Glisan Post Acute

The facility's Self Administration of Medication dated 8/2024 included the following: - No medications are stored at bedside nor self-administered until evaluation complete. - A physician order is obtained indicating the specific medications that resident is able to self-administer. - If the resident chooses to have the medications at the bedside, they are contained in a locked cupboard or drawer. - Medications are indicated on the ""MAR"" as self-administered.-á - The resident is reevaluated for continued ability to self-administer their medications annually and with significant change in condition. 1. Resident 60 was admitted to the facility 7/2025 with diagnosis of metabolic encephalopathy (a syndrome of global brain dysfunction caused by underlying systemic illnesses).-á The Quarterly MDS with an ARD of 12/7/25 revealed Resident 60 had a BIMS score of 13, which indicated the resident was cognitively intact. Observations on 3/9/26 at 10:52 AM, 3/10/26 at 7:19 AM, and 3/12/26 at 8:29 AM revealed Resident 60 had Calcium Magnesium, Benadryl (over-the-counter antihistamine), Calamine lotion (over-the-counter topical medication), multivitamins, and Cetirizine Hydrochloride (over-the-counter antihistamine) on her/his nightstand and bedside table.-á A review of Resident 60's clinical record revealed no self-administration assessment for Calcium Magnesium, Benadryl, Calamine lotion, multivitamins, and Cetirizine Hydrochloride. A review of Resident 60's Medication Administration Record for 3/2026 revealed no indication for medications to be self-administered. On 3/12/26 at 8:49 AM, Staff 29 (CNA) stated she was unaware of any residents being authorized to self-administer medications. She stated if she saw medications at a resident's bedside, she would inform a nurse. On 3/12/26 at 9:33 AM, Staff 11 (CNA) stated residents were not supposed to have medications at their bedside. She stated if she saw medications at a resident's bedside, she would tell a nurse. On 3/12/26 at 9:35 AM, Staff 24 (CMA) stated she ensured residents completely swallowed oral medications safely prior to exiting the room and any medications at the bedside would be reported to a nurse. On 3/12/26 at 9:41 AM, Staff 22 (LPN) stated he did not know of many residents who were authorized to have medications at the bedside. At 9:43 AM, Staff 22 stated Resident 60 was known to purchase her/his own medications from outside of the facility and bring them back to her/his room. At 9:45 AM, Staff 22 entered Resident 60's room and confirmed she/he had Calcium Magnesium, Benadryl, Calamine lotion, multivitamins, and Cetirizine Hydrochloride in her/his room. On 3/13/26 at 10:34 AM, Staff 23 (LPN Resident Care Manager) stated the process for residents to have medications at the bedside included having a self-administration assessment completed for residents. Staff 23 stated he expected for staff to inform management if they observed residents to have medications at the bedside. At 10:47 AM, Staff 23 entered Resident 60's room and confirmed she/he had Calcium Magnesium, Benadryl, Calamine lotion, multivitamins, and Cetirizine Hydrochloride in her/his room. On 3/13/26 at 1:22 PM, Staff 2 (DNS) stated she expected for staff to inform nurses if medications were observed to be in a resident's room. Staff 2 stated residents should not have medications, unless a self-administration assessment was on file. 2. Resident 13 was admitted to the facility 5/2023 with diagnosis of calculus of kidney (solid mineral that forms in the kidneys).-á The Quarterly MDS with an ARD of 12/11/25 revealed Resident 13 had a BIMS score of 15, which indicated the resident was cognitively intact. Observations on 3/9/26 at 10:22AM, 3/11/26 at 11:23 AM and 3/12/26 at 9:49 AM revealed Resident 13's dresser had a bottle of Vitamin B12, a bottle of Caltrate bone vitamins (high-potency calcium and Vitamin D3) and a box of artificial tears. Resident 13's bedside table was also observed to have a bottle of phenol throat spray (over-the-counter antiseptic and anesthetic spray).-á A review of Resident 13's clinical record revealed she/he had a self-administration assessment from 10/11/24 for Vitamin B Complex. The clinical record revealed no self-administration assessment for the last 12 months for Vitamin B12, Caltrate bone vitamins, artificial tears, or phenol throat spray. A review of Resident 13's Medication Administration Record for 3/2026 revealed no indication for medications to be self-administered. On 3/9/26 at 10:22 AM, Resident 13 stated she/he thought it was okay to have the medications in her/his room and had been using the throat spray to relieve her/his throat. On 3/12/26 at 8:49 AM, Staff 29 (CNA) stated she was unaware of any residents being authorized to self-administer medications. She stated if she saw medications at a resident's bedside, she would inform a nurse. On 3/12/26 at 9:33 AM, Staff 11 (CNA) stated residents were not supposed to have medications at their bedside. She stated if she saw medications at a resident's bedside, she would tell a nurse. On 3/12/26 at 9:35 AM, Staff 24 (CMA) stated she ensured residents completely swallowed oral medications safely prior to exiting the room and any medications at the bedside would be reported to a nurse.-á On 3/12/26 at 9:41 AM, Staff 22 (LPN) stated he did not know of many residents who were authorized to have medications at the bedside. At 9:49 AM, Staff 22 entered Resident 13's room and confirmed she/he had a bottle of Vitamin B12, a bottle of Caltrate bone vitamins, a box of artificial tears and a bottle of phenol throat spray in her/his room. Staff 22 stated Resident 13 was not authorized to self-administer the medications. On 3/13/26 at 10:34 AM, Staff 23 (LPN Resident Care Manager) stated the process for residents to have medications at the bedside included having a self-administration assessment completed for residents. Staff 23 stated he expected for staff to inform management if they observed residents to have medications at the bedside. At 10:46 AM, Staff 23 entered Resident 13's room and confirmed there was a bottle of Vitamin B12, a bottle of Caltrate bone vitamins, a box of artificial tears and a bottle of phenol throat spray in her/his room. and confirmed she/he needed to have a self-administration assessment on file.-á On 3/13/26 at 1:22 PM, Staff 2 (DNS) stated she expected for staff to inform nurses if medications were observed to be in a resident's room. Staff 2 stated residents should not have medications, unless a self-administration assessment was on file and self-administration assessments should be reviewed at least once a year. 3. Resident 10 was admitted to the facility 1/2026 with diagnosis of cellulitis of right lower limb.-á The Admissions MDS with an ARD of 1/18/26 revealed Resident 10 had a BIMS score of 15, which indicated the resident was cognitively intact.-á Observations on 3/9/26 at 11:10 AM and 3/13/26 at 10:48 AM revealed Resident 10 had a bottle of nasal saline solution on her/his bedside table. A review of Resident 10's clinical record revealed no self-administration of medication assessment was completed to determine the resident's ability to safely self-administer nasal saline solution. On 3/9/26 at 11:10 AM, Resident 10 stated staff had given her/him the saline solution to use independently. On 3/12/26 at 8:49 AM, Staff 29 (CNA) stated she was unaware of any residents being authorized to self-administer medications. She stated if she saw medications at a resident's bedside, she would inform a nurse. On 3/12/26 at 9:33 AM, Staff 11 (CNA) stated residents were not supposed to have medications at their bedside. She stated if she saw medications at a resident's bedside, she would tell a nurse. On 3/12/26 at 9:35 AM, Staff 24 (CMA) stated she ensured residents completely swallowed oral medications safely prior to exiting the room and any medications at the bedside would be reported to a nurse. Staff 24 stated she thought it was okay for Resident 10 to have the saline nasal solution.-á On 3/12/26 at 9:41 AM, Staff 22 (LPN) stated he did not know of many residents who were authorized to have medications at the bedside. At 9:43 AM, Staff 22 entered Resident 10's room and confirmed the saline nasal spray was on Resident 10's bedside table. Staff 22 stated Resident 10 needed a self-administration assessment.-á On 3/13/26 at 10:34 AM, Staff 23 (LPN Resident Care Manager) stated the process for residents to have medications at the bedside included having a self-administration assessment completed for residents. Staff 23 stated he expected for staff to inform management if they observed residents to have medications at the bedside. At 10:48 AM, Staff 23 entered Resident 10's room and confirmed there was nasal saline solution on Resident 10's bedside and confirmed she/he needed to have a self-administration assessment on file.-á On 3/13/26 at 1:22 PM, Staff 2 (DNS) stated she expected staff to inform nurses if medications were observed to be in a resident's room. Staff 2 stated residents should not have medications, unless a self-administration assessment was on file. -á

Resident 60 is not safe to self- administer medications and all medications were removed from bedside.  Resident on educated on taking outside medications. Resident 13 was assessed to self-administer medications and is able to do so.  Medications were secured in her drawer. Resident 10 was assessed to self-administer medications and is able to do so.  Medications were secured in a lock box. A ll r ooms were evaluat ed for medications at  bed side  and deficiencies were corrected Nurses and medication aides were  educated to not leave medications at bedside.  All staff were educated to notify nurses or med aides if medications were found at bedside.  Nurses were educated to notify RCM if a resident wishes to self-administer medications DNS /Designee will randomly review resident rooms, and med passes to ensure meds are not left at bedside weekly x4, monthly x2, or until compliance is achieved. The results of these audits will be reviewed in QAPI to determine the need for further  oversight.

The facility's 2/2021 Homelike Environment Policy indicated the facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting, including comfortable sound levels.-á Resident 1 was readmitted to the facility in 3/2023 with diagnoses including insomnia.-á Resident 1's 2/5/26 Quarterly MDS revealed the resident was cognitively intact.-á On 3/10/26 at 9:50 AM, Resident 1 was observed in her/his room in bed. Resident 1 stated the backdoor, located just outside of her/his room, was broken and the alarm attached to the door would ""ring and ring and ring"" when the door was not shut properly. Resident 1 stated the sound of the alarm was constant, and at night, it prevented her/him from sleeping. Resident 1 stated the residents at the facility were expected to ""just have to deal"" with the constant sound of the alarm. The door to the resident's room was shut, and at 10:05 AM, the sound of the alarm was heard inside the resident's room. On 3/10/26 from 2:32 PM to 3:54 PM and from inside Resident 1's room with the door shut, the alarm to the backdoor was observed to loudly sound on five different occasions.-á On 3/11/26 from 5:21 AM to 5:26 AM, the alarm to the backdoor was observed to loudly sound. At 5:34 AM, Resident 1 stated the sound of the alarm was ""very intrusive and makes you nuts,"" and stated she/he had complained about the noise to ""everybody and anybody who would listen."" At 5:47 AM, the alarm to the backdoor sounded again.-á On 3/11/26 at 5:59 AM, Staff 20 (CNA) stated residents were constantly going in-and-out of the backdoor, so the alarm sounded ""all of the time at night."" Staff 20 stated the alarm sounded the loudest in Resident 1's room, and he would ""loose his mind"" if he were a resident and had a room by the backdoor because of the constant sound from the door alarm.-á On 3/11/26 at 6:08 AM, Staff 21 (CNA) stated Resident 1 complained she/he ""can't stand the noise"" from the backdoor's alarm. On 3/12/26 at 8:36 AM, Staff 11 (CNA) stated Resident 1 complained the noise from the backdoor's alarm was ""annoying."" Staff 11 further stated the door alarm sounded at least ten times during her shift.-á On 3/12/26 at 9:12 AM, Staff 22 (LPN) stated Resident 1 slept during the day. At 9:16 AM, the alarm to the backdoor sounded and Staff 22 excused himself to turn it off. Upon his return, Staff 22 stated the noise from the alarm was bothersome to the residents, and it sounded at all times of the day, including during the middle of the night.-á-á On 3/12/2026 at 11:58 AM, Staff 1 (Administrator) stated she expected staff to notify her of complaints regarding sound levels at the facility so she could implement systems to address the complaints. Staff 1 further stated she was-á unaware of Resident 1's complaint about the noise from the backdoor alarm and did not consider the alarm sounding throughout the day and night to constitute a homelike environment.-á

The door alarm has been disarmed Other doors were reviewed to ensure they operate appropriately and no alarms are overly sounding Staff educated to report any issues with the doors to maintenance and to silence alarms as soon as possible. Administrator/designee will do random resident interviews regarding sound levels in the building to ensure there are no further issues weekly x 4 , mo nt hly x 2, or until compliance is achieved.  The results of these audits will be reviewed in QAPI to  determine  the need for further oversight.

Resident 62 was admitted to the facility in 2/2026 with diagnoses including acquired absence of larynx (the surgical removal of the voice box [laryngectomy]) and encounter for attention to tracheostomy (a surgically created opening [stoma] in the front of the neck leading directly into the trachea [windpipe] to create a new airway for breathing).-á Resident 62's 2/26/26 Admission MDS revealed the resident had no speech but was able to communicate to and understand others without difficulty. The MDS further revealed the Brief Interview for Mental Status (BIMS) and Resident Mood Interview (PHQ-2 to 9) were not completed as the resident was rarely/never understood.-á On 3/9/26 at 11:51 AM, Resident 62 was observed in her/his room. The resident was nonverbal but able to appropriately communicate with the state surveyor through written communication.-á On 3/11/26 at 11:54 AM, Staff 19 (Social Services Director) stated she was responsible for completing the BIMS and PHQ-2 to 9 interviews. Staff 19 stated she did not attempt a BIMS interview with Resident 62 because the resident was unable to verbally communicate. Staff 19 stated she entered the resident's room on one occasion to attempt the mood interview but was unable to start the interview as the resident was busy with nursing staff. Staff 19 stated she did not reattempt to complete the mood interview with the resident.-á On 3/11/26 at 1:12 PM, Staff 2 (DNS) stated she expected the BIMS and PHQ-2 to 9 interviews to be attempted with all residents using the residents' preferred method of communication. Staff 2 further stated she expected the staff to reapproach and reattempt the interviews if initially refused.-á

Res ident  62 was discharged from the facility All other MDS  that  are in progress  were reviewed to ensure  appropriate interviews were conducted correctly. Social Service Director was re-educated on completing interviews related to the MDS process DNS/Desi gnee will audit random MDS’s weekly x4 and monthly x2, or until compliance is achieved.  The results of these audits will be reviewed in QAPI to determine the need for further oversight.

2. Resident 72 was admitted to the facility in 12/2024 with diagnoses including schizophrenia (mental disorder) (men.-á Resident 72's 12/11/25 Annual MDS revealed the resident was able to make herself/himself understood and understand others without difficulty, required substantial-to-maximal assistance from staff with personal hygiene tasks and she/he did not reject care. Resident 72's 12/24/25 ADL and Behavior Care Plans revealed the following: -The resident preferred to bathe on Wednesday and Sunday evenings and required assistance from one person.-á -The resident required set-up assistance and encouragement as needed with hygiene.-á -The resident's behaviors included talking to herself/himself, hallucinations and delusions.-á A review of Resident 72's Personal Hygiene Task Log from 2/12/26 to 3/12/26 revealed the resident refused personal hygiene care on 2/18/26 and 2/27/26 but was otherwise cooperative.-á On 3/10/26 at 2:03 PM, Resident 72 was observed in her/his room in bed. White hair that curled at the end of some of the strands, approximately one inch in length, was observed on both sides of her/his chin. Resident 72 stated she/he did not have the opportunity to look in the mirror much, so she/he was not always aware if she/he had any facial hair. Resident 72 felt the hair on her/his chin, bothered her/him and wanted the facial hair removed. Resident 72 stated staff did not offer to trim her/his facial hair, but if they had, she/he would accept the offer.-á On 3/13/26 at 8:22 AM, Resident 72 was observed in her/his wheelchair in the dining room. Long white facial hair was observed on either side of the resident's chin. Resident 72 stated she/he wanted her/his chin hair removed but staff had not offered.-á On 3/13/26 at 8:54 AM, Staff 30 (CNA) stated residents were offered facial hair grooming when they received a shower. Staff 30 stated she did not work on Resident 72's scheduled shower days, so she had never offered to assist the resident to shave her/his facial hair, but the resident did not refuse care.-á On 3/13/26 at 9:01 AM, Staff 31 (CNA) stated residents were offered facial hair grooming when they received a shower, and she provided facial hair grooming outside of a scheduled shower only if the resident requested it. Staff 31 stated Resident 72 was ""really cooperative"" with care. Staff 31 further stated she had never offered to assist the resident with facial hair grooming, and she was unaware of the resident's facial hair preference.-á On 3/13/26 at 9:12 AM, Staff 32 (CNA) stated Resident 72 never refused care, but she/he did require some cueing and encouragement to get out of bed. Staff 32 stated she had not offered facial hair grooming assistance to Resident 72.-á On 3/13/26 at 9:57 AM, Staff 28 (RN) stated facial hair grooming was offered by CNAs to residents during their scheduled showers and as needed. Staff 28 stated Resident 72 was cooperative with care, and she had not received any reports of the resident refusing care, including facial hair grooming.-á On 3/13/26 at 10:02 AM, Staff 33 (LPN) stated she was unsure of Resident 72's preferences for facial hair but stated this information was found in the resident's Kardex (a quick reference that provides an overview of patient care plans).-á On 3/13/26 at 10:17 AM, Staff 34 (CNA) stated Resident 72 was cooperative with care, including with trimming her/his facial hair. Staff 34 stated she assisted the resident with a shower on 3/11/26 and she did not offer to assist the resident to trim her/his facial hair.-á On 3/13/26 at 12:27 PM, Staff 7 (LPN Resident Care Manager) stated facial hair grooming was a sensitive subject for some residents, so it was provided per resident request. Staff 7 stated she had not considered residents with a limited access to a mirror or residents who were unable to request the assistance may still be interested in receiving assistance with facial hair grooming. Staff 7 further stated facial hair grooming should be completed according to resident preference, and she was unaware of Resident 72's preference for facial hair.-á -á , 1 Resident 3 was admitted to the facility in 9/2025 with diagnoses including quadriplegia and Type 2 diabetes. On 3/9/26 at 11:10 AM Resident 3 was observed in her/his room. Resident 3's fingernails were long and contained a thick, skin-colored debris beneath the nails.-á The ADL Function CAA dated 8/14/25 indicated Resident 3 required maximum assistance with all ADLs.-á A Physician Order dated 9/10/25 directed a licensed nurse to check Resident 3's fingernails and toenails weekly on bath days and trim as needed.-á A review of the 2/2026 and 3/2026 TAR indicated a licensed nurse was to check Resident 3's fingernails and toenails weekly on bath days and trim as needed.-á-á On 3/10/26 at 2:22 PM Staff 10 (CNA) stated a licensed nurse would have to trim Resident 3's fingernails due to Resident 3 being diabetic. Staff 10 observed Resident 3's nails and stated they were long and needed to be trimmed.-á On 3/10/26 at 2:30 PM Staff 11 (CNA) stated she would cut or trim residents' nails if they were not diabetic. Staff 11 observed Resident 3's nails and stated the fingernails were long. During this observation, Resident 3 stated her/his fingernails needed to be cut and they hurt from being so long.-á On 3/10/26 at 3:18 PM Staff 8 (LPN) stated Resident 3 had previously told her she/he bit her/his fingernails, so she did not need to trim them.-á On 3/10/26 at 3:30 PM Staff 7 (LPN Resident Care Manager) stated Resident 3 was care planned to have her/his nails trimmed by a licensed nurse. Staff 7 further stated the resident had requested to have her/his nails cut and the resident had been treated for a fungal infection on the fingernails and toenails. Staff 7 observed Resident 3's fingernails and stated they were long and needed to be filed. Staff 7 asked Resident 3 when the last time staff had soaked her/his nails and the resident replied it had been a ""long time ago."" On 3/10/26 at 4:30 PM and on 3/12/26 at 3:47 PM Staff 2 (DNS) stated she was aware Resident 3's fingernails were long and the resident was scheduled for weekly nail care by a licensed nurse. Staff 2 acknowledged Resident 3's fingernails had not been trimmed since admission to the facility and stated it had not been reported to her the resident had experienced pain related to the length of her/his fingernails.-á , 1 Resident 3 was admitted to the facility in 9/2025 with diagnoses including quadriplegia and Type 2 diabetes. On 3/9/26 at 11:10 AM Resident 3 was observed in her/his room. Resident 3's fingernails were long and contained a thick, skin-colored debris beneath the nails.-á The ADL Function CAA dated 8/14/25 indicated Resident 3 required maximum assistance with all ADLs.-á A Physician Order dated 9/10/25 directed a licensed nurse to check Resident 3's fingernails and toenails weekly on bath days and trim as needed.-á A review of the 2/2026 and 3/2026 TAR indicated a licensed nurse was to check Resident 3's fingernails and toenails weekly on bath days and trim as needed.-á-á On 3/10/26 at 2:22 PM Staff 10 (CNA) stated a licensed nurse would have to trim Resident 3's fingernails due to Resident 3 being diabetic. Staff 10 observed Resident 3's nails and stated they were long and needed to be trimmed.-á On 3/10/26 at 2:30 PM Staff 11 (CNA) stated she would cut or trim residents' nails if they were not diabetic. Staff 11 observed Resident 3's nails and stated the fingernails were long. During this observation, Resident 3 stated her/his fingernails needed to be cut and they hurt from being so long.-á On 3/10/26 at 3:18 PM Staff 8 (LPN) stated Resident 3 had previously told her she/he bit her/his fingernails, so she did not need to trim them.-á On 3/10/26 at 3:30 PM Staff 7 (LPN Resident Care Manager) stated Resident 3 was care planned to have her/his nails trimmed by a licensed nurse. Staff 7 further stated the resident had requested to have her/his nails cut and the resident had been treated for a fungal infection on the fingernails and toenails. Staff 7 observed Resident 3's fingernails and stated they were long and needed to be filed. Staff 7 asked Resident 3 when the last time staff had soaked her/his nails and the resident replied it had been a ""long time ago."" On 3/10/26 at 4:30 PM and on 3/12/26 at 3:47 PM Staff 2 (DNS) stated she was aware Resident 3's fingernails were long and the resident was scheduled for weekly nail care by a licensed nurse. Staff 2 acknowledged Resident 3's fingernails had not been trimmed since admission to the facility and stated it had not been reported to her the resident had experienced pain related to the length of her/his fingernails.-á -á 2. Resident 72 was admitted to the facility in 12/2024 with diagnoses including schizophrenia (mental disorder) (men.-á Resident 72's 12/11/25 Annual MDS revealed the resident was able to make herself/himself understood and understand others without difficulty, required substantial-to-maximal assistance from staff with personal hygiene tasks and she/he did not reject care. Resident 72's 12/24/25 ADL and Behavior Care Plans revealed the following: -The resident preferred to bathe on Wednesday and Sunday evenings and required assistance from one person.-á -The resident required set-up assistance and encouragement as needed with hygiene.-á -The resident's behaviors included talking to herself/himself, hallucinations and delusions.-á A review of Resident 72's Personal Hygiene Task Log from 2/12/26 to 3/12/26 revealed the resident refused personal hygiene care on 2/18/26 and 2/27/26 but was otherwise cooperative.-á On 3/10/26 at 2:03 PM, Resident 72 was observed in her/his room in bed. White hair that curled at the end of some of the strands, approximately one inch in length, was observed on both sides of her/his chin. Resident 72 stated she/he did not have the opportunity to look in the mirror much, so she/he was not always aware if she/he had any facial hair. Resident 72 felt the hair on her/his chin, bothered her/him and wanted the facial hair removed. Resident 72 stated staff did not offer to trim her/his facial hair, but if they had, she/he would accept the offer.-á On 3/13/26 at 8:22 AM, Resident 72 was observed in her/his wheelchair in the dining room. Long white facial hair was observed on either side of the resident's chin. Resident 72 stated she/he wanted her/his chin hair removed but staff had not offered.-á On 3/13/26 at 8:54 AM, Staff 30 (CNA) stated residents were offered facial hair grooming when they received a shower. Staff 30 stated she did not work on Resident 72's scheduled shower days, so she had never offered to assist the resident to shave her/his facial hair, but the resident did not refuse care.-á On 3/13/26 at 9:01 AM, Staff 31 (CNA) stated residents were offered facial hair grooming when they received a shower, and she provided facial hair grooming outside of a scheduled shower only if the resident requested it. Staff 31 stated Resident 72 was ""really cooperative"" with care. Staff 31 further stated she had never offered to assist the resident with facial hair grooming, and she was unaware of the resident's facial hair preference.-á On 3/13/26 at 9:12 AM, Staff 32 (CNA) stated Resident 72 never refused care, but she/he did require some cueing and encouragement to get out of bed. Staff 32 stated she had not offered facial hair grooming assistance to Resident 72.-á On 3/13/26 at 9:57 AM, Staff 28 (RN) stated facial hair grooming was offered by CNAs to residents during their scheduled showers and as needed. Staff 28 stated Resident 72 was cooperative with care, and she had not received any reports of the resident refusing care, including facial hair grooming.-á On 3/13/26 at 10:02 AM, Staff 33 (LPN) stated she was unsure of Resident 72's preferences for facial hair but stated this information was found in the resident's Kardex (a quick reference that provides an overview of patient care plans).-á On 3/13/26 at 10:17 AM, Staff 34 (CNA) stated Resident 72 was cooperative with care, including with trimming her/his facial hair. Staff 34 stated she assisted the resident with a shower on 3/11/26 and she did not offer to assist the resident to trim her/his facial hair.-á On 3/13/26 at 12:27 PM, Staff 7 (LPN Resident Care Manager) stated facial hair grooming was a sensitive subject for some residents, so it was provided per resident request. Staff 7 stated she had not considered residents with a limited access to a mirror or residents who were unable to request the assistance may still be interested in receiving assistance with facial hair grooming. Staff 7 further stated facial hair grooming should be completed according to resident preference, and she was unaware of Resident 72's preference for facial hair.-á -á

Resident 3 had fingernails cut immediately Resident 72 face was shaved All other residents were reviewed to ensure their nails were trimmed and any unwanted facial hair was removed.  Residents who desired to keep long nails or facial hair were care planned to do so. CNAs were educated on appropriate grooming for residents including nail care and shaving unwanted facial hair. DNS/Designee will conduct random resident observations for compliance weekly x 4 and monthly x 2 , or until comp liance is ach ieved .   The results of these audits will be reviewed in QAPI   to  determine  the  need for further  oversig ht.

An undated Facility Activity Programs Policy Statement indicated: -Activity programs are designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident. -The activities program is provided to support the well-being of residents and to encourage both independence and community interaction. -Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident. -The activities program is ongoing and includes facility organized group activities, independent individual activities and assisted individual activities. -Activities are scheduled 7 (seven) days a week. -Our activity programs consist of individual, small group and large group activities designed to meet the needs and interests of each resident. -All activities are documented in the residentGÇÖs medical record. 1 Resident 3 was admitted to the facility in 9/2025 with diagnoses including quadriplegia and Type 2 diabetes. Resident 3GÇÖs 8/8/25 Activity Care Plan revealed the following: -The resident enjoyed Bible study, cell phone, music, one on one visits, individual activities versus group activities, television and friends and family visits. -In room activities were to be offered, which included an activity calendar, music, books, newspapers and magazines. Resident 3GÇÖs 8/14/25 Admission MDS indicated the resident was cognitively intact. A review of Resident 3GÇÖs Activity Task Records for the 30-day period from 2/9/26 through 3/9/26 revealed no documented in-room activities, no documented one-to-one activity visits, and no documented participation in any facility activity programming. On 3/9/26 at 11:10 AM Resident 3 was observed in her/his room in bed. The resident required total assistance due to quadriplegia and was unable to independently engage in activities without staff assistance. No books, magazines or newspapers were visible in the residentGÇÖs room. Resident 3 stated she/he enjoyed watching television, Bible study, seeing pets and visiting with family over the phone. Resident 3 stated she/he preferred to stay in her/his room and not participate in group activities. Observations of Resident 3 conducted on 3/9/26 through 3/13/26 during various times of the day revealed the resident remained in bed in her/his room with the television on. The resident was not observed participating in any activities, being offered in-room activity materials, or receiving one-to-one visits from activity staff. The residentGÇÖs room did not contain activity materials such as books, magazines, newspapers, puzzles, music devices or other items identified in the residentGÇÖs care plan. On 3/10/26 at 2:22 PM, Staff 10 (CNA) stated Resident 3 spent her/his time in her/his room in bed watching television. Staff 10 stated the resident required staff assistance to use the phone and primarily spoke with family when staff helped dial the number. Staff 10 stated she/he had not observed activity staff offer the resident in-room activities or visit the resident for one-to-one engagement. On 3/10/26 at 2:39 PM, Staff 11 (CNA) stated Resident 3 spent most of the day in bed watching television or movies. Staff 11 stated she/he had not observed Resident 3 participate in group activities or receive one-to-one visits from activity staff. Staff 11 stated she/he had not observed the resident being offered music, reading materials, or other in-room activity options. On 3/10/26 at 3:18 PM, Staff 8 (LPN) stated she was unsure what type of activities the resident preferred other than watching television or movies. Staff 8 stated the activity department was responsible for assessing resident interests and providing appropriate individualized activities. On 3/10/26 at 3:30 PM, Staff 7 (LPN Resident Care Manager) stated she was unable to show documentation to support Resident 3GÇÖs activity engagement other than the care plan noting the resident preferred to remain in her/his room. Staff 7 confirmed she could not locate documentation showing the resident had been offered individualized or one-to-one activities. On 3/10/26 at 4:02 PM, Staff 6 (Activity Director) stated she had spoken with Resident 3 informally but acknowledged she did not document these interactions. Staff 6 stated she had not provided in-room activity materials and had not offered individualized activities such as music, reading materials, or other engagement options to the resident. Staff 6 stated although a volunteer provided Bible study on Saturdays, she had not offered the volunteer to visit Resident 3 individually. On 3/10/26 at 4:30 PM, Staff 2 (DNS) stated residents who are unable or unwilling to attend group activities should receive individualized, one-to-one activity engagement based on their interests and care plan.

Resident 3 was interviewed for activities they enjoy and care plan updated accordingly.  Items were purchased and placed in room Other residents were re-interviewed for activity preferences and their care plans were updated. Activity director was educated  to ensure residents were interviewed for activities of their interests and care plans were updated. Administrator/Designee will randomly audit residents activity care plans and ensure activities are being carried out weekly  x4, monthly x2, or until compliance is achieved.  The results of these interviews will be reviewed in QAPI to determine the need for further oversight and intervention.

The facility's 8/2024 Respiratory Treatment Policy and Procedure indicated residents received respiratory treatments and monitoring according to their physician orders, standards of practice and care plan.-á Resident 62 was admitted to the facility in 2/2026 with diagnoses including acquired absence of larynx (the surgical removal of the voice box [laryngectomy]) and encounter for attention to tracheostomy (a surgically created opening [stoma] in the front of the neck leading directly into the trachea [windpipe] to create a new airway for breathing).-á Resident 62's 2/20/26 Nursing Admission Assessment indicated the resident was cognitively intact, nonverbal and communicated her/his needs in writing.-á Resident 62's 2/20/26 Respiratory Care Plan indicated the following: -Provide respiratory treatments as ordered.-á -Tracheostomy care each shift and as needed.-á A 2/20/26 Progress Note written by Staff 12 (RN) revealed Resident 62 had a tracheostomy that was intact, and she/he was ""competent with self-directed suctioning with help with trach set ups.""-á Resident 62's 2/24/26 Physician Orders directed the following: -The resident's laryngectomy tube insertion site was to be cleaned with soap and water or normal saline every day shift and as needed using a clean technique (a set of infection control practices that involve meticulous handwashing, maintaining a clean workspace and using clean, non-sterile gloves).-á -The resident's stoma was to be cleaned with a saline soaked cotton swab every day and as needed.-á -The resident's tracheostomy ties (a securement device used to hold a tracheostomy tube securely in place, preventing accidental dislodgement or movement) were to be changed on Mondays, Thursdays and as needed.-á -The resident's laryngectomy tube (a short, soft, flexible silicone tube inserted into the stoma after a total laryngectomy) could be removed and cleaned with normal saline every two hours as needed but should otherwise stay in place.-á Resident 62's 2/25/26 Self-Administration of Medication Observation Evaluation revealed the resident was determined to be appropriate to complete oral and laryngectomy tube suctioning (procedures used to remove mucus and secretions from the airway through a stoma) independently.-á A review of Resident 62's 3/2026 TAR revealed laryngectomy site care was completed and the resident's stoma was cleaned with a saline soaked cotton swab every day outside of 3/2/26 when the resident refused and on 3/4/26 when the resident was hospitalized. The TAR also revealed the resident's tracheostomy ties were changed on 3/2/26, 3/5/26 and 3/9/26, and-áthe resident's laryngectomy tube was not removed and cleaned. No evidence was found in Resident 62's clinical record to indicate the type or size of the resident's laryngectomy tube.-á On 3/10/26 at 2:12 PM, Resident 62 was observed in her/his room in bed. Resident 62 used a pen and paper to communicate with the state surveyor. Resident 62 stated she/he completed all of her/his tracheostomy care independently.-á On 3/11/26 at 6:32 AM, Resident 62 stated in writing she/he was going to perform her/his tracheostomy care and offered for the state surveyor to observe. Without washing or sanitizing her/his hands or donning a pair of gloves, Resident 62 retrieved a partially opened package containing a laryngectomy tube and a wipe from an overbed table positioned on the left side of her/his bed and placed it on her/his stained sheets. A book was observed on top of a pink-stained wash cloth on an overbed table to the right of the resident's bed. The resident placed a free-standing mirror on top of the book and removed her/his tracheostomy tie and the laryngectomy tube. The resident placed the blood-tinged tube on the right side of the overbed table on top of the stained washcloth. The resident used the wipe located inside of the partially opened package that also contained a new laryngectomy tube and quickly wiped her/his stoma. Without performing any hand hygiene, the resident removed the new laryngectomy tube from the partially opened package, inserted it into her/his stoma, and attempted to secure the tracheostomy tie. From 6:39 AM to 6:51 AM, the resident attempted but was unable to re-thread her/his tracheostomy ties, and during this time period, placed the new laryngectomy tube both on her/his lap and on the stained washcloth. At 6:52 AM, the resident motioned for the state surveyor to assist her/him to thread the left side of the tracheostomy collar. The state surveyor indicated she was unable to assist with this process, and the resident declined the state surveyor's offer to obtain staff assistance. At 6:55 AM, the resident was able to secure the tracheostomy ties and placed gauze underneath the collar on either side of her/his stoma.-á On 3/11/26 at 10:36 AM, Staff 13 (RN) stated Resident 62 completed her/his tracheostomy care independently since her/his admission to the facility. Staff 13 stated he informed the resident how to perform tracheostomy care, but he had never observed the resident to complete the care. Staff 13 stated his documentation on the TAR for the resident's tracheostomy care indicated the resident had completed the task. Staff 13 stated he did not know the size or type of the resident's laryngectomy tube. Staff 13 further stated this information should be in the resident's physician orders and confirmed it was not.-á On 3/11/26 at 11:23 AM, Staff 14 (Respiratory Therapist) stated she verbally went over the procedure for tracheostomy care with Resident 62, including changing out the laryngectomy tube, but she had never observed the resident to do a return demonstration of the procedure. Staff 14 stated the resident ""seemed pretty capable and knew enough of herself/himself, I felt like he would be okay."" Staff 14 stated she usually obtained the type and size of a resident's laryngectomy tube at admission and thought Resident 62's laryngectomy tube was a size ten.-á On 3/11/26 at 11:35 AM, Staff 15 (RN) stated Resident 62 completed all of her/his tracheostomy care independently, and her documentation in the resident's TAR indicated she confirmed with the resident she/he had completed the care. Staff 15 stated she provided the resident with education about hand hygiene during tracheostomy care but had not provided education on how to clean her/his laryngectomy tube nor had she observed the resident to clean the used tube. Staff 15 further stated she thought the resident's laryngectomy tube was a size eight but she needed to check the resident's physician orders to confirm the size.-á On 3/11/26 at 12:45 PM, Staff 9 (RN) stated Resident 62 completed tracheostomy care independently. Staff 9 stated he provided education to the resident about wearing gloves during tracheostomy care but the resident used her/his bare hands. Staff 9 further stated he did not know the size or type of laryngectomy tube the resident utilized but thought he could find this information in the resident's physician orders.-á On 3/11/26 at 1:01 PM, Staff 17 (LPN Resident Care Manager) stated licensed nurses were expected to observe tracheostomy care for a resident, even if the resident preferred to complete the care independently, unless a Self-Administration of Medication Observation Evaluation was completed. Staff 17 also stated information on the size and type of laryngectomy tubes should be in a resident's physician orders and care plan. Staff 17 stated Resident 62 had not been assessed to complete tracheostomy care independently and no information on the size and type of her/his laryngectomy tube was in either her/his physician orders or care plan.-á On 3/11/26 at 3:24 PM, Staff 12 stated Resident 62 informed him that she/he was able to perform all care related to her/his tracheostomy independently. Staff 12 stated he observed the resident to change out the gauze under her/his tracheostomy tie on 2/20/26, and the resident did not wear gloves or perform hand hygiene prior to completing this care task. Staff 12 stated he had never observed the resident to remove or insert the laryngectomy tube, clean the laryngectomy tube insertion site with soap and water or normal saline or use a cotton swab to clean her/his stoma.-á On 3/11/26 at 1:12 PM and 3:30 PM, Staff 2 (DNS) stated laryngectomy type and size information should be included in a resident's care plan and confirmed this information was not in Resident 62's care plan. Staff 2 stated a resident who wanted to complete tracheostomy care independently was required to complete a return demonstration of the care tasks to a licensed nurse prior to doing so independently. Staff 2 confirmed Resident 62 had not been comprehensive assessed to perform tracheostomy care independently and should have been.-á

Resident 62’s medical record was updated to include the size of his laryngectomy tube.  He was re-assessed on his ability to perform his own tube care and re-educated on the process. The risks versus benefits were discussed with resident due to poor infection control techniques and he understood the risks.  His plan of care was updated to reflect his preferences. Resident is now discharged from the facility No other residents were affected by this deficient practice Nursing staff educated to monitor the resident’s ability to do self-care and re-educate as needed and to report any changes in the residents ability to perform the self-care safely.  RCMs educated to re-assess residents to perform self-care, and update the plan of care as needed and to include size and type of equipment. DNS/Designee will do random audits of charts for compliance and residents who do self care weekly  x4, monthly x2, or until compliance is achieved .   The results of these interviews will be reviewed in QAPI to  determine  the need for further oversight and intervention.

The facility's undated Storage of Medication Policy indicated only licensed nurses, pharmacy staff and those lawfully authorized to administer medications (such as medication aides) are allowed access to the medication carts. Medication rooms, cabinets and medication supplies should remain locked when not in use or attended by persons with authorized access.-á 1. On 3/11/26 from 5:08 AM to 5:22 AM, an unlocked and unattended treatment cart was observed in the east hall across from the nurse's station. Two boxes of enoxaparin (an injectable anticoagulant [blood thinner]) for Resident 15 were observed on top of the cart. CNA staff were in the area, one resident was observed to self-propel in her/his wheelchair near the cart, and the contents of the cart were accessible.-á On 3/11/26 at 5:22 AM, Staff 37 (LPN) acknowledged the treatment cart was unlocked and unattended and confirmed the cart contained insulins. Staff 37 stated the cart should be locked at all times when unattended and medications should not be stored on top of the cart.-á On 3/12/26 from 3:33 PM to 3:37 PM, an unlocked and unattended medication cart was observed on the south side of the facility. CNA staff were in the area, and the contents of the cart were accessible.-á On 3/12/26 at 3:37 PM, Staff 16 (CMA) acknowledged the medication cart was unlocked and unattended and confirmed the cart contained all of the day and evening shift medications for the residents in Rooms 131 through 138. Staff 16 stated the cart should be locked at all times when unattended. On 3/13/26 at 12:40 PM, Staff 2 (DNS) stated she expected medications to be stored inside a locked medication cart when not in use and the medication and treatment carts to be locked and secured at all times when unattended.-á , -á 2. On 3/11/26 at 11:17 AM a treatment cart was observed to be unlocked and unattended in the Intermediate Care Facility (ICF) hallway near the nurse's station.-á On 3/11/26 at 11:21 AM Staff 9 (RN) returned to the treatment cart and stated he left the cart unlocked and unattended. The cart contained residents' insulin, creams and other treatment supplies.-á On 3/11/26 at 11:25 AM Staff 2 (DNS) stated it was her expectation for the treatment carts to be locked when unattended.-á -á

The medication and treatment cart in question were locked immediately Other carts in the building were checked to ensure they were locked and secure Nurses and CMAs were educated that treatment and medication carts must be locked when not in use or attended by persons with authorized access. DNS/Designee will conduct random audits on the carts for compliance weekly  x4, monthly x2, or until compliance is achieved .   The results of these interviews will be reviewed in QAPI to  determine  the need for further oversight and intervention.

Resident 16 was admitted to the facility in 10/2020 with diagnoses including malnutrition. A 12/8/25 Quarterly MDS indicated Resident 16 had a BIMS score of 15 which indicated Resident 16 was cognitively intact.-á A 10/27/20 Care Plan indicated staff coordinated and made arrangements for dental care services and indicated Resident 16 had her/his own teeth.-á A 7/22/25 Dental Treatment Summary indicated Resident 16 had all her/his teeth extracted.-á On 3/9/26 at 2:38 PM, Resident 16 stated she/he had all her/his teeth extracted eight months earlier, had repeatedly asked staff about getting dentures without receiving a response, and was having trouble chewing and eating. On 3/12/26 at 11:35 AM, Staff 42 (CNA) stated Resident 16 had her/his own teeth and did not require assistance to complete dental hygiene.-á On 3/12/26 at 12:21 PM and 1:26 PM, Staff 19 (Social Services Director) stated Resident 16's mouth was swollen after her/his teeth were extracted and she had not scheduled an appointment to begin the denture process. Staff 19 stated the in-house dentist also had not scheduled an appointment, noted the denture process typically began eight weeks after extractions, and acknowledged Resident 16 had not started the process.-á-á On 3/12/26 at 12:38 PM, Staff 43 (Social Services Assistant) stated during a care conference Resident 16 mentioned she/he wanted dentures.-á-á On 3/12/26 at 2:38 PM, Staff 28 (RN) stated she was unsure Resident 16 had dentures.-á On 3/13/26 at 11:35 AM, Staff 17 (LPN Resident Care Manager) stated she expected staff initiate the process to receive dentures within eight weeks after the resident had their teeth extraction.-á-á On 3/13/26 at 12:04 PM, Staff 2 (DNS) stated dental services were not provided timely for Resident 16. Staff 2 stated she expected staff to ensure appropriate dental services were provided. -á -á -á

Resident # 16 had appointment scheduled to get dentures A ll other residents were reviewed for dental concerns and appropriate action taken. Education  for  IDT on dental services to include follow up appointments are made and follow through is completed. DNS/designee  will audit the dental referrals to ensure proper follow through weekly x4 monthly x2, or until compliance is achieved. The results of these audits will be reviewed in QAPI for further intervention.

The facilityGÇÖs 11/2022 Food Receiving and Storage Policy indicated: -All foods stored in the refrigerator or freezer are covered, labeled and dated; -á and; -Foods in the walk-ins are stored off the floor. -á On 3/9/26 at 9:03 AM, observation of the unit refrigerator and the unit freezer revealed the following items: -Two unlabeled, undated plastic bags of hot dogs; -One unlabeled, undated large container of sliced pepperonis; -One unlabeled, undated small container of lemon wedges; -One unlabeled, undated large container of shredded cheese; -One unlabeled plastic container of pulled pork; -One unlabeled medium container of corn dated 3/2; -One unlabeled medium container of chicken fried steak dated 2/17; -One unlabeled medium container of spaghetti sauce dated 12/3; -One box of opened ice cream bars stored on the floor of the freezer; -One box of opened bags of corn stored on the floor of the freezer; -Two unlabeled, undated plastic bags of premade egg patties stored on a shelf in the freezer. -á On 3/9/26 at 9:31 AM Staff 4 (Dietary Manager) acknowledged the unlabeled and undated food items and the food stored on the floor of the freezer and stated food items should be labeled, dated and stored off the floor. -á

The unit refrigerator and freezer was cleaned out and all food was labeled and dated and stored appropriately. Other refrigerators and freezers were checked and all deficiencies were corrected Dietary staff were educated on proper food storage practices to include labeling and dating food and not storing food on the floors of the freezer. Administrator/Designee will audit refrigerators and freezers for compliance  weekly  x4  monthly x2, or until compliance is achieved.   The results of these audits will be reviewed in  QAPI for the need  for further intervention.

The CDC's 2/11/25 Eye Protection for Infection Control website, https://www.cdc.gov/niosh/ppe/eye-safety/infection-control.html , specified to remove eye protection, such as face shields, by only handling the parts that secure it to the head (like plastic temples, elastic bands, or ties) and to avoid touching the front of face shields, as those surfaces are most likely contaminated by sprays or droplets. Non-disposable eye protection should be placed in a designated container for cleaning and disinfection.-á The facility's Droplet/Contact Precautions sign dated 5/2020 included the following:-á - Wear eye protection (face shield or goggles). - Remove mask and eye cover from earpiece or ties to discard - do not grab from front of mask. The facility's Laundry and Linen Policy dated 1/2014 included the following: - Separate soiled and clean linen at all times. - Consider all soiled linen to be potentially infectious and handle with standard precautions. 1. Rooms 134 and 135 were identified as Transmission Based Precautions (TBP) rooms where COVID-19 positive residents resided. On 3/9/26 at 11:45 AM, Staff 24 (CMA) stated before going inside of rooms 134 and 135, everyone was required to don PPE (Personal Protective Equipment), including a face shield due to the two rooms being on TBP Droplet Precautions.-á On 3/9/26 at 12:20 PM, Staff 35 (CNA) was observed exiting room 135 after delivering a meal. She was observed using her ungloved hand to remove the face shield from the front to remove it from her head and placed it behind the hand rails of the wall near room 135. At 12:29 PM, Staff 35 was observed donning PPE, retrieving the face shield from behind the hand rails of the wall, and donning the face shield before entering room 135. At 12:31 PM, Staff 35 was observed exiting room 135, removed the face shield by using her ungloved hand on front of face shield, and placing it behind the hand rails of the wall near room 135. Observations on 3/10/26 at 8:36 AM, 3/10/26 at 1:31 PM and 3/11/26 at 5:24 AM revealed a face shield was tucked behind the hand rails of the wall near room 135. On 3/10/26 at 8:40 AM, Staff 29 (CNA) was observed donning PPE and entered room 135 without a face shield. On 3/10/26 at 8:45 AM, Staff 35 was observed entering room 134 without a face shield. On 3/10/26 at 1:59 PM, Staff 29 was observed entering room 135 without a face shield. At 2:02 PM, Staff 29 stated she knew some staff wore the face shield and others did not. Staff 29 stated she did not wear a face shield, because she used two masks and had her own personal eyeglasses on.-á On 3/10/26 at 2:21 PM, Staff 36 (CNA) came out of room 134 with an N95 and face shield on. She was observed removing her face shield and placing it inside of the PPE cart. Staff 36 was observed still wearing the N95, entering the soiled linen room, then entering nurse's station where she was observed doffing her N95.-á On 3/11/26 at 5:56 AM, Staff 37 (CNA) was observed entering room 134 without donning PPE to deliver a pitcher of water and came out. At 6:08 AM, Staff 37 was observed entering room 134 without donning PPE to deliver briefs and came out.-á On 3/12/26 at 10:51 AM, Staff 38 (LPN/Infection Preventionist) stated she expected staff to follow the signage for TBP Droplet Precautions, including donning PPE and a face shield before staff enter a room. She stated all PPE must be removed before exiting the room, but the face shield could be reused if it was cleaned and disinfected. She stated she expected staff to not handle the face shield by the front, as the front of the face shield could potentially be contaminated.-á On 3/13/26 at 1:22 PM, Staff 2 (DNS) stated if a resident room was identified on TBP for Droplet Precautions, staff were expected to don the required PPE before crossing through the doorway of the room. Staff 2 stated appropriate PPE included a gown, gloves, respirator and face shield which should be donned prior to entrance and doffed upon exit. Staff 2 stated face shields could be reused if cleaned and disinfected, but not stored in or on PPE carts or behind hand rails of the wall.-á 2. Observations on 3/11/26 at 6:14 AM revealed Staff 43 (CNA) placing clean linens onto a shelf inside of the West hall shower room. Observed inside of the shower room were a covered barrel with trash, a covered barrel with soiled linens, and folded wash cloths and bath towels on top of a shower chair. Staff 43 stated when residents were ready to shower, staff took out the barrels for residents to shower. Staff 43 acknowledged a clean linen room was directly across from the shower room and stated she replenished clean linens in both rooms. Observations on 3/12/26 at 8:24 AM revealed folded towels on top of a shower chair, clean linens on a shelf above two barrels, and staff placing a bag into the soiled linen barrel located inside of the West hall shower room.-á On 3/12/26 at 10:17 AM, Staff 44 (CNA) stated the garbage barrel and soiled linen barrel were stored inside of the West hall's shower room due to inadequate space. Staff 44 stated clean linens were not supposed to be stored in the shower room, as there was a clean linen storage across from the shower room. She stated clean linens were placed in the shower room when a resident was ready to shower immediately. On 3/12/26 at 10:51 AM, Staff 38 (LPN/Infection Preventionist) stated clean linens and soiled linens were expected to be kept and stored separately due to the risk of cross contamination. Staff 38 acknowledged the West hall had a garbage barrel and a soiled linens barrel inside of the shower room, as well as a clean linen storage room directly across from the shower room. Staff 38 stated she expected for staff to store clean linens in the clean linen storage room and not in the shower room.-á On 3/13/26 at 1:22 PM, Staff 2 (DNS) stated she expected for clean linens to be stored separately from soiled linens to prevent cross contamination.-á -á

All eyewear was cleaned, disinfected and stored appropriately.  Staff working at the time were educated on proper cleaning and storage of the eyewear and wearing appropriate PPE. Linens were removed from the shower room and sent to laundry for cleaning. All other shower rooms were checked and any deficiencies were corrected. All staff educated on proper PPE donning and doffing to include cleaning and storing of eye wear, and when and what PPE to wear Nursing staff were educated that clean linens were to be stored separately from soiled linens to prevent cross contamination. DNS/Designee will audit shower rooms for compliance weekly  x4  monthly x2, or until compliance is achieved.   The results of these audits will be reviewed in  QAPI for the need  for further intervention. DNS/Designee will random staff entering rooms on transmission based precaustions weekly  x4  monthly x2, or until compliance is achieved.   The results of these audits will be reviewed in  QAPI for the need  for further intervention.

Based on observation and interview it was determined the facility failed to ensure kitchen equipment and food preparation areas were maintained in a clean and sanitary manner for 1 of 1 kitchen reviewed for sanitary kitchen practices. This placed residents at risk of illness and contaminated food. Finding include: The facility's Cleaning and Sanitation of Department: Food and Nutritional Services policy, dated 12/11/15, indicated the following: -The food and nutritional services manager would assure compliance of all cleaning and sanitation tasks needed in the department. Observation of the facility's kitchen on 7/8/25 between the hours of 9:30 AM and 2:30 PM, revealed the following: -A fan was blowing directly into the food preparation area with numerous spots of dust and debris clumps on the fan covering. -There was an orange/brown hard coating completely covering the inside of each oven door, and a black, hard substance covering the entire bottom of the oven and on the oven racks. -The grill had hard, burnt substances on the cooking surface, sticky grease-like splashes and food particles on the grill doors, grease build-up and food particles along the top of the grill doors and in the vents on the lower portion of the grill. -The floor to the left of the grill, between the grill and the food steamer, had an orange, greasy-like substance starting at the front of the grill and going the to the back of the grill. -There was a black substance on the flooring behind the steamer, around a pipe and along the wall edge. -The flooring under the steel prep counter next to the food steamer, which housed bulk food bins of oatmeal, flour and sugar, had a black substance under each bulk bin. The bulk bins had spills and food particles on the outside of the containers and on the lids. -Dried food particles and spills were on the facility's large commercial mixer and the mixer stand. -The food preparation steel counter used to cut and prep food and store clean cookware and cutting boards had numerous food particles and an approximate three inch round object of unknown substance in contact with clean pans and cutting boards. -The steam cart's lower shelf, which stored clean cooking items such as steam table pans and covers, had numerous food particles in contact with the clean items. -The clean dishware storage area had numerous food particles on the shelves where clean dishes were stored. -Stainless steel drawers contained cooking utensils which had a sticky substance spilled on the outside of the drawers and coffee spills inside the drawers. -The majority of the kitchen flooring had black debris build-up, spills and food particles where the floor and baseboards came together. -The wall along the entire food prep counter was coated with a sticky-orange substance which was not cleanable. -Walls throughout the kitchen had various sized spills and splashes which needed to be cleaned. On 7/8/25 at 12:46 PM, Staff 3 (Dietary Aid) stated each kitchen staff was responsible for cleaning their own area each shift. Staff 3 stated she was unaware of any routine cleaning protocols and was not required to document what cleaning she completed. Staff 3 reported "everybody cleans their own stuff as they go." On 7/8/25 at 12:56 PM, Staff 4 (Dishwasher) stated she was unaware of any routine cleaning requirements but the cooks mopped the kitchen area floor and she mopped the dishwashing area floor each shift. On 7/8/25 at 2:05 PM, Staff 2 (Dietary Manager) stated she was new to the position and confirmed the kitchen did not meet her expectations of cleanliness and stated there was "significant" cleaning which needed to be completed. On 7/8/25 at 2:35 PM, Staff 1 (Administrator) acknowledged the kitchen equipment and food preparation areas were not clean and sanitary and stated the cleanliness of the kitchen needed to be "brought up several levels."

The fan was cleaned and repositioned to direct airflow away from food preparation surfaces. Oven doors, racks, and bottoms were cleaned and all visible residue was removed. The grill was thoroughly cleaned, including removal of all burnt-on substances and grease buildup. The floor in that area was scrubbed and all visible black and orange substances were removed. The flooring and bulk bin areas were cleaned and scrubbed of all black substance. The mixer and stand were cleaned and all food particles were removed. The food prep counter and all utensils, knives, and cutting boards were cleaned and sanitized. The steam cart was fully cleaned and sanitized to remove all food particles. The dishware storage area was cleaned and all shelving was wiped down. The stainless steel drawers were cleaned, and sticky substances and spills were removed. The kitchen floor was scrubbed and cleaned to remove all spills and buildup. The wall along the food prep counter was cleaned and the sticky-orange substance was removed. Various walls throughout the kitchen were cleaned and wiped down. A walk thru of the kitchen was conducted to ensure all areas were maintained in a clean and sanitary manner.  Any deficiencies were corrected. The Dietary Manager was re-educated on cleaning standards and food safety expectations. Staff were trained on cleaning task responsibilities, sanitation schedules, and daily maintenance expectations. The Administrator or designee will audit the kitchen for cleanliness 3 times weekly for 1 week, weekly for 4 weeks, and then monthly for 3 months. Audit results will be reviewed during monthly QAPI meetings to determine the need for any further action.

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

Based on interview and record review it was determined the facility failed to reorder a medication in a timely manner resulting in missed medications for 1 of 3 residents (# 7) reviewed for medication administration. This placed residents at risk for increased pain. Findings include: Resident 7 was admitted to the facility in 5/2022 with diagnoses including chronic pain. An 11/14/24 Physician Order included 5 mg of oxycodone scheduled to be administered three times a day to assist with pain reduction. Review of 11/14/24 through 12/15/24 Narcotic Book records for oxycodone revealed Resident 7 did not receive her/his scheduled evening dose on 12/4/24 and scheduled morning dose on 12/5/24. A 12/2/24 Pharmacy fax stated the pharmacy was unable to dispense the medication because no refill was available and new orders were required to receive Resident 7's oxycodone medication. Physician orders were placed on 12/4/24 at 9:00 PM to continue Resident 7's oxycodone at 5 mg three times a day to assist with pain reduction. On 3/19/25 at 12:14 PM Resident 7 stated two doses of her/his scheduled oxycodone was not provided to her/him. Resident 7 stated she/he was told is was not available and the facility needed the provider to write new orders. On 3/19/25 at 12:47 PM Staff 7 (CMA) stated Resident 7 did not receive oxycodone as ordered on 12/4/24's evening dose as a refill was not available and new orders had not been signed. Staff 7 stated medications were requested to be refilled or reordered when ten doses remained. On 3/19/25 at 2:20 PM Staff 5 (Resident Care Manager/LPN) stated information was received from the pharmacy which stated no refill for oxycodone was available two days prior to Resident 7's last available dose. Staff 5 confirmed Resident 7 did not receive her/his oxycodone medication for the evening dose on 12/4/24 and the morning dose on 12/5/24 as new orders were not placed until Resident 7's supply of oxycodone pills was depleted.

Resident #7 was not affected by oxycodone missed on evening 12/4/24 and morning dose 12/5/2024. The director of nursing or designee will complete an audit to ensure residents who have narcotic orders have refills available if they have less than 10 doses remaining. The Director of Nursing or designee will re-educate Nurses and Medication Aids of reordering medication orders when less then 10 doses are remaining to ensure residents have all medications available. The DNS or designee will audit the narcotic reordering process 3 x week for 1 week, 1xweek for 4 weeks and then monthly for 3 months to ensure the reordering process is being followed. Issues will be reviewed during the monthly QAPI meeting and a Performance Improvement Pan will be developed as necessary.

**************************** 411-086-0260 Pharmaceutical Services Refer to F755 ****************************

Based on observation and interview it was determined the facility failed to ensure shower rooms were clean and in good repair for 1 of 3 shower rooms and to accommodate residents with wheelchair arm rests in proper cleanable order for 2 of 7 sampled residents (#28 and 40) reviewed for environment. This placed residents at risk for lack of a clean and homelike environment and with personal equipment in disrepair. Findings include: 1. Multiple random observations from 11/18/24 through 11/20/24 between the hours of 8:00 AM and 4:00 PM revealed the shower on the TCU (Transitional Care Unit) had a black colored substance along the entire metal floor board edging, the left front corner of the shower's flooring had several deep cracks with black substance in the cracks, the overhead fan had a layer of dirt/dust in all vents and made a loud grinding noise. On 11/20/24 at 9:03 AM Staff 14 (Housekeeping Supervisor) confirmed the TCU shower floor board edging was rusted and could not be cleaned, the left corner flooring was cracked and not cleanable and the fan was dirty. Staff 14 acknowledged the TCU shower was not clean or home like. , 2. On 11/18/24 at 10:46 AM Resident 28's left wheelchair arm rest was observed with the black covering torn and about three inches of foam exposed. The surface was in disrepair and uncleanable. Resident 40's left wheelchair arm rest was observed with black tape peeled back from the arm rest. The surface was not cleanable under the peel back tape. On 11/20/24 at 10:27 AM Staff 12 (Maintenance Assistant) acknowledged the residents' wheelchairs which need to be fixed were reported the maintenance department to fix. Staff 12 confirmed Resident 28's and Resident 40's wheelchair arm rests were in poor condition. On 11/20/24 at 11:01 AM Staff 2 (DNS) confirmed Resident 28's and Resident 40's wheelchair arm rests were in poor condition and not cleanable.

Corrective Action(s) for residents identified to have been affected: The TCU shower room was cleaned to ensure the substance along the entire metal floorboard edging, the left front corner of the showers flooring cracks were repaired and cleaned. The vent was cleaned of dirt/dust and the grinding noise was fixed. Identified residents with potential to be affected: The director of maintenance, housekeeping manager or designee will complete an audit of the shower room floors and vents to ensure that they are in good repair and clean. Measures to prevent recurrence: The Administrator or designee will re-educate the housekeeping manager and maintenance director on the requirement to keep the shower rooms clean, homelike, and ensure thorough cleaning and identification of maintenance concerns to be repaired. Monitor of Corrective Action: The Administrator or designee will audit cleanliness of TCU shower room 3 x week for 1 week, 1xweek for 4 weeks and then monthly for 3 months to ensure the cleaning schedule is being followed. Issues will be reviewed during the monthly QAPI meeting and a Performance Improvement Pan will be developed as necessary.

Based on interview and record review it was determined the facility failed to initiate a grievance process for 1 of 2 sampled residents (#169) reviewed for personal property. This placed residents at risk for unaddressed concerns. Findings include: Resident 169 admitted to the facility in 10/2024 with diagnoses of displaced intertrochanteric fracture of left femur and schizophrenia. On 11/18/24 at 12:27 PM Resident 169 stated after he/she arrived staff took her/his clothes to the laundry and did not return them. Resident 169 stated to several staff members that her/his clothing items were missing. Resident 169's 10/31/24 inventory sheet revealed Resident 169 admitted with a shirt, underpants and jeans. On 11/21/24 at 9:54 AM Staff 14 (Housekeeping Supervisor) stated if a resident reported a missing item staff looked for the item. If the item was not found, staff would assist the resident to fill out a grievance form. Staff 14 indicated she/he was not aware Resident 169 was missing clothing. On 11/21/24 at 12:34 PM Staff 22 (CNA) stated resident 169 mentioned her/his clothing was missing, but she did not report it to anyone. On 11/21/24 at 12:58 PM Staff 2 (Director of Nursing) stated if a resident voiced concern regarding missing clothing, staff were to check the inventory sheet and look for the missing items. If items were not found CNAs were to start a grievance and the resident would be reimbursed.

Corrective Action(s) for residents identified to have been affected: Resident 69 is now discharged. However, clothing items were replaced by the housekeeping manager to their satisfaction prior to leaving. Identified residents with potential to be affected: All residents are at risk of missing personal property and grievance process not being initiated properly. Random interviews will be conducted to ensure that nobody else is missing clothes. Measures to prevent recurrence: Administrator or designee will re-educate the staff on initiating the grievance process in relation to missing items. Monitor of Corrective Action: The Administrator or designee will audit 2-3 residents 3 x week for 1 week, 1xweek for 4 weeks and then monthly for 3 months to ensure the grievance process was initiated and no missing items were un reported by staff. Issues will be reviewed during the monthly QAPI meeting and a Performance Improvement Pan will be developed as necessary.

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 2 sampled residents (#9) 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 9 was admitted to the facility in 10/2019 with diagnoses including hemiparesis (partial weakness on one side of the body) and hemiplegia (complete paralysis on one side of the body) following a stroke affecting the left non-dominant side. Resident 9's 9/11/24 Annual MDS Assessment indicated the resident was moderately cognitively impaired, experienced moderate difficulty hearing, the resident's preferred language was Vietnamese and she/he wanted an interpreter to communicate with health care staff. The Communication CAA indicated staff who communicated with the resident needed to elevate their voice, face the resident and minimize background noise due to her/his hearing impairment. Resident 9's 10/2/24 Communication Care Plan revealed the following: -Language: Vietnamese. -The resident was mostly non-English speaking. She/he could say certain simple words. -Telephone interpreter: (503) 535-2151. -The resident could communicate her/his needs. Use interpreter as needed for medical needs. -The resident was to have access to cue cards for communication assistance. On 11/18/24 at 11:32 AM Resident 9 was observed to sit in her/his wheelchair in her/his room. No communication cue cards were observed in the resident's room. The state surveyor communicated with the resident in English, and the resident was able to nod her/his head in response to some basic yes or no questions but was unable to answer specific questions about how long she/he had lived at the facility, the care she/he received at the facility or her/his daily routine. On 11/18/24 at 11:43 AM, 11/18/24 at 2:42 PM and 11/19/24 at 8:55 AM the state surveyor called the phone number listed in Resident 9's Care Plan for an interpreter. On each occasion, the phone did not ring and the screen on the phone read "user busy." On 11/19/24 at 3:49 PM Resident 9 was observed in her/his room in bed. No communication cue cards were observed in the resident's room. With the use of the state's translation service, an interview was conducted with the resident in Vietnamese. Resident 9 stated she/he could only speak and understand "a little English" and "the folks here spoke English." Resident 9 stated there was only one staff person she/he was able to communicate with as this staff person spoke Vietnamese. Resident 9 stated she/he was hard of hearing and needed staff to speak slowly and elevate their voice. Resident 9 stated she/he "sometimes" could not hear or understand the "people who take care of me but I pretend to." Resident 9 did not know what a communication cue card was or if she/he had one. On 11/20/24 at 9:41 AM Staff 23 (CNA) stated Resident 9 primarily spoke Vietnamese, she did "not necessarily use a translation service" when communicating with the resident and she had "never seen cue cards" for the resident. On 11/20/24 at 9:52 AM Staff 28 stated Resident 9 "did not really speak English." Staff 28 stated she "never used a translator" when communicating with the resident and did not know if the facility had a translation service available. Staff 28 stated she had "never seen a cue board" used with Resident 9. Staff 28 further stated she thought the resident's hearing "was good" and she "just spoke loud when [the resident] couldn't understand." On 11/20/24 at 11:09 AM Staff 21 (CNA) stated Resident 9 had trouble hearing people with a quieter voice. Staff 21 stated she found information about a resident's hearing impairment and related interventions in the resident's care plan. On 11/20/24 at 2:38 PM and 3:19 PM Staff 6 (RNCM) stated she "put a picture board" in Resident 9's room "about a month ago" to help with communication but thought the resident's roommate took it shortly after it was provided and it was never replaced. Staff 6 stated the resident experienced difficulty hearing and interventions including "repeating questions, face to face, eliminating loud noises and elevate voice" should be in her/his care plan but were not. On 11/20/24 at 2:53 PM Staff 2 (DNS) confirmed the phone number for the translation service listed in Resident 9's care plan did not work, the resident's care plan was missing necessary interventions related to her/his hearing impairment and communication cue cards were not available to the resident and should have been.

Corrective Action(s) for residents identified to have been affected: Resident #9 was given communicated cue cards and the interpreter services phone number was updated in the Kardex and careplan. Identified residents with potential to be affected: Residents identified to not have English as a primary language and/or hard of hearing are at risk to be affected. An audit was performed to ensure a communication board and interpreter services were updated in the clinical chart. Measures to prevent recurrence: Administrator or designee will re-educate IDT on communication methods for residents who do not speak English as a primary language and/or hard of hearing. Monitor of Corrective Action: The Administrator or designee will audit 2-3 residents 3 x week for 1 week, 1xweek for 4 weeks and then monthly for 3 months to ensure interventions ae in place for necessary hearing impairment and communication methods. Issues will be reviewed during the monthly QAPI meeting and a Performance Improvement Pan will be developed as necessary.

Based on observation, interview and record review it was determined the facility failed to provide adequate bathing for 1 of 3 sampled residents (#37) reviewed for ADLs. This placed residents at risk for unmet hygiene needs. Findings include: Resident 37 was admitted to the facility in 11/2023 with diagnoses including neuromuscular dysfunction of the bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems). Resident 37's 8/25/24 Quarterly MDS Assessment indicated the resident was cognitively intact and dependent upon staff assistance for showers/bathing. Resident 37's 9/23/24 ADL Care Plan revealed the resident was to receive showers on Monday and Friday evenings. Resident 37's 10/25/24 through 11/18/24 Bathing Task sheet revealed the following: -10/25/24, Friday: not applicable. -11/4/24, Monday: resident refused. No documentation was found to indicate the resident was reoffered a shower during the shift, the resident's refusal was reported to the nurse or the resident was reoffered a shower on an alternative shift. -11/8/24, Friday: not applicable. -11/11/24, Monday: resident refused. No documentation was found to indicate the resident was reoffered a shower during the shift, the resident's refusal was reported to the nurse or the resident was reoffered a shower on an alternative shift. -11/18/24, Monday: not applicable. On 11/18/24 at 12:33 PM Resident 37 was observed in her/his room and sat in her/his wheelchair. Resident 37 stated she/he was "lucky if [she/he] got a shower once every two weeks." Resident 37 stated staff were "always too busy" to assist her/him with a shower on her/his scheduled days and "they don't have time on my off days." Resident 37 stated she/he preferred showers in the afternoons, and on shower days, staff would frequently enter her/his room and "say you can have one right now, right now, without any warning." Resident 37 stated she/he needed time to prepare, and if she/he refused, she/he would not be offered a shower at a different time during the shift. Resident 37 further stated she/he was occasionally told she/he could not shower because the shower was broken. On 11/20/24 at 4:07 PM Resident 37 stated she/he"told two people today [she/he] wanted a shower and they said they hope I get one." The resident's room was observed to smell of urine and a plastic bag was observed on the floor in the corner of the room. Resident 37 stated the bag was filled with "a draw sheet and wash cloths from last night." Resident 37 stated she/he used the wash cloths to wipe her/his groin area as she/he often felt "moist and sticky" and the wash cloths would be covered in "urine and blood." On 11/21/24 at 8:15 AM Resident 37 was observed in her/his room and sat in her/his wheelchair. Resident 37 stated she/he did not receive a shower yesterday despite her/his request and stated she/he asked this morning for a shower and was told "we will have to see." On 11/21/24 at 8:21 AM Staff 23 (CNA) stated CNAs were supposed to offer a resident a shower "more than once" if the resident refused, and if the resident continued to refuse, CNAs were to report the refusals to the nurse, document the refusals and let the next shift know so they could reoffer a shower. Staff 23 stated Resident 37 would wait to the last hour of her shift before agreeing to take a shower and then "I have to tell [her/him] I don't have time." On 11/21/24 at 9:03 AM Staff 26 (CNA) stated residents were supposed to be reoffered showers two to three times, and if they still refused, CNAs were to inform the nurse. CNAs were responsible for documenting refusals, and if a CNA documented "not applicable," that would indicate the shower was not offered. Staff 26 stated Resident 37 never refused showers when she worked with her/him. Staff 26 further stated other CNAs did not offer Resident 37 a shower until 8:30 PM or 9:00 PM at night because they knew the resident would refuse at those times. Staff 26 stated other CNAs did not offer showers on alternative days so residents had to wait until their next scheduled day to receive a shower. On 11/21/24 at 9:30 AM Staff 27 (RN) stated Resident 37 preferred to take her/his showers around 4:00 PM to 4:30 PM and "showers were very important" for the resident because she/he "had a lot of folds and could be incontinent in the bed at night." On 11/21/24 at 12:44 PM Staff 2 (DNS) stated CNAs were expected to reoffer a resident a shower three times during their shift, the nurse was expected to document any continued refusals and the "next shift was to do a PRN shower." Staff 2 reviewed Resident 37's clinical record, stated she did not know if the resident was offered a shower on 10/25/24, 11/8/24 or 11/18/24 and confirmed there was no documentation to indicate the resident was reoffered a shower on 11/4/24 or 11/11/24.

Corrective Action(s) for residents identified to have been affected: Resident 37 was offered a shower and accepted on 12/6/2024. Identified residents with potential to be affected: Residents who require ADL assistance for grooming and personal hygiene are at risk for unmet hygiene needs. An audit of missed showers will be performed and corrected as necessary. Measures to prevent recurrence: DNS or designee will re-educate the LN and CNA department the importance of hygiene as well as offering and re-approaching residents who refuse multiple attempts and interventions. Monitor of Corrective Action: The DNS or designee will audit 2-3 resident shower schedules 3 x week for 1 week, 1xweek for 4 weeks and then monthly for 3 months to ensure showers are being offered and re-approached as necessary if refused. Issues will be reviewed during the monthly QAPI meeting and a Performance Improvement Pan will be developed as necessary.

Based on observation, interview and record review it was determined the facility failed to provide an ongoing person-centered activity program for 2 of 4 sampled dependent residents (#s 9 and 36) 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 Activity Evaluation policy, dated 2/2023 and Activities Attendance policy, dated 6/2018 indicated the following: -The activity evaluation was used to develop an individualized activity care plan that allowed the resident to participate in activities of her/his choice and interest. -Each resident's activities care plan related to her/his comprehensive assessment and was reflective of the resident's individual needs. -Attendance and participation was recorded for every resident in group and individual activities on a daily basis. 1. Resident 36 was admitted to the facility in 5/2024 with diagnoses including cardiomyopathy (a disease of the heart muscle), dementia, restlessness and anxiety disorder. Resident 36's 6/11/24 Activities Initial Evaluation revealed the following: -Resident 36 wished to participate in activities while in the facility including group and independent activities such as reading and doing puzzles. -Resident 36 wished to go on outings. Resident 36's 9/5/24 Significant Change MDS revealed the resident had moderate cognitive impairments and Resident 36 considered it somewhat to very important to do the following activities: listen to music, be around animals, keep up with the news, have books, newspapers or magazines to read, do things with groups of people, do favorite activities and go outside when the weather permitted. Resident 36's 9/19/24 Activities Care Plan revealed the following: -Resident 36 had a need for activities that were consistent with her/his abilities and interests. Enjoyable and meaningful activities for Resident 36 included but were not limited to: -Bingo; -Board games; -Using her/his cell phone; -Group activities; -Hair appointments; -Movies; -Nail care; -Smoke breaks; -Special events; -Television (Resident 36 liked watching the History Channel, news, science fiction, space shows and anything related to airplanes) and -Visiting with friends and family. The facility's Activity Calendar revealed the following scheduled activities: -11/18/24 9:00 AM to 10:00 AM: One to one activities 11:00 AM: Ball Toss 2:30 PM: Crafts -11/19/24 9:00 AM to 10:00 AM: One to one activities 11:00 AM: Resident Council Meeting 2:30 PM: Resident shopping -11/20/24 9:00 AM to 10:00 AM: One to one activities 11:00 AM: Ball Toss 2:30 PM: Bingo -11/21/24 9:00 AM to 10:00 AM: One to one activities 11:00 AM: Ball Toss 2:30 PM: Crafts -11/22/24 11:00 AM: Ball Toss 2:30 PM: Bingo 3:30 PM: Movie and popcorn A review of Resident 36's 10/20/24 through 11/20/24 Independent, One to One and Group Activity Logs indicated the resident participated in no activities of any kind in the past 30 days. Random observations of Resident 36 conducted from 11/18/24 through 11/20/24 between the hours of 8:00 AM and 4:00 PM revealed the resident was typically in her/his bed with the blinds drawn. The resident was either asleep or fidgeting in her/his bed. The resident had no TV on, no music playing, and no books, newspapers or magazines in the room. The resident was seen one time up in her/his wheelchair but not engaged in any group activities and no one to one activities occurred in Resident 36's room. On 11/20/24 at 8:08 AM Staff 21 (CNA) reported she had never seen Resident 36 out of her/his bed until, yesterday, 11/19/24. Staff 21 stated she had not seen Resident 36 in any group or one to one activities and she did not notice music playing in the resident's room nor her/his TV turned on. Staff 21 reported the only activity she observed occurring with Resident 36 was sometimes her/his family visited. On 11/20/23 at 8:23 AM Staff 23 (CNA) reported she had not seen Resident 36 engaged in any group or one to one activities. She stated the resident typically was in her/his bed and occasionally the TV was on or the resident's daughter visited. Staff 23 stated Resident 36 had no other "real" activities. On 11/20/24 at 2:20 PM and 11/21/24 at 11:44 AM Staff 9 (Activities Director) and Staff 10 (Activities Assistant) both acknowledged they did not know Resident 36, were unaware of her/his activity preferences and the resident had not been involved in any group or one to one activities. Staff 9 and Staff 10 stated the last activity director left around the third week in 9/2024 and Staff 9 started as the Activity Director on 11/4/24, thus minimal activities occurred since 9/2024. Staff 10 stated she assisted with activities on a "very part-time basis" up until the last few weeks. Staff 10 stated when she assisted with activities, her "primary focus" was on the residents she was familiar with. , 2. Resident 9 was admitted to the facility in 10/2019 with diagnoses including hemiparesis (partial weakness on one side of the body) and hemiplegia (complete paralysis on one side of the body) following a stroke affecting the left non-dominant side. Resident 9's 9/11/24 Annual MDS Assessment indicated the resident was moderately cognitively impaired, the resident's preferred language was Vietnamese and she/he wanted an interpreter to communicate with health care staff. The MDS also indicated listening to music she/he enjoyed, having books, newspapers and magazines to read, being around pets, doing things with groups of people, going outside when the weather was good and participating in religious practices were important activities to the resident. Resident 9's 10/2/24 Activity Care Plan revealed the following: -Activity preferences included to self-propel around the facility, interact with staff and residents, traditional Vietnamese music and food and exercise class. -The resident enjoyed to get her/his nails done, play games and meet with her/his spouse and friends for worship. -The resident wanted to garden when the weather was nicer. -The resident liked to do ball toss for exercise class. Ball toss was one of her/his favorite activities. A review of Resident 9's 10/21/24 through 11/19/24 Activity Tasks which documented activity participation revealed the resident did not participate in a group, one to one or self-directed/independent activity. The facility's 11/2024 Activity Calendar revealed the following scheduled activities: -11/18/24 9:00 AM to 10:00 AM: One to one activities 11:00 AM: Ball Toss 2:30 PM: Crafts -11/19/24 9:00 AM to 10:00 AM: One to one activities 11:00 AM: Resident Council Meeting 2:30 PM: Resident shopping -11/20/24 9:00 AM to 10:00 AM: One to one activities 11:00 AM: Ball Toss 2:30 PM: Bingo -11/21/24 9:00 AM to 10:00 AM: One to one activities 11:00 AM: Ball Toss 2:30 PM: Crafts -11/22/24 11:00 AM: Ball Toss 2:30 PM: Bingo 3:30 PM: Movie and popcorn On 11/19/24 at 3:49 PM Resident 9 was observed in her/his room in bed. With the use of the state's translation service, an interview was conducted with the resident in Vietnamese. Resident 9 stated she/he could only speak and understand "a little English, the folks here spoke English" and the activities were all in English. Resident 9 stated she/he enjoyed listening to Vietnamese music on a music box she/he had "a long time ago, but it was broken so they threw it away." Resident 9 stated she/he "really liked exercise" but had only been invited to the exercise group "once." Resident 9 stated she/he "did not get invited to the group ball toss today," but if she/he had been invited, she/he would have participated. Resident 9 stated she/he enjoyed reading the newspaper but all of the newspapers at the facility were in English. Resident 9 further stated she/he could only read large print and the newspapers were all written in small print. On 11/20/24 at 9:41 AM Staff 23 (CNA) stated Resident 9 "hung out and did [her/his] own thing." Staff 23 stated she had never seen the resident read, listen to music, receive a pet visit or garden. On 11/20/24 at 9:52 AM Staff 28 (CNA) stated Resident 9 "just hung out." Staff 28 stated she did not know if the resident liked pets or to read and was unsure of what type of music the resident enjoyed. Staff 28 stated the resident loved to garden but she had never seen indoor gardening offered at the facility. On 11/20/24 at 10:32 AM Staff 21 (CNA) stated Resident 9 liked group activities and wanted "to be in there and participate." On 11/20/24 at 2:20 PM Staff 9 (Activities Director) stated she started to work at the facility on 11/4/24 and she had seen Resident 9 "in the hallway briefly" but had not "had a chance to speak with [the resident] yet." On 11/20/24 at 2:29 PM and 11/21/24 at 11:43 AM Staff 10 (Activities Assistant) stated activity preference information from a resident's MDS assessment "should go in the care plan." Staff 10 stated her interactions with Resident 9 over the past few weeks consisted of "just saying hi." Staff 10 stated the resident enjoyed to get her/his nails done but she/he "had not been getting them done because she did not have a key to the nail supplies." Staff 10 stated the resident enjoyed to garden but she had never tried indoor gardening, all of her interactions with Resident 9 were in English and all of the reading material she provided the resident was in English. On 11/20/24 at 3:27 PM Staff 1 (Administrator) acknowledged the findings and did not provide any additional information.

Corrective Action(s) for residents identified to have been affected: Resident 9 care plan was updated to reflect activities that meet her interests and activity program was offered to resent to participate in. A new music box was provided to resident. Resident 36 is no longer in the facility. Identified residents with potential to be affected: All residents are at risk of being affected. An audit will be performed to ensure residents who have not been involved in the activities program in the last 30 days are offered activities that meet their needs. Measures to prevent recurrence: Administrator will re-educate the activities department on offering person centered activities to all residents as well as providing activities in residents preferred languages. Monitor of Corrective Action: The Administrator or designee will audit2-3 activity care pan along with activity chart 3 x week for 1 week, 1xweek for 4 weeks and then monthly for 3 months to ensure residents careplan are person centered to activities that meet interests as well as being offered to participate. Issues will be reviewed during the monthly QAPI meeting and a Performance Improvement Pan will be developed as necessary.

Based on interview and record review it was determined the facility failed to ensure physician orders were followed for 1 of 3 sampled residents (#16) reviewed for pain. This placed residents at risk for ongoing pain or over sedation. Findings include: Resident 16 was admitted to the facility in 10/2024 with diagnoses including chronic pain and opioid dependency (a chronic brain disease that causes a person to compulsively seek out opioid pain medications). a. An 11/2/24 Physician Order indicated Resident 16 was prescribed oxycodone (an opioid medication used for pain management) 10 mg every 4 hours as needed for severe pain of 7 to 10 out of a pain scale of 10. A review of Resident 16's 11/2024 MAR revealed the resident was administered 10 mg of oxycodone outside of the physician's parameters on the following days: -11/10/24: pain was documented as 5; -11/13/24: pain was documented as 6; -11/16/24: pain was documented as 5 and -11/20/24: pain was documented as 6. On 11/22/24 at 8:19 AM Staff 2 (DNS) reviewed Resident 16's 11/2024 MAR and acknowledged on 11/10/24, 11/13/24, 11/16/24 and 11/20/24, the resident received 10 mg of oxycodone when she/he should have received 5 mg, and confirmed Resident 16's oxycodone was administered outside of the physician ordered parameters. b. An 11/2/24 Physician Order indicated Resident 16 was prescribed oxycodone (an opioid medication used for pain management) 5 mg every 4 hours as needed for moderate pain of 4 to 6 out of a pain scale of 10. A review of Resident 16's 11/2024 MAR revealed the resident was administered 5 mg of oxycodone outside of the physician's parameters on the following days: -11/11/24: pain was documented as 7 and -11/12/14: pain was documented as 7. On 11/22/24 at 8:19 AM Staff 2 (DNS) reviewed Resident 16's 11/2024 MAR and acknowledged on 11/11/24 and 11/12/24, the resident received 5 mg of oxycodone when she/he should have received 10 mg, and confirmed Resident 16 was administered oxycodone outside of the physician ordered parameters.

Corrective Action(s) for residents identified to have been affected: Resident 16 is no longer in the facility. Identified residents with potential to be affected: The DNS or designee will audit current residents with parameters written in physician orders to ensure medication is being administered correctly. Measures to prevent recurrence: The DNS or designee will re-educate the nurses and medaids on evaluating residents pain level and administering medications per order to ensure residents are receiving the correct dose. Monitor of Corrective Action: The DNS or designee will audit 2-3 resident medication administrator 3 x week for 1 week, 1xweek for 4 weeks and then monthly for 3 months to the order is being followed. Issues will be reviewed during the monthly QAPI meeting and a Performance Improvement Pan will be developed as necessary.

Based on observation, interview and record review it was determined the facility failed to implement interventions to prevent pressure ulcers and skin breakdown for 1 of 1 sampled resident (#37) reviewed for skin conditions. This placed residents at risk for the development of pressure ulcers and skin breakdown. Findings include: Resident 37 was admitted to the facility in 11/2023 with diagnoses including neuromuscular dysfunction of the bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems). Resident 37's 8/25/24 Quarterly MDS Assessment revealed the resident was cognitively intact, at risk to develop pressure ulcers/injuries and to have a pressure reducing device for her/his chair. Resident 37's 11/2024 Physician Orders directed the resident to receive wound care to her/his right and left thigh rear skin tears twice daily. On 11/18/24 at 12:33 PM Resident 37 was observed in her/his room and sat on a folded towel in her/his wheelchair. Resident 37 stated she/he experienced skin irritation and breakdown on her/his "bottom area" and she/he did not have a cushion for her/his wheelchair so she/he had to sit on a folded towel instead. Resident 37 stated the wheelchair was uncomfortable and she/he had asked for a cushion many times and but still did not have one. Random observations of Resident 37 from 11/19/24 to 11/21/24 between 8:15 AM through 4:07 PM revealed the resident to be in bed or in her/his wheelchair. When the resident was observed in her/his wheelchair, she/he sat on a folded towel. On 11/21/24 at 8:15 AM Resident 37 stated the facility offered her/him a cushion for her/his wheelchair about four months ago but it was too thick, caused her/him to sit up too high in her/his wheelchair and was uncomfortable. Resident 37 stated she/he asked again about receiving a cushion for her/his wheelchair "a few weeks ago" and staff "brought back the same one with a stain." Resident 37 further stated she/he asked about trying a different cushion and was told "they did not know." On 11/21/24 at 8:21 AM Staff 23 (CNA) stated Resident 37 was supposed to have a cushion when up in her/his wheelchair, and the resident had regular "complaints about [her/his] bottom hurting." Staff 23 further stated there were days when the resident "was up in the wheelchair a majority of the day." On 11/21/24 at 9:03 AM Staff 26 (CNA) stated Resident 37 usually spent one to three hours up in her/his wheelchair during each day shift. Staff 26 stated she had never seen a cushion in the resident's wheelchair but had seen the resident sit on bath blankets instead. On 11/21/24 at 9:30 AM Staff 27 (RN) stated Resident 37 should sit on a cushion "every time [she/he] was in the wheelchair." On 11/21/24 at 12:44 PM Staff 2 (DNS) reviewed Resident 37's clinical record, confirmed she/he was at risk for the development of pressure ulcers/injuries and stated the resident should have a cushion for her/his wheelchair.

Corrective Action(s) for residents identified to have been affected: Resident #37 was provided a cushion for the wheelchair. Identified residents with potential to be affected: The DNS or designee will audit current residents with risk of developing pressure ulcers/injuries and evaluate need for intervention. Measures to prevent recurrence: The DNS or designee will re-educate the RCM department on evaluating residents on the risk of developing pressure ulcers/injuries and evaluating the need for intervention. Monitor of Corrective Action: The DNS or designee will audit clinical charts on 2-3 residents 3 x week for 1 week, 1xweek for 4 weeks and then monthly for 3 months to ensure the proper protocol is being followed. Issues will be reviewed during the monthly QAPI meeting and a Performance Improvement Pan will be developed as necessary.

Based on observation, interview and record review it was determined the facility failed to provide appropriate treatment and services to prevent further decreases in range of motion for 2 of 3 sampled residents (#s 9 and 10) reviewed for position and mobility. This placed residents at risk for worsening contractures (a permanent tightening of the muscle, tendons and skin causing the joint to shorten and stiffen) and conditions. Findings include: The facility's 8/2024 Restorative Nursing Policy and Procedure revealed the following: -On-going assessment of each resident's functional status occurred no less often than quarterly with completion of the MDS. -If the Resident Care Manager or licensed staff determined the resident had the ability to improve in one or more area of communication, mobility, range of motion, ADL performance, eating or toileting, a therapy referral or restorative nursing referral was initiated. -If the resident expressed a desire to improve in one or more area of communication, mobility, range of motion, ADL performance, eating or toileting, a restorative nursing referral was initiated. -If the Resident Care Manager or licensed staff determined the resident needed to maintain current function in communication, mobility, range of motion, ADL performance, eating or toileting, a restorative nursing referral was initiated. -The restorative nursing referral documented the resident's current functional status, need to improve or maintain functional status, recommended goals, approaches and plan for periodic re-evaluation of the program. Restorative nursing programs were added to the appropriate nursing care plan and in-room care plan. -Residents with the need to improve functional status were re-evaluated monthly to determine effectiveness of the current interventions and need to revise goals or interventions. -Residents with the need to maintain current function status were re-evaluated at least quarterly to determine effectiveness of the current interventions and need to revise goals or interventions. 1. Resident 9 was admitted to the facility in 10/2019 with diagnoses including hemiparesis (partial weakness on one side of the body) and hemiplegia (complete paralysis on one side of the body) following a stroke and affecting the left non-dominant side. Resident 9's 9/10/24 Restorative Nursing Re-Evaluation indicated the resident had a left hand splint/brace, the splint/brace was too big and OT was going to fit her/him for a new one. Resident 9's 9/11/24 Annual MDS Assessment indicated the resident was moderately cognitively impaired, experienced upper and lower extremity impairment on one side, was dependent on assistance from staff for lower body dressing and required substantial/maximal assistance from staff with upper body dressing and personal hygiene. The Functional Abilities CAA indicated the resident experienced contractures on her/his left side and she/he had ROM exercises and a splint to assist with preventing further contractures. Resident 9's 10/2/24 ADL and Left Sided Weakness/Impairment Care Plans revealed the following: -The resident had contractures to the right arm/hand and right leg. -Adaptive devices as recommended by therapy or physician. Monitor for safe use. Monitor/document to ensure appropriate use of adaptive device. -Assist the resident to wear the left hand palm guard daily as tolerated. -The resident was to use a left hand therapy carrot (a device that helps position hands with severe contractures) as tolerated to facilitate contracture management. -Range of motion exercises to be completed several times a day. -Passive ROM program for right and left upper extremities was to be completed daily. -Monitor/document mobility status. If the resident presents with problems or paralysis, obtain an order for PT and OT to evaluate and treat. Resident 9's 10/22/24 Therapy to Nursing Communication indicated the resident was to wear a left hand palm guard and therapy carrot as tolerated daily to facilitate contracture management. Resident 9's 11/2024 Physician Orders directed the resident's left hand palm protector to be in place continuously. The orders directed the licensed nurse to remove the palm protector at least twice per shift in order to inspect and clean the resident's left hand. A review of Resident 9's 10/21/24 through 11/16/24 Daily Exercise Program for Right and Left Upper Extremities Task revealed the following: -10/21/24: no. -10/22/24: not applicable. -10/23/24: not applicable. -10/24/24: not applicable. -10/25/24: not applicable. -10/26/24: not applicable. -10/27/24: not applicable. -10/28/24: no. -10/29/24: no. -11/2/24: no. -11/4/24: not applicable. -11/5/24: not applicable. -11/6/24: not applicable. -11/7/24: no. -11/9/24: not applicable. -11/10/24: no. -11/12/24: no. -11/13/24: not applicable. -11/16/24: no. Instructions listed on Resident 9's Splint/Brace Assistance Task directed staff to assist the resident to wear left hand palm guard daily as tolerated and the resident was to use the left hand therapy carrot as tolerated. A review of Resident 9's Splint/Brace Assistance Task from 10/24/24 through 11/17/24 revealed the following: -10/24/24: not applicable. -10/25/24: not applicable. -10/26/24: not applicable. -10/27/24: not applicable. -10/28/24: no. -10/28/24: no. -11/1/24: no. -11/2/24: no. -11/4/24: not applicable. -11/5/24: not applicable. -11/6/24: no. -11/7/24: no. -11/8/24: no. -11/9/24: not applicable. -11/12/24: no. -11/13/24: not applicable. -11/16/24: no. -11/17/24: no. On 11/18/24 at 11:32 AM Resident 9 was observed in her/his room and sat in her/his wheelchair. The resident's left thumb was tucked in tightly to the palm of her/his hand and the remaining four fingers on her/his left hand pressed in on top of the left thumb. The tip of a therapy carrot was observed in between the resident's thumb and index finger but a majority of the therapy carrot hung out of the resident's hand. The resident was unable to extend any of her/his fingers or thumb on her/his left hand with verbal prompting and indicated she/he used the therapy carrot "sometimes." No splint or brace was observed in the resident's room. On 11/18/24 at 3:09 PM Resident 9 was observed in her/his room in bed. The resident's left thumb was tucked in tightly to the palm of her/his hand and the remaining four fingers on her/his left hand pressed in on top of the left thumb. The tip of a therapy carrot was observed in between the resident's thumb and index finger with a majority of the carrot hanging out of the resident's hand. No splint or brace was observed in the resident's room. On 11/19/24 at 3:49 Resident 9 was observed in her/his room in bed. No splint, brace or therapy carrot was observed in the resident's contracted left hand. With the assistance of a translator, Resident 9 stated her/his left hand "hurt all of the time" and she/he "was very sad about this situation." Resident 9 was unable to answer specific questions about her/his splint, brace or therapy carrot but did state she/he did not participate in any exercise or ROM program at the facility. On 11/20/24 at 9:41 AM Staff 23 (CNA) stated Resident 9 had a brace and a therapy carrot for her/his left hand and the resident put them on and took them off independently. Staff 23 stated she did not know how long each day the resident was supposed to wear the brace or therapy carrot, did not know if the resident had an RA program and stated the resident never refused anything, including to put on her/his therapy carrot or splint when offered. On 11/20/24 at 9:52 AM Staff 28 (CNA) stated she helped to place the therapy carrot in Resident 9's left hand when the resident asked for assistance and the resident was always cooperative. Staff 28 stated PT was responsible for Resident 9's splint and stated she had "not done any RA tasks" with the resident. On 11/20/24 at 10:08 AM Staff 29 (LPN) stated therapy was "still working on getting a new splint so [the resident] did not have one right now." Staff 29 stated he thought Staff 21 (CNA) was responsible for Resident 9's RA program but thought other CNAs could also help. On 11/20/24 at 10:16 AM Staff 30 (Director of Rehab) stated Resident 9 was seen by OT from 9/17/24 and 10/24/24 for left hand contracture management. Staff 30 stated therapy discharge recommendations included the resident to wear the left hand therapy carrot and palm guard daily as tolerated. Staff 30 stated the resident knew she/he needed to wear the therapy carrot and she/he "wanted to use it." Staff 30 further stated the resident wheeled her/himself into the therapy room "a few times after [she/he] was discharged from therapy for help getting the carrot in." On 11/20/24 at 2:38 PM Staff 6 (RNCM) stated the resident was to wear her/his therapy carrot daily as tolerated and staff were to offer her/him the therapy carrot in the morning and reoffer it again should the resident remove it. Staff 6 reviewed the resident's order for the continuous use of the left palm protector and stated she "was not sure when [the resident] should have the palm protector on." Staff 6 reviewed Resident 6's RA tasks and stated she did not know if the RA was offered to the resident when "no" or "not applicable" was documented. On 11/20/24 at 2:53 PM Staff 2 (DNS) stated Resident 9's order for the continuous use of the left palm protector needed clarification and staff were to assist the resident to place her/his therapy carrot daily and reoffer to place it if it was observed hanging out of her/his hand. Staff 2 further stated it was unclear from the documentation if the resident was offered RA as indicated. 2. Resident 10 was readmitted to the facility in 11/2023 with diagnoses including dementia. Resident 10's 1/7/24 Annual MDS Assessment indicated the resident was moderately cognitively impaired and experienced upper extremity impairment on one side. The Pressure Ulcer/Injury CAA indicated the resident experienced left-sided weakness since she/he admitted to the facility. An 11/19/24 Physician Assistant Note revealed the resident experienced chronic left-sided deficits and had left upper extremity contractures and edema. No evidence was found in Resident 10's clinical record to indicate the resident's left upper extremity contractures were comprehensively assessed, ongoing monitoring of her/his contractures was being provided or any support or exercises were being provided to maintain or improve the resident's range of motion/mobility or to prevent further declines. No rationale was found as to why range of motion services were not being provided. On 11/18/24 at 12:08 PM Resident 10 was observed in her/his room in her/his geri chair (a large, padded and wheeled chair designed to help people with limited mobility). Resident 10's fingers and thumb on her/his left hand were observed to curl in towards the palm of her/his hand. Resident 10 stated the facility did not "do anything" for her/his left hand and did "not think they even knew about" her/his contractures. Resident 10 stated she did not participate in any range of motion exercises for her/his left hand, she/he did not have a therapy carrot (a device that helps position hands with severe contractures), splint or brace for her/his left hand and she/he was willing to try anything that could help. On 11/21/24 at 8:12 AM Resident 10 stated her/his left hand "hurt sometimes" and she/he was not able to straighten out her/his fingers or thumb on her/his left hand. On 11/21/24 at 8:31 AM Staff 23 (CNA) stated Resident 10 did not have "movement in the left side of [her/his] body." Staff 23 stated the resident did not have an RA program, she had never seen the resident use a carrot, splint or brace for her/his left hand and the only assignment she had related to the resident's left hand was to "scrub" it. On 11/21/24 at 9:15 AM Staff 26 (CNA) stated Resident 10's left hand contractures had gotten "worse over the years" and "nothing recent was being done for [her/his] hand." On 11/21/24 at 9:39 AM Staff 27 (RN) stated she was not aware of "any RA program for [Resident 10's] upper extremities," and she had seen the resident "use a carrot once or twice." On 11/21/24 at 9:44 AM Staff 30 (Director of Rehab) stated she had not received a referral for Resident 10 to be seen for her/his left-sided weakness. On 11/21/24 at 11:06 AM Staff 4 (LPN-Care Manager) stated a resident's physician and therapy was to be notified if a resident's contracture was observed to worsen, and residents with contractures should have a care plan related to their contractures. Staff 4 stated there was no documentation to indicate Resident 10's contractures were assessed or being monitored and the resident did not have a care plan related to the management of her/his upper extremity contractures. On 11/21/24 at 11:18 Staff 2 (DNS) reviewed Resident 10's clinical record and confirmed the resident's contractures lacked assessment and care planning and stated the resident's contractures "should have been evaluated already by therapy."

Corrective Action(s) for residents identified to have been affected: Resident 10 contractors were properly assessed and care plan created for an upper extremity contracture management program. Resident 9 was evaluated by the therapy department for a left-hand splint/brace that fit properly to actively participate in the restorative aid program and careplan was updated Identified residents with potential to be affected: Residents with limited range of motion are at risk for decreased ROM/Mobility. An audit will be performed of at risk residents and corrected as necessary. Measures to prevent recurrence: The DNS or designee will re-educate the LN and CNA staff on the importance of preventing decreased range of motion/mobility for residents as well as ensuring residents are receiving appropriate services, equipment and assistance to prevent further reduction. Monitor of Corrective Action: The Administrator or designee will 2-3 resident charts with decreased ROM/mobility 3 x week for 1 week, 1xweek for 4 weeks and then monthly for 3 months to the appropriate treatments are in place as well as careplan being followed. Issues will be reviewed during the monthly QAPI meeting and a Performance Improvement Pan will be developed as necessary.

Based on observation, interview and record review it was determined the facility failed to ensure residents who were trauma survivors received trauma-informed care for 1 of 2 sampled residents (#62) reviewed for mood. This placed residents at risk for re-traumatization and decreased quality of life. Findings include: The facility's 8/2024 Trauma-Informed Care Policy and Procedure revealed the following: -The facility screened newly admitted residents for indications of trauma as part of the comprehensive care plan process. -The facility developed an appropriate plan of care and interventions based upon the screening responses and observations of the resident. -The facility avoided re-traumatization that may be experienced due to repeated interviews regarding trauma history. The facility observed the resident for changes in behavior or mood that may indicate a need to modify the plan of care, quarterly. Resident 62 was admitted to the facility in 9/2024 with diagnoses including Post traumatic stress disorder (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event and with triggers that can bring back memories of the trauma accompanied by intense emotional and physical reactions) and stimulant abuse (the continued use of amphetamine-type substances, cocaine or other stimulants that lead to clinically significant impairment or distress). Resident 62's 9/29/24 Hospital History and Physical records revealed the following: -The resident was involved in a motor vehicle accident in 2021 which resulted in paraplegia (the inability to voluntarily move the lower parts of the body). -The resident reported being awake during the entirety of this event during which she/he tried to keep a child alive who died on the scene before emergency medical services arrived. -The resident experienced PTSD/panic symptoms related to this event. -The resident reported night terrors every night since this event in which she/he re-enacted the traumatic event in her/his dreams. -The resident reported regular panic attacks which were triggered by being alone. -The resident had a methamphetamine use disorder, and pain and her/his family's home were triggers for substance abuse. -The resident did not want to discharge to a long-term care facility because these types of facilities reminded the resident of being in a correctional facility and she/he would rather discharge to the streets. Resident 62's 9/30/24 Baseline Care Plan indicated the resident had a known or reported trauma history, received an antidepressant related to her/his diagnosis of PTSD, the medication worked "okay" and she/he had not had any symptoms of PTSD. Resident 62's 10/8/24 Social History Assessment indicated the resident had a diagnosis of PTSD and did not exhibit any behaviors related to this diagnosis. Resident 62's 10/18/24 Admission MDS Assessment indicated the resident was cognitively intact. Resident 62's 11/6/24 Psychosocial-Emotional/Trauma Care Plan revealed the following: -Encourage the resident to express emotions. -Assist to normalize feelings. -Attempt non-pharmacological approaches as indicated such as music therapy, breathing exercises, talking to the resident about her/his feelings, meditation, aroma therapy, reading materials and offering preferred activities. -Evaluate non-verbal cues to assess the degree and severity of pain for pain management. -PTSD triggers include nightmares. Intervention included to wake the resident and reorient to help her/him to get out of the nightmare. Resident 62's 11/2024 MARs revealed the resident received hydroxyzine (an antihistamine used to help control anxiety and tension caused by nervous and emotional conditions) PRN for anxiety on 11/19/24. No evidence was found in Resident 62's clinical record to indicate a care plan for her/his PTSD was developed until 11/6/24, 38 days after the resident admitted to the facility, the resident was asked specific questions related to triggers of her/his traumas, the resident's hospital records were reviewed to help to develop a person-centered trauma care plan, additional staff or relevant family members were offered the opportunity to provide information about the resident's traumas and potential triggers, possible triggers related to the resident's history of incarceration or substance use disorder were considered or why the resident received a PRN medication for anxiety on 11/19/24. On 11/22/24 at 9:50 AM Resident 62 was observed to sit in her/his bed with the privacy curtain pulled and the blinds closed. Resident 62 stated she/he experienced anxiety related to her/his PTSD and a lot of "little things" triggered her/his anxiety, including "hearing a car crash or sirens, doors slamming, people yelling, a loud environment, other residents falling or needing help, being stressed and homeless people asking for a hit of [her/his] vape pen (a battery-operated vaping device) when outside smoking." Resident 62 stated she/he barely watched television because her/his PTSD was triggered by various television shows. Resident 62 stated "the guys across the hallway were hard of hearing so their televisions were up loud," and when this happened, the resident put her/his "head under a pillow or blanket" because there was nothing else she/he could do. Resident 62 stated she/he wanted to discharge to "a normal environment" where it was not so loud. Resident 62 stated Staff 2 (DNS) spoke with her/him briefly about her/his PTSD but she/he had not spoken with anyone at the facility in-depth about potential triggers for re-traumatization. Resident 62 stated she/he had nightmares about her/his "car wreck" every night and she/he fell out of bed once in 10/2024 "trying to run from [her/his] dream." Resident 62 stated she/he was provided with a larger bed after this incident but the facility had otherwise done nothing to help her/him with her/his nightmares. Resident 62 stated she/he had never been woken up by staff from a dream which was her/his preference if she/he was observed to talk in her/his sleep or was hunched over because this meant she/he "was either trying to run from something or hold [her/his] body," and staff had never offered to talk with her/him about her/his nightmares or to assist with any breathing exercises to help her/his anxiety. Resident 62 further stated she/he had an anxiety attack on 11/19/24 when she/he woke up and there were "a lot of people" in her/his room assisting her/his roommate and it was "really loud." Resident 62 stated she/he felt like she/he "had to get out of the room because there were people everywhere." On 11/22/24 at 10:30 AM Staff 23 (CNA) stated "a lot of people" in the room, vehicles and "erratic drivers hitting the breaks a lot" triggered Resident 62's anxiety. Staff 23 stated Resident 62's care plan did not list any triggers related to her/his PTSD or anxiety but she had learned some of the resident's triggers by talking with her/him. On 11/22/24 at 10:48 AM Staff 18 (LVN/LPN) stated cars and car accidents triggered Resident 62's anxiety and the resident experienced nightmares about the car accident she/he was involved in. Staff 18 stated she gave the resident a PRN medication for anxiety on 11/19/24 because the resident stated she/he felt "really anxious" but did not have any additional details about cause of the resident's anxiety. On 11/22/24 at 11:24 AM Staff 7 (Social Services Director) stated she interviewed Resident 62 on her/his day of admission to the facility about her/his PTSD and possible triggers, and the resident told her "confrontation was an issue." Staff 7 stated she had not interviewed the resident about her/his PTSD since admission, did not add confrontation as a trigger for anxiety to the resident's care plan, did not review the resident's clinical record in order to understand other additional triggers of her/his PTSD or ask the resident about other specific potential triggers given her/his history of traumas, including about the environment at the nursing facility. Staff 7 further stated she was not aware the resident experienced nightly night terrors and was not aware she/he experienced an anxiety attack on 11/19/24. On 11/22/24 at 11:51 AM Staff 2 (DNS) confirmed Resident 62's care plan to address her/his PTSD was not developed until 11/6/24 and after the resident experienced a fall out of bed, and the resident's care plan was not comprehensive. Staff 2 further stated she was not aware the resident experienced an anxiety attack on 11/19/24.

Corrective Action(s) for residents identified to have been affected: Resident 62 careplan was updated to reflect person centered trauma informed care, triggers and interventions to avoid re-traumatizing experiences. Identified residents with potential to be affected: Residents with a past trauma history are at risk of being affected. An audit will be performed of at risk residents and corrected as necessary. Measures to prevent recurrence: The Administrator or designee will re-educate the social services department on trauma informed care planning, as well as being person centered involving triggers and interventions Monitor of Corrective Action: The Administrator or designee will audit 1-2 resident charts 3 x week for 1 week, 1xweek for 4 weeks and then monthly for 3 months to ensure person centered trauma informed care plans are being created along with triggers and interventions. Issues will be reviewed during the monthly QAPI meeting and a Performance Improvement Pan will be developed as necessary.

Based on observation, interview and record review it was determined the facility failed to provide necessary behavioral health care and services for 1 of 2 sampled residents (#62) reviewed for behavioral-emotional needs. This placed residents at risk for unmet behavioral and emotional needs and a decrease in their quality of life. Findings include: The facility's 2/2019 Behavioral Health Services and 3/2019 Behavioral Assessment, Intervention and Monitoring Policies revealed: -Residents who exhibit signs of emotional/psychosocial distress receive services and support that address their individual needs and goals for care. -As part of the comprehensive assessment, staff will evaluate, based on input from the resident, family and caregivers, review of medical record and general observations, the resident's typical or past responses to stress, fatigue, fear, anxiety frustration and other triggers and the resident's previous patterns of coping with stress, anxiety and depression. -Interventions will be individualized and part of an overall care environment that supports physical, functional and psychosocial needs, and strives to understand, prevent or relieve the resident's distress or loss of abilities. Resident 62 was admitted to the facility in 9/2024 with diagnoses including Post traumatic stress disorder (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event and with triggers that can bring back memories of the trauma accompanied by intense emotional and physical reactions) and stimulant abuse (the continued use of amphetamine-type substances, cocaine or other stimulants that lead to clinically significant impairment or distress). Resident 62's 9/29/24 Hospital History and Physical records revealed the following: -The resident was involved in a motor vehicle accident in 2021 which resulted in paraplegia (the inability to voluntarily move the lower parts of the body). -The resident experienced PTSD/panic symptoms related to this event. -The resident reported night terrors every night since this event in which she/he re-enacted the traumatic event in her/his dreams. -The resident reported regular panic attacks which were triggered by being alone. -The resident had a methamphetamine use disorder. -The resident benefited from the support of the hospital's IMPACT (Improving Addiction Care Team) peer team, having a peer recovery mentor and participating in virtual Narcotics Anonymous (NA) meetings. -The resident could be a candidate for the Affect App (a smartphone application designed to provide a digital addiction recovery program) after discharge. Resident 62's 10/8/24 Social History Assessment indicated the resident had a diagnosis of PTSD and did not exhibit any behaviors related to this diagnosis. Resident 62's 10/18/24 Admission MDS Assessment indicated the resident was cognitively intact. Resident 62's 11/6/24 Psychosocial-Emotional/Trauma Care Plan revealed the following: -Encourage the resident to express emotions. -Assist to normalize feelings. -Attempt non-pharmacological approaches as indicated such as music therapy, breathing exercises, talking to the resident about her/his feelings, meditation, aroma therapy, reading materials and offering preferred activities. -Evaluate non-verbal cues to assess the degree and severity of pain for pain management. -PTSD triggers included nightmares and the resident was to be woken up and reoriented to help her/him to get out of the nightmare. Resident 62's 11/18/24 Behavior Care Plan revealed the following: -Focused behaviors included yelling, crying, verbal outbursts, constant fidgeting and refusing care. -Interventions included redirection, reminding the resident yelling was not okay, one-to-one conversations, re-approach and music of own choosing. Resident 62's 11/2024 MARs revealed the resident received hydroxyzine (an antihistamine used to help control anxiety and tension caused by nervous and emotional conditions) PRN for anxiety on 11/19/24. No evidence was found in Resident 62's clinical record to indicate the resident was offered the opportunity to receive mental health services or to participate in NA meetings, assistance with obtaining the Affect App, a person-centered care plan was developed to address Resident 62's potential mood symptoms or why the resident received a PRN medication for anxiety on 11/19/24. On 11/22/24 at 9:50 AM Resident 62 was observed to sit in her/his bed with the privacy curtain pulled and the blinds closed. Resident 62 stated she/he had not been offered any counseling, group, peer or therapy services since she/he admitted to the facility and was interested in all of these services as she/he thought "they would help to relieve stress and talk it out." Resident 62 stated the facility's social worker "won't talk to or help [her/him]" and the facility "does nothing" for her/his PTSD and anxiety outside of giving her/him medications. On 11/22/24 at 10:48 AM Staff 18 (LVN/LPN) stated she gave Resident 62 a PRN medication for anxiety on 11/19/24 because the resident stated she/he felt "really anxious" but did not have any additional details about the cause of the resident's anxiety. On 11/22/24 at 11:24 AM Staff 7 (Social Services Director) stated Resident 62's behavior care plan was not person-centered as the resident did not yell, cry, have outbursts, fidget or refuse care and reminding the resident not to yell was an inappropriate intervention for this resident. Staff 7 stated she did not know if music therapy, breathing exercises, meditation or aroma therapy were effective interventions to relieve anxiety for Resident 62. Staff 7 stated she had not asked Resident 62 if she/he was interested in receiving peer support, attending support groups or having any additional mental health support outside of asking the resident if she/he wanted to see a therapist at the time of her/his admission to the facility in 9/2024. Staff 7 further stated she was not aware the resident experienced an anxiety attack on 11/19/24. On 11/22/24 at 11:51 AM Staff 2 (DNS) stated she did not know if any mental health services were offered to Resident 62, she was not aware the resident experienced an anxiety attack on 11/19/24 and the resident's care plan was not person-centered.

Corrective Action(s) for residents identified to have been affected: Resident 62 was offered mental health services/NA meetings and careplan was updated to be person centered. Identified residents with potential to be affected: Residents mental health diagnosis are at risk to be effected by not offering mental health services or have a person centered careplan. An audit will be performed of at risk residents and corrected as necessary. Measures to prevent recurrence: The Administrator or designee will re-educate the social services department on offering mental health services when diagnosis warrant as well as having a person centered careplan for all residents.

Based on observation, interview and record review it was determined the facility failed to accommodate resident food choices for 1 of 7 sampled residents (#37) reviewed for food. This placed residents at risk for food choices not being honored. Findings include: Resident 37 was admitted to the facility in 11/2023 with diagnoses including neuromuscular dysfunction of the bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems). Resident 37's 11/22/23 Food and Nutrition Admission Interview revealed the resident normally ate oatmeal for breakfast and requested a salad with meals. The Interview also indicated the resident did not like peas, green beans, pepper, raisin bread or raisins. Resident 37's 8/25/24 Quarterly MDS Assessment revealed the resident was cognitively intact and on a therapeutic diet. Resident 37's 11/11/24 Nutrition At Risk Evaluation revealed the resident received a regular texture diet with small starch portions and sodium limited to two grams. The resident was to receive a salad with lunch and dinner. On 11/18/24 at 1:31 PM Resident 37 was observed in her/his room and sat in her/his wheelchair. The resident's lunch tray sat on top of her/his bed. Resident 37 removed the lid that covered the plate and revealed her/his lunch of garlic bread, pasta with meat sauce and green beans. Resident 37 stated she/he would not touch her/his lunch because she/he did not like green beans and the green beans touched the other food items on her/his plate. Resident 37 stated she/he was served items she/he disliked "again and again." No salad was observed on the resident's meal tray. Resident 37 handed the state surveyor her/his meal ticket from the lunch tray which indicated the following: -The resident disliked gravies, gravy on meat, sugar free juice, scrambled eggs, green beans, peas and raisin bread. -No salt packs were to be placed on the resident's tray. On 11/19/24 at 12:43 PM Resident 37 was observed in her/his room and sat in her/his wheelchair. The resident's lunch tray with a salt packet sat on top of the resident's bed. Resident 37 removed the lid that covered the plate and revealed meat and potatoes covered in gravy. Resident 37 stated she/he was not going to eat her/his lunch because it was covered in gravy and she/he did not like gravy. No salad was observed on the resident's meal tray. On 11/20/24 at 12:24 PM Staff 25 (Cook) was observed to plate Resident 37's lunch. Staff 25 used a spoon with holes to drain the mushroom gravy from the beef and placed the strained beef on top of a plate of rice and carrots. Staff 25 stated he intended to serve Resident 37 the beef even though it was coated in gravy because he did not want to give Resident 37 "dry meat" and wanted her/him "to have flavor." Staff 25 further stated the resident could come back to the kitchen and get something else if she/he did not like the beef. On 11/20/24 at 12:36 PM Staff 15 (Dietary Director) reviewed Resident 37's meal ticket, stated the resident did not like gravy and she/he should have not been served the beef coated in gravy. Staff 15 further stated he expected the cooks to follow resident preferences. On 11/20/24 at 12:58 PM Resident 37 stated she/he did not want to eat lunch because "it looked like gravy." On 11/20/24 at 1:13 PM Staff 1 (Administrator) acknowledged the findings and did not offer any additional information.

Corrective Action(s) for residents identified to have been affected: Resident 37 tray card ticket was reviewed with dietary manager to update to reflect food preferences. Identified residents with potential to be affected: Residents with allergies, intolerances and preference are at risk of being affected. An audit will be performed of at risk residents and corrected as necessary. Measures to prevent recurrence: The Administrator or designee will re-educate the dietary department on the importance of following resident meal tickets in regards to food preferences. Monitor of Corrective Action: The Administrator or designee will audit meal pass weekly x4, monthly x2, or until compliance is achieved. Issues will be reviewed during the monthly QAPI meeting and a Performance Improvement Pan will be developed as necessary.

Based on observation, interview and record review it was determined the facility failed to maintain sanitary equipment to prevent the unintended presence of potentially harmful substances, label and store food appropriately or handle and prepare food in a sanitary manner for 1 of 1 ice machine, 1 of 1 mobile ice carts and 1 of 1 kitchen reviewed for dining services. This placed residents at risk of illness and contaminated food. Finding include: In the dining room on 11/18/24 at 12:25 PM Staff 21 (CNA) was observed to scoop ice from the large ice machine into the mobile ice cart chest. Staff 21 used the ice scoop located to the left of the ice machine, mounted on the wall and contained in a black container. Staff 21 was then observed to use an ice scoop, stored in a white mesh bag on the mobile ice cart, to place ice into a cup. The white mesh bag had a black substance on the bottom of the bag about the size of a playing card. On 11/18/24 at 12:28 PM Staff 21 stated they did not know if the white mesh bag to hold the scoop was clean or not, but it appeared to have mold growth on the bag. On 11/18/24 at 12:32 PM Staff 2 (DNS) stated they would expect the ice scoop to be contained in a clean environment. Staff 2 and surveyor approached Staff 21 with the mobile ice cart. Staff 21 stated the white mesh bag for the mobile ice cart scoop was thrown away. On 11/18/24 at 12:36 PM Staff 11 (Maintenance Director) confirmed the white mesh bag for the mobile ice cart scoop was thrown away because it was "nasty." On 11/18/24 at 12:37 PM the surveyor used a white paper towel to wipe the bottom inside of the black ice machine scoop holder mounted on the wall left of the ice machine. The paper towel came out with a black flack debris which felt slimy. On 11/18/24 at 12:40 PM Staff 14 (Housekeeping Supervisor) stated the housekeeping department was responsible to clean the ice scoop and its container to the left of the ice machine. Staff 14 placed a cloth rag into the container and wiped the bottom. Staff 14 confirmed the container was not clean and they were unsure exactly how often it was cleaned. On 11/18/24 at 1:45 PM Staff 1 (Administrator) acknowledged this finding and confirmed they expected both ice scoop containers to be clean. , 2. The facility's 11/2022 Food Preparation and Service Policy and Procedure directed the following: -Gloves were to be worn when handling food directly and changed between tasks. -Refrigerators and/or freezers were to be maintained in good working condition. -Frozen foods were to be maintained at a temperature to keep the food frozen solid. Wrappers of frozen foods must stay intact until thawing. -All food was to be appropriately dated to ensure proper rotation by expiration dates. "Received" dates (dates of delivery) were to be marked on cases and on individual items removed from cases for storage. "Use by" dates were to be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food were to be observed and "use by" dates were to indicate once food was opened. -Supervisors were responsible for ensuring food items in the pantry, refrigerators and freezers were not past the "use by" or expiration dates. Supervisors were to contact vendors or manufacturers when expiration dates were in question or to decipher codes on packaging. On 11/18/24 at 9:46 AM during the initial tour of the facility's kitchen, the following was observed in the dry storage area: -an opened bag of French onions, undated; -an opened container of vinegar, undated; -an opened bag of Sloppy Joe seasoning, undated; -an opened bag of biscuit gravy mix, undated; -an opened bag of mashed potato mix, undated; -an opened bag of chicken gravy mix, undated; -an unopened container of horseradish, expired on 6/25/24; -an unopened container of mayonnaise, expired on 7/18/24; -four unopened coleslaw dressings, expiration date unable to be determined; -two unopened containers of ranch dressing, expiration date unable to be determined; and -three unopened containers of mayonnaise, expiration date unable to be determined. On 11/18/24 at 10:00 AM during the initial tour of the facility's kitchen, the following were observed in the facility's walk-in freezer: -a large chunk of ice attached to a pipe in the back of the freezer hung down and was positioned above an open box of corn. The box contained many chunks of ice that appeared to have broken off from the ice chunk that hung above; -a bag of freezer burned asparagus; and -an open bag of bratwurst. On 11/18/24 at 9:52 AM Staff 15 (Dietary Director) stated all of the opened and undated, expired and freezer burned food items should be thrown out. On 11/20/24 at 11:12 AM Staff 15 stated the items with an expiration date that was unable to be determined needed to be removed from the shelf in the dry storage. On 11/20/24 between 11:55 AM and 12:30 PM during a return visit to the kitchen the following was observed during the lunch tray line service: -At 11:55 AM Staff 25 (Cook) was observed to plate resident meal trays and wore gloves. At 11:57 AM Staff 25 opened a drawer in the kitchen, removed two utensils and resumed plating resident meal trays. Staff 25 did not change his gloves after he touched the kitchen drawer. -At 12:06 PM Staff 25 wore the same pair of gloves and opened the door to the facility's freezer, retrieved a salad and a sandwich, removed the sandwich from the bag, placed the sandwich on a plate and resumed plating resident meal trays. Staff 25 did not change his gloves after he touched the door handle to the freezer. -At 12:10 PM Staff 25 wore the same pair of gloves and opened the door to the facility's freezer and retrieved another sandwich. The state surveyor asked Staff 25 at this time about when he was expected to change his gloves to which Staff 25 stated he changed his gloves when he "touched the doors." Staff 25 did not change his gloves and continued to plate resident meal trays. On 11/20/24 at 12:36 PM Staff 15 stated staff were expected to change their gloves between tasks.

Corrective Action(s) for residents identified to have been affected: No residents were identified to be affected by failed maintenance of the black container or white mesh bag that the ice scoops were stored in, or the staff member not changing their gloves after completely another task. The outdated and freezer burn food was thrown away and ice build up repaired. Identified residents with potential to be affected: The Administrator, dietary manager or designee will audit the cleanliness of the black ice scoop container on the wall in the LTC dining room and the white mesh bag on the rolling cooler. As well as the undated, expired and freezer burnt foods in the kitchen and the dietary staff changing gloves between tasks. Measures to prevent recurrence: The Administrator or designee will re-educate the housekeeping and dietary department on the importance of keeping the ice scoop containers clean and sanitary. The Administrator, dietary manager or designee will re-educate the dietary department on the importance of changing gloves between tasks and ensuring all foods are dated, not expired or freezer burnt. Monitor of Corrective Action: The Administrator or designee will audit cleanliness of ice scoop containers 3 x week for 1 week, 1xweek for 4 weeks and then monthly for 3 months to ensure the cleaning schedule is being followed. Issues will be reviewed during the monthly QAPI meeting and a Performance Improvement Pan will be developed as necessary. The Administrator or designee will audit the food storage and walk in freezer/fridge to ensure all items are stored properly, dated and not freezer burnt weekly x4, monthly x2, or until compliance is achieved. Issues will be reviewed during the monthly QAPI meeting and a Performance Improvement Pan will be developed as necessary.

Based on observation and interview it was determined the facility failed to post the current week's menu in a location that was accessible and conspicuous to residents for 1 of 1 facility reviewed for dining. This placed residents at risk for not being aware of food choices. Findings include: On 11/18/24 at 11:32 AM the facility's weekly menu was observed posted on a bulletin board to the left of the dining room door for 11/10/24 through 11/16/24. The weekly menu was printed on an 8.5 inch by 11 inch piece of paper. The menu was in small print, on a busy print colored background and there was an empty manila envelope taped to the wall with the "weekly menu" written on it. On 11/21/24 at 2:25 PM a weekly menu was observed posted on a bulletin board on the southeast hallway, on 8.5 inch by 11 inch paper on large cork board with a busy background paper. The current week's menu was not posted and was dated for the week of 11/10/24 through 11/16/24. No resident menus were observed on the northwest or northeast hallways. On 11/22/24 at 10:38 AM Staff 1 (Administrator) and Staff 15 (Dietary Director) confirmed the resident menus posted were in small print, not easy to read and inaccessible to residents. Staff 15 acknowledged there was no system currently in place for all residents to have access to a menu. Staff 1 confirmed the dates of the previous week's menu posted on the southeast hallway.

Corrective Action(s) for residents identified to have been affected: No residents were affected by the current menu not being posted in LTC hall or the menu being posted in small print on the facilities weekly bulletin board. Identified residents with potential to be affected: All residents have the potential to be affected by not being aware of menu choices for the week. An audit will be performed of menus and corrected as necessary. Measures to prevent recurrence: The Administrator or designee will re-educate the dietary manager on the importance of changing the menu to up to date menus on the LTC hall as well as posting the menus on larger print paper on the bulletin board. Monitor of Corrective Action: The Administrator or designee will audit the LTC and front hall bulletin board weekly x4, monthly x2, or until compliance is achieved/ Issues will be reviewed during the monthly QAPI meeting and a Performance Improvement Pan will be developed as necessary.

******************** 411-087-0100 Physical Environment: Generally Refer to F584 ******************** 411-085-0310 Residents ' Rights: Generally Refer to F585 ******************** 411-086-0110 Nursing Services: Resident Care Refer to F676, F677 and F684 ******************** 411-086-0230 Activity Services Refer to F679 ******************** 411-086-0140 Nursing Services: Problem Resolution & Preventive Care Refer to F686 ******************** 411-086-0150 Nursing Services: Restorative Care Refer to F688 ******************** 411-086-0240 Social Services Refer to F699 and F740 ******************** 411-086-0250 Dietary Services Refer to F806 and F812 ********************

Based on interview and record review it was determined the facility failed to ensure cognitively impaired residents did not have access to excessively hot liquids for 1 of 3 sampled residents (#2) reviewed accidents and hazards. This failure resulted in Resident 1 sustaining a second-degree burn (partial thickness involving the first two layers of skin) to her/his thigh. Findings include: Resident 2 was admitted to the facility in 9/2022 with diagnoses including diabetes. A 11/13/23 progress note indicated Staff 9 (Agency CNA) notified Staff 2 (LPN) that Resident 2 spilled hot coffee on her/his lap. A 11/13/23 facility investigation revealed nursing staff took the coffee cart out of the kitchen prior to the coffee cooling to a safe temperature. Resident 2 was provided with coffee that was too hot (above 155 degrees). The resident was found by Staff 9 after she/he spilled the coffee in her/his lap. A 11/23/23 progress note indicated Resident 2 was assessed to have a second degree burn described as a large area of reddened skin noted to the right lateral thigh with several ruptured blisters with clear fluid drainage. The resident reported pain. On 7/22/24 at 11:02 AM and 7/24/24 at 12:36 PM Staff 7 (Dietary Aide) and Staff 8 (Cook) confirmed the coffee was brewed too hot to serve and was supposed to cool before it was served to residents. On 7/22/24 at 11:28 AM Staff 1 (Administrator) stated staff went into the kitchen and took the coffee cart out prior to the coffee cooling to a safe temperature on 11/13/23 which resulted in Resident 2 receiving a second-degree burn. Staff 1 stated there were no other incidents related to hot coffee temperatures since the 11/13/23 incident. Staff 1 stated the facility had already completed their own corrections. On 7/23/24 at 11:35 AM and 12:15 PM Staff 3 (CNA) and Staff 2 (LPN Resident Care Manager) stated coffee temperatures were not checked prior to Resident 2's incident. The deficient practice was determined to be past non-compliance as the facility self-identified this problem (on 11/13/23) and initiated a plan of correction that included: - Policy/procedure change related to coffee preparation. - audit for other potentially effected residents. - All staff education related to hot liquid safety. - audits of new process for distributing hot beverages to ensure completion. - coffee machine brew temperature lowered. These corrections were completed 11/16/23.

*************************************** OAR 411-086-0140 Nursing Services: Problem Resolution and Preventive Care Refer to F689 **************************************

Based on interview and record review it was determined the facility failed to follow the resident's plan of care for 1 of 1 sampled resident (#1) reviewed for falls. As a result, Resident 1 fell and suffered a subarachnoid hemorrhage (brain bleed), and placed all residents at risk for significant injury. Findings include: Resident 1 admitted to the facility in 11/2011 with diagnoses including heart failure and osteoporosis. The 1/7/24 Annual MDS revealed Resident 1 had moderate cognitive impairment. The 1/15/24 ADL Care Plan revealed Resident 1 required two person extensive assistance for bed mobility and two or more person assistance to transfer with the mechanical lift. The 3/19/24 Progress Notes revealed at 5:30 AM, Resident 1 fell out of bed, hit her/his head on the floor and assessed to have a bruise on her/his scalp. The floor mats were not in place at the time of the fall as they were removed in preparation for the upcoming mechanical lift transfer. At approximately 11:00 AM, the resident complained of increased neck and upper back pain, the provider was notified and the resident was transferred to the hospital for further evaluation. The resident returned to the facility around 10:00 PM. Staff 2's (CNA) 3/19/24 Written Statement indicated he placed the (lift) sling under the resident and rolled the resident to one side, he then began to walk to the other side of the bed to finish when the resident rolled over (out of bed) and hit her/his head on the floor. The 3/19/24 Facility Investigation revealed Staff 2 did not follow Resident 1's care plan. Staff 2 placed the mechanical lift sling under the resident independently, the resident rolled, fell out of the bed onto the floor and hit her/his head. Staff 2 did not utilize a second person for bed mobility in preparation for the resident's transfer out of bed. The 3/19/24 Hospital Records indicated Resident 1 sustained a minimal left parietal subarachnoid hemorrhage (small bleed to the left side of the brain) and a subcutaneous hematoma (bruise) over the left side of the skull. Additionally, the records revealed Resident 1 had left parietal chronic encephalomalacia of the left parietal lobe (long-term bone softening to the left side of the skull). Resident 1 was evaluated by the initial hospital and then transferred to a second hospital where she/he was observed in the intensive care unit. When the resident's code status was determined to be comfort measures only and Resident 1 was assessed to be stable, Resident 1 returned to the facility. The 3/22/24 facility records revealed the facility identified the deficient practice and instituted the following corrections: *Staff 2 was terminated from the facility. *All residents were evaluated by nursing and therapy staff to determine the need for two person assistance with bed mobility and transfers. *All clinical staff were educated on following the residents plan of care with emphasis on bed mobility and transfers. *The DNS initiated both visual and documentation audits related to following residents' care plans for bed mobility and transfers. Audits would review two to three residents, three times a week for one week and then once a week for four weeks. *Quality Assurance Team involved with correction of the identified deficiencies. *Corporate Office involved with audits and discussion of increase in night shift staffing. On 3/27/24 at 9:38 AM, Resident 1 stated a male CNA transferred her/him alone and she fell and hit her/his head. Resident 1 was unable to remember the details of the fall. On 3/27/24 at 10:15 AM, Staff 1 (Administrator) stated Staff 2 did not follow Resident 1's Care Plan for bed mobility and independently assisted Resident 1 with her/his bed mobility while he set up the sling for transfer. Staff 1 stated all aspects for past non-compliance were in place by 3/22/24. On 3/27/24 at 10:20 AM, Staff 1 was notified the incident on 3/19/24 was determined to qualify for the designation as past non-compliance as the facility identified the deficient practice and instituted corrections. Through staff interviews and record review, survey determined past non-compliance was corrected on 3/22/24 when the facility identified deficient practice, initiated corrections and completed staff education.

******************************** OAR 411-086-0140 - Nursing Services: Problem Resolution and Preventive Care Refer to F689 ********************************

Based on observations and interviews it was determined the facility failed to maintain a clean and homelike environment for 1 of 1 facility reviewed for environment. This placed residents at risk for living in an unkempt and along environment. Findings include: Observations of the facility's general environment and residents' rooms on 8/7/23 through 8/10/23 identified the following issues: -Room 102 had a large dirty spot on the floor in the center of the room and the edges of the flooring and the room's corners had a build-up of dirt. The floors under the lip of the closets and cabinets had a build-up of dirt and grime and the metal base of the sliding glass door had a build-up of dirt inside the base and along the edges of the floor. -Rooms 107, 126 and 127 had corners missing in the floor boards. -The flooring in room 106 had a build-up of dirt along the edges and in the corners. There was a large spill in the center of the room and missing flooring under the window. -Room 111 had missing portions of the blinds on the sliding glass door. The floors were dirty and the closets scraped up. There were areas of the wall which needed to be painted. -Room 112's wall, underneath the window, was scraped with black scuff marks for approximately eight feet in length. The closets were scraped and the paint was peeling. The floors were dirty especially along the floor edges and under the lip of the closet and counter area. The blinds were dirty and dusty. -Room 113 had brown smudges on the privacy curtains nearest the window. The floors were dirty, especially around the edges of the flooring, around the sliding glass door and under cabinets. The metal base of the sliding glass door had a build-up of dirt inside the base and along the edges of the floor. The blinds on the sliding glass door had a build-up of dust. -The floors in room 114 were dirty especially along the edges of the flooring and under the lip of the cabinets and counters. -The floors in room 115 were dirty especially along the edges and in the corners and the blinds had a build-up of dust. -Room 118 had large gouges on the wall near the headboard, the fan on the nightstand had a build-up of dust and the paint was scratched and peeling on the closet doors. -Room 124 had repairs that were started behind the bed and not completed. -Room 131 had a bad odor in the room. -Room 133's cabinet was scratched and had missing drawers. -The intermediate and long term care hallway flooring had many spills, dark spots and dirt along the floor edges. -There was torn flooring in the hallway outside of the storage closet near room 121. On 8/10/23 at 2:51 PM Staff 8 (Maintenance Director) stated work orders were submitted through the TELS (an electronic platform to notify maintenance of needed repairs) system or informally via verbal notification. Staff 8 stated he completed routine rounds and audits on a weekly basis. Staff 11 (Housekeeping Director) stated she completed weekly rounds to ensure rooms were clean and homelike. Staff 11 stated housekeeping staff cleaned each resident room on a daily basis. Staff 11 reported housekeeping staff deep cleaned empty rooms when a resident was discharged or moved and deep cleaned occupied rooms when there was an opportunity. A facility walk through was completed with Staff 8 and Staff 11. Staff 8 and Staff 11 both acknowledged the identified rooms were not clean or homelike, the rooms needed to be cleaned more thoroughly and the identified maintenance concerns needed to be repaired.

Corrective Action(s) for residents identified to have been affected Room 102, 107, 111, 113, 114, 115, 126, 127 entire floor was cleaned ensuring the corners, lip of the closets and cabinets were free from build up of dirt and grime. Room 106 flooring was patched. Room 111, 112, 118, 124, 133 cabinets and walls were cleaned and repaired. Room 113 privacy curtain was replaced and cleaned. Room 111, 112, 113 Blinds were cleaned to be free from dust. Room 113 Sliding glass door was cleaned to be free from build-up dirt inside the base and along the floor. Room 131 room was deep cleaned to help with resident odor. The ICF and LTC hallway flooring was cleaned of spills, dark spots and dirt along floor edges. The hallway near room 121 next to storage closet’s floor was repaired. Identified of residents with the potential to be affected The Director of Maintenance, Housekeeping Manager or designee will complete an audit of room floors, blinds, privacy curtain, walls, cabinets, sliding glass doors, edging and odor to identify any other rooms that need repair and cleanings. Measured to prevent recurrence: The Administrator or designee will re-educate the Housekeeping Manager and Maintenance Director on the requirement to keep resident rooms clean, homelike, and ensuring thorough cleaned and identifying any maintenance concerns to be repaired. The deep cleaning audit will be updated to address areas of concern. Measured to prevent recurrence: The Administrator or designee will audit cleanliness 2-3 resident room 3x week for 1 week, 1x week for 4 weeks, then then monthly 3 months. to ensure the cleaning schedule is being followed. Issues will be reviewed during the monthly QAPI meeting, and a Performance Improvement Plan will be developed as necessary. The Administrator is responsible for ensuring compliance.

Based on interview and record review it was determined the facility failed to ensure fall risk interventions were followed for 1 of 1 sampled resident (#13) reviewed for accidents. This resulted in Resident 13 sustaining wrist and leg fractures which placed residents at risk for falls and injuries. Findings include: Resident 13 was admitted to the facility in 2021 with diagnoses including chronic obstructive pulmonary disease (difficulty breathing), stroke and diabetes. Resident 13's Annual MDS dated 6/6/23 indicated the resident was moderately impaired in cognition and needed extensive assistance with ADLs. Resident 13's Care Plan dated 6/21/23 identified the resident was at risk for falls due to gait/balance problems. Interventions on the care plan included: extensive two-person assistance for bed mobility, staff were to anticipate the resident's needs, keep the call light and personal items within reach, the resident was to wear non-skid footwear and promptly respond to all requests for assistance. A FRI dated 6/29/23 indicated Resident 13 was provided care by Staff 6 (CNA) on 6/28/23 when a fall occurred. Staff 6 turned Resident 13 on her/his side for care and the resident rolled off the bed, onto her/his right side, onto the floor. Staff 6 stated she saw the resident roll off of the bed onto her/his right side onto the floor. Staff 6 indicated Resident 13 cut her/his lip open and complained of right wrist pain. Staff 5 (LPN) assessed the resident and the resident stated she/he did not want to go to the hospital. A 6/30/23 Alert Note indicated Resident 13 agreed to go to the hospital on 6/29/23. A hospital Inpatient Progress Note dated 7/3/23 revealed Resident 13 sustained a lip laceration, right wrist fracture and had a nondisplaced tibia (shinbone) fracture that was confirmed on a medical imaging scan. On 8/9/23 at 1:38 PM Staff 6 stated she recalled the incident on 6/28/23 when she was assisting Resident 13 with care. Staff 6 stated the incident happened very quickly and she provided care to Resident 13 alone many times. Staff 6 stated the resident had a visible injury to her bottom lip and her right arm was swollen. Staff 6 acknowledged Resident 13 required two-person extensive assistance with bed mobility at the time of the accident and the care plan was not followed. On 8/9/23 at 1:42 PM Staff 5 (LPN) stated Staff 6 did not follow Resident 13's 6/28/23 bed mobility care plan, which resulted in Resident 13's fall. On 8/10/23 at 12:14 PM Staff 3 (RNCM) stated Resident 13 required two-person extensive assistance for bed mobility at the time of the fall. Staff 3 stated the care plan was not followed and Staff 6 should have had a second person helping her. Staff 3 stated it was her expectation the care plans were always followed.

Corrective Action(s) for residents identified to have been affected Resident #13 was transferred to Legacy Emanual on 6/30/2023 to be evaluated by radiology. She sustained a fracture and returned to the facility. Corrective Action(s) for residents identified to have been affected DNS or Designee will audit Kardex and care plan for residents with 2-person extensive assist for bed mobility to ensure accuracy. Measured to prevent recurrence: DNS or designee will re-educate the CNA’s on how to review Kardex and follow the bed mobility care plan to prevent falls and what two person extensive assist for bed mobility means and expectation the care plan is to be followed. Monitor for Corrective Action: The DNS or designee will audit 2-3 residents that require 2 person extensive assist with bed mobility 3x week for 1 week, 1x week for 4 weeks, then then monthly 3 months. to ensure staff are following the care plan. The results of the audit will be reviewed during the monthly QAPI meeting, and a Performance Improvement Plan will be developed as necessary. The Director of Nursing is responsible for ensuring compliance.

Based on observation, interview and record review it was determined the facility failed to follow physician's orders for supplemental oxygen for 1 of 1 sampled resident (#21) reviewed for oxygen. This placed residents at risk for unmet respiratory needs. Findings include: Resident 21 was admitted to the facility in 2021 with diagnoses including acute respiratory failure. Physician Orders on 7/8/23 indicated Resident 21 required supplemental oxygen to be administered at 2 liters per minute (LPM) as needed for respiratory distress, shortness of breath, difficulty breathing or cyanosis (pale, blue, lips). On 8/7/23 at 2:28 PM, 8/8/23 at 11:40 AM, 8/8/23 at 3:57 PM and 8/9/23 at 2:27 PM Resident 21 was observed receiving supplemental oxygen between 3.5 LPM and 4 LPM. On 8/9/23 at 2:27 PM Staff 18 (LPN) reviewed Resident 21's oxygen orders, observed Resident 21's oxygen flow settings at 4 LPM and confirmed the resident was to receive oxygen at 2 LPM. On 8/10/23 at 1:35 PM Staff 19 (Regional RN) stated he expected the nurses to administer Resident 21's oxygen at 2 LPM per the physician's orders.

Corrective Action(s) for residents identified to have been affected Resident #21 oxygen flow setting was changed to 2LPM per the physician orders. Resident was assessed by LN staff with no adverse reaction. Corrective Action(s) for residents identified to have been affected DNS or Designee audited residents with oxygen orders to ensure oxygen flow setting is set to physical orders. Measured to prevent recurrence: DNS or designee will re-educate the LN and CNA staff of the expectation to follow physician oxygen orders and CNA to get assist from LN if flow rate is needed. Monitor for Corrective Action: The DNS or designee will audit 2-3 residents with o2 orders to ensure the phsycian order is being followed correctly 3x week for 1 week, 1x week for 4 weeks, then then monthly 3 months to ensure staff are following the care plan. The results of the audit will be reviewed during the monthly QAPI meeting, and a Performance Improvement Plan will be developed as necessary. The Director of Nursing is responsible for ensuring compliance.

Based on interview and record review it was determined the facility failed to ensure sufficient staffing to meet resident care needs for 1 of 1 facility reviewed for sufficient and competent staffing. This placed residents at risk for delayed and unmet care needs. Findings include: On 8/7/23 the facility had a census of 63 and provided a list of residents who: -Required one or two-person assistance with bathing: 19. -Were fully dependent for bathing: 31 -Required one or two-person assistance with dressing: 57. -Were fully dependent for dressing: 2. -Required one or two-person assistance with transfers: 32 -Were fully dependent for transfers: 17. -Required one or two-person assistance with toileting: 49. -Were fully dependent for toileting: 2. -Required one or two-person assistance with eating: 19. -Were fully dependent for eating: 1. -Were occasionally or frequently incontinent of bladder: 36. -Were occasionally or frequently incontinent of bowel: 27. -Had behavioral healthcare needs: 10. On 8/9/23 the facility provided a list of 19 residents who required a two-person mechanical lift for transfers. The 5/2023 and 6/2023 Resident Council Notes revealed resident concerns with long call light wait times. 1. Resident 57 was admitted to the facility in 2023 with diagnoses including diabetes and stroke. Resident 57's 5/29/23 Admission MDS indicated the resident was cognitively intact and required extensive assistance of two staff for transfers and toileting. On 8/8/23 at 9:36 AM Resident 57 stated call light response times were delayed up to over an hour so she/he took herself/himself to the bathroom without calling for staff help on many occasions. Resident 57 stated she/he often "teamed up" with her/his roommate to "get things done" instead of relying on staff to provide assistance. Resident 57's 7/26/23 through 8/9/23 call light tracking records indicated the following delayed call light response times: -Call light response times over 20 minutes: 7; -Call light response times over 50 minutes: 1; -Call light response times over one hour: 1. On 8/10/23 at 9:10 AM and 8/11/23 at 10:23 AM Staff 1 (Administrator) reported she was responsible for staffing. Staff 1 stated the facility frequently had many staff who called out on a daily basis which impacted the facility's staffing. She reported a reasonable call light response time was seven minutes. 2. Resident 61 was admitted to the facility in 2023 with diagnoses including necrotizing fasciitis (a flesh-eating bacterial infection). Resident 61's 7/5/23 Admission MDS indicated the resident was cognitively intact and required extensive assistance of one staff for transfers, toileting, dressing and personal hygiene. On 8/7/23 at 2:17 PM Resident 61 stated it often took a long time for CNA's to respond to her/his call light. Resident 61 stated she/he had a colostomy (a surgical procedure that redirects the colon to an opening in the abdomen) and sometimes the colostomy bag leaked feces which smelled and burned her/his skin. Resident 61 stated when she/he had to wait a long time to be cleaned up, she/he felt embarrassed. Resident 61's 7/26/23 through 8/9/23 call light tracking records indicated the following delayed call light response times: -Call light response times over 20 minutes: 15; -Call light response times over 30 minutes: 7; -Call light response times over 40 minutes: 2; -Call light response times over 50 minutes: 2; -Call light response times over one hour: 1. On 8/10/23 at 9:10 AM and 8/11/23 at 10:23 AM Staff 1 (Administrator) reported she was responsible for staffing. Staff 1 stated the facility frequently had many staff who called out on a daily basis which impacted the facility's staffing. She reported a reasonable call light response time was seven minutes. 3. Resident 25 was admitted to the facility in 2022 with diagnoses including chronic respiratory failure and anxiety. Resident 25's 7/7/23 Quarterly MDS indicated the resident was cognitively intact and required extensive assistance of one staff for bed mobility, dressing, toileting and personal hygiene. On 8/8/23 at 9:12 AM Resident 25 reported the facility was understaffed. The resident stated around shift change and meal times staff did not respond to her/his call light in a timely manner. Resident 25's 7/26/23 through 8/9/23 call light tracking records indicated the following delayed call light response times: -Call light response times over 20 minutes: 21; -Call light response times over 30 minutes: 8; -Call light response times over 40 minutes: 3; -Call light response times over 50 minutes: 1; -Call light response times over one hour: 1. On 8/10/23 at 9:10 AM and 8/11/23 at 10:23 AM Staff 1 (Administrator) reported she was responsible for staffing. Staff 1 stated the facility frequently had many staff who called out on a daily basis which impacted the facility's staffing. She reported a reasonable call light response time was seven minutes. 4. Resident 19 was admitted to the facility in 2022 with diagnoses including chronic cholecystitis (inflammation of the gallbladder) and anxiety. Resident 19's 8/6/23 Quarterly MDS indicated the resident was cognitively intact and required extensive assistance of one to two staff for bed mobility, toileting, personal hygiene and total assistance for bathing. On 8/7/23 at 10:23 AM Resident 19 stated answering call lights was not a priority at the facility. Resident 19 reported she/he often waited between 30 minutes to one hour for assistance. Resident 19's 7/26/23 through 8/9/23 call light tracking records indicated the following delayed call light response times: -Call light response times over 20 minutes: 14; -Call light response times over 30 minutes: 9; -Call light response times over 40 minutes: 2; -Call light response times over 50 minutes: 1; -Call light response times over one hour: 2. On 8/10/23 at 9:10 AM and 8/11/23 at 10:23 AM Staff 1 (Administrator) reported she was responsible for staffing. Staff 1 stated the facility frequently had many staff who called out on a daily basis which impacted the facility's staffing. She reported a reasonable call light response time was seven minutes. 5. Interviews with staff revealed the following concerns: -On 8/9/23 at 8:41 AM Staff 9 (CNA) reported staffing was a problem for at least the past month and a half. Staff 9 stated the section she worked in had residents with high acuity needs including at least 10 residents who required two-person mechanical lift transfers. She stated when the facility was short staffed she was unable to get all of the residents up who wanted to get up, was unable to turn residents every two hours and did not get her breaks or lunches. Staff 9 also stated there were many days when the facility was unable to meet the bariatric staffing requirements. -On 8/9/23 at 10:47 AM Staff 16 (CNA) reported that staffing was "horrible" for the past three months. Staff 16 stated many staff called out almost every day. Staff 16 stated the section she usually worked in had many residents who required two-person mechanical lift transfers. She stated when the facility was short staffed she was unable to spend adequate amounts of time with the residents, was unable to turn residents every two hours and call light response times were delayed. Staff 16 stated she was unable to consistently take breaks or lunches. -On 8/9/23 at 11:10 AM Staff 13 (CNA) reported the facility was short staffed CNAs on many days. Staff 13 reported staff frequently called out and she did not always get her breaks and lunches. -On 8/9/23 at 11:23 AM Staff 14 (CNA) stated there was a continued problem with staffing. Staff 14 stated when the facility was short staffed it was hard to answer call lights timely and residents became frustrated and angry because of the delays. -On 8/9/23 at 12:08 PM Staff 15 (CNA) stated staffing was "rough, very rough" almost every day. Staff 15 stated she often did not get breaks or lunches. Staff 15 stated occasionally a non-CNA staff member would help out on the floor but that did not happen very often. On 8/10/23 at 9:10 AM and 8/11/23 at 10:23 AM Staff 1 (Administrator) reported she was responsible for staffing. Staff 1 stated the facility frequently had many staff who called out on a daily basis which impacted the facility's staffing. She stated a reasonable call light response time was seven minutes.

Corrective Action(s) for residents identified to have been affected Resident #57, #61, #25, #19 were interviewed and not affected by long call light wait times. Corrective Action(s) for residents identified to have been affected The Administrator or Designee did a comprehensive review to identify staffing trends to address; this was done through resident interviews, staff interviews to include staff leadership for acuity contribution, call light response audits, and documentation review. The Administrator or Designee met with resident council to review focus areas identified, current and proposed solutions and gathered additional feedback from the council. Measured to prevent recurrence: Regional Director of Operations will review staffing trends and staffing expectations with the Administrator. The Administrator re-educated Staffing Coordinator on requirement to ensure adequate staffing to meet resident needs. The Administrator re-educated the leadership team and floor nurses on requirement to ensure adequate staffing to meet resident needs and what to do if additional staff is needed. The DNS or designee will review assignment sheet with CNA team to assure adequate communication for daily schedule is included. Monitor for Corrective Action: The Administrator or Designee will conduct random audits through resident interview, staff interview, documentation review, and/or observation to ensure adequate staffing is in place to meet resident care needs in a timely matter 3x week for 1 week, 1x week for 4 weeks, then then monthly 3 months. The results of the audit will be reviewed during the monthly QAPI meeting, and a Performance Improvement Plan will be developed as necessary. The Director of Nursing is responsible for ensuring compliance.

Based on interview and record review it was determined the facility failed to ensure residents were free from unnecessary medications for 1 of 6 sampled residents (#166) reviewed for medications. This placed residents at risk for adverse medication consequences. Findings include: Resident 166 was admitted to the facility in 5/2023 with diagnoses including diabetes and respiratory failure. Resident 166's 5/25/23 Admission physician orders indicated the resident was to receive one Bactrim (antibiotic) tablet every Monday, Wednesday and Friday while on Prednisone 20 mg a day or higher dose. Resident 166's 5/2023 and 6/2023 MARs revealed the resident received one Bactrim tablet three times a day every Monday, Wednesday and Friday from 5/26/23 through 6/2/23 which exceeded the prescribed dosage. Starting 6/5/23, Resident 166 received one Bactrim (one time a day) every Monday, Wednesday and Friday until she/he was discharged from the facility. Resident 166's 5/25/23 through 6/8/23 Progress Notes revealed the resident had no adverse medication consequences due to receiving excessive doses of Bactrim. On 8/10/23 at 11:51 AM Staff 3 (RNCM) reviewed Resident 166's 5/25/23 Admission orders and the 5/2023 and 6/2023 MARs. Staff 3 confirmed Resident 166 received two extra doses of Bactrim every Monday, Wednesday and Friday from 5/26/23 through 6/2/23. On 8/10/23 at 1:25 PM Staff 2 (DNS) stated admission orders were checked using a two nurse system. Staff 2 confirmed Resident 166 received unnecessary doses of Bactrim from 5/26/23 through 6/2/23 due to a transcription error which was not identified until 6/5/23. See F842.

Corrective Action(s) for residents identified to have been affected Resident #66 is no longer in the facility. Corrective Action(s) for residents identified to have been affected DNS or Designee will audit residents with antibiotic orders to ensure they were transcribed correctly. Measured to prevent recurrence: DNS or designee will re-educate the LN on the importance of transcribing orders correctly to avoid the risk for adverse medication consequences. The DNS or designee will re-educate the LN’s on using the two nurse check system for accuracy. Monitor for Corrective Action: The DNS or designee will audit physician orders for 2-3 new residents 3x week for 1 week, 1x week for 4 weeks, then then monthly 3 months. to ensure transcribing is done correctly. The results of the audit will be reviewed during the monthly QAPI meeting, and a Performance Improvement Plan will be developed as necessary. The Director of Nursing is responsible for ensuring compliance.

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: 1. On 8/7/23 at 9:05 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 container of fruit salad; -An open and undated bag of cheese slices; -Two containers of butter undated and not labeled; -A container of applesauce undated and not labeled; -A plastic bag of meat dated 4/27/23; -A plastic bag of shredded cheese not labeled or dated; -An open bag of sliced roast beef not sealed, with no opened date; -A plastic bag of boiled eggs not labeled or dated; -Multiple individual containers of salad dressing not labeled or dated; -A box of russet potatoes on the floor; -A plastic bag of sliced ham not labeled or dated; -A plastic bag of sliced meatloaf not labeled or dated; and -Poured drinks on a cart with plastic lids not labeled or dated. Dry storage room: -A box of onions on the floor; and -Two boxes of bread on the floor. On 8/7/23 at 9:07 AM Staff 7 (Dietary Aide) confirmed the identified items were not appropriately dated or stored. Staff 7 stated it was the facility's policy for food items to be labeled and dated immediately after initial use. On 8/9/23 at 9:15 AM Staff 4 (Dietary Manager) stated she checked the dates on stored foods every Saturday and it was her expectation all foods were labeled and dated daily after being opened or used. 2. On 8/7/23 at 9:45 AM the ice machine adjacent to the kitchen was observed to have a pink/brown substance on a plastic shield inside the machine. Condensation was observed dripping over the substance onto the ice. On 8/7/23 at 9:45 AM Staff 3 (RNCM) confirmed the existence of the pink/brown substance inside the ice machine. On 8/7/23 at 9:50 AM Staff 8 (Maintenance Director) stated the ice machine was cleaned every month. Staff 8 acknowledged the presence of the pink/brown substance and confirmed the ice machine should be free of any debris or contaminants.

Corrective Action(s) for residents identified to have been affected No residents were identified to be affected by failed food storage or ice machine. Corrective Action(s) for residents identified to have been affected The Administrator, Dietary Manager or designee will audit the foods in the fridge, freezer and dry storage room for appropriate dated and storage methods. As well as the cleanliness of the ice machine in the Main Dining room. The Maintenance Director or designee will thoroughly clean the ice machine and remove any pink/brown substances from inside the ice machine. Measured to prevent recurrence: The Administrator, Dietary Manager or designee will re-educate the dietary department on the importance of how to properly store food to avoid the risk for food-borne illness and contaminated food. The Administrator, Dietary Manager or designee will re-educate the dietary department on the policy on how to properly date, store, and label foods in the kitchen. The Administrator or designee will re-educate the maintenance department on cleanliness of the ice machine and ensuring there is no presence of debris or contaminants inside the machine. Monitor for Corrective Action: The Administrator or designee will audit the kitchen food storage process and cleanliness of ice machine weekly for 4 weeks, monthly x 2 months to ensure that the proper storage and cleanliness is being completed. The results of the audit will be reviewed during the monthly QAPI meeting, and a Performance Improvement Plan will be developed as necessary. The Administrator is responsible for ensuring compliance.

Based on interview and record review it was determined the facility failed to ensure records were accurate for 1 of 6 sampled residents (#166) reviewed for medications. This placed residents at risk for inaccurate medical records. Findings include: Resident 166 was admitted to the facility in 5/2023 with diagnoses including diabetes and respiratory failure. 1. Resident 166's 5/25/23 Admission physician orders indicated the resident was to receive one Bactrim (antibiotic) tablet every Monday, Wednesday and Friday while on Prednisone 20 mg a day or higher dose. Resident 166's 5/2023 facility signed physician orders indicated the resident was to receive one Bactrim tablet three times a day every Monday, Wednesday, Friday while on Prednisone 20 mg a day or higher dose. On 8/10/23 at 11:51 AM Staff 3 (RNCM) reviewed Resident 166's 5/25/23 Admission orders, the 5/2023 facility signed physician orders and the 5/2023 and 6/2023 MARs. Staff 3 confirmed Resident 166's Admission orders were inaccurately transcribed and instructed staff to administer Bactrim three times a day instead of one time a day as ordered. On 8/10/23 at 1:25 PM Staff 2 (DNS) stated admission orders were checked using a two nurse system. Staff 2 confirmed Resident 166's Admission order for Bactrim was inaccurately transcribed on the facility signed physician orders which resulted in the resident receiving excessive doses of Bactrim. 2. Resident 166's 5/25/23 Admission physician orders indicated the resident was to receive Milk of Magnesia (a laxative) as needed for no bowel movement in 48 hours. Resident 166's 5/2023 facility signed physician orders indicated the resident was to receive Milk of Magnesia as needed for no bowel movement in 72 hours. On 8/10/23 at 11:51 AM Staff 3 (RNCM) reviewed Resident 166's 5/25/23 Admission orders, the 5/2023 facility signed physician orders and the 5/2023 and 6/2023 MARs. Staff 3 confirmed Resident 166's Admission orders were inaccurately transcribed and should have instructed staff to administer Milk of Magnesia if no bowel movement in 48 hours instead of 72 hours. On 8/10/23 at 1:25 PM Staff 2 (DNS) stated admission orders were checked using a two nurse system. Staff 2 confirmed Resident 166's Admission order for Milk of Magnesia was inaccurately transcribed on the facility signed physician orders.

Corrective Action(s) for residents identified to have been affected Resident #66 is no longer in the facility. Corrective Action(s) for residents identified to have been affected DNS or Designee will audit residents with antibiotic orders and bowel medication to ensure they were transcribed correctly and have instructions on how to administer if no bowel movement appropriately. Measured to prevent recurrence: DNS or designee will re-educate the LN on the importance of transcribing orders correctly to avoid the risk for adverse medication consequences. The DNS or designee will re-educate the LN’s on using the two nurse check system for accuracy. Monitor for Corrective Action: The DNS or designee will audit physician orders for 2-3 new orders 3x week for 1 week, 1x week for 4 weeks, then then monthly 3 months. months to ensure transcribing is done correctly. The results of the audit will be reviewed during the monthly QAPI meeting, and a Performance Improvement Plan will be developed as necessary. The Director of Nursing is responsible for ensuring compliance.

Based on observation, interview and record review it was determined the facility failed to perform proper infection control practices for medical equipment and hand hygiene for 1 of 1 nurse reviewed during med pass. This placed residents at risk for infection and cross contamination. Findings include: The Centers for Disease Control and Prevention Best Practices for Assisted Blood Glucose Monitoring and Insulin Administration include: -Wear gloves during blood glucose monitoring and during any other procedure that involves potential exposure to blood or body fluids. -Perform hand hygiene immediately after removal of gloves and before touching other medical supplies intended for use on other persons. CDC's Guideline for Disinfection and Sterilization in Healthcare Facilities (2008) Medical equipment surfaces can become contaminated with infectious agents and contribute to the spread of health-care-associated infections. Noncritical medical equipment surfaces should be disinfected with an EPA-registered low- or intermediate-level disinfectant. Environmental surfaces (e.g., bedside table, medication carts) also could potentially contribute to cross-transmission by contamination of health-care personnel from hand contact with contaminated surfaces, medical equipment, or patients. The CDC's definition of Standard Precautions: In order to perform hand hygiene appropriately, soap, water, alcohol based hand rub, and a sink should be readily accessible in appropriate locations including but not limited to resident care areas, and food and medication preparation areas. Staff must perform hand hygiene (even if gloves are used): -Before and after contact with the resident; -Before performing an aseptic task; -After contact with blood, body fluids, visibly contaminated surfaces or after contact with objects in the resident's room; -After removing personal protective equipment (e.g., gloves, gown, facemask); -After using the restroom; and -Before meals. On 8/9/23 from 7:32 AM to 7:48 AM Staff 20 (LPN) was observed to administer insulin to Resident 35. Staff 20 donned gloves without prior hand hygiene, used the CBG monitoring device to check Resident 35's blood sugar using a lancet (a sharp needle). Staff 20 exited Resident 35's room with the CBG monitoring device and disinfected the device. Staff 20 laid the disinfected CBG monitoring device on the surface of the medication cart without disinfecting the cart or laying down a barrier. Staff 20 removed his gloves and did not perform hand hygiene. Staff 20 then obtained Resident 35's insulin pen and entered the resident's room. Staff 20 did not don gloves or perform hand hygiene prior to administering Resident 35's insulin. Staff 20 disinfected the site on Resident 35's abdomen with an alcohol swab, injected the insulin and wiped away the small blood droplet on Resident 35's abdomen without wearing gloves. On 8/9/23 at 7:45AM Staff 20 acknowledged he failed to perform hand hygiene, failed to disinfect the insulin preparation area of the medication cart and failed to wear gloves when he performed blood glucose monitoring which involved potential exposure to blood or body fluids. Staff 20 stated he was in a hurry and did not take the time to perform hand hygiene. On 8/10/23 at 1:35 PM Staff 19 (Regional RN) stated he expected staff to perform hand hygiene between residents and to wear gloves while performing blood glucose monitoring.

Corrective Action(s) for residents identified to have been affected No residents were identified. Corrective Action(s) for residents identified to have been affected The LN that was identified was re-educated on disinfecting glucometers and use of barriers. Measured to prevent recurrence: LN’s will be re-educated following the CBG checks and glucometer disinfection protocol. LN to demonstrate back to designee proper procedure. Monitor for Corrective Action: RCM or designee will observe random CBG checks and glucometer disinfection with nurse to ensure they are following the policy and procedure for blood sugar checks and disinfection 3x week for 1 week, 1x week for 4 weeks, then then monthly 3 months. The observations will be brought to QAPI for review. The Director of Nursing is responsible for ensuring compliance.

Based on interview and record review it was determined the facility failed to ensure the state minimum bariatric CNA staffing ratios were maintained for 15 of 38 days reviewed for staffing. This placed residents at risk for delayed treatment and unmet care needs. Findings include: On 8/7/23 the facility had three residents approved for the bariatric rate. A review of the Direct Care Staff Daily Reports from 7/1/23 through 8/7/23 revealed the following days when the state minimum bariatric CNA staffing ratios were not met for one or more shifts: -7/2, 7/3, 7/6, 7/9, 7/14, 7/15, 7/16, 7/19, 7/23, 7/24, 7/26, 7/27, 7/28, 8/3 and 8/7. On 8/10/23 at 9:10 AM Staff 1 (Administrator) stated she was responsible for staffing and confirmed the facility failed to meet state minimum bariatric CNA staffing ratios on the identified dates.

Corrective Action(s) for residents identified to have been affected. No residents were identified as being affected from cited deficiency. Corrective Action(s) for residents identified to have been affected The Administrator or designee will review the last 2 weeks of staffing for minimum bariatric staffing levels and identify any concerns or trends. Measured to prevent recurrence: The Administrator will re-educate the staffing coordinator on the current bariatric staffing regulations and the importance of utilizing all options for find coverage and to notify Administrator if minimums are not being met. Monitor for Corrective Action: The Administrator or designee will conduct random audits for minimum bariatric staffing level compliance 3x week for 1 week, 1x week for 4 weeks, then then monthly 3 months. The observations will be brought to QAPI for review. The Administrator is responsible for ensuring compliance.

******************** OAR 411-087-0100 Physical Environment: Generally Refer to F-584. ******************** OAR 411-086-0140 Nursing Services: Problem Resolution and Preventive Care Refer to F-689 and F-757. ******************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F-695. ******************** OAR 411-086-0100 Nursing Services: Staffing Refer to F-725. ******************** OAR 411-086-0250 Dietary Services Refer to F-812. ******************** OAR 411-086-0300 Clinical Records Refer to F-842. ******************** OAR 411-086-0330 Infection Control and Universal Precautions Refer to F-880. ********************

Based on interview and record review it was determined the facility failed to provide a copy of the resident's medical record for 1 of 3 sampled residents (#2) reviewed for medical records. This placed residents and families at risk for the inability to access medical records. Findings include: Resident 2 re-admitted to the facility on 2/14/23 with diagnoses including Stage IV cancer. Review of Resident 2's medical record revealed a 3/7/23 record request signed by both the resident and a family member. There was no evidence in the medical record this request was fulfilled. On 4/11/23 Staff 1 (Administrator) verified the facility did not fulfill Resident 2's record request.

Resident #2 no longer resides at Center. Administrator or Designee reviewed requests for medical records that last 2 weeks. Administrator or Designee re-educated center IDT team on the resident and their legal representatives have the right to access personal and medical records pertaining to the resident. The Administrator or Designee will do random audits on medical records request for compliance weekly x 2 weeks then monthly x 3 months. The Administrator or Designee will report the results of these audits at the facility monthly Quality Assurance meeting for 60 days or until substantial compliance has been achieved as determined by the committee. The Administrator is responsible for ensuring compliance.

1.

Based on interview and record review it was determined the facility failed to monitor and assess Resident 7 after a fall and failed to recognize and treat a change of condition for 1 of 3 sampled residents (#7) reviewed for medications. This failure was determined to be an immediate jeopardy situation because the facility failed to recognize a change of condition which likely resulted in Resident 7's severe health status change and hospitalization. Findings include: The facility's Accident/Incident Policy and Procedure, revised 10/2022, directed staff to complete an incident investigation was to be completed for the following reasons but not limited to: falls with or with out injury, witnessed or unwitnessed; medication errors - if there was a negative effect on the resident or potential risk of harm. Incident reports were to be completed by the charge nurse at the time of the incident. Resident 7 admitted to the facility on 12/30/22 with diagnosis including convulsions (sudden, violent, irregular movement of limb or body). Resident 7's 12/30/22 Physician Order directed staff to administer medications, which included the following: -clobazam (sedative to treat convulsions), 10 mg tablet, two times a day for convulsions. -divalproex sodium extended release of 24 hours (anticonvulsant), 750 mg, two times a day for convulsions. Record review of the 12/30/22 through 1/2/23 MARs revealed Resident 7 was not administered her/his clobazam five times and divalproex sodium two times. Resident 7's 12/30/22 Admission Nursing Database Assessment indicated she/he was alert, orient to person, place and time and confused. Resident 7 had clear speech with the ability to express ideas and wants. A progress note on 1/2/23 at 1:47 AM by Staff 6 (LPN) revealed on 1/1/23 at 6:20 PM during the nurse hand over shift meeting, he received communication from Staff 5 (RN) that Resident 7 experienced an unwitnessed fall at 4:45 PM. Resident 7 was non-responsive for about 20 minutes. The resident later woke up and started to talk. Neuro checks (neurological and motor skill assessments) were in place. As the night unfolded, she/he was alert, oriented to self and situation, hand grips were moderately strong, pupils reactive, and vital signs taken. Her/his lungs were clear, and no shortness of breath observed. Resident 7 was able to communicate her/his needs. On 1/2/23 at 12:30 AM the CNA assigned to Resident 7's room yelled for help. Staff 6 rushed to the room and found Resident 7 lying on the bed non-responsive as foam came out of her/his mouth. Staff extended her/his neck to open the airway, started CPR, Staff 6 asked one of the CNAs to call 911 and a second nurse to bring the crash cart (emergency life sustaining equipment). Staff suctioned the resident while two people continued CPR. Ten minutes later a team six (emergency) medical personnel arrived and took over Resident 7's care. CPR continued for another fifteen minutes as the IV medication ran and then transferred Resident 7 to the hospital. On 1/2/23 at 5:02 AM Staff 5 initiated an incident fall form for Resident 7 for the fall on 1/1/23 at 4:45 PM. The 5:07 AM progress notes was linked to the report which stated the CNA went to room to help roommate, Resident 7 self-transferred to the bathroom and the CNA heard the fall. The CNA alerted this nurse and assisted Resident 7 back to bed. Neuro checks initiated, PERRLA (pupils equal, round, reactive to light and accommodation), grips equal (hand grips), and feet push and pull were equal. On 1/9/23 an investigation by Staff 1 (Administrator) concluded Resident 7 missed five doses of clobazam and two doses of divalproex sodium between 12/30/22 through 1/1/23. The investigation indicated Resident 7 had an unwitnessed fall on 1/1/23 at 6:20 PM and on 1/2/23 at 12:30 AM. Included was a witness statement from Staff 5 completed on 1/8/23. The investigation was focused on the missed medication and not the fall which occurred on 1/1/23 at 4:45 PM. Record review of the Nero check form indicated neuro checks were initiated on 1/1/23 at 4:45 PM. The form directed staff to complete assessments every 15 minutes for four times, then every 30 minutes for four times, then every hour for four times, then every four hours for four times and then every shift for 72 hours. The Neuro check form indicated several blood pressure measurements out of range, as high as 197/95 (normal range for Resident 7 should have been close to 139/68) at 6:00 PM. The form ended with neuro check information at 8:30 PM. No further neuro checks were documented as completed. Record review did not have any additional assessments of Resident 7 or attempts to notify the medical provider for altered mental status after the fall on 1/1/23 at 4:45 PM. The incident report was initiated the following day, after Resident 7 discharged. Review of Resident 7's medical record revealed no evidence of comprehensive nursing assessments, identification of potential harm or risks related to the significant medication errors at the time of the incidents. Hospital Records dated 1/2/23 revealed Resident 7 was found unresponsive at the facility. Emergency Medical Services (EMS) reported the resident was asystole (heart stopped beating) when they arrived at the facility. EMS intubated the resident and brought her/him to the emergency department (ED). Multiple ED notes indicated Resident 7 received ongoing treatments and tests to rule out the cardiac failure. [There were no notes indicating the hospital was aware the resident missed several doses of seizure medications.] On 4/9/23 at 4:09 PM Staff 5 confirmed he wrote a statement on 1/8/23 for the investigation about missed medications and the fall which occurred on 1/1/23 at 4:45 PM. He stated and confirmed Resident 7 was "out of it, mostly non-responsive, for 15-20 minutes" but started to talk and "came back after the time passed". Staff 5 stated he called the on-call doctor and did not get a return call. He stated he was unsure if he had notified the doctor Resident 7 missed doses of the medications prescribed for convulsions. Staff 5 was unsure if the resident hit her/his head during the unwitnessed fall. Staff 5 acknowledged he could send a resident to the hospital if it was urgent, without a doctors order. On 4/9/23 at 4:37 PM Staff 6 confirmed Resident 7 missed doses of clobazam and divalproex sodium. Staff 6 confirmed his progress note on 1/2/23 and the statement that Resident 7 was unresponsive for 20 minutes after the fall and stated the resident was out of it mentally. No contact with the physician was made during his shift and no additional assessments were completed. Staff 6 acknowledged he was not required to have physician permission to send a resident to the hospital if it was urgent. On 4/10/23 at 5:33 AM Staff 7 (CNA) stated he was aware Resident 7 fell on the evening shift on 1/1/23. Staff 7 stated there was no documentation of the fall, he knew Resident 7 was a fall risk and she/he was a bit off her/his base line and slept quit a bit during his shift. Staff 7 checked on Resident 7 repeatedly until he found her/him lying in bed with legs hung off the side of the bed, foam came out of the resident's mouth and was she/he was unresponsive. Staff 7 proceeded to alert the LPN and initiate CPR. On 4/10/23 at 12:03 PM Staff 8 (CNA) stated she was in Resident 7's room when she heard a thud in the bathroom. Staff 8 went to check and found Resident 7 lying face down on the bathroom floor and it looked like she/he hit her/his head. Staff 8 received help from the charge nurse (Staff 5) to assist Resident 7 back to bed. Staff 8 stated Resident 7 had an altered mental status post fall. Staff 8 stated the resident did gain some alertness after 20 minutes but never returned to her/his pre-fall baseline. Staff 8 took Resident 7's vitals through out her shift, stated the vitals were high and she reported them to the charge nurse. Staff 8 stated she had spoken with the resident earlier about many things and the resident was very detail oriented in her/his stories. Resident 7 ate dinner and did talk a little more after dinner but was not back to her/his normal. Staff 8 stated she reported her observations of the resident's changes to the charge nurse through out her shift until 10:00 PM. Staff 8 stated the charge nurse replied to her that he did not know the resident and her/his baseline. On 4/10/23 at 1:06 PM Staff 2 (DNS) stated she expected if a resident had an unwitnessed fall or if it was known the resident hit their head, then neuro checks would be initiated, and completed as it states on the form for the timelines. Staff 2 expected alert charting every shift after a fall and if the resident experienced a change of mental status, call the doctor to report the change and send the resident out to the hospital if they were unable to get direction from the doctor about the change of condition. On 4/10/23 at 4:20 PM the facility was notified of the Immediate Jeopardy (IJ) situation and an immediacy removal plan was requested. On 4/10/23 at 6:08 PM the facility submitted an acceptable immediacy removal plan which would abate the IJ situation. The immediacy removal plan included the following: -Resident 7 no longer in the facility. -Review residents in the last week by 4/10/23 with a change of condition for appropriate assessment/monitoring/notification. -Educate nurses on Change of Condition monitoring to include comprehensive assessment, monitoring and notification of medical provider. If there is no response from on call physician, the Medical Director will be contacted directly. -Audit resident within system for change of condition for assessment, monitoring and notification daily for one week, weekly for three weeks and monthly for three months. -Results of the audits would be reviewed by the QAPI (Quality Assurance and Performance Improvement) team for further review. On 4/11/23 staff interviews verified re-education per the immediacy removal plan was competed. A review of facility documentation revealed all aspects of the immediacy removal plan was implemented. On 4/11/23 at 10:21 AM it was determined the IJ immediacy was removed. , 2. Based on interview and record review it was determined the facility failed to provide wound care monitoring and treatment for 1 of 2 sampled residents (#18) reviewed for wound VAC's (Vacuum Assisted Closure of a wound). This placed residents at risk of worsening of wounds. Findings include: Resident 18 admitted to the facility on 1/7/22 with diagnoses including right toe cellulitis (skin infection), cutaneous (skin) abscess of right foot and diabetes. The 1/7/22 Admission Database (nursing assessment) revealed Resident 18 had a wound VAC to the right lower extremity. The 1/7/22 Admission orders did not include wound VAC care, monitoring and treatment orders. The 1/7/22 Hospital Records revealed Resident 18 had a surgical right foot wound debridement to the bone and used negative pressure wound therapy. The wound VAC was maintained at 125 mmHg (mm of mercury). The 1/10/22 Skin Wound Evaluation indicated it was the first assessment of the wound. The January 2022 TARs revealed no wound VAC care, monitoring or treatment was in place until 1/10/22. The 2/6/22 Facility Investigation indicated the nurses neglected to ensure the wound VAC functioned properly the first two days of admission to the facility. The 2/9/22 facility documentation revealed the resident was admitted on Friday evening (1/7/22) with orders for a wound VAC. The dressing was observed by the admitting RN who assumed the dressing was attached to the VAC. The documentation further revealed no nurse checked to ensure the VAC was set up correctly and functioned properly until day shift on the following Monday (1/10/22). On 4/14/23 at 9:05 AM Staff 1 (Administrator) verifed Resident 18 did not have wound VAC orders on admission and the wound VAC was not properly monitored or cared for until 1/10/22.

Resident #7 and #18 no longer reside at the center. The DNS or Designee reviewed residents in the last week by 4/10/2023 with a change of condition for appropriate assessment/monitoring/notification. The DNS or Designee reviewed current residents with wound vac orders to ensure the correct monitoring and treatment was provided. The DNS or Designee educated nurses on Change of Condition monitoring to include comprehensive assessment, monitoring and notification of medical provider. If there is no response from on-call physician, the Medical Director will be contacted directly. The DNS or Designee re-educate nurses on wound vacs and steps to take for residents admitting with a wound vac that included ensuring the wound vac is set up correctly, functioning properly and there are orders in place for treatment and monitoring. The DNS or Designee will audit residents within Managing Acute Clinical Changes Meeting for change of condition for assessment, monitoring, and notification daily for 1 week, weekly for 3 weeks and monthly for 3 months. The DNS or Designee will audit new admissions with wound vac orders for compliance weekly x 2 weeks then monthly x 3 months. The DNS or Designee will report the results of these audits at the facility monthly Quality Assurance meeting for 60 days or until substantial compliance has been achieved as determined by the committee. The Director of Nursing is responsible for ensuring compliance.

Based on interview and record review it was determined the facility failed to comprehensively assess pressure ulcers upon admission and readmission to the facility for 2 of 3 sampled residents (#s 2 and 13) reviewed for pressure ulcers. This placed residents at risk for a delay in wound treatment. Findings include: 1. Resident 2 admitted to the facility in 2022 with diagnoses including Stage IV Cancer. a. The 1/21/23 Progress Note revealed Resident 2 had an 8 cm round open area to the left buttock. Both Resident 2's family and physician were informed. The 1/25/23 initial wound consultant evaluation revealed Resident 2 had a left medial buttock Stage III pressure ulcer (full-thickness loss of skin). Review of Resident 2's medical record revealed Resident 2 did not have a comprehensive pressure ulcer assessment completed from the time it was first observed on 1/21/23 until the 1/25/23 wound consultant visit. On 4/11/23 at 12:44 PM Staff 2 (DNS) verified the pressure ulcer identified on 1/21/22 was not comprehensively assessed until 1/25/23. b. The 2/14/23 Entry MDS indicated Resident 2 re-admitted to the facility from the hospital. The 2/14/23 SNF (Skilled Nursing Facility) Skin evaluation revealed Resident 2 had a Stage II pressure ulcer (partial-thickness loss of skin with exposed dermis) to the sacrum. The wound assessment did not have measurements, a description of the wound bed, or if drainage, odor or pain was present. [The wound was incorrectly staged as a Stage II and a comprehensive assessment was not completed.] The 2/15/23 Wound Consultant Evaluation revealed a comprehensive assessment of the left medial buttock Stage III (full-thickness loss of skin) pressure ulcer was completed. On 4/11/23 at 12:44 PM and 1:08 PM Staff 2 (DNS) verified the Stage III pressure ulcer was misidentified as a Stage II on 2/14/23 and verified the wound was not comprehensively assessed until 2/15/23. 2. Resident 13 admitted to the facility on 3/7/23 with diagnoses including a Stage III sacral pressure ulcer (full-thickness loss of skin) and left and right hip unstageable pressure ulcers (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough (non-viable yellow, tan, gray, green or brown tissue) or eschar (dead or devitalized tissue)). The 3/7/23 Admission Nursing Database indicated Resident 13 had three pressure ulcers. A comprehensive assessment of the three wounds was not completed. The 3/8/23 initial wound assessment completed by the wound consultant revealed the following wounds: * Wound one was an unstageable pressure ulcer to the sacrum. * Wound two was an unstageable pressure ulcer to the right ischium (hip). * Wound three was an unstageable pressure ulcer to the left ischium. The assessment further stated Resident 13's wound healing was guarded, may be delayed was at a high risk for complications and current and future wounds may be unavoidable due to her/his comorbidities which impaired wound healing. On 4/12/23 at 8:23 AM Staff 2 (DNS) verified the three pressure wounds were not comprehensively assessed until the wound consult assessed the wounds the day after admission to the facility (3/8/23).

Resident # 2 no longer resides at center. Resident #13 comprehensive wound assessment was completed 3/8/2023. The DNS or Designee audited current residents with wound care verifying a comprehensive wound assessment was completed, addressing concerns identified. The DNS or Designee re-educated LNs on assessing wounds the day of admission with admits/readmits to avoid delay in wound treatment. The DNS or Designee will audit new admissions/re-admissions with wounds for comprehensive assessment compliance weekly x 2 weeks then monthly x 3 months. The DNS or Designee will report the results of these audits at the facility monthly Quality Assurance meeting for 60 days or until substantial compliance has been achieved as determined by the committee. The Director of Nursing is responsible for ensuring compliance.

Based on interview and record review it was determined the facility failed to ensure a resident's dietary meal remained free from accident hazards for 1 of 1 sampled resident (#3) reviewed for accidents. This placed residents at risk for choking hazards. Findings include: Resident 3 was admitted to the facility in 6/2022 with diagnoses including pulmonary embolism (blood clot in the artery of the lung). Resident 3's Diet Order last revised as of 6/8/22 indicated a heart healthy diet which included the absence of pre-packaged, processed, canned, or fatty meays, dairy products, and pastries. On 4/4/23 at 11:56 AM Resident 3 stated he/she discovered a two-inch-long, two-inch-wide piece of parchment paper in her/his food while taking a bite of tortellini. Resident 3 stated after pulling the object out of her/his mouth they discovered their lunch tray had pieces of parchment paper in their meal. On 4/5/23 at 11:32 AM Staff 12 confirmed the presence of parchment paper in Resident 3's food. Staff 12 indicated a new kitchen manager had placed a sheet of parchment paper underneath the tortellini to prevent burning it. The food then was then placed on the residents tray with the parchment paper attached to it. On 4/14/23 at 11:11 AM Staff 1 (Administrator) verified findings and acknowledged the resident received food that contained a potential choking hazard.

Resident #3 was assessed with no adverse effects noted to parchment paper found in food. The DNS or Designee reviewed current residents within MACC, addressing concerns identified. The Dietary Manager or Designee re-educated dietary department the importance of visually monitoring food while serving for anything that should not be present on resident trays and ensuring meal trays are free from any choking hazards including parchment paper. The Administrator or designee will conduct random audits on meal trays ensuring they are free from choking hazards weekly x 2 weeks then monthly x 3 months. The Administrator or Designee will report the results of these audits at the facility monthly Quality Assurance meeting for 60 days or until substantial compliance has been achieved as determined by the committee. The Administrator is responsible for ensuring compliance.

Based on interview and record review it was determined the facility failed to ensure there were sufficient qualified staff available to provide care and meet the residents' needs for 1 of 3 sampled residents (#2) reviewed for call lights. This placed residents at risk for unmet care needs. Findings include. Resident 2 admitted to the facility in 2022 with diagnoses including Stage IV Cancer. The resident discharged on 3/7/23. On 3/8/23 a public complaint was received which reported Resident 2 waited 30 or more minutes for the call light to be answered and to receive toileting assistance multiple times a week. The January 2022 and February 2022 Resident Council Notes revealed resident concerns with long call light wait times. Review of Resident 2's Call light Log from 2/1/23 through 3/7/23 revealed 25 calls with call light wait times from 20 minutes up to 1 hour, 31 minutes. On 4/11/23 at 2:33 PM Staff 1 (Administrator) acknowledged Resident 2 had 25 occurrences with call light wait times over 20 minutes and further stated Resident 2 had 17 occurrences with call light wait times over 30 minutes.

Resident # 2 is no longer in the facility. The Administrator or Designee conducted a review of the last 7 days call light response times for current residents, addressing concerns / trends identified. The Administrator or Designee re-educated the staff on the importance of answering call lights timely. The Administrator or Designee re-educated the Staffing Coordinator, leadership team and floor nurses on requirement to ensure adequate staffing to meet resident needs and what to do if additional staff is needed to answer call lights timely. The Administrator or Designee will conduct random audits through resident interview call light response time review for adequate staffing weekly x 2 weeks then monthly x 3 months. The Administrator or Designee will report the results of these audits at the facility monthly Quality Assurance meeting for 60 days or until substantial compliance has been achieved as determined by the committee. The Administrator is responsible for ensuring compliance.

Based on interview and record review it was determined the facility failed to administer prescribed medications to residents for 1 of 3 sampled residents (#7) reviewed for medications. This failure was determined to be an immediate jeopardy situation because the facility failed to follow Resident 7's physician orders and obtain medications which likely resulted in Resident 7's severe change of condition and hospitalization. Findings include: The National Institutes of Health indicated the following: -Depakote [name brand for divalproex sodium], revised 2/2023. Do not stop taking without consulting a healthcare provider. Stopping suddenly can cause serious problems. Stopping a seizure medicine suddenly...can cause seizures. - Clobazam, revised 2/2023. Do not suddenly stop taking Clobazam. Stopping suddenly can cause serious and life-threatening side effects, including, unusual movements, responses, or expressions, seizures, sudden and severe mental or nervous system changes, depression, seeing or hearing things that others do not see or hear, an extreme increase in activity or talking, losing touch with reality, and suicidal thoughts or actions. Call your healthcare provider or go to the nearest hospital emergency room right away if you get any of these symptoms. Resident 7 admitted to the facility on 12/30/22 with diagnosis including convulsions (sudden, violent, irregular movement of limb or body) and type 2 diabetes. Resident 7's 12/30/22 Physician Order directed staff to administer medications which included the following: -clobazam (sedative to treat convulsions), 10 mg tablet, two times a day for convulsions. -divalproex sodium extended release of 24 hours (anticonvulsant), 750 mg, two times a day for convulsions. -Levocarnitine (helps body use certain chemicals), 330 mg tablet, two times a day related to carnitine levels. -Novolog injection solution (insulin), 100 unit, sliding scale for diabetes. -Novolog Flex pen injector (insulin), inject 15 units with meals for held nutritional insulin and per sliding scale. Record review of the 12/30/22 through 1/2/23 MARs revealed the MAR chart codes indicated a medication marked as NA meant the medication was not available. Resident 7's MARs revealed the chart code of NA for the following medications: -12/30/22: clobazam in PM; Levocarnitine in PM; Novolog injection solution at 11:30 AM and 4:30 PM; Novolog Flex pen injector at 12:00 PM. -12/31/22: clobazam in AM/PM; Levocarnitine in AM/PM; and divalproex sodium in AM/PM. -1/1/23: clobazam in AM/PM. Record review of Resident 7's progress notes between 12/30/22 to 1/2/23 indicated staff contacted the pharmacy about the missing medications which were not delivered. Hospital Records dated 1/2/23 revealed Resident 7 was found unresponsive at the facility. Emergency Medical Services (EMS) reported the resident was asystole (heart stopped beating) when they arrived at the facility. EMS intubated the resident and brought her/him to the emergency department (ED). Multiple ED notes indicated Resident 7 received treatments and tests to rule out the cardiac failure. [There were no notes indicating the hospital was aware the resident missed several doses of seizure medications.] On 1/9/23 an investigation by Staff 1 (Administrator) concluded Resident 7 missed five doses of clobazam and two doses of divalproex sodium between 12/30/22 to 1/1/23. On 4/9/23 at 4:09 PM Staff 5 (RN) confirmed he wrote a statement for the investigation about medications. He confirmed he attempted to get the clobazam and divalproex sodium medications from the pharmacy for Resident 7 who had missed multiple doses. For the doses given of divalproex sodium, he used other means to obtain the divalproex sodium medication for Resident 7 other than it being delivered from the pharmacy for Resident 7. Staff 5 reported, although the current pharmacy delivery of resident's medications had improved, there are times when medications were not delivered timely as ordered by physician. On 4/9/23 at 4:37 PM Staff 6 (LPN) confirmed Resident 7 missed doses of clobazam and divalproex sodium due to the pharmacy not delivering the medications. Staff 6 stated the late delivery of medications was still an issue for residents. On 4/10/23 at 9:45 AM Staff 10 (CMA) confirmed the pharmacy continued to not send prescribed medications upon admission. On 4/10/23 at 12:40 PM Staff 4 (LPN/Resident Care Manager) confirmed she was aware Resident 7 missed medications due the pharmacy not sending the medications. On 4/10/23 at 12:52 PM Staff 1 confirmed her investigation with Resident 7 missed medications due to pharmacy not delivering the medications. Staff 1 believed the issue was resolved. On 4/10/23 at 4:20 PM the facility was notified of the Immediate Jeopardy (IJ) situation and a plan of care was requested. On 4/10/23 at 6:08 PM the facility submitted an acceptable immediacy removal plan which would abate the IJ situation. The immediacy removal plan included the following: -Resident 7 no longer in the facility. -Review new admissions in the last week by 4/10/23 to ensure pharmacy needs were met. -Educate nurse to order medications, to ensure every effort to ensure medications were available, pull medication from the storage unit for medications and how to pull from emergency kit. -Educate to notify DNS or Administrator if medications were not available in the medication storage unit. -Audit two to three new admissions weekly for three weeks and monthly for three weeks. -Audit narcotics to ensure the facility had enough medications to last the weekend. -A facility Performance Improvement Plan in place to address the issue. -Results of the audits would be reviewed by the QAPI (Quality Assurance and Performance Improvement) team for further review. On 4/11/23 staff interviews verified re-education per the immediacy removal plan was competed. A review of facility documentation revealed all aspects of the immediacy removal plan was implemented. On 4/11/23 at 10:21 AM it was determined the IJ immediacy was removed.

Resident #7 is no longer a resident in the facility. Review new admissions in the last week by 4/10/2023 to ensure pharmacy services are met and delivered timely. Educate nurses on ordering and receiving medications timely. DNS or designee will monitor that every effort is made to ensure medications are available as ordered: defining quantities of meds on hand to trigger re-ordering of medications; ordering new prescriptions; medications available to pull from medication storage unit (Cubex); calling provider for one time order for medication to pull from emergency kit as needed. Educate nurses to notify DNS or Administrator if medications are not delivered for new admits and are not available in Cubex and to continue to call until they receive instructions/assistance. The pharmacy has agreed, all new admission medications will be sent to the facility stat moving forward unless the med is available in the Cubex. Facility now has standing agreement with pharmacy that regardless of insurance coverage, during the week a 3-day supply of new medications is to be sent and, on the weekends, a 5-day supply is to be sent regardless of specific written approval or not. Audit of 2-3 new admissions weekly for 3 weeks and monthly for 3 months Review narcotics at the end of the week to ensure the facility has enough medications to last through the weekend. A facility Performance Improvement Plan is in place to address the issue. Results of the audits to be reviewed by the QAPI (Quality Assurance and Performance Improvement) team.

Based on observation and interview, it was determined the facility failed to provide sufficient dietary staff to effectively carry out functions of food service for 1 of 2 meals observed for meal times. This placed residents at risk for unmet nutritional needs and food at improper temperatures. Findings include: On 4/4/23 an observation of the lunch meal tray pass was completed. On 4/4/23 at 12:25 PM observation of the kitchen with the presence of Staff 1 (Administrator) showed two dietary staff members prepping trays for lunch service. Staff 1 confirmed dietary staff were delayed passing meal trays due to short staffing in the kitchen. On 4/4/23 at 12:40 PM Staff 12 (Cook) stated lunch was served late due to short staffing and confirmed only two dietary staff including himself working today. Staff 12 pointed to three meal tray carts still needing to be prepped and delivered to the nursing staff for resident delivery. On 4/4/223 at 12:46 PM observations of care staff continuing to pass trays, revealed Resident 4 recieved her/his meal tray. Resident 4 confirmed meal trays were consistently delivered late. On 4/4/23 at 1:00 PM observed Resident 3's meal tray was delivered to the resident. Resident 3 indicated meal trays were delivered late. On 4/4/23 at 1:05 PM one resident was observed to sit in her/his doorway asking where her/his food was. On 4/4/23 at 1:15 PM Staff 13 (LPN) stated meals were frequently an hour or more late which impacted the diabetic residents because she had to administer their insulin. Staff 13 stated one time the dinner meal was not served before the end of her shift which was a problem because it was her responsibility to administer the insulin. Staff 13 further stated two dietary workers was not enough to get the resident meal trays out on time. On 4/4/23 at 1:22 PM last meal tray was observed passed. On 4/14/23 at 11:11 AM Staff 1 (Administrator) verified findings and acknowledged the resident received meal trays late due to insufficient dietary staff.

The Administrator or Designee did a comprehensive review of each meal pass, identifying and addressing trends/concerns. The Administrator or Designee re-educated the Dietary Manager on the requirement to provide sufficient staff to effectively carry out functions of food service, timely meal pass. The Dietary Manager will ensure there is adequate dietary staff to visually monitor trays while serving food. The Administrator or Designee will do random audits via observation and/or staff/resident interview on meal pass compliance weekly x 3 weeks then monthly x 2 months. The Administrator or Designee will report the results of these audits at the facility monthly Quality Assurance meeting for 60 days or until substantial compliance has been achieved as determined by the committee. The Administrator is responsible for ensuring compliance.

**************************************** OAR 411-085-0310 Residents' Rights: Generally Refer to F550 and F573 **************************************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F684 ***************************************** OAR 411-086-0140 Nursing Services: Problem Resolution and Preventive Care Refer to F686 and F689 ***************************************** OAR 411-086-0100 Nursing Services: Staffing Refer to F725 ***************************************** OAR 411-086-0260 Pharmaceutical Services Refer to F755 ***************************************** OAR 411-086-0250 Dietary Services Refer to F802 *****************************************

Based on interview and record review, it was determined the facility failed to assess a surgical wound for 1 of 3 sampled residents (#10) reviewed for wound care. This placed other residents at risk for lack of wound care. Findings include: The facility's Skin at Risk/Skin Breakdown policy, revised 9/2020, stated "Within 8 hours of admission, a licensed nurse examines the resident's entire body to determine if skin impairment is present. Upon admission, skin at risk and any actual skin impairment is identified on the comprehensive care plan with interventions based on risk level identified. A full body skin evaluation is completed weekly by the licensed nurse. Completion of the skin audit is documented." Resident 10 admitted to the facility on 10/29/22 with diagnoses including fractures of the left femur (upper thigh bone), left tibia (lower large leg bone), left fibula (lower small leg bone) and traumatic compartment syndrome (a painful medical condition with muscle pressure reaching dangerous levels) of the lower left leg. Hospital discharge orders dated 10/29/22 indicated the facility was to contact the orthopaedic surgeon for any signs of infection on the resident's surgical wounds and to not start antibiotics prior to contacting the surgeon's office. The facility's "SNF Admission Nursing Database" form was completed by Staff 16 (RN) on 10/29/22 at 1:42 PM. The 'Skin' section, which includes the number of wounds observed, description of the resident's skin status (number of staples, sutures, etc.) was not completed. Resident 10's initial care plan, dated 10/29/22 did not address any wound care related to her/his surgical wounds. Resident 10's most recent comprehensive MDS, dated 11/4/22 revealed a BIMS score of 15 which indicated no cognitive impairment. Progress/nursing notes reviewed from 10/29/22 through 11/24/22 revealed nursing staff and providers had examined the wound but had not taken measurements, completed skin grid sheets or completed the skin assessment evaluation. On 11/23/22, a Skin-Wound Evaluation was completed by Staff 21 (RCM) with the notation "this is the first assessment of the wound." In an interview with Resident 10 on 12/8/22 at 2:39 PM, she/he stated the facility did not begin wound care until after she/he was sent to the hospital on 11/24/22. In an interview with Staff 3 (RCM) on 12/11/22 at 3:08 PM, Staff 3 confirmed Resident 10 should have had a full skin assessment on admission to the facility and weekly thereafter. In an interview with Staff 2 (DNS) on 12/15/22 at 2:30 PM, she confirmed Resident 10 had not received a skin assessment until 11/23/22. On 12/16/22 at 1:00 PM, Staff 1 (Administrator) and Staff 2 (DNS) were notified of the investigation's findings and acknowledged the resident had not received a timely skin assessment.

Resident #10 wound and treatment plan were reviewed and care plan updated Residents with wounds could potentially be affected. DNS or Designee reviewed new admissions for the last 30 days verifying skin assessment upon admission was completed, addressing concerns identified. DNS or Designee identified current resident with wounds verifying weekly skin assessments are being completed, addressing concerns identified. The DNS or Designee re-educated licensed nurses on the requirement to complete skin assessment upon admission. RCMs were re-educated on auditing new admissions for skin assessment completion within MACC meeting and verifying wound rounds are completed weekly on residents with wounds. The DNS or Designee will audit new admissions for skin assessment upon admission compliance weekly x 4 weeks then monthly x 2 months. The DNS or Designee will audit residents with wounds for weekly wound round compliance weekly x 4 weeks then monthly x 2 months. The DNS or Designee will report the results of these audits at the facility monthly Quality Assurance meeting for 60 days or until substantial compliance has been achieved or sustained as determined by the committee. The DNS is responsible to ensure compliance.

Based on observation, interview and record review, it was determined the facility failed to ensure residents received pain medication as ordered for 1 of 3 sampled residents (#10) reviewed for medication. As a result, Resident 10 experienced severe, unrelenting pain for several hours on 10/29/22 and 12/10/22. Findings include: The facility's Pain Management policy and procedure form, revised 10/2022, revealed "the resident is evaluated every shift for signs and symptoms of pain, receiving pain management according to the Preliminary Plan of Care and/or physician order. This data is collected on the MAR, in the interdisciplinary progress notes and through the MACC (Managing Acute Condition Change) process." Resident 10 admitted to the facility on 10/29/22 with diagnoses including fractures of the left femur (upper thigh bone), left tibia (lower large leg bone), left fibula (lower small leg bone) and traumatic compartment syndrome (a painful medical condition with muscle pressure reaching dangerous levels) of the lower left leg. Resident 10's care plan, dated 10/29/22 revealed she/he was care planned for pain management. Interventions implemented were to administer medication as ordered, anticipate the resident's need for pain relief and respond immediately to any complaints of pain and to monitor/record/report to the nurse any complaints of pain or requests for pain treatment. Resident 10's most recent comprehensive MDS, dated 11/4/22 revealed a BIMS score of 15 which indicated no cognitive impairment. Physician Orders for 10/29/22 revealed orders to administer up to 8 mg of Hydromorphone (Dilaudid) every three hours PRN for pain. The facility completed a pain assessment with Resident 10 during the admission process on 10/29/22. The highest acceptable pain level given by the resident was "5" on a 1-10 scale, with 1 being no pain and 10 being severe pain. The 10/2022 MAR revealed on 10/29/22, Resident 10 was not administered pain medication until 10:00 PM. The time of the administration order was 3:30 PM. Nursing/progress notes reviewed for 10/29/22 revealed Resident 10 was admitted to the facility at 1:40 PM and Dilaudid was first administered at 10:00 PM. The facility's "Weights and Vitals Summary" revealed three pain assessments for Resident 10 on 10/29/22 with the first pain level recorded as "0" at 3:34 PM, the second pain level recorded as "10" at 9:55 PM and the third pain level recorded as "9" at 10:00 PM. In an interview with Resident 10 on 12/8/22 at 2:39 PM, she/he stated she/he arrived at the facility on 10/29/22 around 2:00 PM. She/he stated initially there was no pain in her/his left leg as she/he was given Dilaudid before discharging from the hospital. Resident 10 recalled as the afternoon went on, the surgical wounds on her/his lower left leg started to hurt to the point she/he felt her/his leg was "shattered." She/he requested pain medication from staff multiple times and was told the medication was not available. Resident 10 stated she/he was unable to eat dinner due to the pain, she/he felt it was the worst pain she/he had ever experienced and rated it as a "definite 10" on a 1-10 scale, with 1 being no pain to 10 being severe, unmanageable pain. Resident 10 stated facility staff told her/him no available pain medication was a common issue in facilities and the medication would be delivered on the night delivery. Resident 10 recalled a nurse telling her/him about "some type of safe the medication was in, but I don't know if they had the code." Resident 10 stated she/he called the hospital she/he had discharged from requesting re-admission but was told to stay at the facility since the medication was en route from the pharmacy. In a phone interview with Resident 10 on 12/12/22 at 9:00 AM, Resident 10 stated the facility ran out of her/his pain medication on 12/10/22, which caused in her/him to experience severe pain for several hours. A nursing note written by Staff 16 (RN) on 12/10/22 at 5:12 PM revealed "this nurse notified by medication aide that she was giving last dose of Hydromorphone (Dilaudid) at 2:00 PM. Pharmacy contacted to ensure order was current and able to pull from Cubex." A nursing note written by Staff 3 (RCM) on 12/11/22 at 12:42 AM revealed "this RCM called pharmacy related to Dilaudid out. Pharmacy informed this RCM it is too soon and insurance would not cover. RCM gave permission to bill facility and stat Dilaudid medication." A nursing note written by Staff 23 (LPN) on 12/11/22 at 1:08 AM revealed "CNA notified this LN that resident is requesting pain medication...this LN went into resident's room and explained to resident that pharmacy already notified and will deliver STAT which is between 2 -4 hours from the time the other LN made the call around midnight. Resident started cussing and yelling 'I want my pain meds now.' We will reapproach resident once she/he's calm." The facility's "Weights and Vitals Summary" did not reflect any pain levels recorded on 12/10/22 after 5:41 PM. Pain levels were recorded on 12/11/22 at 2:25 AM as "8." A nursing note written by Staff 23 revealed the Dilaudid was administered to Resident 10 at 2:25 AM. In an interview with Staff 22 (Director of Pharmacy Services) on 12/14/22 at 12:47 PM he stated the facility had two regularly scheduled pharmacy deliveries daily which were 2:00 PM and 9:00 PM. He stated the resident's pain medication delivery had been ordered for the night delivery on 10/29/22 at 4:50 PM. Staff 22 stated it was common for nursing facilities to have pain medications such as Dilaudid, morphine and hydrocodone in the Cubex (emergency medication kit used to dispense commonly used medications) for situations like new admissions that required medications prior to pharmacy delivery or if a scheduled narcotic prescription ran out. Staff 22 confirmed the facility had Dilaudid in the Cubex at the time of Resident 10's admission and noted there was a physician's order to administer one dose of the Dilaudid on 10/29/22 at 3:30 PM. Staff 22 stated pharmacy records indicated the Dilaudid was delivered as a "stat" delivery to the facility on 10/29/22 at 10:34 PM and was signed as delivered to by Staff 18 (LPN). He further stated on 12/10/22, the pharmacy was contacted by the facility, a new prescription was requested as well as a new code to dispense an emergency dose of Dilaudid. Staff 22 stated the pharmacy could not approve a new code for an emergency dose due to federal guidelines and the the pharmacy required a new physician's order, which could have been a verbal or faxed order. The pharmacy did not receive any orders from the facility's provider. In an interview with Staff 18 on 12/14/22 at 2:43 PM, she stated she worked at the facility on 10/29/22 from 6:30 PM to 6:30 AM. At the begining of her shift, Staff 16 (RN) told her Resident 10 was getting the medication through the Cubex. Throughout Staff 18's shift she recalled Resident 10 told Staff 18 she/he was very painful. Staff 18 stated she contacted the pharmacy but was on hold three hours. Staff 18 stated she was unable to pull the pain medication from the Cubex because she was agency/pool staff, did not have the codes required to pull the medication and only full time facility staff had the codes. Staff 18 confirmed the pain medication was not delivered to the facility until after 10:00 PM and she immediately administered the maximum ordered dose to the resident. Staff 18 stated she did not contact the facility's provider to request a new order. In an interview with Staff 3 (RCM) on 12/14/22 at 3:08 PM, she confirmed the facility had an emergency kit on site when Resident 10 was admitted to the facility. Staff 3 confirmed that agency or pool nurses were not given the codes to the emergency kit and the expectation was that a full time staff would have to access the emergency kit. She confirmed the facility ran out of the Dilaudid prescription on 12/10/22 at 2:00 PM. Staff 3 stated she was not aware a new order could have been called in to the pharmacy by the provider to dispense an emergency dose from the emergency kit. In an interview with Staff 2 (DNS) on 12/15/22 at 2:30 PM, she confirmed Resident 10 had not received her/his pain medication timely on 10/29/22 or 12/10/22. Staff 1 (Administrator) was notified of the findings of this investigation on 12/16/22 at 1:00 PM and provided no further information.

Resident #10 pain medication administration was reviewed for the last 7 days, new pain assessment was completed with resident and care plan updated Residents prescribed pain medication could be potentially affected. DNS or Designee identified residents with pain and reviewed their pain medication administration records, addressing concerns identified The DNS or Designee re-educated the LNs and medications aids on the importance of administering pain medication as ordered and ensure complaints of pain are responded to timely. Education also included steps to take if medication is not available or if there are Cubex access issues. Agency staff are either entered into the Cubex by the pharmacy prior to shift OR they are paired with a nurse on that shift that has access to the Cubex. Licensed staff, both in house an agency as they come in to work, are alerted to contact the Director of Nursing or the Administrator if they have Cubex access problems. The DNS or Designee will review pain medication administration records within MACC x 1 week then weekly x 2 weeks then monthly x 2 months. The DNS or Designee will report the results of these audits at the facility monthly Quality Assurance meeting for 60 days or until substantial compliance has been achieved or sustained as determined by the committee. The DNS is responsible to ensure compliance.

Based on interview and record review, it was determined the facility failed to meet the dietary needs for 1 of 3 sampled residents (#10) reviewed for food preferences. This placed residents at risk for limited food choices. Findings include: The facility's Food and Nutrition Services policy, reviewed in 2017 stated "residents have the right to choose what they eat and where it comes from." Resident 10 admitted to the facility on 10/29/22 with diagnoses including fractures of the left femur (upper thigh bone), left tibia (lower large leg bone), left fibula (lower small leg bone) and traumatic compartment syndrome (a painful medical condition with muscle pressure reaching dangerous levels) of the lower left leg. Resident 10's most recent comprehensive MDS, dated 11/4/22 revealed a BIMS score of 15 which indicated no cognitive impairment. On 11/7/22, Resident 10 met with Staff 20 (Dietary Manager) and completed the Food and Nutrition Admission Interview. On the section titled "What foods don't you like to eat" Staff 20 documented cooked carrots as a food disliked by Resident 10. On 12/8/22, Resident 10 was served cooked carrots on her/his dinner tray. In an interview with Resident 10 on 12/13/22 at 11:53 AM, she/he stated she/he had talked to facility staff about her/his dislike of cooked carrots and had previously met with Staff 20 to discuss food preferences. Resident 10 stated she/he sent her/his tray back several times when carrots were served prior to 12/8/22. Resident 10 acknowledged on 12/8/22 she/he became angry when she/he saw the carrots on the dinner tray, went to the kitchen and yelled at the kitchen staff. Resident 10 stated as a result of that incident, facility management changed her/his care plan to reflect two staff to be in her/his room at all times. On 12/13/22 at 12:48 PM, Staff 20 confirmed he was aware of Resident 10's dietary preferences and had completed the Food and Nutrition Assessment with Resident 10 on 11/7/22. He stated he highlighted the area on the dietary slip that indicated no carrots but the dietary staff had not read the slips. Staff 20 confirmed Resident 10 had previously complained about carrots being served to her/him. Staff 20 stated he talked to kitchen staff about reading the dietary slips in order to prevent further occurrences. Staff 20 confirmed residents had the right to make their own food choices. On 12/16/22 at 1:00 PM, Staff 1 (Administrator) was notified of the investigation's findings and provided no further information.

Resident #10 food preferences were reviewed, tray ticket and care plan updated. Residents with food preferences have the potential to be affected. Dietary Manager or Designee auditing tray pass compared to tray ticket for food preference compliance, addressing concerns identified. The Administrator or Designee re-educated Dietary Manager and Dietary staff on the importance of honoring food preferences as outlined on the tray ticket. The Dietary Manager or Designee will do random audits of meal tray compared to tray ticket for food preference compliance weekly x 4 weeks then monthly x 2 months. The Administrator or Designee will report the results of these audits at the facility monthly Quality Assurance meeting for 60 days or until substantial compliance has been achieved or sustained as determined by the committee. The Administrator is responsible to ensure compliance.

Based on interview and record review it was determined the facility failed to ensure state minimum staffing ratios were maintained for 20 out of 48 shifts reviewed for staffing. This placed residents at risk for delayed treatment and unmet care needs. Findings include: A review of the Direct Care Staff Daily Reports from 10/1/22 through 11/30/22 revealed the following days and shifts when state minimum staffing ratios were not met: 10/8/22 - night shift. 10/16/22 - day and night shifts. 10/19/22 - evening and nights shifts. 10/31/22 - evening shift left blank. 11/6/22 - day shift left blank. 11/12/22 - evening shift. 11/18/22 - night shift. 11/19/22 - day shift. 11/20/22 - day shift. 11/21/22 - day shift. 11/24/22 - evening and night shift. 11/25/22 - evening shift. 11/26/22 - day and evening shift. 11/27/22 - day shift. 11/28/22 - day and evening shift. On 12/16/22 at 1:00 PM, Staff 1 (Administrator) and Staff 2 (DNS) were notified of the identified dates the facility was staffed below the CNA staffing ratios and provided no further information.

No residents were identified as being affected. The Administrator reviewed the last week of staffing for compliance, identifying and addressing trends and/or concerns. The Administrator re-educated Staffing Coordinator on CNA Staffing Ratios. Facility will utilize our emergency staffing plan when there is possibility of falling under mandated staffing ratio. The Administrator re-educated leadership team and floor nurses on CNA staffing ratios and Emergency Staffing Plan. The Administrator or Designee will audit staffing for OR CNA Staffing ratio compliance weekly x 4 then monthly x 2 months. The Administrator or Designee will report the results of these audits at the facility monthly Quality Assurance meeting for 60 days or until substantial compliance has been achieved or sustained as determined by the committee. The Administrator is responsible to ensure compliance.

******************** OAR 411-086-0110 - Nursing Services: Resident Care Refer to F684 ******************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F697 ******************** OAR 411-086-0250 - Dietary Services Refer to F800 ********************* OAR 411-086-0100 (5): Minimum CNA Staffing Refer to M183

Based on interview and record review it was determined the facility failed to ensure staff spoke to residents in a dignified and respectful manner for 1 of 3 sampled residents (#1) reviewed for abuse. This placed residents at risk for an undignified experience. Findings include: Resident 1 was admitted to the facility in 6/2020 with diagnoses including incomplete quadriplegia (partial paralysis of the arms and legs). Resident 1's 1/4/22 Quarterly MDS indicated the resident was cognitively intact. Resident 1's current Care Plan revealed a behavior monitor focus which indicated the resident had a history of acute mental changes with threatening behaviors, abusive language, rejection of care, yelling, screaming and false accusations. The care plan included interventions such as a respectful and responsible approach and reflective listening. The 1/15/22 facility Risk Management Incident Report indicated Staff 9 became upset, acted scary, and cursed and yelled at Resident 1 in response to Resident 1's comment. Resident 1 told Staff 9 she looked tired because she was out of breath and sweating. Staff 9 misheard the comment and thought Resident 1 said she should retire. The report indicated Staff 9 returned to Resident 1's room and apologized and Resident 1 allowed Staff 9 to provide care for the remainder of the shift. The 1/17/22 Facility Reported Incident Form indicated the facility administration was notified on 1/15/22 at 10:00 AM of an allegation of mistreatment between Staff 9 (Former CNA) and Resident 1. On 8/23/22 at 3:06 PM Resident 1 stated in 1/2022 Staff 9 came into her/his room, "bouncing off the walls," knocked stuff over and looked real tired. Resident 1 stated he jokingly told Staff 9 she needed a break and looked tired. Resident 1 stated Staff 9 "freaked out," yelled at her/him and then left the room. Resident 1 stated Staff 9 returned to her/his room with her/his permission, the two talked and she provided care for the remainder of the shift. Resident 1 stated she/he felt safe during and after the incident. On 8/25/22 at 12:25 PM Staff 9 stated in 1/2022 she was assigned to care for Resident 1 and she recalled the incident. Staff 9 stated she finished providing care for Resident 1 and was tidying up the resident's room. Staff 9 stated at the time, she was overweight, had a hard time breathing and was sweating. Staff 9 stated Resident 1 was disrespectfully and rudely bossing her to pick things up in her/his room and demanded she look under his bed for an item. Staff 9 stated while she was bent over looking under the bed, Resident 1 made a comment and smirked. Staff 9 said she responded by yelling at the resident and then left the room. Staff 9 stated she told Staff 10 what happened, then returned to Resident 1's room and apologized. On 8/25/22 at 2:09 PM Staff 10 (LPN) stated she overheard the verbal interaction between Staff 9 and Resident 1. Staff 10 stated she heard Staff 9 yell at Resident 1 using a condescending tone. Staff 10 stated Staff 9 yelled, "Don't talk to me that way, I am not a piece of crap, I am a caregiver." Staff 10 stated she did not hear Staff 9 threaten Resident 1's safety. Staff 10 stated she immediately walked towards Resident 1's room when she observed Staff 9 leaving the room and crying. Staff 10 stated she spoke to Resident 1 immediately after the incident and Resident 1 said she/he was "ok" and the interaction was "wild." On 8/26/22 at 2:38 PM Staff 1 (Administrator) stated it was determined Staff 9 spoke to Resident 1 in a disrespectful and unacceptable manner, and as a result, Staff 9 was terminated.

Staff #9 is no longer employed by the facility. Resident # 1 has been interviewed and feels he/she is safe and faced no retaliation from the incident. The Director of Nursing or Designee reviewed grievances for the last 30 days for instances of residents being treated with lack of dignity and respect, no other instances identified. Staff have been re-in serviced on treating residents with respect and dignity. The in service was provided by the Administrator and Staff Dev Coordinator and how to speak to residents in a dignified and respectful manner. The Director of Nursing or Designee will review incidents within MACC meeting for escalating behaviors and review notes and conduct interviews if necessary to assure staff use the techniques to handle residents with dignity and respect. This will be done weekly x 2 weeks, then 1 incident a month x 3 months to assure techniques and learned interventions are utilized appropriately. The Administrator or Designee will report the results of these audits at the facility monthly Quality Assurance meeting for 60 days or until substantial compliance has been achieved as determined by the committee. The Administrator is responsible to ensure compliance.

Based on interview and record review it was determined the facility failed to maintain adequate staffing and answer call lights timely to ensure residents were not left soiled for extended periods of time for 1 of 3 sampled residents (#4) reviewed for incontinence care. This placed residents at risk for delayed care and unmet needs. Findings include: Resident 4 was admitted to the facility in 7/2022 with diagnoses including COVID-19. Resident 4's 7/29/22 Admission MDS indicated the resident had adequate vision, was moderately cognitively impaired, was incontinent of bowel and bladder and required extensive assistance with ADLs. On 8/26/22 at 9:09 AM Resident 4 stated she/he was incontinent of bowel and bladder and required staff assistance for incontinent care. Resident 4 stated she/he was able to read the clock on her/his wall, waited extended periods of time for staff to respond to her/his call light after an incontinent episode and often remained in a soiled brief for 45 minutes to up to three hours. Review of Resident 4's toileting bladder and bowel tasks revealed the following instances when no documentation was found to indicate incontinent care was provided: - 7/22/22 night shift; - 7/25/22 day shift; - 7/26/22 night shift; - 7/28/22 evening shift; - 7/29/22 night shift; - 7/30/22 night shift; - 8/1/22 day, evening and night shifts. Review of the 7/2022 and 8/2022 Direct Care Daily Staffing Reports revealed the following when state minimum CNA staffing requirements were not met: - 7/2/22 night shift short one CNA; - 7/3/22 night shift short one CNA; - 7/4/22 night shift short one CNA; - 7/5/22 day shift short one CNA and evening shift short one CNA; - 7/9/22 day shift short two CNAs and evening shift short one CNA; - 7/10/22 day shift short two CNA and night shift short one CNA; - 7/12/22 night shift short one CNA; - 7/16/22 day shift short three CNAs; - 7/17/22 evening shift short one CNA; - 7/19/22 evening shift short one CNA; - 7/20/22 day shift short two CNAs and evening shift short one CNA; - 7/26/22 evening shift two CNAs and night shift short one CNA; - 7/28/22 day shift short one CNA; - 7/31/22 night shift short one CNA; - 8/1/22 night shift short one CNA; - 8/2/22 night shift short one CNA; - 8/3/22 evening shift short .5 CNA; - 8/8/22 evening shift short one CNA; - 8/11/22 evening shift short .5 CNA; - 8/16/22 evening shift short three CNAs; - 8/17/22 evening shift short one CNA; - 8/18/22 evening shift short one CNA; - 8/20/22 evening shift short .5 CNA; - 8/22/22 day shift short one CNA; - 8/23/22 evening shift short one CNA. Review of Resident 4's call light records from 7/22/22 thorough 8/6/22 revealed 48 incidents when it took over 20 minutes for staff to respond: 7/22/22 - 5:06 PM: call light answered in 24 minutes; - 9:38 PM call light answered in 33 minutes; - 11:50 PM call light answered in 33 minutes. 7/23/22 - 10:36 AM call light answered in 44 minutes; - 11:39 AM call light answered in 41 minutes; - 3:26 PM call light answered in 26 minutes; - 5:39 PM call light answered in 25 minutes; - 9:45 PM call light answered in 41 minutes. 7/24/22 - 7:46 AM call light answered in 21 minutes. 7/25/22 - 12:32 AM call light answered in 45 minutes; - 8:57 AM call light answered in 36 minutes; - 11:09 AM call light answered in 26 minutes; - 12:40 PM call light answered in 28 minutes; - 2:00 PM call light answered in 38 minutes; - 6:36 PM call light answered in one hour and 3 minutes. 7/26/22 - 1:03 AM call light answered in 42 minutes; - 3:07 AM call light answered in 49 minutes; - 1:46 PM call light answered in 44 minutes; - 3:14 PM call light answered in 46 minutes; - 6:32 PM call light answered in 23 minutes; - 8:15 PM call light answered in 50 minutes; - 9:37 PM call light answered in 58 minutes. 7/27/22 - 5:24 AM call light answered in 58 minutes; - 6:30 AM call light answered in 39 minutes; - 1:34 PM call light answered in 32 minutes; - 5:21 PM call light answered in 26 minutes; - 6:04 PM call light answered in 28 minutes; - 7:30 PM call light answered in 31 minutes. 7/28/22 - 8:18 AM call light answered in 29 minutes; - 11:12 AM call light answered in 23 minutes; - 1:41 PM call light answered in 51 minutes; - 3:30 PM call light answered in 31 minutes; - 6:43 PM call light answered in 51 minutes. 7/29/22 - 4:38 PM call light answered in 26 minutes. 7/30/22 - 3:30 PM call light answered in 23 minutes; - 11:22 AM call light answered in 33 minutes; - 8:06 PM call light answered in 45 minutes; - 9:48 PM call light answered in 36 minutes. 7/31/22 - 6:51 PM call light answered in 50 minutes; - 11:16 PM call light answered in 41 minutes. 8/1/22 - 6:48 PM call light answered in 55 minutes. 8/2/22 - 5:16 PM call light answered in 41 minutes; - 8:23 PM call light answered in 27 minutes. 8/3/22 - 1:54 PM call light answered in 45 minutes; - 11:47 PM call light answered in 28 minutes. 8/5/22 - 8:54 PM call light answered in 21 minutes; - 1148 PM call light answered in 24 minutes. 8/6/22 - 4:02 PM call light answered in 26 minutes. On 8/26/22 at 2:25 PM Staff 12 (CNA) stated the facility was often short staffed for CNAs and at times, Resident 4 waited up to 40 minutes in a soiled brief. On 8/29/22 at 2:42 PM Staff 1 (Administrator) was notified of the findings of this investigation. Staff 1 stated staffing was a struggle at times and stated a reasonable and timely call light response was 15 minutes.

Resident #4 is no longer in the facility The Administrator or Designee did a comprehensive review to identify staffing trends to address; this was done through resident interviews, staff interviews, call light response audits, and documentation review. The Administrator or Designee met with resident council to review focus areas identified, current and proposed solutions and gathered additional feedback from the council. The Administrator re-educated Staffing Coordinator on requirement to ensure adequate staffing to meet resident needs. The Administrator re-educated leadership team and floor nurses on requirement to ensure adequate staffing to meet resident needs and what to do if additional staff is needed. The Administrator or Designee will conduct random audits through resident interview, staff interview, documentation review, and/or observation to ensure adequate staffing is in place to meet resident care needs in a timely matter weekly x 3 weeks then monthly x 2 months. The Director of Nursing or Designee will report the results of these audits at the facility monthly Quality Assurance meeting for 60 days or until substantial compliance has been achieved as determined by the committee. The Administrator is responsible to ensure compliance.

*********************************** OAR 411-085-0310 Residents' Rights: Generally Refer to F550 *********************************** OAR 411-086-0100 Nursing Services: Staffing Refer to F725 ***********************************

Based on observation, interview and record review it was determined the facility failed to revise care plans related to activities and urinary care for 2 of 2 sampled residents (#s 16 and 42) reviewed for activities and catheter care. This placed residents at risk for outdated care plans. Findings include: 1. Resident 42 admitted to the facility in 2020 with diagnoses including neurogenic bladder (lack of bladder control due to spinal cord problems). A 1/7/22 physician order indicated the resident's foley catheter (a flexible tube inserted through the urethra to the bladder to drain urine) was removed. A 2/14/22 order instructed staff to straight catheterize (use a straight thin tube intermittently to drain urine) the resident every six hours. A review of Resident 42's care plan revealed the bladder care area was last updated on 1/21/21 and indicated the resident had a foley catheter and staff were to check routinely to be sure the bag was draining and tubing was not kinked. A review of the resident's Urinary Tasks from 4/18/22 through 5/18/22 revealed the following: -four times the task was not rated due to "condom catheter" -two times the task was not rated due to "indwelling catheter" Observations were made of the resident between 5/17/22 and 5/25/22 and there was no foley catheter present. On 5/19/22 at 11:57 AM Staff 19 (CNA) reported she looked at the care plan for resident specific care. She stated the resident had a foley catheter for a long time but no longer had one. She reported the nurses straight catheterized the resident. On 5/23/22 at 12:57 PM Staff 18 (CNA) stated she viewed the care plan to know what care to provide to residents. She reported Resident 42 had a foley catheter. On 5/23/22 at 3:23 PM Staff 4 (Resident Care Manager) reported care plans were updated with changes when they occurred. She stated Resident 42 had the foley catheter removed "about three to five months" ago. Staff 4 Stated the care plan should have been updated to reflect the change to use of the straight catheter. , 2. Resident 16 admitted to the facility in 2/2022 with diagnoses including diabetes and depression. The 2/22/22 Admission MDS revealed Resident 16 was very interested in going outside and not very interested in group activities. The assessment was completed by Staff 13 (Activities). The 3/1/22 Activities Initial Interview revealed Resident 16 was currently satisfied with her/his level of activity and staff would continue to monitor through weekly visits three times per week. The 3/22/22 updated care plan revealed Resident 16 did not wish to participate in activities, she/he was able to direct her/his own activities and staff were to remind her/him of group activities. On 5/17/22 at 10:19 AM Resident 16 was observed in bed with no television on and stated she/he wanted to go outside. Resident 16 stated she/he was provided an activity calendar with group activities but it was not helpful because of her/his disability. On 5/17/22 at 1:23 PM and 5/18/22 at 4:54 PM Staff 13 stated she relied on CNAs to get residents up for group activities and acknowledged Resident 16 was not very responsive to group activities when she/he attended. When told about Resident 16's interest to be outside Staff 13 did not recall this information. On 5/18/22 at 5:01 PM Staff 14 (CNA) stated Resident 16 recently wanted to get out of bed and wheel herself/himself outside. Staff 14 also stated the care plan did not list any of Resident 16's interests so conversations and offered activities were limited. On 5/23/22 at 4:03 PM Staff 8 (CNA) stated Resident 16 often visited with her/his spouse who no longer came to visit. Staff 8 stated Resident 16 often requested those visits. On 5/24/22 at 12:21 PM Staff 6 (LPN-Care Manager) expected updated activity care plans for Resident 16 as staff learned about her/him in order to offer care based on her/his needs and requests. On 5/24/22 at 12:58 PM Staff 1 (Administrator) acknowledged care planned activities offered to a resident should reflect her/his needs and interests.

F657 - Care Planning Timing and Revision - " Resident #16 will have his activity assessment and care plan updated to include his current interests and Resident #42 has had his care plan updated to reflect the removal of his catheter. " An audit of residents with catheters in their care plans has been completed and care plans updated as needed. Residents who have had a change in activity involvement since admission were identified and care plans updated to reflect such. " Education was provided to the RCMs on updating care plan when the foley catheter is removed by the regional nurse. " Education was provided to the Activity Director on updating care plans after each quarterly assessment and when a change in level of activity involvement is identified. " The DNS or designee will complete a weekly audit for 4 weeks, then 2x/month of residents care plans for either catheter OR change in activity participation level for 2 residents with catheters or 2 that had their catheters removed; and 3 residents who have been in the building for 30 to 60 days to identify if a change in activity level has been identified and care planned. " Results of the care plan audit will be forwarded to the QAPI committee for review and further recommendations as needed. " The Administrator, DNS and Activity Director are responsible to ensure compliance.

Based on observation, interview and record review it was determined the facility failed to provide activities related to resident preferences for 1 of 1 sampled resident (#16) reviewed for activities. This placed residents at risk for diminished physical, emotional and social well-being. Findings include: Resident 16 admitted to the facility in 2/2022 with diagnoses including diabetes and depression. The 2/22/22 Admission MDS revealed Resident 16 was very interested in going outside and not very interested in group activities. The assessment was completed by Staff 13 (Activities). The 3/1/22 Activities Initial Interview revealed Resident 16 was currently satisfied with her/his level of activity and would continue to monitor through weekly visits three times per week. Review of Resident 16's clinicial record revealed no activities occurred since 2/2022. On 5/17/22 at 10:19 AM Resident 16 was observed in bed with no television on and stated she/he wanted to go outside. Resident 16 stated she/he was provided an activity calendar with group activities but it was not helpful. On 5/17/22 at 1:23 PM and 5/18/22 at 4:54 PM Staff 13 indicated she was frightened of Resident 16, only met with her/him five times since she/he arrived and no visits were recorded. Staff 13 also stated she relied on CNAs to get residents up for group activities and acknowledged Resident 16 was not very responsive to group activities. When told about Resident 16's interest to be outside Staff 13 did not recall the information she entered for the MDS. Staff 13 added she believed Resident 16 would adjust like other residents but it did not happen so her/his social interactions did not occur as planned. On 5/24/22 at 12:58 PM Staff 1 (Administrator) acknowledged no activities occurred for Resident 16.

Activities Director began charting on Resident #16 activity participation daily. The activity assessment was updated and the care plan reviewed and revised as needed to reflect any change in resident interests since the previous assessment. Activities Director will keep daily records of attendance for those residents who attended activities and those residents who were offered to attend. An audit was completed by the Activity Director of residents that have had a potential change in their activity level or interest. Their Activity assessments will be updated and care plans changed as needed to reflect changes in interests and current choice of activities, including self-directed activities. Education was provided to the Activities Director on the importance of addressing the needs of all residents, whether they are self-directed or need group activities.¿¿¿ The Administrator/designee will complete weekly audit to observe 3 residents that participate in activities and 2 that are self directed to ensure their activity preferences were recorded for the week. Results of the activities attendance audit will be forwarded to the QAPI committee for review and further recommendations as needed. The Administrator and Activity Director are responsible to ensure compliance.

Based on observation, interview and record review it was determined the facility failed to ensure respiratory care was provided appropriately for 1 of 2 sampled residents (#59) reviewed for respiratory care. This placed residents at risk for respiratory distress. Findings include: Resident 59 was admitted to the facility in 12/2021 with diagnoses including acute and chronic respiratory failure with hypercapnia (excess carbon dioxide in bloodstream) and hypoxia (low O2 level in body tissues), chronic obstructive lung disease and obstructive sleep apnea (intermittent airflow blockage during sleep). After admission, the medical record revealed Resident 59 experienced multiple respiratory episodes which required re-hospitalization, including: -1/3/22: The resident's O2 sats dropped to 72% (normal O2 sat level: 95%-100%) and she/he experienced difficulty breathing. -1/13/22: The resident's O2 sats dropped to the 80 percent range and she/he experienced respiratory distress. -1/26/22: The resident was noted to have an O2 sat of 79% and was unresponsive. The resident returned to the facility on 2/1/22 with orders for continued use of a BiPAP (bi-level positive airway pressure device - used to maintain consistent breathing for people with respiratory conditions) at night and when sleeping. -2/8/22: The resident was not responding and was found to be short of breath with low O2 sats. The resident returned to the facility on 2/11/22 with the following orders: "must wear BiPAP w/sleep, naps or when resting and 'might' fall asleep." -4/5/22: The resident was found on the floor, confused and not responsive to questions. On 5/17/22 at 12:20 PM Resident 59 was observed in bed with O2 on at 2 L (liters) per minute via NC (nasal cannula). The resident appeared short of breath as she/he talked rapidly and attempted to explain to the surveyor her/his concerns about the nursing staff not providing her/his O2 properly. Resident 59 explained she/he used the NC for O2 during the day unless she/he was sleeping and then would need to be switched to the BiPAP mask. The resident stated staff did not consistently replace the BiPAP mask after administration of medications or when she/he became tired and fell asleep. The resident's 5/2022 TAR indicated the resident was to receive O2 continuously at 2-4 L per minute per NC. There was no specific information included to indicate when to change the resident's O2 administration from the NC to the BiPAP with the mask. Additionally there was no documentation of how many liters per minute of O2 the resident received. On 5/24/22 at 1:17 PM Staff 21 (CMA) indicated she was aware Resident 59 requested to have her/his BiPAP mask replaced immediately after medications were administered. Staff 21 acknowledged the resident was anxious about having the mask re-applied in a timely manner. On 5/24/22 at 1:49 PM Staff 22 (LPN) stated she was aware of the resident's need to have the BiPAP mask replaced after medications. Staff 22 stated the resident was always anxious about having the mask replaced as she/he quickly became short of breath. Staff 22 acknowledged the 5/2022 TAR did not include specific guidance regarding use of the mask with the BiPAP. On 5/25/22 at 11:23 AM Staff 2 (DNS) acknowledged the lack of specific instructions or information on the 5/2022 TAR for Resident 59's use of the mask with the BiPAP. Staff 2 stated staff should document the amount of liters per minute of O2 the resident received.

F695¿ Respiratory care¿ Order updated for resident #59 at the time of survey, but resident has since been discharged. ¿ An audit of residents using a BiPAP, C-PAP and supplemental oxygen will be completed to determine if special instructions should be added to the order on the TAR. Review showed no residents that require a mask be used when short of breath or after medications are administered. Residents also observed for signs of shortness of breath and anxiety. Those in house are comfortable with their current method of oxygen administration. Oxygen orders were also reviewed for liter flow specific to that resident. Education will be provided to the licensed staff on how to complete a BiPAP order including liters of oxygen.¿ Special needs such as re-applying the mask after med administration also need to be part of the instructions as needed. ¿ An audit will be done weekly x 4 weeks, then monthly x 2 months of BiPAP orders and proper administration.¿ Will include a review of special instructions if applicable. Results of the Respiratory Care audit will be forwarded to the QAPI committee for review and further recommendations as needed. The DNS and Administrator are responsible to ensure compliance.

Based on interview and record review it was determined the facility failed to ensure psychotropic drugs were reviewed appropriately for 2 of 5 sampled residents (#s 27 and 38) reviewed for medications. This placed residents at risk for inaccurate medication dosing. Findings include: 1. Resident 27 was admitted to the facility in 2012 with diagnoses including depression, anxiety disorder and chronic pain. Resident 27's medical record revealed she/he received the following psychotropic medications: -Zyprexa (antipsychotic), -Cymbalta (antidepressant) and -Wellbutrin (antidepressant). A Psychoactive Drug Review completed on 3/2/22 indicated Resident 27 displayed the following target behaviors as reasons for use of all three medications: Isolation, lethargy, depressive symptoms, and anxiety. The drug review did not describe resident-specific behaviors for the two different types of medications. Psychoactive Drug Reviews completed on 4/6/22 and 5/4/22 indicated Resident 27 displayed the following target behaviors as reasons for use of all three medications: manipulative behaviors, self limiting, odd behaviors, verbally abusive, threatening behaviors, and depressive mood. The drug review failed to describe resident-specific behaviors for the two different types of medications. On 5/25/33 at 11:47 AM Staff 2 (DNS) acknowledged there should be specific behaviors described for two different types of medications. Staff 2 stated the target behaviors should be detailed to the resident actions and each medication. 2. Resident 38 was admitted to the facility in 2022 with diagnoses including depression, diabetes and a left below the knee amputation. The medical record indicated Resident 38 received Cymbalta (antidepressant) 30 mg every day when she/he was admitted. The resident's 3/31/22 care plan revealed she/he had a mood problem related to depression and adult failure to thrive. Interventions included to report any risk of self harm or suicidal plans. Staff were directed to monitor for signs or symptoms of depression, anxiety or sad mood. Resident 38's medical record revealed the following Progress Notes: -3/28/22: The resident was noted to be tearful, stated she/he would rather be dead and did not want to be on any more medications. -3/30/22: The resident stated she/he would be better off dead than go through what she/he was medically experiencing. The resident denied having a plan to harm herself/himself. -4/4/22: The resident stated she/he would rather be dead than go through what she/he was going through, but had no plan to harm her/himself. A 4/6/22 Psychotropic Drug Review indicated Resident 38 had target behaviors including: restless, failure to thrive, pain, sadness and discomfort. There was no information regarding the resident's expressions of self-harm or ending her/his life. The Psychotropic Drug Review included non-drug interventions: rule out pain and discomfort, offer activities or one-on-one talks and frequent check-ins. The drug review indicated non-drug interventions were noted to be effective and there were no behaviors observed since Resident 38's admission to the facility. A recommendation was made to increase the dose of Cymbalta from 30 mg to 60 mg daily. There was no documentation related to the resident's thoughts of ending her/his life or related interventions included in the drug review. On 5/25/22 at 11:37 AM Staff 2 (DNS) acknowledged the Psychotropic Drug Review lacked information related to the resident's behaviors of harming herself/himself or wishing she/he were dead. Staff 2 agreed the drug review should have included the interventions associated with the resident's thoughts of self-harm and their effectiveness.

F758 Psychotropic Monitoring " Resident #38 has been discharged. Resident #27s Psychotropic Drug Review has been updated to reflect the specific behaviors for each drug. " An audit for other residents with antipsychotics and antidepressants was completed to determine resident specific behaviors associated with both classes of drugs. Residents will have their next Psychotropic Drug Review completed keeping in mind to describe resident specific behaviors for each type of medication. " Education will be provided to the RCMs and Social Service workers by the DNS and Regional Nurse on the need to delineate resident specific behaviors for each class of psychotropic medication. " An audit of the Psychotropic Drug Reviews will be completed by the DNS or designee, reviewing 5 residents review for description of resident specific behaviors for each class of medication. This will be completed monthly x 3 months. " The Psychotropic Drug review audit results will be forwarded to the QAPI committee for review and further recommendations and the need for further education. " The DNS and Social Service Directors are responsible to ensure compliance.

Based on observation, interview and record review it was determine the facility failed to ensure proper monitoring, cleaning and sanitation of equipment, food preparation surfaces and the kitchen for 1 of 1 kitchen and failed to ensure 1 of 1 ice machine was plumbed correctly to prevent the backflow of contaminated matter into the ice machine. This placed residents at risk for food borne illnesses. 1. An 4/7/22 Dish Machine Service Report revealed the chemistry level for the sanitizer was at 50 ppm (parts per million) and the dish machine operated according to the manufacturer's requirements. On 5/16/22 at 1:39 PM during the initial kitchen observation the low temperature dish machine operated without chemical sanitizer and the Dishwasher Temperatures/Sanitizer Log had no chemical levels entered from 5/1/22 through 5/16/22. On 5/16/22 at 2:01 PM Staff 12 (Dietary Aide) was unable to accurately demonstrate how to test the sanitizer level of the dish machine and confirmed the dish washer was operating without chemical sanitizer. On 5/16/22 at 6:20 PM Staff 11 (Dietary Aide) stated he worked in the dish room for two months and was not trained to ensure adequate levels of chemical sanitizer were used to wash dishes in the dish machine. On 5/16/22 at approximately 2:10 PM and on 5/17/22 at 12:10 PM Staff 15 (Dietary Manager) stated the dish machine should operate with adequate levels of chemical sanitizer according to manufacturer guidelines, the Dishwasher Temperatures/Sanitizer Log for 5/2022 contained no data about the chemical levels, and the facility had no additional information to ensure the dish machine chemical levels were adequately monitored or that staff were properly trained on how to measure sanitizer levels for the dish machine. 2. During general kitchen observations on 5/16/22 and 5/17/22 the following was observed: -The oven duct system had grease observed in the vent opening and hanging from the lip of the vent. -The wall behind the oven had dark brown splatters that covered the area and extended to the floor. A black pipe that extended from the back of the refrigerator had a build-up of dirty yellow material with unidentified debris attached. -The garbage can was not covered while not in use and the wall and a metal box attached to the wall behind the trash can were covered with food debris. -Oven mitts were stored in a manner which exposed them to the unclean floor. -A red bucket with murky water and a rag immersed in the water was observed in the preparation sink. -No monthly cleaning logs were posted except one located in the dish room. No entries for the completion of cleaning tasks during the month were found for 5/2022. -A Sanitizing Bucket Log for 5/2022 was posted in the preparation area. No log entry was completed after 8:00 AM on 5/17/22. In the preparation sink two red buckets were observed. One bucket had a towel immersed in a murky solution. On 5/16/22 at 6:17 PM Staff 9 (Dietary Aide) stated the cleaning log was provided only as a guide of what needed to be done daily and it was not necessary to document what was completed. On 5/16/22 at 6:20 PM Staff 11 (Dietary Aide) stated he cooked one day per week and never cleaned or observed anyone clean the vents. Staff 11 also stated there was no system in place to determine routine deep cleaning tasks in the kitchen. He reported random deep cleaning tasks were posted on the kitchen office door for staff to complete. Staff 11 stated at times kitchen staff informed Staff 15 (Dietary Manager) of cleaning tasks they completed based on their own observations. On 5/17/22 at 12:10 PM Staff 15 stated he completed one sanitation audit over two months since he was assigned to the facility and cleaned what he observed. Staff 15 acknowledged the walls, vents and floors were dirty and relocated the oven mitts off the floor. On 5/17/22 at 4:28 PM Staff 10 (Cook) stated she routinely worked as the cook and used the observed bucket with a murky solution to hold the towel after she cleaned contaminated counters. Staff 10 stated she did not know how to ensure the bucket had an adequate level of sanitizer and stated the bucket was not recently changed. On 5/18/22 at 3:23 PM Staff 10 was again observed working in the kitchen. Staff 15 tested the solution in the red bucket in the preparation sink and acknowledged the level of sanitizer was at 100 ppm instead of 200 ppm as required to meet the minimum requirement for the sanitizer solution and was inadequate to properly sanitize the kitchen work surfaces. Staff 15 stated he expected the sanitizer solution to be changed every two hours in order to best maintain the required level of sanitizer. 3. According to the 2017 Food Code 5-202.13: "The water outlet of a drinking water system must not be installed so that it contacts water in sinks, equipment, or other fixtures that use water. Providing an air gap between the water supply outlet and the flood level rim of a plumbing fixture or equipment prevents contamination that may be caused by backflow." On 5/16/22 at approximately 6:30 PM the facility ice machine located in the dining room was observed to have a drain pipe coming from the back panel of the ice machine and extended along the floor approximately four feet where it entered into a wall. The drain pipe was not plumbed to include an air gap between the end of the pipe and where it drained to prevent the potential backflow of contaminated matter. On 5/19/22 at 2:08 PM Staff 1 (Administrator) was shown the ice machine plumbing and stated she was unaware of the requirement for an air gap. On 5/23/22 at 10:35 AM Staff 16 (Maintenance Director) looked at the plumbing from the ice machine into the wall and confirmed water had the potential to backflow based on the plumbing and an air gap was needed.

F812 - Food Procurement¿¿ Robert E. Nelson serviced dish machine on 5/17/2022 and fixed leak in the sanitation line. Ice machine’s drain pipe will be routed to develop an air gap and drained into a pan. Dietary staff have been trained to check sanitation level of the dish machine to operate at adequate levels of chemical sanitizer according to manufactures guidelines. The walls, vents and floors in the kitchen were cleaned by the housekeeping and dietary manager and relocation of the oven mitts to a clean service. A deep cleaning system was put in place to ensure cleanliness of the kitchen. The red bucket of sanitation solution was changed to meet the proper level between 150-400 PPM and store the new wiping cloths in between use. Education will be provided to the kitchen staff on the importance of checking the sanitizing equipment daily for function with test strips, Cleaning and Sanitation of Kitchen, and Food Services Cleaning and Sanitation by reviewing policy. Weekly audits of the sanitation log for the Dish Machine and the ph in the sanitation buckets 3x/week for 4 weeks, then weekly x 8 weeks.¿¿ Proper function of the ice machine’s drain system will be added to TELs, the monthly maintenance checklist) and reviewed monthly for any irregularities. Results of the sanitization and cleaning audit will be forwarded to the QAPI committee for review and further recommendations as needed. The Administrator, Dietary Manager and Housekeeping Manager are responsible to ensure compliance.

OAR 411-086-0060 Comprehensive Assessment and Care Plan

Refer to F657 ********************************************* OAR 411-086-0230 Activity Services Refer to F679 ********************************************* OAR 411-086-0110 Nursing Services: Resident Care Refer to F695 ********************************************* OAR 411-086-0140 Nursing Services: Problem Resolution & Preventive Care Refer to F758 ********************************************* OAR 411-086-0250 Dietary Services Refer to F812 *********************************************

Based on observation, interview and record review, it was determined the facility failed to provide care and services for 1 of 4 sampled residents (#10) reviewed for accidents to prevent elopement from occurring. This placed other residents at risk for elopement. Findings include: Resident 10 was admitted to the facility on 3/26/21 with diagnoses including dementia without behavioral disturbance and amnesia. On 1/3/22 at 11:40 AM, the main facility door was observed locked. Staff were observed to open the front door with a coded keypad next to the door. The resident's care plan dated 3/28/21 revealed Resident 10 was an elopement risk/wanderer related to the resident thinking she/he had to go to work. Interventions were to distract the resident with pleasant diversions, structured activities, food, conversation, television and books. On 3/31/21 at 3:11 PM, a nursing note revealed Resident 10 had been allowed to exit through the front door on 3/30/21 after asking a hospitality aide to open the locked door. Nursing staff observed Resident 10 exit, intervened and assisted the resident back into the building. Resident 10 was put in the Elopement Binder, which was a book with identifying information of residents considered at risk for elopement and the resident was considered a low risk for elopement. On 4/1/21 at 6:41 PM, a nursing note revealed Resident 10 could not be located in the building and had last been seen around 5:00 PM at the nurse's station. Elopement protocols were initiated, searches in the building and neighborhood were conducted but the resident was not located. A subsequent nursing note dated 4/2/21 at 7:20 AM revealed the resident had been returned to the facility the previous evening by Resident 10's friends. The facility's Elopement report, dated 4/5/21, revealed Resident 10 had a SNF (Skilled Nursing Facility) elopement risk evaluation on 3/26/21 which considered her/him a low risk for elopement/wandering. On 3/31/21, another risk assessment was completed due to the resident looking for the patio and the resident stated she/he needed to go to work. The risk assessment indicated Resident 10 was a low risk for elopement but she/he was placed in the Elopement Binder. Facility video surveillance from 4/1/21 at 1:22 PM was reviewed by facility administration and revealed a housekeeper was working as a hospitality aide and allowed Resident 10 out the front door. The housekeeper was unaware Resident 10 was an elopement risk and in the Elopement Binder. At around 5:30 PM, staff were unable to locate Resident 10 and initiated an elopement search. Staff searched throughout the building and neighborhood, attempted to contact the resident's family and friends but were unable to locate anyone or the resident and contacted Law Enforcement. Around 7:40 PM, Resident 10 was returned to the facility by her/his roommate, who reported Resident 10 had walked from the facility to their home, which was several miles away from the facility. Resident 10 stated that she/he needed to get to work. On 1/12/22 at 1:30 PM, Staff 1 (Administrator) confirmed it was an expectation of the facility that residents be free from elopement.

F-689- Free of Accident Hazards/Supervision/Device • Resident #10 no longer resides at facility. • Director of Nursing or designee reviewed current residents for elopement risk, addressing concerns identified. • The Director of Nursing or designee in-serviced staff on the elopement binder. A second elopement binder was created to sit at screening desk. • The Director of Nursing or designee will do random audits via observation, interviews and/or chart/elopement book review for elopement compliance weekly x 3 weeks then monthly x 2 months. • The Director of Nursing or Designee will report the results of these audits at the facility monthly Quality Assurance meeting for 60 days or until substantial compliance has been achieved or sustained as determined by the committee. • The Administrator is responsible to ensure compliance.

***************************************** OAR 411-086-0140 Nursing Services: Problem Resolution & Preventive Care Refer to F689 ****************************************

Based on observations, interviews and record review it was determined the faciliy failed to maintain appropriate infection control practices to prevent the potential spread of the COVID-19 virus and other infectious diseases for two of four hallways, one of one break room, one of one kitchen and one of one screening area reviewed for infection prevention. This placed residents at risk for exposure and contraction of the COVID-19 virus and other infectious diseases. Findings include: 1. The Center for Disease Control (CDC), "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic", revised 9/10/21, instructed healthcare workers to perform hand hygiene before and after all patient contact, before and after removing PPE (Personal Protective Equipment) which included gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process. The Lippincott Manual of Nursing Practice, 10th edition, "Fundamentals of Standard Precautions for Hand Hygiene" indicated hand hygiene is the single most recommended measure to reduce the risk of transmitting micro-organisms. Hand hygiene should be performed between patient contacts; after contact with blood, body fluids, secretions and excretions, and contaminated equipment or articles; before donning and after removing gloves is vital for infection control. Observations were conducted from 11/2/21 through 11/3/21 between the hours of 11:00 AM and 4:00 PM. During these observations, staff were observed not to perform hand hygiene appropriately to prevent the spread of the COVID-19 virus. Examples of observations included: On 11/2/21 at 11:19 AM, Staff 18 (Maintenance) was observed to come into the screening area from outside with no mask or shield donned and his mask was observed to be hanging around his neck. Staff 18 put the mask on with no hand hygiene and left the screening area. On 11/2/21 at 12:01 PM, Staff 8 (CNA) was observed exiting an isolation room and doffed gloves without completing hand hygiene. On 11/2/21 at 12:08 PM, Staff 23 (LPN) was observed to don gloves without completing hand hygiene prior to donning the gloves. On 11/2/21 during shift change at 2:00 PM, Staff 17 (Hospitality Aide) was observed to touch his face shield several times while screening incoming staff without completing hand hygiene. On 11/2/21 at 2:06 PM, residents were observed coming into the building from a smoke break with no cueing from staff to complete hand hygiene. On 11/3/21 at 11:55 AM, Staff 11 (CNA) was observed to be touching her face shield several times during an interview with surveyor and not completing hand hygiene. Staff 11 acknowledged she was aware she was supposed to use Alcohol Based Hand Rub (ABHR) after touching her shield. On 11/3/21 at 12:16 PM, Staff 12 (CNA) was observed to touch her face shield at the food cart, take a food tray from the cart and deliver the tray to a resident room with no hand hygiene. On 11/3/21 at 12:21 PM, a resident was observed to come into the building after a smoke break with no cueing by Staff 13 (LPN/Charge Nurse) to complete hand hygiene. 2. The CDC "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic," revised 9/10/21, indicated facilities should ensure proper use, handling and implementation of PPE which included disinfection, handling and storage methods. Observations were conducted from 11/2/21 through 11/3/21 between the hours of 11:00 AM and 4:00 PM. During these observations, staff were observed not to adhere to the recommended disinfection methods for PPE. Examples of observations included: On 11/2/21 at 11:00 AM, Staff 17 did not sanitize the thermometer between uses when screening the survey team, visitors and staff upon entrance to the building. Staff 17 confirmed he did not consistently disinfect the thermometer. On 11/2/21 at 11:11 AM, an inspection of the face shield storage and disinfection area in the front area of the facility was observed to contain items stored in the bins other than face shields or masks. On 11/2/21 at 11:20 AM, a N-95 mask was observed on the break room table unattended without a barrier. Staff 27 (CNA) confirmed the mask did not belong to him. On 11/2/21 at 11:53 AM, Staff 19 (Laundry Aide) was observed to place her face shield on top of the clean clothing cart, then placed the shield on the clean linen. Staff 19 did not complete hand hygiene after removing the face shield. Staff 19 confirmed she did not complete hand hygiene and did not properly store her face shield. On 11/3/21 at 11:52 AM, Staff 14 was observed in the kitchen on the tray line with his face shield flipped up over his eyes. Staff 15 (Dietary Aide) was observed to be standing next to Staff 14 with no face shield donned. 3. The 10/25/20 CDC Coronavirus 2019 (COVID-19) Strategies for Optimizing the Supply of Eye Protection, revised 9/13/21, indicated if a disposable face shield is reprocessed, it should be reprocessed whenever it is visibly soiled or removed, such as when leaving an isolation area, prior to putting it back on. Staff were to don clean gloves, carefully wipe the inside, followed by the outside of the face shield using a clean cloth saturated with neutral detergent or cleaner wipe. The outside of the face shield was to be wiped with EPA registered disinfect solution. Observations were conducted from 11/2/21 through 11/3/21 between the hours of 11:00 AM and 4:00 PM. During these observations, staff were observed not to adhere to the recommended reprocessing and disinfection methods for eye protection/face shields. Examples of observations included: On 11/2/21 at 12:01 PM, Staff 8 (CNA) was observed exiting an isolation room without disinfecting her face shield. Staff 9 (CNA) was observed cueing Staff 8 on the disinfection process and stated Staff 8 had worked at the facility for several years. On 11/2/21 at 2:14 PM, Staff 14 (Cook) was observed to place his face shield in the storage bin area without disinfecting the shield. Staff 14 indicated he was supposed to disinfect the face shield, then left the facility without doing so. On 11/2/21 at 2:20 PM, Staff 5 (Dietary Manager) confirmed Staff 14 was not following COVID-19 protocols for disinfecting PPE. On 11/3/21 at 2:58 PM, the findings of this investigation were discussed with Staff 2 (DNS). No additional information was received. On 11/8/21 at 9:00 AM, Staff 1 (Administrator) was notified of the findings. No additional information was received.

Infection Control 1. All residents have the potential be impacted. 2. Staff have been inserviced to keep shields or protective glasses on while in resident areas and working in food preparation areas. Staff have been re-inserviced that shields and masks should be disinfected prior to leaving work then stored in the staff members’ cubbie. Hands should be disinfected after cleaning the shield or protective glasses. 3. Staff have been re-inserviced on donning and doffing PPE and wearing it throughout resident care areas and food preparation areas by the DNS or designee. 4. Staff have been re-inserviced on using a barrier when taking masks on including in the hydration room. 5. Staff have been re-inserviced on disinfecting screening tools used to touch staff between screenings. 6. PPE audits will be conducted twice weekly x 2 to assure shields/glasses are worn in resident care areas and in food preparation areas. Then will be audited weekly x 4. PPE storage audit will be done twice weekly x 2, then weekly x 4 to determine compliance with doffing and storage of shields and protective glasses. 7. Findings of the PPE audit and Shield/Glasses audit will be forwarded to the QAPI committee for review and further recommendations. 8. The Administrator and DNS are responsible to insure compliance.

Based on observation, interview and record review it was determined the facility failed to ensure call lights were functioning for 3 of 16 residents (#s 1, 2, and 3) reviewed for call lights. This placed residents at risk for delayed treatment and unmet needs. Findings include: 1. Resident 1 was readmitted to the facility in 10/2021 with diagnoses including pneumonia secondary to COVID-19. Resident 1's Fall Prevention Care Plan, last revised 4/20/21, identified Resident 1 as a high fall risk. The following care plan interventions were in place: -Be sure call light was within reach and encourage resident to use it for assistance as needed. The resident needed prompt responses to all requests for assistance. Initiated 12/13/17; -Call light/personal items within reach. Initiated 10/19/18; -Remind to use call light for assistance. Initiated 4/9/20 and -Place "call before you fall" at bedside. Care plan updated to one person assistance. Initiated 9/15/21. Observations on 11/2/21 at 12:27 PM revealed, in Resident 1's room, there was a hole in the wall where a call light had once been. Resident 1 had no access to a call light and no other auxiliary aides or systems were in place for Resident 1 to summon help. On 11/2/21 at 11:50 PM, Staff 12 (CNA) and Staff 25 (CNA) stated Resident 1 used her/his call light for assistance or got up and came into the hallway to get help. At 11:51 AM, Staff 12 confirmed Resident 1 had no call light in her/his room. On 11/2/21 at 12:27 PM, Resident 1 stated five or six days ago she/he was transferred to her/his current room and no call light was available. Resident 1 stated she/he was a fall risk and was supposed to have assistance transferring but since she/he had no call light, she/he got up on her/his own and went into the hallway to summon help. Resident 1 stated she/he notified Staff 2 (DNS) and Staff 18 (Maintenance) several days ago regarding the lack of a call light and still has no call light. On 11/2/21 at 2:55 PM, Staff 2 (DNS) reported Resident 1 told her on 10/29/21 that she/he had no call light and Staff 2 told Staff 18 (Maintenance) to look into the issue. 2. Resident 2 was admitted to the facility in 8/2021 with diagnoses including COVID-19, urinary tract infection and asthma. Resident 2's Fall Prevention Care Plan, dated 8/18/21, identified Resident 2 as a moderate to high fall risk. The following care plan interventions were in place: -Be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed. The resident needed prompt responses to all requests for assistance and -Call light/personal items within reach. Observations on 11/4/21 at 11:14 AM revealed Resident 2's call light was not functioning and no other auxiliary aides or systems were in place for Resident 2 to summon help. On 11/4/21 at 11:14 AM, Resident 2 reported she/he was moved to her/his current room on 11/3/21 and had no functioning call light. Resident 2 reported she/he used the call light for help the previous day and no one came, resulting in Resident 2 soiling herself/himself. On 11/4/21 at 11:14 AM, Staff 26 (CNA) confirmed Resident 2's call light was not functioning. , 3. Resident 3 was admitted to the facility in 8/2021 with diagnoses including acute osteomylitis (inflammation of the bone caused by infection), Chronic Obstructive Pulmonary Disease, and Diabetes Mellitus 2. A Fall Prevention Care Plan last revised 9/17/21 identified Resident 3 as a fall risk. The following care plan interventions were in place: -Be sure call light was within reach and encourage resident to use it for assistance as needed. Initiated 9/17/21; -Call light/personal items within reach. Initiated 8/27/21; -Remind to use call light for assistance. Initiated 8/27/21. Observations on 11/3/21 at 2:20 PM revealed Resident 3's call light was not functioning and a replacement call light with the wiring and cord attached was observed to be placed in a wheelchair next to the wall. The malfunctioning call light was observed to be attached to the wall. Resident 3 stated she/he had been in the room for about six days, acknowledged the call light in the wall did not work and stated staff had tried to fix it a few days ago.

Call lights functioning 1. Resident # 1, 2, and 3 has a functioning call light at her bedside. 2. An audit of facility call lights was conducted. Call lights were found to be functioning or were repaired as needed. 3. Staff were educated that if a call light is not functioning to list the broken call light on the maintenance log at the nurses station and either move the resident to a bed with a functioning call light OR place a bell within reach of the resident and instruct the to use the bell to call staff. The facility will test 10 call lights per week x 4 weeks to assure the call lights remain operable or are reported for repair. 4. Call light audits will be conducted weekly x 4, then monthly on 10 beds, to assure they are functioning or repaired promptly. The Call Light audits will be forwarded to the QAPI committee for review and further recommendations if needed. 5. The Administrator and DNS are responsible to insure compliance.

Based on interview and record review it was determined the facility failed to ensure a resident was treated with dignity and respect for 1 of 3 sampled residents (#2) reviewed for verbal abuse. This placed residents at risk for impaired dignity. Findings include: Resident 2 was admitted to the facility in 2009 with diagnoses including schizophrenia and a history of stroke. Resident 2's Annual MDS dated 11/10/20 indicated the resident had a BIMS of 12 indicating some cognitive impairment. Resident 2's Quarterly MDS dated 8/13/21 revealed the resident had some physical behavioral symptoms such as hitting and kicking. Resident 2's care plan last revised on 10/24/21 indicated the resident's behaviors included physical aggression, potential for injury to self or others, quick to punch and strike and delusions and hallucinations. On 10/9/21 facility administration was notified of an alleged staff to resident abuse incident involving Resident 2 and Witness 3 (Former CNA). The investigation dated 10/11/21 indicated Resident 2 was hitting, punching and kicking Staff 6 (CNA). Witness 3 (Former CNA) helped mitigate the problem with the resident. Witness 2 (Complainant), who worked as maintenance in a sister facility, heard yelling and went into the resident's room. Witness 2 stated he overhead Witness 3 say to Resident 2 "Don't you ever hit a woman again or we will have a problem." On 10/18/21 at 4:00 PM Witness 3 (Former CNA) stated he observed Resident 2 hitting and punching Staff 6 (CNA). Witness 3 stated he intervened and told the resident she/he was not allowed to hit anyone and if she/he did it again there would be a problem. Witness 3 stated he was a loud person and should have spoken to the resident in a more dignified manner, using different words. On 11/1/21 at 11:43 AM Staff 4 (LPN) stated Resident 2 was punching Staff 6 (CNA) when Witness 3 told the resident to "not touch women like that." Staff 4 stated Witness 3 was not being abusive but was disrespectful towards Resident 2. On 11/1/21 at 12:08 PM Staff 6 (CNA) stated Witness 3's approach to Resident 2 was not in an abusive manner. On 11/5/21 at 10:57 AM Staff 3 (Assistant DNS) stated Resident 2 told her she/he did not feel abused or disrespected by Witness 3 regarding the 10/9/21 incident. On 11/5/21 at 3:08 PM Staff 2 (DNS) stated Witness 3 raised his voice with Resident 2 in a manner which was not abusive but was undignified and disrespectful.

Dignity 1. Staff member #2 is no longer employed by the facility. Resident # 2 has been interviewed and feels he is safe and faced no retaliation from the incident with staff member #2. 2. A review of grievances for the last 30 days show no other instances of residents being treated with a lack of dignity and respect. 3. Staff have been reinserviced on treating residents with respect and dignity, even during episodes where behaviors may have escalated and they need immediate redirection. The inserivce was provided by the SDC/ADNS and focused on diffusing difficult situations. Nursing management will review incidents daily Monday through Friday for escalating behaviors and review notes and conduct interviews if necessary to assure staff use the techniques to handle residents with dignity and respect. This will be done weekly x 2 weeks, then 1 incident a month to assure techniques and learned interventions are utilized appropriately. 4. The incident review will be forwarded to the QAPI committee for review and further recommendations. 5. The DNS and Administrator are responsible to insure compliance.

*********************************** OAR 411-085-0310 Residents' Right: Generally Refer to F550 ***********************************

Based on observations, interviews and record review it was determined the facility failed to ensure residents were free from physical abuse for 1 of 10 sampled residents (#7) reviewed for abuse. This placed residents at risk for being physically abused by a resident. Findings include: Review of the facility's "Abuse: What is it? Who is responsible to report abuse? How to report abuse?" undated document revealed the facility had a system in place to identify and report abuse. The document defined the following: - "Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish..." "Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Abuse includes verbal abuse, sexual abuse, physical abuse, mental abuse, involuntary seclusion, neglect, exploitation and misappropriation against a vulnerable adult..." Resident 7 was admitted to the facility in 5/2021 with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on side of the body) following a stroke which affected her/his left side. Resident 7's 7/16/21 Quarterly MDS Assessment revealed she/he had a BIMS of 12 indicating she/he had moderate cognitive impairment. Resident 7 required extensive two person physical assist for bed mobility and getting dressed. She/he also needed extensive one person physical assistance for moving about on the unit. Resident 7's care plan revealed she/he had left sided weakness and was at risk for injury as a result of being on anticoagulant medications. Interventions included being monitored for bleeding, brushing, pain and swelling. She/he was care planned for psychosocial well-being supports. Resident 8 was admitted to the facility in 5/2009 with diagnoses including schizophrenia. Resident 8's 5/2021 Quarterly MDS Assessment revealed she/he had a BIMS of 13 indicating she/he had intact cognitive response. Resident 8 required supervision with one person physical assist for moving about on the unit. Resident 8's care plan revealed she/he had a diagnosis of schizophrenia and she/he could be more prone to irritation and be short-tempered in the days leading up to her/his Haldol (antipsychotic medication) injection. She/he was monitored for increased agitation, yelling out, striking out and irritability. The Facility Reported Incident dated 7/25/21 revealed Resident 8 hit Resident 7 in the face on 7/25/21 after having a verbal disagreement in regards to Resident 7's missing cup of noodles. The incident was not witnessed by staff but was reported to staff by Resident 7 about 45 minutes after the incident occurred. Resident 7 was observed by staff to have swelling and a small amount of blood on her/his forehead. Resident 7 did not experience any psychosocial harm. Review of the facility's undated investigation of the 7/25/21 incident revealed Residents 7 and 8 were roommates and engaged in a resident to resident altercation after Resident 7 called Resident 8 a thief for taking her/his cup of noodles. Resident 7 reported Resident 8 wheeled her/his wheelchair to Resident 7's side of the room and used a close fist to hit her/him on the head two times. Resident 8 reported she/he hit Resident 7 for cursing her/his mother and father. Resident 7 sustained 2 lacerations on the forehead and left of her/his eye. Nurses separated the residents, assessed for injury, notified appropriate contacts which included the police. Resident 8 was placed on 1:1 supervision. Progress notes revealed Resident 8 admitted to hitting Resident 7 as a result of inappropriate verbal language made towards her/his parents and Resident 7 sustained swelling and a small scant of blood on her/his forehead. On 9/9/21 at 3:23PM Resident 7 was observed in her/his room in bed and stated during an interview she/he was punched in the face by Resident 8 after she/he called Resident 8 a liar. Resident 7 stated Resident 8 walked to Resident 7's left side of the bed and hit her/him causing an injury. Resident 7 indicated she/he had a couple of gashes around her/his eyes and reported the incident to staff. On 9/9/21 at 4:13PM Resident 8 was observed to have no interactions with residents or staff while she/he was at the nurses' station. On 9/9/21 at 4:19PM Staff 7 (NA) stated Resident 8 can get agitated and displays schizophrenia type symptoms. On 9/10/21 at 12:59PM Staff 5 (SSD) stated Resident 8 hit Resident 7 in the face. Resident 7 sustained swelling to her/his forehead and almost could not see. Staff 5 indicated Resident 8 has had increased agitation, yelling out, striking out and irritability which prompted her/his care plan to be updated. On 9/13/21 at 3:05PM Staff 1 (Administrator) confirmed Resident 8 hit Resident 7 in the face. Staff 1 indicated staff were aware of Resident 8's behavioral and mental health needs, and she/he received a Haldol injection every 3 weeks to support her/his behavioral symptoms.

F600- Free from Abuse and Neglect Resident 7 was assessed and monitored for psychosocial affects; room change was done so residents are no longer roommates. Resident 8 was monitored, assessed, with care plan updated, has had no further incidents. Administrator or Designee identified residents with diagnosis of schizophrenia, behavior trends were reviewed, addressing concerns identified. The Administrator or Designee re-educated staff on the requirement to ensure residents are free from physical abuse. The Administrator or Designee will do random audits on behaviors for Residents with a diagnosis of schizophrenia weekly x 3 weeks then monthly x 2 months. The Administrator or Designee will report the results of these audits at the facility monthly Quality Assurance meeting for 60 days or until substantial compliance has been achieved or sustained as determined by the committee. The Administrator is responsible to ensure compliance.

******************************************************** OAR 411-085-0360 Nursing Services: Problem Resolution & Preventive Care Refer to F600 ********************************************************

Based on interview and record review it was determined the facility failed to ensure a safe and homelike environment for 4 of 8 sampled residents (#s 3, 9, 11 and 12) reviewed for environment. This placed residents at risk for lessened quality of life. Findings include: A 7/20/21 progress note indicated facility staff found drug paraphernalia inside a resident's room (Resident 19), which included methamphetamine, two pipes and a scale. A 8/10/21 incident report indicated staff confiscated drug paraphernalia from another resident (Resident 1), which included powdered crystal (methamphetamine), lighters, and a scale. On 9/2/21 at 5:00 PM Resident 3 stated some of the residents in the facility used drugs and she/he did not want to be around it. Resident 3 stated it was frustrating and upsetting that residents at the facility used drugs because the other residents in the facility were trying to get better. On 9/3/21 at 11:54 AM Witness 1 (Complainant) stated she witnessed residents using drugs in the facility smoking area. On 9/3/21 at 1:13 PM Resident 9 stated she/he saw residents smoke methamphetamine from a pipe. Resident 9 stated she/he previously used methamphetamine but stayed away from it and was clean from drugs for the past two years. On 9/8/21 at 2:02 PM Resident 11 stated she/he saw residents use drugs in the smoking area. Resident 11 stated she/he found glass pipes and turned them in to staff members. On 9/8/21 at 2:05 PM Resident 12 stated she/he witnessed drug use at the facility and avoided the areas where residents used drugs because she/he did not want to be around it. On 9/8/21 at 2:29 PM Staff 14 (CNA) stated she saw residents using drugs in the smoking area. On 9/8/21 at 2:41 PM Staff 15 (CNA) stated she saw residents exchange money for drugs in the smoking area. Staff 15 stated she also observed pipes and containers with drugs in them. During interviews with Staff 1 (Administrator) and Staff 2 (DNS) from 9/2/21 through 9/8/21 the staff acknowledged facility staff found drugs and drug paraphernalia for multiple residents in the facility. The staff indicated the drugs and drug paraphernalia were turned over to law enforcement. Staff 1 indicated the ongoing drug use at the facility was not a homelike environment for residents.

The Administrator or Designee interviewed staff and residents to determine any current drug use concerns, addressing concerns identified. The Administrator or Designee did an audit of the exterior of the building to identify any current illegal drug use or drug paraphernalia. The Administrator or Designee re-educated staff on the requirement for maintaining a homelike environment and that drug use activity negatively impacts this, the education also included their role and the importance of taking action and notifying the charge nurse of any drug use or drug paraphernalia so action steps can be taken The Administrator or Designee educated leadership team and licensed nurses on steps to be taken when drug activity is discovered and/or suspected. The Administrator or Designee educated the Admissions coordinator on the expectation that a commitment of sobriety is required for new admissions with history of drug use. The Administrator or Designee will do random audits via staff interview, resident interview, rounds, and/or exterior video camera review for drug use activity weekly x 3 weeks then monthly x 2 months. The Administrator or Designee will report the results of these audits at the facility monthly Quality Assurance meeting for 60 days or until substantial compliance has been achieved or sustained as determined by the committee. The Administrator is responsible to ensure compliance.

Based on observation, interview and record review it was determined the facility failed to ensure sufficient staffing to meet resident care needs in a timely manner for 10 of 13 sampled residents (#s 7, 8, 11, 12, 13, 14, 15, 16, 17 and 18) reviewed for sufficient staffing. This placed residents at risk for delayed treatment and unmet care needs. Findings include: 1. Staffing observations in the facility from 9/2/21 through 9/8/21 revealed the following: a. On 9/2/21 from 12:15 PM to 12:29 PM Staff 3 (CNA) was observed to feed six residents at four different tables in the main dining room. Staff 3 stood next to each resident while she fed them one or two bites of food and then moved on to the next resident. The residents were observed to only eat while Staff 3 fed them. At 12:29 PM Resident 8 was in the main dining room and was observed to yell out for assistance. No staff responded to the resident's calls for assistance as they were assisting other residents in the dining room. At 12:30 PM the surveyor asked Staff 3 if she was going to assist Resident 8 as the resident was yelling for assistance. Staff 3 stated the resident had to wait 30 minutes for staff to assist the resident back to bed. b. On 9/8/21 at 5:58 PM a resident was observed to slowly ambulate in her/his wheelchair in the hallway. The resident asked the surveyor to assist her/him to the resident's room. The surveyor stated he would get a staff member to assist the resident, but the resident declined the offer and stated the staff were too busy to the assist the resident. c. On 9/8/21 at 5:59 PM Resident 8 was observed calling out of her/his room for staff assistance. 2. Record review related to staffing revealed the following: a. A review of the Direct Care Staff Daily Reports from 8/1/21 through 8/7/21 revealed the following days and shifts when state minimum staffing ratios were not met: 8/1/21 - day, evening and night shifts. 8/2/21 - day and evening shifts. Evening shift was short two aides. 8/3/21 - day and evening shifts were both short two aides. 8/4/21 - day, evening and night shifts. Day shift was short three aides. 8/5/21 - day, evening and night shifts. Day shift was short five aides. Evening shift was short two aides. 8/6/21 - day shift was short six aides. 8/7/21 - day and evening shifts. b. A review of the Direct Care Staff Daily Reports from 8/24/21 through 9/7/21 revealed the following days and shifts when state minimum staffing ratios were not met. 8/24/21 - evening shift. 8/25/21 - night shift. 8/26/21 - night shift. 8/31/21 - night shift. 9/1/21 - day, evening and night shifts. Day shift was short four aides. Evening shift was short two aides. 9/2/21 - day, evening and night shift. Evening and night shifts were short two aides. 9/3/21 - day and night shift. 9/4/21 - day, evening and night shifts. Day shift was short two aides. 9/5/21 - day shift. 9/6/21 - night shift. 9/7/21 - night shift. c. A 8/23/21 resident Grievance/Concern form written by Resident 14 indicated long call light wait times in the evenings. Documentation by a facility staff member indicated the resident's average call light response time was 17 minutes and 40 seconds. d. A 8/23/21 resident Grievance/Concern form written by Resident 15 indicated long call light wait times. Documentation by a facility staff member indicated the resident's average call light response time was 18 minutes and 49 seconds. e. A 8/31/21 resident Grievance/Concern form written by Resident 16 indicated excessive call light wait times. Documentation by a facility staff member indicated the resident's average call light response time was 18 minutes and 49 seconds. f. A 9/2/21 resident Grievance/Concern form written by Resident 17 indicated excessive call light wait times. Documentation by a facility staff member indicated the resident's average call light response time was 10 minutes. g. A 9/7/21 resident Grievance/Concern form written by Resident 18 indicated call light wait times greater than 30 minutes in the evenings. Documentation by a facility staff member indicated the resident's average call light response time was 26 minutes. 3. Interviews related to staffing revealed the following: a. On 9/3/21 at 1:02 PM Staff 8 (LPN) stated the aides were not able to complete all resident care needs during their shifts due to low staffing. Staff 8 stated the staff were stretched thin and residents had to wait longer than ten minutes for needed care. b. On 9/3/21 at 1:37 PM Staff 9 (LPN) stated nurses had to help aides complete resident care because the aides were not able to complete them. Staff 9 stated the facility struggled with staffing and the staff were "burned out." c. On 9/7/21 at 1:59 PM Staff 11 (LPN Resident Care Manager) stated the facility had a difficult time filling shifts and managers sometimes had to assist to make sure resident care needs were met. d. On 9/8/21 at 2:02 PM Resident 11 stated the facility's staffing was bad and she/he did not use the call light because it took staff 45 minutes to answer the call light and sometimes did not answer it at all. e. On 9/8/21 at 2:05 PM Resident 12 stated the facility did not have enough staff on duty. Resident 12 stated she/he did not use the call light because staff sometimes did not answer the call light anyway. f. On 9/8/21 at 2:21 PM Resident 13 stated she/he waited up to an hour for assistance after activating the call light. g. On 9/8/21 at 2:29 PM Staff 14 (CNA) stated she was not able to complete resident care needs during her shift. Staff 14 stated some residents did not get showered or fed as a result of the insufficient staffing. h. On 9/8/21 at 2:41 PM Staff 15 (CNA) stated there were not enough staff on duty and she was not able to take care of the residents. Staff 15 stated the aides had to rush in, triage the needs, and rush out. Staff 15 stated sometimes residents did not get showered, or did not get out of bed or receive restorative therapy as a result of the insufficient staffing. i. During interviews with Staff 1 (Administrator) and Staff 2 (DNS) from 9/2/21 through 9/8/21 the staff acknowledged the failure to meet state minimum staffing levels and the excessive call light response times.

F 725 Sufficient Nursing Staff Resident 7,8,11,12,13,14,15,16,17, & 18 were interviewed to identify and address and current unmet needs. The Administrator or Designee did a comprehensive review to identify staffing trends to address; this was done through resident interviews, staff interviews, call light response audits, and documentation review. The Administrator or Designee met with resident council to review focus areas identified, current and proposed solutions and gathered additional feedback from the council. The Administrator re-educated Staffing Coordinator on CNA Staffing Ratios. Facility will utilize the emergency staffing plan when there is possibility of falling under mandated staffing ratio. The Administrator re-educated leadership team and floor nurses on CNA staffing ratios and Emergency Staffing Plan. The Administrator or Designee will conduct random audits through resident interview, staff interview, documentation review, and/or observation to ensure sufficient staffing is in place to meet resident care needs in a timely matter weekly x 3 weeks then monthly x 2 months. The Administrator will Audit CNA staffing ratios within Stand-Up meeting for 2 weeks then weekly for 3 weeks. The Administrator or Designee will report the results of these audits at the facility monthly Quality Assurance meeting for 60 days or until substantial compliance has been achieved or sustained as determined by the committee. The Administrator is responsible to ensure compliance.

Based on interview and record review it was determined the facility failed to ensure state minimum staffing ratios were maintained for 18 of 22 days (34 of 66 shifts) reviewed for staffing. This placed residents at risk for delayed treatment and unmet care needs. Findings include: A review of the Direct Care Staff Daily Reports from 8/1/21 through 8/7/21 revealed the following days and shifts when state minimum staffing ratios were not met: 8/1/21 - day, evening and night shifts. 8/2/21 - day and evening shifts. Evening shift was short two aides. 8/3/21 - day and evening shifts were both short two aides. 8/4/21 - day, evening and night shifts. Day shift was short three aides. 8/5/21 - day, evening and night shifts. Day shift was short five aides. Evening shift was short two aides. 8/6/21 - day shift was short six aides. 8/7/21 - day and evening shifts. A review of the Direct Care Staff Daily Reports from 8/24/21 through 9/7/21 revealed the following days and shifts when state minimum staffing ratios were not met. 8/24/21 - evening shift. 8/25/21 - night shift. 8/26/21 - night shift. 8/31/21 - night shift. 9/1/21 - day, evening and night shifts. Day shift was short four aides. Evening shift was short two aides. 9/2/21 - day, evening and night shift. Evening and night shifts were short two aides. 9/3/21 - day and night shift. 9/4/21 - day, evening and night shifts. Day shift was short two aides. 9/5/21 - day shift. 9/6/21 - night shift. 9/7/21 - night shift. On 9/8/21 at 9:08 AM Staff 1 (Administrator) acknowledged the failure to meet state minimum staffing ratios.

M183 No residents were cited. The Administrator re-educated Staffing Coordinator on CNA Staffing Ratios. Facility will utilize our emergency staffing plan when there is possibility of falling under mandated staffing ratio. The Administrator re-educated leadership team and floor nurses on CNA staffing ratios and Emergency Staffing Plan. The Administrator will Audit CNA staffing ratios within Stand-Up meeting for 2 weeks then weekly for 3 weeks. The Administrator or Designee will report the results of these audits at the facility monthly Quality Assurance meeting for 60 days or until substantial compliance has been achieved or sustained as determined by the committee. The Administrator is responsible to ensure compliance.

******************************************************** OAR 411-086-0140 Nursing Services: Problem Resolution & Preventive Care Refer to F584 ******************************************************** OAR 411-086-0100 Nursing Services: Staffing Refer to F725 ********************************************************