CNA) stated she had two showers scheduled for that night, but she was unable to complete them, including for Resident 15, as she was the only CNA for the hall. Staff 21 stated if she was unable to complete a shower, she marked either "NA" (Not Available) or "RR" (Resident Refused) on the shower task sheet and would let the charge nurse know. The 9/21/21 Bathing/Shower Task Sheet indicated the Resident 15 did not receive a shower and the reason was marked "NA". On 10/6/21 at 11:31 AM Staff 26 (LPN Resident Care Manager) acknowledged Resident 15 did not receive a shower on 9/21/21. Refer to F725. Resident 22 a. Resident 22 admitted to the facility in 2/2017 with diagnoses including heart failure and diabetes. The 6/30/21 Quarterly MDS indicated Resident 22 was cognitively intact and required assistance with bathing. Resident 22's current care plan indicated the resident required staff assistance with bathing. On 9/21/21 at 5:52 PM and 6:23 PM Staff 21 (CNA) stated she had two showers scheduled for that night, but she was unable to complete them, including for Resident 22, as she was the only CNA for the hall. Staff 21 stated if she was unable to complete a shower, she marked either "NA" (Not Available) or "RR" (Resident Refused) on the shower task sheet and would let the charge nurse know. On 9/21/21 at 7:17 PM Resident 22 stated she/he was unable to receive a shower due to staffing shortages and there was only one CNA for 13 residents. Resident 22 stated she/he recently missed two showers due to staffing. Resident 22 stated she/he felt "dirty" when she/he did not receive scheduled showers. The 9/21/21 Bathing/Shower Task Sheet indicated the Resident 22 did not receive a shower and the reason was marked "NA". On 10/6/21 at 11:31 AM Staff 26 (LPN Resident Care Manager) acknowledged Resident 22 did not receive a shower on 9/21/21. Refer to F725. Resident 16 Resident 16's 3/31/21 care plan indicated Resident 16 required assistance with bathing. Review of the April 2021 bathing record indicated Resident 16 was to receive bathing in the evening, PRN. The records indicated the resident received a shower on 4/14/21. No other showers were indicated as given for the month. Interviews were conducted from 9/30/21 through 10/4/21 with Staff 25 (CNA), Staff 33 (CNA), Staff 34 (CNA), Staff 35 (CNA), Staff 36 (CNA) and Staff 38 (CNA); all staff worked with Resident 16. Staff stated the resident was scheduled to receive showers in the evening. Staff stated they could not recall Resident 16 receiving a shower or refusing to be bathed. Staff stated if a scheduled shower was not given the system alerted staff in "red." On 10/4/21 at 10:45 AM and 10/6/21 at 11:31 AM Staff 26 (LPN Resident Care Manager) could not confirm Resident 16 received a shower more than one time in 4/2021. MEDICATION PASS ERRORS Resident 31 Resident 31's 9/16/21 physician order indicated Resident 31 was to receive Depakote (a mood stabilizer) BID and Roxicodone (pain medication) 2.5 mg BID. The 9/2021 MAR indicated Resident 31 was to receive Depakote and Roxicodone between 7 AM and 10 AM. On 9/21/21 at 11:22 AM Staff 6 (CMA) was observed to administer Depakote and Roxicodone to Resident 31. On 9/21/21 at 11:30 AM Staff 6 acknowledged the late medication administration for Depakote and Roxicodone. Resident 32 Resident 32's 9/16/21 physician order indicated Resident 32 was to receive omeprazole once daily prior to meals. The 9/2021 MAR indicated omeprazole was to be administered at 7:30 AM daily. On 9/22/21 at 12:26 PM Staff 7 (LPN) was observed to administer omeprazole to Resident 32. On 9/22/21 at 12:28 PM Staff 7 acknowledged the omeprazole was due before breakfast and the resident did not receive it until 12:26 PM. Resident 33 Resident 33's 9/16/21 physician order indicated Resident 33 was to receive baclofen TID for muscle spasms and gabapentin TID for pain related to stroke. On 9/22/21 at 12:10 PM Staff 7 (LPN) was observed to administer the morning dose of baclofen and gabapentin to Resident 33. The 9/2021 MAR indicated the medications were to be administered between 7 AM and 10 AM. On 9/22/21 at 12:10 PM Staff 7 acknowledged the baclofen and gabapentin were due earlier that morning and stated the afternoon doses would have to be administered later that day since they were both TID medications. A record review was completed on 9/22/21 at 2:55 PM and indicated Resident 33 received the noon dose of baclofen at 2:20 PM. On 9/22/21 at 2:55 PM the administration times of baclofen and gabapentin were reviewed with Staff 29 (Regional RN). On 9/22/21 at 3:06 PM Staff 29 stated the physician was notified of the administration times of baclofen and gabapentin and Resident 33 was placed on alert charting to monitor for potential side effects. Refer to F759 QAPI The 2/2020 Quality Assurance and Performance Improvement (QAPI) Program policy statement revealed the committee would measure current and potential indicators for outcomes of care and quality of life, establish and implement performance improvement projects to correct identified negative or problematic indicators, reinforce and build upon effective systems and processes related to the delivery of quality care and services and establish systems to monitor and evaluate corrective actions. The committee would meet monthly. Review of the facility documents revealed from 1/2020 through 10/4/21 the QAA committee met on 1/28/20, 10/21/20 and 4/1/21. On 10/4/21 at 9:20 AM Staff 1 (Administrator) stated the QAA committee met quarterly and the QAA committee identified quality care deficiencies by reviewing a checklist from each department and reviewing grievances. Staff 1 indicated short staffing levels were identified. On 10/4/21 at 11:45 AM Staff 1 stated he knew the QAA meetings were required to be held at a minimum of every three months. Staff 1 further stated between 1/2020 through 10/4/21 only three QAA meetings were held on 1/28/20, 10/21/20 and 4/1/21. On 10/4/21 at 3:10 PM Staff 2 (DNS) stated the last QAA committee she attended was in 4/2021 and verified the QAA team had not met for over six months. She further stated the QAA committee did not monitor any concerns and no action plans were in place for residents who were at risk for aspiration or falls. On 10/4/21 at 3:15 PM Staff 48 (Social Services) stated the last QAA committee she attended was in 4/2021 and verified the QAA team had not met for over six months. She further stated the QAA committee did not monitor any concerns and no action plans were in place for residents who were at risk for aspiration or falls. The QAA committee did not identify Resident 1, who was at high risk for aspiration, was not supervised along with twelve additional residents at risk for aspiration. The QAA committee did not identify the 33 identified residents at risk for falls and hospitalization. The facility did not have a working system in place to address the residents at high risk for aspiration and falls. Refer to F867 and F868.

"All residents are at risk for Abuse and Neglect "Administrator/DNS or designee to provide in-service on company abuse and neglect policy "Please see Plan of corrections for: F725 -All Residents are at risk of not having sufficient staffing levels to meet their care needs -Regional team member will in-service Administrator, DNS and HR Director on the federal regulation on staffing to acuity to meet residents needs. Facility is currently utilizing 7 agency contracts to fill open nursing shifts, as well as offering incentives to pick up or switch shifts. Facility is also sponsoring 3 PCA in a local NA course. Town hall meetings will be conducted 1 x month to address employee concerns and brainstorm new ideas. -Administrator or designee will audit daily staffing levels versus acuity bi-weekly for 4 weeks. Then weekly x 2 months. Then monthly for 2 months. Results brought to QA F550 -Resident 15, no longer a resident at facility. -All residents that require assistance with toileting are at risk -DNS or designee will in-service-CNA and CMA, Licensed Nurses, IDT on facility standards for call light response of 15 to 20 minutes. Educate staff on dignity related to response of call lights and necessary care. -Administrator/DNS or designee will audit call light responses and audit by interview, 5 residents to ensure needs are met and dignity respected. no less than 5 random shifts weekly x 4 weeks. Then 1 x week for 4 weeks. Then Monthly x 2 month or until substantial compliance met. Results will be brought to QA for 3 months. F759 -Resident 31, 32 and 33 are still residents at facility. -All residents at risk for late administration of medications -DNS or designee will in-service all Licensed nurses and CMA's on medication administration and process of late medication. All LN and CMA, new hires and agency LN/CMA will have Orientation Competency checklist completed -DNS or designee will audit for late meds Monday through Friday weekly no less than 5 times for 4 weeks, weekend med pass will be reviewed on Monday. Then weekly x 2 months and then Monthly x 2month and random live time EMAR audits 3 x weekly for 4 weeks. Then 2 x month for 2 months and then monthly for 2 months. Results will be brought to QA for further review and discussion. F867 -All residents currently on aspiration precautions are currently being reevaluated by contracted SLP. To date, there are 2 residents still requiring reevaluation. This will be completed by Wednesday 10/6/21. -All staff have been in serviced regarding aspiration precautions, policy and procedure for this as well as definitions related to types of supervision. -QAPI meeting will be held with IDT and Medical Director on 10/5/21. Root cause analysis will be completed by Admin./DNS/RNC for residents at risk for aspiration and falls. Action plans will be implemented for residents at risk for aspirations, falls as well as staffing. This information will be brought to QAPI, with set audits and schedules to be determined at QAPI. -Monthly QA meeting will be held by Admin. Or designee with line staff wishing to participate in a staff retention committee. This committee will meet to review any issues or concerns regarding staffing or other issues they may bring forth. Resident safety will be priority. Admin. will bring all information forward to QAPI with issues, concerns and corrective plans. This will be reviewed monthly for 6 months and brought to QAPI for no less than 2 quarters. -Staffing Coordinator and Admin. will meet to review staffing needs no less than 3 times per week. Staffing Coordinator will keep a log of all attempts she makes to cover any call offs that may occur. Admin. will review agency contracts to establish contracts with other agencies. Staffing coordinator will document number of available shifts on a weekly basis. This information will be logged with corrective actions taken and brought to QAPI quarterly. Admin. Will set up a blind survey for staff to participate in to request any concerns they have as well as suggestions. These areas will be brought to monthly QA and quarterly QAPI. F868 "No specific resident "All residents at risk for adverse outcomes for facility failure to identify improvement areas "RDO or Designee will in-service Admin on state QA regulation "Admin or designee will audit monthly QA completion, required attendance 1 x month for next 3 months and then quarterly after.

Based on interview and record review it was determined the facility failed to report timely or failed to report a fall with fracture and potential neglect of care to the appropriate State Agency for 2 of 4 residents (#s 5 and 17) reviewed for falls. This placed residents at risk for neglect and injury. Findings include: 1. Resident 17 admitted to the facility on 3/8/21 with diagnoses including diabetes and a history of repeated falls. Resident 17 discharged from the facility on 4/30/21. The 3/8/21 Admission Fall Assessment indicated Resident 17 was at high risk for falls due to incontinence, medication use, and had experienced multiple falls prior to admission. The resident sustained falls in the facility on 3/15/21, the morning of 3/29/21, and the evening of 3/29/21. a. The 3/29/21 fall investigation indicated Resident 17 had an unwitnessed fall and was found on the floor lying on her/his back in the assisted dining room at approximately 8:15 PM. The resident reported she/he tried to transfer from the locked wheelchair to a dining room chair. Resident 17 reported her/his baseline low back pain worsened significantly after the fall with 6/10 pain noted. The resident had fallen earlier that morning and received neurological checks. Staff 57 (CNA) stated Resident 17 was restless and attempted to get out bed, so he "wheeled" the resident to the assisted dining room to sit with two other residents. Staff 56 (CNA) stated she last visualized the resident in the dining room at 8:00 PM. The summary indicated Resident 17 was sent to the hospital and was diagnosed with a lumbar fracture. The investigation was completed and signed by the administrator on 4/1/21. Hospital records indicated Resident 17 was hospitalized from 3/29/21 through 4/6/21 and sustained a closed compression fractures of the L2 and L3 vertebra. Baseline low back pain was noted as worse after the fall on 3/29/21. On 10/4/21 at 10:53 AM Staff 26 (LPN Resident Care Manager) stated if a resident sustained a fall with fracture the facility would report the incident to the appropriate State Agency. Staff 26 did not believe there was a Facility Reported Incident (FRI) submitted for Resident 17's fall with fracture on 3/29/21. On 10/6/21 at 12:25 PM Staff 1 (Administrator) stated there was no FRI submitted to the appropriate State Agency for Resident 17's 3/29/21 fall with a lumbar fracture. Refer to F689 and F725. b. A fall investigation indicated on 3/15/21 Resident 17 had an unwitnessed fall and was found under her/his bathroom sink by Witness 11 (Former Physical Therapist). The report indicated the resident had no new pain, but had continued left shoulder, hip, and back pain. Pain was rated as 6/10. Later in the report, it was noted Resident 17 had increased pain (8/10). The resident was sent out to the hospital on 3/17/21 for decreased cognition and increased back pain. The investigation indicated concerns regarding Witness 10 (Former LPN) not assessing Resident 17 post fall. The investigation summary indicated neglect could not be ruled out. A Facility Reported Incident (FRI) was received on 3/17/21, two days after the alleged incident occurred. On 10/6/21 at 12:25 PM Staff 1 (Administrator) acknowledged the facility did not submit the FRI report to the appropriate State Agency within the required time frame. Refer to F725 and F689. 2. Resident 5 admitted to the facility in 9/2019 with diagnoses including Parkinson's Disease, Alzheimer's Disease, and muscle weakness. A fall investigation indicated on 8/17/21 at approximately 5:30 AM, Resident 5 was found on the floor mat next to the bed facing the foot of the bed. Resident 5 was observed to have a forehead laceration with "copious amounts" of blood. Witness statements indicated the resident was last observed at 3:00 AM. The resident was transferred to the hospital. On 8/17/21 Hospital Records indicated Resident 5 required sutures to repair her/his head laceration. The 8/19/21 Fall Assessment indicated Resident 5 was a high fall risk and had "multiple" falls (more than two) in the past six months at the facility. On 9/23/21 at 1:40 PM Staff 54 (CNA) stated Resident 5 sustained a fall with injury due to staff being "really busy" and him not being able to check on the resident until after 5:00 AM. Staff 54 stated this was due to resident acuity and staff shortages. Staff 54 stated Resident 5 was sometimes was impulsive and moved around "a lot" in bed and staff had to watch her/him closely. On 10/6/21 at 10:13 AM Staff 5 (LPN Resident Care Manager acknowledged the resident was last visualized two and a half hours prior to being found on the floor and the expectation for high fall risks was frequent checks, which she stated was every fifteen minutes. On 10/6/21 at 12:10 PM Staff 1 (Administrator) and Staff 29 (Regional RN) acknowledged Resident 5 was not observed for over two hours on 8/17/21 and was a high fall risk. The facility was asked to provide evidence a Facility Reported Incident (FRI) was sent to the appropriate State Agency. On 10/6/21 at 12:25 PM Staff 1 stated there was no FRI submitted for Resident 5's 8/17/21 fall with injury. Refer to F725 and F689.

"Resident 17 is no longer a resident at facility. Resident 5 still resides at facility "Resident 5 and All residents are at risk for facility failure to report abuse or neglect in a timely manner Regional Team member will in-service Administrator and DNS on regulations for reporting abuse and neglect. Admin/DNS or designee will in-service All staff on company Abuse and Neglect policy. In-service Nursing staff to contact Admin or DNS to review any minor/major injuries for review. "Administrator/DNS or Designee will audit all falls daily, falls over weekend will be reviewed Monday for next 2 weeks for compliance. Then 1 x week for 2 weeks. Then Random audit of falls monthly for 2 months or until substantial compliance met. Results brought to QA for 3 months

Based on observation, interview and record review it was determined the facility failed to review and revise fall care plans for 2 of 4 sampled residents (#s 5 and 25) reviewed for falls. This placed residents at risk for increased falls and hospitalization. Findings include: 1. Resident 25 admitted to the facility in 2019 with diagnoses including Parkinson's Disease, dementia and a history of falls. On 10/1/21 at 10:02 AM Resident 25 was observed in her/his room at the end of the hall with her/his legs halfway off the bed and feet on the floor. The 9/19/21 Annual MDS Fall CAA revealed Resident 25 was at risk for falls related to impaired gait and balance, a history of falls and the use of anti-depressant medication. The CAA indicated Resident 25 had difficulty with ambulation and periods of increased confusion. The 9/19/21 Annual MDS Dementia CAA revealed Resident 25 needed reminders and cueing for some ADLs and general supervision for safety due to impaired functional mobility and being a fall risk. It further indicated Resident 25 had impaired safety awareness and was not always cognizant of her/his mobility limitations. The 9/30/20 Fall Care Plan revealed Resident 25 was at risk for falls related to decreased mobility, activity intolerance and poor safety awareness secondary to Parkinson's Disease, associated cognitive impairment, and deconditioning. Interventions included to continue RA (restorative aide) program, frequent checks for safety, offer assistance when transferred and to wear non-skid socks. The last intervention revision date was on 1/5/21. The facility fall incident report revealed Resident 25 sustained five falls in a 27 day look-back period between 9/7/21 through 10/4/21. Resident 25 fell on 9/7/21, 9/9/21, 9/28/21 twice and 10/4/21. On 9/29/21 at 1:55 PM Staff 56 (CNA) indicated Resident 25 needed to be monitored more frequently due to being a fall risk. Staff 56 indicated she/he and other staff informed the administrative staff on multiple occasions of the concern. Staff 56 further stated Resident 25 should not be left unattended due to her/his multiple falls but the administrative staff had not updated her/his plan of care. On 10/1/21 at 9:58 AM Staff 12 (CNA) stated Resident 25's room was at the end of the hall, there was not enough staff to monitor Resident 25, she/he was very impulsive and a fall risk. Staff 12 stated she had repeatedly informed management of this concern until she was "blue in the face" however Resident 25's plan of care did not change. On 10/1/21 at 1:21 PM Staff 26 (LPN Resident Care Manager) stated Resident 25 was constantly falling and she was running out of ideas how to update her/his plan of care. Staff 26 stated the intervention of frequent checks meant checking on the resident at least once every two hours. Staff 26 further stated the 9/30/20 Fall Care Plan interventions were not evaluated or revised in a timely manner and were not updated in 9/2021 after any fall. , 2. Resident 5 admitted to the facility in 9/2019 with diagnoses including Parkinson's Disease, Alzheimer's Disease, and muscle weakness. Resident 5's fall care plan was initiated and last updated on 6/2/21. The resident was noted as a high risk for falls due to a history of multiple falls. Interventions included: call light within reach, keep bed in lowest position, place padded mat on both sides of the bed when in bed, non-skid footwear as tolerated, notify the family/responsible party and the physician of any fall, use gait belt with transfers, review and update fall assessment quarterly, post any fall and PRN, and the resident required two-person staff assistance with transfers. A fall investigation indicated on 8/17/21 at approximately 5:30 AM, Resident 5 was found on the floor mat next to the bed facing the foot of the bed. Resident 5 was observed to have a forehead laceration with "copious amounts" of blood. Witness statements indicated the resident was last observed at 3:00 AM. There was no indication of what care plan interventions were in place at the time of the fall other than the fall mat. The investigation summary indicated falls continued to be difficult to prevent and the facility would continue to care plan against major injury. The 8/19/21 fall assessment indicated Resident 5 had multiple falls in the past six months. On 10/6/21 at 10:13 AM Staff 5 (LPN Resident Care Manager) stated the expectation for fall investigations was to state if the resident care plan interventions were in place at the time of the fall, if the care plan was reviewed, if current interventions were effective, and to update interventions to prevent further falls. Staff 5 acknowledged Resident 5's care plan was initiated on 6/2/21 and was not updated since that date. Staff 5 acknowledged the resident was unable to use her/his call light, therefore the intervention for the call light in reach was not appropriate. Refer to F725 and F689.

"Resident 5 and 25 still in facility "All residents are at risk for failure to update Fall care plan revision "DNS or Designee will in-service All Licensed nurses and Care mangers on care plan revision policy. "Administrator/DNS or Designee will audit all falls and falls care plans daily, falls and fall care plans over weekend will be reviewed Monday for 2 weeks for compliance. Then 1 x week for 2 weeks. Then Random audit of falls monthly for 2 months or until substantial compliance met. Results brought to QA for 3 months.

Based on interview and record review it was determined the facility failed to ensure Staff 2 (DNS) adhered to professional standards related to documentation for 1 of 12 sampled residents (#1) reviewed for aspiration precautions and 3 of 3 staff reviewed for nursing competencies. This placed residents at risk for inaccurate records, risk for lack of competent nursing care, and death. Findings include: 851-045-0070 Conduct Derogatory to the Standards of Nursing Defined Conduct that adversely affects the health, safety, and welfare of the public, fails to conform to legal nursing standards, or fails to conform to accepted standards of the nursing profession, is conduct derogatory to the standards of nursing. Such conduct includes, but is not limited to: (4) Conduct related to communication: (c) Entering inaccurate, incomplete, falsified or altered documentation into a health record or agency records. This includes but is not limited to: (A) Documenting nursing practice implementation that did not occur; 1. Resident 1 was admitted to the facility in 12/2012 with diagnoses including multiple sclerosis, dysphagia (difficulty swallowing), and pneumonitis (lung infection) due to inhalation of food and vomit. Resident 1's 6/24/21 physician order indicated Resident 1 was on aspiration precautions with close supervision, no water pitcher or thin liquids at bedside, and small bites, small sips, and "slow rate." On 9/20/21 at 12:42 PM Staff 4 (CNA) was observed exiting Resident 1's room and closed the door. Staff 4 stated Resident 1 had food in her/his room, and she had just set the resident up and she/he was eating independently. On 9/20/21 at 12:47 PM Staff 2 (DNS) stated Resident 1 was "close" supervision on the aspiration form but the care plan indicated intermittent supervision so the resident would be changed to intermittent supervision on the aspiration form. On 9/20/21 at 12:52 PM the Surveyor knocked on Resident 1's closed door looked in room and observed Resident 1 continuing to feed her/himself with no staff present in the resident's room. Two cups of liquid were also observed within reach of the resident. On 9/20/21 at 1:00 PM Resident 1's Aspiration Precaution sign was provided and indicated the resident was "intermittent supervision" with meals. On 9/20/21 at 1:47 PM Staff 2 (DNS) was asked for the assessment or order for intermittent supervision and stated she was unable to find an assessment or order indicating Resident 1 required intermittent supervision. On 9/20/21 at 2:48 PM Staff 1 (Administrator) and Staff 2 (DNS) confirmed the most recent signed [9/2021] physician orders were correct and indicated Resident 1 was close supervision with meals and no liquids at bedside. Staff 2 confirmed Resident 1 had not been assessed by the speech pathologist since 4/2020. Staff 1 and Staff 2 confirmed intermittent supervision was inaccurate. Refer to F689, Example 1. 2. On 9/22/21 a request was made for Staff 30's (LPN), Staff 31's (RN), and Staff 32's (CMA) nursing compentencies. On 9/23/21 at 1:55 PM Staff 1 (Administrator) provided copies of staff competencies for Staff 30 (LPN), Staff 31 (RN) and Staff 32 (CMA). The competencies were listed out by task, review date, and if the staff exceeded, met or failed to meet the job requirements. All three competencies were signed by Staff 2, there was no date indicating when the competencies were checked off, and no date of when they were signed as completed. The designated area for the staff to sign and date to indicate it was completed was left blank on all three staff competency lists. All three staff competencies had the DNS initials with "M" next to her initials (for meets job requirements) for the entire checklist of skills with no dates indicated. a. On 9/23/21 at 2:01 PM and 2:29 PM Staff 30 (LPN) stated he never worked with Staff 2 and she did not review his Charge Nurse competencies. Staff 30 further stated he was not formally checked off for nurse competencies and he worked with several floor nurses but not the DNS. The competency paperwork that was provided by Staff 1 was reviewed with Staff 30 and he stated he had not seen the paperwork before and did not know what it was. b. On 9/23/21 at 2:22 PM Staff 32 (CMA) stated she never worked with Staff 2 and she did not review her for CMA competencies. Staff 32 stated she did not remember staff completing competencies during her training. The competency paperwork that was provided by Staff 1 was reviewed with Staff 32 and she did not recall seeing the paperwork before. c. On 9/23/21 at 2:39 PM Staff 31 (RN) stated she never worked with Staff 2 and did review her for Charge Nurse competencies. Staff 31 further stated she did not recall seeing competency paperwork during or after her training was completed. On 9/24/21 at 9:25 AM Staff 40 (Human Resources) stated staff competencies was something the facility was "working on" and she had not seen a staff competency checklist for any facility staff. On 9/24/21 at 9:28 AM the competencies for Staff 30, Staff 31 and Staff 32 were reviewed with Staff 2. Staff 2 stated she was unsure of the date she signed the competencies. She further acknowledged the competencies were undated and was unsure of the dates the skills checklist took place. Staff 2 stated there were "probably a few staff" that she did not physically observe nurse competencies.

"All residents are at risk for facility staff not meeting professional standards Regional team member will in service Administrator and DNS on professional standard and honesty. Admin/DNS or designee will in service IDT on honesty and professional standards. "HR will audit any new hire orientation checklist to ensure signatures are in place. Weekly x 4 weeks. Then monthly x 2 month. Results to QA for 3 months. Administrator/DNS or Designee will audit Aspiration orders, diets and care plan weekly x 3 months and then monthly x 3 months.

Based on interview and record review it was determined the facility failed to ensure residents received restorative therapies as indicated for 2 of 4 sampled residents (#s 14 and 25) reviewed for rehab services and falls. This placed residents at risk for a decline in ADLs and falls. Findings include: 1. Resident 14 was readmitted to the facility in 6/2021 with diagnoses including hemiplegia (paralysis to one side of the body). The 8/1/21 BIMS indicated Resident 14 was cognitively intact. The 12/4/20 and 6/8/21 restorative nursing plan indicated Resident 14 was to receive range of motion to her/his upper and lower extremities at least three times a week. On 9/30/21 at 9:46 AM Resident 14 stated she/he would benefit from receiving more therapy and her/his time with restorative aides was limited. Resident 14 stated she/he could not move her/his legs independently. On 9/30/21 at 12:50 PM Staff 24 (Restorative Aide) stated Resident 14 needed assistance for range of motion exercises and had restorative therapy ordered three times per week. Staff 24 stated she was only able to offer restorative therapy to residents for about half of the past month due to being pulled to the floor to work as a CNA. Resident 14's ADL sheets indicated she/he received restorative therapy on six occasions in 8/2021 and four occasions in 9/2021. There was no documentation indicating the resident refused. On 10/1/21 at 11:31 AM Staff 22 (Therapy Director) stated Restorative Aides were trained to complete passive and active range of motion for Resident 14. Staff 22 further stated RA was the most appropriate treatment for Resident 14 to maintain her/his range of motion in her/his lower extremities. On 9/30/21 at 11:56 AM Staff 29 (Corporate RN) acknowledged documentation indicated Resident 14 did not receive restorative therapy three times a week as ordered in 8/2021 and in 9/2021. Staff 29 further stated the Restorative Aide was pulled to the floor to work as a CNA. , 2. Resident 25 admitted to the facility in 2019 with diagnoses including Parkinson's Disease, dementia and a history of falls. The 9/19/21 Annual MDS Fall CAA revealed Resident 25 was at risk for falls related to impaired gait and balance, a history of falls. The CAA indicated Resident 25 had difficulty with ambulation. The 9/30/20 Fall Care Plan revealed Resident 25 was at risk for falls and an intervention included: to continue an RA program. The facility fall incident report revealed Resident 25 sustained five falls in a 27 look-back period between 9/7/21 through 10/4/21. Review of the medical record did not indicate an active RA program was in place. On 10/1/21 at 1:21 PM Staff 26 (LPN Resident Care Manager) stated Resident 25 constantly fell and stated Resident 25 did not receive RA.

"Resident 14 and 25 are still residents at facility. Care plans and RA program will be reviewed and updated. "All residents in the RA program are at risk. "Administrator/DNS or designee will in-service RA employees and Care Managers and MDS coordinator on assessment completion and care planning process and protocol for missed RA times. 100% review of RA program and care plans complete. Facility will make all efforts to fill shift including weekends prior to RA working the floor, we will contact agency and offer incentives. If RA is pulled a make up day will be offered. "Administrator/DNS or designee will audit RA program completion and for RA make up day weekly for 4 weeks. Then monthly x 2. Results brought to QA

Based on observation, interview and record review it was determined the facility failed to provide the necessary care and services related to bathing and toileting for 3 of 6 sampled residents (#s 15, 16 and 22) reviewed for bathing and toileting. This placed residents at risk for being unclean, having skin breakdown, and psychosocial harm. Findings include: 1. Resident 15 admitted to the facility in 8/2021 with diagnoses including a traumatic brain injury and a history of falls. The 8/20/21 Bowel and Bladder Evaluation indicated Resident 15 "always" voided appropriately without incontinence and was "never" incontinent of stool. The assessment indicated the resident was alert and oriented and was "always" aware of the need to toilet. The 8/24/21 Admission MDS indicated Resident 15 was occasionally incontinent of bladder and frequently incontinent of bowel. The resident had a BIMs of 8, indicating moderately impaired cognition. The 8/24/21 Urinary Incontinence CAA indicated Resident 15 was occasionally incontinent of bladder and needed assistance with toileting due to diagnoses. The resident was frequently incontinent of bowel since admission but had some toileting awareness. Resident 15 was at risk for skin breakdown due to incontinence and was on Lasix (diuretic) which could exacerbate toileting function with urgency and frequency. The 9/22/21 Care Plan indicated Resident 15 required one-person staff assistance for toileting and had mixed bladder incontinence. Interventions included: the resident's brief size and "incontinent program total incontinence." The Bladder Task Sheets were reviewed from 8/25/21 through 9/23/21 (30 days). Resident 15 was noted as continent of bladder on 13 shifts and was both continent and incontinent on 15 shifts. On 9/23/21 at 8:21 AM Resident 15's call light was observed on. Resident 15 stated to the surveyor she/he needed to "poop." At 8:23 AM Staff 20 (CNA) was observed to turn off the call light and go into another resident room. On 9/23/21 at 8:24 AM Resident 15 stated staff did not assist her/him to the toilet and turned off the call light. The surveyor could smell a strong odor of urine coming from Resident 15's brief. Resident 15 stated she/he was able to use the toilet, but it could take staff up to 20 minutes to assist, so the resident had "accidents" due to staffing shortages. Resident 15 stated staff would often turn off her/his call light without assisting her/him. The resident stated she/he knew when she/he had to have bowel movement or urinate, and staff let the resident soil her/himself and would "just clean me up". At 8:59 AM Resident 15 stated she/he had urinated in her/his brief while waiting and the sensation to have a bowel movement "went away." On 9/23/21 at 9:23 AM staff had still not assisted Resident 15 with toileting, so the surveyor saw Staff 20 and Staff 21 (CNA) donning gowns for a different resident room and stopped them. Staff 20 and staff 21 stated Resident 15 was incontinent per their knowledge. Staff 20 acknowledged she turned off the call light due to not wanting a "long call light time" and stated Resident 15 had wanted "to poop". Staff 20 stated she was unable to assist Resident 15 with toileting due to staffing as she and Staff 21 were the only CNAs for the hall and were working their way down the hall changing residents. On 9/23/21 at 9:30 AM Resident 15 had a scheduled meeting with family and administrative staff with the door closed. Resident 15 was still not changed. At 9:55 AM Resident 15 was assisted with incontinence care. On 10/4/21 at 10:45 AM Staff 26 (LPN RCM) stated Resident 15 was incontinent of bowel and bladder, but when the resident was admitted she/he was mixed incontinence. The resident requested to use the toilet and needed staff assistance, but rarely voided, but Staff 26 stated she wanted staff to keep offering to toilet the resident. Staff 26 acknowledged the long wait time for Resident 15 to receive toileting assistance. Refer to F550 and F725. 2. Resident 22 admitted to the facility in 2/2017 with diagnoses including heart failure and diabetes. The 6/30/21 Quarterly MDS indicated Resident 22 was cognitively intact and required assistance with bathing. Resident 22's current care plan indicated the resident required staff assistance with bathing. On 9/21/21 at 5:52 PM and 6:23 PM Staff 21 (CNA) stated she had two showers scheduled for that night, but she was unable to complete them, including for Resident 22, as she was the only CNA for the hall. Staff 21 stated if she was unable to complete a shower, she marked either "NA" (Not Available) or "RR" (Resident Refused) on the shower task sheet and would let the charge nurse know. On 9/21/21 at 7:17 PM Resident 22 stated she/he was unable to receive a shower due to staffing shortages and there was only one CNA for 13 residents. Resident 22 stated she/he recently missed two showers due to staffing. Resident 22 stated she/he felt "dirty" when she/he did not receive scheduled showers. The 9/21/21 Bathing/Shower Task Sheet indicated Resident 22 did not receive a shower and the reason was marked "NA". On 10/6/21 at 11:31 AM Staff 26 (LPN Resident Care Manager) acknowledged Resident 22 did not receive a shower on 9/21/21. Refer to F725. 3. Resident 15 admitted to the facility in 8/2021 with diagnoses including a traumatic brain injury and a history of falls. The 8/24/21 Admission MDS indicated Resident 15 was moderately cognitively impaired and the resident required staff physical assistance with bathing. Resident 15's current care plan indicated the resident was totally dependent on staff for bathing. On 9/21/21 at 5:52 PM and 6:23 PM Staff 21 (CNA) stated she had two showers scheduled for that night, but she was unable to complete them, including for Resident 15, as she was the only CNA for the hall. Staff 21 stated if she was unable to complete a shower, she marked either "NA" (Not Available) or "RR" (Resident Refused) on the shower task sheet and would let the charge nurse know. The 9/21/21 Bathing/Shower Task Sheet indicated the Resident 15 did not receive a shower and the reason was marked "NA". On 10/6/21 at 11:31 AM Staff 26 (LPN Resident Care Manager) acknowledged Resident 15 did not receive a shower on 9/21/21. Refer to F725. , 4. Resident 16 admitted on 3/31/21 and discharged from the facility on 5/5/21 with diagnoses including a stroke. The 3/31/21 care plan indicated Resident 16 required assistance with bathing. Review of the April 2021 bathing record indicated Resident 16 was to receive bathing in the evening, PRN. The records indicated the resident received a shower on 4/14/21. No other showers were indicated as given for the remainder of the month. Interviews were conducted from 9/30/21 through 10/4/21 with Staff 25 (CNA), Staff 33 (CNA), Staff 34 (CNA), Staff 35 (CNA), Staff 36 (CNA) and Staff 38 (CNA); all worked with Resident 16. Staff stated the resident was scheduled to receive showers in the evening. Staff stated they could not recall Resident 16 receiving a shower or refusing to be bathed. Staff stated if a scheduled shower was not given the system alerted staff in red. On 10/4/21 at 10:45 AM and 10/6/21 at 11:31 AM Staff 26 (LPN Resident Care Manager) indicated she did not change Resident 16's bathing record from PRN to scheduled. Staff 26 stated scheduled bathing would alert staff of when bathing needs to be completed. Staff 26 stated she could not confirm Resident 16 received a shower more than one time in 4/2021.

"Resident 15 and 16 have discharged and Resident 22 is still a resident at facility "All residents are at risk for missed services of bathing and toileting "DNS or designee will in-service all CNAs and Licensed nurses on necessary care of toileting and bathing per care plan and notification process to follow if unable to give shower. "DNS or designee will audit shower sheets and any marked NA or refusal will be followed up with resident directly. If resident denies refusal, facility will complete grievance form and 1:1 education with staff member. Audit call light responses no less than 5 random shifts weekly x 4 weeks. Then 1 x week for 4 weeks. Then Monthly x 2 month or until substantial compliance met. Results will be brought to QA for 3 months

Based on observation, interview and record review it was determined the facility failed to provide an ongoing program to support activity interests and preferences for 3 of 3 sampled residents (#s 5, 12 and 28) reviewed for activities. This placed residents at risk for unmet psychosocial needs. Findings include: 1. Resident 5 was admitted to the facility in 2019 with diagnoses including Alzheimer's disease. The 7/15/21 BIMS indicated Resident 5 was not alert and oriented. The 7/28/21 care plan indicated Resident 5 enjoyed cooking shows, watching TV and listening to music. The resident spent the majority of her/his day in her/his room or in the assisted dining room watching TV or listening to music. The care plan indicated Resident 5 was totally dependent on staff for all care needs. On 9/23/21 at 8:57 AM Resident 5 was observed in the small dining room with no activities were observed. On 10/1/21 at 10:32 AM Resident 5 was observed in the small dining room, a talk show was on TV but the resident was not watching it. There were no other activities observed. On 10/1/21 at 10:44 AM Staff 15 (CNA) stated Resident 5 routinely sat in the dining room with the TV on although she/he did not watch TV. Staff 15 further stated Resident 5 did not receive 1:1 activities. On 10/1/21 at 10:59 AM Staff 39 (Activity Director) stated Resident 5 often sat in the dining room during the day with the TV on and acknowledged the resident did not watch TV. Staff 39 stated she did not have time to do 1:1 activities with Resident 5 and it had been about a month since activities were consistently offered to residents. Staff 39 further stated activities were not offered on the weekends and activities were not documented in the resident's record. 2. Resident 12 was admitted to the facility in 2019 with diagnoses including Alzheimer's disease. The 9/5/21 BIMS indicated Resident 12 was not cognitively intact. The 10/29/20 care plan indicated Resident 12 enjoyed watching the news in the assisted dining room, watching movies in the independent dining room and attending church on Friday. On 10/1/21 at 10:32 AM Resident 12 was observed in the small dining room, a talk show was on TV but the resident was not watching it. There were no other activities observed. On 10/1/21 at 10:43 AM Staff 37 (CNA) stated Resident 12 spent the majority of the time in bed and recently the resident was observed in the day room on a regular basis. Staff 37 stated Resident 12 did not watch TV or participate in activities. On 10/1/21 at 10:44 AM Staff 15 (CNA) stated Resident 12 routinely sat in the dining room with the TV on and she/he did not watch TV. Staff 15 further stated Resident 12 did not receive 1:1 activities. On 10/1/21 at 10:59 AM Staff 39 (Activity Director) stated Resident 12 enjoyed painting, but she did not have time to do 1:1 activities with Resident 12. She further stated it had been about a month since activities were consistently offered to residents. Staff 39 stated Resident 12 did not watch TV but was often up in the day room for "socialization." Staff 39 further stated activities were not offered on the weekends and activities were not documented in the resident's record. 3. Resident 28 was admitted to the facility in 2019 with diagnoses including diabetes. The 6/28/21 Resident Council Minutes indicated residents requested "more bingo." The 9/21/21 BIMS indicated Resident 28 was cognitively intact. The 9/20/21 care plan indicated Resident 28 enjoyed several activities including bingo and puzzles. On 10/1/21 at 10:29 AM Resident 28 stated she/he wanted more tables in the puzzle room so she/he could work on her/his own puzzles. Resident 28 further stated she liked playing bingo and she could not remember the last time it was offered. On 10/1/21 at 10:59 AM Staff 39 (Activity Director) stated Resident 28 loved bingo and puzzles. Staff 39 stated she was aware of Resident 28's request for additional tables in the puzzle room, but it was not provided. Staff 39 stated the last time bingo was offered to residents was a month ago. Staff 39 further stated activities were not offered on the weekends and activities were not documented in the resident's record.

"Resident 5, 12, 28 are still residents at facility "All residents are at risk of not having activities that meet interest or needs. "Administrator or designee will in-service Activity director and weekend managers on documentation, group activity and resident specific programs to meet individual needs. Weekend manager will be responsible to ensure activity program is being completed on weekends. "Administrator or designee will audit all residents for special needs such as cognition, language and staying in room. Will conduct random audit weekly for 4 weeks for resident satisfaction, proper documentation, resident center care plan and group activity. Then monthly for 2 month. Will bring results to QA for further review.

Based on observation, interview and record review it was determined the facility failed to follow physician orders for 1 of 3 sampled residents (# 33) reviewed for medications. This placed residents at risk for adverse side effects of medications. Findings include: Resident 33 was admitted to the facility in 2017 with diagnoses including stroke. The 9/16/21 physician order indicated Resident 33 was to receive baclofen TID for muscle spasms and gabapentin TID for pain related to stroke. On 9/22/21 at 12:10 PM Staff 7 (LPN) was observed to administer the morning dose of baclofen and gabapentin to Resident 33. The 9/2021 MAR indicated the medications were to be administered between 7 AM and 10 AM. On 9/22/21 at 12:10 PM Staff 7 acknowledged the baclofen and gabapentin were due earlier that morning and stated the afternoon doses would be administered later that day since they were both TID medications. A record review was completed on 9/22/21 at 2:55 PM and indicated Resident 33 received the noon dose of baclofen at 2:20 PM. On 9/22/21 at 2:55 PM the administration times of baclofen and gabapentin were reviewed with Staff 29 (Regional RN). On 9/22/21 at 3:06 PM Staff 29 stated the physician was notified of the administration times of baclofen and gabapentin for the morning and afternoon doses and Resident 33 was placed on alert charting to monitor for potential side effects. There was no indication of outcome to Resident 33.

"Resident 33 is still a resident at facility "All residents are at risk for delay of medication with potential med errors "DNS or designee will in-service all Licensed nurses and CMA's on med pass procedure and expectation if anticipate late meds. "DNS or designee will audit med pass times Monday through Friday weekly no less than 5 times for 4 weeks, weekend med pass will be reviewed on Monday. Then weekly x 2 months and then Monthly x 2 month. Results will be brought to QA for further review and discussion.

Based on interview and record review it was determined the facility failed to provide treatment and services to promote healing of a pressure ulcer for 2 of 3 sampled residents (#s 14 and 23) reviewed for pressure ulcers. This failure placed residents at risk for worsening pressure ulcers. Findings include: 1. Resident 14 was readmitted to the facility in 6/2021 with diagnoses including hemiplegia (paralysis to one side of the body) and Stage 4 pressure ulcers on the heel and sacrum. The 8/1/21 BIMS indicated Resident 14 was cognitively intact. On 9/30/21 at 9:46 AM and 10/6/21 at 10:44 AM Resident 14 stated she/he was not able to reposition her/himself independently and staff did not always turn and reposition her/him, especially at night. The 6/29/21 care plan indicated Resident 14 was totally dependent on staff for repositioning and turning in bed. The 8/5/21 physician order indicated Resident 14 was to receive repositioning for pressure relief and offloading. The 8/2021 and 9/2021 ADL sheets indicated 17 shifts where turning and repositioning was not documented. On 9/23/21 at 1:40 PM Staff 49 (CNA) stated there were not enough staff to complete resident care, including turning and repositioning residents. On 9/17/21 at 12:11 PM and 10/6/21 at 9:24 AM Staff 21 (CNA) stated Resident 14 needed assistance turning and repositioning. Staff 21 further stated due to staffing issues she could not complete as many rounds to residents. On 9/27/21 at 5:01 AM Staff 65 (LPN) stated there was only one CNA working on each hall at night and if a resident needed repositioning, the CNA waited until another CNA was available in order to provide resident care. On 9/30/21 10:27 AM Staff 64 (CNA) stated Resident 14 was not able to turn and reposition independently. Staff 64 further stated she was not aware Resident 14 was on a repositioning schedule, but had pressure ulcers on her/his heel and sacrum. On 10/6/21 at 10:26 AM Staff 5 (LPN Resident Care Manager) acknowledged there was no indication on the ADL sheets that Resident 14 was turned or repositioned on 17 shifts. Staff 5 further stated the expectation was for staff to offer to turn and reposition the resident every two hours and document the if the the task was completed. 2. Resident 23 was admitted to the facility in 2020 with diagnoses including diabetes and a pressure ulcer of the sacrum (unspecified stage). The 8/21/21 BIMS indicated Resident 23 was cognitively intact. Resident 23's 9/16/21 outside "wound care and hyperbaric medicine" physician note indicated Resident 23 had a gluteal wound with orders for a continuous wound vacuum. The resident was to return to the clinic in one week. The 9/23/21 progress note indicated the wound clinic was notified that the resident would not be at her/his scheduled appointment on 9/23/21 due to transportation issues. The appointment was rescheduled to 9/29/21. The 9/29/21 progress note indicated the wound clinic was informed that Resident 23 could not be seen due to the transportation company running late. The appointment was rescheduled to 10/6/21. On 10/1/21 at 1:40 PM Resident 23 stated she/he went to an outside wound and hyperbaric clinic for wound care to her/his buttocks and had two follow up appointments that were missed due to transportation issues. The resident further stated she/he was not aware of any future appointments. Resident 23 stated she/he received wound treatments. On 10/1/21 at 2:18 PM Staff 26 (LPN Resident Care Manager) stated there were issues with transportation and the resident missed her/his 9/23/21 and 9/29/21 appointments. She further stated Resident 23 had an appointment scheduled for 10/6/21 (20 days after her/his original appointment).

"Resident 14 and 23 are still residents at facility "All dependent residents are at risk of not being repositioned "DNS or designee will in service all Licensed nurses and CNAs on reposition standards and missed appointment notification process. If appointments are missed, MD will be called to request alternative option. "DNS or designee will audit repositioning and for missed appointments and MD follow up weekly for 4 weeks, no less than 5 random days/shifts. Then weekly x 2 months and then monthly x 2 month. Results will be brought to QA for further review and discussion

1.

Based on observation, interview, and record review it was determined the facility failed to provide supervision for swallowing safety for 1 of 13 residents (#1) identified at risk for aspiration and who was to be supervised while eating. Resident 1 was observed to be left unattended with her/his meal and/or fluids two times during continuous observations. Resident 1 was able to independently feed her/himself. This failure resulted in an immediate jeopardy situation. This placed residents at risk for aspiration and death. Findings include: The 9/2021 Dysphagia Diets and Aspiration Precautions policy statement indicated residents who were identified as close supervision and 1:1 supervision levels were not to be left unattended with the food tray. Resident 1 was admitted to the facility in 12/2012 with diagnoses including multiple sclerosis, dysphagia (difficulty swallowing), and pneumonitis (lung infection) due to inhalation of food and vomit. Resident 1's 6/24/21 physician order indicated Resident 1 was on aspiration precautions with close supervision, no water pitcher or thin liquids at bedside, and small bites, small sips, and "slow rate." Resident 1's 6/29/21 Quarterly MDS indicated the resident was cognitively intact, required supervision with eating and required set up assistance with meals. On 9/20/21 the following was observed during continuous observations: *12:27 PM Resident 1 was observed to have fluids at her/his bedside within reach. The Survey Team asked Staff 3 (Speech Pathologist) about Resident 1's aspiration status. Staff 3 removed the liquids in front of Resident 1 and confirmed there was both juice and water at bedside. Staff 3 stated Resident 1 required close supervision with meals and fluids, but Resident 1 often wanted the door closed and did not like staff watching her/him eat. Staff 3 asked Resident 1 if she/he experienced any choking while drinking and Resident 1 stated "I would not tell you if I did." *Resident 1 was observed to have a pink sign above the bed which indicated the resident was on aspiration precautions and required close supervision with meals and to encourage small bites, small sips, and slow rate. *12:42 PM Staff 4 (CNA) was observed exiting Resident 1's room and closed the door. Staff 4 stated Resident 1 had food in her/his room, just set the resident up, and she/he was eating independently. *12:43 PM Surveyors and Staff 4 entered Resident 1's room and observed the resident eating a pureed meal independently. Staff 4 stated Resident 1 was supposed to be supervised while eating, but the resident refused "all the time." Staff 4 was unable to state other residents who required supervision with eating as she was new to working at the facility. *12:52 PM Surveyor knocked on Resident 1's closed door, looked in the room and observed Resident 1 continuing to feed her/himself with no staff present. Two drinks were also observed within reach of the resident. *12:58 PM Staff 5 (LPN Resident Care Manager) stated Resident 1 required "intermittent supervision" and the facility was in the process of changing the resident's care plan. Staff 5 removed the two drink cups from Resident 1's bedside. Surveyors asked for a copy of Resident 1's updated aspiration precautions and care plan. *1:00 PM Resident 1's Aspiration Precaution sign was provided and indicated the resident was "intermittent supervision" with meals. On 9/20/21 at 12:54 PM Staff 3 (Speech Pathologist) stated she made the aspiration precaution recommendations and the resident care managers filled out the Aspiration Precautions form. Staff 3 stated she was unaware of what intermittent supervision meant. Staff 3 stated she had not assessed Resident 1 in "awhile" and had not upgraded her/his supervision status or precautions. Staff 3 further stated nursing staff were unable to upgrade residents' supervision status without a speech assessment or a physician order. On 9/20/21 at 1:47 PM Staff 2 (DNS) was asked for the assessment or order for intermittent supervision for Resident 1. Staff 2 stated she was unable to find an assessment or order indicating Resident 1 required intermittent supervision. On 9/20/21 at 2:48 PM Staff 1 (Administrator) and Staff 2 (DNS) confirmed the most recent signed physician orders were correct and indicated Resident 1 was close supervision with meals and no liquids at bedside. Staff 2 confirmed Resident 1 had not been assessed by the speech pathologist since 4/2020. Staff 1 and Staff 2 confirmed intermittent supervision was inaccurate. A copy of Resident 1's Risks versus Benefits form related to aspiration precautions was requested by surveyors. On 9/20/21 at 4:21 PM Staff 1 (Administrator) stated there was no Risk versus Benefit documented for Resident 1 related to aspiration precautions. On 9/20/21 at 5:44 PM Staff 1 and Staff 2 were notified of the immediate jeopardy (IJ) situation and were provided a copy of the IJ template related to the facility's failure to ensure residents were adequately supervised during meals. An immediate plan of correction (POC) was requested. On 9/20/21 at 7:19 PM the facility submitted a final POC. The IJ Removal Plan included: -All residents with aspiration precautions will be reviewed to ensure their orders, care plans, and precaution signs all reflect the same information. -All nursing staff will be in-serviced on the policy of aspiration precautions, what it means, the importance of following these precautions, and staff will be asked to "verbally return demonstration." The in-service would be completed by 9/22/21. -If any resident refused the precautions, they would be re-evaluated by speech therapy, the physician would be notified and a Risk versus Benefits assessment would be completed by them or their representative. -All agency staff and nursing new hires would be in-serviced, oriented, and submit competencies prior to the beginning of their shift and would demonstrate back understanding. -The DNS or designee would complete weekly audits of all residents on aspiration precautions to ensure staff were following physician orders. On 10/4/21 at 9:40 AM Staff 1 and Staff 29 (Regional RN) were notified the immediacy was removed based on observations, staff interviews, and record review that the IJ abatement plan was fully implemented. Refer to F658 and F725 2. Based on observation, interview, and record review it was determined the facility failed to ensure residents were free from fall related accidents for 3 of 4 residents (#s 5, 17, and 25) reviewed for falls. This failure resulted in Resident 17 sustaining a lumbar fracture and requiring hospitalization, Resident 5 sustaining a face laceration requiring hospitalization and medical interventions, and this placed other residents at risk for other fall related injuries. Findings include: Resident 17 admitted to the facility on 3/8/21 with diagnoses including diabetes and a history of repeated falls. Resident 17 discharged from the facility on 4/30/21. The 3/8/21 Admission Fall Assessment indicated Resident 17 was at high risk for falls due to incontinence, medication use, and experienced multiple falls prior to admission. The Resident's 3/9/21 Baseline Fall Care Plan indicated Resident 17 was "(high, moderate, low)" risk for falls related to: the resident had an actual fall with "no injury, minor injury, serious injury". Interventions included: monitor for decline or improvement in mobility, wear non-skid socks, and ensure the call light was within reach at all times. The resident required two staff-person assistance with transfers. The resident sustained falls in the facility on 3/15/21, the morning of 3/29/21, and the evening of 3/29/21. The Admission MDS was not completed until 4/10/21, over a month after the resident admitted to the facility and sustained three falls. a.. The 3/22/21 Fall Care Plan indicated to notify the physician and family/responsible party of any fall and to not leave the resident unsupervised in the bathroom/on the bedside commode. The care plan was not updated again until 3/30/21. The intervention of frequent visual checks was not added to the care plan until 3/31/21. The 3/29/21 Fall Investigation indicated Resident 17 had an unwitnessed fall and was found on the floor lying on her/his back in the assisted dining room at approximately 8:15 PM with no staff present. The resident reported she/he tried to transfer from the locked wheelchair to a dining room chair. Resident 17 reported her/his baseline low back pain worsened significantly after the fall with 6/10 pain noted. The resident had fallen earlier that morning and was on neurological checks. Staff 57 (CNA) stated Resident 17 was restless and attempting to get out bed, so he "wheeled" the resident to the assisted dining room to sit with two other residents. Staff 56 (CNA) stated she last visualized the resident in the dining room at 8:00 PM while walking by and the resident was not attempting to transfer. The summary indicated the care plan was followed. Resident 17 was sent to the hospital and was diagnosed with a lumbar fracture. Hospital records indicated Resident 17 was hospitalized from 3/29/21 through 4/6/21 and sustained closed compression fractures of the L2 and L3 vertebra and noted baseline low back pain was worse after the fall on 3/29/21. On 10/1/21 at 2:20 PM Staff 34 (CNA) stated Resident 17 was at times impulsive with transfers. Staff 34 stated concerns related to monitoring residents due to staffing shortages and staff attempted to monitor residents, but a lot of times staff were so busy they were unable to check on the residents. On 10/4/21 at 2:59 PM Staff 57 (CNA) stated he could not recall specifics regarding Resident 17's fall but stated there were issues with staff not being able to monitor residents who were at risk for falls. On 10/5/21 at 11:45 AM Staff 55 (CNA) stated he worked with the resident frequently and the resident was impulsive and tried to self-transfer. Staff 55 stated a few times he "caught [Resident 17] in the act" of transferring and at times "caught" the resident sitting on edge of the bed attempting to get up. Staff 55 stated Resident 17 often did not use her/his call light. Staff 55 stated as long as staff sat and talked with the resident and reassured her/him that staff were there to help, the resident was less impulsive. Staff 55 stated there were issues monitoring residents during the time Resident 17 was in the facility due of staffing shortages. On 10/4/21 at 10:53 AM Staff 26 (LPN Resident Care Manager) stated when a resident fell the charge nurse was responsible to put new interventions in place, but there was a lot of 'turn around" and a lot of time it was not done until Staff 26 did them. Staff 26 stated during the time Resident 17 was in the building she was pulled to work the floor as a nurse. Staff 26 confirmed the 3/29/21 fall was the second unwitnessed fall that day. Staff 26 stated staff monitoring resident, especially on night shift, was harder due to staffing shortages, and more falls happened at night because of this. Staff 26 confirmed assessments of the efficacy of fall interventions were not completed for Resident 17 and fall care plans were not person-centered for Resident 17. Staff 26 confirmed Resident 17 sustained a back fracture related to the fall on 3/29/21. Refer F600, F609 and F725. b. A fall investigation indicated on 3/15/21 Resident 17 had an unwitnessed fall and was found under her/his bathroom sink by Witness 11 (Former Physical Therapist) shortly after working with physical therapy. The resident reported there was no new pain, but had continued left shoulder, hip, and back pain. The pain was rated 6/10; which later worsened to 8/10 pain. The resident was transferred to the hospital on 3/17/21 for decreased cognition and increased back pain. The investigation indicated concerns regarding Witness 10 (Former LPN) not assessing Resident 17 post fall. The investigation summary indicated neglect could not be ruled out. Facility witness statements completed by staff who assisted the resident post fall included: Witness 12 (Former Occupational Therapist), Witness 13 (Former CNA), Witness 14 (Former CNA), Witness 15 (Former Maintenance Director), Witness 16 (Former CNA), and Witness 17 (Former LPN). Staff indicated after the fall, Resident 17 was in significant pain when transferred back to bed and the resident's cognition had worsened from baseline. Witness 14 stated the resident was confused, and she never saw Witness 10 assess the resident post fall or during the rest of her shift. Additionally, Witness 14 notified Witness 10 of approximately five abnormal vital signs for Resident 17. Witness 17 stated Resident 17 reported 8/10 pain at 3:30 PM and later that night requested more pain medications. Witness 17 stated during observations she witnessed CNA staff attempting to make the resident more comfortable due to her/his pain. Multiple statements indicated the resident was confused and kept stating "I don't want to go to jail", when asked about being transferred to the hospital. The resident was also noted as clammy and complained of head and back pain. The neurological flow sheets for Resident 17 were incomplete for 3/15/21. Witness 12, Witness 13, Witness 14, and Witness 17 were contacted for an interview with no responses. On 9/29/21 at 1:36 PM Witness 16 stated after Resident 17's fall, she helped transfer the resident to bed. Resident 17 complained her/his head hurt but Witness 10 instructed staff to put the resident to bed and failed to assess Resident 17. Witness 16 stated Resident 17 was confused and when Witness 10 asked if the resident needed to go to the hospital the resident replied: "I don't want to go to jail." On 10/5/21 at 12:20 PM Witness 11 (Former Physical Therapist) stated Resident 17 completed therapy and was told to wait in her/his room. When Witness 11 entered the room, Resident 17 was on the floor wedged under the sink and had pulled part of the shelving down. Resident 17 had attempted to self-transfer. Resident 17 was unresponsive, eyes open and glazed so Witness 11 checked her/his vitals, performed sternal rubs, and called out for help. Witness 11 stated Witness 10 stood by the door and asked the resident a few questions, but never assessed the resident or performed neurological checks. Witness 11 further stated Witness 10 asked CNA staff and maintenance staff to put the resident back to bed. A change in cognition was noted after the fall by Witness 11. The resident was confused stated, "I don't want to go to Jail" when asked about going to the hospital. On 9/29/21 at 1:58 PM Witness 10 (LPN) stated she was notified of Resident 17's fall and when she entered the room, Resident 17 who was on the ground with a pillow behind her/his head with Witness 11 present. Witness 10 stated she completed a "head to toe assessment" and the resident was responding, but when she asked if the resident needed to go to hospital the resident replied, "I don't want to go to Jail." Witness 10 stated she was in the room the "whole time" and only left when nursing staff got the resident up in the mechanical lift to put her/him into bed. Witness 10 stated she completed neurological checks and during the night Resident 17 stated she/he had back pain, but Witness 10 stated this was not "new pain" for the resident. On 10/6/21 at 12:10 PM Staff 1 (Administrator) acknowledged the findings and stated the allegation Witness 10 did not assess Resident 17 appropriately post fall was correct and stated Resident 17 was transferred to the hospital for increased pain "the next day" [317/21, two days later]. Staff 1 stated witness statements from the facility's investigation regarding Resident 17's fall on 3/15/21 were accurate per his knowledge. Refer to F697 3. Resident 5 admitted to the facility in 9/2019 with diagnoses including Parkinson's Disease, Alzheimer's Disease, and muscle weakness. The 7/15/21 Quarterly MDS indicated Resident 5 had a significant cognitive impairment. Resident 5's fall care plan was initiated and last updated on 6/2/21. The resident was noted as a high risk for falls due to a history of multiple falls. Interventions included: call light within reach, keep bed in lowest position, place padded mat on both sides of the bed, non-skid footwear as tolerated, notify the family/responsible party and the physician of any fall, use gait belt with transfers, review and update fall assessment quarterly, post any fall and PRN. The resident required two-person staff assistance with transfers. A fall investigation indicated on 8/17/21 at approximately 5:30 AM, Resident 5 was found on the floor, on the fall mat next to the bed, facing the foot of the bed. Resident 5 was observed "frail, quiet, and bloody". The resident sustained an upper lip and forehead laceration with "copious amounts" of blood noted. Resident 5 was non-verbal; pain was assessed as "3/10." A witness statement completed by Staff 54 (CNA) indicated the resident's brief was changed at 12:30 AM, the resident was last observed at 3:00 AM and then not observed again until 5:30 AM. The investigation summary indicated falls continued to be difficult to prevent and the facility would continue to care plan against major injury. There was no indication what position the bed was in or if Resident 5 was soiled. Abuse and neglect were ruled out. The resident was transferred to the hospital. On 8/17/21 Hospital Records indicated Resident 5 required sutures to repair her/his head laceration. The 8/19/21 Fall Assessment indicated Resident 5 was a high fall risk and had multiple falls (more than two) in the past six months at the facility. On 9/23/21 at 1:40 PM Staff 54 (CNA) stated Resident 5 sustained a fall with injury due to staff being "really busy" and him not being able to check on the resident until after 5:00 AM. Staff 54 stated Resident 5 sometimes slept through the night but sometimes was impulsive and moved around "a lot" in bed and staff had to watch her/him closely. On 10/6/21 at 10:13 AM Staff 5 (LPN Resident Care Manager) acknowledged there was no indication if the bed was in a low position or if Resident 5 was soiled. Staff 5 acknowledged Resident 5 was a high falls risk and able to pull her/himself up in bed. Staff 5 acknowledged the investigation indicated Resident 5 was last changed around 12:30 AM, which was a "very long time." Staff 5 acknowledged the resident was last visualized two and a half hours prior to being found on the floor and the expectation for high fall risks was frequent checks, which she stated was every fifteen minutes. Refer to F609, F657, and F725. , 4. Resident 25 admitted to the facility in 2019 with diagnoses including Parkinson's Disease, dementia and a history of falls. On 10/1/21 at 10:02 AM Resident 25 was observed in her/his room at the end of the hall lying halfway off the bed. The 9/19/21 Annual MDS Fall CAA revealed Resident 25 was at risk for falls related to impaired gait and balance, a history of falls and the use of anti-depressant medication. The CAA indicated Resident 25 had difficulty with ambulation and periods of increased confusion. The 9/19/21 Annual Dementia CAA revealed Resident 25 needed reminders and cueing for some ADL's and general supervision for safety due to impaired functional mobility and being a fall risk. It further indicated Resident 25 had impaired safety awareness and was not always cognizant of her/his mobility limitations. The 9/30/20 Fall Care Plan revealed Resident 25 was at risk for falls related to decreased mobility, activity intolerance and poor safety awareness secondary to Parkinson's Disease and associated cognitive impairment and deconditioning. Interventions included to continue RA (restorative aide) program, frequent checks for safety, to offer assistance when transferred and to wear non-skid socks. The facility fall incident report revealed Resident 25 sustained five falls in a 27 day look-back period between 9/7/21 through 10/4/21. The 9/7/21 Fall Investigation indicated Resident 25 was found on the floor in her/his room. Resident 25 indicated she/he slid out of bed when she/he attempted to transfer to the wheelchair. The 9/9/21 Fall Investigation indicated Resident 25 was found lying on the floor in her/his room next to the bed with one arm wrapped around the assistive transfer pole. Resident 25 was disoriented and confused. Resident 25 had attempted to transfer into the wheelchair, slipped on the floor and hit her/his head. Resident 25 was last checked on one and a half hours prior to the incident. Resident 25 was transferred to the hospital. The 9/28/21 2:28 AM Fall Investigation indicated Resident 25 was found on the floor of her/his room yelling for help. Resident 25 indicated she/he attempted to stand-up to urinate, slipped and fell to the floor. The investigation indicated Resident 25 wore regular socks and was last seen 40 minutes prior to the fall. The 9/28/21 8:50 AM Fall Investigation indicated Resident 25 was found on the floor next to the bed and transfer pole. Resident 25 indicated she/he slid off the bed when she/he attempted to get up to use the urinal. The investigation indicated Resident 25 was last seen approximately one hour before the fall. A 10/4/21 Progress Note indicated Resident 25 was found on the floor by her/his bed. Resident 25 indicated she/he slid out of bed onto the floor when she/he reached for the urinal. [The Fall Investigation was not yet completed.] On 9/29/21 at 1:55 PM Staff 56 (CNA) indicated Resident 25 needed to be monitored more frequently due to being a fall risk. Staff 56 indicated she/he and other staff informed the administrative staff on multiple occasions of the concern. Staff 56 stated the resident should not be left unassisted due to her/his multiple falls but the administrative staff had not updated her/his plan of care. On 10/1/21 at 9:58 AM Staff 12 (CNA) stated Resident 25's room was at the end of the hall, there was not enough staff to monitor Resident 25, and she/he was very impulsive and a fall risk. Staff 12 stated she had repeatedly informed management of this concern until she was "blue in the face", however Resident 25's plan of care did not change. On 10/1/21 at 1:21 PM Staff 26 (LPN Resident Care Manager) stated Resident 25 was "constantly" falling and she was running out of ideas how to update her/his plan of care. Staff 26 acknowledged no fall interventions were updated in 9/2021 after any of the falls. Staff 26 stated frequent checks were every two hours and further stated this was "not ideal." Staff 26 verified Resident 25 did not receive RA per the care plan interventions and the 9/30/20 Fall Care Plan interventions were not evaluated or revised in a timely manner. Staff 26 verified Resident 25 required more supervision but the facility could not accommodate this need due to current staffing levels. Refer F725. ,

All residents currently in the facility with aspiration precautions and order for close supervision have been reviewed to ensure that their orders, care plans and precautions signs all reflect the same information. All nursing staff will be in serviced on the policy of aspiration precautions, what that means and the importance of following these precautions. Staff will be asked to verbally return demonstration. If any resident is noted to refuse these precautions will be reevaluated by Speech Therapy and if the precautions continue, assigned MD will be notified and a risk vs. benefits will be done with the resident in regards to the risks of them not following the Physicians orders and the potential outcome to their health. Any resident with impaired cognition that refuse to follow physician orders a risk vs Benefit will be completed with resident’s POA/Representative. All nursing staff currently in the building will receive the in-service noted above and all other nursing staff will receive this in-service prior to their next shift. This in servicing will be completed by 9/22/2021 All agency staff and nursing new hires will be in-serviced, oriented and submit competencies prior to the beginning of their shift regarding any residents on aspiration precautions or requiring 1:1 feeding. This will be completed by Admin/DNS or designee. The agency staff and new hire will sign off on in-service and demonstrate back that they understand 1:1 aspiration precaution before their shift begins. All residents requiring supervision for aspiration precautions will be encouraged to eat in assisted dining. Those residents that refuse will be monitored by meal manager or charge nurse of unit. Residents on aspiration precautions that require close supervision and wish to eat in rooms will receive trays at end of meal pass to ensure appropriate staff available to monitor during meals. DNS or designee will complete weekly audits of all residents on aspiration precautions to ensure that staff are following the Physician orders. These audits will be completed weekly for 3 months and will be reviewed at QAPI until substantial compliance has been met for 2 quarters.

Based on interview and record review it was determined the facility failed to ensure the resident was assessed and treated for pain management status post fall for 1 of 3 residents (#17) reviewed for falls. This placed residents at risk for increased pain. Findings include: Resident 17 admitted to the facility on 3/8/21 with diagnoses including diabetes and a history of repeated falls. Resident 17 discharged from the facility on 4/30/21. Physician orders indicated Resident 17 was to receive acetaminophen (pain medication) 650 mg TID for pain and oxycodone (narcotic) 5 mg daily prn for low back pain. A facility fall investigation indicated on 3/15/21 at 2:45 PM Resident 17 had an unwitnessed fall and was found under her/his bathroom sink shortly after working with physical therapy. The resident reportedly stated there was no new pain, but had continued left shoulder, hip, and back pain. Pain was rated 6/10 and later increased to 8/10. The resident was transferred to the hospital on 3/17/21 for decreased cognition and increased back pain. The resident was diagnosed with a UTI. The investigation indicated concerns regarding Witness 10 (Former LPN) not assessing Resident 17 post fall. The investigation summary indicated neglect could not be ruled out. Facility pain monitoring sheets were reviewed 3/8/21 through 3/15/21 and indicated the resident's pain did not exceed 4/10 prior to the fall on 3/15/21, except one time on the first day of admission on 3/8/21. The 3/2021 MAR indicated on 3/15/21 Resident 17 received: *Meloxicam (nonsteroidal anti-inflammatory drug) at 12:50 AM for 4/10 pain and at 11:45 PM for 4/10 pain. *acetaminophen at 8:00 AM for 2/10 pain, 2:00 PM for 2/10 pain, and 8:00 PM for 2/10 pain. *oxycodone at 4:27 PM for 6/10 pain (over an hour and a half after the fall with increased pain). The 3/15/21 neurological flow sheets for Resident 17 were incomplete. Facility witness statements were completed on 3/15/21 through 3/22/21 for the 3/15/21 fall. Statements were completed by: Witness 12 (Former Occupational Therapist), Witness 13 (Former CNA), Witness 14 (Former CNA), Witness 15 (Former Maintenance Director), Witness 16 (Former CNA), and Witness 17 (Former LPN). Staff indicated Resident 17 was in significant pain after the fall and when being transferred back to bed the resident's skin was clammy, and the resident's cognition had worsened from baseline. Witness 14 stated the resident was confused, and she never saw Witness 10 assess the resident post fall or during the rest of her shift. Witness 14 notified Witness 10 of approximately five abnormal vital signs for Resident 17. Witness 17 stated Resident 17 had 8/10 pain at 3:30 PM and later that night asked for more pain medications, and during observations she witnessed CNA staff attempting to make the resident more comfortable due to his pain. Progress notes indicated: *3/16/21 6:51 AM Resident 17 complained of 8/10 back pain and requested PRN oxycodone. It was given on evening shift [3/15/21], so the medical provider was contacted regarding pain and an order was received for a lidocaine (pain medication) patch. *3/16/21 2:23 PM Resident 17 had vocal complaints of pain and was fearful after the unwitnessed fall. Resident 17 refused to get out of bed and be weighed that morning. *3/17/21 6:55 AM Administered PRN pain medication, when sitting up resident stated she/he felt dizzy. *3/17/21 1:31 PM Resident had increased confusion, crying about wife, no complaints of pain. *3/17/21 1:34 PM Staff reported increased back pain and confusion for Resident 17 since the fall on 3/15/21. The resident was transferred to the hospital. On 9/29/21 at 1:36 PM Witness 16 (Former CNA) stated she helped transfer Resident 17 to bed after the fall. Resident 17 kept complaining her/his head hurt but Witness 10 had staff put the resident back to bed and did not assess the resident. On 10/5/21 at 12:20 PM Witness 11 (Former Physical Therapist) stated Resident 17 completed therapy and was told to wait in her/his room. When Witness 11 entered the room Resident 17 was on the floor wedged under the sink and had pulled part of the shelving down. Resident 17 had attempted to self-transfer. Resident 17 was unresponsive, eyes open and glazed. The resident complained of head and neck pain. On 9/29/21 at 1:58 PM Witness 10 (LPN) stated she was notified by Witness 13 of Resident 17's fall. Witness 10 stated she completed a "head to toe assessment" and the resident was responding. Witness 10 stated she completed neurological checks throughout the night and during the night Resident 17 stated she/he had back pain, but Witness 10 stated "that was not new pain." Witness 10 stated earlier she asked the doctors to increase pain medication and they said no, so she/he offered the resident a hot pack and ice. There was no evidence in the medical record that the medical provider was notified and requested to increase pain medications on 3/15/21. On 10/6/21 at 12:10 PM Staff 1 (Administrator) acknowledged the findings and stated the allegation Witness 10 did not assess Resident 17 appropriately post fall was correct and stated Resident 17 was sent out to the hospital for increased pain.

"Resident 17 is no longer at facility "All residents are at risk for unassessed pain and care following falls "DNS or designee will in service all LN's on fall assessment process, recognition of pain and follow up. "DNS or designee will audit all falls daily, falls over weekend will be reviewed Monday for next 2 weeks for compliance. Then 1 x week for 2 weeks. Then Random audit of falls monthly for 2 months or until substantial compliance met. Results brought to QA for 3 months. DNS or designee will audit pain assessments via MAR of 5 random residents with known pain, if greater than 6 on pain scale for 3 consecutive days we will audit for MD notification and follow up.

Based on observation, interview and record review it was determined the facility failed to provide sufficient nursing staff to ensure residents attained or maintained their highest practicable mental, physical and psychosocial well-being for 4 of 4 halls reviewed for staffing. This placed residents at risk for unmet needs. Findings include: A review of residents in the facility indicated 28 residents required two-person staff assistance with transfers and 14 residents required eating assistance and 13 of those residents were at risk for aspiration. The following concerns were reported to the State Survey Agency and the survey team: -On 9/17/21 at 11:07 AM Resident 28 stated there were not enough staff and she/he had to wait "too long" for the call light to be answered. -On 9/17/21 at 12:11 PM Staff 21 (CNA) stated on evening shift she had difficulty completing tasks as the facility was "significantly" short staffed. She stated residents did not receive showers, she could not do as many rounds on her residents, and two-person staff transfers took longer. Staff 20 stated she was frequently the only staff on her hall so call lights could take up to 15 minutes to answer. -9/20/21 at 11:18 AM Staff 11 (CNA) stated besides that day, she had never seen administrative staff work the floor, including assisting with meals. Staff 11 stated due to staffing issues she was unable to take all of her breaks, residents missed showers, and a lot of staff worked multiple double shifts. -9/20/21 at 12:54 PM Staff 63 (Speech Therapy) stated the facility did not have enough staff to accommodate residents. There were many residents on aspiration precautions and not enough CNAs to assist during meals. -On 9/21/21 at 11:30 AM Staff 6 (CMA) stated it was normal for medications to be given late due to one staff being assigned to approximately 32 residents and having to administer PRN medications in between scheduled medications. Staff 6 further stated morning medication pass started around 6:30 AM and she did not finish until 11:45 AM or 12:00 PM. Staff 6 further stated administrative staff were aware of the late medication times and they saw her out on the floor passing medications late on a regular basis. -On 9/21/21 at 11:53 AM Staff 15 (CNA) stated prior to that day she had never seen administrative staff help pass meal trays. The facility had staffing shortages and when she brought staffing or other concerns to administrative staff nothing was done. She stated if a shift was short staffed or someone called out of work, administrative staff did not answer nursing staff phone calls for help. -On 9/21/21 at 12:14 PM Staff 8 (Nurse) stated if the census was lower, nurses were sent home despite acuity needs. -On 9/21/21 at 12:31 PM Staff 27 (CNA) stated there was not always enough staff to meet resident needs and often there were "no shows" or staff called out of work, which left the facility short staffed. -9/21/21 at 3:14 PM Staff 18 (CNA) stated during evening shift there were two CNAs for 300 hall and multiple residents who required assistance and/or supervision with eating. Staff 18 stated call lights took over 15 minutes to answer and residents waited a long time for meal assistance. -On 9/21/21 at 4:51 PM Staff 15 (CNA) and Staff 9 (CNA) stated Thursday mornings and evenings are very busy due to providing multiple resident showers and some showers required 2-3 person assistance. Staff 15 and Staff 9 further stated if there was not time to give a resident a shower then it was documented as "unavailable." -On 9/21/21 at 4:56 PM Staff 31 (Nurse) stated there were many concerns with staffing in the building and issues with call lights "all the time." Treatments did not always get done when there were new admissions, especially on evening shift as there was not enough staff. She stated if staff did not show up for an evening or weekend shift staff tried calling administrative staff, but they never answered. She further stated concerns brought up by staff related to staffing were not addressed by administrative staff. Despite acuity in the building, nurses were sent home if the census was under a certain number. -On 9/21/21 at 5:26 PM Resident 34 stated her/his call light always took over 15 minutes to be answered and it took staff a "long time" to assist her/him to the restroom as she/he was unable to use the toilet independently. -On 9/21/21 at 6:27 PM Staff 33 (CNA) stated she was the only CNA working on her hall and would not be able to complete the two scheduled showers and it would take longer to assist residents who required two-person staff assistance with toileting or transfers. She stated this was typical for evening shifts. Staff 33 further stated call lights took 15 minutes or longer to answer and stated it was directly related to being short staffed. -On 9/21/21 at 7:17 PM Resident 22 stated she/he was told there was only one staff that night to take care of 13 residents on the hall, so she/he was unable to receive her/his shower. Resident 22 stated she/he had missed previous showers due to staffing and the wait time for call lights to be answered was typically 20 minutes. The resident further stated she/he waited a "long time" for her/his brief to be changed. -On 9/21/21 at 7:11 PM Staff 19 (CMA) stated she assisted residents with meals in the dining room in addition to passing medications to residents. -On 9/22/21 at 2:21 PM Staff 12 (CNA) stated it was difficult to complete tasks due to staffing shortages, especially showers. She stated she had come onto her shift and residents had not been changed because the night shift was short staffed. There were multiple resident falls as there were not enough staff to monitor residents. Staff 12 stated concerns regarding staffing were not addressed by administrative staff. -On 9/23/21 at 1:40 PM Staff 54 (CNA) stated despite acuity, CNAs were sent home if the census was below a certain number. He was assigned up to 20 residents on one hall. Staff 54 stated there were issues completing resident care and monitoring residents who were fall risks. He further stated it felt "impossible" do to his job due to resident acuity and concerns were not addressed by management. -On 9/27/21 at 5:07 AM Staff 66 (CNA) stated on evening shift it was harder to complete tasks for residents, including showers, and it was difficult to monitor residents who were fall risks. Staff 66 stated when the census was "lower" the facility sent a CNA home despite resident acuity. -On 9/29/21 at 1:55 PM Staff 56 (CNA) stated residents who were fall risks were not able to be monitored and had fallen due to staffing shortages. -On 9/30/21 at 12:50 PM Staff 23 (Restorative Aide) stated she was often pulled to the floor to work as a CNA and during the past month she had only been able to provide RA for approximately half of the month. -On 10/1/21 at 11:05 AM Staff 58 (Nurse) stated she had difficulty completing treatments and had to stop treatments to take blood sugars and to help assist residents with meals due to staffing shortages. Staff 58 stated she felt like she was "drowning." -On 10/1/21 at 2:20 PM Staff 34 (CNA) stated there were concerns monitoring residents who were fall risks and at times staff could not check on the residents because they were so busy due resident acuity. -On 10/4/21 at 10:11 AM Staff 61 (CNA) stated staff were unable to assist residents with meals or watch residents who were fall risks due to a lack of staffing. Staff 61 stated management staff did not address concerns, including if staff did not show up to work or called out. -On 10/4/21 at 10:53 AM Staff 67 (Nurse) stated staffing and monitoring residents at night was harder due staffing shortages and more falls occurred at night due to this. Staff 67 stated "ideally" the facility should staff to acuity, but they did not. Staff 67 further stated administrative nursing staff were often pulled to work the floor. -On 10/4/21 at 2:59 PM Staff 49 (CNA) stated there were only three CNAs working night shift on October 2nd and there were 56 residents to care for. Staff 49 stated due to acuity levels it was hard to watch residents who were fall risks and there were not enough staff to answer call lights. Staff 49 further stated Staff 1 (Administrator) and Staff 2 (DNS) did not answer phone calls on the weekends. On 10/4/21 at 9:20 AM Staff 1 (Administrator) stated the QAA committee met quarterly and the QAA committee identified quality care deficiencies and short staffing levels were identified. The following staffing concerns were observed by the survey team: -On 9/21/21 at 5:40 PM the meal cart was delivered to the dining room. Staff including CNAs, licensed nurses and a resident care manager were observed to pass meal trays. -On 9/21/21 at 7:14 PM the last resident was assisted out of dining room. -On 9/21/21 at 5:31 PM Resident 34's call light was observed on for 17 minutes and was answered at 5:33 PM (19 minutes total). The resident wanted a beverage. -On 9/21/21 at 6:38 PM Staff 33 wanted to take her lunch, but the charge nurse stated she had to wait as three staff were helping a resident who required three-person staff assistance with cares and there would be no one to watch Staff 33's hall. -On 9/23/21 at 12:10 PM Resident 15's call light was on and the resident was heard telling Staff 20 (CNA) "I want to get in bed". Staff 20 stated her hall partner was assisting a resident with eating so it would be about 10 minutes. Resident 15 replied "I know but I want to go to bed." Staff 20 went to look for a second staff member and at 12:16 PM came back to Resident 15's room and stated her hall partner was still assisting someone, so the resident would have to wait. The resident did not get assistance back to bed until 12:36 PM (26 minutes later). On 10/4/21 at 9:20 AM Staff 1 (Administrator) stated the QAA committee met quarterly and the QAA committee identified quality care deficiencies and short staffing levels were identified. 1. Resident 15 admitted to the facility in 8/2021 with diagnoses including a traumatic brain injury and a history of falls. a. The resident's 9/22/21 care plan indicated Resident 15 required one-person staff assistance for toileting and had mixed bladder incontinence. Interventions included: the resident's brief size and "incontinent program: total incontinence." On 9/23/21 8:21 AM Resident 15's call light was observed on. Resident 15 she/he needed to "poop". At 8:23 AM Staff 20 (CNA) was observed to turn off the call light and go into another room to assist a resident. On 9/23/21 at 8:24 PM Resident 15 stated staff did not assist her/him to the toilet and turned off the call light. The surveyor could smell a strong odor of urine coming from Resident 15. Resident 15 stated she/he was able to use the toilet, but it could take staff up to 20 minutes to assist so the resident had "accidents" due to staffing shortages. Staff would often turn off her/his call light without assisting her/him. The resident knew when she/he had to have bowel movement or urinate, and staff let the resident soil her/himself and would "just clean [Resident 15] up". At 8:59 AM Resident 15 stated she/he had urinated in her/his brief while waiting and the sensation to have a bowel movement "went away". Resident 15 stated she/he felt "frustrated" when she/he was left in a soiled brief. On 9/23/21 at 9:23 AM Staff 20 and Staff 21 (CNA) were observed donning gowns for a different resident room and had still not assisted Resident 15 with toileting. Staff 20 and staff 21 both stated Resident 15 was incontinent per their knowledge. Staff 20 acknowledged she turned off the call light due to not wanting a "long call light time" and stated Resident 15 had wanted "to poop". Staff 20 stated she was unable to assist Resident 15 with toileting due to staffing as she and Staff 21 were the only CNAs for the hall and were working their way down hall changing residents. On 10/6/21 at 11:31 AM Staff 26 (LPN Resident Care Manager) acknowledged the above findings. On 10/6/21 at 12:26 PM Staff 1 (Administrator) acknowledged the above staffing concerns and findings. b. Resident 15's current care plan indicated the resident was totally dependent on staff for bathing. On 9/21/21 at 5:52 PM and 6:23 PM Staff 21 (CNA) stated she had two showers scheduled, but she was unable to complete them, including for Resident 15, as she was the only CNA for the hall. Staff 21 stated there were issues providing showers to residents due to staffing shortages and resident acuity. On 10/6/21 at 11:31 AM Staff 26 (LPN Resident Care Manager) acknowledged Resident 15 did not receive a shower on 9/21/21 due to staffing shortages. On 10/6/21 at 12:26 PM Staff 1 (Administrator) acknowledged the above staffing concerns and findings. 2. Resident 17's 3/8/21 Admission Fall Assessment indicated Resident 17 was at high risk for falls due to incontinence, medication use, and experienced multiple falls prior to admission. The resident sustained falls in the facility on 3/15/21, the morning of 3/29/21, and the evening of 3/29/21. The 3/29/21 fall investigation indicated Resident 17 had an unwitnessed fall and was found on the floor lying on her/his back in the assisted dining room at approximately 8:15 PM. The resident reported she/he tried to transfer from the locked wheelchair to a dining room chair. Resident 17 reported her/his baseline low back pain worsened significantly after the fall with 6/10 pain noted. The resident had fallen earlier that morning and was on neurological checks. Staff 57 (CNA) stated Resident 17 was restless and attempting to get out bed, so he took the resident to the assisted dining room to sit with two other residents. Staff 56 (CNA) stated she last visualized the resident in the dining room at 8:00 PM while walking by and the resident was not attempting to transfer. Resident 17 was sent to the hospital and was diagnosed with a lumbar fracture. Hospital records indicated Resident 17 was hospitalized from 3/29/21 through 4/6/21 and sustained closed compression fractures of the L2 and L3 vertebra and noted baseline low back pain was worse after the fall on 3/29/21. On 10/1/21 at 2:20 PM Staff 34 (CNA) stated Resident 17 was sometimes impulsive with transfers. Staff 34 stated there were concerns monitoring residents due to staffing shortages and staff attempted to monitor residents, but a lot of times staff were so busy they were unable to check on residents. On 10/4/21 at 2:59 PM Staff 57 (CNA) stated he could not recall specifics regarding Resident 17's fall but stated there were issues with staff not being able to monitor residents who were at risk for falls due to resident acuity and not enough staff. On 10/6/21 at 12:26 PM Staff 1 (Administrator) acknowledged the above staffing concerns and findings. 3. Resident 5's fall care plan was initiated and last updated on 6/2/21. The resident was noted as a high risk for falls due to a history of multiple falls. A fall investigation indicated on 8/17/21 at approximately 5:30 AM, Resident 5 was found on the floor mat next to the bed facing the foot of the bed. Resident 5 was observed "frail, quiet, and bloody". The resident sustained an upper lip and forehead laceration with "copious amounts" of blood noted. Resident 5 was non-verbal; pain was assessed as 3/10. The resident was last observed at 3:00 AM and then not observed again until 5:30 AM. The investigation summary indicated falls continued to be difficult to prevent and the facility would continue to care plan against major injury. On 8/17/21 Hospital Records indicated Resident 5 required sutures to repair her/his head laceration. The 8/19/21 fall assessment indicated Resident 5 was a high fall risk and had multiple falls (more than two) in the past six months at the facility. On 9/23/21 at 1:40 PM Staff 54 (CNA) stated Resident 5 sustained a fall with injury due to staff being "really busy" and him not being able to check on the resident until after 5:00 AM due to resident acuity and the facility not having enough staff to provide cares. Staff 54 stated Resident 5 sometimes slept through the night but sometimes was impulsive and moved around "a lot" in bed and staff had to watch her/him closely. On 10/6/21 at 10:13 AM Staff 5 (LPN Resident Care Manager) acknowledged the resident was last visualized two and a half hours prior to being found on the floor and the expectation for high fall risks was frequent checks, which she stated was every fifteen minutes. On 10/6/21 at 12:26 PM Staff 1 (Administrator) acknowledged the above staffing concerns and findings. Refer F609 and F689. 4. Resident 25's 9/19/21 Annual MDS Fall CAA revealed Resident 25 was at risk for falls related to impaired gait and balance, a history of falls and the use of anti-depressant medication. The CAA indicated Resident 25 had difficulty with ambulation and periods of increased confusion. The 9/30/20 Fall Care Plan revealed Resident 25 was at risk for falls related to decreased mobility, activity intolerance and poor safety awareness secondary to Parkinson's Disease and associated cognitive impairment and deconditioning. Interventions included frequent checks for safety. The facility fall incident report revealed Resident 25 sustained five falls in a 27 look-back period between 9/7/21 through 10/4/21. The 9/7/21 Fall Investigation indicated Resident 25 was found on the floor in her/his room. Resident 25 indicated she/he slid out of bed when she/he attempted to transfer to the wheelchair. The 9/9/21 Fall Investigation indicated Resident 25 was found lying on the floor in her/his room next to the bed with one arm wrapped around the assistive transfer pole. Resident 25 was disoriented and confused. Resident 25 had attempted to transfer into the wheelchair, slipped on the floor and hit her/his head. Resident 25 was last checked on one and a half hours prior to the incident. Resident 25 was transferred to the hospital. The 9/28/21 2:28 AM Fall Investigation indicated Resident 25 was found on the floor of her/his room yelling for help. Resident 25 indicated she/he attempted to stand-up to urinate, slipped and fell to the floor. The investigation indicated she/he was last seen 40 minutes prior to the fall. The 9/28/21 8:50 AM Fall Investigation indicated Resident 25 was found on the floor next to the bed and transfer pole. Resident 25 indicated she/he slid off the bed when she/he attempted to get up to use the urinal. The investigation indicated Resident 25 was last seen approximately one hour before the fall. A 10/4/21 Progress Note indicated Resident 25 was found on the floor by her/his bed. Resident 25 indicated she/he slid out of bed onto the floor when she/he reached for the urinal. On 9/29/21 at 1:55 PM Staff 56 (CNA) indicated Resident 25 needed to be monitored more frequently due to being a fall risk. Staff 56 indicated she/he and other staff informed the administrative staff on multiple occasions of the concern and the resident should not be left unassisted due to her/his multiple falls. On 10/1/21 at 9:58 AM Staff 12 (CNA) stated Resident 25's room was at the end of the hall, there was not enough staff to monitor Resident 25, she/he was very impulsive and a fall risk. Staff 12 stated she had repeatedly informed management of this concern until she was "blue in the face" however Resident 25's plan of care did not change. On 10/1/21 at 1:21 PM Staff 26 (LPN Resident Care Manager) stated Resident 25 was constantly falling and was running out of ideas how to update her/his plan of care. Staff 26 acknowledged no fall interventions were updated in 9/2021 after any fall. Staff 26 stated frequent checks were every two hours and further stated this was "not ideal." Staff 26 verified Resident 25 required more supervision but the facility could not accommodate this need due to current staffing levels. On 10/6/21 at 12:26 PM Staff 1 (Administrator) acknowledged the above staffing concerns and findings. 5. a. Resident 31's 9/16/21 physician order indicated Resident 31 was to receive Depakote (a mood stabilizer) BID and Roxicodone (pain medication) 2.5 mg BID. The 9/2021 MAR indicated Resident 31 was to receive Depakote and Roxicodone between 7 AM and 10 AM. On 9/21/21 at 11:22 AM Staff 6 (CMA) was observed to administer Depakote and Roxicodone to Resident 31. On 9/21/21 at 11:30 AM Staff 6 acknowledged the late medication administration for Depakote and Roxicodone. On 10/6/21 at 12:26 PM Staff 1 (Administrator) acknowledged the above staffing concerns and findings. b. Resident 32's 9/16/21 physician order indicated Resident 32 was to receive omeprazole once daily prior to meals. The 9/2021 MAR indicated omeprazole was to be administered at 7:30 AM daily. On 9/22/21 at 12:26 PM Staff 7 (LPN) was observed to administer omeprazole to Resident 32. On 9/22/21 at 12:28 PM Staff 7 acknowledged the omeprazole was due before breakfast and the resident did not receive it until 12:26 PM. On 10/6/21 at 12:26 PM Staff 1 (Administrator) acknowledged the above staffing concerns and findings. c. Resident 33's 9/16/21 physician order indicated Resident 33 was to receive baclofen TID for muscle spasms and gabapentin TID for pain related to stroke. On 9/22/21 at 12:10 PM Staff 7 (LPN) was observed to administer the morning dose of baclofen and gabapentin to Resident 33. The 9/2021 MAR indicated the medications were to be administered between 7 AM and 10 AM. On 9/22/21 at 12:10 PM Staff 7 acknowledged the baclofen and gabapentin were due earlier that morning and stated the afternoon doses would have to be administered later that day since they were both TID medications. A record review was completed on 9/22/21 at 2:55 PM and indicated Resident 33 received the noon dose of baclofen at 2:20 PM. On 9/22/21 at 2:55 PM the administration times of baclofen and gabapentin were reviewed with Staff 29 (Corporate RN). On 10/6/21 at 12:26 PM Staff 1 (Administrator) acknowledged the above staffing concerns and findings. Refer F600, F676, F677, F684, F686, F689, and F759.

"All Residents are at risk of not having sufficient staffing levels to meet their care needs "Regional team member will in-service Administrator, DNS and HR Director on the federal regulation on staffing to acuity to meet residents needs. Facility is currently utilizing 7 agency contracts to fill open nursing shifts, as well as offering incentives to pick up or switch shifts. Facility is also sponsoring 3 PCA in a local NA course. Town hall meetings will be conducted 1 x month to address employee concerns and brainstorm new ideas. "Administrator or designee will audit daily staffing levels versus acuity bi-weekly for 4 weeks. Then weekly x 2 months. Then monthly for 2 months. Results brought to QA

Based on interview and record review it was determined the facility failed to ensure Staff 30 (LPN), Staff 31 (RN), and Staff 32 (CMA) had the appropriate skills and competencies necessary to care for resident needs. This placed residents at risk for lack of competent care. Findings include: 1. On 9/22/21 at 12:07 PM Staff 7 (LPN) was observed passing morning medications to residents over two hours after the medications were due. On 9/22/21 at 12:28 PM Staff 7 stated Staff 30 (LPN) was running late administering morning medications and she was helping out. Staff 7 stated Staff 30 did not usually pass medications, he asked questions, and was late administering morning medication pass. She stated she took over the morning medication pass and Staff 30 was working on passing noon medications on a different hall. On 9/22/21 at 12:32 PM Staff 30 stated he had worked at the facility for a month, it was his first day passing medications, he did not have a routine, and was assigned to pass medications to residents on 2 of 4 halls independently. Staff 30 stated once he was behind with morning medications the CMA and LPN assisted him to finish medication pass. Staff 30 further stated he had not been checked off for nurse competencies including medication pass. 2. On 9/23/21 at 1:55 PM Staff 1 (Administrator) provided copies of staff competencies for Staff 30 (LPN), Staff 31 (RN) and Staff 32 (CMA). The competencies were listed out by task, review date, and whether or not the staff exceeded, met or failed to meet job requirements. All three competencies were signed by Staff 2, there was no date indicating when the competencies were checked off, no date of when they were signed as completed. There was also a place for the staff to sign and date. All three competencies did not include the staff signatures. All three staff competencies had the DNS initials with "M" next to her initials (for met job requirements) for the entire checklist of skills with no dates checked off. a. On 9/23/21 at 2:01 PM and 2:29 PM Staff 30 (LPN) stated he never worked with Staff 2 and she did not check him off for his Charge Nurse competencies. Staff 30 further stated he was not formally checked off for nurse competencies and he worked with several floor nurses but not the DNS. The competency paperwork that was provided by Staff 1 was reviewed with Staff 30 and he stated he had not seen this paperwork before today and did not know what it was. b. On 9/23/21 at 2:22 PM Staff 32 (CMA) stated she never worked with Staff 2 and she did not check her off for her CMA competencies. Staff 32 stated she did not remember staff completing competencies during her training. The competency paperwork that was provided by Staff 1 was reviewed with Staff 32 and she did not recall seeing the paperwork before today. c. On 9/23/21 2:39 PM Staff 31 (RN) stated she never worked with Staff 2 and she did not check her off for her Charge Nurse competencies. Staff 31 further stated she did not recall seeing competency paperwork during or after her training was completed. On 9/24/21 at 9:25 AM Staff 40 (HR) stated staff competencies was something the facility was "working on" and she had not seen a staff competency checklist for any of the facility staff. Staff 40 stated the current process was for staff to request additional training if needed from the staff who originally trained them. On 9/24/21 at 9:28 AM the competencies for Staff 30, Staff 31 and Staff 32 were reviewed with Staff 2. Staff 2 stated she was unsure of the date she signed the competencies. She further acknowledged the competencies were undated and there was no indication of the dates the skills checklist took place. Staff 2 stated there were "probably a few staff" that she did not physically see the competency tasks checked off.

"No specific resident affected "All residents at risk for not having proper oriented charge nurses and CMAs. "DNS or designee will in-service all Licensed nurses and CMA's on medication administration and process of late medication and review job specific orientation checklist with LN and CMA. All LN,CMA,CNA and new hires and agency LN/CMA/CNA will have Orientation Competency checklist completed. Moving forward Orientation Competency checklist will be completed upon hire and annually. "DNS or designee will audit for late meds Monday through Friday weekly no less than 5 times for 4 weeks, weekend med pass will be reviewed on Monday. Then weekly x 2 months and then Monthly x 2 month. HR Director will audit for completion of orientation checklist for current and future license nurse and CMA's weekly x 4 weeks. Then monthly x 2 months and Monthly for 2 months. Results will be brought to QA for further review and discussion.

Based on observation, interview and record review it was determined the facility failed to maintain a medication error rate of less than 5%. There were 5 errors in 35 opportunities resulting in a 14% medication error rate. This placed residents at risk for medication errors and adverse drug reactions. Findings include: 1. Resident 33 was admitted to the facility in 2017 with diagnoses including a stroke. The 9/16/21 physician order indicated Resident 33 was to receive baclofen TID for muscle spasms and gabapentin TID for pain related to stroke. On 9/22/21 at 12:10 PM Staff 7 (LPN) was observed to administer the morning dose of baclofen and gabapentin to Resident 33. The 9/2021 MAR indicated the medications were to be administered between 7 AM and 10 AM. On 9/22/21 at 12:10 PM Staff 7 acknowledged the balcofen and gabapentin were due earlier that morning and stated the afternoon doses would have to be administered later that day since both were TID medications. A record review was completed on 9/22/21 at 2:55 PM and indicated Resident 33 received the noon dose of baclofen at 2:20 PM. On 9/22/21 at 2:55 PM the administration times of baclofen and gabapentin were reviewed with Staff 29 (Corporate RN). On 9/22/21 at 3:06 PM Staff 29 stated the physician was notified of the administration times of baclofen and gabapentin and Resident 33 was placed on alert charting to monitor for potential side effects. 2. Resident 32 admitted to the facility in 2019 with diagnoses including dementia. The 9/16/21 physician order indicated Resident 32 was to receive omeprazole once daily prior to meals. The 9/2021 MAR indicated omeprazole was to be administered at 7:30 AM daily. On 9/22/21 at 12:26 PM Staff 7 (LPN) was observed to administer omeprazole to Resident 32. On 9/22/21 at 12:28 PM Staff 7 acknowledged the omeprazole was due before breakfast and the resident did not receive it until 12:26 PM. 3. Resident 31 was admitted to the facility in 2019 with diagnoses including paranoid schizophrenia. The 9/16/21 physician order indicated Resident 31 was to receive Depakote (a mood stabilizer) BID and Roxicodone (pain medication) BID. The 9/2021 MAR indicated Resident 31 was to receive Depakote and Roxicodone between 7 AM and 10 AM. On 9/21/21 at 11:22 AM Staff 6 (CMA) was observed to administer Depakote and Roxicodone to Resident 31. On 9/21/21 at 11:30 AM Staff 6 acknowledged the late medication administration for Depakote and Roxicodone.

"Resident 31, 32 and 33 are still residents at facility. "All residents at risk for late administration of medications "DNS or designee will in-service all Licensed nurses and CMA's on medication administration and process of late medication to notify MD. All LN and CMA, new hires and agency LN/CMA will have Orientation Competency checklist completed. Moving forward checklist will be completed upon hire and reviewed annually. Facility is completing live time audit of EMAR. LN and CMA's have been educated if they fall behind to ask for assistance. "DNS or designee will audit for late meds Monday through Friday weekly no less than 5 times for 4 weeks, weekend med pass will be reviewed on Monday. Then weekly x 2 months and then Monthly x 2month and random live time EMAR audits 3 x weekly for 4 weeks. Then 2 x month for 2 months and then monthly for 2 months. Results will be brought to QA for further review and discussion.

Based on observations, interview and record reviews it was determined the facility failed to ensure accuracy of resident diet orders for 1 of 13 sampled residents (#1) reviewed for aspiration precautions and failed to ensure Direct Care Staff Daily Reports were maintained for 1 of 1 facility reviewed for staffing. This placed residents at risk for receiving the wrong diet and inaccurate records for staffing ratios. Findings include: 1. Resident 1 was admitted to the facility in 12/2012 with diagnoses including multiple sclerosis, dysphagia, and pneumonitis due to inhalation of food and vomit. Resident 1's 6/24/21 physician order indicated Resident 1 was on aspiration precautions with close supervision, no water pitcher or thin liquids at bedside, and small bites, small sips, and slow rate. On 9/20/21 at 12:42 PM Staff 4 (CNA) was observed exiting Resident 1's room and closed the door. Staff 4 stated Resident 1 had food in her/his room, and she had just set the resident up and she/he was eating independently. On 9/20/21 at 12:47 PM Staff 2 (DNS) stated Resident 1 was "close" supervision on the aspiration form but the care plan indicated intermittent supervision so the resident would be changed to intermittent supervision on the aspiration form. On 9/20/21 at 12:52 PM Surveyor knocked on Resident 1's closed door looked in room and observed Resident 1 continuing to feed her/himself with no staff present in the resident's room. Two cups of liquid were also observed within reach of the resident. On 9/20/21 at 1:00 PM Resident 1's Aspiration Precaution sign was provided and indicated the resident was "intermittent supervision" with meals. On 9/20/21 at 1:47 PM Staff 2 (DNS) was asked for the assessment or order for intermittent supervision and stated she was unable to find an assessment or order indicating Resident 1 required intermittent supervision. On 9/20/21 at 2:48 PM Staff 1 (Administrator) and Staff 2 (DNS) confirmed the most recent signed physician orders were correct and indicated Resident 1 was close supervision with meals and no liquids at bedside. Staff 2 confirmed Resident 1 had not been assessed by the speech pathologist since 4/2020. Staff 1 and Staff 2 confirmed intermittent supervision was inaccurate. , 2. Review of the Direct Care Staff Daily Reports from 7/1/21-9/18/21 revealed inaccurate documentation of the number of staff actually scheduled and the number documented on the reports for the following dates: -7/3/21 -7/7/21 -7/10/21 -8/2/21 -8/7/21 -9/7/21 On 10/1/21 at 12:12 PM Staff 1 (Administrator) acknowledged for inaccurate documentation for the dates identified.

"Resident 1 is still resident at facility "All residents on aspiration precautions are at risk for inaccurate diet. All residents are at risk of inaccurate records of staffing ratios. "Administrator/DNS or designee will in-service all Licensed nurses and HR Director on DHS form procedure. "Administrator or designee will audit DHS forms for accuracy and completion daily for 2 weeks, then weekly for 2 months, then monthly for 2 months. Results brought to QA for further review and discussion. "Administrator/DNS or designee will audit residents on aspiration precautions proper diet orders weekly x 3 months, then monthly x 3 months and then monthly x 2 months. Results brought to QA for further review.

Based on interview and record review it was determined the facility failed to ensure a program of systemic identification, analysis and action was in place related to residents at risk for aspiration and falls for 1 of 1 QAA (Quality Assessment and Assurance) committee reviewed for quality assurance. This failure resulted in Resident 1 who was identified as an aspiration risk with a previous history of aspiration to be observed alone with food and liquids on 9/20/21. Additionally, twelve residents were identified as an aspiration risk and 33 residents were identified to be at risk for falls and hospitalization. This was determined to be an Immediate Jeopardy (IJ) situation. Findings include: The 2/2020 Quality Assurance and Performance Improvement (QAPI) Program policy statement revealed the committee would measure current and potential indicators for outcomes of care and quality of life, establish and implement performance improvement projects to correct identified negative or problematic indicators, reinforce and build upon effective systems and processes related to the delivery of quality care and services and establish systems to monitor and evaluate corrective actions. The committee would meet monthly. Review of the facility documents revealed from 1/2020 through 10/4/21 the QAA committee met on 1/28/20, 10/21/20 and 4/1/21. The 9/2021 Dysphagia Diets and Aspiration Precautions policy statement indicated residents who were identified as close supervision and 1:1 supervision levels were not to be left unattended with the food tray. The 3/18/21 Fall policy statement indicated staff would assess and identify residents at risk for falls, identify pertinent interventions to prevent subsequent falls, monitor and follow-up with the IDT's (interdisciplinary team's) involvement. Refer to F689. On 10/4/21 at 9:20 AM Staff 1 (Administrator) stated the QAA committee met quarterly and the QAA committee identified quality care deficiencies by reviewing a checklist from each department and reviewing grievances. Staff 1 indicated fall trends were tracked and reviewed and short staffing levels were identified. Supporting documentation of the QAA meetings was requested. On 10/4/21 at 11:45 AM Staff 1 stated he knew the QAA meetings were required to be held at minimum every three months. Staff 1 further stated between 1/2020 through 10/4/21 only three QAA meetings were held on 1/28/20, 10/21/20 and 4/1/21. On 10/4/21 at 3:10 PM Staff 2 (DNS) stated the last QAA committee she attended was in 4/2021 and verified the QAA team had not met for over six months, did not monitor any concerns and no action plans were in place for residents who were at risk for aspiration or falls. On 10/4/21 at 3:15 PM Staff 48 (Social Services) stated the last QAA committee she attended was in 4/2021 and verified the QAA team had not met for over six months, did not monitor any concerns and no action plans were in place for residents who were at risk for aspiration or falls. On 10/4/21 at 4:16 PM Staff 1, Staff 2, and Staff 29 (Regional RN) were informed of the identified Immediate Jeopardy for the failure to ensure the facility had a QAA program of systemic identification, analysis and action in place related to aspiration precautions and falls. The QAA committee did not identify Resident 1, who was at high risk for aspiration, was not supervised along with twelve additional residents at risk for aspiration. The QAA committee did not identify the 33 identified residents at risk for falls and hospitalization. The facility did not have a working system in place to address the residents at high risk for aspiration and falls. On 10/4/21 at 5:28 PM the IJ Abatement Plan was received and approved. The Plan included: -All residents with aspiration precautions would be re-evaluated by the contract SLP by 10/6/21. -All staff would be in-serviced regarding aspiration precautions, policy and procedures for aspiration precautions and definitions related to types of supervision. -QAPI meeting would be held with the IDT and Medical Director on 10/5/21. Root cause analysis would be completed by Staff 1, Staff 2, Staff 5 (LPN Resident Care Manager) or Staff 26 (LPN Resident Care Manager). -Monthly QAA meetings would be held and review any issues or concerns regarding staffing or any other issue brought up. Resident safety would be a priority. Administration would bring all concerns forward to QAPI with issues, concerns and corrective plans. This information would be reviewed monthly for six months and brought to QAPI for no less than two quarters. -Staffing Coordinator and Staff 1 would meet to review staffing needs no less than three times per week. The Staffing Coordinator would keep a log of all attempts made to cover any "call off" shifts which occurred. Staff 1 would review agency contracts to establish contracts with other [staffing] agencies. The staffing coordinator would document the number of available shifts on a weekly basis and log the corrective actions taken and bring to QAPI quarterly. Staff 1 would set up a blind survey for staff to participate in to request any concerns or suggestions they had. These concerns would be brought to the monthly QAA and quarterly QAPI meetings. On 10/6/21 at 12:07 PM observation, interview and record review verified the IJ Abatement Plan for the residents at risk for aspiration and falls were implemented. Review of the IJ Abatement Plan revealed the plan was fully implemented. ,

"All residents currently on aspiration precautions are currently being reevaluated by contracted SLP. To date, there are 2 residents still requiring reevaluation. This will be completed by Wednesday 10/6/21. All staff have been in serviced regarding aspiration precautions, policy and procedure for this as well as definitions related to types of supervision. QAPI meeting will be held with IDT and Medical Director on 10/5/21. Root cause analysis will be completed by Admin./DNS/RNC for residents at risk for aspiration and falls. Action plans will be implemented for residents at risk for aspirations, falls as well as staffing. This information will be brought to QAPI, with set audits and schedules to be determined at QAPI. Monthly QA meeting will be held by Admin. Or designee with line staff wishing to participate in a staff retention committee. This committee will meet to review any issues or concerns regarding staffing or other issues they may bring forth. Resident safety will be priority. Admin. will bring all information forward to QAPI with issues, concerns and corrective plans. This will be reviewed monthly for 6 months and brought to QAPI for no less than 2 quarters. Staffing Coordinator and Admin. will meet to review staffing needs no less than 3 times per week. Staffing Coordinator will keep a log of all attempts she makes to cover any call offs that may occur. Admin. will review agency contracts to establish contracts with other agencies. Staffing coordinator will document number of available shifts on a weekly basis. This information will be logged with corrective actions taken and brought to QAPI quarterly. Admin. Will set up a blind survey for staff to participate in to request any concerns they have as well as suggestions. These areas will be brought to monthly QA and quarterly QAPI.

Based on interview and record review it was determined the facility failed to have the QAA (Quality Assessment and Assurance) committee meet quarterly for 1 of 1 QAA Committees reviewed for quality assurance. This failure resulted in falls with hospitalization and a fracture, and placed residents at increased risk of aspiration. Findings include: The Quality Assurance and Performance Improvement Program policy and procedure revealed the QAA committee was to meet monthly to review reports, evaluate data, monitor QA related activities and make adjustments to the plan. Review of the facility documents revealed from 1/2020 through 10/4/21 the QAA committee met on 1/28/20, 10/21/20 and 4/1/21. On 10/4/21 at 3:10 PM Staff 2 (DNS) stated the last QAA committee she attended was in 4/2021 and verified the QAA team had not met for over six months. She further stated the QAA committee did not monitor any concerns and no action plans were in place for residents who were at risk for aspiration precautions or falls. On 10/4/21 at 3:15 PM Staff 48 (Social Services) stated the last QAA committee she attended was in 4/2021 and verified the QAA team had not met for over six months. She further stated the QAA committee did not monitor any concerns and no action plans were in place for residents who were at risk for aspiration precautions or falls. On 10/4/21 at 11:45 AM Staff 1 (Administrator) stated he was aware the QAA committee was supposed to meet at minimum quarterly and verified the QAA committee only met three times between 1/2020 and 10/4/21. Refer to F689 and F867.

"All residents at risk for adverse outcomes for facility failure to identify improvement areas "RDO or Designee will in-service Administrator on state QA regulation "Administrator or designee will audit monthly QA completion, required attendance 1 x month for next 3 months and then quarterly after.

Based on observation, interview and record review it was determined the facility failed to follow CDC Infection Control Guidelines related to PPE (Personal Protective Equipment) Usage for 2 of 4 halls reviewed for infection control. This placed residents and staff at risk for potential exposure to COVID-19 infection. Findings include: Per CDC Guidance: -Implement Universal Use of Personal Protective Equipment for Health Care Providers (HCP): -SARS-CoV-2 infection is not suspected in a patient presenting for care (based on symptom and exposure history), HCP working in facilities located in counties with substantial or high transmission should also use PPE as described below: -Eye protection (i.e., goggles or a face shield that covers the front and sides of the face) should be worn during all patient care encounters. On 9/27/21 at 5:35 AM Staff 60 (RN) was observed near the nurses' station not wearing a face shield. Staff 60 stated she was not told by staff that she needed to wear a face shield and was unsure of what the facility expectations were. On 9/27/21 at 5:46 AM Staff 66 (CNA) was observed in the 400 hall not wearing a face shield. Staff 66 stated he had a face shield he just forgot to put it on. On 9/27/21 at 6:22 AM Staff 59 (CNA) was observed in the 200 hall not wearing a face shield. Staff 59 stated she was not sure if she needed to wear one and staff did not ask her to wear a face shield. On 9/27/21 at 8:45 AM Staff 2 (DNS) stated expectation was that staff wear face shields at all times.

"No specific resident "All residents at risk for spread of infection due to staff noncompliance with face shields "Admin/DNS or designee will in service ALL STAFF on face shield policy per county, state and CDC guidelines at the highest standard set. "Administrator/DNS or designee will Audit random shifts weekly for 4 weeks, no less than 5 times. Then monthly for 2 month. Results brought to QA for further review and discussion

Based on interview and record review it was determined the facility failed to ensure minimum CNA staffing ratios were maintained for 17 of 62 days reviewed for minimum CNA staffing. This placed residents at risk for delayed care. Findings include: Due to Oregon's current statewide hospital capacity crisis, the Oregon Department of Human Services, Safety, Oversight and Quality Unit temporarily revised the Oregon Administrative Rules (OARs) related to certified nursing assistant staffing, effective immediately. The Department temporarily amended the minimum certified nursing assistant ratios as follows: Current OARs for Certified Nursing Assistants (411-086-0100(C)): o DAY SHIFT: 1 certified nursing assistant per 7 residents. o EVENING SHIFT: 1 certified nursing assistant per 9.5 residents. o NIGHT SHIFT: 1 certified nursing assistant per 17 residents. Effective August 24th, 2021, Temporary OARs for Certified Nursing Assistants (411-086-0100(C)): o DAY SHIFT: 1 certified nursing assistant per 8.5 residents. o EVENING SHIFT: 1 certified nursing assistant per 12 residents. o NIGHT SHIFT: 1 certified nursing assistant per 18 residents. The Department also temporarily expanded definitions of who can be counted towards the minimum certified nursing assistant ratios. Effective immediately, nursing facilities may temporarily utilize the services of nursing assistants, personal care assistants, physical therapists and occupational therapists to account for up to 25% of the required minimum staff required on each shift. The revised staffing ratios and use of staff other than certified nursing assistants to meet the minimum CNA staffing ratio is a temporary measure and will only be allowed during this statewide emergency. A review of the facility's Direct Care Staff Daily Reports from 7/1/21 through 8/31/21 revealed the following dates when the required state minimum CNA staffing ratios were not met for one or more shifts: - 7/1/21 - 7/3/21 - 7/5/21 - 7/7/21 - 7/8/21 - 7/10/21 - 7/12/21 - 7/20/21 - 7/26/21 - 8/1/21 - 8/2/21 - 8/7/21 - 8/13/21 - 8/14/21 - 8/22/21 - 8/23/21 - 8/29/21 On 10/1/21 at 12:12 PM Staff 1 (Administrator) acknowledged the lack of required CNAs on duty on the identified dates.

"All Residents are at risk of not having sufficient staffing levels to meet their care needs •Regional team member will in-service Administrator, DNS and HR Director on the federal regulation on staffing to acuity to meet residents needs. Facility is currently utilizing 7 agency contracts to fill open nursing shifts, as well as offering incentives to pick up or switch shifts. Facility is also sponsoring 3 PCA in a local NA course. Town hall meetings will be conducted 1 x month to address employee concerns and brainstorm new ideas. •Administrator or designee will audit daily staffing levels versus acuity bi-weekly for 4 weeks. Then weekly x 2 months. Then monthly for 2 months. Results brought to QA

***************************** 411-085-0310 Resident's Rights: Generally Refer to F550 ***************************** 411-086-0360 Resident Furnishings, Equipment Refer to F558 ***************************** 411-085-0360 Abuse Refer to F600 and F609 ***************************** 411-086-0060 Comprehensive Assessment and Care Plan Refer to F657 ***************************** 411-086-0110 Nursing Services: Resident Care Refer to 658, F684 and F697 ***************************** 411-086-0100 Nursing Services: Resident Care Refer to F676, F677 and F759 ***************************** 411-086-0230 Activity Services Refer to F679 ***************************** 411-086-0140 Nursing Services: Problem Resolution & Preventive Care Refer to F686 and F689 ***************************** 411-086-0100 Nursing Services: Staffing Refer to F725 and F726 ***************************** 411-086-0300 Clinical Record Refer to F842 ***************************** 411-085-0220 Quality Assurance Refer to F867 and F868 ***************************** 411-086-0330 Infection Control and Universal Precations Refer to F880 *****************************