Pilot Butte Rehabilitation Center

1.-á Resident 15 was admitted to the facility in 12/2024 with diagnoses including depression and muscle wasting. -á Resident 17 was admitted to the facility in 12/2025 with diagnoses including traumatic brain injury, brain damage and adjustment disorder. -á Resident 15's Annual MDS dated 12/11/25 indicated she/he was cognitively intact. -á Resident 17's Admission MDS dated 12/24/25 indicated she/he was moderately cognitively impaired. -á A Grievance Form dated 2/3/26 documented Resident 15 had been verbally abused by Resident 17. Resident 17 had called Resident 15 ""pussy"" and ""faggots"" and making threats. The form noted Resident 17 denied name-calling and threats and had been advised to request a staff member when upset. Further documentation indicated Resident 17 had improved and that lashing out had decreased. Recommended actions included continued monitoring. -á Resident 17's Care Plan dated 3/18/26 documented a risk for behavior symptoms including outbursts of yelling and cursing when redirected or educated.-á Interventions included approaching resident in a calm manner, reapproaching later if agitated or uncooperative, and keeping Resident 17 in a supervised area when out of bed. -á On 6/15/26 at 1:34 PM, Resident 15 stated Resident 17 cursed at her/him about once a month. Resident 15 stated the cursing did not make her/him feel good and made her/him uncomfortable. Resident 15 also stated the verbal behavior made her/him feel uncomfortable when directed at staff. -á On 6/23/26 at 8:12 AM, Staff 35 (CNA) stated on 2/3/26 Resident 17 said a lot of ""nasty thingsGÇ¥ and had cursed at Resident 15. Staff 35 stated Resident 17 was so loud the whole facility knew what was happening and attempts had been made to stop the resident. On 6/24/26 at 10:09 AM, Staff 16 (Social Services Director) stated she followed up with Resident 15 about her/his grievance concern and educated Resident 15 about Resident 17GÇÖs difficulty controlling verbal outburst.-á Staff 16 stated she did not have an opinion on whether the 2/3/26 incident constituted verbal abuse and stated it would depend on the residentsGÇÖ feelings.-á -á On 6/24/26 at 11:43 AM, Staff 1 (Administrator) stated Resident 17 had been vocal in public spaces and directed verbal interactions toward staff rather than residents. Residents had become upset and had complained about Resident 17. Staff 1 stated residents who were interviewed did not indicate they had been verbally abused by Resident 17.-á -á 2. Resident 16 was admitted to the facility in 8/2022 with diagnoses including stroke. -á Resident 17 was admitted to the facility in 12/2025 with diagnoses including traumatic brain injury, brain damage and adjustment disorder. -á Resident 16's MDS dated 12/5/25 indicated she/he was cognitively intact. -á Resident 17's Admission MDS dated 12/24/25 indicated she/he was moderately cognitively impaired. -á A Grievance Form dated 2/3/26 documented Resident 17 had verbally abused Resident 16, calling her/him GÇ£pussy"" and ""faggots"" and making threats. Resident 17 denied name-calling and threats and had been advised to request a staff member when upset. Further documentation indicated Resident 17 had improved and that lashing out had decreased. Recommended actions included continued monitoring. -á Resident 17's Care Plan dated 3/18/26 documented she/he was at risk for behavior symptoms with verbal outbursts of yelling and cussing when Resident 17 was redirected or educated.-á Interventions included approach resident in a calm manner, re-approach later if agitated or uncooperative. Resident 17 was to be in a supervised area when out of bed. -á On 6/15/26 at 1:26 PM, Resident 16 stated Resident 17 had threatened to attack her/him. Resident 17 called her/him derogatory statements. Resident 16 stated it ""pisses"" her/him off because it brought up bad memories from childhood. -á On 6/23/26 at 8:12 AM, Staff 35 (CNA) stated on 2/3/26 Resident 17 said a lot of ""nasty thingsGÇ¥ and had cursed at Resident 16. Staff 35 stated Resident 17 was so loud the whole facility knew what was happening and attempts had been made to stop the resident.-á -á On 6/24/26 at 10:09 AM, Staff 16 (Social Services Director) stated she followed up with Resident 16 about her/his grievance concern and educated Resident 16 about Resident 17GÇÖs difficulty controlling verbal outburst.-á Staff 16 stated she did not have an opinion on whether the 2/3/26 incident constituted verbal abuse and stated it would depend on the residentsGÇÖ feelings.-á -á On 6/24/26 at 11:43 AM Staff 1 (Administrator) stated Resident 17 had been vocal in public spaces and directed verbal interactions toward staff rather than residents. Residents had become upset and had complained about Resident 17. Staff 1 stated residents who were interviewed did not indicate they had been verbally abused by Resident 17.-á -á 3. Resident 18 was admitted to the facility in 9/2022 with diagnoses including stroke. -á Resident 17 was admitted to the facility in 12/2025 with diagnoses including traumatic brain injury, brain damage and adjustment disorder. -á Resident 17's Admission MDS dated 12/24/25 indicated she/he was moderately cognitively impaired. -á Resident 18's MDS dated 4/1/26 indicated she/he was cognitively intact. -á A Grievance Form dated 3/13/26 documented Resident 18 was ""extremely"" uncomfortable due to Resident 17's actions. Resident 17 had been yelling curse words and ""vile"" names at residents and staff. The documented follow-up action was to continue educating, therapy and care planning for Resident 17. -á A Behavior Note dated 3/13/26 documented Resident 17 was upset about the dining room seating arrangement and had screamed homophobic slurs at residents and refused to calm down. -á Resident 17's Care Plan dated 3/18/26 documented she/he was at risk for behavior symptoms with verbal outbursts of yelling and cussing when Resident 17 was redirected or educated.-á Interventions included approach resident in a calm manner and re-approach later if agitated or uncooperative. Resident 17 was to be in a supervised area when out of bed. -á Resident 18GÇÖs revised care plan documented the resident had declining health status, with interventions to include promoting a calm, quiet environment.-á -á A Behavior Note dated 6/13/26 documented Resident 17 had been kicking and screaming at residents and had called them names. -á On 6/17/26 at 8:09 AM, Resident 18 stated Resident 17 was verbally abusive. Resident 17 had told her/him ""I'm going to knock your ass,"" sometime in the second week of 6/2025. Resident 18 stated she/he had not felt safe in the facility due to Resident 17's behaviors. -á On 6/23/26 at 12:07 PM, Staff 43 (CNA) stated on 3/13/26, in the dining room with multiple residents present a resident had been placed in a seat where Resident 17 considered her/his spot. Staff 43 stated Resident 17 had yelled, ""you gay little faggot,"" at a resident. -á On 6/24/26 at 8:27 AM, Staff 15 (LPN) stated on 3/13/26 Resident 17 had been yelling at Resident 18 and another resident. Staff 15 did not recall specific words but stated Resident 17 had used many ""colorful words."" -á On 6/24/26 at 11:43 AM, Staff 1 (Administrator) stated Resident 17 had been vocal in public spaces and directed verbal interactions toward staff rather than residents. Residents had become upset and had complained about Resident 17. Staff 1 stated residents who were interviewed did not indicate they had been verbally abused by Resident 17.-á -á 4. Resident 19 was admitted to the facility in 7/2025 with diagnoses including depression and stroke. -á Resident 17 was admitted to the facility in 12/2025 with diagnoses including traumatic brain injury, brain damage and adjustment disorder. -á Resident 17's Admission MDS dated 12/24/25 indicated she/he was moderately cognitively impaired. -á A Grievance Form dated 3/13/26 documented Staff 43 (CNA) had been advocating for Resident 19 due to verbal abuse from Resident 17. Resident 19 had been moved to different seating and had felt alienated from other resident because of being accused of taking Resident 17's dining room spot. Resident 19 had been tired of being called ""foul"" names. -á A separate Grievance Form dated 3/13/26 documented Resident 17 had been screaming and yelling and had claimed Resident 19 took her/his spot. Resident 20 had been tired of seeing Resident 19 being insulted and bullied. -á A Behavior Note dated 3/13/26 documented Resident 17 had been upset about the dining room seating arrangement, screamed homophobic slurs at residents and refused to calm down. -á Resident 17's revised care plan dated 3/18/26 documented she/he was at risk for behavior symptoms with verbal outbursts of yelling and cussing when Resident 17 was redirected or educated.-á Interventions included approach resident in a calm manner, re-approach later if agitated or uncooperative. Resident 17 was to be in a supervised area when out of bed. -á Resident 19's Significant Change MDS dated 3/24/26 indicated she/he was severely cognitively impaired. -á On 6/17/26 at 8:11 AM, Witness 10 (Resident) stated she/he had heard Resident 17 calling Resident 19 a ""faggot."" -á On 6/23/26 at 12:07 PM, Staff 43 confirmed she had completed the 3/13/26 grievance for Resident 19. Staff 43 stated Resident 17 entered the dining room and Resident 19 had been seated in a spot Resident 17 considered her/his own. Resident 17 stated to Resident 19, ""you gay little faggot."" Staff 43 stated Resident 19 had been tearful. Staff 43 removed Resident 19 because attempting to remove Resident 17 would have escalated the situation. Resident 19 had been placed by the nurse's station outside the dining room, and she/he had appeared sad after leaving the dining room. Staff 43 stated she had not heard any response related to the outcome of the grievance.-á-á-á-á -á On 6/24/26 at 8:27 AM, Staff 15 (LPN) stated on 3/13/26 Resident 17 had been yelling at Resident 19 and another resident. Staff 15 did not remember specific words but stated Resident 17 used many ""colorful words."" -á On 6/24/26 at 11:43 AM, Staff 1 (Administrator) stated Resident 17 had been vocal in public spaces and directed verbal interactions toward staff rather than residents. Residents had become upset and had complained about Resident 17. Staff 1 stated residents who were interviewed did not indicate they had been verbally abused by Resident 17. -á

? Residents #17-No longer is in facility, they remained on 1:1 until discharge ? Residents #15 -No negative effect noted related to practice. The resident was placed on Alert Charting, for monitoring any Psychosocial harm, Care plans were reviewed and updated ? Residents #16- No negative effect noted related to practice. The resident was  placed on Alert Charting, for monitoring any Psychosocial harm, Care plans were reviewed and updated ? Residents #18- No negative effect noted related to practice. The resident was  placed on Alert Charting, for monitoring any Psychosocial harm, Care plans were reviewed and updated ? Residents #19-No negative effect noted related to practice. The resident was  placed on Alert Charting, for monitoring any Psychosocial harm, Care plans were reviewed and updated ? The facility staff and residents were interviewed for feeling safe with in the facility and concerns were addressed as appropriate ? Education was provided to facility Administrator and Director of Nursing by the governing body as it relates to abuse prevention in F-600 review of the grievance process ? Education was provided to facility Administrator, Director of Nursing and Social Services by the governing body as it relates to the grievance policy and of the grievance process ? Education was provided to facility staff as it relates to abuse neglect prevention by Administer or designee ? Education abuse prevention will be provided on hire, annual and PRN ? Education for new hires on abuse prevention will be audited weekly x3 weeks monthly x 2 months ? Will review education to staff on abuse training at monthly QAPI meeting new hire abuse prevention education x3 months for needs of adjustments to plan

1.-á Resident 8 was admitted to the facility in 2/2024 with diagnoses including complex pain syndrome and anxiety disorder. -á A 12/23/25 Narcotic Log (pg. 1) for Resident 8 indicated lorazepam 0.5 mg one tablet every two hours as needed for anxiety was ordered. Staff documented the medication was administered 11 times from 12/23/26 through 1/7/26 and Staff 3 (LPN) administered the medication 10 of those times. -á Resident 8's 12/2025 and 1/2026 MARs included lorazepam 0.5 mg, one tablet every two hours as needed for anxiety and oxycodone every four hours as needed for chronic pain. Staff documented the medication had been administered 11 times from 12/23/25 through 1/7/266, and Staff 3 administered the medication 10 of those times. Staff documented oxycodone had been administered 50 times from 12/23/26 through 1/7/26, and Staff 3 administered the medication 26 of those times.-á -á A Facility Reported Incident Form (FRI) dated 1/8/26 was submitted to the State Survey Agency, which alleged that Staff 3 (LPN) had administered narcotic medications to certain residents more frequently than other staff. -á An undated FRI Investigation included a review of facility narcotic logs, which indicated Staff 3 was the nurse who had administered narcotic medications and had not allowed the CMA to administer the narcotics. Staff 3 was suspended pending investigation and later resigned. Two CMAs reported concerns with Staff 3's behavior which included ""frantic"" disposal of medications which made confirmation of wasted medications difficult. Some residents asked for pain medications when documentation showed they had already received pain medications. During the audit it was noted an issue did occur related to the documentation of the disposal of medications and the facility could not account for medications within the narcotic log. -á On 6/22/26 at 9:46 AM, Staff 3 stated she would not provide a statement. -á On 6/23/26 at 11:42 AM, Staff 37 (CMA) stated a lot of medications were administered at night by Staff 3 and he was uncertain why a resident would need medication while they were sleeping. Staff 37 stated Resident 8 was administered lorazepam during the night and Resident 8 always slept through the night. -á On 6/23/26 at 10:46 AM, Staff 38 (CMA) stated she was the one who reported the concern. She had reported the concern around 11/2025, and an audit was completed and the concern continued so she reported the concern again. Staff 38 stated she was uncomfortable to count with Staff 3 because her behaviors were erratic. Staff 38 stated there were pages with an X on them but no documentation of where the medication was. She informed hospice because Resident 8 was an eight out of 10 pain and it was documented she/he was getting more medications at night but still in pain. -á On 6/24/26 at 11:35 AM, Staff 1 (Administrator) stated the facility had determined misappropriation of Resident 8's medications occurred. -á 2. Resident 18 was admitted to the facility in 2/2024 with diagnoses including phantom limb syndrome with pain. -á A Facility Reported Incident Form (FRI) dated 1/8/26 was submitted to the State Survey Agency, which alleged that Staff 3 (LPN) had administered narcotic medications to certain residents more frequently than other staff. -á A Medication Audit Reconciliation Narrative dated 1/13/26 documented all medication carts were audited and reconciled. All narcotic counts were reviewed and verified. During the audit two pages had been removed from the narcotic book and the corresponding medication cards for the entries could not be accounted for Resident 18's Percocet. -á An undated FRI Investigation included a review of facility narcotic logs, which indicated Staff 3 was the nurse who had administered narcotic medications and had not allowed the CMA to administer the narcotics. Staff 3 was suspended pending investigation and later resigned. Two CMAs reported concerns with Staff 3's behavior which included ""frantic"" disposal of medications which made confirmation of wasted medications difficult. Some residents asked for pain medications when documentation showed they had already received pain medications. During the audit it was noted an issue did occur related to the documentation of the disposal of medication and the facility could not account for medications within the narcotic log. -á On 6/22/26 at 9:46 AM, Staff 3 stated she would not provide a statement. -á On 6/22/26 at 8:30 AM and 6/24/26 at 11:35 AM, Staff 1 (Administrator) stated the facility had determined misappropriation of Resident 18's medications. Resident 18 had two narcotic log pages torn out of the logbook and her/his Percocet medication was unaccounted for. -á 3. Resident 21 was admitted to the facility in 12/2025 with diagnoses including palliative care and chronic pain. -á A 12/2025 MAR indicated to administer morphine tablet every four hours for moderate to severe pain. On 12/25/25 Resident 21 was documented as having morphine administered four times with three of these times administered by Staff 3 (LPN).-á -á A Facility Reported Incident Form (FRI) dated 1/8/26 was submitted to the State Survey Agency, which alleged that Staff 3 (LPN) had administered narcotic medications to certain residents more frequently than other staff. -á A Medication Audit Reconciliation Narrative dated 1/13/26 documented all medication carts were audited and reconciled. All narcotic counts were reviewed and verified, during the audit two pages had been removed from the narcotic book and the corresponding medication cards for the entries could not be accounted for Resident 21's morphine. -á An undated FRI Investigation included a review of facility narcotic logs, which indicated Staff 3 was the nurse who had administered narcotic medications and had not allowed the CMA to administer the narcotics. Staff 3 was suspended pending investigation and later resigned. Two CMAs reported concerns with Staff 3's behavior which included ""frantic"" disposal of medications which made confirmation of wasted medications difficult. Some residents asked for pain medications when documentation showed they had already received pain medications. During the audit it was noted an issue did occur related to the documentation of the disposal of medication and the facility could not account for medications within the narcotic log. -á On 6/23/26 at 10:46 AM, Staff 38 (CMA) stated she was the one who reported the concern. She had reported the concern about around 11/2025, and an audit was completed and the concern continued so she reported again. Staff 38 stated she was uncomfortable to count with Staff 3 because her behaviors were erratic. A couple of morphine narcotic books were crossed out but no one had signed off on the medication for them to be destroyed. Staff 38 thought Staff 3 and Staff 37 had destroyed the medications. -á On 6/24/26 at 11:35 AM, Staff 1 (Administrator) stated the facility had determined misappropriation of Resident 21's medications. -á The deficient practice was identified as Past Noncompliance based on the following: -á On 1/18/26, the deficient practice was identified by the facility and was corrected when the facility completed a root cause analysis of the incident and determined there was misappropriation of medications.-áThe Plan of Correction included: -á1. Staff educated on medication administration, medication count, disposal and storage of medications.-á 2. Police report placed for potential crime. 3. Staff 3 resignation accepted. 4. Pharmacy consulted to perform a medication cart audit. 5. Narcotic audits to be completed weekly for four months, then monthly for three months. Audits would be brought to QAPI for review and education opportunities. -á -á

1.-á Resident 15 was admitted to the facility in 12/2024 with diagnoses including depression and muscle wasting. -á A 2/3/26 Grievance Form documented Resident 15 was verbally abused by Resident 17 and was called ""pussy"" and ""faggots."" Resident 17 also threatened physical assault to Resident 15. -á There was no documented evidence Resident 15's report of being verbally abused by Resident 17 was reported to the State Survey Agency for the incident on 2/3/26. -á On 6/24/26 at 11:43 AM, Staff 1 (Administrator) stated she did not feel the allegation of verbal abuse rose to the level to report to the State Agency. -á 2. Resident 16 was admitted to the facility in 8/2022 with diagnoses including stroke. -á A 2/3/26 Grievance Form documented Resident 16 was verbally abused by Resident 17 and was called ""pussy"" and ""faggots."" -á There was no documented evidence Resident 16's report of being verbally abused by Resident 17 was reported to the State Survey Agency for the incident on 2/3/26. -á On 6/24/26 at 11:43 AM, Staff 1 (Administrator) stated she did not feel the allegation of verbal abuse rose to the level to report to the State Agency.-á -á 3.-á Resident 18 was admitted to the facility in 9/2022 with diagnoses including stroke. -á A 3/13/26 Grievance Form documented Resident 18 was ""extremely"" uncomfortable by Resident 17's actions. Resident 17 was yelling curse words and ""vile"" names at residents and staff.-á -á A Behavior Note dated 3/13/26 documented Resident 17 was upset about the seating arrangement in the dining room. Resident 17 screamed homophobic slurs at other residents and refused to calm down. -á On 6/24/26 at 8:27 AM, Staff 15 (LPN) stated on 3/13/26 Resident 17 was yelling at Resident 18 and another resident. Staff 15 did not remember specific words but stated Resident 17 used many ""colorful words."" -á There was no documented evidence Resident 18's report of being verbally abused by Resident 17 was reported to the State Survey Agency for the incident on 3/13/26. -á On 6/24/26 at 11:43 AM, Staff 1 (Administrator) stated she did not feel the allegation of verbal abuse rose to the level to report to the State Agency. -á 4.-á Resident 19 was admitted to the facility in 7/2025 with diagnoses including depression and stroke. -á A Grievance Form dated 3/13/26 documented Staff 43 (CNA) had been advocating for Resident 19 due to being verbally abused by Resident 17. Resident 19 had been tired of being called ""foul"" names. -á On 6/23/26 at 12:07 PM, Staff 43 stated Resident 17 called Resident 19 a ""gay little faggot."" -á There was no documented evidence the 3/13/26 Grievance Report of Resident 19 being verbally abused by Resident 17 was reported to the State Survey Agency. -á On 6/24/26 at 11:43 AM. Staff 1 (Administrator) stated she did not feel the allegation of verbal abuse rose to the level to report to the State Agency. -á -á

? Residents #17-No longer is in facility. They remained on 1:1 until discharge ? Residents #15 -No negative effect noted related to practice. The resident was  placed on Alert Charting, for monitoring any Psychosocial harm, Care plans were reviewed and updated ? Residents #16- No negative effect noted related to practice. The resident was  placed on Alert Charting, for monitoring any Psychosocial harm, Care plans were reviewed and updated ? Residents #18- No negative effect noted related to practice. The resident was placed on Alert Charting, for monitoring any Psychosocial harm, Care plans were reviewed and updated ? Residents #19- No negative effect noted related to practice. The resident was  placed on Alert Charting, for monitoring any Psychosocial harm, Care plans were reviewed and updated ? The Administrator or designee interviewed facility staff and residents whose BIMS are 12 or above for feeling safe with in the facility or any other concerns related verbal abuse, review and clarification was conducted on the interview with FRI summation r/t and events identified. ? Administrator or designer conducted education to the IDT on reporting to State agency, as it pertains to CMS guidance in F-609 ? Administrator or designer will audit facility events, including but not limited to clinical documentation, grievances, resident council, and care conference concerns for need to report to State agency, weekly x4 weeks, and monthly x2 months, and PRN there after ? ? Regional?Director?of Clinical Services and/ or RVP will review?the?grievance?log monthly?for 3 months to for?adequate response.?RRDCS / RVP will review incident investigation to ensure any abuse/ neglect?has?been reported/ resident protected and thorough investigation completed.? ? The Administer or designee will review new facility events in the morning meeting for validation of reporting to State Agency, as it pertains to CMS guidelines in F-609 weekly x4 weeks, and monthly x2 months, and PRN thereafter. ? Audits will be forwarded to QAPI committee x2 months to validate compliance, identify trends, and education needs

1. Resident 15 was admitted to the facility in 12/2024 with diagnoses including depression and muscle wasting. -á A Grievance Form dated 2/3/26 documented Resident 15 had been verbally abused by Resident 17. Resident 17 had called Resident 15 ""pussy"" and ""faggots"" and making threats. The form noted Resident 17 denied name-calling and threats and had been advised to request a staff member when upset. Further documentation indicated Resident 17 had improved and that lashing out had decreased. -á There was no documented evidence the facility conducted a thorough investigation to determine whether verbal abuse had occurred.-á -á On 6/24/26 at 10:09 AM Staff 16 (Social Services Director) stated no formal investigation was completed. -á On 6/24/26 at 11:43 AM Staff 1 (Administrator) stated when the facility received a resident grievance form, interviews should be conducted with both staff and residents and document the information on a progress note or on the grievance form. Staff 1 provided no additional information to show a thorough investigation had been completed.-á -á 2. Resident 16 was admitted to the facility in 8/2022 with diagnoses including stroke. -á A Grievance Form dated 2/3/26 documented Resident 17 had verbally abused Resident 16, calling her/him GÇ£pussy"" and ""faggots"" and making threats. Resident 17 denied name-calling and threats and had been advised to request a staff member when upset. Further documentation indicated -áResident 17 had improved and lashing out had decreased. Recommended actions included continued monitoring. -á There was no documented evidence the facility conducted a thorough investigation to determine whether verbal abuse had occurred.-á -á On 6/24/26 at 10:09 AM, Staff 16 (Social Services Director) stated no formal investigation was completed. -á On 6/24/26 at 11:43 AM, Staff 1 (Administrator) stated when the facility received a resident grievance form, interviews should be conducted with both staff and residents and document the information on a progress note or on the grievance form. Staff 1 provided no additional information to show a thorough investigation had been completed.-á -á 3.-á Resident 18 was admitted to the facility in 9/2022 with diagnoses including stroke. -á A Grievance Form dated 3/13/26 documented Resident 18 was ""extremely"" uncomfortable due to Resident 17's actions. Resident 17 had been yelling curse words and ""vile"" names at residents and staff. The documented action had been to continue education and therapy and complete care planning for Resident 17. -á A Behavior Note dated 3/13/26 documented Resident 17 was upset about the dining room seating arrangement and had screamed homophobic slurs at residents and refused to calm down. -á On 6/23/26 at 12:07 PM, Staff 43 (CNA) stated she had not heard anything from administration related to the grievance. -á There was no documented evidence the facility conducted a thorough investigation to determine whether verbal abuse had occurred.-á -á On 6/24/26 at 11:43 AM, Staff 1 (Administrator) stated when the facility received a resident grievance form, interviews should be conducted with both staff and residents and document the information on a progress note or on the grievance form. Staff 1 provided no additional information to show a thorough investigation had been completed.-á -á 4.-á Resident 19 was admitted to the facility in 7/2025 with diagnoses including depression and stroke. -á A Grievance Form dated 3/13/26 documented Staff 43 (CNA) had been advocating for Resident 19 due to verbal abuse from Resident 17. Resident 19 had been moved to different seating and had felt alienated from other resident because of being accused of taking Resident 17's dining room spot. Resident 19 had been tired of being called ""foul"" names. -á A separate Grievance Form dated 3/13/26 documented Resident 17 had been screaming and yelling and had claimed Resident 19 took her/his spot. Resident 20 had been tired of seeing Resident 19 being insulted and bullied. -á A Behavior Note dated 3/13/26 documented Resident 17 had been upset about the dining room seating arrangement, screamed homophobic slurs at residents and refused to calm down. -á On 6/17/26 at 8:11 AM, Witness 10 (anonymous resident) stated she/he had heard Resident 17 calling Resident 19 a ""faggot.""-á -á There was no documented evidence the facility conducted a thorough investigation to determine whether verbal abuse had occurred.-á -á On 6/23/26 at 12:07 PM, Staff 43 confirmed she had completed the 3/13/26 grievance for Resident 19. Staff 43 stated Resident 17 entered the dining room and saw Resident 19 was seated in a spot Resident 17 considered her/his own. Resident 17 called Resident 19, a ""gay little faggot."" Staff 43 stated Resident 19 had been tearful.-á Staff 43 stated she had not heard any response related to the outcome of the grievance.-á-á-á-á -á On 6/24/26 at 11:43 AM, Staff 1 (Administrator) stated when the facility received a resident grievance form, interviews should be conducted with both staff and residents and document the information on a progress note or on the grievance form. Staff 1 provided no additional information to show a thorough investigation had been completed.-á -á

? Residents #17-No longer is in facility. They remained on 1:1 until discharge ? Residents # 15-No negative effect noted related to practice. The resident was  placed on Alert Charting, for monitoring any Psychosocial harm, Care plans were reviewed and updated ? Residents #16- No negative effect noted related to practice. The resident was  placed on Alert Charting, for monitoring any Psychosocial harm, Care plans were reviewed and updated ? Residents #18- No negative effect noted related to practice. The resident was  placed on Alert Charting, for monitoring any Psychosocial harm, Care plans were reviewed and updated ? Residents #19- No negative effect noted related to practice. The resident was  placed on Alert Charting, for monitoring any Psychosocial harm, Care plans were reviewed and updated ? The Administrator or designee interviewed facility staff and resident whose BIMS was a 12 or above for feeling safe with in the facility or any other concerns related verbal abuse, review and clarification was conducted on the interview with FRI summation r/t and events identified. ? Education was conducted by the governing body to the Administrator and Director of Nursing on timely completion and through investigation as it pertains to CMS guidance in F-610 ? The Director of Nursing or designee will review clinical notes, grievances, care conference notes, and resident council concerns during morning meetings weekly for 4 weeks, monthly for 2 months, and as needed thereafter. ? The Administrator or designee will review new investigation in the clinical meeting for validation of timely and thoroughly investigated incidents as it pertains to CMS guidelines in F-610 and audit clinical documentation including but not limited to Chart notes, Care conferences, resident council, and grievances weekly x4 weeks, and monthly x2 months, and PRN thereafter. ? Audits will be forwarded to QAPI committee x2 months to validate compliance, identify trends, and education needs.

Resident 4 was admitted to the facility in 1/2026 with diagnoses including mild cognitive impairment and second-degree burns to lower limbs. -á a. Resident 4's Care Plan dated 1/30/26 indicated the discharge destination was a shelter, noting she/he had been homeless. Interventions included planning with community resources to support independence post-discharge. -á -áA Social Services Note dated 4/1/26 documented Resident 4 had been informed that her/his discharge plan was unsafe, that the resident understood, and the resident was her/his own responsible party and had chosen to proceed.-á -á A Discharge Summary dated 4/2/26 indicated reason for Resident 4's discharge was Medicaid had been denied and that Resident 4 had been discharged to ""houseless."" It documented multiple discussions regarding safety concerns and noted Resident 4's continued intention to live in her/his vehicle. A home care referral was completed, and services would include physical, occupational, and speech therapy. -á A Discharge Summary MDS dated 4/2/26 indicated Resident 4 was cognitively intact and required supervision or touching assistance with walking 10 feet. -á There was no documented evidence in Resident 4's clinical record that a home health care referral was completed as indicated in the Discharge Summary.-á -á A Physical Therapy Discharge Summary signed 4/3/26 documented Resident 4 would ambulate 200 feet over uneven pavement using a front wheel walker with modified independent. On 3/20/24 Resident 4 completed 200 feet two times over uneven pavement with a front-wheel walker and stand by assistance. At the time of therapy discharge on 4/1/26, testing Resident 4's ability to ambulate 200 feet over uneven pavement was not completed prior to discharge. -á On 4/6/26 the State Survey agency received a complaint indicating Resident 4 had admitted to the facility for burns sustained to her/his legs from a propane heater living in her/his vehicle. The resident discharged back to her/his truck and fell and sustained a spine fracture and skull fracture. -á A 4/13/26 hospital Discharge Summary indicated Resident 4 was admitted to the hospital on 4/3/26 with a shattered neck break, closed fracture of the forehead and closed fracture to odontoid (small bony peg on the second neck bone to help turn the head side to side.) Resident 4 was found on the ground outside of her/his vehicle on 4/3/26. -á On 6/16/26 at 10:51 AM and on 6/17/26 at 7:58 AM, attempts to contact Resident 4 were unsuccessful. -á On 6/18/26 at 8:47 AM, Witness 9 (Transitional Care Advisor for Home Health Care) stated no home health services referral was received for Resident 4's 4/2/26 discharge. -á On 6/24/26 at 10:00 AM, Staff 16 (Social Services Director) stated usually emails would go back and forth for home health services referrals. Staff 16 stated Resident 4 was questioned about moving into her/his vehicle and Resident 4 had the right to make ""bad choices"" and it was not in her control. No email exchanges with home health were provided. -á On 6/24/26 at 11:25 AM, Staff 1 (Administrator) stated if a discharge summary indicated a resident was referred to home health services, she would expect the referral to be placed.-á -á Resident 4 was admitted to the facility in 1/2026 with diagnoses including displaced fracture of second cervical vertebra, fracture of vault of skull, and fracture of the neck. -á-á-á-á-á-á-á-á-á-á-á-á-á-á-á b. A 4/17/26 Admission MDS indicated Resident 4 was moderately cognitively impaired.-á -á A 5/24/26 Physician Communication form from Staff 25 (RN) to the physician documented Resident 4 wished to discharge because of money concerns. Staff 25 documented that Resident 4 did not appear cognitively able to live independently and had confusion. A physician response dated 5/27/26 indicated Resident 4 discharged before she/he could be seen and Resident 4 left against medical advice. The physician had told Resident 4 not to discharge until she/he was cleared by neurosurgery. -á A 5/25/26 Physician Progress note indicated Resident 4 was upset and wanted to leave against medical advice. Resident 4 did not have a safe discharge plan and appeared confused intermittently during discussion. Resident 4 had a history of mild cognitive impairment. It was recommended Resident 4 stay at the facility until she/he was cleared by the neurosurgeon rather than leaving the facility against medical advice. -á There was no documented evidence in Resident 4's clinical record that she/he signed leaving the facility against medical advice or a referral for home health services was completed.-á -á A 5/26/26 Discharge Summary documented anticipated discharge date was 5/27/26 and was a resident driven discharge. Discharge was to a business parking lot. Resident 4 was a fall risk and no longer wished to move forward with liquidating assets to obtain Medicaid. Resident 4 was aware that it meant she/he had to discharge from the facility. Functional level of status was toileting hygiene maximal assistance of one-person and moderate assistance of one person for bathing and dressing. Home care equipment none, home care referral was completed for physical and occupational therapy. Resident 4 would follow up on her/his own for future appointments. -á A 5/27/26 Discharge Notice and Order Request indicated Resident 4 needed physical and occupational therapy. Nursing and social services were needed. Additional nursing instructions were for neck brace management and medication management.-á -á On 6/16/26 at 10:51 AM and on 6/17/26 at 7:58 AM, attempts to contact Resident 4 were unsuccessful. -á On 6/16/26 at 12:01 PM, Witness 8 (Friend) stated Resident 4 was confused and her/his ""mind is not at all there."" Witness 8 stated Resident 4 was living in an RV park and a person who works at the park had checked in with her/him. -á On 6/18/26 at 8:47 AM, Witness 9 (Transitional Care Advisor for Home Health Care) stated no home health services referral was received for Resident 4's 5/27/26 discharge. Witness 9 stated a medical agency had reached out to her not the facility. Witness 9 stated she personally never spoke with Resident 4. -á On 6/17/26 at 8:47 AM, on 6/18/26 at 9:43 AM, and on 6/24/26 at 11:25 AM, Staff 1 (Administrator) stated if a discharge summary indicated a resident was referred to home health services, she would expect the referral to be placed. Staff 1 stated Staff 16 (Social Services Director) was unavailable during Resident 4's second discharge and Staff 1 did not document notes. Staff 1 stated Resident 4 did not want to get rid of her/his assets. Witness 8 had informed her that Resident 4 would be on Witness 8's property in a fifth wheel trailer. Staff 1 stated Resident 4 did not discharge against medical advice, and it was a coordinated discharge with the physician. -á -á

? Residents #-4 No longer is in facility ? Education was provided to facility Social Worker on F-627 and expectation on discharge planning follow up and discharge audit tool ? A review of the last 7 days discharges was conducted, and any issues were resolved as appropriately ?? ? Social Worker or designer will audit facility discharges for follow up needs, weekly x4 weeks, and monthly x2 months, and PRN there after ? Audits with be reviewed at the monthly QAPI meeting new hire abuse prevention education x3 months for need of adjustments to plan.

Resident 36 was admitted to the facility in 8/2022 with diagnoses including dementia.-á Resident 36 had a responsible party who made her/his medical decisions.-á A review of the resident's clinical record on 9/16/25 revealed an order for Depakote Sprinkles (a medication used to impact agitation and mood) on 8/21/25. -á A review of the resident's MAR revealed the first dose of Depakote Sprinkles was administered on 8/22/25.-á No record of informed consent by the resident representative was found during the initial record review completed 9/16/25.-á-á Further review of the clinical record on 9/18/25 revealed a Psychotropic Medication Consent dated 9/18/25.-á-á On 9/18/25 at 3:21 PM, Staff 26 (RN) stated she did not know she needed to obtain informed consent from the resident representative before administering Depakote Sprinkles.-á-á On 9/18/25 at 3:34 PM, Staff 14 (RN/Assistant DNS) stated staff were required to obtain informed consent from the resident or resident representative prior to administering a psychotropic medication.-á , -á Resident 6 was admitted to the facility in 1/2025 with diagnoses including depression and bipolar disorder. -á A Physician's order revealed Resident 6 received Depakote (a mood stabilizer) daily. -á Review of the clinical record revealed no evidence the risks and benefits of Depakote were discussed with her/him. -á On 9/18/25 at 8:47 AM, Staff 11 (Regional Director of Clinical Operations) and Staff 14 (Assistant Director of Nursing Services) verified the risks and benefits were not reviewed with Resident 6. -á -á -á -á

Corrective Action: Residents #6 consent was obtained for risk and benefits for Depakote Residents #36 consent was obtained for risk and benefits for Depakote Identification of Others: The facility’s residents’ on Depakote were audited for the required consents and any issues identified were corrected. Systemic Changes:  Education will be provided to the nursing department on the process of obtaining consents for any resident taking Depakote. Monitoring:   An audit of residents on Depakote will be completed on new orders and medication changes including Depakote and will be reviewed by IDT weekly x3 weeks and monthly x2 months and PRN thereafter. Responsible Party: Director of nursing

2:-áResident 51 was admitted to the facility in 8/2023 with diagnoses including infection.-á On 9/18/25 at 8:30 AM, Staff 21 (CNA) stated she was assisting Staff 24 (CNA) to provide care for Resident 51 on 4/27/25. Staff 21 stated Staff 24 was rough with the resident while placing a chuck (a device used to help reposition a resident) under the resident. She stated Staff 24 told Resident 51 she/he was ""not exactly easy to move"" when Resident 51 objected to the rough treatment by Staff 24. Staff 21 stated Staff 24 then jerked the chuck under the resident to reposition him without counting (a method used to be sure staff reposition the resident in unison) and the resident told Staff 24 he was hurting him. Staff 21 stated Staff 24 ignored the resident and left the room after repositioning her/him without providing the resident additional care.-á -áOn 9/19/25 at 10:27 AM, Staff 16 (Social Services Director) stated Resident 51 informed her on 4/28/25 that Staff 24 had been abusive to her/him while providing care.-á -áA review of the investigation 5/1/25 by Staff 3 (former Administrator) and Staff 2 (DNS) revealed the facility ""could not rule out abuse"" to Resident 51 by Staff 24.-á-á -áResident 51 was not available for interview. -áAn attempt to interview Staff 24 on 9/16/25 was not successful.-á -áStaff 2 was not available for interview. -áAttempts to interview Staff 3 on 9/18/25 were not successful.-á On 9/19/25 at 10:33 AM, Staff 1 (Administrator), Staff 15 (Regional VP) and Staff 11 (Regional Director of Clinical Operations) acknowledged Resident 51 was abused by Staff 24.-á , Resident 47 was admitted to the facility in 4/2024 with diagnoses including quadriplegia, Amyotrophic Lateral Sclerosis (ALS, a progressive disease which affects physical function). -á A care plan dated 4/23/24 directed staff to encourage Resident 47 to reposition frequently for pressure relief. -á The Documentation Survey Report 10/1/24 indicated Resident 47 was not repositioned on the night shift. -á The Alleged Neglect investigation dated 10/2/24 revealed Staff 2 (DNS) was notified Resident 47 did not receive care during the night shift on 10/1/24. Resident 47 stated Staff 5 (Former CNA) was ""useless,"" entered the room, turned off the call light, and did not provide care. Resident 47 also reported she/he was not offered any hydration or toileting. Due to ALS, Resident 47 was unable to eat or hydrate independently. -á On 9/16/25 at 8:14 AM, Staff 5 stated Resident 47 did receive care the night of 10/1/25. -á On 9/16/25 at 8:25 AM, Staff 8 (CNA) stated Resident 47 was very upset on the morning of 10/2/24. Staff 5 reported she could not assist Resident 47 due to back issues. -á On 9/16/25 at 11:07 AM, Staff 6 (Former Nurse's Aide Student) stated she saw Staff 5 enter Resident 47GÇÖs room and turn off the call light. Staff 5 then told Staff 6 not to enter the room, saying she would take care of it. Staff 6 reported the concern to Staff 2 on the morning of 10/2/24. -á On 9/16/25 at 11:12 AM, Staff 7 (CNA) stated she did not go into Resident 47's room because Staff 5 was assigned to her/his room. -á On 9/16/25 at 11:43 AM, Staff 9 stated she came in the morning of 10/2/24 and Resident 47 complained about night shift from 10/1/24 not taking care of her/him. Staff 6 told her Staff 5 kept turning off Resident 47's call light. -á On 9/19/25 at 7:17 AM, Staff 1 (Administrator) stated staff were expected to provide care and services and not neglect residents. -á

Corrective Action: Residents # 47 & 51-No longer reside in facility Identification of Others: The facility residents were interviewed to see if they feel safe in the facility and have any concerns, any identified concerns were addressed. Systemic Changes: Education to staff on abuse prevention. Education for new hires on abuse prevention will be audited weekly x3 weeks monthly x2 months. Monitoring: Administrator or designee will review grievances and incident reports daily x2 weeks then weekly x2 months to validate that no potential abuse or neglect has occurred. Any negative findings will be addressed and presented to the QAPI committee for review. Responsible Party: Administrator

3. Resident 47 was admitted to the facility in 4/2024 with diagnoses including quadriplegia, Amyotrophic Lateral Sclerosis (ALS, a progressive disease which affects physical function). -á A facility reported incident dated 10/3/24 at 10:00 AM indicated on 10/2/24 at 12:00 PM, Staff 4 (CNA) reported Staff 5 did not provide care to Resident 47 during the night shift on 10/1/24. -á Attempts to interview Staff 4 on 9/16/25 and 9/18/25 were unsuccessful. -á On 9/16/25 at 11:07 AM, Staff 6 (Former Nurse's Aide Student) stated she observed Staff 5 enter Resident 47GÇÖs room and turn off the call light during night shift on 10/1/24 without providing care or services. Staff 6 reported the concern to Staff 2 between 6:00 AM and 7:00 AM on 10/2/24. -á Staff 2 was not available for interview. -á On 9/19/25 at 7:19 AM, Staff 1 (Administrator) stated she would expect staff to report an allegation of neglect to the State agency within 24 hours if no major injury occurred. -á , 1. Resident 21 was admitted to the facility 8/25/25 with diagnoses including pelvic fracture.-á -áOn 9/15/25 at 3:52 PM, Resident 21 stated she/he reported an allegation of abuse by Staff 33 (RN) and Staff 34 (CNA) that occurred on 9/7/25. The resident alleged an RN, and a CNA gave her/him a suppository against her/his will. Resident 21 also alleged Staff 34 forcefully placed her hand on the resident's hip to hold her/him down. Resident 21 stated she/he spoke to Staff 2 (DNS) and Staff 1 (Administrator) about the incident and wanted to file a grievance.-á The facility reported the alleged abuse to the State Agency on 9/16/25.-á -áOn 9/16/25 at 7:53 AM, Staff 2 stated she and Staff 1 spoke with the resident and the staff involved when they learned of the incident 9/8/25. Staff 2 stated she did not take further action. -áOn 9/19/25 at 10:33 AM, Staff 1 (Administrator), Staff 15 (Regional VP) and Staff 11 (Regional Director of Operations) stated allegations of abuse should be reported to the state agency within 2 hours.-á 2: Resident 51 was admitted to the facility in 8/2023 with diagnoses including infection.-á On 4/28/25 Resident 51 reported she/he had been verbally and physically abused by Staff 24 (CNA). Staff 2 (DNS) and Staff 3 (former Administrator) learned of the alleged abuse on 4/28/25 at 12:15 PM and a FRI was submitted to the State Agency on 4/28/25 at 3:49 PM. Resident 51 was not available for interview. Staff 2 was not available for interview. -áAn attempt to interview Staff 24 on 9/16/25 was not successful.-á -áAttempts to interview Staff 3 on 9/18/25 were not successful.-á On 9/18/25 at 8:30 AM, Staff 21 (CNA) stated she was assisting Staff 24 to provide care for Resident 51 on 4/27/25. Staff 21 stated Staff 24 handled the resident roughly while placing a chuck (a device used to help reposition a resident) under the resident. She stated Staff 24 told Resident 51 she/he was ""not exactly easy to move"" when Resident 51 objected to the rough handling by Staff 24. Staff 21 stated Staff 24 then jerked the chuck under the resident to reposition her/him without counting (a method used to be sure staff reposition the resident in unison). The resident told Staff 24 he was hurting her/him. Staff 21 stated Staff 24 ignored the resident and left the room after repositioning her/him without providing additional care.-á On 9/19/25 at 10:27 AM, Staff 16 (Social Services Director) stated Resident 51 informed her on 4/28/25 Staff 24 had been abusive to her/him while providing care. On 9/19/25 at 10:33 AM, Staff 1 (Administrator), Staff 15 (Regional VP) and Staff 11 (Regional Director of Operations) stated allegations of abuse should be reported to the state agency within 2 hours and stated facility records showed the alleged abuse was not reported timely.-á -á

Corrective Action: Resident # 21 had no negative outcome by this practice Residents # 47 & 51 are no longer in the facility Identification of Others: The Administrator or designee reviewed the last 14 days of facility events for the need to report to the State and any issues noted were corrected as appropriate. The facility residents were interviewed to see if they feel safe in the facility and have any concerns, any identified concerns were addressed. Systemic Changes: Education was conducted by a member of the governing body to the Administrator and Director of Nursing Services on reporting to State agency, as it pertains to CMS guidance in F-609. Monitoring: The Administer or designee will review new facility events in the morning meeting for validation of reporting to State Agency, as it pertains to CMS guidelines in F-609. Any negative findings will be addressed and presented to the QAPI committee for review Responsible Party: Administrator

Resident 6 was admitted to the facility in 1/2025 with diagnoses including kidney failure. A review of Resident 6's clinical record revealed she/he was transferred to the hospital on 12/23/24. No evidence was found in the clinical record to indicate a written notice of the facilityGÇÖs bed hold policy was provided to the resident or her/his representative. No documentation was found indicating the Ombudsman was notified of the transfer. On 9/18/25 at 8:47 AM, Staff 11 (Regional Director of Clinical Operations) and Staff 14 (Assistant Director of Nursing Services) verified a written bed hold notification was not provided to Resident 6 or her/his representative at the time of transfer to the hospital, and the Ombudsman was not notified of the transfer.

Corrective Action: Resident # 6 had no negative outcome by this practice. Identification of Others: Medical Records reviewed the last 4 weeks of facility discharges and reported as required to the Ombudsman. Reside nt currently at hospital were reviewed to ensure bed hold was provided.  Resident discharged to hospital will be provided with a bed hold. Systemic Changes: Education will be provided by the Administrator or designee to social services and licensed nurses regarding the policy related to bed holds. Education will be provided by the Administrator or designee to medical records regarding when to notify the Ombudsman related to transfers and discharges. Monitoring: Administrator or designer will audit facility discharges in the morning meeting for bed holds and notification to the ombudsman, weekly x3 weeks, and monthly x2 months, and PRN thereafter. Audits for bed holds and notification to the Ombudsman will be forwarded to QAPI committee x2 months to validate compliance, identify trends, and education needs. Responsible Party: Administrator or designee

1. Resident 2 was admitted to the facility in 9/2022 with a diagnosis of heart disease.-á -á Per Mayo Clinic: Hypokalemia (low potassium) symptoms of irregular heart rhythms were the most worrisome complication of very low potassium levels, particularly in people who have heart disease -á Resident 2's 8/11/25 Basic Metabolic Panel results revealed her/his potassium level was 2.7 (normal range 3.4-4.9).-á -á Resident 2's Progress Notes revealed: -On 8/11/25 Resident 2 was seen by her/his physician at the medical clinic and laboratory samples were obtained.-á -On 8/12/25 her/his physician called the facility with orders to transport Resident 2 to the local emergency department due to a critically low potassium level. The note indicated Resident 2 refused to be transported to the hospital due to the cost of the transportation.-á -On 8/13/25 at 8:42 AM Resident 2 was transported to the hospital for a critically low potassium level. -On 8/13/25 at 5:03 PM Resident 2 was admitted to the hospital with a diagnosis of NSTEMI (Non-ST-elevation Myocardial Infarction/type of heart attack where a partial blockage of the artery reduces blood flow to the heart causing muscle damage).-á -á -á Resident 2's clinical record revealed no documentation Resident 2's physician was informed the resident was not sent to the emergency department per physician orders on 8/12/25 and there was no documented monitoring of the resident after she/he refused to go to the hospital.-á -á -á -á On 9/17/25 at 3:49 PM Staff 31 (LPN) stated Resident 2's physician called the facility and provided orders to send Resident 2 to the emergency room due to a critically low potassium level. When the emergency medical technicians arrived, they informed Resident 2 the cost of the transport would likely not be covered with insurance, and she/he would need to pay for transportation. Resident 2 did not want to pay for transportation. Staff 31 stated she did not call the physician to inform him the orders were not implemented.-á -á -á On 9/17/25 at 3:06 PM Staff 32 (LPN Patient Care Coordinator) stated there was no indication the staff communicated with Resident 2's physician that orders to send Resident 2 to the emergency room were not followed and verified there was no monitoring of Resident 32 until she/he was transported to the hospital the following day, despite being at risk for complications related to low potassium levels.-á -á -á -á 2. Resident 5 was admitted to the facility in 9/2024 with a diagnosis of kidney disease.-á -á -á Resident 5's 9/2/25 Order Summary Report revealed she/he had dialysis on Mondays, Wednesdays, and Fridays from 6:00 AM to 9:00 AM. Orders also included Resident 5 was to be administered Aspirin (non-steroidal anti-inflammatory) daily, calcium acetate (binds with phosphate in food) with meals daily, midodrine (treats low blood pressure) every Monday, Wednesday, and Friday, Allopurinol (treats gout) daily, omeprazole (treats acid reflux) daily, and a multivitamin (supplement) daily. Resident 5's 8/2025 and 9/2025 MAR revealed she/he did not receive Allopurinol on 8/6/25, 8/11/25, 8/15/25, 9/3/25, and 9/15/25, midodrine on 8/6/25, 8/11/25, 8/27/25, 9/3/25, and 9/15/25, multivitamin on 8/6/25, 8/11/25, 8/27/25, 9/3/25, and 9/15/25, omeprazole on 8/6/25, 8/27/25, 9/1/25, 9/3/25, calcium acetate 8/6/25 AM dose, 8/22/25 AM dose, 8/27/25 AM dose, 8/29/25 AM dose, 9/3/25 AM dose, 9/10/25 AM dose, 9/12/25 AM dose, and 9/15/25 AM dose, and Aspirin on 8/6/25, 8/11/25, 8/27/25, 9/3/25, and 9/15/25. -á On 9/18/25 at 3:06 PM Staff 14 (Assistant DNS) stated Resident 5 had dialysis early mornings on Monday, Wednesday, and Friday, and staff often did not provide the medications as ordered on dialysis days.-á -á -á 3. Resident 8 was admitted to the facility in 2/2024 with a diagnosis of dementia. -á -á Resident 8's 9/2/25 Order Summary Report revealed she/he was to be administered Bisacodyl (laxative) tablets PRN if she/he did not have a bowel movement for two days. -á -á Resident 8's bowel record from 8/20/25 through 9/18/25 revealed she/he did not have a bowel movement for two days from 8/20/25 through 8/23/25, 9/5/25 through 9/7/25, and 9/15/25 though 9/17/25. -á Resident 8's 8/2025 and 9/2025 MAR revealed she/he was not administered Bisacodyl after not having a bowel movement for two days on 8/22/25, 9/1/25, 9/7/25, and 9/17/25. -á On 9/18/25 at 8:44 AM Staff 35 (RN) stated the night shift staff ran a bowel report for all residents. If a resident did not have a bowel movement for three days bowel care was initiated.-á -á -á On 9/18/25 at 3:06 PM Staff 14 (Assistant DNS) stated the facility's bowel protocol was to provide bowel care after a resident did not have a bowel movement for three days. Staff 14 verified staff did not follow Resident 8's physician orders for bowel care which were to be administered if she/he did not have a bowel movement for two days.-á-á -á -á

Corrective Action: Resident # 2 has returned to the facility and is stable at this time. Resident #5 medications were reviewed with the physician and medication schedule adjusted. Resident #8 bowel meds standing orders have been revised to provide clearer parameter. Identification of Others: Residents with any critical lab results in the last 7 days were reviewed to ensure provider notification and assessment documented. Residents on dialysis treatment were reviewed to ensure medication administration times do not conflict with dialysis schedule. Residents' bowel movements have been reviewed for last 7 days to ensure bowel protocol implemented as indicated. Systemic Changes: Licensed nurses were educated on critical labs, provider notification, assessment, and documentation by Director of Nursing/ designee. Licensed nurses were educated on medication scheduling during scheduled dialysis times by Director of Nursing/ designee. Bowel protocol updated per Medical Director.  Education was provided to the licensed nurses on bowel protocol by Director of Nursing/ designee. Monitoring: Critical labs will be audited daily during clinical meeting M-F to ensure appropriate provider notification, assessment and documentation.  Any identified issues will be addressed. Residents on dialysis will be audited weekly to ensure medications are appropriately scheduled around dialysis times.  Any identified issues will be addressed. Bowels will be audited by nurse managers daily (M-F) to ensure bowel protocol followed per physician orders for 2 weeks, then weekly x 2 months. Any identified issues will be addressed. Audits will be forwarded to QAPI committee x2 months to validate compliance, identify trends, and education needs Responsible Party: Director of Nursing or designee

An undated Water Temperature Instructions sheet for logging facility water audits revealed: Test the water at various locations thought the facility. For burn prevention the domestic water temperatures were to be kept below 120 degrees Fahrenheit.-á -á 1.Resident 9 was admitted to the facility in 7/2025 with a diagnosis of anxiety.-á Resident 9's 6/22/25 Quarterly MDS revealed she/he was-ácognitively intact. On 9/16/25 at 2:42 PM with Staff 38 (Maintenance Director) Resident 9's sink water was observed to be 123.3 degrees F. Staff 38 stated he checked the water weekly but usually did the audits in the morning, and the water temperatures were never that high.-á On 9/17/25 at 7:48 AM Resident 9 stated she/he loved the hot water. On 9/16/25 at 3:36 PM Staff 1 (Administrator) stated the water audits should not be done at the same time each week to ensure the water temperature variances were identified throughout the day and temperatures should be below 120 degrees F. -á 2. Resident 16 was admitted to the facility in 9/2022 with a diagnosis of diabetes.-á Resident 16's 7/1/25 Quarterly MDS Revealed she/he was-ácognitively intact. On 9/16/25 at 2:42 PM with Staff 38 (Maintenance Director) Resident 9's sink water was observed to be 123.3 degrees F. Staff 38 stated he checked the water weekly but usually did the audits in the morning, and the water temperatures were never that high.-á On 9/17/25 at 7:48 AM Resident 16 stated she/he loved-áthe hot water. On 9/16/25 at 3:36 PM Staff 1 (Administrator) stated the water audits should not be done at the same time each week to ensure the water temperature variances were identified throughout the day and temperatures should be below 120 degrees F.-á -á -á3. Resident 19 was admitted to the facility in 8/2025 with a diagnosis of a stroke.-á Resident 19's 8/5/25 Admission MDS revealed she/he was-ácognitively intact. On 9/16/25 at 2:29 PM with Staff 38 (Maintenance Director) Resident 19's sink water was observed to be 132.1 degrees F. Staff 38 stated he checked the water weekly but usually did the audits in the morning, and the water temperatures were never that high.-á On 9/17/25 at 8:03 AM Resident 19 stated she liked the water hot. On 9/16/25 at 3:36 PM Staff 1 (Administrator) stated the water audits should not be done at the same time each week to ensure the water temperature variances were identified throughout the day and the temperatures should be below 120 degrees F.-á -á -á4. Resident 26 was admitted to the facility in 7/2025 with a diagnosis of a stroke.-á On 9/16/25 at 2:35 PM with Staff 38 (Maintenance Director) Resident 2's sink water was observed to be 124.7 degrees F. Staff 38 stated he checked the water temperatures weekly but usually did the audits in the morning, and the water temperatures were never that high.-á On 9/16/25 at 3:36 PM Staff 1 (Administrator) stated the water audits should not be done at the same time each week to ensure the water temperature variances were identified throughout the day and the temperatures should be below 120 degrees F.-á -á On 9/16/25 at 3:33 PM Staff 28 (LPN) stated residents did not report hot water concerns and usually staff had to let the water run for a while for the water to become warm enough for residents to shower.-á-á -á On 9/16/25 at 3:35 PM Staff 21 (CNA) stated residents usually reported the water was not warm enough.-á -á On 9/17/25 Resident 26 was not available for an interview. -á 5. Resident 32 was admitted to the facility in 10/2024 with a diagnosis of heart disease.-á Resident 32's 8/5/25 Quarterly MDS revealed she/he was cognitively impaired. On 9/16/25 at 2:35 PM with Staff 38 (Maintenance Director) Resident 32's sink water was observed to be 124.7 degrees F. Staff 38 stated he checked the water temperatures weekly but usually did the audits in the morning, and the water temperatures were never that high. On 9/16/25 at 3:33 PM Staff 28 (LPN) stated residents did not report hot water concerns and usually staff have to let the water run for a while for the water to become warm enough for residents to shower.-á-á On 9/16/25 at 3:35 PM Staff 21 (CNA) stated residents usually reported the water was not warm enough.-á On 9/16/25 at 3:36 PM Staff 1 (Administrator) stated the water audits should not be done at the same time each week to ensure the water temperature variances were identified throughout the day and the temperatures should be below 120 degrees F.-á -á -á6. Resident 33 was admitted to the facility in 8/2024 with a diagnosis of liver disease.-á Resident 33's 8/11/25 Annual MDS revealed she/he was-ácognitively intact. On 9/16/25 at 2:29 PM with Staff 38 (Maintenance Director) Resident 33's sink water was observed to be 132.1 degrees F. Staff 38 stated he checked the water weekly but usually did the audits in the morning, and the water temperatures were never that high.-á On 9/16/25 at 3:36 PM Staff 1 (Administrator) stated the water audits should not be done at the same time each week to ensure the water temperature variances were identified throughout the day and the temperatures should be below 120 degrees F. On 9/17/25 at 8:57 AM Resident 33 stated the staff-áassisted her/him with the water, and she/he did not-áhave any concerns with the temperatures. -á 7. Resident 52 was admitted to the facility in 9/2025 with a diagnosis of respiratory failure.-á Resident 52's 9/16/25 Admission MDS Revealed she/he was-ámoderately cognitively impaired. On 9/16/25 at 2:35 PM with Staff 38 (Maintenance Director) Resident 52's sink water was observed to be 124.7 degrees F. Staff 38 stated he checked the water weekly but usually did the audits in the morning, and the water temperatures were never that high.-á On 9/16/25 at 3:36 PM Staff 1 (Administrator) stated the water audits should not be done at the same time each week to ensure the water temperature variances were identified throughout the day and the temperatures should be below 120 degrees F. -á 8. Resident 54 was admitted to the facility in 9/2025 with a diagnosis of heart failure.-á -á Resident 54's 9/13/25 Admission MDS revealed she/he was cognitively intact. -á On 9/16/25 at 2:34 PM with Staff 38 (Maintenance Director) Resident 54's sink water was observed to be 129.4 degrees F. Staff 38 stated he checked the water weekly but usually did the audits in the morning, and the water temperatures were never this high.-á On 9/16/25 at 3:36 PM Staff 1 (Administrator) stated the water audits should not be done at the same time each week to ensure the water temperature variances were identified throughout the day. On 9/16/25 at 3:33 PM Staff 28 (LPN) stated residents did not report hot water concerns and usually staff have to let the water run for a while for the water to become warm enough for residents to shower.-á-á On 9/16/25 at 3:35 PM Staff 21 (CNA) stated residents usually reported the water was not warm enough.-á Resident 54 was not available to be interviewed. On 9/16/25 at 3:36 PM Staff 1 (Administrator) stated the water audits should not be done at the same time each week to ensure the water temperature variances were identified throughout the day.-á -á 9. Resident 55 was admitted to the facility in 9/2025 with a diagnosis of heart disease. Resident 55's 9/14/25's Admission MDS revealed she/he-áwas cognitively intact. On 9/16/25 at 2:29 PM with Staff 38 (Maintenance Director) Resident 55's sink water was observed to be 132.1 degrees F. Staff 38 stated he checked the water weekly but usually did the audits in the morning, and the water temperatures were never that high.-á On 9/16/25 at 3:36 PM Staff 1 (Administrator) stated the water audits should not be done at the same time each week to ensure the water temperature variances were identified throughout the day and the temperatures should be below 120 degrees F.-á On 9/17/25 at 8:59 AM Resident 55 stated she/he did not-áthink the water was too hot and the temperature was just fine. -á 10. Resident 58 was admitted to the facility in 9/2025 with a diagnosis of a hip fracture. Resident 58's 9/10/25 Admission Profile indicated-áshe/he had some short-term memory issues but was able to communicate without difficulty. On 9/16/25 at 2:29 PM with Staff 38 (Maintenance Director) Resident 58's sink water was observed to be 132.1 degrees F. Staff 38 stated he checked the water weekly but usually did the audits in the morning, and the water temperatures were never that high.-á On 9/17/25 at 8:55 AM Resident 58 stated she/he did not-áhave concerns with the water being too hot. On 9/16/25 at 3:36 PM Staff 1 (Administrator) stated the water audits should not be done at the same time each week to ensure the water temperature variances were identified throughout the day and the temperatures should be below 120 degrees F. -á -á -á

Corrective Action: Resident ‘s # 9,16,19,26,32,33,52,54,55,58 had no negative outcome related to water temperatures outside required parameters. Identification of Others: The Administrator or designee reviewed the last 14 maintenance water temperature checks within the facility and any issues noted were corrected as appropriate. Systemic Changes: Education was conducted by the Administer to the Maintenance Director on water temperature logs, hours, and ranges and times for temperature monitoring. Monitoring: Maintenance will audit water temperatures at various times and locations weekly x3 weeks, and monthly x2 months, and PRN there after Audits will be forwarded to QAPI committee x2 months to validate compliance, identify trends, and education needs. Responsible Party: Administrator or designee

On 9/15/25 at 11:29 AM, Staff 19 (Dietary Manager) picked up and sorted meal tickets with gloved hands and then picked up bread without washing his hands and changing gloves.-á On 9/15/25 at 11:30 AM, Staff 19 opened the walk-in cooler with gloved hands and then handled raw foods without washing his hands and donning clean gloves. On 9/15/25 at 11:31 AM, Staff 20 opened the walk-in cooler and removed condiments with his bare hands and then touched clean dishes without washing his hands and donning gloves. On 9/17/25 at 11:12 AM, Staff 19 picked up a clipboard with gloved hands then picked up cooked meat without washing his hands and donning clean gloves.-á -áOn 9/17/25 at 11:28 AM, Staff 19 stated CNAs help residents complete meal tickets each morning. Staff 19 stated the tickets were a contaminated surface.-á On 9/17/25 at 11:31 AM, Staff 19 took a meal ticket with gloved hands and placed it on a cutting board and after plating the food, placed the ticket on the tray and picked up the next ticket, placing it on the cutting board.-á -áOn 9/17/25 at 11:49 AM, Staff 19 sorted meal tickets with gloved hands then placed a quesadilla on the same cutting board, cut it, and placed it on a plate without washing his hands or changing gloves. -áOn 9/17/25 at 12:59 PM, Staff 19 stated he was aware he should not touch items in the kitchen that are not sanitized with gloved hands without washing his hands and donning clean gloves.-á -áOn 9/18/25 at 12:45 PM, Staff 19 stated the kitchen staff had not been using proper hand hygiene while preparing and plating resident meals.-á -áOn 9/18/25 at 1:05 PM, Staff 20 stated he was aware the walk-in cooler handle and the meal tickets were contaminated surfaces, and he acknowledged touching both with gloved hands and not washing his hands or changing his gloves afterward.-á On 9/19/25 at 10:33 AM, Staff 1 (Administrator), Staff 15 (Regional VP) and Staff 11 (Regional Director of Clinical Operations) acknowledged the facility failed to practice proper hand hygiene.-á -á -á -á -á -á -á -á

Corrective Action: Education provided to dietary staff on proper hand hygiene and food handling practices. Identification of Others: No negative outcomes were identified from this deficient practice. Systemic Changes: Meal ticket process updated to reduce risk of cross contamination. Kitchen staff educated on proper hand hygiene and food handling practices. Monitoring: Administrator or designee to round in kitchen daily x 2 weeks, then daily x4 weeks to ensure staff are performing proper hand hygiene and adhering to required food handling practices. Responsible Party: Administrator or designee

2. Resident 1 was admitted to the facility in 6/2025 with diagnoses including chronic kidney disease, and disorders of the bladder. The facilityGÇÖs Transmission-Based Precautions Policy and Procedure revised 11/2024, indicated the following: Enhanced Barrier Precautions (EBP) were implemented alongside standard precautions to reduce transmission of multidrug-resistant organisms (germs that resist treatment with multiple antibiotics). EBP required targeted use of glove and gowns during high-contact resident care activities such as transferring and device care, including urinary catheter use. -á PPE included gloves and gown prior to the high-contact care. Face protection (mask, goggles, or face shield) may also be needed if there was risk for splash or spray. a. -á A 6/25/25 care plan indicated Resident 1 was at risk for infection due to a history of aspiration (inhaling food or fluid into the lungs), pneumonia, indwelling catheter (tube placed in the bladder to drain urine), and a history of multiple UTIs. Interventions included to implement EBP during high-contact care activities such as transferring, and urinary catheter care. On 9/17/25 at 9:17 AM, Staff 13 (CNA) and Staff 12 (CNA) were observed assisting Resident 1 with a transfer using a mechanical lift. Both staff wore gloves; no other PPE was observed. On 9/17/25 at 9:26 AM, Staff 13 and Staff 12 stated they understood EBP applied to changing briefs or emptying a catheter, and they would wear full PPE during those tasks. They did not believe gowns were required for transferring Resident 1 with a mechanical lift. On 9/17/25 at 9:27 AM, the EBP sign posted next to Resident 1's room indicated all health care personnel must wear gloves and gown for high contact resident care activities including bathing, transferring, changing linens, assisting with toileting and providing hygiene. On 9/19/25 at 7:14 AM, Staff 11 (Regional Director of Clinical Operations) stated staff were expected to follow the EBP sign and policy for using the proper PPE while caring for a resident. b. On 9/18/25 at 2:01 PM, Staff 18 (Hospice RN) was overheard informing Resident 1 her/his catheter was leaking, and she was going to turn on the light to change the catheter. Staff 18 was observed wearing gloves but no gown. At 2:19 PM, Staff 18 removed her gloves; no gown was observed. Staff 18 confirmed she changed Resident 1's catheter and wore only gloves. She acknowledged a gown should be worn during catheter care. -á -á On 9/19/25 at 7:14 AM Staff 11 (Regional Director of Clinical Operations) stated staff were expected to follow the EBP sign and policy for using the proper PPE while caring for residents. , 1. Resident 24 was admitted to the facility in 8/2025 with a diagnosis of cellulitis (infection of the skin). -á Resident 24's Care Plan initiated 8/29/25 revealed she/he was used a walker with transfers and was to be supervised. Resident 24 had a history of a drug-resistant organism in her/his urine, was at times incontinent, and had cellulitis to her/his leg requiring precautions during high contact activities.-á -á On 9/17/25 at 9:20 AM a Contact Isolation sign was observed outside of Resident 24's door. The sign directed staff to put on a gown and gloves prior to entering the resident's room. Staff 36 was observed to enter Resident 24's room after putting on a disposable gown and gloves. Resident 24 exited the room and Staff 36 followed her/him after she removed her gloves and performed hand hygiene. Staff 36 did not remove her disposable gown. Staff 36 stated she did not remove the gown because she did not want Resident 24 to walk down the hall without assistance.-á On 9/18/25 at 12:21 PM Staff 14 (IP) stated staff should have removed the gown prior to exiting the room.-á -á -á -á

Corrective Action: Resident # 1 and # 24 had no negative outcomes related to this practice. Identification of Others: The Hospice Nurse was educated by the Infection Control Nurse PPE and policy adherence. Systemic Changes: Education was conducted by the infection control preventionist nurse on PPE donning and doffing, adhering to signs and policy to facility staff and hospice providers. Monitoring: The director of nursing or designee will audit adherence to the policy by doing infection control rounds weekly x3 weeks, and monthly x2 months, and PRN thereafter. Audits will be forwarded to QAPI committee x2 months to validate compliance, identify trends, and education needs. Responsible Party: Administrator or designee

A review of the Direct Care Staff Daily Reports (DCSDRs) from 8/14/25 through 9/14/25 revealed the census was not documented on 11 night shifts. On 9/18/25 at 10:05 AM, Staff 17 (Staffing Coordinator) confirmed the census was not completed. She stated she had not reviewed the DCSDRs to verify the sheets were complete. -á On 9/19/25 7:04 AM, Staff 1 (Administrator) stated she expected staff to document the census on DCSDR each shift.

Corrective Action: Direct Care Staffing Report census lines were updated. Identification of Others: All residents have the potential to be affected by this deficiency. Systemic Changes: Education provided to nurses regarding direct staff reporting requirements. Monitoring: Monitoring: The DNS or designee will validate accuracy and thorough completion of the Direct Care Staff Daily Reports daily x 2 weeks and then weekly x 2 months. Any negative findings will be promptly addressed and presented to the monthly QAPI Meeting for review. Responsible Individual : Executive Director or designee

The facility's Direct Care Staff Daily Reports were reviewed for the following dates: 1/4/25, 1/5/25, 1/11,25, 1/12/25, 1/18/25, 1/19/25, 1/25/25, 1/26/25, 2/1/25, 2/2/25, 2/8/25, 2/9/25, 2/15/25, 2/16/25, 2/22/25, 2/23/25, 3/1/25, 3/2/25, 3/8/25, 3/9/25, 3/15/25, 3/16/25, 3/22/25, 3/23/25, 3/29/25, 3/30/25, and 8/14/25 through 9/14/25. Seven of the days lacked eight consecutive hours of RN coverage between the start of day shift and the end of evening shift. The dates were as follows: -1/25/25, 2/1/25, 2/22/25, 3/8/25, 8/16/25, 9/9/25, and 9/10/25. On 9/18/25 at 10:05 AM, Staff 17 (Staffing Coordinator) confirmed the above dates did not have RN coverage for eight consecutive hours between the start of day shift and the end of evening shift. On 9/19/25 7:04 AM, Staff 1 (Administrator) stated the facility was trying to accommodate staff shift preferences.

Corrective Action: Staffing updated to include RN coverage no less than eight consecutive hours between the start of day shift and end of evening shift 7 days a week. Identification of Others: Identification of Others: This deficiency has the potential to affect all residents within the facility. An audit of resident records was completed to validate that there were no unmet assessments or care needs of current residents. Systemic Changes: Systemic Changes: The Executive Director, Director of Nursing and Staffing Coordinator were educated on the minimum licensed nurse staff requirements and RN staffing requirements as they pertain to OAR 411-86-0100(4). Monitoring: Monitoring: The DNS or designee will validate that a registered nurse is scheduled and works the required hours. An audit to confirm this will be completed daily x 2 weeks and then weekly x 2 months. Any negative findings will be promptly addressed and presented to the monthly QAPI Meeting for review. Responsible Individual : Director of nursing or designee

Based on interview and record review it was determined the facility failed to ensure a resident was safe from elopement for 1 of 1 sampled resident (#1) reviewed for elopement. This failure was determined to be an immediate jeopardy situation due to the facility failed to follow the Resident 1's care plan and provide adequate supervision, which resulted in Resident 1's elopement from the facility. Findings include: Resident 1 admitted to the facility on 8/2024 for a 5-day respite stay with diagnoses including Alzheimer's Disease, dementia, anxiety disorder and restlessness. On 9/5/24 at 11:53 AM, Witness 1 (Family) stated on 8/15/24 she was notified Resident 1 was found in the middle of a roundabout, confused and carrying a teddy bear by a local law enforcement officer. The officer notified Resident 1's family. Witness 1 stated Resident 1 told her she/he wanted to leave the facility so when someone opened the door, she/he walked out. The 8/12/24 BIMS (an assessment tool used to assess cognition) revealed Resident 1 had severe cognitive impairment. The 8/12/24 Ambulation Care Plan revealed Resident 1 was independent with ambulation. The 8/13/24 Behavior Care Plan revealed Resident 1 was at risk for behavior symptoms related to elopement due to dementia, sun downs (the emergence or worsening of symptoms, like agitation, confusion or aggressiveness, in the late afternoon or early evening) and her/his first time away from home. Interventions included to encourage Resident 1 to remain in a supervised area when out of bed, monitor every 15 minutes and to redirect when wandering. The 8/13/24 Elopement Evaluation revealed Resident 1 was at risk for elopement. The 8/13/24 Progress Note revealed Resident 1 was confused, wandered throughout the facility and was exit seeking. The 8/14/24 Progress Note revealed Resident 1 wandered around the facility "trying to get out" and stated she/he wanted to go home. Resident 1 attempted to open each door she/he approached, all she/he thought of was to leave and was a high elopement risk. The 8/28/24 Facility Investigation revealed Resident 1 was at the facility for a five day respite stay, was ambulatory, could "almost run if [she/he] want to", "went to every door in the facility to try and get out", set off two alarms, needed frequent visual checks and was a high risk for elopement and falls. On 8/15/24, Staff 6 (CNA) last observed Resident 1 between 5:30 PM and 5:45 PM when the resident walked back and forth in the hallway, appeared agitated and excited and stated, "I want to go home. I am going home today." The investigation further indicated Witness 2 (Visitor) observed Resident 1 in the lobby when Resident 1 sat down and began to talk out loud to herself/himself. Resident 1 abruptly stood up and stated she/he was going for a walk and followed another visitor out the door. The investigation summary indicated Staff 5 (CNA) last saw the resident at 6:30 PM in her/his room and Witness 2 observed her/him in the lobby between 7:00 PM and 7:15 PM. Resident 1 was found in the street by a police officer at approximately 7:30 PM and the facility staff was notified of the elopement at 7:45 PM when Resident 1 was returned to the facility by the police officer. Per record review the distance from the facility to where the resident was found was approximately 1.8 miles. Per Google Earth and Mapquest, the resident would have walked alongside a four lane highway, crossed the highway, walked along a busy street and transversed through three roundabouts before she/he was found in the third roundabout by the local police. Record review revealed 30-minute visual checks were in place from 8/13/24 at 6:45 AM through 8/15/24 at 3:30 PM. Resident 1's visual checks stopped nearly four hours before she/he eloped on 8/15/24 after 7:00 PM. In addition, Resident 1's care plan of 15-minute checks was not followed. On 9/5/24 at 10:56 AM, Staff 5 stated she was the last person to observe Resident 1 at 6:30 PM, when she attempted to wake up the resident for dinner. This was 30-45 minutes before Resident 1's elopement. Staff 5 further stated, "after a while, the police came saying she was missing." On 9/5/24 at 11:20 AM, Staff 8 (CNA) stated Resident 1 was very confused, stayed by the door and was exit seeking the entire time at the facility. If staff attempted to redirect her/him, Resident 1 would get very angry, shake, grind her/his teeth and then immediately begin to exit seek again out all of the doors. On 9/6/24 at 11:46 AM, Staff 9 (CNA) stated Resident 1 was exit-seeking and pulling on the doors, but did not see any staff redirect her/him and did not redirect Resident 1 herself. On 9/5/24 at 12:37 PM, Staff 12 (CNA) stated Resident 1 was exit-seeking from the moment she/he woke up and constantly tried to find a way out using any of the four doors. Staff 12 further stated all staff were aware of the exit seeking behavior but did not redirect Resident 1 unless she/he was at the main entry door. Staff 12 stated not all staff on evening and night shift were aware of the care planned safety checks so the checks did not always get done. On 9/5/24 at 12:20 PM, Staff 2 (DNS) and Staff 4 (Admission Nurse/Resident Care Manager) verified Resident 1 was a high risk for elopement. Staff 2 stated Resident 1's care plan should have had individualized interventions in place to prevent elopement and acknowledged there was no documented evidence Resident 1's care plan was followed by encouraging her/him to remain in a supervised area when out of bed, monitoring her/his location every 15 minutes and redirecting when she/he wandered. Staff 2 stated the every 30 minute monitoring "fell off" at 3:30 PM on 8/15/24 because staff were unaware of the need to do this . Staff 2 acknowledged Resident 1 was found approximately two miles away from the facility by a local law enforcement officer and staff were unaware of the elopement until 7:45 PM when the resident was brought back to the facility. Staff 2 stated, she/he "picked a time that was a good time when all the staff were busy." On 9/5/24 at 2:05 PM, Staff 1 (Administrator) and Staff 2 (DNS) were notified of the Immediate Jeopardy (IJ) situation and provided a copy of the IJ template related to the facility's failure to put into place individualized care plan interventions and to follow the residents care plan to prevent elopement. On 9/5/24 at 4:17 PM, an acceptable facility IJ removal plan was submitted by the facility. The plan indicated the facility would implement the following actions: *Current residents identified as elopement risks would have their care plans reviewed to reflect person centered care. *All current residents would be reassessed for risk of elopement. Any identified residents' plan of care would be updated to include individualized, personalized interventions. *The elopement book would be updated to include any newly identified residents. *All facility staff would be educated on the residents identified at risk for elopement and their individualized care plan interventions as well as procedures to initiate if a resident eloped. Education would be completed by 9/6/24 at 2:30 PM. Staff who were on leave or under COVID restrictions would be required to complete the education prior to returning work. *Daily audits would be completed starting 9/6/24 by the Interdisciplinary Team (IDT) to ensure residents were properly identified for elopement risk, elopement care plans were individualized, and staff followed care plan elopement interventions. Any identified issues would be immediately corrected. *Daily audits would continue for 14 days, then weekly for three months. Results of the audits would be presented to the QAPI team. The IJ was removed on 9/6/24 at 2:00 PM, as confirmed by onsite verification by the survey team on 9/9/24.

How the safety of the identified resident is immediately ensured: Resident discharged from facility on 8/15/24 How the safety of residents throughout the facility will be ensured: Current residents identified as elopement risks will have their care plans reviewed and adjusted to reflect person centered care. 9/6/24 All current residents reassessed for elopement risk. For any identified residents, the plan of care will be updated to include individualized, personized interventions. Complete 9/6/24 The elopement book will be updated to include any newly identified residents. Complete 9/6/24 Measures taken to ensure the same issue does not occur: In-service all facility staff in all departments on identified residents with elopement risk and individualized care plan interventions as well as procedures to initiate if a resident elopes. All facility staff will be educated starting 9/5/24 evening shift, all-staff meeting on 9/6/24 at 1:30 pm ending 2:30 pm and ongoing for remaining staff prior to starting their next shift. Staff who are on planned vacation, FMLA, or covid restrictions will be required to complete education prior to returning to work. Auditing practices: Audits will be completed daily starting 9/6/24 by IDT to ensure that residents are appropriately identified for elopement risk, elopement care plans are individualized, and staff are following care plan elopement interventions. Any identified issues will be immediately corrected. Audits will continue daily for 14 days then weekly for 3 months. Results of the audits will be presented to the QAPI team. Responsible parties: Administrator / DNS

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

Based on interview, and record review it was determined the facility failed to obtain consent to administer medication for 1 of 5 (#16) sampled residents reviewed for unnecessary medications. This placed residents at risk for uninformed care. Findings include: Resident 16 admitted to the facility in 12/2019 with diagnoses including dementia, restlessness and agitation. A review of Resident 16's Physician Orders revealed an 4/11/24 order for buspirone (a medication in the anxiolytic drug class used to treat anxiety). A review of Resident 16's medical record revealed an 4/11/24 signed consent for buspirone listed as an antidepressant medication. The consent went over the risks and benefits for an antidepressant medication. On 5/30/24 at 4:03 PM Staff 2 (DNS) stated buspirone was an anxiolytic medication, not an antidepressant medication. Staff 2 acknowledged Resident 16 and her/his representative were not given informed consent for buspirone.

1.What corrective action will be accomplished for those residents found to have been affected by the deficient practice? ¿ Residents #16 Buspirone consent was reviewed for risk and benefits for anxiolytic 2. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective actions will be taken? ¿ The facility residents anxiolytic consents where audited and issues were addressed and corrected as appropriate ¿ Education was provided to the social service and the nursing department on consents and anxiolytic by the director of nursing or designee 3. Measures the facility will take or the systems will alter to ensure that the problem does not occur. ¿ An anxiolytic audit will be completed on new orders and changes in the clinical meeting by IDT weekly x3 weeks and monthly x 2 months and PRN there after 4. How the corrective actions will be monitored to ensure the deficient practice will not recur i.e., what quality assurance program will be put into place? New anxiolytic audits will be reviewed at a monthly QAPI meeting x3 months for needs of adjustments to plan. 5. Person/People Responsible: Director of Nursing Services or designee

Based on interview and record review it was determined the facility failed to evaluate a resident's choice for bathing for 1 of 1 sampled resident (#18) reviewed for choices. This place residents at risk for lack of honored choices. Findings include: Resident 18 admitted to the facility in 2023 with diagnoses including stroke and anxiety. The 3/4/24 Quarterly MDS indicated Resident 18 required partial to moderate assistance for bathing and was cognitively intact. A 11/29/24 care plan indicated to provide Residents 18's bathing according to his/her preferences two times a week. The Task: Shower form for Resident 18 indicated the following: -On 5/1/24 at 9:30 PM the resident refused her/his shower. -On 5/4/24 at 8:30 PM the resident refused her/his shower. -On 5/11/24 at 9:54 PM the resident refused her/his shower. On 5/28/24 at 9:23 AM Resident 18 stated she/he refused showers because staff offered showers at night when she/he wanted to be in bed. Resident 18 stated she was told by CNAs her/his showers were scheduled at night. Resident 18 requested a different time for bathing and no changes were made to her/his bathing schedule. On 5/29/24 at 8:39 AM Staff 5 (Resident Care Manager) stated an investigation regarding Resident 18's shower refusals was not started as expected. Staff 5 acknowledged Resident 18 should be aware an alternative shower schedule was available.

1.What corrective action will be accomplished for those residents found to have been affected by the deficient practice? ¿ Residents #18 was interviewed, and shower schedule was updated based on interview 2. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective actions will be taken? ¿ The facility residents were interviewed and shower schedules were updated as appropriate ¿ Education was provided to the nursing department on residents right to choose shower schedules by the director of nursing or designee 3. Measures the facility will take or the systems will alter to ensure that the problem does not occur. ¿ Shower audit will be completed, and preferences will be reviewed on new admissions, trending refusals, completion, and request for changes of shower schedules in the clinical meeting by IDT weekly x3 weeks and monthly x 2 months and PRN there after 4. How the corrective actions will be monitored to ensure the deficient practice will not recur i.e., what quality assurance program will be put into place? Shower schedule audits will be reviewed at monthly QAPI meeting x3 months for needs of adjustments to plan. 5. Person/People Responsible: Director of Nursing Services or designee

Based on interview and record review it was determined the facility failed to ensure advance directive information was provided to residents for 3 of 4 sampled residents (#s 11, 34, and 40) reviewed for advance directives. This placed residents at risk for lack of end-of-life choices being honored. Findings include: 1. Resident 11 admitted to the facility in 2023 with a diagnosis of surgical infection. An 4/6/24 quarterly MDS revealed Resident 11 had impaired cognition. An 4/11/24 Care Conference form indicated Resident 11 had an advance directive. On 5/29/24 at 10:01 AM Staff 9 (Social Service Director) stated if the Care Conference form indicated the resident had an advance directive, a copy was to be in the resident's clinical record. On 5/29/24 at 2:18 PM Staff 2 (DNS) stated Resident 11 did not have an advance directive. Staff 2 also stated there was no documentation to indicate Resident 11 or her/his representative were provided information regarding advance directives. On 5/29/24 at 2:50 PM Witness 3 (Family) and Witness 4 (Family) stated the facility did not provide information related to advance directives. Witness 3 also stated he did not know anything about advance directives. 2. Resident 34 admitted to the facility in 2024 with a diagnosis of skin infection. A 5/7/24 quarterly MDS revealed Resident 34 was cognitively intact. A 5/23/24 Care Conference form indicated Resident 34 had an advance directive. On 5/29/24 at 8:08 AM Resident 34 stated she/he did not have an advance directive, did not want and advance directive, and the facility did not provide information related to advance directives. On 5/29/24 at 9:53 AM Staff 9 (Social Service Director) stated Resident 34 did not have an advance directive in her/his clinical record and would provide documentation if advance directive information was provided. No additional information was provided. 3. Resident 40 admitted to the facility in 2024 with a diagnosis of UTI. A 5/10/24 admission MDS revealed Resident 40 was cognitively intact. A 5/20/24 Care Conference form revealed Resident 40 had an advance directive. On 5/29/24 at 9:46 AM Resident 40 stated she/he did not have an advance directive and the facility did not provide information regarding advance directives. On 5/29/24 at 9:50 AM Staff 9 (Social Service Director) stated if the record indicated a resident had an advance directive it should be in the resident's clinical record. A request was made to Staff 9 to provide Resident 40's advance directive or documentation to indicate advance directive information was provided. No additional information was provided.

1.What corrective action will be accomplished for those residents found to have been affected by the deficient practice? ¿ Resident #11s advance directive choices were reviewed and information was given to as appropriate ¿ Resident #34 No longer is in the facility ¿ Resident # 40 No longer is in the facility 2. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective actions will be taken? ¿ The facility residents were reviewed to assess the needs for advance directives and were updated as appropriate ¿ Education was provided to the IDT on Advanced Directives as it relates to F-578 by the governing body Crystal Snarr RN or designee 3. Measures the facility will take or the systems will alter to ensure that the problem does not occur. ¿ An advance directive audit will be completed on new admissions, quarterly and with change of condition by IDT weekly x3 weeks and monthly x 2 months and PRN there after 4. How the corrective actions will be monitored to ensure the deficient practice will not recur i.e., what quality assurance program will be put into place? Advance Directive audits will be reviewed at monthly QAPI meeting x3 months to assess for needs of adjustments to the plan. 5. Person/People Responsible: Social Service

Based on interview and record review it was determined the facility failed to provide an Advanced Beneficiary Notice for 1 of 3 (#5) sampled residents reviewed for Beneficiary Notification. This placed residents at risk for financial loss. Findings include: Resident 5 admitted to the facility in 8/2016 with diagnoses including respiratory failure. Resident 5 had a skilled Medicare stay from 1/10/23 through 1/19/23. Resident 5 remained in the facility after 1/19/23 on Medicaid. A review of Resident 5's medical record revealed no evidence of an Advanced Beneficiary Notice (ABN) issued to her/him after his Medicare stay. On 5/31/24 at 9:08 AM Staff 3 (Regional Nurse Consultant) acknowledged Resident 5 was not issued an ABN upon payor change from Medicare to Medicaid on 1/19/23.

1.What corrective action will be accomplished for those residents found to have been affected by the deficient practice? ¿ Resident #5 was issued a SNF ABN 2. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective actions will be taken? ¿ All current facility residents were reviewed for potential ABN needs and were updated as appropriate ¿ Education was provided to the IDT on SNF ABNs as it relates to F-582 by the governing body Crystal Snarr RN or designee 3. Measures the facility will take or the systems will alter to ensure that the problem does not occur. ¿ SNF ABN audit will be completed with change of payor source and Need for ABN in the clinical meeting by IDT weekly x3 weeks and monthly x 2 months and PRN there after 4. How will the corrective actions be monitored to ensure the deficient practice will not recur i.e., what quality assurance program will be put into place? Advanced Beneficiary Notice audits will be reviewed at monthly QAPI meeting x3 months for needs of adjustments to plan. 5. Person/People Responsible: Administrator

Based on observation and interview it was determined the facility failed to maintain comfortable temperature levels for 1 of 2 (Pine Meadow Hall) halls observed for environment. This placed residents at risk for uncomfortable temperatures. Findings include: Resident 26 admitted to the facility in 2024 with diagnoses including ALS (a nervous system disease). On 5/28/24 at 10:17 AM Resident 26 stated her/his room and the hall were too cold and made her/his body hurt. Resident 26 stated she/he reported this to management and nursing staff, but nothing was done to resolve the temperature issue. On 5/30/24 at 10:39 AM Staff 15 (CNA) and Staff 16 (CNA) stated Pine Meadow Hall was cold and residents complained about it. Multiple random observations from 5/28/24 through 5/31/24 revealed Resident 26's room and Pine Meadow Hall were cold. The thermostat for the hall was set to 68 degrees. On 5/30/24 at 1:04 PM Staff 14 (Maintenance Director) stated he tested the temperature in residents' rooms but did not document the results or complete audits. Staff 14 stated he was aware of Resident 26's complaints of being cold, but he kept the thermostats at 74 degrees. On 5/30/24 at 1:10 PM Staff 2 (DNS) verified the thermostat in Pine Meadow Hall was set for 68 degrees and should be set for 71 degrees to 81 degrees to keep residents comfortable, and acknowledged she was aware Resident 26 complained of the hall and her/his room being cold.

1. What corrective action will be accomplished for those residents found to have been affected by the deficient practice? Hallway thermostat in identified hall was immediately inspected for proper function and temperature setting set forth by regulation 483.10(i)(6), Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81¿F . The thermostat was found to be set at 68 degrees F and was immediately adjusted to bring the hallway temperature to a range of 71-81 deg F. 2. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective actions will be taken? The Maintenance Director inspected all thermostats in resident hallways for proper operation and temperature setting. Any temperatures identified as being outside the regulation range of 71-81 deg F were immediately adjusted to maintain regulation temperatures. 3. Measures the facility will take, or the systems will alter to ensure that the problem does not occur. In-service performed with Maintenance Director and Maintenance Assistant on maintaining the proper temperature in all resident hallways according to regulation 483.10(i)(6), Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81¿F. The Maintenance Director, or designee, will audit hallway temperatures weekly and document temperature reading using the facilitys TELS maintenance tracking software. 4. How will the corrective actions be monitored to ensure the deficient practice will not recure what quality assurance program will be put into place? Resident Council will offer feedback regarding comfort levels of hallway temperatures and make suggestions to the IDT on temperature adjustments. Any requests will be addressed promptly by the Maintenance Director and/or Administrator. The Maintenance Director, or designee, will report audits to QAPI Committee x3 months. Persons responsible for monitoring systems put in place: Administrator / Maintenance Director or designee

Based on interview and record review it was the determined the facility failed to prevent abuse for 3 of 3 (#s 14, 21, and 31) sampled residents reviewed for abuse. This placed residents at risk for abuse. Findings include: 1. Resident 14 admitted to the facility in 2022 with diagnosis including stroke. A 3/5/24 Quarterly MDS revealed Resident 14 was cognitively intact. A 3/27/24 revised care plan indicated Resident 14 was incontinent of bowel and required one staff to assist with bowel care. A 5/14/24 Alleged Abuse investigation for Resident 14 indicated a CNA reported an allegation of abuse because Resident 14 was questioned why she/he no longer had Staff 23 (former Agency CNA) provide her/his care. Resident 14 stated Staff 23 completed her/his personal care and wiped her/him roughly stating Staff 23 tried to "stick a wipe and her finger up her/his butt." Resident 14 told Staff 23 she was rough during care. Resident 14 indicated Staff 23 continued to provide rough care, became upset and told her/him not to tell her how to complete her job. On 5/28/24 at 1:33 PM Resident 14 confirmed she/he told Staff 23 to "stop and she kept going" during personal care after her/his bowel movement. On 5/31/24 at 1:16 PM Staff 1 (Administrator) acknowledged the facility investigation revealed abuse occurred between Staff 23 and Resident 14. , 2. Resident 21 admitted to the facility in 8/2023 with diagnoses including spinal stenosis (a narrowing of the spinal canal which can cause pressure on the spinal cord of nerves). A 2/25/24 Quarterly MDS revealed Resident 21 was cognitively intact. A 5/14/24 Incident Reported revealed Resident 21 reported Staff 23 (former agency CNA) was verbally rude and was rough with care. On 5/14/24 a FRI form was submitted to the State Agency by the facility. On 5/28/24 at 8:49 AM Resident 21 stated Staff 23 was verbally abusive and was rough with care. Resident 21 stated she/he asked Staff 23 to be gentle with care, but she was not. On 5/30/24 at 5:31 PM Staff 23 stated she encouraged Resident 21 to be more independent and Resident 21 became mad at her. On 5/31/24 at 8:46 AM Staff 2 (DNS) stated Resident 21 had a skin assessment completed after the allegation, no physical injuries were noted. Staff 2 stated Resident 21 was placed on alert charting after the allegation to monitor for psychosocial harm, and no psychosocial harm was noted. On 5/31/23 at 1:37 PM Staff 1 (Administrator) confirmed the investigation for the allegation of abuse concluded Staff 23 was abusive toward Resident 21. 3. Resident 31 admitted to the facility in 1/2024 with diagnoses including hemiplegia (paralysis of half of the body) affecting the left side of the body. A 5/5/24 Quarterly MDS revealed Resident 31 was cognitively intact. A 5/14/24 Incident Report revealed Resident 31 reported Staff 23 (former agency CNA) was emotionally and physically abusive. On 5/14/24 a FRI form was submitted to the State Agency by the facility. On 5/28/24 at 9:55 AM Resident 31 stated Staff 23 called her/him a liar when Resident 31 stated she/he needed to be put back in bed. Resident 31 stated it took three hours for Staff 23 to put her/him back in bed. Resident 31 stated once Staff 23 put her/him in bed, she changed her/his incontinent brief. Resident 31 stated Staff 23 jerked her/him around "like a rag doll", and "shoved" her/him into the wall. Resident 31 stated she/he requested Staff 23 be careful and Staff 23 replied "I have 40 some patient here, if I took time to turn them all carefully, I would not be able to do my job." On 5/30/24 at 5:31 PM Staff 23 stated Resident 31 wanted to lay down right after lunch, she/he was a two-person transfer and she was not able to lay her/him down right away, and Resident 31 became angry with her. On 5/31/23 at 8:46 AM Staff 2 (DNS) stated Resident 31 had a skin assessment completed after the allegation, and no physical injuries were noted. Staff 2 stated Resident 31 was placed on alert charting after the allegation to monitor for psychosocial harm, and no psychosocial harm was noted. On 5/31/23 at 1:37 PM Staff 1 (Administrator) confirmed the investigation for the allegation of abuse concluded Staff 23 was abusive toward Resident 31.

1. What corrective action will be accomplished for those residents found to have been affected by the deficient practice? ¿ Resident #14 -No negative effect noted related to practice ¿ Resident #31-No longer is in facility ¿ Resident #21- No negative effect noted related to practice 2. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective actions will be taken? ¿ The facility residents were interviewed to assess their feelings of safety within the facility and identify any concerns with care ¿ Education was provided to facility staff as it relates to abuse and neglect prevention by Administer or designee 3. Measures the facility will take or the systems will alter to ensure that the problem does not occur. ¿ Education on abuse and neglect prevention will be provided on hire, annual and PRN ¿ Education for new hires on abuse and neglect prevention will be audited weekly x3 weeks monthly x 2 months. 4. How will the corrective actions be monitored to ensure the deficient practice will not recur i.e., what quality assurance program will be put into place? ¿ Will review education to staff on abuse training at monthly QAPI meeting new hire abuse prevention education x3 months for needs of adjustments to plan. 5. Person/People Responsible: Administrator

Based on interview and record review it was determined the facility failed to revise care plans for 2 of 5 sampled residents (#s 2 and 34) reviewed for unnecessary medications. This placed residents at risk for lack of appropriate care. Findings include: 1. Resident 2 admitted to the facility in 2024 with diagnoses including end stage kidney disease and stroke. A 5/24/24 hospital Discharge Summary indicated Resident 2 admitted to the hospital due to a hematoma (pool of mostly clotted blood) in her/his chest wall while on an oral anticoagulant. Resident 2's discharge medications included no anticoagulant medication. A 5/24/24 revised care plan indicated to provide interventions, monitor and prevent bleeding for Resident 2 due to the use of her/his anticoagulant medication. On 5/31/24 at 9:22 AM Staff 5 (Resident Care Manager) stated the orders for Resident 2 were not checked twice as expected when Resident 2's anticoagulant medication was discontinued. Staff 5 acknowledged Resident 2's care plan was not revised. , 2. Resident 34 admitted to the facility in 2024 with a diagnosis of dementia. Resident 34's clinical record revealed she/he was started on Ativan (antianxiety medication) during 3/2024. A Care Plan revised on 3/12/24 revealed Resident 34 was at risk for side affects of Ativan. The Care Plan did not include what caused Resident 34 to be anxious or resident specific interventions to provide prior to the administration of Atvian. On 5/30/24 at 3:03 PM Staff 5 (Resident Care Manager) stated after Resident 34's Atvian was initiated a care plan was not updated to include resident specific behaviors or interventions for the use of Ativan. Refer to F758.

1. What corrective action will be accomplished for those residents found to have been affected by the deficient practice? ¿ Resident #2s Care Plan was reviewed and updated ¿ Resident #34-No longer is in the facility 2. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective actions will be taken? ¿ The facility residents care plans were reviewed and updated as appropriate ¿ Education was provided to IDT as it relates to care plan revision by the governing body Crystal Snarr RN 3. Measures the facility will take or the systems will alter to ensure that the problem does not occur. ¿ Audits will be conducted for need for care plan revision on admission, quarterly annually and with change of condition weekly x3 weeks monthly x 2 months by the director of nursing or designee 4. How the corrective actions will be monitored to ensure the deficient practice will not recur i.e., what quality assurance program will be put into place? ¿ Audits of care plans revision will be reviewed at monthly QAPI meeting x3 months for needs of adjustments to plan. 5. Person/People Responsible: Director of Nursing

Based on interview and record review it was determined the facility failed to follow physician orders for 2 of 2 sampled residents (#s 7 and 9) reviewed for accidents and hospice. This placed residents at risk for unmet care needs. Findings include: Resident 9 admitted to the facility in 2017 with diagnoses including end of life care and restless leg syndrome. An 10/10/23 Cognitive Loss CAA revealed Resident 9 stated rest, repositioning and medications were helpful to address her/his pain relief and discomfort. The 11/2/23 physician order indicated Resident 9 was to receive Benztropine (restless leg medication) every evening at bedtime. A review of Resident 9's clinical record for 5/2023 revealed Resident 9 missed eight doses of her/his Benztropine. On 5/28/24 at 8:20 AM Resident 9 stated she/he went without the medication she needed for her/his restless leg syndrome for eight days. On 5/29/23 at 3:38 PM Staff 2 (DNS) acknowledged the resident missed eight doses of her/his medication. , 2. Resident 7 admitted to the facility in 2/2024 with diagnoses including depression. A 5/21/24 MDS indicated Resident 7 had moderate cognitive impairment. A 5/22/24 Progress Note revealed Resident 7 felt unsafe with the resident in room 9A near her/him and measures were put in place to keep Resident 7 "safe." A 5/23/24 care plan indicated Resident 7 and the resident in room 9A were not to have contact with each other per Resident 7's preference. On 5/29/24 at 12:25 PM Staff 9 (Social Service Director) stated the resident in room 9A was Resident 33 and was not in room 9A anymore. On 5/29/24 at 4:51 PM Resident 7 stated she/he was uncomfortable with Resident 33 because she/he sat too close to her/him and Resident 7 stated Resident 33 was "wacky." On 5/30/23 at 12:26 PM Resident 7 was observed in the dining room and Resident 33 was observed pulling up a chair and sitting next to Resident 7. Staff in the dining room did not intervene. At 12:31 PM Staff 9 (Social Service Director) was informed of the observation by the surveyor. Staff 9 spoke with a staff member in the dining room and Resident 33 was moved to another table. On 5/30/24 at 1:45 PM Staff 1 (Administrator) and Staff 2 (DNS) confirmed Resident 7 was care planned to not have contact with Resident 33 and acknowledged ongoing training was needed. Staff 2 acknowledged Resident 7's care plan was not updated after Resident 33 moved out of room 9A.

1. What corrective action will be accomplished for those residents found to have been affected by the deficient practice? ¿ Resident #9 No negative outcome medication was validated to be in house ¿ Resident #7 No negative outcome Care Plan was updated ¿ Resident #33 -No negative outcome from practice Care Plan was updated 2. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective actions will be taken? ¿ The Facility residents orders were reviewed and updated as appropriate ¿ Education was provided to the facility Management nurses on transcribing new orders by the director of nursing ¿The Facility residents care plans were reviewed and updated as appropriate ¿ Education was provided to the facility Management nurses on care plan revision by the governing body Crystal Snarr RN 3. Measures the facility will take or the systems will alter to ensure that the problem does not occur. ¿ Audits will be conducted for need for care plan revision on admission, quarterly annually and with change of condition by the director of nursing or designee weekly x3 weeks monthly x 2 months. ¿ Audits will be conducted on order entry and transcribing by the director of nursing or designee weekly x3 weeks monthly x 2 months. 4. How will the corrective actions be monitored to ensure the deficient practice will not recur i.e., what quality assurance program will be put into place? ¿ Audits of care plans revision and order entry will be reviewed at monthly QAPI meeting x3 months for needs of adjustments to plan. 5. Person/People Responsible: Director of Nursing

Based on interview and record review it was determined the facility failed to scheduled an audiology exam for 1 of 1 sampled resident (#22) reviewed for communication needs. This placed residents at risk for unmet needs. Findings include: Resident 22 admitted to the facility in 4/2023 with diagnoses including a stroke. A 1/24/24 Provider Progress Note revealed Resident 22 requested to see a hearing doctor. An 4/27/24 MDS revealed Resident 22 was cognitively intact. On 5/28/24 at 9:48 AM Resident 22 stated she/he was hard of hearing and was recommended hearing aids at a doctor's appointment approximately eight months ago. On 5/29/24 at 12:21 PM Staff 9 (Social Service Director) stated Resident 22 should have had a hearing appointment set up but was unable to locate the information. A 5/29/24 Progress Note revealed Resident 22's son was called to confirm or schedule a yearly hearing exam for Resident 22. On 5/31/24 at 8:06 AM Staff 5 (RN Resident Care Manager) stated she was aware Resident 22 was hard of hearing and acknowledged Resident 22 did not see a hearing doctor.

1. What corrective action will be accomplished for those residents found to have been affected by the deficient practice? ¿ Resident # 22 -Hearing was addressed as appropriate 2. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective actions will be taken? ¿ The Facility residents were evaluated for hearing needs and addressed as appropriate ¿ Education was provided to the IDT on follow up of resident hearing needs by the governing body Crystal Snarr RN 3. Measures the facility will take or the systems will alter to ensure that the problem does not occur. ¿ Audits will be conducted to assess for hearing services needs by the director of nursing or designee weekly x3 weeks monthly x 2 months. 4. How the corrective actions will be monitored to ensure the deficient practice will not recur i.e., what quality assurance program will be put into place? ¿ Audits of hearing needs will be reviewed at monthly QAPI meeting new hire x3 months for needs of adjustments to plan. 5. Person/People Responsible: Social Service

Based on observation, interview and record review it was determined the facility failed to accurately assess pressure wounds and follow physician orders for 2 of 3 sampled residents (#s 4 and 19) reviewed for pressure ulcers. This placed resident at risk for worsening wounds. Findings include: 1. Resident 4 admitted to the facility in 2023 with diagnoses including stroke and aphasia (speech or language deficit due to brain injury). A 12/9/23 physician order indicated to float Resident 4's heels while in bed, apply skin prep to her/his heels each shift and ensure a foam boot was applied to her/his right heel at all times. The 4/19/24 Quarterly MDS indicated Resident 4 had a Stage 4 (deep wound that may impact muscles, ligaments, and bone) pressure ulcer to the heel. The 5/2024 TAR indicated on each shift through 5/29/24 Resident 4's heels were floated while in bed, skin prep was applied to her/his heels each shift and a foam boot was applied to her/his right heel at all times. The 5/22/24 revised care plan indicated to administer treatments as ordered and encourage Resident 4 to float her/his heels. On 5/29/24 at 12:06 PM Resident 4 was observed in bed with her/his heels resting on the bed and her/his feet exposed to the air. On 5/29/24 at 1:03 PM Staff 22 (CNA) stated she was not assigned to care for Resident 4 on 5/29/24, but confirmed her/his heels should be floated and boots applied to her/his feet. On 5/30/24 at 9:53 AM and 10:06 AM Staff 6 (LPN) stated Staff 26 (RN) changed Resident 2's treatments a week prior and Resident 2's feet were to remain exposed to the air. Staff 6 stated on 5/29/24 she did not verify Resident 2's heels were floated or was informed Resident 2 refused. On 5/30/24 at 10:00 AM Staff 16 (CNA) stated Resident 2 typically refused to float her/his heels and she did not inform nursing of the resident's refusal on 5/29/24. On 5/31/24 at 9:01 AM Staff 5 (Resident Care Manager) stated she was not informed of Resident 2's refusals to float her/his heels and acknowledged any changes to Resident 2's treatments should be updated in the resident's clinical record and followed. , 2. Resident 19 admitted to the facility in 2023 with diagnoses including bladder cancer. A 11/18/23 Incident Note indicated Resident 19 had an open area to the sacrum (triangular bone at the bottom of the spine) and discolored area approximately 2 cm x 1 cm on the right side of the gluteal cleft. A 11/24/23 Incident Note indicated Resident 19 had a small approximately 0.2 cm open area with a very small unmeasurable purple spot on her/his sacrum at the intragluteal cleft. A 12/1/2023 Incident Note indicated Resident 19 was on alert related to an open area with a very small unmeasurable purple spot on her/his sacrum at intragluteal cleft. A 12/12/23 Skin and Wound Evaluation indicated Resident 19 had a Stage 4 (deep wound that may impact muscles, ligaments, and bone) wound to her/his coccyx (tail bone). A 12/14/23 Progress Note indicated Resident 19 had a small sacral pressure wound. The 12/2023 TAR indicated Resident 19 had a small sacral pressure wound. 12/5/23 and 1/5/24 physician orders indicated staff were to provide wound care to small sacral pressure wound. A 1/26/24 Skin and Wound Evaluation indicated Resident 19 had a Stage 4 in-house acquired pressure ulcer. There were no further Skin and Wound Evaluations until 3/1/24. On 5/31/24 at 11:22 AM Staff 5 (Resident Care Manager) acknowledged the wound was a deep tissue injury from the beginning and was not assessed accurately, and the TAR and the physician order were not accurate describing the wound as a small sacral wound. On 5/31/24 at 11:51 AM Staff 3 (Regional RN) stated staff assessed the wound inaccurately when the wound started. Staff 2 acknowledged from 1/26/24 to 3/1/24 there were no weekly Skin and Wound Evaluations completed.

1. What corrective action will be accomplished for those residents found to have been affected by the deficient practice? ¿ Resident # 2s orders, Care plan and heels were reviewed and changes made as appropriate ¿Resident # 19s Skin and wound evaluation was completed, orders and Care plan reviewed and any issues were addressed as appropriate 2. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective actions will be taken? ¿ The Facility residents were evaluated for skin evaluation, treatment orders and Care plans updates any issues were addressed as appropriate ¿ Education was provided to the nursing staff on follow for Care plans adherence, orders followed and skin and wound evaluations completed and accurate , by the director of nursing. 3. Measures the facility will take or the systems will alter to ensure that the problem does not occur. ¿ Audits will be conducted for accurate completion of skin evaluation, rounding for Care plan adherence and order follow up by the director of nursing or designee weekly x3 weeks monthly x 2 months and PRN thereafter. 4. How will the corrective actions be monitored to ensure the deficient practice will not recur i.e., what quality assurance program will be put into place? ¿ Audits of skin evaluations, Care plan adherence and Order follow up will be reviewed at monthly QAPI meeting x3 months for needs of adjustments to plan. 5. Person/People Responsible: Director of Nursing

Based on observation, interview, and record review it was determined the facility failed to provide adequate supervision for 1 of 2 sampled residents (#33) reviewed for accidents. This placed residents at risk for injury. Findings include: Resident 22 admitted to the facility in 4/2024 with diagnoses including a stroke. An 4/5/24 MDS revealed Resident 33 had moderate cognitive impairment. A 5/15/24 Elopement Evaluation revealed Resident 33 was a moderate risk for elopement. A 5/29/24 review of Resident 33's care plan revealed no evidence of an elopement care plan. Resident 33 was observed during random observations from 5/28/24 through 5/31/24 to ambulate with a walker up and down the hallways, through the dining room, front lobby and occasionally resident rooms throughout the day. On 5/30/24 at 1:54 PM Staff 1 (Administrator) and Staff 2 (DNS) confirmed Resident 33 was at risk for elopement but was not care planned at risk for elopement.

1. What corrective action will be accomplished for those residents found to have been affected by the deficient practice? ¿ Resident # 22 No negative effect to resident ¿Resident # 33 -Care plan was reviewed and updated as appropriate 2. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective actions will be taken? ¿ The Facility residents were evaluated for needs in care and addressed as appropriate ¿ Education was provided to the management nurses on care plan updates by the director of nursing. 3. Measures the facility will take or the systems will alter to ensure that the problem does not occur. ¿ Audits will be conducted for accurate completion for care plan by the director of nursing or designee weekly x3 weeks monthly x 2 months and PRN thereafter. 4. How the corrective actions will be monitored to ensure the deficient practice will not recur i.e., what quality assurance program will be put into place? ¿ Audits of the care plan will be reviewed at monthly QAPI meeting x3 months for needs of adjustments to plan. 5. Person/People Responsible: Director of Nursing

Based on interview and record review it was determine the facility failed to implement orders and consistently monitor a dialysis (a procedure to remove excess waste products and fluid from the blood) access site for 1 of 1 sampled resident (#2) reviewed for dialysis. This placed residents at risk for dialysis complications. Findings include: Resident 2 admitted to the facility in 2024 with diagnoses including end stage kidney disease and stroke. A 3/4/24 Admission MDS indicated Resident 2 received dialysis. A 5/20/24 RD Nutrition Assessment indicated Resident 2 required an early breakfast and late lunch on dialysis days and to avoid high phosphorus and potassium food options at meals. A 5/21/24 Nursing Note indicated receipt of a new diet order for Resident 2 to avoid high phosphorus and potassium foods. A 5/24/24 revised care plan indicated to assess Resident 2's dialysis shunt for bruit (whooshing) and thrill (vibration) daily and provide diet according to orders. The 5/2024 TAR indicated no post-dialysis monitoring of bruit, thrill or pressure site dressing. On 5/28/24 at 2:09 PM Resident 2 stated she/he left for dialysis before breakfast in the mornings and did not return until late for lunch. Resident 2 stated she/he was provided no food until she/he returned from dialysis. On 5/29/24 at 1:32 PM Staff 2 (DNS) acknowledged the dialysis site should be monitored daily by nursing and food should be sent with Resident 2 to dialysis. On 5/29/24 at 2:53 PM Staff 4 (Dietary Manager) stated he was not aware Resident 2 required special meal accommodations due to dialysis and did not revise diet restrictions to address high potassium and phosphorus foods. On 5/29/24 at 3:50 PM Staff 13 (RD) acknowledged Resident 2's diet restriction should be on her/his meal ticket and the appropriate foods provided.

1. What corrective action will be accomplished for those residents found to have been affected by the deficient practice? ¿ Resident # 2- Orders were reviewed and TAR was updated as appropriate. Diet communication was sent to the kitchen for the diet needs. 2. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective actions will be taken? ¿ Facility residents audited. No other residents within the facility are currently, on dialysis ¿ Education was provided to the nurses on diet communication to the kitchen and dietary needs by the director of nursing or designee. . ¿ Education was provided to the nurses on order needs for dialysis residents by the director of nursing or designee. 3. Measures the facility will take or the systems will alter to ensure that the problem does not occur. ¿ Audits will be conducted for orders on dialysis and dietary communication by director of nursing or designee weekly x3 weeks, monthly x 2 months and PRN thereafter. 4. How will the corrective actions be monitored to ensure the deficient practice will not recur i.e., what quality assurance program will be put into place? ¿ Audits of dialysis and dietary communication will be reviewed at monthly QAPI meeting x3 months for needs of adjustments to plan. 5. Person/People Responsible: Director of Nursing

Based on interview and record review it was determined the facility failed to ensure a resident was assisted with discharge planning arrangements for 1 of 1 sampled resident (#11) reviewed for care planning. This placed residents at risk for increased anxiety. Findings include: Resident 11 admitted to the facility in 2023 with a diagnosis of surgical infection. Resident 11's clinical record revealed her/his home was six miles from the facility. A 12/8/23 Quarterly MDS revealed Resident 11 was able to answer questions but had moderate cognitive issues. A 1/10/24 Care Conference form revealed Witness 3 (Family) and Witness 4 (Family) attended the care conference. The form indicated Witness 3 and Witness 4 requested they be notified before Resident 11 was discharged to ensure they had "things set up" for the resident's care. The form indicated Resident 11 wanted "to go home." Concerns related to the resident's discharge were the resident's mental status and weakness. The form did not indicate what needed to be set up at the resident's home to ensure it was ready for her/his care. An 4/11/24 Care Conference form revealed Resident 11's family had a meeting to discuss discharge and the plan was for Resident 11 to discharge home with caregivers. The form also indicated the Resident's family felt it was better for Resident 11 to return home. The family requested a home evaluation. The facility notified the family the resident needed 24/7 support. The form also indicated family would provide care, but did not specify who, if a home evaluation was to be completed, or what equipment or steps were needed to ensure a safe discharge. On 5/28/24 at 10:04 AM Resident 11 stated discharge planning was confusing. Resident 11 stated she/he should have been discharged one month prior but no one at the facility communicated with her/him. A 5/28/24 Progress note revealed Resident 11 approached staff to inquire about her/his discharge home. Resident 11 requested staff call family. The note indicated Witness 4 reported they were waiting for the local unit to "get things approved." On 5/29/24 at 12:06 PM Staff 7 (Therapy Director) stated Resident 11 exhausted her/his therapy benefits and was not eligible for additional therapy. Therapy ended 4/6/24. Staff 7 stated the resident did not improve with therapy and often did not want to get out of bed. Resident 11 would not be able to go home alone and Resident 11 reported she/he had a roommate. Staff 7 stated she was not sure who would provide care for Resident 11. Staff 7 stated therapy could do a home evaluation if the resident lived within 10 miles of the facility. Staff 11 was not sure the distance to Resident 11's home. Staff 7 stated caregiver training was not provided. On 5/29/24 at 12:06 PM and 5/30/24 at 11:46 AM Staff 9 (Social Service Director) stated the resident had a roommate at her his home but was not sure who lived with the resident. Staff 7 also stated the resident required a ramp to enter the home and did not provide information to the family related to resources. Staff 7 stated the family was waiting for the local unit to assist with the resident's financial status. Staff 7 stated she informed the family to call her if they needed help but thought the family did not want the resident to return home. Staff 7 stated she did not speak to the local unit. A request was made to provide documentation of assistance provided to the Resident 11's family to assist with the plan for her/his discharge. No additional information was provided. On 5/29/24 at 2:50 PM Witness 3 and Witness 4 stated therapy was to evaluate the home for the resident's discharge but it was not completed. Witness 3 stated they even called hospice to see if they could provide assistance with getting the resident home. Witness 3 and Witness 4 stated the facility never worked with them to assist with transfers or how to care for the resident. They lived with the resident and the resident wanted to go home. The facility did not help at all. On 5/29/24 at 3:37 PM Witness 5 (Local Unit) stated it was the facility responsibility to ensure the resident had all the needed equipment and supervision to go home. Resident 11 was just approved for financial assistance. Witness 5 stated the local unit could help with a ramp to the resident's home. Witness 5 stated the facility did not communicate with her/him regarding the resident's discharge or financial eligibility status.

1. What corrective action will be accomplished for those residents found to have been affected by the deficient practice? ¿ Resident #11 No negative effect to resident. A care conference was scheduled to discussed Discharge wishes and plan 2. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective actions will be taken? ¿ The facility residents were evaluated for needs in their care conference related to discharge planning and addressed as appropriate ¿ Education was provided to Social Services on Discharge planning by the Administer or designee. 3. Measures the facility will take or the systems will alter to ensure that the problem does not occur. ¿ Audits will be conducted for discharge planning by the Administer or designee weekly x3 weeks monthly x 2 months and PRN thereafter. 4. How the corrective actions will be monitored to ensure the deficient practice will not recur i.e., what quality assurance program will be put into place? ¿ Audits of discharge planning will be reviewed at monthly QAPI meeting x3 months for needs of adjustments to plan. 5. Person/People Responsible: Administrator

Based on interview and record review it was determined the facility failed to ensure non-pharmacological interventions were provided prior to PRN antianxiety medication administration for 1 of 5 sampled residents (#37). This placed residents at risk for sedation. Findings include: Resident 37 admitted to the facility in 2024 with a diagnosis of dementia. Resident 37's Care Plan was updated on 3/12/24 to indicate the resident was at risk for side affects of Ativan (antianxiety medication). A 5/2024 MAR revealed Resident 37 was to be administered Ativan PRN. The resident was administered Ativan 53 times. Only one time the medication was documented as not effective. 5/2024 progress note revealed Resident 37 had anxiety and PRN Ativan was administered. The Ativan was frequently administered at the same time as oxycodone (narcotic pain medication), therefore it was indeterminate if a decrease in the resident's pain level would have decreased her/his anxiety. The Progress notes did not describe how Resident 37's anxiety presented or what specific interventions were provided to decrease her/his anxiety. On 5/29/24 at 8:20 AM Staff 24 (CNA) stated at times Resident 37 was anxious because she/he had delusions (false belief of reality) and often did not remember she/he resided in the facility. Resident 37 usually wanted to be with her/his family. When able, staff called Resident 37's family which helped the resident's anxiety. If the resident had behaviors it was reported to the nurse. On 5/30/24 at 1:54 PM Staff 25 (LPN) stated if a PRN pscyhotropic medication was administered, staff were to document on the MAR or in the Progress Notes what the behavior was and what interventions were provided prior to administration. The MAR usually had interventions specific to the resident and staff could select the interventions provided. On 5/30/24 at 3:03 PM Staff 5 (Resident Care Manager) stated if a PRN antianxiety medication was to be administered staff were to identify the cause and provide interventions specific to the anxiety. Staff 5 stated Resident 37's anxiety improved after the resident became accustomed to the environment. A request was made to Staff 5 to provide documentation interventions specific to anxiety were provided. No additional information was provided.

1. What corrective action will be accomplished for those residents found to have been affected by the deficient practice? ¿ Resident #37s non-pharmacological interventions were added to the orders for psychotropic medication - no negative effect related to practice noted 2. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective actions will be taken? ¿ The facility residents orders were evaluated for non-pharmacological interventions with psychotropic medication and addressed as appropriate ¿ Education was provided to the facility nurses on non-pharmacological intervention with psychotropic medication by the Director of nursing or designee. 3. Measures the facility will take or the systems will alter to ensure that the problem does not occur. ¿ Audits will be conducted for non-pharmacological interventions when new psychotropic medications are initiated by the director of nursing or designee weekly x3 weeks monthly x 2 months and PRN thereafter. 4. How will the corrective actions be monitored to ensure the deficient practice will not recur i.e., what quality assurance program will be put into place? ¿ Audits of Non-pharmacological interventions will be reviewed at monthly QAPI meeting x3 months for needs of adjustments to plan. 5. Person/People Responsible: Director of Nursing

Based on interview and record review it was determined the facility failed to ensure orders for a hypertensive medication were implemented for 1 of 5 sampled residents (#2) reviewed for medications. This placed residents at risk for abnormal heart rhythms. Findings include: Resident 2 admitted to the facility in 2024 with diagnoses including high blood pressure and end stage kidney disease. A 5/13/24 revised care plan indicated Resident 2 had altered cardiovascular status, to monitor vital signs, provide medications per physician order and report any abnormalities. A 5/24/24 hospital Discharge Summary indicated to continue Resident 2's metoprolol succinate (medication to control abnormal heart rhythms). The 5/2024 MAR indicated Resident 2's metoprolol succinate was last administered by the facility on 5/21/24. On 5/31/24 at 9:22 AM Staff 5 (Resident Care Manager) stated the orders for Resident 2 were not checked twice as expected when Resident 2 returned from the hospital (on 5/24/24). Staff 5 acknowledged Resident 2's metoprolol succinate was not administered as ordered.

1. What corrective action will be accomplished for those residents found to have been affected by the deficient practice? ¿ Resident #2s orders for anti-hypertensive medication were clarified and added to the order set 2. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective actions will be taken? ¿ The facility residents orders for anti-hypertensive medications were reviewed and addressed as appropriate ¿ Education was provided to the facility nurses on new order transcription by the Director of nursing or designee. 3. Measures the facility will take or the systems will alter to ensure that the problem does not occur. ¿ Audits will be conducted on new orders for hypertension medication by the director of nursing or designee weekly x3 weeks monthly x 2 months and PRN thereafter. 4. How will the corrective actions be monitored to ensure the deficient practice will not recur i.e., what quality assurance program will be put into place? ¿ Audits of new orders for hypertension medication will be reviewed at monthly QAPI meeting x3 months for needs of adjustments to plan. 5. Person/People Responsible: Director of Nursing

Based on observation, interview, and record review it was determined the facility failed to provide therapeutic diets to 3 of 4 (#s 2, 23, and 28) sampled residents reviewed for food. This placed residents at risk for unmet nutritional needs. Findings include: 1. Resident 2 admitted to the facility in 2024 with diagnoses including end stage kidney disease and diabetes. A 5/24/24 Summary of Care Document for Resident 2 included discharge orders for a diabetic diet. On 5/29/24 at 2:53 PM Staff 4 (Dietary Manager) stated residents who required diabetic diets were individually interviewed to determine what level of diet compliance each resident wanted and Resident 2's preferences were added to her/his meal ticket to reflect her/his requests. Staff 4 acknowledged there were no prescribed recipes used or portion control guideline for staff preparing meals to follow for therapeutic diets including residents who required a diabetic diet. On 5/29/24 at 3:50 PM Staff 13 (RD) acknowledged the facility approved therapeutic diets, which included a diabetic diet, should be printed and followed. , 2. Resident 23 admitted to the facility in 2024 with a diagnosis of malnutrition. A 2/2/24 Admission MDS indicated Resident 23 was cognitively intact. An 4/23/24 physician order indicated Resident 23 was to have nutritionally enhanced meals. A review of Resident Council minutes dated 4/22/24 revealed residents were not receiving what they ordered at mealtimes. On 5/29/24 at 9:13 AM Resident 23 was observed sitting in her/his bedroom with a plate of one small pancake and a small sausage patty, and there were no beverages. Resident 23 stated she/he always ordered oatmeal for breakfast but never received it. On 5/29/24 at 12:30 PM Staff 4 (Dietary Manager) stated if a resident did not complete a meal order the facility prepared whatever was on the menu. Staff 4 acknowledged he was aware Resident 28 always wanted fruit but sometimes it was not provided. 3. Resident 28 admitted to the facility in 2023 with diagnoses including diabetes. A 5/10/24 Significant Change MDS indicated the resident was cognitively intact. A physician order dated 10/12/23 revealed Resident 28 was to receive a CCHO (low carbohydrate) diet related to her/his diagnosis of diabetes. On 5/28/24 at 10:42 AM Resident 28 stated she/he was a diabetic and was not to receive extra carbohydrates. Resident 28 stated she/he marked out carbohydrates on her/his meal order but still received the carbohydrates, and did not receive the fruit she/he ordered. On 5/29/24 at 12:30 PM Staff 4 (Dietary Manager) stated if a resident did not complete a meal order the facility prepared whatever was on the menu. Staff 4 acknowledged he was aware Resident 28 always wanted fruit but sometimes it was not provided.

1. What corrective action will be accomplished for those residents found to have been affected by the deficient practice? Resident 28 no longer resides in the facility. Diet orders for residents 22, 23, and 2 were immediately audited by the Dietary Manager and Registered Dietitian. Physician orders were cross referenced with data in residents chart, on diet order report, and on tray cards in kitchen. Any issues noted were immediately corrected as appropriate. 2. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective actions will be taken? The Dietary Manager and Registered Dietician reviewed diet orders for every resident residing in the facility. Physician orders were cross referenced with data in residents chart, on diet order report, and on tray cards in kitchen. Any issues noted were immediately corrected as appropriate. 3. Measures the facility will take, or the systems to be altered to ensure that the problem does not occur. Education was conducted by the Administrator, Dietary Manager, and Registered Dietician to Admissions Nurses, Resident Care Managers, Speech Therapists, and Charge Nurses on the correct procedure for entering diet orders into resident charts and ensuring diet change orders are efficiently and effectively delivered to the Dietary Department. The Dietary Manager and/or Registered Dietician will conduct education to all current Dietary Staff focused on ensuring any resident with a therapeutic diet receive accurate meal items on the tray card comparable with residents diet orders. The Dietary Manager will complete 100% audit of all residents in the facility once every month by comparing physician orders and each residents diet on tray card to ensure no discrepancies are noted on the diet. The Dietary manager will promptly correct any identified discrepancy. Administrator, or designee, will audit the diet type report against dietary tray cards weekly x4 weeks, monthly x 2 months and PRN thereafter. 4. How will the corrective actions be monitored to ensure the deficient practice will not recure what quality assurance program will be put into place? The Administrator, or designee, will review all diet changes daily in the morning meeting for validation of accuracy and complete documentation. Dietary Manager will report findings to QAPI committee x 3 months. Persons responsible for monitoring the systems put in place: Administrator / Dietary Manager or designee

Based on observation, interview and record review it was determined the facility failed to ensure meals were palatable, attractive, and at an appetizing temperature for 1 of 1 kitchen and 3 of 4 sampled residents (#s 9, 11 and 23) reviewed for food quality. This placed residents at risk for unmet nutritional needs. Findings include: 1. Resident 9 admitted to the facility in 2023 with diagnoses including cancer. An 10/10/23 Significant Change MDS indicated the resident was cognitively intact. On 5/28/24 at 11:23 AM Resident 9 stated the food was always cold and the meat was chewy. On 5/30/24 at 12:35 PM a test tray was delivered to surveyors. The plate warmer was cool to touch, the meat was hard, and the rice was lukewarm. On 5/30/24 at 12:37 PM Staff 2 (DNS) and Staff 3 (Regional RN) acknowledged the food was not hot and the meat was hard. 2. Resident 23 admitted to the facility in 2024 with a diagnosis of malnutrition. A 2/2/24 Admission MDS indicated Resident 23 was cognitively intact. On 5/29/24 at 1:03 PM Resident 23's lunch had raw hamburger in the taco casserole. On 5/29/24 at 1:05 PM Staff 4 (Dietary Manager) verified the hamburger was raw. On 5/30/24 at 12:35 PM a test tray was delivered to surveyors. The plate warmer was cool to touch, the meat was hard, and the rice was lukewarm. On 5/30/24 at 12:37 PM Staff 2 (DNS) and Staff 3 (Regional RN) acknowledged the food was not hot and the meat was hard. , 3. Resident 11 admitted to the facility in 2023 with a diagnosis of surgical infection. An 4/6/24 quarterly MDS revealed Resident 11 was able to answer questions but had moderate cognitive impairment. On 5/28/24 at 10:07 AM Resident 11 stated she/he ate in her/his room and the food was cold by the time it arrived. On 5/30/24 at 12:35 PM a test tray was delivered to surveyors. The plate warmer was cool to touch, and the rice was lukewarm. On 5/30/24 at 12:37 PM Staff 2 (DNS) acknowledged the food was not hot.

1. What corrective action will be accomplished for those residents found to have been affected by the deficient practice? In-Service training to be completed with all Dietary staff to include hot and cold holding temperatures, re-thermalizing and cooling processes, and preparation of altered-texture foods to ensure consistent compliance with regulatory food temperature requirements. Food delivery system to be altered by utilizing electric heated insulated food carts and Camwarmer heat retentive pellets within non-electric insulated food cart. 2. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective actions will be taken? In addition to the above in-service training, Registered Dietician and Dietary Manager to complete regular temperature monitoring to include: Monitoring of Hot and Cold food items upon preparation, during holding process, and upon final plating to ensure both safe and palatable temperatures are maintained. 3. Measures the facility will take, or the systems will alter to ensure that the problem does not occur. Tracking of above temperature monitoring practices to be completed during each meal period, and any variation from a regulatory standard to be promptly reported to Dietary Manager and corrected in accordance with above provided training. A member of the Pilot Butte Rehabilitation leadership, or designee, to receive a "test tray" each meal x 1 week, daily x 3 weeks, and weekly x 8 weeks to observe for palatability, temperature, flavor and appearance. Observations of this tray to be documented and reported to the Administrator and Dietary Manager. Food and beverage related observations/concerns to be discussed in monthly Resident Council meeting and all observations/suggestions to be addressed promptly by PBR IDT team. 4. How will the corrective actions be monitored to ensure the deficient practice will not recure what quality assurance program will be put into place? In-Service training records, temperature logs, and test tray observation results to be reported to QAPI committee monthly to review and ensure effectiveness and sustained compliance. 5. Persons responsible for monitoring the systems put in place: Administrator / Dietary Manager or designee

Based on observation, interview and record review it was determined the facility failed to honor resident food preferences for 2 of 4 (#s 22 and 28) sampled residents reviewed for food. This placed residents at risk for unmet needs. Findings include: 1. Resident 22 admitted to the facility in 4/2023 with diagnoses including diabetes. An 4/27/24 MDS revealed Resident 22 was cognitively intact. On 5/28/24 at 9:49 AM Resident 22 stated she/he frequently did not get what was requested when her/his meal was delivered. Resident 22 stated for breakfast she/he received scrambled eggs, an English muffin and cold cereal with no milk. Resident 22 requested milk for her/his cereal but was informed there was no milk available. On 5/29/24 at 12:03 PM Resident 22 stated she/he requested scrambled eggs for breakfast, but instead received a pancake, fruit and raisin bran. On 5/29/24 at 12:53 PM Resident 22 stated she/he requested a ham and cheese sandwich, a salad and Jello for lunch, but instead she/he received chicken casserole. On 5/29/24 at 11:47 AM Staff 4 (Dietary Manager) stated if a resident did not complete a meal request he looked at the dietary profile to figure out what the resident wanted. , 2. Resident 28 admitted to the facility in 2023 with diagnoses including diabetes. A 5/10/24 Significant Change MDS indicated the resident was cognitively intact. A physician order dated 10/12/23 revealed Resident 28 was to receive a CCHO (low carbohydrate) diet related to her/his diagnosis of diabetes. On 5/28/24 at 10:42 AM Resident 28 stated she/he had a diabetic diet and was not to receive a lot of carbohydrates. Resident 28 stated she/he marked out carbohydrates on her/his meal order, but still received the carbohydrates On 5/29/24 at 2:53 PM Staff 4 (Dietary Manager) acknowledged there was no written documentation on portion sizes or what type of restrictions each resident should have with diets including CCHO (controlled carbohydrate), NEM (nutritionally enhanced meal) or NAS (no added salt).

1. What corrective action will be accomplished for those residents found to have been affected by the deficient practice? Resident 28 no longer resides in the facility. Dietary Manager immediately interviewed residents 22 and 23 to ensure the Dietary Department has accurate records of resident food preferences and promptly corrected the residents Dietary Profile and tray cards to reflect the residents current food preferences. 2. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective actions will be taken? The Dietary Manager, or designee, will interview all residents currently in the facility to ensure the Dietary Department has accurate records of resident food preferences and will promptly correct the residents Dietary Profile and tray cards to reflect the residents current food preferences. 3. Measures the facility will take, or the systems it will alter to ensure that the problem does not occur. During resident care conferences the Dietary Manager, or designee, will review the food preferences on file to confirm accuracy and will promptly make changes to the residents Dietary Profile and tray cards if resident requests an alteration. The Dietary Department personnel will receive in-service training on the importance of adhering to resident food preferences and how to promptly report to the resident if supply shortages force an alternative choice. Resident survey will be distributed each month inquiring whether food preferences are being successfully met. 4. How will the corrective actions be monitored to ensure the deficient practice will not recure what quality assurance program will be put into place? Resident Council will report any instances of food preference deficiencies. Resident survey and Resident Council will be reviewed with IDT in monthly QAPI meeting and any deficiencies or patterns of supply shortages will be addressed promptly. 5. Persons responsible for monitoring the systems put in place: Administrator / Dietary Manager or designee

Based on observation, interview, and record review it was determined the facility failed to ensure beard restraints were worn during meal preparation for 1 of 1 sampled kitchen reviewed for sanitary food practices. This placed residents at risk for contaminated food. Findings include: A review of the facility's policy "Dietary Dress Code" dated 1/2024 revealed beards must be clean, well-groomed and must be completely covered with a beard covering. On 5/28/24 at 8:10 AM Staff 4 (Dietary Manager) and Staff 26 (Cook) were observed preparing food in the kitchen without beard restraints. Staff 4 indicated he was not aware staff had to wear beard coverings. On 5/29/24 at 12:01 PM Staff 13 (RD) acknowledged staff were to wear beard restraints while working in the kitchen.

1. What corrective action will be accomplished for those residents found to have been affected by the deficient practice? Dietary staff were instructed to immediately DON beard nets and hair restraints and were instructed to wear them both when cooking, preparing, or assembling food, such as stirring pots or assembling the ingredients of a salad. 2. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective actions will be taken? Dietary staff will receive in-service training focused on Hair restraint regulations outlined by the Food Code of the FDA. 3. Measures the facility will take, or the systems will alter to ensure that the problem does not occur. Dietary Manager, or designee, will audit proper use of hair restraints daily x4 weeks, monthly x2 months and PRN thereafter. Any failure to comply with Food Code regulations will be promptly addressed with the staff member by the Dietary Manager or designee. Failure to comply will result in disciplinary action up to termination. 4. How will the corrective actions be monitored to ensure the deficient practice will not recure what quality assurance program will be put into place? The Dietary Manager will report audit findings to QAPI IDT x3 months. Audits will be reviewed for patterns and compliance and any staff compliance issues will be promptly addressed by Administrator and/or Dietary Manager. 5. Persons responsible for monitoring the systems put in place: Administrator / Dietary Manager or designee

Based on interview and record review it was determined the facility failed to provide immunizations to 1 of 5 sampled residents (#21) reviewed for immunizations. This placed residents at risk for infections. Findings include: Resident 21 was admitted to the facility in 8/2023 with diagnoses including chronic respiratory failure. A review of Resident 21's immunizations revealed she/he was not offered a Prevnar 20 vaccine, but was eligible to receive the Prevnar 20 vaccine. On 5/30/24 at 2:44 PM Staff 2 (DNS) acknowledged Resident 21 was eligible for a Prevnar 20 vaccine and it was not offered to her/him.

1. What corrective action will be accomplished for those residents found to have been affected by the deficient practice? ¿ Resident # 21was offered the Prevnar 20 2. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective actions will be taken? ¿ The facility residents Prevnar 20 vaccine eligibility was evaluated and addressed as appropriate ¿ Education on Prevnar 20 provided to Nurse Managers by the director of nursing or designee. 3. Measures the facility will take or the systems will alter to ensure that the problem does not occur. ¿ Audits will be conducted for eligibility of residents for Prevnar 20 by the director of nursing or designee weekly x3 weeks monthly x 2 months and PRN thereafter. 4. How will the corrective actions be monitored to ensure the deficient practice will not recur i.e., what quality assurance program will be put into place? ¿ Audits of Prevnar 20 will be reviewed at monthly QAPI meeting x3 months for needs of adjustments to plan. 5. Person/People Responsible: Director of Nursing

*************************************** OAR 411-085-0310 Resident Rights Generally Refer to F552 and F561 **************************************** OAR 411-086-0040 Admission of Residents Refer to F578 **************************************** OAR 411-085-0320 Residents' Rights: Charges and Rates Refer to F582 **************************************** OAR 411-087-0450 Heating & Ventilation System Refer to F584 **************************************** OAR 411-085-0360 Abuse Refer to F600 **************************************** OAR 411-086-0060 Comprehensive Assessment and Care Plan Refer to F657 **************************************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F684, F685, F698, and F760 ***************************************** OAR 411-086-0140 Nursing Services: Problem Resolution & Preventive Care Refer to F686, F689, F758, and F883 *************************************** OAR 411-086-0240 Social Services Refer to F745 *************************************** OAR 411-086-0250 Dietary Services Refer to F803, F804, F806, and F812 **************************************

Based on interview and record review it was determined the facility failed to report to the State Agency an unwitnessed fall with serious bodily injury for 1 of 3 sampled residents (#101) reviewed for accidents. This placed residents at risk for additional accidents and potential abuse. Findings Include: Resident 101 was admitted to the facility in 8/2023, with diagnoses including hip fracture, history of falls, and dementia with cognitive decline. An Incident Report dated 8/31/23 indicated a nurse was called to Resident 101's room because of a fall. The resident was found lying in bed with a skin tear above the left eye and another on the right elbow. There were no witnesses listed. The nurse found bruising and excess fluid when she assessed the elbow. The resident was sent out to the hospital. A 9/1/23 at 3:20 PM, Alert Progress Note indicated Resident 101 was on alert charting due to multiple recent falls. The most recent fall was on 8/31/23 and resulted in a fractured elbow requiring surgery and a laceration above the eye. A review of the medical record for Resident 101 revealed no evidence a Facility Reported Incident, for the fall with a major injury, was submitted by the facility to the State Survey Agency. On 4/16/24 at 11:41 AM, Staff 1 (Administrator) confirmed the facility did not notify the state agency of the resident's fall with a major injury.

1. What corrective action will be accomplished for those residents found to have been affected by the deficient practice? Resident # 101 no longer resides in the facility. 2. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective actions will be taken? The Administrator or designee reviewed the last 14 days of facility events for the need to report to the State and any issues noted were corrected as appropriate. 3. Measures the facility will take, or the systems will alter to ensure that the problem does not occur. Education was conducted by the governing body (Crystal Snarr Regional Director of Clinical Operations) to the Administrator and Director of Nursing Services on reporting to State agency, as it pertains to CMS guidance in F-609 Administrator or designer conducted education to the IDT on reporting to State agency, as it pertains to CMS guidance in F-609 Administrator or designer will audit facility events for need to report to State agency. Weekly x4 weeks, monthly x2 months, and PRN there after 4. How will the corrective actions be monitored to ensure the deficient practice will not recur. What quality assurance program will be put into place? The Administer or designee will review new facility events in the morning meeting for validation of reporting to State Agency, as it pertains to CMS guidelines in F-609 weekly x4 weeks, monthly x2 months, and PRN thereafter. Audits will be forwarded to QAPI committee x2 months to validate compliance, identify trends, and education needs. 5. The Administer or designee will be responsible for oversight of corrections. 6. Alleged date of compliance: 5/14/24

Based on interview and record review it was determined the facility failed to thoroughly investigate an unwitnessed fall with a major injury and rule out potential abuse or neglect for 1 of 3 sampled residents (#101) reviewed for falls. This placed resident at risk for additional falls and potential abuse. Findings include: Resident 101 was admitted to the facility in 8/2023, with diagnoses including hip fracture and repeated falls. Resident 101's care plan revised on 9/25/23, indicated the resident was at risk for falls, had a history of falls prior to admission and had multiple recurrent falls while at the facility despite fall interventions in place. An Incident Report dated 8/31/23, indicated a nurse was called to Resident 101's room because of a fall. The resident was found lying in bed with a skin tear above the left eye and another on the right elbow. The resident said she/he could not extend the arm all the way. The resident did not remember hitting her/his head but stated she/he must have since there was a skin tear to her/his left eyebrow. There were no witnesses listed. The nurse found bruising and excess fluid when she assessed the elbow. The resident was sent out to the hospital. A 9/1/23 at 3:20 PM Alert Progress Note, indicated Resident 101 was on alert due to multiple recent falls. The most recent fall was on 8/31/23 and resulted in a fractured elbow requiring surgery. The resident also had a laceration above the eye. Review of the 8/31/23 facility's fall investigation, contained no new or additional investigation information. The investigation was not thorough and did not address the following: -How did the resident get back into bed? -Was the resident's roommate a witness? -Why was there no statement from the roommate? -Was the CNA interviewed or written statement obtained? -How long since the resident was last checked on? -Why was the resident trying to go to the bathroom alone when she/he was care planned for assistance? -How did the wheelchair get away from the resident? -Were the care planned interventions implemented? -There was no information in the document related to the resident's fractured elbow or eye laceration. -There was no indication that abuse and neglect were ruled out or how they were ruled out. -There was no documentation the unwitnessed fall with a major injury was reported to the state agency. On 4/16/24 at 11:41 AM, Staff 1 (Administrator) confirmed the investigation document provided for Resident 101's fall with a major injury was not complete or thorough. Staff 1 had no additional information to provide.

1. What corrective action will be accomplished for those residents found to have been affected by the deficient practice? Resident # 101 no longer resides in the facility. 2. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective actions will be taken? The Administrator or designee reviewed the last 14 days of facility events for thorough investigation and timely completion. Any issues noted were corrected as appropriate. 3. Measures the facility will take, or the systems will alter to ensure that the problem does not occur. Education was conducted by the governing body (Crystal Snarr Regional Director of Clinical Operations) to the Administrator and Director of Nursing Services on timely completion and thorough investigation as it pertains to CMS guidance in F-610 Administrator or designer will audit facility events, weekly x4 weeks, and monthly x2 months, and PRN there after 4. How will the corrective actions be monitored to ensure the deficient practice will not recure what quality assurance program will be put into place? The Administer or designee will review facility events in the morning meeting for validation of timely and thoroughly investigated incidents as it pertains to CMS guidelines in F-610 weekly x4 weeks, monthly x2 months, and PRN thereafter. Audits will be forwarded to QAPI committee x2 months to validate compliance, identify trends, and education needs. 5. The Executive Director or designee will be responsible for oversight of corrections. 6. Alleged date of compliance: 5/14/24

Based on interview and record review it was determined the facility failed to ensure the environment was free of potential accident hazards for 1 of 3 sampled residents (#103) reviewed for accidents. This placed the residents at risk for potential accidents. Findings include: Resident 103 was admitted to the facility in 7/2022 with diagnoses including neck fracture and a history of falls. A Facility Reported Incident Form dated 8/16/22 indicated on 8/15/22 at 8:06 PM a CNA found Resident 103 on the floor in her/his bathroom. The nurse who arrived to assess the resident indicated the toilet was not attached to the floor. The toilet was on its side with a four wheel dolly beside it. No signs were placed on the resident's door or the bathroom door to not use the toilet. No evening staff members were notified the toilet was not secured to the floor. A written statement dated 8/15/22 by the facility Maintenance Director indicated the maintenance department was notified the toilet in Resident 103's bathroom was very loose because the floor mounting screws were stripped. He pulled the toilet, put it on a four wheel dolly and put it against the wall in preparation for repairs the next morning. The statement indicated he did not make sure there were Out of Order signs posted. On 4/10/24 at 2:35 PM Staff 1 (Administrator) confirmed the Maintenance Director failed to lock the door, notify evening staff, or place signage to prevent use of the toilet.

1. What corrective action will be accomplished for those residents found to have been affected by the deficient practice? Resident # 103 no longer resides in the facility. 2. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective actions will be taken? The Administrator or designee reviewed the last 14 days of Maintenance issues within the facility and any issues noted were corrected as appropriate. 3. Measures the facility will take, or the systems will alter to ensure that the problem does not occur. Education was conducted by The Administer to the Maintenance Director on the need to secure an unsafe environment, which may include locking the door, notifying staff, and placing signage to prevent use of areas in need of maintenance that my cause injury. Administrator or designer will audit Maintenance request , weekly x4 weeks, and monthly x2 months, and PRN there after 4. How will the corrective actions be monitored to ensure the deficient practice will not recure what quality assurance program will be put into place? The Administer or designee will conduct audits within the facility to identify potential issues that may need maintenance weekly x4 weeks, monthly x2 months, and PRN thereafter. The Administer or designee will review new Maintenance issues in the morning meeting for lock the door, notify staff, or place signage to prevent use of areas in need of maintenance, weekly x4 weeks, and monthly x2 months, and PRN thereafter. Audits will be forwarded to QAPI committee x2 months to validate compliance, identify trends, and education needs. 5. The Administer or designee will be responsible for oversight of corrections. 6. Alleged date of compliance: 5/14/24

Based on interview, and record review it was determined the facility failed to ensure state minimum CNA staffing requirements were maintained for 17 of 30 days reviewed for staffing. This placed residents at risk for delayed resident care. Findings include: A review of the Direct Care Staff Daily Reports from 9/1/23 through 9/30/23 revealed the following days when state minimum CNA staffing requirements were not met: 9/1, 9/2, 9/5, 9/7, 9/8, 9/9, 9/10, 9/11, 9/12, 9/14, 9/15, 9/17, 9/20, 9/22, 9/23, 9/24, and 9/25. -Day shift: 9/7, 9/8, and 9/17; -Day and evening shift: 9/9, 9/10, and 9/12; -Evening shift: 9/1, 9/2, 9/14, 9/15, and 9/20; -Night shift: 9/5, 9/22, 9/23, and 9/24; -Day shift and night shift: 9/25; and -Day, evening and night shift: 9/11/23. On 4/17/24 at 10:08 AM, Staff 1 (Administrator) acknowledged the dates had less than the required CNA staff.

1. What corrective action will be accomplished for those residents found to have been affected by the deficient practice? Residents within the facility were interviewed for care needs met. Any issues identified were addressed as appropriate. 2. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective actions will be taken? The Administrator or designee reviewed the last 14 days of Staffing and any issues noted were addressed as appropriate. 3. Measures the facility will take, or the systems will alter to ensure that the problem does not occur. Education was conducted by the governing body (Crystal Snarr Regional Director of Clinical Operations) to the Administrator and Director of Nursing Services on Staff requirements as it pertains to OAR guidance in M183 Administrator or designer conducted education to the IDT on Staff requirements as it pertains to OAR guidance in M183 Administrator or designer will audit staffing , weekly x4 weeks, and monthly x2 months, and PRN there after 4. How will the corrective actions be monitored to ensure the deficient practice will not recure what quality assurance program will be put into place? The Administer or designee will review staffing in the morning meeting to validate compliance as it pertains to OAR M183 weekly x4 weeks, and monthly x2 months, and PRN thereafter. Audits will be forwarded to QAPI committee x2 months to validate compliance, identify trends, and education needs. 5. The Administer or designee will be responsible for oversight of corrections. 6. Alleged date of compliance: 5/14/24

******************************* OAR 411-085-0360 Abuse Refer to F609, F610 ******************************* OAR 411-086-0140 Nursing Services: Problem Resolution and Preventative Care Refer to F689 *******************************

Based on interview and record review it was determined the facility failed to ensure resident representatives were notified of a change of condition for 1 of 1 sampled resident (#9) reviewed for notification of change. This placed residents and resident representatives at risk for lack of information. Findings include: Resident 9 was admitted to the facility in 2023 with diagnoses including dementia. Resident 9's face sheet revealed Witness 2 (Family Member) was her/his responsible party, medical power of attorney, and emergency contact. A 1/23/23 Admission MDS revealed Resident 9 had a BIMS of 7 which indicated severe cognitive impairment. A 2/18/23 Progress Note revealed Resident 9 choked on hot chocolate which resulted in facility staff performing the Heimlich Maneuver on her/him. There was no documentation Witness 2 was notified. On 2/23/23 at 4:49 PM Witness 2 stated he was not notified of Resident 9's choking episode but expected to be notified. On 2/23/23 at 5:45 PM Staff 19 (LPN) indicated she was present for Resident 9's choking incident and did not recall Witness 2 was notified. On 2/24/23 at 12:08 PM Staff 8 (Resident Care Manager) reviewed the choking incident from 2/18/23 and stated it did not appear the family was notified of the incident.

• Identified Resident(s): Resident #9 no longer resides within the facility. • Similar Residents: Facility has reviewed other current residents of the facility that have had a choking incident in the last 3 months that required the Heimlich maneuver to ensure that responsible parties were notified, no further issues were noted. • Corrective Action: Facility will educate licensed nurses to ensure that residents representatives are notified timely and appropriately with resident changes of condition including choking episodes that require the Heimlich maneuver as it relates to the regulation. • Surveillance: The DON or designee will review choking incidents during daily clinical meeting to ensure that resident representatives are notified appropriately for changes of condition, any noted issues will be addressed immediately and any noted trends will be brought to the facility QAPI process as deemed appropriate. • Person Responsible: Director of Nursing

Based on interview and record review it was determined the facility failed to revise care plans related to fluid restrictions and medical devices for 2 of 2 sampled residents (#s 13 and 184) reviewed for dialysis and care planning. This placed residents at risk for lack of adequate care. Findings include: 1. Resident 184 was admitted to the facility in 2/2023 with diagnoses including end stage renal disease (kidney failure) and heart failure. A 2/17/23 physician order indicated Resident 184 was limited to 1200 ml of fluids each day. The 2/20/23 revised care plan did not include information related to Resident 184's fluid restriction. On 2/22/23 at 11:09 AM Staff 8 (Resident Care Manager) stated she often did not see orders directly entered into the system by the physician and offsite staff currently assisted with care plan updates. Staff 8 acknowledged Resident 184's care plan related to fluid restrictions was not updated timely. , 2. Resident 13 was admitted to the facility in 2019 with diagnoses including breast cancer. A care plan revised 11/23/22 indicated Resident 13 wore compression stockings. The compression stockings were to be placed on the resident in the morning and taken off in the evening. On 10/3/20 the physician order for the compression stockings was discontinued. On 2/22/23 at 11:09 AM Staff 8 (Resident Care Manager) stated she often did not see orders directly entered into the system by the phyician and offsite staff currently assisted with care plan updates.

• Identified Resident(s): Resident #184 no longer resides within the facility. Resident #13 ted hose orders were clarified to ensure that MD orders are followed, and the care plan revised appropriately. • Similar Residents: The facility has reviewed other current residents of the facility with fluid restrictions and orders for Ted hose to ensure that MD orders and care plans are in place to reflect the resident’s current care status. • Corrective Action: Facility will educate licensed nurses to ensure residents with fluid restrictions and/or Ted hose have appropriate care planning in place to ensure the resident’s current care needs accurately reflect the resident current status as it relates to the regulation. • Surveillance: RCMs or designee will review care plans at least quarterly with the MDS schedule to ensure that residents with fluid restrictions and/or utilizes ted hose have appropriate care planning in place to reflect resident current care needs. Any noted issues will be addressed immediately and any noted trends will be brought to the facility QAPI process as deemed appropriate. • Person Responsible: Director of Nursing

Based on observation, interview and record review it was determined the facility failed to ensure professional standards were followed related to proper infection control techniques for 2 of 2 sampled residents (#s 1 and 19) reviewed for wound care and diabetic testing. This placed residents at risk for cross contamination. Findings include: Oregon Administrative Rule 851-045-0060 Scope of Practice Standards for Registered Nurses: * Be knowledgeable of the professional nursing practice and performance standards and adhere to those standards: * Be accountable for individual RN actions, maintain competency in one's RN practice role and ensure unsafe nursing practices are addressed immediately. 1. Resident 1 was admitted to the facility in 2017 with diagnoses including paraplegia (paralysis of the lower body). On 2/23/23 at 3:04 PM Staff 12 (RN) was observed to perform a dressing change on Resident 1. Staff 12 donned clean gloves, removed the dirty dressing from the wound, and then proceeded to clean the wound and open dressings with dirty gloves. On 2/23/23 at 3:10 PM Staff 12 acknowledged she did not change her dirty gloves before cleaning the wound and opening new dressing packages. 2a. Resident 19 was admitted to the facility in 2023 with diagnoses including leg fracture and diabetes. On 2/22/23 at 8:14 AM Staff 12 (RN) was observed to perform a CBG (machine used to test blood sugar) check on Resident 19 and cleaned the CBG machine that was used for multiple residents with alcohol wipes. On 2/22/23 8:18 AM Staff 12 stated she always used alcohol wipes to clean the CBG machine. On 2/22/23 at 11:23 AM Staff 3 (DNS) stated EPA (Environmental Protection Agency) approved wipes should be used on the glucometer and alcohol wipes were not to be used. Staff 3 stated she would place the correct wipes on the medication carts and confirmed an appropriate cleansing wipe should have been used. 2b. On 2/22/23 at 8:14 AM Staff 12 (RN) was observed to perform a CBG check on Resident 19 and placed the lancet (device to take a blood sample) in the garbage can in resident 19's room. On 2/22/23 8:18 AM Staff 12 stated she always placed the lancets in the garbage can. On 2/22/23 at 11:23 AM Staff 3 (DNS) stated lancets are to be placed in the sharps container to avoid cross contamination.

• Identified Resident(s): Resident #19 no longer resides within the facility. Resident #1 has had no negative effects noted at this time related to dressing change. Staff #12 has been educated on proper dressing change procedures and CBG machine cleaning as it relates to infection control practices. • Similar Residents: Residents with treatment dressings and residents that require blood sugar checks are at risk, no negative outcomes related to dressing changes or blood sugar testing have been noted. • Corrective Action: Facility will educate licensed staff on the proper infection control practices of dressing changes, the cleaning procedure for the CBG machine, and the disposal of lancets to ensure infection prevention and control meet the professional standards of nursing as it relates to the regulation. • Surveillance: The facility ICP or designee will do glucometer checklists with new nursing staff upon hire and annually to ensure that licensed staff are completing dressing changes, cleaning of the CBG machine, and disposal of lancets according to the most current infection control practices. Any noted issues will be addressed immediately, trends will be addressed in the facility’s routine QAPI program per the ICP audits. • Person Responsible: Infection Control Preventionist

Based on observation, interview and record review it was determined the facility failed to ensure qualified staff assessed wounds for 2 of 2 LPNs reviewed for wound care. This placed residents at risk for receiving inadequate treatment. Findings include: The Oregon State Board of Nursing Scope of Practice Standards for Licenses Practical Nurses, Oregon Administrative Rules 851-045-0050 and 851-045-0060 outlined the following: -The Primary Legal Differences Between RN and LPN Practice: The RN uses broad knowledge to determine (1) what data is appropriate to the client's health status based on data collected by the RN or other team members (2) synthesizes the data to determine reasoned conclusions (nursing diagnosis) (3) develops and authors the plan of care (4) supervises the implementation of the plan (5) modifies the plan as information regarding the client's condition changes. The LPN uses basic knowledge to determine (1) the client's status at the time of intervention (2) implements the plan of care authored by the RN (3) determines if the plan of care is achieving measurable outcomes (4) collaborates with the RN and contributes to plan of care when a change is needed or when the plan has achieved its goals. -The RN performs a comprehensive assessment by Collecting data: The practice act does not require the RN to self-collect the data. Validating the data: utilizing a variety of resources such as: the client, members of the healthcare team, literature. Normal from abnormal data: Sorting, selecting, recording, evaluating, synthesizing, and communicating data. Developing reasoned conclusions that identify client problems and risks. Develop a client centered plan of care based on the analysis that establishes priorities in the plan of care, identifies measurable outcomes. Resident 10 was admitted to the facility in 2022 with diagnoses including end of life care. A 11/9/22 Admission Profile revealed Staff 4 (LPN) indicated Resident 10's right knee had red painful sores. The Initial Non-Pressure Skin Condition Assessment indicated Staff 4 assessed the right knee as eschar (dead tissue that eventually sloughs off from healthy tissue after injury) with redness. The wound was 2.5 cm x 2.5 cm. Hospice orders indicated to leave the wound open to air. A 11/20/22 Non-Pressure Skin Condition Assessment revealed Staff 4 assessed Resident 10's right knee wound which was assessed as a 1.0 cm x 1.6 cm abrasion with redness, a scab and painful. A 1/6/23 Non-Pressure Skin Condition Assessment revealed Staff 8 (Resident Care Manager-LPN) assessed Resident 10's right knee wound as a scabbed wound which measured 3.0 cm x 3.0 cm. Staff 8 indicated treatment had changed due to worsening of slough tissue. The order indicated for staff to cleanse the right knee, pat dry, apply betadine (topical antiseptic) to eschar (slough is not visible when eschar covers a wound). A 1/13/23 Non-Pressure Skin Condition Assessment revealed Staff 8 assessed Resident 10's right knee wound as a scabbed wound which measured 3.0 cm x 2.5 cm. Staff 8 indicated a small amount of slough in center of the wound with drainage (slough is not visible when eschar covers a wound). A 1/26/23 Non-Pressure Skin Condition Assessment revealed Staff 8 assessed Resident 10's right knee wound as a healing open wound to right knee which measured 2.5 cm x 3.0 cm with a depth of 0.2 cm. The wound was described as slightly larger with larger amounts of slough in the middle of the wound (a wound cannot be accurately assessed with slough in the wound). Wound care orders were changed per hospice. On 2/23/23 at 9:40 AM Staff 23 (RN) and Staff 26 (Hospice Physician) removed the dressing to Resident 10's right knee. The wound was large and beefy red with drainage. Staff 26 indicated the wound started as a small lesion and had enlarged. Staff 26 stated the resident was on hospice, the leg had no circulation with no pulse in the foot and the resident was malnourished. Staff 26 stated the wound would likely not heal due to all the comorbidities of Resident 10. On 2/23/23 at 11:41 AM Staff 4 stated she completed the admission assessment for Resident 10 and continued to assess her/his wounds. Staff 4 stated at the time of the admission she used the documentation from the hospital to assess the wound but did the additional wound assessments on her own. Staff 4 stated the resident had a small scab to the right knee on admission. Staff 4 stated the facility process was for LPNs to assess and measure the wounds and document on a skin sheet. Staff 4 stated there was no RN who supervised the wound assessments and a RN did not observe the actual wound. Staff 4 acknowledged an LPN was not qualified to perform assessments for residents or for residents' wounds and she practiced outside of the scope of practice for an LPN. On 2/24/23 at 4:57 PM Staff 1 (Regional Administrator) and Staff 3 (DNS) stated the LPNs should not perform assessments of any kind on the residents. Staff 3 acknowledged the LPNs worked out of their scope of practice.

• Identified Persons: Resident #10 has had her wound assessed by a Registered Nurse, current assessment is accurate and current plan of care is appropriate. Staff #4 and Staff #8 have been educated on the current guidelines of LPN scope of practice according to the Oregon State Board of Nursing. • Similar Residents: Facility has reviewed current residents of the facility with wound assessments to ensure Registered nurses are assessing wounds within the facility, orders and care plans updated as appropriate. • Corrective Action: Facility will educate licensed nurses of the facility to ensure that Registered nurses are completing assessments and that Licensed Practical Nurses are working within their scope of practice as it relates to the guidelines and regulations. • Surveillance: The DON or designee will review current wound assessments weekly via weekly wound report to ensure that Registered Nurses are completing assessments and that LPNs are working within their scope of practice per the regulations. Any identified issues will be addressed immediately, and any noted trends will be brought to the facility QAPI program as deemed appropriate. • Person Responsible: Director of Nursing.

Based on observation, interview and record review it was determined the facility failed to ensure dependent residents received required assistance with ADLs for 1 of 2 sampled residents (#232) reviewed for ADLs. This placed resident at risk for unmet needs. Findings include: Resident 232 was admitted to the facility in 2021 with diagnoses including pelvic fracture. On 2/21/23 at 4:32 PM Witness 3 (Complainant) stated Resident 232 was not showered or provided with a bed bath for many days while in the facilty. The 8/2021 Documentation Survey Report revealed Resident 232 did not receive a bed bath or a shower from 8/5/21 through 8/10/21 (six days) and 8/13/21 through 8/20/21 (eight days). On 2/22/23 at 2:04 PM Staff 14 (CNA) stated there were times showers were missed or not offered. On 2/23/23 at 8:36 AM Staff 8 (Resident Care Manager) reviewed Resident 232's shower records and confirmed a shower or bed bath was not documented as completed. Staff 8 also stated this was during a COVID-19 outbreak and there was a plastic wall which separated the shower from the residents in the COVID-19 unit, but a bed bath should have been offfered. On 2/23/23 at 3:12 PM Staff 17 (CNA) stated during 8/2021 the facility had a COVID-19 outbreak, staffing was "horrible", and there was limited help available to assist with resident care.

• Identified Resident(s): Resident #232 no longer resides within the facility. • Similar Residents: Facility has reviewed residents that are dependent on assistance for showers to ensure that showers are being offered/completed routinely per resident/responsible party preference. • Corrective Action: Facility will educate licensed staff on providing care for dependent residents including showers to ensure that resident care needs are met as it relates to the regulation. • Surveillance: RCMs or designee will conduct weekly shower audits for dependent residents to ensure ongoing compliance with ADLs are provided for dependent residents. Any noted issues will be addressed immediately and any noted trends will be brought to the facility QAPI program as deemed appropriate. • Person Responsible: Director of Nursing.

Based on interview and record review it was determined the facility failed to obtain physician orders for 1 of 1 sampled resident (#233) reviewed for catheters. This placed residents at risk for unmet care needs. Findings include: Resident 233 was admitted to the facility in 2023 with diagnoses including retention of urine. On 2/20/23 at 10:16 AM Resident 233 stated the facilty staff were to use an external catheter on her/him but the facility did not have the correct size. A review of Resident 233's Physician Orders revealed no orders for an external catheter. A review of Resident 233's Progress Notes revealed Resident 233 had an external catheter in place on 2/17/23 and 2/23/23. A review of Resident 233's Urinary Continence tasks revealed an external catheter was documented as in place on 2/18/23 and 2/23/23. On 2/23/23 at 4:10 PM Staff 12 (RN) stated Resident 233 used an external catheter. On 2/23/23 at 5:45 PM Staff 19 (LPN) stated Resident 233 tried an external catheter, however the facility did not have the correct size. On 2/24/23 at 8:45 AM Staff 9 (LPN) stated Resident 233 had an external catheter but was unsure if there was an order for it. On 2/24/23 at 12:13 PM Staff 8 (Resident Care Manager) reviewed Resident 233's record and stated her/his family member brought in two external catheters and the facility staff used them on Resident 233. Staff 8 confirmed there was no order for staff to use an external catheter on Resident 233.

• Identified Resident(s): Resident #233 no longer resides within the facility. • Similar Residents: Facility has reviewed other residents of the facility with catheters to ensure the accurate and appropriate orders are in place and that care plans currently reflect resident status. • Corrective Action: Facility will educate Licensed Nurses to ensure that appropriate and accurate orders are in place for residents with catheters as it relates to the regulation and that residents received treatment and care in accordance with professional standards of practice. • Surveillance: RCMs or designee will conduct routine monthly audits of resident orders to ensure that residents with catheters have appropriate and accurate orders in place. Any noted issues will be corrected immediately and any noted trends will be brought to the facility QAPI program as deemed appropriate. • Person Responsible: Director of Nursing.

Based on observation, interview and record review it was determined the facility failed to follow physician orders and provide care and services to promote the healing of pressure ulcers for 1 of 2 sampled residents (#1) reviewed for pressure ulcers. Resident 1 developing a facility acquired unstageable pressure ulcer. Findings include: Resident 1 was admitted to the facility in 2017 with diagnoses including paraplegia (paralysis of the lower body) and a Stage IV (a deep wound that reaches bone, ligaments or muscles) pressure ulcer of the sacral region (region between the bottom on the spine and the tailbone). a. A 9/7/21 physician order indicated to float Resident 1's heels and apply soft boots to both lower extremities at all times. A 9/17/21 care plan indicated Resident 1 was to use pillows for repositioning to reduce pressure and wear soft boots while in bed. A 11/29/22 New Pressure ulcer investigation revealed Staff 4 (LPN) observed Resident 1 with no boots on and a large thick scab on her/his right heel. Resident 1 stated "they never put my boots on." A 11/30/22 Initial Skin Ulcer Assessment indicated Resident 1 had an unstageable facility acquired pressure ulcer to her/his right heel with 100 percent eschar (a collection of dead tissue that is flush with the skin) that measured 3.0 cm x 4.0 cm. The 1/20/23 Annual MDS indicated Resident 1 had one Stage IV wound on admission and one facility acquired unstageable wound. On 2/23/23 at 10:08 AM Staff 4 stated on 11/29/22 she observed Resident 1 did not wear her/his soft boots and during the investigation nurses informed her that because the soft boots were not working CNAs were informed not to put them on Resident 1. On 2/23/23 at 2:56 PM Staff 7 (RN) stated in 11/2022 Resident 1 had soft boots that exposed her/his heel to the pressure of the bed so Staff 7 stated she chose not to use pillows but "dangled" Resident 1's foot off the edge of the bed. On 2/24/23 at 5:13 PM Staff 3 (DNS) stated Resident 1's care plan should be followed and match her/his physician's order to avoid pressure ulcers. b. The 10/5/22 Admission History and Physical hospital notes indicated Resident 1 had a stable sacral region (area between the bottom of the spine and he tailbone) pressure ulcer "to the bone" with no infections and no drainage. The 10/12/22 Weekly Skin Ulcer Measurement Wound Evaluation revealed Resident 1's Stage IV wound on the coccyx (tailbone) had a wound bed that contained 100 percent granulation (part of the wound healing process in which new skin is formed) and measured 1.5 cm x 2.2 cm and was 0.3 cm in depth. The 10/2022 TAR indicated beginning on 10/14/22 Resident 1's sacral wound was to be cleansed with wound cleaner, patted dry, skin prepped, a collagen pad applied to the wound bed and covered with an absorbent dressing every day. The 12/15/22 Weekly Skin Ulcer Measurement Wound Evaluation revealed Resident 1's Stage IV coccyx wound bed contained 90 percent granulation with ten percent slough (dead tissue), small drainage, maceration (skin associated with improper wound care) and measured 1.6 cm x 3 cm and was 0.3 cm in depth. The 1/26/23 revised care plan indicated Resident 1's pressure ulcers were to show signs of healing, declines in the skin were to be reported to the physician and the resident was to be educated on the importance of changing positions and turning to avoid pressure ulcers. The 2/2023 TAR indicated the 10/14/22 order for Resident 1's sacral wound treatment was not changed. The 2/15/23 Weekly Skin Ulcer Measurement Wound Evaluation revealed no significant changes during the week to Resident 1's coccyx wound and the wound measured 1.5 cm x 2.5 cm x 0.5 cm in depth. A 2/15/23 physician visit progress note revealed Resident 1's Stage IV coccyx pressure ulcer had dressing present (the wound was not observed). During random observations from 2/20/23 at 1:24 PM to 2/24/23 at 10:18 AM Resident 1 was observed on a pressure relief air mattress in bed with pillows under her/his feet and at her/his side. Resident 1 indicated she/he preferred to remain in bed. On 2/23/23 at 10:08 AM Staff 4 (LPN) stated she often completed Resident 1's wound evaluations, Resident 1's treatment for her/his coccyx was discussed during morning meetings and Staff 4 agreed there was no noticeable improvements to the resident's coccyx wound since 10/2022. Staff 4 stated the facility was not as aggressive as possible with Resident 1's wound care due to the lack of a permanent DNS since 7/2022 and acknowledged Resident 1's coccyx wound was "just left" without further consideration. Staff 4 stated Resident 1's coccyx wound and wound interventions were discussed with her/him many times and an updated risk benefit document was needed since it was last signed in 2019. On 2/24/23 at 5:13 PM Staff 3 (DNS) acknowledged since Resident 1's wound healing stalled in the healing process she would involve the physician and look for different options.

• Identified Resident(s): Resident #1 physician orders and care planned interventions have been reviewed and updated for her treatment for pressure ulcers. • Similar Residents: Facility has reviewed other current residents of the facility with pressure ulcers to ensure that appropriate treatment orders are in place and that appropriate interventions are in place to appropriately reflects resident current status. • Corrective Action: Facility will educate licensed nurses of the facility on obtaining appropriate treatment orders and implementing appropriate skin care interventions to promote skin health and prevent facility-acquired pressure ulcers as it relates to the regulation. Licensed staff also educated on ensuring the care plan interventions are appropriate and being followed. • Surveillance: The DON or designee will review current wound assessments weekly via weekly wound report to ensure that residents have appropriate orders, treatments, and interventions in place to promote skin health and prevent facility-acquired pressure ulcers. Analysis of wound reports and wound audits will be brought to the facility QAPI program for at least 3 months to ensure facility to ensure ongoing compliance with treatment and prevention of facility-acquired pressure ulcers. • Person Responsible: Director of Nursing

Based on observation, interview and record review it was determined the facility failed to ensure appropriate foot care was provided for residents with compromised mobility for 1 of 1 sampled resident (#2) reviewed for ADLs. This placed resident at risk for unmet foot care needs. Finding include: Resident 2 admitted to the facility in 2020 with diagnoses including stoke with paralysis on the right side and contractures (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). The Kardex (CNA directions for resident care) in place for 2/2023 indicated staff were to apply lotion to both feet and legs twice daily. On 2/22/23 at 1:26 PM Resident 2 was observed in her/his room. The resident's feet were observed and found to be very dry with flaky skin which flew into the air when her/his socks were removed. The big toe of the left foot laid over the next toe and had reddened areas of skin between the two toes where the toes pressed against each other. The right big toe also laid over the second toe and had two reddened areas where the toes pressed together. The toes on the left foot were also seen to have fungus in between the toes which was not identified in the medical record or currently being addressed. On 2/22/23 at 1:45 PM Staff 35 (LPN) was asked to check the resident's feet issues. She acknowledged the skin was very dry and flaky, the feet were in poor condition, there was pus and reddened areas between the big toes and the second toes of each foot and there was fungus between the toes. On 2/22/23 at 2:08 PM Staff 8 (Resident Care Manager) reviewed the resident's feet and observed the fungus between the resident's toes, the toenails and the flaky skin. She also said the red areas between the toes were not open yet but were at risk to open and she would request the physician to provide assistance.

• Identified Resident(s): Resident #2 feet have been assessed and appropriate treatment orders have been obtained, plan of care has been updated with appropriate interventions to promote foot health. • Similar Residents: Facility has reviewed other residents of the facility with compromised mobility to ensure appropriate foot care and treatments are in place to promote foot health, care plans updated as appropriate. • Corrective Action: Facility will educate licensed nurses on the ensure that the facility is promoting foot health, obtaining appropriate orders/treatments, and care planning interventions as it relates to the regulatory guidelines. • Surveillance: RCMs or designee will conduct weekly foot skin audits per resident shower schedule to ensure ongoing compliance with promoting foot health. Any noted issues will be addressed immediately and any noted trends will be brought to the facility QAPI program as deemed necessary. • Person Responsible: Director of Nursing.

Based on observation, interview and record review, it was determined the facility failed to ensure nursing staff were able to demonstrate competency in skills and techniques necessary to care for residents for 1 of 1 facility reviewed for staffing. This placed residents at risk for lack of proper treatment and care by competent staff. Findings include: The new hire paperwork for Staff 12 (RN) was reviewed. Staff 12 did not complete a Skilled Nursing New Hire Checklist which included orientation to the Needle Stick Protocol. On 2/21/23 at 8:14 AM Staff 12 was observed to use a blood glucose monitor to test an unidentified resident in the dining room at a table with multiple residents present. Staff 12 indicated the facility allowed this practice. On 2/24/23 at 3:29 PM Staff 3 (DNS) was asked about the nursing staff training for new hires and staff to ensure nursing staff were able to to demonstrate competency and skills. Staff 3 acknowledged the facility had no method to verify that the skills of nursing staff were reviewed prior to 1/2023 and she was in the process to remedy the issue. On 2/24/23 at 5:21 PM Staff 1 (Regional Administrator) acknowledged there was no verification that orientation and skill demonstration for Staff 12 was completed when she was hired in 11/2022.

• Identified Staff: Staff #12 has completed a skilled nursing new hire checklist competency and has been re-educated on CBG testing to ensure nursing skills and techniques are followed. • Similar Residents: Diabetic residents of the facility with CBG testing are at risk for this deficiency. Facility has conducted an audit of care licensed nurses to ensure that nursing competencies are current including facility needle stick protocol. • Corrective Action: The facility will educate the licensed nurses of the facility to ensure that current nursing competencies are acquired, including the facility needle stick protocol, as it related to the regulation to demonstrate skills and techniques necessary to care for residents. • Surveillance: DNS or designee will audit current licensed nurses competency education and ongoing with monthly with new hires, annually, and as needed to ensure that nurses maintain competencies to demonstrate appropriate skills and techniques to provide care for residents of the facility. Any noted issues will be corrected immediately and any noted trends will be brought to the facility QAPI program as deemed appropriate. • Person Responsible: Director of Nursing.

Based on observation, interview and record review the facility failed to utilize hygienic practices when handling food, ensure temperature logs were completed for the dishwasher and ensure a cleaning schedule was followed for 1 of 1 kitchen. This placed residents at risk for foodborne illness. Findings include: 1. On 2/20/23 at 8:19 AM Staff 28 (Cook) was in the kitchen at the steam table without a hairnet in place. Staff 28 stated she just got back from break and did not replace her hairnet. On 2/22/23 at 11:10 AM Staff 28 was observed preparing for lunch in the kitchen without a hairnet in place. On 2/22/23 at 11:39 AM Staff 26 (Dietary Manager) entered the kitchen, put on gloves and began to dish out cake. Staff 26 was asked if he washed his hands and he stated he did not. On 2/22/23 at 11:47 AM Staff 30 (Dietary aide) began to assist in preparing trays for meal service while wearing a dirty apron from the dish room. Staff 30 stated he did not know if it was okay to wear the apron. Staff 26 told Staff 30 he needed to remove the apron. On 2/22/23 at 12:06 PM Staff 27 (Cook) entered the kitchen through the back door during meal service, walked through the kitchen and uncovered food without wearing a face mask or hairnet or washing his hands. On 2/23/23 at 12:25 PM Staff 26 stated he was aware of various issues with hygienic practices in the kitchen. 2. A review of the 2/2023 Dish Machine temperature log revealed the dish machine temperatures were not verified from 2/16/23 through 2/19/23. On 2/20/23 at 8:29 AM Staff 26 (Dietary Manager) confirmed the lack of dish machine temperatures and stated he was having a hard time getting the staff to complete this task. 3. A review of the Daily Cleaning Schedule for the kitchen revealed the cleaning tasks were not signed as completed on 2/13/23, 2/14/23, 2/15/23, 2/20/23, 2/21/23 and 2/22/23. On 2/24/23 at 10:28 AM Staff 26 (Dietary Manager) acknowledged the cleaning logs were not completed.

• Identified Staff: Staff #26, #27, #28, #30 were educated on infection control practices for food handling, kitchen sanitation, and food procurement requirements of the facility. • Similar Residents: Current residents of the facility are identified as at risk for kitchen sanitation and infection control practices. No negative outcomes have been noted to the current residents of the facility. • Corrective Action: The facility will educate the dietary staff on the infection control and sanitation requirements related to food procurement to ensure that the food is stored, prepared, and served in the facility meets the regulatory requirements as related to the regulation. • Surveillance: The dietary manager or designee will conduct routine weekly audits on infection control practices in the kitchen including wearing of hair nets, hand washing, and glove use. The dietary manager or designee will also conduct routine weekly audits to ensure that dish machine temperatures and the cleaning of the kitchen are completed to maintain and ensure kitchen sanitation. Any noted issues will be corrected immediately and any noted trends will be addressed at the facility QAPI program as deemed appropriate. • Person Responsible: Administrator

1.

Based on observation, interview and record review it was determined the facility failed to follow proper infection control practices for 2 of 2 sampled residents (#s 1 and 19) reviewed for wound care and diabetic testing. This placed residents at risk for cross contamination. Findings include: a. Resident 1 was admitted to the facility in 2022 with diagnoses including paraplegia (paralysis of the lower body). On 2/23/23 at 3:04 PM Staff 12 (RN) was observed to perform a dressing change on Resident 1. Staff 12 donned clean gloves, removed the dirty dressing from the wound, did not change her gloves and proceeded to clean the wound and open clean dressings with dirty gloves. On 2/23/23 at 3:10 PM Staff 12 acknowledged she did not change her dirty gloves before cleaning the wound and opening new dressing packages. b. Resident 19 was admitted to the facility in 2023 with diagnoses including leg fracture and diabetes. On 2/22/23 at 8:14 AM Staff 12 (RN) was observed to perform a CBG check on Resident 19 and proceeded to cleanse the CBG machine, which was used for multiple residents, with an alcohol wipe. On 2/22/23 8:18 AM Staff 12 stated she always used alcohol wipes to clean the CBG machine. On 2/22/23 at 11:23 AM Staff 2 (DNS) stated EPA (Environmental Protection Agency) approved wipes should be used on the glucometer and alcohol wipes were not to be used. Staff 2 stated she would place the correct wipes on the medication carts and confirmed an appropriate cleansing wipe should have been used. c. On 2/22/23 at 8:14 AM Staff 12 (RN) was observed to perform a CBG check on Resident 19 and proceeded to place the lancet in the garbage can in Resident 19's room. On 2/22/23 8:18 AM Staff 12 stated she always placed the lancets in the garbage can. On 2/22/23 at 11:23 AM Staff 2 (DNS) stated lancets are to be placed in the sharps container to avoid cross contamination and injury. , 2. Based on observation, interview and record review it was determined the facility failed to ensure infection control policies and procedures were followed related to PPE use and isolation procedures during a COVID-19 outbreak for 1 of 1 facility reviewed for infection control. Finding include: a. Facility staff reported as of 1/14/23 they had a COVID-19 outbreak in the facility. On 2/20/23 at 7:40 AM during an initial facility entry observation, six staff were observed in the facility without eye protection. There were three staff at the front reception area, two staff at the nurse's station and one CNA student in the hallway. On 2/20/23 at 1:11 PM one CNA was observed in the CNA charting area with eyewear on the top of her head. On 2/23/23 at 3:01 PM Staff 2 (Regional Administrator) was observed coming out of the DNS's office and walking through the building to a back hallway without a face shield or goggles. On 2/24/23 at 9:03 AM Staff 3 (DNS), Staff 8 (Resident Care Manager) and Staff 5 (Regional Nurse Consultant) were present in an infection control interview and acknowledged eye protection should be worn during a COVID-19 outbreak. b. On 2/21/23 at 10:03 AM Room 30 was observed to be on isolation precautions related to COVID-19. The door to Room 30 was left open and there was no staff in or near the room. On 2/21/23 at 10:14 AM Staff 35 (LPN) observed the open door to Room 30 and acknowledged the door should be closed while the room was on isolation precautions and she shut the door. On 2/22/23 at 9:42 AM Room 30 was again observed to have the door open with no staff in or near the room. Room 30 was on isolation precautions related to COVID-19. On 2/23/23 at 9:55 AM Staff 36 (Activities Director) observed the door to Room 30 was open and acknowledged the door should be closed when a resident was on isolation precautions related to COVID-19 and she shut the door. On 2/24/23 at 9:03 AM Staff 3 (DNS), Staff 8 (Resident Care Manager) and Staff 5 (Regional Nurse Consultant) were present in an infection control interview and acknowledged room doors should be closed for rooms on isolation precautions. , c. On 2/20/23 at 8:19 AM Staff 26 (Dietary Manager) was in the kitchen with another staff while not wearing a face mask. Staff 26 stated he had just arrived and wanted to ensure the delivery was put away prior to putting on a face mask. On 2/20/23 at 12:45 PM Staff 1 (Regional Administrator) was observice walking through the 30 hall with eye protection on top of his head. On 2/20/23 at 12:44 PM Staff 30 (Dietary Aide) pushed the meal cart down the resident hall with his face mask below his nose. On 2/22/23 at 7:40 AM Staff 31 (Housekeeping Assistant) was observed in the hallway with his face mask folded in half on his face. Staff 31 stated he was aware of how he was to wear the face mask and corrected it. On 2/22/23 at 8:08 AM Room 9 was observed to have a precautions cart in place with a sign at the door indicating Special Droplet Precautions were to be in place. Staff 24 (CNA) was observed to remove her face mask, place it in her pocket, place an N95 mask on, put on a gown and gloves and enter Room 9. At 8:15 AM Staff 24 disposed of the N95 mask, gown and gloves, then placed the face mask from her pocket back onto her face. Staff 24 stated she was unsure how far she could have gone without a face mask and did not have a clean mask prepared to put on so she placed the mask in her pocket back on her face after leaving the room with precautions. On 2/22/23 at 10:30 AM Staff 33 (Housekeeping Supervisor) exited the soiled linen room with a pair of gloves on and opened the door to Room 8 with the same gloves on. Staff 33 stated she carried gloves in her pocket and switched them out often. On 2/23/23 at 9:42 AM Staff 31 (PT) was observed in Room 4 wearing a face mask and had a used N95 mask around her neck. Staff 31 stated the N95 was the mask she wore from home and forgot it was still there. On 2/23/23 at 2:55 PM Staff 8 (Resident Care Manager) was observed with a resident and multiple other staff in the DNS's office and her face mask was under her chin. Staff 8 stated her mask was probably off. On 2/23/23 at 3:12 PM Staff 17 (CNA) stated infection control was very lax in the facility and it was hard to know what to do because facility administration entered COVID-19 positive rooms without proper PPE in place. On 2/24/23 at 1:37 PM Staff 3 (DNS) stated she expected staff to wear face masks and eye protection, stated the procedure for donning and doffing PPE was on the doors of resident rooms on transmission based precations and staff should not store their masks in their pockets. On 2/25/23 at 11:30 AM Staff 29 (Cook) was observed to push the meal cart through the building towards the nurses station without a face mask or eye protection in place. d. In random observations from 2/20/23 through 2/24/23 no residents were observed to be asked or encouraged to wear a mask when out of their rooms or in common areas. On 2/20/23 at 1:43 PM Resident 234 stated she/he was encouraged just at the beginning of her/his stay in the facility to wear a procedure mask but was not reminded or encouraged since then. On 2/20/23 at 2:18 PM Resident 11 stated facility staff did not suggest or encourage her/him to wear a face mask when out of her/his room On 2/21/23 at 4:23 PM Witness 3 (Complainant) stated residents in the facilty were told they did not need to wear a face mask. On 2/22/23 at 4:51 PM Staff 34 (CNA) stated residents and visitors did not need to wear masks when in the facility and in the common areas. On 2/23/23 at 3:12 PM Staff 17 (CNA) stated at the beginning of the COVID-19 pandemic residents were encouraged to wear masks when in common areas but guidance changed to no masks were encouraged to be worn by residents when they were out of their rooms. On 2/24/23 at 1:37 PM Staff 3 (DNS) stated masks were to be offered to residents in the facilty.

• Identified Resident(s)/Staff: a.)Resident #19 no longer resides within the facility. Resident #1 has had no negative effects noted at this time related to dressing change. Staff #12 has been educated on proper dressing change procedures and CBG machine cleaning as it relates to infection control practices. b.)Numerous staff members infection control practices were identified for this alleged deficiency which put the facility at further risk for infection control issues related to the COVID outbreak. • Similar Residents: a.) Residents with treatment dressings and residents that require blood sugar checks are at risk, no negative outcomes related to dressing changes or blood sugar testing have been noted. b.) Residents and staff of the facility were noted to be at risk related to infection control practices during the facility’s COVID outbreak related to this alleged deficiency. • Corrective Action: a.) Facility will educate licensed staff on the proper infection control practices of dressing changes, the cleaning procedure for the CBG machine, and the disposal of lancets to ensure infection prevention and control meet the professional standards of nursing as it relates to the regulation. b.) Facility will educate employees of the facility as directed by the directed plan of correction utilizing a root cause analysis to direct education on appropriate PPE usage for transmission-based precautions including handwashing, environmental cleaning, accepted donning and doffing, following transmission-based precautions, appropriate infection control sanitation, offering and encouragement of resident utilization of source control, and the monitoring of residents as it relates to the current infection control guidelines per CMS and CDC guidelines. • Surveillance: The infection control preventionist or designee will conduct routine weekly infection control audits to include handwashing, infection control sanitation, PPE usage, following transmission-based precautions, environmental cleaning, donning and doffing, resident source control utilization, and resident symptom monitoring to ensure ongoing compliance as it relates to the regulation and accepted guidelines. The facility will review these audits in the facility QAPI program for at least 3 months to ensure accepted infection control practices are in place, followed, and maintained. • Person Responsible: Infection control preventionist.

Based on interview and record review it was determined the facility failed to ensure appropriate COVID-19 testing was conducted for staff during a COVID-19 outbreak for 1 of 1 facility reviewed for infection control. This place residents a risk for COVID-19 infections. Findings include: Facility staff reported as of 1/14/23 they had a COVID-19 outbreak in the facility. The facility's COVID-19 Testing Requirements policies and procedures included the following: * Facilities were required to test residents and staff in a manner consistent with current standards of practice for Covid-19. * Outbreak: Upon identification of a single case of Covid-19 infection in any staff or residents, the testing should begin immediately, but not earlier than 24 hours after the exposure, if known. * Broad-based testing: "testing is recommended immediately and, if negative, again 48 hours after the first negative test and, if negative, and again 48 hours after the second negative test. This will typically be at day 1, day 3, and day 5. If additional Covid-19 positive individuals were identified the facility would test everyone every 3 to 7 days until no new positives for 14 days". The facility chose to follow the Broad-based testing procedures which indicated staff should be tested two times per week during the current outbreak. A review of the staff testing tracking sheets for 2/5/23 through 2/24/23 (three weeks) indicated at least 20 staff members did not fully complete the required testing. On 2/24/23 at 3:59 PM Staff 2 (Administrator in Training) acknowledged testing was not completed per their policies and procedures and recommended guidelines for COVID-19.

• Identified Staff: Facility currently out of outbreak. Numerous staff were generally identified for this alleged deficiency during outbreak. • Similar Residents: Residents and staff of the facility were noted to be at risk related to infection control practices related to testing during the facility’s COVID outbreak related to this alleged deficiency. • Corrective Action: Facility will educate staff on the facility process consistent with the regulatory guidelines related to outbreak testing per the current and accepted CMS/CDC guidelines. • Surveillance: Infection control preventionist or designee will conduct routine weekly audits during facility COVID outbreaks to ensure testing is completed per regulatory guidelines to maintain compliance. Any noted issues will be addressed in the facility stand up meeting for further follow-up, and noted trends will result in follow-up with the progressive disciplinary process of facility. • Person Responsible: Infection control Preventionist

Based on observation and interview it was determined the facility failed to provide a safe, functional and sanitary environment for 1 of 1 laundry rooms reviewed for infection control. This placed residents at risk for contaminated laundry and staff at risk for injury. Finding include: On 2/24/23 at 1:25 PM an observation was conducted of the laundry area of the facility. A washer and dryer were in place for residents' personal laundry. There was a black hose from the back of the washing machine to the center of the room by the floor by the drain. In the center of the room was a trough drain for the commercial washer located in the same room. The commercial washer drain was covered with a piece of plywood cut to fit the drain with a small open area to allow the black hose from the residents' washing machine to drain into the trough. The black hose did not reach inside the drain and water could be seen draining from the hose wetting the wood floor cover for the drain, and the wood drain cover, which was part of the room's floor, was saturated with water such that it was falling apart, was not cleanable, and was not safe to walk on. The drain area obstructed access to the washer and dryer and staff had to load laundry from the side of the machine and not the front. When the wood covering was lifted off the drain, the drain floor and walls were covered in a black sludgy substance which looked and smelled unsanitary. On 2/24/23 at 2:25 PM Staff 6 (Maintenance Director) indicated the current condition of the area was not safe or sanitary and it needed significant repair. He acknowledged the floor was a safety hazard.

• Identified issue: The drainage hose of the washer has been rectified, the cover replaced, and laundry room sanitized appropriately. • Similar Residents: This alleged deficiency put the facility residents and staff at risk for related to the functional and sanitary environment by placing residents at risk for contaminated laundry and risk for staff injury. • Corrective Action: Facility will educate laundry and housekeeping staff on the sanitation and maintenance of the laundry room as it relates to the regulation to provide a clean and safe environment. • Surveillance: The maintenance person or designee will conduct routine monthly inspection of the newly repaired laundry room environment to ensure on-going compliance and report any issues noted in the facility standup meeting. Any noted trends will be brought to the facility QAPI program as deemed appropriate. • Person Responsible: Administrator

Based on interview and record review it was determined the facility failed to ensure background checks were completed for 1 of 6 newly hired sampled staff (#50) reviewed for background checks. This placed residents at risk for abuse. Findings include: On 2/24/23 at 3:47 PM Staff 15 (Business Office Manager) reviewed the background check for Staff 50 (LPN) and was unable to provide evidence of a background check was conducted, stating it was not yet started for Staff 50 due to her not having a current driver's license. Staff 15 stated Staff 50 was working as an LPN without a completed criminal background check. On 2/24/23 a review of the schedule for Staff 50 revealed she worked in the facility since 2/2/23 as an LPN. On 2/24/23 at 3:50 PM Staff 2 (Administrator in Training) confirmed the criminal background check for Staff 50 was not started and she worked in the facility as an LPN.

• Identified Staff: Staff #50 background check has been completed per the regulatory requirements. • Similar Residents: Facility has reviewed the current employees background checks to ensure that they have appropriate background checks in place with follow-up as appropriate. • Corrective Action: Human Resources has been educated on the regulatory guidelines of employee background checks to ensure that employees are eligible for employment in our health care facility. • Surveillance: The administrator or designee will conduct routine weekly audits of new employees for the next 3 months to ensure that background checks are being completed per the regulatory guidelines. Any noted issues will be addressed immediately and any noted trends will be further investigated for appropriate action. • Person Responsible: Administrator

********************************* OAR 411-086-0130 Nursing Services: Notification - Refer to F580 ********************************* OAR 411-086-0060 Comprehensive Assessment and Care Plan - Refer to F657 and F659 ********************************* OAR 411-086-0110 Nursing Services: Resident Care - Refer to F658, F677, F684 and F687 ********************************* OAR 411-086-0140 Nursing Services: Problem Resolution and Preventative Care -Refer to F686 and F886 ******************************** OAR 411-086-0100 Nursing Services: Staffing -Refer to F726 ******************************** OAR 411-086-0250 Dietary Services -Refer to F812 ******************************** OAR 411-086-0330 Infection Control and Universal Precautions -Refer to F880 ******************************** OAR 411-087-0100 Physical Environment Generally -Refer to F921 ********************************